The Deceptive Appeal of Direct-to-Consumer Genetics

Update in Hematology and Oncology: Evidence Published in 2015

Changes in Hospital–Physician Affiliations in U.S. Hospitals and Their Effect on Quality of Care

Background: Growing evidence shows that hospitals are increasingly employing physicians. Objective: To examine changes in U.S. acute care hospitals that reported employment relationships with their physicians and to determine whether quality of care improved after the hospitals switched to this integration model. Design: Retrospective cohort study of U.S. acute care hospitals between 2003 and 2012. Setting: U.S. nonfederal acute care hospitals. Participants: 803 switching hospitals compared with 2085 nonswitching control hospitals matched for year and region. Intervention: Hospitals' conversion to an employment relationship with any of their privileged physicians. Measurements: Risk-adjusted hospital-level mortality rates, 30-day readmission rates, length of stay, and patient satisfaction scores for common medical conditions. Results: In 2003, approximately 29% of hospitals employed members of their physician workforce, a number that rose to 42% by 2012. Relative to regionally matched controls, switching hospitals were more likely to be large (11.6% vs. 7.1%) or major teaching hospitals (7.5% vs. 4.5%) and less likely to be for-profit institutions (8.8% vs. 19.9%) (all P values <0.001). Up to 2 years after conversion, no association was found between switching to an employment model and improvement in any of 4 primary composite quality metrics. Limitations: The measure of integration used depends on responses to the American Hospital Association annual questionnaire, yet this measure has been used by others to examine effects of integration. The study examined performance up to 2 years after evidence of switching to an employment model; however, beneficial effects may have taken longer to appear. Conclusion: During the past decade, hospitals have increasingly become employers of physicians. The study's findings suggest that physician employment alone probably is not a sufficient tool for improving hospital care. Primary Funding Source: Agency for Healthcare Research and Quality and National Science Foundation Graduate Research Fellowship.

Visceral Vistas: Basil Hirschowitz and the Birth of Fiberoptic Endoscopy

Fiberoptic endoscopy was developed at the University of Michigan in the 1950s by gastroenterology fellow Basil Hirschowitz and 2 physicists. Previous methods to visualize the gastrointestinal lumen used rigid instruments that relied on rudimentary optical systems. They were limited in reach and caused patients considerable discomfort. Fiberoptic technology dramatically changed endoscopic practice. The fiberoptic endoscope, or fiberscope, was a flexible instrument that allowed direct inspection of the gastrointestinal lumen. Although many practicing endoscopists initially resisted its adoption, the fiberscope ultimately held sway. Studying the period from the fiberscope's first introduction in the late 1950s to its more widespread acceptance in the late 1960s may help us understand how a new technology makes its way into routine clinical practice.

Update on Novel Drugs for Primary Care Practice: Drugs Approved by the U.S. Food and Drug Administration in 2015

Pharmacist-Led Chronic Disease Management: A Systematic Review of Effectiveness and Harms Compared With Usual Care

Background: Increased involvement of pharmacists in patient care may increase access to health care and improve patient outcomes. Purpose: To determine the effectiveness and harms of pharmacist-led chronic disease management for community-dwelling adults. Data Sources: MEDLINE, Cochrane Library, CINAHL, and International Pharmaceutical Abstracts from 1995 through February 2016, and reference lists of systematic reviews and included studies. Study Selection: 65 patient populations in 63 studies conducted in the United States of any design reported outcomes of pharmacist-led chronic disease management versus a comparator for community-dwelling adults in the United States. Studies set in retail pharmacies were excluded. Data Extraction: Data extraction done by a single investigator was confirmed by a second investigator; risk of bias was assessed by 2 investigators; and strength of evidence was determined by consensus. Data Synthesis: Pharmacist-led care was associated with similar numbers of office visits, urgent care or emergency department visits, and hospitalizations (moderate-strength evidence) and medication adherence (low-strength evidence) compared with usual care (typically continuing a prestudy visit schedule). Pharmacist-led care increased the number or dose of medications received and improved study-selected glycemic, blood pressure, and lipid goal attainment (moderate-strength evidence). Mortality and clinical events were similar (low-strength evidence). Evidence on patient satisfaction was mixed and insufficient. The reporting of harms was limited. Limitations: Interventions were heterogeneous. Studies were typically short-term and designed to assess physiologic intermediate outcomes rather than clinical events. Reporting of many clinical outcomes of interest was limited, and often they were not the study-defined primary end points. Conclusion: Pharmacist-led chronic disease management was associated with effects similar to those of usual care for resource utilization and may improve physiologic goal attainment. Further research is needed to determine whether increased medication utilization and goal attainment improve clinical outcomes. Primary Funding Source: Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative.

Control of an Outbreak of Middle East Respiratory Syndrome in a Tertiary Hospital in Korea

Background: In 2015, a large outbreak of Middle East respiratory syndrome (MERS) occurred in the Republic of Korea. Half of the cases were associated with a tertiary care university hospital. Objective: To document the outbreak and successful control measures. Design: Descriptive study. Setting: A 1950-bed tertiary care university hospital. Patients: 92 patients with laboratory-confirmed MERS and 9793 exposed persons. Measurements: Description of the outbreak, including a timeline, and evaluation of the effectiveness of the control measures. Results: During the outbreak, 92 laboratory-confirmed MERS cases were associated with a large tertiary care hospital, 82 of which originated from unprotected exposure to 1 secondary patient. Contact tracing and monitoring exposed patients and assigned health care workers were at the core of the control measures in the outbreak. Nontargeted screening measures, including body temperature screening among employees and visitors at hospital gates, monitoring patients for MERS-related symptoms, chest radiographic screening, and employee symptom monitoring, did not detect additional patients with MERS without existing transmission links. All in-hospital transmissions originated from 3 patients with MERS who also had pneumonia and productive cough. Limitations: This was a retrospective single-center study. Statistical analysis could not be done. Because this MERS outbreak originated from a superspreader, effective control measures could differ in endemic areas or in other settings. Conclusion: Control strategies for MERS outbreaks should focus on tracing contacts of persons with epidemiologic links. Adjusting levels of quarantine and personal protective equipment according to the assumed infectivity of each patient with MERS may be appropriate. Primary Funding Source: Samsung Biomedical Research Institute.

Comparative Effect of Contrast Media Type on the Incidence of Contrast-Induced Nephropathy: A Systematic Review and Meta-analysis: Annals of Internal Medicine: Vol 164, No 6

Background: Iodine contrast media are essential components of many imaging procedures. An important potential side effect is contrast-induced nephropathy (CIN). Purpose: To compare CIN risk for contrast media within and between osmolality classes in patients receiving diagnostic or therapeutic imaging procedures. Data Sources: PubMed, EMBASE, Cochrane Library, Clinical Trials.gov, and Scopus through June 2015. Study Selection: Randomized, controlled trials that reported CIN-related outcomes in patients receiving low-osmolar contrast media (LOCM) or iso-osmolar contrast media for imaging. Data Extraction: Independent study selection and quality assessment by 2 reviewers and dual extraction of study characteristics and results. Data Synthesis: None of the 5 studies that compared types of LOCM reported a statistically significant or clinically important difference among study groups, but the strength of evidence was low. Twenty-five randomized, controlled trials found a slight reduction in CIN risk with the iso-osmolar contrast media agent iodixanol compared with a diverse group of LOCM that just reached statistical significance in a meta-analysis (pooled relative risk, 0.80 [95% CI, 0.65 to 0.99]; P = 0.045). This comparison's strength of evidence was moderate. In a meta regression of randomized, controlled trials of iodixanol, no relationship was found between route of administration and comparative CIN risk. Limitations: Few studies compared LOCM. Procedural details about contrast administration were not uniformly reported. Few studies specified clinical indications or severity of baseline renal impairment. Conclusion: No differences were found in CIN risk among types of LOCM. Iodixanol had a slightly lower risk for CIN than LOCM, but the lower risk did not exceed a criterion for clinical importance. Primary Funding Source: Agency for Healthcare Research and Quality.

Screening for Colorectal Cancer in Asymptomatic Average-Risk Adults

Screening for Colorectal Cancer in Asymptomatic Average-Risk Adults