Revisiting the National Institutes of Health Fair Pricing Condition: Promoting the Affordability of Drugs Developed With Government Support

Should Health Care Demand Interpretable Artificial Intelligence or Accept “Black Box” Medicine?

Amnesia, Adverse Effects, and the Angel of History

Effectiveness and Safety of Apixaban Compared With Rivaroxaban for Patients With Atrial Fibrillation in Routine Practice: A Cohort Study: Annals of Internal Medicine: Vol 172, No 7

Background: Apixaban and rivaroxaban are the most commonly prescribed direct oral anticoagulants for adults with atrial fibrillation, but head-to-head data comparing their safety and effectiveness are lacking. Objective: To compare the safety and effectiveness of apixaban versus rivaroxaban for patients with nonvalvular atrial fibrillation. Design: New-user, active-comparator, retrospective cohort study. Setting: A U.S. nationwide commercial health care claims database from 28 December 2012 to 1 January 2019. Patients: Adults newly prescribed apixaban (n = 59 172) or rivaroxaban (n = 40 706). Measurements: The primary effectiveness outcome was a composite of ischemic stroke or systemic embolism. The primary safety outcome was a composite of intracranial hemorrhage or gastrointestinal bleeding. Results: 39 351 patients newly prescribed apixaban were propensity score matched to 39 351 patients newly prescribed rivaroxaban. Mean age was 69 years, 40% of patients were women, and mean follow-up was 288 days for new apixaban users and 291 days for new rivaroxaban users. The incidence rate of ischemic stroke or systemic embolism was 6.6 per 1000 person-years for adults prescribed apixaban compared with 8.0 per 1000 person-years for those prescribed rivaroxaban (hazard ratio [HR], 0.82 [95% CI, 0.68 to 0.98]; rate difference, 1.4 fewer events per 1000 person-years [CI, 0.0 to 2.7]). Adults prescribed apixaban also had a lower rate of gastrointestinal bleeding or intracranial hemorrhage (12.9 per 1000 person-years) compared with those prescribed rivaroxaban (21.9 per 1000 person-years), corresponding to an HR of 0.58 (CI, 0.52 to 0.66) and a rate difference of 9.0 fewer events per 1000 person-years (CI, 6.9 to 11.1). Limitation: Unmeasured confounding, incomplete laboratory data. Conclusion: In routine care, adults with atrial fibrillation prescribed apixaban had a lower rate of both ischemic stroke or systemic embolism and bleeding compared with those prescribed rivaroxaban. Primary Funding Source: Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital.

What Is the Optimal Primary Care Panel Size?: A Systematic Review: Annals of Internal Medicine: Vol 172, No 3

Background: Primary care for a panel of patients is a central component of population health, but the optimal panel size is unclear. Purpose: To review evidence about the association of primary care panel size with health care outcomes and provider burnout. Data Sources: English-language searches of multiple databases from inception to October 2019 and Google searches performed in September 2019. Study Selection: English-language studies of any design, including simulation models, that assessed the association between primary care panel size and safety, efficacy, patient-centeredness, timeliness, efficiency, equity, or provider burnout. Data Extraction: Independent, dual-reviewer extraction; group consensus rating of certainty of evidence. Data Synthesis: Sixteen hypothesis-testing studies and 12 simulation modeling studies met inclusion criteria. All but 1 hypothesis-testing study were cross-sectional assessments of association. Three studies each provided low-certainty evidence that increasing panel size was associated with no or modestly adverse effects on patient-centered and effective care. Eight studies provided low-certainty evidence that increasing panel size was associated with variable effects on timely care. No studies assessed the effect of panel size on safety, efficiency, or equity. One study provided very-low-certainty evidence of an association between increased panel size and provider burnout. The 12 simulation studies evaluated 5 models; all used access as the only outcome of care. Five and 2 studies, respectively, provided moderate-certainty evidence that adjusting panel size for case mix and adding clinical conditions to the case mix resulted in better access. Limitation: No studies had concurrent comparison groups, and published and unpublished studies may have been missed. Conclusion: Evidence is insufficient to make evidence-based recommendations about the optimal primary care panel size for achieving beneficial health outcomes. Primary Funding Source: Veterans Affairs Quality Enhancement Research Initiative.

The Ins and Outs of Microplastics

Early Detection of Sporadic Pancreatic Ductal Adenocarcinoma: Problems, Promise, and Prospects

Patients With Opioid Use Disorder Deserve Trained Providers

Shining the Light on Mental Health in a Population at Risk: Cerebral Palsy and Other Developmental Disabilities

Sodium–Glucose Cotransporter-2 Inhibitors and Severe Urinary Tract Infections: Reassuring Real-World Evidence