In the News
for the Week of 6-17-08
- Bill on Medicare payments to doctors stalls in Senate
- Racial disparities in diabetes tracked to individual physician level
- Raw tomatoes investigated for Salmonella outbreak
- Mammogram facility characteristics affect accuracy
- Cancer treatment getting more expensive for Medicare
- Women, Mexican Americans at higher risk for subarachnoid hemorrhage
Annals of Internal Medicine
- Open-access experiment falls short of same-day appointment goal
- Hearing impairment common among adults with diabetes
- Coffee drinkers have slightly lower death rates
- HIV screening cost-effective in patients over 55
Toolkits and resources
- Updated risk-of-death charts show patients the dangers of smoking
- Joint Commission to hold medication safety symposium
- Boxed warning for becaplermin to reflect increased cancer risk
- Morphine sulfate recalled due to oversized tablet
- Zoledronic acid can now be used to prevent new fractures
From ACP Hospitalist
- Recommend your colleagues as Hospitalists of the Year
From ACP online
- What they’re saying on the blogs
From the College
- College Master lauded by White House for work on AIDS
- The Doctors Company rewards members with 2008 dividend
- EHR Partners Program unveiled
Cartoon caption contest
- Put words in our mouth: vote for your favorite entries
Bill on Medicare payments to doctors stalls in Senate
The Senate last week voted against a measure to avert a scheduled July 1 Medicare physician reimbursement cut of 10.6%. Medicare legislation crafted by Sen. Max Baucus (D-MT), S. 3101, narrowly failed to garner the 60 votes needed to allow the Senate to proceed to consideration of the bill.
Senate leaders of both parties have said they support replacing the cuts with positive updates as well as other key provisions championed by ACPincluding funding for a medical home demonstration project and increased payments for internists’ office visits and other evaluation and management services.
On June 6, Mr. Baucus, chairman of the Senate Finance Committee, introduced S. 3101. The bipartisan bill is co-sponsored by Sens. Olympia Snowe (R-ME), Gordon Smith (R-OR) and Jay Rockefeller (D-WV). Several days later, Sen. Chuck Grassley (R-IA), ranking member of the Senate Finance Committee, also introduced an alternative Medicare bill that had similar provisions to stop the physician payment cuts but did not include ACP-supported benefit expansions, or improved coverage for preventive services and mental health, as were in S. 3101. The bills also differ on how to pay for the new spending. Democrats favor redirecting excess spending on Medicare Advantage plans to pay for the improvements in traditional Medicare while most Republicans (and the White House) are opposed to such offsets. It was this issue, not the physician payment provisions, which derailed an agreement last week. Still, nine Republican Senators crossed over to vote for S. 3101.
Both bills not only would avert the scheduled Medicare cuts, but provide other significant benefits for internists. Both bills include provisions to:
- Provide 18 months of positive updates to replace devastating SGR payment cuts;
- Increase funding for the Medicare medical home demonstration;
- Change the way CMS determines budget neutrality adjustments so as to increase the relative value units—resulting in higher overall payments—for evaluation and management services provided by internists, effective January 1.
- Develop a methodology for providing targeted increases for primary care services, initially limited to physicians in Physician Scarcity Areas.
Despite the setback from last week’s Senate vote, ACP has succeeded in getting its key priorities addressed and supported in the bills introduced and supported by Democrats and Republicans alike. Negotiations among Senate leaders from both parties will resume again soon. ACP will keep you up to date on the negotiations and how members may help the efforts.
For the latest information, visit ACP’s legislative action center..
Racial disparities in diabetes tracked to individual physician level
Black patients with type 2 diabetes have worse outcomes than white patients, even when they are treated by the same physician, a new study found.
For the study, researchers collected data from a 14-center multispecialty group practice in eastern Massachusetts. They included 90 primary care physicians, all of whom treated at least five white and five black patients diagnosed with diabetes mellitus. Overall, the study recorded outcomes for 4,556 white patients and 2,258 black patients who had been treated by the physicians within the past two years.
White patients were significantly more likely than blacks to have an HbA1c of less than 7% (47% vs. 39%), LDL cholesterol under 100 mg/dL (57% vs. 45%) and blood pressure under 130/80 mm Hg (30% vs. 24%). The two groups received annual A1c and LDL tests were similar among the two groups, although black patients were less likely to receive a prescription for a statin. The study was published in the June 9 Archives of Internal Medicine.
The study authors conducted regression analyses to see whether the disparities could be attributed to patients’ sociodemographic factors, variations between physicians or differences within physician panels. They found no significant disparity between physicians, and that 13% to 38% of the disparities could be attributed to sociodemographic factors. However, the biggest difference, accounting for 66% to 75% of disparities, was within the physicians' panels. Also, high-performing physicians and those who treated many black patients did no better on the measures.
An accompanying editorial by AHRQ Director Carolyn Clancy posed two possible explanations. Although testing rates were the same, other aspects of care delivery (medication teaching, communication) could have been worse for black patients, or black patients could have been less actively engaged and likely to engage in behavior change, she said. Study authors suggested that potential solutions include greater attention from physicians to racial disparities as well as social factors that affect their patients, such as affordability of medications, access to healthy foods, and opportunities to exercise. More effective engagement between the health care system and the community and increased patient education may be required, they said..
Raw tomatoes investigated for Salmonella outbreak
Raw tomatoes are the likely suspect in an ongoing, multi-state outbreak of human Salmonella serotype Saintpaul infections.
Roma and round tomatoes have been identified as the likely source of the infections, according to investigations by the CDC, state public health officials, the Indian Health Service and the FDA. However, officials have not concluded which specific types caused the outbreak.
Since mid-April, 228 persons infected with Salmonella Saintpaul with the same genetic fingerprint have been identified in 23 states (see map), with Texas (68 people), New Mexico (55), Illinois (29), and Arizona (19) having the most cases. At least 25 people were hospitalized. No deaths have been officially attributed to this outbreak. However, a man in his sixties who died in Texas from cancer had an infection with the outbreak strain, which may have contributed to his death.
The previous rarity of this strain and the outbreak in all U.S. regions suggest that the tomatoes are distributed throughout much of the country. Clinical presentation of Salmonella and advice to consumers about safe sources of tomatoes and what foods to avoid (including those with raw tomatoes as an ingredient) are online.
The Government Accountability Office faulted the Bush Administration for its lack of FDA funding to protect the country's food supply, according to a Wall Street Journal report online (subscription required).
States with reported outbreaks of Salmonella serotype Saintpaul
Mammogram facility characteristics affect accuracy
Mammogram facilities with certain characteristics rate higher on an evaluation of screening accuracy, according to a new study.
In the observational study, researchers analyzed data from 44 facilities which had performed 484,463 mammograms on 237,669 women between 1992 and 2002. The mean sensitivity of the mammograms was 79.6% and the mean specificity was 90.2%. Facilities varied significantly in specificity but not sensitivity.
Using an analysis measure of accuracy, the study authors concluded that several characteristics of the facilities were associated with better accuracy. Accuracy was better in facilities that did only screening mammograms (not screening and diagnostic ones), those that had breast imaging specialists interpreting the mammograms, ones that did not perform double readings (and independent double readings were better than consensus double readings), and those that conducted audit reviews two or more times per year. Facility volume and the method of audit review were not associated with differences in accuracy.
The study authors suggested that their findings could allow women and their physicians to choose facilities based on the characteristics found to be significant. Facilities could also change their structures and processes to maximize quality, they said. The finding about double readings was a surprise, the authors noted, and could mean that double reading is not implemented effectively in practice or that only some methods of it work well.
The Journal of the National Cancer Institute is online..
Cancer treatment getting more expensive for Medicare
The cost of cancer care for Medicare beneficiaries rose dramatically during the 1990s, according to a new study.
Researchers used the Surveillance, Epidemiology, and End-Results Medicare-linked database to find 306,709 people age 65 or older who were diagnosed with breast, lung, colorectal, or prostate cancer between 1991 and 2002. They analyzed the cost of cancer treatment for each patient from two months before diagnosis to 12 months after, including surgery, chemotherapy, radiation, and other hospitalizations. The study was published online June 10 by the Journal of the National Cancer Institute.
During the study period, the average cost per lung cancer patient rose $7,139 to $39,891 (in inflation-adjusted dollars). Colorectal care went up $5,345 to $41,134 and breast cancer care rose $4,189 to an average of $20,964. The cost of treatment for prostate cancer declined slightly ($196) to $18,261, due to a decline in the use of surgery.
Hospitalizations accounted for the largest portion of these payments by Medicare, which exceeded $6.7 billion in 2002. According to the study authors, a substantial portion of the cost increases were due to greater use of chemotherapy and expensive new drugs. Radiation use also increased for all of the cancers except colorectal.
The cost trend increases are likely to continue in the future, and Medicare policy makers need to consider more efficient targeting of costly therapies, the study authors concluded. Because the study ended in 2002, it did not include many new expensive drugs as well as the expansion of the Medicare drug benefit, the authors noted.
The Journal of the National Cancer Institute is online.
Women, Mexican Americans at higher risk for subarachnoid hemorrhage
Mexican Americans and women may be at higher risk for subarachnoid hemorrhage, a new study found.
Researchers screened the medical records of 29,901 people in Southwest Texas, 38% of whom were non-Hispanic whites, 55% of whom were Mexican American, and 6% of whom were African American. The median age was 70, and 60% were women. Researchers validated 5,540 cerebrovascular events during the calendar years of 2000-2006; of those, 107 cases were subarachnoid hemorrhages that were used in the final analysis. The study was published in the June 11 online issue of Neurology.
Subarachnoid hemorrhage was 67% more common in Mexican Americans compared with non-Hispanic whites, and 74% more common in women compared with men, after adjustments for age. There were no significant racial/ethnic/gender differences in prevalence of hypertension, excessive alcohol use, tobacco use, hospital length of stay or in-hospital mortality—except that men had greater excessive alcohol use than women.
Past research suggests genetics may play a role in the higher risk of subarachnoid hemorrhage for Mexican Americans, the authors noted. Prior studies have also shown lower treatment rates of hypertension in Hispanics, and more poorly controlled hypertension in racial/ethnic minorities, they said. Past research also suggests that differences in hypertension, smoking and alcohol use, and the role of estrogen, might explain the gender disparity, but more research needs to be done on this, as well as on the possibility of a gender/ethnicity interaction in subarachnoid hemorrhage, the authors said.
The Neurology abstract is online.
The American Academy of Neurology press release is online.
Annals of Internal Medicine.
Open-access experiment falls short of same-day appointment goal
A small study of primary care practices that experimented with open-access scheduling showed no improvement in patient satisfaction or no-show rates, concluded a study in the June 17 Annals of Internal Medicine.
In the study, six primary care practices in the Boston area implemented open-access scheduling between October 2003 and June 2006. Five of the six were able to implement the new scheduling within four months and reduced their mean wait time for third available appointments from 21 to eight days for 15-minute visits and from 39 to 14 days for 30-minute visits. However, none of the practices achieved same-day access and there were no significant improvements in patient or staff satisfaction levels.
While noting the study's limitations, including a small sample size and the lack of control practices, the authors suggested that their findings point to a need for broader evaluation of open-access scheduling, which has been promoted as a way to ease pressure on busy physician practices and improve efficiency.
The six practices encountered several unexpected barriers that prevented them from successfully implementing the open-access model, including:
- Extended provider leaves, some of them unplanned, that caused unexpected fluctuations in appointment availability;
- The difficulty of assessing appointment demand due to a lack of specific data on each physician's panel size;
- Practices did not fully embrace or devote sufficient resources to the goal of achieving same-day access.
As pay-for-performance incentives focus on improving access to care, more practices will be considering open-access, said the authors, highlighting the need for rigorous large-scale evaluations of this model.
The Annals article is online..
Hearing impairment common among adults with diabetes
Hearing impairment is common in adults with diabetes, and diabetes seems to be an independent risk factor for the condition, according to a new analysis of the National Health and Nutrition Examination Survey.
Researchers analyzed data from 5,140 adults aged 20 to 69 who completed an audiometric examination and a diabetes questionnaire between 1999 and 2004. Hearing impairment was more prevalent among adults with diabetes. Age-adjusted prevalence of low- or mid-frequency hearing impairment of mild or greater severity assessed in the worse ear was 21.3% among 399 adults with diabetes compared with 9.4% among 4,741 adults without diabetes.
These differences in hearing between people with and without diabetes were present in both sexes; all groups of race or ethnicity, education and income; and all age groups but the oldest. Similarly, age-adjusted prevalence of high-frequency hearing impairment of mild or greater severity assessed in the worse ear was 54.1% among adults with diabetes compared to 32% among adults without diabetes.
“It is possible that high blood sugar levels damage the small blood vessels and nerves of the inner ear, resulting in hearing impairment," said the study’s lead author. "People with diabetes might benefit from having their hearing checked."
The study was released early online and will appear in the July 1 print issue of Annals of Internal Medicine. View the report in streaming video format..
Coffee drinkers have slightly lower death rates
Drinking large amounts of coffee (up to six cups per day) does not increase a person's risk for dying sooner than expected and may actually be protective, according to a new study.
Researchers analyzed data of 84,214 women who had participated in the Nurses' Health Study and 41,736 men who had participated in the Health Professionals Follow-up Study. Study participants completed questionnaires every two to four years that included questions about how frequently they drank coffee, other diet habits, smoking, and health conditions. The researchers then compared the frequency of death from any cause, death due to heart disease, and death due to cancer among people with different coffee-drinking habits.
Women consuming two to three cups of caffeinated coffee per day had a 25% lower risk of death from heart disease during the follow-up period (which lasted from 1980 to 2004) as compared with non-consumers, and an 18% lower risk of death caused by something other than cancer or heart disease. For men, this level of consumption was associated with neither a higher nor a lower risk of death during the follow-up period.
After accounting for other risk factors, such as body size, smoking, diet, and specific diseases, the researchers found that people who drank more coffee were less likely to die during the follow-up period. This was mainly because of lower risk for heart disease deaths among coffee drinkers. The researchers found no association between coffee drinking and cancer deaths. These relationships did not seem to be related to caffeine because people who drank decaffeinated coffee also had lower death rates than people who did not drink coffee.
View the report in streaming video format..
HIV screening cost-effective in patients over 55
A new study examined the cost-effectiveness of HIV screening in patients from age 55 to 75. Recently revised screening guidelines issued by the CDC recommend screening for all patients aged 13 to 64.
The study looked at economic effects of voluntary HIV screening in 8,672 inpatients and outpatients at six Department of Veterans Affairs Health Care Systems whose HIV status was unknown. The authors concluded that if the tested population has an HIV prevalence of 0.1% or greater, HIV screening in persons from age 55 to 75 is cost-effective.
The authors also suggest that to be cost-effective, screening decisions in patients older than age 64 should include factors such as whether the patient is at increased risk, has a partner at risk for contracting HIV, or has other life-threatening conditions. Advanced age alone should not preclude screening for HIV.
The Annals of Internal Medicine is online.
Toolkits and resources.
Updated risk-of-death charts show patients the dangers of smoking
Researchers have created simple, one-page charts for physicians’ offices that present the 10-year chance of dying from various causes according to age, sex and smoking status.
The researchers used the National Center for Health Statistics Multiple Cause of Death Public Use File and Census Data from 2004 to calculate age- and sex-specific death rates for various causes of death. They then combined data from the National Health Interview Survey on smoking prevalence and the relative risks of death from various causes for smokers to determine age-, sex-, and smoking-specific death rates. Finally, they accumulated these risks for various starting ages and made two charts for men and two for women.
The charts present the 10-year risks of dying from heart disease; stroke; lung, colon, breast, cervical, ovarian, and prostate cancer; pneumonia; influenza; AIDS; chronic obstructive pulmonary disease; accidents; and all causes. A simple form of the chart shows risks for current and never smokers; a more complex form includes former smokers. The study on the charts is published in the June 10 online issue of the Journal of the National Cancer Institute; the charts are published courtesy of the Dartmouth Institute for Health Policy and Clinical Practice.
The charts, updated from earlier versions, provide two elements people need if they are to make sense of health risks: the magnitude of the risk and a context, the researchers said. Posting the charts in examination rooms and handing them to patients may help facilitate discussion about disease risk, as well as highlight the dangers of smoking, they added.
The risk-of-death charts are online.
The Journal of the National Cancer Institute abstract is online..
Joint Commission to hold medication safety symposium
The Medication Safety Symposium: Teaming Up for Medication Management and Systems Improvement, convened by The Joint Commission and Joint Commission Resources, will take place August 5-7 at the Westin River North Hotel in downtown Chicago.
Due to the intricate relationships among all who are responsible for safe medication outcomes, the symposium is grounded in an interdisciplinary approach. The symposium’s purpose is to examine the major issues that influence medication safety. It will be taught by pharmacists, nurses and physicians who will provide proven approaches and solutions that they have used to overcome these issues in their organizations. In turn, faculty will share tools to effect these changes via a conference CD-ROM that participants can use in their home organizations to speed the change process.
More information is online.
Boxed warning for becaplermin to reflect increased cancer risk
A boxed warning will be added to the becaplermin (Regranex Gel 0.01%) label about an increased risk of cancer death in patients who use three or more tubes of the cream, the FDA said last week.
The product is used to treat leg and foot ulcers that aren’t healing in diabetic patients. A retrospective study compared cancer incidence and cancer death among 1,622 patients exposed to Regranex to 2,809 otherwise similar patients who were not exposed. There was no overall increase in cancer among those who used the cream, but there was a five-fold higher risk of cancer death in those who were exposed to three or more tubes of Regranex, the FDA said.
Providers should carefully weigh the risks and benefits of using Regranex; it’s not recommended for use on patients with known malignancies, an FDA official said.
The FDA release is online..
Morphine sulfate recalled due to oversized tablet
ETHEX Corp. is recalling several lots of morphine sulfate 30-mg and 60-mg extended-release tablets because they may contain tablets of twice the appropriate thickness.
Oversized tablets may contain up to twice as much the labeled level of active morphine sulfate. The lots were distributed under an "ETHEX" label between June 2006 and May 2008. The 30-mg product is a pink oval tablet with "30" on one side and "E" on the other. The 60-mg product is a white oval tablet with "60" on one side and "E" on the other. ETHEX Corp. originally recalled only one lot of the 60-mg product but extended the recall on June 13.
No reports of unexpected side effects or injury from the tablet have been received, the FDA press release said.
The recalled lot numbers are available in the FDA press release online.
The original press release regarding the recall is online..
Zoledronic acid can now be used to prevent new fractures
Zolderonic acid (Reclast) has been approved to prevent new fractures in patients who recently had a low-trauma hip fracture.
The once-yearly, intravenous biphosphonate is already indicated to treat osteoporosis. The FDA decided to expand the drug’s use based on data from a trial that showed a 35% reduction in the risk of new clinical fractures in patients treated with zolderonic acid. The risk of new spine fractures was reduced by 46% and new non-spine fractures by 27%, according to a release by the drug’s manufacturer.
Side effects may include transient post-dose symptoms like fever and muscle pain, which usually resolve within three days. These effects can also be reduced by adminstering paracetamol or ibuprofen shortly after Reclast infusion.
The drug manufacturer’s press release is online.
From ACP Hospitalist.
Recommend your colleagues as Hospitalists of the Year
ACP Hospitalist is seeking candidates for its first annual Hospitalists of the Year issue. To recommend a colleague who made notable contributions to the field in 2008, whether through cost savings, improved work flow, patient safety, leadership, mentorship or quality improvement, readers can fill out the online form. All recommendations must be received by July 14. Hospitalists of the Year will be profiled in our November 2008 issue.
From ACP Internist.
What they're saying on the blogs
Join the ACP Internist's community on its blogs, featuring daily updates on news that just can't wait. Find popular features such as Medical News of the Obvious, which trains its critical eye this week on news from, among other sources, the Associated Professional Sleep Society's annual meeting. Post your comments today.
From the College.
College Master lauded by White House for work on AIDS
Anthony S. Fauci, MACP, received the Presidential Medal of Freedom, the nation’s highest civil award, in recognition of his efforts to advance understanding and treatment of HIV/AIDS.
Anthony S. Fauci, MACP
Dr. Fauci, director of the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health (NIH), has made many contributions to the understanding and treatment of immune-mediated and infectious diseases, and he oversees an extensive research portfolio of basic and applied research to prevent, diagnose and treat such conditions. Dr. Fauci has studied HIV/AIDS and treated HIV-infected patients since the early days of the pandemic. As a key White House advisor on AIDS, he was a leading architect of the U.S. President’s Emergency Plan for AIDS Relief.
The medal, given to those who contribute to U.S. security or national interests, world peace or cultural or other significant public or private endeavors, will be awarded at a White House ceremony on June 19..
The Doctors Company rewards members with 2008 dividend
Members participating in the ACP-sponsored Professional Liability Insurance Program offered by The Doctors Company will receive a 5% premium dividend beginning with the annual renewal period on July 1.
ACP selected The Doctors Company, a leading medical malpractice carrier, as its sponsored professional liability insurance company in January 2001 after a comprehensive review of underwriters specializing in medical liability insurance. “The Doctors Company offers the best combination of financial strength, coverage features, competitive premium rates, exclusive premium discounts and aggressive claims handling of any insurer,” said ACP Executive Vice President and CEO John Tooker, FACP.
In addition to the dividend, the ACP-sponsored program offers many benefits to members: a 5% program discount upon underwriting approval, a 5% premium credit for completing Maintenance of Certification (MOC) in internal medicine or a subspecialty, inclusion in the Tribute® Plan, a unique financial benefit program that rewards physicians for their commitment to superior patient care, the financial backing of a highly-rated insurer with over $2.6 billion in assets, and aggressive claims defense.
Dividend distributions will appear as credits against current premiums effective with renewals beginning July 1, 2008. For additional information regarding professional liability insurance provided by The Doctors Company exclusively to ACP members, contact The Doctors Company at (800) 352-0320 or TDCSales@thedoctors.com. The ACP-sponsored Program is available in most states.
Additional dividend details and qualification information are available online..
EHR Partners Program unveiled
A new program to help ACP’s practicing physicians purchase and install EHR systems was unveiled last week. The EHR Partners Program, a service offered exclusively to ACP members, responds to needs for guidance in selecting and implementing practice-based EHRs.
Despite the great number of products available, EHR adoption rates remain low, especially in solo and small practices. The financial risk to a practice is one of the most frequently cited barriers to adoption.
The Partners Program is a collaborative effort between ACP and participating certified EHR partner companies. With the companion EHR Adoption Roadmap, ACP now provides a wide range of information and support for practices considering EHR implementation.
“ACP has developed this program in response to members’ need for EHR systems that match selected criteria,” explained ACP President Jeffrey P. Harris, FACP. “We feature an interactive comparison tool that can assist physicians in narrowing their EHR choices.”
The 2008 EHR Partners Program focuses solely on EHR applications that have achieved 2006 and/or 2007 certification by CCHIT. CCHIT looks at baseline criteria for functionality, security and interoperability.
When available, four sources of information were used to evaluate participating EHR systems:
- EHR vendor responses to a Request for Information (RFI);
- ACP-member responses to an EHR satisfaction survey that focused on usability and implementation support;
- A demonstration of the product based on a patient visit; and
- A site visit to a physician practice with an EHR-partner installation.
Current EHR Partner Program members and their products are:
|EHR Partner||EHR Partner’s Product|
|GE Healthcare||Centricity EHR|
|McKesson||Practice Partner Patient Records|
|MedInformatix (acentec)||MedInformatix EMR|
A news release on the EHR Partners Program is online.
Cartoon Caption Contest.
Put words in our mouth: vote for your favorite entry
ACP InternistWeekly's cartoon caption contest continues. ACP staff has selected four finalists for the latest contest and is now asking readers to vote for their favorite caption to determine the winner.
Go online to view the cartoon and pick the winner, who receives a copy of "Medicine in Quotations," ACP's comprehensive collection of famous sayings relating to sickness and health, disease and treatment and a portrait of medicine throughout recorded history.
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.
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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