Public Release: 

Annals of Internal Medicine tip sheet for March 17, 2015

American College of Physicians

1. ACP advises against screening for heart disease in low risk adults

ACP releases High Value Care advice for one of the most common diagnostic tests in the United States

The American College of Physicians (ACP) advises against screening for cardiac disease in adults at low risk for coronary heart disease (CHD) with resting or stress electrocardiography, stress echocardiography, or stress myocardial perfusion imaging. Published in Annals of Internal Medicine, "Cardiac Screening with Electrocardiogram, Stress Echocardiography, or Myocardial Perfusion Imaging," aims to provide physicians with practical advice based on the best available evidence.

Although CHD the single leading cause of death in the United States, the benefits of cardiac screening in low-risk adults have long been questioned, lead author Dr. Roger Chou writes for ACP's High Value Care Task Force. Despite potential harms and insufficient evidence of benefits, cardiac screening tests are still frequently obtained in clinical practice -- and perhaps increasing. Electrocardiography is among the most commonly performed diagnostic tests in the United States.

Health care practices associated with high costs and limited or no benefits provide little value. There is no evidence that cardiac screening of low-risk adults with resting or stress ECG, stress echocardiography, or stress MPI improves patient outcomes, but is associated with potential harms and increased costs.

Rather than screening low risk adults for CHD, physicians should start a cardiovascular risk assessment with a global risk score that combines individual risk factor measurements into a single quantitative estimate of risk. Physicians should focus on strategies for mitigating cardiovascular risk by treating modifiable risk factors such as smoking, diabetes, hypertension, hyperlipidemia, overweight, and encouraging healthy levels of exercise.

ACP's advice does not pertain to patients with symptoms or to athletes for pre-participation screening.

Note: The URL will be live when the embargo lifts. For an embargoed PDF, please contact Megan Hanks. For an interview, please contact Steve Majewski at smajewski@acponline.org or 215-351-2514.

2. Culture-based screening strategy reduced incidence of immigration-related tuberculosis in U.S.

Implementation of the culture-based algorithm may have substantially reduced the incidence of tuberculosis (TB) among newly arrived, foreign-born persons in the United States, according to an article being published in Annals of Internal Medicine. Immigration has a substantial effect on the incidence of TB, so immigrants and refugees bound for the United States are required to have overseas TB screening. Before 2007, a smear-based algorithm that could not diagnose smear-negative/culture-positive TB was used to screen this population. Since then, the Centers for Disease Control and Prevention revised the screening strategy to use a more inclusive culture-based algorithm. Researchers reviewed health records to determine the increase of smear-negative/culture-positive TB cases diagnosed overseas between 2007 and 2012 and compared that figure with the decline of reported TB cases among foreign-born persons within one year after arrival in the United States. The data showed that the increased annual number of TB cases detected in immigrants and refugees closely matched in magnitude a decrease in the number reported TB cases, suggesting that the culture-based algorithm effectively reduced TB incidence.

Note: The URL will be live when the embargo lifts. For an embargoed PDF, please contact Megan Hanks. To speak with an author from the CDC, please contact Candice Burns Hoffmann at hqx5@cdc.gov or 404-547-4670.

3. Two studies examine cost-effectiveness of new hepatitis C treatments

New hep C treatments prove cost-effective for most patients

Compared to usual care, new drug therapies for hepatitis C virus (HCV) are cost-effective for most patients, according to an article published in Annals of Internal Medicine. New therapies for HCV have shorter treatment durations and higher rates of sustained virologic response than existing regimens; however, these new regimens are extremely expensive and the potential patient population is huge. Researchers reviewed published research to compare the cost-effectiveness of standard treatments for HCV to new regimens containing sofosbuvir for treatment-naïve patients with HCV genotype 1, 2, or 3. The researchers found that newer regimens were cost-effective for genotype 1 (about 75 percent of HCV patients) and probably genotype 3, but were not cost-effective for patients with genotype 2. Some regimens could be cost-effective with a sufficient reduction in the cost of sofosbuvir. With a price reduction, new regimens may reduce the cost of HCV treatment over the long term, as well.

Note: The URL will be live when the embargo lifts. For an embargoed PDF or author contact information, please contact Megan Hanks. To interview the lead author, please contact Elaine St. Peter at estpeter@partners.org or 617-525-6375.

At current costs, widespread use of new hep C treatments would strain payers' budgets

New treatments for HCV are cost-effective in most patients, but their use would cost government and private insurers $136 billion over the next 5 years, according to an article published in Annals of Internal Medicine. That cost is $65 billion more than that with the older drugs, without a significant reduction in overall cost of HCV care. New treatment regimens for HCV have proven effective and more tolerable than standard care, yet enthusiasm for the new drugs has been dampened by their costs. Researchers reviewed published literature to evaluate the cost-effectiveness and budget impact of therapy with regimens containing the new drugs (sofosbuvir and ledipasvir). They found that sofosbuvir-ledipasvir would substantially reduce the clinical burden of HCV disease, but treating all eligible patients with HCV in the United States would have an immense budgetary impact. The regimen provides better value for money in patients who have genotype 1 HCV, are in advanced stages of disease, or are younger. The researchers concluded that at current prices for newer regimens, government and private insurers will need additional financial resources or will need to prioritize patients for HCV treatment.

Note: The URL will be live when the embargo lifts. For an embargoed PDF or author contact information, please contact Megan Hanks. To interview the lead author, please contact Katrina Burton at KBurton@mdanderson.org or 713-792-8034.

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