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Medicare coverage leads to more
screening
After 10 years of research, a
rare skin disease is traced to a chemical used in MRIs
Et cetera
Higher risk for cardiac patients
HIV screening should be routine
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Medicare coverage
leads to more screening
With a change in federal policy, the number of early diagnoses of colon
cancer has risen.
The expansion of Medicare in 1998 to cover colonoscopies appears to
have led to both an increase in demand for the screening procedure and
a rise in early-stage colon cancer diagnoses, according to a study by
Yale researchers.
“We found that after the Medicare policy change, the use of colonoscopies
went up and there was a corresponding increase in the likelihood that
patients with colon cancer would be diagnosed at an early, curable stage,”
said lead investigator Cary P. Gross, M.D., associate professor of medicine.
His study appeared in the December 20 issue of JAMA: The Journal
of the American Medical Association.
In 1998 the Medicare reimbursement policy was changed to cover the procedure,
which costs roughly $800, for older patients with increased colon cancer
risk. The policy was expanded again in 2001 to cover colonoscopy screenings
for everyone 65 and older.
As a general internist at the Primary Care Center at Yale-New Haven Hospital,
Gross sees firsthand how reluctant patients are to undergo a colonoscopy.
“I thought it was important to test the assumption that reimbursement
had been a major barrier to obtaining a colonoscopy,” he said.
The researchers studied patients in the Surveillance, Epidemiology and
End Results Medicare-linked database between 1992 and 2002. They adjusted
for such factors as the increasing awareness of colon cancer screening
during the study period, given the high-profile efforts of TV anchorwoman
Katie Couric to draw attention to the importance of the procedure with
an on-air colonoscopy in March 2000. (Couric’s husband had died
of colon cancer two years earlier.)
Gross’ team found that the new Medicare policies were associated
with a substantial increase in colonoscopy use among beneficiaries without
cancer, as well as an increased likelihood of early diagnosis for patients
who developed cancer. Before Medicare started covering the screening
procedure, 22.5 percent of Medicare beneficiaries who developed colon
cancer were diagnosed at an early stage. After Medicare began providing
coverage for older at-risk patients, that number rose to 25.5 percent.
When coverage was expanded again, to include all Medicare recipients
over 65, 26.3 percent of patients diagnosed with colon cancer were diagnosed
at an early stage.
“Our analysis suggests that the new Medicare policy was associated
with improved health by identifying more patients with early-stage disease,”
Gross said. But he was quick to add that, despite these encouraging signs,
nearly three-quarters of all patients diagnosed with colon cancer still
receive the diagnosis after the disease has spread beyond the early stage.
Although his study suggests that cost had been a barrier for some patients,
Gross said it also showed that “the new reimbursement policy was
not a sufficient intervention to alter the decision process about having
a colonoscopy for many older people.”
Noting that colonoscopies can also prevent colon cancer by removing precancerous
lesions, Gross said the next step is to assess the impact of Medicare
colonoscopy reimbursement on the incidence of colon cancer and to develop
strategies to increase the use of screening colonoscopies at the population
level.
—Jennifer Kaylin
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After 10 years of
research, a rare skin disease is traced to a chemical used in MRIs
In 1997 investigators in California came across a mysterious skin disease.
It often started with redness of the skin and warmth, but as it progressed,
the skin swelled, tightened and turned brown, becoming almost “woody.”
The unnamed disease led to disability, reduced mobility of the joints
and could be fatal.
After almost 10 years of research, Shawn E. Cowper, M.D., assistant professor
of dermatology and pathology, has provided additional evidence that the
disorder affects a small number of patients with kidney disease who undergo
magnetic resonance imaging (MRI) scans with contrast. The disease that
he identified in 2001, with Philip LeBoit, M.D., of the University of
California, San Francisco, is now called nephrogenic systemic fibrosis
(NSF). Cowper started a registry of the disease that now numbers about
235 cases.
At first Cowper thought the disorder affected only the skin. It turns
out that it is mediated by a cell involved in wound healing that was
originally identified in 1992 by Richard Bucala, M.D., Ph.D., professor
of medicine (rheumatology), pathology and epidemiology (microbial diseases).
While pondering its causes, Cowper noticed that most of the patients
in his registry had undergone vascular imaging. Working with investigators
in Bridgeport, Conn., he examined the records of 467 patients receiving
dialysis. Three developed NSF following MRI, and all three had received
the contrast agent gadolinium. Another 84 patients received gadolinium
but did not develop the disease. In March, Cowper published a study in
the Clinical Journal of the American Society of Nephrology,
linking gadolinium to NSF, which occurs only in patients with advanced
kidney disease.
Based on Cowper’s work and a Danish study, the Food and Drug Administration
issued a public health advisory last year warning of the dangers to kidney
patients who receive a contrast-enhanced MRI. “What’s really
key now, and what everybody is excited about finding, is what makes these
3 percent different than the other 97 percent who have renal failure
and have been exposed to gadolinium without developing NSF,” said
Cowper.
Understanding the mechanism behind NSF may explain why it occurs. In
contrast agents, gadolinium is bound to a chelate, a molecule that keeps
it from interacting with the body and allows it to be quickly eliminated
by the kidneys. But patients with advanced kidney disease can’t
efficiently rid themselves of such toxins as gadolinium, which may build
up, dissociate from the chelate and do damage.
Unfortunately, all contrast agents used for routine MRIs in the United
States contain gadolinium. Kidney patients who must undergo an MRI with
contrast are advised to undergo dialysis immediately afterward, but no
one is certain that this will decrease the chances of developing NSF.
“There are a lot of questions that need to be answered before anyone
declares this disease gone, or even this technique safe,” said
Cowper.
—Jill Max
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et cetera
Higher risk for cardiac patients
About a third of heart attack patients also have an active, noncardiac
condition that could warrant admission to the hospital, Yale researchers
reported in the American Journal of Medicine in October. And
patients who have acute conditions such as stroke, kidney failure and
pneumonia may have poorer outcomes, according to first author Judith
H. Lichtman, M.P.H. ’88, Ph.D., assistant professor of epidemiology.
“Relatively little is known about the care and outcomes of heart
attack patients who arrive at the hospital with an additional, active
noncardiac condition.
Lichtman and colleagues studied 1,145 patients with acute myocardial
infarction who were discharged from Yale-New Haven Hospital between January
1997 and June 2000, and rated the additional noncardiac conditions in
these patients by severity. Life-threatening conditions included active
bleeding, major stroke, metastatic cancer, abdominal aortic aneurysm
rupture, acute psychosis, major trauma and others.
“More research is needed to describe these complex patients to
identify opportunities to improve their clinical management,” said
Lichtman.
—John Curtis
HIV screening should be routine
Voluntary screening for HIV should be routine for all adults, not just
those at high risk, according to a study by Yale researchers. The team
reports in the December 5 issue of the Annals of Internal Medicine that
routine HIV screening is cost-effective, even in communities where as
few as two in 1,000 people have undiagnosed HIV infection. Early identification
of HIV leads to better health outcomes and longer life expectancies in
HIV-infected persons.
The study provides strong support for the Centers for Disease Control
and Prevention guidelines issued in September 2006 that recommend routine
HIV screening of all persons age 13 to 64 in all health care settings.
“Early identification of HIV saves lives,” said principal
investigator A. David Paltiel, M.P.P.M., Ph.D., professor of public health
and management sciences.
—J.C.
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