Beyond the Discharge: Principles of Effective Care Transitions Between Settings

ACP Comments to HITPC-Stage 3 MU-Cover Letter

ACP Response to the Senate HELP Committee on Lowering Health Care Costs

Strengthening the Public Health Infrastructure

State Experimentation with Reforms to Expand Access to Healthcare

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

How is the Shortage of Primary Care Physicians Affecting the Quality and Cost of Medical Care?

No Health Insurance? It's Enough to Make You Sick: Scientific Research Linking the Lack of Health Coverage to Poor Health.

Addressing the Increasing Burden of Health Insurance Cost Sharing

Financing Long-Term Care

How Would You Manage This Patient With Heart Failure With Preserved Ejection Fraction?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 176, No 12

The proportion of patients with new-onset heart failure who have preserved rather than reduced left ventricular ejection fraction (HFpEF and HFrEF) has been increasing over recent decades. In fact, HFpEF now outweighs HFrEF as the predominant heart failure subtype and likely remains underdiagnosed in the community. This is due in part to an aging population and a rise in other risk factors for HFpEF, including obesity and associated cardiometabolic disease. Whereas the diagnosis of HFrEF is relatively straightforward, the diagnosis of HFpEF is often more challenging because there can be other causes for symptoms, including dyspnea and fatigue, and cardinal physical examination findings of elevated jugular venous pressure or pulmonary congestion may not be evident at rest. In 2022, the American College of Cardiology, the American Heart Association, and the Heart Failure Society of America published a comprehensive guideline on heart failure that included recommendations for the management of HFpEF. The use of diuretics for the management of congestion remained the only class 1 (strong) recommendation. New recommendations included broader use of sodium–glucose cotransporter-2 inhibitors (SGLT2i, class 2a), and angiotensin receptor–neprilysin inhibitors (class 2b). In 2023, the American College of Cardiology published an expert consensus decision pathway for the management of HFpEF that suggests treatment strategies based on sex assigned at birth, ejection fraction, clinical evidence of congestion, and candidacy for SGLT2i therapy. Here, 2 experts, a cardiologist and a geriatrician, discuss their approach to the diagnosis and management of HFpEF and how they would apply guidelines to an individual patient.

The Integration of Care for Mental Health, Substance Abuse, and Other Behavioral Health Conditions Into Primary Care

Efficacy of a Very-Low-Calorie Weight Loss Diet Plus Exercise Compared With Exercise Alone on Hip Osteoarthritis Pain: A Randomized Controlled Trial: Annals of Internal Medicine: Vol 178, No 9

Background: Exercise is recommended to manage hip osteoarthritis, but weight loss recommendations are conflicting. Objective: To evaluate the efficacy of a weight loss diet added to exercise on change in hip pain. Design: 2-group superiority randomized trial. (ClinicalTrials.gov: NCT04825483) Setting: Community. Participants: 101 adults with hip osteoarthritis and overweight or obesity. Intervention: Both the exercise only group and very-low-calorie diet (VLCD) plus exercise group were provided with a 6-month home exercise program via 5 telehealth consultations. The VLCD plus exercise group also received a VLCD via 6 telehealth consultations. Measurements: The primary outcome was 6-month change in hip pain severity (11-point scale; range 0 to 10, with higher scores indicating worse pain; minimum clinically important difference of 1.8). Secondary end points included other measures of hip pain, physical function, quality of life, body weight, body composition, and adverse events. Results: 99 (98%) and 95 (94%) participants provided 6- and 12-month primary outcomes, respectively. Although VLCD plus exercise lost 8.5% more weight than exercise only, VLCD plus exercise was not more effective for change in hip pain severity (mean difference, −0.6 units [95% CI, −1.5 to 0.3]) at 6 months. Between-group differences for other secondary outcomes at 6 months favored VLCD plus exercise except Hip Disability and Osteoarthritis Outcome Score (HOOS) pain and function. At 12 months, weight, body mass index, HOOS pain and function, and overall hip improvement, but not quality of life and physical activity, favored VLCD plus exercise. There were no serious related adverse events. Limitation: Participants were unblinded. Conclusion: Adding a weight loss diet to exercise did not change hip pain but improved most secondary outcomes. Primary Funding Source: National Health and Medical Research Council.

The Cost-Effectiveness of Semaglutide and Tirzepatide for Patients With Knee Osteoarthritis and Obesity

Background: Glucagon-like peptide-1 receptor agonists (GLP1RAs) lead to substantial weight loss and pain reduction in persons with knee osteoarthritis and obesity. Objective: To evaluate the cost-effectiveness of 2 GLP1RAs, semaglutide and tirzepatide, for patients with osteoarthritis and obesity. Design: Osteoarthritis Policy Model, a validated microsimulation model of knee osteoarthritis, to estimate lifetime benefits and costs of weight loss strategies. Data Sources: Published data to derive treatment-related weight loss, pain reduction, and costs of GLP1RAs from the U.S. Office of Health Policy. Target Population: Persons with knee osteoarthritis and obesity in the United States. The base-case cohort had a Western Ontario and McMaster Universities Osteoarthritis Index pain score of 71 (0 to 100, 100 worst) and a mean body mass index (BMI) of 40 kg/m2. Time Horizon: Lifetime. Perspective: Health care, societal. Intervention: Semaglutide, tirzepatide, laparoscopic sleeve gastrectomy (LSG), Roux-en-Y gastric bypass (RYGB), and diet and exercise. Outcome Measures: Quality-adjusted life-years (QALYs), cost, and incremental cost-effectiveness ratios (ICERs). Results of Base-Case Analysis: Tirzepatide provided greater health benefits at lower costs than semaglutide and yielded a $57 400 per QALY ICER versus diet and exercise. For those eligible, RYGB provided greater health benefits at lower costs than the 2 GLP1RAs and had a $30 700 per QALY ICER versus LSG. Results of Sensitivity Analysis: Tirzepatide’s ICER was most sensitive to changes in medication costs, treatment efficacy, and cohort baseline BMI. Tirzepatide had a 64% and semaglutide had a 34% probability of being cost-effective at a $100 000 per QALY threshold. Limitation: Data from multiple sources. Conclusion: Both tirzepatide and semaglutide would be widely considered cost-effective when compared directly with usual care. Tirzepatide would offer the most favorable return on investment to decision makers whose cost-effectiveness thresholds exceed $57 400 per QALY. Primary Funding Source: The Arthritis Foundation and National Institute of Arthritis and Musculoskeletal and Skin Diseases.

Polymyalgia Rheumatica

This issue provides a clinical overview of polymyalgia rheumatica, focusing on risk factors, diagnosis, treatment, and practice improvement. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of additional science writers and physician writers.

Defining the Safety and Efficacy of Cannabis for Chronic Pain: Novel Approaches and Reframing Objectives

In chronic nonspecific neck pain, adding Alexander Technique lessons or acupuncture to usual care improved pain

Source Citation MacPherson H, Tilbrook H, Richmond S, et al. Alexander technique lessons or acupuncture sessions for persons with chronic neck pain: A randomized trial. Ann Intern Med. 2015;163:653-62. 26524571

Should You Treat This Acutely Ill Medical Inpatient With Venous Thromboembolism Chemoprophylaxis?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 172, No 7

Venous thromboembolism (VTE), which includes both deep venous thrombosis and pulmonary embolism, is a common and potentially fatal condition. Medical inpatients are at high risk for VTE because of immobility as well as acute and chronic illness. Several randomized trials demonstrated that chemoprophylaxis, or low-dose anticoagulation, prevents VTE in selected medical inpatients. The 2018 American Society of Hematology clinical practice guideline on prophylaxis for hospitalized and nonhospitalized medical patients conditionally recommends chemoprophylaxis for non–critically ill medical inpatients, leaving much to the discretion of the treating physician. Here, 2 experts, a hematologist and a hospitalist, reflect on the care of a woman hospitalized with a rheumatologic disorder. They consider the risks and benefits of chemoprophylaxis, discuss VTE risk stratification, and recommend which patients should receive chemoprophylaxis and with which agents.

The Chylomicronemia Syndrome Is Most Often Multifactorial: A Narrative Review of Causes and Treatment: Annals of Internal Medicine: Vol 170, No 9

The chylomicronemia syndrome occurs when triglyceride levels are severely elevated (usually >16.95 mmol/L [1500 mg/dL]) and is characterized by such clinical features as abdominal pain, acute pancreatitis, eruptive xanthomas, and lipemia retinalis. It may result from 1 of 3 conditions: the presence of secondary forms of hypertriglyceridemia concurrent with genetic causes of hypertriglyceridemia, termed multifactorial chylomicronemia syndrome (MFCS); a deficiency in the enzyme lipoprotein lipase and some associated proteins, termed familial chylomicronemia syndrome (FCS); or familial partial lipodystrophy. Most chylomicronemia syndrome cases are the result of MFCS; FCS is very rare. In all these conditions, triglyceride-rich lipoproteins accumulate because of impaired plasma clearance. This review describes the 3 major causes of the chylomicronemia syndrome; their consequences; and the approaches to treatment, which differ considerably by group.

Forgiving Physician Debt