In the News for the Week of 3-28-06
- Sign up now for practice management advice
- New book gives comprehensive overview of menstrual disorders
Clinical news in the headlines
- Test for breast cancer risk yields false negatives
- Second treatments may help some with depression
- ACP Journal Club: Atypical antipsychotics increased risk of death for dementia patients
- Medicare will cover testing for defibrillators
Access to care
- Language-services grants now available to acute-care hospitals
- New weekly e-mail series provides key reviews for residents
- Former ACP President named to AARP board
Going to Annual Session and need help with practice management? ACP's Practice Management Center (PMC) specialists will be onsite to discuss your day-to-day business of medicine and practice management issues. Stop by the PMC Booth, which will be located in the ACP Exhibit booth, #927, in the Exhibit Hall.
Or make an appointment in advance for a personal consultation on coding, computers, practice assessment or starting a practice. Appointments last 15-20 minutes and you can bring any background materials.
If you are considering buying practice software for billing, scheduling, e-prescribing or electronic health records, PMC staff can walk you through the steps of this complex decision-making process, including planning, selecting and implementing a new office computer system.
Attendees can also try out PMC’s new self-assessment benchmarking tool “Practice Snapshot.” You can also make an appointment to input your practice data, run a report and review results with a PMC specialist. When you call to schedule your appointment, PMC staff will tell you what data you need to bring with you.
Call 800-338-2746, ext. 4565, or e-mail email@example.com by Tuesday, April 4, to schedule your appointment during Exhibit Hall hours. Or stop by the PMC booth in the Exhibit Hall and make an appointment. Appointments will be made as time permits for each specialist.
"Menstrual Disorders," the newest book in ACP's acclaimed Women's Health Series, blends internal medicine, gynecology, adolescent medicine and other medical subspecialties in a comprehensive overview of this critical women's health topic.
The book is divided into three sections that cover the adolescent patient, the range of menstrual disorders from adolescence through menopause, and the relationship between menstrual disorders and other medical illnesses. Topics covered include polycystic ovary syndrome, bleeding disorders, reproductive and contraceptive issues, and hormone replacement therapy.
ACP's Women's Health Series provides in-depth coverage of diseases, disorders, and health and wellness issues unique to female patients. The series gives physicians the knowledge they need to optimize patient care, from the initial approach to the patient through diagnosis, treatment and long-term management.
The 272-page "Menstrual Disorders" book is available to members for $40 ($45 for non-members). Order online or call ACP Customer Service at 800-523-1546, ext. 2600 or 215-351-2600 (M-F, 9 a.m.-5 p.m. ET). Product code 330351050.
Physicians going to Annual Session can also attend a book signing with "Menstrual Disorders" co-editor Deborah B. Ehrenthal, FACP, on Thursday, April 6, 3:45-4:30 p.m., at the Books section of the ACP Exhibit booth, #927 in the Exhibit Hall.
For more information, see "New book presents medical side of menstrual disorders" in the April ACP Observer.
Clinical news in the headlines
A recent study found that a genetic test commonly used to screen for inherited mutations that put women at higher risk for breast and ovarian cancer led to a significant number of false negatives.
The study, published in the March 22 Journal of the American Medical Association (JAMA), looked at test results of 300 U.S. women who came from families with four or more cases of breast or ovarian cancer, but had negative results for BRCA1 and BRCA2 mutations. Using multiple DNA-based and RNA-based screening methods, the researchers determined that 17% of the women carried previously undetected mutations and that 12% had variations on the BRCA1 and BRCA2 mutations.
The results are likely to increase pressure on the Salt Lake City-based Myriad Genetics, which makes the only commercially available test for BRCA1 and BRCA2 mutations, said the March 22 New York Times. The New York Times noted that some critics have charged that the company’s monopoly has hindered the development of more effective testing methods.
Experts interviewed in the article pointed out that women from families without a strong history of cancer have a very small chance of receiving false-negative results. In addition, Ashkenazi Jews, a group at relatively high risk for the mutations, tend to have specific types that are not missed by the test. The article also noted that the test rarely misses mutations in women who have the same mutation as their mother.
The study’s authors said the lifetime risks for breast cancer for U.S. women with BRCA1 and BRCA2 mutations are as high as 80%. They said their results should trigger increased use of other available testing approaches that may pick up on mutations being missed by commercial testing.
The JAMA article is free online.
The New York Times is online.
Adding or substituting a second medication when initial treatment with an antidepressant fails may help some depressed patients, according to studies published last week.
One study in the March 23 New England Journal of Medicine (NEJM) tracked 565 adult patients with nonpsychotic major depressive disorder who had not responded to citalopram after about 12 weeks of treatment. The patients, who continued to take citalopram, were given either up to 60 mg of buspirone or up to 400 mg of sustained-release bupropion daily. Researchers found that both groups had about a 30% remission rate.
A second study in the same issue tested the effectiveness of switching depressed patients who did not respond to initial treatment with citalopram to another SSRI. In that study, 727 adult patients in primary and psychiatric care settings were given either sustained-release bupropion (up to 400 mg), sertraline (up to 200 mg) or extended release venlafaxine (up to 375 mg). One of four patients in the study responded to the second treatment, regardless of which antidepressant they were given.
The studies involve a subset of a larger study funded by the National Institutes of Health that is tracking 2,800 depressed adults in the care of primary care physicians and psychiatrists, said the March 23 New York Times. Previous reported results found that one in three patients responded to citalopram hydrobromide (Celexa). The current studies did not include a placebo or control group.
The findings are encouraging, an accompanying NEJM editorial said, because they confirm that patients who do not respond to one SSRI may do well on another. However, said the editorial, the results also indicate that between 76% and 79% of patients had recurrences lasting an average of 16 to 17 years. In addition, many patients were unemployed or lacked health insurance—a group of patients which previous data have shown often receive no treatment or experience extensive treatment delays.
Physicians interviewed by the New York Times noted that the studies do not provide a definitive answer to whether switching drugs or adjunctive treatment is better when first-line therapy fails. Experts interviewed also said the results should be viewed with caution because the studies lacked control groups.
The New York Times is online.
A review of trials involving older patients with dementia found that treatment with atypical antipsychotic drugs increased patients’ risk of death.
The review included 15 randomized controlled trials with the majority of patients suffering from Alzheimer's disease in both nursing home and outpatient settings. After a median of 10 weeks, patients treated with apripiprazole, olanzapine, risperidone or quetiapine were more likely to die during the study period or within 30 days of stopping treatment than patients taking placebo. The review is abstracted in the March-April ACP Journal Club.
The review reaffirms a 2005 FDA advisory about increased mortality in older patients with dementia given antipsychotic drugs, said reviewer Calvin Hirsch, ACP Member, of the University of California, Davis in Sacramento, Calif. The review found that antipsychotic drugs caused one death for every 85 patients treated or one excess death for every 12 patient years of treatment.
However, the risks associated with older antipsychotic drugs, such as haloperidol, are even greater, Dr. Hirsch pointed out. In another study, antipsychotic drugs were associated with a 1.37 relative risk for death during the first six months of use compared with atypical antipsychotic drugs.
Together, these studies emphasize the importance of assessing each patient individually, he said. The most appropriate indication for antipsychotic drug use in dementia is in cases where delusions, hallucinations, and agitation or aggression become highly disturbing to the patient’s caregiver.
In less severe cases, physicians should emphasize behavioral alternatives to medication, said Dr. Hirsch. When antipsychotic drugs are prescribed, they should be given in the lowest effective dose and tapered periodically to determine the need for ongoing use.
Peer ratings for this review: general internal medicine/family practice/general practice, geriatrics, hospitalists: 6/7 stars. Neurology: 5/7 stars.
ACP Journal Club is online.
Medicare last week agreed to cover the cost of testing with a device that predicts patients’ suitability for implantable heart defibrillators.
The noninvasive microvolt T-wave alternans (MTWA) test detects minute heartbeat fluctuations during controlled exercise, said a March 22 CMS news release. Following the test, software analyzes the microvolt changes and produces a report to be interpreted by a physician.
If the test is positive, the patient is said to be at risk for sudden cardiac death and a strong candidate for a defibrillator, said the March 22 Wall Street Journal. The need for a defibrillator is less clear, said the article, if testing is negative, indicating only a 3% chance of a serious heart event within two years.
Defibrillator manufacturers used criteria established by Medicare to estimate that about 1.3 million Americans are candidates for the devices, the Wall Street Journal said. The criteria are based on two large studies showing that implanted defibrillators saved lives among patients with low heart performance and signs of heart failure.
Analysts interviewed in the article said that access to the test might help some doctors overcome reluctance to implant the devices due to financial worries, surgical risks and uncertainty over whether the patient is a suitable candidate. Another expert interviewed cited data showing that Medicare could save about $700 million annually if doctors limited implantations to patients with abnormal test results.
The CMS is not making the test a condition of covering implantation, said the Wall Street Journal. The Heart Rhythm Society and the American College of Cardiology (ACC) have opposed such a requirement, citing studies suggesting that the test is not definitive enough to be the sole basis for decisions on whether to implant.
An ACC spokesman told the Wall Street Journal that making the test an option gives doctors the tools they need to make a decision while allowing them to use their judgment on patients who are borderline candidates for defibrillators. The test currently costs about $400.
Medicare had already been reimbursing for the test in some states, and last week’s decision is expected to trigger more coverage by private insurers, the Wall Street Journal said. Currently about 10% of private insurers cover the test, which is made by the Bedford, Mass.-based Cambridge Heart Inc.
The Wall Street Journal is online (subscription required).
The CMS news release is online.
Access to care
The fourth annual Cover the Uninsured Week event with be held May 1-7, with national and local events highlighting the growing problems of uninsured Americans.
The event is part of a national initiative that the Robert Wood Johnson Foundation began funding in 2003. Cover the Uninsured Week 2006 activities will include press conferences, business summits, health and enrollment fairs, small business seminars, campus seminars, and interfaith activities.
All of these events are designed to raise awareness of the nearly 46 million Americans living without health coverage, including more than 8 million children. ACP is a national supporter of Cover the Uninsured Week events.
And ACP has prepared a PowerPoint presentation on "Why Expanding Access to Health Insurance Matters," available free to members interested in speaking to groups during Cover the Uninsured Week. To receive a copy, please contact Jack Ginsburg in ACP's Washington office.
More information about national activities and events in your area are online.
Charity care provided by U.S. physicians fell by 8% over the past decade, according to a national study, weakening the health care safety net for the nation’s growing numbers of uninsured.
The proportion of U.S. physicians providing charity care dropped to 68% in 2004-05 from 76% in 1996-97, concluded a survey of 6,600 physicians released last week by the Center for Studying Health System Change (HSC). The actual number of doctors providing charity care has remained fairly stable because the overall population of U.S. practicing physicians increased from 347,000 to 397,000 during the same time period.
Most of the decrease in care relative to the number of uninsured has occurred since 2000-01, said a March 23 HSC news release. That’s because uninsured numbers have increased substantially from 39.4 million in 2000 to 45.5 million in 2004.
Overall, surgical specialists were most likely to provide free care, probably because they are often on call at hospital emergency rooms, said the release. Charity care was also high in small group practices and among solo practitioners while care provided by larger groups and academic or hospital-based practices dropped sharply, the release said.
At the same time, the percentage of physicians in solo or two-physician practices declined from 40% to 31% over the same 10-year period, said the release. By contrast, the percentage of doctors in large groups, hospitals and medical schools increased from 21% to 26%.
Less charity care by physicians means increasing demands on emergency rooms and more untreated patients, according to the March 23 Washington Post. The article cited a related study, which found that fewer Americans received routine care in 2003, when only 46% of uninsured people had a regular doctor compared with 52% in 1996.
The problem is being attributed to the increasing demands on physicians’ time, reduced payment rates and high medical-school debt, said the Washington Post. An AMA official interviewed in the article noted that 70% of doctors still offer some charity care.
The HSC news release is online.
The Washington Post is online.
Hospitals serving significant patient populations with limited English proficiency can now apply for a new $60,000 language-services grant.
The nonprofit Robert Wood Johnson Foundation will give grants to 10 hospitals willing to work together—including sharing their data—to improve language services. The application deadline is April 26, 2006. The goal of the grant program is to develop models of high-quality language services as well as effective measures and benchmarks for language-service performance.
To be eligible, hospitals must be non-federal, general acute-care hospitals with a minimum of 10,000 discharges per year. Besides serving a substantial number of patients with limited English skills, hospitals must currently operate a language-services program that involves onsite professional interpreters.
Hospitals must also be able to collect and report data by race, ethnicity, preferred language and other demographics. The program is not language specific.
Applicants must also propose two clinical measures they hope to improve with a project grant. One of those measures must address care quality for patients with cardiovascular disease, depression or diabetes mellitus.
Electronic applications must be received by April 26. Two conference calls are slated for March 30 and April 3 to answer questions.
More information is online.
ACP Medicine is launching a new Weekly Curriculum e-mail series, designed to give program directors and residents an important review of key elements in internal medicine and patient care. ACP Medicine is ACP's continually updated reference.
Here's how the e-mail program works: ACP Medicine Weekly Curriculum will send subscribing program directors and residents an e-mail each week that contains three or four questions based on a particular condition recently updated or revised in ACP Medicine.
Residents will send their answers to their program director using a convenient link, then check those answers again on ACP Medicine Online (which is free to all ACP Associate Members). ACP Medicine Online provides not only the answers to questions, but detailed descriptions of alternatives and full text of related material.
In addition to the weekly e-mails, programs receive the two-volume ACP Medicine and an annual subscription to ACP Medicine Online for the program director or coordinator, for $349.
For more information, see the Weekly Curriculum section at ACP Medicine Online. The e-mail program will also be demonstrated at the upcoming Association of Program Directors in Internal Medicine in Philadelphia, April 2-5, in booth 305.
William J. Hall, MACP, a former College President, has been appointed to the AARP's board of directors and will begin his six-year board term next month. AARP is a nonprofit organization that advocates for its more than 35 million adult members age 50 and over.
Dr. Hall, who served as ACP President in 2001-02, is professor of medicine and director of the Center for Healthy Aging at the University of Rochester School of Medicine in Rochester, N.Y. He is also one of three clinical leaders of a project ACP has launched with the RAND Corp. to test redesign strategies for geriatrics practices.
Board certified in geriatrics, Dr. Hall was recently appointed to the American Geriatric Society's public education committee and is past chair of that organization's annual meeting program committee. He also serves on the board of directors of the Association of Directors of Geriatric Academic Programs and serves on the geriatrics training advisory panel for the Donald W. Reynolds Foundation Geriatrics Training Initiative.
Besides serving as College President, Dr. Hall sat on the Board of Regents in 1996-2003, was Chair of the Board of Governors in 1997-98 and was Governor for the New York Upstate Chapter in 1993-97.
More information is online.
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Copyright 2006 by the American College of Physicians.
A 72-year-old woman is evaluated during a routine examination. She has very severe COPD with multiple exacerbations. She has dyspnea at all times with decreased exercise capacity. She does not have cough or any change in baseline sputum production. She is adherent to her medication regimen, and she completed pulmonary rehabilitation 1 year ago. She quit smoking 1 year ago. Her medications are a budesonide/formoterol inhaler, tiotropium, and an albuterol inhaler as needed. Following a physical and pulmonary exam, what is the most appropriate next step in management?
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