American College of Physicians: Internal Medicine — Doctors for Adults ®

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In the News for the Week of 2-21-06

Quality improvement

Advocacy update

Clinical news in the headlines

Medicare news

Health disparities

ACP news


Quality improvement

Wanted: practices interested in geriatric redesign

In partnership with the RAND Corp., ACP is seeking medical groups willing to participate in a pilot project to test management strategies of selected conditions in geriatric patients.

The project will test different interventions in managing incontinence, falls and heart failure. Participating physicians will receive training from project staff in identifying and managing patients with these conditions, as well as educational materials. The project will begin this spring and continue for two years.

"It is exceedingly difficult for doctors to manage the multiple chronic problems of older persons within the current time constraints of an office visit," said David B. Reuben, FACP, director of the geriatrics program at the University of California, Los Angeles (UCLA). "This program is aimed at reorganizing practice so geriatric conditions can be comprehensively addressed without adding to the length of the office visit."

Dr. Reuben, who is currently the president of the American Geriatrics Society, is one of the project's three clinical leaders, along with William J. Hall, MACP, of the University of Rochester School of Medicine in Rochester, N.Y., and Neil Wenger, ACP Member, who is also at UCLA.

Practices must have at least three or more physicians willing to participate, a significant portion of their patient population age 75 or older, and one non-MD who can act as quality coordinator and interact with project staff. Prior experience with ACPNet data submission is helpful but not required.

For more information, contact Kyle Bartlett, PhD, Grant Administrator, at 800-523-1546, ext. 2838, or 215-351-2838.

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Advocacy update

ACP Services PAC completes its first year

ACP Services Political Action Committee (PAC) ended its first full year of operation, raising nearly $58,000 and making contributions to 26 candidates for the U.S. House of Representatives and the Senate.

ACP Services PAC is dedicated to protecting the interests of internists and their patients by backing candidates for federal office who understand and support the concerns of the internal medicine community.

“The PAC plays a key role in helping our grassroots members build stronger relationships with their Congressional representatives,” said ACP Services PAC Chair Joseph W. Stubbs, FACP.

In 2005, the top five states with the most PAC contributors were New York, California, Florida, Alaska, and Virginia.

The PAC is administered by ACP Services Inc., which was established in 1998 as a 501c6 organization to provide advocacy, practice management and other services for internist-members. ACP members automatically are also members of ACP Services Inc. As a 501c3 organization, ACP is prohibited by the Internal Revenue Code from establishing a PAC.

For more information, contact Laura Allendorf or visit the PAC home page.

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Clinical news in the headlines

Annals: statins, beta-blockers and heart event severity; high-hospital volume and pneumonia care

The following articles appear in the Feb. 21 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.

  • Statins and beta-blockers may reduce severity of a first heart event. In a study of more than 4,000 patients with a first-time heart disease event, researchers found that those who had been taking statins or beta-blockers were more likely to be diagnosed with angina than myocardial infarction.

    While statins and beta-blockers are already known to improve factors that lead to heart disease, this study shows that the drugs may also influence the severity of coronary heart disease when it first causes symptoms.

  • Hospital volume and experience with pneumonia do not translate into better care. Many studies have shown that hospitals and doctors who provide a high volume of care for some surgical procedures and medical conditions also provide higher quality care. While this relationship may be true for some conditions, a new study shows that it does not apply to pneumonia.

    This retrospective cohort study of 3,243 hospitals across the U.S., with 23,480 pneumonia patients cared for by 9,741 physicians, found no association between caring for large numbers of pneumonia patients and close adherence to selected guidelines for appropriate pneumonia care. In fact, greater pneumonia volume was associated with less adherence to recommendations on vaccination recommendations and on speedy administration of antibiotics. Moreover, high-volume providers did not have better patient outcomes.

    Researchers conclude that quality improvement efforts for pneumonia should focus on improving how quickly antibiotics are administered and boosting inpatient vaccination rates.

  • Preclinical carotid artery disease found in people with rheumatoid arthritis. A study compared 98 people with rheumatoid arthritis (RA) but no symptoms of heart disease to 98 patients without RA, and found that those with RA had a three-fold increase in atherosclerosis in their carotid arteries. Researchers found carotid-artery atherosclerosis in 44% of patients with RA, compared to 15% of those without RA. Patients in the two groups were matched for age, sex and ethnicity.

    RA patients are prone to premature death from heart disease even when they have few observable heart disease risk factors. Researchers suggested that RA's arthritic inflammation may be linked to arterial plaque, but they acknowledged that the study does not prove this link exists.

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ACP Journal Club: Clopidogrel boosts survival after coronary-intervention

A recent study provided further evidence that clopidogrel reduces mortality in patients with ST-elevation myocardial infarction (STEMI) who undergo percutaneous coronary intervention (PCI).

In the study, 1,863 adults with STEMI were given either 300 mg of clopidogrel followed by 75 mg/d or placebo, while all patients received aspirin or unfractionated heparin, two to eight days before angiography.

After 30 days, patients in the clopidogrel group had a relative risk reduction of 44% for cardiovascular death, recurrent MI or stroke from PCI compared with patients in the placebo group. The study is abstracted in the March-April ACP Journal Club, which is now available online.

Patients taking clopidogrel also had a lower rate of recurrent MI or stroke before PCI and did not experience significantly more bleeding than the placebo group. The results are supported by several previous large trials, said reviewer Steven Borzak, FACP, of Florida Cardiovascular Research LC in Atlantis, Fla. In addition, another large trial currently underway is studying the effects of clopidogrel taken longterm for secondary and high-risk primary prevention.

The combined results of these trials indicate several key effects of clopidogrel, Dr. Borzak said. The drug is effective soon after hospitalization, is best when taken several days before PCI and continued for months afterward, and does not add significantly to the risk of bleeding caused by aspirin.

Optimal dosages of clopidogrel remain to be worked out, Dr. Borzak noted.

Peer ratings for this review: emergency medicine: 7/7 stars;
hospitalists, cardiologists, internists and subspecialists: 6/7 stars

ACP Journal Club is online.

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Data add to controversy on estrogen and heart disease

Using more data from the Women’s Health Initiative, some researchers in a new study now claim that estrogen did not increase the risk of heart disease for postmenopausal women who had had a hysterectomy and may have some protective effects for younger women.

The study examined data from 10,739 women age 50-79 who had undergone hysterectomy and had received either 0.625 mg/d of conjugated equine estrogens or placebo for almost seven years. There was no overall significant difference in coronary events between the two groups but the risk of heart disease was slightly lower among women age 50-59 in the estrogen group.

Released in 2004, initial results of women who had had a hysterectomy and were taking estrogen found that estrogen neither increased nor decreased their heart disease risk, according to the Feb. 14 Washington Post. The latest results appear in the Feb. 13 Archives of Internal Medicine.

Many postmenopausal women stopped taking estrogen after earlier studies suggested the hormone could increase their risk of heart disease. This latest study is the first to look specifically at younger women, the Washington Post reported. However, many experts—including some engaged in the research—disagree that the results support the hypothesis that estrogen may cut younger women's risk of heart disease.

Some experts interviewed by the Washington Post said the findings supporting estrogen’s protective effects are too weak to justify taking it to prevent heart disease, especially because the hormone increases the risk for strokes and blood clots. However, there was some consensus that estrogen is safe and effective when used for short periods to relieve symptoms such as hot flashes.

An Archives of Internal Medicine abstract is online.

The Washington Post is online.

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Calcium, vitamin D supplements may fail to prevent hip fractures

A large federal study of postmenopausal women concluded that taking calcium and vitamin D supplements led to a slight improvement in bone density but did not prevent hip fractures.

The seven-year study, part of the Women's Health Initiative, found a 1% improvement in bone density among women who took 1000 mg of elemental calcium as calcium carbonate with 400 IU of vitamin D daily. Women who took the supplements also had a 17% higher risk of developing kidney stones. The results appear in the Feb. 16 New England Journal of Medicine (NEJM).

The findings contradict the commonly held assumption that supplements help prevent osteoporosis and that all women over age 50 should take them, said the Feb. 16 New York Times. Some experts interviewed in the article said that only women not getting enough calcium in their diet should take supplements, due to the higher risk of kidney stones.

The authors noted that among women who were at least 80% compliant in taking supplements, the risk of hip fractures was reduced by 26%, or four fewer hip fractures per 10,000 women. In addition, they said, calcium supplements might prove effective at higher doses as other trials have shown a benefit among women taking 600 IU of vitamin D or higher daily.

While the study indicated an increased risk of kidney stones among women taking supplements, the possible reduced risk of fracture shouldn't be ignored, an accompanying editorial said. However, physicians should be aware that supplements alone are not enough to prevent fractures and additional therapies—such as antiresorptive medications or teriparatide—might be appropriate for high-risk patients.

The New England Journal of Medicine abstract is online.

The New York Times is online.

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Medicare news

Seniors trust satisfaction scores over quality measures

Seniors using Medicare’s report cards on its managed care plans are largely ignoring quality data, relying instead on patient satisfaction scores to make enrollment decisions, according to new research.

Over an eight-year study period, beneficiaries who based their choices on Medicare HMO report cards did so on the basis of enrollee satisfaction scores. Other quality measures, such as mammography rates, did not affect enrollment. The study, which covered the period from 1994-2002, was published in the February National Bureau of Economic Research (NBER) Digest.

The results indicate that consumers are relying on indicators that have no real impact on health, according to the Feb. 16 Washington Post. The report cards also included quality measurements on proper care for diabetes as well as best practices related to disease screening and prevention.

The report’s authors said they were disconcerted that consumers appeared to ignore objective quality measures in favor of other patients’ opinions about such things as parking lots and waiting rooms. They also noted that the report cards prompted switching among beneficiaries already in HMOs but were not very effective in bringing traditional Medicare enrollees into Medicare managed care plans.

The NBER Digest is online.

The Washington Post is online.

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Health disparities

Spanish speakers have trouble getting Rx labels

A recent study found that many pharmacies cannot provide labels in Spanish even in predominantly Hispanic neighborhoods.

The study, published in the Journal of Health Care for the Poor and Underserved, surveyed more than 160 pharmacies in the Bronx section of New York, said the Feb. 14 New York Times. Researchers found that three out of 10 Spanish-speaking patients did not understand the instructions on their medications. Labels in Spanish were not consistently available even in neighborhoods where Spanish speakers made up between 11% and 71% of the population.

The authors noted that providing instructions only in English increases the risk for medication mistakes, the New York Times said. They recommended that doctors in all parts of the country include a request for Spanish labels on prescriptions when appropriate and advise Spanish-speaking patients to ask for such labels at their pharmacy.

The study noted that smaller, independent druggists were more likely to offer Spanish labels but only if patients specifically requested them.

The New York Times is online.

ACP Foundation is now conducting research on prescription bottle labels. More information is online.

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ACP news

Governors seek member comments on resolutions

The Board of Governors is seeking feedback from ACP members on 19 resolutions that will be discussed at the spring 2006 Board of Governors meeting in April. Comments must be received by March 17, 2006.

The resolutions cover a wide range of issues, including teaching professionalism in medical schools and residencies, promoting legislation to allow retired physicians to volunteer with no threat from medical malpractice litigation, and developing policy to support funding for cognitive and case management services.

The complete text of each resolution is available for review. Members can provide feedback via an easy-to-use online response form.

All comments will be forwarded to the appropriate ACP Governor to use as part of their testimony at the meeting. ACP's resolution process allows chapters to bring issues before the Board of Governors as resolutions.

If approved, the resolution is forwarded to the Board of Regents for review and action.

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A 76-year-old woman is evaluated for a 3-month history of left knee pain of moderate intensity that worsens with ambulation. She reports minimal pain at rest and no nocturnal pain. There are no clicking or locking symptoms. She has tried naproxen and ibuprofen but developed dyspepsia; acetaminophen provides mild to moderate relief. The patient has hypertension, hypercholesterolemia, and chronic stable angina. Medications are lisinopril, metoprolol, simvastatin, low-dose aspirin, and nitroglycerin as needed. Following a physical exam, lab results and radiograph, what is the next best step in management?

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