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

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ACP InternistWeekly



In the News for the Week of July 9, 2013




Highlights

Patients who achieve low cholesterol levels still get lipid tests

One-third of patients with coronary heart disease who had low-density lipoprotein cholesterol levels less than 100 mg/dL underwent repeat lipid testing anyway, a study found. More...

Survey finds many patients OK with placebos in primary care

A majority of patients favored allowing placebo treatments in medical care, especially when they were used honestly and transparently, a recent telephone survey found. More...


Test yourself

MKSAP Quiz: dizziness, shortness of breath and palpitations

This week's question asks readers to evaluate a 76-year-old woman in the emergency department with dizziness, shortness of breath, and palpitations that began acutely 1 hour ago. More...


Peripheral artery disease

Unsupervised walking regimen may improve fitness in patients with PAD

A home-based walking exercise program significantly improved walking endurance, physical activity, and speed in patients with peripheral artery disease (PAD), according to a recent trial. More...


Readmissions

New models predict risk of readmission after PCI

Researchers have developed two models to predict patients' risk of readmission within 30 days of percutaneous coronary intervention (PCI). More...


Rheumatology

Biological compared with conventional treatment may not improve work loss in early rheumatoid arthritis

Infliximab improved radiologic results but did not result in less work loss compared with conventional combination therapy in patients with early rheumatoid arthritis who did not respond sufficiently to methotrexate, a new study reports. More...


Physician survey

AHRQ seeks physician input on shared decision-making tools

The Agency for Healthcare Research and Quality (AHRQ) is seeking physician input on the development of new clinical tools and workshops to support shared health care decision making. More...


From ACP Internist

The next issue of ACP Internist is online and coming to your mailbox.

Stories this month cover pain in the elderly, ACOs, and the Physician Payments Sunshine Act, among other topics. More...


From ACP Hospitalist

Who's tops at your hospital? Let us know this month!

ACP Hospitalist is seeking candidates for its sixth annual Top Hospitalists issue in November, which will feature the best and brightest in hospital medicine. Let us know what your colleagues have accomplished in 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


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Patients who achieve low cholesterol levels still get lipid tests

One-third of patients with coronary heart disease who had low-density lipoprotein cholesterol (LDL-C) levels less than 100 mg/dL underwent repeat lipid testing anyway, a study found.

Researchers used data on patients with coronary heart disease treated at seven Veterans Affairs centers and associated community clinics. Of nearly 27,947 patients with LDL-C levels of less than 100 mg/dL, 9,200 (32.9%) had additional lipid assessments without treatment intensification during the 11 months following their initial result (12,686 total additional panels; mean, 1.38 additional panel per patient).

After adjustment for facility-level clustering, patients were more likely to undergo repeat testing if they had diabetes (odds ratio [OR], 1.16; 95% CI, 1.10 to 1.22), a history of hypertension (OR, 1.21; 95% CI, 1.13 to 1.30), greater illness burden (OR, 1.39; 95% CI, 1.23 to 1.57), or more frequent primary care visits (OR, 1.32; 95% CI, 1.25 to 1.39). Patients were less likely to undergo repeat testing if they received care at a teaching facility (OR, 0.74; 95% CI, 0.69 to 0.80), received care from a physician versus a nonphysician provider (OR, 0.93; 95% CI, 0.88 to 0.98) or had a documented high level of medication adherence (OR, 0.75; 95% CI, 0.71 to 0.80).

Researchers also found that even among the 13,114 patients who met the optimal LDL-C target level of less than 70 mg/dL, repeat lipid testing was performed in 8,177 (62.4%) during the 11 follow-up months. Results appeared online July 1 at JAMA Internal Medicine.

Many reasons exist to do extra tests, researchers noted, including a habit of ordering comprehensive laboratory tests rather than focusing on one clinical issue, or a sense of comfort to clinicians that they are being vigilant. Still, the authors continued, repeated lipid testing might be a cost-saving area to target in clinical practice, especially in light of upcoming guidelines expected to adopt a statin dose-based treatment approach in place of the current treat-to-target approach.

"With a mean lipid panel cost of $16.08 based on Veterans Health Administration laboratory cost data, this is equivalent to $203,990 in annual costs for one VA network and does not take into account the cost of the patient's time to undergo lipid testing and the cost of the provider's time to manage these results and notify the patient," researchers wrote.

An editorial noted that the study "delivers an important message regarding a type of waste that is likely widespread in health care and that goes under the radar because it involves a low-cost test. However, it is precisely these low-cost, high-volume tests and procedures that need to be addressed if significant savings from reduction of waste are to be realized."


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Survey finds many patients OK with placebos in primary care

A majority of patients favored allowing placebo treatments in medical care, especially when they were used honestly and transparently, a recent telephone survey found.

Researchers surveyed 853 Northern California patients, ages 18 to 75, who had been seen by a primary care clinician for a chronic health problem in the previous six months. Patients were asked some general questions about their beliefs on placebos and given specific scenarios in which a placebo might be used. Results were published online by BMJ on July 2.

Only 21.9% of the survey respondents said that it was never acceptable for physicians to recommend placebos, with 76.2% saying it was acceptable to prescribe a placebo that's expected to benefit and not harm the patient. However, only half of the respondents approved of prescribing a placebo of uncertain benefit.

Respondents had complicated views on honesty and placebos: Over 80% believed that placebos can only be effective if patients don't know they are taking a placebo. However, slightly less than half thought it was acceptable for a physician to call a placebo "real medicine." When given a scenario in which a patient asked for antibiotics to treat a cold and was given a placebo instead, more than half the respondents thought finding out the medication was a placebo would negatively impact the patient's future relationship with the physician.

The respondents expressed willingness to try placebos in their own care. Given a scenario of moderate stomach pain with no clear cause, two-thirds of respondents would be willing to try a medication that their doctor said might help through a placebo effect, and in another scenario, over half would be willing to take a placebo for chronic abdominal pain that had been shown in studies "to produce relief through mind-body self-healing processes."

The survey's results reveal a disconnect among clinical practice guidelines (which recommend against placebo use), physicians' practices and patient opinions, the study authors concluded. The survey participants were more highly educated than the overall U.S. population, and yet their conflicting answers about "open" placebos raise questions about how well they understand the concept of placebos. Based on the survey's findings, physicians may want to consider discussing placebos with their patients and tailoring treatment according to patients' preferences and beliefs on the subject, the authors concluded.



Test yourself


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MKSAP Quiz: dizziness, shortness of breath and palpitations

A 76-year-old woman is evaluated in the emergency department for dizziness, shortness of breath, and palpitations that began acutely 1 hour ago. She has a history of hypertension and heart failure with preserved ejection fraction. Medications are hydrochlorothiazide, lisinopril, and aspirin.

mksap.gif

On physical examination, she is afebrile, blood pressure is 80/60 mm Hg, pulse rate is 155/min, and respiration rate is 30/min. Oxygen saturation is 80% with 40% oxygen by face mask. Cardiac auscultation reveals an irregularly irregular rhythm, tachycardia, and some variability in S1 intensity. Crackles are heard bilaterally one-third up in the lower lung fields.

Electrocardiogram demonstrates atrial fibrillation with a rapid ventricular rate.

Which of the following is the most appropriate acute treatment?

A: Adenosine
B: Amiodarone
C: Cardioversion
D: Diltiazem
E: Metoprolol

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


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Peripheral artery disease


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Unsupervised walking regimen may improve fitness in patients with PAD

A home-based walking exercise program significantly improved walking endurance, physical activity, and speed in patients with peripheral artery disease (PAD), according to a recent trial.

To determine whether a home-based walking exercise program could improve functional performance in patients with PAD with and without intermittent claudication, researchers in Chicago studied 194 patients, including 72.2% without classic symptoms of intermittent claudication, from July 2008 to December 2012. Participants were randomized into two groups to assess their six-month change in six-minute walk performance, the primary outcome measure. The control group attended weekly 60-minute group sessions in which health care professionals provided lectures on managing hypertension, cancer screening and vaccinations. The intervention group added a home-based, group-mediated cognitive behavioral walking routine.

Secondary outcomes included change in treadmill walking, accelerometer-measured physical activity, the Walking Impairment Questionnaire (WIQ), and Physical and Mental Health Composite Scores from the 12-item Short-Form Health Survey. Results appeared in the July 3 Journal of the American Medical Association.

Participants in the intervention group significantly increased their six-minute walk distance from 357.4 m before the intervention to 399.8 m after, compared to 353.3 m and 342.2 m for those in the control group (mean difference between groups, 53.5 m [95% CI, 33.2 m to 73.8 m]; P<0.001). Maximum treadmill walking time in the intervention group increased from 7.91 min to 9.44 min compared to the control group's improvement from 7.56 min to 8.09 min (mean difference, 1.01 min [95% CI, 0.07 min to 1.950 min]; P=0.04). Accelerometer-measured physical activity over seven days (in activity units) in the intervention group improved from 778.0 to 866.1 compared to the control group's 671.6 to 645.0 (mean difference, 114.7 [95% CI, 12.82 to 216.5]; P=0.03).

The WIQ distance score in the intervention group went from 35.3 to 47.4 compared to the control group's 33.3 to 34.4 (mean difference, 11.1 [95% CI, 3.9 m to 18.1]; P=0.003), and the WIQ speed score in the intervention group went from 36.1 to 47.7 compared to the control group's 35.3 to 36.6 (mean difference, 10.4 [95% CI, 3.4 to 17.4]; P=0.004).

The researchers noted that these findings have implications for the large number of patients with PAD who are unable or unwilling to participate in supervised exercise programs. "Supervised treadmill exercise is associated with a 50% to 200% improvement in maximal treadmill walking performance in PAD," the authors wrote. "However, most patients with PAD do not participate in supervised exercise. Medical insurance typically does not pay for supervised exercise for patients with PAD and traveling to exercise sessions is burdensome. Home-based exercise could provide a feasible therapeutic option that is accessible to most patients with PAD."



Readmissions


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New models predict risk of readmission after PCI

Researchers have developed two models to predict patients' risk of readmission within 30 days of percutaneous coronary intervention (PCI).

The models were based on data from all 30-day readmissions after PCI at nonfederal Massachusetts hospitals in 2005 to 2008: 3,760 readmissions out of a total of 36,060 PCI patients surviving to initial discharge. Two-thirds of the patients were used to develop the multivariable models and the other third was used to validate them. Results were published by Circulation: Cardiovascular Quality and Outcomes on July 2.

The first model used only variables known before PCI and showed that significant predictors of readmission included older age, female sex, Medicare or state insurance, congestive heart failure and chronic kidney disease. The second model used variables known at discharge and found readmissions to be associated with lack of a beta-blocker prescription at discharge, post-PCI vascular or bleeding complications, and extended length of stay. The C-statistic, a measure used with logistic regression analysis to indicate the ability of a model to predict the studied outcome (with a range of 0.50 to 1.00, with higher values indicating higher predictive ability), was calculated for both models. The pre-PCI model had a C-statistic of 0.68, which was modestly improved to 0.69 with the addition of the post-PCI variables.

The models could help clinicians and hospitals risk-stratify patients by readmission risk and potentially develop interventions to reduce 30-day readmissions in high-risk patients, the study authors said. The two models could potentially lead to different interventions, for example, more intensive case management or changes in the surgical plan for patients identified as high risk by the pre-PCI model or involvement of home care or more rapid follow-up in patients identified by the post-PCI model.

The causes of the observed associations are not entirely certain, the authors acknowledged. For example, beta-blocker use may actually reduce readmissions, but it's also possible that prescriptions are a marker of high-quality, careful discharge or that patients with more stable blood pressure are likely to both receive beta-blockers and to not be readmitted. The study was also limited by its use of only Massachusetts hospitals and an inability to distinguish between preventable and unpreventable readmissions. The models also include a large number of variables (11 pre-PCI and 19 post) and so will likely require information technology tools for implementation.



Rheumatology


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Biological compared with conventional treatment may not improve work loss in early rheumatoid arthritis

Infliximab improved radiologic results but did not result in less work loss compared with conventional combination therapy in patients with early rheumatoid arthritis who did not respond sufficiently to methotrexate, a new study reports.

Researchers analyzed data from a parallel, randomized open-label trial of patients from 15 rheumatology clinics in Sweden who were randomly assigned to receive additional treatment with infliximab or conventional combination treatment with sulfasalazine and hydroxychloroquine after three to four months of unsuccessful treatment with methotrexate. Patients were included if they were of working age (<63 years), had been diagnosed with rheumatoid arthritis according to revised American College of Rheumatology criteria, had not previously been treated with disease-modifying antirheumatic drugs (DMARDs), had not received oral or stable glucocorticoid therapy for at least four weeks, and had a disease activity score above 3.2 on a 28-joint count scale.

The infliximab group received infliximab, 3 mg per kg of body weight, at 0, 2 and 6 weeks and then every 8 weeks. The conventional treatment group received 1,000 mg of oral sulfasalazine twice daily and 400 mg of oral hydroxychloroquine daily. Main outcome measures were monthly sick leave and disability pension days 21 months after randomization. The study results were published online July 1 by JAMA Internal Medicine.

Two hundred four patients were eligible for randomization. Of these, 105 were randomly assigned to biological treatment and 99 were assigned to conventional treatment. The study drug was never administered to seven patients in the biological group or to four patients in the conventional treatment group. A total of 124 patients, 72 in the biological group and 52 in the conventional treatment group, followed the study protocol for 21 months. At baseline, the mean work loss in both groups was 17 days per month. At 21 months, the mean changes in work loss were −4.9 days per month in the biological group and −6.2 days in the conventional group, an adjusted mean difference of 1.6 days per month. When the authors looked only at patients who received at least one dose of the assigned treatment, the adjusted mean difference was 1.5 days per month; in per protocol analysis, it was 0.3 day per month.

The authors noted that their study was not blinded and that it included only patients who were of working age. However, they concluded that although biological treatment yields superior findings on radiographic assessments, it did not differ from conventional combination treatment in terms of work loss. "Treatment including a biological agent was not superior to conventional treatment in terms of effect on work loss over a 21-month period in patients with early [rheumatoid arthritis] with methotrexate treatment failure," the authors wrote. "Although a substantial improvement in work loss was achieved in both arms, the persisting gap relative to the general population indicates a need for more effective treatment strategies and earlier diagnosis of [rheumatoid arthritis]."

The author of an accompanying editorial pointed out that both treatment regimens, those that included biological agents and those that did not, substantially reduced the number of work days lost. "In the real world, in which payers approve biological agents only for patients in whom conventional DMARDs have failed, the true implication of the current findings may be that biological combination treatments may have an acceptable employment outcome even when initiated after conventional DMARDs have proved insufficient," the editorialist wrote. "In the real-world situation of sequential use of combinations, first excluding and only after that including biological agents, the outcome might not match that achieved after simultaneous randomization, but [this] fine study…indicates that it may be good enough."



Physician survey


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AHRQ seeks physician input on shared decision-making tools

The Agency for Healthcare Research and Quality (AHRQ) is seeking physician input on the development of new clinical tools and workshops to support shared health care decision making.

ACP supports AHRQ's effort to raise awareness and encourage use of evidence-based tools from the Effective Health Care (EHC) Program. These tools help clinicians and consumers learn about the effectiveness, benefits and risks of treatment options for many common conditions.

AHRQ has designed a survey to better understand the needs and preferences of physicians for new tools to use with patients. ACP members who complete the survey before July 15, 2013, can order free bulk copies of EHC clinician and consumer brochures. Participants will receive an access code to place their orders after completing the survey.

To access the survey, click here.



From ACP Internist


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The next issue of ACP Internist is online and coming to your mailbox.

The next issue of ACP Internist is online and coming to your mailbox. Stories include the following:

acpi-20130709-internist.jpg

Take time to ease the pain of elderly patients. Assessing and managing pain can be complicated in elderly patients. Learn which tools work, which tools don't, and how to optimize treatment.

Success in ACOs depends on collaboration. Physicians should consider culture, autonomy and resources before jumping in. Also, get specifics on access to data, and remember to plan for a possible exit strategy.

Spotlight cast on industry gifts, payouts to physicians. The Physician Payments Sunshine Act goes into effect Aug. 1. We detail what physicians need to know.

Also, Test Yourself with the MKSAP Quiz about the sudden onset of pleuritic chest pain or challenge your medical knowledge with our latest acrostic puzzle feature.



From ACP Hospitalist


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Who's tops at your hospital? Let us know this month!

ACP Hospitalist is seeking candidates for its sixth annual Top Hospitalists issue in November, which will feature the best and brightest in hospital medicine. Let us know what your colleagues have accomplished in 2013. Did they take charge of a key quality or safety initiative? Do they always go out of their way to educate patients or help new physicians? Maybe they are amazing at tricky diagnoses, or selfless about volunteer outreach. Whatever the contribution, if it helped further hospital medicine, we'd like to hear about it.

Recommending a physician is easy: Just visit our online form and tell us which physician you think we should feature and why. The deadline is July 24, 2013. We look forward to receiving your suggestions!

Note: ACP Hospitalist's Top Hospitalist issue is not part of the ACP National Awards Program. Self-nomination is not permitted. Candidates need not be ACP members. The selection process is not scientific. Editorial board members are solely responsible for determining those profiled in the Top Hospitalists issue.



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-20130709-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 C: Cardioversion. This item is available to MKSAP 16 subscribers as item 10 in the Cardiovascular Medicine section. More information is available online.

This patient with atrial fibrillation is hemodynamically unstable and should undergo immediate cardioversion. She has hypotension and pulmonary edema in the setting of rapid atrial fibrillation. In patients with heart failure with preserved systolic function, usually due to hypertension, the loss of the atrial "kick" with atrial fibrillation can sometimes lead to severe symptoms. The best treatment in this situation is immediate cardioversion to convert the patient to normal sinus rhythm. Although there is a risk of a thromboembolic event since she is not anticoagulated, she is currently in extremis and is at risk of imminent demise if not aggressively treated. In addition, she acutely became symptomatic 1 hour ago, and while this is not proof that she developed atrial fibrillation very recently, her risk of thromboembolism is low if the atrial fibrillation developed within the previous 48 hours.

Adenosine can be useful for diagnosing a supraventricular tachycardia and can treat atrioventricular node-dependent tachycardias such as atrioventricular nodal reentrant tachycardia, but it is not useful in the treatment of atrial fibrillation.

Amiodarone can convert atrial fibrillation to normal sinus rhythm as well as provide rate control, but immediate treatment is needed and amiodarone may take several hours to work. Oral amiodarone may be a reasonable option for long-term atrial fibrillation prevention in this patient given the severity of her symptoms, especially if she has significant left ventricular hypertrophy.

Metoprolol or diltiazem would slow her heart rate; however, she is hypotensive and these medications could make her blood pressure lower. In addition, she is in active heart failure, and metoprolol or diltiazem could worsen the pulmonary edema.

Key Point

  • Patients with atrial fibrillation who are hemodynamically unstable should undergo immediate cardioversion.

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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?

Find the answer

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