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

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In the News
for the Week of 3-9-10

Highlights

  • A1c predicts cardiovascular disease, death in nondiabetics
  • Guidelines suggest more informed consent for prostate cancer screening

Test yourself

  • MKSAP Quiz: optimal management of coronary artery disease

Reducing medical errors

  • Electronic prescriptions reduce errors sevenfold
  • Primary care doctors should help patients keep med lists current

Cardiology

  • Aspirin does not reduce CV events in persons with low ankle-brachial index

Anemia management

  • Effects of large ESA and iron doses vary with hematocrit level

FDA update

  • Glucose test strips recalled

CMS update

From ACP Internist

  • The next issue of ACP Internist is online and coming to your mailbox

From the College

  • Annual business meeting scheduled for Internal Medicine 2010
  • New ACP Perks program gives discounts for members

Cartoon caption contest

Physician editor: Darren Taichman, FACP


Highlights

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A1c predicts cardiovascular disease, death in nondiabetics

Compared to fasting glucose tests, A1c levels are similarly predictive of diabetes development and better predict cardiovascular disease and death, a new study of nondiabetic adults found.

The study used blood samples from more than 11,000 black or white adults participating in the Atherosclerosis Risk in Communities study. Using a baseline reference risk of 5.0% to 5.5%, the study found that study participants with an A1c of 5.5% to less than 6% had an 86% increased risk of being diagnosed with diabetes, while patients with A1cs between 6% and 6.5% and over 6.5% had 4 and 16 times the risk, respectively. The same trends were true for coronary heart disease and stroke. Study participants with A1cs under 5% had a reduced risk for all three outcomes. The associations remained significant after adjustment for baseline fasting glucose level, whereas the association between fasting glucose and cardiovascular disease and death was not significant after adjustment.

The association between A1c and death from any cause was found to have a J-shaped curve (with a low point between 5% and 5.5%), which suggests that there should be further research on the health risks of a low-normal glycemic state, the study authors concluded. The study also looked at racial differences in A1c. Although blacks had higher baseline A1cs and were less likely to be diagnosed with diabetes, the association between A1c and cardiovascular disease followed the same pattern for both studied races. The study was published in the March 4 New England Journal of Medicine.

The results indicated that even patients with A1cs in the normal range may be at an increased risk for coronary heart disease, stroke and death, the authors concluded. This finding is complicated by the fact that other trials have found little benefit, and sometimes harm, in lowering A1cs to prevent cardiovascular outcomes, the authors noted. Still, the study provides support for the recent recommendation to use A1c as a diagnostic test for diabetes, they concluded.

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Guidelines suggest more informed consent for prostate cancer screening

Better informed consent and personal decisions could lead to increased screening intervals for prostate cancer in some men, suggested new guidelines from the American Cancer Society.

New prostate cancer screening guidelines recommend that physicians discuss the pros and cons of testing, that digital rectal exams (DREs) be optional, and that previous prostate-specific antigen (PSA) tests should be used to guide informed consent and follow-up frequency, according to guidelines published online March 3 by CA: A Cancer Journal for Clinicians.

What hasn't changed:

  • Men whose life expectancy is less than 10 years should not be screened for early detection of prostate cancer;
  • Black men and those with a family history of earlier onset are at higher risk and should be offered informed decision making at an earlier age;
  • PSA level of 4.0 ng/mL is a reasonable threshold for further evaluation.

The guidelines now state:

  • PSA screening is recommended with or without DRE;
  • Screening intervals can be extended to every two years for men whose PSA is less than 2.5 ng/mL;
  • An individualized risk assessment that incorporates other risk factors for prostate cancer for PSA levels between 2.5 ng/mL and 4.0 ng/mL should be considered, particularly for those at risk for high-grade cancer.

Men at average risk should receive this information beginning at age 50. Black men and men with a father or brother diagnosed with prostate cancer before age 65 years should receive this information at age 45. Men with multiple family members diagnosed with prostate cancer before age 65 should receive this information beginning at age 40.

Because individuals use different values to balance the potential of lowering a man's probability of dying from cancer and the deleterious effects of treatment, the guidelines encourage clinicians and patients to use prostate cancer screening decision aids. If a man is unable to decide, the clinician can use discretion based on knowledge of the man's general health preferences and values.

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Test yourself

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MKSAP Quiz: optimal management of coronary artery disease

A 58-year-old woman with known coronary artery disease presents for a general evaluation. She had coronary angiography and a percutaneous intervention with dilation and stenting of a mid-right coronary artery lesion 1 year ago. At that time, a 70% lesion on the distal left anterior descending artery was observed. Left ventricular function at that time was normal, and a stress imaging study performed 6 months after the intervention demonstrated no ischemia. The patient experiences rare episodes of chest discomfort, which occur with marked activity and are promptly relieved by rest. She has nitroglycerin available but has not needed to use it for many months. Her cardiovascular risk factors include hyperlipidemia, prior tobacco use, a family history of coronary artery disease, and a history of hypertension. Current medications include atenolol, 50 mg daily, atorvastatin, 40 mg daily, ramipril, 10 mg daily, aspirin, 81 mg daily, and sublingual nitroglycerin as needed.

Physical examination shows a heart rate of 80/min and a blood pressure of 140/80 mm Hg bilaterally. The cardiac examination is normal. The jugular venous pressure and carotid and peripheral vascular examinations are unremarkable. The LDL cholesterol is 68 mg/dL (1.76 mmol/L) and creatinine and hemoglobin concentrations are normal.

What is the optimal management for this patient?

A) Add a calcium-channel blocker
B) Increase the angiotensin-converting enzyme inhibitor
C) Increase the β-blocker
D) Add a long-acting nitrate
E) Increase the atorvastatin

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

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Reducing medical errors

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Electronic prescriptions reduce errors sevenfold

Clinicians using an electronic system to write prescriptions were seven times less likely to make errors than those writing prescriptions by hand.

To evaluate the effects of e-prescribing on medication safety, researchers looked at prescriptions written by clinicians at 12 community practices in the Hudson Valley region of New York. The authors compared the number and severity of prescription errors between 15 clinicians who adopted e-prescribing and 15 who continued to write prescriptions by hand. The study was published online Feb. 26 by the Journal of General Internal Medicine.

Researchers conducted a prospective, non-randomized study using pre-post design of 15 clinicians who adopted e-prescribing with concurrent controls of 15 paper-based clinicians from September 2005 through June 2007. Authors reviewed 3,684 paper-based prescriptions at the start of the study and 3,848 paper-based and electronic prescriptions at one year of follow-up.

For e-prescribing adopters, error rates decreased nearly sevenfold, from 42.5 per 100 prescriptions (95% CI, 36.7 to 49.3) at baseline to 6.6 per 100 prescriptions (95% CI, 5.1 to 8.3) one year after adoption (P<0.001). For non-adopters, error rates remained at 37.3 per 100 prescriptions (95% CI, 27.6 to 50.2) at baseline and 38.4 per 100 prescriptions (95% CI, 27.4 to 53.9) at one year (P=0.54). Examples included incomplete directions and prescribing a medication but omitting the quantity. A small number of errors were more serious, such as prescribing incorrect dosages. Although most errors would not seriously harm patients, they'd likely result in callbacks and lost time.

E-prescribing completely eliminated illegibility errors (87.6 per 100 prescriptions at baseline for e-prescribing adopters, 0 at one year).

All the practices that adopted e-prescribing received technical assistance from a health information technology service provider. The study noted that, without extensive technical support, it is difficult for practices to implement e-prescribing.

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Primary care doctors should help patients keep med lists current

Presenting a physician-validated medication list upon hospital admission significantly protects against medication errors, said researchers who now suggest that primary care physicians should help patients and caregivers maintain, review and update their lists.

Pharmacists at Northwestern Memorial Hospital in Chicago conducted the study for 14 months in 2006-2007. They retrieved the previous days' admissions and obtained from the electronic medical records the physician-obtained medical history, as well as admission medication orders and patient demographics for 651 adult inpatients with 5,701 prescriptions.

The pharmacists then interviewed the patients, checked their prescription bottles, and consulted with pharmacies to reconcile information and compare it with medication orders to identify unexplained history and order discrepancies. Those resulting in order changes were considered errors, and were classified by drug class, type of error and the potential to cause harm had it not been caught. Findings were published online Feb. 24 by the Journal of General Internal Medicine.

Among the group, 35.9% experienced 309 order errors and 85% had errors originate in medication histories, almost half of which were omissions. Cardiovascular agents were commonly in error (29.1%). If undetected, 52.4% of order errors could have potentially required increased monitoring or intervention to preclude harm and 11.7% were rated as potentially harmful. Factors significantly associated with errors potentially requiring monitoring or causing harm included age older than 65 (odds ratio [OR], 2.17; 95% CI, 1.09 to 4.30) and number of prescription medications (OR, 1.21; 95% CI, 1.14 to 1.29). Presenting a medication list (OR, 0.35; 95% CI, 0.19 to 0.63) or prescription bottles (OR, 0.55; 95% CI, 0.27 to 1.10) at admission helped.

Researchers wrote that attempts to improve the accuracy of medication histories should focus on older patients with a large number of medications, and that primary care physicians should help patients maintain complete, accurate and understandable medication lists.

Unexplained discrepancies occurred even though the researchers and the prescribing physician used the same medication lists or bottles. Researchers attributed this to physicians copying lists or prescription labels verbatim without systematically reviewing each medication. This step is important, they said, because labels on prescription bottles may not accurately reflect current regimens, newly prescribed medications or recent changes. A medication reconciliation toolkit is online.

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Cardiology

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Aspirin does not reduce CV events in persons with low ankle-brachial index

Aspirin does not reduce cardiovascular events in asymptomatic persons with low ankle-brachial index, according to a recent study.

Researchers in Scotland conducted the Aspirin for Asymptomatic Atherosclerosis trial, an intention-to-treat randomized, double-blind placebo-controlled trial involving 3,350 Scottish men and women 50 to 75 years of age who had no clinical coronary artery disease but had a low ankle-brachial index (ABI) on screening. Participants were assigned to receive 100 mg of enteric-coated aspirin per day or placebo. The study’s primary end points included initial fatal or nonfatal coronary event, stroke or revascularization; secondary end points were all initial vascular events, including angina, intermittent claudication or transient ischemic attack, and all-cause mortality. The study results appear in the March 3 Journal of the American Medical Association.

Study participants were followed for a mean of 8.2 years. During that time, 357 had a coronary event, stroke or revascularization, with no statistically significant difference between the aspirin and placebo groups (13.7 events per 1,000 person-years vs. 13.3 events per 1,000 person-years; hazard ratio [HR], 1.03; 95% CI, 0.84 to 1.27). Likewise, no statistically significant difference was seen between groups in the 578 participants who experienced an initial vascular event (22.8 events per 1,000 person-years vs. 22.9 events per 1,000 person-years; HR, 1.00; 95% CI, 0.85 to 1.17). All-cause mortality was also similar in the aspirin and placebo groups (176 deaths vs. 186 deaths; HR, 0.95; 95% CI, 0.77 to 1.16). Thirty-four participants in the aspirin group and 20 in the placebo group had major hemorrhage requiring hospital admission (2.5 per 1,000 person-years vs. 1.5 per 1,000 person-years; HR, 1.71; 95% CI, 0.99 to 2.97).

The authors acknowledged that their study had a limited power to detect a small aspirin effect, that the study population included many more women than men (approximately 70% vs. approximately 30%), and that overall rates of cardiovascular and cerebrovascular events were low. They questioned whether a larger trial in this area would be warranted, given that the number of events prevented was small and that aspirin therapy can have harmful side effects. The authors concluded that aspirin did not reduce cardiovascular events in asymptomatic persons with a low ABI, but did not rule out the possibility that other interventions in this population, such as statins, may be helpful.

“These data do not support recommendations for ABI screening in an effort to ultimately reduce CVD event rates in patients at risk for peripheral artery disease,” an accompanying editorial said. “Future studies using different markers of increased risk are needed, including the ABI, to address whether therapeutic or lifestyle modifications affect outcomes among patients identified by those markers.”

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Anemia management

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Effects of large ESA and iron doses vary with hematocrit level

More aggressive treatment with erythropoiesis-stimulating agents (ESAs) and iron benefitted dialysis patients with lower hematocrit levels but increased mortality risks in the patients with high hematocrit, a new study found.

Researchers used data from the Medicare end-stage renal disease program to analyze the anemia management practices of U.S. dialysis centers. The main outcome was all-cause mortality, and the study found the highest mortality rates in patients with hematocrit below 30% (2.1% monthly) and the lowest (0.7%) in those with hematocrit of 36% or above. The study was published in the March 3 Journal of the American Medical Association.

Among the patients in the under 30% hematocrit group, the lowest mortality rates were seen in dialysis centers that used larger doses of ESAs. Similarly, more use of iron was associated with lower mortality in patients with hematocrit below 33%. However, for patients with hematocrit of 36% or higher, the centers that used ESAs and iron more intensively had higher mortality rates. For ESAs, the association between bigger doses and higher mortality extended to patients with hematocrit between 33% and 35.9%.

The cause of these findings is uncertain, the study authors said. It’s unlikely that greater mortality relates directly to higher doses of ESA and iron, since the largest doses were given to the patients with the lowest hematocrit levels. Previous trials have found higher mortality risk associated with targeting of higher hematocrit levels, the authors noted. They concluded that, whatever the cause, greater use of ESAs and iron in patients with higher hematocrit levels is problematic and further research should be conducted to identify optimal treatment algorithms.

The FDA recently required the development of a risk management program for ESAs, as reported in a recent issue of ACP InternistWeekly.

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FDA update

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Glucose test strips recalled

Eight lots of OneTouch SureStep Test Strips, used for home glucose monitoring, are being recalled by manufacturer LifeScan, the FDA announced last week.

The test strips are being recalled because they may provide falsely low glucose results when the glucose level is higher than 400 mg/dL. A list of affected lots is online. Lot numbers are located on the outer carton and test strip vial.

Approximately 14,000 packages (50- and 100-count) of OneTouch SureStep Test Strips were distributed nationwide between Aug. 1, 2009 and Jan. 28, 2010, the FDA reported. Patients with access to other testing materials should discontinue using the strips. If other options are not available, patients should contact a health care professional if a reading above 400 mg/dL appears, the FDA said.

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CMS update

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Guidance offered on consultation codes

Late last week CMS issued guidance for physicians and other clinicians on changes in coding related to the elimination of CPT consultation codes from Medicare. The change in policy has been in effect since Jan. 1.

The new guidance, provided as an MLN Matters article, answers specific questions about how to determine which evaluation and management code should be substituted for the previously used consultation code, based on where the visit occurs and the complexity of the service provided.

Additional guidance from ACP on the consultation coding change can be found online.

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PECOS enrollment requirement delayed

CMS has announced a further delay of the deadline for referring or ordering physicians to enroll in the Provider Enrollment Chain and Ownership System (PECOS). Clinicians now have until Jan. 3, 2011, to enroll in the new Internet-based enrollment system. If a physician’s enrollment record is not up-to-date by the new deadline, CMS will reject any claims submitted after that date.

To check to see if you have an enrollment record with PECOS, and verify that the information in it is up-to-date, visit the Medicare.gov Web site.

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From ACP Internist

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The next issue of ACP Internist is online and coming to your mailbox

The March issue of ACP Internist features articles on:

Depression screening. Guidelines call for internists to screen for depression, but only if they can offer support once they make a diagnosis. Internists who’ve already achieved this describe how they did so, and how it’s benefited their patients.
Remote monitoring. Telemedicine programs help physicians ensure continuity of care for elderly patients with chronic conditions. The goal is to catch problems early and improve self-management. Another goal: provide physician reimbursement.
The real doctor behind the fake one. ACP Member Lisa Sanders is the technical advisor to television's “House, M.D.” Get a behind-the-scenes look at how medical practice makes its way onto the show, and how it doesn't. (Hint: The character is “a jerk.”)

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From the College

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Annual business meeting scheduled for Internal Medicine 2010

All Members, Fellows, Masters, Associates and Affiliates are invited to attend the 2010 ACP Annual Business Meeting, to be held Saturday, April 24, 2010 from 12:45 p.m. to 1:45 p.m. during Internal Medicine 2010 in Toronto, Canada.

ACP President Joseph W. Stubbs, FACP, will preside as the current officers will retire from office, and the 2010-2011 Officers, Regents, and Governors will be introduced. Annual reports will be presented by Treasurer W. James Stackhouse, MACP, and by Executive Vice President/Chief Executive Officer John Tooker, FACP, MBA. There will be an open forum for members’ questions.

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New ACP Perks program gives discounts for members

ACP has introduced a new program providing discounts to members on business-related products and services. “ACP Perks” is primarily intended for small and medium-sized practices and was created through an affiliation with BizUnite, a leading business platform that designs services specifically for cooperatives, franchises, and other membership organizations.

ACP Perks gives members access to discounts with more than 30 business service providers under the BizUnite umbrella, including well-known brands like Chase Paymentech, Staples, FedEx, Sprint, ADP and OfficeMax. With affiliate organizations such as ACP encompassing about 202,000 locations, BizUnite is able to leverage purchasing power into substantial overhead savings for both members and vendors in the group.

For example, ACP members can enjoy 40% to 70% savings on the top 350 office supply items from Staples, as well as significant reductions on merchant credit card fees through Chase Paymentech. Earglue, a leader in on-hold and in-office messaging services, will give ACP members a 50% discount for the first six months of a contract.

More information is available online.

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Cartoon caption contest

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Put words in our mouth

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

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

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MKSAP answer and critique

The correct answer is C) Increase the β-blocker. This item is available online to MKSAP 14 subscribers in the Cardiovascular Medicine section, Item 120.

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 patient has chronic stable angina. The initial step for improving symptom control is medication adjustment. Prehypertension is noted on examination in this patient and improved blood pressure control with a target less than 130/85 mm Hg would be advisable. In addition, the resting heart rate would suggest that she is not receiving adequate β-blocker therapy (goal for resting heart rate, 55-60/min); an increased dosage of atenolol would be appropriate for this patient.

Long-acting nitrates and calcium-channel blockers are indicated for patients with chronic coronary artery disease and could be considered if the increase in β-blocker does not improve blood pressure control. The patient is on an adequate dose of angiotensin-converting enzyme inhibitor (ramipril) and increasing this is unlikely to improve her angina. Her LDL cholesterol is less than 70 mg/dL (<1.81 mmol/L), which meets current guidelines, thus an increase in atorvastatin is not required at this time.

Key Points

  • Medical therapy is the basis for treatment of patients with chronic stable angina.
  • Medical therapy in patients with stable angina is directed toward the restoration of the supply/demand balance of myocardial oxygen and the prevention of platelet aggregation.

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 48-year-old man is evaluated during a follow-up visit for urinary frequency. He reports no hesitancy, urgency, dysuria, or change in urine color. He has not experienced fevers, chills, sweats, nausea, vomiting, diarrhea, or other gastrointestinal symptoms. He feels thirsty very often; drinking water and using lemon drops seem to help. He has a 33-pack-year history of smoking. He has hypertension, chronic kidney disease, and bipolar disorder. Medications are amlodipine, lisinopril, and lithium. He has tried other agents in place of lithium for his bipolar disorder, but none has controlled his symptoms as well as lithium. What is the most appropriate treatment intervention for this patient?

Find the answer

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