In the News for the Week of 7-31-07
- Obesity spreads through friends, family
- Low health literacy affects survival
- Employment demand for internists, hospitalists rises
- CMS proposes new payment system for ambulatory surgical centers
- Pulmonary artery catheter use declines in U.S. hospitals, study shows
- Greater prophylaxis use needed to prevent outpatient VTEs
- Drop in breast cancer parallels drop in hormone use
- Lyme disease guidelines stress prevention, short-term antibiotic use
- Canned food recall is expanded
- Panel recommends raloxifene to prevent breast cancer in some women
- FDA allows restricted use of tegaserod maleate for bowel problems
- Legislators urged to support Children’s Health and Medicare Protection
- Master awarded National Medal of Science by President Bush
- National Changing Diabetes Program presents federal spending report to Congress
- Fellow named co-chair of health information technology committee
Social networks have a significant impact on a person's risk of obesity, greater even than the effect of genetics, according to a new study. Researchers followed more than 12,000 people from 1971 to 2003 and found that study participants whose friends, siblings or spouses became obese were more likely to become obese themselves.
Study participants, who were part of the Framingham Heart Study, were assessed for body mass index repeatedly during the 32-year period. Participants who had a friend who became obese had a 57% increased risk of obesity. A sibling who became obese elevated the risk by 40% and an obese spouse increased it by 37%. Neighbors had no effect on one another and same-sex relationships had a greater impact than opposite-sex relationships, the research found. The study was published in the July 26 New England Journal of Medicine.
The findings suggest that once a person becomes obese, people close to him or her may find it more socially acceptable to gain weight, said the study's lead author in the July 26 Washington Post. The researchers found that even friends who lived hundreds of miles apart could affect each other's weights. They also established that the changes were not a result of smoking cessation.
Since the study shows that social networks appear to be a factor in the obesity epidemic, it may be possible to harness this social force to slow the epidemic, the study authors concluded. Therefore, public health and medical interventions may be more cost-effective than previously thought because counter-obesity efforts could rapidly spread from person to person, they said.
The New England Journal of Medicine is online.
The Washington Post is online.
Elderly patients with low health literacy have a higher risk of all-cause mortality and cardiovascular death than their more literate peers, a new study found.
The prospective study of 3,260 Medicare enrollees in four U.S. metropolitan areas tested patients' functional health literacy and rated them as having adequate, marginal and inadequate health literacy. About a quarter of the patients had inadequate health literacy skills and of that group, 39.4% died during the six-year study period. Only 18.9% of the adequate literacy group died.
After controlling for patients' health at the outset, the study found that those with inadequate health literacy had a 50% higher risk of all-cause mortality. Researchers noted several possible mechanisms by which the association between literacy and mortality might occur, including worse self-management skills, less adherence to medication regimens and less understanding of chronic disease. Although the study controlled for annual income, researchers noted that net worth may have been a confounding factor as only half of eligible Medicare patients participated in the study and nonparticipants had higher socioeconomic status. The study was published in the July 23 Archives of Internal Medicine.
Previous studies had suggested a link between poor literacy and higher mortality rates, but this research is the most comprehensive to date, an expert told the July 23 Washington Post. The findings highlight the importance of providing medical information in ways that low-literacy patients can understand, including breaking instructions down into key points, using the teach-back method, or using alternate formats such as videos.
The Archives of Internal Medicine are online.
The Washington Post is online.
Demand for general internists and hospitalists has increased in the last year, according to a new report by a national physician search and consulting firm.
The 2007 Review of Physician Recruiting Incentives by Merritt, Hawkins & Associates examined more than 3,000 recruiting assignments from April 2006 through March 2007, and found that:
- Internal medicine was the second most requested search; the third was for hospitalists. Family practice was No. 1;
- Searches conducted for general internists rose by 120% from 2003 to 2007;
- The average offer made to recruit internal medicine specialists rose to $174,000 from $162,000;
- Hospitals offered employment to doctors in 43% of the searches compared with 23% the prior year;
- Specialties with the greatest income offers in a year were urologists, otolaryngologists, cardiologists, orthopedic surgeons, emergency medicine doctors and family practitioners;
- Signing bonuses ranging from $5,000 to $100,000 were offered in 72% of searches, compared with 46% of searches two years ago.
More openings in primary care reflect the fact that fewer medical students are choosing to practice internal medicine and family medicine, and a growing elderly population is driving up demand, said a Merritt, Hawkins & Associates news release. Hospitalist positions are becoming more popular as doctors seek to avoid reimbursement and malpractice hassles.
The 2007 Review of Physician Recruiting Incentives is online.
CMS recently proposed a new rule that would significantly change reimbursement for procedures at ambulatory surgical centers (ASCs).
The goal of the rule, CMS said in a press release, is to make payments to ASCs equivalent to those for similar procedures performed in a physician's office or a hospital outpatient department. The new rule would add approximately 790 procedures to the list of those eligible for ASC payment but would set ASC payment rates at 65% of those for outpatient procedures.
The rule is cause for concern among most ASCs, the July 23 Modern Healthcare reported, because it would substantially lower reimbursement rates for many procedures (gastroenterology procedures, for example, are currently reimbursed at 89% of outpatient rates). The new rate is higher than CMS's original proposal of 62% but lower than the 75% supported by the American Association of Ambulatory Surgery Centers, according to Modern Healthcare.
CMS is accepting comments on the new rule until Sept. 14. A final rule will be published in the fall.
The CMS press release is online.
Modern Healthcare is online.
Use of pulmonary artery catheters in hospitalized patients decreased sharply in the U.S. between 1993 and 2004, a new study found.
Researchers at Dartmouth Medical School used data from the Nationwide Inpatient Sample, part of the Agency for Healthcare Research and Quality's Cost and Utilization Project, to conduct a time trend analysis of pulmonary catheter use in hospitalized patients 18 years of age and older. The primary outcome measure was pulmonary artery catheterizations per 1,000 medical admissions per year. The results appear in the July 26 Journal of the American Medical Association.
The authors found that use of pulmonary artery catheters decreased by 65% from 1993 to 2004, from 5.66 per 1,000 medical admissions to 1.99 per 1,000 medical admissions. The authors detected a change in trend following the 1996 publication of a study suggesting that pulmonary artery catheterization was associated with increased mortality. Among diagnoses that are often associated with pulmonary artery catheterization, rates of use declined most for myocardial infarction (81%) and least for septicemia (54%). The authors concluded that rates of pulmonary artery catheterization had decreased over time because physicians were appropriately responding to evidence that this invasive procedure doesn't reduce mortality in critically ill patients.
The Journal of the American Medical Association is online.
Two studies released last week highlighted the importance of preventing venous thromboembolism (VTE) in recently hospitalized patients and evaluated the effectiveness of various VTE prophylaxis measures.
In the first study, researchers reviewed the records of 1,897 patients who had a VTE--73.7% of which occurred in outpatient settings. Of the outpatient VTEs, about 60% of patients had undergone surgery or hospitalization in the past three months and two-thirds of those patients had the VTE within a month of visiting the hospital. The research also found that less than half of the recently hospitalized patients had received VTE prophylaxis during their hospitalization.
The second article was a meta-analysis of anticoagulant VTE prophylaxis trials in hospitalized medical patients, including more than 48,000 patients from 36 randomized controlled trials. The analysis found that unfractionated heparin, 5000 U three times daily, was more effective than unfractionated heparin, twice daily, in preventing deep venous thrombosis (DVT). The study also showed that low-molecular-weight heparin was one-third more effective than unfractionated heparin in preventing DVT.
Both studies were published in the July 23 Archives of Internal Medicine. An accompanying editorial predicted that outpatient VTE will be the hot button issue of 2008. It noted that Medicare has instituted process measures for VTE in surgical patients, but proposed that the measures should be expanded to include hospitalized medical patients, whom the first study found to be also at high risk for VTE.
A recent drop in breast cancer rates parallels a decline in the use of hormone replacement therapy, but not in mammography rates, a new study found.
The study reviewed patient records of 7,386 women with invasive breast cancer who were treated from 1980 through 2006 at Kaiser Permanente Northwest. Breast cancer rates rose from the early 1980s to 2002, then dropped 17% from 2003 through 2006, it found. The drop occurred in tandem with a 75% drop in menopausal hormone therapy after 2002, while mammography rates remained unchanged. Moreover, a 15% rise in breast cancer rates from 1992 to 2002 matched a rise in hormone use, while mammography rates stayed even. The study appears in the August issue of the Journal of the National Cancer Institute.
Prescriptions for estrogen and progestin dropped by almost half in 2003, after the Women’s Health Initiative study showed hormone replacement therapy was linked to breast cancer risk, the July 25 Los Angeles Times said. It is probably not the case that hormone therapy causes breast cancer, an editorial to the study said. More plausible is the idea that stopping hormone therapy slows the growth of tumors, it said, making them less likely to be detected.
The Los Angeles Times is online.
The Infectious Diseases Society of America's guidelines on Lyme disease and other tick-borne infections recommend prompt preventive treatment with antibiotics following high-risk tick bites. The group also recommends a short-course treatment with antibiotics following infection but, in a move that has caused some controversy, it found no evidence of the effectiveness of long-term antibiotic use for chronic symptoms.
A person who has been bitten by the Ixodes scapularis, or deer tick, should receive a single dose of doxycycline (up to 200 mg for adults and from 4 mg/kg to a maximum of 200 mg for children age 8 and older), the guidelines state, provided that the following conditions have been met:
- the tick is identified as an adult or nymphal I. scapularis estimated to have been attached for 36 hours
- prophylaxis can be started within 72 hours from when the tick was removed;
- the local rate of infection of these ticks with Borrelia burgdorferi is estimated to be 20%; and
- doxycycline treatment is not contraindicated.
Diagnosed tick-borne diseases should be treated with oral antibiotics for 10 to 28 days. However, the guidelines state, there is no convincing evidence to support continued use of antibiotics for chronic symptoms following the completion of recommended treatment. Not only is long-term antibiotic therapy not supported by evidence, but it also may be dangerous, the guidelines state. Potential negative effects include infections due to long-term intravenous administration of antibiotics, infection of the bowel by Clostridium difficile, and fostering of drug-resistant superbugs.
The International Lyme and Associated Diseases Society (ILADS), has criticized the IDSA for recommending against long-term antibiotic therapy, charging that the decision may prompt insurers to deny payment to physicians who recommend long-term treatment for some patients. In an unprecedented move, the Connecticut Attorney General's office earlier this year launched an investigation into possible antitrust violations in connection with the development of the IDSA guidelines.
IDSA, which has cooperated fully with the investigation, noted on its Web site that the attorney general's move threatens the role of all professional societies in educating their members. "The guidelines are intended to help them [physicians] reach decisions about the best course of treatment," said IDSA President Henry Masur, FACP, in a statement. "They are suggestions based on the best available science—but they are by no means mandatory. IDSA cannot and would not dictate an individual physician’s actions."
The guidelines also include recommendations for preventing and treating two other diseases caused by deer tick bites: human granulocytic anaplasmosis (HGA) and babesiosis.
The guidelines were published in the Nov. 1, 2006 Clinical Infectious Diseases.
The IDSA president's statement is online.
See also, "Experts spar over treatment for 'chronic' Lyme disease" in the January/February 2007 ACP Observer.
The FDA last week expanded its recall of canned chili sauce that may be tainted with a botulism-causing toxin to include more products and a wider range of dates.
The expanded recall covers more than 90 products with 25 brand names, and applies to all “best by” dates. Most are kinds of chili or corned beef hash. The recall originally applied only to 10-ounce cans of Hot Dog Chili Sauce, sold under the brand names Castleberry’s, Austex and Kroger, with limited "best by" dates.
Four people were hospitalized with botulism after consuming that sauce, but are expected to survive, said a July 21 FDA news release. An official with producer Castleberry's Food Company said the company thinks the problem arose from under-processing on one line of its production facility. The line has been shut down.
Botulism is caused by the bacterium Clostridium botulinum and causes symptoms including double or blurred vision, drooping eyelids, slurred speech, difficulty swallowing, dry mouth and progressive muscle weakness. Consumers who have any of the recalled cans are urged to throw them out without opening them, because the toxin could sicken people through skin contact or inhalation.
The FDA release and a full list of recalled products can be found online.
An FDA panel recommended that the osteoporosis drug raloxifene (brand name: Evista) be approved for use in preventing breast cancer for postmenopausal women who are at high risk of the disease.
Raloxifene has been shown to reduce the risk of breast cancer among postmenopausal women with osteoporosis and postmenopausal women at high risk for breast cancer, but it also increases their risks for blood clots and stroke, the July 24 Washington Post reported.
Last June, a study of raloxifene and tamoxifen—the only drug currently approved for reducing breast cancer risk—found both drugs reduced the risk of breast cancer by about 50%. Raloxifene was less effective in preventing non-invasive breast cancers, however, the Post reported.
The Washington Post is online.
The FDA is allowing the restricted use of tegaserod maleate (Zelnorm) to treat bowel problems in certain patients, after it pulled the drug in March when clinical trial data suggested a link to heart attacks, strokes and angina.
The drug can now be used to treat irritable bowel syndrome with constipation and chronic idiopathic constipation in women younger than 55 for whom no other treatment has provided relief, as well as patients whose conditions improved with Zelnorm in the past, the FDA said in a release.
The FDA release is online.
Manufacturer Novartis’ press release is online.
ACP expressed support for the Children’s Health and Medicare Protection (CHAMP) Act of 2007 in a letter sent last week to the leaders of the U.S. House of Representatives Ways and Means and Energy and Commerce committees. The CHAMP Act (H.R. 3162) combines the reauthorization and strengthening of the State Children’s Health Insurance Program (SCHIP) with fixes to the Medicare program.
Medicare payments to physicians are scheduled to be cut by 10% in 2008 and they will be reduced in subsequent years due to a flaw in the formula used to calculate physician payments. Under the CHAMP Act, physician payments would increase in 2008 and 2009 although further legislation will be needed to avert payment cuts after 2009.
In the letter, ACP President David C. Dale, FACP, expressed support for funding for both of these programs, which would be accomplished by a combination of reducing payments to Medicare Advantage plans and an increase in federal taxes on tobacco. According to the Congressional Budget Office, Medicare Advantage plans are paid an average of 12% more than traditional Medicare, despite being available to only a limited number of beneficiaries. The increase in federal taxes on tobacco will have an added benefit to providing funding for SCHIP and Medicare, as well as the fact that higher taxes have been shown to reduce smoking rates.
“It is critical for Congress to vote for health care for children and seniors,” Dr. Dale said.
ACP’s press release is online.
In a subsequent alert sent Friday to ACP members Dr. Dale noted that congressional "representatives need to hear from internists now about why they should vote 'yes' on The CHAMP Act." He asked ACP members to follow up by contacting their congressional offices by email or phone.
For more information about contacting your members of Congress to ask for their support please visit ACP's Legislative Action Center.
Anthony S. Fauci, MACP, of Washington, D.C., was one of eight distinguished individuals awarded the National Medal of Science by President Bush on July 27 at the White House. Dr. Fauci, who practices at the National Institute of Allergy and Infectious Diseases, was recognized for his work on HIV.
Specifically, Dr. Fauci is credited for pioneering the understanding of the mechanisms involved in the regulation of the human immune system and for his scrutiny of HIV pathology which served as the foundation for the current treatment of HIV disease. The National Medal of Science honors individuals for pioneering scientific research in a range of fields, including physical, biological, mathematical, social, behavioral and engineering sciences.
More information about the National Medal of Science is online.
One out of every eight federal health care dollars is spent treating people with diabetes, according to a study released by the National Changing Diabetes Program (NCDP) and conducted by Mathematica Policy Research, Inc. (MPR). ACP is an official partner of the NCDP and serves on the Steering Committee. The study was released June 19 at a briefing on Capitol Hill with the Congressional Diabetes Caucus.
The study is the first of its kind to identify and analyze federal spending on diabetes across all government agencies. According to the findings released at the briefing, the federal government spends $80 billion more each year to treat people with diabetes than it spends on those without the disease. Nearly all federal agencies—18 out of 21—are in some way responsible for funding that affects diabetes. The research also identifies missed opportunities for the federal government to coordinate diabetes efforts across agencies.
At the briefing, NCDP and its partners presented Congress with a set of recommendations for increasing federal leadership for diabetes in response to the study findings. Recommendations included the creation of a National Diabetes Coordinator to align diabetes efforts across all federal agencies.
ACP applauds the NCDP for bringing the attention of policymakers to the vast disparity in federal spending between treatment of diabetes and prevention of disease, as is the case for many chronic diseases. In conjunction with the College’s ongoing efforts to improve awareness and outcomes in the lives of people with chronic diseases such as diabetes, ACP supports NCDP’s mission of improving the effectiveness of the American health care system in delivering coordinated care for chronic disease. ACP believes this study is an important first step in achieving that goal.
Information about the event and the recommendations, the full report, and sign-up for the NCDP e-newsletter are online.
Richard K. Kasama, FACP, has been appointed co-chair of the Patient Care Coordination (PCC) Planning Committee for Integrating the Healthcare Enterprise (IHE).
The IHE brings together stakeholders to implement standards to increase the interoperability of health information technology. Its goal is to allow health information to pass seamlessly from application to application, system to system, across multiple health care settings. The PCC domain specifically addresses the interoperability of patient information, such as medical summaries, allergies and lab results.
Dr. Kasama, the New Jersey Chapter Governor-elect designee, will begin his two-year appointment as co-chair of the PCC Planning Committee this fall as the domain kicks off its fourth-year planning cycle. Dr. Kasama works at Cooper University Hospital and the University Renal Associates in Haddonfield, N.J.
More information on IHE and ACP’s affiliation with them is online.
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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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