Annals
Established in 1927 by the American College of Physicians

FOR THE PRESS

18 May 2010 Annals of Internal Medicine Tip Sheet

Annals of Internal Medicine is published by the American College of Physicians on the first and third Tuesday of every month. These highlights are not intended to substitute for articles as sources of information. For a copy of an article, call 1-800-523-1546, ext. 2656, or 215-351-2656, or visit www.annals.org. Past highlights are accessible as well.

1. Fracture Prevention Proven Cost-effective in Men Treated for Prostate Cancer

Androgen deprivation therapy (ADT) is used to treat some men with prostate cancer. Because both advanced age and androgen deficiency are associated with low bone mineral density (BMD), men with prostate cancer who receive treatment with ADT are at a particularly increased risk for osteoporosis-related fractures. Researchers created a computer model to simulate the progression of prostate cancer and the incidence of hip fracture among men aged 70 years with locally advanced or high-risk localized prostate cancer. The men were started on a two-year course of ADT after radiation therapy. The researchers analyzed the data to assess the cost-effectiveness of measuring BMD before initiating ADT, and then following with alendronate therapy to prevent fracture. The analysis suggests that in a population of men with prostate cancer treated with ADT, screening for bone density followed by treatment of those with osteoporosis is more cost-effective than no screening and no treatment, and more cost-effective than treating all men.

2. Less Invasive CT Angiography Helps Physicians Determine Which Patients Need More Invasive Testing for Heart Disease

While invasive coronary angiography (ICA) is the reference standard for diagnosing coronary artery disease (CAD), less invasive, less expensive tests are often used to rule out CAD in patients presenting with chest symptoms. Computed tomography coronary angiography, or CTCA, has become a popular noninvasive test option. Researchers evaluated the accuracy and clinical utility of a stress test and CTCA for identifying which patients with chest symptoms should receive ICA on the basis of their pretest probability of disease. The researchers observed 517 patients referred for evaluation of chest symptoms by using stress testing or ICA. They found that CTCA worked best for patients with intermediate pretest probability of disease because the test can identify which of these patients are most likely to benefit from ICA.

3. Varying Rules for Assigning Physician Cost Profiles Leads to Inconsistent Categorization

In the medical field, a cost profile is a comparison of a physician’s various expenditures against his or her peers. Many health plan administrators use cost profiles to place physicians in a cost category (high cost, average cost, low cost, or low sample size) for various applications, such as physician “report cards” and tiering programs. Physician organizations have questioned whether the rules used to attribute costs to a physician affect the cost category to which that physician is assigned. Researchers evaluated the effect of 12 different attribution rules on physician cost profiles. Under each of the 12 different attribution rules, a cost profile was created for the physicians in the aggregated claims database and the physicians were assigned to one of the cost categories. The researchers found that compared with the most commonly used rule, 17 percent to 61 percent of physicians would be assigned to a different category if a different rule were used. This means that two different health plans in the same region may assign the same physician to a different cost category simply because they use different rules. The researchers conclude that those who assign cost categories to physicians must be transparent about the rule they use to make decisions.

4. Clinical Observation: High-dose N-Acetylcysteine Therapy with Oseltamivir Shows Potential in Treating H1N1

In animal experiments, administering high-dose N-acetylcysteine with the influenza drug oseltamivir seemed to protect against death due to influenza infection. A recent case suggests that there might be a role for N-acetylcysteine in treating H1N1 pneumonia in clinical practice. In the case, a 48-year-old woman with H1N1 pneumonia was admitted to the intensive care unit where she was treated with oral oseltamivir and intravenous antibiotics. The next day, her oseltamivir dose was doubled and she was started on a high-dose N-acetylcysteine continuous intravenous infusion. According to the physician authors, the patient improved rapidly on high-dose N-acetylcysteine therapy plus antiviral medications. Since N-acetylcysteine is a category B drug for pregnancy and is an affordable drug with a stable oral formulation, it could be advantageous for use in pregnant women and in countries with limited resources. The authors believe that future studies should examine whether high-dose N-acetylcysteine could be useful in treating influenza.