In the News for the Week of 12-5-06
- Lower literacy, multiple medications cause medical misunderstandings
- HIV treatment holidays increase death, disease risk
- Pfizer halts cholesterol drug trials
- CDC provides information about polonium 210
- Study finds Medicare Advantage plans more costly
- Medicare Part D—overbudget for Humana, underbudget for government
- Annals of Internal Medicine:
- Type of physician organization impacts quality of care
- Screening all adults for HIV is cost effective
- Rosiglitazone has modest glycemic benefit over other diabetes meds
- New course takes doctors from charts to computers
- College news videos win awards
- Workshop proposals solicited for Internal Medicine 2008
- ACP announces awardees and new masters for 2007
- ACP and CMS release Medicare informational materials
- Aetna now paying for new codes
A new study, released at the ACP Foundation’s National Health Communications Conference, found that patients had difficulty comprehending five common prescription label instructions as to how much and how often medication should be taken. Misunderstanding was particularly high among those with lower literacy (eighth grade level or below) and those who took many prescription drugs. In the study, researchers interviewed 395 English-speaking adults in three states.
Study findings included:
- Although 70.7% of patients with low literacy correctly stated the instructions "Take two tablets by mouth twice daily," only 34.7% could demonstrate the number of pills to be taken daily.
- The rates of understanding individual labels ranged from 67.1% for the instructions for trimethoprim ("Take one tablet by mouth twice daily for seven days") to 91.1% for the instructions on the label for felodipine ("Take one tablet by mouth once each day").
- Most patients did not pay attention to the auxiliary (warning) labels (e.g., "Do Not Take Dairy Products Within One Hour Of This Medication") and those with low literacy were more likely to ignore them.
The study indicates that currently recommended methods for confirming patient understanding, such as the "teach-back" technique in which patients are asked to repeat instructions to demonstrate their understanding, may be inadequate for identifying potential errors in medication administration, said study authors. To improve health literacy, the researchers recommend that the text and format of existing primary and auxiliary labels on prescription medication containers should be redesigned and standardized. The study will appear in the Dec. 19 issue of Annals of Internal Medicine.
The study is online.
More information about the conference is online.
HIV patients who take breaks from their medication are more than twice as likely to die or develop opportunistic disease as those who stay on medication continuously, a new study found.
The study involved 5,472 HIV patients in 33 countries, all of whom had a CD4+ cell count of more than 350 per cubic millimeter. About half of the patients continuously received antiretroviral therapy (viral suppression group) while the remaining participants (drug conservation group) deferred therapy until the CD4+ count dropped below 250 per cubic millimeter, then used therapy until the CD4+ count increased to more than 350 per cubic millimeter.
Opportunistic disease or death from any cause occurred in 120 patients in the drug conservation group (3.3 events per 100 person years) compared with 47 participants in the viral suppression group (1.3 events per 100 person years). Hazard ratios for death from any cause and major cardiovascular, renal and heptic disease were 1.8 and 1.7, respectively. The study was published in the Nov. 30 issue of the New England Journal of Medicine.
Researchers expected cardiovascular disease rates to be 15% lower in the drug conservation group than in the viral suppression group as heart problems are a common side effect of the medication, said the Nov. 30 Los Angeles Times. In fact, 65 people in the drug conservation group developed at least one episode of cardiovascular problems, renal or hepatic disease, compared with 39 in the viral suppression group.
The study was halted after 16 months, when the increased risk of death became apparent. The researchers noted that the study provides clear evidence that episodic antiviral therapy guided by CD4+ count carries some risk, as the increased risk of death or disease in the drug conservation group appears to be attributable patients going longer periods with reduced CD4+ counts.
The New England Journal of Medicine abstract is online.
The Los Angeles Times is online.
Pfizer Inc. last week suspended phase 3 trials evaluating its cholesterol drug torceptrapib due to an unexpected increase in deaths among patients receiving the drug along with atorvastatin, compared with participants who received atorvastatin alone.
Pfizer, which faces patent expiration on its brand name drug Lipitor (atorvastatin) in 2010, has two similar drugs in development, said the Dec. 4 San Diego Union Tribune. It is not known whether the complications seen with torceptrapib apply to the entire class of drugs, known as CETP inhibitors, or are specific to torceptrapib.
In the trial, 82 patients taking the combination of torcetrapib and atorvastatin died, compared with 51 deaths among patients taking atorvastatin alone. There were a total of 7,500 participants in each group. Torcetrapib, which represented a new class of medications that raise HDL cholesterol, was intended for use in combination with a statin, said the San Diego Union Tribune.
The San Diego Union Tribune is online.
The FDA release is online.
The CDC has issued a health update about polonium 210 (Po-210), the radioactive material blamed for the death of a former Russian spy in the United Kingdom.
According to the CDC, Po-210 is a radioactive material that occurs naturally at very low concentrations in the environment; although it can be produced in university or government nuclear reactors, it requires expertise to do so. Po-210 is used in tobacco for consumer use as well as some industrial applications such as static eliminators, which are devices designed to eliminate static electricity in processes such as paper rolling, manufacturing sheet plastics and spinning synthetic fibers.
The CDC emphasized that exposures to this radionuclide in London represent a very rare event and that Po-210 is a radiation hazard only if it is taken into the body through breathing, eating or entering a wound. The element is not an external hazard to the body because neither polonium nor its radiation will penetrate intact skin or membranes and most external traces of it can be removed through careful washing.
Health care workers providing care for a contaminated patient would not be exposed to Po-210 unless they inhaled or ingested contaminated bodily fluids. Normal hygiene practices in hospitals for microbial contamination are sufficient to protect workers from radiological contamination.
More information is online.
Medicare Advantage plans cost the government significantly more than traditional fee-for-service coverage would, a new study of 2005 Medicare payments found. The study, conducted by the Commonwealth Fund, determined that the government spent an extra 12.4% on the private managed care plans last year.
Comparing payments to Medicare Advantage plans with funds spent on comparable enrollees in fee-for-service plans in 2005, the difference totaled more than $5.2 billion. Divided up among the 5.6 million Medicare Advantage enrollees, the extra cost is $922 per person, the study found.
Based on the study, Commonwealth Fund officials concluded that legislators should review Medicare Advantage plans to see whether money could be better spent elsewhere in the Medicare program, such as on improved benefits or lower premiums. Critics from the insurance industry disagreed with the study’s statistics in the Nov. 30 New York Times. Data used in the study was collected by the Medicare Payment Advisory Commission, an independent federal body, but the critics questioned the method used to tally the numbers, the article said.
The study is online.
The New York Times is online.
Humana, the largest insurer offering doughnut-hole coverage for seniors, has announced that it will no longer cover brand-name prescriptions during the gap. This year, the Humana PDP Complete plan was one of relatively few Part D plans that paid for prescriptions during the Medicare coverage gap.
Company officials said that the plan had paid out $1.33 in benefits for every $1 it took in last year, according to the Nov. 29 Los Angeles Times. When constructing the 2006 plan structure, Humana assumed that other companies would also offer doughnut-hole coverage and therefore underestimated the cost of the plan, a company official told the Los Angeles Times.
While charging a higher premium, the Humana plan will continue to cover generic drugs during the doughnut hole, which rises to just over $3,050 next year. Less than one-third of Part D plans offer any coverage for the gap, found a recent study by the Kaiser Family Foundation.
By contrast, recently released statistics from the CMS show that the federal government will spend about $30 billion on Part D this year, instead of a projected $43 billion. The CMS attributed the savings to three major factors: lower than expected enrollment, competition and a slowing in the rise of drug prices, the Nov. 29 Washington Post reported.
The Los Angeles Times is online.
The Washington Post is online.
The Dec. 5 issue of Annals of Internal Medicine includes an article about the quality of care provided by different types of physician organizations and a study of the cost-effectiveness of HIV screening for all adults. The full text is available to College members and subscribers online.
Type of physician organization impacts quality of care. A study of 119 physician groups in 1999-2000 found that integrated medical groups (IMGs) delivered higher quality on four of six care measures than individual practice associations (IPAs), with both groups performing well on the remaining two measures. IMGs used electronic medical records and quality improvement strategies more often than IPAs, but this use did not explain differences in quality of care. An editorial writer said that the study actually shows that large IMGs perform better on the selected measures (since all IMGs in the study were large), and that since the study was observational and cross-sectional, it cannot be inferred that the size and structure of an integrated group cause the differences in quality. But the study is important, the writer says, because it contributes to the “Holy Grail” of physician-quality studies: to determine the relationships between physician organization structure, quality improvement processes and outcomes.
Screening all adults for HIV is cost effective. A mathematical decision model study found that screening all adults for HIV with a same-day rapid test was cost effective when the prevalence of HIV in the community was as low as 0.20%. Authors recommended routine, voluntary rapid HIV testing for all adults, except in settings where evidence shows that the prevalence of undiagnosed HIV infection is below 0.2%. This study entirely supports the shift from targeted screening based on patient risk factors to routine screening based on prevalence and incidence thresholds, the authors said. The findings support recent CDC guidelines calling for routine HIV screening of all adults and adolescents. An editorial noted that—reminiscent of successful screening programs for syphilis and tuberculosis—the cost-effectiveness question will change from whether we should screen for HIV to when we should stop.
A recent study compared rosiglitazone, metformin and glyburide as initial treatments for type 2 diabetes patients and found risks and benefits for each but no definitively superior treatment.
In the double-blind, randomized, controlled trial, 4,360 patients were treated for a median of four years. The primary outcome was time to monotherapy failure, defined as a confirmed level of fasting plasma glucose of more than 180 mg per deciliter.
Researchers found a cumulative incidence of monotherapy failure at five years of 15% with rosiglitazone, 21% with metformin, and 34% with glyburide. Glyburide was associated with a lower risk of cardiovascular events than rosiglitazone or metformin. Rosiglitazone was associated with more weight gain and edema than either metformin or glyburide, but with fewer gastrointestinal events that metformin and less hypoglycemia than glyburide. The article was posted online on Dec. 4 and will be published in the Dec. 7 New England Journal of Medicine.
Study authors concluded that relative costs of the medications, profiles of adverse events and potential risks and benefits should be considered in choosing among them. An accompanying editorial said that given the modest glycemic benefit and higher cost of rosiglitazone, metformin remains the logical choice when initiating pharmacotherapy for type 2 diabetes.
The New England Journal of Medicine abstract is online.
The editorial is online.
Along with the traditional armamentarium of stethoscopes and tendon hammers, computers and personal digital assistants are increasingly essential tools in the delivery of healthcare. ACP’s 10 x 10 program offers physicians a means to engage in the rapidly changing landscape of health care technology.
A collaboration between the College, Oregon Health & Science University and American Medical Informatics Association, 10 x 10 is an introduction for physicians who want to become more involved in HIT projects in their institutions or medical practices. The program consists of an 11-week, online curriculum followed by one day of face-to-face activities, which will be held prior to the ACP’s Internal Medicine 2007 annual meeting.
Since the program was launched in 2005, over 120 people have completed the course, with many going on to advanced study in the field. Competences participants can expect to take away from the program include:
- implementing EHRs in ambulatory, hospital and other settings
- clinical decision support in health care settings
- computerized provider order entry to enhance clinical decisions
- basic principles of health care quality assessment, including pay-for-performance programs, and how the EHR enables them
- telemedicine and barriers to its use
The registration deadline is Jan. 3, 2007. Participants in the program may earn up to 56 Category 1 CME credits.
More information is online.
Registration is online.
ACP's Communications Department recently received two awards from the Philadelphia Chapter of the Public Relations Society of America for its work promoting ACP activities.
The staff picked up top honors for its January 2006 Annals of Internal Medicine video news release, "Regular Exercise Reduces Risk of Dementia and Alzheimer’s Disease." The team placed second for its December 2005 video, "Yoga Improves Back Function and Lessens Low Back Pain.” Judges praised the videos for explaining a complex medical issue in a manner easily understood by the general public.
Over the past five years, the department has won a total of 11 national and regional public relations awards for a variety of ACP projects.
Links to all of the Communication Department's video news releases are online.
Two of the College’s subcommittees, Clinical Skills (CSSC) and Medical Informatics (MISC), are now accepting proposals for workshops at Internal Medicine 2008, May 15-17, 2008 in Washington, D.C.
The CSSC welcomes all proposals but places a priority on interactive workshops that focus on the acquisition or improvement of physical examination skills, communication skills, and procedural skills. The CSSC is most interested in workshops that have a high likelihood of changing physician behavior using proven teaching techniques or new and innovative teaching strategies that have yet to be tested.
The MISC places a priority on interactive workshops that focus on the use of technology and computer applications in the care of patients and the management of medical practice. Ideally, workshops should encourage physicians’ use of technology and computer applications shown to improve quality of care, patient safety, and practice management efficiency.
The deadline for proposals is May 1, 2007.
The ACP Awards Committee recently announced that the Board of Regents approved a number of individuals and institutions to receive College awards and Masterships at Internal Medicine 2007. In total, the Regents selected 18 new awardees and 50 new Masters. A full list of the recipients is online.
Please join the awards committee in congratulating the awardees and new Masters and feel free to pass the word along to your colleagues. If you would like to personally congratulate any of the new awardees or Masters, please contact Meghann Williams, Coordinator, Awards-Convocation and Diversity, at firstname.lastname@example.org, 800-523-1546, ext. 2714 or 215-351-2714; or Martha Cornog, Manager of Membership Services, email@example.com, ext. 2696, or 215-351-2696. Staff will relay messages of congratulations to the awardees.
An additional announcement of the winners is being sent to all who wrote supporting letters for nominations. The supporters are invited to enhance their nominations for the next cycle as well as submit new nominations.
ACP and the CMS have recently released informational materials focused on the needs of practicing physicians and their Medicare patients. These materials can be easily downloaded for office use and consist of:
- The updated “Medicare Prescription Drug Coverage and You” brochure was developed for patients by ACP and explains the Part D benefit. It also provides resources for further information and assistance.
- A CMS-developed color poster that can be hung in your office to announce the start of the 2007 open enrollment period for the Part D drug benefit. It provides a patient check list of issues to consider when choosing a Part D drug plan and offers resources for further assistance in choosing a plan.
- A CMS-developed information sheet titled “Important Updates to Medicare’s Diabetes-related Services in 2007” that provides a summary of the Part B-covered preventive services available for Medicare beneficiaries with or at risk for diabetes.
As of Nov. 12, 2006, Aetna is paying for claims for urinalysis dipstick and pulse oximetry when performed on the same date as evaluation and management (E/M) services. In order to qualify for reimbursement, the E/M codes reported must be appended with Modifier 25.
Aetna will reprocess qualified claims for services that occurred after May 1, 2006. These claims will be automatically reprocessed, and physicians do not need to resubmit them.
More information about these changes 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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