In the News
for the Week of 7-13-10
- Task force issues draft osteoporosis screening recommendations, calls for public comment
- Glucosamine ineffective for low back pain
- MKSAP Quiz: Managing COPD
- PSA screening halves cancer mortality
- CMS delays enforcement deadline for new enrollment system
- URAC seeks comments on new Patient Centered Health Care Home toolkits
From the College
- College Master awarded National Research for Women and Families honor
Cartoon caption contest
- Put words in our mouth
Physician editor: Darren Taichman, FACP
Task force issues draft osteoporosis screening recommendations, calls for public comment
The U.S. Preventive Services Task Force (USPSTF) released draft recommendations on osteoporosis screening last week and invited public comment before finalization.
In 2002, the USPSTF recommended bone density screening for women 65 years or older and women age 60 to 64 years at increased risk for osteoporotic fractures. At the time, the Task Force made no recommendations for or against screening men or women in other patient populations. The updated draft recommendations call for screening in women ages 65 years and older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old woman with no additional risk factors. However, the Task Force concluded that current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men.
In the accompanying background review, which was published early online July 6 by Annals of Internal Medicine, researchers reviewed studies published between 2001 and 2009 to determine:
- the effectiveness and harms of osteoporosis screening in reducing fractures for men and postmenopausal women without known previous fractures,
- the performance of risk assessment instruments and bone measurement tests in identifying osteoporosis,
- optimal screening intervals, and
- the efficacy and harms of medications to reduce primary fractures.
The researchers found that although methods to identify risk for osteoporotic fractures are available and medications to reduce fractures are effective, no trials directly evaluate screening effectiveness, harms and intervals.
The draft recommendation statement will be available for comment on the USPSTF website until August 3. The USPSTF will consider posted comments when finalizing the recommendations..
Glucosamine ineffective for low back pain
Oral glucosamine did not reduce pain compared to placebo among patients with chronic low back pain and degenerative lumbar osteoarthritis (OA) after a six-month intervention or one year of follow-up.
A double-blind, randomized, placebo-controlled trial conducted at Oslo University Hospital Outpatient Clinic in Norway was performed with 250 patients older than 25 years of age who had chronic low back pain lasting more than six months and degenerative lumbar OA. The results appear in the July 7 Journal of the American Medical Association.
Patients were evenly randomized to 1,500 mg of oral glucosamine daily or placebo for six months, with assessment of effect after the intervention period and at one year. (In Norway, glucosamine is only available by prescription.) Patients could take their usual painkillers or nonsteroidal anti-inflammatory drugs, and continue their usual physical therapies.
The primary outcome was pain-related disability measured with the Roland Morris Disability Questionnaire (RMDQ). Secondary outcomes were numerical scores from pain-rating scales of patients at rest and during activity, and from the quality-of-life EuroQol-5 Dimensions (EQ-5D) instrument.
At baseline, mean RMDQ scores were 9.2 (95% CI, 8.4 to 10.0) for glucosamine and 9.7 (95% CI, 8.9 to 10.5) for the placebo group (P=0.37). At six months, the mean RMDQ score was the same for the glucosamine and placebo groups (5.0; 95% CI, 4.2 to 5.8). At one year, the mean RMDQ scores were 4.8 (95% CI, 3.9 to 5.6) for glucosamine and 5.5 (95% CI, 4.7 to 6.4) for the placebo group.
No statistically significant difference in change between groups was found when assessed after the six-month intervention period and at one year using the assessments of RMDQ (P=0.72), low back pain at rest (P=0.91), low back pain during activity (P=0.97), and quality-of-life EQ-5D (P=0.20). Mild adverse events were reported in 40 patients in the glucosamine group and 46 in the placebo group (P=0.48).
Researchers commented that glucosamine may still work elsewhere in the body, a conclusion supported by other studies. For example, OA of the knee contains more of the proinflammatory target for glucosamine than OA of the hip.
MKSAP Quiz: Managing COPD
A 70-year-old man with a 7-year history of chronic obstructive pulmonary disease is evaluated for increased fatigue. The patient has daily cough and has had two exacerbations in the past 8 months. He has smoked a pack of cigarettes a day for the past 55 years and has recently stopped smoking. His medications are albuterol as needed, salmeterol, and tiotropium.
On physical examination, vital signs are normal. Breath sounds are decreased, and heart sounds are distant. Oxygen saturation is 93% with the patient breathing ambient air. Spirometry shows an FEV1 of 39% of predicted and an FEV1/FVC ratio of 60%. Chest radiograph shows hyperinflation. The patient is referred for pulmonary rehabilitation.
Which of the following additional therapies would be indicated for this patient?
A) Inhaled corticosteroids
C) Oral corticosteroids
Click here or scroll to the bottom of the page for the answer and critique.
PSA screening halves cancer mortality
Prostate-specific antigen (PSA) testing reduces mortality by half over 14 years, although the risk of overdiagnosis is substantial and the number needed to treat is at least as high as in breast cancer screening, concluded researchers in a Swedish registry-based study.
Beginning in 1994, the ongoing study evenly randomized 20,000 men ages 66 to 80 years old to either a screening group invited for PSA testing every 2 years or to a control group. Men in the screening group were invited every two years up to the upper age limit (median 69 years, range 67 to 71 years) and men with raised PSA concentrations were offered digital rectal exams, trans-rectal ultrasound and laterally directed sextant biopsies. The primary endpoint was prostate-cancer specific mortality, analyzed according to the intention-to-screen principle. Results were published in The Lancet Oncology.
In each group, 48 men were excluded from the analysis because of death, emigration or prevalent prostate cancer. Among the screening group, 7,578 (76%) attended at least once. During a median follow-up of 14 years, 1,138 men in the screening group and 718 in the control group were diagnosed with prostate cancer, resulting in a cumulative prostate-cancer incidence of 12.7% in the screening group and 8.2% in the control group (hazard ratio 1.64; 95% CI, 1.50 to 1.80; P<0.0001). The absolute cumulative risk reduction of death from prostate cancer at 14 years was 0.4% (95% CI, 0.17% to 0.64%), from 0.9% in the control group to 0.5% in the screening group. The rate ratio for death from prostate cancer was 0.56 (95% CI, 0.39 to 0.82; P=0.002) in the screening compared with the control group, which corresponded to "no effect on overall mortality (similar number of men at risk at 14 years, and similar number of total deaths in the study group)," the authors noted. The rate ratio of death from prostate cancer for attendees compared with the control group was 0.44 (95% CI, 0.28 to 0.68; P=0.0002). Overall, 293 (95% CI, 177 to 799) men needed to be invited for screening and 12 needed to be diagnosed to prevent one prostate cancer death.
The authors wrote, "In a programme in which all the men started screening at 50 years of age, some men could instead be diagnosed at a curable stage; therefore, potential for larger mortality reduction exists." However, they acknowledged, prostate cancer is a slowly developing disease and overdiagnosis and overtreatment are major concerns.
An editorial highlighted the point that study results do not support widespread testing or immediate treatment. "About 40% of men in the screening group were placed on active monitoring protocols; 28% remained on these protocols. Moreover, the results show that in certain circumstances, PSA testing and early diagnosis reduces death from prostate cancer. It does not imply that PSA screening programmes should now be introduced internationally."
Cancer diagnoses often given quickly, impersonally
Almost 20% of cancer patients are informed of their diagnosis over the phone, and almost half are told in a conversation lasting less than 10 minutes, according to a recent survey.
The data were gathered from a questionnaire given to 460 oncology patients being treated at the National Institutes of Health (NIH) Clinical Center in Bethesda, Md. The surveyed patients had been referred to the NIH from around the U.S. and some foreign countries, and slightly more than a third of them had lymphoma and leukemia. Another 22% had brain cancer, 14% had prostate cancer and 27% had some other type of cancer.
More than half of the patients (54%) reported learning of their cancer diagnosis in a physician’s office, while 18% learned over the phone and 28% were told in the hospital. Of the patients who were diagnosed in the hospital, 43% got the news in their room, 23% in the emergency department, 13% in the recovery room, 7% in the radiology department and 13% in other locations, including one patient who discovered the diagnosis by reading a radiology report.
As for the length of the conversation, 8% said it was less than a minute, 36% between 1 and 10 minutes, and 35% 11 to 30 minutes. About 30% of patients said there was no discussion of treatment options. The survey also asked how satisfied patients were with the way they were informed, and being informed in person and during a longer discussion were associated with greater satisfaction. Patients also reported anecdotes of the conversations, describing notifications that were left on answering machines or made on holidays.
The study authors acknowledged that some situations may require notification over the phone or in an impersonal location like an emergency department, but “having more than 20% of patients told their diagnosis in an impersonal manner suggests too many physicians are either unaware of or not practicing good communication skills,” they said. They recommended that the delivery of a cancer diagnosis be done face-to-face in a personal setting, last longer than 10 minutes, and include additional information beyond just the diagnosis, such as treatment options.
Patients who don’t get such a conversation may be not only more dissatisfied with the experience, but also more likely to change physicians after the diagnosis. More than half of the studied patients changed physicians—many because of a referral—but 10% gave poor communication as a reason for switching and 12% cited general dissatisfaction. The study was published online by the Journal of Clinical Oncology on July 6..
E-mail improved care for diabetics
E-mail between patients and primary care physicians was associated with more effective care and control of glycemia, cholesterol and blood pressure, according to a study of Kaiser Permanente practices.
The study included 35,000 Southern California patients who had diabetes, hypertension or both. Data were collected on patients’ use of e-mail and their performance on Healthcare Effectiveness Data and Information Set (HEDIS) measures. The patients who used e-mail were matched to non-e-mailing controls who were similar based on HEDIS measures, age, sex, primary care clinician and diagnostic cost group score. HEDIS scores for overall effectiveness of care and specific diabetes and hypertension measures were compared for the two months after patients began e-mailing.
After the two months, statistically significant differences were found between diabetic e-mailers and non-e-mailers for HbA1c screening and control, cholesterol screening and control, retinopathy and nephropathy screening and blood pressure control. The performance of non-e-mailing patients on these measures declined over the study period, while e-mailing patients made small gains. Little difference was seen among the groups of hypertension patients whether they e-mailed or didn’t e-mail. The study also found that multiple e-mail threads—more than one message and response between the patient and physician—were associated with better performance on HEDIS measures.
Study authors acknowledged that their research was limited by the possibility of self-selection bias among patients who chose to use the e-mail system, despite the effort at matching controls. It was also unclear what portion of the findings could have been due to resources in the online patient portal other than e-mail, which included appointment reminders and online access to instructions and test results. The researchers proposed several possible mechanisms for the improvement found by the study, including increased continuity of care, patient-physician connectedness and support for patient self-management.
The study authors called for further research to confirm the potential of e-mail to improve primary care, and noted that better insurance reimbursement for e-mailing could provide an impetus for physicians to offer this service to their patients. The study appears in the July Health Affairs.
ACP Internist recently covered advice on using e-mail in practice.
CMS delays enforcement deadline for new enrollment system
The Centers for Medicare and Medicaid Services (CMS) will not automatically reject claims submitted by clinicians related to the failure of individuals to enroll in the Provider Enrollment, Chain and Ownership System (PECOS) by July 6. CMS requires all clinicians to enroll in the PECOS system by that deadline and had previously indicated that claims submitted by a clinician for services order by or referred from a non-PECOS-enrolled clinician could be rejected.
The intent is to make sure that those ordering and referring services are legitimate by having updated enrollment information on file with CMS. The requirement to be enrolled in the new system will technically be in effect; however, clinicians should not see any change in the processing of submitted claims. The Affordable Care Act passed earlier this year requires CMS to take prompt action to ensure that clinicians who order or refer are included in the new enrollment system. It was designed to prevent fraud by ensuring that only eligible clinicians and suppliers can order or perform services for Medicare beneficiaries.
To see if you have an enrollment record with PECOS, and if the information in it is up-to-date, please visit the Medicare.gov website.
URAC seeks comments on new Patient Centered Health Care Home toolkits
URAC is seeking public comments about its new Patient Centered Health Care Home program. Specifically, URAC seeks comments on the PCHCH definition, PCHCH principles, and the overall design, as well as the first of three toolkits designed to help practices navigate the process of transforming into a Patient Centered Health Care Home. The Health Care Practice Assessment toolkit is now available on the URAC website. Two more will be made available for comment later this summer. Comments are due August 12.
From the College.
College Master awarded National Research for Women and Families honor
Omega C. Logan Silva, MACP, the second African-American woman to earn an ACP Mastership, has been awarded the Foremother Award of the National Research Center for Women & Families. Dr. Silva was the first woman president of Howard University Medical Alumni Association, the second African-American president of the American Medicine Women’s Association, the founder of the International Women in Medicine, and winner of the Bertha Van Hoosen Award. Dr. Silva is well known for her long-time advocacy efforts for universal health care and ongoing support of women in medicine.
More information about the award and the National Research Center for Women & Families is available online.
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.
MKSAP answer and critique
The correct answer is A) Inhaled corticosteroids. This item is available to online to MKSAP 15 subscribers as item 71 in Pulmonary and Critical Care Medicine.
This patient has severe (GOLD stage III) chronic obstructive pulmonary disease (COPD) defined as FEV1/FVC <70% and FEV1 30% to 50% of predicted with or without chronic symptoms (cough, sputum production). Treatment for this patient includes support for his smoking cessation, short-acting bronchodilators as needed, and regular treatment with one or more long-acting bronchodilators, as well as an inhaled corticosteroid, along with pulmonary rehabilitation.
Oral corticosteroids are not recommended for regular use in a long-term maintenance program because there has been no consistent evidence of efficacy or superiority compared with other agents that have fewer adverse effects. Low-dose theophylline reduces exacerbation in patients with COPD but does not increase post-bronchodilator lung function significantly. High-dose theophylline is an effective bronchodilator but due to its potential toxicity inhaled bronchodilators are again preferred. Leukotriene modifiers, such as montelukast, are not recommended in COPD. Many studies have evaluated leukotriene modifiers in COPD, but the improvement in lung function and symptoms with these agents is modest at best.
Two recent long-term studies of more than 11,000 patients have evaluated treatment for patients with GOLD stages II to IV. The TORCH study and the UPLIFT study showed that in patients with COPD, combination therapy with bronchodilators and an inhaled corticosteroid improved quality of life and pulmonary function without significant adverse effects. Patients enrolled in pulmonary rehabilitation programs benefit with respect to both exercise tolerance and symptoms of dyspnea and fatigue. The minimum length of an effective rehabilitation program is 2 months, but the longer the program continues, the more effective the results are.
- Treatment of GOLD stage III chronic obstructive pulmonary disease includes short-acting bronchodilators as needed and regular treatment with one or more long-acting bronchodilators with an inhaled corticosteroid and pulmonary rehabilitation.
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A 67-year-old man is evaluated for a 6-month history of worsening exertional dyspnea. He has severe COPD, previously with minimal exertional symptoms, but now notes activity-limiting shortness of breath when walking short distances. He does not have chest pain, gastrointestinal symptoms, or sleep-related symptoms. Medical history is otherwise unremarkable. Medications are a twice-daily fluticasone/salmeterol inhaler and an as-needed albuterol/ipratropium metered-dose inhaler. He has a 55-pack-year smoking history but quit when COPD was diagnosed. Following a physical exam, chest radiograph, and transthoracic echocardiogram, what is the most appropriate diagnostic test to perform next?
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