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

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In the News for the Week of 6-19-07

News highlights

  • Women advised to look for early symptoms of ovarian cancer
  • Sicker patients score higher on quality care measurements
  • U.S. death rate drops for men with diabetes, but not women

Hospital medicine

  • Preoperative hematocrit may predict postoperative outcome
  • Quality and cost not linked in cardiac surgery, study finds

Clinical news

  • Cardiovascular disease a risk factor for kidney disease, study finds
  • Annals of Internal Medicine:
    • Substance in soy products increased bone density compared to placebo
    • Two views on stopping randomized trials early because of apparent benefit

Patient care

  • Patients want a fair shake

College news

  • Multimedia concussion injury tool kit available
  • ACP encourages Congress to support comparative effectiveness
  • Regent chair receives leadership award

News highlights

Women advised to look for early symptoms of ovarian cancer

A group of cancer experts have identified a set of symptoms that may be early warning signs of ovarian cancer.

The recommendations, issued jointly by the Gynecologic Cancer Foundation, the Society of Gynecologic Oncologists and the American Cancer Society, advise women to look for the following symptoms:

  • bloating;
  • pelvic or abdominal pain;
  • difficulty eating or feeling full quickly; and
  • urinary symptoms (frequency or urgency).

Experiencing any of these symptoms almost every day for more than a few weeks should trigger a visit to a gynecologist, said a June 13 Gynecologic Cancer Foundation news release.

The disease, the fifth leading cause of cancer deaths among U.S. women, is 90% curable in its earliest stage but there has been a common belief that there are no early warning signs, said the news release. Since there is no screening test for ovarian cancer, symptom recognition and regular pelvic exams are the primary modes of detection.

It is the first official recognition of early symptoms of ovarian cancer and may lead to earlier diagnosis or prolonged survival among affected women, said the June 13 New York Times. However, the article noted, it is too soon to tell whether the measures will lead to a spike in testing or unnecessary operations.

New or persistent symptoms should be taken most seriously, as opposed to bloating related to menstrual periods or chronic indigestion, said an expert interviewed by the New York Times. While the symptoms are ones that could apply to many women, the experts acknowledged, they are cause to consult a specialist when they persist or worsen.

The Gynecologic Cancer foundation news release is online.

The New York Times is online.

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Sicker patients score higher on quality care measurements

Amid concerns that pay-for-performance (P4P) measures may punish doctors who see sicker patients, a study concluded the opposite is true: Sick patients score higher on quality of care measures.

Concerns about P4P include:

  • measures that don't reflect the number and severity of conditions;
  • diseases such as major depression that affect the care of other conditions; and
  • a perceived mismatch between primary care providers' resources and the needs of patients with multiple diseases.

Researchers assessed measurements of the quality of medical care (defined as whether patients were offered recommended services) given to 7,680 patients, 956 of whom had three or more chronic conditions. Patients were all involved in one of three cohorts, Community Quality Index, Assessing Care of Vulnerable Elders or the Veterans Health Administration.

Researchers analyzed the percentage of quality indicators compared to the number of chronic medical conditions each patient had. Among the three cohorts, quality of care increased with each additional condition by 2.2% (95% CI, 1.7% to 2.7%) in the Community Quality Index cohort; by 1.7% (95% CI, 1.1% to 2.4%) in the Assessing Care of Vulnerable Elders cohort; and by 1.7% (95% CI, 0.7% to 2.8%) in the Veterans Health Administration cohort. The study was published in the June 14 New England Journal of Medicine.

The relationship between quality of care and the number of conditions varied slightly when adjusted for the difficulty of delivering care, and diminished but remained positive when adjusted for patient characteristics, use of health care and care provided by specialists. Researchers noted that finding essentially the same relationship in three different cohorts, and using two different sets of quality indicators, increases the likelihood that the effect is real rather than an artifact of any one particular study.

"Comprehensive, clinically detailed sets of care processes received can be used to assess the quality of care without creating a disincentive for providers to avoid patients with the most prevalent chronic conditions," the researchers concluded.

The New England Journal of Medicine is online (subscription required).

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U.S. death rate drops for men with diabetes, but not women

A new analysis of data from three large national databases found that in the 29 years between 1971 and 2000, the death rate of men with diabetes has dropped significantly, but the death rate for women with diabetes did not decline at all.

In the study, released online this week by Annals of Internal Medicine, researchers looked at data from 20,000 people, aged 35 to 74, and followed participants for up to 12 years. They found that the death rates from all causes in men with diabetes fell steeply from 42.6 to 24.4 annual deaths per 1,000 people, a 43% relative reduction in age-adjusted death rate, while the death rate from cardiovascular disease (CVD), the most common cause of death in people with diabetes, fell from 26.4 to 12.8. In the same period, neither the all-cause nor CVD death rate for women with diabetes declined.

The study showed that the overall death rate for people who did not have diabetes fell from 14.4 to 9.5 annual deaths per 1,000 people. When the authors analyzed the data by sex and by diabetes status, the difference in women with and without diabetes appeared. The study found that the death rate of men with diabetes remained higher than that of men without diabetes but over the decades it decreased in parallel with the decrease in men without diabetes. That trend was not present in women with diabetes.

The study did not investigate the reasons for the sex-related difference in death rates. The lead author suggested that the difference could be explained by past research which found that women have had less improvement in heart disease risk factors in recent years and that women receive less aggressive care for heart disease and risk factors. Other studies suggest that heart disease and diabetes may take a subtly different form in women, and that different types of treatments are needed.

The study will be published in the Aug. 7 print edition of Annals of Internal Medicine.

Annals of Internal Medicine is online.

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Hospital medicine

Preoperative hematocrit may predict postoperative outcome

A new retrospective study of a large national database found that abnormal hematocrit levels may predict worse outcomes in patients undergoing noncardiac surgery.

Researchers used data from the Veterans Administration National Surgical Quality Improvement Program database to examine hematocrit level and patient outcome after surgery in 310,311 veterans aged 65 or older. Patients were classified as being anemic (hematocrit less than 39%), normal (hematocrit 39% to 53.9%), or polycythemic (hematocrit 54% or greater) before surgery. After surgery, the authors used 30-day mortality rate as the primary outcome measure and a composite end point of 30-day mortality rate and cardiac events as the secondary outcome measure. The study was published in the June 13 Journal of the American Medical Association.

The authors found that the 30-day mortality rate increased by 1.6% for every preoperative percentage-point deviation, positive or negative, from normal hematocrit values. The adjusted risk of cardiac events and death at 30 days also increased in patients with abnormal hematocrits. Further analysis indicated that patients with hematocrits of 39% to 51% had the lowest risk; values lower than 39% and higher than 51% were associated with worse outcomes. These findings were observed in all subgroups except women and patients undergoing emergent surgery.

Because the study was observational, the authors could not determine whether the relationship they observed was causal, and they recommended additional studies to determine whether treating abnormal hematocrits before surgery would improve postoperative outcomes. An accompanying editorial praised the study's overall quality but recommended against applying the results outside the research setting.

The Journal of the American Medical Association article is online.

The Journal of the American Medical Association editorial is online.

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Quality and cost not linked in cardiac surgery, study finds

Higher costs of care are not necessarily associated with better outcomes, according to a new Pennsylvania study of costs and results of coronary artery bypass graft surgery (CABG).

The report from the Pennsylvania Health Care Cost Containment Council (PHC4), an independent state agency, included hospital-specific payment data and inpatient mortality rates for cardiac surgery for 2005. The average payments for the procedure varied dramatically, with some hospitals receiving an average of nearly $100,000 per procedure and others getting less than $20,000. However, the report found no significant difference in lengths of stay or mortality rates between the best- and worst-paid hospitals.

Although the report was designed to be risk-adjusted for the complexity of cases, some hospital administrators disputed the findings on the basis that their facilities’ average costs of care were driven up by sicker patients, the June 14 Philadelphia Inquirer reported. The Pennsylvania report is the first to cite Medicare and insurance payments to hospitals, although New Jersey, New York, California and Massachusetts offer similar public reporting of hospital outcomes.

Overall, the report found that in-hospital patient mortality after CABG surgery was down to 1.90% in 2005, from 1.98% in 2004. Readmission rates, at both seven and 30 days, were up, however. Of the 17,331 cardiac surgery patients tracked in 2005, 4.4% had a hospital-acquired infection. The report is intended to empower health care purchasers and consumers, the executive director of the PHC4 told the Inquirer. The results make it clear that health care in the U.S. is not being paid for in a simple, straightforward or logical manner, he added.

The Philadelphia Inquirer is online.

The PHC4 report is online.

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Clinical news

Cardiovascular disease a risk factor for kidney disease, study finds

Cardiovascular disease (CVD) is an independent risk factor for kidney function decline and the development of kidney disease, a new study found.

The study pooled data from two longitudinal, community-based studies of 13,826 people who had kidney function measured at regular intervals over about nine years. Baseline CVD was defined by stroke, angina, claudication, transient ischemic attack, coronary angioplasty or bypass and recognized or silent MI. Kidney function decline was primarily defined by an increase in serum creatinine level of at least 0.4 mg/dL, and development of kidney disease was defined by the same increase in which the baseline level was less than 1.4 mg/dL in men and less than 1.2 mg/dL in women. Kidney function decline and disease were secondarily defined by reductions in estimated glomerular filtration rate (eGFR).

In serum creatinine level-based models, 3.8% of patients had kidney function decline and 2.3% developed kidney disease. Baseline CVD was present in 12.9% of patients, and was associated with an increased risk of all outcomes (odds ratio 1.70; 95% CI, 1.36-2.13), with an odds ratio of 1.75 for serum creatinine level. For eGFR, the odds ratio was 1.28 for kidney function decline and 1.54 for development of kidney disease. The study was published in the June 11 Archives of Internal Medicine.

Primary care doctors and cardiologists should check for development and progression of kidney disease when caring for individuals with preexisting CVD or multiple CVD risk factors, an editorial writer advised. These doctors also should be vigilant for possible complications from kidney disease that could require consultation by a nephrologist, he said.

The Archives of Internal Medicine study is online.

The Archives of Internal Medicine editorial is online.

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Annals: Soy products increased women’s bone density

The following articles appear in the June 19, 2007 issue of Annals of Internal Medicine. This issue also includes a study finding that different descriptions of treatment benefits influenced patients’ acceptance of the treatments. Another meta-analysis showed that acupuncture has no meaningful short-term benefit. The full text is available to College members and subscribers online.

  • Substance in soy products increased bone density compared to placebo. In a randomized placebo-controlled trial involving 389 women with osteopenia, those who took 54 mg/d of genistein, a phytoestrogen derived from soy products, had greater bone mineral density and improved markers of bone metabolism after two years than women who took a pill containing only calcium and vitamin D. Those who took the genistein pills did not have increased endometrial thickness, a problem with some hormone treatments for low bone density. The genistein group had more gastrointestinal side effects than the control group.

  • Two views on stopping randomized trials early because of apparent benefit. The authors of one article on this subject say that stopping randomized trials early because of apparent benefit raises “serious ethical problems” because truncated trials systematically overestimate treatment effects. This problem is especially severe when the number of outcome events is small, the writers say. The author of the other article disagrees, saying that the primary purpose of a clinical trial is not to get an accurate assessment of the risk and benefits associated with a given treatment. It is “to decide which treatment is more efficacious, with statistical control over how often false-positive and false-negative conclusions are made.” This writer says that randomized controlled trials and data monitoring committees “must balance many competing and worthwhile medical, statistical, ethical, and social goals.”

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Patient care

Patients want a fair shake

Miss Manners would say it's expected, but researchers wanted evidence: Patients want to shake their doctors’ hands and exchange first and last names when introduced. Researchers reported their conclusions in the June 11 Archives of Internal Medicine, noting that appropriate greetings "can set a positive tone for the encounter and increase the chance of developing a therapeutic clinical relationship."

Researchers asked closed-ended questions by phone of 415 patients about their preferences for shaking hands, using patient names and using physician names. Most (78.1%) of the surveyed patients said they want a physician to shake their hand, 50.4% want their first name to be used when physicians greet them, and 56.4% want physicians to introduce themselves using their first and last names.

Researchers also had access to an existing set of videotaped patient visits, of which they reviewed 123 initial visits to assess whether physicians shook hands, used the patient's name and used his or her own full name. The videotapes revealed that physicians and patients shook hands in 82.9% of visits. But in 50.4% of the initial encounters, physicians did not mention the patient's name at all. Physicians tended to use their first and last names when introducing themselves.

Researchers noted: "While greetings may seem a rather mundane aspect of physician-patient communication, attention to this task can set a positive tone for the encounter and increase the chances of developing a therapeutic clinical relationship."

The Archives of Internal Medicine is online (subscription required).

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College news

Multimedia concussion injury tool kit available

A newly revised multimedia tool kit for physicians on the management of concussions and mild traumatic brain injuries, “Heads Up: Brain Injury in Your Practice,” is now available online.

The kit, released by the Centers for Disease Control and Prevention (CDC), contains practical, easy-to-use clinical information and tools for physicians on the early diagnosis, management and appropriate referral process for patients with concussion. One of the key components, the Acute Concussion Evaluation (ACE) assessment tool, provides a framework for initial evaluation and diagnosis for patients of all ages.

In addition to the ACE, the kit contains a “Facts for Physicians” booklet, The ACE Care Plan, which provides information to help guide patient recovery, fact sheets in English and Spanish on preventing concussions, a palm card for the on-field management of sports-related concussions and a CD-ROM with additional downloadable materials and resources. ACP, along with other professional medical organizations, voluntary organizations and expert work groups, partnered with CDC to update the tool kit.

The toolkit is online.

More information about CDC’s educational materials, research and programs is online.

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ACP encourages Congress to support comparative effectiveness

ACP President David C. Dale, FACP, testified last week before the House Ways and Means Committee, Subcommittee on Health about the importance of comparative effectiveness data. At the hearing, Dr. Dale said that the availability of sound effectiveness data would be extremely useful in the clinical setting.

“ACP strongly supports Congressional efforts to provide Medicare and all stakeholders within the health care community with improved access to information about the relative strengths and weaknesses of various clinical products, procedures and services,” Dr. Dale told the subcommittee. “The College believes that the greatest value of comparative effectiveness data is to help answer the question of what works best and for whom it works best–given the clinical conditions of the patient and the patient preferences. Better information will enable physicians and empower patients to engage in well-informed, shared decision-making.”

The hearing focused on opportunities for the federal government to expand the research on the relative effectiveness of health care services. Health policy experts across the political spectrum agree that such information is a sorely needed public good, and that greater investment in comparative effectiveness research is critical to assuring high-quality care and reducing unnecessary spending.

ACP recommended that Congress find or create an entity that would systematically develop evidence on the relative effectiveness of various health care services. In order to be effective, the entity should be an unbiased independent entity protected from both governmental and private sector influence and have the characteristics of transparency, strong stake holder involvement, a priority-setting process to create the greatest healthcare impact, and the ability to make its findings accessible and understandable. Dr. Dale pointed out the entity that currently best matches this list of characteristics is the Agency for Healthcare Research and Quality.

ACP’s press release is online.

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Regent chair receives leadership award

Joel S. Levine, FACP, Chair of the Board of Regents, received the James Addison Sewall Award at the recent graduation ceremony of the University of Colorado at Denver and Health Sciences Center.

The award is given to a faculty member “who has made exceptional contributions of leadership and vision to the UCHSC.” Dr. Levine is professor of medicine and senior associate dean for clinical affairs at the School of Medicine.

More information about the award is online.

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Copyright 2007 by the American College of Physicians.

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