In the News
for the Week of 12-14-10
- Improving systems of care theme of IHI’s national conference
- Guidelines issued for preventing first strokes
- MKSAP Quiz: Type 2 diabetes management
- Daily aspirin associated with reduced cancer deaths
- Highly sensitive troponin T assay predicts cardiac risk in healthy patients
- New food allergy guidelines aid diagnosis, management
- Medicare has new HCPCS codes for seasonal flu vaccines
- ACP reminds physicians and public: Get your flu shot
- NHSC application period now open
From the College
- Updated ACP Diabetes Care Guide features enhancements for residents
- 2011-12 Chair-elect chosen by Board of Regents
- Free health care reform brochure for patients available
- Last call for applications for ACP’s Washington internship
Cartoon caption contest
- Put words in our mouth
For the record
- Clarification to a previous issue
Physician editor: Darren Taichman, FACP
Improving systems of care theme of IHI’s national conference
ORLANDO—Can depression be effectively managed in primary care? Are you using registries to track patients’ progress? What are other physician groups doing to address overuse of specialty services? These are just a few of the quality of care issues addressed last week at the Institute for Healthcare Improvement's 22nd annual National Forum, which attracted more than 6,000 health care professionals.
Managing depression: Two workshops focused on effective models for managing depression in the primary care setting.
Henry Ford Health System is piloting a new model in seven of its 27 clinics that has increased the number of patients being screened, identified and treated for depression, said presenters Terri Robertson, PhD, and M. Justin Coffey, MD. The model calls for embedding psychiatric nurse practitioners in primary care clinics to coordinate with physicians, train medical assistants to use screening tools and provide clinical care. Medical assistants are trained to administer a two-part questionnaire to all patients as they arrive for an office visit. Patients who respond ‘yes’ to one or both questions are then asked to take an expanded questionnaire based on the PHQ-9, which is embedded into the clinic's electronic health record system. Patients’ answers are entered directly into the EHR and results are calculated and analyzed before the physician arrives in the exam room, freeing up the physician to focus on discussing the results with the patient. Since the pilot began at Henry Ford three years ago, 90% of patients who screened positive are being managed by their physician with a combination of cognitive behavioral therapy and pharmacotherapy and among that group, 67% of patients received pharmacotherapy and 53% had a full response to treatment, the presenters said.
The Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) model has been implemented in 83 primary care clinics in Minnesota and Wisconsin over the past two and a half years. Nine health plans support the initiative using a common payment code for evidence-based collaborative depression care management. The model relies on the PHQ-9 questionnaire as a simple tool to identify depression and track patients' response to treatment, said presenters Tim Hernandez, MD, of Family Health Services Minnesota and Nancy Jaeckels, vice president of the nonprofit Institute for Clinical Systems Improvement. Other key elements include using a computerized tracking system or registry to follow patient progress, make follow-up contacts and collect data and documentation, and taking a team approach to patient care. So far, the DIAMOND program, which began in March 2008, has improved response and remission rates among patients at participating clinics while reducing overall costs. According to data from the University of Washington’s Project IMPACT (Improving Mood—Promoting Access to Collaborative Treatment), the per patient per year cost was 50% less for DIAMOND care management ($18,290) compared with usual care ($30,634).
Using specialty services effectively: If you want to lower physician use of specialty services, targeting “high utilizers” is usually a dead-end strategy, said presenter Neil Baker, MD, of IHI, which is partnering with the American College of Cardiology on an initiative to optimize use of specialty services. Instead, show physicians data on the wide variation in specialty care costs across the country and evidence that higher utilization is not associated with better outcomes. Then ask physicians to develop reasonable clinical standards that everyone in the group agrees to follow, he said. A case in point is the Palo Alto Medical Foundation, a large multispecialty group with over 900 physicians in the San Francisco Bay Area. The group gets top ratings for quality but is unaffordable for many patients, said Lawrence Shapiro, MD, of PAMF. In an effort to cut costs, PAMF launched an initiative in its ob/gyn group to reduce specialty referral costs for patients with post-menopausal bleeding (PMB). After physicians agreed to adhere to a common clinical standard for PMB patients, the group recorded savings of almost $780,000 over nine months, largely due to fewer biopsies and greater use of ultrasound for diagnosis. “The doctors have to be at the center of the process,” said Dr. Shapiro. “At first they might argue about the data but then they start talking to each other.”
Guidelines issued for preventing first strokes
Prevention remains the best approach for reducing the burden of stroke, and at-risk people can be identified and targeted for specific interventions, according to guidelines from the American Heart Association and the American Stroke Association.
The new paper is a complete revision of the organizations' 2006 statement on strokes. The guidelines were published online on Dec. 6 by Stroke.
The guidelines included recommendations on how physicians should deal with patients’ modifiable and nonmodifiable risk factors. Among the nonmodifiable factors, family history can be useful to identify those who may be at increased risk of stroke. Dosing with vitamin K antagonists on the basis of pharmacogenetics is not recommended. Genetic screening of the general population is not recommended, although referrals for genetic counseling may be considered for patients with rare genetic causes of stroke. Noninvasive screening for unruptured intracranial aneurysms in patients with a relative with subarachnoid hemorrhage or intracranial aneurysms was also not recommended, except in certain patients with particularly high-risk family histories.
The guidelines also found well-documented evidence for treating a number of modifiable risk factors, including blood pressure (to a goal of less than 140/90 mm Hg or 130/80 mm Hg in patients with diabetes or renal disease) and smoking (which should be addressed at every patient encounter). Physical activity (150 minutes of moderate exercise per week) and healthy eating (such as the DASH diet) are also recommended.
For patients with diabetes and hypertension, the guidelines suggest an angiotensin-converting enzyme inhibitor or an angiotensin II receptor blocker; statins, especially in those with additional risk factors, to lower risk of a first stroke, and possibly monotherapy with a fibrate to lower stroke risk. Adding a fibrate to a statin is not useful for decreasing stroke risk, the guidelines said.
The guidelines also addressed the role of aspirin for primary stroke prevention, recommending that it be used for cardiovascular (including but not specific to stroke) prophylaxis in persons whose risk is sufficiently high for the benefits to outweigh the risks associated with treatment (a 10-year risk of cardiovascular events of 6% to 10%). They concluded that it is not useful for preventing a first stroke in low-risk people or persons with diabetes or diabetes plus asymptomatic peripheral artery disease in the absence of other established cardiovascular disease.
MKSAP Quiz: Type 2 diabetes management
A 68-year-old woman comes to the office for a follow-up evaluation. She has had type 2 diabetes mellitus for the past 13 years and has experienced two early-morning hypoglycemic episodes in the past 3 months. Although her self-monitoring of fasting blood glucose levels over the past 6 months has consistently shown results in the 110 to 140 mg/dL (6.1 to 7.8 mmol/L) range, her hemoglobin A1c value during this same period has exceeded 8.5%. Her current diabetes regimen consists of metformin, 850 mg three times daily, and insulin detemir, 38 units at night. She has no other medical problems.
Which of the following is the most appropriate next step in management?
A) Add exenatide to her regimen
B) Check her serum fructosamine level
C) Increase the insulin detemir dosage
D) Measure 2-hour postprandial glucose levels
Click here or scroll to the bottom of the page for the answer and critique.
Daily aspirin associated with reduced cancer deaths
Daily aspirin therapy may reduce death from several types of cancer, a new study has shown.
Researchers performed a meta-analysis of randomized trials that compared daily aspirin use with no aspirin use and had a mean duration of scheduled trial treatment of at least four years. The goal of the meta-analysis was to determine the effect of aspirin on risk for death from gastrointestinal and nongastrointestinal cancer. The study results were published online Dec. 7 by Lancet.
Eight trials involving 25,670 patients and 674 deaths from cancer were eligible for inclusion in the study. The authors found that overall, assignment to aspirin therapy reduced cancer death (pooled odds ratio [OR], 0.79; 95% CI, 0.68 to 0.92; P=0.003). Analysis of individual patient data from seven of the trials (23,535 patients, 657 deaths from cancer) found that aspirin’s benefit was not apparent until after five years of follow-up (hazard ratios [HR], 0.66; 95% CI, 0.50 to 0.87 and 0.46; 95% CI, 0.27 to 0.77 for all cancer and for gastrointestinal cancer, respectively; P=0.003 for both comparisons). The 20-year risk for death, which was assessed using data on 1,634 deaths from cancer in 12,659 patients in three trials, was also lower in the aspirin groups than in the control groups (HR for all solid cancer, 0.80; 95% CI, 0.72 to 0.88, P<0.0001; HR for gastrointestinal cancer, 0.65; 95% CI, 0.54 to 0.78; P<0.0001). Greater benefit was seen with longer duration of aspirin therapy. Aspirin taken for five years individually benefited esophageal, pancreatic, brain and lung cancer, but more years of therapy were required before an individual effect was seen for stomach, colorectal and prostate cancer. In lung and esophageal cancer, a benefit was seen only for adenocarcinomas. Aspirin’s benefit did not seem to be related to dose (75 mg/d and up), sex, or smoking status but did increase as patients grew older, with an absolute reduction in 20-year risk for death from cancer of 7.08% (95% CI, 2.42% to 11.74%) in those at least 65 years of age.
The authors pointed out that they only included trials that assessed daily aspirin use and that the trials did not include enough women to allow assessment of breast cancer or other gynecologic cancer, among other potential limitations. However, they concluded that daily aspirin therapy reduced cancer-related deaths during and after the included trials, with benefit increasing as duration of treatment increased. They called for future studies to examine aspirin’s effects on cancer incidence overall and on cancer in women, as well as over longer and shorter periods of follow-up.
Highly sensitive troponin T assay predicts cardiac risk in healthy patients
The results of a highly sensitive assay for cardiac troponin T (cTnT) can predict cardiovascular events in apparently healthy populations, according to new research.
As part of the Dallas Heart Study, cTnT levels were measured using both standard and highly sensitive assays in more than 3,500 patients ages 30 to 65. The standard assay found detectable cTnT in only 0.7% of the study participants, while the highly sensitive test found it in 25%. The results were published in the Dec. 8 Journal of the American Medical Association.
The researchers stratified participants based on their cTnT levels (according to the highly sensitive test) and compared their mortality rates as well as cardiac structure and function measured by MRI. Only 7.5% of people in the lowest cTnT group had left ventricular hypertrophy compared to 48.1% in the highest cTnT group. Mortality also increased from 1.9% in the lowest group to 28.4% in the highest. After adjusting for traditional cardiac risk factors, the study found that cTnT was independently associated with all-cause mortality (adjusted hazard ratio, 2.8 in the highest cTnT group).
Another study in the same issue tested the highly sensitive cTnT assay’s ability to predict heart failure in more than 4,000 community-dwelling elderly patients. The biomarker was detectable in the majority of patients (66.2%) and associated with an increased risk of heart failure and cardiovascular death at higher concentrations (4.8 deaths per 100 in highest group compared to 1.1 in patients with undetectable levels). This study continued cTnT measurements over time and found that increases of more than 50% were also associated with cardiovascular events.
The results indicate that the highly sensitive cTnT assay has potential clinical utility, especially given its success at predicting mortality in patients who would be considered low risk according to the Framingham score (which is based on sex, age, cholesterol, blood pressure and diabetes and smoking status), concluded the authors of the first study. In both studies, there was significant overlap between cTnT and N-terminal pro-brain-type natriuretic peptide, suggesting that more accurate predictions may be achieved by use of both tests together. However, appropriate therapeutic responses to cTnT results will have to be established before the highly sensitive tests can be recommended for widespread screening, the researchers advised.
The authors of the first study also warned about the potential effects of the highly sensitive test if it is used in the hospital for diagnosis of acute myocardial infarction: Diagnostic sensitivity would be improved, but specificity would decline, potentially leading to false-positive diagnoses and unnecessary treatment.
New food allergy guidelines aid diagnosis, management
The National Institute of Allergy and Infectious Diseases (NIAID) last week issued comprehensive food allergy guidelines to help primary care physicians and subspecialists diagnose and manage patients.
The complete guidelines were published online at the NIAID food allergy guidelines portal, along with a clinician summary and frequently asked questions. The guidelines establish consistent terminology and definitions, diagnostic criteria and patient management practices.
According to the guidelines, food allergies should be considered in those presenting with anaphylaxis or any combination of other symptoms that occur within minutes to hours of ingesting food, especially in young children and/or if symptoms have followed the ingestion of a specific food on more than one occasion. Following a detailed history and physical, a skin prick test may help identify foods at issue, although it alone is not considered diagnostic. The guidelines include a list of additional tests that should not be used for diagnosis.
Intradermal tests and routine total serum IgE should not be used, and the atopy patch test should not be used in noncontact food allergies, the guidelines said. Food elimination diets may be useful in diagnosis, and double-blind, placebo-controlled food challenges are a gold standard, the guidelines said.
Management of allergy patients should include avoidance of the food that causes the allergy, as well as education, careful attention to food labels and regular growth checks. The panel did not recommend avoiding potentially allergenic foods as a means of managing eosinophilic esophagitis, food protein-induced allergic proctocolitis or asthma. There are no medications recommended to prevent food allergies, but antihistamines may be used to manage symptoms. Drug therapies have been used when the allergen is difficult to avoid or results in nutritional deficiencies. The panel does not recommend restricting maternal diet during pregnancy or lactation to prevent later food allergies.
Treatment for food-induced anaphylaxis should be prompt and rapid, with intramuscular epinephrine as first-line therapy in all cases, and then adjunctive treatments such as bronchodilation, antihistamines and supplemental oxygen. Any patient treated for anaphylaxis should be discharged with:
- an anaphylaxis emergency action plan,
- two doses of an epinephrine auto-injector,
- a plan for monitoring auto-injector expiration dates,
- a referral for further evaluation by an allergist or immunologist and
- printed information about anaphylaxis and its treatment.
Recent studies estimate that food allergy affects nearly 5% of children younger than 5 years old and 4% of teens and adults. Its prevalence appears to be on the rise, according to NIAID.
Medicare has new HCPCS codes for seasonal flu vaccines
The Centers for Medicare and Medicaid Services (CMS) has created specific codes and payment rates for billing vaccinations during the 2010-2011 influenza season.
Physicians billing for flu vaccines provided on or after Jan. 1 will need to use new codes instead of CPT code 90658. The new codes are: Q2035 (Afluria), Q2036 (Flulaval), Q2037 (Fluvirin), Q2038 (Fluzone), and Q2039 (Not Otherwise Specified flu vaccine). Until Jan. 1, practices can continue to use the CPT code; however, it should not be billed in conjunction with the new Q codes.
Additional information can be found in the Nov. 19 issue of MLN Matters..
ACP reminds physicians and public: Get your flu shot
ACP has signed on to "An Open Letter to the American People,” along with many other organizations in the public health community, to remind the public of the importance of getting vaccinated against the flu.
The CDC recommends that everyone 6 months and older receive an annual flu vaccine. The 2010-2011 flu vaccine protects against the 2009 H1N1 flu virus and two additional flu viruses that research indicates may cause the most illness this season. More immunization resources from ACP are available online.
NHSC application period now open
The application period for the National Health Service Corps (NHSC) loan repayment program is now open.
There are changes to this year’s program as a result of the Affordable Care Act. The repayment amounts for the program have increased. Physicians now can receive up to $170,000 for 5 years of service in the Corps. In addition, the options for service terms have been increased to make the program more flexible and the credit awarded for teaching has increased. Applications for Fiscal Year 2011 must be received by May 26, 2011. For additional information about the NHSC, please visit the program’s website.
From the College.
Updated ACP Diabetes Care Guide features enhancements for residents
The free ACP Diabetes Care Guide has been updated and includes enhancements for residents learning to care for diabetes patients.
Through 80 case-based, self-assessment questions, physicians and their clinical teams can learn to deliver optimal care including overviews of treatment, seminal clinical studies, drug treatments, and patient communication skills. Program directors and supervisors have access to tools to monitor residents' learning progress.
The online ACP Diabetes Care Guide is concise, authoritative, and up-to-date, an ideal educational format for clinical teams learning to improve their care of patients with diabetes. It is free, and now available online..
2011-12 Chair-elect chosen by Board of Regents
At their November meeting, the Board of Regents elected Phyllis A. Guze, FACP, of Riverside, Calif., as the 2011-12 Chair-elect of the Board of Regents.
Dr. Guze will assume her position as Chair at the conclusion of the Annual Business Meeting at Internal Medicine 2012 in New Orleans. More information about Dr. Guze will be provided in the March ACP Internist when the results of the election of new Regents and President-elect are reported..
Free health care reform brochure for patients available
Print copies of the joint ACP and AARP Consumer Guide to Understanding Health System Reform are now available for order. The free brochures, available in both English and Spanish, are meant to be shared with your patients to help answer their questions about health care reform. Guides will be shipped in bundles of 100. The order form is available on the College website..
Last call for applications for ACP’s Washington internship
Dec. 15 is the last day for students and residents to submit applications for the College’s newly created Health Policy Internship Program.
The interns will work with staff in ACP’s Washington office 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 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.
Cartoon caption contest.
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 email@example.com. ACP staff will choose finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.
For the record.
Clarification to a previous issue
In last week's ACP InternistWeekly, the headline of the item on tuberculosis prevention in HIV patients should have read "WHO issues guidelines on TB prevention in people with HIV in resource-constrained settings." The item has been updated..
MKSAP answer and critique
The correct answer is D) Measure 2-hour postprandial glucose levels. This item is available to MKSAP 15 subscribers as item 33 in the Endocrinology and Metabolism section.
This patient requires measurement of her 2-hour postprandial blood glucose levels. A common clinical scenario in diabetes management is the patient whose hemoglobin A1c values are suboptimal despite fasting blood glucose monitoring results suggesting good glycemic control. Several possible explanations for this phenomenon exist, including a falsely altered hemoglobin A1c value in the setting of hemoglobinopathy or hemolytic anemia; however, there is no reason to suspect a blood disorder in this patient. The most common cause is elevated postprandial blood glucose levels. The possibility of postprandial hyperglycemia should be assessed by measuring blood glucose levels 2 hours after meals several times each week. If elevated blood glucose levels are noted postprandially, the addition of a mealtime rapid-acting insulin analogue, such as insulin aspart, insulin lispro, or insulin glulisine, is appropriate. These insulin preparations, which have peak action within 30 to 90 minutes and a duration of action of 2 to 4 hours, successfully modulate the postprandial rise in glucose.
Although adding exenatide to insulin may reduce postprandial hyperglycemia, it would not reveal the reason for the discrepancy between the fasting blood glucose levels and the hemoglobin A1c values. Exenatide is approved by the U.S. Food and Drug Administration for use in combination with metformin, with a sulfonylurea, or with a combination of metformin and a sulfonylurea but not with insulin.
When a hemoglobinopathy or a hemolytic anemia is responsible for incorrect hemoglobin A1c readings, another biochemical measure of long-term glucose levels, such as fructosamine or glycated albumin, can be used instead of hemoglobin A1c. Because these conditions are unlikely in this patient, measurement of her serum fructosamine level is inappropriate.
Basal insulin analogues, such as insulin glargine and insulin detemir, are effective agents to control fasting glucose levels and, in most circumstances, hemoglobin A1c values. However, they cannot reduce postprandial glucose excursions. Additionally, increasing the dosage of insulin detemir may increase the incidence of overnight hypoglycemia without addressing postprandial glucose spikes.
- When the hemoglobin A1c value is higher than that suggested by the fasting glucose readings, the postprandial glucose level should be checked.
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