Peripheral Artery Disease Undiagnosed in Primary Care
Nearly half of patients diagnosed with peripheral artery disease (PAD) in the PAD Awareness, Risk, and Treatment: New Resources for Survival (PARTNERS) program had not known previously that they had the disease, according to a report of the trial printed in the September 19, 2001, issue of the Journal of the American Medical Association (2001;286:1317–1324). The study’s authors, who were led by Alan T. Hirsch of the Vascular Medicine Program at the University of Minnesota Medical School, commented: “In as much as PAD affects between 8 and 12 million US residents, effective long-term care of patients with PAD will require increased diagnostic efforts and appropriate medical interventions in community-based, primary care settings to decrease limb-specific symptoms, improve quality of life, and decrease systemic cardiovascular risk.”
The authors screened a total of 6417 patients and found PAD in 29% of them. A total of 55% of those with only PAD were newly diagnosed, and 35% of those with PAD and cardiovascular disease had never before been told that they had the disease. The authors said that their multicenter study, which was conducted at 27 sites in 25 cities and 350 primary care practices through the United States, shows that PAD is easily detected by the measurement of the ankle-brachial index. However, it is frequently not detected in primary care settings. “The high 29% PAD prevalence documented in this community survey supported our hypothesized underdiagnosis, because a new PAD diagnosis was established in approximately half of those with the disease,” they wrote. “These data demonstrate that although more than half of the patients with PAD have leg symptoms, relatively few reported classic Rose claudication.” The authors noted that most asymptomatic patients who have PAD can be diagnosed only by the ankle-brachial index measurement described in the study. Physicians who used only the classic history of claudication to detect the disease may miss 85% to 90% of PAD diagnoses. In addition, patients with PAD are less likely to be treated aggressively with antiplatelet therapy or to receive therapy for hypertension and hyperlipidemia than patients with cardiovascular disease, even though they too are at high risk for ischemic events.
In an accompanying editorial, Kenneth Ouriel, MD, of the Department of Vascular Surgery at the Cleveland Clinic, wrote that the study “is an important reminder for primary care clinicians to be cognizant of PAD and its associated signs and symptoms. The Doppler ankle-brachial index should be added to the diagnostic armamentarium.”
Limited Medicare Reform Predicted This Year
Congress is likely to approve some measures of Medicare reform this year, but broad reform that includes a prescription drug benefit is unlikely, according to the Centers for Medicare and Medicaid Services Administrator Thomas Scully, as reported by CongressDaily in its September 20, 2001, edition. Scully predicted that any fixes passed in Congress this year would be short-term.
He told a National Health Council meeting the short-term fixes to Medicare+Choice would probably be approved, and he predicted that Congress would add funds to the Medicare managed care plans to shore up the program, which has seen considerable defections among insurers. Reductions in the anticipated budget surplus would hinder a Medicare reform bill that would cost extra money.
The Older You Are, the Lower Your Medical Costs in the Last Year of Life
It has been a long-held axiom that the last year of life is the most expensive, but new information published in the September 19, 2001, issue of the Journal of the American Medical Association demonstrates that the cost of medical treatment in the last year of life declined with age (2001;286:1349–1355).
In their study, the authors, who were led by Norman G. Levinsky, MD, of Boston University Medical Center, analyzed sample Medicare data for beneficiaries aged 65 years and older from Massachusetts and California who died in 1996. For those aged 65 through 74, the average expenditures per Massachusetts beneficiary were $35 300 and per California beneficiary, $27 800. However, for those over the age of 85, the average expenditure was $22 000 in Massachusetts and $21 600 in California. “The pattern of decreasing Medicare expenditures with age is pervasive, persisting throughout the last year of life in both states for both sexes, for black and white beneficiaries, for persons with varying levels of comorbidity, and for those receiving hospice versus conventional care, regardless of cause and site of death.”
The authors found that the aggressiveness of care decreased with patient age, regardless of the cause of death, and that decrease in money spent for hospital services was responsible for 80% of the decrease in Medicare expenditures. They noted that the decreasing expenditure pattern may result from decisions made by patients and their families with regard to their desires for aggressive treatment. Or, the decrease in aggressive care may denote a pattern of age discrimination. “Analysis of the clinical care of individuals will be required to separate these possibilities,” noted the authors.
In the Aftermath
In the wake of the tragedies at the World Trade Center and the Pentagon, the American Red Cross collected >330 000 units of blood from people across the nation who wanted to contribute to the recovery. More than 700 000 people called the blood-collecting agency wanting to set up appointments to donate, and another 50 000 registered online at http://www.redcross.org.
The blood collection was far in excess of what was needed in New York and Washington, DC, and it helped to relieve the chronic blood shortage that has plagued the nation in recent year. Officials of the Red Cross are encouraging all people to keep their donation appointments. Much of the collected blood will be frozen to prolong its usefulness. Members of the blood collection community said they hoped the willingness to donate blood would prove a more permanent solution to the blood shortage in the future.
On September 21, 2001, the US Department of Health and Human Services released $35 million in emergency grants to hospitals and other healthcare providers to help cover the expenses related to the World Trade Center disaster on September 11, 2001. The funds are part of $126 million in federal funds being provided to health and social service institutions. Five million dollars of the $35 million is being sent to the New York State Department of Health to give to hospitals right away. In a statement released by the agency, the funds are designated to help cover “extraordinary and potentially debilitating expenses related to disaster response.”