In the News for the Week of 7-17-07
- More than a third of primary care patients report sleep troubles
- Depression treatment lowers suicide risk for all ages, studies suggest
- Medicare reports promising results from first year of P4P demo
- Study shows association between inhaled corticosteroids, pneumonia in patients with COPD
- Elderly patients often continue sleeping pills after hospitalization, study finds
- Annals of Internal Medicine
- Older diabetes drugs have similar or superior effects to newer medications
- Gonorrhea becoming resistant to antibiotic fluoroquinolones
- Cancer rates vary according to ethnicity in Asian-American community
Health care access
- Medicare sees surge in services when uninsured, chronically ill turn 65
- First skin patch to treat dementia from Alzheimer’s, Parkinson’s approved
- FDA approves robotic arm brace for strokes
- Physician and Congressional leaders convene on Capitol Hill
- ACP members elected to AMA leadership positions
More than a third of adults who visit primary care practices has trouble sleeping, a new study found.
For the study, nearly 2,000 adults at five primary care practices took a four-page survey on demographic and health status items, including sleep problems. Participants were 68% women, 58% white, 30% African American and 9% Latino. The mean age was 50 years. More than 30% reported fair/poor health, with hypertension, joint or back pain, depression, diabetes and heart disease being the most common conditions. Results from the sleep questions showed that:
- 34% woke up at least three times a night
- 14% had symptoms of sleep apnea
- 28% had symptoms of restless legs syndrome at least weekly
- 55% felt sleepy at least once a week during daily activities
- 37% dozed off at least once a week during daily activities
- 33% snored loudly at least once a week
Patients who rated their health as poor had significantly higher rates of all sleep disturbance items, as did those with hypertension, pain syndromes and depression. Older adults reported more daytime dozing, while younger adults reported more insomnia, snoring and apnea. Women were more likely to experience insomnia, and less likely to snore. The study is in the July/August issue of the Journal of the American Board of Family Medicine.
The authors caution that while their study’s questionnaire was used to identify sleep complaints suggestive of specific diagnoses, not all patients with symptoms would meet diagnostic criteria for specific syndromes, such as insomnia or sleep apnea. Positive responses to such questions should be the beginning of diagnostic inquiries. When managing sleep complaints, clinicians should take into account a patient’s history of symptoms, current medications and other modifiable medical and mental health issues, the authors said.
The Journal of the American Board of Family Medicine is online.
Treating depression with drugs or therapy seems to reduce the risk of suicide in all age groups, according to two new studies in the July 2007 American Journal of Psychiatry. The studies are particularly timely, given a recent FDA move to warn young adults about potential suicide risks from antidepressants.
The first study reviewed records of 109,256 people in a prepaid health plan who were treated for depression. It found suicide attempts were most common in the month before treatment began, fell in the first month of treatment and continued to drop as treatment continued. The pattern occurred for all types of treatment—psychotherapy, medication or a combination of the two—and was seen in all age groups, including young adults and adolescents.
The second study examined data from the Veterans Health Administration on 226,866 depressed patients. It found the rate of suicide attempts after starting selective serotonin reuptake inhibitors, or SSRIs, was about one-third the rate among those who didn’t take an antidepressant. Suicide attempt rates were significantly higher before SSRI treatment than immediately after it. Those taking tricyclic antidepressants also had a lower suicide attempt rate than those who took nothing. Treatment effects were seen both for men aged 18 to 25 and for older adults.
The authors of the two studies said they feared that FDA warnings on antidepressants might scare people away from treatment that could help them, the July 10 New York Times reported. In 2005, the FDA acted on results from clinical trials and ordered a black box warning for antidepressants, saying they could increase the risk of suicide among children and adolescents. After reviewing more data, the agency updated the notice last May to include a warning about risk of suicide among adults age 18 to 24.
While the two new studies don’t definitively prove that antidepressants and psychotherapy reduce suicide risk, they do suggest it is more likely that suicidal behavior leads to treatment than that treatment leads to suicidal behavior, an editorial writer noted.
The New York Times is online.
Results from the first year of Medicare's chronic care pay-for-performance demonstration suggest that rewarding doctors for coordinating care and keeping patients out of the hospital leads to better outcomes and lower overall costs.
The Medicare Physician Group Practice Demonstration, which began in April 2005 and continues through 2008, offers bonuses, in addition to traditional fee-for-service reimbursement, for meeting certain quality markers, said a July 11 CMS news release. In the first year, rewards were based on how well physicians followed evidence-based guidelines for diabetics, such as HbA1c control, lipid testing and eye and foot exams. Measurements focusing on congestive heart failure, coronary artery disease, hypertension and cancer screening will be added in years two and three.
However, while all 10 of the physician groups that participated improved care for diabetics, only two groups received bonus payments, said the July 12 New York Times. The University of Michigan Faculty Practice and the Marshfield Clinic in Wisconsin received a total of $7.3 million for saving Medicare $9.5 million.
The fact that eight of these large groups with access to sophisticated tracking systems did not meet the threshold for bonus payments indicates how difficult it might be for smaller practices to participate in P4P, said the New York Times. However, Medicare officials quoted in the article noted that there was an upward trend during the first year, and predicted that most practices would receive bonuses in the final two years of the program.
A CMS news release is online.
The New York Times is online.
Inhaled corticosteroids can lead to hospitalization for pneumonia in patients with chronic obstructive pulmonary disease (COPD), a new study found.
Researchers at McGill University in Montreal analyzed prescription and hospitalization records between 1988 and 2003 for a cohort of 175,906 elderly COPD patients and for 95,768 matched controls to determine whether inhaled corticosteroids and pneumonia were related. The results appear in the July 15 American Journal of Respiratory and Critical Care Medicine.
During follow-up (1,241,741 patient years), approximately 14% of the cohort (23,942 patients) was hospitalized for pneumonia. The adjusted rate ratio was 1.70 (95% CI, 1.63 to 1.77) for pneumonia hospitalization associated with current inhaled corticosteroid use and 1.53 (CI, 1.30 to 1.80) for pneumonia hospitalization and death within 30 days. The highest doses of inhaled corticosteroids were associated with the greatest hospitalization risk (rate ratio, 2.25 [CI, 2.07 to 2.44]).
An accompanying editorial noted that these findings confirm those of an earlier randomized, placebo-controlled trial and recommended that additional large prospective studies should be performed. "The finding of an association between pneumonia frequency and inhaled corticosteroid use in studies of a different design, in different populations, and with evidence of a dose-response relationship means that the findings may be real and that these observations cannot simply be dismissed," the editorialist wrote.
The American Journal of Respiratory and Critical Care Medicine is online.
Elderly patients who are first prescribed benzodiazepines during or soon after a hospital stay are often still taking them months later, according to a study.
Researchers at the Institute for Clinical Evaluative Sciences in Toronto examined retrospective data on 405,128 patients age 66 years or older who were hospitalized between April 1, 1992, and March 31, 2005. The objective of the study was to determine how often elderly adults who are prescribed benzodiazepines in association with a hospital stay continue taking them after discharge. The results appear in the July Journal of General Internal Medicine.
Overall, 12,484 patients (3.1%) who had not taken benzodiazepines in the year before hospitalization received prescriptions for the drugs within a week of hospital discharge. Of this group, almost 50% (6,136 patients, or 1.5% of the cohort) were categorized as "new chronic benzodiazepine users," meaning they were still taking the drug within eight days to six months of hospitalization.
New long-term benzodiazepine use was most common in women, patients who stayed in the hospital longer, those with ICU or nonsurgical stays, those with greater overall comorbidity, those with a previous diagnosis of alcoholism and those with prescriptions for more medications.
In a press release, the study's lead author pointed out the associated risks of the drugs, such as residual daytime sedation, fall-related injuries and possible dependence.
"Initiatives such as the development of electronic medical records and more formal medication lists, or models of care that facilitate communication and coordination between hospital and community-based physicians, may help to further reduce the risk of new, chronic benzodiazepine prescriptions, particularly when targeted to the higher-risk patients identified in our study," he said.
The Institute for Clinical Evaluative Sciences is online.
The Journal of General Internal Medicine is online.
The following articles will appear in the July 17, 2007 online issue of Annals of Internal Medicine. The full text is available to College members and subscribers online.
Older diabetes drugs have similar or superior effects to newer, pricier medications
A literature review on the benefits and harms of oral drugs for type 2 diabetes mellitus found that older agents, such as second-generation sulfonylureas and metformin, have similar or superior effects on glycemic control, lipids and other intermediate end points compared to newer, more expensive drugs, such as thiazolidinediones, alpha-glucosidase inhibitors and meglitinides. This is the first systematic review to compare all drugs on a full range of intermediate end points—evidence that is urgently needed to guide therapy since new oral diabetes drugs continue to emerge on the market, authors say. (This review, published early online, will appear in the Sept. 18, 2007, print edition of Annals of Internal Medicine.)
Gonorrhea becoming resistant to antibiotic fluoroquinolones
A 16-year monitoring program has found gonorrhea is becoming resistant to fluoroquinolones, after having become resistant to sulfonamides, penicillins, tetracyclines and ciprofloxacin in the last 60 years. The first fluoroquinolone-resistant gonorrheal bacteria were found in 1991. By 2003, 70% of participating clinics in the study reported them. The CDC no longer recommends using fluoroquinolones and instead recommends cephalosporins, which are more expensive and often need to be injected. Separately, a second study found that only 0.24% of people age 14 to 29 have gonorrhea, while 2.2% of people in this age group have chlamydia. Adolescents have the highest rate of both infections.
A new report found significant differences in cancer incidence among different Asian-American ethnic groups.
The report, which appears in the July 11 CA, a journal published by the American Cancer Society, summarized data on cancer incidence, mortality, risk factors and screening for five large Asian-American ethnic groups in California: Chinese, Filipino, Vietnamese, Korean and Japanese. Researchers looked at four common cancers (prostate, breast, lung, colon/rectum) and three sites that often affect Asian Americans (stomach, liver, cervix).
Generally, researchers found that groups with more recent immigration histories, such as Koreans and Vietnamese, were more likely to have cancers that are not as prevalent in the West, such as stomach and liver. Groups that have been in the U.S. longer, such as Japanese and Filipinos, had a higher incidence of cancers that are common in the U.S., such as colorectal and breast.
Other findings from the study included:
- Chinese women had the second highest lung cancer mortality rate
- Filipino men had the highest mortality rate from lung cancer
- Filipino women had the highest mortality rate for breast cancer
- Vietnamese men had the highest death rates from liver cancer and their incidence rate is more than seven times higher than the rate among non-Hispanic white men
- Korean men and women had the highest rates of stomach cancer
- Japanese men had the highest incidence and mortality rates for colorectal cancer
Clinicians need to be aware of the heterogeneity of the Asian-American community, the study's lead author told the July 11 New York Times. For example, the high rates of liver cancer found among Vietnamese men may be linked to chronic infection from the hepatitis B virus, which is widespread in eastern Asia and in recent U.S. immigrants from that area.
The American Cancer Society article is online.
The New York Times is online.
Health care access
Previously uninsured adults with chronic diseases significantly increase their use of health care services when they become eligible for Medicare, according to a new study that followed a large group of adults both before and after they became eligible for government health benefits.
In the study, researchers used data on 5,158 adults, more than half of whom were diagnosed with hypertension, diabetes, heart disease or stroke before age 65, who participated in the Health and Retirement Study from 1992-2004. They found that previously uninsured adults with chronic diseases reported 13% more doctor visits, 20% more hospitalizations and 51% higher medical expenditures than previously insured adults. The study appears in the July 12 New England Journal of Medicine.
The greater use of health services among the previously uninsured continued through to age 72, said the authors. The findings suggest that the costs of expanding health insurance coverage to adults before they reach retirement age would be partly offset by savings from reduced health care use after age 65, said the authors, especially by those with cardiovascular disease or diabetes.
The study also found that having Medicare coverage greatly reduced previously uninsured adults' out-of-pocket medical costs, an effect that may be even greater now under Medicare's new prescription drug benefit.
The New England Journal of Medicine abstract is online.
The FDA has approved the first daily skin patch to treat dementia associated with mild to moderate Alzheimer’s disease and Parkinson’s disease.
A study, sponsored by manufacturer Novartis Pharmaceuticals, found the Exelon Patch improves memory and the ability to perform everyday activities when compared to placebo, Novartis said. It also found more than 70% of caregivers prefer the patch because it is easier to use, the company said.
While the drug in the patch, rivastigmine (brand name: Exelon), is already available in capsule form, the patch delivers a continuous dose throughout the day. The patch minimizes the gastrointestinal side effects commonly seen with cholinesterase inhibitors, with a clinical trial yielding three times fewer reports of nausea and vomiting from the patch than from the capsule form of the drug, Novartis said in a release.
The patch, expected to be available in pharmacies soon, is applied to the back, chest or upper arm, and delivers medicine through the skin over the course of 24 hours.
The FDA record of approval is online.
The Novartis release is online.
The FDA last week gave marketing approval for a robotic arm brace that is meant to help stroke survivors regain use of partially paralyzed arms and learn how to move affected muscles again.
The e100 NeuroRobotic System by manufacturer Myomo, Inc. has sensors that detect muscle contractions on the skin’s surface, then help the wearer control simple arm movements. A patient may then strengthen neurologic and motor pathways that could help him or her regain more independent movement.
A recent small study of the device and associated treatment found that patients who exercised with the arm brace for 18 hours over roughly six weeks experienced a 23% improvement in upper extremity function, according to the New York Times.
The device is meant for use in clinical settings. There are no known side effects or risks, Myomo, Inc said.
Myomo’s press release is online.
The New York Times is online.
For more about advances in stroke rehabilitation, see the July/August ACP Observer.
College executive vice president and CEO John Tooker, FACP, MBA, met with leaders of Congress last week to ask for their help in stabilizing physician payments under Medicare.
Dr. Tooker—along with Rick Kellerman, MD, president of the American Academy of Family Physicians, and John Crosby, executive director of the American Osteopathic Association—met with members of Congress to discuss legislative strategies aimed at reforming the flawed Medicare physician payment formula. The three physician leaders visited the offices of Senate Majority Leader Harry Reid (D-NV), Senate Republican Leader Mitch McConnell (R-KY), House Speaker Nancy Pelosi (D-CA), and House Republican Leader John Boehner (R-AL).
“We all agree that the ‘pay for’ is complex, but mechanisms exist to support the creation of a package that provides positive, stable and predictable Medicare payment updates and provides a pathway to repeal of the SGR,” said Dr. Tooker.
The groups agree that Medicare should reimburse physicians in a manner that reflects the costs of providing care to beneficiaries and not be based upon an inaccurate and inequitable financial formula that fails to account for changes in practice patterns, coverage determinations and new treatment options and technologies.
A press release about the event is online.
Four ACP members were elected to leadership positions by the House of Delegates of the American Medical Association (AMA) during the AMA's 2007 annual meeting in June.
Nancy H. Neilsen, MACP, PhD, was elected president-elect; Cyril M. Kim Hetsko, FACP, was re-elected as trustee; Barbara McAneny, FACP, was re-elected to the council of medical service; and Sandra Adamson Fryhofer, MACP, was elected to the council on science and public health.
The House of Delegates is the AMA's principal voting and policy-making body.
The press releases are online.
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Copyright 2007 by the American College of Physicians.
A 49-year-old man is evaluated during a routine examination. He is asymptomatic but is concerned about his risk for cardiovascular disease. Medical history is notable for hypertension. He is a nonsmoker, and he works as an executive at a highly successful company. Family history is noncontributory. His only medication is hydrochlorothiazide. Following a physical exam and cholesterol and glucose testing, what is the most appropriate next step in management?
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