In the News for the Week of 11-7-06
- Regulators warn against false diabetes cures and treatments
- FDA approves new drug to treat hepatitis B
- Annals of Internal Medicine:
- Disabled patients less likely to get breast-conserving surgery
- Colorectal screening unnecessary in older people with three or more chronic diseases
- Epirubicin plus CMF more effective than CMF alone in early breast cancer
- Measuring PSA velocity may detect prostate cancer at curable stage
- ACP works with major corporations to reform primary care
- ACP members take awards at AAMC meeting
- College names nominees for ACP officers and regents
Medicare payments for many evaluation and management services (E/M) will increase next year, but unless Congress acts to stop it, a 5% overall cut to physician payments will effectively cancel out the initial benefit for internists from the changes, according to an ACP analysis of a final rule announced by the CMS announced last week.
The 2007 Medicare Physician Fee Schedule will implement changes in physician work relative value units (RVUs) that were first proposed in June. Work RVUs are among the factors that Medicare uses to determine payment rates for different services. By increasing the RVUs for office visits and other face-to-face services, CMS would begin to pay physicians more for the time they spend with patients, leading to better outcomes. CMS based the increased work RVUs on evidence submitted by the College and other physician organizations showing that the physician work associated with E/M services has increased substantially over the past 10 years.
The RVU increases will result in a shift of approximately $4 billion to office visits and other E/M services. According to CMS, internists would gain an average of 5% in total Medicare payments because of the E/M increases, but the SGR cut will reduce overall 2007 Medicare payments to internists by about the same amount, resulting in no net gain in payments.
The SGR formula was created in 1997 and ties physician payments to growth in the overall economy. When growth in physician expenditures exceeds growth in the economy the difference is subtracted from physician payments. This is the seventh consecutive year that physicians have faced SGR-related payment cuts. ACP is urging Congress to take action to eliminate the SGR cut in a post-election “lame duck” session.
“The initial potential benefit to Medicare patients that would result emphasizing the value of personalized, primary care, will be cancelled out by the 5% SGR cut,” said ACP President Lynne M. Kirk, FACP, in a letter to lawmakers. “This lost potential makes it even more imperative that Congress not allow the SGR cut to go into effect.”
Because of the RVU increases, internists will still fare better than most other physician specialties, many of which will experience cuts of 10% or more because of the SGR cut and the redistribution of dollars from their services to increasing pay for E/M services. Over the longer term, internists and their patients will benefit with higher Medicare payments from the improved RVUs and also from private payers that follow Medicare's lead on rates.
The CMS announcement is online.
A new study found that two-thirds of depression victims can eventually feel better if they try several medications, but the likelihood of relapse increases with each new treatment.
All of the 3,671 adults in the study were diagnosed with major depression, and started on citalopram (brand name: Celexa), a selective serotonin reuptake inhibitor, said the Nov. 1 New York Times. Thirty-seven percent saw their depression go into remission. The rest switched to a second antidepressant or continued with citalopram and added another treatment, which helped 31% of that group, according to the New York Times.
Third and fourth treatment steps helped 14% and 13% of the remaining depression sufferers, respectively. The cumulative remission rate was 67%. Those who required more treatment steps had higher relapse rates within a one-year follow-up phase.
The results underscore the need for a better understanding of individual responses to different depression treatments, and the challenge of finding broadly effective treatments, said the National Institute of Mental Health, which funded the study. The study was published in the November issue of the American Journal of Psychiatry.
The American Journal of Psychiatry abstract is online.
The NIMH release is online.
The New York Times is online.
The FDA and the Federal Trade Commission have launched a campaign to stop deceptive Internet advertisements and the sale of products falsely claiming to cure or treat diabetes.
The FTC has sent warning letters to 112 Web sites—84 domestic and 28 foreign—that it deemed were inappropriately targeting consumers. About 25% of the sites changed their claims or removed pages after the letters were sent. The FDA issued warnings to another 24 firms for marketing dietary supplements with dishonest claims of treating, curing or preventing diabetes.
In addition, the FTC launched a consumer education campaign—called “Be smart, be skeptical!”—to teach consumers how to avoid false diabetes cures. It includes a teaser Web site for a phony cure called Glucobate. When consumers attempt to order the drug, they are directed to a link about how to avoid misleading advertisements.
The FDA release is online.
The FDA last week approved telbivudine (brand name: Tyzeka) to treat adults with chronic hepatitis B (HBV). There are now six FDA-approved drugs to treat hepatitis B, but telbivudine contains an active substance that has never before been approved for marketing in any form in the U.S., said the FDA.
A year-long international clinical trial of 1,367 patients with chronic HBV produced evidence of telbivudine’s effectiveness, including the suppression of the hepatitis B virus and improved liver inflammation. The drug is not a cure, nor has it been shown to reduce the risk of transmission of HBV, said an Oct. 25 FDA news release. According to government statistics, about 70,000 Americans are infected yearly with chronic hepatitis B, which can be spread through contact with infected blood.
Mild to moderate side effects include elevated creatinine phosphokinase, upper respiratory tract infection, fatigue, headache, abdominal pain and cough, said the FDA. Some patients also had muscle pain or weakness after several weeks or months of use.
There have been reports of fatal cases where patients suffered severe enlargement and accumulation of fat in the liver among drugs in the same class as telbivudine, said the FDA. Telbivudine is made by Novartis Pharma AG and marketed by Idenix Pharmaceuticals AG.
The FDA release is online.
The Washington Post is online.
The following articles appear in the Nov. 7 issue of Annals of Internal Medicine. This issue also includes a review which found that inhaled insulin is an effective treatment for some patients. The Full text is available to College members and subscribers online.
Disabled patients less likely to get breast-conserving surgery. A new study of records of women younger than 65 who received a diagnosis of localized breast cancer and who also received disability payments from the federal government found that women with disabilities were less likely than those without disabilities to be treated with breast-conserving surgery. Women with disabilities also did not survive as long after breast cancer was diagnosed, but the shorter survival could not be explained by the difference in treatment.
Colorectal screening unnecessary in older people with three or more chronic diseases. A study of people age 67 years and older who were diagnosed with colon cancer found that those with three or more chronic diseases at the time of diagnosis had life expectancies of five years or less (diseases included myocardial infarction, congestive heart failure, peripheral vascular disease, cerebrovascular disease, chronic obstructive pulmonary disease, dementia, paralysis, diabetes, renal failure, liver disease, ulcers, rheumatologic disease, AIDS, hip fracture, and atrial fibrillation). Life expectancy was strongly related to both age and the burden of chronic illness. The study’s authors reported that since randomized trials have shown that a mortality difference between screened and unscreened patients does not become clear until five years after screening, physicians should consider the patient’s age and number and nature of chronic diseases when deciding whether to screen and when to stop screening. An editorial cautions that screening decisions — and treatment decisions — should not be based on life expectancy numbers alone, but also patients’ preferences.
A recent study of adjuvant treatments for early breast cancer found epirubicin plus cyclophosphamide, metotrexate and fluorouracil (CMF) to be superior to CMF alone.
In the study, researchers followed 2,391 women with early breast cancer for a median of 48 months. Some women received four cycles of epirubicin every three weeks, followed by four cycles of CMF, while the others received eight cycles of CMF alone. The study found relapse-free and overall survival rates to be significantly higher in the epirubicin-CMF group than in the CMF-alone group (five-year relapse-free survival, 76% vs. 69%; five-year overall survival, 82% vs. 75%).
Hazard ratios for relapse and death from any cause also favored epirubicin plus CMF over CMF alone. The overall incidence of adverse effects was significantly higher with epirubicin plus CMF but it did not significantly affect the delivered-dose intensity or quality of life. The study was published in the Nov. 2 New England Journal of Medicine.
The study is unusual in that it combined the results of two independent trials, noted an accompanying editorial. The study’s report also did not include the number of patients who receive adjuvant radiation therapy or tamoxifen. This and other studies have shown that adjuvant chemotherapy reduces the risk of recurrence and increases the rate of survival among women with early breast cancer, but the magnitude of the benefit is modest, and many patients have to be treated to benefit a few, noted the editorial. Because of the toxic effects and cost of adjuvant chemotherapy, the editorial suggests that physicians tailor the aggressiveness of treatment to the risk of recurrence and offer lower-risk patients a less aggressive regimen with fewer side effects, such as CMF or doxorubicin plus cyclophosphamide.
A new study found that changes in measuring a man's prostate-specific antigen (PSA) velocity may identify men with life-threatening prostate cancer at a point when the disease is curable.
Using a mathematical formula that estimates the PSA gradient over time, researchers analyzed PSA velocities in 980 men who participated in the Baltimore Longitudinal Study of Aging for up to 39 years. They determined that PSA velocity measured 10-15 years before diagnosis—when most men's PSA is below 4.0 ng/mL—was associated with survival 25 years later. Men with a higher PSA velocity—increasing more than 0.35 per year—had a 54% survival rate, while those whose PSA rose more slowly had a 92% survival rate. The study was published in the Nov. 1 issue of the Journal of the National Cancer Institute.
The findings suggest that men should consider getting a baseline PSA at age 40 to use as a comparison for future changes, study authors told the Oct. 31 Washington Post. However, critics cautioned that a study with only 20 deaths was too small to prove the value of PSA velocity.
The study abstract is online.
The Washington Post is online.
In cooperation with IBM and the American Academy of Family Physicians (AAFP), the College recently co-hosted a meeting of senior executives from a dozen leading U.S. corporations to begin seeking ways to provide better healthcare for their employees. Almost all of the companies attending the meeting subsidize health care for their employees and agreed that action needs to be taken to redesign health benefits and financing to support patient-centered primary care as the backbone of a reformed health care system.
John Tooker, FACP, ACP Executive Vice President, spoke to attendees about the country’s impending primary care crisis. The executives then discussed steps to transform the current health care environment into one that emphasizes patient-centric primary care. Three general actions were agreed upon:
- Move forward with a pilot program of the patient-centered medical home, which would be undertaken by several corporations who are self-insured, such as IBM.
- Create a description of how patient-centered primary care results in better outcomes and lower costs for corporations to consider as they redesign their own benefit plans.
- Work jointly with legislative affairs groups of the attendee corporations to seek changes in Medicare policies to support patient centered primary care.
Two industry coalition organizations agreed to organize these and future joint activities in collaboration with ACP and AAFP.
More information about the collaboration is online.
ACP members made an impressive showing at the annual meeting of the Association of American Medical Colleges. Five ACP members were honored, out of a total of six awards presented to physicians in any specialty.
The following College members were honored:
- Jordan J. Cohen, MACP, President Emeritus of the Association of American Medical Colleges, received the Abraham Flexner Award for Distinguished Service to Medical Education, in recognition of his career-long contributions to medical schools and to the medical education community as a whole.
- Eugene Braunwald, MACP, the Hersey Distinguished Professor of Theory and Practice of Medicine at Harvard Medical School and former chair of the Department of Medicine at Brigham and Women's Hospital, received the David E. Rogers Award from the AAMC and the Robert Wood Johnson Foundation for his contributions to coronary artery disease research--specifically his work on limitation of myocardial infarct size.
- Francois M. Abboud, MACP, the Edith King Pearson Chair in Cardiovascular Research, professor of medicine and molecular physiology and biophysics, and former chair of the Department of Medicine at the University of Iowa Roy J. and Lucille A. Carver College of Medicine, received the AAMC award for Distinguished Research in the Biomedical Sciences. He was honored for his characterization of the heart’s role as a neurosensory organ.
- Molly Cooke, FACP, and Jeffrey Wiese, FACP, were selected for the AAMC’s Alpha Omega Alpha Robert J. Glaser Distinguished Teacher Award, which recognizes outstanding teaching and contributions to medical education. Dr. Cooke is Governor for ACP’s California Northern Chapter and professor of medicine and endowed chair in the division of internal medicine at the University of California, San Francisco School of Medicine. Dr. Wiese is an associate professor and associate chairman of medicine at the Tulane University Health Sciences Center and chief of medicine and president of the medical faculty at the Medical Center of Louisiana at New Orleans.
More information about the awards is online.
The election process for College Officers and Regents is currently underway. The voting body consists of the Board of Regents and the Board of Governors, who are elected by popular vote in their respective jurisdictions. Officers and Regents will take office at the conclusion of the Annual Business Meeting on Saturday, April 21, in San Diego. Members are encouraged to review candidate qualifications and share their views with their Governors before Jan. 2.
At their October meeting, the Regents elected William B. Applegate, FACP, Winston-Salem, N.C. as Chair-elect. Dr. Applegate will assume the Chair at the conclusion of the 2008 Annual Business meeting in Washington, DC. Joel E. Levine, FACP, Denver, Chair-elect of the Board of Regents and David C. Dale, FACP, Seattle, President-elect, will assume office as Chair and President of the Board of Regents, respectively, at the conclusion of the 2007 Annual Business Meeting in San Diego.
Two candidates, Donald W. Hatton, FACP, Lawrence, Kansas, and Sara L. Wallach, FACP, Fair Haven, N.J., are seeking to serve as Chair-elect of the Board of Governors. The College’s Governors have been casting ballots online, with the winner to be announced later this month. The winning candidate will serve as Chair-elect from May 2007 to May 2008 and take office 2008-09.
The ACP Nominations Committee also made the following nominations:
Board of Governors
- President-elect - Jeffrey P. Harris, FACP, Millwood, Va.
- Treasurer - W. James Stackhouse, MACP, Goldsboro, N.C.
Board of Regents
- Virginia U. Collier, FACP, Newark, Del.
- Robert G. Luke, MACP, Cincinnati, Ohio
- Lawrence G. Smith, FACP, Great Neck, N.Y.
- J. Fred Ralston Jr., FACP, Fayetteville, Tenn.
- Allan H. Goroll, FACP, Boston
- JosÚ A. Rodriguez-Portales, FACP, Santiago, Chile
Non governor nominees:
- Talmadge E. King, Jr., FACP, San Francisco
- Barbara J. Turner, FACP, Philadelphia
Biographical sketches of the candidates will be posted online in the November ACP Observer.
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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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