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

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In the News
for the Week of 2-15-11

Highlights

  • Conference coverage: potential benefits, limitations of ACO model discussed
  • AHA issues statement on cerebral venous thrombosis diagnosis, management

Test yourself

  • MKSAP Quiz: drug-resistant hypertension

Heart failure

  • Wireless hemodynamic monitoring associated with less hospitalization
  • Cardiac resynchronization therapy effective in less symptomatic heart failure

Procedures

Transitions of care

  • Failure to follow up on inpatient test results is common

Education

  • VA establishes Centers of Excellence in Primary Care Education

Internal Medicine 2011

  • ACP Job Placement Center calls for job seekers’ profiles
  • ACP Annual Business Meeting to be held

From the College

  • College Master selected for Perry A. Lambird Award
  • New ethics case study on Medscape CME

Cartoon caption contest

  • Vote for your favorite entry

Physician editor: Darren Taichman, FACP

Editorial note: ACP InternistWeekly will not be published next week due to the Presidents’ Day holiday.


Highlights

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Conference coverage: potential benefits, limitations of ACO model discussed

WASHINGTON—Accountable care organizations (ACOs) were the topic of much speculation and debate at two recent conferences.

The specifics of ACOs will remain uncertain until the Centers for Medicare and Medicaid Services (CMS) releases rules on the new provider organizations (which were created under health care reform to bring together inpatient and outpatient clinicians to improve quality while reducing cost), but experts offered preliminary perspectives at the annual National Health Policy Conference on Feb. 7 and a seminar at the Brookings Institute on Feb. 1.

Given the uncertainty about what ACOs will be, several speakers focused on what they will not be—not a new name for the current silo system, or an HMO, or an incentive to withhold care. “The focus is not withholding care but reducing waste,” said CMS administrator Donald Berwick, MD. “We now invest in volume and throughput. The ACO will invest in value and outcome.”

How value and outcomes will be measured is still uncertain, speakers said. The health care law requires ACOs to be measured in a number of areas, including processes of care, clinical outcomes, patient experience, care coordination, and transitions, said John Pilotte, acting director of CMS’s performance-based payment policy staff. The cost of care provided by ACOs will also be measured, and compared to benchmarks based on each organization’s past performance. If costs are lower than benchmarks, Medicare will share the savings with the ACO. The ACO will be responsible for distributing the shared savings and collecting and reporting on the quality measures.

Shared savings will provide an incentive for physicians and hospitals to provide the most cost-effective care, possibly reducing demand for expensive technologies, and give more power to primary care physicians to refer patients to the most cooperative specialists, said Hal Luft, PhD, of the Palo Alto Medical Foundation Research Institute. However, some speakers argued that the shared saving system does not go far enough, and the clinicians should also share the risk of losing money if the cost of care exceeds benchmarks.

The ACO model may conflict with anti-trust regulations by establishing financial relationships between clinicians, and even more if the clinicians’ financial cooperation spread to negotiations with private payers. A cooperative workgroup of the Department of Justice, the Office of the Inspector General and Federal Trade Commission is currently working on these issues, Dr. Berwick said.

Other issues about ACO implementation still to be resolved include allocation of patients to ACOs (prospective or retrospective), preventing cherry-picking of patients (or the reverse, dumping of costly patients), communicating with patients about ACOs, measurement methods of ACO quality, and privacy and data-sharing, the speakers said. Dr. Berwick expressed pleasure with the level of public interest in these issues, and gave a hint that the forthcoming ACO regulations would offer some flexibility. “An ACO won’t be one thing. It will be a collection of models,” he said.

ACP issued a policy statement on ACOs in April 2010 and joined the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Osteopathic Association in releasing joint principles on ACOs in November 2010.

—Stacey Butterfield, associate editor

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AHA issues statement on cerebral venous thrombosis diagnosis, management

The American Heart Association (AHA)/American Stroke Association last week issued a scientific statement on the diagnosis, treatment and management of cerebral venous thrombosis (CVT).

CVT is uncommon, representing 0.5% to 1% of all strokes, and usually affects individuals younger than age 50. Diagnosis and management can be difficult because of the diverse underlying risk factors, and the lack of uniformity in treatment, the statement said. Recommendations for diagnosis and treatment include the following:

  • In patients with suspected CVT, perform routine blood studies comprising complete blood count, chemistry panel, prothrombin time and activated partial thromboplastin time (Class I, Level C evidence).
  • In patients with headache associated with atypical features, perform imaging of the cerebral venous system to exclude CVT (Class IIa, Level C evidence).
  • Although a plain computed tomography (CT) scan or magnetic resonance imaging (MRI) scan is useful in the initial evaluation of patients with suspected CVT, a negative plain CT or MRI doesn't rule out CVT. If CVT is suspected and either scan is negative, perform a venographic study. The study should also be performed to define the extent of CVT, when CT or MRI suggests the condition. (Class I, Level C evidence).
  • For patients with CVT, use initial anticoagulation with adjusted-dose unfractionated heparin or weight-based low-molecular-weight heparin in full anticoagulant doses, followed by vitamin K antagonists, whether or not intracerebral hemorrhage is present (Class IIa, Level C evidence).
  • It's reasonable to admit patients with CVT to a stroke unit for treatment and to prevent clinical complications (Class IIa, Level C evidence).

For long-term management of CVT, the statement authors recommend the following:

  • Test for prothrombotic conditions, including protein C, protein S, antithrombin deficiency, antiphospholipid condition, prothrombin G20210A mutation and factor V Leiden. Testing for proteins C and S and antithrombin deficiency is generally indicated two to four weeks after completing anticoagulation. The value of testing is very limited in patients taking warfarin or in the acute setting (Class IIa, Level B evidence).
  • Patients with provoked CVT (associated with a transient risk factor) can continue with vitamin K antagonists for three to six months, with a target INR of 2.0 to 3.0. Patients with unprovoked CVT can continue vitamin K antagonists for six to 12 months, with the same target INR (Class IIb, Level C evidence).
  • In patients with recurrent CVT, venous thromboembolism (VTE) after CVT, or first CVT with severe thrombophilia, consider indefinite anticoagulation with a target INR of 2.0 to 3.0.
  • Consider consultation with a physician expert in thrombosis to aid in prothrombotic testing and care of CVT patients (Class IIb, Level C evidence).

The recommendations also include evaluation and management of CVT during pregnancy. The statement was published online Feb. 3 by Stroke. Its educational value has been affirmed by the American Academy of Neurology, the American Association of Neurological Surgeons, and the Congress of Neurological Surgeons. The Ibero-American Stroke Society and the Society of NeuroInterventional Surgery have endorsed the recommendations, as well.

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Test yourself

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MKSAP Quiz: drug-resistant hypertension

A 43-year-old man is evaluated for drug-resistant hypertension. Hypertension was diagnosed 1 year ago and has been difficult to control despite maximum dosages of lisinopril, metoprolol, and nifedipine. The patient reports feeling well.

On physical examination, temperature is 36.5 °C (97.7 °F), blood pressure is 146/92 mm Hg, pulse rate is 88/min, respiration rate is 17/min, and BMI is 27. The general physical examination and funduscopic examination are unremarkable.

Laboratory studies:

Electrolytes  
–Sodium 143 mEq/L (143 mmol/L)
–Potassium 3.3 mEq/L (3.3 mmol/L)
–Chloride 101 mEq/L (101 mmol/L)
–Bicarbonate 33 mEq/L (33 mmol/L)
Creatinine 1.0 mg/dL (88.4 µmol/L)
Random (spot) urine potassium Inappropriately high
Urinalysis Normal

Which of the following is the most appropriate next diagnostic test for this patient?

A) CT of the adrenal glands
B) Determination of serum aldosterone to plasma renin activity ratio
C) Digital subtraction renal angiography
D) Measurement of plasma metanephrine and normetanephrine levels

Click here to see the answer and critique for this question.

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Heart failure

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Wireless hemodynamic monitoring associated with less hospitalization

A wireless implantable hemodynamic monitoring system showed a significant reduction in hospitalizations for heart failure patients, researchers found.

Patients (n=550) from 64 American centers in a single-blind trial were randomly assigned to receive a wireless implantable pulmonary artery hemodynamic monitoring system or to a control group receiving standard care for at least six months. Patients had New York Heart Association class III heart failure, irrespective of the left ventricular ejection fraction, and a previous hospital admission for heart failure. Only patients were masked to their assignment group. Results were released online Feb. 10 in The Lancet.

The primary efficacy endpoint was the rate of heart-failure-related hospitalizations at six months. In six months, 83 heart-failure-related hospitalizations were reported in the treatment group (n=270), compared with 120 in the control group (n=280; rate, 0.31 vs. 0.44; hazard ratio [HR], 0.70; 95% CI, 0.60 to 0.84; P<0.0001). During a mean follow-up of 15 months, the treatment group had a 39% reduction in heart-failure-related hospitalization compared with the control group (153 vs. 253; HR, 0.64; 95% CI, 0.55 to 0.75; P<0.0001). Non-heart-failure-related hospitalizations were not different between the groups.

The treatment group had a greater reduction in pulmonary artery mean pressure, more days alive outside the hospital, and better quality of life than the control group during six months of follow-up. Survival rates in the treatment and control groups at six months were similar (255 [94%] vs. 260 [93%]; HR, 0.77; 95% CI, 0.40 to 1.51; P=0.45).

Length of stay for heart-failure-related hospitalizations was 2.2 days (SD, 6.8) in the treatment group versus 3.8 days (SD, 11.1) in the control group (P=0.02). The treatment group had a significantly greater number of changes to drugs for heart failure (2,468; mean, 9.1 per patient [SD, 7.4]) than did the control group (1,061; 3.8 per patient [SD, 4.5]; P<0.0001).

The first primary safety endpoint of the study was device-related or system-related complications (DSRCs). These were defined as adverse events related to the wireless pressure sensor or external electronics that required invasive treatment other than an intramuscular drug administration or a right-heart catheterization. Patients had 98.6% freedom from DSRC (95% CI, 97.3 to 99.4).

The second primary safety endpoint was pressure-sensor failure, defined as an inability to obtain readings. No pressure-sensor failures occurred. There were 15 serious adverse events, eight related to DSRC and seven related to the implantation procedure.

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Cardiac resynchronization therapy effective in less symptomatic heart failure

Cardiac resynchronization therapy (CRT) can benefit patients with less symptomatic heart failure, a new meta-analysis indicates.

The study researchers had previously found that CRT reduces morbidity and mortality in patients with symptoms of advanced heart failure. In the current study, they updated their earlier review to examine the effects of CRT in patients whose heart failure was less symptomatic. They performed a literature search from 1950 to December 2010 of studies in all languages and selected randomized, controlled trials comparing CRT with usual care and right or left ventricular pacing in adult patients with heart failure whose left ventricular ejection fraction was 0.40 or less. The primary study endpoint was all-cause mortality; however, researchers also examined heart failure hospitalizations, quality of life, and functional outcomes. The study results were published online Feb. 15 by Annals of Internal Medicine.

Data from 25 trials including 9,082 patients were analyzed. CRT decreased all-cause mortality (risk ratio, 0.83; 95% CI, 0.72 to 0.96) and hospitalizations for heart failure (risk ratio, 0.71; 95% CI, 0.57 to 0.87) among patients with New York Heart Association (NYHA) class I and II symptoms, but did not improve functional outcomes or quality of life. CRT did improve functional outcomes in patients with NYHA class III or IV symptoms while reducing all-cause mortality (risk ratio, 0.78; 95% CI, 0.67 to 0.91) and heart failure hospitalizations (risk ratio, 0.65; 95% CI, 0.50 to 0.86).

The authors noted that their study's subgroup analyses were underpowered and did not include sufficient data for patients who had NYHA class I symptoms, chronic kidney disease, bradyarrhythmias, atrial fibrillation, or right bundle-branch block. However, they concluded that CRT was effective in patients with reduced left ventricular ejection fraction, heart failure symptoms and prolonged QRS duration, regardless of their NYHA class. "Establishing criteria for case selection so that CRT devices are preferentially implanted in the patients who are most likely to benefit is of vital importance for researchers, clinicians, and policymakers," the authors wrote.

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Procedures

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Warming local anesthetics reduced injection pain

Warming local anesthetics before injecting them significantly reduces the pain of the injection, according to a study published Feb. 8 in Annals of Emergency Medicine.

The meta-analysis of 18 studies with 831 patients found a mean difference of −11 mm (95% CI, −14 to −7 mm; I2=90%) on a 100-mm scale in favor of warming local anesthetics to body temperature. All anesthetics appear to sustain efficacy after warming. Subgroup analysis showed the following:

  • Eight studies investigating the effect of warming on buffered local anesthetics yielded similar results: −7 mm (95% CI, −12 to −3 mm; I2=81%).
  • Patient-reported pain from unbuffered local anesthetics at body temperature showed a mean difference of −13 mm (95% CI, −20 to −6 mm; I2=92%) compared to anesthetics at room temperature in 14 studies.
  • Patient-reported pain was reduced by warmed anesthetics when administered subcutaneously (n=14 studies: mean difference, −14 mm [95% CI, −19 to −8 mm]) and intradermally (n=3 studies: mean difference, −5 mm [95% CI, −9 to −1 mm]; P<0.05).
  • The effect occurred regardless of whether epinephrine was in the solution, although it was larger when it was (mean difference, −20 mm; 95% CI, −32 to −8 mm; n=6 studies) than when it was not (mean difference, −6 mm; 95% CI, −9 to −4 mm; n=12 studies) (P<0.0001).

Among the sensitivity analyses conducted, warming injections prior to administering them consistently produced a clinically meaningful reduction in pain regardless of:

  • needle gauge (range, 19 to 30, with all but two studies using between 25 and 30),
  • rate of injection (five studies reported rates faster than 0.1 mL/s; five studies reported rates slower than 0.1 mL/s), and
  • volume of injection (range, 0.5 mL to 150 mL, with all but two studies using between 0.5 mL and 11 mL.)

Injections were warmed using controlled water baths, incubators, fluid warmers, baby food warmers, a warming tray and a syringe warmer. Warming anesthetics can be done in almost any clinical setting with already available equipment, the authors noted. Anecdotal reports suggest that some emergency physicians warm injections in their hands.

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Transitions of care

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Failure to follow up on inpatient test results is common

A significant percentage of tests performed in the hospital are not followed up, according to a new systematic review.

The review included 12 studies, eight of which were conducted in the U.S, all of which quantified the proportion of diagnostic tests that were performed on inpatients but not pursued. The review found wide variation. For admitted patients, 20.04% to 61.6% of tests were not followed up, corresponding to 1% to 22.9% of patients.

There was even greater variation in follow-up on tests performed in the emergency department, with estimates ranging from 1% to 75% of tests not followed up, or 0% to 16.5% of patients. Several studies observed serious negative outcomes resulting from the failure to follow up, including missed cancer diagnoses. The review was published online by BMJ Quality and Safety on Feb. 7.

The review authors noted particular problems with critical test results, which were apparently lost to follow up due to communication breakdowns, including noncompliance with guidelines calling for results to be phoned to practitioners. Patients who moved across health care settings, for example from inpatient to outpatient or from the emergency department to another setting, also posed challenges for follow-up. This finding highlights the “need for systems, policies and practices which facilitate communication of information across different settings,” the study authors said.

The review also looked at the role of various medical records systems, but found no evidence of any association between the type of record system used and follow-up of test results. Electronic, paper, and mixed electronic/paper systems all had high rates of missed results. Electronic systems that can be accessed by clinicians in and out of the hospital and those that include a function for clinicians to endorse results may be helpful, but they would require further study, and should be combined with other strategies. Test result management systems should be flexible and integrated into clinical work practices, the review authors concluded.

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Education

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VA establishes Centers of Excellence in Primary Care Education

The Veterans Administration issued a call for proposals in August 2010 to establish Centers of Excellence in Primary Care Education. The centers, which are part of the VA’s New Models of Care initiative, will develop and test approaches to preparing residents, advanced practice nurses, and others for primary care practice.

Of 37 competing VA facilities, five VA Medical Centers were selected through peer review: Boise, Idaho; Cleveland; San Francisco; Seattle; and West Haven, Conn. Each Center of Excellence will receive approximately $1 million in funding per year for five years, depending on the VA's budget allocation. The VA will also provide additional trainee positions and funding as needed

More information is available online.

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Internal Medicine 2011

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ACP Job Placement Center calls for job seekers’ profiles

Physicians looking for a new job may submit a profile to the ACP Job Placement Center, a service available at Internal Medicine 2011, to be held April 7-9 in San Diego. The center, located in the San Diego Convention Center’s Exhibit Hall, Booth #1601, provides physicians with tools to assist in job searches as well as the opportunity to meet with potential employers.

Profiles will be included in one of two booklets distributed only to Job Placement Center sponsors and exhibitors who have submitted a job posting based on your criteria. After reviewing a profile, a recruiter may contact the physician to schedule a private on-site interview at the center. Profiles can be submitted online.

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ACP Annual Business Meeting to be held

All Members, Fellows, Masters, Associates and Affiliates are encouraged to attend ACP's Annual Business Meeting during Internal Medicine 2011. Current College Officers will retire from office and incoming Officers, new Regents and Governors-Elect will be introduced.

The meeting will be held Saturday, April 9, 2011 at the San Diego Convention Center from 12:45 p.m. to 1:45 p.m., with J. Fred Ralston Jr., FACP, ACP President, presiding. Dennis R. Schaberg, MACP, will present the Annual Report of the Treasurer. A key feature of the meeting is the presentation of ACP's priorities for 2011-12 by Executive Vice President and Chief Executive Officer Steven E. Weinberger, FACP. Members will have the opportunity to ask questions following Dr. Weinberger's presentation.

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From the College

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College Master selected for Perry A. Lambird Award

Isabel Hoverman, MACP, has been awarded the 2010 Perry A. Lambird Award from COLA, a clinical laboratory accreditation organization based in Bethesda, Md.

The Perry A. Lambird Award is a national award given annually to a professional in the health care industry "who exemplifies the values and ideals of Dr. Lambird, a COLA founder and leader who was dedicated to improving the quality of laboratory testing," the organization said in a press release.

Dr. Hoverman, the 2011 Chair of The Joint Commission's Board of Commissioners and a former College Regent, is clinical assistant professor of medicine at the University of Texas Medical Branch at Galveston.

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New ethics case study on Medscape CME

A new case study in the ACP professionalism case study series, "Patient/Physician/Family Caregiver Relationships: When the Family Caregiver is a Physician," is now available on Medscape for CME credit. The study looks at the challenges physicians face when they become caregivers for their own family members.

The ACP Ethics Case Studies use hypothetical examples to elaborate on controversial or subtle aspects of issues not addressed in detail in ACP's Ethics Manual, the Physician Charter on Professionalism, or other ACP position statements. Other studies in the series, which was introduced in September 2009, focus on physician work stoppages, serving as an expert witness, criteria for authorship, and considerations for ending the patient-physician relationship.

Additional ethics resources, including the ACP Ethics Manual and the Physician Charter on Professionalism, are available online.

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Cartoon caption contest

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Vote for your favorite entry

ACP InternistWeekly's cartoon caption contest continues. Readers can vote for their favorite captions to determine the winner.

"You've got a virus. Let me write you a script for Norton."
"That wasn't a seizure. That was a power surge."
"Congratulations! You're my first mouse call."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting ends on Monday, Feb. 28, with the winner announced in the March 1 issue.

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MKSAP answer and critique

The correct answer is B) Determination of serum aldosterone to plasma renin activity ratio. This item is available to MKSAP 15 subscribers as item 63 in the Endocrinology and Metabolism section.

This patient has drug-resistant hypertension, unprovoked hypokalemia, and probable metabolic alkalosis; he also has an inappropriately high urine potassium level. In this setting, primary hyperaldosteronism is a very likely cause of his hypertension and hypokalemia, especially given his age. The best screening test for primary hyperaldosteronism is a determination of the ratio of serum aldosterone (in ng/dL) to plasma renin activity (in ng/mL/min). A ratio greater than 20, particularly when the serum aldosterone level is greater than 15 ng/dL (414 pmol/L), is consistent with the diagnosis of primary hyperaldosteronism.

After biochemical confirmation of hyperaldosteronism, localization procedures are appropriate to differentiate aldosterone-producing adenomas, which are amenable to surgical resection, from bilateral hyperplasia, which is medically treated. Given the high incidence of incidental adrenal lesions, however, imaging studies, such as CT of the adrenal glands, should not be performed before autonomous production of aldosterone is confirmed through biochemical testing.

This patient does not fit the demographic or clinical profile of a patient with renovascular hypertension, and thus evaluating the renal arteries with digital subtraction renal angiography is not indicated. Renovascular hypertension due to fibromuscular disease of the renal arteries usually presents in patients younger than 35 years, and azotemia is rarely present. Atherosclerotic renovascular hypertension is more common in patients older than 55 years and is frequently associated with vascular disease in other vessels; azotemia is often present.

This patient did not have any symptoms or signs suggestive of a pheochromocytoma (palpitations, headache, tremor, diaphoresis). Therefore, screening for a pheochromocytoma with measurement of the plasma metanephrine and normetanephrine levels is inappropriate, especially when there is a more likely cause suggested by the electrolyte abnormalities.

Key Point

  • Patients with hypertension should be screened for primary hyperaldosteronism if they are young, have hypokalemia, or have difficult-to-control blood pressure; such screening includes determination of the serum aldosterone to plasma renin activity ratio, with a ratio greater than 20 strongly suggesting the diagnosis.

Click here to return to the rest of ACP InternistWeekly.

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Copyright 2011 by the American College of Physicians.

Test yourself

A 66-year-old man comes for a preoperative evaluation before total joint arthroplasty of the left knee. He has a 25-year history of rheumatoid arthritis. He has had progressive pain in his left knee with activity, which limits his ability to hike. The patient has similar pain in the right knee, but it is less severe. He reports no recent morning stiffness. He is able to climb two or three flights of stairs without chest pain or shortness of breath. He has no other medical problems and reports no additional symptoms. Medications are methotrexate and folic acid. Following a physical exam and lab tests, what is the next best step in management?

Find the answer

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