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

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ACP InternistWeekly



In the News for the Week of 1-24-12




Highlights

Older women with normal bone mineral density may be able to defer retesting

Older women with bone mineral density (BMD) testing T scores greater than −1.50 have a low likelihood to develop osteoporosis and can defer retesting for 15 years, researchers concluded. More...

ACP workgroup compiles list of low-value tests

A workgroup of internists convened by ACP has developed a list of 37 clinical situations in which medical tests are commonly used but do not provide high value. More...


Test yourself

MKSAP Quiz: acute left-sided flank pain

This week's quiz asks readers to evaluate a 58-year-old woman who is hospitalized for acute left-sided flank pain. More...


COPD

High-dose vitamin D does not reduce COPD exacerbations, study finds

Supplementation with high doses of vitamin D did not reduce exacerbations of chronic obstructive pulmonary disease (COPD) in most patients in a small new study. More...


Depression

Antidepressants work for patients with comorbidities

Patients with comorbidities can be safely and effectively treated for major depressive disorder (MDD) with antidepressants, even combination therapy, with no more adverse effects than their healthier counterparts, researchers concluded. More...


Dermatology

Teledermatology consults could change diagnosis, management

Consultations with a specialist via teledermatology changed diagnosis and management and could improve clinical outcomes for skin conditions, according to a new study. More...


FDA update

Brentuximab gets boxed warning

A boxed warning has been added to lymphoma drug brentuximab vedotin (Adcetris) regarding its association with progressive multifocal leukoencephalopathy (PML). More...

Possibility of mixed drugs from Endo Pharmaceuticals

The FDA recently warned physicians and the public about the possibility of packaging mix-ups of some prescription opiate medications and over-the-counter non-opiate products manufactured and packaged for Endo Pharmaceuticals by Novartis Consumer Health. More...


CMS update

CMS delays Recovery Audit Prepayment Review and PMD demos

In mid-November, CMS announced a new Recovery Audit Prepayment Review demonstration and a Prepayment Review and Prior Authorization for Power Mobility Devices (PMD) demonstration. More...


Internal Medicine 2012

ACP Job Placement Center calls for job seekers' profiles

Physicians looking for a new job may submit a job seeker's profile to the ACP Job Placement Center, a service available at Internal Medicine 2012, to be held April 19-21 in New Orleans. More...


From the College

ACP immunization webinar series on efficient vaccine ordering

ACP will host the webinar "Efficient Vaccine Ordering" at 5 p.m. EST on Feb. 23, 2012 as part of the ACP immunization webinar series. More...

Internal Medicine 2013 proposals sought

The Clinical Skills Committee (CSC) is now accepting proposals for Internal Medicine 2013, to be held April 11-13, 2013. More...

Key Contact Program is now Advocates for Internal Medicine Network

The College's grassroots advocacy program has a new name. The Key Contact Program is now the Advocates for Internal Medicine Network (AIMn). More...

College to participate in CMS call on Advanced Payment Model

On Wed., Jan. 25, ACP will be joining with CMS and other medical societies to discuss the new Advanced Payment Model. More...


Cartoon caption contest

Put words in our mouth

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


Physician editor: Daisy Smith, MD, FACP



Highlights


.
Older women with normal bone mineral density may be able to defer retesting

Older women with bone mineral density (BMD) testing T scores greater than −1.50 have a low likelihood to develop osteoporosis and can defer retesting for 15 years, researchers concluded.

Researchers studied 4,957 women, 67 years of age or older, with normal BMD (T score at the femoral neck and total hip, −1.00 or higher) or osteopenia (T score, −1.01 to −2.49) and with no history of hip or clinical vertebral fracture or of treatment for osteoporosis, followed prospectively for up to 15 years.

Researchers then measured the estimated time for 10% of women to develop osteoporosis, with adjustment for estrogen use and other clinical risk factors. Incident hip and clinical vertebral fractures and treatment with bisphosphonates, calcitonin or raloxifene were treated as competing risks. Results appeared in the Jan. 19 New England Journal of Medicine.

Estimated time to osteoporosis was 16.8 years (95% CI, 11.5 to 24.6 years) for women with normal BMD, 17.3 years (95% CI, 13.9 to 21.5 years) for women with mild osteopenia, 4.7 years (95% CI, 4.2 to 5.2 years) for women with moderate osteopenia, and 1.1 years (95% CI, 1.0 to 1.3 years) for women with advanced osteopenia.

For women with osteopenia at baseline, significant predictors of osteoporosis were T-score group, age, body mass index (BMI), current estrogen use, and the interaction of T-score group by BMI (P<0.02). Non-significant predictors included any fracture after 50 years of age, current smoking, previous or current use of oral glucocorticoids, and self-reported rheumatoid arthritis (all P>0.20). Baseline T score is the most important factor, the authors concluded.

The authors wrote, "During the 15-year study period, less than 1% of women with T scores indicating normal BMD and 5% of women with T scores indicating mild osteopenia at their first assessment made the transition to osteoporosis, with an estimated testing interval of about 15 years for 10% of women in each of these groups to make the transition. This finding suggests that if BMD testing is deferred for 15 years among women with T scores greater than −1.50, there is a low likelihood of a transition to osteoporosis during that period."

Clinicians can reevaluate patients sooner if there is evidence of decreased activity or mobility, weight loss or other risk factors not considered in the analyses. The estimated time to osteoporosis decreased with increasing age, so that a screening interval of three years instead of five years might be considered for women 85 years of age or older who have moderate osteopenia, the authors said.


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ACP workgroup compiles list of low-value tests

A workgroup of internists convened by ACP has developed a list of 37 clinical situations in which medical tests are commonly used but do not provide high value.

annals.jpg

The list was developed by a consensus-based process and was published in the Jan. 17 Annals of Internal Medicine, with a goal of promoting thoughtful discussions about which tests and interventions promote high-value, cost-conscious care. The list includes a variety of inpatient and outpatient situations in which the experts felt use of a test may provide no benefit or be harmful, including several cardiac tests, cancer screens and diagnostic studies.

Some situations in which the workgroup unanimously concluded that a test does not reflect high-value care include:

  • obtaining exercise electrocardiogram for screening in low-risk asymptomatic adults,
  • screening for colorectal cancer in adults older than 75 years or in adults with a life expectancy of less than 10 years,
  • performing preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology,
  • performing imaging studies in patients with nonspecific low back pain,
  • performing brain imaging studies (CT or MRI) to evaluate simple syncope in patients with normal findings on neurologic examination, and
  • performing imaging studies, rather than a high-sensitivity D-dimer measurement, as the initial diagnostic test in patients with low pretest probability of venous thromboembolism.

The workgroup also suggested some general principles for providing high-value care with testing. First, diagnostic tests usually should not be performed if the results will not change management. Second, in situations where the pre-test probability of disease is low, the likelihood of a false-positive could be higher than the likelihood of a true-positive, potentially leading to expensive and harmful further testing. Finally, when considering the cost of a test, downstream costs, such as follow-up testing, should be considered, the group said.

An editorial accompanying the article noted that some physicians will likely take issue with some of the items on the list and invited all readers of the article to take a brief Web survey to indicate their agreement or disagreement. The editorial also suggested a number of questions that physicians should ask themselves to determine whether a test will provide value, including whether the test results are available from another source, what effects giving or not giving the test are likely to have, and whether the test is being ordered primarily to reassure the patient.



Test yourself


.
MKSAP Quiz: acute left-sided flank pain

A 58-year-old woman is hospitalized for acute left-sided flank pain. She has had fever and night sweats for 1 month and a 9.1-kg (20-lb) weight loss over 6 months.

mksap.jpg

On physical examination, temperature is 37.7 °C (99.8 °F), blood pressure is 135/88 mm Hg, pulse is 88/min, and respiration rate is 18/min. Heart sounds are normal. There is an early diastolic low-pitched sound after the S2 with a diastolic murmur at the apex. There is tenderness of the left costophrenic angle. The abdomen is soft with normal bowel sounds and no tenderness. She does not have rash or petechiae, splinter hemorrhages, or Janeway lesions. Funduscopic examination is normal.

Laboratory studies:

Leukocyte count 14,000/uL (14.0 × 109/L) with no left shift
Creatinine 1.3 mg/dL (99.2 µmol/L)
Blood urea nitrogen 14 mg/dL (5.0 mmol/L)
Urinalysis Microscopic hematuria, no crystals, negative for protein

Twelve-lead electrocardiography shows normal sinus rhythm. Echocardiogram shows a 5- by 4-cm left atrial echogenic mobile globular mass attached to the atrial septum with diastolic protrusion into the left ventricle. Abdominal radiograph shows a normal gas pattern and no renal calculi. Contrast-enhanced CT scan of the abdomen and pelvis shows a wedge-shaped hypoperfusion defect in the upper pole of the left kidney. Mean transmitral valve inflow gradient is 15 mm Hg. Three sets of blood cultures are negative for growth after 5 days.

Which of the following is the most appropriate treatment?

A) Cardiac surgery for resection of mass
B) Mitral valve replacement
C) Systemic anticoagulation with heparin
D) Vancomycin and tobramycin

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


.

COPD


.
High-dose vitamin D does not reduce COPD exacerbations, study finds

Supplementation with high doses of vitamin D did not reduce exacerbations of chronic obstructive pulmonary disease (COPD) in most patients in a small new study.

annals.jpg

Researchers in Belgium performed a randomized, single-center, double-blind, placebo-controlled trial to determine whether high-dose vitamin D supplementation would help reduce exacerbations in patients with COPD.

Patients were screened over 1.5 years from 2008 to 2009 and were eligible for the study if they smoked or had smoked, were over 50, had been diagnosed with COPD according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria, and had an FEV1 less than 80% of predicted. Those with a history of hypercalcemia, sarcoidosis or active cancer were excluded, as were patients who had been treated with vitamin D supplements for other conditions and patients who had received long-term azithromycin treatment.

One hundred eighty-two patients were randomly assigned to receive a monthly oral vitamin D dose of 100,000 IU (n=91) or placebo (n=91) for one year in addition to their usual treatment. Most of the patients (79.6% overall) were men, and the mean age in both the vitamin D and placebo groups was 68 years. The study's primary outcome was time to first COPD exacerbation; secondary outcomes were exacerbation rate, time to second exacerbation, time to first hospitalization, quality of life, FEV1, and death. Results appear in the Jan. 17 Annals of Internal Medicine.

Although patients in the vitamin D group experienced a significant increase in mean serum 25-hydroxyvitamin D (25-[OH]D) levels compared with the placebo group (mean between-group difference, 30 ng/mL; P<0.001), median time to first COPD exacerbation, exacerbation rates, FEV1, time to first hospitalization, quality of life, and death did not differ significantly between groups. The authors found in a post hoc analysis, however, that COPD exacerbations did significantly decrease (rate ratio, 0.57; P=0.042) in patients in the vitamin D group who had had severe vitamin D deficiency at baseline (serum 25-[OH]D level <10 ng/mL).

The authors acknowledged that their study involved only one center and had a small sample size. However, they concluded that high-dose vitamin D supplementation in patients with COPD did not reduce exacerbation incidence, although it may have helped in patients with severe vitamin D deficiency at baseline.

"Although our results demonstrate that supplementation beyond what is recommended for bone health does not reduce exacerbations in patients with moderate to very severe COPD, they corroborate the suggestion that vitamin D deficiency is a potential risk in some patients," the authors wrote.

They called for further studies to examine the necessity and safety of recommending high-dose vitamin D to treat chronic disease, especially in patients with immune-related diseases who are vitamin-D deficient.



Depression


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Antidepressants work for patients with comorbidities

Patients with comorbidities can be safely and effectively treated for major depressive disorder (MDD) with antidepressants, even combination therapy, with no more adverse effects than their healthier counterparts, researchers concluded.

The Combining Medications to Enhance Depression Outcomes (CO-MED) trial consisted of 12 weeks of acute care and 16 weeks of follow-up treatment. It was a multisite, single-blind, randomized trial that compared the efficacy of traditional selective serotonin reuptake inhibitor (SSRI) monotherapy (escitalopram plus placebo) versus that of two antidepressant medication combinations (escitalopram plus bupropion-SR, and venlafaxine-XR plus mirtazapine) in patients with chronic and/or recurrent, nonpsychotic MDD. Clinicians were not blinded to maximize safety and to allow them to make informed flexible dosing decisions.

Patients underwent the Self-Administered Comorbidity Questionnaire, a self-report that assesses the presence of medical problems, their severity, and whether the condition limits functioning. Conditions on the questionnaire included heart disease, high blood pressure, lung disease, diabetes, gastrointestinal tract disorders, kidney disease, liver disease, anemia or other blood disease, cancer, arthritis, thyroid disease, and chronic back pain. Also, respondents could add three more conditions.

At 12 and 28 weeks, researchers compared unadjusted and adjusted outcomes (symptom severity, tolerability and functioning) among patients with none, one, two, and three or more general medical conditions. Results appeared in the January/February Annals of Family Medicine.

Of the 665 evaluable patients, 328 (49.5%) reported having no general medical conditions, 158 (23.8%) reported having one condition, 98 (14.8%) reported having two conditions and 79 (11.9%) reported having at least three conditions. (Two participants did not complete the questionnaire.)

There were no differences in outcomes associated with antidepressant monotherapy and either of the antidepressant combination therapies, regardless of the number of general medical conditions a patient had. Specifically, within each group having a given number of conditions, the three treatments did not differ significantly by efficacy or tolerability at weeks 12 and 28.

The authors concluded that the almost complete lack of difference among patients with differing numbers of conditions shows that all patients can receive equally safe and effective treatment for MDD with antidepressants without risk of additional adverse effects or intolerability. Combination antidepressant therapy had no additional benefit over SSRI monotherapy for patients with general medical conditions and comorbid, chronic or recurrent MDD.

"Not surprisingly, participants with general medical conditions and comorbid MDD were more likely to be treated for depression by their primary care physician than a psychiatric care professional," the authors wrote. "This greater likelihood of treatment in primary care could occur for a variety of reasons, the most obvious being that patients with general medical conditions and comorbid MDD may prefer to be treated by a single physician rather than use a separate mental health professional for their depression."



Dermatology


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Teledermatology consults could change diagnosis, management

Consultations with a specialist via teledermatology changed diagnosis and management and could improve clinical outcomes for skin conditions, according to a new study.

Researchers at the University of California, Davis, performed a retrospective analysis of medical records for 1,500 patients evaluated by the university's teledermatology program from 2003 to 2005. Diagnoses and resulting treatments recommended by the patients' referring clinicians were compared with those determined by the teledermatologists. If patients had at least two teledermatology visits in a year, the researchers assessed for changes in outcomes. The study results appear in the January Archives of Dermatology.

The mean patient age was 35.2 years, with a range of 3 months to 88 years; 75.5% of patients were male and 24.5% were female. A mean of 15 days passed between referral and initial dermatology visit. The researchers found that teledermatology consultations changed diagnosis in 69.9% of patients and changed treatment plans in 97.7%. The three most common changes in diagnosis were from skin infection to primary inflammatory process, from malignant lesion to benign lesion, and from benign lesion to malignancy.

Three hundred thirteen patients had at least two teledermatology visits in a year, and of this group, 68.7% had clinical improvement. Number of teledermatology visits (P<0.001) and changes in diagnosis (P=0.01) and management (P<0.001) were significantly associated with better clinical outcomes in multivariate analysis.

The researchers cautioned that their results may not be generalizable to the entire U.S. population and that they could not precisely assess the effect of teledermatology on clinical outcomes because their trial was not randomized or controlled. However, they concluded that teledermatology consultations usually changed diagnosis and management and were associated with improved clinical outcomes. They predicted that the efficiency and ease of teledermatology will continue to improve along with improved technology.

"Continued research in clinical outcomes is necessary to ensure that this health care delivery modality is continually evaluated to deliver quality dermatologic care," they wrote.



FDA update


.
Brentuximab gets boxed warning

A boxed warning has been added to lymphoma drug brentuximab vedotin (Adcetris) regarding its association with progressive multifocal leukoencephalopathy (PML).

At the time of the drug's approval in August 2011, one case of PML was described in the Warnings and Precautions section of the label. Since then, two additional cases have been reported. Due to the serious nature of PML, the boxed warning was added, according to an FDA statement. Clinicians should hold the drug if PML is suspected and discontinue it if a diagnosis of PML is confirmed.

In addition, a new contraindication was added against use of the drug in combination with bleomycin due to increased risk of pulmonary toxicity.


.
Possibility of mixed drugs from Endo Pharmaceuticals

The FDA recently warned physicians and the public about the possibility of packaging mix-ups of some prescription opiate medications and over-the-counter non-opiate products manufactured and packaged for Endo Pharmaceuticals by Novartis Consumer Health. A stray pill of one medication may have ended up in the bottle of another product.

According to an FDA advisory, patients and health care professionals should examine opiate medicines made by Endo and ensure that all tablets are the same. The agency also expects shortages for these products and is working with the manufacturer to minimize the impact. A recall was issued for potentially affected over-the-counter products, including Excedrin, NoDoz, Bufferin and Gas-X.



CMS update


.
CMS delays Recovery Audit Prepayment Review and PMD demos

In mid-November, CMS announced a new Recovery Audit Prepayment Review demonstration and a Prepayment Review and Prior Authorization for Power Mobility Devices (PMD) demonstration.

These demonstrations were scheduled to begin Jan. 1. However, CMS received many comments/suggestions regarding these demonstrations and is still assessing the comments. Therefore, CMS will be delaying the implementation of both programs. The agency will provide at least 30 days' notice before the demonstrations begin.

The Part A to Part B rebilling demonstration remains on schedule and began on Jan. 1, 2012. Please continue to check online for updated information.



Internal Medicine 2012


.
ACP Job Placement Center calls for job seekers' profiles

Physicians looking for a new job may submit a job seeker's profile to the ACP Job Placement Center, a service available at Internal Medicine 2012, to be held April 19-21 in New Orleans. The Center, located in the New Orleans Ernest N. Morial Convention Center, Booth 430, 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 based on job seekers' criteria and distributed only to Job Placement Center sponsors and exhibitors who have submitted a job posting. 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.



From the College


.
ACP immunization webinar series on efficient vaccine ordering

ACP will host the webinar "Efficient Vaccine Ordering" at 5 p.m. EST on Feb. 23, 2012 as part of the ACP immunization webinar series.

The webinar will address how health care professionals can optimize ordering vaccines for their practice with manufacturer discounts/bulk ordering, returning unused vaccine, and other money-saving options to help ease the financial burden of purchasing vaccines. More information on the webinar is available online.


.
Internal Medicine 2013 proposals sought

The Clinical Skills Committee (CSC) is now accepting proposals for Internal Medicine 2013, to be held April 11-13, 2013. The CSC welcomes all proposals but places a priority on interactive workshops that focus on the acquisition or improvement of physical examination skills, communication skills and procedural skills.

The CSC is most interested in workshops that have a high likelihood of changing physician behavior using proven teaching techniques or new and innovative teaching strategies that have yet to be tested. To submit a proposal to the committee, please contact Ted Warren or go to the ACP Future Meetings page for the Internal Medicine 2013 application.


.
Key Contact Program is now Advocates for Internal Medicine Network

The College's grassroots advocacy program has a new name. The Key Contact Program is now the Advocates for Internal Medicine Network (AIMn).

The name change was undertaken at the urging of the councils of Student Members, Associates and Young Physicians to find a name that more directly reflected the advocates' role. AIMn is designed to help ACP members interested in government advocacy engage with their members of Congress on issues of importance to medical students, internists and their patients.

Join the 8,000 AIMn members and/or find more information online.


.
College to participate in CMS call on Advanced Payment Model

On Wed., Jan. 25, ACP will be joining with CMS and other medical societies to discuss the new Advanced Payment Model.

The Advanced Payment Model is a program for Accountable Care Organizations (ACOs) that is designed to facilitate the participation of small practices by allowing them to collect a pre-payment of expected savings that would be generated through their participation. This "Advanced Payment" would allow practices to better invest in building care coordination capabilities and other program criteria. In addition, the program will not require repayment of the advance in the event that savings are not achieved.

The call will be held on Jan. 25, at 7 p.m. EST, 800-837-1935, Conference ID 45474183. There will be an opportunity to ask questions during the call. There will be an opportunity to ask questions during the call. Additional information about ACOs and the Advanced Payment Model is available online from ACP.



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.

acpi-20120124-cartoon.jpg

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.


.


MKSAP Answer and Critique



The correct answer is A) Cardiac surgery for resection of mass. This item is available to MKSAP 15 subscribers as item 18 in the Cardiology section. More information about MKSAP 15 is available online.

This patient has evidence of a systemic embolism to the left kidney causing flank pain and hematuria. No evidence of renal calculi is present. The history of fever, night sweats, and weight loss is consistent with a systemic illness. Echocardiography shows a left atrial mass with features consistent with a tumor, as evidenced by attachment to the atrial septum, echogenic texture, mobility, and protrusion into the mitral valve orifice obstructing inflow. This mass is most likely a left atrial myxoma, the most common tumor type of the left atrium. A left atrial myxoma does not metastasize to other organs, but it has significant associated morbidity. Left atrial myxoma causes fever, night sweats, and weight loss, and may embolize to the brain or other organs such as the kidney, as seen in this patient. Cardiac surgery to remove the left atrial mass is the best treatment and would be curative if the mass is a benign tumor. A primary malignant tumor is also a possibility, but surgical removal would also be the correct approach.

Echocardiography in this patient shows severe transmitral valve obstruction with a mean gradient of 15 mm Hg. Rheumatic mitral stenosis on auscultation can cause an early high-pitched diastolic sound (an opening snap) and a diastolic decrescendo murmur, similar to the findings in this patient. However, the opening sound in this patient is a low-pitched sound associated with a left atrial myxoma, a so-called "tumor plop." Furthermore, the patient's echocardiogram is inconsistent with primary mitral valve disease. The diastolic murmur in this patient is secondary to obstruction of the mitral valve orifice by the tumor, effectively a functional mitral stenosis. Thus, the appropriate cardiac surgery is removal of the left atrial mass rather than mitral valve replacement.

The left atrial mass is highly unlikely to be a thrombus given the presence of sinus rhythm and not atrial fibrillation. Systemic anticoagulation with heparin is not indicated.

The presentation of fever, night sweats, and weight loss is typical of endocarditis, and thus this diagnosis should be considered. However, blood cultures failed to confirm bacteremia, and echocardiography showed no vegetations. Empiric antibiotic therapy with vancomycin and tobramycin for presumed endocarditis in this patient who is hemodynamically stable and has an alternative explanation for her symptoms is not warranted.

Key Point

  • Surgical removal of left atrial myxoma is curative and is the appropriate primary treatment.

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Test yourself

A 50-year-old man is evaluated in follow-up for a recent diagnosis of cirrhosis secondary to nonalcoholic steatohepatitis. He has a history of asthma, type 2 diabetes mellitus, hyperlipidemia, and obesity. His current medications are inhaled fluticasone, montelukast, insulin glargine, insulin lispro, simvastatin, and lisinopril. Following a physical exam, lab studies, and upper endoscopy, what is the most appropriate treatment?

Find the answer

MKSAP 16 Holiday Special: Save 10%

MKSAP 16 Holiday Special:  Save 10%

Use MKSAP 16 to earn MOC points, prepare for ABIM exams and assess your clinical knowledge. For a limited time save 10% when you use priority code MKPROMO! Order now.

Maintenance of Certification:

What if I Still Don't Know Where to Start?

Maintenance of Certification: What if I Still Don't Know Where to Start?

Because the rules are complex and may apply differently depending on when you last certified, ACP has developed a MOC Navigator. This FREE tool can help you understand the impact of MOC, review requirements, guide you in selecting ways to meet the requirements, show you how to enroll, and more. Start navigating now.