Annals
Established in 1927 by the American College of Physicians

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20 September 2011 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 215-351-2653 or e-mail Angela Collom at acollom@acponline.org

1. ACP on Health Care Cost Crisis: Cost-Conscious Care Training Crucial for Residents

Residents must prove competent in six general areas of medical practice to complete their training based on criteria established by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS). Steven E. Weinberger, MD, Executive Vice President and CEO of the American College of Physicians proposes a seventh ACGME/ABMS general competency, "Cost-Conscious Care and Stewardship of Resources," so that residents "understand the need for stewardship of resources and practice cost-conscious care, including avoiding the overuse and misuse of diagnostic tests and therapies that do not benefit patient care but add to health care costs." The costs of medical care are unsustainable. Dr. Weinberger notes that government efforts to control health care costs do not actually control the cost of care; they control health care payments. The challenge for physicians is to seize opportunities to simultaneously control costs and improve care. Dr. Weinberger writes that residents must recognize and understand the issues surrounding escalating costs and the need for cost-containment. "In short, they must become part of the solution to control health care costs, not only today but for the rest of their professional lives."

2. BPA Link to Diabetes Inconclusive

Bisphenol A (BPA) is a chemical found in hard-plastic containers including water bottles, baby bottles, and the coating of food cans. In recent years, evidence has emerged suggesting that BPA exposure may contribute to chronic disease. Previous animal studies have suggested that BPA is an endocrine disruptor that may contribute or exacerbate the development of type 2 diabetes. Researchers in China tested urinary concentrations of BPA and blood glucose levels in 3,423 residents 40 and older to examine the association between BPA exposure and self-reported type 2 diabetes. Based on results, the researchers could not confirm a previously reported association between BPA and diabetes. Additional studies are needed to draw a more definitive conclusion about the safety of BPA.

3. Local Incidence Data May Improve Diagnosis of Strep Throat, Common Infectious Diseases

About 600 million cases of group A streptococcal pharyngitis, or strep throat, occur annually worldwide. Despite its prevalence, strep throat can be difficult to diagnose. Current guidelines advocate classifying risk in adults through use of the Centor score (0 to 4). Patients are assigned 1 point each for presence of exudates, history of fever, presence of swollen anterior cervical lymph nodes, and absence of cough. But even if guidelines are followed, the accuracy of the rapid strep test is limited. Researchers studied records of 82,062 patients who visited a retail pharmacy clinic for pharyngitis to see if using local incidence data (biosurveillance) to modify the Centor score could improve diagnostic accuracy in patients aged 15 and older. The researchers calculated the recent local proportion positive (RLPP) based on the number of positive strep cases diagnosed in the area during the previous 14 days. This information was used to modify Centor scores. If the RLPP was greater than 0.30, patients with a Centor score of 1 would be treated as a 2, which would translate to 62,527 previously missed cases annually, while misclassifying 18,446 cases. If the RLPP was less than 0.20, patients with a Centor score of 3 would be treated as a 2. This would spare unnecessary antibiotics for 166,616 patients, while missing 18,812 cases.

4. USPSTF Drafts Updated Recommendation on ECG Screening in Asymptomatic Adults

Coronary heart disease (CHD) is the leading cause of death in adults, yet many do not experience symptoms before a major CHD event. Traditional risk factors such as age, sex, blood pressure, cholesterol levels, cigarette smoking, and diabetes, can help predict future CHD events but do not explain all excess risk. Some argue that adding resting or exercise electrocardiography (ECG) to screening examinations could improve the identification of individuals at high risk for heart disease. Yet, in 2004, the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence to support adding resting or exercise ECG to screening assessment and recommended against screening ECG in adults at low risk for CHD. In preparation for an update to the Task Force’s 2004 recommendation, this review considers randomized, controlled trials and prospective cohort studies published between 2002 and 2011. While some abnormalities on ECG are risk factors for CHD events, the authors did not identify any studies that evaluate how ECG screening affects clinical outcomes compared with no screening. The most recent evidence review reaffirms the original recommendation. The author of an accompanying editorial explains that the idea behind screening is that early detection and treatment will improve life expectancy and quality of life, and prevent major clinical events. However, in some instances – such as ovarian cancer, neuroblastoma, or patients with CHD and diabetes -- screening does not prevent adverse outcomes. In other words, “prediction does not imply prevention.”