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ACP InternistWeekly



In the News for the Week of July 8, 2014




Highlights

Task Force confirms recommendation against screening for asymptomatic carotid artery stenosis

The U.S. Preventive Services Task Force reconfirmed its recommendation against screening for carotid artery stenosis in the general adult population in adults without a history of transient ischemic attack, stroke, or other neurologic signs or symptoms. More...

Practices report gradual shifts toward tying pay to quality and patient satisfaction metrics

Quality measures are a small but possibly increasing percentage of total compensation for physicians, a recent report found. More...


Test yourself

MKSAP Quiz: treatment of community-acquired pneumonia

A 72-year-old man is hospitalized for treatment of community-acquired pneumonia. Despite 4 days of treatment with intravenous fluids and antibiotics appropriate for the bacteria cultured from sputum and blood, he remains febrile with mild tachycardia. The patient subsequently develops mild hypotension and is transferred to the intensive care unit. Following blood cultures, a physical exam, and lab results, what is the most appropriate next step in management? More...


Back pain

Glucocorticoid injections may not help in lumbar spinal stenosis

Epidural injections of glucocorticoids plus lidocaine to treat spinal stenosis performed no better than injections of lidocaine alone in a new trial. More...


Substance abuse

Linking inpatient and outpatient buprenorphine treatment reduced opioid abuse

A program that started hospitalized, opioid-dependent patients on buprenorphine and linked them to outpatient care effectively reduced their opioid use, a new study found. More...


Education

ACP and MedU collaborate on High Value Care course for medical students

ACP and MedU have created an online High Value Care course for medical students based on a curriculum developed by ACP and the Alliance for Academic Internal Medicine (AAIM). More...


From ACP Internist

The July/August issue of ACP Internist is online and coming to your mailbox

The July/August issue of ACP Internist is now online and coming to your mailbox. More...


From the College

ACP on KevinMD.com: Does California ballot initiative protect patients or let in a Trojan horse?

Yul Ejnes, MD, MACP, a past chair of ACP's Board of Regents, a practicing internist in Cranston, R.I., and a member of ACP Internist's editorial board, continues his monthly column at KevinMD.com about an initiative on the November ballot in California. 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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Task Force confirms recommendation against screening for asymptomatic carotid artery stenosis

The U.S. Preventive Services Task Force reconfirmed its recommendation against screening for carotid artery stenosis in the general adult population in adults without a history of transient ischemic attack, stroke, or other neurologic signs or symptoms. The decision is a D recommendation, meaning there is strong or moderate evidence that there is no benefit, or that the harms outweigh the benefits.

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The recommendation statement and evidence review were published in the July 8 Annals of Internal Medicine.

Researchers conducted a systematic review of 56 published studies and found no evidence of a benefit for screening for carotid artery stenosis in the general population but did find a small to moderate risk for harms, such as stroke, myocardial infarction, and mortality, resulting from the interventions that may follow positive screening results.

The most feasible screening test for carotid artery stenosis (defined as 60% to 99% stenosis) is ultrasonography, the report stated. Although the test has high sensitivity and specificity, in practice ultrasonography yields many false-positive results in the general population, which has a prevalence of carotid artery stenosis of between 0.5% to 1%. The Task Force authors wrote that there are no externally validated, reliable tools that can determine who is at higher risk for carotid artery stenosis, or at higher risk for stroke when carotid artery stenosis is present.

In selected trial participants with asymptomatic carotid artery stenosis, carotid endarterectomy (CEA) performed by selected surgeons reduced the absolute incidence of all strokes or perioperative death by approximately 3.5% compared with medical management. However, these studies are now decades old, so the difference is probably smaller with current optimal medical management. The recommendation also noted that the magnitude of these benefits would be less in asymptomatic people in the general population. For the general primary care population, the magnitude of benefit is small to none. "There is no evidence that identification of asymptomatic carotid artery stenosis leads to any benefit from adding or increasing medication doses beyond current standard medical therapy for cardiovascular disease prevention," the authors wrote.

An accompanying editorial noted that although the data clearly support the Task Force's recommendation against population screening, these types of screenings are still offered to the public at health fairs and other settings. He noted that the American Academy of Neurology, as part of the ABIM Foundation's Choosing Wisely campaign, states that physicians should not recommend endarterectomy for asymptomatic carotid stenosis unless the complication rate is low (<3%). "Although this may need to be revised in the future," the editorialist wrote, "an appropriate additional recommendation could be, 'Don't perform population screening for asymptomatic carotid artery stenosis.'"


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Practices report gradual shifts toward tying pay to quality and patient satisfaction metrics

Quality measures are a small but possibly increasing percentage of total compensation for physicians, a recent report found.

According to the "MGMA Physician Compensation and Production Survey: 2014 Report Based on 2013 Data," primary care physicians who were not part of an accountable care organization or a patient-centered medical home reported that an average of 5.96% of their total compensation was based on quality measures, compared to specialists, who reported that an average of 5.70% of their total compensation was based on them. Some groups of physicians, including anesthesiologists, internists, and hospitalists, reported that a greater percentage of their total compensation was tied to quality metrics. In 2012, primary care physicians and specialists reported that an average of 6.58% and 4.04%, respectively, of their total compensation was based on quality measures, but those data included primary care physicians who were part of an accountable care organization or patient-centered medical home.

Physician compensation is likely to be increasingly tied to these metrics as reimbursement is aligned more closely with quality and cost measures, the MGMA predicted in a press release last week.

Practices also said that patient satisfaction had a small role in physician compensation. For primary care physicians, the percentage of compensation tied to patient satisfaction increased slightly, while specialists reported that an average of 2.31% of their compensation was tied to patient satisfaction compared with 1.61% in 2012.

Both primary care physicians and specialists reported that compensation increased slightly in 2013, with medians of $232,989 and $402,233, respectively, versus $220,942 and $396,233 in 2012.



Test yourself


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MKSAP Quiz: treatment of community-acquired pneumonia

A 72-year-old man is hospitalized for treatment of community-acquired pneumonia. Despite 4 days of treatment with intravenous fluids and antibiotics appropriate for the bacteria cultured from sputum and blood, he remains febrile with mild tachycardia. The patient subsequently develops mild hypotension and is transferred to the intensive care unit. Results of two subsequent blood cultures are negative for bacteria. Medical history is significant for hypertension treated with amlodipine and recurrent osteoarthritis treated with intra-articular injections of triamcinolone several times a year; his last injection occurred 3 months ago.

mksap.gif

Physical examination shows a pale and anxious man. Temperature is 38.0 °C (100.4 °F), blood pressure is 110/68 mm Hg supine and 102/64 mm Hg sitting, pulse rate is 102/min supine and 124/min sitting, and respiration rate is 21/min; BMI is 33. Lung examination reveals crackles and egophony in the right lower lobe area. Other physical examination findings are unremarkable.

Laboratory studies:

Albumin 2.7 g/dL (27 g/L)
Electrolytes
Sodium 139 mEq/L (139 mmol/L)
Potassium 3.6 mEq/L (3.6 mmol/L)
Chloride 109 mEq/L (109 mmol/L)
Bicarbonate 23 mEq/L (23 mmol/L)
Cortisol 9.5 µg/dL (262 nmol/L)
Thyroid-stimulating hormone Normal

Which of the following is the most appropriate next step in management?

A: Adrenocorticotropic hormone stimulation test
B: Hydrocortisone
C: Pseudomonal antibiotic coverage
D: Vasopressor support

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


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Back pain


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Glucocorticoid injections may not help in lumbar spinal stenosis

Epidural injections of glucocorticoids plus lidocaine to treat spinal stenosis performed no better than injections of lidocaine alone in a new trial.

Researchers conducted a randomized, double-blind, multisite trial to gain more data on the effectiveness of epidural glucocorticoid injections for treating symptoms of lumbar spinal stenosis. Patients who were at least 50 years old and had lumbar central spinal stenosis and moderate to severe leg pain and disability were assigned to receive either epidural injections of glucocorticoids plus lidocaine or epidural injections of lidocaine alone. The primary outcomes, which were scores on the Roland-Morris Disability Questionnaire (RMDQ) and patient self-rating of leg pain intensity, were measured 6 weeks after randomization. RMDQ scores are measured on a scale of 1 to 24, with higher scores indicating more disability, and leg pain intensity was measured on a scale of 0 (no pain) to 10 (worst pain imaginable). The study results were published in the July 4 New England Journal of Medicine.

Four hundred patients at 16 centers in the U.S. were involved in the study. Two hundred patients were randomly assigned to the glucocorticoid-lidocaine group, and 200 patients were randomly assigned to the lidocaine-alone group. The mean age was approximately 68 years in both groups, and most patients (55%) were women. Small between-group differences in RMDQ score and leg pain intensity were seen at 3 weeks (average treatment effect, −1.8 points and −0.6 point, respectively; P<0.001 and P=0.02). At 6 weeks, both groups showed improvement in the RMDQ score from baseline, but no significant between-group difference was seen (−4.2 points in the glucocorticoid-lidocaine group and −3.1 points in the lidocaine-alone group; adjusted difference in average treatment effect, −1.0 point; P=0.07). The same was true for intensity of leg pain at 6 weeks (adjusted difference in average treatment effect, −0.2 point; P=0.48).

A statistically significant difference in RMDQ score was seen at 6 weeks after post hoc adjustment for baseline duration of pain, but it was small (average treatment effect, −1.2 points; P=0.03), and no significant difference in leg pain intensity was noted (average treatment effect, −0.3 point; P=0.32). Overall, 21.5% of patients in the glucocorticoid-lidocaine group and 15.5% in the lidocaine-alone group experienced 1 or more adverse event (P=0.08), and 67% versus 54%, respectively, said they were very or somewhat satisfied with their treatment (P=0.01).

The authors noted that some patients received transforaminal injections while others received interlaminar injections and that their study was not designed to compare the effectiveness of the 2 methods. They also noted that their study did not include a sham injection group. However, they concluded that based on their results, epidural injections of glucocorticoids and lidocaine offer no benefit compared with lidocaine alone for relieving symptoms of lumbar spinal stenosis.

The author of an accompanying editorial said that the study's results call the benefits of epidural glucocorticoid injections into question and suggested that insurance companies may want to reconsider requiring a trial of such injections before approving surgery. "On the basis of the largely negative results of the present trial and the lack of other rigorous data to support the use of glucocorticoid injections in these patients, I will remain cautious in prescribing epidural glucocorticoid injections for patients with lumbar spinal stenosis," the editorialist wrote. "Patients should be informed that the current best available data have not provided support for a clinically significant long-term benefit overall and that complications are possible."



Substance abuse


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Linking inpatient and outpatient buprenorphine treatment reduced opioid abuse

A program that started hospitalized, opioid-dependent patients on buprenorphine and linked them to outpatient care effectively reduced their opioid use, a new study found.

The trial randomly assigned 139 opioid-dependent patients who were hospitalized between Aug. 1, 2009, and Oct. 31, 2012, to either 5-day buprenorphine detoxification with treatment referral information at discharge or an alternative intervention. The intervention consisted of buprenorphine induction, inpatient dose stabilization, and postdischarge transition to maintenance buprenorphine opioid agonist treatment (OAT) provided by the hospital's primary care clinic. Results were published online by JAMA Internal Medicine June 30.

Patients in the intervention group were significantly more likely to enter maintenance OAT than those in the detox group (72.2% vs. 11.9%; P<0.001). At 6 months, which was the end of the study's follow-up, 12 (16.7%) of the intervention group and only 2 (3.0%) of the detox patients were receiving buprenorphine OAT (P=0.007). At the same time, the researchers queried patients about their illicit opioid use and found that the intervention group reported much less use in the prior 30 days (incidence rate ratio, 0.60; P<0.01). Available urine drug tests were used to confirm that the participants' self-reports were not dramatically underreporting use.

The intervention was an effective means for getting hospitalized patients who were not seeking addiction treatment connected with a program and using fewer opioids, the researchers concluded. However, the dropoff in OAT participation during the 6-month follow-up is a problem, they acknowledged. The same treatment program has a retention rate of 51% at 12 months for patients who initiate outpatient therapy, although those patients are likely to be more motivated and less medically ill. Another limitation of the study is its generalizability: Hospitals without affiliated outpatient programs might have more difficulty linking patients to postdischarge treatment.

If hospitals wanted to implement such a program, they would need to identify drug users systematically, develop an active referral network of buprenorphine prescribers, and have a dedicated inpatient substance use consulting team to initiate and bridge treatment, the study authors said. According to an accompanying editorial, the study is "groundbreaking," but one of the major obstacles to widespread adoption of the model is a shortage of outpatient physicians and inpatient clinical staff (physicians or nonphysicians who could advise them) trained in buprenorphine treatment.

Some other recent publications assessed the use, and probable overuse, of opioids in the U.S. A survey of active military (more than 2,000 recently deployed members of an infantry brigade) found that 44% reported chronic pain and 15.1% reported opioid use in the past month. Almost half of those who had used opioids had no or mild pain in the past month, which should be cause for concern about overuse, concluded the authors of the research letter, also published by JAMA Internal Medicine on June 30.

Rates of opioid prescribing vary widely from state to state, according to a new report in the CDC's July 1 Morbidity and Mortality Weekly Report. Overall, in 2012, prescribers wrote 82.5 opioid prescriptions per 100 persons, but rates varied 2.7-fold and were highest in the South. Prescriptions for long-acting/extended-release and high-dose opioids, which may lead to more abuse and overdoses, were highest in the Northeast. The results indicate the need to identify problematic prescribing practices, the authors concluded. Another report in the same issue described how the state of Florida has successfully accomplished this and reduced deaths from prescription opioid use.



Education


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ACP and MedU collaborate on High Value Care course for medical students

ACP and MedU have created an online High Value Care course for medical students based on a curriculum developed by ACP and the Alliance for Academic Internal Medicine (AAIM).

The online course is intended to help medical students evaluate the benefits, harms, and costs of tests and treatment options so they can make high-value care a reality in clinical practice. The course has 6 modules that include short interactive virtual patient cases, brief instructional videos, embedded links, and key teaching points. The course is available to any school or student with a subscription to MedU.

Funding to create the High Value Care course was provided by the Josiah Macy Jr. Foundation, the ABIM Foundation, and AAIM.

ACP's High Value Care initiative is designed to help doctors and patients understand the benefits, harms, and costs of tests and treatment options for common clinical issues so they can pursue care together that improves health, avoids harms, and eliminates wasteful practices.

MedU is the leading provider of virtual patient cases for undergraduate medical education with over 90% adoption by North American medical schools and 1 million cases completed annually.



From ACP Internist


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The July/August issue of ACP Internist is online and coming to your mailbox

The July/August issue of ACP Internist is now online, with top stories including the following.

DME requests pose practice problems. Documentation requirements for some types of durable medical equipment (DME) are increasing, but DME requests can also be time-consuming in other ways for physician practices.

acpi-20140708-internist.jpg

Seeking common ground on CKD screening. ACP's 2013 guideline on screening, monitoring, and treatment of stage 1 to 3 chronic kidney disease (CKD) raised an immediate response from leaders of the American Society of Nephrology. Learn where the 2 organizations agree and disagree about screening for CKD.

Changes coming for colon cancer screening.Colonoscopies are an obvious target in the current push to decrease health care costs, given their expense and utilization, said experts at Digestive Disease Week in Chicago in May.

These and other stories, plus the latest Test Yourself with the MKSAP Quiz, are online.



From the College


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ACP on KevinMD.com: Does California ballot initiative protect patients or let in a Trojan horse?

Yul Ejnes, MD, MACP, a past chair of ACP's Board of Regents, a practicing internist in Cranston, R.I., and a member of ACP Internist's editorial board, continues his monthly column at KevinMD.com. In this post, Dr. Ejnes looks at an initiative on the November ballot in California that will raise the cap on noneconomic damages in medical malpractice cases.



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-20140708-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 B: Hydrocortisone. This item is available to MKSAP 16 subscribers as item 55 in the Endocrinology and Metabolism section. More information is available online.

This patient should be treated with stress doses of hydrocortisone as the next step in management. His pneumonia was treated appropriately with intravenous fluids and antibiotics. However, despite optimal therapy, he continues to do poorly. Although his persistent illness could indicate progression into sepsis and septic shock, it is more likely that his poor response to therapy is the result of adrenal insufficiency. The repeated injections of triamcinolone most likely have suppressed his endogenous pituitary-adrenal axis and put him at increased risk for adrenal insufficiency. The timing of the symptoms is crucial in that they occurred 3 months after the last triamcinolone injection. Although the measured serum cortisol level is within the normal range, it is inappropriately low (even for a serum albumin level of 2.7 g/dL [27 g/L]) for the degree of stress (including hypotension) that he is experiencing. If the plasma adrenocorticotropic hormone (ACTH) level had been measured, it would have been inappropriately low or low-normal as a result of chronic suppression by previous glucocorticoid administration. This subnormal response to hypotension and stress is commonly observed in patients with central adrenal insufficiency.

The most appropriate management, therefore, is to treat this patient with stress doses of hydrocortisone. Glucocorticoid deficiency is associated with increased morbidity and mortality in critically ill patients. When the diagnosis is highly suspected, especially in the proper clinical setting (including previous exposure to glucocorticoids), treatment should be instituted immediately, even if the diagnosis cannot be firmly established in a timely manner.

In a stable patient, an ACTH stimulation test would be an appropriate study to assess for adrenal suppression caused by exogenous glucocorticoids. However, in a patient with likely adrenal insufficiency and vasomotor instability, immediate treatment is indicated before further study.

Although the patient is at risk for a hospital-acquired infection, possibly with a pseudomonal infection, even adequate antibiotic treatment may not be successful without treating his possible adrenal insufficiency.

Continued therapy with intravenous fluids and antibiotics is appropriate, although adding vasopressors without addressing his potential underlying adrenal suppression is not adequate therapy.

Key Point

  • In a critically ill patient at high risk for adrenal insufficiency, the most appropriate management is treatment with stress doses of hydrocortisone.

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