Current Directions in Performance Measurement and Quality Improvement and Uniform Procedure Coding. Statement for hearing of the the Practicing Physicians Advisory Council (PPAC).

Catastrophic Health Insurance and Medical Assistance Reform Act. Testimony given before the Finance Committee, US Senate.

Small Business Pooling Arrangements and Association Health Plans

The Role of the Department of Veterans Affairs in Geriatric Care

Revitalizing Internal Medicine: Recommendations for Resolving Payment and Practice Hassle Issues

Prescription Drug Importation as a Policy Option to Lower the Cost of Medications in the U.S.

Orphan Drug Development

Medicare Private Contracting

Recommendations on Medicare Modernization Act Premium Support: Preparing for a Future of Choice

Medicare Budget Issues. Testimony given before the Congressional Finance Committee.

Xylazine Adulteration of the Heroin–Fentanyl Drug Supply: A Narrative Review: Annals of Internal Medicine: Vol 176, No 10

Xylazine is an animal sedative, approved by the U.S. Food and Drug Administration, that is commonly used in veterinary medicine and is not approved for human use. Since 2016, xylazine has consistently appeared in the illicitly manufactured fentanyl supply and has significantly increased in prevalence, likely due to its low cost, easy availability, and presumed synergistic psychoactive effect. Clinical experience along with the available pertinent research were used to review xylazine adulteration of the drug supply and provide guidance on the care of patients exposed to xylazine. This review discusses xylazine pharmacology, animal and human clinical effects, and what is known to date about care of patients experiencing acute overdose, xylazine–fentanyl withdrawal, and xylazine-associated wounds.

The Pendulum Swings on Glucocorticoids in Rheumatoid Arthritis

Would You Screen This Patient for Cognitive Impairment?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 176, No 10

Dementia, according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, is defined by a significant decline in 1 or more cognitive domains that interferes with a person’s independence in daily activities. Mild cognitive impairment (MCI) differs from dementia in that the impairment is not sufficient to interfere with independence. For the purposes of this discussion, cognitive impairment (CI) includes both dementia and MCI. Various screening tests are available for CI. These tests ask patients to perform a series of tasks that assess 1 or more domains of cognitive function or ask a caregiver to report on the patient’s abilities. A positive result on a screening test does not equate to a diagnosis of CI; rather, it should lead to additional testing to confirm the diagnosis. On review of the evidence, the U.S. Preventive Services Task Force (USPSTF) concluded in 2020 that the evidence was insufficient to assess the balance of benefits and harms of screening for CI in older adults (“I statement”). The USPSTF did clarify that although there is insufficient evidence, there may be important reasons to identify CI. In this article, 2 experts review the available evidence to answer the following questions: What screening tools are available, and how effective are they in identifying patients with CI? What interventions are available for patients found to have CI, to what extent do they improve patient outcomes, and what, if any, negative effects occur? And, would they recommend screening for CI, and why or why not?

Changes in Induced Medical and Procedural Abortion Rates in a Commercially Insured Population, 2018 to 2022: An Interrupted Time-Series Analysis: Annals of Internal Medicine: Vol 176, No 11

Background: During the COVID-19 pandemic, access to in-person care was limited, and regulations requiring in-person dispensing of mifepristone for medical abortions were relaxed. The effect of the pandemic and accompanying regulatory changes on abortion use is unknown. Objective: To estimate changes in the incidence rate of induced medical and procedural abortions. Design: Serial cross-sectional study with interrupted time-series analyses. Setting: Commercially insured persons in the United States. Participants: Reproductive-aged women. Intervention: Onset of the COVID-19 pandemic in March 2020 and subsequent regulatory changes affecting the in-person dispensing requirement for mifepristone. Measurements: Monthly age-adjusted incidence rates of medical and procedural abortions were measured among women aged 15 to 44 years from January 2018 to June 2022. Medical abortions were classified as in-person or telehealth. Linear segmented time-series regression was used to calculate changes in abortion rates after March 2020. Results: In January 2018, the estimated age-adjusted monthly incidence rate of abortions was 151 per million women (95% CI, 142 to 161 per million women), with equal rates of medical and procedural abortions. After March 2020, there was an immediate 14% decrease in the monthly incidence rate of abortions (21 per million women [CI, 7 to 35 per million women]; P = 0.004), driven by a 31% decline in procedural abortions (22 per million women [CI, 16 to 28 per million women]; P < 0.001). Fewer than 4% of medical abortions each month were administered via telehealth. Limitation: Only abortions reimbursed by commercial insurance were measured. Conclusion: The incidence rate of procedural abortions declined during the COVID-19 pandemic, and this lower rate persisted after other elective procedures rebounded to prepandemic rates. Despite removal of the in-person dispensing requirement for mifepristone, the use of telehealth for insurance-covered medical abortions remained rare. Amid increasing state restrictions, commercial insurers have the opportunity to increase access to abortion care, particularly via telehealth. Primary Funding Source: Health Resources and Services Administration.

Clinical Effectiveness of Cognitively Enhanced Tai Ji Quan Training on Global Cognition and Dual-Task Performance During Walking in Older Adults With Mild Cognitive Impairment or Self-Reported Memory Concerns: A Randomized Controlled Trial: Annals of Internal Medicine: Vol 176, No 11

Background: Mild cognitive impairment (MCI) negatively impacts cognition and dual-task abilities. A physical–cognitive integrated treatment approach could mitigate this risk for dementia. Objective: To compare the effectiveness of cognitively enhanced tai ji quan versus standard tai ji quan or stretching exercise in improving global cognition and reducing dual-task walking costs in older adults with MCI or self-reported memory concerns. Design: 3-group, randomized (1:1:1), superiority trial. (ClinicalTrials.gov: NCT04070703) Setting: Community residential homes. Participants: 318 older adults with self-reported memory decline or concern and a Clinical Dementia Rating (CDR) global score of 0.5 or lower at baseline. Intervention: Cognitively enhanced tai ji quan (n = 105), standard tai ji quan (n = 107), or stretching (n = 106). All groups exercised at home via real-time videoconferencing, 1 hour semiweekly for 24 weeks. Measurements: The co–primary endpoints were change in Montreal Cognitive Assessment (MoCA; range, 0 to 30) and dual-task walking costs (difference between single- and dual-task gait speed, expressed in percentage) from baseline to 24 weeks. Secondary outcomes included CDR–Sum of Boxes (CDR-SB), Trail Making Test B, Digit Span Backward (DSB), and physical performance tests. Outcomes were assessed at 16, 24 (primary endpoint), and 48 weeks (6 months after intervention). Results: A total of 304 participants (96%) completed the 24-week assessment. Cognitively enhanced tai ji quan outperformed standard tai ji quan and stretching with a greater improvement in MoCA score (mean difference, 1.5 points [98.75% CI, 0.7 to 2.2 points] and 2.8 points [CI, 2.1 to 3.6 points], respectively) and in dual-task walking (mean difference, 9.9% [CI, 2.8% to 16.6%] and 22% [CI, 13% to 31%], respectively). The intervention effects persisted at 48-week follow-up. Limitation: There was no nonexercise control group; participants had subjective or mild cognitive impairment. Conclusion: Among community-dwelling older adults with MCI, cognitively enriched tai ji quan therapy was superior to standard tai ji quan and stretching exercise in improving global cognition and reducing dual-task gait interference, with outcomes sustained at 48 weeks. Primary Funding Source: National Institute on Aging.

Adoption of Internal Medicine Milestone Ratings and Changes in Bias Against Black, Latino, and Asian Internal Medicine Residents

Background: The 2014 adoption of the Milestone ratings system may have affected evaluation bias against minoritized groups. Objective: To assess bias in internal medicine (IM) residency knowledge ratings against Black or Latino residents—who are underrepresented in medicine (URiM)—and Asian residents before versus after Milestone adoption in 2014. Design: Cross-sectional and interrupted time-series comparisons. Setting: U.S. IM residencies. Participants: 59 835 IM residents completing residencies during 2008 to 2013 and 2015 to 2020. Intervention: Adoption of the Milestone ratings system. Measurements: Pre-Milestone (2008 to 2013) and post-Milestone (2015 to 2020) bias was estimated as differences in standardized knowledge ratings between U.S.-born and non–U.S.-born minoritized groups versus non-Latino U.S.-born White (NLW) residents, with adjustment for performance on the American Board of Internal Medicine IM certification examination and other physician characteristics. Interrupted time-series analysis measured deviations from pre-Milestone linear bias trends. Results: During the pre-Milestone period, ratings biases against minoritized groups were large (−0.40 SDs [95% CI, −0.48 to −0.31 SDs; P < 0.001] for URiM residents, −0.24 SDs [CI, −0.30 to −0.18 SDs; P < 0.001] for U.S.-born Asian residents, and −0.36 SDs [CI, −0.45 to −0.27 SDs; P < 0.001] for non–U.S.-born Asian residents). These estimates decreased to less than −0.15 SDs after adoption of Milestone ratings for all groups except U.S.-born Black residents, among whom substantial (though lower) bias persisted (−0.26 SDs [CI, −0.36 to −0.17 SDs; P < 0.001]). Substantial deviations from pre-Milestone linear bias trends coincident with adoption of Milestone ratings were also observed. Limitations: Unobserved variables correlated with ratings bias and Milestone ratings adoption, changes in identification of race/ethnicity, and generalizability to Milestones 2.0. Conclusion: Knowledge ratings bias against URiM and Asian residents was ameliorated with the adoption of the Milestone ratings system. However, substantial ratings bias against U.S.-born Black residents persisted. Primary Funding Source: None.

Suspected Bronchiectasis and Mortality in Adults With a History of Smoking Who Have Normal and Impaired Lung Function: A Cohort Study: Annals of Internal Medicine: Vol 176, No 10

Background: Bronchiectasis in adults with chronic obstructive pulmonary disease (COPD) is associated with greater mortality. However, whether suspected bronchiectasis—defined as incidental bronchiectasis on computed tomography (CT) images plus clinical manifestation—is associated with increased mortality in adults with a history of smoking with normal spirometry and preserved ratio impaired spirometry (PRISm) is unknown. Objective: To determine the association between suspected bronchiectasis and mortality in adults with normal spirometry, PRISm, and obstructive spirometry. Design: Prospective, observational cohort. Setting: The COPDGene (Genetic Epidemiology of Chronic Obstructive Pulmonary Disease) study. Participants: 7662 non-Hispanic Black or White adults, aged 45 to 80 years, with 10 or more pack-years of smoking history. Participants who were former and current smokers were stratified into normal spirometry (n = 3277), PRISm (n = 986), and obstructive spirometry (n = 3399). Measurements: Bronchiectasis identified by CT was ascertained using artificial intelligence–based measurements of an airway-to-artery ratio (AAR) greater than 1 (AAR >1), a measure of bronchial dilatation. The primary outcome of “suspected bronchiectasis” was defined as an AAR >1 of greater than 1% plus 2 of the following: cough, phlegm, dyspnea, and history of 2 or more exacerbations. Results: Among the 7662 participants (mean age, 60 years; 52% women), 1352 (17.6%) had suspected bronchiectasis. During a median follow-up of 11 years, 2095 (27.3%) died. Ten-year mortality risk was higher in participants with suspected bronchiectasis, compared with those without suspected bronchiectasis (normal spirometry: difference in mortality probability [Pr], 0.15 [95% CI, 0.09 to 0.21]; PRISm: Pr, 0.07 [CI, −0.003 to 0.15]; obstructive spirometry: Pr, 0.06 [CI, 0.03 to 0.09]). When only CT was used to identify bronchiectasis, the differences were attenuated in the normal spirometry (Pr, 0.04 [CI, −0.001 to 0.08]). Limitations: Only 2 racial groups were studied. Only 1 measurement was used to define bronchiectasis on CT. Symptoms of suspected bronchiectasis were nonspecific. Conclusion: Suspected bronchiectasis was associated with a heightened risk for mortality in adults with normal and obstructive spirometry. Primary Funding Source: National Heart, Lung, and Blood Institute.

Fatal Drug Overdose Risks of Health Care Workers in the United States: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 176, No 8

Background: Despite an unprecedented increase in drug overdose deaths in the United States, the risks faced by U.S. health care workers, who often have access to controlled prescription drugs, are not known. Objective: To estimate risks for drug overdose death among health care workers relative to non–health care workers. Design: Prospective cohort study. Setting: United States. Participants: Health care workers (n = 176 000) and non–health care workers (n = 1 662 000) aged 26 years or older surveyed in 2008 and followed for cause of death through 2019. Measurements: Age- and sex-standardized drug overdose deaths were determined for 6 health care worker groups (physicians, registered nurses, other treating or diagnosing health care workers, health technicians, health care support workers, and social or behavioral health workers) and non–health care workers. Adjusted drug overdose death hazards (and 95% CIs) were also evaluated, with adjustment for age, sex, race/ethnicity, marital status, education, income, urban or rural residence, and region. Results: Approximately 0.07% of our study sample died of a drug overdose during follow-up. Among health care workers, annual standardized rates of drug overdose death per 100 000 persons ranged from 2.3 (95% CI, 0 to 4.8) for physicians to 15.5 (CI, 9.8 to 21.2) for social or behavioral health workers. Compared with those for non–health care workers, the adjusted hazards of total drug overdose death were significantly increased for social or behavioral health workers (adjusted hazard ratio, 2.55 [CI, 1.74 to 3.73]), registered nurses (adjusted hazard ratio, 2.22 [CI, 1.57 to 3.13]), and health care support workers (adjusted hazard ratio, 1.60 [CI, 1.19 to 2.16]), but not for physicians (adjusted hazard ratio, 0.61 [CI, 0.19 to 1.93]), other treating or diagnosing health care workers (adjusted hazard ratio, 0.93 [CI, 0.44 to 1.95]), or health technicians (adjusted hazard ratio, 1.13 [CI, 0.75 to 1.68]). Results were generally similar for opioid-related overdose deaths and unintentional overdose deaths. Limitation: Unmeasured confounding, uncertain validity of cause of death, and one-time assessment of occupation. Conclusion: Registered nurses, social or behavioral health workers, and health care support workers were at increased risk for drug overdose death, suggesting the need to identify and intervene on those at high risk. Primary Funding Source: National Heart, Lung, and Blood Institute.

Gabapentinoids and Risk for Severe Exacerbation in Chronic Obstructive Pulmonary Disease: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 177, No 2

Background: North American and European health agencies recently warned of severe breathing problems associated with gabapentinoids, including in patients with chronic obstructive pulmonary disease (COPD), although supporting evidence is limited. Objective: To assess whether gabapentinoid use is associated with severe exacerbation in patients with COPD. Design: Time-conditional propensity score–matched, new-user cohort study. Setting: Health insurance databases from the Régie de l’assurance maladie du Québec in Canada. Patients: Within a base cohort of patients with COPD between 1994 and 2015, patients initiating gabapentinoid therapy with an indication (epilepsy, neuropathic pain, or other chronic pain) were matched 1:1 with nonusers on COPD duration, indication for gabapentinoids, age, sex, calendar year, and time-conditional propensity score. Measurements: The primary outcome was severe COPD exacerbation requiring hospitalization. Hazard ratios (HRs) associated with gabapentinoid use were estimated in subcohorts according to gabapentinoid indication and in the overall cohort. Results: The cohort included 356 gabapentinoid users with epilepsy, 9411 with neuropathic pain, and 3737 with other chronic pain, matched 1:1 to nonusers. Compared with nonuse, gabapentinoid use was associated with increased risk for severe COPD exacerbation across the indications of epilepsy (HR, 1.58 [95% CI, 1.08 to 2.30]), neuropathic pain (HR, 1.35 [CI, 1.24 to 1.48]), and other chronic pain (HR, 1.49 [CI, 1.27 to 1.73]) and overall (HR, 1.39 [CI, 1.29 to 1.50]). Limitation: Residual confounding, including from lack of smoking information. Conclusion: In patients with COPD, gabapentinoid use was associated with increased risk for severe exacerbation. This study supports the warnings from regulatory agencies and highlights the importance of considering this potential risk when prescribing gabapentin and pregabalin to patients with COPD. Primary Funding Source: Canadian Institutes of Health Research and Canadian Lung Association.

Universal Masking in Health Care Settings: A Pandemic Strategy Whose Time Has Come and Gone, For Now

First medication for severe frostbite approved | ACP Hospitalist

Buprenorphine, cannabis, and other periop challenges | ACP Hospitalist

It takes a team to prevent falls | ACP Hospitalist

A path for patients returning after joint replacement | ACP Hospitalist

Bedside sitters, pneumothorax, and more | ACP Hospitalist

Fecal transplants, contrast, and more | ACP Hospitalist

MKSAP quiz on mechanical ventilation | ACP Hospitalist

MKSAP quiz on chest pain | ACP Hospitalist

Expanding the reach of palliative care | ACP Hospitalist

The battle for high-value care | ACP Hospitalist