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

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In the News for the Week of 10-2-07

News highlights

  • Death rate from breast cancer continues decline
  • HDL level predicts cardiovascular events
  • Specialty groups issue cardiac rehabilitation guidelines
  • Legislation delays tamper-resistant prescription pad requirement

Hospital medicine

  • Hospitalist care reduces length of stay for complex conditions, study finds
  • S. aureus infection, economic burden higher but related mortality lower in U.S. hospitals

Clinical news

  • Annals of Internal Medicine:
    • ACP and APS issue comprehensive guidelines for treating low back pain
    • Trial of two drugs finds one better at suppressing hepatitis B virus
    • All screening models for breast cancer gene mutations work, with reservations
  • A more sensitive test for colorectal cancer screening

Screening and prevention

  • Annual checkups represent 8% of ambulatory visits
  • Telephone outreach more likely to help depressed workers

College news


News highlights

Death rate from breast cancer continues decline

The breast cancer death rate in the U.S. continues to drop by about 2% per year, but advances in detection and treatment have benefited some races much more than others, according to a new report from the American Cancer Society (ACS).

Between 1995 and 2004, the breast cancer death rate for white and Hispanic women in the U.S. fell by 2.4% while it decreased only 1.6% for black women and there was no change for Asian-Americans or American Indians. The divergence between white and black women is a trend that began in the early 1980s and has resulted in death rates for black women being 36% higher by 2004, said an ACS representative. The ACS attributed the general decline in deaths to prevention efforts, early detection and treatment advances.

The report, Breast Cancer Facts & Figures 2007-2008, found a decline in incidence of breast cancer among white women from 2001 to 2004. There was also a drop in the use of mammography and hormone replacement therapy (HRT) among these women. Black women had stable rates of mammography and HRT use and no decline in incidence, leading ACS experts to conclude that the overall drop in incidence may be due in part to a decline in mammogram use.

The report also found that while the incidence of smaller tumors has declined by about 3.8% per year since 2000, the incidence of larger tumors has been increasing 1.7% per year since 1992. The authors suggested that the trends may be related to increases in obesity among postmenopausal women and/or use of HRT. The report also offered a list of means by which women can potentially reduce their risk of breast cancer, including avoiding obesity, limiting alcohol and exercising.

The report and a press release are online.

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HDL level predicts cardiovascular events

Levels of high-density lipoprotein (HDL) cholesterol appear to be a predictor of cardiovascular events even in patients with low levels of low-density lipoprotein (LDL) cholesterol, according to a new study.

Researchers did a post hoc analysis of data from the industry-funded Treating to New Targets study. The analysis included 9,770 patients who had clinically evident coronary heart disease and received either 10 mg or 80 mg of atorvastatin per day. Patients’ levels of HDL and LDL cholesterol were measured at three months, and related to the primary outcome of the study: time to a first major cardiovascular event. The study was published in the Sept. 27 New England Journal of Medicine.

The analysis found that HDL levels were a significant inverse predictor of major cardiovascular events across the entire study cohort. When the patients’ LDL levels were taken into account, the importance of HDL levels was less noticeable, but met the researchers’ standard for borderline significance. Among patients with the lowest LDL levels (less than 70 mg per deciliter), the patients with the highest HDL had significantly lower cardiovascular risk than those with the lowest HDL (hazard ratio, 0.61).

The analysis shows that if a patient’s HDL can be raised enough, the LDL is unimportant, a study author told the Sept. 26 Washington Post. The study also explains the residual cardiovascular risk that has been found in patients with low LDL levels and proves that treatment of HDL levels is important, he said. New medications to raise HDL are desperately needed, said the author, who is currently researching the effects of potential HDL-raising drugs.

The New England Journal of Medicine is online.

The Washington Post is online.

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Specialty groups issue cardiac rehabilitation guidelines

A coalition of cardiac specialty groups has issued new performance measures aimed at spurring more patients to enter cardiac rehabilitation programs as well as improving the programs’ quality.

The performance measures were compiled by the American Association of Cardiovascular and Pulmonary Rehabilitation, the American College of Cardiology (ACC) and the American Heart Association. “This is a call to arms,” said the director of the Mayo Clinic’s Cardiovascular Health Clinic in a statement.

Fewer than 30% of eligible patients participate in cardiac rehabilitation programs following cardiovascular disease events, often because they aren’t referred, the new guidelines said. Studies have found the programs reduce the risk of death for people with heart conditions by 20% to 25%. Eligible patients include anyone who, in the last year, has had myocardial infarction/acute coronary syndrome, percutaneous intervention, coronary artery bypass surgery, stable angina, heart valve surgery, or heart and/or lung transplantation.

One aim of the new performance measures is to make referral to cardiac rehabilitation “as automatic as giving aspirin during a heart attack,” according to an ACC statement. To that end, the document offers sample referral forms and outlines the best way to collect and analyze referral data. Another goal of the measures is to improve the safety and quality of care of the programs by, for example, setting standards on things like medical supervision, patient monitoring, documentation and communication.

The performance measures are online via the American College of Cardiology.

The ACC press release is online.

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Legislation delays tamper-resistant prescription pad requirement

Congress passed legislation last week to delay the implementation of the tamper-resistant prescription pad requirement under Medicaid. The new regulation was to go into effect on Oct. 1, and would have required that all prescriptions for Medicaid patients be written on tamper-resistant paper.

The new legislation will delay the implementation date by six months. The provision requiring tamper-resistant paper was included in legislation that was passed in May of this year. Based on recommendations from ACP and other medical groups, Congress felt that this did not allow enough time for providers and pharmacies to adequately comply.

The regulation will require all handwritten (non-electronic) prescriptions for Medicaid patients to be written on tamper-resistant prescription paper. The federal government will not pay for prescriptions that do not follow the new regulation. The College recommends that physicians continue to prepare for the April implementation.

Further guidance and a complete list of exceptions are available from the College’s Practice Management Center.

FAQs about the tamper-resistant prescription pad law from CMS are also online.

A letter from the College to CMS regarding the new law is online.

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Hospital medicine

Hospitalist care reduces length of stay for complex conditions, study finds

Care by teaching hospitalists can lead to shorter hospital stays for patients who require close monitoring and complicated discharge planning, according to a new study.

Researchers at Montefiore Medical Center in New York compared patients cared for by teaching hospitalists with those cared for by nonhospitalists over a two-year period. The study's main objective was to determine which groups of patients would benefit most from hospitalist care. The results appear in the Sept. 24 Archives of Internal Medicine.

The study sample was composed of 9,037 discharges, 2,913 from hospitalists and 6,124 from nonhospitalists. The mean length of stay was 5.01 days for the hospitalist group and 5.87 days for the nonhospitalist group. Reductions in length of stay were greatest in patients who required complex discharge planning and in those with conditions--congestive heart failure, asthma, stroke and pneumonia--that required close oversight.

The hospitalist and nonhospitalist groups did not differ significantly in rates of readmission, in-hospital mortality or 30-day mortality, although the authors acknowledged that few physicians were studied (five in the hospitalist group and 54 in the nonhospitalist group) and that small differences in readmission or mortality rates may not have been able to be detected. The authors attributed their findings to hospitalists' skill at working with other staff members to facilitate discharge planning, the continuous care they provide, and their ability to monitor patients with complicated conditions.

The Archives of Internal Medicine is online.

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S. aureus infection, economic burden higher but related mortality lower in U.S. hospitals

Infection rates and the economic burden of Staphylococcus aureus have increased in U.S. hospitals, but related inpatient mortality rates have decreased, according to a new study.

Researchers used the Nationwide Inpatient Sample, a federal database, to examine trends in S. aureus infection, economic burden and in-hospital mortality for all hospital stays and specific groups of stays (related to surgical procedures, invasive cardiovascular surgery, invasive orthopedic surgery and invasive neurosurgery) from 1998 to 2003. The study was published online on Sept. 21 and will appear in the Nov. 1 Clinical Infectious Diseases.

From 1998 to 2003, S. aureus infection rates increased significantly for all inpatient stays (0.74% to 1.0%), surgical stays (0.90% to 1.3%) and invasive orthopedic surgical stays (1.2% to 1.8%). Infection rates for neurosurgical stays remained the same from 1998 to 2000 but increased from 1.4% in 2000 to 1.8% in 2003. Total economic burden of S. aureus infection also increased in all groups. In-hospital deaths related to S. aureus infection, however, decreased significantly for all stays (7.1% to 5.6%) and for surgical stays (7.1% to 5.5%) over the six-year period.

The authors speculated that the decrease in S. aureus-associated inpatient mortality rate may be due to improved infection control practices in U.S. hospitals or to improved treatment of methicillin-resistant strains, and that the observed increased infection prevalence may be due to improved detection and reporting. The authors noted that their study used ICD-9-CM codes that did not distinguish between methicillin-resistant and methicillin-susceptible S. aureus and that the former has been shown to more negatively affect mortality rates, cost and length of stay. They recommended that future studies should try to look at specific strains of S. aureus to determine the effects of each, and that hospitals should increase their efforts to reduce risk of nosocomial infections.

Clinical Infectious Diseases is online.

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Clinical news

Annals: ACP and APS issue comprehensive guidelines for treating low back pain

Clinicians should not routinely order imaging and other diagnostic tests to treat low back pain, according to joint guidelines released today by ACP and the American Pain Society (APS).

The recommendations, published in the Oct. 2 Annals of Internal Medicine, include an algorithm to guide clinicians in obtaining and interpreting information during the first patient visit and placing patients into one of three general categories:

  • Nonspecific low back pain (85% of patients fall in this category)
  • Back pain potentially associated with spinal conditions, such as spinal stenosis, sciatica or vertebral compression fracture
  • Back pain potentially associated with another specific cause, such as cancer.

The recommendations say that clinicians should not routinely order imaging or other diagnostic tests such as X-rays, CAT scans and MRIs for patients with nonspecific low back pain. They should reserve these tests for patients who have severe or progressive neurologic deficits or suspected underlying conditions, such as cancer or infection.

The guidelines were developed by a multidisciplinary panel of experts convened by ACP and APS in 2006 to develop questions and the scope of an evidence report on low back pain, to review its results and come up with recommendations for primary care physicians to diagnose and treat low back pain. The guidelines are designed for primary care physicians and other clinicians and do not address invasive therapies performed by specialists. The APS will publish a separate guideline covering invasive procedures for low back pain in 2008.

The guidelines are online along with reviews of the evidence on medication for back pain and nonpharmacologic therapies. A streaming video report on the study is also online.

The following articles also appear in the current online issue of Annals of Internal Medicine. The full text is available to College members and subscribers online.

  • Trial of two drugs finds one better at suppressing hepatitis B virus. A 52-week randomized trial involving 135 people with chronic hepatitis B virus (HBV) compared an older drug, adefovir dipivoxil, and a newer drug, telbivudine. Researchers found that telbivudine was better at suppressing blood virus levels than adefovir. A group of patients who were switched at 24 weeks from adefovir to telbivudine also showed reduced levels of the virus at 52 weeks compared with the group who continued on adefovir for 52 weeks. Researchers say the study results support the concept that maximizing viral suppression early in the course of therapy is linked to improved efficacy responses and less resistance, suggesting that agents providing the greatest viral suppression may be preferable as initial therapy. This study is being released early online and will be published in the Dec. 4 print edition.

  • All screening models for breast cancer-causing gene mutations work, with reservations. Researchers applied seven prediction models to 3,342 families to determine an individual family member’s probability of having a BRCA1/BRCA2 mutation and compared the results with actual genetic tests for the mutations. They found that the seven models were similarly good at discriminating between people with a BRCA1/BRCA2 mutation and people without such mutations, but the models did make mistakes. Researchers found that predictions varied widely when the seven models were applied to one person, so genetic counselors may want to consider using several predictive models before recommending genetic testing. The genetic mutation tests are expensive, so clinicians should use screening tests to try to determine if a person is likely to have the mutation before proceeding with the testing. An editorial writer urged families to keep track of family members’ medical history and urged clinicians to ask about it.

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A more sensitive test for colorectal cancer screening

The FlexSure OBT fecal immunochemical test was more sensitive at detecting left-sided colorectal cancer than the Hemoccult Sensa guaiac test, a new study found.

The two tests were developed to improve screening by being more sensitive than the guaiac test that is currently recommended by the U.S. Preventive Services Task Force and the Institute of Medicine, which has fairly low sensitivity, the study’s authors said. The study was published in the Sept. 25 Journal of the American Cancer Institute.

The authors prospectively assessed the individual performance of the two tests, as well as a combination of the two, in 5,841 subjects with average risk for colorectal cancer. They sought to determine the tests’ sensitivity and specificity for detecting advanced neoplasms in the left colon within two years of screening. Colonoscopy was advised for patients with positive test results and sigmoidoscopy was advised for those with negative test results.

Within two years of screening, 139 patients were diagnosed with advanced neoplasm, including 128 adenomas and 14 cancers. FlexSure OBT test was 82% sensitive and 96.9% specific for detecting left-sided colorectal cancer, compared with 64.3% sensitivity and 90.1% specificity for Hemoccult Sensa. For detecting advanced colorectal adenomas, the FlexSure OBT was 29.5% sensitive and 97.3% specific; the Hemoccult Sensa was 41.3% sensitive and 90.6% specific.

The immunochemical test could replace the guaiac test since the latter’s sensitivity for cancer is greater, the study’s authors said. Though the guaiac test was more sensitive than the immunochemical test for advanced adenomas, this may be a result of the peroxidase sensitivity of the former being set so high that it detected lower levels of bleeding than the immunochemical test, they said. “The study does show that an immunochemical test is probably better than a guaiac test for screening for colorectal cancers, but the specific immunochemical test of choice is still unclear,” said the accompanying editorial.

The Journal of the National Cancer Institute article and editorial are online.

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Screening and prevention

Annual checkups represent 8% of ambulatory visits

More than 44 million American adults receive a preventive health examination (PHE) every year and about 19 million women receive preventive gynecological exams (PGE), according to a recent study.

Using a retrospective analysis of 8,413 ambulatory visits from 2002 to 2004, researchers calculated the frequency and characteristics of annual preventive exams in the U.S. The analysis was intended to supplement the limited data currently available on the subject and assist in the debate over the value of preventive exams, researchers said. They found that PHEs and PGEs represent 8% of ambulatory visits made by adults every year, and cost an estimated total of $7.8 billion. The study was published in the Sept. 24 Archives of Internal Medicine.

Of the patients who received a PHE or PGE, 75% and 57%, respectively, had made a clinic visit within the previous 12 months, and only 20% of preventive services included in the analysis were provided during a preventive visit. According to the study authors, this research supports the idea of emphasizing preventive care outside of PHEs and PGEs. The researchers noted that although many evidence-based preventive services (such as mammograms and Pap smears) were obtained during the preventive visits, many PHEs included tests, such as complete blood cell counts and urinalyses, which have not been proven to improve patient outcomes.

The study also found variations in the receipt of PHEs and PGEs by geographic region, age and insurance status. If every American adult were to receive an annual PHE, the U.S. health care system would have to absorb approximately 145 million more visits per year, the study authors calculated. However, the analysis did not determine how many of the patients who received a PHE or PGE made the visit for reasons other than preventive care, and what non-preventive issues may have been addressed during the exam, study authors acknowledged.

The Archives of Internal Medicine is online.

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Telephone outreach more likely to help depressed workers

Depressed workers who received regular telephone calls from care managers were more likely to improve and in the process save their companies money than those who received standard care, a new study found.

Study volunteers from 16 large companies took an online depression screening test. Of the 604 who screened as at least moderately depressed and were chosen for the study, half were advised to consult a doctor for possible depression (i.e., usual care). The other half received several phone calls from their insurance company’s mental health care managers, who encouraged the workers to receive treatment and checked in periodically on their progress. If patients refused to get in-person treatment, the health care managers offered psychotherapy by phone.

The intervention group saw their symptoms improve 31% after 12 months compared with 22% for the usual care group, while recovery for the intervention group was 26% versus 18% for the usual care patients. Intervention patients worked more than two weeks per year more than the usual care group, and were more likely still to be employed (93% vs. 88%) by year’s end. The intervention group was also 70% more likely to receive mental health specialty treatment--which research has shown is more apt to meet evidence-based recommendations than non-specialty care, the authors noted. The study appears in the Sept. 26 Journal of the American Medical Association.

Though the study’s authors didn’t do a formal cost-benefit analysis, they noted that the additional hours the intervention group worked add up to $1,800 per employee, more than the cost of the intervention, which was $100 to $400 per employee. Depression affects about 6% of employees each year and costs more than $30 billion in lost productivity each year, a co-author said in the Sept. 25 Washington Post.

The Journal of the American Medical Association is online.

The Washington Post is online.

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College news

October ACP Observer online

Read about how more U.S. medical students are studying abroad, as well as the issues faced by foreign students who come to study in the U.S. in the October 2007 issue of ACP Observer, now online. Also, look for coverage on the increasing ranks of women in primary care, as many of their male counterparts opt for specialties.

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New caption contest

Pen the winning caption to the cartoon below and win a framed print of the cartoon, signed by the artist. E-mail all entries to observerstaff@acponline.org by Oct. 15. The winner of our September caption contest, for which we received more than 100 entries, will be announced in the next edition of ObserverWeekly.

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ACP ObserverWeekly is a weekly newsletter produced by the staff of ACP Observer. It is automatically sent to all College members who have an e-mail address on file with ACP.

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Copyright 2007 by the American College of Physicians.

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