Joyce Frieden

Despite explicit requirements, a number of speakers at medical meetings do not disclose financial conflicts of interest, a study has found.

“Currently, disclosures by physicians are largely self-reported, but there is reason to suspect that this may change in the near future,” Dr. Kanu Okike of Brigham and Women's Hospital and Massachusetts General Hospital, in Boston, and colleagues wrote. “Legislation requiring all drug and device manufacturers to publicly disclose payments to physicians is currently pending in the U.S. Congress and has been met with widespread support.”

The authors analyzed payments made to physicians in 2007 by five makers of total hip and knee prostheses that together account for nearly 95% of the market (N. Engl. J. Med. 2009;361:1466–74). They compared the payments with conflict of interest disclosures made by physicians who either presented at or served as board or committee members at the 2008 annual meeting of the American Academy of Orthopaedic Surgeons (AAOS).

A total of 1,347 payments were made to 1,162 physicians during 2007. Overall, 166 physicians received payments from multiple companies, and 282 payments exceeded $100,000. One-fourth of the payments (344) were made to presenters or board/committee members at the AAOS meeting.

In 70% of the 299 cases that could be evaluated for topic relatedness, the payment was directly related to the topic of the presentation at the meeting.

The overall disclosure rate for the payments was 71%, including 79% for directly related payments, 50% for indirectly related payments, and 49% for unrelated payments. Of 91 surveyed physicians who did not disclose payments, 36 cited unrelated topics among their reasons.

The authors cited the high rate of nondisclosure as the most notable finding of their study, saying that the disclosures didn't occur “despite instructions directing each participant to make a disclosure 'if he or she has received something of value from a commercial company or institution, which relates directly or indirectly to the subject of their presentation.'” They also noted that the 43 nondisclosed payments relating directly to the presentations totaled $4.3 million.

Limitations of the study included assessing payment relatedness by comparing the presentation topic with the specialty of the companies in question, which “could have underestimated the number of unrelated payments and, consequently, the overall rate of disclosure,” they wrote.

As for their own disclosures, the authors noted that coauthors Dr. Mininder Kocher, Dr. Charles Mehlman, and Dr. Mohit Bhandari have received grants from or consulted for a number of medical device firms, including several of those mentioned in the study.

Despite explicit requirements, a number of speakers at medical meetings do not disclose financial conflicts of interest, a study has found.

“Currently, disclosures by physicians are largely self-reported, but there is reason to suspect that this may change in the near future,” Dr. Kanu Okike of Brigham and Women's Hospital and Massachusetts General Hospital, in Boston, and colleagues wrote. “Legislation requiring all drug and device manufacturers to publicly disclose payments to physicians is currently pending in the U.S. Congress and has been met with widespread support.”

The authors analyzed payments made to physicians in 2007 by five makers of total hip and knee prostheses that together account for nearly 95% of the market (N. Engl. J. Med. 2009;361:1466–74). They compared the payments with conflict of interest disclosures made by physicians who either presented at or served as board or committee members at the 2008 annual meeting of the American Academy of Orthopaedic Surgeons (AAOS).

A total of 1,347 payments were made to 1,162 physicians during 2007. Overall, 166 physicians received payments from multiple companies, and 282 payments exceeded $100,000. One-fourth of the payments (344) were made to presenters or board/committee members at the AAOS meeting.

In 70% of the 299 cases that could be evaluated for topic relatedness, the payment was directly related to the topic of the presentation at the meeting.

The overall disclosure rate for the payments was 71%, including 79% for directly related payments, 50% for indirectly related payments, and 49% for unrelated payments. Of 91 surveyed physicians who did not disclose payments, 36 cited unrelated topics among their reasons.

The authors cited the high rate of nondisclosure as the most notable finding of their study, saying that the disclosures didn't occur “despite instructions directing each participant to make a disclosure 'if he or she has received something of value from a commercial company or institution, which relates directly or indirectly to the subject of their presentation.'” They also noted that the 43 nondisclosed payments relating directly to the presentations totaled $4.3 million.

Limitations of the study included assessing payment relatedness by comparing the presentation topic with the specialty of the companies in question, which “could have underestimated the number of unrelated payments and, consequently, the overall rate of disclosure,” they wrote.

As for their own disclosures, the authors noted that coauthors Dr. Mininder Kocher, Dr. Charles Mehlman, and Dr. Mohit Bhandari have received grants from or consulted for a number of medical device firms, including several of those mentioned in the study.

Despite explicit requirements, a number of speakers at medical meetings do not disclose financial conflicts of interest, a study has found.

“Currently, disclosures by physicians are largely self-reported, but there is reason to suspect that this may change in the near future,” Dr. Kanu Okike of Brigham and Women's Hospital and Massachusetts General Hospital, in Boston, and colleagues wrote. “Legislation requiring all drug and device manufacturers to publicly disclose payments to physicians is currently pending in the U.S. Congress and has been met with widespread support.”

The authors analyzed payments made to physicians in 2007 by five makers of total hip and knee prostheses that together account for nearly 95% of the market (N. Engl. J. Med. 2009;361:1466–74). They compared the payments with conflict of interest disclosures made by physicians who either presented at or served as board or committee members at the 2008 annual meeting of the American Academy of Orthopaedic Surgeons (AAOS).

A total of 1,347 payments were made to 1,162 physicians during 2007. Overall, 166 physicians received payments from multiple companies, and 282 payments exceeded $100,000. One-fourth of the payments (344) were made to presenters or board/committee members at the AAOS meeting.

In 70% of the 299 cases that could be evaluated for topic relatedness, the payment was directly related to the topic of the presentation at the meeting.

The overall disclosure rate for the payments was 71%, including 79% for directly related payments, 50% for indirectly related payments, and 49% for unrelated payments. Of 91 surveyed physicians who did not disclose payments, 36 cited unrelated topics among their reasons.

The authors cited the high rate of nondisclosure as the most notable finding of their study, saying that the disclosures didn't occur “despite instructions directing each participant to make a disclosure 'if he or she has received something of value from a commercial company or institution, which relates directly or indirectly to the subject of their presentation.'” They also noted that the 43 nondisclosed payments relating directly to the presentations totaled $4.3 million.

Limitations of the study included assessing payment relatedness by comparing the presentation topic with the specialty of the companies in question, which “could have underestimated the number of unrelated payments and, consequently, the overall rate of disclosure,” they wrote.

As for their own disclosures, the authors noted that coauthors Dr. Mininder Kocher, Dr. Charles Mehlman, and Dr. Mohit Bhandari have received grants from or consulted for a number of medical device firms, including several of those mentioned in the study.

Despite explicit requirements, a number of speakers at medical meetings do not disclose financial conflicts of interest, a study has found.

“Currently, disclosures by physicians are largely self-reported, but there is reason to suspect that this may change in the near future,” Dr. Kanu Okike of Brigham and Women's Hospital and Massachusetts General Hospital and colleagues wrote in the New England Journal of Medicine. “Legislation requiring all drug and device manufacturers to publicly disclose payments to physicians is currently pending in the U.S. Congress and has been met with widespread support.”

The authors analyzed payments made to physicians in 2007 by five makers of total hip and knee prostheses that together account for nearly 95% of the market.

Payment listings were found on each company's Web site and included a wide range of direct and indirect expenditures (N. Engl. J. Med. 2009;361:1466-74).

The authors compared the payments with conflict-of-interest disclosures made by physicians who either presented at or served as board or committee members at the 2008 annual meeting of the American Academy of Orthopaedic Surgeons (AAOS).

A total of 1,347 payments were made to 1,162 physicians during 2007. Overall, 166 physicians received payments from multiple companies, and there were 282 payments that exceeded $100,000. Approximately one-fourth of the payments (344) were made to presenters or board/committee members at the AAOS meeting.

In 70% of the 299 cases that could be evaluated for topic relatedness, the payment was directly related to the topic of the presentation at the meeting.

The overall disclosure rate for the payments was 71%, including 79% for directly related payments, 50% for indirectly related payments, and 49% for unrelated payments.

The researchers also surveyed 91 physicians who did not disclose payments; 36 physicians responded to the survey. Reasons for nondisclosure included the payment being unrelated to the presentation topic (39%) and misunderstanding the disclosure requirements (14%).

In addition, 11% of respondents reported that the payment had been disclosed but was inaccurately printed in the program.

The authors cited the high rate of nondisclosure as the most notable finding of their study, saying that the disclosures didn't occur “despite instructions directing each participant to make a disclosure 'if he or she has received something of value from a commercial company or institution, which relates directly or indirectly to the subject of their presentation.'”

They also noted that the 43 nondisclosed payments relating directly to the presentations totaled $4.3 million.

Limitation of the study included assessing payment relatedness by comparing the presentation topic with the specialty of the companies in question, which “could have underestimated the number of unrelated payments and, consequently, the overall rate of disclosure,” they wrote.

As for their own disclosures, the authors noted that co-authors Dr. Mininder Kocher, Dr. Charles Mehlman, and Dr. Mohit Bhandari have received grants from or consulted for a number of medical device manufacturing companies, including several of those mentioned in the study.

No other conflicts of interest were reported.

Despite explicit requirements, a number of speakers at medical meetings do not disclose financial conflicts of interest, a study has found.

“Currently, disclosures by physicians are largely self-reported, but there is reason to suspect that this may change in the near future,” Dr. Kanu Okike of Brigham and Women's Hospital and Massachusetts General Hospital and colleagues wrote in the New England Journal of Medicine. “Legislation requiring all drug and device manufacturers to publicly disclose payments to physicians is currently pending in the U.S. Congress and has been met with widespread support.”

The authors analyzed payments made to physicians in 2007 by five makers of total hip and knee prostheses that together account for nearly 95% of the market.

Payment listings were found on each company's Web site and included a wide range of direct and indirect expenditures (N. Engl. J. Med. 2009;361:1466-74).

The authors compared the payments with conflict-of-interest disclosures made by physicians who either presented at or served as board or committee members at the 2008 annual meeting of the American Academy of Orthopaedic Surgeons (AAOS).

A total of 1,347 payments were made to 1,162 physicians during 2007. Overall, 166 physicians received payments from multiple companies, and there were 282 payments that exceeded $100,000. Approximately one-fourth of the payments (344) were made to presenters or board/committee members at the AAOS meeting.

In 70% of the 299 cases that could be evaluated for topic relatedness, the payment was directly related to the topic of the presentation at the meeting.

The overall disclosure rate for the payments was 71%, including 79% for directly related payments, 50% for indirectly related payments, and 49% for unrelated payments.

The researchers also surveyed 91 physicians who did not disclose payments; 36 physicians responded to the survey. Reasons for nondisclosure included the payment being unrelated to the presentation topic (39%) and misunderstanding the disclosure requirements (14%).

In addition, 11% of respondents reported that the payment had been disclosed but was inaccurately printed in the program.

The authors cited the high rate of nondisclosure as the most notable finding of their study, saying that the disclosures didn't occur “despite instructions directing each participant to make a disclosure 'if he or she has received something of value from a commercial company or institution, which relates directly or indirectly to the subject of their presentation.'”

They also noted that the 43 nondisclosed payments relating directly to the presentations totaled $4.3 million.

Limitation of the study included assessing payment relatedness by comparing the presentation topic with the specialty of the companies in question, which “could have underestimated the number of unrelated payments and, consequently, the overall rate of disclosure,” they wrote.

As for their own disclosures, the authors noted that co-authors Dr. Mininder Kocher, Dr. Charles Mehlman, and Dr. Mohit Bhandari have received grants from or consulted for a number of medical device manufacturing companies, including several of those mentioned in the study.

No other conflicts of interest were reported.

Despite explicit requirements, a number of speakers at medical meetings do not disclose financial conflicts of interest, a study has found.

“Currently, disclosures by physicians are largely self-reported, but there is reason to suspect that this may change in the near future,” Dr. Kanu Okike of Brigham and Women's Hospital and Massachusetts General Hospital and colleagues wrote in the New England Journal of Medicine. “Legislation requiring all drug and device manufacturers to publicly disclose payments to physicians is currently pending in the U.S. Congress and has been met with widespread support.”

The authors analyzed payments made to physicians in 2007 by five makers of total hip and knee prostheses that together account for nearly 95% of the market.

Payment listings were found on each company's Web site and included a wide range of direct and indirect expenditures (N. Engl. J. Med. 2009;361:1466-74).

The authors compared the payments with conflict-of-interest disclosures made by physicians who either presented at or served as board or committee members at the 2008 annual meeting of the American Academy of Orthopaedic Surgeons (AAOS).

A total of 1,347 payments were made to 1,162 physicians during 2007. Overall, 166 physicians received payments from multiple companies, and there were 282 payments that exceeded $100,000. Approximately one-fourth of the payments (344) were made to presenters or board/committee members at the AAOS meeting.

In 70% of the 299 cases that could be evaluated for topic relatedness, the payment was directly related to the topic of the presentation at the meeting.

The overall disclosure rate for the payments was 71%, including 79% for directly related payments, 50% for indirectly related payments, and 49% for unrelated payments.

The researchers also surveyed 91 physicians who did not disclose payments; 36 physicians responded to the survey. Reasons for nondisclosure included the payment being unrelated to the presentation topic (39%) and misunderstanding the disclosure requirements (14%).

In addition, 11% of respondents reported that the payment had been disclosed but was inaccurately printed in the program.

The authors cited the high rate of nondisclosure as the most notable finding of their study, saying that the disclosures didn't occur “despite instructions directing each participant to make a disclosure 'if he or she has received something of value from a commercial company or institution, which relates directly or indirectly to the subject of their presentation.'”

They also noted that the 43 nondisclosed payments relating directly to the presentations totaled $4.3 million.

Limitation of the study included assessing payment relatedness by comparing the presentation topic with the specialty of the companies in question, which “could have underestimated the number of unrelated payments and, consequently, the overall rate of disclosure,” they wrote.

As for their own disclosures, the authors noted that co-authors Dr. Mininder Kocher, Dr. Charles Mehlman, and Dr. Mohit Bhandari have received grants from or consulted for a number of medical device manufacturing companies, including several of those mentioned in the study.

No other conflicts of interest were reported.

WASHINGTON — After months of internal debate, the Senate Finance Committee passed a health care reform bill aimed at expanding health coverage and making health insurance more affordable. The 14-9 vote in favor of the bill was split largely along party lines, with Sen. Olympia Snowe of Maine the lone Republican to cross over and vote for the bill along with 13 Democratic colleagues.

“The status quo has produced one glaring common denominator,” Sen. Snowe said before casting her vote. “The problem has grown worse, not better.” She said that although she had many reservations about the bill, “when history calls, history calls.”

Democrats were generally more positive about the measure. “This is clearly not anyone's ideal bill, but it is a good bill,” said Sen. Charles Schumer (D-N.Y.). “It will make health care a whole lot better than it is today.”

The bill, which would cost $829 billion over 10 years, is estimated to reduce the federal deficit by $81 billion, according to an analysis by the Congressional Budget Office. Individuals would be required to purchase health insurance coverage either on their own or from their employers, with tax credits for low- and middle-income families to help pay for the cost of coverage. Individuals who failed to purchase insurance would be subject to fines of $750—phased in gradually over a 4-year period—with exceptions for certain hardship cases. Employers would not be required to provide coverage to their full-time employees, but those who do not would be subject to a fine of up to $400 per employee.

Sen. John Kerry (D-Mass.) said he was “very concerned” that the committee had not looked carefully enough at an employer mandate. “One hundred and sixty million people get their health insurance today through their employer, but that number is going down,” he said. “Employers have an incentive to shift costs to workers and to drop [health] insurance.” He noted that when Massachusetts introduced an employer mandate as part of its universal coverage plan, the number of people insured through their employers increased.

The bill does not include a “public option,” a provision favored by many Democrats that would allow consumers to purchase coverage from a health plan offered by the federal government in competition with private health plans.

The measure passed by the committee does include insurance exchanges that would allow people who could not purchase coverage through their employers to choose from a variety of health plans.

On the other side of the aisle, Republican committee members were concerned about increasing government intrusion into health care. “This bill is already moving on a slippery slope toward more and more government control of health care,” including the biggest expansion of Medicaid since it was created in 1965, said ranking committee member Sen. Charles Grassley (R-Iowa).

Republicans also expressed concern that the measure would do little to control costs. “The bill's actual cost is hidden by delaying effective dates,” said Sen. Jim Bunning (R-Ky.). “Since [much] of this bill doesn't go into effect until 2014, the true 10-year cost of the fully implemented bill is approximately $1.8 trillion.” He also noted that the bill still leaves approximately 25 million people without coverage.

Sen. Max Baucus (D-Mont.), the Finance Committee chair, emphasized what he considered some of the bill's more positive aspects. “Folks who are satisfied with their current health insurance coverage could keep it,” he said. “People would not be required to change health plans. … Our bill would require insurance companies to renew policies as long as policyholders paid their premiums. No longer would insurance companies be able to drop coverage when people get sick.”

The Finance Committee bill will now have to be reconciled with another version of the bill passed by the Senate Committee on Health, Education, Labor, and Pensions. The final Senate bill will then have to be reconciled with a bill currently making its way through the House of Representatives.

WASHINGTON — After months of internal debate, the Senate Finance Committee passed a health care reform bill aimed at expanding health coverage and making health insurance more affordable. The 14-9 vote in favor of the bill was split largely along party lines, with Sen. Olympia Snowe of Maine the lone Republican to cross over and vote for the bill along with 13 Democratic colleagues.

“The status quo has produced one glaring common denominator,” Sen. Snowe said before casting her vote. “The problem has grown worse, not better.” She said that although she had many reservations about the bill, “when history calls, history calls.”

Democrats were generally more positive about the measure. “This is clearly not anyone's ideal bill, but it is a good bill,” said Sen. Charles Schumer (D-N.Y.). “It will make health care a whole lot better than it is today.”

The bill, which would cost $829 billion over 10 years, is estimated to reduce the federal deficit by $81 billion, according to an analysis by the Congressional Budget Office. Individuals would be required to purchase health insurance coverage either on their own or from their employers, with tax credits for low- and middle-income families to help pay for the cost of coverage. Individuals who failed to purchase insurance would be subject to fines of $750—phased in gradually over a 4-year period—with exceptions for certain hardship cases. Employers would not be required to provide coverage to their full-time employees, but those who do not would be subject to a fine of up to $400 per employee.

Sen. John Kerry (D-Mass.) said he was “very concerned” that the committee had not looked carefully enough at an employer mandate. “One hundred and sixty million people get their health insurance today through their employer, but that number is going down,” he said. “Employers have an incentive to shift costs to workers and to drop [health] insurance.” He noted that when Massachusetts introduced an employer mandate as part of its universal coverage plan, the number of people insured through their employers increased.

The bill does not include a “public option,” a provision favored by many Democrats that would allow consumers to purchase coverage from a health plan offered by the federal government in competition with private health plans.

The measure passed by the committee does include insurance exchanges that would allow people who could not purchase coverage through their employers to choose from a variety of health plans.

On the other side of the aisle, Republican committee members were concerned about increasing government intrusion into health care. “This bill is already moving on a slippery slope toward more and more government control of health care,” including the biggest expansion of Medicaid since it was created in 1965, said ranking committee member Sen. Charles Grassley (R-Iowa).

Republicans also expressed concern that the measure would do little to control costs. “The bill's actual cost is hidden by delaying effective dates,” said Sen. Jim Bunning (R-Ky.). “Since [much] of this bill doesn't go into effect until 2014, the true 10-year cost of the fully implemented bill is approximately $1.8 trillion.” He also noted that the bill still leaves approximately 25 million people without coverage.

Sen. Max Baucus (D-Mont.), the Finance Committee chair, emphasized what he considered some of the bill's more positive aspects. “Folks who are satisfied with their current health insurance coverage could keep it,” he said. “People would not be required to change health plans. … Our bill would require insurance companies to renew policies as long as policyholders paid their premiums. No longer would insurance companies be able to drop coverage when people get sick.”

The Finance Committee bill will now have to be reconciled with another version of the bill passed by the Senate Committee on Health, Education, Labor, and Pensions. The final Senate bill will then have to be reconciled with a bill currently making its way through the House of Representatives.

WASHINGTON — After months of internal debate, the Senate Finance Committee passed a health care reform bill aimed at expanding health coverage and making health insurance more affordable. The 14-9 vote in favor of the bill was split largely along party lines, with Sen. Olympia Snowe of Maine the lone Republican to cross over and vote for the bill along with 13 Democratic colleagues.

“The status quo has produced one glaring common denominator,” Sen. Snowe said before casting her vote. “The problem has grown worse, not better.” She said that although she had many reservations about the bill, “when history calls, history calls.”

Democrats were generally more positive about the measure. “This is clearly not anyone's ideal bill, but it is a good bill,” said Sen. Charles Schumer (D-N.Y.). “It will make health care a whole lot better than it is today.”

The bill, which would cost $829 billion over 10 years, is estimated to reduce the federal deficit by $81 billion, according to an analysis by the Congressional Budget Office. Individuals would be required to purchase health insurance coverage either on their own or from their employers, with tax credits for low- and middle-income families to help pay for the cost of coverage. Individuals who failed to purchase insurance would be subject to fines of $750—phased in gradually over a 4-year period—with exceptions for certain hardship cases. Employers would not be required to provide coverage to their full-time employees, but those who do not would be subject to a fine of up to $400 per employee.

Sen. John Kerry (D-Mass.) said he was “very concerned” that the committee had not looked carefully enough at an employer mandate. “One hundred and sixty million people get their health insurance today through their employer, but that number is going down,” he said. “Employers have an incentive to shift costs to workers and to drop [health] insurance.” He noted that when Massachusetts introduced an employer mandate as part of its universal coverage plan, the number of people insured through their employers increased.

The bill does not include a “public option,” a provision favored by many Democrats that would allow consumers to purchase coverage from a health plan offered by the federal government in competition with private health plans.

The measure passed by the committee does include insurance exchanges that would allow people who could not purchase coverage through their employers to choose from a variety of health plans.

On the other side of the aisle, Republican committee members were concerned about increasing government intrusion into health care. “This bill is already moving on a slippery slope toward more and more government control of health care,” including the biggest expansion of Medicaid since it was created in 1965, said ranking committee member Sen. Charles Grassley (R-Iowa).

Republicans also expressed concern that the measure would do little to control costs. “The bill's actual cost is hidden by delaying effective dates,” said Sen. Jim Bunning (R-Ky.). “Since [much] of this bill doesn't go into effect until 2014, the true 10-year cost of the fully implemented bill is approximately $1.8 trillion.” He also noted that the bill still leaves approximately 25 million people without coverage.

Sen. Max Baucus (D-Mont.), the Finance Committee chair, emphasized what he considered some of the bill's more positive aspects. “Folks who are satisfied with their current health insurance coverage could keep it,” he said. “People would not be required to change health plans. … Our bill would require insurance companies to renew policies as long as policyholders paid their premiums. No longer would insurance companies be able to drop coverage when people get sick.”

The Finance Committee bill will now have to be reconciled with another version of the bill passed by the Senate Committee on Health, Education, Labor, and Pensions. The final Senate bill will then have to be reconciled with a bill currently making its way through the House of Representatives.

Revised thyroid cancer guidelines from the American Thyroid Association call for less use of fine-needle aspiration and of radioiodine, based on evidence that in some circumstances, more treatment did not necessarily yield better outcomes.

Under the new guidelines, “fewer people are going to have a biopsy of their thyroid nodule because we now have ultrasound-based criteria for which nodules should be biopsied, not just based on the size of the nodule but on the way they look on ultrasound,” Dr. David Cooper, chair of the ATA task force that revised the guidelines, said in an interview. Biopsy is warranted for nodules that are greater than 50% cystic and for those larger than 2 cm that have a spongiform appearance. Dr. Cooper discussed the guidelines at the American Thyroid Association meeting in September in Palm Beach, Fla.; they are scheduled to be published in the November issue of Thyroid.

The guidelines also address the use of radioactive iodine (RAI), said Dr. Cooper, professor of medicine at Johns Hopkins University, Baltimore. “We now state that patients who have tumors 1 cm or less should not get RAI; before, we did not specifically address this situation.”

Patients with multifocal micropapillary thyroid cancers are another group that would not get remnant ablation under the new guidelines. “The idea behind remnant ablation after surgery is that rates of recurrence might be lowered,” explained Dr. Cooper. “But for very small tumors and microtumors, there is no evidence that the rate of recurrence is less if you give RAI than if you don't. Since there's the potential for harm in RAI, we're saying it's not indicated. That's a big shift also.”

For patients who have undergone a total or near-total thyroidectomy for differentiated thyroid cancer, the use of central neck dissection is less definite under the new guidelines. “In the old guidelines [Thyroid 2006;16:109-42], we said patients should be considered for a central neck dissection routinely, because there is a very high rate of metastatic disease,” he said. “But it turns out that when you do that, the complications of the surgery are higher. Now we've toned it down a bit and say that central neck dissection should be done in patients with bigger primary tumors but not if they have a smaller tumor.”

In terms of long-term management for differentiated thyroid cancer patients, the new guidelines also provide advice for management of patients who have not had radioactive iodine remnant ablation. “In patients who have not undergone remnant ablation who are clinically free of disease and have undetectable suppressed serum thyroglobulin and normal neck ultrasound, the serum TSH may be allowed to rise to the low normal range (0.3-2 mU/L),” according to the guidelines.

The timing of PET scans is another issue addressed by the guidelines, Dr. Cooper said. Rather than using PET scans to detect residual cancer only after all other methodologies—including empiric RAI therapy—have not revealed a recurrence, “we're now saying, before you do RAI, you may do a PET scan, especially if the serum thyroglobulin is above 10 ng/mL,” he said.

The new guideline recommends that PET scans also may be used “as part of initial staging in poorly differentiated thyroid cancers and invasive Hurthle cell carcinomas, especially those with other evidence of disease on imaging or because of elevated serum thyroglobulin levels; as a prognostic tool in patients with metastatic disease to identify those patients at highest risk of rapid disease progression and disease-specific mortality; and as an evaluation of posttreatment response following systemic or local therapy of metastatic or locally invasive disease.”

The change in the PET scan recommendation is being made because tumors that are PET-scan positive usually cannot be treated with RAI, “so if it's positive [with PET] it would lead the doctor not to use RAI and think of some alternate form of therapy.”

On the subject of chemotherapy, Dr. Cooper noted that refractory thyroid cancer often does not respond well to standard chemotherapy regimens. “Now we're recommending considering the use of newer agents, such as the tyrosine kinase inhibitors sunitinib or sorafenib, or enrolling in a clinical trial.

Dr. Cooper said he had no conflicts of interest to declare with regard to the guidelines.

Nodules larger than 2 cm that have a spongiform appearance (above) should be biopsied.

Source Courtesy Dr. Susan Mandel

Revised thyroid cancer guidelines from the American Thyroid Association call for less use of fine-needle aspiration and of radioiodine, based on evidence that in some circumstances, more treatment did not necessarily yield better outcomes.

Under the new guidelines, “fewer people are going to have a biopsy of their thyroid nodule because we now have ultrasound-based criteria for which nodules should be biopsied, not just based on the size of the nodule but on the way they look on ultrasound,” Dr. David Cooper, chair of the ATA task force that revised the guidelines, said in an interview. Biopsy is warranted for nodules that are greater than 50% cystic and for those larger than 2 cm that have a spongiform appearance. Dr. Cooper discussed the guidelines at the American Thyroid Association meeting in September in Palm Beach, Fla.; they are scheduled to be published in the November issue of Thyroid.

The guidelines also address the use of radioactive iodine (RAI), said Dr. Cooper, professor of medicine at Johns Hopkins University, Baltimore. “We now state that patients who have tumors 1 cm or less should not get RAI; before, we did not specifically address this situation.”

Patients with multifocal micropapillary thyroid cancers are another group that would not get remnant ablation under the new guidelines. “The idea behind remnant ablation after surgery is that rates of recurrence might be lowered,” explained Dr. Cooper. “But for very small tumors and microtumors, there is no evidence that the rate of recurrence is less if you give RAI than if you don't. Since there's the potential for harm in RAI, we're saying it's not indicated. That's a big shift also.”

For patients who have undergone a total or near-total thyroidectomy for differentiated thyroid cancer, the use of central neck dissection is less definite under the new guidelines. “In the old guidelines [Thyroid 2006;16:109-42], we said patients should be considered for a central neck dissection routinely, because there is a very high rate of metastatic disease,” he said. “But it turns out that when you do that, the complications of the surgery are higher. Now we've toned it down a bit and say that central neck dissection should be done in patients with bigger primary tumors but not if they have a smaller tumor.”

In terms of long-term management for differentiated thyroid cancer patients, the new guidelines also provide advice for management of patients who have not had radioactive iodine remnant ablation. “In patients who have not undergone remnant ablation who are clinically free of disease and have undetectable suppressed serum thyroglobulin and normal neck ultrasound, the serum TSH may be allowed to rise to the low normal range (0.3-2 mU/L),” according to the guidelines.

The timing of PET scans is another issue addressed by the guidelines, Dr. Cooper said. Rather than using PET scans to detect residual cancer only after all other methodologies—including empiric RAI therapy—have not revealed a recurrence, “we're now saying, before you do RAI, you may do a PET scan, especially if the serum thyroglobulin is above 10 ng/mL,” he said.

The new guideline recommends that PET scans also may be used “as part of initial staging in poorly differentiated thyroid cancers and invasive Hurthle cell carcinomas, especially those with other evidence of disease on imaging or because of elevated serum thyroglobulin levels; as a prognostic tool in patients with metastatic disease to identify those patients at highest risk of rapid disease progression and disease-specific mortality; and as an evaluation of posttreatment response following systemic or local therapy of metastatic or locally invasive disease.”

The change in the PET scan recommendation is being made because tumors that are PET-scan positive usually cannot be treated with RAI, “so if it's positive [with PET] it would lead the doctor not to use RAI and think of some alternate form of therapy.”

On the subject of chemotherapy, Dr. Cooper noted that refractory thyroid cancer often does not respond well to standard chemotherapy regimens. “Now we're recommending considering the use of newer agents, such as the tyrosine kinase inhibitors sunitinib or sorafenib, or enrolling in a clinical trial.

Dr. Cooper said he had no conflicts of interest to declare with regard to the guidelines.

Nodules larger than 2 cm that have a spongiform appearance (above) should be biopsied.

Source Courtesy Dr. Susan Mandel

Revised thyroid cancer guidelines from the American Thyroid Association call for less use of fine-needle aspiration and of radioiodine, based on evidence that in some circumstances, more treatment did not necessarily yield better outcomes.

Under the new guidelines, “fewer people are going to have a biopsy of their thyroid nodule because we now have ultrasound-based criteria for which nodules should be biopsied, not just based on the size of the nodule but on the way they look on ultrasound,” Dr. David Cooper, chair of the ATA task force that revised the guidelines, said in an interview. Biopsy is warranted for nodules that are greater than 50% cystic and for those larger than 2 cm that have a spongiform appearance. Dr. Cooper discussed the guidelines at the American Thyroid Association meeting in September in Palm Beach, Fla.; they are scheduled to be published in the November issue of Thyroid.

The guidelines also address the use of radioactive iodine (RAI), said Dr. Cooper, professor of medicine at Johns Hopkins University, Baltimore. “We now state that patients who have tumors 1 cm or less should not get RAI; before, we did not specifically address this situation.”

Patients with multifocal micropapillary thyroid cancers are another group that would not get remnant ablation under the new guidelines. “The idea behind remnant ablation after surgery is that rates of recurrence might be lowered,” explained Dr. Cooper. “But for very small tumors and microtumors, there is no evidence that the rate of recurrence is less if you give RAI than if you don't. Since there's the potential for harm in RAI, we're saying it's not indicated. That's a big shift also.”

For patients who have undergone a total or near-total thyroidectomy for differentiated thyroid cancer, the use of central neck dissection is less definite under the new guidelines. “In the old guidelines [Thyroid 2006;16:109-42], we said patients should be considered for a central neck dissection routinely, because there is a very high rate of metastatic disease,” he said. “But it turns out that when you do that, the complications of the surgery are higher. Now we've toned it down a bit and say that central neck dissection should be done in patients with bigger primary tumors but not if they have a smaller tumor.”

In terms of long-term management for differentiated thyroid cancer patients, the new guidelines also provide advice for management of patients who have not had radioactive iodine remnant ablation. “In patients who have not undergone remnant ablation who are clinically free of disease and have undetectable suppressed serum thyroglobulin and normal neck ultrasound, the serum TSH may be allowed to rise to the low normal range (0.3-2 mU/L),” according to the guidelines.

The timing of PET scans is another issue addressed by the guidelines, Dr. Cooper said. Rather than using PET scans to detect residual cancer only after all other methodologies—including empiric RAI therapy—have not revealed a recurrence, “we're now saying, before you do RAI, you may do a PET scan, especially if the serum thyroglobulin is above 10 ng/mL,” he said.

The new guideline recommends that PET scans also may be used “as part of initial staging in poorly differentiated thyroid cancers and invasive Hurthle cell carcinomas, especially those with other evidence of disease on imaging or because of elevated serum thyroglobulin levels; as a prognostic tool in patients with metastatic disease to identify those patients at highest risk of rapid disease progression and disease-specific mortality; and as an evaluation of posttreatment response following systemic or local therapy of metastatic or locally invasive disease.”

The change in the PET scan recommendation is being made because tumors that are PET-scan positive usually cannot be treated with RAI, “so if it's positive [with PET] it would lead the doctor not to use RAI and think of some alternate form of therapy.”

On the subject of chemotherapy, Dr. Cooper noted that refractory thyroid cancer often does not respond well to standard chemotherapy regimens. “Now we're recommending considering the use of newer agents, such as the tyrosine kinase inhibitors sunitinib or sorafenib, or enrolling in a clinical trial.

Dr. Cooper said he had no conflicts of interest to declare with regard to the guidelines.

Nodules larger than 2 cm that have a spongiform appearance (above) should be biopsied.

Source Courtesy Dr. Susan Mandel

Although strides have been made in use of psychotropic medications in children and adolescents, concerns remain over whether these medications are prescribed appropriately.

That's one reason that the American Academy of Child & Adolescent Psychiatry gives for issuing a new practice parameter on psychotropic medication use.

“Strategies to address the overuse or inappropriate use of medications (e.g., the Food and Drug Administration advisory 'black box' warning for antidepressants) may actually create barriers to care and may result in unintended negative consequences,” according to Dr. John Walkup and his colleagues at the academy's Work Group on Quality Issues. “Rather than advocating for restricting access to medication treatment, this parameter advocates for high-quality assessment and prescribing practices to enhance outcomes for children and to address societal concerns about how children with psychiatric disorders are treated.”

The parameter lists 13 principles that should be followed in prescribing psychotropic medications to children, beginning with the need for a medical history and a psychiatric evaluation—and, when needed, a medical evaluation—before beginning pharmacotherapy (J. Am. Acad. Child Adolesc. Psychiatry 2009;48:961-73). Other principles included:

▸ Communicate with other professionals involved with the child to obtain collateral history and set the stage for monitoring outcome and side effects during the medication trial. “Early communication elicits the support of key professionals for the treatment plan … and may reduce the chance of misunderstandings during treatment,” the authors noted. “Follow-up among professionals during treatment enables all professionals who are involved to be up to date with the treatment plan and that treatment is well coordinated.”

▸ Develop a psychosocial and psychopharmacological treatment plan based on the best available evidence. Traditionally, psychosocial treatment is recommended before pharmacological treatment, but there are some exceptions to this principle, according to the authors. For instance, “randomized controlled trials suggest that medication management for attention-deficit hyperactivity disorder (ADHD) is the first-line treatment, and that medication combined with behavioral treatment may be required for optimal outcome in children with more complex problems.”

▸ Develop a plan to monitor the patient, short and long term. Although there are few data to help determine how long to monitor a child after medication is discontinued, “the duration of follow-up reflects the risk for relapse in the short term and risk for recurrence of illness over the longer term,” the authors wrote.

▸ Provide feedback about the diagnosis, and educate the patient and family regarding the child's disorder and the treatment and monitoring plan. The authors noted that in some families, “extended psychoeducation to address specific attitudinal or psychological issues regarding medication and/or specific psychosocial interventions to stabilize the home environment may be necessary” for successful treatment.

▸ Complete and document the assent of the child and consent of the parents before initiating medication treatment and at important points during treatment. The parameter states that assent/consent is an ongoing process. “It is recommended that before initiation of any additional psychotropic medications, at the transition to the maintenance phase, and before a discontinuation trial, the prescriber, patient, and family review the rationale for treatment; the past treatment experience; and the benefits, risks, and alternative treatments for each additional medication or the next phase of treatment.”

Dr. Walkup has received research support from Eli Lilly & Co., Pfizer Inc., and Abbott Laboratories, and his spouse is a consultant to Abbott. Another parameter author, Dr. Oscar Bukstein, has received research support or consulting or speaking fees from McNeil Pediatrics and Novartis Pharmaceuticals.

Although strides have been made in use of psychotropic medications in children and adolescents, concerns remain over whether these medications are prescribed appropriately.

That's one reason that the American Academy of Child & Adolescent Psychiatry gives for issuing a new practice parameter on psychotropic medication use.

“Strategies to address the overuse or inappropriate use of medications (e.g., the Food and Drug Administration advisory 'black box' warning for antidepressants) may actually create barriers to care and may result in unintended negative consequences,” according to Dr. John Walkup and his colleagues at the academy's Work Group on Quality Issues. “Rather than advocating for restricting access to medication treatment, this parameter advocates for high-quality assessment and prescribing practices to enhance outcomes for children and to address societal concerns about how children with psychiatric disorders are treated.”

The parameter lists 13 principles that should be followed in prescribing psychotropic medications to children, beginning with the need for a medical history and a psychiatric evaluation—and, when needed, a medical evaluation—before beginning pharmacotherapy (J. Am. Acad. Child Adolesc. Psychiatry 2009;48:961-73). Other principles included:

▸ Communicate with other professionals involved with the child to obtain collateral history and set the stage for monitoring outcome and side effects during the medication trial. “Early communication elicits the support of key professionals for the treatment plan … and may reduce the chance of misunderstandings during treatment,” the authors noted. “Follow-up among professionals during treatment enables all professionals who are involved to be up to date with the treatment plan and that treatment is well coordinated.”

▸ Develop a psychosocial and psychopharmacological treatment plan based on the best available evidence. Traditionally, psychosocial treatment is recommended before pharmacological treatment, but there are some exceptions to this principle, according to the authors. For instance, “randomized controlled trials suggest that medication management for attention-deficit hyperactivity disorder (ADHD) is the first-line treatment, and that medication combined with behavioral treatment may be required for optimal outcome in children with more complex problems.”

▸ Develop a plan to monitor the patient, short and long term. Although there are few data to help determine how long to monitor a child after medication is discontinued, “the duration of follow-up reflects the risk for relapse in the short term and risk for recurrence of illness over the longer term,” the authors wrote.

▸ Provide feedback about the diagnosis, and educate the patient and family regarding the child's disorder and the treatment and monitoring plan. The authors noted that in some families, “extended psychoeducation to address specific attitudinal or psychological issues regarding medication and/or specific psychosocial interventions to stabilize the home environment may be necessary” for successful treatment.

▸ Complete and document the assent of the child and consent of the parents before initiating medication treatment and at important points during treatment. The parameter states that assent/consent is an ongoing process. “It is recommended that before initiation of any additional psychotropic medications, at the transition to the maintenance phase, and before a discontinuation trial, the prescriber, patient, and family review the rationale for treatment; the past treatment experience; and the benefits, risks, and alternative treatments for each additional medication or the next phase of treatment.”

Dr. Walkup has received research support from Eli Lilly & Co., Pfizer Inc., and Abbott Laboratories, and his spouse is a consultant to Abbott. Another parameter author, Dr. Oscar Bukstein, has received research support or consulting or speaking fees from McNeil Pediatrics and Novartis Pharmaceuticals.

Although strides have been made in use of psychotropic medications in children and adolescents, concerns remain over whether these medications are prescribed appropriately.

That's one reason that the American Academy of Child & Adolescent Psychiatry gives for issuing a new practice parameter on psychotropic medication use.

“Strategies to address the overuse or inappropriate use of medications (e.g., the Food and Drug Administration advisory 'black box' warning for antidepressants) may actually create barriers to care and may result in unintended negative consequences,” according to Dr. John Walkup and his colleagues at the academy's Work Group on Quality Issues. “Rather than advocating for restricting access to medication treatment, this parameter advocates for high-quality assessment and prescribing practices to enhance outcomes for children and to address societal concerns about how children with psychiatric disorders are treated.”

The parameter lists 13 principles that should be followed in prescribing psychotropic medications to children, beginning with the need for a medical history and a psychiatric evaluation—and, when needed, a medical evaluation—before beginning pharmacotherapy (J. Am. Acad. Child Adolesc. Psychiatry 2009;48:961-73). Other principles included:

▸ Communicate with other professionals involved with the child to obtain collateral history and set the stage for monitoring outcome and side effects during the medication trial. “Early communication elicits the support of key professionals for the treatment plan … and may reduce the chance of misunderstandings during treatment,” the authors noted. “Follow-up among professionals during treatment enables all professionals who are involved to be up to date with the treatment plan and that treatment is well coordinated.”

▸ Develop a psychosocial and psychopharmacological treatment plan based on the best available evidence. Traditionally, psychosocial treatment is recommended before pharmacological treatment, but there are some exceptions to this principle, according to the authors. For instance, “randomized controlled trials suggest that medication management for attention-deficit hyperactivity disorder (ADHD) is the first-line treatment, and that medication combined with behavioral treatment may be required for optimal outcome in children with more complex problems.”

▸ Develop a plan to monitor the patient, short and long term. Although there are few data to help determine how long to monitor a child after medication is discontinued, “the duration of follow-up reflects the risk for relapse in the short term and risk for recurrence of illness over the longer term,” the authors wrote.

▸ Provide feedback about the diagnosis, and educate the patient and family regarding the child's disorder and the treatment and monitoring plan. The authors noted that in some families, “extended psychoeducation to address specific attitudinal or psychological issues regarding medication and/or specific psychosocial interventions to stabilize the home environment may be necessary” for successful treatment.

▸ Complete and document the assent of the child and consent of the parents before initiating medication treatment and at important points during treatment. The parameter states that assent/consent is an ongoing process. “It is recommended that before initiation of any additional psychotropic medications, at the transition to the maintenance phase, and before a discontinuation trial, the prescriber, patient, and family review the rationale for treatment; the past treatment experience; and the benefits, risks, and alternative treatments for each additional medication or the next phase of treatment.”

Dr. Walkup has received research support from Eli Lilly & Co., Pfizer Inc., and Abbott Laboratories, and his spouse is a consultant to Abbott. Another parameter author, Dr. Oscar Bukstein, has received research support or consulting or speaking fees from McNeil Pediatrics and Novartis Pharmaceuticals.

WASHINGTON — A Health and Human Services Department advisory committee is moving to make it easier for physicians to meet federal requirements for adopting electronic health records.

The Health IT Policy Committee has recommended that providers who adopt EHRs after 2011 or 2012—the first years that federal stimulus money for adoption will be available—have to meet only 2011-2012 requirements for “meaningful use” of EHRs in their first year of adoption. They will then need to meet additional requirements each year in order to continue getting the money, although they will receive less than they would have if they had adopted EHRs earlier.

“A rising tide floats all boats, but if you're not in the water, it just doesn't help,” said Dr. Paul Tang, cochair of the committee's meaningful use working group. “So we're just trying to find a way to get people to deal with it, even if it's a little bit late.”

Under the Recovery Act (formally known as the American Recovery and Reinvestment Act of 2009), $19 billion in stimulus money has been set aside to encourage adoption of health information technology, including EHRs. The money includes up to $44,000 in financial incentives for each physician who purchases a certified EHR system and who makes “meaningful use” of it.

To put the law into effect, the government has to define “meaningful use” and set standards for system certification and health information exchange. The HIT Policy Committee, chaired by Dr. David Blumenthal, national coordinator for health information technology at HHS, will make recommendations; the actual regulations will be written by staff members at the Centers for Medicare and Medicaid Services (CMS).

At a recent HIT Policy Committee meeting, committee member Gayle Harrell, former Florida state legislator and the wife of a retired ob.gyn., expressed concern that some of the meaningful use requirements were aimed more at primary care physicians and would not be appropriate for specialists. Dr. Tang agreed that the working group would try to make sure that specialists' needs were addressed when the recommendations were finalized, and noted that not all measures would apply to all specialties. The committee agreed to accept the meaningful use working group's recommendations.

Ms. Harrell also raised the question of whether specialists would now be liable for information presented in the EHR that falls outside of their purview. “Would an ophthalmologist have to verify whether or not I had a mammogram?” she asked.

Dr. Blumenthal said he didn't think the liability issue was within the committee's scope. “I think we have to stay focused on what we think appropriate good care should be, and we can't sort out the medical liability system here.” Ms. Harrell agreed, but noted that “this presents a real fear out there for many people.”

The standards and certification subcommittee also presented the following five recommendations to the committee:

▸ Focus certification on meaningful use.

▸ Leverage the certification process to improve progress on security, privacy, and interoperability.

▸ Improve the objectivity and transparency of the certification process.

▸ Expand certification to include a range of software sources, such as open-source and self-developed systems.

▸ Develop a short-term transition plan for certification.

Dr. Neil Calman, CEO of the Institute for Family Health, N.Y., said he was concerned that the last recommendation would send the wrong message to providers who were already certified by the Certification Commission for Health Information Technology, currently the government's only approved certifying body. “It basically makes it sound like CCHIT is temporary,” he said.

But working group cochair Paul Egerman said that was not the message the group meant to convey. “That was not at all what was intended,” he replied.

The committee agreed to adopt the working group's main recommendations but to let working group members rework some of the specifics.

WASHINGTON — A Health and Human Services Department advisory committee is moving to make it easier for physicians to meet federal requirements for adopting electronic health records.

The Health IT Policy Committee has recommended that providers who adopt EHRs after 2011 or 2012—the first years that federal stimulus money for adoption will be available—have to meet only 2011-2012 requirements for “meaningful use” of EHRs in their first year of adoption. They will then need to meet additional requirements each year in order to continue getting the money, although they will receive less than they would have if they had adopted EHRs earlier.

“A rising tide floats all boats, but if you're not in the water, it just doesn't help,” said Dr. Paul Tang, cochair of the committee's meaningful use working group. “So we're just trying to find a way to get people to deal with it, even if it's a little bit late.”

Under the Recovery Act (formally known as the American Recovery and Reinvestment Act of 2009), $19 billion in stimulus money has been set aside to encourage adoption of health information technology, including EHRs. The money includes up to $44,000 in financial incentives for each physician who purchases a certified EHR system and who makes “meaningful use” of it.

To put the law into effect, the government has to define “meaningful use” and set standards for system certification and health information exchange. The HIT Policy Committee, chaired by Dr. David Blumenthal, national coordinator for health information technology at HHS, will make recommendations; the actual regulations will be written by staff members at the Centers for Medicare and Medicaid Services (CMS).

At a recent HIT Policy Committee meeting, committee member Gayle Harrell, former Florida state legislator and the wife of a retired ob.gyn., expressed concern that some of the meaningful use requirements were aimed more at primary care physicians and would not be appropriate for specialists. Dr. Tang agreed that the working group would try to make sure that specialists' needs were addressed when the recommendations were finalized, and noted that not all measures would apply to all specialties. The committee agreed to accept the meaningful use working group's recommendations.

Ms. Harrell also raised the question of whether specialists would now be liable for information presented in the EHR that falls outside of their purview. “Would an ophthalmologist have to verify whether or not I had a mammogram?” she asked.

Dr. Blumenthal said he didn't think the liability issue was within the committee's scope. “I think we have to stay focused on what we think appropriate good care should be, and we can't sort out the medical liability system here.” Ms. Harrell agreed, but noted that “this presents a real fear out there for many people.”

The standards and certification subcommittee also presented the following five recommendations to the committee:

▸ Focus certification on meaningful use.

▸ Leverage the certification process to improve progress on security, privacy, and interoperability.

▸ Improve the objectivity and transparency of the certification process.

▸ Expand certification to include a range of software sources, such as open-source and self-developed systems.

▸ Develop a short-term transition plan for certification.

Dr. Neil Calman, CEO of the Institute for Family Health, N.Y., said he was concerned that the last recommendation would send the wrong message to providers who were already certified by the Certification Commission for Health Information Technology, currently the government's only approved certifying body. “It basically makes it sound like CCHIT is temporary,” he said.

But working group cochair Paul Egerman said that was not the message the group meant to convey. “That was not at all what was intended,” he replied.

The committee agreed to adopt the working group's main recommendations but to let working group members rework some of the specifics.

WASHINGTON — A Health and Human Services Department advisory committee is moving to make it easier for physicians to meet federal requirements for adopting electronic health records.

The Health IT Policy Committee has recommended that providers who adopt EHRs after 2011 or 2012—the first years that federal stimulus money for adoption will be available—have to meet only 2011-2012 requirements for “meaningful use” of EHRs in their first year of adoption. They will then need to meet additional requirements each year in order to continue getting the money, although they will receive less than they would have if they had adopted EHRs earlier.

“A rising tide floats all boats, but if you're not in the water, it just doesn't help,” said Dr. Paul Tang, cochair of the committee's meaningful use working group. “So we're just trying to find a way to get people to deal with it, even if it's a little bit late.”

Under the Recovery Act (formally known as the American Recovery and Reinvestment Act of 2009), $19 billion in stimulus money has been set aside to encourage adoption of health information technology, including EHRs. The money includes up to $44,000 in financial incentives for each physician who purchases a certified EHR system and who makes “meaningful use” of it.

To put the law into effect, the government has to define “meaningful use” and set standards for system certification and health information exchange. The HIT Policy Committee, chaired by Dr. David Blumenthal, national coordinator for health information technology at HHS, will make recommendations; the actual regulations will be written by staff members at the Centers for Medicare and Medicaid Services (CMS).

At a recent HIT Policy Committee meeting, committee member Gayle Harrell, former Florida state legislator and the wife of a retired ob.gyn., expressed concern that some of the meaningful use requirements were aimed more at primary care physicians and would not be appropriate for specialists. Dr. Tang agreed that the working group would try to make sure that specialists' needs were addressed when the recommendations were finalized, and noted that not all measures would apply to all specialties. The committee agreed to accept the meaningful use working group's recommendations.

Ms. Harrell also raised the question of whether specialists would now be liable for information presented in the EHR that falls outside of their purview. “Would an ophthalmologist have to verify whether or not I had a mammogram?” she asked.

Dr. Blumenthal said he didn't think the liability issue was within the committee's scope. “I think we have to stay focused on what we think appropriate good care should be, and we can't sort out the medical liability system here.” Ms. Harrell agreed, but noted that “this presents a real fear out there for many people.”

The standards and certification subcommittee also presented the following five recommendations to the committee:

▸ Focus certification on meaningful use.

▸ Leverage the certification process to improve progress on security, privacy, and interoperability.

▸ Improve the objectivity and transparency of the certification process.

▸ Expand certification to include a range of software sources, such as open-source and self-developed systems.

▸ Develop a short-term transition plan for certification.

Dr. Neil Calman, CEO of the Institute for Family Health, N.Y., said he was concerned that the last recommendation would send the wrong message to providers who were already certified by the Certification Commission for Health Information Technology, currently the government's only approved certifying body. “It basically makes it sound like CCHIT is temporary,” he said.

But working group cochair Paul Egerman said that was not the message the group meant to convey. “That was not at all what was intended,” he replied.

The committee agreed to adopt the working group's main recommendations but to let working group members rework some of the specifics.

Revised thyroid cancer guidelines from the American Thyroid Association call for less use of fine-needle aspiration and of radioiodine, based on evidence that in some circumstances, more treatment did not necessarily yield better outcomes.

Under the new guidelines, “fewer people are going to have a biopsy of their thyroid nodule because we now have ultrasound-based criteria for which nodules should be biopsied, not just based on the size of the nodule but on the way they look on ultrasound,” Dr. David Cooper, chair of the ATA task force that revised the guidelines, said in an interview. Biopsy is warranted for nodules that are greater than 50% cystic and for those larger than 2 cm that have a spongiform appearance. Dr. Cooper discussed the guidelines at the American Thyroid Association meeting in September in Palm Beach, Fla.; they are scheduled to be published in the November issue of Thyroid.

The guidelines also address the use of radioactive iodine (RAI), said Dr. Cooper, professor of medicine at Johns Hopkins University, Baltimore. “We now state that patients who have tumors 1 cm or less should not get RAI. Before, we did not specifically address this situation.”

Patients with multifocal micropapillary thyroid cancers are another group that would not get remnant ablation under the new guidelines. “The idea behind remnant ablation after surgery is that rates of recurrence might be lowered,” explained Dr. Cooper. “But for very small tumors and microtumors, there is no evidence that the rate of recurrence is less if you give RAI than if you don't. Since there's the potential for harm in RAI, we're saying it's not indicated. That's a big shift also.”

For patients who have undergone a total or near-total thyroidectomy for differentiated thyroid cancer, the use of central neck dissection is less definite under the new guidelines. “In the old guidelines [Thyroid 2006;16:109-42], we said patients should be considered for a central neck dissection routinely, because there is a very high rate of metastatic disease,” he said. “But it turns out that when you do that, the complications of the surgery are higher. Now we've toned it down a bit and say that central neck dissection should be done in patients with bigger primary tumors but not if they have a smaller tumor.”

In terms of long-term management for differentiated thyroid cancer patients, the new guidelines also provide advice for management of patients who have not had radioactive iodine remnant ablation. “In patients who have not undergone remnant ablation who are clinically free of disease and have undetectable suppressed serum thyroglobulin and normal neck ultrasound, the serum TSH may be allowed to rise to the low normal range (0.3 to 2 mU/L),” according to the guidelines.

The timing of PET scans is another issue addressed by the guidelines, Dr. Cooper said. Rather than using PET scans to detect residual cancer only after all other methodologies—including empiric RAI therapy—have not revealed a recurrence, “we're now saying, before you do RAI, you may do a PET scan, especially if the serum thyroglobulin is above 10 ng/mL,” he said. The new guidelines recommend that PET scans also may be used as part of initial staging in poorly differentiated thyroid cancers and invasive Hurthle cell carcinomas, as a prognostic tool in patients with metastatic disease to identify those patients at highest risk of rapid disease progression and disease-specific mortality, and as an evaluation of posttreatment response following systemic or local therapy of metastatic or locally invasive disease.

The change in the PET scan recommendation is being made because tumors that are PET-scan positive usually cannot be treated with RAI, “so if it's positive [with PET] it would lead the doctor not to use RAI and think of some alternate form of therapy, perhaps surgery or possibly some sort of chemotherapy.”

On the subject of chemotherapy, Dr. Cooper noted that refractory thyroid cancer often does not respond well to standard chemotherapy regimens. “In the old guidelines, we said that when there was nothing else to do, you could use standard chemotherapy; now we're recommending considering the use of newer agents, such as the tyrosine kinase inhibitors sunitinib or sorafenib, or enrolling in a clinical trial. We no longer recommend standard chemotherapy for patients whose cancer is not treatable with radioactive iodine.” No tyrosine kinase inhibitor has yet been approved for thyroid cancer treatment.

Dr. Cooper said he hoped the new guidelines “will change practice and benefit patients with thyroid nodules and thyroid cancer. The main benefit will be in not exposing very-low-risk patients to procedures or therapies that are unlikely to improve outcomes, and reserving more aggressive procedures and therapies for patients with more advanced disease.”

Dr. Cooper said he had no relevant conflicts of interest to declare.

Criteria based on the size and appearance of thyroid nodules on ultrasound will limit the use of biopsies. Nodules larger than 2 cm that have a spongiform appearance (right) should be biopsied.

Source Courtesy Dr. Susan Mandel

Revised thyroid cancer guidelines from the American Thyroid Association call for less use of fine-needle aspiration and of radioiodine, based on evidence that in some circumstances, more treatment did not necessarily yield better outcomes.

Under the new guidelines, “fewer people are going to have a biopsy of their thyroid nodule because we now have ultrasound-based criteria for which nodules should be biopsied, not just based on the size of the nodule but on the way they look on ultrasound,” Dr. David Cooper, chair of the ATA task force that revised the guidelines, said in an interview. Biopsy is warranted for nodules that are greater than 50% cystic and for those larger than 2 cm that have a spongiform appearance. Dr. Cooper discussed the guidelines at the American Thyroid Association meeting in September in Palm Beach, Fla.; they are scheduled to be published in the November issue of Thyroid.

The guidelines also address the use of radioactive iodine (RAI), said Dr. Cooper, professor of medicine at Johns Hopkins University, Baltimore. “We now state that patients who have tumors 1 cm or less should not get RAI. Before, we did not specifically address this situation.”

Patients with multifocal micropapillary thyroid cancers are another group that would not get remnant ablation under the new guidelines. “The idea behind remnant ablation after surgery is that rates of recurrence might be lowered,” explained Dr. Cooper. “But for very small tumors and microtumors, there is no evidence that the rate of recurrence is less if you give RAI than if you don't. Since there's the potential for harm in RAI, we're saying it's not indicated. That's a big shift also.”

For patients who have undergone a total or near-total thyroidectomy for differentiated thyroid cancer, the use of central neck dissection is less definite under the new guidelines. “In the old guidelines [Thyroid 2006;16:109-42], we said patients should be considered for a central neck dissection routinely, because there is a very high rate of metastatic disease,” he said. “But it turns out that when you do that, the complications of the surgery are higher. Now we've toned it down a bit and say that central neck dissection should be done in patients with bigger primary tumors but not if they have a smaller tumor.”

In terms of long-term management for differentiated thyroid cancer patients, the new guidelines also provide advice for management of patients who have not had radioactive iodine remnant ablation. “In patients who have not undergone remnant ablation who are clinically free of disease and have undetectable suppressed serum thyroglobulin and normal neck ultrasound, the serum TSH may be allowed to rise to the low normal range (0.3 to 2 mU/L),” according to the guidelines.

The timing of PET scans is another issue addressed by the guidelines, Dr. Cooper said. Rather than using PET scans to detect residual cancer only after all other methodologies—including empiric RAI therapy—have not revealed a recurrence, “we're now saying, before you do RAI, you may do a PET scan, especially if the serum thyroglobulin is above 10 ng/mL,” he said. The new guidelines recommend that PET scans also may be used as part of initial staging in poorly differentiated thyroid cancers and invasive Hurthle cell carcinomas, as a prognostic tool in patients with metastatic disease to identify those patients at highest risk of rapid disease progression and disease-specific mortality, and as an evaluation of posttreatment response following systemic or local therapy of metastatic or locally invasive disease.

The change in the PET scan recommendation is being made because tumors that are PET-scan positive usually cannot be treated with RAI, “so if it's positive [with PET] it would lead the doctor not to use RAI and think of some alternate form of therapy, perhaps surgery or possibly some sort of chemotherapy.”

On the subject of chemotherapy, Dr. Cooper noted that refractory thyroid cancer often does not respond well to standard chemotherapy regimens. “In the old guidelines, we said that when there was nothing else to do, you could use standard chemotherapy; now we're recommending considering the use of newer agents, such as the tyrosine kinase inhibitors sunitinib or sorafenib, or enrolling in a clinical trial. We no longer recommend standard chemotherapy for patients whose cancer is not treatable with radioactive iodine.” No tyrosine kinase inhibitor has yet been approved for thyroid cancer treatment.

Dr. Cooper said he hoped the new guidelines “will change practice and benefit patients with thyroid nodules and thyroid cancer. The main benefit will be in not exposing very-low-risk patients to procedures or therapies that are unlikely to improve outcomes, and reserving more aggressive procedures and therapies for patients with more advanced disease.”

Dr. Cooper said he had no relevant conflicts of interest to declare.

Criteria based on the size and appearance of thyroid nodules on ultrasound will limit the use of biopsies. Nodules larger than 2 cm that have a spongiform appearance (right) should be biopsied.

Source Courtesy Dr. Susan Mandel

Revised thyroid cancer guidelines from the American Thyroid Association call for less use of fine-needle aspiration and of radioiodine, based on evidence that in some circumstances, more treatment did not necessarily yield better outcomes.

Under the new guidelines, “fewer people are going to have a biopsy of their thyroid nodule because we now have ultrasound-based criteria for which nodules should be biopsied, not just based on the size of the nodule but on the way they look on ultrasound,” Dr. David Cooper, chair of the ATA task force that revised the guidelines, said in an interview. Biopsy is warranted for nodules that are greater than 50% cystic and for those larger than 2 cm that have a spongiform appearance. Dr. Cooper discussed the guidelines at the American Thyroid Association meeting in September in Palm Beach, Fla.; they are scheduled to be published in the November issue of Thyroid.

The guidelines also address the use of radioactive iodine (RAI), said Dr. Cooper, professor of medicine at Johns Hopkins University, Baltimore. “We now state that patients who have tumors 1 cm or less should not get RAI. Before, we did not specifically address this situation.”

Patients with multifocal micropapillary thyroid cancers are another group that would not get remnant ablation under the new guidelines. “The idea behind remnant ablation after surgery is that rates of recurrence might be lowered,” explained Dr. Cooper. “But for very small tumors and microtumors, there is no evidence that the rate of recurrence is less if you give RAI than if you don't. Since there's the potential for harm in RAI, we're saying it's not indicated. That's a big shift also.”

For patients who have undergone a total or near-total thyroidectomy for differentiated thyroid cancer, the use of central neck dissection is less definite under the new guidelines. “In the old guidelines [Thyroid 2006;16:109-42], we said patients should be considered for a central neck dissection routinely, because there is a very high rate of metastatic disease,” he said. “But it turns out that when you do that, the complications of the surgery are higher. Now we've toned it down a bit and say that central neck dissection should be done in patients with bigger primary tumors but not if they have a smaller tumor.”

In terms of long-term management for differentiated thyroid cancer patients, the new guidelines also provide advice for management of patients who have not had radioactive iodine remnant ablation. “In patients who have not undergone remnant ablation who are clinically free of disease and have undetectable suppressed serum thyroglobulin and normal neck ultrasound, the serum TSH may be allowed to rise to the low normal range (0.3 to 2 mU/L),” according to the guidelines.

The timing of PET scans is another issue addressed by the guidelines, Dr. Cooper said. Rather than using PET scans to detect residual cancer only after all other methodologies—including empiric RAI therapy—have not revealed a recurrence, “we're now saying, before you do RAI, you may do a PET scan, especially if the serum thyroglobulin is above 10 ng/mL,” he said. The new guidelines recommend that PET scans also may be used as part of initial staging in poorly differentiated thyroid cancers and invasive Hurthle cell carcinomas, as a prognostic tool in patients with metastatic disease to identify those patients at highest risk of rapid disease progression and disease-specific mortality, and as an evaluation of posttreatment response following systemic or local therapy of metastatic or locally invasive disease.

The change in the PET scan recommendation is being made because tumors that are PET-scan positive usually cannot be treated with RAI, “so if it's positive [with PET] it would lead the doctor not to use RAI and think of some alternate form of therapy, perhaps surgery or possibly some sort of chemotherapy.”

On the subject of chemotherapy, Dr. Cooper noted that refractory thyroid cancer often does not respond well to standard chemotherapy regimens. “In the old guidelines, we said that when there was nothing else to do, you could use standard chemotherapy; now we're recommending considering the use of newer agents, such as the tyrosine kinase inhibitors sunitinib or sorafenib, or enrolling in a clinical trial. We no longer recommend standard chemotherapy for patients whose cancer is not treatable with radioactive iodine.” No tyrosine kinase inhibitor has yet been approved for thyroid cancer treatment.

Dr. Cooper said he hoped the new guidelines “will change practice and benefit patients with thyroid nodules and thyroid cancer. The main benefit will be in not exposing very-low-risk patients to procedures or therapies that are unlikely to improve outcomes, and reserving more aggressive procedures and therapies for patients with more advanced disease.”

Dr. Cooper said he had no relevant conflicts of interest to declare.

Criteria based on the size and appearance of thyroid nodules on ultrasound will limit the use of biopsies. Nodules larger than 2 cm that have a spongiform appearance (right) should be biopsied.

Source Courtesy Dr. Susan Mandel

New draft hyperthyroidism treatment guidelines from the American Thyroid Association and the American Association of Clinical Endocrinologists emphasize that although radioactive iodine is a good treatment for the disorder, patients need to consult with their physicians about all three available treatment options: radioactive iodine, surgery, and antithyroid medications, according to Dr. Rebecca Bahn.

“Physicians in the United States have long considered radioactive iodine [RAI] be the preferred treatment for Grave's disease,” Dr. Bahn, chair of the guideline task force, said in an interview. “We're recommending that the patient and the physician have a careful and clear discussion about the three treatment options, and that any of the three options are viable. It's really a decision between the patient and the physician.” Dr. Bahn presented the draft guidelines in September at the annual meeting of the American Thyroid Association in Palm Beach, Fla.

That is not to say that there aren't some situations in which one procedure is preferable to another, said Dr. Bahn, professor of medicine and a consultant in endocrinology at the Mayo Clinic, Rochester, Minn. For example, “pregnant women should not receive radioactive iodine, and patients with medical problems that put them at high risk for surgery should not choose surgery. But our overall recommendation is that the patient and the physician should make the decision following a careful discussion.”

Another major change in the guidelines deals with antithyroid drug therapy. “It used to be that propylthiouracil (PTU) or methimazole could be used interchangeably, but there's now good evidence that there's a very serious hepatic necrosis associated with PTU; it's rare, but it's not at all associated with methimazole,” she said. “So our guidelines will say that if you're going to use antithyroid drugs you should use methimazole except in certain instances.”

On the other hand, women who have Grave's disease that is diagnosed in the first trimester of pregnancy should be started on PTU, because methimazole is associated with certain birth defects, Dr. Bahn said. “Also, if the patient is found to have minor side effects with methimazole, in some cases PTU might be used. But the overall drug of choice in most instances is methimazole.”

In the case of hyperthyroidism caused by nodules, “for definitive treatment we don't recommend antithyroid drugs because the patient would have to be on those essentially forever,” she said. “In some instances, such as patients with a relatively short life expectancy or iodine-induced disease, these medications may be used, but in general, the treatment is surgery or RAI.” In particular, the task force is recommending that for toxic multinodular goiter, near-total or total thyroidectomy should be performed. If the toxic adenoma is in the thyroid isthmus, an ipsilateral thyroid lobectomy or isthmectomy should be performed.

The guidelines also address the treatment of hyperthyroidism in patients with Grave's ophthalmopathy. “For the 50% of Grave's patients who have evidence of mild eye disease, any [Grave's disease] treatment option is fine, but if RAI is chosen, then the physician and patient need to talk about the risk-benefit ratio of using prednisone” for 6-8 weeks to prevent the eye disease from worsening as a result of RAI. Patients who are at higher risk of worsening eye disease include smokers and patients with high anti-TSH receptor antibodies, she said. “They are most likely to progress if not given concurrent steroids.”

Dr. Bahn said she expects the task force will give a final draft of the guidelines to the boards of both the ATA and AACE for their approval in late fall and hopes that the guidelines will be ready for publication in early 2010. Dr. Bahn said she had no conflicts to declare with regard to the guidelines.

New draft hyperthyroidism treatment guidelines from the American Thyroid Association and the American Association of Clinical Endocrinologists emphasize that although radioactive iodine is a good treatment for the disorder, patients need to consult with their physicians about all three available treatment options: radioactive iodine, surgery, and antithyroid medications, according to Dr. Rebecca Bahn.

“Physicians in the United States have long considered radioactive iodine [RAI] be the preferred treatment for Grave's disease,” Dr. Bahn, chair of the guideline task force, said in an interview. “We're recommending that the patient and the physician have a careful and clear discussion about the three treatment options, and that any of the three options are viable. It's really a decision between the patient and the physician.” Dr. Bahn presented the draft guidelines in September at the annual meeting of the American Thyroid Association in Palm Beach, Fla.

That is not to say that there aren't some situations in which one procedure is preferable to another, said Dr. Bahn, professor of medicine and a consultant in endocrinology at the Mayo Clinic, Rochester, Minn. For example, “pregnant women should not receive radioactive iodine, and patients with medical problems that put them at high risk for surgery should not choose surgery. But our overall recommendation is that the patient and the physician should make the decision following a careful discussion.”

Another major change in the guidelines deals with antithyroid drug therapy. “It used to be that propylthiouracil (PTU) or methimazole could be used interchangeably, but there's now good evidence that there's a very serious hepatic necrosis associated with PTU; it's rare, but it's not at all associated with methimazole,” she said. “So our guidelines will say that if you're going to use antithyroid drugs you should use methimazole except in certain instances.”

On the other hand, women who have Grave's disease that is diagnosed in the first trimester of pregnancy should be started on PTU, because methimazole is associated with certain birth defects, Dr. Bahn said. “Also, if the patient is found to have minor side effects with methimazole, in some cases PTU might be used. But the overall drug of choice in most instances is methimazole.”

In the case of hyperthyroidism caused by nodules, “for definitive treatment we don't recommend antithyroid drugs because the patient would have to be on those essentially forever,” she said. “In some instances, such as patients with a relatively short life expectancy or iodine-induced disease, these medications may be used, but in general, the treatment is surgery or RAI.” In particular, the task force is recommending that for toxic multinodular goiter, near-total or total thyroidectomy should be performed. If the toxic adenoma is in the thyroid isthmus, an ipsilateral thyroid lobectomy or isthmectomy should be performed.

The guidelines also address the treatment of hyperthyroidism in patients with Grave's ophthalmopathy. “For the 50% of Grave's patients who have evidence of mild eye disease, any [Grave's disease] treatment option is fine, but if RAI is chosen, then the physician and patient need to talk about the risk-benefit ratio of using prednisone” for 6-8 weeks to prevent the eye disease from worsening as a result of RAI. Patients who are at higher risk of worsening eye disease include smokers and patients with high anti-TSH receptor antibodies, she said. “They are most likely to progress if not given concurrent steroids.”

Dr. Bahn said she expects the task force will give a final draft of the guidelines to the boards of both the ATA and AACE for their approval in late fall and hopes that the guidelines will be ready for publication in early 2010. Dr. Bahn said she had no conflicts to declare with regard to the guidelines.

New draft hyperthyroidism treatment guidelines from the American Thyroid Association and the American Association of Clinical Endocrinologists emphasize that although radioactive iodine is a good treatment for the disorder, patients need to consult with their physicians about all three available treatment options: radioactive iodine, surgery, and antithyroid medications, according to Dr. Rebecca Bahn.

“Physicians in the United States have long considered radioactive iodine [RAI] be the preferred treatment for Grave's disease,” Dr. Bahn, chair of the guideline task force, said in an interview. “We're recommending that the patient and the physician have a careful and clear discussion about the three treatment options, and that any of the three options are viable. It's really a decision between the patient and the physician.” Dr. Bahn presented the draft guidelines in September at the annual meeting of the American Thyroid Association in Palm Beach, Fla.

That is not to say that there aren't some situations in which one procedure is preferable to another, said Dr. Bahn, professor of medicine and a consultant in endocrinology at the Mayo Clinic, Rochester, Minn. For example, “pregnant women should not receive radioactive iodine, and patients with medical problems that put them at high risk for surgery should not choose surgery. But our overall recommendation is that the patient and the physician should make the decision following a careful discussion.”

Another major change in the guidelines deals with antithyroid drug therapy. “It used to be that propylthiouracil (PTU) or methimazole could be used interchangeably, but there's now good evidence that there's a very serious hepatic necrosis associated with PTU; it's rare, but it's not at all associated with methimazole,” she said. “So our guidelines will say that if you're going to use antithyroid drugs you should use methimazole except in certain instances.”

On the other hand, women who have Grave's disease that is diagnosed in the first trimester of pregnancy should be started on PTU, because methimazole is associated with certain birth defects, Dr. Bahn said. “Also, if the patient is found to have minor side effects with methimazole, in some cases PTU might be used. But the overall drug of choice in most instances is methimazole.”

In the case of hyperthyroidism caused by nodules, “for definitive treatment we don't recommend antithyroid drugs because the patient would have to be on those essentially forever,” she said. “In some instances, such as patients with a relatively short life expectancy or iodine-induced disease, these medications may be used, but in general, the treatment is surgery or RAI.” In particular, the task force is recommending that for toxic multinodular goiter, near-total or total thyroidectomy should be performed. If the toxic adenoma is in the thyroid isthmus, an ipsilateral thyroid lobectomy or isthmectomy should be performed.

The guidelines also address the treatment of hyperthyroidism in patients with Grave's ophthalmopathy. “For the 50% of Grave's patients who have evidence of mild eye disease, any [Grave's disease] treatment option is fine, but if RAI is chosen, then the physician and patient need to talk about the risk-benefit ratio of using prednisone” for 6-8 weeks to prevent the eye disease from worsening as a result of RAI. Patients who are at higher risk of worsening eye disease include smokers and patients with high anti-TSH receptor antibodies, she said. “They are most likely to progress if not given concurrent steroids.”

Dr. Bahn said she expects the task force will give a final draft of the guidelines to the boards of both the ATA and AACE for their approval in late fall and hopes that the guidelines will be ready for publication in early 2010. Dr. Bahn said she had no conflicts to declare with regard to the guidelines.

Society Endorses Food Bill

The Endocrine Society has endorsed H.R. 3625, the Food Marketing in Schools Assessment Act. First introduced in 2007 by Rep. Carolyn McCarthy (D-N.Y.) and reintroduced last month, the measure would require the Secretary of Education to assess the nutritional quality of foods and beverages marketed in schools and how they're marketed. The “brand and product logos, names, or information on educational materials; book covers; school supplies; posters; vending machine exteriors; scoreboards; displays; signs; equipment; buses; buildings; and other school property” would be the subjects of a report due by July 1, 2011. “This study will provide insight for policy makers, parents, and school administrators to determine whether the messages directed at school children lead to unhealthy choices and if policies need to be changed,” Dr. Robert Vigersky, president of the Endocrine Society, said in a statement.

Obesity Counseling Found Ineffective

Primary care obesity screening followed by a series of counseling sessions failed to improve body mass index, physical activity, or nutrition in overweight or mildly obese children, a study in the British Medical Journal found. A total of 139 overweight and mildly obese children aged 5–10 years underwent four brief consultations with their physicians over 12 weeks. But compared with that of a control group after 1 year, the intervention group's body mass index had not fallen significantly, the study found. Money might be better spent on obesity-prevention activities at the community and population levels, rather than on individual counseling by primary care physicians, the authors concluded.

Agency Calls for Fee Efficiency

Medicare should review and possibly reduce more fees when physicians provide multiple services to individual patients on the same day, the Government Accountability Office recommended. The GAO said that the Centers for Medicare and Medicaid Services has reduced payments for some imaging and surgical services furnished together, but even those don't reflect physician time saved. “For example, when two services are furnished together, a physician reviews a patient's medical records once, but the time for that activity is generally reflected in fees paid for both services,” the report stated. Expanding payment policies designed to reflect multiple-service efficiencies could save more than $500 million each year, the GAO said.

Doubts on Effectiveness Research

Although comparative effectiveness research may provide better information about what treatments work best, it's not clear that it will result in better health or less spending, according to the RAND Corporation. Its study concluded that new incentives will be needed to change patient and provider behavior. However, federal law prohibits using the results of federally funded comparative effectiveness research to guide payment policies. So it will be hard to develop incentives for driving down health spending, the study said. In the near term, any spending reduction created from such research would be offset by the costs associated with generating, coordinating, and disseminating the findings. “While increasing research aimed at determining the most effective treatments for a wide array of diseases should have benefits, there is not enough evidence at this point to predict exactly what the result might be for the cost of the nation's health care system,” Elizabeth McGlynn of RAND said in a statement.

Boomers Ring Up Big Hospital Bills

U.S. hospitals spent nearly $56 billion caring for baby boomers in 2007, almost as much as on older patients, according to a report from the Agency for Healthcare Research and Quality. The agency reported that baby boomers (adults aged 55–64 years) were similar to adults aged 65–74 years in lengths of hospital stays, costs, and percentages of elective hospitalizations. Overall, baby boomers had 4.7 million hospitalizations in 2007 and accounted for 16% of the total hospital costs in the United States. Coronary atherosclerosis was the most common reason adults aged 55–64 years were hospitalized, accounting for 7.8 hospital stays per 1,000 patients. Osteoporosis ranked second on the list, with 6.9 stays per 1,000 patients.

Society Endorses Food Bill

The Endocrine Society has endorsed H.R. 3625, the Food Marketing in Schools Assessment Act. First introduced in 2007 by Rep. Carolyn McCarthy (D-N.Y.) and reintroduced last month, the measure would require the Secretary of Education to assess the nutritional quality of foods and beverages marketed in schools and how they're marketed. The “brand and product logos, names, or information on educational materials; book covers; school supplies; posters; vending machine exteriors; scoreboards; displays; signs; equipment; buses; buildings; and other school property” would be the subjects of a report due by July 1, 2011. “This study will provide insight for policy makers, parents, and school administrators to determine whether the messages directed at school children lead to unhealthy choices and if policies need to be changed,” Dr. Robert Vigersky, president of the Endocrine Society, said in a statement.

Obesity Counseling Found Ineffective

Primary care obesity screening followed by a series of counseling sessions failed to improve body mass index, physical activity, or nutrition in overweight or mildly obese children, a study in the British Medical Journal found. A total of 139 overweight and mildly obese children aged 5–10 years underwent four brief consultations with their physicians over 12 weeks. But compared with that of a control group after 1 year, the intervention group's body mass index had not fallen significantly, the study found. Money might be better spent on obesity-prevention activities at the community and population levels, rather than on individual counseling by primary care physicians, the authors concluded.

Agency Calls for Fee Efficiency

Medicare should review and possibly reduce more fees when physicians provide multiple services to individual patients on the same day, the Government Accountability Office recommended. The GAO said that the Centers for Medicare and Medicaid Services has reduced payments for some imaging and surgical services furnished together, but even those don't reflect physician time saved. “For example, when two services are furnished together, a physician reviews a patient's medical records once, but the time for that activity is generally reflected in fees paid for both services,” the report stated. Expanding payment policies designed to reflect multiple-service efficiencies could save more than $500 million each year, the GAO said.

Doubts on Effectiveness Research

Although comparative effectiveness research may provide better information about what treatments work best, it's not clear that it will result in better health or less spending, according to the RAND Corporation. Its study concluded that new incentives will be needed to change patient and provider behavior. However, federal law prohibits using the results of federally funded comparative effectiveness research to guide payment policies. So it will be hard to develop incentives for driving down health spending, the study said. In the near term, any spending reduction created from such research would be offset by the costs associated with generating, coordinating, and disseminating the findings. “While increasing research aimed at determining the most effective treatments for a wide array of diseases should have benefits, there is not enough evidence at this point to predict exactly what the result might be for the cost of the nation's health care system,” Elizabeth McGlynn of RAND said in a statement.

Boomers Ring Up Big Hospital Bills

U.S. hospitals spent nearly $56 billion caring for baby boomers in 2007, almost as much as on older patients, according to a report from the Agency for Healthcare Research and Quality. The agency reported that baby boomers (adults aged 55–64 years) were similar to adults aged 65–74 years in lengths of hospital stays, costs, and percentages of elective hospitalizations. Overall, baby boomers had 4.7 million hospitalizations in 2007 and accounted for 16% of the total hospital costs in the United States. Coronary atherosclerosis was the most common reason adults aged 55–64 years were hospitalized, accounting for 7.8 hospital stays per 1,000 patients. Osteoporosis ranked second on the list, with 6.9 stays per 1,000 patients.

Society Endorses Food Bill

The Endocrine Society has endorsed H.R. 3625, the Food Marketing in Schools Assessment Act. First introduced in 2007 by Rep. Carolyn McCarthy (D-N.Y.) and reintroduced last month, the measure would require the Secretary of Education to assess the nutritional quality of foods and beverages marketed in schools and how they're marketed. The “brand and product logos, names, or information on educational materials; book covers; school supplies; posters; vending machine exteriors; scoreboards; displays; signs; equipment; buses; buildings; and other school property” would be the subjects of a report due by July 1, 2011. “This study will provide insight for policy makers, parents, and school administrators to determine whether the messages directed at school children lead to unhealthy choices and if policies need to be changed,” Dr. Robert Vigersky, president of the Endocrine Society, said in a statement.

Obesity Counseling Found Ineffective

Primary care obesity screening followed by a series of counseling sessions failed to improve body mass index, physical activity, or nutrition in overweight or mildly obese children, a study in the British Medical Journal found. A total of 139 overweight and mildly obese children aged 5–10 years underwent four brief consultations with their physicians over 12 weeks. But compared with that of a control group after 1 year, the intervention group's body mass index had not fallen significantly, the study found. Money might be better spent on obesity-prevention activities at the community and population levels, rather than on individual counseling by primary care physicians, the authors concluded.

Agency Calls for Fee Efficiency

Medicare should review and possibly reduce more fees when physicians provide multiple services to individual patients on the same day, the Government Accountability Office recommended. The GAO said that the Centers for Medicare and Medicaid Services has reduced payments for some imaging and surgical services furnished together, but even those don't reflect physician time saved. “For example, when two services are furnished together, a physician reviews a patient's medical records once, but the time for that activity is generally reflected in fees paid for both services,” the report stated. Expanding payment policies designed to reflect multiple-service efficiencies could save more than $500 million each year, the GAO said.

Doubts on Effectiveness Research

Although comparative effectiveness research may provide better information about what treatments work best, it's not clear that it will result in better health or less spending, according to the RAND Corporation. Its study concluded that new incentives will be needed to change patient and provider behavior. However, federal law prohibits using the results of federally funded comparative effectiveness research to guide payment policies. So it will be hard to develop incentives for driving down health spending, the study said. In the near term, any spending reduction created from such research would be offset by the costs associated with generating, coordinating, and disseminating the findings. “While increasing research aimed at determining the most effective treatments for a wide array of diseases should have benefits, there is not enough evidence at this point to predict exactly what the result might be for the cost of the nation's health care system,” Elizabeth McGlynn of RAND said in a statement.

Boomers Ring Up Big Hospital Bills

U.S. hospitals spent nearly $56 billion caring for baby boomers in 2007, almost as much as on older patients, according to a report from the Agency for Healthcare Research and Quality. The agency reported that baby boomers (adults aged 55–64 years) were similar to adults aged 65–74 years in lengths of hospital stays, costs, and percentages of elective hospitalizations. Overall, baby boomers had 4.7 million hospitalizations in 2007 and accounted for 16% of the total hospital costs in the United States. Coronary atherosclerosis was the most common reason adults aged 55–64 years were hospitalized, accounting for 7.8 hospital stays per 1,000 patients. Osteoporosis ranked second on the list, with 6.9 stays per 1,000 patients.

The United States lacks about 3,000 cardiologists, and that shortage will only get worse in the coming years, according to a nationwide study conducted by the American College of Cardiology.

“Our guess is that the deficit in cardiologists is probably going to widen and even double by the time we get to 2030 and 2050,” Dr. George Rodgers, lead author of the study and chair of the ACC Board of Trustees Workforce Task Force, said in a teleconference. “The drivers [of this deficit] are the aging of the population … and the epidemic of obesity and heart disease that follows that, along with diabetes. We feel there is going to be significant worsening there.”

Dr. Rodgers and his colleagues surveyed more than 6,000 office-based cardiology practices, more than 1,000 office-based pediatric cardiology practices, and 110 chiefs of cardiology at academic medical centers to see how many job openings were posted. The Lewin Group, a consulting firm, also projected cardiology workforce needs over the next 20 years based on data from sources including the American Medical Association Masterfile, the Association of American Medical Colleges Over 50 Survey, and the Medicare Part B analysis file. The study was funded by the ACC (J. Am. Coll. Cardiol. 2009;54: 1195–208).

“Today there is an active workforce of 24,000 cardiologists in America; the problem is, we only produce 750–800 new cardiologists every year,” said Dr. Rodgers, who is in private practice in Austin, Tex. “And we have a large portion of the workforce—43%—who are age 55 and over and who might be considering retirement.”

Health care reform is another potential confounder, he said. “We're certainly in favor of health care reform.” But if it succeeds in insuring the estimated 47 million people who now have none, “they'll have better access and create more demand.”

Greater success in treating heart disease and other ailments has increased the need for cardiovascular specialists, Dr. Janet Wright, vice president for science and quality at the college, said during the teleconference. “There has been a 29% reduction in death and disability from heart disease in last 8 years, but that also translates into more and more people managing cardiac problems in addition to other medical issues. The population is living longer but trying to manage more medications and more illnesses, and they need more doctors as well.”

The supply of cardiologists also suffers from racial and gender inequity, Dr. Rodgers said. Hispanics and African Americans make up 25% of the U.S. population, but they accounted for 10% of cardiology fellows in 2006–2007, and women make up 12% of the general cardiology workforce, the study found

Geographic maldistribution problems could be reduced by producing incentives for cardiovascular specialists to want to go to rural and inner-city areas, Dr. Rodgers said, citing financial incentives such as loan forgiveness. “Many physicians end up with debt of over $100,000 because of educational loans,” he said.

Dr. Rodgers offered the following suggestions:

▸ Increase funding for cardiology fellowship slots. “Are there not enough internal medicine residents who want to become cardiologists? That's certainly not the case—for every fellowship position in cardiology there are 1½ eligible candidates,” he said. “And of the 179 [cardiology] fellowship programs in country, most say they could certainly expand, but they don't have the funding to do it. That's a key problem we need to address with Washington.”

▸ Encourage more coordinated care. “Team care and working with nurse practitioners and physician assistants who are trained to deliver care in a cardiovascular environment,” also could ease the situation, he said. “The ACC is working on a core curriculum to supplement the training these professionals have so they can be more adept at cardiovascular care. But we also need to teach cardiologists how to work in a team care environment. That's a little bit of a paradigm shift for many, but we feel this is an underutilized approach.”

▸ Improve work-life balance. “The demand on cardiologists is tremendous—they have night call and weekend call, and they also must be available on a moment's notice to go to the hospital and open up a closed artery when someone is having a heart attack,” he said. This demand can be addressed systematically, for example by having interventional cardiologists coordinate on-call coverage, “but if your community is short with regard to interventional cardiologists, it's a problem.”

The United States lacks about 3,000 cardiologists, and that shortage will only get worse in the coming years, according to a nationwide study conducted by the American College of Cardiology.

“Our guess is that the deficit in cardiologists is probably going to widen and even double by the time we get to 2030 and 2050,” Dr. George Rodgers, lead author of the study and chair of the ACC Board of Trustees Workforce Task Force, said in a teleconference. “The drivers [of this deficit] are the aging of the population … and the epidemic of obesity and heart disease that follows that, along with diabetes. We feel there is going to be significant worsening there.”

Dr. Rodgers and his colleagues surveyed more than 6,000 office-based cardiology practices, more than 1,000 office-based pediatric cardiology practices, and 110 chiefs of cardiology at academic medical centers to see how many job openings were posted. The Lewin Group, a consulting firm, also projected cardiology workforce needs over the next 20 years based on data from sources including the American Medical Association Masterfile, the Association of American Medical Colleges Over 50 Survey, and the Medicare Part B analysis file. The study was funded by the ACC (J. Am. Coll. Cardiol. 2009;54: 1195–208).

“Today there is an active workforce of 24,000 cardiologists in America; the problem is, we only produce 750–800 new cardiologists every year,” said Dr. Rodgers, who is in private practice in Austin, Tex. “And we have a large portion of the workforce—43%—who are age 55 and over and who might be considering retirement.”

Health care reform is another potential confounder, he said. “We're certainly in favor of health care reform.” But if it succeeds in insuring the estimated 47 million people who now have none, “they'll have better access and create more demand.”

Greater success in treating heart disease and other ailments has increased the need for cardiovascular specialists, Dr. Janet Wright, vice president for science and quality at the college, said during the teleconference. “There has been a 29% reduction in death and disability from heart disease in last 8 years, but that also translates into more and more people managing cardiac problems in addition to other medical issues. The population is living longer but trying to manage more medications and more illnesses, and they need more doctors as well.”

The supply of cardiologists also suffers from racial and gender inequity, Dr. Rodgers said. Hispanics and African Americans make up 25% of the U.S. population, but they accounted for 10% of cardiology fellows in 2006–2007, and women make up 12% of the general cardiology workforce, the study found

Geographic maldistribution problems could be reduced by producing incentives for cardiovascular specialists to want to go to rural and inner-city areas, Dr. Rodgers said, citing financial incentives such as loan forgiveness. “Many physicians end up with debt of over $100,000 because of educational loans,” he said.

Dr. Rodgers offered the following suggestions:

▸ Increase funding for cardiology fellowship slots. “Are there not enough internal medicine residents who want to become cardiologists? That's certainly not the case—for every fellowship position in cardiology there are 1½ eligible candidates,” he said. “And of the 179 [cardiology] fellowship programs in country, most say they could certainly expand, but they don't have the funding to do it. That's a key problem we need to address with Washington.”

▸ Encourage more coordinated care. “Team care and working with nurse practitioners and physician assistants who are trained to deliver care in a cardiovascular environment,” also could ease the situation, he said. “The ACC is working on a core curriculum to supplement the training these professionals have so they can be more adept at cardiovascular care. But we also need to teach cardiologists how to work in a team care environment. That's a little bit of a paradigm shift for many, but we feel this is an underutilized approach.”

▸ Improve work-life balance. “The demand on cardiologists is tremendous—they have night call and weekend call, and they also must be available on a moment's notice to go to the hospital and open up a closed artery when someone is having a heart attack,” he said. This demand can be addressed systematically, for example by having interventional cardiologists coordinate on-call coverage, “but if your community is short with regard to interventional cardiologists, it's a problem.”

The United States lacks about 3,000 cardiologists, and that shortage will only get worse in the coming years, according to a nationwide study conducted by the American College of Cardiology.

“Our guess is that the deficit in cardiologists is probably going to widen and even double by the time we get to 2030 and 2050,” Dr. George Rodgers, lead author of the study and chair of the ACC Board of Trustees Workforce Task Force, said in a teleconference. “The drivers [of this deficit] are the aging of the population … and the epidemic of obesity and heart disease that follows that, along with diabetes. We feel there is going to be significant worsening there.”

Dr. Rodgers and his colleagues surveyed more than 6,000 office-based cardiology practices, more than 1,000 office-based pediatric cardiology practices, and 110 chiefs of cardiology at academic medical centers to see how many job openings were posted. The Lewin Group, a consulting firm, also projected cardiology workforce needs over the next 20 years based on data from sources including the American Medical Association Masterfile, the Association of American Medical Colleges Over 50 Survey, and the Medicare Part B analysis file. The study was funded by the ACC (J. Am. Coll. Cardiol. 2009;54: 1195–208).

“Today there is an active workforce of 24,000 cardiologists in America; the problem is, we only produce 750–800 new cardiologists every year,” said Dr. Rodgers, who is in private practice in Austin, Tex. “And we have a large portion of the workforce—43%—who are age 55 and over and who might be considering retirement.”

Health care reform is another potential confounder, he said. “We're certainly in favor of health care reform.” But if it succeeds in insuring the estimated 47 million people who now have none, “they'll have better access and create more demand.”

Greater success in treating heart disease and other ailments has increased the need for cardiovascular specialists, Dr. Janet Wright, vice president for science and quality at the college, said during the teleconference. “There has been a 29% reduction in death and disability from heart disease in last 8 years, but that also translates into more and more people managing cardiac problems in addition to other medical issues. The population is living longer but trying to manage more medications and more illnesses, and they need more doctors as well.”

The supply of cardiologists also suffers from racial and gender inequity, Dr. Rodgers said. Hispanics and African Americans make up 25% of the U.S. population, but they accounted for 10% of cardiology fellows in 2006–2007, and women make up 12% of the general cardiology workforce, the study found

Geographic maldistribution problems could be reduced by producing incentives for cardiovascular specialists to want to go to rural and inner-city areas, Dr. Rodgers said, citing financial incentives such as loan forgiveness. “Many physicians end up with debt of over $100,000 because of educational loans,” he said.

Dr. Rodgers offered the following suggestions:

▸ Increase funding for cardiology fellowship slots. “Are there not enough internal medicine residents who want to become cardiologists? That's certainly not the case—for every fellowship position in cardiology there are 1½ eligible candidates,” he said. “And of the 179 [cardiology] fellowship programs in country, most say they could certainly expand, but they don't have the funding to do it. That's a key problem we need to address with Washington.”

▸ Encourage more coordinated care. “Team care and working with nurse practitioners and physician assistants who are trained to deliver care in a cardiovascular environment,” also could ease the situation, he said. “The ACC is working on a core curriculum to supplement the training these professionals have so they can be more adept at cardiovascular care. But we also need to teach cardiologists how to work in a team care environment. That's a little bit of a paradigm shift for many, but we feel this is an underutilized approach.”

▸ Improve work-life balance. “The demand on cardiologists is tremendous—they have night call and weekend call, and they also must be available on a moment's notice to go to the hospital and open up a closed artery when someone is having a heart attack,” he said. This demand can be addressed systematically, for example by having interventional cardiologists coordinate on-call coverage, “but if your community is short with regard to interventional cardiologists, it's a problem.”