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

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In the News
for the Week of 7-22-08

Highlights

  • Congress successfully halts Medicare payment cuts; look for adjustments to some July claims
  • Breast self-screening doesn’t reduce cancer deaths
  • Commonwealth Fund rates U.S. system performance lower than past years

Geriatrics

  • Elderly patients more satisfied when accompanied on medical visits
  • Physician outreach effort led to drop in injury-related falls in elderly
  • Knee-hip replacement outcomes worth the risk and recovery

Tools and resources

  • Employer’s handbook on medical home now available online
  • Influenza experts call for increased immunization rates

FDA news

  • CT scans could interfere with medical devices

Test yourself

  • MKSAP quiz: Abdominal pain

From the College

  • Regents approve clinical guidelines on pharmacological treatment of depression
  • ACP Foundation offering chapters grants for health literacy

From ACP Internist

  • Discuss mandatory e-prescribing on the blog
  • Cartoon caption contest

Highlights

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Congress successfully halts Medicare payment cuts; look for adjustments to some July claims

Physicians got a reprieve from a scheduled 10.6% Medicare payment cut last week when Congress voted to override a presidential veto of legislation to avert the cut scheduled to take effect July 1. As a result, payment rates will be unchanged in the second half of this year and increase by 1.1% in 2009, instead of the planned 5.4% cut.

The legislation (H.R. 6331) will also increase payments for office and hospital visits, a provision specifically requested by ACP; allow internists to qualify for higher payments from quality reporting under the Physician Quality Reporting Initiative; and allocate funding for a Medicare medical home demonstration project. ACP’s Web site has more on the bill’s impact on internists and patients.

CMS is instructing contractors to automatically reprocess claims submitted between July 1, the date of the scheduled cut, and July 15, to reflect the new legislation. Claims submitted to Medicare during the first two weeks of July are likely to be processed at the reduced rate with the additional 10.6% mailed to physicians in later adjustments. July 1 could be the exception since CMS has not yet instructed contractors to hold claims for longer than the mandated 14 days following receipt.

The College has developed an online calculator for physicians to determine how the bill will affect their individual practices. Also, go online for more on how the legislation affects payment rates and claims processing.

A list of highlights of the legislation also are available on the American Medical Association’s Web site.

Also included in the Medicare update was a mandate to e-prescribe, with financial incentives and penalties set to begin between 2009 and 2013. But many physicians don’t use e-prescribing and say they aren’t ready to start. Read more about the issue on the ACP Internist blog.

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Breast self-screening doesn’t reduce cancer deaths

Breast self-exams don’t reduce cancer deaths, researchers reaffirmed based on a follow-up of their original study.

Because breast self-exams have been promoted as a way to diagnose breast cancer earlier and decrease mortality, researchers looked at two large population-based studies involving 388,535 women which compared breast self-examination with no intervention. They reported their results in The Cochrane Review as a follow-up to their original research published in 2003.

The studies included women in two randomized studies from Russia and China that compared breast self-examination with no intervention. No statistically significant difference in breast cancer mortality existed between the groups (relative risk 1.05, CI 0.90 to 1.24; 587 deaths). In Russia, more cancers were found in the breast self-examination group than in the control group (relative risk 1.24, CI 1.09 to 1.41). This was not the case in China (relative risk 0.97, CI 0.88 to 1.06).

The study noted that nearly twice as many biopsies with benign results were performed in the screening groups (3,406) compared with the control groups (1,856) (relative risk 1.88, 95% CI 1.77 to 1.99).

Researchers concluded there was no benefit to mortality from self-screening, but added “It is possible that increased breast awareness may have contributed to the decrease in mortality from breast cancer that has been noted in some countries. Women should, therefore, be encouraged to seek medical advice if they detect any change in their breasts that may be breast cancer.”

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Commonwealth Fund rates U.S. system performance lower than past years

The performance of the U.S. health care system is falling further behind that of other industrialized countries, especially on measures of access and preventable mortality, according to an annual scorecard from the Commonwealth Fund.

The U.S.’s overall scores have not improved since the private foundation began issuing the scorecards in 2006, and the country has fallen from 15th out of 19 to last place on a measure of mortality amenable to medical care. Compared with benchmarks of top performance achieved internationally and within the U.S., the average performance of the American health system scored 65 out of 100 in the 2008 report.

Exceptions to the overall trend were found in metrics that have been the focus of national improvement campaigns or public reporting, the report said. Such areas included hospital standardized mortality rates and control of diabetes and high blood pressure. Based on these findings, the authors suggested that similar attention should be paid to areas of U.S. health care which are particularly lacking, such as mental health care, primary care, hospital readmissions and adverse drug events.

The scorecard also found that the U.S. was particularly deficient in efficiency, scoring 53 out of 100 on inappropriate, wasteful or fragmented care; avoidable hospitalizations; variation in quality and costs; administrative costs; and use of information technology. Reducing insurance administration, improving primary care, and increasing care coordination could substantially reduce health care expenditures, the report said.

Geriatrics

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Elderly patients more satisfied when accompanied on medical visits

Elderly patients who brought a companion to their routine medical visits were more satisfied with their physicians, a new study found.

In the study, 12,000 community-dwelling Medicare beneficiaries were surveyed on whether they were accompanied and how satisfied they were with their physicians. Overall, 38.6% of the beneficiaries were accompanied, and their companions performed a number of tasks, including recording physician instructions (44%), providing information about the patient’s medical conditions and needs (42%), asking questions (41%) and explaining physicians’ instructions (30%). The study was published in the July 14 Archives of Internal Medicine.

Accompanied patients were more highly satisfied with their physician’s technical skills (odds ratio, 1.15), information giving (OR, 1.19) and interpersonal skills (OR, 1.18) than those who came alone. The patients with the most actively engaged companions rated their physicians even higher on information giving and interpersonal skills (OR, 1.42 and 1.29, respectively). This relationship was strongest among beneficiaries with the worst self-rated health. Among the sickest patients, more physician-companion communication resulted in higher patient ratings of the physician’s communication skills.

The study authors concluded that more systematic recognition and integration of visit companions may benefit quality of care for vulnerable older adults. Specifically, physicians who fear that the presence of family members could impede care should be comforted by the generally positive effect seen in the study and they should consider the potential value of these companions in improving care for elderly patients, the authors said. Education to prepare physicians (and patient companions) for these interactions might make them even more valuable, they concluded.

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Physician outreach effort led to drop in injury-related falls in elderly

An educational program for primary care physicians led to a significant decrease in fall-related injuries and among elderly patients, reported a study in the July 17 New England Journal of Medicine.

In the study, researchers compared rates of injuries from falls among adults age 70 and older in two regions in Connecticut, one that implemented educational interventions based on evidence from the Connecticut Collaboration for Fall Prevention and another with no educational interventions. Before the intervention, both regions had adjusted rates of serious fall-related injuries of 31-32 per 1,000 person years. After a two-year evaluation period, the adjusted rate of serious fall-related injuries was 9% lower in the intervention region than in the usual care region (28.6 vs. 31.4 per 1,000 person years, respectively) and fall-related use of medical services was 11% lower.

The intervention encouraged physicians to adopt effective risk assessments and strategies, including reduction in medications; management of postural hypotension; management of visual and foot problems; hazard reduction; and balance, gait and strength training.

The Connecticut Collaboration for Fall Prevention’s Web site offers educational and training resources for physicians. According to the site, the most common health problems that increase the risks of falling are:

  • problems walking or moving around,
  • four or more medications,
  • foot problems, unsafe footwear,
  • blood pressure drops too much on standing up or dizziness,
  • problems with seeing, and
  • trip hazards in the home.

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Knee-hip replacement outcomes worth the risk and recovery

Elderly patients who had hip or knee replacements for severe osteoarthritis took several weeks to recover but experienced excellent long-term outcomes, a conclusion that should be shared with all patients considering major surgery, researchers said.

Because osteoarthritis of the hip and knee is a common cause of pain and disability in elderly patients, researchers conducted a prospective cohort study to examine decision making and clinical outcomes for patients 65 years or older with symptoms uncontrolled by conservative treatments. Researchers wanted to compare the risks of surgery and the discomfort of recovery to the potential benefits of surgery, and reported their results in the Archives of Internal Medicine.

The study assessed osteoarthritis symptoms and functional status at baseline at 12 months using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. Patients scored a mean of 56 on a 100-point scale. During a 12-month follow-up, 51 patients (29%) had joint replacement surgery (30 knee and 21 hip replacements).

The patients who underwent surgery had postoperative symptoms and function assessed 6 weeks, 6 months and 12 months after surgery. Seven had postoperative complications. The complication rate was 16.0% for patients aged 60 to 74 years and 18.8% for those 75 years or older; (P > .99). Also, 38.3% had postoperative pain lasting more than 4 weeks.

Median recovery time to independent walking was 12 days and to ability to perform household chores was 49 days, with similar times for patients ages 65 to 74 and 75 or older. At 12 months, WOMAC scores improved by 24 points in the patients who had surgery and 0.5 point in the patients who did not have surgery (P < .001) Among patients 75 years or older, improvements were 19 and 0.3 points (P < .001).

This study prospectively studied patients with severe osteoarthritis and did not focus only on the results from those referred for surgery, so it extends previous research into surgery’s effectiveness, authors concluded.

Researchers wrote, “Some research suggests that elderly patients are reluctant to have joint replacement surgery, undervalue the benefits, and are concerned about recovery and the need for help after surgery. Providing patients with more information about the experience of other elderly patients may affect patients’ attitudes and preferences.”

Tools and resources

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Employer’s handbook on medical home now available online

The Patient-Centered Medical Home: A Purchaser Guide, a handbook for understanding the medical home model and taking action to advance its implementation, is now available through the Patient Centered Primary Care Collaborative (PCPCC). The PCPCC is a coalition representing the country’s national business leaders, consumer groups, organizations—including ACP—representing primary care physicians and other health care stakeholders.

The guide begins with a definition of the medical home concept and sets out advantages of its implementation for employers based on effectiveness for improving outcomes and lowering health-care costs. A central impetus of the guide is to spur employer activity. One section illuminates a three-step “jump start” to help employers begin to advance the patient-centered medical home model (PCMH). Six strategies purchasers can use also are included:

  • Participate in a regional pilot;
  • Incorporate PCMH into insurer procurement and performance assessment activity;
  • Align payment strategy with PCPCC adoption objectives;
  • Build coalitions in support of PCMH;
  • Engage consumers; and
  • Integrate PCMH into other corporate health strategies.

The Purchaser Guide offers five case studies of PCMH initiatives and includes 21 summary examples of PCMH models in operation throughout the U.S. One case study of the PCMH in practice in North Carolina saved the state’s Medicaid program approximately $124 million in a single year. The guide also includes sample insurance contract language and a Request for Information document designed to assist purchasers who want to work with health plans to advance PCMH.

The Patient-Centered Medical Home: A Purchaser Guide can be downloaded free of charge. More information about the PCPCC is online.

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Influenza experts call for increased immunization rates

Leading influenza experts called for increasing flu immunizations in the U.S., stressing that the medical community is capable of providing better protection against a disease that causes over 200,000 hospitalizations and 36,000 deaths annually.

The recommendation, published in a July supplement to The American Journal of Medicine, supports guidelines from CDC and is aimed at reducing influenza-related illness and death, particularly among high-risk populations including children, the elderly, and those with chronic conditions. Earlier this year, the CDC expanded its recommendations to include all children 6 months through 18 years of age, bringing the number of Americans recommended for immunization to an unprecedented 250 million.

Experts assert in the supplement that the medical community could better use routine office visits as opportunities to immunize recommended individuals. Although the authors emphasize different aspects of influenza immunization in the recommendation, all agree that vaccination should be offered by health care providers from October through January and beyond. The new recommendation is expected to take effect no later than the 2009-10 influenza season.

ACP commended the National Foundation for Infectious Diseases and CDC in their efforts to encourage physicians to vaccinate their patients at every available opportunity throughout the entire influenza season.

FDA news

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CT scans could interfere with medical devices

CT scans may cause malfunctions in some implanted and external medical devices, according to a new public health notification from the FDA.

The agency reports having received a small numbers of adverse event reports in which CT scans may have interfered with devices including pacemakers, defibrillators, neurostimulators and implanted or externally worn drug infusion pumps. No deaths have been reported to date, and the FDA is continuing to investigate the issue.

The notification offered recommendations for CT procedures in which a medical device is in or immediately adjacent to the programmed scan range, including:

  • If practical, try to move external devices out of the scan range;
  • Ask patients with neurostimulators to shut off the device temporarily while the scan is performed;
  • Minimize X-ray exposure to the implanted or externally worn electronic medical device by:
  • Using the lowest possible X-ray tube current consistent with obtaining the required image quality; and
  • Making sure that the X-ray beam does not dwell over the device for more than a few seconds;

For CT procedures that require scanning over the medical device continuously for more than a few seconds, as with CT perfusion or interventional exams, attending staff should be ready to take emergency measures to treat adverse reactions if they occur, the FDA said. Patients should also be asked to check the function of their devices after scanning, and contact a health care provider if they suspect any problems. Problems with electronic medical devices that might be caused by CT scanner interference include:

  • generation of spurious signals, including cardiac defibrillation pulses,
  • misinterpretation of signals produced by the x-rays as actual biological signals,
  • missed detection of actual biological signals, and
  • resetting or reprogramming of device settings.

Test yourself

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MKSAP quiz: Abdominal pain

ACP Internist has brought back its MKSAP quiz. This popular feature was so heavily requested by our readers that we’re restoring it weekly in our e-mail updates.

Case Study:
A 57-year-old woman is evaluated for a 6-month history of worsening cough and that has been for the past 6 weeks accompanied by exertional dyspnea. She is otherwise healthy. She was first evaluated for cough 3 months ago; chest radiograph and spirometry were normal, and evaluation for gastroesophageal reflex disease was negative. Therapy with antihistamines, inhaled albuterol, and a proton pump inhibitor provided minimal relief. The cough has now worsened with continued white/yellow sputum production and fatigue. The patient is an avid runner, but she now has marked dyspnea after running for 10 minutes. She is a lifelong nonsmoker and has no history of recurrent infections or sinopulmonary disease.

On physical examination, the temperature is 36 C (97.3 F), blood pressure is 103/66 mm Hg, pulse rate is 67/min, respiration rate is 14/min, and BMI is 21. The nasopharynx and oropharynx are clear; there is no cervical lymphadenopathy. Examination of the chest shows a few mid-inspiratory crackles in the right posterior mid-lung field and occasional late expiratory squeaks in the right lung. The rest of the examination is normal. CT scan of the chest is shown; there is no mediastinal lymphadenopathy.

CT scan of chest
Click image for larger view

Which of the following is the most appropriate next step in the management of this patient?

      A. Therapy with levofloxacin
      B. Bronchoscopy
      C. Sputum culture and analysis for acid-fast bacilli
      D. Methacholine challenge test
      E. Measurement of serum immunoglobulins

Click here or scroll to the bottom of the page for the correct answer.

From the College

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Regents approve clinical guidelines on pharmacological treatment of depression

The Board of Regents took action on several important items at its July 12-13 meeting in Philadelphia, including approval of a guideline for drug treatment of depression and a position paper that gives doctors guidance on developing relationships with family caregivers. The Regents voted to:

  • Urge Congress to pass legislation that would allow Medicare patients to use a preventive health benefit along with an evaluation and management visit on the same day. The legislation would also mandate a reimbursement level that would account for the time and effort it takes to advise patients on preventive benefits.
  • Approve a clinical guideline on the use of second-generation antidepressants to treat depressive disorders. The guideline will be published in an upcoming issue of the Annals of Internal Medicine.
  • Approve a position paper that gives physicians ethical guidance on how to develop relationships with family caregivers. The principles include that clinical encounters should be patient-centered, such that patients participate in decisions and are as autonomous as possible; that physicians routinely assess a patient’s wishes about the nature and degree of caregiver participation; that the patient, caregiver and family are up-to-date on the patient’s condition and prognosis; and that the physician be alert for signs of distress in the caregiver.
  • Expand medical student membership to countries outside ACP chapters for students enrolled in a medical school that is recognized by the American Medical Association. These students can be members for as long as they are enrolled in medical school.

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ACP Foundation offering chapters grants for health literacy

The ACP Foundation has established a Health Literacy Awards Program for ACP chapters to increase awareness of health literacy and the foundation at the chapter level. Five $10,000 grants will be available in 2009. The awards will be made in two installments: $5,000 at the start of the project and an additional $5,000 when the chapter fulfills all of the project goals, anticipated outcomes and a final report is received. A completed grant application and budget are required for project review.

The grant application and budget are online as a PDF or Word document.

Proposals are due Sept. 15 by e-mail foundation@acponline.org or fax to 215-351-2612. For questions, contact Stacey Dailey at sdailey@acponline.org or 215-351-2809.

From ACP Internist

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Discuss mandatory e-prescribing on the blog

The recent Medicare legislation included a mandate to e-prescribe, with financial incentives and penalties set to begin between 2009 and 2013. But many physicians don’t use e-prescribing and say they aren’t ready to start. Read more about the issue on the ACP Internist’s blog.

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Cartoon caption contest

ACP InternistWeekly wants readers to create captions for this cartoon and help choose the winner.

cartoon caption contest

E-mail all entries to acpinternist@acponline.org by July 25. ACP staff will choose three finalists and post them in the July 29 issue of ACP InternistWeekly for an online vote by readers. The winner will appear in the Aug. 5 issue.

Pen the winning caption and win a $50 gift certificate good for any ACP product, program or service.

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MKSAP Answer

C. Sputum culture and analysis for acid-fast bacilli, to diagnose nontuberculous mycobacterial lung disease.

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 view the complete MKSAP syllabus and critique on this topic (subscribers only) or 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.

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Test yourself

A 76-year-old woman is evaluated for a 3-month history of left knee pain of moderate intensity that worsens with ambulation. She reports minimal pain at rest and no nocturnal pain. There are no clicking or locking symptoms. She has tried naproxen and ibuprofen but developed dyspepsia; acetaminophen provides mild to moderate relief. The patient has hypertension, hypercholesterolemia, and chronic stable angina. Medications are lisinopril, metoprolol, simvastatin, low-dose aspirin, and nitroglycerin as needed. Following a physical exam, lab results and radiograph, what is the next best step in management?

Find the answer

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