ACP Comment Letter to CMS on MACRA Proposed Rule

ACP Comments to CMS on the 2019 Quality Payment Program/Physician Fee Schedule Proposed Rule

Formularies and Pharmacy Benefit Management, Reinventing Managed Care Series

Ambulatory Care Formularies and Pharmacy Benefit Management by Managed Care Organizations

Improving the Quality of Care: Clinical Research and Practice Guidelines. Draft - Physician Payment Review Commission. Background Paper for Conference

Results of the General Accounting Office's Examination of Physician Practice Expenses. Testimony given before the Ways and Means Committee, Subcommittee on Health.

Medicare Physician Practice Expense Regulations. Testimony given before the Senate Appropriations Committee's Subcommittee on Labor, Health and Human Services and Education, and related agencies.

Issues that Affect the Delivery of Quality Care to Medicare Beneficiaries. Testimony given to the Subcommittee on Labor, Health and Human Services and Education, Appropriations Senate Committee on Appropriations.

Impact of Resource-based Practice Expenses, Other Physician Payment Issues. Testimony given before the Ways and Means Committee, U.S. House of Representatives.

Statement at the Hearing on Marketing Provision of Privacy under HIPAA

Telehealth for Substance Use Disorders: A Rapid Review for the 2021 U.S. Department of Veterans Affairs and U.S. Department of Defense Guidelines for Management of Substance Use Disorders

Background: Approximately 20.4 million Americans met criteria for a substance use disorder (SUD) in 2019; however, only about 12.2% of persons with an SUD receive specialty care. Telehealth offers alternatives to traditional forms of substance use treatment. Purpose: To synthesize recent findings on the efficacy of telehealth for SUDs. Data Sources: MEDLINE, Embase, PubMed, and the Cochrane Library from January 2015 through August 2021 (English language only). Study Selection: Randomized controlled trials (RCTs) of adults with a diagnosis of SUD based on the Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases. Data Extraction: One investigator abstracted data and assessed study quality, and a second checked for accuracy. Data Synthesis: This rapid review synthesized evidence from 17 RCTs. Evidence is very uncertain that telehealth provided as videoconference therapy (1 RCT) or web-based cognitive behavioral therapy (CBT) (3 RCTs) has similar effects to in-person therapy for improving abstinence from alcohol or cannabis. Low-strength evidence suggests that web-based CBT has similar effects for improving abstinence in multiple SUDs (2 RCTs). Low-strength evidence suggests that adding supportive text messaging to follow-up care improves abstinence and amount of alcohol per day (2 RCTs) but does not improve emergency department visits or frequency of consumption (2 RCTs). Enhanced telephone monitoring likely reduces readmissions for SUD detoxification compared with usual follow-up alone (1 RCT) but does not reduce days of substance use (low-strength evidence). Limitation: Narrative synthesis, heterogeneity of telehealth interventions, no assessment of publication bias, and study methodology. Conclusion: Evidence is very uncertain that telehealth is similar to in-person care for SUD outcomes. Limited evidence suggests some benefit of adding telehealth to usual SUD care. Primary Funding Source: U.S. Department of Veterans Affairs Veterans Health Administration.

Reversing the Tide of Racial and Ethnic Disparities in Excess Deaths During the COVID-19 Pandemic

Characteristics and Outcomes of Hospitalized Pregnant Women With Influenza, 2010 to 2019: A Repeated Cross-Sectional Study: Annals of Internal Medicine: Vol 175, No 2

Background: Pregnant women may be at increased risk for severe influenza-associated outcomes. Objective: To describe characteristics and outcomes of hospitalized pregnant women with influenza. Design: Repeated cross-sectional study. Setting: The population-based U.S. Influenza Hospitalization Surveillance Network during the 2010–2011 through 2018–2019 influenza seasons. Patients: Pregnant women (aged 15 to 44 years) hospitalized with laboratory-confirmed influenza identified through provider-initiated or facility-based testing practices. Measurements: Clinical characteristics, interventions, and in-hospital maternal and fetal outcomes were obtained through medical chart abstraction. Multivariable logistic regression was used to evaluate the association between influenza A subtype and severe maternal influenza-associated outcomes, including intensive care unit (ICU) admission, mechanical ventilation, extracorporeal membrane oxygenation, or in-hospital death. Results: Of 9652 women aged 15 to 44 years and hospitalized with influenza, 2690 (27.9%) were pregnant. Among the 2690 pregnant women, the median age was 28 years, 62% were in their third trimester, and 42% had at least 1 underlying condition. Overall, 32% were vaccinated against influenza and 88% received antiviral treatment. Five percent required ICU admission, 2% required mechanical ventilation, and 0.3% (n = 8) died. Pregnant women with influenza A H1N1 were more likely to have severe outcomes than those with influenza A H3N2 (adjusted risk ratio, 1.9 [95% CI, 1.3 to 2.8]). Most women (71%) were still pregnant at hospital discharge. Among 754 women who were no longer pregnant at discharge, 96% had a pregnancy resulting in live birth, and 3% experienced fetal loss. Limitation: Maternal and fetal outcomes that occurred after hospital discharge were not captured. Conclusion: Over 9 influenza seasons, one third of reproductive-aged women hospitalized with influenza were pregnant. Influenza A H1N1 was associated with more severe maternal outcomes. Pregnant women remain a high-priority target group for vaccination. Primary Funding Source: Centers for Disease Control and Prevention.

Firearm Purchasing During the COVID-19 Pandemic: Results From the 2021 National Firearms Survey

Background: The surge in background checks beginning in March 2020 suggested an acceleration in firearm purchases. Little was known about the people who bought these guns. Objective: To estimate the number and describe characteristics of firearm purchasers over a period spanning prepandemic and pandemic time, characterize new gun owners, and estimate the number of persons newly exposed to household firearms. Design: Probability-based online survey conducted in April 2021. Survey weights generated nationally representative estimates. Setting: United States, 1 January 2019 to 26 April 2021. Participants: 19 049 of 29 985 (64%) English-speaking adults responded to the survey invitation; 5932 owned firearms, including 1933 who had purchased firearms since 2019, of whom 447 had become new gun owners. Measurements: The estimated number and characteristics of adults who, since 2019, have purchased firearms, distinguishing those who became new gun owners from those who did not, and the estimated number of household members newly exposed to firearms. Results: An estimated 2.9% of U.S. adults (7.5 million) became new gun owners from 1 January 2019 to 26 April 2021. Most (5.4 million) had lived in homes without guns, collectively exposing, in addition to themselves, over 11 million persons to household firearms, including more than 5 million children. Approximately half of all new gun owners were female (50% in 2019 and 47% in 2020 to 2021), 20% were Black (21% in 2019 and in 2020–2021), and 20% were Hispanic (20% in 2019 and 19% in 2020–2021). By contrast, other recent purchasers who were not new gun owners were predominantly male (70%) and White (74%), as were gun owners overall (63% male, 73% White). Limitations: Retrospective assessment of when respondents purchased firearms. National estimates about new gun owners were based on 447 respondents. Conclusion: Efforts to reduce firearm injury should consider the recent acceleration in firearm purchasing and the characteristics of new gun owners. Primary Funding Source: The Joyce Foundation.

Effectiveness of Motivational Interviewing in Managing Overweight and Obesity: A Systematic Review and Meta-analysis: Annals of Internal Medicine: Vol 175, No 6

Background: Motivational interviewing (MI) is potentially useful in management of overweight and obesity, but staff training and increased delivery time are barriers, and its effectiveness independent of other behavioral components is unclear. Purpose: To assess the independent contribution of MI as part of a behavioral weight management program (BWMP) in controlling weight and improving psychological well-being. Data Sources: 6 electronic databases and 2 trial registries, searched from database inception through 24 September 2021. Study Selection: Randomized controlled trials in adults or adolescents aimed at weight loss or maintenance and comparing programs incorporating MI versus interventions without MI. Data Extraction: Two reviewers independently screened studies, extracted data, and assessed risk of bias. Outcomes included weight, anxiety, depression, quality of life, and other aspects of psychological well-being. Pooled mean differences or standardized mean differences were obtained using random- and fixed-effects meta-analyses. Data Synthesis: Forty-six studies involving 11 077 participants, predominantly with obesity, were included. At 6 months, BWMPs using MI were more effective than no/minimal intervention (−0.88 [95% CI, −1.27 to −0.48] kg; I 2 = 0%) but were not statistically significantly more effective than lower-intensity (−0.88 [CI, −2.39 to 0.62] kg; I 2 = 55.8%) or similar-intensity (−1.36 [CI, −2.80 to 0.07] kg; I 2 = 18.8%) BWMPs. At 1 year, data were too sparse to pool comparisons with no/minimal intervention, but MI did not produce statistically significantly greater weight change compared with lower-intensity (−1.16 [CI, −2.49 to 0.17] kg; I 2 = 88.7%) or similar-intensity (−0.18 [CI, −2.40 to 2.04] kg; I 2 = 72.7%) BWMPs without MI. Studies with 18-month follow-up were also sparse; MI did not produce statistically significant benefit in any of the comparator categories. There was no evidence of subgroup differences based on study, participant, or intervention characteristics. Too few studies assessed effects on psychological well-being to pool, but data did not suggest that MI was independently effective. Limitations: High statistical heterogeneity among studies, largely unexplained by sensitivity and subgroup analyses; stratification by comparator intensity and follow-up duration resulted in pooling of few studies. Conclusion: There is no evidence that MI increases effectiveness of BWMPs in controlling weight. Given the intensive training required for its delivery, MI may not be a worthwhile addition to BWMPs. Primary Funding Source: National Institute for Health Research Biomedical Research Centre. (PROSPERO: CRD42020177259)

Association Between Socioeconomic Disadvantage and Decline in Function, Cognition, and Mental Health After Critical Illness Among Older Adults: A Cohort Study: Annals of Internal Medicine: Vol 175, No 5

Background: Older adults admitted to an intensive care unit (ICU) are at risk for developing impairments in function, cognition, and mental health. It is not known whether socioeconomically disadvantaged older persons are at greater risk for these impairments than their less vulnerable counterparts. Objective: To evaluate the association between socioeconomic disadvantage and decline in function, cognition, and mental health among older survivors of an ICU hospitalization. Design: Retrospective analysis of a longitudinal cohort study. Setting: Community-dwelling older adults in the National Health and Aging Trends Study (NHATS). Participants: Participants with ICU hospitalizations between 2011 and 2017. Measurements: Socioeconomic disadvantage was assessed as dual-eligible Medicare–Medicaid status. The outcome of function was defined as the count of disabilities in 7 activities of daily living and mobility tasks, the cognitive outcome as the transition from no or possible to probable dementia, and the mental health outcome as the Patient Health Questionnaire-4 score in the NHATS interview after ICU hospitalization. The analytic sample included 641 ICU hospitalizations for function, 458 for cognition, and 519 for mental health. Results: After accounting for sociodemographic and clinical characteristics, dual eligibility was associated with a 28% increase in disability after ICU hospitalization (incidence rate ratio, 1.28; 95% CI, 1.00 to 1.64); and nearly 10-fold greater odds of transitioning to probable dementia (odds ratio, 9.79; 95% CI, 3.46 to 27.65). Dual eligibility was not associated with symptoms of depression and anxiety after ICU hospitalization (incidence rate ratio, 1.33; 95% CI, 0.99 to 1.79). Limitation: Administrative data, variability in timing of baseline and outcome assessments, proxy selection. Conclusion: Dual-eligible older persons are at greater risk for decline in function and cognition after an ICU hospitalization than their more advantaged counterparts. This finding highlights the need to prioritize low-income seniors in rehabilitation and recovery efforts after critical illness and warrants investigation into factors leading to this disparity. Primary Funding Source: National Institute on Aging.

The Race to Understand Post–COVID-19 Conditions

Changes in Health Care Spending, Use, and Clinical Outcomes After Nonfatal Firearm Injuries Among Survivors and Family Members: A Cohort Study: Annals of Internal Medicine: Vol 175, No 6

Background: Despite increasing awareness of firearm-related deaths, evidence on the clinical and economic implications of nonfatal firearm injuries is limited. Objective: To measure changes in clinical and economic outcomes after nonfatal firearm injuries among survivors and their family members. Design: Cohort study. Setting: MarketScan Medicare and commercial claims data, 2008 to 2018. Participants: 6498 survivors of firearm injuries matched to 32 490 control participants and 12 489 family members of survivors matched to 62 445 control participants. Intervention: Exposure to nonfatal firearm injury as a survivor or family member of a survivor. Measurements: Changes in health care spending, use, and morbidity from preinjury through 1 year postinjury relative to control participants, on average and by type and severity of firearm injury. Results: After nonfatal firearm injury, medical spending increased $2495 per person per month (402%) and cost sharing increased $102 per person per month (176%) among survivors relative to control participants (P < 0.001) in the first year after injury, driven by an increase in the first month of $25 554 (4122%) in spending and $1112 (1917%) in cost sharing per survivor (P < 0.001). All categories of health care use increased relative to the control group. Survivors had a 40% increase in pain diagnoses, a 51% increase in psychiatric disorders, and an 85% increase in substance use disorders after firearm injury relative to control participants (P < 0.001), accompanied by increased pain and psychiatric medications. Family members had a 12% increase in psychiatric disorders relative to their control participants (P = 0.003). These overall clinical and economic changes were driven by intentional firearm injuries and more severe firearm injuries. Limitation: Precision of diagnostic codes and generalizability to other patient populations, including Medicaid and uninsured patients. Conclusion: In survivors, nonfatal firearm injuries led to increases in psychiatric disorders, substance use disorders, and pain diagnoses, alongside substantial increases in health care spending and use. In addition, mental health worsened among family members. Primary Funding Source: National Institutes of Health.

How Would You Manage This Male Patient With Hypogonadism?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 174, No 8

Male hypogonadism is defined as an abnormally low serum testosterone concentration or sperm count. As men age, often in the context of obesity and other comorbid conditions, serum testosterone levels may decrease. Normalizing serum testosterone levels in male adults with hypogonadism may improve symptoms related to androgen deficiency, but controversies exist regarding the long-term benefits and risks of hormone supplementation in this setting. In 2020, the American College of Physicians published a clinical guideline for the use of testosterone supplementation in adult men based on a systematic review of available evidence. Among their recommendations were that clinicians discuss whether to initiate testosterone treatment in men with age-related low testosterone with sexual dysfunction who want to improve sexual function and not initiate testosterone treatment in men with age-related low testosterone to improve energy, vitality, physical function, or cognition. Here, two clinicians with expertise in this area, one a generalist and the other an endocrinologist, debate the management of a patient with sexual symptoms and a low serum testosterone level. They discuss the diagnosis of male hypogonadism, the indications for testosterone therapy, its potential benefits and risks, how it should be monitored, and how long it should be continued.

Allopurinol Initiation and All-Cause Mortality Among Patients With Gout and Concurrent Chronic Kidney Disease: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 175, No 4

Background: Two recent randomized clinical trials of escalating doses of allopurinol for the progression of chronic kidney disease (CKD) reported no benefits but potentially increased risk for death. Whether the risk could occur in patients with gout and concurrent CKD remains unknown. Objective: To examine the relation of allopurinol initiation, allopurinol dose escalation, and achieving target serum urate (SU) level after allopurinol initiation to all-cause mortality in patients with both gout and CKD. Design: Cohort study. Setting: The Health Improvement Network U.K. primary care database (2000 to 2019). Participants: Patients aged 40 years or older who had gout and concurrent moderate-to-severe CKD. Measurements: The association between allopurinol initiation and all-cause mortality over 5-year follow-up in propensity score (PS)–matched cohorts was examined. Analysis of hypothetical trials were emulated: achieving target SU level (<0.36 mmol/L) versus not achieving target SU level and dose escalation versus no dose escalation for mortality over 5-year follow-up in allopurinol initiators. Results: Mortality was 4.9 and 5.8 per 100 person-years in 5277 allopurinol initiators and 5277 PS-matched noninitiators, respectively (hazard ratio [HR], 0.85 [95% CI, 0.77 to 0.93]). In the target trial emulation analysis, the HR of mortality for the achieving target SU level group compared with the not achieving target SU level group was 0.87 (CI, 0.75 to 1.01); the HR of mortality for allopurinol in the dose escalation group versus the no dose escalation group was 0.88 (CI, 0.73 to 1.07). Limitation: Residual confounding cannot be ruled out. Conclusion: In this population-based data, neither allopurinol initiation, nor achieving target SU level with allopurinol, nor allopurinol dose escalation was associated with increased mortality in patients with gout and concurrent CKD. Primary Funding Source: Project Program of National Clinical Research Center for Geriatric Disorders.

A quick heart failure stay | ACP Hospitalist

Systemic corticosteroids improved outcomes in CAP, meta-analysis finds | ACP Hospitalist

Midline catheters appear safe in patients with advanced CKD | ACP Hospitalist

ACP addresses ethics of physician fundraising from ‘grateful patients' | ACP Hospitalist

See your hedges | ACP Hospitalist

Look over your hedges | ACP Hospitalist

Hospital antibiograms may not be accurate for selecting initial empiric therapy | ACP Hospitalist

EHR-based intervention reduced repetition of blood typing and screening | ACP Hospitalist

Two-step testing for Clostridioides difficile appears safe in multicenter study | ACP Hospitalist

Higher risk of false-positive HIV test in those testing positive for COVID-19 infection | ACP Hospitalist