In the News for the Week of 4-4-06
Clinical news in the headlines
- First avian flu vaccine less effective than hoped
- Annals: Articles focus on controlling common chronic diseases
- Transition period for Part D drug plan reverts to 30 days
Health care access
- Uninsured a small factor in overcrowded emergency rooms
- New cancer Web site caters to Asian language speakers
- Book events: meet new authors, save on existing titles
Clinical news in the headlines
The first vaccine produced to combat avian influenza provided protection in only half of those who received two high-dose intramuscular injections, concluded a new study.
The findings, published in the March 30 New England Journal of Medicine (NEJM), highlight the importance of finding better vaccines, said the March 29 Washington Post. The government, which already knew of the potential problems, ordered $162 million in doses of the vaccine last summer for its emergency stockpile.
In the study, 451 healthy adults age 18-64 were randomly assigned to receive two intramuscular doses of subvirion influenza A (H5N1) vaccine in doses of 90, 45, 15 or 7.5 µg of hemagglutinin antigen or placebo. Among those who received two injections of the highest dose, 28 days apart, 54% reached the immunogenicity threshold of an antibody titer of 1:40 or greater. That dose is 12 times that of normal seasonal influenza vaccines.
Because of the high doses given, the current national stockpile of vaccines would cover only 4 million people, said the Washington Post. Those shots likely would go to workers in health care or vaccine production facilities if an epidemic broke out. Researchers are giving volunteers in the study a third dose of the H5N1 vaccine to see if it provides further protection.
The good news from the study is that even the highest doses appear to be safe, with the most common side effect being mild pain at the injection site, said an accompanying NEJM editorial by Gregory A. Poland, FACP. However, with the current worldwide manufacturing capacity estimated at 900 million doses, only 75 million people worldwide could be fully immunized at the high doses used in the study.
One of the best hopes for developing more effective vaccines, said the editorial, is administering lower doses of vaccine with an adjuvant, such as MF59, which is used in Europe. Previous studies demonstrated that a new influenza A vaccine administered in two doses as low as 7.5 µg each with MF59 was more effective than vaccine alone, said Dr. Poland, suggesting that such a strategy might increase the number of doses available.
The Washington Post is online.
The following articles appear in the April 4 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.
Diabetes care improves but much to be done. In the study, researchers found that care over the past decade has improved, but that two in five people with diabetes still have poor control of cholesterol, one in three has poor blood pressure control, and one in five has poor control of blood sugar levels. Researchers, using data from two national population-based surveys, looked at the proportion of Americans with diabetes who had adequate control of blood sugar, blood pressure and cholesterol levels, and who had recommended yearly eye and foot examinations.
Setting goals helps reduce mild hypertension. In this study, researchers found that people with mild cases can successfully make and sustain lifestyle changes that reduce their risk for heart disease. In an 18-month study to measure the effect of positive lifestyle changes on blood pressure control, 810 adult volunteers with borderline or mild hypertension were assigned to one of three groups: repeated counseling with specific goals for weight loss, exercise, and diet; or lifestyle counseling alone. Participants in the first two groups lost more weight, had better diets and were less likely to have hypertension after 18 months than those who received only advice.
Doctors change course when treatments fail. In a third article, researchers measured quality of care by monitoring whether physicians changed treatment when patients did poorly. The retrospective cohort study looked at health records of 253,238 adult patients in a large health care system with poor control of hypertension, cholesterol and/or diabetes. They found that, over the course of eight months, many patients had their treatments modified. The results seemed to indicate that clinically appropriate care was being provided, said the authors. The most frequent changes in therapy were adding drugs and increasing drug dosages.
VA singled out for systemizing quality diabetes care. And finally, an editorial notes that many of the risk factors for America’s big three chronic conditions—hypertension, high cholesterol and diabetes—are intertwined. The editorial’s authors, including the chief medical officer of the U.S. Department of Veterans Affairs health system, point to the VA as an example of a large health system that has successfully systemized care for more than 1 million veterans with diabetes, generally exceeding the quality of care provided by Medicare and commercial plans. They emphasize that while health plans initiate changes, physicians are essential in making quality improvement efforts work.
Medicare Part D’s benefit transition period, which earlier was expanded from 30 to 90 days due to implementation problems, reverts to 30 days beginning April 1, 2006.
This transition period, applicable to beneficiaries already on a medication and who are applying for their 'first fill' of a non-formulary drug, lets them receive a supply for at least 30 days.
The transition period gives physicians and patients the time to either replace the non-formulary drug with a therapeutic equivalent within the formulary or to request a formulary exception.
The beneficiaries' cost share for the non-formulary first fill will normally be at the plan's Tier III, which is typically 25% to 33% of the drug's cost.
The Centers for Medicare and Medicaid Services (CMS) has put together a transition tool kit that provides information for beneficiaries, physicians and their staff on drug plan formularies, drug utilization management tools frequently used by plans (such as prior authorization, step therapy, quantity limits) and the exceptions/appeals process. The tool kit also includes a slide presentation on these issues.
More information about the transition period and tool kit is online.
Health care access
A new study of emergency room use found that the uninsured accounted for a relatively small percentage of emergency room visits, contrary to common perceptions, and that most visits were made by patients with health insurance.
The uninsured make up 15% of emergency room visits, according to a study released last week by the nonprofit American College of Emergency Physicians, said the March 29 Los Angeles Times. The findings indicated that increasing access to health care insurance will not by itself ease overcrowding in an emergency department.
The study, conducted by researchers at the Robert Wood Johnson Foundation and the University of California, San Francisco, surveyed 32,669 U.S. households in 2001. Researchers found that frequent emergency room users, defined as those who used the service four or more times a year, made up less than a tenth of all users but 28% of all visits.
Of the frequent users, 84% were insured and 81% had a regular doctor, said the Los Angeles Times. About half of this group was insured through Medicaid or Medicare while one-third had commercial insurance.
Experts interviewed by the Los Angeles Times said that emergency room crowding is largely due to patients who cannot get appointments with their regular doctor or who are waiting for regular hospital beds. Other experts noted that a shortage of on-call physicians and nurses also contributes to the problem.
The Los Angeles Times is online.
A new Web site funded by the National Cancer Institute will provide information about cancer prevention and treatment in several Asian languages.
The site, developed by the American Cancer Society and the Asian American Network for Cancer Awareness, Research and Training, is aimed at helping physicians educate cancer patients with limited English proficiency, said the March 28 Sacramento Bee. The project, called the Asian Pacific Islander Cancer Education Materials Tool, is based at the University of California, Davis School of Medicine in Sacramento.
Asians traditionally have had a relatively low risk of cancer but their cancer death rate has been rising rapidly, said the article. Cancer is the leading cause of death for Asian American women and Asians are at relatively high risk for cervical, liver and certain other cancers, compared with other groups.
According to information on the new Web portal, visitors to the site will have free access to cancer information that has been reviewed by the participating groups for accuracy and cultural relevance. Patients can search the Web site for information by cancer type, language, source, topic or key words.
The Sacramento Bee is online.
You also can access the Asian Pacific Islander Cancer Education Materials Tool online.
Meet the editors of two new ACP books at the ACP Books booth (#927) at Annual Session in Philadelphia this week.
Deborah B. Ehrenthal, FACP, co-editor of “Menstrual Disorders,” will be available on Thursday, April 6, from 3:45-4:30 p.m. Edward J. Huth, MACP, and T. Jock Murray, MACP, will sign the new second edition of their popular “Medicine in Quotations” book on Friday, April 7, from 3:45 to 4:30 p.m. Both book signings will be held during the afternoon break.
Also, for the duration of Annual Session, attendees can enjoy special discounts of up to 50% on selected titles at the ACP Books booth.
You can also order both books online or by calling ACP Customer Service at 800-523-1546, ext. 2600 or 215-351-2600 (M-F, 9 a.m.-5 p.m. ET).
In a new free DVD, 39 physicians discuss how introducing systematic quality improvements into their practices has improved patient care and increased efficiency.
The new video, entitled "Putting Quality Into Practice: Physicians in Their Own Voices," captures the stories of physicians in both solo and small group practices who were early adopters of quality improvement. Each physician describes the benefits of using these quality measures, many of which were relatively easy to put into place.
The video is a joint venture of the American Board of Internal Medicine, the National Committee for Quality Assurance (NCQA) and the Commonwealth Fund. John Tooker, FACP, ACP's Executive Vice President and CEO, sits on the NCQA's board of directors.
“The ‘Putting Quality into Practice’ program is an inspiring testimonial to what practicing physicians can do and are doing to improve the quality of care of their patients,” said Dr. Tooker. “As the national quality improvement movement matures, this program can be an important resource for all those who wish to participate.”
The Association of American Medical Colleges (AAMC) has launched an online educational publishing site that allows faculty to disseminate and exchange teaching resources.
MedEdPORTAL provides access to tutorials, cases, lab manuals, assessment tools and other teaching resources. Visitors to the site can search by keyword or choose from lists of disciplines and hot topics. Disciplines range from anesthesiology to undergraduate medical education while hot topics include alternative/complementary medicine and substance abuse, among others. The vast majority of the materials are peer-reviewed.
The AAMC is also asking for your help: it would like to grow its library of materials, and invites you to submit your own listing.
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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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