In the News for the Week of 12-12-06
- Congress rejects 5% Medicare physician payment cut
- Major employers launch personal EHR system
- E. coli outbreak at Taco Bell
- JCAHO issues draft patient safety goals for 2008
- Physicians advised to avoid paroxetine (Paxil) use in pregnancy
- ACP Journal Club: Clinical pathway reduces hospitalizations in nursing home residents with pneumonia
- PCI after accepted period for myocardial salvage doesn’t reduce death, reinfarction rates in heart attack patients
- Candidates sought for Councils of Young Physicians, Associates and Student Members
- Survey provides free book on implementing EHR systems
Congress over the weekend took action to avert a planned 5% cut in physician fees in 2007, replacing it with a freeze on payments. Combined with the previously announced 5% increase in average Medicare payments to internists resulting from higher fees for evaluation and management services, internists should realize substantial gains in their total Medicare payments next year.
ACP grassroots efforts were instrumental in achieving the measure, which is expected to be signed by President Bush over the next week. Throughout 2006, nearly 12,000 e-mails and faxes expressing concern about the Medicare Physician Fee Schedule were sent to Congress via ACP's Legislative Action Center from more than 3,300 ACP members. Thousands more used the Grassroots Hotline to call their members of Congress.
Congress' efforts on the final day of the 2006 legislative session resulted in several positive changes for physicians:
- Thanks to the cancellation of the 5% cut and recent changes to the relative values for E/M services (championed by ACP), most ACP members will actually see a substantial gain in total Medicare payments next year, not a freeze.
- A transitional pay for reporting program beginning on July 1, 2007 will be voluntary. Internists will only have to report on three measures to qualify for an additional bonus of up to 1.5% for measures reported from July 1, 2007 through Dec. 31, 2007.
- The framework for a 2008 pay-for-reporting program uses consensus-based measures endorsed by the National Quality Forum and the AQA.
- An ACP proposal for a medical home demonstration has been adopted. It provides internists who participate in the pilot with a "care coordination fee" for managing the care of patients with multiple chronic conditions and the ability to share in savings from reductions in hospital admissions. Referred to in the legislation as the Patient-Centered Medical Home (PC-MH), the demonstration is a key component of ACP's efforts to reform Medicare to recognize the value of care managed by a patient's personal internist in partnership with the patient.
- The new legislation maintains the floor on geographic adjustments. This means that internists in states that would have lost income if the floor expired will not see cuts.
Look in the January ACP Observer for more details about the legislation and ACP’s efforts. Information is also online.
Five major U.S. corporations have joined together to create an electronic database of personal health records for their employees. The system, expected to be operational in the next six months, will be available to about 2.5 million workers and dependents.
The five employers—Applied Material, BP America, Intel, Pitney Bowes and Wal-Mart—contributed $1.5 million each to build the system, according to the Dec. 7 Los Angeles Times. Nonprofit Omnimedix Institute of Portland, Ore., will collect the information, such as scanned documents and X-rays, from users, pharmacies, physicians, hospitals and insurers. Participation in the program is voluntary.
Employees would control who has access to their information and what information is released to doctors. They also will be able to update their records with, for example, family histories of illness, said the Los Angeles Times. The employers hope that the new system, called Dossia, will reduce promote healthier behavior and effective treatments, and reduce administrative costs.
The list of businesses funding the database is expected to grow to 10 in the coming months, the Washington Post reported. In support of the new system, the National Association of Manufacturers has announced plans to spearhead an effort to persuade more corporations to adopt electronic health records. Also this week a group of major insurers is expected to unveil a model medical record that could be adopted nationwide, the Los Angeles Times said.
The Los Angeles Times is online.
The Washington Post is online.
An E. coli outbreak among patrons of Taco Bell restaurants has hit five states and sickened at least 64 people as of Monday.
Samples of green onions obtained from the restaurants tested negative for E. coli 0157, said the CDC's Dec. 11 update. A sample of chopped white onions collected from an open bin in a Taco Bell in Nassau County, N.Y., tested postitive for the 0157 strain, but that strain's DNA fingerprint pattern is different from the outbreak strain, said the agency. As of Monday, no other food items had been identified as containing E. coli.
As of Monday, cases had been reported in New Jersey (28), New York (22), Pennsylvania (11), Delaware (2), and South Carolina (1). Illness onset dates range from Nov. 20 to Dec. 2, the CDC said. Of the 64 cases, 50 people were hospitalized and eight developed hemolytic-uremic syndrome. So far, 38 cases have been confirmed--meaning that the E. coli 0157 strain has the DNA fingerprint of the outbreak.
Healthy adults usually recover from E. coli within a week, according the FDA. Symptoms include diarrhea, often bloody and accompanied by severe abdominal cramps. The CDC advised anyone who has developed symptoms after eating at a Taco Bell restaurant to see a physician and notify the local health department.
The CDC's current update on E-coli is online.
The FDA is online.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has released its list of draft goals to be considered for inclusion in the 2008 National Patient Safety Goals. JCAHO is currently soliciting comments on the goals from health care professionals, providers, consumers and other stakeholders.
The proposed goals would require health care organizations to:
- improve recognition and response to changes in a patient’s condition;
- reduce the risk of post-operative complications for patients with obstructive sleep apnea;
- prevent patient harm associated with health care worker fatigue; and
- prevent catheter misconnections.
The commission has also drafted requirements, including requiring organizations to investigate and initiate planning for the use of technology to assist with patient identification and reducing the likelihood of patient harm associated with anticoagulation therapy.
The goals and requirements are developed by a panel of patient safety experts, including nurses, physicians, risk managers and pharmacists. During the review period, which ends Jan. 26, 2007, health care professionals are invited to submit comments addressing the relevance, priority, clarity, ability to measure compliance, time needed to implement and cost of implementation of JCAHO’s proposals.
The full list of goals and requirements is online.
The FDA recently warned five pharmacies to stop compounding and distributing standardized versions of topical anesthetic creams. The compounded anesthetic creams can pose a serious public health risk with reactions including seizures and irregular heartbeats, the FDA said.
Two deaths have been connected to compounded creams, which contain high doses of local anesthetics including lidocaine, tetracaine, benzocaine and prilocaine, the FDA said. The anesthetics are often used by clinics and spas to lessen pain in procedures such as laser hair removal, tattoos and skin treatments.
FDA-approved topical anesthetic products are commercially available and routinely used in health care settings. Pharmacies traditionally compound products for individual patients who need a treatment that is not commercially available. However, the FDA has found that some pharmacies are marketing their compounded anesthetics for general distribution rather than individual patients. The pharmacy-developed creams often include ingredients at higher strengths than found in FDA-approved products.
Warning letters were sent to the Triangle Compounding Pharmacy, University Pharmacy, Custom Scripts Pharmacy, Hal’s Compounding Pharmacy and New England Compounding Center. Health care professionals and consumers are asked to notify the FDA’s MedWatch program at 1-800-FDA-1088 of any complaints or problems with compounded drugs.
The FDA release is online.
Physicians should take care when prescribing methadone for pain relief, as there have been reports of death and life-threatening events in patients receiving the drug, the FDA said in a MedWatch alert. The FDA recently updated the methadone label following an extensive review of medical literature.
The adverse events, such as respiratory depression and cardiac arrhythmias, are the possible result of unintentional methadone overdoses, drug interactions, and methadone’s cardiac toxicities (QT prolongation and Torsades de Pointes). Some of the unintentional overdoses were due to prescribers being unaware of methadone’s pharmacokinetics and potential adverse effects, the FDA said.
Methadone doses for pain should be carefully selected and slowly titrated to analgesic effect, even in patients who are opioid tolerant. Methadone’s elimination half life (8-59 hours) is longer than its duration of analgesic action (4-8 hours.). Cross-tolerance between methadone and other opioids is incomplete, which makes the conversion of patients from other opioids complex and doesn’t eliminate the possibility of overdose, the FDA said.
The FDA recommends that physicians:
- Read and carefully follow prescribing information
- Carefully weigh risks and benefits of prescribing
- Avoid prescribing 40 mg tablets for pain. This product is only FDA-approved for detoxification and maintenance treatment of narcotic addiction.
- Closely monitor patients who receive methadone, especially during treatment initiation and dose adjustments.
The FDA suggests healthcare professionals tell patients:
- Pain relief from methadone doesn’t last as long as methadone in your body. Do not take more methadone than prescribed because it can build up in your body and cause death.
- Pain relief from methadone should last longer after you’ve taken it for a while.
- Methadone can cause life-threatening changes to breathing. It can also cause changes to your heartbeat that may not be felt.
- Seek medical attention immediately if you experience symptoms suggesting arrhythmia such as palpitations, dizziness, lightheadedness or fainting; or if you have symptoms suggesting overdose like slow or shallow breathing, extreme tiredness, blurred vision, inability to think/talk/walk normally, or feeling faint, dizzy or confused.
The FDA alert is online.
The use of paroxetine (Paxil) should be avoided, when possible, by pregnant women or women planning to become pregnant due to the potential risk of fetal heart defects, newborn persistent pulmonary hypertension and other negative effects, the American College of Obstetricians and Gynecologists’ Obstetric Practice Committee said in an opinion issued Dec. 1.
Exposure to selective serotonin reuptake inhibitors (SSRIs) late in pregnancy has been associated with short-term complications in newborns including jitteriness, mild respiratory distress, excessively rapid respiration and admission to the neonatal ICU, the committee said. Unpublished data regarding the use of paroxetine during the first trimester of pregnancy have also raised concerns about an increased risk of congenital heart malformations.
In December 2005, paroxetine manufacturer GlaxoSmithKline (GSK) revised the drug’s label to change the pregnancy precaution to category D, which indicates positive evidence of human fetal risk. Fetal echocardiography should be considered for women exposed to paroxetine in early pregnancy, the ACOG committee said.
The risk of paroxetine, or other SSRIs, during pregnancy must be weighed against the risk of depression relapse if the medication is discontinued, as untreated depression has risks including low weight gain and alcohol abuse, the ACOG committee said.
The ACOG release is online.
A study of nursing home residents found that a nurse-led clinical pathway was more effective than usual care in reducing hospitalizations for pneumonia.
In the randomized controlled trial, researchers followed 680 nursing home residents in Hamilton, Ontario, Canada who had at least two of the following symptoms: new or increased cough, new or increased sputum production, temperature >38°C, pleuritic chest pain, and new or increased findings on chest examination.
Residents in the clinical pathway group were treated with hypodermoclysis for dehydration and levofloxacin, 500 mg once daily for 10 days. Residents were transferred to the hospital if they did not meet any of the following criteria: pulse <100/min, respiratory rate <30/min, systolic blood pressure >90 mm Hg, and oxygen saturation >92%. In the usual care group, physicians and nursing home staff made treatment decisions. The study is abstracted in the November/December ACP Journal Club.
The study found that 8% of the clinical pathway group was hospitalized, compared with 20% of the usual care group, a weighted absolute risk reduction of 12% (number needed to treat = 9). The reduced hospitalizations resulted in a cost savings of $1,016 per resident, or $1,517 per resident based on U.S. costs of hospitalization, therapy, consultations, diagnostic imaging and professional fees, said the authors. The groups did not differ in mortality, quality of life or adverse events.
This and other studies have shown that a clinical pathway for on-site treatment administered by a trained study nurse can reduce hospitalization and save money in the treatment of nursing home residents with pneumonia, as well as in the management of other clinical problems in older patients, including Alzheimer disease and congestive heart failure, said Journal Club reviewer Henry S. Sacks, FACP, of the Mount Sinai School of Medicine. Unfortunately, he noted, the current structure of the U.S. health care system does not provide financial incentives to implement such systems, so their future in U.S. health care is uncertain.
Peer ratings for this review: Pulmonologists, Geriatricians, General internal medicine/ family practitioners/ general practitioners: 6/7 stars.
Hospitalists: 5/7 stars.
ACP Journal Club is online.
Percutaneous coronary intervention (PCI) doesn’t reduce the occurrence of death, reinfarction or heart failure in stable patients with occlusion of the infarct-related artery identified after the currently accepted period for myocardial salvage has passed (three to 28 days), a new study found.
The randomized study involved 2,166 stable patients who had persistent total occlusion of the infarct-related artery three to 28 days after myocardial infarction and who met a high-risk criterion (an ejection fraction of <50% or proximal occlusion). About half the patients were assigned to routine PCI and stenting with optimal medical therapy, and the other half to optimal medical therapy alone.
PCI did not reduce the occurrence of death, reinfarction, or heart failure, and there was a trend toward excess reinfarction during four years of follow-up in stable patients with occlusion of the infarct-related artery 3 to 28 days after myocardial infarction.
The four-year cumulative rate of death, myocardial reinfarction or heart failure was 17.2% in the PCI group and 15.6% in the medical therapy group. Only six reinfarctions (0.6%) were related to assigned PCI procedures. Rates of heart failure and death were similar for both groups. Additionally, patients in the PCI group tended to have excess reinfarctions. The article appeared in the Dec. 7 online edition of the New England Journal of Medicine.
The results indicate that, for most myocardial infarction survivors without spontaneous or inducible myocardial ischemia in whom left ventricular systolic function isn’t depressed, routine coronary angiography isn’t warranted, according to an editorial in the New England Journal of Medicine. Survivors should receive a beta-adrenergic blocker indefinitely, unless there is an intolerance or contraindication. For the small minority of patients who can’t be treated with beta-adrenergic blockers, it is conceivable that PCI may be beneficial days, weeks or months after myocardial infarction, the editorial said.
The New England Journal of Medicine abstract is online.
The Council of Young Physicians (CYP), the Council of Associates (COA), and the Council of Student Members (CSM) are currently seeking candidates to fill all vacant seats for 2007-2008. Each council meets twice a year in Philadelphia and is responsible for developing College policy, creating Internal Medicine workshops and advocating for their respective constituencies on Capitol Hill.
Regional seats in the CYP are available in the Midwestern and Northeastern zones, as well as two at-large seats. Positions in the COA are open in the Northeast, Southern, Midwestern and Western zones, as well as in the Canada and Latin America zones and in Uniformed Services. The CSM has seats available in the Central, Central Atlantic, Midwest, New England, North Atlantic, North Central, Pacific and Southeastern regions.
CYP candidates must be Members or Fellows of the College who are within sixteen years of graduation from medical school as of May 1, 2007; COA candidates must be Associate members of the College; and CSM candidates must be current Medical Student Members. The deadline for submitting nomination materials is Jan. 15, 2007.
The ACP’s councils for younger members are a unique opportunity for young physicians to become actively involved in the major issues shaping their profession. Those interested in joining any of these councils are encouraged to learn more about the council body of their choice.
For CYP information, contact Amy Allen Collins at (800)523-1546 ext. 2692 or go online.
For COA information, contact Jodi Siegrist at (800)523-1546 ext. 2611 or go online.
For CSM information, contact Patty Moore at (800)523-1546 ext. 2749 or go 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 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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