Journal Cover Annals of Internal Medicine
  [SJR: 5.378]   [H-I: 318]   [275 followers]  Follow
   Full-text available via subscription Subscription journal
   ISSN (Print) 0003-4819 - ISSN (Online) 1539-3704
   Published by American College of Physicians Homepage  [4 journals]
  • Risk-Targeted Lung Cancer Screening A Cost-Effectiveness Analysis
    • Authors: Kumar V; Cohen JT, van Klaveren D, et al.
      Abstract: Background:Targeting low-dose computed tomography (LDCT) for lung cancer screening to persons at highest risk for lung cancer mortality has been suggested to improve screening efficiency.Objective:To quantify the value of risk-targeted selection for lung cancer screening compared with National Lung Screening Trial (NLST) eligibility criteria.Design:Cost-effectiveness analysis using a multistate prediction model.Data Sources:NLST.Target Population:Current and former smokers eligible for lung cancer screening.Time Horizon:Lifetime.Perspective:Health care sector.Intervention:Risk-targeted versus NLST-based screening.Outcome Measures:Incremental 7-year mortality, life expectancy, quality-adjusted life-years (QALYs), costs, and cost-effectiveness of screening with LDCT versus chest radiography at each decile of lung cancer mortality risk.Results of Base-Case Analysis:Participants at greater risk for lung cancer mortality were older and had more comorbid conditions and higher screening-related costs. The incremental lung cancer mortality benefits during the first 7 years ranged from 1.2 to 9.5 lung cancer deaths prevented per 10 000 person-years for the lowest to highest risk deciles, respectively (extreme decile ratio, 7.9). The gradient of benefits across risk groups, however, was attenuated in terms of life-years (extreme decile ratio, 3.6) and QALYs (extreme decile ratio, 2.4). The incremental cost-effectiveness ratios (ICERs) were similar across risk deciles ($75 000 per QALY in the lowest risk decile to $53 000 per QALY in the highest risk decile). Payers willing to pay $100 000 per QALY would pay for LDCT screening for all decile groups.Results of Sensitivity Analysis:Alternative assumptions did not substantially alter our findings.Limitation:Our model did not account for all correlated differences between lung cancer mortality risk and quality of life.Conclusions:Although risk targeting may improve screening efficiency in terms of early lung cancer mortality per person screened, the gains in efficiency are attenuated and modest in terms of life-years, QALYs, and cost-effectiveness.Primary Funding Source:National Institutes of Health (U01NS086294).
      PubDate: Tue, 06 Feb 2018 00:00:00 GMT
  • Individualized Glycemic Control for U.S. Adults With Type 2 Diabetes A
           Cost-Effectiveness Analysis
    • Authors: Laiteerapong N; Cooper JM, Skandari M, et al.
      Abstract: Background:Intensive glycemic control in type 2 diabetes (glycated hemoglobin [HbA1c] level <7%) is an established, cost-effective standard of care. However, guidelines recommend individualizing goals on the basis of age, comorbidity, diabetes duration, and complications.Objective:To estimate the cost-effectiveness of individualized control versus uniform intensive control (HbA1c level <7%) for the U.S. population with type 2 diabetes.Design:Patient-level Monte Carlo–based Markov model.Data Sources:National Health and Nutrition Examination Survey 2011–2012.Target Population:The approximately 17.3 million persons in the United States with diabetes diagnosed at age 30 years or older.Time Horizon:Lifetime.Perspective:Health care sector.Intervention:Individualized versus uniform intensive glycemic control.Outcome Measures:Average lifetime costs, life-years, and quality-adjusted life-years (QALYs).Results of Base-Case Analysis:Individualized control saved $13 547 per patient compared with uniform intensive control ($105 307 vs. $118 854), primarily due to lower medication costs ($34 521 vs. $48 763). Individualized control decreased life expectancy (20.63 vs. 20.73 years) due to an increase in complications but produced more QALYs (16.68 vs. 16.58) due to fewer hypoglycemic events and fewer medications.Results of Sensitivity Analysis:Individualized control was cost-saving and generated more QALYs compared with uniform intensive control, except in analyses where the disutility associated with receiving diabetes medications was decreased by at least 60%.Limitation:The model did not account for effects of early versus later intensive glycemic control.Conclusion:Health policies and clinical programs that encourage an individualized approach to glycemic control for U.S. adults with type 2 diabetes reduce costs and increase quality of life compared with uniform intensive control. Additional research is needed to confirm the risks and benefits of this strategy.Primary Funding Source:National Institute of Diabetes and Digestive and Kidney Diseases.
      PubDate: Tue, 06 Feb 2018 00:00:00 GMT
  • Improving Decisions About Transport to the Emergency Department for
           Assisted Living Residents Who Fall
    • Authors: Williams JG; Bachman MW, Lyons MD, et al.
      Abstract: Background:Residents of assisted living facilities who fall may not be seriously ill or injured, but policies often require immediate transport to an emergency department regardless of the patient's condition.Objective:To determine whether unnecessary transport can be avoided.Design:Prospective cohort study.Setting:One large county with a single system of emergency medical services.Participants:Convenience sample of residents in 22 assisted living facilities served by 1 group of primary care physicians.Intervention:Paramedics providing emergency medical services followed a protocol that included consulting with a physician by telephone.Measurements:The number of transports after a fall and the number of time-sensitive conditions in nontransported patients.Results:Of the 1473 eligible residents, 953 consented to participate in the study (mean age, 86 years; 76% female) and 359 had 840 falls in 43 months. The protocol recommended nontransport after 553 falls. Eleven of these patients had a time-sensitive condition. At least 7 of them received appropriate care: 4 requested and received transport despite the protocol recommendation, and 3 had minor injuries that were successfully managed on site. Three additional patients had fractures that were diagnosed by outpatient radiography. The final patient developed vomiting and diarrhea, started palliative care, and died 60 hours after the fall. At least 549 of the 553 patients (99.3% [95% CI, 98.2% to 99.8%]) with a protocol recommendation for nontransport received appropriate care.Limitation:The resources required for this program will preclude use in some locations.Conclusion:Shared decision making between paramedics and primary care physicians can prevent transport to the emergency department for many residents of assisted living facilities who fall.Primary Funding Source:None.
      PubDate: Tue, 06 Feb 2018 00:00:00 GMT
  • Associations Between Marijuana Use and Cardiovascular Risk Factors and
           Outcomes A Systematic Review
    • Authors: Ravi D; Ghasemiesfe M, Korenstein D, et al.
      Abstract: Background:Marijuana use is increasing in the United States, and its effect on cardiovascular health is unknown.Purpose:To review harms and benefits of marijuana use in relation to cardiovascular risk factors and clinical outcomes.Data Sources:PubMed, MEDLINE, EMBASE, PsycINFO, and the Cochrane Library between 1 January 1975 and 30 September 2017.Study Selection:Observational studies that were published in English, enrolled adults using any form of marijuana, and reported on vascular risk factors (hyperglycemia, diabetes, dyslipidemia, and obesity) or on outcomes (stroke, myocardial infarction, cardiovascular mortality, and all-cause mortality in cardiovascular cohorts).Data Extraction:Study characteristics and quality were assessed by 4 reviewers independently; strength of evidence for each outcome was graded by consensus.Data Synthesis:13 and 11 studies examined associations between marijuana use and cardiovascular risk factors and clinical outcomes, respectively. Although 6 studies suggested a metabolic benefit from marijuana use, they were based on cross-sectional designs and were not supported by prospective studies. Evidence examining the effect of marijuana on diabetes, dyslipidemia, acute myocardial infarction, stroke, or cardiovascular and all-cause mortality was insufficient. Although the current literature includes several long-term prospective studies, they are limited by recall bias, inadequate exposure assessment, minimal marijuana exposure, and a predominance of low-risk cohorts.Limitation:Poor- or moderate-quality data, inadequate assessment of marijuana exposure and minimal exposure in the populations studied, and variation in study design.Conclusion:Evidence examining the effect of marijuana on cardiovascular risk factors and outcomes, including stroke and myocardial infarction, is insufficient.Primary Funding Source:National Heart, Lung, and Blood Institute. (PROSPERO: CRD42016051297)
      PubDate: Tue, 06 Feb 2018 00:00:00 GMT
  • Provider Types and Outcomes in Obstructive Sleep Apnea Case Finding and
           Treatment A Systematic Review
    • Authors: Kunisaki KM; Greer N, Khalil W, et al.
      Abstract: Background:Obstructive sleep apnea (OSA) diagnosis and care models rely on sleep specialist physicians (SSPs) and can be expensive and inefficient.Purpose:To assess OSA case-finding accuracy and comparative effectiveness of care by non–sleep specialists (NSSs) and SSPs.Data Sources:MEDLINE and CINAHL from January 2000 through July 2017.Study Selection:English-language trials or observational studies comparing case finding or care by SSPs versus providers not specifically trained as SSPs (NSSs) for adults with suspected or diagnosed OSA.Data Extraction:One investigator extracted data and assessed risk of bias and strength of evidence, with confirmation by a second investigator. Primary outcomes were patient-centered (mortality, access to care, quality of life, patient satisfaction, adherence, symptom scores, and adverse events). Intermediate outcomes included resource use, costs, time to initiation of treatment, and case finding.Data Synthesis:Four observational studies (n = 580; mean age, 52 years; 77% male) reported good agreement between NSSs and SSPs on appropriate diagnostic testing and classification of OSA severity (low-strength evidence). Five randomized trials and 3 observational studies (n = 1515; mean age, 52 years; 68% male) found that care provided by NSSs and SSPs resulted in similar quality of life, adherence, and symptom scores (low-strength evidence). Evidence was insufficient for access to care and adverse events.Limitations:Many outcomes were reported infrequently or not at all. Many NSSs had extensive training or experience in sleep medicine, which limits generalizability of findings to providers with less experience.Conclusion:Care by NSSs and SSPs resulted in similar outcomes in adults with known or suspected OSA. Studies are needed to determine care model implementation and reproducibility of results in nonacademic settings and among less experienced NSSs.Primary Funding Source:Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative. (PROSPERO: CRD42016036810 [full Veterans Affairs Evidence-based Synthesis Program report])
      PubDate: Tue, 06 Feb 2018 00:00:00 GMT
  • Should This Patient Receive Hormone Therapy for Her Menopausal
           Symptoms' Grand Rounds Discussion From Beth Israel Deaconess Medical
    • Authors: Reynolds EE; Bates C, Richardson M, et al.
      Abstract: Hormone therapy (HT) was widely prescribed in the 1980s and 1990s and has been controversial since the initial results of the Women's Health Initiative (WHI) trial in the early 2000s suggested that it increased risk for breast cancer and coronary heart disease and did not prolong life. However, more recent data and reexamination of the WHI results suggest that HT is safe and effective for many women when used around the time of menopause. Two experts debate the 2017 Hormone Therapy Position Statement of The North American Menopause Society, which recommends HT as first-line treatment of vasomotor symptoms, and apply it to the care of Ms. R, a 52-year-old woman with severe hot flashes, sleep disturbance, and irritability.
      PubDate: Tue, 06 Feb 2018 00:00:00 GMT
  • Recommended Immunization Schedule for Adults Aged 19 Years or Older,
           United States, 2018*
    • Authors: Kim DK; Riley LE, Hunter P, et al.
      Abstract: The Advisory Committee on Immunization Practices (ACIP) presents the recommended Immunization Schedule for Adults Aged 19 Years or Older for 2018. This schedule has been approved by the ACIP, American College of Physicians, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, and American College of Nurse-Midwives.
      PubDate: Tue, 06 Feb 2018 00:00:00 GMT
  • Opportunities and Challenges in Genomic Sequencing for Precision Cancer
    • Authors: Cheng ML; Solit DB.
      Abstract: Cancer is defined by diverse somatic and germline alterations that promote aberrant cell growth. Tumor genomic profiling to guide therapy is now part of standard management in several solid tumor types. The authors discuss how recent technical advances in next-generation sequencing technology, coupled with decreasing costs, present an opportunity to improve patient outcomes through routine, prospective tumor and germline genomic profiling.
      PubDate: Tue, 06 Feb 2018 00:00:00 GMT
  • Model-Based Eligibility for Lung Cancer Screening: Where Theory Meets
    • Authors: Green AK; Bach P.
      Abstract: Cheung and colleagues argue for moving from lung cancer screening based on the National Lung Screening Trial eligibility criteria toward risk-based testing, and Kumar and colleagues examine the cost-effectiveness of risk-based screening. The editorialists discuss the findings of these studies and note that regardless of the criteria used to identify persons for testing, lung cancer screening remains woefully underutilized.
      PubDate: Tue, 06 Feb 2018 00:00:00 GMT
  • Improving Care for Ground-Level Falls in Assisted Living
    • Authors: Growdon ME; Inouye SK.
      Abstract: Williams and colleagues' prospective cohort study examined an intervention to avoid unnecessary transport to the emergency department for residents in assisted living facilities who fall. The editorialists discuss the findings and conclude that the study provides an example of a much-needed health care innovation pushing our health system toward the triple aim of improving patient experience and population health and reducing costs of care.
      PubDate: Tue, 06 Feb 2018 00:00:00 GMT
  • Long Coat Doctor
    • Authors: Bertram PD.
      Abstract: The letter was on my desk when I returned from lunch. Although the envelope was unremarkable, the name on the return address caught my attention and unlocked a distant memory.
      PubDate: Tue, 06 Feb 2018 00:00:00 GMT
  • Racial Differences in the Relationship of Glucose Concentrations and
           Hemoglobin A 1c Levels
    • Authors: Garg R.
      PubDate: Tue, 06 Feb 2018 00:00:00 GMT
  • Racial Differences in the Relationship of Glucose Concentrations and
           Hemoglobin A 1c Levels
    • Authors: Bergenstal RM; Gal RL, Beck RW.
      PubDate: Tue, 06 Feb 2018 00:00:00 GMT
  • Implantable Cardioverter-Defibrillators for Primary Prevention in Patients
           With Ischemic or Nonischemic Cardiomyopathy
    • Authors: Littmann L.
      PubDate: Tue, 06 Feb 2018 00:00:00 GMT
  • Implantable Cardioverter-Defibrillators for Primary Prevention in Patients
           With Ischemic or Nonischemic Cardiomyopathy
    • Authors: Shah R.
      PubDate: Tue, 06 Feb 2018 00:00:00 GMT
  • Implantable Cardioverter-Defibrillators for Primary Prevention in Patients
           With Ischemic or Nonischemic Cardiomyopathy
    • Authors: Kołodziejczak M; Andreotti F, Navarese E.
      PubDate: Tue, 06 Feb 2018 00:00:00 GMT
  • MACRA: Big Fix or Big Problem'
    • Authors: Huffstutter J.
      PubDate: Tue, 06 Feb 2018 00:00:00 GMT
  • MACRA: Big Fix or Big Problem'
    • Authors: McWilliams J.
      PubDate: Tue, 06 Feb 2018 00:00:00 GMT
  • Correction: On the Communicability of Chronic Diseases
    • PubDate: Tue, 06 Feb 2018 00:00:00 GMT
  • Ezekiel
    • Authors: DePew R.
      PubDate: Tue, 06 Feb 2018 00:00:00 GMT
  • Cellulitis and Soft Tissue Infections
    • Authors: Bystritsky R; Chambers H.
      Abstract: Cellulitis and soft tissue infections are a diverse group of diseases that range from uncomplicated cellulitis to necrotizing fasciitis. Management of predisposing conditions is the primary means of prevention. Cellulitis is a clinical diagnosis and thus is made on the basis of history and physical examination. Imaging may be helpful for characterizing purulent soft tissue infections and associated osteomyelitis. Treatment varies according to the type of infection. The foundations of treatment are drainage of purulence and antibiotics, the latter targeted at the infection's most likely cause.
      PubDate: Tue, 06 Feb 2018 00:00:00 GMT
  • Annals Graphic Medicine - Memento Mori
    • Authors: Dueck K.
      PubDate: Tue, 06 Feb 2018 00:00:00 GMT
  • Cost-Effectiveness of Individualized Management of Diabetes Among U.S.
    • PubDate: Tue, 06 Feb 2018 00:00:00 GMT
  • Transport to the Emergency Department for Assisted Living Residents Who
    • PubDate: Tue, 06 Feb 2018 00:00:00 GMT
  • Systemic Infection With Dirofilaria repens in Southwestern France
    • Authors: Blaizot R; Receveur M, Millet P, et al.
      PubDate: Tue, 06 Feb 2018 00:00:00 GMT
  • Preventing Lung Cancer Mortality by Computed Tomography Screening: The
           Effect of Risk-Based Versus U.S. Preventive Services Task Force
           Eligibility Criteria, 2005–2015
    • Authors: Cheung LC; Katki HA, Chaturvedi AK, et al.
      PubDate: Tue, 06 Feb 2018 00:00:00 GMT
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