How Can Our Nation Conserve and Distribute Health Care Resources Effectively and Efficiently?

ACP Comments on Proposed 2024 Physician Fee Schedule, Medicare Shared Savings Program, and Quality Payment Program Rule

ACP Comments on Proposed 2024 Physician Fee Schedule, Medicare Shared Savings Program, and Quality Payment Program Rule

ACP Comments on Proposed 2024 Physician Fee Schedule, Medicare Shared Savings Program, and Quality Payment Program Rule

ACP Comments on Proposed 2024 Physician Fee Schedule, Medicare Shared Savings Program, and Quality Payment Program Rule

ACP Comments on Proposed 2024 Physician Fee Schedule, Medicare Shared Savings Program, and Quality Payment Program Rule

ACP Comments on 2022 Physician Fee Schedule and Quality Payment Program Proposed Rule

The Urban Health Penalty: New Dimensions and Directions in Inner-City Health Care.

ACP Comment Letter on CMS Draft Quality Measures Development Plan

ACP Comments on 2020 Medicare Physician Fee Schedule, Quality Payment Program, and other Medicare Part B Updates Proposed Rule

A Patient Price Guide for Prescription Medication

Toward Unbiased Evaluation of Postacute Sequelae of SARS-CoV-2 Infection: Challenges and Solutions for the Long Haul Ahead

Trends in Concurrent Opioid and Benzodiazepine Prescriptions in the United States, 2016 to 2019

Characteristics of High-Need, High-Cost Patients: A “Best-Fit” Framework Synthesis: Annals of Internal Medicine: Vol 175, No 12

Background: Accurately identifying high-need, high-cost (HNHC) patients to reduce their preventable or modifiable health care use for their chronic conditions is a priority and a challenge for U.S. policymakers, health care delivery systems, and payers. Purpose: To identify characteristics and criteria to distinguish HNHC patients. Data Sources: Searches of multiple databases and gray literature from 1 January 2000 to 22 January 2022. Study Selection: English-language studies of characteristics and criteria to identify HNHC adult patients, defined as those with high use (emergency department, inpatient, or total services) or high cost. Data Extraction: Independent, dual-review extraction and quality assessment. Data Synthesis: The review included 64 studies comprising multivariate exposure studies (n = 47), cluster analyses (n = 11), and qualitative studies (n = 6). A National Academy of Medicine (NAM) taxonomy was an initial “best-fit” framework for organizing the synthesis of the findings. Patient characteristics associated with being HNHC included number and severity of comorbid conditions and having chronic clinical conditions, particularly heart disease, chronic kidney disease, chronic lung disease, diabetes, cancer, and hypertension. Patients' risk for being HNHC was often amplified by behavioral health conditions and social risk factors. The reviewers revised the NAM taxonomy to create a final framework, adding chronic pain and prior patterns of high health care use as characteristics associated with an increased risk for being HNHC. Limitation: Little evidence distinguished potentially preventable or modifiable health care use from overall use. Conclusion: A combination of characteristics can be useful for identifying HNHC patients. Because of the complexity of their conditions and circumstances, improving their quality of care will likely also require an individualized assessment of care needs and availability of support services. Primary Funding Source: Agency for Healthcare Research and Quality. (PROSPERO: CRD42020161179)

Cannabis-Based Products for Chronic Pain: A Systematic Review: Annals of Internal Medicine: Vol 175, No 8

Background: Contemporary data are needed about the utility of cannabinoids in chronic pain. Purpose: To evaluate the benefits and harms of cannabinoids for chronic pain. Data Sources: Ovid MEDLINE, PsycINFO, EMBASE, the Cochrane Library, and Scopus to January 2022. Study Selection: English-language, randomized, placebo-controlled trials and cohort studies (≥1 month duration) of cannabinoids for chronic pain. Data Extraction: Data abstraction, risk of bias, and strength of evidence assessments were dually reviewed. Cannabinoids were categorized by THC-to-CBD ratio (high, comparable, or low) and source (synthetic, extract or purified, or whole plant). Data Synthesis: Eighteen randomized, placebo-controlled trials (n = 1740) and 7 cohort studies (n = 13 095) assessed cannabinoids. Studies were primarily short term (1 to 6 months); 56% enrolled patients with neuropathic pain, with 3% to 89% female patients. Synthetic products with high THC-to-CBD ratios (>98% THC) may be associated with moderate improvement in pain severity and response (≥30% improvement) and an increased risk for sedation and are probably associated with a large increased risk for dizziness. Extracted products with high THC-to-CBD ratios (range, 3:1 to 47:1) may be associated with large increased risk for study withdrawal due to adverse events and dizziness. Sublingual spray with comparable THC-to-CBD ratio (1.1:1) probably is associated with small improvement in pain severity and overall function and may be associated with large increased risk for dizziness and sedation and moderate increased risk for nausea. Evidence for other products and outcomes, including longer-term harms, were not reported or were insufficient. Limitation: Variation in interventions; lack of study details, including unclear availability in the United States; and inadequate evidence for some products. Conclusion: Oral, synthetic cannabis products with high THC-to-CBD ratios and sublingual, extracted cannabis products with comparable THC-to-CBD ratios may be associated with short-term improvements in chronic pain and increased risk for dizziness and sedation. Studies are needed on long-term outcomes and further evaluation of product formulation effects. Primary Funding Source: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. (PROSPERO: CRD42021229579)

When and How Would You Screen This Patient for Cervical Cancer?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 175, No 2

Successful screening programs based on cervical cytology have dramatically reduced the incidence of cervical cancer in the United States. Human papillomavirus immunization is poised to reduce it further as an increasing percentage of vaccinated women reach adulthood. A recent guideline from the American Cancer Society advises that cervical cancer screening begin at age 25 and that high-risk human papillomavirus testing is the preferred screening test. The U.S. Preventive Services Task Force recommends screening begin at age 21 and that cytology remain incorporated into screening. Here, 2 experts debate how to apply these guidelines to Ms. L, a 22-year-old woman who has never undergone cervical cancer screening.

Risk for Reinfection After SARS-CoV-2: A Living, Rapid Review for American College of Physicians Practice Points on the Role of the Antibody Response in Conferring Immunity Following SARS-CoV-2 Infection

An update is available for this article. Background: The strength and duration of immunity from infection with SARS-CoV-2 are important for public health planning and clinical practice. Purpose: To synthesize evidence on protection against reinfection after SARS-CoV-2 infection. Data Sources: MEDLINE (Ovid), the World Health Organization global literature database, ClinicalTrials.gov, COVID19reviews.org, and reference lists. Study Selection: Longitudinal studies that compared the risk for reinfection after SARS-CoV-2 infection versus infection risk in individuals with no prior infection. Data Extraction: Two investigators sequentially extracted study data and rated quality. Data Synthesis: Across 18 eligible studies, reinfection risk ranged from 0% to 2.2%. In persons with recent SARS-CoV-2 infection compared with unvaccinated, previously uninfected individuals, 80% to 98% of symptomatic infections with wild-type or Alpha variants were prevented (high strength of evidence). In the meta-analysis, previous infection reduced risk for reinfection by 87% (95% CI, 84% to 90%), equaling 4.3 fewer infections per 100 persons in both the general population (risk difference, −0.043 [CI, −0.071 to −0.015]) and health care workers (risk difference, −0.043 [CI, −0.069 to −0.016]), and 26.6 fewer infections per 100 persons in care facilities (risk difference, −0.266 [CI, −0.449 to −0.083]). Protection remained above 80% for at least 7 months, but no study followed patients after the emergence of the Delta or Omicron variant. Results for the elderly were conflicting. Limitation: Methods to ascertain and diagnose infections varied. Conclusion: Before the emergence of the Delta and Omicron variants, persons with recent infection had strong protection against symptomatic reinfections for 7 months compared with unvaccinated, previously uninfected individuals. Protection in immunocompromised persons, racial and ethnic subgroups, and asymptomatic index case patients is unclear. The durability of protection in the setting of the Delta and Omicron variants is unknown. Primary Funding Source: Agency for Healthcare Research and Quality. (PROSPERO: CRD42020207098)

Lifting the Illusion

Development and Validation of the Summary Elixhauser Comorbidity Score for Use With ICD-10-CM–Coded Data Among Older Adults

Background: Older adults have many comorbidities contributing to mortality. Objective: To develop a summary Elixhauser (S-Elixhauser) comorbidity score to predict 30-day, in-hospital, and 1-year mortality in older adults using the 38 comorbidities operationalized by the Agency for Healthcare Research and Quality (AHRQ). Design: Retrospective cohort study. Setting: Medicare beneficiaries from 2017 to 2019. Patients: Persons hospitalized in 2018 (n = 899 844) and 3 disease-specific hospitalized cohorts. Measurements: Weights were derived for 38 comorbidities to predict 30-day, in-hospital, and 1-year mortality. The S-Elixhauser score was internally validated and calibrated. Individual Elixhauser comorbidity indicators (38 comorbidities), the modified application of the AHRQ-derived Elixhauser summary score, the Charlson comorbidity indicators (17 comorbidities), and the Charlson summary score were externally validated. The c-statistic was used to evaluate discrimination of a comorbidity score model. Results: The S-Elixhauser score was well calibrated and internally validated, with a c-statistic of 0.705 (95% CI, 0.703 to 0.707) in predicting 30-day mortality, 0.654 (CI, 0.651 to 0.657) for in-hospital mortality, and 0.743 (CI, 0.741 to 0.744) for 1-year mortality. In external validation of other comorbidity indices for 30-day mortality, the c-statistic was 0.711 (CI, 0.709 to 0.713) for the individual Elixhauser comorbidity indicators, 0.688 (CI, 0.686 to 0.690) for the AHRQ Elixhauser score, 0.696 (CI, 0.694 to 0.698) for the Charlson comorbidity indicators, and 0.690 (CI, 0.688 to 0.693) for the Charlson summary score. In 3 disease-specific populations, the discrimination of the S-Elixhauser score in predicting 30-day mortality ranged from 0.657 to 0.732. Limitation: Validation of the S-Elixhauser comorbidity score and head-to-head comparison with other comorbidity scores in an external population are needed to evaluate comparative performance. Conclusion: The S-Elixhauser comorbidity score is well calibrated and internally validated but its advantage over the AHRQ Elixhauser and Charlson summary scores is unclear. Primary Funding Source: National Institute on Aging.

Interns Are Increasingly Using Mental Health Services, but More Can Still Be Done

MKSAP Quiz: 10-month history of generalized weakness

Coprescription of naloxone for acute use in case of overdose may benefit primary care patients taking opioids for chronic pain

ARBs may offer same efficacy, better tolerability than ACE inhibitors

How to motivate your mentees | ACP Hospitalist

The perennial puzzle of pneumonia | ACP Hospitalist

Ceftolozane-tazobactam associated with better outcomes for multidrug-resistant P. aeruginosa | ACP Hospitalist

Improving interpretation for inpatients | ACP Hospitalist

Texting for hospitalists | ACP Hospitalist

Corticosteroids appear safe but ineffective in M. pneumoniae pneumonia | ACP Hospitalist

Bloodstream infection, hemodialysis associated with worse outcomes in C. auris | ACP Hospitalist

Creative writing for clinicians | ACP Hospitalist

Acting interns satisfied by experiences on teaching services without residents | ACP Hospitalist

Patients with low-risk S. aureus bacteremia may not need routine imaging | ACP Hospitalist