In the news

Proposal to expand coverage for PET scans

Under a proposal announced in early January, Medicare would expand coverage of positron emission tomography (PET) for initial diagnostic testing in beneficiaries with cancer. Since 2005, Medicare has covered PET scans only under its Coverage with Evidence in Development (CED) program, which requires the collection of clinical information about the effect of the test on the beneficiary's cancer care.

Based on the evidence collected under the program, CMS experts determined that coverage should be provided for one PET scan to guide initial cancer treatment strategy. The scans, which use a radioactive tracer to evaluate glucose metabolism in tumors and normal tissue, can help physicians distinguish benign from cancerous lesions and better determine the extent of a tumor's growth or metastasis, a CMS press release noted. This is the first time that Medicare has expanded coverage based on evidence collected in the CED program. CED will still be required for PET scans for subsequent treatment, with some exceptions.

CMS accepted public comments on the proposed decision through Feb. 5, 2009 and will issue a final national coverage determination in April 2009.

Average heart attack has gotten less severe

The severity of myocardial infarctions has declined since the 1980s, according to a community surveillance study.

The Artherosclerosis Risk in Communities Study tracked residents of four diverse communities in North Carolina, Maryland, Minnesota and Mississippi between 1987 and 2002. Data were collected on more than 10,000 heart attacks in patients age 35 to 74 and several markers of severity were selected. The research was published online Jan. 19 by the journal Circulation.

The study found that between 1987 and 2002, the percent of myocardial infarctions with major ECG abnormalities decreased. Specifically, there was a 1.9% decrease in initial STsegment elevation and a 3.9% decrease in the proportion of patients with subsequent Q-waves, and 4.5% fewer had any major Q-wave. The maximum creatine kinase and creatine kinase-MD values also declined, as did the percent with shock. The study was motivated by researchers' speculation that recent declines in deaths from coronary heart disease were due to a decline in severity of myocardial infarctions (MIs). Based on the study's findings, the authors concluded that MI severity may be one contributing factor.

Genotype-guided warfarin therapy not cost-effective in most cases

Routine genetic testing before warfarin therapy is not costeffective for most patients, a recent analysis concluded.

The review, published in the Jan. 20 Annals of Internal Medicine, used a decision model to evaluate the cost-effectiveness of genotype-guided warfarin dosing. The base case was a 69- year-old man with newly diagnosed nonvalvular atrial fibrillation and no contraindications to warfarin. Researchers found that, at its current cost of $400 per test, genetic testing before therapy would cost $170,000 more per quality-adjusted life-year gained than standard warfarin dosing.

In 2007, the FDA added labeling to warfarin suggesting that physicians consider genetic testing before giving the drug in order to ensure more accurate dosing and decrease the risk for major bleeding in patients at high risk. The study notes that patients with variants in two genes (cytochrome P450 CYP2C9 and vitamin K epoxide reductase VKORC1) have greater variation in international normalized ratio and three times the risk for bleeding during the induction phase of anticoagulant therapy.

Besides a drop in the cost of the genetic test, rapid turnaround time in hospitals might improve the cost-effectiveness of genotype-guided dosing, the authors said. Another strategy is hybrid dosing, in which warfarin is initiated while test results are pending, with subsequent dose revision, a method currently being evaluated in a multicenter randomized trial funded by the National Institutes of Health (Clarification of Optimal Anticoagulation through Genetics).

Good hospitals are wired and already delivering better care

Wired hospitals with automated notes and records, order entry, and clinical decision support had fewer complications, less mortality and lower costs, a study concluded.

Researchers conducted a cross-sectional study of 72 general acute care hospitals located in 10 metropolitan statistical areas in Texas. They measured automation based on physician interactions with the information system to determine whether more automation reduced rates of inpatient mortality, complications, costs and length of stay. The results were published in the Jan. 26 Archives of Internal Medicine.

For 167,233 patients older than age 50 admitted between December 2005 and May 2006:

  • A 10-point increase in the automation of notes and records was associated with a 15% decrease in the adjusted odds of fatal hospitalizations (0.85 [95% CI, 0.74 to 0.97]);
  • Better order entry was associated with decreases in the adjusted odds of death for myocardial infarction (9%) and coronary artery bypass graft procedures (55%);
  • For all causes of hospitalization, higher decision support scores were associated with a 16% decrease in the adjusted odds of complications (0.84 [95% CI, 0.79 to 0.90]);
  • Hospitals with the highest third of the notes and records scores had a 1.4% adjusted rate of mortality, compared with a 1.9% adjusted rate among hospitals in the lowest third. Or, for every 1,000 patients, five fewer died at hospitals with the better notes and records scores; and
  • Higher scores on test results, order entry, and decision support lowered hospital costs by $110, $132, and $538, respectively (P< 0.05).

An accompanying editorial said that “More of such analyses should be done, and they are likely to be helpful in convincing policy experts including skeptics like those at the [Congressional Budget Office] of the benefits when these technologies are in routine use.”

In other news, health care ratings company HealthGrades found that Medicare patients treated at top-rated hospitals nationwide across the most common Medicare diagnoses and procedures are 27% less likely to die and have an average 8% lower risk of complications during their stay than those admitted to all other hospitals. That's 152,666 potentially preventable deaths and 11,772 major complications between 2005 and 2007. HealthGrades compared the top 5% of hospitals in terms of mortality and complication rates across 26 procedures and diagnoses (HealthGrades used its term “Distinguished Hospitals for Clinical Excellence”) and analyzed nearly 41 million patient records from CMS to arrive at the conclusion, posted on the company's Web site.