In the News for the Week of 11-20-07
- Mutant adenovirus outbreak blamed for illnesses, deaths
- Rosiglitazone boxed warning to reflect heart attack risk
- Aetna and Blue Cross to use new physician ranking model in New York
- Annals: Much of geriatricians’ patient care is unreimbursed
- New measure of hemoglobin predicts mortality in dialysis patients
- Mental health issues in returning soldiers more common than thought
- Part D open enrollment begins for Medicare beneficiaries
- Changes announced to acceptable documentation for I-9 forms
ACP publishing news
- Cartoon caption contest: And the winner is ...
- Read the latest news for medical students in the November issue of IMpact
- Coming soon: new leadership development program for members
- Call for spring 2008 Board of Governors resolutions
- Clinical guidelines content available for PDA download
- CME opportunity: New diabetes documentary airs this month
Editorial note: ACP ObserverWeekly will not be published the week of Nov. 27 due to the Thanksgiving holiday.
Adenovirus 14 (Ad14), a mutant variation of the common cold virus, has caused 10 deaths and at least 140 cases of severe respiratory illness requiring hospitalization, the CDC reported last week.
The first case involved an infant in New York who died in May 2006, the CDC reported in the Nov. 16 Morbidity and Mortality Weekly Report (MMWR). Since then, clusters of cases have been confirmed in Oregon, Washington and Texas, resulting in 53 hospitalizations—including 24 admitted to the ICU—and nine deaths.
The Ad14 isolates from all four states were identical, but distinct from the Ad14 strain that emerged in 1955, suggesting that this is a new variant of the virus, said the MMWR. The CDC did not find any evidence of direct transmission between any of the clusters identified.
The outbreak has affected people of all ages, including healthy young adults. In Oregon, for example, 30 Ad14 patients identified ranged from age two weeks to 82 years, with a median age of 53.4 years. Twenty-two of those patients required hospitalization, 16 were admitted to the ICU and seven died, all from severe pneumonia, according to the report.
Several antiviral drugs, including ribavirin, vidarabine, and cidofovir, have been used to treat adenoviral infections such as Ad14, but none have shown “definitive efficacy,” the CDC said.
Adenoviruses can be shed in respiratory secretions and feces and can survive for weeks on environmental surfaces, making them hard to control, said the report. Follow the CDC’s guidelines for care of patients with pneumonia in suspected cases of adenoviral pneumonia. Physicians are also advised to consult their state health departments for assistance.
The MMWR article is online.
The maker of rosiglitazone (Avandia) is revising its boxed warning to include an increased risk of heart attacks from the diabetes drug, the FDA said last week.
Health care providers should closely monitor patients who take rosiglitazone for cardiovascular risks, the FDA said. Patients with type 2 diabetes and underlying heart disease, or who are at high risk for heart attack, should discuss the revised warning with their provider when they evaluate options for treatment, it added.
The FDA has studied data in the last year on the risk of chest pain, heart attacks, heart-related death and all-cause death in patients taking rosiglitazone. In July, an FDA panel advised that the drug stay on the market but carry a stronger warning. In August, the entire class of thiazolidinediones, including rosiglitazone, added boxed warnings saying the drugs may cause or worsen heart failure.
Thus far, the FDA said, it hasn’t found enough evidence to indicate the risk of heart attack or deaths is different with rosiglitazone than with some other oral type 2 diabetes drugs. A meta-analysis of 42 clinical studies, mostly comparing rosiglitazone to placebo, showed the former was associated with a higher risk of myocardial ischemic events. Three other studies comparing rosiglitazone to other oral antidiabetic agents or placebo didn’t confirm or exclude the risk, however. The maker of rosiglitazone has agreed to conduct a long-term study on potential risk, the FDA said.
The FDA release is online.
The New York State Attorney General’s office announced last week that Aetna and Empire Blue Cross Blue Shield will adopt the Attorney General’s model for physician ranking programs. New York State Attorney General Andrew Cuomo had previously announced on Oct. 29 that CIGNA had agreed to use the new model.
The model was created in consultation with, and is supported by, the American Medical Association and the Medical Society of the State of New York, along with a host of consumer advocacy groups including the Consumers Union and the National Partnership for Women & Families. The model reforms doctor-ranking programs by compelling insurers to fully disclose to consumers and physicians all aspects of their ranking system. As part of the model, the insurer must retain an oversight monitor who will oversee compliance with all aspects of the agreement and report to the Attorney General every six months.
Under the model the plans will have to make sure their physician ranking systems:
- identify the degree to which their rankings are based on cost;
- use established national standards to measure quality and cost efficiency, including measures endorsed by the National Quality Forum;
- disclose to physicians how rankings are designed and provide a process to appeal rankings; and
- disclose to consumers how rankings are designed and provide a process to register complaints about the system.
The following articles will appear in the Nov. 20, 2007, issue of Annals of Internal Medicine. The full text is available to College members and subscribers online.
Physicians spend much time providing unreimbursed care. A new study found that physicians caring for older adults spent nearly eight hours a week on patient care in addition to office visits. This time may be spent talking with families or ordering medicines or specialist care. Medicare pays physicians only for face-to-face visits. At an average of 6.7 minutes of care provided outside of office visits for every 30 minutes seeing a patient, approximately one-fifth of the geriatricians’ care was provided without pay. An editorial writer says that the findings for geriatricians are applicable to all adult primary care. The writer described two reform proposals which would pay for currently unreimbursed time. “If physicians are to improve their care coordination performance, they need time to do the work and must be paid for the work,” he said.
Lumbar supports reduced low back pain but not sick days. A new randomized controlled trial found that health care workers with existing low back pain given one of four lumbar supports and counseling about healthy work methods had less pain than a control group that received only the counseling. The lumbar-support groups did not have fewer work absences than the control group.
Head-to-head comparison of arthritis drugs did not find a clear winner. A systematic review of published literature of drugs for rheumatoid arthritis showed no clinically important differences in efficacy among two major classes of drugs, synthetic disease-modifying antirheumatic drugs (DMARDS) and anti-tumor necrosis factor drugs. The DMARDs evaluated were methotrexate, leflunomide and sulfasalazine. The anti-tumor necrosis factor drugs were adalimumab, etanercept, and infliximab. Researchers found that in patients previously receiving a single drug, combination therapy with DMARDs improved response rates, but available evidence does not indicate which combination strategy is best. This article was released early online at the Web site of Annals of Internal Medicine. It will appear in the Jan. 15, 2008, print edition of the journal.
Variability in hemoglobin levels is a strong predictor of mortality in patients with end-stage renal disease, according to a new study of dialysis patients.
In the study of about 35,000 dialysis patients, researchers used a new metric called Hb-Var, which measures variability of hemoglobin levels independent of absolute values and trends over time. The study found that greater hemoglobin variability, as measured by higher Hb-Var scores, predicted mortality in the patients. After adjusting for other factors, they determined that each 1 gram/deciliter increase in Hb-Var resulted in a 33% increased risk of death.
The study found that the relationship between Hb-Var and mortality remained significant after adjustment for absolute hemoglobin levels and trends in hemoglobin levels over time.
They also determined that patient characteristics accounted for very little of the variation in the variability metric, and concluded that greater hemoglobin variability is independently associated with higher mortality. The study will appear in the December issue of the Journal of the American Society of Nephrology.
Based on the study results, Hb-Var may be a valuable measurement of the effects of low hemoglobin in end-stage renal disease, study authors said. The findings could eventually lead to changes in the management of anemia, such as adjustment of the type, dose and timing of treatment with erythropoietin and iron, the authors concluded.
The consistency of results across various modeling strategies, said the authors, supports the theory that Hb-Var represents an important physiologic stress. It was unclear, however, whether the association between Hb-Var and mortality was due to the absence of hemoglobin variability, the absolute hemoglobin level achieved, or the absence of temporal hemoglobin trend, or a combination of these factors, said the authors.
The study is online.
Chlamydia infections in the U.S. set a new record last year for the number of reported cases of a sexually transmitted disease, according to a new report from the CDC.
In 2006, the CDC received reports of 1,030,911 diagnoses of chlamydia, an increase of 5.6% from 2005. The 2006 statistics work out to an incidence rate of 347.8 cases per 100,000 population, but CDC experts warned that more than half of chlamydia infections may go unreported. The CDC attributed the increase to greater use of screening and more sensitive diagnostic tests, although it noted that the number of reported cases may also reflect an increase in actual infections.
The CDC report, “Trends in Reportable Sexually Transmitted Diseases," also found increases in the reported rates of gonorrhea and syphilis. Between 1975 and 1997, gonorrhea rates had shown a steady decline, dropping a total of 74%. In the past two years, the rates have increased to reach 120.9 cases per 100,000 population. An increasing number of gonorrhea cases (13.8%) also demonstrate resistance to fluoroquinolones, the CDC said. The syphilis rate has been increasing for the past six years, reaching 3.3 cases per 100,000 population, with higher rates in men than women.
Based on these statistics, CDC officials urge health care providers to test their patients for these infections, especially since the vast majority of chlamydia cases are asymptomatic. Providers who do identify an infection should encourage their patients to come back for follow-up testing and try to ensure that the patient’s partner also receives treatment, the experts said.
The CDC report is online.
A transcript of the briefing by CDC officials is online.
Vaccines have successfully reduced the incidence of vaccine-preventable diseases in the U.S. to an all-time low, according to a new historical analysis of morbidity and mortality conducted by the CDC.
The report found that cases of diphtheria, mumps, pertussis and tetanus declined more than 92% since vaccination was recommended, while deaths from the diseases declined by at least 99%. Other diseases, targeted more recently by vaccination, showed slightly smaller but still dramatic declines. Hepatitis A cases and deaths declined by about 87%, while acute hepatitis B declined by 80%. For varicella, cases declined 85% and deaths went down 82%. Invasive pneumococcal disease saw the smallest declines, dropping 34% in cases and 25% in deaths.
The study also noted that vaccines have resulted in the elimination of endemic transmission of poliovirus, measles and rubella in the U.S. and the worldwide eradication of smallpox. The report, which was based on primary historical sources and the most recent morbidity and mortality data, was published in the Nov. 14 Journal of the American Medical Association.
These statistics could be improved further by ensuring routine access to pertussis, influenza, pneumococcal and zoster vaccines, the study authors said. In order to improve vaccination rates among adults, both clinicians and patients need a greater understanding of the benefits of vaccination, they suggested. The authors also recommended the adoption of vaccination provisions as part of adult preventive health care.
The analysis is online.
U.S. veterans are more likely to have mental health problems three to six months after returning from Iraq than when they first come home, a new study found.
The longitudinal study assessed 88,235 U.S. soldiers via a self-report questionnaire and a two brief interview with a health provider upon their immediate return from Iraq and an average of six months later. The soldiers’ mean age was 30.4 years; 91% were men. They were screened for posttraumatic stress disorder (PTSD), major depression, alcohol misuse or other mental health problems. The study was published in the November 14 Journal of the American Medical Association.
Subjects reported more mental health distress, and were referred for mental health services at higher rates, in the second assessment. Reservist and National Guard units had higher rates than active-duty soldiers, as well. Between the first and second assessment, PTSD reports rose from 11.8% to 16.7% for active soldiers and from 12.7% to 24.5% for reserve soldiers. Also changed were depression (active 4.7% to 10.3%; reserve, 3.8% to 13%), concern about interpersonal conflict (active 3.5% to 14%; reserve 4.2% to 21%), and overall mental health risk (active 17% to 27%; reserve 17.5% to 35.5%).
Reservists may have higher rates of mental health problems at the second assessment than active-duty soldiers, in part, due to the stress of transition into civilian employment and the lack of day-to-day support from military peers, the authors said. Combining the first and second assessments reveals that 20.3% of active-duty soldiers and 42.4% of reserve soldiers need mental health treatment within six months of returning home from Iraq. Clinicians should be aware of the risk and the importance of intervening as early as possible, the authors said.
The Journal of the American Medical Association is online.
Open enrollment for Medicare Part D plans began last Thursday, Nov. 15 and will last through Dec. 31.
The CMS has announced that they have enhanced the tools to help beneficiaries navigate their open enrollment information, including a new plan finder that offers more information and greater clarity on available drug plans, including out-of-pocket costs, pharmacy networks, and important Medicare news and updates. The 2008 Plan Finder allows beneficiaries to compare prescription drug plans, view premiums, formularies, and availability of coverage in the gap.
All Medicare beneficiaries should be encouraged to review their current plans and determine if a better fit exists in their area, especially since some plans will have substantial increases in their premium prices.
Of particular significance to physicians’ practices, there will be a change to vaccine billing when the new plan year starts on Jan. 1. Under new rules, vaccine administration costs, in addition to the vaccine cost, will need to be billed directly to the Part D plan instead of CMS. This will mean that most physicians will need to bill their patients and have the patient apply for reimbursement to their Part D plan.
Medicare officials also recently sent letters to nearly 2 million low-income beneficiaries who are exempt from paying a monthly premium to inform them that they will be moved to a new plan. Low-income beneficiaries can switch their drug plans at any time, so if they receive a reassignment notice from the government, they should carefully review their new plan. If they need assistance doing so they can consult 1-800-Medicare, or contact the State Health Insurance Assistance Program, which has counselors in every state.
CMS has 2008 Medicare prescription drug plan and health plan information online through the Medicare Prescription Drug Plan finder.
The US Citizenship and Immigration Services recently announced changes to the Form I-9, effective immediately. The revised Form I-9 makes several changes to the list of documentation employers may accept for employment eligibility verification. One document, the Employment Authorization Document (Form I-766) was added to the list of acceptable documentation, while the following five documents were removed from the list:
- Certificate of U.S. Citizenship (Form N-560 or N-570),
- Certificate of Naturalizations (Form N-550 or N-570),
- Alien Registration Receipt Card (Form I-151),
- the unexpired Reentry Permit (Form I-327), and
- the unexpired Refugee Travel Document (Form I-571).
All employers, including physician practices, are required to complete a Form I-9 for every employee hired in the US within three days of hire. Form I-9 confirms the identity and eligibility of all workers. Employers must examine certain document(s) from a specific list, attest that they did so, and keep it in the personnel file of the employee. These changes apply to all new employees; practices do not need to have current employees complete the new form.
The revised Form I-9 is online.
More information about these changes is online.
ACP publishing news
ObserverWeekly has compiled the results from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption. This issue’s winning cartoon caption comes from Steven J. Meyerson, ACP Member, an internist specializing in geriatrics at Baptist Hospital of Miami in Miami. Close to 200 ObserverWeekly readers cast their ballots online to choose the winning entry. Thanks to all who voted!
Dr. Meyerson receives a complimentary copy of "Medicine in Quotations," ACP's comprehensive collection of famous sayings relating to sickness and health, disease and treatment and a portrait of medicine throughout recorded history. A new contest will appear in December.
The winning entry:
"I wonder how much I'm going to have to shell out this time"
The winning caption received 37% of the votes. The two runners up were:
"That's the advantage of being a geriatrician. You arrive before your patients" (35%)
"It wasn't until today that I finally realized what was meant by getting older and losing your hare." (29%)
The summer after your first year of medical school is an ideal time to pursue opportunities and interests outside the traditional classroom. Read what other medical students are considering for what may be their last summer off: Travel, research, shadowing or just relaxing with family. This and other stories are in the November issue of IMpact, ACP's newsletter for medical students.
ACP will introduce the Leadership Enhancement and Development (LEAD) program at Internal Medicine 2008 in Washington, D.C. this May. LEAD is designed to provide internal medicine physicians with the skills, knowledge, and experiences necessary for effective leadership in medical settings and the community at large.
The program targets internists early in their careers, and will kick off with a pre-course on May 14 called “Essential Competencies for the Emerging Leader.” Expert faculty will give instruction on self assessment, communication, team building, negotiation, and conflict resolution. Additional courses throughout IM 2008 include: Negotiation Skills for Women Physicians, How to Be an Effective Leader, Negotiating Residency and Employment issues for IMGS, and Leading and Managing Change. IM 2008 attendees will also have the opportunity to develop leadership advocacy skills by attending the events associated with Leadership Day on Capitol Hill.
The LEAD Program also provides many opportunities for leadership growth through active participation in local chapter events. Ask your Governor how you might hone your skills by helping with the chapter scientific meeting, serving on a committee, or reaching out to others. An online discussion group devoted to leadership challenges will be unveiled in the spring as well.
Participants who successfully meet five out of seven criteria over the course of three years will receive a Certificate of Completion for the program from ACP. More information on the Certificate will be available at IM 2008.
The deadline for submitting new resolutions to be heard at the May 2008 Board of Governors meeting is Friday, Jan. 11, 2008. Initiating a resolution provides ACP members an opportunity to focus attention at the ACP national level on a particular issue or topic that concerns them. Members must submit resolutions to their Governor and/or chapter council. A resolution becomes a resolution of the chapter once the chapter council approves it.
In accordance with the ACP BOG Resolutions Process, resolutions should clearly distinguish the action requested within its resolved clause(s) as either a policy resolve (“Resolved that ACP policy…”), or a directive, which requests action/study on an issue (“Resolved that the Board of Regents…”). If more than one action is proposed, each should have its own resolved clause. Please contact your Governor if you have any questions regarding the resolution format.
The Board of Governors votes on new resolutions which are then presented to the Board of Regents for action. Once the Board of Regents votes on these recommendations, resolutions are adopted as policy, accepted as reaffirmation of current policy, or forwarded to College staff and/or committees for study or implementation.
Information is online.
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 and are based on the highest quality scientific evidence. The goal is to provide clinicians with a clinical practice guideline based on the best evidence available; to make recommendations based on that evidence; to inform clinicians of when there is no evidence; and finally, to help them deliver the best health care possible.
Recommendation summaries for all current guidelines for your PDA are online.
A documentary on diabetes, for which physicians can earn CME credit, debuted on the Discovery Channel this month. The documentary, “Diabetes: A Global Epidemic” can also be viewed online or downloaded as a podcast.
The documentary is divided into four hour-long segments:
- Insulin initiation: glycemic control with postprandial glucose monitoring,
- Effectively managing anticoagulation,
- Insulin initiation: targeting type 2 diabetes, and
- Diabetes: A global epidemic
The series is supported by an unrestricted educational grant to Discovery Health from Novo Nordisk.
Details of the program can be found online.
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Copyright 2007 by the American College of Physicians.
A 66-year-old man comes for a preoperative evaluation before total joint arthroplasty of the left knee. He has a 25-year history of rheumatoid arthritis. He has had progressive pain in his left knee with activity, which limits his ability to hike. The patient has similar pain in the right knee, but it is less severe. He reports no recent morning stiffness. He is able to climb two or three flights of stairs without chest pain or shortness of breath. He has no other medical problems and reports no additional symptoms. Medications are methotrexate and folic acid. Following a physical exam and lab tests, what is the next best step in management?
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