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

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In the News for the Week of 12-4-07

News highlights

  • High-trauma fractures can indicate osteoporosis
  • CMS proposes new payment system for hospitals
  • Overuse of CT scans may be increasing cancer risks

Hospital medicine

  • FCC offers telecommunications assistance to rural health care centers
  • Joint Commission adds set of outpatient performance measures

Clinical news

  • Coronary risk profiles slightly improve lipid levels
  • Annals: ACP issues papers on U.S. health care system, pay for performance

Women’s health

  • New risk model for breast cancer in black women
  • Algorithm may help predict women's risk of fractures

ACP publishing news

  • Caption contest: Put words in our mouth
  • Send in your cases of medical diagnosis

College news

  • ACP and AMA conducting physician practice information survey
  • ACP Foundation proposes simplified, standardized prescription labels
  • Clarification

News highlights

High-trauma fractures can indicate osteoporosis

Broken bones from car accidents and high falls may be as indicative of bone density problems as the low-trauma fractures usually associated with osteoporosis, according to a new study.

The findings came from a combined analysis of two prospective cohort studies of Americans age 65 and older—one that followed 8,022 women for nine years and another that tracked 5,995 men for five years. The subjects’ hip and spine bone mineral density (BMD) were assessed by dual-energy X-ray absorptiometry, and fractures from both high trauma (motor vehicle crashes and falls from greater than standing height) and low trauma (falls from standing height and other less severe trauma) were recorded.

In total, 264 women and 94 men sustained a high-trauma fracture and 3,211 women and 346 men sustained a low-trauma fracture. The researchers found that each 1-SD reduction in BMD was associated with almost identically increased risk for both high-trauma and low-trauma fractures. Among women, the risk for subsequent fracture was also the same whether the patient had an initial low-trauma (31% increased risk) or high-trauma (34% increased risk) fracture. The study was published in the Nov. 28 Journal of the American Medical Association.

This study contradicts the common belief that patients with high-trauma fractures do not need to be evaluated for osteoporosis, the study authors said. Older patients who sustain such injuries should be considered for BMD testing and, if indicated, further evaluated for osteoporosis, said an accompanying editorial. The findings also have the potential to change clinical trials dealing with osteoporosis in which high-trauma fractures are usually excluded as end points, the editorial concluded.

The study and editorial are online.

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CMS proposes new payment system for hospitals

CMS presented a report to Congress last week recommending further changes to Medicare reimbursement for hospitals.

Under the new system, called "value-based purchasing," CMS would cut all payments to hospitals by 2% to 5% and designate that money as an incentive pool, the Wall Street Journal reported. Hospitals would then "earn back" money according to their total performance scores. Total performance scores would be calculated by taking into account such quality measures as clinical process of care, outcomes, and patient perspectives of care. The scores would be compiled over 12 months and would be based on whether a hospital met national thresholds and benchmarks or improved over its own performance in the previous 12 months. The transition from a pay-for-reporting system to the new system would take place over three years, CMS said in a press release.

While a CMS official called the plan "another step down the pay-for-performance road," a spokeswoman for Premier Inc., a previous CMS partner in pay-for-performance efforts, expressed concern that the new system could be considered a "cost-cutting program" rather than a program that rewards hospitals for improved quality, the Wall Street Journal reported.

The plan, which requires congressional approval before implementation, also includes provisions to enhance CMS' Hospital Compare Web site and make additional quality data available to consumers.

The Department of Health and Human Services' press release is online.

The Wall Street Journal is online (subscription required).

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Overuse of CT scans may be increasing risks of cancer

Physicians may be overusing computed tomography (CT) scanning as a diagnostic tool, thus unnecessarily increasing patients' risk of cancer from radiation exposure, a new study reported.

While CT scanning represents perhaps the single most important advance in diagnostic radiology, researchers said, it also involves much higher doses of radiation than plain-film radiography. Using data on CT scan use combined with individual risk estimates, researchers estimated that 1.5% to 2% of all cancers in the U.S. may be attributable to radiation from CT scans. The review article appears in the Nov. 29 New England Journal of Medicine.

Follow-up studies of atomic-bomb survivors have provided more than 50 years of data on radiation-related cancer risks among adults and children who were exposed to the same range of organ doses as those delivered during CT studies, the authors said. Even though most diagnostic CT scans have a favorable ratio of benefit to risk, they said, studies have questioned its use in specific situations, such as blunt trauma, seizures, chronic headaches and for diagnosing acute appendicitis in children.

Particularly worrisome, the authors noted, is the use of CT scans as part of defensive medicine or repeated scans due to lack of communication throughout the medical system. Also problematic, they said, is the fact that many physicians underestimate the risks of CT scans compared with other radiologic studies.

The authors recommended three strategies to reduce overall radiation exposure:

  • Reduce the CT-related dose in individual patients by, for example, using the automatic exposure control option in the latest scanners;
  • Replace CT use whenever practical with other options, such as ultrasonography and magnetic resonance imaging; and
  • Decrease the number of CT studies prescribed, considering that an estimated one-third of all CT scans are not justified by medical need, leading to more than 20 million U.S. adults and 1 million children per year being unnecessarily exposed to potentially dangerous levels of radiation.

The New England Journal of Medicine is online.

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Hospital medicine

FCC offers telecommunications assistance to rural health care centers

The Federal Communications Commission recently announced an effort to improve health care access in the rural U.S.

Under the Rural Health Care Pilot Program (RHCPP), the FCC will devote $417 million to the construction of broadband telehealth networks in 42 states and three U.S. territories, the agency reported in a press release. The FCC estimates that these networks will benefit approximately 6,000 hospitals, universities and clinical centers in the rural U.S. by improving access to medical specialists in more urban areas via videoconferencing and other methods.

Program participants are eligible to receive funding for up to 85% of the costs involved with setting up their broadband systems, and must implement the Department of Health and Human Services' health information technology standards where feasible, the FCC said. Projects must be competitively bid and will be reviewed quarterly as well as audited.

The FCC's press release is online.

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Joint Commission adds set of outpatient performance measures

The Joint Commission recently announced that it would add a set of seven outpatient measures to the existing core measure sets that can be used to satisfy its ORYX requirements for performance measurement.

The new measures, which are listed in CMS' Outpatient Prospective Payment System for 2008 and are partially based on CMS' Physician Quality Reporting Initiative, will help hospitals meet several measurement requirements with one data collection effort, the Joint Commission said in a press release.

Joint Commission-accredited hospitals are required to begin collecting and submitting data to the Joint Commission for at least four core measure sets or for a combination of core measure sets and noncore measures beginning with Jan. 1, 2008, discharges. Hospitals that opt to use the outpatient measure set must confirm their selection by Jan. 1, 2008, while data collection must begin by April 2008. Other available measure sets include those for heart failure, acute myocardial infarction, pneumonia, pregnancy and related conditions, surgical conditions and asthma care for children.

The Joint Commission's press release is online.

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Clinical news

Coronary risk profiles slightly improve lipid levels

Patients who are given a printed evaluation of their coronary risk are more likely to successfully meet their lipid targets, according to a new study.

The randomized, controlled trial included 3,053 Canadian patients at high risk for untreated hyperlipidemia who were followed for a year. Half the patients received one-page computer printouts which included their eight-year cardiovascular risk and cardiovascular age (patient’s age minus the difference between patient’s life expectancy and average life expectancy), and the other half received usual care. The study was published in the Nov. 26 Archives of Internal Medicine.

The researchers found small but measurable differences in the efficacy of lipid therapy between the two groups. Patients who received risk profiles lowered their LDL by 51.2 mg/dL compared with 48.0 mg/dL in the controls. Overall, the profile group was 26% more likely to reach their lipid targets. The study also found that the risk profiles had a greater impact on the patients with the worst profiles.

The study authors concluded that statin therapy can be enhanced by informing patients of their calculated coronary risk. Informing patients of their risk can increase the effectiveness of primary prevention by identifying patients most likely to benefit from treatment and reassuring lower-risk patients, they said. An accompanying editorial noted that communicating this information to patients would be made easier by computerized decision support systems to assist physicians with coronary risk predictions.

  • Share your experience. ACP Observer would like to know how you talk to patients about their risk for cardiovascular and other diseases. Our February issue will include a cover story about different methods of explaining risk, and we’d like to get our readers’ input on what does (and doesn’t) work to make patients understand risk and/or agree to treatment. E-mail your thoughts and experiences to observerstaff@acponline.org.

The study and editorial are online.

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Annals: ACP issues papers on U.S. health care system, pay for performance

The following articles will appear in the Dec. 4, 2007, online edition of Annals of Internal Medicine. This issue also includes guidelines on screening for high blood pressure and a study of medication-related emergency department visits by older adults. The full text is available to College members and subscribers online.

  • ACP prescribes remedies to achieve universal coverage, quality and lower costs. A new evidence-based paper analyzes health care in the U.S. and 12 other industrialized countries and identifies lessons that could be applied to achieve a high-performing health care system. Among other recommendations, the paper suggests that the U.S. government adopt either a pluralistic system or a single-payer approach to achieving health coverage for all Americans. Rather than endorsing either pathway, ACP calls on the public and policymakers to consider the strengths and weaknesses of each approach. The paper was developed by ACP's Health and Public Policy Committee and approved by the Board of Regents in October 2007 and reflects comments from members of the Board of Governors, Board of Regents, ACP Councils and selected expert advisors. The paper, "Achieving a High Performance Health Care System with Universal Access: What the USA Can Learn from Other Countries," and its accompanying editorial will be published on the Annals of Internal Medicine Web site on Dec. 4 and will appear in the print edition on Jan. 1.

    ACP has also developed a new non-partisan tool on the College’s Web site that analyzes the health care reform proposals of the presidential candidates, drawing on the recommendations outlined in the College’s position paper. The tool will be updated continually throughout the 2008 election cycle. An online members-only discussion area is also available.

  • Pay-for-performance programs must put patients first. A new ACP position paper says that pay-for-performance programs that provide incentives for good performance on a few specific elements of a single disease or condition may lead to better health care for some patients but can also have unintended consequences. The paper, "Pay-for-Performance Principles That Promote Patient-Centered Care: An Ethics Manifesto," notes several possible consequences of some P4P programs, such as an incentive to drop difficult patients whose outcome measures do not meet the quality standards or who cannot comply with treatment plans. The paper was developed by the ACP Ethics, Professionalism and Human Rights Committee and will appear in the Dec. 4 edition of Annals of Internal Medicine. A longer version is posted on the ACP Web site.

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Women’s health

New risk model for breast cancer in black women

Researchers have developed a new model that more accurately predicts black women’s risk of breast cancer, according to a study released last week.

The model that is currently in wide use, the Breast Cancer Risk Assessment Tool (also known as the Gail model), was based on data from white women, so researchers conducted a new study to evaluate the risks for black women. Based on data from 1,607 black women with invasive breast cancer and 1,647 controls, they developed a new model that uses age at menarche, affected family members, and number of benign biopsy examinations. They then combined this information with incidence data from the National Cancer Institute and assessed the model’s accuracy using data from the Women’s Health Initiative.

The new model found that black women age 45 or older actually have a higher risk for breast cancer than predicted by the old model. As an example, the researchers reviewed eligibility data from the Study of Tamoxifen and Raloxifene and found that 30% of black women were actually high-risk enough to qualify for the trial (a 5-year risk of 1.66%), while the old model found only 14.5% of the women to qualify. The study was published online in the Journal of the National Cancer Institute on Nov. 27.

Additional studies are needed to validate the new model, study authors said, but in the meantime, they recommend the use of the new tool, known as the CARE model, for counseling black women about breast cancer and determining their eligibility for prevention trials. The National Cancer Institute will update its online risk calculator to include the new findings by next spring, the Nov. 27 Washington Post reported.

The Journal of the National Cancer Institute is online.

The Washington Post is online.

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Algorithm may help predict women's risk of fractures

An algorithm based on 11 clinical variables may help predict the five-year risk of hip fracture among postmenopausal women, according to newly analyzed data from the Women's Health Initiative (WHI).

Using data on 93,676 women of various ethnic backgrounds who participated in the observational component of the WHI and 68,132 women who participated in the clinical trial, researchers developed an algorithm based on clinical factors that predicted hip fracture. The model was tested on a subset of women who had undergone dual-energy X-ray absorptiometry (DXA) scans to assess bone mass density.

After identifying occurrence of hip fracture during follow-up periods of approximately eight years, researchers found that 11 factors predicted hip fracture within five years: age, self-reported health, weight, height, race/ethnicity, self-reported physical activity, history of fracture after age 54, parental hip fracture, current smoking, current corticosteroid use and treated diabetes.

The study does not indicate whether women defined as being at high risk by the algorithm would benefit from measures to prevent hip fracture, the authors noted. Some women classified as at high risk in the study did not have low T scores, considered the gold standard for defining osteoporosis. Age continues to be the most powerful predictor of fracture risk, they added, but the addition of other clinical variables enhances physicians' ability to predict individual risk.

Further research is needed to determine the clinical implications of the algorithm and confirm treatment benefits, the authors concluded. However, knowing the five-year risk of fracture will allow physicians and patients to better assess the benefits of medical interventions when weighed against lifestyle considerations.

The JAMA abstract is online.

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ACP publishing news

Caption contest: Put words in our mouth

ObserverWeekly wants readers to create captions for this cartoon--and help choose the winner.

E-mail all entries to observerstaff@acponline.org by Dec. 17. ACP staff will choose three finalists and post them in the Dec. 18 issue of ObserverWeekly for an online vote by readers. The winner will appear in the Jan. 8 issue.

Pen the winning caption and win a $50 gift certificate good for any ACP product, program or service.

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Send in your cases of medical diagnosis

Jerome Groopman, FACP, author of the bestselling "How Doctors Think," and endocrinologist Pamela Hartzband, ACP Member, both Harvard faculty members, will discuss the art of medical diagnosis and decision making through a series of case studies suggested by readers.

In every other issue of ACP Internist (formerly ACP Observer), Drs. Groopman and Hartzband will present a case suggested by a physician reader willing to share his or her experience, and provide commentary on the thinking process that led to his or her diagnosis.

Please e-mail your ideas or suggestions to observerstaff@acponline.org. Physicians whose cases are selected for publication will be contacted by Drs. Groopman or Hartzband. Full details are online.

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College News

ACP and AMA conducting physician practice information survey

For the first time in nearly a decade, the American College of Physicians (ACP), the American Medical Association (AMA), and more than 70 other medical specialty societies have worked together to coordinate a comprehensive multi-specialty survey of America’s physician practices. The purpose of the survey is to collect up-to-date information on physician practice characteristics in order to positively influence national decision makers. Thousands of practices will be surveyed in 2007 and 2008, from virtually all physician specialties to ensure accurate and fair representation for all physicians and their patients.

This project is unique because it explores both the clinical and business side of medical practice. This information is important for the nation’s policy-makers to learn what is truly involved in running a practice that provides expert patient care while operating a business that is sustainable. A complete understanding of the landscape and the requirements for today’s care is critical. These data will allow medicine to articulate practice concerns to national policy-makers that will lead to policy initiatives that not only help in the short-term but will allow future generations of doctors to continue providing superior care to their patients.

There is a small section in this study pertaining to practice expenses and the amounts that are attributable to you. Please encourage your staff to make these numbers available. The Centers for Medicare and Medicaid Services recently announced that the results of this study are considered critical to update physician payment. This is a vital part of the research and we need to have accurate and complete data. This information remains confidential. The survey firm will not identify any individuals or entities participating in this research to any of the participating organizations.

Dmrkynetec has been retained to conduct the Physician Practice Information survey among a representative random sample of practices in each of the participating specialties. The survey is an important and necessary vehicle for positive change. Please watch for this survey and do your part in completing it in a thorough and accurate manner if selected to represent our specialty.

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ACP Foundation proposes simplified, standardized prescription labels

ACP Foundation researchers have proposed an evidence-based system of simplified, standardized dosing instructions for prescription medication container labels. A Universal Medication Schedule (UMS) would standardize prescription drug labels, and clarify their content and layout.

Misunderstanding prescription labels is a widespread problem, researchers said at the Sixth Annual National Health Communication Conference co-sponsored by the American College of Physicians Foundation and the Institute of Medicine. At the conference, researchers said:

  • 46% of adults misunderstand at least one prescription container label, according to a December 2006 study published in Annals of Internal Medicine.
  • 90 million Americans--about half of the adult population--suffer from low health literacy.
  • A randomized trial of 500 patients found that patient comprehension of the UMS label was five times greater compared to a typical label.

A white paper released by the ACP Foundation in October recommends standards for improving patient understanding of prescription medication container labels:

  • Use a UMS to convey and simplify dosage/use instructions.
  • Use explicit text to describe dosage/interval in instructions.
  • Organize label in a patient-centered manner.
  • Include distinguishable front and back sides to the label.
  • When possible, include indication for use.
  • Simplify language, avoiding unfamiliar words/medical jargon.
  • Improve typography, using a larger, sans serif font.
  • When applicable, use numeric vs. alphabet characters.
  • Use typographic cues (bolding and highlighting) for patient content only.
  • Use horizontal text only.
  • Use a standard icon system for signaling and organizing auxiliary warnings and instructions.

An ACP press release and white paper are online. The Annals study is online.

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Clarification

An article in the Nov. 20 edition reported that a boxed warning for the diabetes drug rosiglitazone (Avandia) was revised to include an increased risk of heart attacks. The phrase should have read "potential increased risk" of cardiovascular events.

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Copyright 2007 by the American College of Physicians.

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