In the News for the Week of 9-26-06
- Government recommends universal HIV screening
- Wal-mart to sell discounted generic prescriptions
- Update on E. coli in spinach
- Warning label updated on birth-control patch
Health care access
- U.S. health care system gets low scores
- ACP Journal Club: Dietetic assistants improved outcomes in older women with hip fracture
- AHRQ releases evidence report on tests for heart failure
- Fellowship prepares minority physicians for leadership
- ACP opposes implementation of ICD-10 diagnosis codes
- ACP Fellows featured in fall PBS series
- ACP Foundation featured in panel on diabetes
The CDC last week released new recommendations urging routine HIV screening for anyone between the ages of 13-64, unless they opt out. Pre-test counseling and separate, written consent for HIV testing should no longer be required, said the agency, and consent should be incorporated into general consent for medical care.
Guidelines for HIV testing of pregnant women were also revised, said a Sept. 21 CDC news release. Under the new system, HIV testing should be provided in the third trimester not only for women at high risk for HIV, but also for women in areas with high HIV prevalence among women of childbearing age or in facilities with at least one HIV diagnosis per 1,000 pregnant women screened.
The goal is to ensure that everyone who receives medical care also has the opportunity to learn if they are infected with HIV, said CDC officials. Making the HIV test a normal part of care for all Americans is also an important step toward removing the stigma still associated with testing, the statement added.
The “Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings” were published in CDC’s Morbidity and Mortality Weekly Report (MMWR). CDC will issue additional guidance for health care providers in early 2007, which will provide examples of model approaches and practical tools for implementation in various types of health care settings.
The CDC guidelines are online.
The New York Times is online.
Wal-Mart last week announced plans to begin selling nearly 300 generic prescription drugs for as little as $4 for a month's supply. Company officials said that the 291 drugs will include the most frequently prescribed drugs for common illnesses, including cardiac disease, asthma, diabetes, glaucoma, Parkinson's disease and thyroid conditions.
The pilot program was launched last week in Tampa Bay at 65 Wal-Mart, Neighborhood Market and Sam’s Club pharmacies. Wal-Mart plans to expand the program statewide in January and to begin rolling it out nationally during 2007, according to a Sept. 21 company news release. The company said it is working with 30 drug companies and will offer such commonly prescribed medications as metformin to treat diabetes and the hypertension drug lisinopril.
Statistics from the National Association of Chain Drug Stores show that people typically pay an average of $28.74 per month for a generic drug prescription and $96.01 for month's supply of a branded drug, noted the Sept. 21 New York Times. The article also reported that the Generic Pharmaceutical Association estimates that generic medicines account for 56% of all U.S. prescriptions but only 13% of the total amount spent on all prescription drugs combined.
The generic drug program is the latest in a series of changes that the discount chain has made over the past year in response to public criticism of its employee health insurance program. It has also introduced lower-premium coverage, extended coverage to employees’ families and expanded in-store clinics.
The New York Times is online.
The Wal-Mart news release is online, along with a list of available discounted drugs.
The number of people affected by a recent outbreak of E. coli in packaged spinach had risen to 173, including one death, the government reported over the weekend. Two more deaths also are under investigation for links to the tainted spinach.
Since the outbreak became known two weeks ago, the FDA has urged people not to eat fresh, raw spinach and supermarkets have pulled the product from their shelves, said the Sept. 24 New York Times. The contamination has been traced to three counties in California: Monterey, San Benito and Santa Clara, said a Sept. 24 FDA update.
California spinach growers and processors are currently working on new food-safety measures. Federal officials have required the industry to adopt the measures before they will lift the consumer warning on fresh spinach. Possible safety measures include improved water and soil testing and beefed-up sanitation standards for field workers and packaging plants.
While the FDA has said that spinach grown in other areas is safe, said the New York Times, consumers are advised not to buy spinach unless they can verify where it was grown.
The FDA update is online.
The New York Times is online.
The FDA last week updated the label on the ethinyl estradiol/norelgestromin (brand name: Ortho Evra) birth-control patch to reflect the results of a study that found women using the patch faced twice the risk of clots than did women on the pill.
The case-control study, sponsored by manufacturer Johnson & Johnson, showed an approximate two-fold increase in the risk of medically verified venous thromboembolism (VTE) events in users of the patch compared to users of norgestimate-containing oral contraceptives containing 35 mg of estrogen, said a Sept. 20 FDA news release. However, another study found that the risk of non-fatal VTE events associated with the use of the patch is similar to the risk associated with the use of oral contraceptive pills.
Even though the results of the two studies are conflicting, the results of the one epidemiology study support concerns regarding the potential for patch use to increase the risk of blood clots in some women, said the FDA release. Longer follow-up for VTE, heart attack and stroke has been requested by FDA. In the Sept. 20 Washington Post, the manufacturer stated that data will continue to be collected on both studies for another 18 to 24 months.
The FDA has recommended that women with concerns or risk factors for thromboembolic disease should talk with their healthcare provider about using the patch versus other contraceptive options.
The FDA statement is online.
The Washington Post article is online.
Health care access
The U.S. health care system scored only 66 out of a possible 100 points in a Commonwealth Fund report measuring 37 national indicators of health outcomes, quality, access and efficiency. The group's annual scorecard findings indicate that if the U.S. improved its performance in key areas, an estimated 100,000 to 150,000 lives and $50 billion to $100 billion would be saved annually.
"Why not the best? Results from a national scorecard on U.S. health system performance," issued last week, gave the U.S. particularly low marks for quality of care at the beginning and end of life. The country was ranked 15th out of 19 countries on potentially preventable deaths and last among industrialized countries on healthy life expectancy at birth or age 60, and infant mortality.
In addition to scoring poorly on indicators compared with other countries, U.S. national averages vary greatly from state to state, region to region and across hospitals and health plans, said a Sept. 20 Commonwealth Fund news release. As a whole, the U.S. scored particularly low in efficiency (51 out of 100), pulled down by indicators of over-use/waste, poor access, and cost/quality variation. The overall low score for efficiency also reflects the fact that the U.S. is far behind other countries in use of electronic health records, said the report, and has much higher insurance administrative costs.
The purpose in issuing the scorecard was to bring attention to opportunities to improve, with benchmarks to motivate change, said Fund officials. An overarching theme is the extent to which lack of health care coverage and gaps in access to care drive up costs and pull down quality of care in the U.S.
A study of older women with acute nonpathologic hip fracture found that the use of dietetic assistants (DAs) improved postoperative clinical outcomes.
In a randomized controlled trial, 318 women age 65 or older with acute nonpathologic hip fracture received either personal attention of DAs or conventional care by nurses and dieticians. After four months, the DA group had fewer deaths in the trauma unit and lower mortality than the conventional group.
Patients in the DA group received help with such things as selecting appropriate foods, coordinating meal orders and ordering nutritional supplements. DAs also gave extra encouragement and feeding help to very frail patients. The study is abstracted in the September-October ACP Journal Club.
The intervention provided by DAs (6 hours every day) was intensive and well beyond the current nutrition support on many surgical wards, noted Journal Club reviewer Gustavo Duque, MD, PhD, of McGill University in Montreal. The positive effect on mortality found in the intervention group could be explained by the closer-than-usual supervision provided by the DAs, he said. This trial was unblinded for patients and caregivers (although the outcome assessors were blinded) and thus co-interventions could account for at least part of the impressive difference in patient-important outcomes.
Dr. Duque also pointed out that the mortality rate after hip fractures in this study (10% in the routine-nursing group) seems to be higher than the usual North American mortality rate (± 6%) in similar populations. The authors do not mention cause of death, which may have helped to explain the differences in mortality rate found in their study.
Peer ratings for this review: Hospitalists, geriatricians 6/7 stars.
ACP Journal Club is online.
A new report released by the Agency for Healthcare Research and Quality (AHRQ) found that tests for the natriuretic peptides BNP and NT-proBNP can be used to rule out heart failure in patients seen in emergency rooms, clinics, and primary care settings. While elevated levels of these peptides do not confirm that heart problems are causing a patient's symptoms, relatively low levels make it unlikely that these heart problems are present.
The report was prepared at the request of the American Association of Clinical Chemistry and the American College of Chest Physicians, to use in updating relevant clinical practice guidelines. The ACP and the American College of Emergency Physicians will be partners in the dissemination and use of the report. AHRQ's Evidence-based Practice Center at McMaster University in Ontario, Canada, conducted the systematic literature review and prepared the report.
The report is available online.
The Commonwealth Fund/Harvard University Fellowship in Minority Health Policy (CFHUF) awards five one-year, degree-granting fellowships per year. This innovative fellowship is designed to prepare physicians, particularly minority physicians, for leadership roles in formulating and implementing public health policy and practice on a national, state, or community level.
Supported by The Commonwealth Fund and administered by the Minority Faculty Development Program at Harvard Medical School, the fellows will complete academic work leading to a Master of Public Health (MPH) degree at the Harvard School of Public Health. Through program activities, they will gain experience in and understanding of major health issues facing minority, disadvantaged, and underserved populations. CFHUF also offers a Master of Public Administration (MPA) degree at John F. Kennedy School of Government to physicians possessing an MPH.
The program hopes to support the development of a cadre of leaders in minority health, well-trained academically and professionally in public health, health policy, health management and clinical medicine, as well as actively committed to careers in public service. The fellowship is currently seeking potential candidates who would like to gain exposure to and understanding of major health issues facing minority and disadvantaged populations.
Applications and more information are online.
On Sept. 21, ACP urged the rejection of new ICD-10 diagnosis codes in a joint letter to the Chairmen and ranking members of the Senate Health, Education, Labor and Pensions Committee; the House Energy and Commerce Committee, and the House Ways and Means Committee.
At the beginning of September, the House of Representatives passed the Health Information Technology Promotion Act of 2006 (HR 4157). The purpose of this bill is to advance the adoption of health information technology; however it contains an additional provision to replace the currently used ICD-9 diagnosis codes with a new system of ICD-10 codes.
ACP, and other organizations which signed onto the letter, noted that the new coding system was exhaustive and would inevitably result in a significant cost to physician practices. Practices would need to update the health information technology that they have already acquired, including practice management systems, and the increased workload caused by the transition would decrease their productivity.
The ACP position, expressed in this letter, is different from the position taken by many others, including Blue Cross and Blue Shield Association and the American Medical Association. These organizations are asking only to delay implantation of the ICD-10 diagnosis codes until 2012.
The full text of the letter is online.
Anne Peters, FACP, and Richard Shannon, FACP, will be featured in a four-part television series, “Remaking American Medicine…Health Care for the 21st Century,” scheduled to air on PBS in October.
The series, comprised of four segments, “Silent Killer,” “First Do No Harm,” “The Stealth Epidemic,” and “Hand in Hand,” is an engaging narrative of health professionals, administrators and patients striving to ignite positive change in key areas of health care including quality improvement, health information technology, access to heath care and episodic chronic condition care. All of these issues have been and continue to be addressed by the ACP.
The series debuts with “Silent Killer,” which tells the story of a grieving mother who loses her 18-month-old daughter to negligence at a world renowned hospital and later returns to partner with the same institution to promote safety advocacy. “First Do No Harm” examines the impact of hospital-acquired infections and medical error and the efforts of physicians to correct it; “The Stealth Epidemic” draws attention to the absence of crucial preventative care of chronic diseases; and the last episode, “Hand in Hand,” addresses why it is important for providers to maintain strong relationships with their patients in an increasingly complex medical system.
Dr. Peters, professor of medicine and director of the University of Southern California's diabetes program, will be featured in the “The Stealth Epidemic” segment for her successful work improving the management, and specifically the prevention, of chronic conditions. Dr. Shannon, chief of medicine at Allegheny General Hospital in Pittsburgh, will discuss his achievement in reducing hospital-acquired infections in the segment, “First Do No Harm.”
The PBS series is scheduled to air on Thursdays at 10 p.m. during October. ACP is a national partner in the Remaking American Medicine campaign.
More information about Remaking American Medicine is online.
Peter L. Salgo, FACP, will host the PBS show “Second Opinion,” which begins its third season on Oct. 2. The ACP Foundation worked closely with producers on the season premiere, which deals with Type 2 diabetes.
“Second Opinion” features a panel of medical professionals and lay people having in-depth discussions about medical decisions. Dr. Salgo presents real-life medical cases to teams of medical professionals who grapple with diagnosis and treatment options. The goal of the series is to improve doctor/patient communication and empower viewers to take charge of their own health care.
Terry Davis, PhD, chair of the Foundation's Health Literacy Advisory Board, worked closely with the show's producers on the premiere and participates in the panel discussion. The program, which addresses patient health literacy, features the ACP Foundation's "Everyday Guide to Living with Diabetes."
Local schedule information for “Second Opinion” is online.
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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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