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

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In the News
for the Week of 10-19-10

Highlights

  • Hospice care use rising, but timing still needs improvement
  • Cancer screens for cancer patients reveal 'auto-pilot' culture

Test yourself

  • MKSAP Quiz: gradual memory loss

Cardiology

  • Prior aspirin use a marker for recurrent events post-ACS, but not mortality
  • Dental procedures may pose transient, minimal cardiovascular risk

Diabetes care

  • Peer support lowered A1cs in male veterans

COPD

  • Follow up lowers readmissions, return ED visits for COPD patients

FDA news

From ACP Hospitalist

  • The next issue is online and coming to your mailbox

From the College

  • ACP Members receive QuantiaMD Community Choice Awards
  • New ACP Online medical students page
  • Prominent speakers addressed Board of Governors at fall meeting
  • Latest issue of ACP International newsletter online

Cartoon caption contest

Physician editor: Darren Taichman, FACP


Highlights

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Hospice care use rising, but timing still needs improvement

The use of hospice has increased in recent years, but a significant proportion of patients are still entering the program too early or too late, according to a collection of studies published last week.

Two studies looked at health care resources used by heart failure patients in the last six months of their lives. A retrospective cohort study of U.S. patients, which included more than 200,000 Medicare beneficiaries who died in 2000-2007, found that use of hospice increased from 19% to nearly 40% over the course of the study. Yet the average number of days the patients spent in intensive care increased from 3.5 to 4.6 and adjusted Medicare costs increased by 11%. About 80% of patients were hospitalized during their last six months.

A similar study of Canadian heart failure patients also found increasing costs over the time period, although the Canadian costs were substantially lower (an average cost of $27,983 in Canadian dollars in 2006 [equivalent to $24,674 in U.S.] vs. a mean cost of $36,216 in 2007 in the U.S. study.) The percentage of Canadian patients dying in the hospital decreased from 60% to 54% and hospitalization rates during the last six months decreased from 84% to 76% during the study.

Study authors noted that further reductions in hospitalization rates and deaths may be limited by the relative unavailability of hospice care in Canada compared to the U.S. Both studies noted that increasing costs appeared do not appear to be driven by use of costly invasive cardiac procedures, rates of which remained low throughout the study period in both countries.

The U.S. study also assessed the length of patients’ stays in hospice and found that the percentage of patients who entered hospice only shortly before their deaths remained steady: about 19% stayed three days or less and about 37% were in hospice for less than a week. Another study, also published online by the Archives of Internal Medicine, assessed hospice use among men dying of prostate cancer between 1992 and 2005. Of the patients who used hospice (53% of the total), 22% were in it for less than a week. Such short stays don’t allow patients to receive the full benefits of enrollment in hospice, the study authors noted.

The study of prostate cancer patients did find an increase in the use of hospice over time. By 2003, 62% of the patients were in hospice. Hospice patients were less likely to receive high-intensity care, including imaging, hospitalization, ICU stays, and emergency department visits, the study found. Increasing the appropriate use of hospice care for patients at the end of life could both improve the quality of death and reduce ineffective health care expenditures, the study authors concluded.

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Cancer screens for cancer patients reveal 'auto-pilot' culture

Patients with advanced cancers frequently undergo cancer screening tests that are unlikely to benefit them, researchers concluded.

Researchers tracked via SEER the use of mammography, Pap smear, prostate-specific antigen (PSA) testing, and lower gastrointestinal (GI) endoscopy in 87,736 fee-for-service Medicare enrollees diagnosed with advanced lung, colorectal, pancreatic, gastroesophageal, or breast cancer between 1998 and 2005. Results appear in the October 13 Journal of the American Medical Association.

In the cohort, 61% had stage IIIB-IV lung cancer, 14% had stage IV colorectal cancer, 14% had advanced stage pancreatic cancer, and 11% advanced gastroesophageal cancer or stage IV breast cancer. The cohort was matched by demographics to 87,307 cancer-free Medicare enrollees.

Among women with advanced cancer, 8.9% (95% confidence interval [CI], 8.6%-9.1%) received at least one screening mammography and 5.8% (95% CI, 5.6%-6.1%) received at least one Pap smear. Among the cancer-free cohort, 22.0% (95% CI, 21.7%-22.5%) and 12.5% (95% CI, 12.2%-12.8%) received screens, respectively. Screening rates were higher in women with a history of receiving the same screening test.

Among men with advanced cancer, 15.0% (95% CI, 14.7%-15.3%) received PSA testing compared with 27.2% (95% CI, 26.8%-27.6%) of controls. Again, screening rates were higher in men with a history of screening.

Lower GI endoscopy was performed in 1.7% (95% CI, 1.6%-1.8%) of all patients with cancer and in 6.1% (95% CI, 5.2%-7.0%) of patients with a history of screening. In comparison, 4.7% (95% CI, 4.6%-4.9%) of controls received lower GI endoscopy screening. Cholesterol was tested in 19.5% (95% CI, 19.3%-19.8%) of patients with advanced cancer and in 37.4% (95% CI, 37.0%-37.7%) of controls.

Half of the patients who received mammographies, Pap smears, or PSA tests did so within 10 months of cancer diagnosis, and half of the patients with a lower GI endoscopy screening received it within 18 months. Most patients screened had testing within 36 months of diagnosis.

Screening before diagnosis was the strongest predictor of screening afterward. Researchers, who described a culture of screening on "auto-pilot," wrote that, "The most plausible interpretation of our data is that efforts to foster adherence to screening have led to deeply ingrained habits. … There is substantial evidence that even when physicians recognize that life expectancy is limited, they do not consistently communicate prognosis, and patients may use denial as a coping strategy to face impending loss."

Overscreening leads to overdiagnosis, the screens are not without risks, and they contribute to health care overutilization in an already expensive system, the authors noted.

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Test yourself

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MKSAP Quiz: gradual memory loss

An 84-year-old man is evaluated for the gradual onset of progressive memory loss over the past 2 years. In the past 4 months, he has twice been unable to find his way home after going to the local supermarket; his wife now goes with him whenever he leaves the house. His wife also has assumed responsibility for the household finances after the patient overdrew their checking account for the third time because of subtraction errors in their checkbook. He has hypertension treated with hydrochlorothiazide and hypothyroidism treated with levothyroxine. His mother had onset of Alzheimer dementia at age 79 years and died at age 86 years. His only other medication is a daily multivitamin.

On physical examination, temperature is 36.9 °C (98.4 °F), blood pressure is 130/80 mm Hg, pulse rate is 72/min, respiration rate is 14/min, and BMI is 25. His level of alertness, speech, and gait are normal. His score on the Folstein Mini–Mental State Examination is 24/30, including 0/3 on the recall portion.

Results of laboratory studies, including a complete blood count, serum vitamin B12 measurement, thyroid function tests, and a basic metabolic panel, are normal.

An unenhanced MRI of the brain shows no abnormalities.

Which of the following is the most appropriate treatment at this time?

A) Donepezil
B) Memantine
C) Quetiapine
D) Sertraline
E) Discontinuation of all current medications

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

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Cardiology

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Prior aspirin use a marker for recurrent events post-ACS, but not mortality

Prior aspirin use was associated with more comorbidities and coronary disease and a higher risk of recurrent myocardial infarction (MI), but not mortality, after acute coronary syndrome (ACS).

Researchers evaluated 66,443 ACS patients from a merged database of 16 prospective, multicenter, randomized, placebo-controlled trials from the Thrombolysis in Myocardial Infarction trials. They evaluated the differences in ACS type, total mortality, and the composite end point of death, MI, recurrent ischemia, or stroke between prior aspirin and nonprior aspirin users. They reported results in the October 19 issue of the Journal of the American College of Cardiology.

Among the study population, 17,839 (26.8%) were identified as prior aspirin users. They were on average 3.5 years older (63 vs. 59) and had more coronary risk factors, such as diabetes, hypertension, hyperlipidemia and family history, and more evidence of coronary artery disease than non-aspirin users (all P<0.0001). Prior aspirin users were also more likely than non-aspirin users to take other cardiovascular medications before presenting with ACS.

Multivariate analysis found prior aspirin use was an independent predictor of less severe ACS at presentation (odds ratio [OR]: 0.59; 95% confidence interval [CI]: 0.54-0.64 for STEMI vs. UA/NSTEMI and OR: 0.57; 95% CI: 0.52 to 0.63 for NSTEMI vs. UA).

There was no difference in total mortality between prior aspirin users and non-aspirin users at day 30 (OR: 1.01; 95% CI: 0.90-1.13) or by the last follow-up visit (mean 328 days) (hazard ratio: 1.03; 95% CI: 0.95-1.11). Prior aspirin use was modestly associated with recurrent MI (OR: 1.26; 95% CI: 1.12-1.43) and the composite end point of death, MI, recurrent ischemia or stroke (OR: 1.16; 95% CI: 1.08-1.24).

The authors wrote, "After adjustment for baseline characteristics, prior aspirin use did predict recurrent MI and ischemic events, but was not an independent predictor of total mortality after an ACS. As such, prior aspirin use should best be considered a marker of a patient population at high risk for recurrent adverse events after ACS."

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Dental procedures may pose transient, minimal cardiovascular risk

Invasive dental treatments may be associated with an increase in the risk for vascular events, researchers reported.

To investigate whether invasive dental treatment transiently increases the risk for vascular events, researchers conducted a self-controlled case series of 9.9 million people in a Medicaid claims database. Included in the study were patients who had a first hospitalization for ischemic stroke or myocardial infarction at least 24 weeks after their enrollment period began.

Researchers tracked all persons exposed to invasive dental treatment, defined as those that could result in bacteremia and induce an inflammatory response, including periodontal therapy or tooth extractions, who also had a discharge diagnosis of ischemic stroke or myocardial infarction from 2002 to 2006. The incidence of ischemic stroke and myocardial infarction in periods immediately after invasive dental treatment was compared with the incidence in all other observed time periods. Results appeared in the Annals of Internal Medicine.

The study identified 1,152 vascular events. The rate of myocardial infarction (n=525) was higher in the first 4 weeks after an invasive dental treatment compared with baseline (incidence ratio, 1.56 [95% CI, 0.98 to 2.47]) and decreased over 24 weeks. For ischemic stroke (n=650), a slightly elevated risk was seen during the first four weeks after an invasive dental treatment (incidence ratio, 1.39 [95% CI, 0.89 to 2.15]), although this was less marked and the pattern wasn't as clear. No events occurred on the same day as an invasive dental procedure and the incidence rates decreased to the baseline rate within six months.

The positive association remained after exclusion of persons with diabetes, hypertension, or coronary artery disease or persons with prescriptions for antiplatelet or salicylate drugs before treatment.

The authors concluded, "… invasive dental treatment may be associated with a transient increase in the risk for stroke and myocardial infarction in adults. The short-lived adverse effects are nevertheless likely to be outweighed by long-term benefits of invasive dental treatment to vascular health."

An accompanying editorial raised the point that patients undergoing dental surgery often discontinue aspirin before their procedures, a potential trigger for a subsequent coronary event. The editorialists advised against routinely discontinuing aspirin before invasive dental procedures.

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Diabetes care

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Peer support lowered A1cs in male veterans

A peer support program helped veterans with diabetes control their disease, a recent study found.

The randomized controlled trial included 244 men who had an A1c greater than 7.5% in the six months before the start of the study. They were randomized to receive either a nurse care management program, which entailed a 1.5 hour educational session, self-management materials and contact information for a nurse care manager, or reciprocal peer support. The peer support program included a similar educational session, but also additional training in peer communication skills. The participants in the peer-support group were matched with a peer of similar age and encouraged to talk weekly on the phone. They were also invited to optional group sessions at one, three and six months.

After six months, the mean A1c of the peer-support group had decreased from 8.02% to 7.73%. The other group had an increase in A1c (from 7.93% to 8.22%) resulting in an overall change between groups of 0.58% (P=0.004). Patients who had an A1c of over 8% to start showed even greater improvement associated with the peer program. Those in the peer group had a decrease of 0.88% compared to a 0.07% decrease in the other group. The patients with peer support were also more likely to initiate insulin therapy (8 patients vs. 1 patient in the care management group). The results were published in the Oct. 19 Annals of Internal Medicine.

The decreases in A1c are similar to those achieved by most oral antiglycemic medications, the study authors noted, and peer-support programs are less resource-intensive than many interventions. The increase in insulin use in the peer-support group may indicate that patients’ experiential concerns about insulin may be best addressed by another patient, the researchers speculated.

The study was limited by its length, relatively low uptake and inclusion of only male veterans in a similar age cohort who were likely to have common sense of identity. However, other research has shown peer-support interventions to be more acceptable to women than men. The model appears to be an effective and efficient means of allowing patients to help themselves and each other and therefore deserves further exploration as method of providing support for diabetes self-care, the study authors concluded. An accompanying editorial pointed out that the health care reform law has endorsed community support, including peer support programs, especially for medically underserved populations.

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COPD

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Follow up lowers readmissions, return ED visits for COPD patients

Chronic obstructive pulmonary disease (COPD) patients who had a follow-up visit shortly after hospital discharge were less likely to visit the ED or be readmitted within 30 days than those without follow up, a new study found.

In a retrospective cohort study, researchers used enrollment and claims data from 62,746 Medicare patients who were hospitalized for COPD at least once between 1996 and 2006. For patients with more than one admission, the researchers randomly selected one admission per patient per year. All patients had an identifiable primary care provider (PCP), meaning they had visited that PCP three or more times in the year before hospitalization.

The researchers used Cox proportional hazard regression with time-dependent covariates to determine the risk of 30-day ED visit and readmission for patients with or without a follow-up visit to their PCP or pulmonologist within 30 days of discharge. About 74% of patients were exclusively treated by their PCP, while 26% were co-treated with a pulmonologist in the year before hospitalization. Results were published in the October 11 Archives of Internal Medicine.

Sixty-seven percent of patients with COPD had an outpatient visit with their PCP or pulmonologist within 30 days of discharge (that percentage increased from 65% in 1996 to 71% in 2006, P<.001). Among those who had follow-up, 86.7% occurred with a PCP, 6.7% with a pulmonologist, and 6.6% with both. Patients who had no follow-up visit were more likely to have a longer length of hospital stay, be older than 85 years, have multiple comorbidities, be black and be admitted through the ED. Receiving care at a large hospital or teaching hospital, and/or in a city, was also associated with less follow up.

The 30-day rate of postdischarge ED visits in patients with follow up was 21.7% compared to 26.3% for non-follow up patients (P<.001). Thirty-day readmissions were 18.9% for the follow-up patients and 21.4% patients without follow up (P<.001). Of those readmitted, the top three reasons were COPD, pneumonia or respiratory infection, and heart failure. In a multivariate, time-dependent analysis, follow-up visits were associated with 14% fewer ED visits (hazard ratio [HR], 0.86; 95% CI, 0.83-0.90) and 9% fewer readmissions (HR, 0.91; 95% CI, 0.87-0.96).

The results suggest discharge planning that emphasizes early outpatient follow up may reduce readmissions for COPD patients, and that planners should pay particular attention to older and/or black adults, and those with multiple comorbidities, the study authors said. Study limitations include that some patients may have had follow-up visits with non-PCP/pulmonologist clinicians; that information on quality of care during hospitalization wasn't taken into account; and that the observational design means associations could come from confounding variables, the authors noted.

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FDA news

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Sibutramine pulled from the market

The weight loss drug sibutramine (Meridia) has been removed from the U.S. market because of clinical trial data indicating an increased risk of heart attack and stroke, the FDA announced recently.

The FDA requested the market withdrawal after reviewing data from the Sibutramine Cardiovascular Outcomes Trial (SCOUT), part of a post-market requirement to look at cardiovascular safety of sibutramine after European approval of the drug. The trial demonstrated a 16% increase in the risk of serious heart events, including non-fatal heart attack, non-fatal stroke, the need to be resuscitated once the heart stopped, and death, in patients given sibutramine compared to those given placebo.

In light of the risk of heart attack or stroke, use of sibutramine was not justified by the very modest weight loss achieved by patients taking the drug, FDA officials said. Physicians are advised to stop prescribing the medication. Patients should stop taking it and talk to their health care provider about alternative weight loss and weight loss maintenance programs, the agency advised.

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Bisphosphonates to carry warning about femur fractures

The labels of bisphosphonate drugs will now carry a warning describing the risk of subtrochanteric and diaphyseal femur fractures, the FDA announced last week.

Information about the risk of these atypical fractures will be added to the warnings and precautions section of the labels of all bisphosphonate drugs approved for the prevention or treatment of osteoporosis, including Fosamax, Fosamax Plus D, Actonel, Actonel with Calcium, Boniva, Atelvia, and Reclast (and their generic equivalents). The new regulations also require that a medication guide be given to patients when they pick up their bisphosphonate prescription.

The FDA’s action was based on data showing that the unusual femur fractures have been predominantly reported in patients taking bisphosphonates. It is not clear if bisphosphonates are the cause of the fractures, which are very uncommon and appear to account for less than 1% of all hip and femur fractures overall, the agency noted.

The FDA recommends that physicians be aware of the possible risk of atypical subtrochanteric and diaphyseal femur fractures in patients taking bisphosphonates and discontinue potent antiresorptive medications (including bisphosphonates) in patients who have evidence of a femoral shaft fracture. Clinicians should also evaluate any patient who presents with new thigh or groin pain to rule out a femoral fracture. Because the risk of fractures may relate to long-term use of bisphosphonates, it’s also appropriate to consider periodic reevaluation of the need for continued therapy, particularly in patients who have been treated for over five years.

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From ACP Hospitalist

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The next issue is online and coming to your mailbox

The October issue of ACP Hospitalist is online. Don't miss stories on:

The different ways hospitals pay. Incentive compensation aims to improve quality and productivity.

Hypertensive emergencies. Not everyone with extremely high blood pressure meets the criteria.

Depression increases readmission risk, merits screening. Depression may pose as big a risk for hospital readmission as other, better known factors.

These features and more, including Test Yourself with the MKSAP Quiz: Hypertension, are now online.

Are you involved in hospital medicine? Then you should be getting ACP Hospitalist and ACP HospitalistWeekly. Click here to subscribe.

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From the College

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ACP Members receive QuantiaMD Community Choice Awards

Sixteen physicians and medical leaders have been chosen by the 100,000+ member QuantiaMD® community to receive the inaugural QuantiaMD Community Choice Award for innovation and excellence in sharing knowledge.

The awards are bestowed upon those experts whose presentations have been rated 5 Stars by at least 1,000 members. Of the nearly 1,200 presenters on QuantiaMD, six ACP members were selected to receive the inaugural award:

John G. Bartlett, MACP, John’s Hopkins University
Wiliam Harley, FACP, ID Associates, Gastonia, NC
Howard Heit, FACP, Georgetown University
Marc Matrana, Associate Member, MD Anderson Cancer Center
Daniel J. Sexton, FACP, Duke University School of Medicine
Leon G. Smith, Sr., MACP, University of Medicine & Dentistry of New Jersey

More information and presentations by the QuantiaMD Community Choice Award winners are online.

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New ACP Online medical students page

The newly reorganized medical student landing page of the ACP Web site offers unique and useful resources to students in an interactive, easy-to-navigate setting.

Career guidance, competitions and quiz questions, multimedia material, peer groups, social networking groups and mentoring programs, blogs, and a newsletter including advocacy updates, feature profiles and in-depth perspectives are all available with just one click.

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Prominent speakers addressed Board of Governors at fall meeting

The September meeting of the ACP Board of Governors featured Don Berwick, MD, the Administrator of the Centers for Medicare and Medicaid Service, who spoke about health care and delivery system reform. Health and Human Services Secretary Kathleen Sebelius addressed the Governors through a video message and introduced Dr. Berwick. David Blumenthal, FACP, MPP, the National Coordinator for Health Information Technology, also spoke to the Governors about fostering the meaningful use of electronic health records.

To read more about the Board of Governors meeting and the remarks by Dr. Berwick, visit the ACP Advocate blog.

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Latest issue of ACP International newsletter online

The October edition of the ACP International newsletter was recently released. Articles of interest include:

  • Selected translations of ACP Clinical Guidelines available. Selected ACP Clinical Guidelines and Patient Summaries have been translated into Spanish.
  • Internal Medicine: Global Perspectives. A feature designed to give different perspectives from across the global medical community. William J. Hall, MACP, president of the International Society of Internal Medicine, is profiled.
  • ACP Leaders on the Road. ACP President J. Fred Ralston, Jr., FACP, discusses his recent ACP Ambassador travel to Jamaica.
  • Register now for Internal Medicine and win a VIP evening in San Diego. Register to attend Internal Medicine 2011 by January 3 and be automatically entered to win a special VIP evening in San Diego, including a complementary dinner, theater tickets, and limo transportation.

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Cartoon caption contest

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Put words in our mouth

ACP InternistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

E-mail all entries to acpinternist@acponline.org. ACP staff will choose finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.

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MKSAP Answer and Critique

The correct answer is A) Donepezil. This item is available to MKSAP 15 subscribers as item 11 in the Neurology module.

This patient should receive donepezil. The Folstein Mini–Mental State Examination (MMSE) discriminates well between the major stages of dementia used for prognosis and management purposes. The MMSE score range of 21 to 25 corresponds to mild dementia, 11 to 20 to moderate dementia, and 0 to 10 to severe dementia. This patient has Alzheimer dementia and is at a mild to moderate stage of impairment. The most appropriate medication with which to begin treatment is an acetylcholinesterase inhibitor of which there are currently three: donepezil, rivastigmine, and galantamine. Multiple large, prospective, randomized, double-blind, placebo-controlled studies have shown in patients with mild, moderate, or severe Alzheimer dementia the efficacy of donepezil (and its superiority to placebo) in the preservation of instrumental and functional activities of daily living and in the reduction of caregiver stress. Other studies have found that patients treated with donepezil have improved cognitive function compared with those treated with placebo. Donepezil was safe and well tolerated in this patient group.

Memantine is also used to treat Alzheimer dementia, but only in patients with moderate to severe impairment. There is no evidence that memantine has any effect in earlier stages of Alzheimer dementia or that it alters the course of the disease. With a score of 24/30 on the MMSE, this patient has mild dementia, which makes memantine an inappropriate treatment. In patients with severe dementia, memantine can be used alone or added to an acetylcholinesterase inhibitor.

Quetiapine is an antipsychotic drug, and sertraline is an antidepressant agent. Although both can be used in patients with Alzheimer dementia, their use is limited to treatment of behavioral symptoms of psychosis and depression, respectively, neither of which this patient has exhibited. However, if these medications are to be used in such patients, the risks must first be carefully weighed against the benefits. The U.S. Food and Drug Administration has reported that the use of second-generation antipsychotic medications (aripiprazole, olanzapine, quetiapine, and risperidone) in elderly patients with dementia is associated with increased mortality.

Although it is important to consider the potential cognitive side effects of prescription (and nonprescription) medications, those taken by this patient are not associated with such effects. Therefore, there is no need to risk potential harm to this patient by discontinuing his blood pressure and thyroid medications.

Key Point

  • First-line pharmacotherapy for mild Alzheimer dementia is an acetylcholinesterase inhibitor.

Click here to return to the rest of ACP InternistWeekly.

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Copyright 2010 by the American College of Physicians.

Test yourself

A 66-year-old man comes for a preoperative evaluation before total joint arthroplasty of the left knee. He has a 25-year history of rheumatoid arthritis. He has had progressive pain in his left knee with activity, which limits his ability to hike. The patient has similar pain in the right knee, but it is less severe. He reports no recent morning stiffness. He is able to climb two or three flights of stairs without chest pain or shortness of breath. He has no other medical problems and reports no additional symptoms. Medications are methotrexate and folic acid. Following a physical exam and lab tests, what is the next best step in management?

Find the answer

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