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

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ACP InternistWeekly



In the News for the Week of April 1, 2014




Highlights

PCMH model may make its mark on high-risk patients

A patient-centered medical home (PCMH) pilot in Pennsylvania was found to significantly reduce costs for high-risk patients, according to a report finding very different results from an analysis published a month ago on the same pilot project. More...

New study examines incidence, potential reasons for primary medication nonadherence in primary care

Primary medication nonadherence is common in primary care and may be improved by lower costs to patients and increased follow-up, according to a new study. More...


Test yourself

MKSAP Quiz: 3-month history of left knee pain

A 76-year-old woman is evaluated for a 3-month history of left knee pain of moderate intensity that worsens with ambulation. She reports minimal pain at rest and no nocturnal pain. There are no clicking or locking symptoms. She has tried naproxen and ibuprofen but developed dyspepsia; acetaminophen provides mild to moderate relief. The patient has hypertension, hypercholesterolemia, and chronic stable angina. Medications are lisinopril, metoprolol, simvastatin, low-dose aspirin, and nitroglycerin as needed. Following a physical exam, lab results and radiograph, what is the next best step in management? More...


Cardiology

New afib guideline covers novel anticoagulants, ablation

A new guideline for managing nonvalvular atrial fibrillation recommends using a more comprehensive risk calculator, diminishing aspirin's role, adding 3 new anticoagulants to treatment options, and increasing use of radiofrequency ablation. More...


Infectious disease

CDC reports new data on hospital-acquired infections

The CDC released 2 different reports on hospital-acquired infection (HAI) rates in the U.S. last week. More...


Drug safety

Anxiolytic, hypnotic drugs may be associated with increased long-term mortality

Anxiolytic and hypnotic drugs may be associated with increased long-term mortality, according to a new study. More...


Internal Medicine 2014

It's not too late to submit a Job Seeker's Profile to the ACP Job Placement Center

Looking for a job? ACP's Job Placement Center offers career opportunities during Internal Medicine 2014, to be held April 10-12 in Orlando, Fla. More...


From ACP Internist

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

Stories are online for the April issue of ACP Internist, including new hypertension guidelines, maintaining men's health in middle age, and referrals to rehabilitation. More...


From the College

There's still time to participate in ACP and MGMA's online cost survey

ACP and Medical Group Management Association (MGMA) are working together to provide physicians an opportunity to participate in an exciting, new, and much shorter MGMA 2014 Cost Survey. More...


Cartoon caption contest

No cartoon caption contest this week

There will be no cartoon caption contest this week. The contest will resume with the regular editions of ACP InternistWeekly published after Internal Medicine 2014. More...

Editor's note: ACP InternistWeekly readers will receive daily updates from Internal Medicine 2014 in Orlando on April 10-12. There will be no issue of ACP InternistWeekly on April 8 or April 15.


Physician editor: Philip Masters, MD, FACP



Highlights


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PCMH model may make its mark on high-risk patients

A patient-centered medical home (PCMH) pilot in Pennsylvania was found to significantly reduce costs for high-risk patients, according to a report finding very different results from an analysis published a month ago on the same pilot project.

Previously, a study in the Journal of the American Medical Association reported that implementation of a medical home practice model improved quality only minimally and did not reduce health care costs or utilization in 32 practices in the greater Philadelphia area.

The new paper, published online March 24 in the American Journal of Managed Care, instead said that 17 practices within the pilot project had significantly reduced costs and utilization for the highest-risk patients, particularly with respect to inpatient care.

Total per-member per-month costs decreased significantly more for the PCMH group than for controls in the high-risk group, with the PCMH group seeing an adjusted total savings of $107 in the first year and $75 in the second, driven by lower inpatient costs, the report said. The PCMH group experienced a significantly greater reduction in inpatient admissions compared to the control group, 61 hospitalizations per thousand in the first year, 48 in the second, and 94 in the third.

"The findings of this study add new texture to the existing PCMH literature," the authors wrote. For patients with highest risk scores in the pool of matched patients and practices, PCMH model adoption was shown to lead to a significant relative reduction in total costs in years 1 and 2 and significantly lower numbers of inpatient admissions in all 3 years.

"This suggests that the average patient may not be the relevant unit of observation for evaluating the impact of PCMH adoption," the authors wrote. "Rather, high risk patients with multiple comorbidities are the most logical targets for interventions aimed at supporting self-management, conveying test results in a timely and clear fashion, and coordinating follow-up and specialist care. Researchers may miss cost and utilization improvements if they confine their analyses to the typical patient, since health care costs are primarily driven by relatively rare events concentrated in few individuals. For example, during the baseline year, all cases and controls had 73 and 78 admissions per 1,000 patients, respectively; but among the high-risk pool, these numbers increased to 566 and 540."


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New study examines incidence, potential reasons for primary medication nonadherence in primary care

Primary medication nonadherence is common in primary care and may be improved by lower costs to patients and increased follow-up, according to a new study.

annals.jpg

Researchers in Canada performed a prospective study of primary care patients to determine the incidence of primary medication nonadherence as well as the drug, patient, and physician characteristics associated with it. Patients' incident prescriptions from 2006 and 2009 were obtained from primary care electronic health records and were linked to drug insurer data on drugs dispensed from community pharmacies. The researchers defined primary nonadherence as failure to fill an incident prescription within 9 months and used multivariate alternating logistic regression to estimate predictive factors associated with nonadherence. Results appeared in the April 1 Annals of Internal Medicine.

Overall, 15,961 patients treated by 131 physicians were included in the study. The study population's mean age was 61.55 years, and 62.3% were women. Of the 37,506 incident prescriptions written for these patients, 31.3% were not filled. Prescriptions for higher-cost drugs, skin agents, gastrointestinal drugs, and autonomic drugs were the least likely to be filled, while anti-infective drugs had the lowest incidence of nonadherence by pharmacologic class. Lower odds of nonadherence were associated with older age (odds ratio per 10 years, 0.89; 95% CI, 0.85 to 0.92), eliminated copayments in low-income groups (odds ratio, 0.37; 95% CI, 0.32 to 0.41), and a larger proportion of physician visits with the prescribing physician (odds ratio per 0.5 increase, 0.77; 95% CI, 0.70 to 0.85).

The authors noted that they did not assess the need for the prescribed therapies (e.g., whether they were prescribed to be filled "as needed") or patients' attitudes and beliefs about medication. However, they concluded that primary nonadherence is common in primary care and may be addressed through lower prescription costs and more patient contact with the prescribing physician. "Future research should estimate the contribution of medication attitudes and beliefs to the likelihood of primary nonadherence as well as the effect of nonadherence on subsequent illness, death, and health care use," they wrote. "If primary nonadherence is an important contributor to avoidable illness, then policy interventions to minimize risk for primary nonadherence for the most vulnerable groups … should be evaluated."



Test yourself


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MKSAP Quiz: 3-month history of left knee pain

A 76-year-old woman is evaluated for a 3-month history of left knee pain of moderate intensity that worsens with ambulation. She reports minimal pain at rest and no nocturnal pain. There are no clicking or locking symptoms. She has tried naproxen and ibuprofen but developed dyspepsia; acetaminophen provides mild to moderate relief. The patient has hypertension, hypercholesterolemia, and chronic stable angina. Medications are lisinopril, metoprolol, simvastatin, low-dose aspirin, and nitroglycerin as needed.

mksap.gif

On physical examination, vital signs are normal. BMI is 32. Range of motion of the left knee elicits crepitus. There is a small effusion without redness or warmth and tenderness to palpation along the medial joint line. Testing for meniscal or ligamentous injury is negative.

Laboratory studies, including complete blood count and erythrocyte sedimentation rate, are normal.

Radiographs of the knee reveal medial tibiofemoral compartment joint-space narrowing and sclerosis; small medial osteophytes are present.

Which of the following is the next best step in management?

A: Add celecoxib
B: Add glucosamine sulfate
C: MRI of the knee
D: Weight loss and exercise

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


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Cardiology


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New afib guideline covers novel anticoagulants, ablation

A new guideline for managing nonvalvular atrial fibrillation recommends using a more comprehensive risk calculator, diminishing aspirin's role, adding 3 new anticoagulants to treatment options, and increasing use of radiofrequency ablation.

The 2014 Guideline for the Management of Patients with Atrial Fibrillation was released last week by the American Heart Association, American College of Cardiology, and the Heart Rhythm Society, in collaboration with the Society of Thoracic Surgery.

The first recommendation is to use a more comprehensive thromboembolic risk calculator, the CHA2DS2-VASc calculator, to estimate a patient's risk of having a stroke. Compared to the CHADS2 score, the CHA2DS2-VASc score for nonvalvular atrial fibrillation adds 3 additional risk variables (female sex, 65 to 74 years of age, and vascular disease) and increases the maximum point score from 6 to 9.

The second recommendation suggests diminishing the role of aspirin in patients with atrial fibrillation who have a low stroke risk, due to weak data showing that it decreases stroke risk. No studies, with the exception of the Stroke Prevention in Atrial Fibrillation-1, showed benefit for aspirin alone in preventing stroke among patients with atrial fibrillation, the experts found.

The third recommendation suggested adding 3 new anticoagulants to the treatment options for nonvalvular atrial fibrillation: dabigatran (based on the Randomized Evaluation of Long-Term Anticoagulation Therapy [RELY]), rivaroxaban (based on the Rivaroxaban Versus Warfarin in Nonvalvular Atrial Fibrillation trial [ROCKET AF]) and apixaban (based on the Apixaban Versus Warfarin in Patients with Atrial Fibrillation [ARISTOTLE] trial).

"All 3 new oral anticoagulants represent important advances over warfarin because they have more predictable pharmacological profiles, fewer drug-drug interactions, an absence of major dietary effects, and less risk of intracranial bleeding than warfarin," the authors wrote. "They have rapid onset and offset of action such that bridging with parenteral anticoagulant therapy is not needed during initiation, and bridging may not be needed in patients on chronic therapy requiring brief interruption of anticoagulation for invasive procedures. However, strict compliance with these new oral anticoagulants is critical."

The fourth recommendation favored increasing the role of radiofrequency ablation in treating atrial fibrillation, given increased recognition that it can be used effectively.



Infectious disease


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CDC reports new data on hospital-acquired infections

The CDC released 2 different reports on hospital-acquired infection (HAI) rates in the U.S. last week.

First, data from the National Healthcare Safety Network (which includes more than 12,500 hospitals and health care facilities) was used to compare hospital infection rates from 2008 to 2012. The resulting HAI Progress Report showed significant reductions in several kinds of infections nationally in that time period, including a 44% decrease in central line-associated bloodstream infections (CLABSIs) and a 20% decrease in the measured surgical-site infections. These improvements approach 5-year goals set by the agency in 2009, the report noted.

However, decreases in methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile were minimal between 2011 and 2012 (4% and 2%, respectively). Catheter-associated urinary tract infections actually increased 3% between 2009 and 2012. Additional preventive efforts are needed for these types of infections, the report concluded. State-specific rates of HAIs were also measured and, although there were significant variations, no states performed above the national average on all 4 measured infection types. The full report, including individual state statistics, was published online by the CDC.

To determine the prevalence of hospital-acquired infections other than those 4 types reported to the Safety Network, CDC researchers also conducted a 1-day survey in 2011 of the medical records of more than 11,000 patients from 183 hospitals across the country. Results from this survey were reported in the March 27 New England Journal of Medicine.

Four percent of the surveyed patients had at least 1 hospital-acquired infection (95% CI, 3.7 to 4.4). The most common types were pneumonia (21.8%), surgical-site infections (21.8%), and gastrointestinal infections (17.1%). Clostridium difficile caused more than two-thirds of the gastrointestinal infections and was the most commonly reported pathogen overall (responsible for 12.1% of the infections), although researchers noted that their definition of C. difficile infection was very sensitive.

Although device-associated infections (such as CLABSI) have gained much attention in recent years, they accounted for only 25.6% of the studied infections, the researchers noted. The focus of prevention efforts should be expanded to include HAIs that are not associated with devices or procedures, they recommended. Overall, the survey found lower rates of HAIs than older estimates, but these measurements are difficult to compare, the authors said. They concluded that about 1 in 25 U.S. hospital patients develops an HAI and that there were 648,000 patients with 721,800 HAIs in U.S. hospitals in 2011.



Drug safety


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Anxiolytic, hypnotic drugs may be associated with increased long-term mortality

Anxiolytic and hypnotic drugs may be associated with increased long-term mortality, according to a new study.

Researchers in the United Kingdom performed a retrospective cohort study using data from 273 primary care practices to examine whether anxiolytic and hypnotic drugs were related to increased risk for premature death. Study drugs were divided into 3 classes: benzodiazepines, "Z" drugs (zaleplon, zolpidem, and zopiclone), and any other anxiolytic or hypnotic drugs. (Zopiclone is not commercially available in the United States.) All included patients were required to be at least 16 years of age and to have received at least 2 prescriptions of a study drug, one of them a first-ever prescription, between January 1998 and December 2001. These patients were matched by age, sex, and practice with controls who did not receive any of the study drugs during this period. The study's main outcome measure was all-cause mortality as determined from primary care practice records. Results were published online March 19 by BMJ.

The study included data from 34,727 patients who received the study drugs and 69,418 matched controls who did not. Overall, 76.3% of patients in the study-drug group received a prescription for a benzodiazepine, 38.8% received a prescription for a "Z" drug, and 13.4% received a prescription for 1 or more other study drugs. Diazepam, temazepam, and zopiclone were the individual drugs most commonly prescribed. After a mean follow-up of 7.6 years, the researchers found that patients who were prescribed the study drugs had a significantly higher prevalence of physical and psychiatric comorbid conditions, as well as a higher prevalence of prescriptions for other drugs.

Patients who used any of the study drugs during the first year after recruitment into the study had an age-adjusted hazard ratio of 3.46 (95% CI, 3.34 to 3.59) for mortality over the follow-up period; this hazard ratio was 3.32 (95% CI, 3.19 to 3.45) after adjustment for additional potential confounders. All 3 classes of study drugs showed a dose-response relationship. The researchers excluded deaths in the first year of the study and calculated that approximately 4 excess deaths per 100 people were related to use of the study drugs over the follow-up period.

The authors concluded that their findings support previous evidence pointing to an association between anxiolytic and hypnotic drugs and mortality but noted that their results should be interpreted with care because of the potential effect of important limitations. "While we have largely excluded immortal time bias and selection bias, we are unable to exclude the possibility that the results were due to confounding by indication or to residual confounding by unmeasured or incompletely measured factors, such as socioeconomic status," the authors wrote. "This applies especially to deaths in the first year of observation."



Internal Medicine 2014


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It's not too late to submit a Job Seeker's Profile to the ACP Job Placement Center

Looking for a job? ACP's Job Placement Center offers career opportunities during Internal Medicine 2014, to be held April 10-12 in Orlando, Fla. Submit a Job Seeker's Profile (mini-CV) to be included in 1 of 2 booklets based on your criteria. Your profile is guaranteed to be distributed to participating employers who submit a job posting to the center. You do not have to attend the meeting to submit a profile.

All physicians who submit a Job Seeker's Profile (limit, 1 mini-CV per physician) will be eligible for a drawing for a $100 Amazon gift card on April 12. Winners will be contacted by e-mail.

The Job Placement Center, located in the Orange County Convention Center, Exhibit Hall B2, Booth #1075, provides physicians with tools to assist in job searches, as well as the opportunity to meet with potential employers.

Submit your profile online today.



From ACP Internist


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

Stories are online for the April issue of ACP Internist:

acpi-20140401-internist.jpg

For hypertension, how low to go? Updated blood pressure guidelines may create more questions than closure, internists have found as they try to determine how aggressively to treat hypertension and what goals to set for patient subpopulations such as diabetics. Experts react to the "paradigm shift" in lowering hypertension.

Maintaining men's health in middle age. Adrenopause, somatopause, andropause … manopause? They all give internists pause when considering men's health at middle age. As men try to maintain optimum health, doctors need to define what exactly that is.

Refine your referrals to physical rehab with thought, timeliness. Internists can vastly improve outcomes for patients by referring patients to physical rehabilitation earlier, more often, and for more conditions than they might think.

More stories and the latest MKSAP Quiz are now online.



From the College


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There's still time to participate in ACP and MGMA's online cost survey

ACP and Medical Group Management Association (MGMA) are working together to provide physicians an opportunity to participate in an exciting, new, and much shorter MGMA 2014 Cost Survey.

The survey gathers financial and other data that can help with managing costs, comparing physician and staff compensation, optimizing clinician and office staffing, and managing practice finances. Participants in the survey will receive a free report comparing their own practice to benchmarks of their peers.

Your participation in this influential survey will make a difference to your ACP peers and the industry. Historically, internal medicine and small practices have been under-represented, and your participation can help to ensure that reliable benchmarks are available. The survey deadline is April 18. To participate, go online. Registration and participation are free and confidential.

If you have questions, please contact MGMA's Data Solutions toll-free at 877-275-6462, ext. 1895, or by e-mail.



Cartoon caption contest


.
No cartoon caption contest this week

There will be no cartoon caption contest this week. The contest will resume with the regular editions of ACP InternistWeekly published after Internal Medicine 2014.


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MKSAP Answer and Critique



The correct answer is D: Weight loss and exercise. This item is available to MKSAP 16 subscribers as item 8 in the Rheumatology section. More information is available online.

Weight loss and exercise are indicated for this patient with knee osteoarthritis. Her knee pain, which is worse with weight bearing, is suggestive of tibiofemoral knee osteoarthritis, a diagnosis supported by the presence of medial joint line tenderness and radiographic findings of medial tibiofemoral compartment joint-space narrowing. The strongest risk factors for osteoarthritis are advancing age, obesity, female gender, joint injury (caused by occupation, repetitive use, or actual trauma), and genetic factors. Obesity, in particular, is the most important modifiable risk factor for knee osteoarthritis. Several trials have demonstrated that weight loss and/or exercise programs can offer relief of pain and improved function comparable to the benefits of NSAID use. In long-term studies, sustained weight loss of approximately 6.8 kg (15 lb) has resulted in symptomatic relief.

Celecoxib carries an increased myocardial risk and is therefore not appropriate for this patient who has coronary artery disease. Although celecoxib has a lower risk of gastrointestinal ulcers than other NSAIDs, it can still cause dyspepsia, which occurred in this patient after taking naproxen and ibuprofen.

There have been several contradictory studies regarding glucosamine sulfate in the management of osteoarthritis. After several favorable smaller studies, a trial sponsored by the National Institutes of Health showed no effectiveness in reducing pain. A recently conducted meta-analysis also found negative results for the use of glucosamine sulfate.

MRI of the knee would be indicated to evaluate for meniscal or other ligamentous injuries, none of which is suggested by this patient's history (the knee locking or giving way) or examination findings (negative examination for tendinous or ligamentous injury).

Key Point

  • Obesity is the most important modifiable risk factor for knee osteoarthritis, and weight loss and exercise are recommended to reduce pain and improve function.

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