In the News for the Week of 7-10-07
- Diagnosis downgraded for TB traveler
- CDC advisory urges all health care workers to get flu shots
- CMS proposes physician payments for next year
- Physicians often choose for incapacitated patients without surrogates, survey finds
- CMS cracks down on transplant programs
- ACP Journal Club: Antioxidant supplements do not decrease mortality
- Sense of smell predicts cognitive problems
- Nearly one-third of adults report alcohol use disorder
- Member discount for eHealth Initiative Conference
- Cover the Uninsured Week activities continue into the summer
Test results released last week revealed that Andrew Speaker, the Atlanta lawyer who was quarantined by the CDC after traveling with drug-resistant tuberculosis, has the multiple-drug-resistant (MDR-TB) form of the disease. Previous tests performed by the CDC had led experts to conclude that he had the more serious, extremely drug-resistant strain (XDR-TB).
The new results were released by the National Jewish Medical and Research Center in Denver, where Mr. Speaker is being treated in isolation. The findings are based on tests run at both National Jewish and the CDC on three separate samples taken from the patient, the July 4 New York Times reported.
MDR-TB is significantly more curable than XDR-TB and the results will impact treatment for Mr. Speaker, as well as for anyone else who is found to have contracted the disease from him. An operation to remove a diseased section of Mr. Speaker’s lung had been planned for later this month, but may no longer be necessary, the New York Times said.
The discrepancy in test results is not unusual in drug-resistance testing, said an expert at National Jewish. Specimens obtained in different ways or at different times can provide different results, he said, but the hospital is now certain of the diagnosis of MDR-TB. A CDC representative said that the agency stood by the XDR-TB diagnosis of the original test and would have taken the same actions—issuing a federal isolation order—whether Mr. Speaker had MDR- or XDR-TB. In a prepared statement released at last week’s press conference, Mr. Speaker criticized the government’s treatment of him and expressed relief at the new diagnosis.
The New York Times is online.
The CDC's influenza vaccine advisory for 2007-08 urges all health care workers to be vaccinated and suggests that clinics be kept open later in the flu season.
The recommendations from the CDC’s Advisory Committee on Immunization Practices were published in the June 29 Morbidity and Mortality Weekly Report and otherwise remained unchanged for all age groups. Principal reminders and changes include:
- Immunization providers should offer vaccines and schedule clinics throughout the influenza season, not just at the start;
- Health care facilities should consider the level of vaccination coverage among its workers to be one measure of a patient safety quality program and implement policies to encourage vaccination, like obtaining signed statements from workers who decline vaccination;
- Health care professionals should use the 2007-08 trivalent vaccine virus strains A/Solomon Islands/3/2006 (H1N1)-like (new for this season), A/Wisconsin/67/2005 (H3N2)-like, and B/Malaysia/2506/2004-like antigens;
- Children aged 6 months to 8 years should receive two doses if they haven’t been vaccinated before, while those who received one dose in their first year of vaccination should receive two doses the following year; and
- All people, including school-age children, who want to reduce their risk of contracting seasonal flu should be vaccinated.
“In general, health-care providers should begin offering vaccination soon after vaccine becomes available and if possible by October,” the CDC report said. “Vaccination efforts should continue throughout the season.”
Vaccine administered in December or later is likely to benefit even if flu activity has already begun, the CDC said. The majority of adults have antibody protection against influenza virus infection within two weeks after vaccination.
The MMWR report is online.
Influenza information is on the CDC Web site.
Increases in relative value units (RVUs) for physician work at nursing facilities and an across-the-board payment cut were among the proposed changes to Medicare physician payments for 2008 released by the CMS last week.
The nursing facility work RVU increases are due in large part to the efforts of the American Medical Directors Association (AMDA) working in conjunction with ACP and other medical groups. Work RVUs determine approximately 55% of the payment for a service. If the proposed changes are approved, physicians will see the new payment rates start on Jan. 1, 2008. According to the AMDA, payments for the physician work associated with nursing facility services could increase by more than $196 million in 2008.
“These increases in value are a testament to the extraordinary level of work required of physicians that work in nursing facilities” said ACP President David C. Dale, FACP. “This increase in value should help to make work in nursing homes as attractive as work in other settings.”
The proposed rule, Medicare Program; Proposed Revisions to Payment Policies Under the Physician Fee Schedule, and Other Part B Payment Policies for Calendar Year 2008, also included several other issues of importance to internists.
- CMS projects that the rule will have an average negative impact of 11% on the average general internist in 2008. A 9.9% cut was expected based on the statutorily required sustainable growth rate (SGR) formula and the rest of the cut is based on other provisions in the rule.
- The Physician Quality Reporting Initiative (PQRI) would continue into 2008. Under the proposal, next year’s PQRI program will include all of the performance measures from this year’s program as well as new measures currently in development.
- The fax exemption to electronic prescribing standards for Medicare Part D transactions would be eliminated. This could place significant limitations on the use of computer-generated faxes for prescription purposes.
The CMS press release is online.
Information from AMDA is online.
Physicians often make end-of-life decisions for incapacitated ICU patients without surrogates, usually without review, a new study reported.
Researchers surveyed attending physicians at seven ICUs about the care of 3,011 critically ill patients. The goal of the survey was to determine how often physicians cared for patients who were incapacitated and had not designated a surrogate decision maker, and how end-of-life care decisions were made in these situations. The results were published in the July 3 Annals of Internal Medicine.
Respondents reported that 37 patients overall were incapacitated and had no surrogate or advance directive. Among this group, 36 decisions were made about writing do-not-resuscitate orders and 25 decisions were made about withdrawing life support. These decisions were reviewed in only seven patients; in the others, the ICU team or the ICU team and another attending physician were the sole decision makers. Only one patient's case received judicial review, the standard recommended by ACP. Overall, 5.5% of patients who died in the ICU were incapacitated and had no surrogate decision maker or advance directive.
Additional research on best practices in this situation is warranted, the study authors said, pointing out that hospitals, professional societies and state laws vary widely. "Further research, careful ethical analysis, and public debate are needed to determine the relative benefits and burdens of different approaches to these difficult decisions," the authors concluded.
Annals of Internal Medicine is online.
A Q&A with the lead author of the study will appear in the August 2007 issue of ACP Hospitalist.
Three hospitals in Indiana, Minnesota and Texas are the latest to receive letters of warning from CMS about their transplant programs, the Los Angeles Times reported last week.
On June 29, CMS warned St. Vincent Indianapolis Hospital, Abbott Northwestern Hospital in Minneapolis and Christus Santa Rosa Hospital-Medical Center in San Antonio that their heart transplant programs did not meet federal requirements, the Los Angeles Times reported. The hospitals have 30 days to submit a plan to correct the problems or lose Medicare funding for the procedure. A fourth hospital, University of Kentucky Chandler Hospital, has agreed to forgo Medicare funding for heart transplants, according to the article.
The Los Angeles Times conducted an investigation in June 2006 and found that 20% of the nation's transplant programs had sub-par patient survival rates or didn't perform enough procedures annually to meet Medicare requirements. Since then, CMS has been cracking down on hospitals whose transplant programs are borderline. In addition to the four hospitals cited this June, nine others no longer receive federal funding and five are operating under Medicare-approved corrective plans, according to the Los Angeles Times.
The Los Angeles Times is online.
A new meta-analysis of trials comparing antioxidant supplements to placebo in healthy adults and patients with chronic diseases found that the supplements did not decrease mortality.
The review included 68 randomized, controlled trials, 47 of which were secondary prevention trials. Acute, infectious and malignant diseases except for nonmelanoma skin cancer were excluded. Study subjects took beta-carotene; vitamins A, C, or E; or selenium, separately or in combination, and controls received placebo or no intervention.
Overall, the groups did not differ for mortality. However, a meta-analysis of the high-quality trials found that as a whole supplements increased mortality with borderline significance and that beta-carotene (RR, 1.07 [CI, 1.02 to 1.11]), vitamin A (RR, 1.16 [CI, 1.10 to 1.24]) or vitamin E (RR, 1.04 [CI, 1.01 to 1.07]), alone or in combination, also increased mortality. The subgroup analysis found that vitamin C and selenium had no significant effect on mortality. The study is abstracted in the July/August ACP Journal Club.
The results of the review are believable because of the careful, prespecified protocol, comprehensive sensitivity analyses and precise confidence limits, and therefore have major public health implications, said Journal Club reviewer Daniel G. Hackam, MD, PhD, of the University of Toronto. Extrapolating from the review’s findings, Dr. Hackam concluded that several thousand deaths each year may result from use of antioxidant supplements. He urged clinicians and other health advocates to correct the public perception that supplements have favorable health effects.
Peer ratings for this review: GIM/FP/GP, Geriatrics: 5/7 stars. Cardiology, Oncology, Nephrology: 6/7 stars.
ACP Journal Club is online.
Older people who have difficulty identifying smells have an increased risk of developing cognitive impairment, according to a new study. Previous research has looked at olfactory problems in patients with cognitive decline or Alzheimer disease, but this study is the first to uncover a link in people with no cognitive problems.
The longitudinal cohort study began with 589 older people who had no cognitive impairment. The participants’ ability to identify odors was assessed at baseline with a 12-item Brief Smell Identification Test, in which a microcapsule containing a familiar odor is placed under the nose. During a follow-up period of up to five years, 177 of the study participants developed mild cognitive decline.
The study found that people who scored below average on the odor identification test were 50% more likely to develop mild cognitive impairment (MCI) than those who scored above average. Impaired odor identification was also associated with a lower level of global cognition at baseline and more rapid decline in episodic memory, semantic memory and perceptual speed. The study was published in the July 2007 Archives of General Psychiatry.
The results support the theory that Alzheimer disease begins with problems in specialized areas of the brain and then spreads to involve major thinking areas, the lead author of the study told the July 3 Washington Post. Although the study showed that smell testing can predict cognitive decline, currently the testing has little application to clinical practice because no treatments exist to prevent the progression of Alzheimer disease and related cognitive decline, he noted.
The Archives of General Psychiatry is online.
The Washington Post is online.
More than 30% of U.S. adults have met diagnostic criteria for an alcohol use disorder at some point in their lives, yet few have been treated for it, a new study found.
Researchers gathered data on alcohol use through face-to-face interviews in 2001-02 with a representative sample of 43,093 adults age 18 and older. About 42% of men and 19% of women reported a history of alcohol use or dependence in their lives, with whites, Native Americans, younger and unmarried adults and those with lower incomes most likely to report dependence. Lifetime rates were highest among middle-aged Americans.
Prevalence of lifetime and 12-month alcohol abuse was 17.8% and 4.7%, while prevalence of lifetime and 12-month alcohol dependence was 12.5% and 3.8%. Alcohol abuse, according to the American Psychiatric Association’s diagnostic manual, is a drinking-related failure to fulfill major obligations at work, school or home; social or legal problems; and drinking in hazardous situations. Alcohol dependence is marked by compulsive drinking, preoccupation with drinking and tolerance to alcohol or withdrawal symptoms.
Only 24% of those with alcohol dependence were ever treated, slightly less than the treatment rate found 10 years earlier. The average age of dependence onset was 22.5 years, while the average age of first treatment was 29.8 years. For alcohol abuse, the average age of onset was 21.9 years, while first treatment occurred at the average age of 32.1 years. Treatment could include being seen by a health professional, or going to a 12-step program or crisis center. The study was conducted by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and was published in the July 2007 Archives of General Psychiatry.
“A lost decade between alcohol use disorder onset and treatment leads to personal disability and societal damage,” said NIAAA director Ting-Kai Li, MD “[The study data] can be used by researchers and health professionals to target preventive and treatment interventions for populations at greatest risk.”
The Archives of General Psychiatry is online.
The NIAAA release is online.
The Washington Post is online.
See also, "Special Focus: Alcohol abuse and related disorders" in the April 2007 ACP Observer.
The first generic versions of terbinafine hydrochloride (brand name: Lamisil) were approved by the FDA last week for the treatment of nail fungus infections (onychomycosis).
The agency approved applications from multiple generic drug manufacturers for 250-mg tablets of terbinafine hydrochloride. A generic version of the over-the-counter Lamisil cream (terbinafine hydrochloride, 1%) was also approved for treatment of athlete’s foot. The Lamisil patent expired on June 30.
According to the trade magazine Drug Topics, Lamisil tablets are the 57th highest-selling brand-name prescription drug in the U.S. by retail dollars.
The FDA news release is online.
FDA monthly reports of first-time generics are online.
The FDA recently approved Corin Group’s Cormet hip resurfacing implant, which will create competition for another hip resurfacing system that was approved by the FDA last year, the July 4 New York Times reported.
Hip resurfacing is a popular alternative to total hip replacement for younger patients with hip failure because it preserves more of a patient’s thigh bone, making it easier to replace the original implant with a total hip in the future if needed, the New York Times said. Smith & Nephew’s Birmingham hip resurfacing system was approved in May 2006, it said.
Stryker Corporation, which has a 10-year distribution agreement with Corin on U.S. sales of the implant, said it won’t start marketing the new implant until enough surgeons have completed a training program that the companies developed in cooperation with the FDA. The program will help doctors identify which patients are most likely to have good outcomes from the implant. Stryker hopes to begin marketing by late September, a company news release said.
An FDA panel reviewed clinical trial results on the implant in February, and found that about 8% of the 302 resurfacing patients needed revision surgery within two years, the New York Times said.
The New York Times is online.
The Stryker Corporation release is online.
As a strategic partner to eHealth Initiative’s (eHI) Fourth Annual Conference, the College and its members are eligible for a 20% discount at the conference, which will be held October 11-12, 2007 in Washington, D.C.
The conference, “Policy for Improving the Quality of Healthcare through HIT at the National, State and Local Levels,” brings together national, state and community leaders to discuss the latest developments in health care improvement strategies, technologies and initiatives. Expert speakers will present on a number of topics, and an in-depth overview of a model of a health information exchange network (HIE) will be introduced. The conference will also feature the national release of the eHI Blueprint for Improving America’s Health and Healthcare through Information and Information Technology, a blueprint for achieving transformation in health care through health IT and health information exchange.
The eHI is a nonprofit organization that seeks to drive improvement in the quality, safety, and efficiency of health care through information technology.
Conference information and registration are online.
While Cover the Uninsured Week concluded its activities in April, efforts to obtain health insurance coverage for the uninsured continue. The State Children’s Health Insurance Program (SCHIP), which covers 6 million children, is set to expire on Sept. 30 unless Congress reauthorizes the program.
Ten years ago, Congress created SCHIP to cover children whose parents work but cannot afford health insurance on their own. Thanks to SCHIP, millions of children can now see a doctor when they are sick and get the care they need to stay healthy. Because of the importance of reauthorizing this program, Cover the Uninsured Week is continuing its activities this summer.
Plans include press conferences that are being organized in mid-August in the following states: Indiana, Iowa, Maine, Minnesota, Missouri, Montana, New Hampshire, Oregon, Utah and Virginia (for information, contact Ariane Holm.)
Cover the Uninsured Week is the nation's largest campaign to draw attention to the plight of America's 45 million uninsured. Led by the Robert Wood Johnson Foundation, the campaign brings together business owners, educators, students, patients, hospital staff, physicians, nurses, and many others to speak out on behalf of the uninsured and demand that national leaders make the issue of the uninsured their top priority. 2007’s Cover the Uninsured Week included more than 3,300 events in all 50 states.
ACP is a national supporter of Cover the Uninsured Week events and ACP chapters have helped in the past to organized local events for CTUW.
Information about getting involved is online.
About ACP ObserverWeekly
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Copyright 2007 by the American College of Physicians.
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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