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


In the News
for the Week of 11-2-10


  • MGMA conference: EHR implementation hindered by Medicare cuts
  • Risk for death higher at start of and immediately after opiate substitution treatment

Test yourself

  • MKSAP Quiz: progressive dysphagia


  • Dabigatran may be cost-effective for stroke prophylaxis in atrial fibrillation


  • Fall prevention and urinary incontinence care improved by intervention


  • Updated guidelines suggest caution with chemo-induced anemia

CDC update

From ACP Internist

  • The next issue is online and coming to your mailbox

Cartoon caption contest

Physician editor: Darren Taichman, FACP


MGMA conference: EHR implementation hindered by Medicare cuts

NEW ORLEANS—Electronic health records (EHRs) are helping medical practices’ bottom lines, but the threat of Medicare reimbursement cuts may lead them to stop investing in the technology, according to new survey data released by the Medical Group Management Association (MGMA) at its annual meeting last week.

One survey found that practices that implemented EHRs reported better financial performance than those that didn’t. Specifically, EHR-using practices owned by hospitals and integrated delivery systems (IDS) reported $42,042 more in operating margin per full-time-equivalent (FTE) doctor than practices using paper records. EHR-using practices not owned by a hospital or IDS reported $49,916 more in operating margin. Further, non-hospital and IDS-owned practices that had had an EHR for five years reported 10.1% higher operating margins than those who were in the first year of having an EHR.

Practices may be loathe to implement EHRs, however, given the looming threat of reimbursement cuts due to Medicare’s sustainable growth rate (SGR) formula, a second survey found. Forty-five percent of practices reported they would likely delay buying an EHR system in response to the 23.6% cut set for Dec.1, and the additional 6.5% cut set for Jan. 1, 2011. “It’s a supreme irony that, on the one hand, the government is offering incentives to practices to purchase EHRs, but then plans to cut the SGR so they can’t buy EHRs,” said William Jessee, MD, MGMA president and CEO, at a press conference.

About half of survey respondents also said they would stop seeing new Medicare patients if the cuts go through, and 28% said they would stop treating all Medicare patients altogether. Sixty-one percent said they were likely to reduce administrative support staff; 54% would reduce clinical staff; and 77% would delay buying new clinical equipment and/or facilities, the survey found. Indeed, data from August show about a third of practices already started reducing the number of new appointments for Medicare patients, and cut staff, once Congress failed to definitively act on Medicare cuts by a June 1 deadline.

A third survey found that hospital- and IDS-owned practices reported considerably lower revenue than non-hospital-owned groups for 2009. The median revenue for a multispecialty practice not owned by a hospital was $798,608, compared to $448,597 for a hospital-owned group, per FTE. “A lot of it is how you account for revenue,” explained Dr. Jessee. “Non-hospital-owned practices count ancillaries, for example; hospital-owned practices don’t.”

Specialists in hospital- and IDS-owned practices reported median total compensation of $294,984, compared to $353,549 in non-hospital and IDS-owned practices. Yet primary care physicians working in the former type of practice reported median income of $192,116, compared to $179,688 in the latter, the survey found. “The need for primary care coverage and referrals in hospital- and IDS-owned practices may contribute to the overall difference in compensation,” said Jeffrey Milburn of the MGMA Health Care Consulting Group, in a press release.
—Jessica Berthold, associate editor

Risk for death higher at start of and immediately after opiate substitution treatment

Patients receiving opiate substitution treatment have a higher risk for death at the beginning of treatment and immediately after it ends, according to a new study.

Researchers in the United Kingdom examined data from primary care patients who had been diagnosed with substance misuse and had received a methadone or buprenorphine prescription during 1990-2005. Main outcome measures were all-cause mortality and rate ratios for periods on and off treatment, adjusted for multiple factors including age, sex, comorbid conditions and calendar year. Mortality rates in opiate users and the general population were also compared. The study results were published online Oct. 26 by BMJ.

Data from 5,577 patients with 267,003 prescriptions for opiate substitution treatment were analyzed. Patients were followed until one year after their last prescription expired, date of death before their last prescription expired, or date at which they transferred out of the primary care practice. The authors found crude mortality rates of 0.7 per 100 person-years when patients were receiving opiate substitution treatment and 1.3 per 100 person-years while patients were not receiving treatment. Corresponding standardized mortality ratios were 5.3 (95% CI, 4.0 to 6.8) and 10.9 (95% CI, 9.0 to 13.1), respectively. Risk for death was approximately twice as high in men using opiates as in women (mortality rate ratio, 2.0 [95% CI, 1.4 to 2.9]).

During the first two weeks of opiate substitution treatment, the crude mortality rate was 1.7 per 100 person-years, or 3.1 times (95% CI, 1.5 to 6.6 times) higher than during the remainder of treatment. Crude mortality rates after treatment stopped were 4.8 per 100 person-years at weeks 1-2, 4.3 per 100 person-years at weeks 3-4, and 0.95 per 100 person-years afterward. These rates were 9 times (95% CI, 5.4 to 14.9 times), 8 times (95% CI, 4.7 to 13.7 times) and 1.9 times (95% CI, 1.3 to 2.8 times) greater than was the baseline mortality risk during treatment.

The authors noted that their study may have overestimated or underestimated mortality rates during and after treatment, and that follow-up was incomplete, among other limitations. However, they concluded that mortality risk is higher when opiate substitution treatment is started and immediately after it is stopped, and that clinicians and patients should be aware of this issue.

“We hypothesize that the raised risk of death in the first month of treatment and especially in the month after the end of treatment may negate any protective effect of opiate substitution treatment, unless treatment is prolonged,” they wrote. They called for additional research to test their hypothesis and to determine how the average duration of opiate substitution treatment affects drug-related mortality rates.


Test yourself

MKSAP Quiz: progressive dysphagia

A 74-year-old woman is evaluated for 3 years of progressive dysphagia, first for solid foods and now for both solid foods and liquids; she has had frequent episodes of regurgitation of undigested food and has lost 6.8 kg (15 lb) during the past 6 months. Her medical history includes stenting of the left anterior descending coronary artery 1 year ago after which she has had symptomatic residual distal stenosis. She had a cerebrovascular accident 2 years ago and still has mild residual right hemiparesis. Her medications include metoprolol, clopidogrel, enalapril, aspirin, and hydrochlorothiazide

On physical examination, the patient is thin (BMI 20) and appears ill, although not in distress. Vital signs are normal. Chest radiograph shows a dilated esophagus with an air/fluid level and changes of chronic aspiration in the right lung base. Barium esophagography shows “bird beak” narrowing of the distal esophagus and mega-esophagus with retained fluid in the esophageal body. Esophageal manometry shows aperistalsis of the esophageal body and incomplete lower esophageal sphincter relaxation with swallowing. On esophagogastroduodenoscopy, the endoscope passes through the lower esophageal sphincter without resistance; there are no masses in the esophagus or the gastric cardia.

Which of the following additional interventions is most likely to improve survival for this patient?

A) Anticholinergic therapy
B) Botulinum toxin injection
C) Laparoscopic myotomy
D) Pneumatic dilatation

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



Dabigatran may be cost-effective for stroke prophylaxis in atrial fibrillation

Dabigatran may be a cost-effective method of stroke prophylaxis in patients with atrial fibrillation (AF), according to a new study.

The FDA recently approved dabigatran, a fixed-dose, oral direct thrombin inhibitor, for stroke prophylaxis in AF. Researchers used a computer model to perform a decision analysis comparing the quality-adjusted survival, costs, and cost-effectiveness of three treatment strategies for stroke prevention in patients with AF: adjusted-dose warfarin (target international normalized ratio, 2.0 to 3.0), low-dose dabigatran (110 mg twice daily), or high-dose dabigatran (150 mg twice daily). The study results were published online Nov. 2 by Annals of Internal Medicine.

The target population was patients 65 years and older with nonvalvular AF, risk factors for stroke and no contraindications to anticoagulation. In the base-case analysis, the quality-adjusted life expectancy was 10.28 quality-adjusted life-years (QALYs) with warfarin, 10.70 QALYs with low-dose dabigatran and 10.84 QALYs with high-dose dabigatran. Total costs for the three regimens were $143,103, $164,576 and $168,398, respectively.

Compared with warfarin, the incremental cost-effectiveness ratios were $51,229 per QALY for low-dose dabigatran and $45,372 per QALY for high-dose dabigatran. In the sensitivity analysis, the incremental cost-effectiveness ratio was $50,000 per QALY when high-dose dabigatran was estimated to cost $13.70 per day but remained under $85,000 per QALY for all model inputs evaluated. High-dose dabigatran became more cost-effective when risk for stroke and intracranial hemorrhage increased.

The authors noted that the efficacy and adverse event rates used in their model came mainly from one randomized, controlled trial and that dabigatran costs were based on those in the United Kingdom. However, they concluded that high-dose dabigatran may be a cost-effective alternative to warfarin in patients age 65 years or older with an increased stroke risk, depending on U.S. drug prices.



Fall prevention and urinary incontinence care improved by intervention

A practice redesign project was successful in getting primary care practices to provide recommended geriatric care, a new study found.

The project, in which ACP was a partner, compared five practices that received Assessing Care of Vulnerable Elders Practice Redesign for Improved Medical Care for Elders (ACOVEprime) intervention with five control practices. At both intervention and control clinics, all patients 75 and older were screened for fall risk and urinary incontinence. The intervention practices received assistance through efficient collection of data related to the conditions, medical record prompts, patient education materials and physician decision support.

Overall, 47% of the 6,051 patients screened positive for falls or urinary incontinence. In the intervention practices, 60% of the patients received recommended care for falls, compared to 37.6% in the control practices (P<0.001). Clinicians in these practices were more likely to perform a fall history, orthostatic blood pressure measurement, and gait and balance examination. The intervention practices also complied more frequently with recommendations for urinary incontinence treatment (47.2% vs. 27.8% of patients, P<0.001). They were more likely to ask about incontinence history and start with behavioral treatments.

The use of recommended care in the control practices was similar to that seen in other studies, while the intervention brought practices up to quality levels usually seen for nongeriatric medical conditions, the study authors noted. They found that the intervention appeared to be effective at all five sites, although the one site which used a fully integrated electronic health record showed higher quality scores than the others.

The results prove that such an intervention can be implemented in medium and small practices without a research infrastructure, and that quality improvement supported by professional societies has broad potential to reach such practices, the study authors concluded. The study was published in the Oct. 25 Archives of Internal Medicine.

The project was also notable for its efficiency and acceptability to the practices, according to an accompanying commentary. All of the participants were volunteers interested in improving geriatric care and they received the incentive of potential Maintenance of Certification credit, the study authors noted. Components of the intervention are available on the ACP website.



Updated guidelines suggest caution with chemo-induced anemia

Physicians need to use caution when giving erythropoiesis-stimulating agents (ESAs) to cancer patients who have chemotherapy-induced anemia, according to new guidelines.

With rare exceptions, ESAs should not be given to cancer patients who are not receiving chemotherapy, according to joint guidelines issued by the American Society of Hematology and the American Society of Clinical Oncology.

Clinicians should discuss potential harms and benefits of ESAs and of red blood cell transfusions with patients undergoing myelosuppressive chemotherapy who have hemoglobin of 10 g/dL or less. Individual preferences for assumed risk should contribute to shared decisions on managing chemotherapy-induced anemia. Risks include mortality, venous thromboembolism, tumor progression and stroke.

If used, ESAs should be administered at the lowest dose possible and should raise hemoglobin levels to the lowest concentration possible to avoid transfusions. Available evidence does not validate hemoglobin levels between 10 g/dL and 12 g/dL either as thresholds for starting treatment or as therapy targets for ESA.

Starting doses and dose modifications after response or nonresponse should follow Food and Drug Administration-approved labeling. The FDA-approved starting dose of epoetin is 150 U/kg three times a week or 40,000 U weekly subcutaneously. The FDA-approved starting dose of darbepoetin is 2.25 µg/kg weekly or 500 µg every 3 weeks subcutaneously.

ESAs should be discontinued after six to eight weeks in nonresponders. The committee cautioned against ESA use under other circumstances. ESAs should be avoided in cancer patients not receiving chemotherapy, except for those with lower-risk myelodysplastic syndromes.

The updated guidelines appeared online Oct. 25 ahead of print in the Nov. 18 issue of Blood and the Nov. 20 issue of the Journal of Clinical Oncology.


CDC update

Tdap vaccine recommendations expanded

Recommended uses of the Tdap (tetanus, diphtheria, pertussis) vaccine were broadened last week by the Advisory Committee on Immunization Practices, which makes recommendations to the CDC.

Previously, the experts had recommended a single vaccination with Tdap for adults 11-64. The new recommendations call for a booster of Tdap for all people in this group, reported the Oct. 27 Los Angeles Times. The recommendations were also expanded to recommend Tdap vaccination of adults who have an unknown vaccination history or who received a tetanus or diphtheria vaccine within the past five years, because the experts concluded that the risks of adverse effects from repeat vaccination are low. The preferred time for initial Tdap vaccination is 11 or 12 years old, the committee noted.

Although the vaccine is not approved for people under age 10 or over 64, the ACIP also recommended it for certain segments of these populations. Children aged 7 to 9 who have not received the DTaP vaccine should get a Tdap booster, the experts advised. The vaccine may also be used in place of a tetanus booster for adults 65 and older, the committee said. Older adults who are likely to have close contact with infants under 12 months of age should get the Tdap vaccine to reduce the risk of infection to infants.

The committee also recommended that teenagers receive a booster dose of the meningitis vaccine at age 16, based on data showing waning immunity five years after vaccination, according to an Oct. 27 Reuters report. The conclusions of the ACIP are usually accepted by the CDC, and become official recommendations when published in the agency’s Morbidity and Mortality Weekly Report.


From ACP Internist

The next issue is online and coming to your mailbox

The November/December issue of ACP Internist is online, featuring stories about: Marijuana requests: Relief or ‘permission’?
Fourteen states have legalized medical marijuana. Internists who have issued the controversial authorizations describe how they sort out legitimate uses from trivial requests.

Know the patient to achieve statin benefits.
That statins work is without question. And with costs falling due to many drugs in the class going generic, physicians are now refining when to prescribe the ubiquitous drug class based on the degree of risk.

Wisconsin clinic’s patients save time by ‘rooming’ themselves.
An outpatient family practice clinic tried to reduce wait times by letting patients direct themselves to open exam rooms. As a result, wait times fell by half and patient satisfaction rose to its highest levels in 11 months.

More stories and Test Yourself with the MKSAP Quiz are available online.


Cartoon caption contest

And the winner is …

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

"I thought we were going to have problems with the capitated system."

This issue's winning cartoon caption was submitted by Daniel Bendetowicz, FACP, of Ft. Meyers, Fla. Readers cast 187 ballots online to choose the winning entry. Thanks to all who voted! The winning entry captured 47.1% of the votes.

The runners-up were:
"I liked it better when you guys just gave us pens."
"Dr. Granzinski's meeting with the head of the hospital."


MKSAP answer and critique

The correct answer is B) Botulinum toxin injection. This item is available to MKSAP 15 subscribers as item 26 in the Gastroenterology and Hepatology module.

This patient’s history is typical for achalasia, an uncommon but important primary motility disorder of the esophagus. Although endoscopic evaluation is required to investigate the possibility of a mass lesion leading to partial esophageal obstruction, the diagnosis of achalasia is made manometrically using esophageal motility studies. The manometric diagnosis usually includes an elevated lower esophageal sphincter resting pressure, failure of the lower esophageal sphincter to relax with swallowing, and diminished or absent peristalsis of the esophageal body. Radiologic findings of note in achalasia include a “bird’s beak” abnormality of the distal esophagus, widening of the esophagus, and, less commonly, megaesophagus with an air/fluid level. CT of the chest can be employed to differentiate achalasia from pseudoachalasia, the latter mimicking the true motility disorder but caused by a mass lesion at the distal esophagus or gastric cardia.

Treatment of achalasia is usually pneumatic dilatation of the esophagus or surgical myomectomy, the latter of which can be done laparoscopically. Pneumatic dilatation, even in experienced hands, is associated with a 5% to 10% risk of esophageal perforation. Botulinum toxin injection can afford relief of achalasia in patients like this one who because of age or comorbidities are not candidates for endoscopic or surgical intervention. Botulinum toxin inhibits the release of acetylcholine from nerve endings and has been used successfully for decades to treat certain spastic disorders of skeletal muscle such as blepharospasm and torticollis. Anticholinergic therapy is not indicated for achalasia.

Key Point

  • Botulinum toxin injection can afford relief of achalasia in patients who because of age or comorbidities are not candidates for endoscopic or surgical intervention.

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 67-year-old man is evaluated for a recent diagnosis of primary hyperparathyroidism after an elevated serum calcium level was incidentally detected on laboratory testing. Medical history is significant only for hypertension, and his only medication is ramipril. Following a physical exam and lab studies, what is the most appropriate management of this patient?

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