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

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In the News for the Week of 2-6-07

News highlights

  • CDC issues guidelines to fight flu pandemic
  • FDA strengthens drug review process
  • Gritty air raises risk of heart disease, death in older women

Clinical news

  • Annals of Internal Medicine:
    • More very elderly starting dialysis, but survival rate low
    • Sleep apnea diagnosed without overnights in a sleep lab
  • More accurate stroke diagnosis with MRI than CT

Quality improvement

  • CMS pilot shows P4P slightly improves hospital quality
  • Community grants for treatment of chronic disease

College news

  • CSM Chair receives Foundation Leadership award
  • Former regent heads new medical school

News highlights

CDC issues guidelines to fight flu pandemic

The CDC issued guidelines last week on how communities can fight the spread of pandemic flu, including a severity index that recommends increasingly stronger measures.

Modeled after the index used for hurricanes, the Pandemic Severity Index (PSI) ranks severity from categories 1 (moderate) to 5 (extreme), with severity primarily determined by the percentage of infected people who die. A category 1, which would kill less than 0.1% of the ill or fewer than 90,000 Americans, is equivalent to a severe seasonal influenza season. A pandemic with the intensity of the 1918 flu pandemic would be a category 5, with the potential to kill at least 1.8 million, or at least 2% of those infected.

Actions the CDC recommends to limit the spread of the disease range, according to severity levels, from asking ill, contagious persons to remain at home to closing schools and child care programs, telecommuting and avoiding public gatherings. Cities and states would decide when to invoke measures like closing schools and postponing concerts, the Feb. 1 Washington Post said.

The CDC, which also kicked off a series of radio and television public service announcements last week on pandemic preparedness, said it will refine its pandemic flu guidelines as needed based on research, exercises and experience.

The CDC guide is available online.

The Washington Post is online.

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FDA strengthens drug review process

The FDA last week outlined a series of changes intended to improve the safety of drugs and other medical products. The report responds to criticisms presented in the Institute of Medicine’s September 2006 review of the agency.

Some but not all of the IOM’s recommendations are included in the FDA’s new plan, noted the Jan. 31 New York Times. Major proposed changes include:

  • a pilot program to assess drug safety 18 months after introduction
  • a new advisory panel on risk communications
  • collaboration with the Veteran’s Health Administration to track newly approved products
  • a database of genetic codes associated with negative drug outcomes
  • screening tests to identify patients most at risk for drug problems

The proposed changes reflect an effort to strengthen the science that supports the medical product safety system and improve communication and information flow among all key stakeholders, agency officials said. The timeline for implementation of the changes is still uncertain.

Unsatisfied with the proposed changes, a bipartisan group of senators last week introduced several pieces of legislation that propose changes to the drug review process, including reorganizing the FDA, requiring drug manufacturers to disclose the results of all clinical trials involving humans, and restricting consumer advertising, the Jan. 31 New York Times reported.

The FDA news release is online.

The New York Times is online.

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Gritty air raises risk of heart disease, death in older women

Long-term exposure to fine particulate air pollution increases the risk of heart disease and death in older, post-menopausal women, a new study found.

The study, published in the Feb. 1 New England Journal of Medicine, examined 65,893 postmenopausal women age 50-79 who were enrolled in the Women's Health Initiative from 1994-1998. The women had no history of cardiovascular disease. The authors assessed each woman’s exposure to air pollutants using the monitor nearest her residence, and hazard ratios were estimated for the first cardiovascular event. The women were studied from 1994-1998 with a median follow-up of six years.

A total of 1,826 women had one or more fatal or nonfatal cardiovascular events as of August 2003. Each increase of 10 millionths of a gram per cubic meter of air was associated with a 76% increase in the risk of death from cardiovascular disease, and a 24% increase in the risk of a cardiovascular event. Results were adjusted for demographic factors like income as well as health factors, such as smoking status and diabetes.

Results suggest that the EPA’s average annual limit of fine particulates, which is 15 millionths of a gram for every cubic meter of air, should be lower, said a pollution specialist interviewed by the New York Times.

The New England Journal of Medicine Abstract is online.

The New York Times is online.

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Clinical news

Annals: More very elderly starting dialysis, but survival rate low

The Feb. 6 issue of Annals of Internal Medicine includes a study of very elderly patients on dialysis and an article about diagnosing sleep apnea without an overnight in the sleep lab. The full text is available to College members and subscribers online.

  • Increased number of very elderly beginning dialysis but only 46% alive one year later. The number of octogenarians (people aged 80 to 89) and nonagenarians (people 90 to 99) who began dialysis increased from 7,054 people in 1996 to 13,577 people in 2003, according to a new study. Overall, one-year survival rates for patients on dialysis did not materially change from 1996 to 2003, remaining at about 50%. Survival rates for these very elderly are substantially lower than those previously reported. Researchers used data from a large national kidney data system. Risk for death was strongly associated with older age, inability to walk (nonambulatory status) and the number of chronic conditions a person had. Authors suggest that physicians, patients and families considering placing an older person on dialysis should discuss realistic estimates of survival, expected quality of life and the patient’s values. The authors noted that end-stage renal disease is a reflection of underlying multi-organ system dysfunction and may be better managed by a palliative approach.

  • Sleep apnea can be diagnosed without overnights in a sleep lab. Exclusively ambulatory techniques and equipment were as successful at identifying and treating sleep apnea as the current method of polysomnography, which requires several supervised overnight stays in a sleep laboratory. The ambulatory method involved identifying high-probability patients with a standardized clinical assessment and at-home portable sleep monitoring and auto-titration of continuous positive airway pressure (CPAP). Sixty-eight patients with high likelihood of having sleep apnea were assigned to groups that received polysomnography or the sleep tests at home. Both groups received continuous positive airway pressure at home through a CPAP machine with face mask and hose. After three months, the groups had the same results on three outcome measures, and those who received the initial diagnosis at home were more likely to adhere to the use of the CPAP treatment.

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More accurate stroke diagnosis with MRI than CT

MRI scans are a better tool for diagnosing acute stroke than CT scans, a recent study found. The more sensitive diagnosis provided by MRIs showed superior results in detecting acute ischemic stroke, the most common form of stroke.

Researchers followed 356 patients with suspected stroke who arrived consecutively at the NIH Stroke Center. Stroke specialists conducted emergency clinical assessments with all patients before initiating both CT and MRI scans. When the scans were reviewed by four experts, MRIs revealed acute ischemic stroke in 164 of 356 patients, compared with 35 out of the 356 revealed by CT scans.

The results show that immediate non-contrast MRI is about five times more sensitive and twice as accurate as immediate non-contrast CT for diagnosing ischemic stroke, but the scans are equally effective in the diagnosis of acute intracranial hemorrhage, according to the NIH, which conducted the study. The study was published in the Jan. 27 issue of The Lancet.

Based on the study’s findings, MRI should become the preferred imaging technique for diagnosing patients with acute stroke, although further research is needed to determine whether advanced contrast enhanced CT techniques can produce the same level of clinical information more quickly and with less expense, study authors said.

The NIH news release is online.

The Lancet is online.

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Quality improvement

CMS pilot shows P4P slightly improves hospital quality

A recent study analyzing results from a CMS pay-for-performance (P4P) demonstration project concluded that performance bonuses modestly improved the quality of care at participating hospitals.

Researchers compared results from the 207 hospitals involved in the P4P pilot with 406 hospitals that participated in a national public-reporting initiative that did not include financial incentives. The P4P group showed greater improvement in all composite quality measures, including heart failure, acute myocardial infarction and pneumonia.

After adjusting for confounders, the overall differential between the P4P hospitals and the other group was 2.9%. The study was published in the Feb. 1 New England Journal of Medicine.

The study also found that baseline performance was inversely related to improvement--the lowest-rated P4P hospitals showed an average improvement of 16.1% while the highest-rated improved just 1.9%. Study authors concluded that additional research is needed to determine whether the benefits of P4P outweigh the costs and whether different incentives would stimulate more improvement.

An accompanying editorial recommended that CMS adopt a series of regional models to explore the effect of differing levels of incentives and formulas for payment as opposed to instituting a single new payment system for Medicare.

The New England Journal of Medicine article and editorial are online.

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Community grants for treatment of chronic disease

Several communities across the country received grant funding last week aimed at improving care for people with chronic diseases.

Aligning Forces for Quality, a program of the Robert Wood Johnson Foundation, awarded a total of $14 million to groups in Cincinnati, Cleveland, Grand Rapids, Mich., Humboldt, Calif., Kansas City, Mo., Madison, Wis., Portland, Maine, Portland, Ore., Western New York and York, Pa. They join four pilot communities announced in 2006– Detroit, Memphis, Minneapolis-St. Paul and Seattle– in the three-year program.

Foundation officials said the grant program’s ultimate goal is to better understand how local market forces can work together to drive and sustain improved outcomes for the chronically ill. To that end, the program is looking for the communities to make incremental progress in three key areas:

  • Public reporting
  • Consumer engagement
  • Quality improvement

The communities will each receive grants of up to $600,000 to use over three years for planning, convening, coordination and infrastructure development. In addition to their grant awards, communities can also receive technical assistance.

More information is online.

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College news

CSM Chair receives Foundation Leadership Award

Jim Small, chair of the ACP’s Council of Student Members, has been selected as a recipient of the 2007 AMA Foundation Leadership Awards. The awards recognize future leaders who have demonstrated strong non-clinical leadership skills in medicine or community affairs and have an interest in further developing these skills within organized medicine.

The objective of the awards program is to encourage involvement in organized medicine and to continue leadership development among the country's brightest and most energetic medical students, residents, young physicians and international medical graduates. Mr. Small, who is also an ACP Alternate AMA Delegate, will attend a special leadership awards dinner and ceremony as well as the AMA National Advocacy Conference in Washington, D.C., Feb. 11-14.

More information about the awards is online.

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Former regent heads new medical school

Edward H. Shortliffe, MACP, has been appointed founding dean of the Tucson-based University of Arizona's College of Medicine's new Phoenix campus . A former regent of the College, Dr. Shortliffe is a nationally renowned clinician, educator and expert in the field of biomedical informatics.

Dr. Shortliffe currently teaches at Columbia University in New York City, where he is the Rolf A. Scholdager Professor and chair of the department of biomedical informatics at Columbia College of Physicians and Surgeons. He also is a professor in the departments of medicine and computer science at Columbia.

During the 1970s, Dr. Shortliffe developed the medial expert system known as MYCIN, widely acknowledged as the first of its kind. Before joining the Columbia faculty, he was chief of general internal medicine, associate chair of medicine for primary care and associate dean for information resources and technology at Stanford University.

The Arizona legislature approved funding for the new Phoenix campus, a collaboration of the UA and Arizona State University, in an effort to alleviate a statewide doctor shortage. Dr. Shortliffe will assume the post after March 1 and the school will admit its first class of 24 four-year medical students this July.

More information is online.

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Copyright 2007 by the American College of Physicians.

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