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

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In the News
for the Week of 6-30-09

Highlights

  • 7% of patients not told about abnormal lab results
  • No need to monitor bisphosphonate effects in first three years
  • Knee replacements worth the price, and surgeon's experience matters

Test yourself

  • MKSAP quiz: breast cancer risk

Internists and compensation

  • Compensation for primary and specialty care losing against inflation
  • Still time to earn bonus payment for Medicare reporting

Immunization update

  • CDC encourages pneumococcal vaccination during H1N1 outbreak

From ACP Internist

  • Latest issue online and coming to your mailbox

From the College

  • ACP books available on new eBooks Web site
  • Survey asks internists to evaluate value of genomics agency's services
  • Embracing a culture of cost-effective health care
  • ACP Practice SolutionsSM introduces medical home toolkit

Cartoon caption contest

Editorial note: ACP InternistWeekly will not be published next week due to the Independence Day holiday.

Physician editor: Darren Taichman, ACP Member


Highlights

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7% of patients not told about abnormal lab results

Abnormal test results were not reported to patients more than 7% of the time in a recent study of primary care practices.

Researchers reviewed medical records for more than 5,000 patients of 23 primary care practices. They found 1,889 abnormal test results, 135 of which were not communicated to the patients. Some of the uncommunicated results included a cholesterol level of 318 mg/dL, a hemoglobin A1c of 18.9%, and a potassium level of 2.6 mEq/L. The study was published in the June 22 Archives of Internal Medicine.

The rates of failure to inform varied among the practices, with a range from 0% to 26.2%. The study also looked at the processes used by the clinics to inform patients, and found that better processes resulted in better management of test results, as well as greater physician satisfaction with the systems. Very few practices had explicit rules; most relied on physicians to develop their own systems. Practices with a combination of electronic and paper records most often failed to inform patients. There was no significant difference in rates between the fully electronic and paper-based practices.

Study authors noted that many of the practices used the “no news is good news” system for informing patients of test results, which the Agency for Healthcare Research and Quality advises against. The authors suggested that the problem be approached systematically, rather than by individual physicians. For example, they observed some medical practices in which the electronic medical record routed all test results to the responsible physician and recorded whether the physician reviewed the results.

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No need to monitor bisphosphonate effects in first three years

Routine monitoring of bone density is unnecessary for women in their first three years of bisphosphonate treatment, according to a new study.

The Fracture Intervention Trial compared the effects of alendronate and placebo in 6,459 postmenopausal women with low bone density. The patients’ bone density was measured at hip and spine at baseline and one, two and three years after randomization. For this study, published online by BMJ last week, researchers then calculated the between-person and within-person variation in density over three years.

Overall, three years of treatment resulted in a 0.30 g/cm2 increase in hip density compared to a 0.012 g/cm2 decrease in the placebo group. The between-person differences were small and 97.5% of patients had an increase of at least 0.019 g/cm2. Such an increase would be sufficient to continue therapy in most patients and therefore individual monitoring of response is not necessary, the study authors concluded. They noted that although the National Osteoporosis Foundation and the American Association of Clinical Endocrinologists currently recommend monitoring during the first two years, densitometry may be unnecessarily consuming health care resources.

The study also found a high correlation between hip and spine density, indicating that measurements from two sites have little advantage over the use of one site. Because other oral bisphosphonates, including risedronate and ibandronate, operate similarly to alendronate, it is reasonable to generalize the study’s results to these other medications, the authors said. Clinicians may have other reasons for monitoring treatment, such as measuring adherence, but direct interviewing could accomplish that goal, the study authors said. Therefore, they recommended against routine monitoring during the first three years after bisphosphonate therapy is started.

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Knee replacements worth the price, and surgeon's experience matters

Total knee arthroplasty is cost-effective, and high-volume hospitals get better outcomes at a lower cost, researchers reported based on a computer model of quality-adjusted life expectancy and quality of life years.

Approximately 12% of adults 60 years and older have knee osteoarthritis, a figure expected to rise as life expectancy and obesity increase, researchers reported. More than a half-million knee replacements were done in 2005 at a cost of $11 billion.

Researchers developed a computer model based on Medicare claims data and cost and outcomes data from national and international sources. They projected lifetime costs and quality-adjusted life expectancy for different risk populations and varied total knee arthroscopy intervention and hospital volume. Cost-effectiveness of knee replacement was estimated across all patient risk and hospital volume permutations. Finally, they conducted sensitivity analyses to determine various parameters' influences on cost-effectiveness. They reported results in the Archives of Internal Medicine.

Knee replacement increased quality-adjusted life expectancy (QALE) from 6.822 to 7.957 quality-adjusted life years (QALYs), researchers reported. Lifetime costs rose from $37,100 without knee replacement to $57,900 after knee replacement, resulting in an incremental cost-effectiveness ratio of $18,300 per QALY. For high-risk patients, knee replacement increased QALE from 5.713 to 6.594 QALY for a cost-effectiveness ratio of $28,100 per QALY.

Researchers further stratified the study population by hospital procedure volume (low, 1-25 per year; medium, 26-200; high, more than 200) and risk categories based on the likelihood of perioperative complications by age, comorbidities, and poverty status. At all risk levels, knee replacement was costlier and less effective in low-volume centers than high-volume ones. Compared to no knee replacement, cost-effectiveness at a high-volume center for low-risk patients was $9,200 per QALY and for medium-risk patients it was $17,400 per QALY. For high-risk patients, the cost-effectiveness in a medium-volume center was $26,600 per QALY compared to no replacement.

Furthermore, knee replacement for high-risk patients in a high-volume center increased quality-adjusted life expectancy from 6.608 to 6.630 years at an additional cost of $3,000, an incremental cost-effectiveness ratio of $135,700 per QALY, researchers said. For high-risk patients, knee replacement in low-volume centers cost more and did not produce as effective outcomes as surgeries performed in either high- or medium-volume centers. Compared with no knee replacement, surgery in low-volume centers had a cost-effectiveness ratio of $29,800 per QALY for high-risk persons.

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Test yourself

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MKSAP quiz: breast cancer risk

A 47-year-old white, premenopausal woman is evaluated during a routine examination. She had her first menstrual period at 14 years of age, and her first live birth at age 32 years. Results of two previous breast biopsies were benign. Her family history includes a mother who had BRCA1/2-negative breast cancer. Physical examination is normal.

MKSAP quiz: breast cancer riskThe patient is concerned about developing breast cancer and wants to know if there is anything she can do to reduce her risk for this disease. The National Cancer Institute's online breast cancer risk prediction tool is used to determine that her breast cancer risk over the next 5 years is 3.5%.

Which of the following is the most appropriate intervention for lowering this patient's breast cancer risk?

A) Raloxifene
B) Tamoxifen
C) Conjugated equine estrogen
D) Bilateral prophylactic mastectomy

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

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Internists and compensation

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Compensation for primary and specialty care losing against inflation

Physician pay in primary and specialty care declined against inflation in 2008, and internists fared the worst in primary care, according to the Medical Group Management Association's report, "Physician Compensation and Production Survey: 2009 Report Based on 2008 Data."

Inflation rose 3.8% last year. All primary care physicians had a 1.73% decrease when adjusted for inflation (2% increase before adjustment; median of $186,044). Internists experienced a 3.37% loss against inflation (0.34% increase before adjustment; median of $191,198) and fared the worst among their primary care counterparts.

Specialists had a 1.59% decrease when adjusted for inflation (2.19% increase before adjustment; median of $339,738). Emergency medicine physicians, dermatologists and general surgeons all reported flat salaries before inflation was factored in, with losses of up to 3.2% percent after inflation. Gastroenterology, up 7.38%, and pulmonary medicine, up 6.65%, were among the few specialties that posted gains last year. Psychiatry posted a 1.32% loss in compensation before inflation last year, and its five-year increase was 7.16%, half that of other specialties.

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Still time to earn bonus payment for Medicare reporting

Physicians and other eligible professionals can still qualify to earn incentive payments through the Physician Quality Reporting Initiative (PQRI) for 2009. A new half-year reporting period begins July 1, and physicians who have not yet begun reporting may choose to do so then. To be eligible to receive the half-year incentive payment, physicians need to report three different PQRI quality measures for 80% of the applicable Medicare patients they see between July 1 and December 31.

The PQRI program was introduced by CMS in July 2007. The program pays physicians a bonus for reporting quality data to CMS on their claims forms. More information about the program and how you can participate is available on ACP's Web site.

CMS has also announced a list of Qualified Registries that can report 2009 PQRI data on behalf of physicians. Physicians who are interested in using registries to report data should contact one listed on the PQRI Web site.

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Immunization update

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CDC encourages pneumococcal vaccination during H1N1 outbreak

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) recommends a single dose of the 23-valent pneumococcal polysaccharide vaccine (PPSV23) for all people 65 years of age and older and for persons 2 to 64 years of age with certain high-risk conditions because they are at increased risk of pneumococcal disease and serious flu complications.

The CDC recommends a single revaccination at least five years after the initial one for people 65 years and older who were first vaccinated before age 65 years as well as for people at highest risk, such as those who have no spleen and those who have HIV infection, AIDS or malignancy. Emphasis should be placed on vaccinating people aged less than 65 years who have established high-risk conditions because PPSV23 coverage among this group is low and because people in this group appear to be overrepresented among severe cases of novel influenza A (H1N1) infection. PPSV23 among people without current indications for vaccination is not recommended at this time. The entire recommendation and PPSV23 coverage estimates are online.

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From ACP Internist

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Latest issue online and coming to your mailbox

The next issue of ACP Internist is online and coming to your mailbox. In July we digest:

  • A brave new world of consumer gene tests. Direct-to-consumer tests are common—and sometimes wrong. Learn how to work with patients who seek medical advice based on what they uncover about their genomes.
  • Cardiac care critical for diabetic patients. Even the experts feel like they’re missing potential cardiological complications in diabetic patients. They consider how to screen this population effectively.
  • Start at the top to get to the bottom of a diagnosis. ACP Member C. Christopher Smith reconsiders a patient’s self-reported diagnosis of irritable bowel syndrome to uncover the true cause of his symptoms.
ACP Internist

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From the College

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ACP books available on eBooks Web site

More than 40 books published by ACP Press are now available for purchase in digital format. Visitors can search the full text of an entire book, view sample pages online before making a purchase and purchase digital copies of books at reduced prices. A personalized electronic bookshelf allows readers to store, read and manage eBooks, and Flash technology creates an electronic version of each page identical to the print version. Users can bookmark pages, add notes, e-mail a selected page to a friend, and place a link to an eBook on their personal blogs or Web sites. The abilities to purchase individual chapters of a book and download an eBook for offline reading are coming soon.

Print versions of books are available through ACP's print product catalog.

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Survey asks internists to evaluate value of genomics agency's services

The Centers for Disease Control and Prevention is asking internists to evaluate the products and process of Evaluation of Genomic Applications in Practice and Prevention, a multi-disciplinary working group establishing an evidence-based process to assess the effectiveness of genetic tests moving from research to clinical practice. Participation is voluntary and anonymous. The survey is available online.

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Embracing a culture of cost-effective health care

Steven Weinberger, FACP, continues his monthly blog column for KevinMD.com with a look at the some of the reasons for the overuse or misuse of diagnostic testing.

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ACP Practice SolutionsSM introduces medical home toolkit

three-minute video tourACP's Medical Home Builder (MHB) is being offered to support practices moving toward a Patient-Centered Medical Home (PCMH) model.

A self-evaluation will direct practices to relevant strategies, practical tools such as chart forms, templates for office policies, informative videos, voiceover slides, Web sites and documents. Click here for a three-minute video tour.

ACP offers the MHB as an affordable way for PCMH project organizers to provide easily accessible online guidance. Based on an intuitive interface, this self-paced program will guide practices through a thorough yet simple process for evaluating their practice in seven different important areas:

  • patient-centered care and communication,
  • access and scheduling,
  • organization of practice,
  • care coordination and transitions in care,
  • use of technology,
  • population management, and
  • quality improvement and performance improvement.

Price:

PCMH Project Size
License Fee *
Per Practice Fee
10 or fewer practices
$750
$85
11-20 practices
$1,050
$85
21-50 practices
$1,350
$85
>50 practices
Please contact ACP
(see below)
 

*Up to 7 AMA PRA Category 1 credit(s)™ are available at no additional charge to ACP members as part of the license fee.

Please contact Paula Woodward at CPII@acponline.org or 202-261-4556 for more information.

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Cartoon caption contest

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And the winner is …

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 Bryan D. Kraft, ACP Associate Member. He will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 261 ballots online to choose the winning entry. Thanks to all who voted!

Your patellar reflexes appear to be 3+.
"Your patellar reflexes appear to be 3+."

The winning entry captured 63.6% of the votes.

The runners up were:
"How should I treat the middle leg in a hokey-pokey?"
"I put my pants on one leg at a time, just like you do."

ACP Internist's cartoon caption contest continues next week.

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MKSAP Answer and Critique

The correct answer is B) Tamoxifen. This item is available online to MKSAP subscribers in the Hemotology/Oncology section, Item 88.

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.

This patient has a substantially elevated risk for breast cancer compared with a woman of the same age who is at average risk for breast cancer (3.5% absolute risk vs. 1.1% absolute risk). Tamoxifen has been shown in randomized trials to decrease the risk for breast cancer by approximately 50% in pre- and postmenopausal women who have an absolute risk of breast cancer over the subsequent 5 years of at least 1.66% and is a reasonable intervention in this patient. Although she is likely to derive net benefits from the use of tamoxifen given her elevated breast cancer risk, the patient must be informed of the potential harms of this therapy, including hot flushes, endometrial cancer, thromboembolic disease, and ocular problems. Tamoxifen is the only Food and Drug Administration-approved medication for use in the reduction of breast cancer risk.

Although raloxifene has been associated with a nearly 60% decrease in breast cancer risk in a placebo-controlled trial on osteoporosis prevention, breast cancer was only a secondary endpoint, and the trial was restricted to postmenopausal women; therefore, its use in this patient would not be appropriate. Likewise, in the Women's Health Initiative trial, when compared with placebo, conjugated equine estrogen was associated with a borderline-significant decreased risk for breast cancer (RR, 0.77 [95% CI, 0.59 to 1.01]). However, this trial also included only postmenopausal women, and the results would therefore not be applicable to this patient.

Because she is unlikely to have a mutation in a high-risk breast cancer gene considering the absence of BRCA1 and BRCA2 mutations in her only relative with breast cancer, bilateral prophylactic mastectomy is an overly extreme and unreasonable intervention in this setting.

Key Points

  • Tamoxifen decreases breast cancer risk by approximately 50% in pre- and postmenopausal women who have an elevated risk for this disease.
  • Tamoxifen is the only Food and Drug Administration-approved medication for use in decreasing breast cancer risk.

Click here to 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.

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Copyright 2009 by the American College of Physicians.

Test yourself

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Find the answer

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