ACP Concerns Regarding Efforts to Increase Meaningful Electronic Health Record Implementation

Comprehensive Tobacco Control Legislation, S. 1415. Letter to the Senate.

Coalition letter to Medicaid Committees in support of extending Medicaid Pay Parity

ACP Supports the Community TEAMS Act

ACP Response to CMS' RFI on Stark Physician Self-Referral Law

ACP Letter to ONC on Draft United States Core Data for Interoperability v5

ACP Letter to House Sponsors of the Patient Protection and Affordable Care Enhancement Act (H.R. 1425)

ACP Letter to Congressional Leadership Addressing ACP Policy Priorities

ACP Comments on the 2015 Edition of Certification Criteria Proposed Rule

Medicare Payment for Physician Services

When Would You Screen This 39-Year-Old Woman for Breast Cancer? Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Breast cancer is the second leading cause of cancer death among women in the United States. Screening mammography, which aims to detect asymptomatic breast cancers at earlier and more intervenable stages, has reduced breast cancer mortality, but not overall mortality, in randomized trials. As of 2024, the U.S. Preventive Services Task Force now recommends biennial screening mammography for women aged 40 to 74 years (grade B recommendation). In these rounds, 2 experts, the first a primary care physician and member of the Task Force and the second an epidemiologist and family practitioner, debate this recommendation in the context of Ms. R, a 39-year-old woman. They discuss the benefits and harms of breast cancer screening, the ideal age and frequency at which to conduct screening, and the key points to include when having a conversation with a patient about breast cancer screening.

Principles of Managed Care: A Position Paper From the American College of Physicians

Most U.S. health plans use managed care strategies, including health care use management and clinician networks. Most Medicare, Medicaid, and commercial insurance enrollees are covered by managed care plans. Managed care is ostensibly used to steer patients toward high-quality clinicians and facilities and contain costs; however, prior authorization, narrow clinician networks, and other managed care strategies often restrict access to necessary care, causing frustration among patients and physicians. In this position paper, the American College of Physicians offers policy recommendations to protect patients from onerous managed care processes, reduce administrative burdens associated with managed care, and ensure that patients can promptly access high-value, medically necessary care.

Palliative Care Educational App for Family Caregivers of Homebound Patients With Incurable Cancer: A Single-Center Randomized Trial: Annals of Internal Medicine: Vol 178, No 12

Background: Home-based palliative care relies on empowered family caregivers to overcome the limited availability of palliative care professional resources in managing incurable cancer. Objective: To explore whether adding a palliative care educational app to clinical palliative care could enhance health-related quality of life (HRQoL) in homebound patients with incurable cancer. Design: Single-center, open-label, individual randomized trial. (Chinese Clinical Trial Registry: ChiCTR2300077346) Setting: Single site in Shanghai, China. Participants: Patients with incurable cancer (aged ≥18 years; Karnofsky Performance Status ≤70) receiving palliative care along with consistent family caregivers (aged ≥18 years) enrolled between 28 July and 3 November 2023. Intervention: Patient–caregiver pairs were randomly assigned in a 1:1 ratio to either the intervention group (the app plus palliative care as usual [app]) or the control group (palliative care as usual). The app provided multimedia education on symptom and adverse effect management and nursing information for family caregivers. Measurements: The primary outcome was the mean between-group difference at month 2 in the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) score, with the summary score ranging from 0 to 100 and higher scores indicating better outcomes. The primary analysis used the intention-to-treat approach. Results: Of 154 randomly assigned pairs, 147 completed baseline assessments (intervention: n = 74; control: n = 73). The mean age of patients was 59.9 years, and 42.9% were female. At month 2, EORTC QLQ-C30 summary scores were 51.9 (95% CI, 45.4 to 58.5) in the intervention group and 35.7 (CI, 28.6 to 42.9) in the control group, with a mean difference of 16.2 (CI, 9.3 to 23.1). Limitations: Single-center design in China, Chinese-only WeChat app platform, unknown education levels of caregivers and patients, open-label design, and short 2-month follow-up with self-reported outcomes. Conclusion: The palliative care educational app through WeChat improved HRQoL among patients with incurable cancer at 2 months. This finding has implications for future study and development. Primary Funding Source: Shanghai Xingchuan Health Technology Co., Ltd.

How Would You Treat Tricuspid Valve Infective Endocarditis in a Patient Who Uses Injection Drugs? Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Infective endocarditis is a common and morbid condition involving prolonged hospital stays, significant disability, and a high mortality rate. The current crises of injection drug use and opioid use disorder have contributed to high rates of infective endocarditis in the United States. Endocarditis in patients who inject drugs involves additional management complexity for multiple reasons. Several infective endocarditis management guidelines exist, including from the American Heart Association and the European Society of Cardiology. In light of the unique challenges of caring for this particular population, in 2022 the American Heart Association published a scientific statement specifically focusing on infective endocarditis in people who inject drugs. In these rounds, 2 experts in their respective fields, an infectious diseases specialist and a cardiac surgeon, discuss medical management, interventional approaches, and the value of multidisciplinary care for tricuspid valve endocarditis in a person who uses injection drugs, both in general and in relation to Mr. Y, a 30-year-old man with a history of substance use disorder, methicillin-sensitive Staphylococcus aureus bacteremia, and right-sided endocarditis.

Primary Care Physician Time Spent in Patient Care: An Observational Study Using Electronic Health Record Logs

Background: Given a marked expansion in the work of primary care in recent decades, it is critical to have an accurate understanding of the time involved in managing a primary care panel and the determinants of this time. Objective: To estimate the yearly work effort involved for primary care physicians (PCPs) in caring for a patient panel, explore how work effort varies by clinical full-time equivalent (cFTE) status, and identify patient panel factors associated with differential time expenditure. Design: Cross-sectional, observational study using electronic health record and administrative data scaled by a literature-based estimate of activities inadequately captured by these data sources. Setting: 33 clinics in the Mass General Brigham health system. Participants: 406 attending PCPs who delivered care for at least 9 months in 2021. Measurements: Total yearly time expenditure per patient and full-time PCP. Results: The median work effort for a full-time PCP was 2844.3 yearly hours (IQR, 2324.9 to 3478.9 yearly hours), or 61.8 weekly hours (IQR, 50.5 to 75.6 weekly hours), for a 1.0-cFTE physician assuming a 46-week work year. This translates to a median of 1.7 hours (IQR, 1.4 to 2.2 hours) per patient per year. Part-time PCPs spent more time per patient on average than full-time PCPs. Patient medical advice request volume and certain panel characteristics, including greater average age, medical complexity, and percentage of patients with Medicaid, were associated with greater yearly PCP time expenditure per patient. Limitation: Derivation of data from a single integrated health system and lack of information about practice structures and staff supports for PCPs. Conclusion: Primary care physicians spend a median of 62 weekly hours caring for a patient panel. Panel characteristics and patient message volume are associated with time expenditure. These findings provide valuable insights for designing sustainable primary care roles and adjusting panel size expectations. Primary Funding Source: The Physicians Foundation.

Impact of Study Hypotheses on Results From Randomized Clinical Trials: Comparison Between Standard and Noninferiority Randomized Clinical Trials

Background: In embarking on randomized clinical trials (RCTs), researchers can hypothesize that a more intensive treatment is better than a less intensive treatment (positive hypothesis) or that a less intensive treatment is similar or noninferior to a more intensive treatment (negative hypothesis). Researchers may design noninferiority RCTs (NI-RCTs) to support negative hypotheses and standard RCTs (S-RCTs) to support negative or positive hypotheses. Regardless of hypotheses, S-RCTs and NI-RCTs should produce consistent results when assessing similar participants, interventions, control, and outcomes. Objective: To compare effect estimates in S-RCTs with positive hypotheses versus NI-RCTs and in S-RCTs with negative hypotheses versus NI-RCTs. Design: Meta-research. Setting: 98 meta-analyses. Participants: 468 RCTs, including 153 NI-RCTs and 315 S-RCTs (149 positive and 166 negative hypotheses). Intervention: S-RCTs as the exposure and NI-RCTs as the control. Measurements: The ratio of effect estimates between S-RCTs and NI-RCTs in each meta-analysis was combined across meta-analyses. Results: Standard RCTs with positive hypotheses produced effect estimates 1.47 (95% CI, 1.27 to 1.70) times larger than NI-RCTs; among RCTs rated as having low risk of bias for blinding, the ratio was 1.01 (CI, 0.70 to 1.45), whereas among those rated as having high or unclear risk of bias for blinding, the ratio was 1.81 (CI, 1.41 to 2.33). Standard RCTs with negative hypotheses did not produce statistically different effect estimates from NI-RCTs (ratio, 0.93 [CI, 0.84 to 1.03]). Limitation: Findings may be limited by residual differences between S-RCTs and NI-RCTs in the same meta-analysis. Conclusion: The researchers’ hypotheses may bias the results of published RCTs, especially those with high or unclear risk of bias for blinding. The effect of researchers’ hypotheses should be assessed in systematic reviews and clinical practice guidelines when RCTs addressing the same clinical question report conflicting hypotheses. Primary Funding Source: The Shenzhen Municipal Government, Guangdong Province, China, and the Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences.

Lyme Disease

Lyme disease, caused by Borrelia burgdorferi, is the most common vector-borne disease in the United States, and the range of its tick vector continues to expand. Most Lyme disease cases are diagnosed with the onset of the erythema migrans rashes, which can be single or multiple and vary from a homogeneous erythema to bull’s-eye patterns. Serologic antibody testing is of low sensitivity at onset but becomes highly sensitive after a few weeks. Early dissemination may lead to neurologic and cardiac complications. Mono- or oligoarticular arthritis may develop in untreated patients. Antibiotic treatment is highly effective, but approximately 10% of treated patients experience persistent symptoms.

The Incubation Periods of Mpox Virus Clade Ib

Background: Mpox virus (MPXV) clade Ib, first detected in the Democratic Republic of the Congo (DRC) in September 2023, spread internationally within months, prompting an emergency declaration from the World Health Organization. Data on its incubation period, which both shapes outbreak dynamics and informs epidemic response strategies, remain limited. Objective: To estimate the incubation periods of mpox clade Ib, examining evidence for differences by route of exposure and demographic factors. Design: Bayesian analysis of clinical surveillance data collected between June and October 2024. Setting: South Kivu, DRC, the epicenter of the current mpox clade Ib global outbreak. Participants: Clinically attended persons with confirmed mpox clade Ib infection. Measurements: Demographic characteristics, exposure history, symptom onset, and transmission route. Results: Among 37 polymerase chain reaction–confirmed cases with high viral load (cycle threshold values <34), the median incubation period from exposure to rash was 13.6 days (95% credible interval [CrI], 9.6 to 19.0 days). Five percent of cases are expected to develop a rash within 3.1 days (CrI, 1.3 to 5.5 days) and 95% within 32.3 days (CrI, 22.4 to 45.8 days). The incubation period seemed to differ by putative transmission route: Sexual transmission had a shorter median (10.3 days [CrI, 3.1 to 20.3 days]) than nonsexual transmission (13.5 days [CrI, 9.5 to 19.1 days]), although the CrIs overlapped. Limitation: Surveillance data lacked detailed exposure histories and a lower bound for exposure periods, but models accounted for these uncertainties, yielding robust median estimates. Conclusion: Evidence from this study suggests that clade Ib may have a longer incubation period than other MPXV clades, and this may vary by transmission route. The shorter incubation for sexual transmission mirrors patterns seen in the predominantly sexually transmitted clade IIb outbreak, highlighting the potential role of exposure route in disease progression. These findings have implications for global recommendations on postexposure monitoring periods and prophylaxis. Primary Funding Source: Gates Foundation and Geneva Centre for Emerging Viral Diseases.

Projected Effects of Proposed Cuts in Federal Medicaid Expenditures on Medicaid Enrollment, Uninsurance, Health Care, and Health

In January 2025, the Republican majority in the House of Representatives’ Budget Committee offered a list of possible spending reductions to offset revenue losses from proposed tax cuts. In May, the Committee advanced a bill incorporating several reductions on the list. The Committee estimated that the 6 largest potential Medicaid cuts (for example, work requirements for some Medicaid enrollees) would each reduce the federal government’s Medicaid outlays by at least $100 billion over 10 years. On the basis of the Committee’s estimates of savings; Congressional Budget Office analyses; and peer-reviewed studies of the coverage, financial, and health impacts of past Medicaid expansions and contractions, the authors project the likely effects of each option and of the House bill advanced by the Budget Committee in May. Each option individually would reduce federal Medicaid outlays by between $100 billion and $900 billion over a decade, increase the ranks of the uninsured by between 600 000 and 3 900 000 and the annual number of persons forgoing needed medical care by 129 060 to 838 890, and result in 651 to 12 626 medically preventable deaths annually. Enactment of the House bill advanced in May would increase the number of uninsured persons by 7.6 million and the number of deaths by 16 642 annually, according to a mid-range estimate. These figures exclude harms from lowering provider payments and shrinking benefits, as well as possible repercussions from states increasing taxes or shifting expenditures from other needs to make up for shortfalls in federal Medicaid funding. Policy makers should weigh the likely health and financial harms to patients and providers of reducing Medicaid expenditures against the desirability of tax reductions, which would accrue mostly to wealthy Americans.

Does the Patient Want TV?