In the News for the Week of 10-3-06
- CDC report finds overcrowding in many emergency departments
- FDA issues new advisory on heart surgery drug
- Pseudoephedrine goes behind the counter
Health care access
- Insurance premiums rising more slowly for employers
- Annals of Internal Medicine:
- Medical misdiagnoses in the office caused by multiple breakdowns
- Meeting clinical targets for hemodialysis patients
- Advice program for primary care doctors didn’t improve depression outcomes
- Islet transplantation not sustainable in type 1 diabetes patients
- Residents invited to apply for research grants
- Regents Chair asks Congress to act now on payment reform
- Pretest MKSAP 14 questions and qualify for free products
Almost half of U.S. emergency departments (EDs) were crowded in 2003 and 2004, causing some hospitals to divert traffic to other hospitals and some patients to wait for urgent care, said a CDC report released last week.
The report by the CDC’s National Center for Health Statistics said the problem is particularly acute in metropolitan areas, where almost two-thirds of EDs reported crowded conditions. An ED was considered crowded if ambulances had to be diverted to other hospitals; people in need of urgent care had to wait more than an hour; or more than 3% of patients left without being seen.
The crowding was due to a shrinking supply of facilities coupled with increased demand for services, said the Sept. 28 Washington Post. Between 1994 and 2004, the annual number of visits to EDs rose by 18%. During the same period, the number of hospitals operating 24-hour EDs declined by 12%. Nursing shortages are another problem; at half of the metropolitan EDs more than 5% of nursing positions are vacant.
The CDC report drew the attention of the Senate Health subcommittee on bioterrorism and public health preparedness. Last week the subcommittee convened a panel of experts to help identify ways to reduce overcrowding and improve coordination. The experts’ suggestions included increased federal funding for nursing education, better Medicare and Medicaid reimbursement, and financial incentives for primary care physicians to see patients after hours.
The Washington Post is online.
The CDC report is online.
The FDA last week issued a new safety advisory about a widely used heart surgery drug after learning of additional potential risks revealed in a study that the drug manufacturer had failed to report during a safety review.
In a Sept. 29 statement, the FDA said that it had not known about preliminary findings from a study conducted by Bayer Pharmaceuticals on its drug, aprotinin injection (Trasylol), until after a Sept. 21 public meeting held to discuss the drug's risk-benefit profile. The agency had been conducting a review of the drug since January 2006 based on the results of two published studies: one that reported an increase in the risk of kidney failure, heart attack and stroke in patients treated with the drug compared with similar drugs (New England Journal of Medicine, Jan. 26, 2006), and a second that reported an increase in kidney dysfunction compared to another drug (Transfusion, online edition, Jan. 20, 2006).
Preliminary results of the new observational study conducted by Bayer, which examined 67,000 hospital records of patients undergoing coronary artery bypass graft surgery, indicated that aprotinin injection may increase the chance of death, serious kidney damage, congestive heart failure and strokes, said the FDA statement. Bayer said it had not reported the new data because it was preliminary, according to the Sept. 30 New York Times.
The agency noted that assessing the drug's risk is complicated because none of the three studies were randomized controlled trials; instead, patients were assigned treatment by their physicians. Therefore, said the FDA statement, patients receiving aprotinin injection may have had a higher chance for serious complications to begin with as compared with patients receiving other drugs or no drug.
The FDA did not recommend against using the drug, but advised physicians to:
- carefully monitor patients for the occurrence of toxicity, particularly to the kidneys, heart or brain and report adverse events to Bayer Pharmaceuticals or to the FDA MedWatch program (1-800-FDA-1088 or www.fda.gov/medwatch/index.html)
- limit the use of aprotinin injection to situations where the clinical benefit of reduced blood loss outweighs the potential risks of the drug.
The New York Times is online.
The FDA statement is online.
Pharmacies moved all products containing pseudoephedrine behind their counters last week, in line with new federal sales restrictions that took effect Sept. 30.
Under the new rules, all pseudoephedrine products must be kept behind the pharmacy counter and consumers must show photo ID and have their purchases and addresses entered into a logbook. Since April, pharmacies have already been limiting purchases of pseudoephedrine to 3.6 grams per day and 9 grams every 30 days.
The new restrictions have motivated many decongestant manufacturers to replace the pseudoephedrine in their products with the older ingredient phenylephrine, according to the Sept. 26 Washington Post. This move has stirred controversy, said the Washington Post, with some critics questioning the effectiveness of phenylphrine. The government has classified phenylphrine as “generally recognized as safe and effective” since 1976 and the FDA recently rejected a request to conduct further studies.
The regulations are intended to reduce the illegal production of crystal methamphetamine. Methamphetamine now leads cocaine, marijuana and heroin as the top illegal drug problem in 48% of the nation’s counties, according to a June 2006 survey by the National Association of Counties.
The Washington Post is online.
Health care access
Premium increases for employer-sponsored health insurance slowed in 2006, but were still more than double the rate of inflation, according to an annual survey conducted by the Kaiser Family Foundation and the Health Research and Educational Trust.
The average premium rose 7.7% this year, compared with 9.2% in 2005 and 13.9% in 2003. This was the slowest rate of premium growth since 2000. Overall, premiums have increased 87% over the past six years. Family health coverage now costs an average of $11,480 annually, with the workers paying an average of $2,973, said the Sept. 27 Washington Post.
The percentage of employers offering health insurance stayed about the same as last year at 61%. While nearly all business with 200 or more workers offered health benefits, fewer than half of the firms with three to nine workers did. Despite increasing premiums, the study found little use of high-deductible health savings plans. Only 7% of employers offered consumer-driven plans, and about 4% of workers enrolled.
The 2006 Employer Health Benefits Survey polled about 3,159 companies with three or more workers between January and May 2006.
The survey summary is online.
The Washington Post is online.
The following articles appear in the Oct. 3 issue of Annals of Internal Medicine. This issue includes an article about the most common errors in office malpractice claims. The Full text is available to College members and subscribers online.
Medical misdiagnoses in the office caused by multiple breakdowns. A study of 181 closed malpractice claims in which patients alleged a missed or delayed diagnosis in an ambulatory setting found that 59% of these errors were associated with serious harm and 30% resulted in death. Most errors occurred at four main “breakdown” points in the diagnostic process: failure to order an appropriate diagnostic test, failure to create a proper follow-up plan, failure to obtain an adequate history or perform an adequate physical examination, and incorrect interpretation of diagnostic tests. A median of three process breakdowns occurred per error, and two or more clinicians were involved in 43% of cases.
Hemodialysis patients whose care meets clinical targets have fewer hospitalizations and deaths. A survey of 15,287 patients receiving long-term hemodialysis found that those who got better quality of care were less likely to be hospitalized or to die than those who got worse care. The measures of quality of care were anemia, serum albumin levels, functioning vascular access, and dialysis adequacy.
Advice program for primary care doctors didn’t improve depression outcomes. A study of 375 patients with depression found that those whose doctors used a depression decision support program did not get better. They did report more satisfaction with their care and were more likely to have received antidepressant medications than the usual-care group. An editorial writer discusses why the results of this study might differ from previous studies.
A new study found that islet transplantation with the use of the Edmonton protocol can successfully restore long-term endogenous insulin production and glycemic stability in patients with type 1 diabetes mellitus, but that the insulin independence is usually not sustainable.
The trial was inspired by a smaller study in 2000, which demonstrated that islet transplantation could result in a one-year graft survival rate of more than 80%. In the new study, published in the Sept. 28 New England Journal of Medicine, 36 patients at nine centers in the U.S., Canada and Europe underwent islet transplantation from the pancreases of deceased donors.
The primary end point of the trial was defined as insulin independence with adequate glycemic control one year after transplantation. Of the 36 subjects, 44% met the primary end point, while 10% had partial function and 28% had complete graft loss within one year. In total, 58% of the subjects reached insulin independence at some point during the trial, but 76% had become insulin-dependent again by two years after transplantation.
The study showed that the Edmonton protocol can be performed with promising short-term results, but that medium- to long-term results are not durable and need more work, noted an accompanying editorial. One unusual finding was that patients with minimal residual islet function had no further hypoglycemic episodes. That finding could suggest that even a small number of islets may protect against this life-threatening complication, said the editorial.
The American Board of Internal Medicine (ABIM) is offering 10 grants for residency research projects using ABIM Practice Improvement Modules (PIMs). The projects should evaluate the use of PIMs to engage trainees in modern quality improvement.
The small grants, up to $5,000 each, will be awarded to proposals that include a meaningful measurement and evaluation plan for assessing at least one area of the PIM. As a component of ABIM’s Maintenance of Certification Program, PIMs can be applied to residency projects that address practice-based learning and improvement and systems-based practice.
Residents, fellows, program directors and faculty are invited to submit proposals. Preference will be given to trainee-initiated proposals but all projects must have a faculty collaborator.
The proposals will be evaluated for research design and compliance, and then awarded on a rolling basis. Proposals should include details of the project, goals of the study, study design and methodology, a plan for monitoring outcomes and a budget. No applications will be accepted after Nov. 1, 2006.
Applications and more information are online.
William E. Golden, FACP, Chair of ACP’s Board of Regents testified before the House of Representatives Energy & Commerce Committee, Subcommittee on Health Sept. 28, about the pressing need to reform Medicare payments to physicians.
At the hearing, “Medicare Physician Payment: 2007 and Beyond,” Dr. Golden testified that, “It is essential that Congress take immediate action to reform the dysfunctional Medicare physician payment system.”
Without any intervention from Congress, Medicare payments to physicians will be cut by 5.1% on Jan. 1, 2007, due to the flawed sustainable growth rate (SGR) formula that is used to calculate the physician fee schedule. This is the sixth year that the formula has potentially cut physician payments. However, with the exception of 2002, every year Congress has passed legislation that prevented the cuts from going into effect.
Dr. Golden urged Congress to replace the 2007 SGR cuts with a positive update, and to work on permanent payment-system reform.
“Medicare payments are dysfunctional because they reward high-volume, episodic, and fragmented care that undervalues the relationships between physicians and their patients and, as a result, often does not produce desired outcomes,” Dr. Golden noted. “Instead, we need a payment system that is centered on patients’ needs, one that recognizes the value of a patient’s relationship with their personal physician, and one that provides incentives for physicians to engage in continuous quality improvement and measurement supported by health information technology.”
During a question and answer session following the testimony, the subcommittee chair expressed interest in the College's proposal for a Medicare pilot of the medical home model of care, which is based on the notion that team-oriented care led by the patient's personal physician both improves quality and reduces cost. ACP has proposed that qualified practices be eligible for payments for practice expenses and care coordination expenses associated with providing this type of care.
The full text of Dr. Golden’s testimony is online.
ACP is looking for physicians willing to complete tests from the new 14th edition of the Medical Knowledge Self-Assessment Program (MKSAP) during a limited period between Oct. 10 and Oct. 24, 2006. Participants may submit as many as four tests to receive up to four selected MKSAP products at no charge (one product per pretest).
The project is aimed at pretesting MKSAP multiple-choice questions before publication. Results of these pretests will provide data that MKSAP 14 subscribers can later use to compare their performance to that of their peers. The pretest results will be published in MKSAP 14’s performance interpretation guidelines with norm tables in December 2007.
A limited number of physicians will be enrolled in this time-limited pretest program. After completing each pretest, you can choose one of four valuable rewards, including MKSAP 14 Online, MKSAP 14 Self-Assessment Updates, Prep for Boards 2 and MKSAP 13 Update, until you have earned the maximum of four rewards.
More information and the free pretesting kit are online starting Oct. 10.
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Copyright 2006 by the American College of Physicians.
A 67-year-old man is evaluated for a 6-month history of worsening exertional dyspnea. He has severe COPD, previously with minimal exertional symptoms, but now notes activity-limiting shortness of breath when walking short distances. He does not have chest pain, gastrointestinal symptoms, or sleep-related symptoms. Medical history is otherwise unremarkable. Medications are a twice-daily fluticasone/salmeterol inhaler and an as-needed albuterol/ipratropium metered-dose inhaler. He has a 55-pack-year smoking history but quit when COPD was diagnosed. Following a physical exam, chest radiograph, and transthoracic echocardiogram, what is the most appropriate diagnostic test to perform next?
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