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

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ACP InternistWeekly



In the News for the Week of December 18, 2012




Highlights

Diabetes risk from statins may be offset by reduction in cardiovascular events

Atorvastatin, 80 mg/d, carries a higher risk of developing diabetes than do lower doses, but only among patients who already have multiple risk factors, a study found. More...

EHR use and compliance with meaningful use measures continue to rise

More physicians are using electronic health records (EHRs) generally and in the specific ways mandated by the Centers for Medicare and Medicaid Services' meaningful use objectives, according to two recent surveys. More...


Test yourself

MKSAP Quiz: 4-week history of wheals

A 27-year-old woman is evaluated for a 4-week history of wheals, characterized by a burning sensation without pruritus. Each individual lesion persists for 48 hours and slowly resolves, leaving a bruise. Following a history and physical exam, what is the most appropriate management? More...


Colonoscopy

Postpolypectomy risk stratification guidelines from the U.S. and U.K. compared

Guidelines used in the United Kingdom to stratify postpolypectomy patients may more accurately predict risk of advanced colorectal neoplasia than current U.S. guidelines, a study found. More...


Transitions of care

More information on medication changes may improve post-discharge adherence in patients with stroke

Providing more details to primary care physicians (PCPs) about medication changes during hospitalization can help improve adherence after discharge, according to a new study. More...


CMS update

Resources available to help clinicians comply with new PQRS requirements

The Physician Quality Reporting System (PQRS) 2012 reporting year will be the last year for physicians to participate in PQRS and receive an incentive payment of 0.5% of the total allowed charges for Physician Fee Schedule (PFS) covered services, without risk of penalty. More...


From the College

Practice transformation is more than checking boxes

Yul Ejnes, MD, MACP, continues his column at KevinMD.com, suggesting how physicians can engage and inspire their practice teams to achieve a shared vision that focuses on desired outcomes rather than process. More...


Cartoon caption contest

And the winner is …

ACP InternistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption. More...

Nonpublishing notice: ACP InternistWeekly will not be published for the next two weeks due to the Christmas and New Year's holidays.


Physician editor: Daisy Smith, MD, FACP



Highlights


.
Diabetes risk from statins may be offset by reduction in cardiovascular events

Atorvastatin, 80 mg/d, carries a higher risk of developing diabetes than do lower doses, but only among patients who already have multiple risk factors, a study found.

Researchers examined data from more than 15,000 patients with coronary disease but without diabetes at baseline in two trials, TNT (Treating to New Targets) and IDEAL (Incremental Decrease in Endpoints Through Aggressive Lipid Lowering). They considered four risk factors that independently predicted new-onset diabetes, including fasting blood glucose above 100 mg/dL, fasting triglycerides above 150 mg/dL, body mass index above 30 kg/m2, and history of hypertension. Results appeared online at the Journal of the American College of Cardiology.

Among 8,825 patients with no or one diabetes risk factor at baseline, new-onset diabetes developed in 142 patients in the 80-mg atorvastatin group compared with 148 of those taking 10 mg of atorvastatin or 20 to 40 mg of simvastatin (3.22% vs. 3.35%; hazard ratio [HR], 0.97; 95% CI, 0.77 to 1.22).

Of the 6,231 patients with two to four risk factors, new-onset diabetes developed in 448 of 3,128 in the 80-mg atorvastatin group and in 368 of 3,103 in the lower-dose groups (14.3% vs. 11.9%; HR, 1.24; 95% CI, 1.08 to 1.42; P=0.0027). Researchers noted that cardiovascular events were significantly reduced with 80 mg of atorvastatin in both low- and high-risk groups.

"These results should reassure physicians treating patients at low risk for diabetes," the authors wrote. "Such patients do not appear to incur an increased risk of diabetes with high-dose atorvastatin and derive benefit in terms of CV [cardiovascular] event reduction. Among the 6,231 patients in the TNT and IDEAL trials at high risk for NOD [new-onset diabetes], treatment with atorvastatin 80 mg compared with a lower statin dose was associated with 80 more cases of NOD and the prevention of 94 major CV events in 58 patients."

Furthermore, the impact of new-onset diabetes is relatively minor compared to the cardiovascular events included in the study, such as death, myocardial infarction, resuscitated cardiac arrest, and fatal or nonfatal stroke, the authors said.

The authors continued, "In considering the balance between NOD and CV event prevention, it is worth noting that the microvascular and macrovascular complications of diabetes occur relatively uncommonly during the first decade after diagnosis. Many patients with established vascular disease, such as those in this study, will die from an atherosclerotic event before they develop complications from diabetes."


.
EHR use and compliance with meaningful use measures continue to rise

More physicians are using electronic health records (EHRs) generally and in the specific ways mandated by the Centers for Medicare and Medicaid Services' meaningful use objectives, according to two recent surveys.

The CDC's National Center for Health Statistics recently found that the percentage of physicians using EHRs increased from 48% in 2009 to 72% in 2012, according to a press release from the Department of Health and Human Services.

The National Electronic Health Records Survey expands on those findings by assessing office-based physician adoption of specific meaningful use measures. Use of e-prescribing has risen from 38% of physicians in 2009 to 55% in 2011 and 73% today. Computerized order entry for medication orders rose from 45% in 2009 to 80% in 2012. While still lower, the percentage of physicians that can provide patients with clinical summaries of their visits saw a particularly steep increase between 2011 and 2012—from 38% to 56%.

The survey assessed attainment of 13 of the 15 Stage 1 meaningful use objectives, and found that more than half of physicians met at least 12 of them in 2012. Computerized clinical quality measures was the only measure on which the survey respondents fell short of that mark; 43% of surveyed physicians reported computer recording of these measures. At least two-thirds of physicians met nine of the 13 objectives.

The report also looked at some Stage 2 objectives. The ability to exchange secure messages with patients substantially increased, from 28% of physicians in 2011 to 40% in 2012. Viewing of imaging results through electronic technology has grown more slowly than other functionalities, the report noted, but 59% of physicians are now able to do that, compared to 50% in 2009.

"These findings represent important national progress toward the goals of improving health and health care through the use of advanced health information technology," the report from the Office of the National Coordinator for Health Information technology concluded.



Test yourself


.
MKSAP Quiz: 4-week history of wheals

A 27-year-old woman is evaluated for a 4-week history of wheals, characterized by a burning sensation without pruritus. Each individual lesion persists for 48 hours and slowly resolves, leaving a bruise. Current medications are diphenhydramine, hydroxyzine, cetirizine, and oral contraceptives. The patient's mother has systemic lupus erythematosus.

mksap.gif

On physical examination, vital signs are normal. She has scattered edematous indurated erythematous plaques consistent with wheals. There are scattered ecchymoses at the sites of fading lesions. The patient has no facial lesions or rash, and her mucous membranes are normal. There is no joint swelling or tenderness.

Which of the following is the most appropriate management?

A: Discontinue oral contraceptives
B: Radioallergosorbent testing
C: Skin biopsy
D: Thyroid function testing

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


.

Colonoscopy


.
Postpolypectomy risk stratification guidelines from the U.S. and U.K. compared

Guidelines used in the United Kingdom to stratify postpolypectomy patients may more accurately predict risk of advanced colorectal neoplasia than current U.S. guidelines, a study found.

annals.jpg

Researchers conducted a pooled analysis of four prospective studies involving 3,226 postpolypectomy patients treated at academic and private clinics in the U.S. between 1984 and 1998. All of the studied patients received an initial polypectomy and then a follow-up colonoscopy six to 18 months later. The analysis measured rates of advanced neoplasia (defined as an adenoma ≥ 1 cm, high-grade dysplasia, > 25% villous architecture or invasive cancer) found at follow-up. Results appeared in the Dec. 18 Annals of Internal Medicine.

When patients were stratified by the U.S. criteria, 11.2% of higher-risk patients and 3.8% of lower-risk patients had advanced neoplasia at follow-up. Use of U.K. criteria found 4.4% of low-risk patients, 9.9% of intermediate-risk patients and 18.7% of high-patients to have advanced neoplasia. All of the U.S. guidelines' lower-risk patients were considered low risk by the U.K. guidelines, too. The U.S. guidelines' higher-risk patients were distributed across all three of the U.K. categories.

Under the U.K. guidelines, high-risk patients would receive a clearing colonoscopy at one year instead of waiting three years. Researchers calculated that following this criterion and recommendation would have detected advanced adenomas 2 years earlier in 19% with lesions at 1 year, while requiring 0.03 more colonoscopies per 5 years for all followed patients.

Another major difference between the guidelines is that the U.K. set does not consider histologic features, the authors noted. This resulted in more patients being classified as low risk under the U.K. system. Those patients were found more likely to have advanced neoplasia than others in the U.K. low-risk group, suggesting that histologic characteristics might provide a modest additional amount of discrimination, the authors said. They called for further study of this area.

Finally, they noted that "quality of the initial colonoscopy may be the principal determinant of 1-year advanced colorectal neoplasia," indicating the importance of colonoscopy improvement efforts.



Transitions of care


.
More information on medication changes may improve post-discharge adherence in patients with stroke

Providing more details to primary care physicians (PCPs) about medication changes during hospitalization can help improve adherence after discharge, according to a new study.

Researchers performed an open, prospective, interventional two-phase study at a clinic in Germany to examine adherence to discharge medication in patients with ischemic stroke. Adherence was evaluated before and after implementation of a systematic intervention administered by a clinical pharmacist.

Patients were included in the study if they had a transient ischemic attack or ischemic stroke and were taking at least two drugs during their hospital stay and at discharge. The first phase of the study, involving the control group, took place from January 2011 to June 2011. The second phase, involving the intervention group, took place from October 2011 to March 2012.

Patients in the control group received a letter at discharge meant to inform their PCP about their main diagnosis, any diagnostic findings, laboratory test results, complications and medications. Patients in the intervention group received a letter in which a clinical pharmacist listed medications at both admission and discharge and detailed the reasons behind all changes that occurred during the hospital stay, including reasons for any new drugs, discontinued drugs, and modifications, particularly antithrombotic drugs and simvastatin.

After three months, patients' PCPs were interviewed about patients' current medication lists to evaluate adherence to the medications included in the discharge letter, defined as continued therapy from discharge to three months. The study results were published online Dec. 6 by Stroke.

A total of 312 patients, 156 in each group, were included in the study. The mean age was 70.7 in the control group and 72.3 in the intervention group, and slightly over half of the patients in each group were men. Overall adherence to the medications in the discharge letter increased from 83.3% in the control group to 90.9% in the intervention group (P=0.01). Adherence to antithrombotic drugs and statin therapy both differed significantly between the control and intervention groups (83.8% vs. 91.9% and 69.8% vs. 87.7%; P=0.033 and P<0.001, respectively).

The authors stated that medication adherence after discharge appears to be better when more information about medication changes is provided. They speculated that PCPs' adherence to discharge medications was better because they were given the rationale behind the changes made during hospitalization.

They specifically noted the difference in statin therapy between groups, with fewer discontinuations or dosage reductions, writing that the higher adherence rate in the intervention group reflected physicians' improved awareness of the benefits of statins after a cerebrovascular event.

"Providing detailed information on medication changes can lead to substantially improved adherence to discharge medication, probably resulting in better secondary stroke prevention," the authors concluded.



CMS update


.
Resources available to help clinicians comply with new PQRS requirements

The Physician Quality Reporting System (PQRS) reporting regulations are changing. The 2012 reporting year will be the last year for physicians to participate in PQRS and receive an incentive payment of 0.5% of the total allowed charges for Physician Fee Schedule (PFS) covered services, without risk of penalty.

The PQRIwizard is an online tool designed to help physicians and other eligible professionals quickly and easily participate in the PQRS. ACP members can purchase the PQRIwizard at a discounted rate. The deadline for submission of the PQRS 2012 reporting year is March 14, 2013. More information on the fee schedule is available online as is information on the PQRIwizard.



From the College


.
Practice transformation is more than checking boxes

Yul Ejnes, MD, MACP, immediate past chair of ACP's Board of Regents, a practicing internist in Cranston, R.I., and a member of ACP Internist's editorial board, continues his column at KevinMD.com, one of the Web's leading destinations for provocative physician commentary. In this month's post, Dr. Ejnes suggests how physicians can engage and inspire their practice teams to achieve a shared vision that focuses on desired outcomes rather than process.



Cartoon caption contest


.
And the winner is …

ACP InternistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

acpi-20121218-cartoon.jpg

"OK, OK, I'll order a stool FIT instead!"

This issue's winning cartoon caption was submitted by Thomas F. Imperiale, MD, FACP. Readers cast 98 ballots online to choose the winning entry. Thanks to all who voted! The winning entry captured 45.9% of the votes.

The runners-up were:

"Sorry, our waiting room got downsized."

"This is not the best way to get your LDL to drop."


.


MKSAP Answer and Critique



The correct answer is C: Skin biopsy. This item is available to MKSAP 16 subscribers as item 14 in the Dermatology section.

MKSAP 16 released Part A on July 31. More information is available online.

This patient has atypical urticaria, and the diagnostic test of choice is skin biopsy to evaluate for the presence of vasculitis. Her individual lesions last longer than a few hours and are not pruritic. The presence of burning, tingling, or painful wheals is unusual for simple urticaria. Lesions that last for more than 24 hours and resolve with bruising are concerning for urticarial vasculitis. Approximately 50% of patients with urticarial vasculitis have an underlying autoimmune disease such as systemic lupus erythematosus.

Many medications may trigger urticaria. Oral contraceptives can cause urticarial eruptions, including chronic urticaria, typically through progesterone exposure. This frequently manifests as a cyclic urticaria. Urticarial vasculitis is less frequently caused by medications and has not been associated with oral contraceptives.

Patients with a clear food or environmental trigger for urticarial eruptions may benefit from radioallergosorbent (RAST) testing; however, this patient is presenting with atypical urticarial lesions with signs and symptoms concerning for urticarial vasculitis. RAST testing plays no role in the diagnosis of urticarial vasculitis.

Thyroid function testing is indicated in the evaluation of chronic urticaria, in which patients have regular episodes of urticaria over a period of more than 6 weeks. Given the atypical presentation of this patient's wheals and the lack of historical features or physical examination findings consistent with thyroid disease, testing is not indicated at this time.

Key Point

  • Lesions that persist for more than 24 hours and resolve with bruising should be biopsied to evaluate for urticarial vasculitis.

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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?

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