In the News for the Week of 6-12-07
- P4P doesn’t change hospital cardiac care, study finds
- Survey reports average physician pay increases
- Elderly falls, drug overdoses drive increase in accidental death rate
- Aerobic exercise helps patients with heart failure
- Better treatment, lower risk factors caused drop in cardiac deaths
- ACP Journal Club: Inactivated influenza vaccine prevented influenza in healthy adults
- Folic acid doesn’t decrease colorectal adenoma risk
- ACP applauds introduction of physician workforce legislation
- Call for 2008 College Regent and Officer nominations
- Internal Medicine 2007 highlights online
Pay-for-performance (P4P) has little impact on hospitals’ care for patients with acute myocardial infarction, according to a new study of the government’s largest-ever P4P pilot project.
Researchers compared adherence to American College of Cardiology/American Heart Association guidelines in 54 hospitals enrolled in CMS’ P4P pilot and 446 hospitals involved in a voluntary quality improvement program. Both groups showed improvement during the 2003-06 study period, and the P4P group improved at a slightly higher rate on two measures—prescribing aspirin at discharge and counseling patients on smoking cessation.
Overall, however, the study found that P4P was not associated with a significant improvement in quality of care or outcomes for heart attacks or in-hospital mortality over the control group. The researchers also did not find any negative impacts from P4P, with both hospital groups showing similar improvements in care measures that were not subject to financial incentives. The study was published in the June 6 Journal of the American Medical Association.
The findings do not mean that CMS should give up the idea of P4P, the study’s lead author told the May 5 Washington Post. It is possible that larger financial incentives—this pilot paid out a total of $17.55 million—would have more of an impact, he suggested. The authors noted that additional research is needed to determine the optimal role of payment incentives in future quality-improvement initiatives.
The Journal of the American Medical Association is online.
The Washington Post is online.
The salaries of specialist physicians in the private sector are increasing more rapidly than those of academic specialists, according to a new survey by the Medical Group Management Association (MGMA). Among primary care doctors, the trend is reversed, with academic physicians experiencing greater percentage gains in pay.
According to the study, private-sector specialists saw a 6.61% increase in 2006 (to a median of $316,620 annually) while academic specialists gained 3.59% (median $202,000). In primary care, academics made 5.51% more than in 2005 (to $142,251) while those in private practice received a 3.89% increase (to $168,111).
The gains in academic primary care could be due to competition with the private sector for new physicians, said an MGMA representative. A few academic specialties had little or no increase in compensation in 2006. Neurology, ophthalmology and ob/gyn all saw less than 2% increases in pay.
Both general and specialist physicians are doing well compared to the rest of America, according to another study. Doctors took 13 of the top 15 spots on Forbes’ annual list of the best-paid occupations in the U.S. Anesthesiologists had the top mean salary at $184,340, followed by surgeons and ob/gyns. General internists came in sixth with an average annual salary of $160,860. Family physicians/general practitioners took the ninth spot with an average of $149,850 per year.
MGMA is online.
The Forbes study is online.
Accidental deaths in the U.S. rose by 21% between 1995 and 2005, with much of the increase caused by drug overdoses and falls among the elderly, a new report found.
Deaths from falls of people age 65 and older rose 31% between 1999 and 2003, the National Safety Council report said. (The report attributes death within one year of a fall to the fall.) Accidental poisoning deaths—usually from illegal, prescription or over-the-counter drug overdoses—rose 11% between 2002 and 2003, with poisoning now the fastest-rising cause of accidental death. Poisoning death rates are increasing the most among white women—more than 300% in 10 years.
Motor vehicle crashes are the top cause of accidental death, but that figure dropped by 16% since 1992. Deaths from workplace accidents are also down 17% since 1992. In total, there were 113,000 accidental deaths in 2005, a 1% increase over 2004. At the current rate, the nation’s all-time high of 116,385 accidental deaths—set in 1969—could be surpassed in the next few years, the council said.
The NSC release is online.
The NSC data is online.
The Washington Post is online.
Patients with stable heart failure can benefit from an aerobic exercise program, according to a new study. Researchers found that patients who did aerobic exercise but not weight training raised their ejection fractions and shrunk the size of their enlarged hearts.
The meta-analysis included data from 14 separate randomized trials involving a total of 812 patients with heart failure. In nine studies, patients did aerobic exercise—walking or bicycling, for example—for 20 to 60 minutes approximately three times a week, at an intensity equal to 60% to 80% of their peak ability. In four studies, patients supplemented aerobic exercise with strength training, and in one study, patients did only strength training. Study participants were clinically stable but had markedly abnormal heart function, with an average ejection fraction of just 23%.
In the aerobic exercisers, ejection fraction improved 2.59% on average and there were decreases in both end-diastolic volume (11.49 mL, on average) and end-systolic volume (12.87 mL). By comparison, patients who combined aerobic exercise with strength training showed no significant improvements in ejection fraction or the size of the heart. The study was published in the June 19 Journal of the American College of Cardiology.
Study authors speculated that weight lifting may not have shown the same benefits as aerobic exercise because strength training results in a heightened pressure load, which may actually increase the stress on the heart. Earlier studies have reported conflicting results on the effect of exercise on the heart’s size and function, but exercise’s effect on ventricular remodeling had not previously been known. The findings should provide guidance in the development of exercise plans for patients with heart failure, the authors said.
The Journal of the American College of Cardiology is online.
Decline in U.S. deaths from coronary heart disease from 1980-2000 can be attributed about equally to better medical treatments and a reduction of risk factors, a June 7 New England Journal of Medicine study found.
The study sought to uncover the reasons why the death rate for coronary heart disease was cut by almost half between 1980 and 2000. Using the IMPACT statistical model that incorporated risk factors like smoking, high blood pressure, diabetes and exercise habits, researchers found that medical treatments accounted for 47% of the drop, while reduced risk factors accounted for 44% of the decline.
The decreases caused by individual treatments and risk factor changes were:
- 11%: secondary preventive therapies after myocardial infarction;
- 10%: initial treatments for acute myocardial infarction or unstable angina;
- 9%: treatments for heart failure;
- 5%: revascularization for chronic angina;
- 12%: other medical therapies;
- 24%: reductions in total cholesterol;
- 20%: reduction in systolic blood pressure;
- 12%: reduced smoking prevalence;
- 5%: increased physical activity;
The risk factor reductions were partially offset by an increase in deaths due to greater body-mass index (8% increase in deaths) and diabetes (10% increase in deaths). Together, diabetes and obesity caused an additional 60,000 cardiac deaths. If these increases continue, the two conditions could end up canceling out the progress made against heart disease, said a study author in the June 6 Washington Post.
The New England Journal of Medicine is online.
The Washington Post is online.
A black box warning about the risk of heart failure will be added to diabetes drugs rosiglitazone (Avandia) and pioglitazone (Actos), the FDA commissioner told Congress last week.
The new warning is separate from the FDA’s ongoing analysis of recently publicized research suggesting that rosiglitazone may raise the risk of heart attack, reported the June 7 New York Times. The FDA requested the label changes from manufacturers GlaxoSmithKline and Takeda Pharmaceuticals on May 23, two days after publication of the study and editorial in the New England Journal of Medicine (NEJM).
Last week, the NEJM published online interim results from the RECORD trial, a 4,447-patient manufacturer-sponsored study of rosiglitazone. The randomized trial, which compared metformin plus sulfonylurea with one of the drugs plus rosiglitazone, had inconclusive results. Researchers found no evidence of increased death from cardiovascular causes, but there was an increased risk of heart failure. Because the study group had an unexpectedly low rate of events and a high rate of lost follow-up, the data was insufficient to determine whether the drug was associated with an increase in myocardial infarction.
Despite the study’s inconclusive results, one of the accompanying editorials urged physicians against the use of rosiglitazone. Another editorial advised patients and physicians to carefully weigh the risks and benefits of the drug. According to that article, a combined analysis of data from RECORD and other trials indicates that rosiglitazone increases heart attack risk by 33%, equivalent in magnitude but opposite in effect to the health benefits of statin drugs.
The New England Journal of Medicine is online.
The New York Times is online.
The FDA approved a new glucose monitoring system for diabetics that requires sensor replacements weekly instead of every three days.
The STS-7 Continuous Glucose Monitoring System measures glucose levels every five minutes for a week, information that can be used to detect trends and patterns in glucose levels that can’t be captured by fingerstick measurements. The device can, for example, detect when glucose levels drop overnight, or suggest how diet and exercise affect levels. Patients can program an alarm to sound if their glucose level reaches pre-determined lows or highs.
The STS-7 System uses a disposable sensor just below the skin in the abdomen to measure glucose levels in interstitial fluid. A three-day version of the system received FDA approval in March 2006. FDA approved the weekly version based on results of a study by manufacturer DexCom Inc. of 72 patients with diabetes at five clinical sites in the U.S. that found it a safe and effective way to detect glucose trends in adults. Patients must still use fingerstick tests to determine if they need additional insulin, however.
The FDA is online.
A new study found that inactivated influenza vaccine prevents laboratory-confirmed influenza caused by circulating strains in healthy adults.
The randomized, placebo-controlled trial was conducted at two university sites and two community sites in Michigan with healthy adults age 18-46 who hadn’t received an influenza vaccine for the 2004-05 season. Patients were given inactivated influenza vaccine or matching placebo by intramuscular injection, or live attenuated influenza vaccine or matching placebo by intranasal spray.
With the placebo groups combined for analysis, results showed the inactivated influenza vaccine had a higher rate of vaccine efficacy than did placebo for each influenza confirmation method. Using cell culture to confirm, the cumulative incidence of influenza with inactivated influenza vaccine was 1.3% vs. 5.8% with placebo; using real-time polymerase chain reaction the incidence was 1.9% vs. 7.3% for placebo. The live attenuated influenza vaccine did not differ from placebo, nor did the inactivated and live attenuated vaccines differ for efficacy. The study is abstracted in the May/June ACP Journal Club.
The study is of interest because it’s not known how best to protect high-risk individuals from influenza infection in seasons with a mismatch between vaccine strains and circulating virus, said Journal Club reviewer Bruno Granwehr, ACP Member, of the University of Texas Medical Branch. The finding that only inactivated vaccine protected against influenza better than placebo was especially striking for type B influenza, indicating the need for a future study to assess the relative protection efficacy against type A and type B viruses by available vaccines.
Peer ratings for this review: GIM/FP/GP, Infectious Disease: 6/7 stars. Public Health: 4/7 stars.
ACP Journal Club is online.
High doses of folic acid don’t decrease the risk of colorectal adenomas in people prone to them, and may in fact increase their risk for advanced lesions and multiple adenomas, a study in the June 6 Journal of the American Medical Association found.
The double-blind trial randomly assigned 1,012 patients with a recent history of colorectal adenomas to receive 1 mg/day of folic acid or placebo. Within three years, 97% of patients had a colonoscopy screening. The incidence of at least one colorectal adenoma was 44.1% for those who took folic acid vs. 42.4% for the placebo group (RR 1.04, 95% CI 0.90-1.20, p=.58), while incidence of an advanced lesion was 11.4% and 8.6%, respectively (RR 1.32, 95% CI 0.90-1.92, p=.15).
A second follow-up of 607 patients at 3-5 years found incidence of at least one colorectal adenoma was 41.9% for the folic acid group and 37.2% for placebo (RR 1.13, 95% CI 0.93-1.37, p=.23) while incidence of at least one advanced lesion was 11.6% vs. 6.9%, respectively (RR 1.67, 95% CI 1.00-2.80, p=.05). Folic acid was associated with higher risks of having three or more adenomas and of developing prostate cancer, though the authors warned that the latter result might be spurious.
The study results may have been affected by the fortification of the food supply with folate, which began in 1996, shortly after study enrollment began, the authors said. Some who reviewed the study said that folic acid fortification, now required in some U.S. foods, shouldn’t be increased, and that other countries considering the practice should be careful, the June 6 Washington Post reported.
The Journal of the American Medical Association is online.
The Washington Post is online.
On June 6, Michael C. Burgess, MD (R-Texas 26th) and Henry Cuellar (D-Texas 28th), introduced the bipartisan High-Need Physician Workforce Incentives Act of 2007. The legislation would establish a mix of scholarships, loan repayment funds and tax incentives to entice more students to medical school, as well as create incentives for students to become general physicians in high-need areas.
“Rep. Burgess and Rep. Cuellar have recognized the critical importance of enacting legislation to reverse a rapid decline of physicians going into primary care and other generalist fields,” said David C. Dale, FACP, president of ACP. “We enthusiastically endorse their efforts to provide scholarships and debt relief for physicians who choose primary care and agree to practice in critical shortage areas.”
In addition to the incentives to encourage more students to become primary care physicians, the bill creates a “primary care physician retention and medical home enhancement grants.” The proposal directs HRSA to make grants to states to provide financial aid for care management to physicians in medically underserved areas to support patient-centered care in a qualified medical home. The proposal’s medical home model is based on the Patient-Centered Medical Home (PCMH) endorsed by ACP and other medical groups.
Rep. Burgess also introduced two other bills, one that would create a pathway to eliminating Medicare cuts from the Sustainable Growth Rate (SGR) Formula and another that would provide grants to new primary care residency programs.
ACP’s press release is online.
As part of the ongoing effort by the College to include ACP Members in the nominations process, the 2007-08 Nominations Committee solicits your recommendations to fill new Regent positions on the Board that will become vacant in 2008.
When considering potential candidates for Regent, please keep in mind such qualifications as commitment to the College, dependability, leadership qualities and the ability to represent the College in numerous and diverse arenas. Letters of nomination should highlight these characteristics and should specify the reasons you feel your nominee is qualified for the position. Regent nominees must be Fellows or Masters. The Nominations Committee is particularity interested in receiving nominations of women, ethnic minorities, international medical graduates, chairs of medicine and practicing physicians. All nominations will be given careful consideration by the Nominations Committee.
The nomination of an individual for first-term Regent must be submitted by a standard structured nominating proposal. A letter of nomination is required and should include:
- A brief description of the nominee’s current activities
- Special attributes the candidate would bring to the Board of Regents
- Previous and current service in College-related activities
- Service in organizations other than the College (medical and non-medical)
A seconding letter must be submitted for each nomination. Without the appropriate material the nomination will not be advanced for review. Potential candidates for Regent are required to have one letter of nomination and two letters of support (the author of which will be identified by the nominator). Officer and Regent candidates must have new letters of nomination and support each year, as the old letters will be discarded. If candidates receive more than two letters (nomination and support) these additional letters will be discarded.
Please send your confidential nominations, no later than Aug. 1, 2007 to:
ATTN: Mrs. Florence Moore
American College of Physicians
190 N. Independence Mall West
Philadelphia, PA 19106-1572
If you have any questions, please contact Florence Moore toll free at (800) 523-1546, ext 2814, or directly at (215) 351-2814.
Materials and information from Internal Medicine 2007, including printable course handouts and a downloadable Power Point presentation of “take home messages” from the meeting are now available online under the “Internal Medicine 2007” heading on ACP's home page.
Nearly 300 courses were presented at Internal Medicine 2007 in San Diego on the latest advances in internal medicine and its subspecialties. Nearly 7,000 meeting attendees had their choice of three learning tracks focusing on core topics, hospital medicine and diabetes. The problem of language access in health care, the redefining of medical professionalism, and the introduction of resources produced by the ACP-ACP Foundation Diabetes Initiative were featured in media briefings.
Seven sessions were held on ethics, professionalism and end-of-life care. Topics included Pay for Performance, palliative care, the pitfalls of office-based research, and the challenges of advocating for patients and colleagues. A total of 23 courses were held on the subject of diabetes, and three resources from the ACP-ACP Foundation’s Diabetes Initiative, funded by a three year unrestricted educational grant from Novo Nordisk, were introduced. ACP’s report on language access in health care, “Language Services for Patients with Limited English Proficiency: Results of a National Survey of Internal Medicine Physicians,” was also released.
Internal Medicine 2008 will be held May 15-17 in Washington, D.C. Information and to registration is online.
Complete coverage of Internal Medicine 2007 is in the June issue of ACP Observer.
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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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