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

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In the News
for the Week of 10-28-08

Highlights

  • Medical practice costs rising faster than revenues, MGMA reports
  • Americans cut back on doctor appointments, pills to save money
  • Record number of reports of prescription drug deaths, injuries in early 2008

Test yourself:

  • MKSAP quiz: fever, cough and wheezing

Clinical guidelines

  • Guidelines updated for gastroesophageal reflux disease

Cardiology

  • Heart failure patients have higher fracture risk

Diabetes management

  • Diabetes groups provide new guidance on use of glitizones for diabetes

Advocacy

Online resources

  • New patient-centered medical home section on ACP Web site

Medicare news

  • CMS to hold conference call for providers about ICD-10 coding

From ACP Internist

  • Cast your health care ballot
  • On the blog: Highlights from Chest 2008
  • Cartoon caption contest: October's winning entry

Highlights

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Medical practice costs rising faster than revenues, MGMA reports

SAN DIEGO—Cost increases for drugs and support staff outpaced revenue for many practices last year, said members of the Medical Group Management Association (MGMA) at the group's annual gathering here last week. (More session highlights are available on ACP Internist's blog.)

According to the MGMA survey, which was based on 2007 data, operating costs rose faster than revenue in many group practices. Multispecialty group practices reported a 5.5% increase in median total revenue, but a 6.5% increase in operating costs last year. Cardiology saw even more drastic differentials, with revenue decreasing 0.61% and costs increasing 6.3%. Overall, operating expenses have increased from 58 cents to 61 cents per dollar of revenue over the past decade for all specialties, according to MGMA data.

Pharmaceutical and support staff costs were major drivers of the cost increases. For multispecialty groups, drug supply costs jumped 17% in 2007, on top of a 33% increase in 2006. Specialties throughout primary care showed similar trends, MGMA reported. Support staff costs increased 15.8% for family practices in 2007 and other groups showed similar trends, the report found.

--By Stacey Butterfield, staff writer

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Americans cut back on doctor appointments, pills to save money

Nearly half of Americans say they or a family member have skipped pills, and/or postponed or cut back on health care appointments and screenings in the past year to save money, according to results of a Kaiser Family Foundation poll released last week.

Thirty-six percent of interviewees said they or a family member didn't pursue medical care they needed, and 31% skipped a recommended test or treatment as of early October, the report said. That compares with 29% and 24%, respectively, in April 2008. About 20% of those who reported skipping care in October said their conditions got worse as a result. In addition, 27% said they or a family member didn't fill a prescription, and 22% said they cut pills or skipped doses compared with 23% and 19% in April, the poll said. Twelve percent had problems getting mental health care, up 4% from April.

About one in three reported their family has had problems paying medical bills in the past year, up from about 25% two years ago. Of those who make less than $30,000 per year, 46% reported problems paying medical bills, according to the October Kaiser Health Tracking Poll: Election 2008. Those who reported problems said the bills were in the thousands of dollars, not the hundreds. Lower-income families were more likely to skip or postpone appointments.

U.S. hospitals have also recently reported an increase in emergency room patients, including more uninsured patients, and elective surgeries and diagnostic tests at hospitals have fallen 1%-2% in recent months, compared with a usual increase of 2%-4% per year, the Oct. 22 Washington Post reported.

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Record number of reports of prescription drug deaths, injuries in early 2008

A record number of reports of deaths and serious injuries from prescription drugs were reported to the FDA in the first three months of 2008, with varenicline (Chantix, Champix) accounting for the greatest number of serious injuries, said a new report by the nonprofit Institute for Safe Medication Practices (ISMP).

There were 20,745 new reports of serious injuries from drug therapy and 4,824 reported deaths, a fatality increase of 2.6 times the previous quarter. Of these, 1,001 new injury cases were from varenicline, including 50 new deaths, the report said. Varenicline-related injuries included many accidents, falls, suicides and blackouts.

Heparin, the subject of a massive product recall after it was found to be contaminated via supplies from China, was associated with 779 serious injuries, the second highest number, and 102 deaths, the most of any drug. Many, but not all, of the heparin deaths were due to contamination, the report said.

In other recent drug news:

  • 24% of new-generation biological drugs cause serious reactions that lead to safety warnings soon after they are approved in the U.S. and Europe, often within five years, a study in the Oct. 22 Journal of the American Medical Association found.
  • The FDA needs better data management and inspections of overseas facilities, the General Accounting Office said in a September report. Divergent information in databases could cause confusion about which foreign facilities to inspect.

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Test Yourself

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MKSAP quiz: fever, cough and wheezing

A 35-year-old woman has a 3-day history of fever, productive cough, and wheezing. Her 2-year old son recently had a cough and fever to 38.9 °C (102 °F) that subsequently resolved. The patient has mild asthma that has not required treatment. She has a 10-pack-year smoking history but stopped smoking 3 years ago.

On physical examination, she coughs frequently and has mildly audible wheezing. Temperature is 38.2 °C (100.8 °F), pulse rate is 100/min, respiration rate is 16/min, and blood pressure is 115/75 mm Hg. Examination of the chest reveals bronchial breath sounds and a few crackles in the lateral right lower chest near the mid-axillary line. Arterial oxygen saturation is 94% by pulse oximetry with the patient breathing room air.

The leukocyte count is 11,900/ μL (11.9 × 109/L) with 80% neutrophils, 2% band forms, 14% lymphocytes, and 4% monocytes. A chest radiograph shows right middle lobe consolidation.

In addition to starting inhaled bronchodilators, which of the following is most appropriate at this time?

A) Await results of sputum culture before beginning therapy
B) Begin trimethoprim–sulfamethoxazole
C) Begin ciprofloxacin
D) Begin azithromycin
E) Begin gentamicin

Click here or scroll to the bottom for the answer.

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Clinical guidelines

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Guidelines updated for gastroesophageal reflux disease

The American Gastroenterological Association updated guidelines to manage gastroesophageal reflux disease (GERD).

The guidelines advise that:

  • proton pump inhibitors (PPIs) are more effective than histamine-2 receptor antagonists (H2RAs),
  • twice-daily PPIs work for patients not controlled by once-daily dosing,
  • PPIs should be used long-term if clinically effective, and then titrated down to the lowest effective dose based on symptom control,
  • prescribe PPIs instead of recommending antireflux surgery when they would have similar outcomes. Antireflux surgery is an alternative for patients who are responsive but intolerant of PPIs, or patients with persistent troublesome symptoms, especially regurgitation, despite PPI therapy. Weigh the benefits against surgical consequences such as dysphagia, flatulence, an inability to belch and postsurgery bowel symptoms, and
  • patients should undergo endoscopy with biopsy for esophageal GERD with troublesome dysphagia. Biopsies should target suspected metaplasia, dysplasia, or in the absence of visual abnormalities, normal mucosa (at least 5 samples to evaluate for eosinophilic esophagitis).

Physicians should not:

  • use alarm symptoms (other than troublesome dysphagia) as a screening tool to identify patients with GERD at risk for esophageal adenocarcinoma,
  • prescribe once- or twice-daily PPIs or H2RAs for acute treatment of patients with potential laryngitis or asthma in the absence of a concomitant esophageal GERD syndrome,
  • use routine endoscopy in subjects with erosive or nonerosive reflux disease to assess for disease progression, or
  • recommend less than daily dosing of PPI therapy as maintenance therapy in patients with an esophageal syndrome who previously had erosive esophagitis.

There is no or insufficient evidence that:

  • routine upper endoscopy diminishes the risk of death from esophageal cancer,
  • endoscopic screening for Barrett's esophagus and dysplasia in adults 50 years or older with more than five years of heartburn reduces mortality from esophageal adenocarcinoma, or
  • antireflux surgery is recommended for patients with an esophageal syndrome with or without tissue damage whose symptoms are medically well controlled, or as an antineoplastic measure in patients with Barrett's metaplasia.

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Cardiology

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Heart failure patients have higher fracture risk

Patients with heart failure may have an increased risk of hip and other orthopedic fractures, suggesting that they should be screened and treated for osteoporosis, a recent study found.

Using a population-based cohort of patients age 65 or older who presented at emergency rooms for cardiovascular disease over a three-year period, researchers compared 2,041 patients with a new diagnosis of heart failure (HF) with a control group of 14,253 patients with non-HF cardiovascular diagnoses. In the year following the ER visit, 4.6% of the HF patients sustained an orthopedic fracture (1.3% sustained hip fractures), compared with 1% of the control group (0.1% hip fractures). The study was published online Oct. 20 by the American Heart Association journal Circulation.

The mechanism linking heart failure and fractures is unclear, said the authors in an AHA news release. They speculated that possible reasons for the association might be elevation of the parathyroid hormone as heart failure worsens; poor adherence to strict diets prescribed for heart failure patients (such as insufficient vitamin D); and lack of exercise. The findings highlight that many older adults are not getting adequate screening and/or treatment for osteoporosis, they added.

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Diabetes management

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Diabetes groups provide new guidance on use of glitizones for diabetes

In an updated consensus statement on the management of type 2 diabetes, experts offered new guidance about thiazolidinediones, including advising against the use of rosiglitizone due to cardiovascular risks.

The update of the 2006 statement by the American Diabetes Association and the European Association for the Study of Diabetes notes that several analyses have suggested a 30%-40% increased risk for myocardial infarction with rosiglitazone, whereas pioglitazone has been shown to have no significant effects on cardiovascular disease. Given that there are other options, the committee recommended against using rosiglitazone but recommended use of pioglitazone or glucagons-like peptide-1 agonists (exenatide) in cases where hypoglycemia is particularly undesirable, such as in patients with hazardous jobs.

The groups continued to recommend a tiered approach to diabetes management:

  • lifestyle interventions and metformin at diagnosis with a glycemic goal of less than 7% A1C;
  • basal insulin or sulfonylurea if the target is not reached;
  • Initiation of insulin if none of the above therapies work.

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Advocacy

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ACP launches advocacy e-newsletter

The ACP Advocate, a biweekly e-newsletter focused on public policy issues affecting internal medicine, is now available free to College Members. ACP's Governmental Affairs Division will discuss such issues as the potential impact of a new President and Congress on the health care system, what Washington is doing about the primary care shortage, and how Congress plans to fix the Medicare payment system.

Look for these stories in the inaugural issue:

E-mail the ACP Advocate editors with comments or questions.

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Online resources

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New patient-centered medical home section on ACP Web site

A new patient-centered medical home (PCMH) section is now available on ACP's Web site to assist members in planning for a PCMH-oriented practice.

The section offers a basic explanation of the PCMH, what practices can expect and plan for when implementing changes, how to make changes most effectively, examples of projects that currently test the model, quick links to key PCMH organizations and recent publications and articles.

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Medicare news

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CMS to hold conference call for providers about ICD-10 coding

CMS will hold a conference call on Nov. 12 for Part A and B Medicare providers about its proposed transition to ICD-10 coding.

The ICD-10-CM/PCS National Provider Conference Call will include an overview of ICD-10, how it differs from ICD-9-CM, and what providers will need to consider when updating information technology systems to use the new codes. Instructions to register for the call are online , as is a copy of the presentation to be given during the call and additional information about this and other calls.

ACP opposes ICD-10-CM implementation, and has asked CMS to suspend adoption of the diagnosis code portion for physicians and other outpatient entities. ACP believes the potential benefits of this proposed adoption within the ambulatory setting are far outweighed by the related administrative burdens and costs. A study co-funded by ACP determined that a practice with three physicians and two administrative staff would spend $83,290 to convert to ICD-10. A large practice with 100 providers would spend more than $2.7 million.

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From ACP Internist

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Cast your health care ballot

With Election Day approaching and so many casting early ballots, ACP Internist is asking its readers which candidate's health care plan they favor, Sen. John McCain's or Sen. Barack Obama's, and whether their proposed health care reforms will influence your vote.

Need help deciding? ACP has a toolkit that analyzes the candidate's plans, then vote. Cast your ballot by Nov. 5; results will appear in an upcoming issue of ACP InternistWeekly. (This poll is not considered scientific and does not constitute an endorsement by the American College of Physicians.)

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On the blog

ACP Internist highlights the best of Chest 2008, and look for the latest edition of Medical News of the Obvious, new every Monday.

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Cartoon caption contest: October's winning entry

ACP InternistWeekly has compiled the results from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

This issue's winning cartoon caption was submitted by Matt Thorpe, ACP Student Member, a first-year student in the MD/PhD program at the University of Illinois at Urbana Champaign. He will receive a $50 gift certificate good for any ACP product, program or service. Readers cast 260 ballots online to choose the winning entry. Thanks to all who voted!

The winning entry:

Actually I was an ass before I went to medical school.
"Actually I was an ass before I went to medical school."

The winning caption received 45.4% of the votes cast. The runners-up were:

"I know it's shocking, but that's the standard of care for a broken leg." (37.7%)
"Once I figured out how to talk, I decided medical school couldn't be that hard." (16.9%)

The cartoon contest continues in the Nov. 4 issue of ACP InternistWeekly.

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MKSAP answer

D) Begin azithromycin

The complete MKSAP critique on this topic is available to subscribers in Infectious Disease: Item 114.

ACP's Medical Knowledge Self-Assessment Program (MKSAP) allows you to:

  • Update your knowledge in all areas of internal medicine
  • Prepare for ABIM certification or recertification
  • Support your clinical decisions in practice
  • Assess your medical knowledge with 1,200 multiple-choice questions

To order the latest edition of MKSAP, go online.

Return to the rest of ACP InternistWeekly.

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About ACP InternistWeekly

ACP InternistWeekly is a weekly newsletter produced by the staff of ACP Internist. It is automatically sent to all College members who have an e-mail address on file with ACP.

To add your e-mail address to your member record and to begin receiving ACP InternistWeekly, please click here.

Copyright 2008 by the American College of Physicians.

Test yourself

A 42-year-old woman is evaluated for an 8-month history of crampy abdominal pain and three loose bowel movements per day. The pain is relieved by a bowel movement. There are no nocturnal bowel movements, and there is no blood or dark tarry material in the stool. She has not had fever, night sweats, or weight loss. She has a history of Hashimoto disease and is treated with levothyroxine. Following a physical exam, rectal exam, and lab tests, what is the most appropriate next step in management?

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