In the News for the Week of 11-21-06
- Report tracks infection rates at individual hospitals
- Angioplasty no better than drugs three-plus days after heart attack
- CDC campaign focuses on preventing falls among elderly
- Annals of Internal Medicine:
- Support programs help dementia patients and caregivers
- Anemia drugs may raise cardiovascular risk for kidney disease patients
- ACP Foundation sponsoring conference on health literacy
- ACP offers patient education material on triglycerides
- Complimentary literature available for young physician members
- Free video, patient letter on meningitis available from NFID
- Survey provides free book on implementing EHR systems
Editorial Notice: Observer Weekly will not be published on Nov. 28, 2006 due to the Thanksgiving holiday.
A new report on hospital-acquired infections in Pennsylvania's 168 hospitals found 19,154 cases in which patients contracted hospital-acquired infections during 2005, a rate of 12.2 per 1,000 cases. The report, the first in the nation to measure infection rates at individual hospitals, noted that the infections resulted in an extra 400,000 inpatient days and at an estimated cost of $1 billion.
Compiled by the Pennsylvania Health Care Cost Containment Council (PHC4), the study noted that infection rates varied widely between hospitals. However, it did not explain whether high infection statistics could be attributed to better tracking systems rather than high infection rates, noted the Nov. 15 Philadelphia Inquirer. Representatives of PHC4 said that because of variations in tracking, the report should be used as baseline for future performance, not to compare hospitals.
The report tracked four types of hospital-acquired infections:
- bloodstream infections from IVs inserted in large veins
- ventilator-associated pneumonia
- urinary-tract infections from catheters and
- surgical-site infections.
The report is online.
The Philadelphia Inquirer is online.
Stable patients with a blocked artery who had angioplasty plus stenting three to 28 days after a heart attack did no better than patients on drug therapy alone, a new study found.
The five-year study randomly assigned 2,166 patients in 27 countries to routine angioplasty with stenting combined with drug therapy, or to drug therapy alone. Most patients had blockages in only one coronary artery. Drug therapy for both groups included aspirin, blood-pressure lowering ACE inhibitors, beta blockers, cholesterol-lowering therapy, and clopidogrel. Measuring from the onset of symptoms, the minimal time from the myocardial infarction to angiography was just over 24 hours.
There was no statistically significant difference in major cardiovascular events between the two groups over an average of three years and up to five years. At four years, the rate of death, heart attack or serious heart failure was 17.2% in the angioplasty group compared with 15.6% in the medical therapy group.
The results indicate that opening of a heart-attack related coronary artery should only be reserved for certain patients, like those who are unstable or continue to have chest pain after heart attack, said study chair Judith Hochman, M.D., Clinical Chief of Cardiology and Director of the Cardiovascular Clinical Research Center, New York University School of Medicine.
Though not statistically significant, the trend toward more heart attacks in the angioplasty group bears further study, Hochman said in an NIH release. The study, which will be published in the Dec. 7 issue of the New England Journal of Medicine, was funded by the NIH’s National Heart, Lung and Blood Institute.
The New England Journal of Medicine is online.
The NIH release is online.
The CDC last week made updated brochures and posters available to health care providers and the public in an effort to reduce falls among the elderly.
Fall-related death rates for those age 65 and older increased by more than 55% between 1993 and 2003, with more men dying from falls than women, a new CDC report said. In 2003, more than 13,700 older adults died from falls, making them the leading cause of injury deaths among people 65 and older. Almost 1.8 million seniors were treated in the ER for nonfatal injuries from falls in 2003, the report said.
Two CDC brochures are available to help older adults and their families and caregivers prevent falls. “What YOU Can Do to Prevent Falls” explains steps that older adults can take to reduce their risk of falling, such as exercising regularly and having regular eye exams. “Check for Safety: A Home Fall Prevention Checklist for Older Adults” offers a list of hazards to look for in the home and tips for reducing the hazards, such as keeping objects off stairs and using non-slip backing on rugs.
Four posters, designed for use in health care facilities, senior centers and other community organizations, highlight the prevention messages in the brochures. All are available in English, Spanish, and Chinese. Materials are available online.
The CDC report is online.
The CDC has designated Nov. 27-Dec. 3 National Influenza Vaccination Week. The center encourages flu vaccine providers to enhance vaccine availability during this time by scheduling additional clinics, extending clinic hours and encouraging mass vaccination at retail clinics and other locations.
CDC officials last week expressed concern that an abundance of unused flu vaccine this year could result in millions of doses being thrown out, which might discourage manufacturers from making enough in future years, the Nov. 14 Philadelphia Inquirer reported.
Although 77 million doses were distributed by Nov. 3, there were scattered shortages across the U.S. due to distribution problems. More than 110 million doses are being made for the 2006-07 flu season, compared with the previous record of 95 million in 2002-03, when 12 million doses went unused and one manufacturer stopped making shots, the Philadelphia Inquirer said.
The CDC's latest flu-shot recommendations cover 218 million of the U.S.’ 300 million people. November and early December are good times to be vaccinated, since flu activity usually doesn’t peak until February or later, the CDC said.
The CDC particularly recommends the following groups get vaccinated:
- Children aged 24 months to 59 months
- Adults aged 50 and above
- Pregnant women
- People with chronic illnesses like heart disease or diabetes
- Health care personnel, caregivers and others in close contact with high risk persons
The CDC release is online.
The Philadelphia Inquirer is online.
The FDA revised the Precautions/Neuropsychiatric Events and Patient Information sections of the prescribing information for Tamiflu (olsetamivir phosphate) last week to suggest patients be closely monitored for signs of unusual behavior after taking the drug.
The new label says that people with the flu, especially children, “may be at an increased risk of self-injury and confusion shortly after taking Tamiflu,” and advises consumers to contact a healthcare professional immediately if such behavior occurs.
The label change came after postmarketing reports of more than 100 cases of neuropsychiatric events in patients taking the drug. Most patients were children from Japan, where the drug already carries precautionary language. Tamiflu is made by Roche Holding AG.
The FDA said that the relationship between the behavior and the drug isn’t known, but the revised label is meant to mitigate a potential risk, the Nov. 13 Washington Post reported. New data from Roche suggests the psychiatric problems seen in some patients taking the drug are a result of the flu itself and not the drug, the FDA said two days after it announced the label change.
The FDA Medwatch Safety Alert is online.
The Washington Post is online.
The Nov. 21 issue of Annals of Internal Medicine includes two articles and an editorial about programs to improve the well-being of dementia patients and their caregivers. This issue also includes an article about internal medicine residents’ career decisions and a study of insurance coverage for patients with non-ST-segment elevation acute coronary syndromes. The full text is available to College members and subscribers online.
Support program improves lives of dementia caregivers. Researchers in this study assigned 423 Hispanic, white, and black caregivers either to a group that received intensive support or to a control group that received written educational materials. After receiving help and counseling about how to manage stress, take care of their own health, improve social support networks, and manage problem behaviors of their patients with dementia, the caregivers in the support group reported improved quality of life and had significantly less depression than those in the control group.
Coordinated support for caregivers improved dementia care. In this study, researchers assigned 408 pairs of people with dementia and their caregivers to one of two groups. In one group, case managers helped the caregivers get needed services and care from various doctors and community agencies. In the other group, caregivers and patients were responsible for coordinating their own doctor visits and social services. Pairs in the coordinated system—both caregivers and patients—received more and higher-quality health and social services than those in the usual-care group. Sixty-four percent of patient care in the coordinated group met 23 dementia care guidelines vs. 33% in the usual-care group.
Editorial: What do we do now? These studies show the kind of interventions that improve quality of life for both caregivers and patients and improve patient care, says an accompanying editorial. The magnitude of benefit and quality of evidence supporting these interventions considerably exceed those of currently approved pharmacologic therapies for dementia, the editorial notes. However, few clinicians will be able to implement the programs for their patients because Medicare and other providers do not pay for most caregiver support services or team-based case management services for elderly persons with dementia. Since dementia patients and their caregivers are not likely to form the vocal lobby needed to work for these changes to Medicare law, the editorial writers call upon the medical profession to advocate on their behalf.
Two new studies of anemia resulting from chronic kidney disease found that normalization of hemoglobin levels may not be beneficial to patients’ health. In both studies, the use of epoetin to raise hemoglobin levels did not result in fewer cardiovascular events among patients with chronic kidney disease.
In the Cardiovascular Risk Reduction by Early Anemia Treatment with Epoetin Beta (CREATE) trial, 603 patients with stage 3 or 4 chronic kidney disease were assigned a target hemoglobin value in either the normal range (13-15 g per deciliter, group 1) or the subnormal range (10.5-11.5 g per deciliter, group 2). Subcutaneous epoetin beta was initiated at randomization (group 1) or when hemoglobin fell below 10.5 (group 2). Over the three year study period, researchers found that the two groups had similar incidence of cardiovascular events and group 1 patients had a shorter mean time to dialysis.
The Correction of Hemoglobin and Outcomes in Renal Insufficiency (CHOIR) trial randomly assigned 1,432 chronic kidney disease patients to receive epoetin alfa targeted to achieve a hemoglobin level of either 13.5 g per deciliter or 11.3 g per deciliter. The trial found that the higher target was associated with a 34% increased risk of death, myocardial infarction, hospitalization for congestive heart failure (without renal-replacement therapy), and stroke without achieving any improvement in the quality of life. Both studies were published in the Nov. 16 New England Journal of Medicine.
Overall, there was no significant difference in mortality rates between groups in either study, although the absolute number of deaths was higher in the high-hemoglobin groups, noted an accompanying editorial. The most surprising finding was that high hemoglobin levels did not ameliorate left ventricular hypertrophy in the CREATE study and increased the risk of congestive heart failure in both trials, said the editorial. These findings should encourage physicians to treat anemia less aggressively, the CHOIR study’s lead author told the Nov. 16 New York Times.
The New York Times is online.
Over half of all U.S. adults - 90 million people - have difficulty understanding and acting on health information. The ACP Foundation is focused on finding practical and evidence-based solutions to the problems of low health literacy.
The upcoming Fifth Annual National Health Communication Conference will bring together leading researchers and stakeholders from around the country to take a solution-oriented approach to low health literacy. The ACP Foundation conference, cosponsored by the Institute of Medicine, will be held at the National Academy of Sciences in Washington, D.C. on Nov. 29.
The conference provides an opportunity for attendees from a variety of sectors, including medicine, industry, pharmaceuticals, media, insurance, patient advocacy and government, to learn about the growing problem of low health literacy and discuss potential solutions.
Conference topics include:
- The prescription drug labeling project: Providing our patients with better information about their medications
- The business case for health and productivity management: What’s the return on investment?
- Current research in advances to solutions of the problems of low health literacy
- Using information technology to accommodate patients’ levels of health literacy
Conference information is online.
“Understanding and Managing Your Triglycerides” is the newest offering in ACP’s line of patient education materials. This ACP Special Report provides information on triglycerides, what they are, how they affect health and how to screen for and treat associated diseases and conditions.
ACP Special Reports feature evidence-based health information presented in a patient-friendly format with nonclinical, easy-to-read language. They present treatment and management details that patients can follow to counter the effects of a disease, condition or health problem. Many physicians use the special reports and other patient education literature as an effective way of promoting patient self-education. They are ideal for use in exam rooms and waiting rooms.
ACP Special Reports are also available on many other topics including:
- Heart Failure
- Diabetes (available in Spanish and English)
- Peripheral Artery Disease.
ACP members can order bulk packs of ACP Special Reports at no charge by calling 866-439-9857 Monday through Friday from 9 a.m. to 8 p.m.
The report can also be ordered online.
As a benefit of membership, ACP members are eligible to receive a free copy of products developed by the Council of Young Physicians (CYP) for members’ reference and professional use, including the Young Physician Practice Management Survival Handbook and the Pocket Guide to Selected Preventive Services for Adults.
The Survival Handbook is a valuable resource for physicians who are just starting out and may not be sure how to proceed with the nuts and bolts of running and managing a practice. The Pocket Guide is a proactive way to encourage preventive care in daily practice, and includes selected screening services.
To receive a copy of either the Pocket Guide or the Survival Handbook, contact Amy Allen Collins, Administrator, Young Physicians and Volunteerism Programs at 1-800-523-1546 ext. 2692 (toll free), 215-351-2692 (local), 215-351-2759 (fax) or by email at firstname.lastname@example.org.
More information is available online.
A free educational video on meningococcal disease is now available to physicians and other providers as part of the National Foundation for Infectious Diseases’ S.T.O.P. Meningitis program. The brief video, created in collaboration with leading medical and advocacy groups including ACP, can be used to educate clinicians, office staff, parents and patients about the disease and the importance of vaccination.
A new patient recall letter is also available to assist providers in implementing the CDC’s recommendations to routinely vaccinate pre-teens 11-12 years old during the preadolescent doctor visit, as well as previously unvaccinated teenagers before they enter high school and college freshmen living in dormitories. The letter can be easily customized and sent to parents. It is available online.
Other resource materials, including reimbursement tip sheets, vaccine delivery tip sheets and waiting room posters are available online.
Researchers at the University of Maryland’s Robert H. Smith School of Business are conducting a survey to learn more about the use of electronic health records (EHRs) in physician practices. Earlier this year, members of the College’s Center for Practice Innovation (CPI) participated in the initial round of surveying for this project.
The survey, being conducted by the Smith School’s Center for Health Information and Decision Systems (CHIDS) focuses on examining the factors that influence the adoption and use of EHR systems, and the impact of these systems on the practices that implement them. CHIDS is a research and development center established to examine the challenges associated with the introduction and integration of information and decision technologies in the health care sector.
CHIDS is looking for practicing physicians, or anyone at a physician’s office who is involved in decisions related to EHR adoption, to complete their survey. The first 500 responders will receive a copy of the book Implementing the Electronic Health Record: Case Studies and Strategies for Success, edited by Joe Miller and published by HIMSS. The estimated time to complete the survey is 15-20 minutes.
The survey is online.
More information about the CPI is online.
More information about the CHIDS project is online.
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Copyright 2006 by the American College of Physicians.
A 66-year-old man comes for a preoperative evaluation before total joint arthroplasty of the left knee. He has a 25-year history of rheumatoid arthritis. He has had progressive pain in his left knee with activity, which limits his ability to hike. The patient has similar pain in the right knee, but it is less severe. He reports no recent morning stiffness. He is able to climb two or three flights of stairs without chest pain or shortness of breath. He has no other medical problems and reports no additional symptoms. Medications are methotrexate and folic acid. Following a physical exam and lab tests, what is the next best step in management?
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