Effect of Social Vulnerability on Efficacy of Bariatric Surgery Versus Medical and Lifestyle Intervention for Type 2 Diabetes: Analysis of the ARMMS-T2D Consortium of Randomized Trials

Background: Social determinants of health (SDOH) can affect metabolic health. Objective: To determine the effect of social vulnerability on the comparative effectiveness of metabolic bariatric surgery or medical and lifestyle intervention on glycemia and weight outcomes in people with type 2 diabetes (T2D). Design: Analysis of the effect modification of baseline Area Deprivation Index (ADI; a metric of social vulnerability) on longitudinal outcomes between randomized treatment groups using linear mixed-effects models. (ClinicalTrials.gov: NCT02328599) Setting: 4 U.S. academic centers. Participants: 258 participants with T2D enrolled in 4 randomized controlled trials of surgical versus medical management and a longitudinal observational follow-up study. Measurements: ADI linked to ZIP code data at randomization; weight loss and hemoglobin A1c (HbA1c) level at the end of the active intervention period (7 to 12 years). Results: Baseline characteristics were well balanced between the surgical and medical therapy groups after adjustment for study site and stratification by high versus low ADI. Surgery was more effective than medical therapy in reducing HbA1c level among persons with high ADI (net difference, −1.29% [95% CI, −1.95% to −0.63%]) and those with low ADI (net difference, −0.95% [CI, −1.29% to −0.62%]). Surgery was also more effective than medical therapy at producing weight loss across ADIs, with respective net differences of −10.6% (CI, −15.2% to −5.9%) for high ADI and −13.3% (CI, −15.7% to −10.9%) for low ADI. The interaction between ADI and intervention group was not significant for either HbA1c (P = 0.37) or weight loss (P = 0.31). Limitations: Small sample size; parent trials were not designed to address effect modification by ADI. Conclusion: Surgery was superior to medical therapy for people with T2D regardless of social deprivation. This study did not detect statistically significant differences in the comparative advantage of surgery over medical therapy by ADI. Primary Funding Source: National Institutes of Health.

Forgiveness

Losing Our Culture

Ensuring Safe Practice by Late Career Physicians: Institutional Policies and Implementation Experiences

Background: Late career physicians (LCPs; physicians working beyond age 65 to 75 years) may be at higher risk for delivering unsafe care. To oversee LCPs, some health care organizations (HCOs) have adopted LCP policies requiring cognitive, physical, and practice performance screening assessments. Despite recent controversies, little is known about the content and implementation of such policies. Objective: To characterize key features of LCP policies and the perspectives of medical leaders responsible for policy development and implementation. Design: Mixed-methods study using content analysis and key informant interviews. Setting: 29 U.S. HCOs with LCP policies active in 2020. Participants: 21 purposively sampled interviewees in physician leadership roles at 18 HCOs. Measurements: Descriptive statistics of policy features and content analysis of interviews. Results: Although policies had many commonalities—mandatory universal screening at a trigger age around 70 years, a strategy of screening followed by in-depth assessment of positive results, and commitment to patient safety as the key motive—they varied substantially in the testing required, funding, processes after a positive screening result, and decision making around concerning results. Policies prioritized institutional discretion in interpreting and responding to test results; many lacked clear language about appeals or other procedural protections for physicians. Leaders were generally satisfied with policies but reported preemptive retirements as physicians approached the screening age and cautioned that substantial investment in cultivating physicians’ buy-in was required for successful rollout. Limitations: Sampled policies and interviews may not be representative of all HCOs. The analysis excluded the experiences of HCOs that tried and failed to implement LCP screening. Conclusion: Policies about LCPs are considered successful by institutional leaders. Policy variations and early adopters’ implementation experiences highlight opportunities to improve physician acceptance and program rigor. Primary Funding Source: The Greenwall Foundation.

Quality Indicators for Pain in Adults: A Review of Performance Measures by the American College of Physicians

Pain is a debilitating symptom generally caused by injuries or various conditions. It can be acute, subacute, or chronic and can have a significant impact on a patient’s quality of life. The goal of managing pain is to relieve or reduce suffering and improve patient functioning. Several performance measures that address the treatment of pain are used in payment, public reporting, or accountability programs. The American College of Physicians (ACP) embraces performance measurement as a means to improve quality of care. ACP believes that a performance measure must be methodologically sound and evidence-based to be considered for inclusion in payment, accountability, or reporting programs. However, a plethora of performance measures that provide minimal or no value to patient care have inundated physicians, practices, and systems with the burden of collecting and reporting data. ACP’s Performance Measurement Committee (PMC) reviews performance measures using a validated process to recognize high-quality performance measures, address gaps and areas for improvement in performance measures, and help reduce reporting burden. There is a need for a higher standard for a performance measure when reputation and reimbursement are on the line. This paper aims to present a review of current performance measures for pain to inform physicians, payers, and policymakers in their selection and use of performance measures. The PMC reviewed 6 performance measures for pain relevant to internal medicine physicians, of which 3 were considered valid at their intended levels of attribution (“Use of Imaging for Low Back Pain,” “Use of Opioids at High Dosage in Persons Without Cancer,” and “Use of Opioids From Multiple Providers in Persons Without Cancer”). This paper also proposes a performance measure concept to address a quality-of-care gap based on the current clinical guideline from ACP and the American Academy of Family Physicians, “Nonpharmacologic and Pharmacologic Management of Acute Pain From Non–low Back, Musculoskeletal Injuries in Adults.”

Qualitative Analysis of Patients’ and Physicians’ Attitudes and Behaviors Toward Billing Patient Portal Messages

Multiple Sclerosis

Many groundbreaking advances have occurred in the field of multiple sclerosis since this series last reviewed the disorder in 2014. The U.S. Food and Drug Administration has approved 7 new medications for relapsing–remitting multiple sclerosis and approved the first medication for primary progressive multiple sclerosis. The McDonald criteria for diagnosing multiple sclerosis were updated in 2017. New blood tests can now differentiate patients with multiple sclerosis from those with neuromyelitis optica spectrum disorder, and 3 new medications have been approved specifically for the latter disorder. Also, new medications for treating the symptoms of multiple sclerosis have been introduced.

Preventing Firearm-Related Death and Injury

Deaths and injuries from firearms are significant public health problems, and clinicians are in a unique position to identify risk among their patients and discuss the importance of safe firearm practices. Although clinicians may be ill-prepared to engage in such discussions, an adequate body of evidence is available for support, and patients are generally receptive to this type of discussion with their physician. Here, we provide an overview of existing research and recommended strategies for counseling and intervention to reduce firearm-related death and injury.

Clostridioides difficile Infection

Clostridioides difficile (formerly Clostridium difficile) infection is the most frequently identified health care–associated infection in the United States. C difficile has also emerged as a cause of community-associated diarrhea, resulting in increased incidence of community-associated infection. Clinical illness ranges in severity from mild diarrhea to fulminant colitis and death. Appropriate management of infection requires understanding of the various diagnostic assays and therapeutic options as well as relevant measures to infection prevention. This article provides updated recommendations regarding the prevention, diagnosis, and treatment of incident and recurrent C difficile infection.

Concussion

Concussions are a common injury for which patients often present first to primary care physicians. They can affect the day-to-day function of patients in school and work, as well as in sports and recreational activities. Recognizing common physical signs and symptoms after injury facilitates timely diagnosis and treatment, permitting initiation of an active management approach to recovery while preventing secondary injury. For persons with persistent symptoms, active rehabilitation may be utilized, with the goal of returning patients to full function.