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

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In the News
for the Week of 9-14-10

Highlights

  • Long-term oral bisphosphonates may double esophageal cancer risk
  • New reports signal health care costs for this decade

Test yourself

  • MKSAP Quiz: multiple sclerosis

Cardiology

  • Updated performance measures released on cardiac rehab referral

CMS update

  • CMS to hold call on reporting provision of Affordable Care Act

Therapeutics

FDA update

From ACP Internist

  • The next edition is online and coming to your mailbox

From the College

  • Candidates announced for Board of Governors Chair-elect
  • ACP supports Saudi physicians upholding medical ethics
  • ACP provides ethical guidance on using incentives to promote personal responsibility

Cartoon caption contest

Physician editor: Darren Taichman, FACP


Highlights

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Long-term oral bisphosphonates may double esophageal cancer risk

People who take oral bisphosphonates for bone disease over five years may be doubling their risk of developing esophageal cancer, according to a new study.

Researchers from the University of Oxford’s Cancer Epidemiology Unit and the Medicines and Healthcare Products Regulatory Agency analyzed data from the UK General Practice Research Database, which has patient records for six million people registered with a National Health Service general practitioner. They reported results online in BMJ.

Researchers reviewed data on men and women more than 40 years old, uncovering 2,954 with esophageal cancer, 2,018 with stomach cancer and 10,641 with colorectal cancer diagnosed between 1995 and 2005. Each case was compared with five controls matched for age, sex, general practice and observation period.

Esophageal cancer increased in people with one or more previous prescriptions for oral bisphosphonates compared with those with no such prescriptions (relative risk [RR], 1.30; 95% CI, 1.02 to 1.66; P=0.02). Risk nearly doubled for people with 10 or more prescriptions than for those with one to nine prescriptions (RR, 1.93; 95% CI, 1.37 to 2.70). Risk more than doubled for those who used bisphosphonates for more than three years (average five) compared to no prescription (RR, 2.24; 95% CI, 1.47 to 3.43).

Stomach and colorectal cancers were not associated with prescription of bisphosphonate compared with no prescription (RR, 0.87; 95% CI, 0.64 to 1.19 and RR, 0.87; 95% CI, 0.77 to 1.00, respectively).

Risk did not differ significantly by bisphosphonate type, and risk in those with 10 or more bisphosphonate prescriptions did not vary by age, sex, smoking, alcohol intake, or body mass index; by diagnosis of osteoporosis, fracture, or upper gastrointestinal disease; or by prescription of acid suppressants, nonsteroidal anti-inflammatory drugs, or corticosteroids.

Typically, esophageal cancer develops in one per 1,000 people (0.5 per 1,000 in women and 1.5 per 1,000 in men) at age 60 to 79 over five years. According to incidence data published by the World Health Organization, researchers estimate that with five years’ use of oral bisphosphonates, this would double to two cases (in women one case and in men three cases per 1,000).

An editorial from an FDA epidemiologist said, “The possibility of adverse effects on the oesophagus should prompt doctors who prescribe these drugs to consider risks versus benefits.” It also suggests doctors “tell patients to report difficulty in swallowing and throat, chest, or digestive discomfort so that they can be promptly evaluated and possibly advised to discontinue the drug.”

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New reports signal health care costs for this decade

Health care will cost slightly more than previously predicted, according to new estimates by Medicare's actuary. Spending this decade could increase 6.3% annually as health care reform legislation is implemented, according to the report published in Health Affairs.

The Centers for Medicare and Medicaid Service's Office of the Actuary report stated that total national health spending is estimated to have grown 5.8% in 2009 and to have reached $2.5 trillion. This year, spending is expected to grow 5.1%, 1.2% faster than previously estimated because of changes in law and regulations.

For 2011, national health spending is projected to grow at 4.2%, or 1% slower than prior CMS projections. This was attributed to changes to the Medicare sustainable growth rate system, which postponed a 21.3% pay cut until December 2010, as well as changes to COBRA premium subsidies, high-risk pools and care for dependents less than 26 years old. These provisions are estimated to increase national health spending by $10.2 billion through 2013.

Insurance expansions set to take effect in 2014, such as expanding Medicaid coverage and state health insurance exchanges, are expected to increase national health spending 9.2% in 2014. Prior to health care reform's passage, health care spending was estimated to grow 6.6%.

For 2015-2019, health care spending is now projected to increase 6.7%, or 0.1% less than previously projected. Expanding coverage will create relatively faster spending growth rates through 2016 and then slow from reductions to Medicare provider payment updates and an excise tax on high-cost insurance plans starting in 2018.

By 2019, 92.7% of the population will have health insurance, 10% more than without health reform.

In other news, USA Today reported that health care spending this year grew at its slowest rate in a half-century, a sign that people are forgoing medical care during the recession.

The paper mined government data and concluded medical spending increased at its slowest pace on record, a 2.7% annual rate per person in the first half of 2010. After inflation, that's a 0.2% decline in the first six months of 2010.

Americans spent 1.6% less on prescriptions per person after adjustment for inflation. This reflects not only the recession, but more use of generics and insurers' abilities to negotiate lower prices. Hospitals saw a 1.1% drop in patient spending, which the American Hospital Association attributed to patients and the economy.

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Test yourself

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MKSAP Quiz: multiple sclerosis

A 30-year-old man has a recent diagnosis of multiple sclerosis (MS). He experienced two transient neurologic episodes in the past six months, one involving optic neuritis and the other minor partial myelitis; he recovered completely from both events and is currently asymptomatic. MS was diagnosed after an MRI of the brain showed white matter lesions typical of the disease. He has no other pertinent personal or family medical history.

Which of the following MS subtypes best describes the course of his disease?

A) Benign
B) Primary progressive
C) Relapsing-remitting
D) Secondary progressive

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

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Cardiology

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Updated performance measures released on cardiac rehab referral

The American College of Cardiology Foundation (ACCF), the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) and the American Heart Association (AHA) recently issued updated performance measures on referral to cardiac rehabilitation programs.

Cardiac rehab has been shown to improve outcomes after cardiac events, but only one in five patients receive it, the organizations said in a press release. The updated measures are meant to help hospitals and clinicians improve tracking referral rates, use tools to improve enrollment, and assess and improve care quality, the release said.

Changes from the organizations' 2007 measures for referral from an outpatient setting include the following:

  • "Patient refusal" should not be considered a reason for not providing a cardiac rehab referral.
  • Appropriate medical exclusions for referral were modified to stress that cardiac rehab programs are able to adapt to patients' individual medical needs and that only patients with life-threatening medical conditions should be presumed incapable of participating.
  • "Lack of [cardiac rehab] programs near a patient's home" was specifically defined as no cardiac rehab program within 60 minutes of a patient's home.
  • Rehab programs' standards of practice require that the referring clinician receive care coordination communications covering such topics as treatment changes, adverse responses to treatment or new nonemergent conditions that he or she will need to address. The referring clinician should also receive a progress report after the program is completed.

The updated measures were published Aug. 30 by Circulation, the Journal of the American College of Cardiology, and the Journal of Cardiopulmonary Rehabilitation and Prevention.

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CMS update

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CMS to hold call on reporting provision of Affordable Care Act

CMS will host a teleconference Sept. 24 to solicit comments on the reporting provision of the Patient Protection and Affordable Care Act of 2010. The call will specifically focus on the implementation of confidential physician feedback reports and the value-based payment modifier to the physician fee schedule. The call is open to the public, but participants must pre-register with CMS online.

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Therapeutics

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Assistance available to pay for oral colchicine

Patients taking oral colchicine may be eligible for payment assistance from the manufacturer.

Only one manufacturer of oral colchicine, Mutual, has had its version of the drug approved by the FDA. Other versions, which were "grandfathered in" and whose manufacturers have chosen not to undergo FDA evaluation, will soon be removed from the U.S. market through the FDA's Unapproved Drugs Initiative, which targets drugs that have not been through the FDA drug approval process. Because of changes to the FDA screening standards over time, grandfathered drugs currently on the market have not undergone the complete FDA evaluation for safety and effectiveness.

In response to the resulting price increase for its drug, Mutual has established the Colcrys Patient Assistance Program, which is tiered to help patients in a variety of socioeconomic situations. Information about the program can be found on the Colcrys website.

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FDA update

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Tigecycline gets warning for mortality risk

The label of tigecycline (Tygacil) has been revised to warn of an increased mortality risk associated with the drug compared to other antibiotics, according to a recent FDA announcement.

The increased risk was found using a pooled analysis of 13 clinical trials, in which death occurred in 4.0% (150/3788) of patients receiving tigecycline and 3.0% (110/3646) of patients receiving comparator antibiotics. The cause of the excess deaths is uncertain, but it is likely that most deaths in patients were related to progression of the infection, the FDA said. The agency advises that alternative medications be considered in patients with severe infections.

The increased risk was seen most clearly in patients treated for hospital-acquired pneumonia, especially ventilator-associated pneumonia, but was also seen in patients with complicated skin and skin structure infections, complicated intra-abdominal infections and diabetic foot infections. Tigecyline is not approved for the treatment of hospital-acquired pneumonia (including ventilator-associated pneumonia) or diabetic foot infection, but it is approved for complicated skin and skin structure infections, complicated intra-abdominal infections and community-acquired pneumonia.

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From ACP Internist

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The next edition is online and coming to your mailbox

ACP Internist's September edition is now online. The latest edition includes:

History is key after childhood disease. A generation ago, most children with severe disabilities died before reaching adulthood. Now, more than 90% survive. From cancer or congenital heart disease to cystic fibrosis and Down syndrome, pediatric survivors need internists who can coordinate chronic care.

Should doctors worry about online ratings? Consumers have free rein to anonymously post negative comments online about their physicians. Some are fighting back, while others learn how to turn potentially negative postings into a positive promotional tool for their practices.

Targeting rural health scholars keeps doctors in Kansas. Small-town practice has appeal to physicians who were born and raised in such communities. The Scholars in Rural Health program seeks to expose medical students to underserved areas, nurture a desire to practice primary care and offer incentives such as loan forgiveness.

These stories and more about primary care in Cuba, how one practice re-engineered itself and the latest MKSAP Quiz on new-onset atrial fibrillation are available at www.acpinternist.org.

 

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From the College

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Candidates announced for Board of Governors Chair-elect

Michael C. Sha, FACP, and Thomas G. Tape, FACP, are seeking election as Chair-elect of the Board of Governors. The College’s Governors have been casting ballots online, with the winner to be announced October 2010. The winner will begin his term at the conclusion of Internal Medicine 2011 and take office as Chair in April 2012.

Dr. Sha received his medical degree from the Indiana University School of Medicine, where he also completed his residency and fellowship training. He is board certified by the American Board of Internal Medicine, with added qualifications in geriatric medicine. He is an assistant professor of clinical medicine at the Indiana University School of Medicine. Dr. Sha received his ACP Fellowship in 2006. He became Governor of the Indiana Chapter in 2008 and is a member of the Chapter Subcommittee and the Ethics, Professionalism and Human Rights Committee. He chaired the Council of Young Physicians and Council of Associates and has served two ex-officio terms on the Board of Regents. Dr. Sha is also a member of the Board of Trustees for the Indiana State Medical Association.

Dr. Tape received his medical degree from the Washington University Medical School in St. Louis, Mo. He completed his residency and general internal medicine at the Strong Memorial Hospital, University of Rochester. Dr. Tape is board certified by the American Board of Internal Medicine. Presently, he is a professor of medicine, chief, Section of General Internal Medicine, and vice chair for clinical affairs, Department of Internal Medicine at the University of Nebraska College of Medicine. Dr. Tape is also an attending physician at the Nebraska Medical Center and the Omaha Veterans Affairs Medical Center, Omaha, Neb. He received his ACP Fellowship in 1991. He became Governor of the Nebraska Chapter in 2008. He is the vice chair of the Medical Service Committee.

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ACP supports Saudi physicians upholding medical ethics

The American College of Physicians and Physicians for Human Rights sent a letter to the Minister of Health of Saudi Arabia in support for Saudi physicians and hospitals who have refused to intentionally inflict a spinal cord injury in retribution for an alleged attack that resulted in another person’s paralysis. “Consistent with the principle of nonmaleficence,” the letter states, “in medical ethics—to do no harm—we are confident that the use of medical facilities, procedures and personnel to maim human beings is, under all circumstances including the punishment of convicted criminals, abhorrent to physicians everywhere.”

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ACP provides ethical guidance on using incentives to promote personal responsibility

A new ACP position paper provides ethical guidance for the use of incentives to promote personal responsibility for health.

In “Ethical Considerations for the Use of Patient Incentives to Promote Personal Responsibility for Health: West Virginia Medicaid and Beyond,” authors stress the importance of such programs in a comprehensive strategy promoting well-being and prevention using evidence-based practice, and discourage discriminatory programs that may punish patients for unhealthy behaviors.

The paper’s release underlines provisions in the Patient Protection and Affordable Care Act, which includes state grant funding to develop initiatives providing incentives to Medicaid beneficiaries for prevention of chronic diseases. ACP used the West Virginia Medicaid program as a reference point because the program is one of the first of its kind to use such incentives.

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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 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) Relapsing-remitting. This item is available to MKSAP 15 subscribers as item 25 in the Neurology module.

This patient experienced an episode of transient neurologic dysfunction (an attack) at disease onset and thus has relapsing-remitting MS. Eighty-five percent of patients with MS have this type of disease onset. In relapsing-remitting MS, relapse frequency declines over time, and relapses do not become more severe with increasing disease duration; however, recovery from individual events may be slower and less complete.

Primary progressive MS, which the other 15% of patients with MS have at disease onset, is defined as gradually worsening neurologic function over more than 1 year without recovery. This patient has recovered completely from two neurologic episodes and is currently asymptomatic. Therefore, he cannot be classified as having primary progressive MS.

Secondary progressive MS is characterized by gradual, unremitting development of new symptoms over months to years in a patient who previously had a relapsing-remitting course. The lifetime risk of conversion from relapsing-remitting to secondary progressive disease is greater than 50%, but the onset and rate of the progressive phase are highly variable and not predictable for individual patients. The median time from MS onset until conversion to the secondary progressive phase typically ranges from 10 to 15 years. The establishment of a secondary progressive course is a risk factor for substantial disability, such as loss of independent ambulatory function; the median time from MS onset to the point at which unilateral gait assistance (such as a cane) is required is 15 to 25 years. This patient first had transient symptoms only 6 months ago and thus cannot be characterized as having secondary progressive disease.

Benign MS is defined loosely as no or minimal neurologic impairment 15 or more years after MS onset. This category may encompass as many as 20% of all patients with MS. The definition of benign MS is controversial because continued follow-up of such patients often uncovers late progressive disease and disability accrual. However, a small minority of patients with MS live a long and essentially unrestricted life. The factors that predict a benign course early in the disease have not yet been identified. This patient’s MS diagnosis is too recent to be categorized as benign at this point.

Key point

  • Multiple sclerosis begins as a relapsing-remitting disorder in 85% of patients and a primary progressive disorder in 15% of patients; those with the relapsing-remitting type have a greater than 50% risk of developing a secondary progressive disease course.

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.

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Copyright 2010 by the American College of Physicians.

Test yourself

A 66-year-old man is evaluated for vague abdominal pain of several months' duration and a 10-kg (22-lb) weight loss. He drinks alcohol socially but does not smoke. The patient is otherwise well, has good performance status, and takes no medications. Following a physical exam, lab studies, and a CT scan, what is the most appropriate initial management of this patient?

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