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

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ACP InternistWeekly



In the News for the Week of August 6, 2013




Highlights

Self-monitoring leads to slightly better blood pressure control, review finds

Self-measurement of blood pressure improved management of hypertension in the first year after initiation, but long-term effects are uncertain, according to a recent systematic review. More...

Decision aids increased knowledge about prostate cancer but didn't affect screening rates

Decision aids improved participants' informed decision making about prostate cancer screening but did not change the actual screening rates, a study found. More...


Test yourself

MKSAP Quiz: management of tobacco use

A 59-year-old man is evaluated during a follow-up examination. He has COPD and hypertension. He has an 80-pack-year history of cigarette use, but has recently decreased his smoking to a half pack of cigarettes daily. Medications are ipratropium and amlodipine. He is barrel-chested with diffuse wheezing on lung examination. What is the most appropriate management of this patient's tobacco use? More...


Nephrology

Analysis notes that CKD guidelines may lead to overdiagnosis, overtreatment

The current definition of chronic kidney disease (CKD) based on estimated glomerular filtration rate (eGFR) has led to one in eight people being labeled as having the condition, compared to the actual treatment rate of one person for every 3,000 to 5,000 for end-stage renal disease (ESRD), a recent analysis found. More...


Readmissions

EMR-based risk stratification plus increased support for highest-risk patients improves readmission rates in heart failure

Risk stratification using an electronic medical record (EMR) combined with the use of evidence-based interventions for patients at highest risk helped reduce readmissions for heart failure, a new study found. More...


Physician Payments Sunshine Act

National call to be held on Physician Payments Sunshine Act

Applicable industries began tracking transfers of value to physicians and teaching hospitals under the Physician Payments Sunshine Act (also known as Open Payments) on Aug. 1. More...

CMS releases mobile app to help physicians track transfers of value

CMS has released a mobile app, Open Payments Mobile for Physicians, to assist physicians in keeping track of transfers of value received from applicable industries that are covered under the Physician Payments Sunshine Act. More...


From the College

ACP launches "I.M. Proud to Be an Internist" campaign

As part of ACP's ongoing efforts to communicate the unique value of internal medicine, the College is launching an initiative to fortify the identity of internists and reinforce pride in the profession of internal medicine. More...


Cartoon caption contest

Put words in our mouth

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


Physician editor: Daisy Smith, MD, FACP



Highlights


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Self-monitoring leads to slightly better blood pressure control, review finds

Self-measurement of blood pressure improved management of hypertension in the first year after initiation, but long-term effects are uncertain, according to a recent systematic review.

annals.jpg

Reviewers included in their meta-analysis 52 prospective studies that compared self-measured blood pressure (SMBP) monitoring with or without additional support (which included education, counseling or Web support, among other supportive interventions) to usual care or an alternative SMBP intervention. Results were published in Annals of Internal Medicine on Aug. 6.

In the 26 studies that compared SMBP with no support to usual care, moderate-strength evidence showed a benefit to the self-monitoring (difference in systolic and diastolic blood pressures, −3.9 mm Hg and −2.4 mm Hg, respectively). However, by 12 months, there was no difference between the groups. The 25 studies that included additional support for SMBP patients showed higher-strength evidence and a longer lasting effect (differences ranging from −3.4 to −8.9 mm Hg systolic and −1.9 to −4.4 mm Hg diastolic at 12 months).

However, the 13 studies that directly compared SMBP interventions with and without support provided low-strength evidence that the extra support made no difference, and in the overall analysis, there was insufficient evidence of the effect of SMBP on any clinical outcomes. Still, the review authors concluded that SMBP without additional support lowered blood pressure compared to usual care, at a magnitude that would be clinically relevant on a population level if it were sustained over time.

Given the lack of evidence about SMBP's effects beyond 12 months, and the limitations of the included studies (underpowering, different additional support interventions in every study), the authors called for additional research to resolve current uncertainty about the long-term clinical effectiveness of SMBP. In addition to lowering clinic-measured blood pressure, the intervention's potential benefits include tailoring treatment to patients' individual needs, potentially avoiding overtreatment as well as undertreatment, they noted.


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Decision aids increased knowledge about prostate cancer but didn't affect screening rates

Decision aids improved participants' informed decision making about prostate cancer screening but did not change the actual screening rates, a study found.

Patients were randomly assigned to groups receiving print-based decision aids (n=628), Web-based interactive decision aids (n=625) or usual care (n=626) and were then assessed at baseline, one month and 13 months for prostate cancer knowledge, decisional conflict, decisional satisfaction and whether they underwent screening.

Decision aid materials included six sections: introductory material, screening tests and possible results, treatment options and risks, prostate cancer risk factors and encouragement to discuss screening with a physician, a 10-item values clarification tool, and resources for more information. The Web-based materials added interactive tools and displays. Results were published online July 29 by JAMA Internal Medicine.

Print and Web interventions resulted in greater knowledge (assessed by an 18-item true/false scale of knowledge of testing, screening controversy, risk factors, treatment benefits and limitations and natural history of disease) than usual care. At one month, the adjusted mean difference between the Web education trial arm and usual care was estimated as a β-coefficient of 2.26 (95% CI, 1.88 to 2.64; P<0.001). The difference for print compared to usual care was a β-coefficient of 2.40 (95% CI, 2.02 to 2.78; P<0.001).

At 13 months, the effect was a β-coefficient of 1.46 (95% CI, 1.07 to 1.84; P<0.001) for Web education versus usual care and a β-coefficient of 1.54 (95% CI, 1.17 to 1.91; P<0.001) for print versus usual care. There was no difference in effect between Web and print materials at one or 13 months.

Both the Web and print decision aids led to reduced decisional conflict. At 13 months, the effect was still significant but was smaller than at one month. Again, there was no difference between Web and print materials at one or 13 months.

Participants in the print arm were more likely to report high decisional satisfaction than those in usual care at one and 13 months. Participants in the Web arm also reported greater decisional satisfaction than those in the usual care arm at one month but not at 13 months. Finally, print participants reported significantly greater satisfaction than Web participants at one month but not at 13 months.

Despite all the noted differences in knowledge, decisional conflict and decisional satisfaction, there was no significant difference in the eventual screening rates between the baseline assessment and the 13-month assessment and no significant differences among the print, Web and usual care arms.

"Given the demonstrated beneficial effects of these [decision aids], work is now needed to understand how to deliver them to patients in a systematic manner," the researchers wrote. "Possible avenues include personal health records, distribution in health care provider offices, or via the websites of large health care organizations. The ongoing questions concerning the impact of [prostate cancer] screening on disease-related mortality and on men's long-term quality of life highlight the need for promoting widespread informed decision making among patients and their physicians."

An accompanying editorial stated that because screening rates weren't affected by the decisional aids, a future challenge may involve communicating with men who may have already decided about screening on the basis of limited information. "The fact that screening rates were highly stable and unaffected by the intervention may imply that patients, physicians, and clinical systems often operate in stable patterns with respect to screening," the editorial stated.



Test yourself


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MKSAP Quiz: management of tobacco use

A 59-year-old man is evaluated during a follow-up examination. He has COPD and hypertension. He has an 80-pack-year history of cigarette use, but has recently decreased his smoking to a half pack of cigarettes daily. Medications are ipratropium and amlodipine.

mksap.gif

On physical examination, temperature is 37.3 °C (99.2 °F), blood pressure is 138/92 mm Hg, pulse rate is 96/min, and respiration rate is 22/min. BMI is 29. He is barrel-chested with diffuse wheezing on lung examination. The remainder of the physical examination is normal.

Which of the following is the most appropriate management regarding this patient's tobacco use?

A: Assess his interest in smoking cessation
B: Prescribe bupropion
C: Prescribe nicotine replacement therapy
D: Refer for smoking cessation counseling

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


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Nephrology


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Analysis notes that CKD guidelines may lead to overdiagnosis, overtreatment

The current definition of chronic kidney disease (CKD) based on estimated glomerular filtration rate (eGFR) has led to one in eight people being labeled as having the condition, compared to the actual treatment rate of one person for every 3,000 to 5,000 for end-stage renal disease (ESRD), a recent analysis found.

The result is overdiagnosis and overtreatment of people unlikely to ever progress to ESRD, reviewers said in an analysis published online July 30 in BMJ.

A 2002 guideline defined CKD by eGFR based on serum creatinine or cystatin C levels and an assessment of kidney damage most commonly derived from albuminuria. The reviewers noted that, by these criteria, anyone with an eGFR below 60 mL/min/1.73 m2 for three months or longer could be diagnosed as having CKD of stage 3A or greater, even if they have no other signs of kidney disease.

The goal had been to capture patients who progressed all the way to ESRD unchecked, especially in the African-American community, the authors wrote. This definition has resulted in almost 14% of U.S. adults being labeled as having CKD. A third of the people who meet the definition of CKD also meet the definition of stage 3A. Most are older than 65, and many have an eGFR that falls within the 5th to 95th percentile for their age. About 75% have no urine markers of kidney damage, such as albuminuria.

Reviewers suggested several ways for clinicians to improve CKD management:

  • Share uncertainty about diagnostic thresholds and measurements with patients.
  • Look for potential evidence of anemia, abnormal urinalysis results or abnormalities on renal ultrasonography.
  • Be aware of the variability of results when testing eGFR and albuminuria and of the need to repeat the tests, soon after the first test and again after three months.
  • Avoid the label of CKD for people age 65 years and older with eGFR stage 3A without albuminuria.
  • Recognize that older people with stable but modestly reduced eGFR of 45 to 59 mL/min/1.73 m2 are unlikely to have a high risk unless they have persistent overt albuminuria.


Readmissions


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EMR-based risk stratification plus increased support for highest-risk patients improves readmission rates in heart failure

Risk stratification using an electronic medical record (EMR) combined with the use of evidence-based interventions for patients at highest risk helped reduce readmissions for heart failure, a new study found.

Researchers at a teaching hospital in Texas performed a prospective controlled before-and-after study of adult inpatients with heart failure and those with two concurrent control conditions, acute myocardial infarction (MI) and pneumonia. They used a risk prediction model in an EMR-based software program, which extracts real-time clinical and nonclinical data from the patients' records in the first 24 hours after heart failure admission, to stratify 30-day readmission risk each day.

Patients deemed at highest risk for readmission were given intensive evidence-based interventions using existing hospital resources. The study's main outcome measure was readmission for any reason and to any hospital within 30 days of discharge. The study results were published online July 31 by BMJ Quality & Safety.

Eight hundred thirty-four patients were discharged with a diagnosis of heart failure during the preintervention period (Dec. 1, 2008, to Nov. 30, 2009), and 913 patients were discharged with a diagnosis of heart failure during the postintervention period (Dec. 1, 2009, to Nov. 30, 2010). In the concurrent control group, 637 patients were discharged with acute MI or pneumonia in the preintervention period and 597 were discharged in the postintervention period. The mean age in both the heart failure group and the control group was 58 years.

In the heart failure group, the unadjusted rate of 30-day readmission was 26.2% before the intervention and 21.2% afterward, representing a relative reduction of 19% (P=0.01). This decline was also seen in adjusted analyses (adjusted odds ratio, 0.73; P=0.01). Unadjusted readmission rates for acute MI and pneumonia, the concurrent control group, did not change after the intervention (15.5% before vs. 16.7% after; P=0.56); adjusted analyses also showed no difference (adjusted odds ratio, 1.09). The authors calculated that the number needed to treat ratio for heart failure patients in the postintervention period was 20.

The trial was not randomized or double-blind, took place in only one safety-net hospital, and did not examine cost-effectiveness. In addition, among other limitations, data on heart failure patients in other nonintervention hospitals were not available, the authors noted. However, they concluded that their study provided "preliminary evidence" that stratifying risk and allocating resources using EMR-based tools can help reduce readmission rates in patients with heart failure.

"By concentrating care management efforts on about one-quarter of patients with [heart failure] we were able to demonstrate a 26% relative reduction in the odds of readmission and an absolute reduction of 5.0 readmissions per 100 index admissions," they wrote. Future studies, they said, should examine the cost-effectiveness of this and similar approaches to allocation of resources.



Physician Payments Sunshine Act


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National call to be held on Physician Payments Sunshine Act

Applicable industries began tracking transfers of value to physicians and teaching hospitals under the Physician Payments Sunshine Act (also known as Open Payments) on Aug. 1.

Data from August through December 2013 will be transferred to the Centers for Medicare and Medicaid Services (CMS) and will be placed on a public website in September 2014. Physicians have no reporting obligations—all reporting is conducted by the covered industries—but they have the right to review and dispute the data reported about them before the data are placed on the public website.

CMS will offer a National Provider Call on Aug. 8, 2013, from 1:30 to 3:00 p.m. that will tell clinicians what they need to know about the Open Payments program. Topics will include an update on program policy, with a focus on third-party payments, indirect payments and the physician resource toolkit. To register, visit MLN Connects Upcoming Calls online. The College recommends that all members take advantage of this opportunity.

For more information on the Physician Payments Sunshine Act, see the article in the July/August ACP Internist.


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CMS releases mobile app to help physicians track transfers of value

CMS has released a mobile app, Open Payments Mobile for Physicians, to assist physicians in keeping track of transfers of value received from applicable industries that are covered under the Physician Payments Sunshine Act.

Use of this app is completely voluntary; it is available for users' own information collection and to serve as a personal storage depository only. It does not interact with CMS systems or CMS contractors and cannot be used directly for data reporting. Please note that CMS will not validate the accuracy of data stored in the app, nor will it be responsible for protecting data stored in the app (although users will be prompted to create and use a password when they access the app). The app can be downloaded directly from app stores by searching for "Open Payments Mobile for Physicians."



From the College


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ACP launches "I.M. Proud to Be an Internist" campaign

As part of ACP's ongoing efforts to communicate the unique value of internal medicine, the College is launching an initiative to fortify the identity of internists and reinforce pride in the profession of internal medicine.

The core of this initiative is a new definition of internal medicine, crafted with input from other internal medicine organizations, that ACP, and hopefully others, will use to clarify how internists are unique and define what sets us apart.

Find out more about the campaign online, as well as how you can help highlight the unique qualities of internists and reinforce the value internal medicine brings to patients and to health care. Show your internal medicine pride with new logoed products, and share your thoughts on ACP's Twitter stream using the hashtag #IMDefined.



Cartoon caption contest


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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-20130806-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: Assess his interest in smoking cessation. This item is available to MKSAP 16 subscribers as item 27 in the General Internal Medicine section. More information is available online.

Current recommendations are that all clinicians assess tobacco use at every visit, encourage every patient to make a quit attempt, and counsel patients appropriately. Patients who exhibit medical illnesses related to smoking present an opportunity for clinicians to increase the patient's awareness of the connection between the unhealthy behavior and its negative consequences. Even if time does not allow for an in-depth counseling session, all patients should be asked about their smoking at every visit, and a brief, clear message about quitting should be provided to all patients. A recommended strategy for counseling is to follow the "five A's": Ask every patient at every visit about their smoking; Advise all smokers to quit; Assess their current interest in quitting; Assist by offering resources and/or medications, and Arrange for follow-up.

It is not clear yet whether this patient is truly interested in quitting. Thus it would be inappropriate to prescribe either smoking cessation aids or counseling until the physician has determined that the patient is indeed ready to quit.

Key Point

  • Tobacco use should be assessed at every visit, and patients who smoke should be encouraged to make a quit attempt and counseled appropriately.

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Test yourself

A 48-year-old man is evaluated during a follow-up visit for urinary frequency. He reports no hesitancy, urgency, dysuria, or change in urine color. He has not experienced fevers, chills, sweats, nausea, vomiting, diarrhea, or other gastrointestinal symptoms. He feels thirsty very often; drinking water and using lemon drops seem to help. He has a 33-pack-year history of smoking. He has hypertension, chronic kidney disease, and bipolar disorder. Medications are amlodipine, lisinopril, and lithium. He has tried other agents in place of lithium for his bipolar disorder, but none has controlled his symptoms as well as lithium. What is the most appropriate treatment intervention for this patient?

Find the answer

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