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

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ACP InternistWeekly



In the News for the Week of 1-31-12




Highlights

Ambulatory physician referrals nearly doubled in past 10 years

The probability that an ambulatory visit resulted in a referral to another physician almost doubled from 1999 to 2009, while the absolute number of visits resulting in a physician referral increased 159% during the decade, according to a study. More...

Most Medicare demos fail to reduce costs, analysis indicates

The Congressional Budget Office (CBO) has analyzed recent Medicare demonstration projects and concluded that most have not reduced costs, but those that did had certain specific characteristics. More...


Test yourself

MKSAP Quiz: pruritic hives for 12 weeks

This week's quiz asks readers to evaluate a 60-year-old woman with a 12-week history of pruritic hives. More...


Infectious disease

Oral HPV infection affects 7% of population, more men than women

The overall prevalence of oral human papillomavirus (HPV) infection was nearly 7% among men and women ages 14 to 69 years in the United States, and was higher among men than among women, a study found. More...


Cardiology

Sexual activity safe for most CVD patients

Most patients with cardiovascular disease (CVD) can safely engage in sexual activity, according to a new scientific statement from the American Heart Association. More...


From the College

ACP's State of the Nation's Health Care Address tells Congress across-the-board cuts won't work

On Thursday, Jan. 26, ACP, in its annual State of the Nation's Health Care Address, told Congress that the across-the-board sequestration cuts called for by last year's budget deal must be replaced with fiscally and socially responsible policies. 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: Philip Masters, MD, FACP



Highlights


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Ambulatory physician referrals nearly doubled in past 10 years

The probability that an ambulatory visit resulted in a referral to another physician almost doubled from 1999 to 2009, while the absolute number of visits resulting in a physician referral increased 159% during the decade, according to a study.

During the same time, referral rates for Medicare patients more than doubled (from 4.2% to 9.7%; P=0.003). Combined with the increase in the number of visits annually, the total number of Medicare visits resulting in a referral increased more than 350%, the study found.

Researchers analyzed a sample of 845,243 visits from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey for the study, the results of which appeared in the Jan. 23 Archives of Internal Medicine.

From 1999 to 2009, the probability that an ambulatory visit to a physician resulted in a referral increased from 4.8% to 9.3% (94%; P<0.001). The 159% increase in absolute visits that resulted in a physician referral represents a numeric increase from 41 million visits to 105 million.

In office-based physician practices, physician referral rates increased 97% from 1999 to 2009 (from 4.4% to 8.6%; P=0.004). Outpatient department-based practices associated with hospitals had an 84% increase from 9.0% to 16.6% (P<0.001) despite a baseline referral rate more than twice as high as office-based physicians.

For primary care physicians, changes in referral rates varied according to the principal symptom:

  • cardiovascular (from 8.5% to 14.9%; P=0.001),
  • dermatologic (from 10.1% to 15.4%; P=0.03),
  • ear/nose/throat (from 4.5% to 8.5%; P<0.001),
  • gastrointestinal (from 12.3% to 17.7%; P=0.007), and
  • orthopedic (from 12.4% to 16.5%; P=0.003).

Other kinds of visits, such as general/viral, gynecologic/breast, and ocular, had statistically nonsignificant changes.

Specialist physicians also significantly increased their referrals for three of the same symptom categories:

  • ear/nose/throat (from 3.8% to 7.4%; P=0.01),
  • gastrointestinal (from 3.8% to 10.6%; P<0.001), and
  • orthopedic (from 4.6% to 8.8%; P<0.001).

Specialists also increased referrals for gynecologic/breast (from 3.7% to 5.8%; P=0.04) and psychiatric (from 1.9% to 3.5%; P=0.005) issues.

One possible reason for the increase in referrals is that care is becoming increasingly complex, the authors wrote. The need to fit more clinical demands into the same length of an appointment may also play a role, the authors wrote. Finally, there are more specialists to refer to.

An editorialist commented that primary care physicians and specialists are beginning to communicate about the needs of their patients through electronic health records and even phone calls, which could focus the need for consultation and therefore eliminate many visits.

"For this new vision of patient referral to be fully realized, we will need financing reform," the editorial stated. "As long as visits are reimbursed but electronic communication and cognitive time are not, referral visits will only grow. If, instead, payments for groups of patients are bundled, then generalists and specialists can organize their services in the most cost-effective way."


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Most Medicare demos fail to reduce costs, analysis indicates

The Congressional Budget Office (CBO) has analyzed recent Medicare demonstration projects and concluded that most have not reduced costs, but those that did had certain specific characteristics.

The CBO issue brief reviewed 10 projects, six that focused on disease management and care coordination and four that were value-based payment demonstrations. All of the care coordination projects used nurses as care managers and sought to reduce hospital admissions. On average, the programs achieved little or no reduction in admissions, but the effects of the programs varied considerably. Some programs reduced admissions by 15% or more, while in others admissions rose by at least 15%.

In most of the care coordination programs, the care manager was not integrated into the physician's office and had only telephone contact with patients. The CBO analysis found that these two design elements were associated with the results of the programs; care coordinators who interacted more closely with physicians and patients were more likely to reduce admissions. However, even these more successful programs did not, for the most part, achieve enough savings to offset the fees they were paid for the demonstration. Whether the practice's fees were at risk in the demonstration did not appear to affect the success or failure of a program.

The four value-based demonstration programs in the analysis were the Physician Group Practice Demonstration, the Premier Hospital Quality Incentive Demonstration, the Medicare Participating Heart Bypass Center Demonstration and the Home Health Pay-for-Performance Demonstration. Only the bypass demonstration yielded significant savings for Medicare, reducing expenditures for bypass surgery by about 10%. The bypass demonstration was the only one of the four that used a bundled payment system to reduce costs. Participating hospitals and physicians were motivated to accept a discounted, bundled payment for their services due to competitive pressures in their markets, the CBO brief noted.

These findings suggest that substantial changes to payment and delivery systems will be required before demonstrations like these can significantly reduce spending or improve care, the brief concluded. The author also cited several other lessons to be taken from these demonstrations, including the need to gather timely data, focus on transitions of care, use team-based care, target high-risk patients, and limit the fees paid to participating clinicians.



Test yourself


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MKSAP Quiz: pruritic hives for 12 weeks

A 60-year-old woman is evaluated for pruritic hives that have persisted for 12 weeks. The lesions appear, resolve within hours, and leave no residual mark but reappear at a later time. She does not associate the hives with any particular foods or exposures. Her medical history is significant for a 40-year history of asthma. She was diagnosed four months ago with peripheral vascular disease and was started on aspirin and a supervised exercise program. In addition to aspirin, her current medications are beclomethasone, salmeterol, albuterol (as needed), lisinopril, and simvastatin.

mksap.jpg

Physical examination discloses wheals on the trunk and extremities with no angioedema.

Which of the following is the most appropriate management option?

A) Discontinue aspirin
B) Discontinue lisinopril
C) Initiate prednisone
D) Radioallergosorbent test (RAST) for pollen
E) Skin biopsy

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


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Infectious disease


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Oral HPV infection affects 7% of population, more men than women

The overall prevalence of oral human papillomavirus (HPV) infection was nearly 7% among men and women ages 14 to 69 years in the United States, and was higher among men than among women, a study found.

A cross-sectional study was conducted as part of the National Health and Nutrition Examination Survey (NHANES) 2009-2010. Participants (n=5,579) performed a 30-second oral rinse and gargle with mouthwash at mobile testing centers. HPV types were detected through DNA via polymerase chain reaction tests. Demographics were obtained through questionnaires. Results appeared in the Jan. 26 Journal of the American Medical Association.

The prevalence of oral HPV infection was 6.9% (95% CI, 5.7% to 8.3%). The most prevalent type was HPV type 16, at 1% (95% CI, 0.7% to 1.3%), which indicates an estimated 2.13 million infected individuals in the U.S. Oral HPV infection had two peak prevalence periods by age, first among individuals ages 30 to 34 years (7.3%; 95% CI, 4.6% to 11.4%) and second among those ages 60 to 64 years (11.4%; 95% CI, 8.5% to 15.1%).

Men had a significantly higher prevalence than women of any oral HPV infection (10.1% [95% CI, 8.3% to 12.3%] compared to 3.6% [95% CI, 2.6% to 5.0%], P<0.001; unadjusted prevalence ratio [PR], 2.80 [95% CI, 2.02 to 3.88]).

Infection was less common among those without a history of any type of sexual contact compared to those with (0.9% [95% CI, 0.4% to 1.8%] vs. 7.5% [95% CI, 6.1% to 9.1%], P<0.001; PR, 8.69 [95% CI, 3.91 to 19.31]), and risk increased with number of sexual partners (P<0.001 for trend) and cigarettes smoked per day (P<0.001 for trend).

The authors wrote, "[V]accine efficacy against oral HPV infection is unknown, and therefore vaccination cannot currently be recommended for the primary prevention of oropharyngeal cancer. Given an analysis of U.S. cancer registry data recently projected that the number of HPV-positive oropharyngeal cancers diagnosed each year will surpass that of invasive cervical cancers by the year 2020, perhaps such vaccine trials are warranted."

An editorial commented that "[C]linicians should encourage their patients who engage in oral sex to use barrier protection. Physicians should also be vigilant for the signs and symptoms of oropharyngeal cancer, such as persistent odynophagia, dysphagia, dysphonia, otalgia, a feeling of globus, a neck mass, or unexplained weight loss, and perform a thorough head and neck evaluation if present."



Cardiology


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Sexual activity safe for most CVD patients

Most patients with cardiovascular disease (CVD) can safely engage in sexual activity, according to a new scientific statement from the American Heart Association.

A multidisciplinary group of experts developed the evidence-based statement to synthesize and summarize existing data into recommendations and foster communication between clinicians and patients about sexual activity. The statement specifically addresses several different conditions, including coronary artery disease, heart failure, valvular heart disease and arrhythmias.

In general, the experts concluded that patients with stable symptoms and good functional capacity have low risk of cardiovascular events from sexual activity (Class IIa, Level of Evidence B recommendation). Any patients with unstable or severe symptoms should be stabilized before sexual activity (III, C). To determine which category a patient falls into, a comprehensive history and physical is reasonable before a physician provides a recommendation (IIa, C). If a patient's risk is uncertain after examination, exercise testing can be useful (IIa, C).

Cardiovascular drugs that can improve symptoms and survival should not be withheld because of concerns about sexual function, the statement said (III, C). Recent data do not show clear relationships between most of these drugs and erectile dysfunction. For patients who do have sexual dysfunction and stable CVD, PDE5 inhibitors can be useful (I, A). However, the drugs are absolutely contraindicated in patients taking nitrates (III, B).

Physicians should assess anxiety and depression regarding sexual activity in their CVD patients, the statement recommended (I, B). They should also counsel both the patient and spouse or partner about sexual activity following an acute cardiac event, new CVD diagnosis or ICD implantation (I, B). Suggestions to the patient for making activity safer could include "being well rested at the time of sexual activity, avoiding unfamiliar surroundings and partners to minimize stress during sexual activity, avoiding heavy meals or alcohol before sexual activity, and using a position that does not restrict respiration."

The statement was also endorsed by the American Urological Association, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association of Cardiovascular and Pulmonary Rehabilitation, International Society of Sexual Medicine, American College of Cardiology Foundation, Heart Rhythm Society, and Heart Failure Society of America. It was published online by Circulation on Jan. 19.



From the College


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ACP's State of the Nation's Health Care Address tells Congress across-the-board cuts won't work

On Thursday, Jan. 26, ACP, in its annual State of the Nation's Health Care Address, told Congress that the across-the-board sequestration cuts called for by last year's budget deal must be replaced with fiscally and socially responsible policies.

ACP President Virginia L. Hood, MBBS, MPH, FACP, said that an alternative framework of cuts is needed to ensure that funding is preserved for critical programs. The report also laid out specific questions needed that should be asked to evaluate the health care stances of candidates for president and Congress.

Additional information about the report can be found on ACP's website.



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-20120131-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.


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MKSAP Answer and Critique



The correct answer is A) Discontinue aspirin. This item is available to MKSAP 15 subscribers as item 29 in the Dermatology section. More information about MKSAP 15 is available online.

Individuals with the triad of asthma, nasal polyps, and aspirin sensitivity may experience hives with exposure to aspirin. Although this patient has no history of nasal polyps, they may have been missed, and an examination at this time might be revealing. This patient was recently diagnosed with peripheral vascular disease and was started on aspirin. Patients who are sensitive to aspirin may also react to benzoic acid derivatives, tartrazine, or natural salicylates. In such patients, elimination of aspirin or dietary triggers may result in resolution of the hives without the need for medication. Sodium benzoate is commonly added to foods as a preservative. Tartrazine (FD&C yellow number 5) also cross-reacts with aspirin but has largely been eliminated from food products and medications in the United States. It could still be found in products manufactured overseas, however.

Prednisone can be helpful in patients with acute urticaria refractory to antihistamines, but it plays no role in the management of chronic urticaria. Laboratory testing and imaging studies should be directed by signs or symptoms. Radioallergosorbent testing (RAST) for pollen would be appropriate in a patient with a history that suggests seasonal allergy and hives in response to pollen exposure. Skin biopsy is indicated if urticarial vasculitis is suspected by the presence of urticarial plaques that are fixed in location for more than 24 hours. This patient's hives last a few hours and then resolve, making the diagnosis of urticarial vasculitis unlikely and a skin biopsy unnecessary. Although angiotensin-converting enzyme inhibitors such as lisinopril may cause angioedema, they are rarely a cause of urticaria.

Key Point

  • Patients with asthma and nasal polyps may experience hives due to aspirin sensitivity.

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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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