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HospitalistWeekly 11-26-08

Highlights

• Insurers support universal coverage with individual mandate

Cardiology

• Study connects predicted probability of thrombolysis to PE mortality
• Recommendations on ICD as primary prevention for post-MI patients

FDA update

• Bacteria prompts acne cream recall

From ACP Internist

• On the blog: Racial profiling, sad docs

Cartoon caption contest

• November's winning entry

Editorial note: ACP HospitalistWeekly will not be published next week due to the Thanksgiving holiday.

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Highlights

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Insurers support universal coverage with individual mandate

Two major health insurance groups announced last week that they will provide coverage for all Americans, if the government mandates that everyone purchase health insurance.

Under the proposal, the members of America's Health Insurance Plans (AHIP) and the BlueCross BlueShield Association would no longer reject applicants based on their health status or exclude pre-existing conditions from coverage. Their proposal is contingent on Congress enacting an enforceable individual coverage mandate.

Mandatory coverage, a controversial issue in the recent presidential election, was not a component of President-elect Barack Obama's health reform plan. His transition team declined to comment on the insurers' proposal, reported the Nov. 20 New York Times. In support of their proposal, the groups contend that requiring insurers to provide coverage to all applicants without forcing consumers to purchase insurance would provide an incentive for people to wait until they were sick to buy insurance, and thereby raise overall premiums. The AHIP statement also urged expansion of the Medicare and SCHIP programs.

There are several additional components to the AHIP proposal for health care reform, including:

• Establish an insurance coverage verification system, an automatic enrollment process and effective enforcement of the requirement that all individuals purchase and maintain coverage;
• Promote affordability by: providing refundable, advanceable tax credits for moderate-income individuals and working families; and promoting tax equity whether coverage is obtained through an employer or the individual market; and
• Ensure premium stability for those with existing coverage through a broadly funded reimbursement mechanism that spreads costs for the highest-risk individuals.

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Cardiology

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Study connects predicted probability of thrombolysis to PE mortality

Thrombolysis was associated with a significantly higher risk of death among hospitalized pulmonary embolism (PE) patients who are hemodynamically uncomplicated, according to a recent study.

Research published in the Archives of Internal Medicine evaluated data from a statewide Pennsylvania sample. It found that both during the hospitalization and in the 30 days following admission, almost one-third of the deaths among patients who received thrombolysis and about 15% of deaths among patients who did not receive thrombolysis occurred in a small subgroup of hemodynamically unstable patients.

The unadjusted overall 30-day mortality rate for patients who received thrombolytic therapy was 17.4% compared with 8.6% for those who did not. Risk of in-hospital and 30-day mortality appears to be elevated for patients who were unlikely candidates for this therapy, but not for patients with a relatively high predicted probability of receiving thrombolysis. Furthermore, patients who received thrombolytic therapy were less likely to have diagnoses of lung disease, heart failure, and/or cerebrovascular disease and more likely to have diagnoses of ischemic heart disease, pulmonary vascular disease, and/or syncope.

Patients who received thrombolytic therapy were more likely than those who did not to register a higher pulse rate, lower systolic blood pressure, higher respiration rate, hypothermia, hypoxemia, renal insufficiency and/or acidosis. They were also more likely to have an elevated troponin level, abnormal PCO2, higher mean or systolic pulmonary arterial pressure and/or cardiomegaly.

The American College of Chest Physicians guideline recommends against the use of thrombolytic therapy in hemodynamically uncomplicated patients with PE.

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Recommendations on ICD as primary prevention for post-MI patients

A review spells out which factors to consider when deciding whether to recommend implantable cardioverter-defibrillators (ICDs) as primary prevention in high-risk patients who have had myocardial infarction.

ICDs are an established device as secondary prevention for patients who have survived a life-threatening ventricular arrhythmia. Major trials also suggest a benefit to ICD use in high-risk patients in whom life-threatening arrhythmias haven't yet occurred, but the studies' limitations make the picture less clear, the reviewer said in the Nov. 20 New England Journal of Medicine.

When selecting primary prevention patients for ICD, physicians should start by assessing ejection fraction (EF), then consider other factors, the reviewer said. Generally, those with an EF of 25% or less after MI are candidates, while those with higher than 35% EF aren't, the reviewer said. For patients with EF between 25% and 35%, studies suggest those at the lower end see more benefit than those near the top; thus additional factors in this 25%-35% EF group can tip the balance. These additional factors include:

• Heart failure. Those with symptomatic heart failure or a history of heart failure seem more likely to benefit from an ICD, particularly in the 26%-30% group. If a patient's EF is on the borderline, a heart failure history adds support for ICD therapy.
• QRS duration. Doctors should take into account a prolonged duration of the QRS interval (120 milliseconds or more), which studies have associated with a benefit from ICDs in the 26%-35% EF group.
• Ventricular tachycardia (VT). Ambient nonsustained VT or VT induced by programmed electrical stimulation increase the indication for ICD in those with 26% to 35% EF.

Patients with none of the above factors can defer ICD implementation, especially if their EF is between 30%-35%. In addition, ICD isn't appropriate for patients with serious comorbidities and expected survival of one year or less. Some research suggests people age 75-plus years are just as likely to benefit as younger patients, but these patients should be in reasonably good shape both physically and mentally to be considered for ICD, the reviewer said.

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FDA update

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Bacteria prompts acne cream recall

Three brands of 10% benzoyl peroxide acne cream are being recalled because samples of the products contained Burkholderia cepacia, an FDA alert and manufacturer's press release said.

The affected one-ounce tubes are "DG Maximum Strength Acne Medicated Gel" (Dollar General), "Kroger Acne Gel 10% Benzoyl Peroxide Acne Medication" (Kroger) and "Equate: Medicated Acne Gel" (Wal-Mart).

The products may carry a heightened risk of infections in people with cuts, scrapes, rashes and other skin conditions, as well as in those with weakened immune systems. No adverse events have been reported.

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From ACP Internist

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On the blog: racial profiling, sad docs

On the ACP Internist blog this week genetics expert W. Gregory Feero looks at racial profiling. We also assess new research on the unhappiness of primary care providers and physician substance abuse. As usual, a new Medical News of the Obvious arrives every Monday.

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Cartoon caption contest

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November's winning entry

ACP HospitalistWeekly has compiled the results from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption. This week's contest was a squeaker, with the winning entry tied or leading with less than a handful of votes all week.

This issue's winning cartoon caption was submitted Leslie Thompson Harris, ACP Associate Member, an internal medicine PGY-1 resident at Gundersen Lutheran Medical Center, La Crosse, Wis. She will receive a copy of "Medicine in Quotations," ACP's comprehensive collection of famous sayings relating to sickness and health, disease and treatment and a portrait of medicine throughout recorded history. Readers cast 296 ballots online to choose the winning entry. Thanks to all who voted!

The winning entry:

"Next time, try a licensed acupuncturist."

The winning caption received 45.9% of the votes cast. The runners-up were:
" You'll be pleased to know the apple came through unscathed."." (42.9%)
"Please tell me you at least won the costume contest." (11.1%)

December's Grand Prize cartoon contest will pit the three top vote getters from 2008 head-to-head, with one lucky voter winning a $100 gift certificate. Voting begins in the Dec. 9 issue of ACP HospitalistWeekly.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated