In the News
for the Week of 6-29-10
- Primary care pay increased in 2009; subspecialties were mixed
- ACGME recommends restricting first-years to 16 duty hours per day
- MKSAP Quiz: Maintenance of epilepsy drug
- Specialist groups issue clinical alert to guide clopidogrel prescribers
- Digoxin may be harmful in hemodialysis patients
- Most physicians think free lunches, small gifts OK
- Statins may reduce recurrence risk after radical prostatectomy
- Not too late to earn Medicare bonus payment
Primary care shortage
- HRSA offers grant funds to expand primary care
- Mylotarg withdrawn from market
From ACP Internist
- The next issue of ACP Internist is online and coming to your mailbox
From ACP Hospitalist
- Suggest a colleague as a Top Hospitalist
From the College
- ACP's Steven Weinberger, FACP, blogs at KevinMD
- Internists elected at AMA House of Delegates meeting
- New clinical information section launches on College website
Cartoon caption contest
- And the winner is …
Physician editor: Darren Taichman, FACP
Editorial note: ACP InternistWeekly will not be published next week due to the Independence Day holiday.
Primary care pay increased in 2009; subspecialties were mixed
Primary care physician pay increased by a median of 2.8% in 2009, according to a Medical Group Management Association survey. MGMA attributed the rise to employers’ and payers’ increased commitment to primary care, but noted legislation regarding Medicare payments still presents a threat. A comparison of specialties is here.
Dermatologists' pay rose 12.2% due to elective procedures and increased demand, while ophthalmologists saw a 7.7% increase in 2009 from laser refractive surgery. While subspecialists were still better paid than generalists, declines in pay occurred in OB/GYN (1.1%) and invasive cardiology (0.2%). HEM/ONC continued a slow, flat trend, due to declining reimbursement for administering drugs—a trend this group partly compensated for by treating more patients with the better-paid therapeutics..
ACGME recommends restricting first-years to 16 duty hours per day
The Accreditation Council for Graduate Medical Education (ACGME) recommended that first-year residents' duty hours be capped at 16 per day. Citing differences in capabilities and the need for more supervision, the Council said first-years work longer and that fatigue among them leads to more errors.
The draft standards propose significant changes to first-year resident training, including more detailed directives for supervision and stricter requirements for duty hour exceptions. The group published its statement online June 23 in the New England Journal of Medicine.
The group received position statements from more than 100 medical organizations, heard personal testimony, and discussed the issue with the Institute of Medicine, patient advocates, sleep physiologists, patient safety experts and educators. While the same standards are applied to different specialties and levels of training, educators wanted more flexibility.
ACGME wrote, "As residents mature in knowledge, experience and clinical judgment, the standards permit them to gradually move from a structured, directly supervised, time-limited setting to more advanced training, then to the independent practice of medicine, in which the structure of work and the allotment of time are dictated by patients' needs and physician professionalism. This progression logically begins with a more highly controlled first year of residency."
The standards will be available for comment until August 9 on the ACGME website. The new proposed restrictions follow ACGME's original limitations placed in 2003. The organization had said at that time it would revisit the issue in five years. If adopted by ACGME, the restrictions would take effect July 2011.
The American Medical Student Association said it supported the move and called for 16-hour shifts for second- and third-year residents.
MKSAP Quiz: Maintenance of epilepsy drug
A 65-year-old woman comes to the office for her annual examination. She reports that she had a tonic-clonic seizure at age 24 years after the birth of her daughter but has been seizure-free on phenytoin since that time. The patient also has osteoporosis, diagnosed after a screening bone density scan. Current medications include phenytoin, alendronate, calcium, and vitamin D.
Physical examination findings are normal.
Which of the following is the most appropriate next step in management?
A) Check the serum phenytoin level
B) Continue the current dosage of phenytoin
C) Discontinue the phenytoin in a tapered fashion
D) Substitute lamotrigine for the phenytoin
Click here or scroll to the bottom of the page for the answer and critique.
Specialist groups issue clinical alert to guide clopidogrel prescribers
Two cardiology groups released a clinical alert to guide doctors prescribing clopidogrel after the FDA added a boxed warning to the label about genetic variations that affect the drug's efficacy.
The FDA estimates that 2% to 14% of patients poorly metabolize clopidogrel (Plavix). Although there is increasing information about specific genetic variations that might affect metabolism, the agency says there is not sufficient evidence to develop specific recommendations related to genetic testing in patients.
In light of the FDA warning, the American College of Cardiology (ACC) Foundation and the American Heart Association (AHA) issued a statement outlining key issues to consider and recommendations for practice. The statement says that:
- Evidence-based guidelines from the ACC, AHA or other professional societies for using antiplatelet therapies should remain the foundation of care. If clopidogrel is prescribed, clinicians should ensure that patients take it as prescribed.
- Clinicians must be aware that in certain patients with either acute or chronic coronary artery disease, genetic variability in response to clopidogrel can affect its inhibition of platelet function.
- Careful clinical judgment, including weighing the risks and benefits, is needed in considering all therapies. The new boxed warning points out that for clopidogrel, if there is a lack of efficacy, the outcome could be fatal.
- Results from ongoing clinical trials in large groups of patients will provide more information about the predictive value of genetic testing and better inform the role genotyping might play in personalizing medicine and optimizing outcomes.
- Genetic testing to determine if a patient is a “poor metabolizer” may be considered before starting clopidogrel therapy in patients believed to be at moderate or high risk for poor outcomes, such as patients undergoing elective high-risk percutaneous coronary intervention procedures.
- Using alternative antiplatelet therapies or altering the dosing of clopidogrel may be reasonable options in patients who experience an adverse event while taking clopidogrel and have been taking the drug as prescribed.
The statement authors cautioned that patients currently taking clopidogrel should not stop the drug unless advised by their clinician.
The American Academy of Family Physicians, the Society for Cardiovascular Angiography and Interventions and the Society for Thoracic Surgeons have also endorsed the recommendations, which will appear July 20 in the Journal of the American College of Cardiology and Circulation: Journal of the American Heart Association. The document will also be available on the ACC and AHA websites.
Digoxin may be harmful in hemodialysis patients
Digoxin may increase mortality rates in patients with end-stage renal disease undergoing hemodialysis, according to a new study.
Although digoxin is widely used to treat cardiovascular disease, including in patients with end-stage renal disease, its safety in those receiving hemodialysis is unknown. Cellular changes in potassium during the procedure may affect the drug's efficacy and toxicity. Researchers performed an observational cohort study in 120,864 incident dialysis patients to determine the relationship between digoxin and mortality rates. The study results were published early online June 24 by the Journal of the American Society of Nephrology.
Of the 120,864 patients, 4,549 used digoxin. Digoxin use was associated with a 28% higher risk for death in adjusted models (hazard ratio [HR], 1.28; 95% CI, 1.25 to 1.31). Risk for death was also increased in patients with increasing serum digoxin levels (HR, 1.19 per ng/mL increase; 95% CI, 1.05 to 1.35), especially in those with lower levels of potassium before beginning dialysis (HR, 2.53 for potassium levels below 4.3 mEq/L and 0.86 for potassium levels over 4.6 mEq/L). Variables such as patient characteristics, disease severity, and treating physician did not seem to affect the relationship between mortality and high serum digoxin and low serum potassium levels.
The study had potential unmeasured confounders, such as lack of information on cardiac parameters, and some patients may have been misclassified based on medical record data, among other limitations, the authors noted. However, they concluded that digoxin is associated with mortality in patients undergoing hemodialysis and that it should be used with caution in this group. "Strict [potassium] and digoxin level management is recommended when patients with [end-stage renal disease] remain on digoxin until its overall safety is better evaluated through randomized, controlled trials," they wrote.
Most physicians think free lunches, small gifts OK
Physicians of all specialties, but especially surgeons, continue to see gifts from the pharmaceutical and device industries in a positive light, according to a recent survey.
Almost 600 physicians and medical students in the Mount Sinai School of Medicine consortium were asked about their attitudes toward industry interaction. A majority of the respondents favored the use of samples as well as industry sponsorship of lunches, educational materials and medical school and residency programs. More than half also thought it was acceptable to receive dinner at a modest restaurant if an educational component was included and to have industry pay for travel expenses to a conference.
Just less than half of the survey participants found it appropriate to accept a small gift (less than $50) from a company, and only a quarter thought it was OK to take a larger gift. The surveyed physicians also thought that they personally were less likely to be affected by free food or gifts than their colleagues: Only about 35% said it would affect their prescribing, while 52% said their colleagues would be influenced. The study was published in the June Archives of Surgery.
Surgeons, trainees and respondents who weren’t familiar with their own institution’s guidelines on the subject were more likely to have a positive attitude toward pharma interactions and gifts. This may be because less attention has been paid to this issue by surgical journals and societies, according to the study authors. A critique that accompanied the article also noted the importance of distinguishing between types of interactions with industry; development of new surgical techniques requires collaboration between clinicians and device makers, but the benefit of a free pen or sandwich does not outweigh the risk of influence, the critique said.
Based on the survey’s results, one can conclude that physicians generally may be out of synch with public thinking about industry interactions, the study authors said. Despite changes in medical school policies and governmental concern about the issue, physician attitudes are similar to those found in studies going back to 2001. Physician attitudes are not likely to change until the entire culture of medicine rejects industry influences more thoroughly, the authors concluded.
Statins may reduce recurrence risk after radical prostatectomy
Statins may reduce the risk of biochemical prostrate cancer recurrence after radical prostatectomy, according to a new study.
Researchers used data from five Veterans Administration Medical Centers to examine whether statin use was associated with outcomes in men who had had radical prostatectomy. Time to prostate-specific antigen (PSA) recurrence was compared in men who were taking statins (n=236) and those who were not (n=1,083). The study results were published early online June 28 and will appear in the July 15 Cancer.
Statin users were followed for a median of 24 months, while nonstatin users were followed for a median of 38 months. Men taking statins tended to be older and heavier and to have had radical prostatectomy more recently than those not taking statins. They also were diagnosed with prostate cancer at a lower clinical stage and with lower PSA levels but had higher Gleason scores at biopsy. Thirty-seven statin users (16%) and 267 nonusers (25%) had biochemical recurrence during follow-up. Once the authors adjusted for clinical and pathologic factors, risk for PSA recurrence was 30% lower in statin users compared with nonusers (hazard ratio, 0.70; 95% CI, 0.50 to 0.97; P=0.03). This lowered risk was found to be dose dependent, with hazard ratios of 1.08 (95% CI, 0.66 to 1.73) for the equivalent of less than 20 mg of simvastatin, 0.57 (95% CI, 0.32 to 1.00) for the equivalent of 20 mg of simvastatin, and 0.50 (95% CI, 0.27 to 0.93) for the equivalent of more than 20 mg of simvastatin.
The authors pointed out that statin users and nonusers differed significantly, possibly leading to residual confounding, and that the study was not powered to examine prostate cancer deaths or overall mortality, among other limitations. However, they concluded that statins were associated with a dose-dependent lower risk for PSA recurrence in men who had had a radical prostatectomy. They called for further studies in other settings and, if their findings are confirmed, a randomized, controlled trial.
"Given that statins have proven efficacy in preventing cardiovascular mortality, if it is definitively proven that statins reduce recurrence after surgery, then the potential influence statins could have on overall and disease-specific mortality is substantial," they wrote.
Not too late to earn Medicare bonus payment
Physicians interested in participating in the 2010 Physician Quality Reporting Initiative (PQRI) still have time to qualify for incentive payments. A new six-month reporting period begins on July 1. Physicians who wish to begin reporting for the second half of the year can qualify for an incentive payment of 2% of their total Medicare Part B allowed charges for services performed during the reporting period.
Physicians who have not yet participated in the PQRI program can begin by reporting PQRI data for July 1 through Dec. 31, 2010 using any of the following four options:
- claims-based reporting of individual measures for 80% or more of applicable patients on at least three individual measures or on each measure if fewer than three measures apply,
- claims-based reporting of one measures group for 80% or more of applicable Medicare Part B fee-for-service patients of each eligible professional (with a minimum of 8 patients),
- registry-based reporting of at least three individual PQRI measures for 80% or more of applicable Medicare Part B fee-for-service patients of each eligible professional or
- registry-based reporting of one measures group for 80% or more of applicable Medicare Part B fee-for-service patients of each eligible professional (with a minimum of 8 patients).
Eligible professionals do not need to sign up or pre-register to participate in the 2010 PQRI. However, they should take some preparatory steps before undertaking PQRI reporting. Additional information about the PQRI, including instructions on how to get started, is available online. CMS also recently released a manual that describes the current PQRI program policies.
Primary care shortage.
HRSA offers grant funds to expand primary care
The Health Resources and Services Administration announced last week that it would offer funding for primary care training through its Primary Care Residency Expansion Program. The goal of the five-year, $168-million program is to increase the number of residents training in primary care.
Eligible applicants include public or nonprofit private hospitals, schools of medicine or osteopathic medicine, or select public or private nonprofit entities. To receive grant funds, an applicant or partner organization must be accredited as a residency training program in family medicine, general internal medicine, and/or general pediatrics by the Accreditation Council of Graduate Medical Education or by the American Osteopathic Association.
The application deadline is July 19. More information is available online. A technical assistance call to help applicants understand, prepare and submit a grant application was recorded Friday, June 25 and will remain available until 5:00 p.m. EST on July 19. Those interested should call 800-294-6358.
Mylotarg withdrawn from market
Leukemia drug gemtuzumab ozogamicin (Mylotarg) was voluntarily withdrawn from the U.S. market last week by manufacturer Pfizer, according to an announcement from the FDA.
The withdrawal was requested by the FDA after results from a recent clinical trial raised safety concerns, including an association with veno-occlusive disease, and the drug failed to demonstrate clinical benefit to patients.
The drug had been approved in May 2000 under the accelerated approval program for patients with acute myeloid leukemia. Under accelerated approval, manufacturers are required to conduct additional clinical trials after approval to confirm the drug’s benefit. Since it’s been withdrawn, the drug will no longer be commercially available to new patients. Those who are currently receiving it may complete their therapy following consultation with their health care professional.
From ACP Internist.
The next issue of ACP Internist is online and coming to your mailbox
The July/August issue of ACP Internist features the following articles:
Rheumatoid arthritis hurts the whole body. Taking care of a patient with rheumatoid arthritis involves a partnership between internists and subspecialists, and management of cardiovascular risks, cancer or infections.
Doctors debate the ethics of assisted suicide. The medical community and the world at large are looking at how physician-assisted suicide is playing out in Washington, Oregon and Montana. Are these states a bellwether or a death knell for legalizing the issue elsewhere? And how should physicians respond when presented with such requests from their patients?
Attribution error confounds a diagnosis after colon cancer. A rapid deterioration in mental status confounds doctors caring for a colon cancer patient admitted to the hospital for nausea and vomiting. An internist reviews the patient's history for the clue to the right diagnosis.
From ACP Hospitalist.
Suggest a colleague as a Top Hospitalist
ACP Hospitalist is seeking candidates for our third annual Top Hospitalists issue. We're looking for hospitalists who made notable contributions to the field in 2010, whether through exceptional clinical skills, improved work flow, patient safety, cost savings, leadership, mentorship or quality improvement.
Do you know a colleague who might qualify? Fill out our form and tell us who and why. All recommendations must be received by July 16, when our editorial advisory board will pick the winners. Top Hospitalists will be profiled in our November 2010 issue.
From the College.
ACP's Steven Weinberger, FACP, blogs at KevinMD
Steven Weinberger, FACP, ACP's deputy executive vice president and senior vice president for medical education and publishing, continues his monthly column at KevinMD.com, one of the Web's most influential medical blogs. This month's column looks at how to increase the attractiveness of general internal medicine..
Internists elected at AMA House of Delegates meeting
Cecil Wilson, MACP, former chair of the ACP Board of Regents, was inaugurated as the 165th president of the American Medical Association at the 2010 annual meeting of the AMA House of Delegates held in Chicago on June 11-16.
Dr. Wilson follows fellow internists James Rohack, FACP, and Nancy Nielson, MACP, as president of the AMA. Donna Sweet, MACP, also a former chair of the ACP Board of Regents, was re-elected to the Council on Medical Service. Barbara McAneny, FACP, Stephen Permut, FACP, and Carl Sirio, FACP, were elected to the Board of Trustees..
New clinical information section launches on College website
ACP has launched a new online Clinical Information section on its website. Multimedia content, quiz questions and the latest clinical guidelines are all easily accessible from the landing page, as are a number of diverse resources, from ACP's quality improvement programs to point-of-care tools and special clinical topic collections such as bioterrorism. The redesigned section allows easier browsing of clinical news and insight and faster searching of ACP’s journals, publications, guidelines and interactive tools.
Cartoon caption contest.
And the winner is …
ACP InternistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.
".sessalg deen yam uoY"
This issue's winning cartoon caption was submitted by Matthew C. Bowen, a student member from Des Moines University in Iowa. Readers cast 95 ballots online to choose the winning entry. Thanks to all who voted!
The winning entry captured 45.3% of the votes.
The runners-up were:
"No, you don't have situs inversus; you have 'sighted inversus.'
"In a world of no drug reps, no standardized eye charts."
MKSAP Answer and Critique
The correct answer is C) Discontinue the phenytoin in a tapered fashion. This item is available to online to MKSAP 15 subscribers as item 74 in Neurology.
Phenytoin therapy should be discontinued in this patient in a tapered fashion. Although lifelong antiepileptic drug therapy is required for some patients and for some types of epilepsy, this is by no means always the case. As a general rule, discontinuation of antiepileptic drugs should be considered for patients who have been seizure free for 2 or more years. Medications should not be withdrawn in patients with epilepsy syndromes known to be lifelong, with underlying structural brain lesions, with symptomatic neurologic disorders, or (in most cases) with a history of medically refractory seizures. The risk of recurrent seizure when the patient is no longer taking the medication must always be balanced against the risks associated with continued antiepileptic drug treatment. Unfortunately, too many patients are treated unnecessarily for years because of the common misconception that antiepileptic drug therapy can never be safely discontinued. This patient has been seizure free for more than 40 years; in fact, the decision to initiate therapy was questionable because she only had a single event. Now she has osteoporosis, a condition that can be worsened by continued exposure to phenytoin. Therefore, the most appropriate next step in management is to gradually withdraw the medication.
Because the phenytoin will be withdrawn, there is no need to determine a blood level prior to tapering the medication; the results will not affect when or how the medication will be tapered. This patient has been seizure free for more than 2 years and thus meets the criteria for careful withdrawal of the antiepileptic medication. There is no indication to substitute lamotrigine for the phenytoin or to continue the phenytoin.
- Patients on antiepileptic medication who have been seizure free for 2 years should be considered for medication withdrawal.
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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.
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Copyright 2010 by the American College of Physicians.
A 38-year-old woman is evaluated during a follow-up visit. She has a history of well-controlled hypertension and type 1 diabetes mellitus. She is at 16 weeks' gestation with her first pregnancy. Prior to conception she was taking lisinopril, which was discontinued in anticipation of the pregnancy, and labetalol was initiated. Other medications are insulin glargine, insulin lispro, and a prenatal vitamin. Following a physical exam and lab studies, what is the most appropriate step in the management of this patient's hypertension? .
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