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

Advertisement

ACP InternistWeekly



In the News for the Week of July 30, 2013




Highlights

Physicians view other parties as responsible for reducing costs of health care

Physicians believe other parties, including trial lawyers, health insurance companies, and hospitals and health systems, bear greater responsibility than they do for reducing health care costs, according to a recent survey. More...

Majority of TTEs appropriate but may not change management, study finds

Most transthoracic echocardiograms (TTEs), even those done for appropriate clinical indications, have little effect on patient management, according to a new study. More...


Test yourself

MKSAP Quiz: 3-month history of progressively worsening diarrhea

A 19-year-old woman is evaluated for a 3-month history of progressively worsening diarrhea, abdominal pain, and weight loss. Her brother was diagnosed with Crohn disease at age 16 years. Following a physical exam and colonoscopy, what is the most effective maintenance treatment? More...


Neurology

Some statins may offer protective effect for Parkinson's disease

Continued lipophilic statin therapy was associated with a decreased incidence of Parkinson's disease compared to starting and then stopping therapy, especially among female and elderly patients, a study found. More...


Women's health

Avoidance of estrogen caused excess deaths in hysterectomized women

After publication of the Women's Health Initiative (WHI), estrogen use declined significantly among women aged 50 to 59, likely resulting in avoidable deaths of those who had hysterectomies, a recent analysis found. More...


Perioperative care

Patients may safely continue aspirin to the day of pancreas surgery

Patients undergoing major pancreas operations can continue taking aspirin through the morning of surgery with no increased risk of bleeding, a study found. More...


CMS update

Guidance on transitional care codes and preview of 2014 Medicare Fee Schedule

CMS released its proposed rule for next year's Medicare Physician Fee Schedule on July 19. More...


From the College

Physicians can earn CME online with ACP Clinical Shorts

ACP Clinical Shorts is a series of short educational videos that clinicians can order to earn CME from their computers or mobile devices. More...

Call for spring 2014 Board of Governors resolutions

The deadline for submitting new resolutions to be heard at the spring 2014 Board of Governors meeting is Sept. 25, 2013. 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


.
Physicians view other parties as responsible for reducing costs of health care

Physicians believe other parties, including trial lawyers, health insurance companies, and hospitals and health systems, bear greater responsibility than they do for reducing health care costs, according to a recent survey.

Researchers conducted a cross-sectional survey in 2012 designed to determine physicians' beliefs about methods of addressing health care costs as well as the role physicians should play. The surveyed physicians were randomly selected from the American Medical Association Masterfile and were asked to assess perceived stakeholder responsibility for controlling costs, enthusiasm for different cost-controlling strategies, their professional role in cost containment, and perceived barriers to and consequences of cost-conscious practice. The degree of the respondents' cost-consciousness, defined as the extent to which they pay attention to and feel an obligation to address health care costs in their practice, was derived from an 11-point scale, with higher scores reflecting a greater level of cost-consciousness. The study results appear in the July 24/31 Journal of the American Medical Association.

The survey was mailed to 3,897 physicians, and 2,556 (65%) responded. Those who responded were mostly men (70%) and were most likely to work in a group/HMO practice (64%). In the survey results, the parties most commonly reported to have a "major responsibility" for reducing costs of health care were trial lawyers (60%), health insurance companies (59%), hospitals and health systems (56%), pharmaceutical and device manufacturers (56%) and patients (52%). In contrast, 36% of respondents thought practicing physicians had a major responsibility, 19% thought employers did, and 27% thought physician professional societies did. Most of the physicians surveyed reported being "very enthusiastic" about reducing health care costs by "promoting continuity of care" (75%), "expanding access to quality and safety data" (51%), and "limiting access to expensive treatments with little net benefit" (51%). Seventeen percent of respondents were very enthusiastic about high-deductible health care plans and about higher patient copayments. Only 6% were very enthusiastic about penalties for avoidable readmissions, and only 7% were very enthusiastic about elimination of fee-for-service payment models.

Most of the physicians surveyed said they were aware of the costs of the tests and treatments they recommend (76%), should follow clinical guidelines that discourage marginally beneficial care (79%), should work primarily toward patients' best interests even when doing so is costly (78%) and should be more involved in limiting use of unnecessary tests (89%). Eighty-five percent of respondents disagreed that they "should sometimes deny beneficial but costly services to certain patients because resources should go to other patients that need them more." Seventy percent of respondents agreed that they enjoyed practicing medicine less because of the threat of lawsuits.

In multivariable logistic regression models, compensation by salary plus a bonus or salary only was independently associated with enthusiasm for eliminating fee for service (odds ratios, 3.3 and 4.3, respectively), while in multivariable linear regression models, working in a group or government practice and receiving a salary plus a bonus were associated with increased levels of cost-consciousness. A negative association was observed between cost-consciousness and responding affirmatively that the uncertainty involved with patient care is disconcerting.

The study authors pointed out that data in the American Medical Association Masterfile are self-reported and that the opinions of all U.S. physicians may not be represented in their study, among other limitations. They said that their study results may reflect tensions in physicians' professional role, which requires them to serve both individual patients and society as a whole.

"Physicians clearly struggle with these tensions and how they can act individually and collectively to provide optimal, sustainable quality care," the study authors wrote. "They also recognize themselves as just one component of a multifaceted system of stakeholders responsible for addressing increasing costs."

Given the survey findings, the authors wrote, cost-conscious care should start with strategies that physicians largely support in order to "create momentum for such efforts." The authors also recommended that more drastic financing changes be phased in gradually and be carefully monitored to avoid unintended negative effects.

The authors of an accompanying editorial called the current state of U.S. health care "an 'all-hands-on-deck' moment" and said that the survey results indicate physicians are not yet ready to lead. The fact that only one-third of physicians claimed a major role in controlling costs "is a denial of responsibility," the authors wrote. In addition, although physicians supported the use of cost-effectiveness data, limited access to costly treatments with little benefit, and incorporation of cost information into electronic decision support tools, these methods "largely relieve the physician from being the decision-maker and taking responsibility for cost control," they said.

Physicians now recognize that health care costs are a problem but are not willing to accept primary responsibility for finding a solution and would prefer others to do so, the study authors wrote. "This could marginalize and demote physicians," they concluded. "Physicians must commit themselves to act like the captain of the health care ship and take responsibility for leading the United States to a better health care system that provides higher-quality care at lower costs."


.
Majority of TTEs appropriate but may not change management, study finds

Most transthoracic echocardiograms (TTEs), even those done for appropriate clinical indications, have little effect on patient management, according to a new study.

Researchers in Texas retrospectively reviewed medical records of TTEs at one medical center and classified them according to appropriate use criteria developed in 2011 and assessed clinical impact. The two cardiologists who judged appropriate use criteria were blinded to clinical impact, and the two cardiologists who assessed clinical impact were blinded to appropriate use criteria. When the cardiologists disagreed and could not reach consensus on either clinical impact or appropriate use, a third cardiologist, also blinded, adjudicated. A TTE could be classified as leading to an active change in care, continuation of current care, or no change in care. The study's main outcome measures were prevalence of appropriate, inappropriate and uncertain TTEs based on appropriate use criteria and the prevalence of the three clinical impact categories. The results were published online July 22 by JAMA Internal Medicine.

All TTEs ordered at University of Texas Southwestern Medical Center from April 1 through April 30, 2011, were reviewed and 535 were included in the analysis. Most of the study patients were women (58.7%); 55.3% were white, 21.1% were African American and 8.2% were Hispanic. The mean age was 58 years. Fifty-seven percent of TTEs were ordered for inpatients, and general internists (38.5%) and cardiologists (31.2%) were the specialists most likely to order the tests.

The researchers found that 31.8% of TTEs led to an active change in care, 46.9% led to continuation of current care and 21.3% led to no change in care. Based on the 2011 appropriate use criteria, 91.8% of TTEs were appropriate, 4.3% were inappropriate, and 3.9% were of uncertain appropriateness. A similar proportion of appropriate and inappropriate TTEs led to active change in care (32.2% vs. 21.7%, respectively; P=0.29). Outpatient TTEs were slightly less likely than inpatient ones to be judged appropriate (86.5% vs. 95.7%, respectively; P<0.001).

The study was limited by its reliance on electronic medical records, which may have provided incomplete information and led to misclassification of clinical impact, the authors noted. They also pointed out that they were unable to assess patient satisfaction and that their results may not be generalizable to other practice settings, among other limitations. They concluded, however, that while almost all TTEs in their study were considered appropriate by 2011 criteria, fewer than one-third led to an active change in care. In addition, almost half led to continuation of current care and approximately 21% resulted in no change in care.

"The discrepancy between appropriateness and clinical impact is striking and suggests that the [appropriate use criteria] as currently implemented are unlikely to facilitate optimal use of TTE," they wrote. They called for further research examining the necessity of TTE in medical care.

The author of one of two invited commentaries said that while the existing appropriate use criteria are "meticulous," the evidence on how and when to best use echocardiography is slim. The current study, he said, "demonstrates that the concepts of appropriateness and usefulness may diverge considerably. Transthoracic echocardiograms cost more than $1 billion per year to Medicare alone, and many TTE procedures performed by the book may still not lead to improved outcomes." He called for additional randomized trials of diagnostic testing focusing on specific clinical scenarios. "Such trials may cost more than collecting observational data, but for common tests and indications, their results may be definitive, eventually saving far more money," he wrote.

The second invited commentary noted the limitations of a retrospective review of electronic medical records and said that the results should be confirmed prospectively before major conclusions are drawn. "Certainly, the [appropriate use criteria] are not without remaining flaws and ideally should result in a categorization scheme that can be demonstrated to have a consistent, but necessarily invariable, effect on medical decision making," the authors wrote. "This retrospective study points the way for further prospective studies looking at the impact of echocardiography and how it affects physician decision making."



Test yourself


.
MKSAP Quiz: 3-month history of progressively worsening diarrhea

A 19-year-old woman is evaluated for a 3-month history of progressively worsening diarrhea, abdominal pain, and weight loss. Her brother was diagnosed with Crohn disease at age 16 years.

On physical examination, temperature is 37.4 °C (99.3 °F), blood pressure is 110/65 mm Hg, pulse rate is 90/min, and respiration rate is 20/min. Abdominal examination reveals tenderness to palpation in the right lower quadrant with no guarding or rebound tenderness. Perianal and rectal examinations are normal.

Colonoscopy discloses evidence of moderately to severely active Crohn disease involving the terminal ileum; the diagnosis is confirmed histologically. Magnetic resonance enterography shows active inflammation involving the distal 20 cm of the ileum without other bowel inflammation or obstruction. There is no evidence of abscess or phlegmon.

Which of the following is the most effective maintenance treatment?

A: Ciprofloxacin and metronidazole
B: Infliximab
C: Mesalamine
D: Prednisone
E: Surgical resection

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


.

Neurology


.
Some statins may offer protective effect for Parkinson's disease

Continued lipophilic statin therapy was associated with a decreased incidence of Parkinson's disease compared to starting and then stopping therapy, especially among female and elderly patients, a study found.

Researchers in Taiwan recruited patients without Parkinson's disease who started statin therapy between 2001 and 2008. Results were published online July 24 by Neurology.

Among the 43,810 patients who began taking statins, the incidence rate for Parkinson's disease was 1.68 per 1 million person-days for lipophilic statins (lovastatin, fluvastatin, simvastatin, atorvastatin) and 3.52 per 1 million person-days for hydrophilic statins (pravastatin, rosuvastatin). Continued statin therapy was associated with a decreased risk of Parkinson's disease (hazard ratio [HR], 0.42; 95% CI, 0.27 to 0.64) compared to stopping statins.

There was no association between use of hydrophilic statins and incidence of Parkinson's disease, researchers wrote. Among lipophilic statin users, there was a significant benefit to continuing simvastatin (HR, 0.23; 95% CI, 0.07 to 0.73) and atorvastatin (HR, 0.33; 95% CI, 0.17 to 0.65), especially in women (simvastatin: HR, 0.11, 95% CI, 0.02 to 0.80; atorvastatin: HR, 0.24; 95% CI, 0.09 to 0.64). Researchers also noted a beneficial effect in patients over 65 (HR, 0.42; 95% CI, 0.21 to 0.87). However, long-term use of either type of statin did not show a statistically significant dose or duration response effect on Parkinson's disease.

The researchers also looked at the relationship between stopping or continuing statins and mortality. Continuing lipophilic statins resulted in a significantly decreased risk of death compared to stopping them (HR, 0.31; 95% CI, 0.18 to 0.54), but this was only a trend for hydrophilic statins (HR, 0.48; 95% CI, 0.23 to 1.00).

The researchers wrote, "Since PD [Parkinson's disease] is a neurodegenerative disorder with a long pre-symptomatic period, there may be a window of opportunity for modification of the disease process before onset of motor symptoms. In this context, we speculated that lipophilic statins may act through modifying the level or sensitivity of dopamine receptors in striatum, rather than holding the neuronal degeneration process."

An editorial noted that while there may be a biological basis for statins reducing Parkinson's disease, more research is needed to identify exactly what mechanisms are at work, including genetic factors. The editorialists wrote, "Current clinical and experimental data provide some compelling evidence that the benefits of statins probably extend beyond their anti-hyperlipid therapeutic effect. For those who have to be on statins, it is a comforting thought that there is a potential added advantage of having a lower risk of PD, and possibly other neurologic disorders as well."



Women's health


.
Avoidance of estrogen caused excess deaths in hysterectomized women

After publication of the Women's Health Initiative (WHI), estrogen use declined significantly among women aged 50 to 59, likely resulting in avoidable deaths of those who had hysterectomies, a recent analysis found.

Estrogen reduces overall mortality primarily through a reduction in coronary heart disease-related deaths, and estrogen-only therapy had previously been routinely prescribed for women in their 50s who had undergone a hysterectomy to optimize its beneficial effect on mortality. However, following publication of the WHI study, the use of hormone therapy declined precipitously among postmenopausal women, including the use of estrogen-only treatment in women in their 50s who had undergone hysterectomy despite subsequent research that showed a mortality benefit to estrogen treatment in this patient group. This raised the concern that decreased estrogen treatment in this group of women might lead to increased mortality.

Researchers combined data from the WHI, the U.S. Census, the National Hospital Discharge Survey and several recent studies of estrogen use to make their calculations. The WHI Estrogen-Alone Trial showed an increased mortality rate of 13 per 10,000 women per year when a placebo, instead of estrogen, was given to women between ages 50 and 59 who had a hysterectomy. The census and the National Hospital Discharge Survey provided annual estimates of this population, and previously published studies showed that use of oral estrogen alone dropped steadily after 2001. For example, before the WHI publication, about 90% of women having both a hysterectomy and oophorectomy took estrogen therapy, compared to only about a third today, the researchers reported.

Based on these figures, a minimum of 18,601 women in this group (ages 50 to 59, with a hysterectomy) died prematurely between 2002 and 2011 due to their failure to take estrogen, the researchers calculated. When higher estimates of hysterectomy and mortality rates are used, as many as 91,610 women may have died prematurely during that period due to the avoidance of estrogen therapy, they concluded. Results were published by American Journal of Public Health on July 18.

The findings show the urgent need for informed discussion among women and clinicians about the actual findings of the WHI, the authors said. Women's decisions to avoid estrogen therapy have been influenced by clinicians' and the media's failures to differentiate among the various findings on the harms and benefits of estrogen therapy, particularly for specific groups of women who might benefit from treatment. Women in their 50s who have had hysterectomies, in particular, need accurate information about the potential benefits to their health, the authors concluded.



Perioperative care


.
Patients may safely continue aspirin to the day of pancreas surgery

Patients undergoing major pancreas operations can continue taking aspirin through the morning of surgery with no increased risk of bleeding, a study found.

A retrospective study examined patients who underwent elective pancreatoduodenectomy, distal pancreatectomy or total pancreatectomy between October 2005 and February 2012. Of 1,017 patients, 289 (28.4%) remained on aspirin through the morning of surgery at Thomas Jefferson University Hospital in Philadelphia, a practice that has been advised at that facility since 2005. Results were published online first July 24 by Surgery.

For the aspirin and no-aspirin groups, rates were similar for estimated blood loss during surgery (median, 400 mL vs. 400 mL, P=0.661), blood transfusion any time during the index admission (29% vs. 26%, P=0.37) and the postoperative duration of hospital stay (median, 7 days vs. 6 days, P=0.103).

The aspirin group had a slightly increased rate of cardiovascular complications (10.1% vs. 7%, P=0.107), which researchers suggested may reflect the cardiovascular health problems that led to beginning aspirin therapy. Rates were similar between the two groups for pancreatic fistulae (15.1% vs. 13.5%, P=0.490) and hospital readmissions (16.9% vs. 14.9%, P=0.451).

Researchers noted that continuing aspirin should be an acceptable and preferable practice, especially in patients who would benefit from antiplatelet therapy. Previous research shows that the mean interval between aspirin discontinuation and acute cardiac events is 8.5±3.6 days. Patients who stop taking aspirin 7 to 10 days before invasive procedures could experience thrombosis exactly at the time of exposure of platelets to defects in the endothelium that stem from major surgery.

They wrote, "Despite many surgeons' fears that preoperative aspirin use increases bleeding, this study (among others in nonpancreatic surgery) shows that this apprehension appears unfounded."



CMS update


.
Guidance on transitional care codes and preview of 2014 Medicare Fee Schedule

CMS released its proposed rule for next year's Medicare Physician Fee Schedule on July 19.

A summary of the proposed rule, including information about next year's payments and other changes for 2014, is posted to the Running a Practice section of ACP's website.

CMS also released additional guidance on using the transitional care management codes 99495 and 99496. Official descriptions of what the services contain and instructions on how to bill the service are in the "CMS MedLearn Matters: TCM Fact Sheet" posted on the ACP website.



From the College


.
Physicians can earn CME online with ACP Clinical Shorts

ACP Clinical Shorts is a series of short educational videos that clinicians can order to earn CME from their computers or mobile devices.

Each Clinical Short video is less than 15 minutes long and provides concise answers to challenging clinical situations. After viewing each video, users answer a three-question quiz and then submit online for CME credit.

Subscribers to ACP Clinical Shorts will receive one year of unlimited access to 28 videos. Register now for your one-year subscription.


.
Call for spring 2014 Board of Governors resolutions

The deadline for submitting new resolutions to be heard at the spring 2014 Board of Governors meeting is Sept. 25, 2013.

Initiating a resolution provides ACP members an opportunity to focus attention at the ACP national level on a particular issue or topic that concerns them. When drafting a resolution, don't forget to consider how well it fits within ACP's Mission and Goals. In addition, be sure to use the College's Strategic Plan to guide you when proposing a resolution topic. Members must submit resolutions to their Governor and/or chapter council. A resolution becomes a resolution of the chapter once the chapter council approves it.

In accordance with the ACP Board of Governors Resolutions Process, resolutions should clearly distinguish the action requested within its resolved clause(s) as either a policy resolve ("Resolved that ACP policy…"), or a directive, which requests action/study on an issue ("Resolved that the Board of Regents…"). If more than one action is proposed, each should have its own resolved clause. Please contact your Governor if you have any questions regarding the resolution format.

The Board of Governors votes on new resolutions, which are then presented to the Board of Regents for action. Members are encouraged to use the Electronic Resolutions System (ERS) to research the status of past resolutions before proposing a new resolution. Visit your chapter website and link to the ERS under the "Advocacy" heading.



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-20130730-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 B: Infliximab. This item is available to MKSAP 16 subscribers as item 17 in the Gastroenterology and Hepatology section. More information is available online.

The most appropriate treatment is an anti-tumor necrosis factor (anti-TNF) agent such as infliximab. This patient has moderately to severely active Crohn ileitis associated with weight loss and significant symptoms. The SONIC study showed better clinical outcomes when patients with recently diagnosed moderate to severe Crohn disease were treated aggressively with anti-TNF therapy with or without an immunomodulator such as azathioprine or 6-mercaptopurine. Anti-TNF therapy alone was superior to azathioprine monotherapy, and the combination of these two agents resulted in the highest rates of remission and mucosal healing. The decision to use thiopurine or anti-TNF monotherapy versus combination therapy is based on an individual patient's severity of symptoms and risk factors for developing complications of their disease balanced against the potential side effects of these treatments. An alternative to the immediate use of anti-TNF therapy is the simultaneous initiation of an immunomodulator and corticosteroids with a goal to taper off of corticosteroids within 3 months. If symptoms are not completely controlled after stopping the corticosteroids, then an anti-TNF agent could be added at that time.

Antibiotics are effective in the treatment of abscess and wound infections associated with inflammatory bowel diseases, but their efficacy as primary treatment for Crohn disease and ulcerative colitis is not well established.

Because Crohn disease is a transmural disease, the 5-aminosalicylic acid agents have not proved to be as efficacious as they are in ulcerative colitis. They are often used in the treatment of mild disease but are ineffective in moderate to severe disease.

Corticosteroid therapy on its own may help improve initial symptoms, but the majority of patients will also require maintenance therapy with an immunosuppressant medication to avoid becoming corticosteroid dependent. More aggressive use of anti-TNF agents with an immunomodulator results in higher rates of remission and mucosal healing compared with initial treatment with corticosteroids.

Surgical evaluation would be important if there was concern for perforation, abscess, obstruction, or medically refractory disease, but it would not be the appropriate next step in this patient's management.

Key Point

  • The most effective treatment for patients with recently diagnosed moderately to severely active Crohn disease is anti-tumor necrosis factor therapy with or without an immunomodulator such as azathioprine or 6-mercaptopurine.

Click here to return to the rest of ACP InternistWeekly.

Top




About ACP InternistWeekly

ACP InternistWeekly is a weekly newsletter produced by the staff of ACP Internist. It is automatically sent to all College members who have an e-mail address on file with ACP.

To add your e-mail address to your member record and to begin receiving ACP InternistWeekly, please click here.

Copyright © by 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

New Leadership Webinars

New Leadership Webinars

The ACP Leadership Academy is offering FREE webinars covering the core tenets of leadership, leadership in hospital medicine, finance, and more.

Join ACP Today!

Join ACP Today!

ACP membership connects you with like-minded colleagues and provides access to a variety of clinical resources, practice tools, and ways to earn MOC and CME.