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

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In the News
for the Week of 11-23-10

Highlights

  • Americans more likely to incur high medical costs, insurance snafus than global counterparts
  • Erectile dysfunction a useful marker for cardiovascular risk in diabetics

Test yourself

  • MKSAP Quiz: recurrent nasal symptoms

Cardiology

  • Appropriate uses considered for echocardiography in common clinical scenarios
  • Telemonitoring no more effective than usual care after hospitalization in heart failure patients

Breast cancer

  • MRI screening associated with improved survival in women at high risk for breast cancer

Medicare update

From ACP Hospitalist

  • The next issue is online

From the College

  • ACP reminds physicians, public about importance of screening for HIV
  • ACP’s Washington office accepting internship applications

Cartoon caption contest

  • Vote for your favorite entry

Physician editor: Darren Taichman, FACP

Editorial note: ACP InternistWeekly will not be published next week due to the Thanksgiving holiday.


Highlights

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Americans more likely to incur high medical costs, insurance snafus than global counterparts

Americans were the most likely among adults in 11 countries to incur high medical expenses, even when insured, and to spend time on insurance paperwork and disputes or to have payments denied, although they have better access to specialist services than many.

The Commonwealth Fund conducted its 13th annual health policy survey to learn how the insurance designs of various countries affect access, financial protection when sick, and the complexity of health insurance. The 11 countries included Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States.

The survey consisted of computer-assisted telephone interviews using a common questionnaire that was translated as needed. Study populations ranged from 1,000 to 3,500 in each country. Results appeared online Nov. 18 at Health Affairs. Questions addressed topics such as affordability, access and ease-of-use.

In terms of affordability, 35% in the U.S. spent $1,000 or more out-of-pocket for health care, compared to 25% in Switzerland and 21% in Australia. Spending $1,000 or more was rarest in the United Kingdom (1%) and Sweden (2%). Also, the U.S. is the only country in which 20% of adults reported serious problems paying health care bills, compared to all other countries, which reported single-digit percentages.

The U.S. led in insurance disputes. Americans were the most likely (17%) of all 11 countries to report spending a lot of time on insurance paperwork or disputes, and 25% of U.S. adults reported that they were denied insurance reimbursement or were reimbursed less than they expected. Meanwhile, 31% of U.S. adults reported some type of insurance-related concern in the past two years. More than twice as many adults younger than 65 years old reported spending a lot of time on paperwork, disputes with insurers or insurance surprises than those covered by Medicare (35% vs. 16%, respectively).

In terms of access, countries varied in their capacity to provide 24/7 health care outside of hospital emergency departments. Far exceeding all other countries, 93% of the Swiss reported a same- or next-day appointment the last time they were sick, compared to 57% of Americans. About two-thirds of adults in Canada, France, Sweden, and the U.S. said it was difficult to get after-hours care without going to the emergency department, nearly twice the rate reported in the Netherlands, New Zealand, and the United Kingdom. Swiss adults, along with German and U.S. adults, were more likely than adults in the other countries to report quick access to specialists; more than 80% in each country saw a specialist within four weeks. They also had the best rates of less than four weeks' wait time for elective surgery.

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Erectile dysfunction a useful marker for cardiovascular risk in diabetics

Erectile dysfunction (ED) was associated with a range of cardiovascular events in men with type 2 diabetes, including an elevated risk of coronary heart disease and cerebrovascular disease.

In a cohort analysis of the ADVANCE (Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified-Release Controlled Evaluation) trial population, 6,304 men with type 2 diabetes ages 55 to 88 years were asked about ED and followed for five years through clinical exams and assessment of fatal and nonfatal cardiovascular outcomes, cognitive decline and dementia. Results appeared in the Nov. 22 issue of the Journal of the American College of Cardiology.

At baseline, half the men (3,158 of 6,304) reported ED. Men with ED had statistically significantly worse cardiovascular risk factors, morbidity and drug use because of the large sample size, although absolute differences were generally modest. Men with ED were older, heavier, had lower cognitive function, were more likely to have chronic ill health, and were less physically active. However, they were less likely to smoke, had lower total blood cholesterol, and had lower diastolic blood pressure.

During a mean of five years' follow-up, there were 695 deaths from any cause, 1,579 fatal and nonfatal cardiovascular events, 773 fatal and nonfatal coronary heart disease events, 411 fatal and nonfatal cerebrovascular disease events, 58 cases of dementia, and 1,013 cases of cognitive decline.

After adjustment for existing illness, psychological health and cardiovascular risk factors, baseline ED was associated with an elevated risk of all cardiovascular events (hazard ratio [HR] 1.19; 95% CI, 1.08 to 1.32), coronary heart disease (HR, 1.35; 95% CI, 1.16 to 1.56), and cerebrovascular disease (HR, 1.36; 95% CI, 1.11 to 1.67). Men with ED at baseline and at two-year follow-up had the highest risk for these outcomes.

Authors wrote that, while their study demonstrated an association between ED and cardiovascular outcomes, "[R]ather than having a direct, independent effect on CVD, it is more likely that erectile dysfunction is a marker of CVD risk."

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Test yourself

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MKSAP Quiz: recurrent nasal symptoms

A 35-year-old man has a 16-year history of recurrent nasal congestion, sneezing, and rhinorrhea that begin in the early spring. He feels uncomfortable and is having difficulty concentrating at work. The patient had eczema as a child. Medical history is otherwise unremarkable. He has no allergies and takes no medications. A sister has asthma.

Vital signs, including temperature, are normal. Examination of the nose reveals a widened bridge, a horizontal nasal crease, pale nasal mucosa, and a clear mucoid discharge. The lungs are clear to auscultation.

Which of the following is the most efficacious initial treatment?

A) Intranasal azelastine
B) Intranasal fluticasone
C) Oral fexofenadine
D) Oral pseudoephedrine

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

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Cardiology

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Appropriate uses considered for echocardiography in common clinical scenarios

In the face of new evidence and new technologies, 10 medical specialty and subspecialty societies reviewed common clinical scenarios where echocardiography is frequently considered.

The review combines and updates the original transthoracic and transesophageal echocardiography appropriateness criteria published in 2007 and the original stress echocardiography appropriateness criteria published in 2008. New to the report are:

  • new clinical data, changes in test utilization patterns, and clarifications to echocardiography use,
  • expanded tables with more comprehensive coverage of various clinical situations,
  • revised or new clinical scenarios such as valvular heart disease, perioperative evaluation and evaluation of thoracic aortic disease, and
  • indications to better address evolving therapeutic options such as cardiac resynchronization therapy or treatment/follow-up of pulmonary hypertension.

Also, writers tried to harmonize the indications across noninvasive modalities, and also added sections of specific assumptions and definitions to clarify interpreting the review.

The complete review was published online Nov. 19 by the Journal of the American College of Cardiology. The 202 indications (clinical scenarios) were derived from common applications or anticipated uses, as well as from current clinical practice guidelines and results of studies.

Indications were scored on a scale of 1 to 9, to designate appropriate use (median, 7 to 9), uncertain use (median, 4 to 6), and inappropriate use (median, 1 to 3). Authors acknowledged that the division was somewhat arbitrary, and the numbers should be viewed as a continuum.

Ninety-seven indications were rated as appropriate, 34 were rated as uncertain, and 71 were rated as inappropriate. In general, echocardiography is appropriate for initial diagnosis when there is a change in clinical status or when the results of the echocardiogram are anticipated to change patient management. Routine testing when there is no change in clinical status or when results of testing are unlikely to modify management was more likely to be inappropriate.

In the report, 18 tables document appropriate use by test and condition (such as "TTE [Transthoracic Echocardiogram] for Cardiovascular Evaluation in an Acute Setting" or "Stress Echocardiography for Assessment of Viability/Ischemia"), while three more tables break down all tests into their indications of appropriate, uncertain or inappropriate.

Also new, one table specifically covers contrast use as applied to all of the echocardiographic modalities and another covers indications related to patients with adult congenital heart disease, a growing population.

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Telemonitoring no more effective than usual care after hospitalization in heart failure patients

Telemonitoring after hospitalization for heart failure did not improve outcomes compared with usual care, according to a new study.

Researchers performed a six-month multicenter trial in which 1,653 patients recently hospitalized for heart failure were randomly assigned to receive usual care or telemonitoring. All patients were given educational information on heart failure, along with a scale to weigh themselves if needed. Patients in the telemonitoring group also received instructions on how to report their symptoms and weight daily over the phone using an interactive voice-response system; these data were reviewed by the patients' clinicians, who then took action as necessary. The study's primary end point was any hospital readmission or death from any cause up to 180 days after enrollment. Heart failure hospitalizations, hospital days, and number of hospitalizations were secondary end points. The study results were published online Nov. 16 by the New England Journal of Medicine.

Overall, 826 patients were assigned to the telemonitoring group and 827 were assigned to the usual care group. Forty-two percent of the patients were women, 39% were black and the mean age was 61 years. The primary end point did not differ significantly between the groups (52.3% vs. 51.5%; difference, 0.8 percentage point [95% CI, −4.0 to 5.6 percentage points]; P=0.75). In the telemonitoring group, 49.3% of patients were readmitted to the hospital for any reason and 11.1% died, versus 47.4% and 11.4% in the usual care group (differences, 1.9 percentage points [95% CI, −3.0 to 6.7 percentage points]; P=0.45 and −0.2 percentage point [95% CI, −3.3 to 2.8 percentage points]; P=0.88). The study groups also did not differ significantly in rates of the secondary end points. Approximately 14% of patients assigned to the telemonitoring system never used it, and only approximately 55% continued to use the system at least three times a week by the end of the study. No adverse events were reported in either group.

The authors noted that the automated telemonitoring used in their study might have been more effective if it had involved more direct contact between clinicians and patients. However, they also pointed out that even though patients were actively encouraged to participate in telemonitoring and were given considerable support, a significant number did not adhere to instructions or did not use the system at all.

The authors concluded that telemonitoring had no effect on outcomes compared with usual care in patients who had recently been hospitalized for heart failure. Previous studies showing a benefit, they wrote, were probably too small and had methodologic weaknesses that affected their results.

"There remains a need for strategies to improve heart-failure outcomes, and our findings indicate the importance of a thorough, independent evaluation of disease-management strategies before their widespread implementation," the authors concluded.

An accompanying editorial pointed out other potential reasons why the intervention might not have improved outcomes, including that the symptoms measured may not have accurately predicted clinical deterioration. Although the telemonitoring system was set up to alert clinicians to "variances" indicating a potential clinical problem, they noted, the timeliness and appropriateness of the clinicians' responses were not detailed. The trial's "neutral findings," the editorialists wrote, "highlight a need for caution before inserting additional loops into disease management."

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Breast cancer

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MRI screening associated with improved survival in women at high risk for breast cancer

Screening with magnetic resonance imaging (MRI) along with mammography and clinical breast exams may improve survival rates in women at high risk for breast cancer, a new study has found.

Researchers in the Netherlands analyzed long-term results of the Dutch MRI Screening Study to evaluate the effects of screening for breast cancer in four different risk groups: women with a BRCA1 mutation, women with a BRCA2 mutation, women at high cumulative lifetime risk (CLTR) due to family history (30% to 50%), and women at moderate CLTR due to family history (15% to 30%). All women in the study received biannual clinical breast exams plus annual mammography and MRI. The study results were published early online Nov. 15 by the Journal of Clinical Oncology.

Data were analyzed for 2,157 women, 599 of whom carried a BRCA mutation. Ninety-seven cases of primary breast cancer were detected. MRI was more sensitive than mammography for invasive cancer (77.4% vs. 35.5%; P<0.00005) but not for ductal carcinoma in situ (DCIS) (38.5% vs. 69.2%; P=0.388). Patients with BRCA1 mutations were more likely than those in the other three risk groups to have lower mammography sensitivity, larger tumors (>1 cm) at diagnosis, a lower proportion of DCIS, a higher proportion of interval cancer, and a higher proportion of cancer diagnosed before age 30. Rates of cumulative distant metastasis-free and overall survival at six years in BRCA1 and BRCA2 carriers with invasive breast cancer were 83.9% (95% CI, 64.1% to 93.3%) and 92.7% (95% CI, 79.0% to 97.6%), respectively. Both survival rates were 100% in women with invasive cancer in the familial risk groups. Overall, 42.7% of breast cancer cases were detected only on MRI. Although randomization was not possible due to ethical reasons, the authors analyzed results from 26 historical cohorts and found a median overall survival rate of 74.5% (range, 50% to 95%) over five years.

The current study confirmed earlier results in this cohort suggesting that intensive surveillance, including MRI, can detect breast cancer earlier in women at high risk, the authors concluded. Of particular importance, they noted, was the large difference in mammography sensitivity in women with BRCA1 mutations compared with BRCA2 mutations (25.0% vs. 61.5%; P=0.04).

The authors concluded that the sensitivity of MRI is "strongly superior" to that of mammography and that their findings affirm the American Cancer Society's recommendation of annual MRI screening in women with a 20% to 25% CLTR for breast cancer. They also noted that BRCA1 carriers might need more frequent screening, different treatments or different preventive measures given the unfavorable clinical characteristics associated with this mutation.

Another study published early online Nov. 18 by The Lancet Oncology found a benefit in screening mammography for moderate-risk women before age 50. A total of 6,710 U.K. patients younger than 50 who were at moderate risk for breast cancer but who were unlikely to have a BRCA mutation received mammography annually for four years, beginning at study enrollment between Jan. 16, 2003 and Feb. 28, 2007 until Nov. 30, 2009. One hundred thirty-six were diagnosed with breast cancer; of these, 77% were diagnosed at screening, 21% were diagnosed symptomatically between screenings, and 2% were diagnosed symptomatically after missing a scheduled mammogram. Data from two other trials were used for comparison, one the control group of a trial of average-risk women followed for up to 10 years and one a study of women with a family history of breast cancer.

The authors found that cases of invasive cancer in their study were smaller and had a more favorable grade than those in the average-risk comparison group, and were less likely to be node positive than those in either the average-risk or family history comparison group. Predicted 10-year mortality rate was also statistically significantly lower in the current study than in the average-risk comparison group. The authors concluded that yearly mammograms are likely to prevent breast cancer deaths in women at moderate familial risk.

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Medicare update

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Senate acts to prevent Medicare cut

On Nov. 18, the Senate unanimously approved legislation that would avert the Medicare payment cut scheduled for Dec. 1. The House is expected to take up and pass identical legislation when it returns from Thanksgiving, on Nov. 29, that would prevent the cut from going into effect.

The legislation extends current payment rates for 30 days, allowing Congress additional time before the end of the year to prevent the payment cut from going into effect on Jan. 1. ACP will continue to press the “lame duck” Congress to pass legislation that would fix payments through the end of 2011. ACP will then advocate that the new 112th Congress, which takes office in January, enact a long-term solution to the sustainable growth rate (SGR).

For additional information, and to find out how to help let Congress know the importance of preventing these payment cuts, visit the ACP Legislative Action Center.

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From ACP Hospitalist

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The next issue is online

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

Top Hospitalists. Meet this year's crop of outstanding physicians working in hospital medicine.
End-of-life-care disputes. Education, conversation and empathy can help mediate disagreements.
Peripheral neuropathy. Learn the right way to diagnose this common, painful condition.

These features and more, including Test Yourself with the MKSAP Quiz: Renal insufficiency, 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 reminds physicians, public about importance of screening for HIV

In support of World AIDS Day on Dec. 1, ACP is reminding physicians to adopt routine screening for HIV and encourage patients to be tested.

ACP recommends that physicians offer screening to all patients older than 13, regardless of their risk factors, and should determine the need for repeat screening intervals on a case-by-case basis. These recommendations are part of ACP's guidance statement on screening for HIV in health care settings.

The CDC estimates that more than 200,000 individuals are unaware of their HIV infection, and these individuals account for more than half of all new sexually transmitted HIV infections. Numerous studies show that once individuals learn that they are HIV positive, they take steps to prevent HIV transmission to their partners.

It's important for individuals to know their HIV status so that they can get treatment to extend their lives and also decrease their risk of infecting anyone else.

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ACP’s Washington office accepting internship applications

The College’s Washington office is now accepting applications for a newly created Health Policy Internship Program. The interns will work with ACP staff to plan ACP’s annual Leadership Day and will be responsible for researching and presenting students and residents at Leadership Day with information on health policy issues relevant to those groups. Applicants must be enrolled in an accredited medical school or internal medicine training program and must be a member of ACP. One Associate member and one medical student member will be chosen for the month-long spring internship.

Additional details are available on the College website.

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Cartoon caption contest

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Vote for your favorite entry

ACP InternistWeekly's cartoon caption contest continues. Readers can vote for their favorite captions to determine the winner.

"I should have listened when you told me Ehlers-Danlos and monkey bars don't mix."
"Most men your age would be more than pleased to be able to touch their toes."
"If this impresses you, just wait until the genital exam."
"I've never seen a case of palmar fasciitis."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting continues through the Thanksgiving holiday and ends on Monday, Dec. 6, with the winner announced in the Dec. 7 issue.

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MKSAP answer and critique

The correct answer is B) Intranasal fluticasone. This item is available to MKSAP 15 subscribers as item 6 in the General Internal Medicine section.

This patient has allergic rhinitis, for which intranasal corticosteroids are the most efficacious therapy. Intranasal corticosteroids, oral antihistamines, intranasal antihistamines, oral antihistamine/oral decongestant combination products, and intranasal cromolyn sodium are all superior to placebo. Studies have shown that intranasal corticosteroids are superior to both intranasal and oral antihistamines for relief of sneezing and nasal obstruction. Some corticosteroid preparations (for example, fluticasone) may also relieve ocular symptoms such as itching and tearing. Although intranasal corticosteroids are associated with minimal systemic bioavailability, this finding should not limit their use. Growth retardation has been reported with long-term administration of intranasal beclomethasone in children but has not been reported with use of other intranasal corticosteroid preparations. Epistaxis is the most common side effect of intranasal corticosteroids and occurs in approximately 10% of patients. However, this is not usually severe enough to warrant discontinuation of the drug. The rare side effect of nasal perforation can be avoided by using proper spray technique.

Oral second-generation (nonsedating) antihistamines (for example, fexofenadine) can either be used alone or as additional therapy for control of mild symptoms. However, the patient described here has more severe symptoms that are affecting his comfort and ability to work and therefore make intranasal corticosteroids the preferred therapy.

Azelastine is an intranasal H1-antihistamine that improves nasal congestion but is less effective than corticosteroids in relieving other symptoms.

Oral decongestants, including pseudoephedrine, also relieve nasal congestion but not rhinorrhea, itching, or sneezing.

Other effective therapeutic agents for allergic rhinitis include oral leukotriene modifiers (to be used as add-on therapy only), topical cromolyn sodium, and nasal saline irrigation. Immunotherapy may be considered when symptoms are not well controlled by other agents. Oral corticosteroids may also be used for brief periods to relieve severe symptoms. Intranasal ipratropium bromide is generally indicated for patients with nonallergic rhinitis but can also be used for patients with allergic rhinitis associated with profuse rhinorrhea.

Key Point

  • Intranasal corticosteroids are superior to antihistamines for treating patients with allergic rhinitis.

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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