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

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In the News
for the Week of 3-2-10

Highlights

  • Studies show limited evidence for vitamin D
  • Lower pay drives doctors to cut hours
  • Successful strategies found for refusing antidepressant requests

Test yourself

  • MKSAP Quiz: dietary counseling for class II obesity

Diabetes care

  • Rosiglitazone, CVD link worrisome but inconclusive, cardiologists say

Flu update

  • ACIP recommends seasonal flu vaccine for almost everyone

Patient safety

  • New surveillance system aims to improve safe use of medicines and vaccines in pregnancy

FDA update

  • FDA reviewing safety of HIV drug combo
  • Asthma drugs get risk management program

Practice management policy

From the College

  • ACP seeks member feedback on new Clinical Information page for Web site
  • ACP solicits member input on CDC survey
  • College Master to be named president of International Society of Internal Medicine

Cartoon caption contest

Physician editor: Darren Taichman, FACP


Highlights

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Studies show limited evidence for vitamin D

Two meta-analyses, published in the March 2 Annals of Internal Medicine, found only limited associations between vitamin D supplementation and cardiovascular health.

The first analysis included 13 observational studies and 18 trials. The majority of the studies found no effect of vitamin D on development of glycemia or diabetes. In the observational studies, lower vitamin D levels or intake was associated with increased risk for hypertension and possibly also cardiovascular disease, but the association was not as strong as previous studies have reported, the authors noted. This could mean that the previous findings are due to reverse causation (healthier people taking more vitamin D), or other health benefits of vitamin-D-heavy diets, the meta-analysis authors suggested.

The other analysis included 17 prospective studies and randomized trials of patients on dialysis and the general population. The analysis found a consistently strong inverse association between vitamin D use and cardiovascular mortality in the patients on dialysis, but the results are not generalizable to healthy populations without further study, the authors said. The randomized trials found a slight but statistically insignificant reduction in cardiovascular risk in people taking moderate to high doses of vitamin D.

The authors of both studies, and an accompanying editorial, called for large randomized trials of vitamin D supplementation. The evidence for vitamin D is more promising than that for other vitamins or mineral supplements, the editorialist said, but it’s insufficient to support widespread high-dose vitamin D supplementation at this time. Research to determine the optimal dose, benefits and potential harm should be a public health research priority, the editorialist concluded.

ACP Internist covered the controversy over vitamin D supplementation in November 2009.

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Lower pay drives doctors to cut hours

Lower reimbursement in the past decade has been linked to doctors cutting their hours from a mean of 55 hours per week to 51, the equivalent of losing 36,000 physicians a year.

Researchers conducted a retrospective analysis of trends in hours worked among U.S. physicians using Census Bureau survey information between 1976 and 2008. (Researchers and the U.S. Department of Labor use the same data to calculate employment trends among many professions.) They reported results in the Feb. 24 Journal of the American Medical Association.

Average physician reimbursement fell nationwide by 25% between 1995 and 2006 after adjusting for inflation. This is the same decade in which physicians began to cut back their hours, after having stable hours-per-workweek averages for the previous two decades.

Mean hours worked per week decreased by 7.2% between 1996 and 2008 among all physicians (n=116,733; 54.9 hours per week in 1996-1998 to 51.0 hours per week in 2006-2008; 95% CI, 5.3%-9%; P<0.001. When researchers excluded residents, whose hours decreased due to duty hour limits in 2003, physician hours decreased by 5.7% (95% CI, 3.8%-7.7%; P<0.001).

Mean hours worked by nonresident physicians were strongly associated with the fee index (correlation=0.965, P<0.001) and even more strongly associated with the fee index from the prior year (correlation=0.969, P<0.001).

The decrease in hours was largest for nonresident physicians younger than 45 years (7.4%; 95% CI, 4.7%-10.2%; P<0.001) and those working outside of the hospital (6.4%; 95% CI, 4.1%-8.7%; P<0.001). The decrease was smallest for those 45 years or older (3.7%; 95% CI, 1%-6.5%; P=0.008) and working in the hospital (4%; 95% CI, 0.4%-7.6%; P=0.03).

A 5.7% decrease in hours out of a workforce of approximately 630,000 physicians in 2007 equals a loss of approximately 36,000 doctors. The authors wrote, "This trend toward lower hours, if it continues, will make expanding or maintaining current levels of physician supply more difficult," although more medical schools or international medical graduates could mitigate the problem, they suggested.

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Successful strategies found for refusing antidepressant requests

A patient-based approach is the best way to refuse to prescribe medically inappropriate antidepressants while keeping patient satisfaction high and preserving the physician-patient relationship, a study found.

More than 10% of patient visits involve drug requests, and may involve brands seen in direct-to-consumer advertising. Physicians do not want to jeopardize patient satisfaction, and need strategies to refuse medically inappropriate treatments.

Studies conflict on whether the refusal itself lowers patient satisfaction, so researchers looked at whether satisfaction depends on what the physician says, rather than what he or she writes on a prescription pad.

Researchers looked at 152 primary care physicians from four locations in California and New York between May 2003 and May 2004. They trained 18 insured, middle-aged, white women to play patients with specific complaints; the women then randomly made 298 unannounced visits. The standardized patients were not blinded to the design of the study but were unaware of its hypotheses. The authors reported results in the Feb. 22 Archives of Internal Medicine.

The standardized patients presented with subacute fatigue and insomnia accompanied by an unrelated orthopedic complaint referable to low back strain or carpal tunnel syndrome, and then requested a brand-specific antidepressant or any antidepressant, or made no request. Standardized patients asking for antidepressants did so within the first 10 minutes of the visit or before the physical examination, and repeated their request if the first request did not lead to a prescription.

The standardized patients requested antidepressants in 199 visits; they were not prescribed in 88 visits (44%), 84 of which were available for analysis. In 53 of those visits (63%), physicians used one of three strategies that explicitly incorporated the patient perspective: exploring the context of the request, referring to a mental health professional, and offering an alternative diagnosis. Twenty-six visits (31%) involved biomedical approaches, such as sleep aids or a diagnostic workup. In 5 visits (6%), physicians rejected the request outright.

The relationship between the approach used and visit satisfaction was examined using the Fisher exact test. The 26 visits with scores of 9 or 10 were classified as providing excellent satisfaction, and the remaining 58 with scores of less than 9 were classified as less than excellent satisfaction. The standardized patients were significantly more likely to report excellent visit satisfaction despite denial with a patient perspective-based strategy (43%) over other strategies (10%) (P=0.001).

The authors concluded, "In an era of increasing constraints on health care systems and practitioners and significant influence of [direct-to-consumer advertising], learning to say no to patient requests will become more important."

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Test yourself

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MKSAP Quiz: dietary counseling for class II obesity

A 56-year-old woman is evaluated during a routine annual visit. The patient would like to lose weight. She works as a teacher and is physically active, walking briskly 2 or 3 times a week for 20 or 30 minutes. She does not smoke and drinks alcohol only on occasion. Her medical history includes hypertension and hyperlipidemia, both well controlled with medications.

On physical examination, the blood pressure is 135/88 mm Hg. The BMI is 36. The remainder of the physical examination is normal. Laboratory studies include a fasting plasma glucose level of 105 mg/dL (5.83 mmol/L) and a serum thyroid-stimulating hormone level of 2.5 µU/mL (2.5 mU/L). A diagnosis of class II obesity is established. A goal is set for a 5% to 15% reduction in weight.

Which of the following diets should be advised for this patient?

A) A balanced low-calorie diet (1,200 to 1,500 Kcal/day)
B) A very-low-calorie diet (<1,000 Kcal/day)
C) A reduced-fat diet (fat constitutes <30% of total caloric intake/day)
D) A low-carbohydrate diet (<35 g of carbohydrates/day)

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

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Diabetes care

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Rosiglitazone, CVD link worrisome but inconclusive, cardiologists say

Data on the relationship between thiazolidinediones and cardiovascular risks, particularly ischemic heart disease, are inconclusive, concluded a new science advisory from the American Heart Association and the American College of Cardiology Foundation.

The advisory, which was published online Feb. 23 by Circulation, summarized existing research on the type 2 diabetes drugs, especially focusing on the medications’ impact on macrovascular complications. Conventional risk-reduction measures, such as lifestyle modification, are the best proven methods of reducing macrovascular disease, and there is inconclusive evidence that rosiglitazone (but not pioglitazone) may harm rather than help.

However, there are insufficient data to recommend the use of pioglitazone over rosiglitazone, the advisory concluded. The experts recommended that thiazolidinediones not be used with an expectation of preventing ischemic heart disease events. The drugs increase the risk of heart failure and should not be used in patients with class III or IV congestive heart failure, they noted.

The advisory called for immediate additional research into the cardiovascular effects of these drugs and asked the FDA to require such trials as a part of approval of new glucose-lowering agents. The FDA also issued a statement on rosiglitazone and cardiovascular safety last week, noting that data from the RECORD trial are still being reviewed. No new conclusions or recommendations are being issued at this time and the agency’s full review will be presented in July 2010, according to an FDA communication.

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Flu update

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ACIP recommends seasonal flu vaccine for almost everyone

Vaccination against seasonal flu should now be recommended for almost all Americans, according to a vote made by the Advisory Committee on Immunization Practices last week.

The expert panel, which provides recommendations to the CDC, voted 11-0 (with one abstention) to recommend seasonal vaccination for everyone except infants younger than 6 months and people with egg allergies or prior severe reactions to flu vaccine. This adds healthy people between 19 to 49—a group that was hit hard by the H1N1 flu—to the list of recommended vaccine recipients, noted the Feb. 24 Washington Post.

At the same meeting, the committee also added the new high-dose flu shot to the list of vaccination options for patients over 65. They also approved the inclusion of the H1N1 strain in the seasonal vaccine for the 2010-2011 flu season.

The World Health Organization had previously recommended that the strain be included in next year’s vaccine. Also last week, an expert committee from that organization announced that it is premature to conclude that the H1N1 epidemic has peaked. They noted that an accurate death toll of the epidemic is difficult to calculate and that the virus still could mutate or mix with another more dangerous strain, Reuters reported on Feb. 23.

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Patient safety

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New surveillance system aims to improve safe use of medicines and vaccines in pregnancy

The American Academy of Allergy, Asthma & Immunology is launching a new system to gather information on safe use of medications and vaccines in pregnant women.

The Vaccines and Medications in Pregnancy Surveillance System (VAMPSS) consists of a prospective surveillance arm and a case-control surveillance arm. The former, coordinated by the Organization of Teratology Information Specialists (OTIS), will prospectively enroll and follow pregnant women who are exposed to vaccines or medications, comparing their outcomes with those of pregnant women who have not been exposed. The latter, coordinated by the Slone Epidemiology Center at Boston University, will enroll mothers of infants with congenital malformations and mothers of those without and compare prevalence of vaccines and certain medications. Both arms will collect information directly from mothers, who will be asked about all medicines taken, regardless of how they were obtained, and all vaccines received.

VAMPSS will first focus on asthma and influenza. Women are encouraged to enroll in the study so they and their infants can be followed through pregnancy and the post-partum period. Clinicians can help support VAMPSS by referring pregnant patients to OTIS at 877-311-8972. VAMPSS was developed in consultation with the FDA, was initially funded by the Agency for Health Care Research and Quality and the U.S. Office of Biomedical Advanced Research and Development Authority, and uses an independent advisory committee composed of representatives of obstetric and pediatric medical specialty groups, the CDC, NIH and a consumer representative. More information is available online.

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FDA update

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FDA reviewing safety of HIV drug combo

The FDA is conducting a safety review on the use of saquinavir (Invirase) in combination with ritonavir (Norvir), the agency announced last week.

The antiviral medications are given together to treat HIV infection, but trial data suggest that the combination may cause prolonged QT or PR intervals. While the analysis is ongoing, the FDA is not recommending that patients stop taking the drugs.

However, clinicians should be aware of this potential risk, noted an FDA press release. The drugs should not be used in patients already taking medications known to cause QT interval prolongation, including class IA (such as quinidine) or class III (such as amiodarone) antiarrhythmic drugs, or in patients with a history of QT interval prolongation. Health care professionals and patients are also encouraged to report any adverse events or side effects to the FDA MedWatch program.

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Asthma drugs get risk management program

A new risk management program has been instituted for the use of long-acting beta-agonists (LABAs) to treat asthma, the FDA announced last week.

The changes are based on an FDA analysis that found an increased risk of severe exacerbation of asthma symptoms, leading to hospitalizations and some deaths in patients on the drugs. LABAs are available in single-ingredient products (Serevent and Foradil) and combination products containing inhaled corticosteroids (Advair and Symbicort). LABAs are now contraindicated without the use of an asthma controller medication, such as an inhaled corticosteroid.

LABAs should only be used long term in patients whose asthma cannot be adequately controlled on asthma controller medications and for the shortest duration of time required to achieve control of asthma symptoms. If possible, the medications should be discontinued once asthma control is achieved, an FDA press release said. Pediatric and adolescent patients requiring LABA treatment should be prescribed a combination product containing both the LABA and an inhaled corticosteroid to improve compliance with both medications. The agency has also called for additional clinical trials.

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Practice management policy

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Medicare payment cut goes into effect

Congress has failed to pass legislation to halt a 21% cut in Medicare payment rates to physicians, allowing the cut to go into effect on March 1.

In December, Congress had passed temporary legislation delaying the scheduled payment cut until March 1. This temporary delay was passed with the idea that a long-term fix to the Medicare payment problems caused by the Sustainable Growth Rate (SGR) formula could be included in broader health care reform legislation. With the health care reform legislation stalled, Congress failed to pass any additional legislation before the March 1 deadline.

Medicare contractors will be holding March Medicare claims for 10 days. Congress is still attempting to pass legislation fixing the payment cut before contractors begin paying the March claims. If Congress succeeds in passing legislation within this timeframe, physicians should see minimal effect on their claims processing.

For more than a decade, physicians have faced perennial cuts in Medicare reimbursement due to the flawed Sustainable Growth Rate (SGR) formula, which has been used to determine Medicare physician payments. Congress has stepped in virtually every year to stop the scheduled cuts and pass short-term reprieves, thereby postponing the need to find a permanent solution to the problem and allowing the looming cuts—and the cost of eliminating them—to grow.

For information about additional changes to the Medicare program this year, and to follow congressional action on the payment cut, please visit the Running a Practice section of the ACP Web site.

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From the College

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ACP seeks member feedback on new Clinical Information page for Web site

In an effort to better meet the needs of members, ACP has redesigned the Clinical Information landing page for the ACP Web site. The page was reorganized according to features that are viewed or accessed most. Members who participate in a survey about the new page are eligible to win a $50 ACP gift certificate.

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ACP solicits member input on CDC survey

ACP is making available to its members a Web survey on the Evaluation of Genomic Applications in Practice and Prevention (EGAPP) project, sponsored by the CDC. The survey focuses on hereditary nonpolyposis colorectal cancer or Lynch syndrome and UGT1A1 testing and is intended to determine physicians' level of awareness and interest in the EGAPP process.

EGAPP is a nonfederal, multidisciplinary working group whose goal is to establish a systematic, evidence-based process to assess the effectiveness of selected genetic tests that are in transition from research to clinical and public health practice. Participation in the survey is voluntary and is estimated to take 7 to 10 minutes. Responses are anonymous and will not be linked to identity or e-mail address. Click here to participate by March 31, 2010.

Read ACP Internist columnist and genomics expert W. Gregory Feero, MD, PhD, as he discusses EGAPP's impact on internal medicine.

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College Master to be named president of International Society of Internal Medicine

William J. Hall, MACP, a former ACP president and current member of the ACP International Council, will be named president of the International Society of Internal Medicine this month. Dr. Hall has been ISIM's president-elect since 2008. He will take office as president at the upcoming World Congress of Internal Medicine in Melbourne, Australia, scheduled for March 20-25, 2010.

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Cartoon caption contest

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And the winner is …

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

This issue's winning cartoon caption was submitted by Steven Lipari, a fourth-year medical student from the University of British Columbia in Vancouver, Canada, who will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 111 ballots online to choose the winning entry. Thanks to all who voted!


"The good news is that you have excellent depth perception."

The winning entry captured 69.4% of the votes.

The runners-up were:
"Never allow a patient to juggle during a radiologic exam."
"Eye, eye, eye, such a problem."

ACP Internist continues its cartoon caption contest next week.

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MKSAP answer and critique

The correct answer is A) A balanced low-calorie diet (1,200 to 1,500 Kcal/day). This item is available online to MKSAP 14 subscribers in the General Internal Medicine section, Item 57.

ACP's Medical Knowledge Self-Assessment Program (MKSAP) allows you to:

  • Update your knowledge in all areas of internal medicine
  • Prepare for ABIM certification or recertification
  • Support your clinical decisions in practice
  • Assess your medical knowledge with 1,200 multiple-choice questions

To order the latest edition of MKSAP, go online.

The standard of weight loss against which dietary interventions are compared is counseling for exercise and a balanced low-calorie diet. Against this standard, very-low-calorie diets are more difficult to adhere to and have not been found more effective at 1 year. Low-fat and low-carbohydrate diets have limited evidence to support their long-term efficacy. Low-carbohydrate diets, in particular, have not been well evaluated in persons older than 53 years of age and/or those with comorbid conditions. There is evidence from randomized, controlled trials that participation in Weight Watchers' proprietary program leads to a loss of 3.2% of initial weight at 2 years. The Weight Watchers program recommends a balanced low-calorie diet, exercise, and behavioral modification.

Obesity is defined by the World Health Organization (WHO) as patients who have a BMI of 30 or higher. This patient has class II obesity. There are three classes of obesity; class I is associated with a BMI of 30 to 34.9, class II with a BMI of 35 to 39.9, and class III with a BMI of 40 or greater. The WHO has defined success in management of the obese patient as a 5% to 15% reduction in initial weight. This patient has several risk factors for cardiovascular disease including obesity, hypertension, and hyperlipidemia. Obesity is also a risk factor for breast cancer among postmenopausal women. Therefore, weight reduction is an important intervention with respect to risk factor modification in this patient.

Key Point

  • The standard of weight loss against which dietary interventions are compared is counseling for exercise and a balanced low-calorie diet.

Click here to return to the rest of ACP InternistWeekly.

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About ACP InternistWeekly

ACP InternistWeekly is a weekly newsletter produced by the staff of ACP Internist. It is automatically sent to all College members who have an e-mail address on file with ACP.

To add your e-mail address to your member record and to begin receiving ACP InternistWeekly, please click here.

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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