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

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In the News for the Week of 11-13-07

News highlights

  • New primary care guidelines issued for adolescent depression
  • Conference coverage: Cardiac risks and new drugs top rheumatologists' agenda
  • Studies look at relationships between weight and serious disease

Hospital medicine

  • Experts cite need to standardize hospital safety ratings
  • Cardiac resynchronization therapy of little benefit in some heart failure patients, study finds
  • Statewide system improves reperfusion times for acute MI

Clinical news

  • ACP Journal Club: Screening ultrasonography for abdominal aortic aneurysm reduced mortality in older men

FDA news

  • FDA strengthens warnings, changes labels for anemia drugs
  • First silver-coated breathing tube approved for marketing

ACP publishing news

  • Vote online for the best cartoon caption
  • Cases sought for new column on the ‘art of diagnosis’
  • HEALTH TiPS--what you can do about the flu

College news

  • Clinical guidelines content available for PDA download
  • Certifying measures announced for patient-centered medical home
  • Governors choose chair-elect
  • Chapter awards announced
  • ACP President-Elect testifies before Congress about Medicare payment cuts

News highlights

New guidelines issued for adolescent depression

The November issue of Pediatrics has new clinical practice guidelines to identify, treat and manage depression in patients aged 10-21.

The guidelines, developed for primary care physicians by an expert committee, combine evidence- and consensus-based methodologies. They cover identification of at-risk youth, assessment, diagnosis and initial management; and summarize the strength of each recommendation as well as the evidence base.

Among the recommendations are:

  • Monitor the psychosocial functioning of youth as part of routine care, and be especially vigilant for those with depression risk factors like family history or trauma;
  • Conduct direct interviews with the patient and caregivers when assessing depression. If depression is diagnosed, discuss treatment options with patients as well as caregivers;
  • Set treatment plans with specific goals in settings, including school, peer and home, and establish safety plans for times of suicidality or crisis. Also, connect patients with community mental health resources;
  • Consider trying 6-8 weeks of active support and monitoring for mildly depressed patients before starting treatment;
  • Consider consulting a mental health specialist if a patient is moderately or severely depressed, or has comorbid substance abuse or other psychosis;
  • Reassess diagnosis and treatment if there is no improvement after 6-8 weeks.

The Pediatrics articles on depression assessment and management are online.

A toolkit for depression management is online.

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Conference coverage: Cardiac risks and new drugs top rheumatologists' agenda

BOSTON-- The cardiovascular and other consequences of arthritis, as well as new data on experimental treatments for a variety of rheumatologic diseases were among the research findings presented at last week's 71st annual meeting of the American College of Rheumatology in Boston.

Among the 2,300 abstracts presented at the meeting were two studies evaluating the increased cardiovascular risks affecting patients with rheumatoid arthritis (RA). Using a government database that included 33,000 patients with RA, British researchers found that the patients with RA had 65% increased risk of stroke when compared with controls. Meanwhile, researchers at the Mayo Clinic developed a new approach to predict patients’ risk of cardiovascular events within 10 years of diagnosis. They found that most patients diagnosed with RA in their 60s had cardiovascular risk equal to that of non-RA patients about a decade older, effectively doubling their risk, study authors said.

Offering some hope for those higher risk patients, a study of the California Medicaid database found that aggressive combination treatment of RA can reduce the risk of heart attack. Researchers compared the number of heart attacks in patients who took methotrexate alone or in combination with TNF-inhibitors and found that patients on combined therapy had an 80% reduced risk compared to those on methotrexate alone.

Drug treatment of arthritis entails some potential consequences of its own, noted another study by the same researchers. Using the California Medicaid database again, they determined that recent decreases in use of COX-2 inhibitors may be associated with an increase in the number of serious ulcer complications in elderly users of non-steroidal anti-inflammatory drugs (NSAIDs). According to their data, the percentage of elderly patients taking NSAIDs without some form of gastroprotective medication (proton pump inhibitors or misoprostol) more than doubled between 2004 and 2005.

Other studies of note at the conference included a successful trial of fish oil as a treatment for lupus, a study finding that early arthritis treatment improved chances of remission, and results from phase III trials of some new medications for arthritis.

--by Stacey Butterfield, staff writer

More information about the conference is online.

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Studies look at relationship between weight and serious diseases

Two studies released last week examine the relationship between excess body weight and mortality, suggesting that while being overweight or obese increases a person's risk for cancer and heart disease, having a few extra pounds may decrease the risk of death from other causes.

In one study, published in the Nov. 7 Journal of the American Medical Association, researchers looked at National Health and Nutrition Examination Survey (NHANES) data on cause-specific risks of mortality and BMI for the period 1971-2002, combined with underlying cause of death statistics on 2.3 million U.S. adults in 2004.

Being underweight (BMI <18.5) was associated with a significantly increased mortality from noncancer, non-cardiovascular disease (CVD) causes, but not with cancer or CVD mortality. Overweight (BMI 25-30) was associated with significantly decreased mortality from noncancer, non-CVD causes and was not associated with death from cancer or heart disease (obesity was associated with cancers considered obesity-related). However, obesity (BMI >30) was associated with significantly increased CVD mortality, and overweight and obesity combined were associated with increased mortality from diabetes and kidney disease.

The results show that the association of BMI with death varies by cause of death, said the authors. They noted that this study helps clarify earlier findings of excess overall mortality associated with underweight and obesity but not with overweight.

In another study, published in the Nov. 6 BMJ, researchers followed 1.2 million U.K. women aged 50-64 who participated in the Million Women Study from 1996-2001, and followed up for cancer incidence or mortality for an average of five to seven years. They found that increasing BMI was associated with significant increase in risk for many cancers.

For example, increasing BMI was associated with a relative risk (per 10-unit increase of BMI) of 2.89 for endometrial cancer, relative risk of 2.38 for adenocarcinoma of the esophagus and relative risk of 1.53 for kidney cancer. Menopausal status appeared to be an indicator of risk for several cancers. For example, postmenopausal women had a higher risk of breast cancer while premenopausal women had a higher risk of colorectal cancer than other women studied.

The authors noted that, among postmenopausal women in the U.K., 5% of all cancers (about 6,000 per year) could be attributed to overweight or obesity. About half of all cases of endometrial cancer and adenocarcinoma of the esophagus in postmenopausal women can be attributed to overweight or obesity, they added, a major modifiable risk factor.

The JAMA abstract is online.

The BMJ article is online.

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Hospital medicine

Experts cite need to standardize hospital safety ratings

As hospitals face increasing pressure to evaluate and improve safety and quality of care, a team of experts has come out with a standardized framework to help them develop meaningful safety scorecards.

Researchers at Johns Hopkins University adapted elements of the "Users’ Guide to the Medical Literature: A Manual for Evidence-Based Clinical Practice," to address three key questions: "Is the measure important?" "Is the measure valid?" and "Can the measure be used to improve safety in health care organizations?" Their commentary appears in the Nov. 7 Journal of the American Medical Association.

The resulting worksheet to evaluate a patient safety scorecard guides hospitals through a series of questions aimed at determining whether their institution meets the three criteria above. For example, under "Is the measure valid?" the scorecard asks, "Is the measure supported by empirical evidence or a consensus of experts?" and "Does the measure have face validity—i.e., do clinicians believe that improvement in performance on the measure will be associated with improved patient outcomes or, for performance measures, is the outcome preventable?" Under "Can this measure be used to improve safety in the organization?" hospitals are asked to consider, "Do the benefits of knowing the information provided by this performance measure outweigh the costs of data collection?"

As the need to track progress on safety mounts, said the authors, the proposed framework can help health care organizations develop scorecards that effectively address the question, "Are patients safer?"

An excerpt of the JAMA article is online. (full text requires subscription).

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Cardiac resynchronization therapy of little benefit in some heart failure patients, study finds

Patients with moderate to severe heart failure and a narrow QRS interval may not benefit from cardiac resynchronization therapy (CRT), according to a new study.

Researchers performed a randomized, double-blind trial to determine whether CRT would benefit patients with narrow QRS syndromes and left ventricular mechanical dyssynchrony. Patients were eligible to participate if they had moderate chronic heart failure due to ischemic or nonischemic cardiomyopathy, an ejection fraction less than 0.35 and a QRS interval less than 130 ms. One hundred seventy-two patients were randomly assigned to receive CRT or no CRT and underwent cardiopulmonary exercise testing at six months. The primary end point was an increase in peak oxygen consumption of 1.0 mL per kg of body weight per minute or greater. The study results were published online Nov. 6 by the New England Journal of Medicine.

At six months, the CRT and control groups did not differ significantly in achievement of the primary end point (46% vs. 41%, respectively). In subgroup analyses, oxygen consumption increased in patients with prolonged QRS intervals who received CRT but did not change in patients with narrow QRS intervals. Although a greater proportion of patients in the control group than in the CRT group had heart failure events that required intravenous therapy (22.3% vs. 16.1%), the difference was not statistically significant.

The authors noted that their method of identifying mechanical dyssynchrony may have affected the study results because it lacked specificity. However, they concluded that CRT is not effective for improving peak oxygen consumption in patients with moderate heart failure, mechanical dyssynchrony and a QRS interval less than 130 ms.

The New England Journal of Medicine is online.

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Statewide system improves reperfusion times for acute MI

A statewide system in North Carolina substantially improved coronary reperfusion times for patients with acute ST-segment elevation myocardial infarction (STEMI), a new study reports.

The Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments (RACE) study set out to determine whether establishing a statewide system for reperfusion would result in more rapid treatment and more appropriate therapy for eligible patients. The study involved 10 hospitals that offered percutaneous coronary intervention (PCI) and 55 hospitals that didn't. Participating PCI hospitals agreed to allow ED physicians or paramedics to activate the catheterization laboratory at any time with one telephone call and accept incoming STEMI patients regardless of bed availability, among other requirements.

Regional coordinators and representatives from the PCI hospitals worked with the non-PCI hospitals to discuss coordination of care. Coronary reperfusion plans were established at all of the participating hospitals, focusing on early diagnosis; appropriate on-site therapy; EMS, ED, and catheterization lab processes; and patient transfer. Researchers collected and analyzed data on reperfusion times and rates three months before and three months after the year-long intervention. The results were published online Nov. 4 by the Journal of the American Medical Association.

Median times to reperfusion improved significantly after the intervention was implemented. Door-to-device times decreased from 85 minutes to 74 minutes for primary procedures performed at PCI hospitals and from 165 minutes to 128 minutes for procedures in patients transferred to PCI hospitals. Door-to-needle times decreased from 35 to 29 minutes at non-PCI hospitals, and "door-in door-out" times for patients transferred from non-PCI to PCI hospitals decreased from 120 minutes to 71 minutes. Clinical outcomes, including death and cardiac arrest, did not change significantly after the intervention in patients who presented to or were transferred to PCI hospitals.

The researchers concluded that this statewide, regionally based intervention substantially improved quality of care in patients with STEMI, attributing its success in part to its involvement of all hospital and EMS systems and use of regional coordinators. However, they wrote, more research is needed to determine whether such programs can reduce STEMI-related morbidity and mortality.

The Journal of the American Medical Association is online.

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Clinical news

ACP Journal Club: Screening ultrasonography for abdominal aortic aneurysm reduced mortality in older men

A new study found that at least for older men, screening ultrasonography for abdominal aortic aneurysm (AAA) reduced mortality and was cost-effective in the long term.

In the randomized, controlled trial, 33,883 British men between the ages of 65 and 74 were invited for screening ultrasonography for AAA and their outcomes were compared with a control group of 33,887 who were not invited to screening. The measured outcomes were AAA-related mortality, all-cause mortality, and cost per quality-adjusted life-year (QALY) gained.

At a mean 7.1 years, the screening group had a lower incidence of AAA-related mortality compared to controls (.31% vs. .58%). The men who were screened also had a lower rate of all-cause mortality (20% vs. 21%). Researchers calculated the cost per QALY at $19,500 for AAA-related mortality and $7,600 for all-cause mortality. Based on U.S. costs, the study found a cost-effectiveness of $30,800 per QALY gained. The study is abstracted in the November/December ACP Journal Club.

Using data from the study, Journal Club reviewer Christopher M. Rembold, FACP, of the University of Virginia, calculated the five-year number needed to screen (NNS) for men who smoked (335), all men (536), nonsmoking men (1,340), women who smoked (2,011), all women (3,217), and nonsmoking women (8,044). These values compare favorably with NNS statistics for other screening strategies (e.g., mammography, dyslipidemia), Dr. Rembold said. He concluded that AAA screening at age 65 seems to be especially effective in men who have ever smoked and may also benefit nonsmoking men, and women who have ever smoked.

Peer ratings for this review: Cardiology, Geriatrics: 6/7 stars. Primary Care: 5/7 stars.

ACP Journal Club is online.

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FDA news

Stronger warnings and label changes for anemia drugs

The FDA last week approved changes to the boxed warnings and labels of erythropoiesis-stimulating agents (ESAs) to reflect risks for patients with cancer and chronic kidney failure.

For cancer patients, the drugs, epoetin alfa (Epogen, Procrit) and darbepoetin alfa (Aranesp), caused tumor growth and shortened survival in patients with advanced breast, head and neck, lymphoid and non-small-cell lung cancer at doses that aimed for a hemoglobin level of 12 g/dL or more. It’s unclear if the risk exists for smaller doses, the FDA said.

The new boxed warning also states that ESAs should be used in cancer patients only when treating anemia specifically caused by chemotherapy, and they should be stopped when the chemotherapy course is done. ESAs haven’t been shown to improve quality of life, fatigue or well-being for cancer patients or HIV patients undergoing AZT therapy, the new labels say.

For kidney failure patients, ESAs should be used to maintain a hemoglobin level between 10 g/dL to 12 g/dL, the warning says. Maintaining higher levels raises the risk of death and serious cardiovascular reactions like stroke, heart attack or heart failure.

The FDA release is online.

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First silver-coated breathing tube approved for marketing

The FDA cleared for marketing a breathing tube that is coated with a thin layer of silver to help prevent ventilator-associated pneumonia in hospitals.

The coating on the Agento endotracheal tube is meant for patients who must rely on a ventilator to breathe for 24 hours or more. Its silver lining is known to have antimicrobial properties, the FDA said.

In a multicenter clinical trial comparing the silver-coated tube to an uncoated tube, the percentage of patients who developed pneumonia was reduced from 7.5% to 4.8%. The silver tube also delayed the onset of pneumonia, the FDA said.

The FDA release is online.

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ACP publishing news

Vote online for your favorite cartoon caption

ObserverWeekly's cartoon contest continues with a twist. ACP staff has selected three finalists for the latest caption contest and are now asking readers to vote for their favorite in order to determine the winner.

Go online to view the cartoon and then pick the winner, who receives a copy of ACP Press' "Medicine in Quotations." The winning caption will appear in the Nov. 20 issue.

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Cases sought for new column on the “art of diagnosis”

Jerome Groopman, FACP, author of the bestselling “How Doctors Think,” and his wife, endocrinologist Pamela Hartzband, ACP Member, will debut as regular columnists in the January 2008 issue. Drs. Groopman and Hartzband, both professors at Harvard Medical School and staff physicians at Beth Israel Deaconess Medical Center in Boston, will discuss the art of medical diagnosis and decision making through a series of case studies suggested by readers.

Please email your ideas or suggestions to observerstaff@acponline.org. Physicians whose cases are selected for publication will be contacted by Drs. Groopman or Hartzband. Look for an introduction and full details on the column in the January 2008 issue, when the College's newspaper re-launches as ACP Internist.

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HEALTH TiPS--what you can do about the flu

The ACP Foundation recently developed a HEALTH TiP for Influenza (Flu). This easy-to-read format, available in both English and Spanish, was created to help educate patients on the flu. It includes information on the flu season and when to receive the flu vaccine, helps to dispel myths surrounding the flu vaccine, and describes ways to avoid spreading the flu to others. The flu HEALTH TiP was made possible by an unrestricted educational grant from sanofi pasteur. ACP members can order their free HEALTH TiPS through the ACP Foundation.

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College news

Clinical guidelines content available for PDA download

Recommendation summaries for 15 current ACP Clinical Guidelines are now available for downloading to your PDA. Unlike other guidelines, ACP’s Clinical Guidelines follow a rigorous development process (ACP’s Clinical Efficacy Assessment Project—CEAP) and are based on the highest-quality scientific evidence. Several areas of internal medicine are represented, such as screening for cancer and other major diseases, diagnosis, treatment and medical technology.

To access recommendation summaries for all current guidelines as a single collection for your PDA, visit here.

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Certifying measures announced for the patient-centered medical home

The Patient Centered Primary Care Collaborative (PCPCC), a coalition representing national business leaders, policymakers and 330,000 primary care physicians, said last week it intends to use a set of clinical and operational criteria to allow primary care practices to voluntarily be recognized as patient-centered medical homes. The criteria, developed by the independent National Committee for Quality Assurance (NCQA), were announced at a national health care summit sponsored by the PCPCC.

NCQA developed the criteria for the certification program in conjunction with the College, the American Academy of Family Physicians, the American Academy of Pediatrics and the American Osteopathic Association. The criteria provide a road map for practices to follow in becoming patient-centered medical homes and are based on a series of requirements including patient registries, care management programs, electronic prescribing and follow-up on tests.

The medical home concept re-centers health care on the patient’s needs and priorities by providing primary and preventive care that is personalized for each patient. It emphasizes the use of health information technology, including electronic health records, to help prevent and manage chronic disease, and features consumer conveniences such as same-day scheduling and secure e-mail communication. The medical home strengthens the patient-physician relationship by allowing the doctor and a team of health professionals to spend more time with each patient, and to develop an individualized plan of care.

Information about the Patient Centered Primary Care Collaborative and the NCQA guidelines is online.

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Governors choose chair-elect

Molly Cooke, FACP has been elected the next Chair-elect for the Board of Governors. She will officially take office in May 2008. Dr. Cooke will become Chair at the close of the Annual Business Meeting in April 2009 and serve in that capacity for one year.

She is the current Governor of the Northern California Region and serves on the board of the All-California ACP Services organization, which works with the legislature to advance the interests of internists and patients in California. At the national level, she serves as vice-chair of the College’s Health and Public Policy Committee. She has established a professional development program for faculty members in the department of medicine at UCSF and has served as an advocate for women physicians.

Major professional contributions include seminal work in HIV ethics in the early years of the epidemic, and more recently a number of contributions in the area of medical education, including establishment of UCSF’s Academy of Medical Educators. She has been active in the educational, advocacy and governance activities of ACP, both regionally and nationally.

Dr. Cooke received her medical degree from Stanford University and served her residency and fellowship at the University of California, San Francisco, where she is a professor of medicine. She is a general internist whose practice focuses on the care of patients with HIV and other chronic illness. She speaks conversational Spanish.

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Chapter awards announced

Members, Fellows and Masters who have demonstrated by their example and conduct an abiding commitment to excellence in medical care, education, research, or service to their community, their chapter and ACP have received chapter awards.

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ACP President-Elect testifies before Congress about Medicare payment cuts

Focusing on his experience as a physician in a small medical practice in rural Virginia, Jeffrey P. Harris, FACP, president-elect of ACP, testified last week before the House Small Business Committee Subcommittee on Regulations, Healthcare and Trade.

“As a community small business, we discovered first-hand the financial struggles that Medicare payments to physicians played on our practice,” noted Dr. Harris. “These practices are medicine’s small businesses, where much of their revenue is tied directly to Medicare’s flawed reimbursement rates and formulas.”

On Jan. 1, physicians face a 10.1% cut in Medicare reimbursements due to the flawed Sustainable Growth Rate (SGR) formula that is used to calculate Medicare payments to physicians. The SGR formula was created in 1997 and ties physician payments to growth in the overall economy. When growth in physician expenditures exceeds growth in the economy, the difference is subtracted from physician payments. The SGR formula has led to scheduled annual cuts for six consecutive years.

“Research shows that health care managed and coordinated by a patient’s personal physician, using systems of care centered on patients’ needs, can achieve better outcomes for patients and potentially lower costs by reducing complications and avoidable hospitalizations,” continued Dr. Harris. “Instead of encouraging high-quality and efficient care centered on patients’ needs, however, existing Medicare payment policies have contributed to a fragmented, high volume, over-specialized and inefficient model of health care delivery that fails to produce consistently good quality outcomes for patients.”

The College is asking Congress to avert the immediate SGR cut, but also go a step beyond. It wants Congress to set a timeline for completely eliminating the use of the SGR formula, and to direct Medicare to change payment policies to support patient-centered, physician-guided care management based on the patient-centered medical home model of care.

More information about Dr. Harris’s testimony is online.

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