In the News for the Week of 3-27-07
- Alzheimer’s disease rates up 10% in five years
- Gonorrhea rates rise in Western states
- FDA tightens conflict of interest rules for advisors
- ACP Journal Club: Lifestyle intervention prevented type 2 diabetes even after program ended
- 1 in 7 atherothrombosis patients has CV event in a year
- Childhood leukemia survivors face higher risk of second cancer
Cardiology conference highlights
- Studies question effects of preventative PCI and lowering HDL cholesterol
Prevention and treatment news
- AHRQ offers checklists of recommended screenings
- Antibiotics overprescribed for sinus infections, study finds
- ACP to partner with world’s leading risk and insurance services firm
- New patient education DVDs on Alzheimer’s and insomnia
- ACP briefs Congress on patient-centered care
- ACP supports Resident Physician Shortage Act
More than 5 million Americans currently have Alzheimer’s disease--up 10% from five years ago--and the number could reach 16 million by 2050 as baby boomers age, the Alzheimer's Association said last week in a report entitled “2007 Alzheimer’s Disease Facts and Figures.”
While death rates declined for heart disease, stroke, breast cancer and prostate cancer between 2000 and 2004, Alzheimer’s disease deaths rose 33%, and it was the seventh leading cause of death in 2004. The main risk factor for the disease is age, though there are currently 200,000 to 500,000 people under age 65 who have early onset Alzheimer’s disease or other dementias, the report said.
Medicare costs for Alzheimer’s disease are expected to more than double to $189 billion by 2015, the report said. Already, Medicare spends nearly three times as much for people with Alzheimer’s and other dementias than for the average beneficiary: $13,207 per year versus $4,454 per year, the March 21 New York Times reported.
Estimates were based on research by the Rush Alzheimer’s Disease Center in Chicago, which analyzed incidence of the disease locally and then extrapolated it to national prevalence using census data, the New York Times said.
The Alzheimer’s Association release is online.
The New York Times is online.
Gonorrhea rates in eight Western U.S. states increased 42% between 2000 and 2005, while rates declined 5%-22% in other regions, the March 16 Morbidity and Mortality Weekly Report said.
After years of stable rates, gonorrhea occurrence rose from 57.2 to 81.5 cases per 100,000 people in Alaska, California, Hawaii, Nevada, New Mexico, Oregon, Utah and Washington. The rise, which occurred in both sexes and most age and racial/ethnic groups, appeared to result both from better testing practices and greater incidence, the CDC said.
Between 2000 and 2004, test volume at 21 public laboratories in the eight states rose 87%, and the proportion tested with more sensitive DNA tests climbed to 86% from 49%, which suggests the increase is partly due to improved testing efforts. At the same time, data from select states and cities showed that more men with gonorrhea symptoms sought treatment, which suggests an actual increase in the number of infections since symptomatic people usually seek treatment regardless of screening efforts.
CDC researchers are urging health care providers throughout the country to stay alert for increases in gonorrhea; to enhance surveillance, prevention and control programs; and to screen and treat the disease according to national and local guidelines.
The MMWR release is online.
Medical experts who advise the FDA will face more scrutiny regarding potential conflicts of interest, under draft guidelines released by the agency last week. The new rules would exclude many scientists and physicians from FDA advisory boards because of financial ties to companies whose products they evaluate.
Under the proposed guidelines, an expert who has had $50,000 or more worth of financial ties to a company in the past year would be disqualified from participating in an FDA advisory panel. Those with less than $50,000 in ties could be recommended to participate as a nonvoting member. Only experts with no financial conflict of interest would be permitted to vote on the advisory boards.
The FDA currently screens prospective advisory committee participants for conflicts, but grants waivers when it is determined that the need for an individual’s expertise outweighs potential conflict of interest. Included areas of potential conflict, under the new and old systems, include stock ownership, research and consulting arrangements.
The new guidelines, which are open for public comment for the next 60 days, allow for the FDA commissioner to make exceptions for individual experts but that will be done rarely, FDA officials said in the March 22 Washington Post. Agency officials did not know how many current advisory board members would be affected by the new rules, but said that it would have a significant impact. The changes follow recent criticism of the FDA from both Congress and the Institute of Medicine.
The FDA press release is online.
The Washington Post is online.
A new trial found a lifestyle intervention program continued to prevent type 2 diabetes in high-risk patients after the program was stopped.
In the randomized controlled trial, researchers followed 522 Finnish patients who had body mass index > 25 and impaired glucose tolerance on two occasions. For a median of four years, the patients were assigned to receive either general oral and written information about diet and exercise or a lifestyle intervention, including dietary counseling with a nutritionist and individualized physical training sessions.
The participants were followed for a median of three additional years after the lifestyle intervention ended and measured on five goals: weight loss, percentage of energy intake from fat, percentage of energy from saturated fat, fiber intake and physical activity. At one year after the intervention, 18% of the intervention group and 7% of the control group had achieved four of the five lifestyle goals. Over the whole study period, the intervention group also had a lower incidence of diabetes, 4.3%, compared with 7.4% of controls. The study is abstracted in the March/April ACP Journal Club.
The study provides evidence that an intensive lifestyle intervention can reduce the risk for type 2 diabetes in high-risk persons, said Journal Club reviewer Frank Sullivan, MD, of the University of Dundee in Scotland. Because patients in the control group were informed of their at-risk status and given advice as well as follow-up, the real effect of the program may be even more marked for at-risk persons who have not been identified, Dr. Sullivan noted. However, questions remain about whether avoiding or delaying the development of diabetes produces benefits in important morbidities and mortalities, he added.
Peer ratings for this review: Primary Care, Internal Medicine, Endocrinology: 6/7 stars.
ACP Journal Club is online.
Survivors of acute lymphoblastic leukemia (ALL), the most common cancer in children and adolescents, are at higher risk of developing secondary cancer for at least the next 30 years of their lives, a new study found.
In the retrospective study, researchers followed 2,169 patients treated for ALL between 1962 and 1998. The studied patients had all achieved complete remission and were followed for a median of 18.7 years. The study found that 4.2% of the patients developed a secondary cancer within 15 years, 5.4% within 20 years and almost 11% after 30 years. The study was published in the March 21 issue of the Journal of the American Medical Association.
Most of the malignancies were low-grade tumors, such as meningiomas and basal cell carcinomas. However, the incidence of more aggressive cancers was also significantly higher than in the general population--13.5 times the normal rate. Researchers attributed the increased risk to treatments used for ALL, particularly radiation and drugs known as epipodophyllotoxins.
The findings highlight the need for continued careful followup of ALL survivors, the study authors concluded. The risk for children being treated today is likely much lower because the use of radiation is much less common, according to the March 20 Washington Post. In recent years, research on the disease has focused on developing targeted drugs that destroy tumor cells without impacting healthy cells.
The Journal of the American Medical Association is online.
The Washington Post is online.
Patients with atherosclerotic arterial disease have a high risk of cardiovascular events, even if they show no symptoms, a new study found. Data from the Reduction of Atherothrombosis for Continued Health (REACH) Registry show that 1 in 7 of these patients had a CV event within a year.
Researchers in the international prospective trial followed 68,236 patients with coronary artery disease, cerebrovascular disease, peripheral arterial disease or at least three risk factors for atherothrombosis. After one year, the patients with established atherosclerotic disease had a mortality rate of 2.81% and a rate of 14.41% for cardiovascular death, myocardial infarction, stroke or hospitalization for revascularization or cardiovascular disease.
Patients with disease in more than one vascular bed faced an even higher risk of CV events, the study found. Those with atherosclerotic disease in three or more beds had a 26.29% chance of CV event or hospitalization for revascularization--more than five times higher than the rate for patients with multiple risk factors and twice that for patients with disease in only one vascular bed. The study was published in the March 21 issue of the Journal of the American Medical Association.
The results confirm previous REACH data showing that patients are undertreated with statins and antiplatelet therapies, noted an accompanying editorial. Blood pressure is generally treated well, but cholesterol and other risk factors are not so actively treated, a study author told the March 20 Washington Post. The authors are currently working on a risk-factor predictor for patients, based on data from the REACH study.
The Washington Post is online.
Cardiology conference highlights
Two studies presented at last weekend's American College of Cardiology Annual Scientific Session in New Orleans reported that two measures thought to slow the progression of heart disease--preventative percutaneous coronary intervention (PCI) and raising HDL cholesterol--had no significant effect on outcomes.
In the first study, 2,287 patients with myocardial ischemia and significant coronary artery disease at 50 centers were assigned to undergo either PCI with optimal medical therapy or optimal medical therapy alone. After a median follow-up period of 4.6 years, the cumulative primary-event rates were 19% in the PCI group and 18.5% in the medical therapy group, with no significant differences between the two groups in the composite of death, myocardial infarction and stroke; hospitalization for acute coronary syndrome; or myocardial infarction.
The authors noted that the findings reinforce existing clinical practice guidelines stating that PCI can be safely deferred in patients with stable coronary artery disease provided intensive medical therapy is provided. An editorial noted that the findings are understandable since tight stenoses, which are responsible for stable angina, are a marker for many more nonobstructive, lipid-laden lesions that have a high likelihood of triggering an acute coronary syndrome. It is not surprising, the editorial continued, that one or more stable, tight lesions did not reduce rates of subsequent MI and death.
In the second study, 1,188 patients with coronary disease who underwent intravascular unltrasonography were treated with atorvastatin to reduce levels of LDL cholesterol to less than 100 mg/deciliter. They were then randomly assigned to receive either atorvastatin monotherapy or atorvastatin plus 60 mg of torcetrapib daily.
After 24 months, patients receiving combination therapy had a 61% relative increase in HDL cholesterol and a 20% relative decrease in LDL cholesterol. However, that group also showed an increase in systolic blood pressure of 4.6 mm Hg and no decrease in the progression of coronary atherosclerosis compared with the atorvastatin-alone group.
The authors speculated that the increase in blood pressure in the combination therapy group may have counterbalanced the effects of increasing HDL cholesterol, and that it is possible that the HDL cholesterol produced by torcetrapib is dysfunctional. An editorial noted that part of the adverse effects in the study were caused by the toxicity of torcetrapib, in particular, and were not related to the entire class of drugs known as CETP (cholesteryl ester transfer protein) inhibitors.
Both articles were released early on the New England Journal of Medicine's Web site and will appear in the journal's March 29, 2007 print edition.
The New England Journal of Medicine is online.
Prevention and treatment news
The Agency for Healthcare Research and Quality last week released two new evidence-based checklists designed for patients that explain the medical checkup tests men and women need to stay healthy throughout their lifetimes.
The pocket-sized brochure, called “Your Checklist for Health”, shows the screening tests, preventive medicine and lifestyle behaviors recommended by the U.S. Preventive Services Task Force for each sex. For men, it includes recommendations about cholesterol checks, high blood pressure tests and colorectal cancer screening. For women, it includes recommendations about screening for osteoporosis, obesity and breast cancer, among other things.
The brochure, available in English and Spanish, also includes a chart to record a patient’s screening test history and to help plan follow-up appointments.
The AHRQ release is online.
Antibiotics may be being overused in the treatment of sinus infections, according to a new study of national patient data. Researchers found that antibiotics are prescribed for a majority of patients with acute and chronic rhinosinusitis, despite evidence that most cases are viral not bacterial.
Using data from the National Center for Health Statistics, the study examined 14.28 million physician visits for chronic rhinosinusitis and 3.12 million visits for acute rhinosinusitis, from 1999 to 2002. Antibiotics were prescribed in about 70% of chronic infections, and about 83% of acute cases. In total, rhinosinusitis was the diagnosis in 21% of adults receiving antibiotics in 2002. The study was published in the March issue of the Archives of Otolaryngology.
Based on these statistics, study authors concluded that the use of antibiotics far outweighs the predicted incidence of bacterial causes of rhinosinusitis. The possibility of overuse of antibiotics is troublesome because it could contribute to development of more drug-resistant bacteria. Physicians and patients may believe that the antibiotics are effective in cases that actually would have resolved without treatment, study authors said.
There are currently no approved medications or recommended treatments for sinus infections, noted the March 19 Washington Post. One study author suggested that physicians consider saline flushing for the treatment of most cases of rhinosinusitis. The older remedy is available over the counter and less expensive than prescriptions, he told the Washington Post.
The Archives of Otolaryngology are online.
The Washington Post is online.
ACP will be expanding and enhancing its insurance offerings through Marsh Affinity Group Services, a service of Seabury & Smith, Inc., which will manage the College’s member group insurance program beginning in January 2008. Seabury and Affinity Group Services are part of Marsh Inc., the world’s leading risk and services firm.
ACP EVP and CEO, John Tooker, FACP, said, “Marsh is an industry leader known for its emphasis on insurers’ financial strength, extensive product selection and strong customer service. After a careful review of proposals from eight potential broker/administrators, ACP’s Member Insurance Subcommittee and Finance Committee recommended the selection of Marsh, which was approved by the Board of Regents. All agreed that Marsh had the most to offer ACP members in terms of its extensive product portfolio, its use of technology to maximize service, and its ability to design innovative products for our diverse membership.”
Marsh’s strengths also include the ability to provide personalized product offerings, 24-hour access to its insurance information via the Web, and options to meet the needs of ACP’s international members. Marsh Affinity Group Services provides life and health, professional liability, and other property/casualty insurance programs for members of associations and affinity groups. It serves more than 350 membership organizations, including more than 95 professional medical associations. Marsh’s parent company, Marsh & McLennan Companies, Inc. (MMC), is a global professional services firm, in business since 1871.
An important aspect of the College’s decision in selecting Marsh was that members, currently insured through ACP’s group insurance program, will see a continuation of their current plans with no disruption in service. Marsh does business with the same insurance companies as the current broker/administrator, assuring that insured members will be able to continue with their current plans.
During 2007, the College’s current insurance vendor, Group Insurance Administrators (GIA), will continue to provide the same level of service and commitment to ACP and its members that they’ve always shown, while working with Marsh to ensure a smooth transition of operations by January 2008. Dr. Tooker added, “The College is grateful for the many years of excellent service that GIA has delivered to ACP members.”
Two new patient education resources on Alzheimer’s disease and insomnia are now available free to ACP members. Each topic is covered extensively in a DVD and guidebook with information to help patients understand the causes, risk factors and treatment options of each disease.
“Alzheimer’s Disease: A Guide for Patients and Families” provides information about the possible warning signs of Alzheimer’s, how it is diagnosed, who is at risk, the stages of the disease, treatment and support options, and how to plan for future care. The guidebook includes a workbook section with questions to discuss with family members and caregivers.
“Guide to Restful Sleep” provides information about insomnia and its causes, as well as tips for better sleep and how to work with a physician to explore treatment choices. The restful sleep guidebook includes a workbook section with suggested questions to ask a doctor and a chart to record sleep patterns.
More information about ACP’s patient education materials and downloadable versions of both guidebooks are online.
To order patient education materials, call ACP’s Customer Service Department at 800.523.1546 ext. 2600. Patient education videos can be ordered online.
ACP recently held a briefing for congressional legislative assistants on the importance of patient-centered care. The briefing, “Patient-Centered Primary Care: An Approach to Redesigning Medical Care to Achieve Better Outcomes at Lower Cost,” covered Congress’s role in patient-centric care through Medicare policies and other programs.
Lynne M. Kirk, FACP, president of ACP, and Robert Doherty, senior vice president of ACP’s Department of Governmental Affairs and Public Policy, presented ACP’s vision for the Patient-Centered Medical Home. They were joined by Robert Berenson, MD, senior fellow at The Urban Institute and Christine Dodd, governmental programs executive for the IBM Corporation.
In her remarks Dr. Kirk expressed the frustration she feels as a physician dealing with a system that reimburses physicians based on volume of services rather than coordinated-quality care. She went on to discuss the importance of primary care medicine and how the patient-centered medical home could increase the effectiveness of primary care.
The 109th Congress enacted legislation that mandates a demonstration project of a Medicare medical home, which will include payment for care coordination by physicians. This is an excellent start to restructuring Medicare payment policies to support patient-centered primary care, but results from the demonstration likely will not be available until 2012 or later, said Dr. Kirk. The ACP believes that there are many other steps that Congress can take now to support redesign of payment policies to support a patient-centered medical home, she added.
Materials from the briefing, including presentations from Mr. Doherty and Dr. Berenson are online.
In a letter to Senator Bill Nelson (D-FL) last week, ACP expressed support for the Resident Physician Shortage Act of 2007 (S. 588).
The legislation, if passed, would increase the Medicare caps on graduate medical education positions for states with a shortage of resident physicians. A state is considered to have a shortage of resident physicians if its ratio of resident physicians per 100,000 people is below the national median level.
ACP President Lynne M. Kirk, FACP, applauded the effort to address the physician workforce crisis by calling for an increase in the number of Medicare-supported physician residency positions.
ACP is concerned about the looming crisis in the supply of primary care physicians, particularly the pending undersupply of general internists and the potential impact on the health care of the U.S. population, Dr. Kirk wrote in the letter. This decline is occurring just as evidence suggests that the need for primary care physicians, who can provide the coordination and management services needed to treat chronic illnesses for adults, will continue to rise, she added.
Dr. Kirk concluded by noting that more needs to be done to ensure there are enough general internists to care for an aging population. Increasing GME caps alone will not be effective in assuring an adequate supply of physicians, and specifically, general internists, without changes in reimbursement policies, student debt, and other factors that discourage physicians from going into primary care and encourage those who already are in practice to leave primary care, she said.
A similar letter was sent to Representative Kendrick Meek (D-FL) regarding the House companion bill H.R. 1093.
The full text of the letter is online.
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A 67-year-old man is evaluated for a 6-month history of worsening exertional dyspnea. He has severe COPD, previously with minimal exertional symptoms, but now notes activity-limiting shortness of breath when walking short distances. He does not have chest pain, gastrointestinal symptoms, or sleep-related symptoms. Medical history is otherwise unremarkable. Medications are a twice-daily fluticasone/salmeterol inhaler and an as-needed albuterol/ipratropium metered-dose inhaler. He has a 55-pack-year smoking history but quit when COPD was diagnosed. Following a physical exam, chest radiograph, and transthoracic echocardiogram, what is the most appropriate diagnostic test to perform next?
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