Converting Medicare to a Defined Contribution Program, An ACP-ASIM Preliminary Position Paper.

Converting Medicare to a Defined Contribution Program

Assessing Physician Performance in Managed Care, Reinventing Managed Care Series

Medicare Physician Fee Schedule for Calendar Year 2002. Letter to the Centers for Medicare & Medicaid Services (CMS).

Prospective Payment System (PPS) for Hospital Outpatient Services. Joint Letter to the Health Care Financing Administration

Medicare Shared Savings Program Comments and Recommendations to CMS in Response to Proposed Policy and Payment Changes

2015 Medicare Physician Fee Schedule Final Rule Comment Letter

Medicare FY Budget 1997. Letter to U.S. President William Jefferson Clinton.

Medicare Advantage Program Sign On Letter

Letter to Sen. Orrin Hatch Sharing ACP's Vision for Health Care Reform

Correction: Previously Undisclosed Potential Conflict of Interest by an Author of American College of Physicians Clinical Guidelines

In acute soft tissue injuries, NSAIDs do not differ from acetaminophen for pain reduction

Source Citation Jones P, Lamdin R, Dalziel SR. Oral non-steroidal anti-inflammatory drugs versus other oral analgesic agents for acute soft tissue injury. Cochrane Database Syst Rev. 2020;8:CD007789. 32797734

Comparing Use of Low-Value Health Care Services Among U.S. Advanced Practice Clinicians and Physicians

Background: Many physicians believe that advanced practice clinicians (APCs [nurse practitioners and physician assistants]) provide care of relatively lower value. Objective: To compare use of low-value services among U.S. APCs and physicians. Design: Service use after primary care visits was evaluated for 3 conditions after adjustment for patient and provider characteristics and year. Patients with guideline-based red flags were excluded and analyses stratified by office- versus hospital-based visits, acute versus nonacute presentations, and whether clinicians self-identified as the patient's primary care provider (PCP). Setting: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS), 1997 to 2011. Patients: Patients presenting with upper respiratory infections (URIs), back pain, or headache. Measurements: Use of guideline-discordant antibiotics (for URIs), radiography (for URIs and back pain), computed tomography (CT) or magnetic resonance imaging (MRI) (for headache and back pain), and referrals to other physicians (for all 3 conditions). Results: 12 170 physician and 473 APC office-based visits and 13 359 physician and 2947 APC hospital-based visits were identified. Although office-based clinicians saw similar patients, hospital-based APCs saw younger patients (mean age, 42.6 vs. 45.0 years; P  < 0.001), and practiced in urban settings less frequently (49.7% vs. 81.7% of visits; P < 0.001) than hospital-based physicians. Unadjusted and adjusted results revealed that APCs ordered antibiotics, CT or MRI, radiography, and referrals as often as physicians in both settings. Stratification suggested that self-identified PCP APCs ordered more services than PCP physicians in the hospital-based setting. Limitation: NHAMCS reflects hospital-based APC care; NAMCS samples physician practices and likely underrepresents office-based APCs. Conclusion: APCs and physicians provided an equivalent amount of low-value health services, dispelling physicians' perceptions that APCs provide lower-value care than physicians for these common conditions. Primary Funding Source: U.S. Health Services and Research Administration, Ryoichi Sasakawa Fellowship Fund, and National Institutes of Health.

Telemedicine Versus In-Person Primary Care: Treatment and Follow-up Visits

Background: Beyond initial COVID-19 pandemic emergency expansions of telemedicine use, it is unclear how well primary care telemedicine addresses patients’ needs. Objective: To compare treatment and follow-up visits (office, emergency department, hospitalization) between primary care video or telephone telemedicine and in-person office visits. Design: Retrospective design based on administrative and electronic health record (EHR) data. Setting: Large, integrated health care delivery system with more than 1300 primary care providers, between April 2021 and December 2021 (including the COVID-19 pandemic Delta wave). Patients: 1 589 014 adult patients; 26.5% were aged 65 years or older, 54.9% were female, 22.2% were Asian, 7.4% were Black, 22.3% were Hispanic, 46.5% were White, 21.5% lived in neighborhoods with lower socioeconomic status, and 31.8% had a chronic health condition. Measurements: Treatment outcomes included medication or antibiotic prescribing and laboratory or imaging ordering. Follow-up visits included in-person visits to the primary care office or emergency department or hospitalization within 7 days. Outcomes were adjusted for sociodemographic and clinical characteristics overall and stratified by clinical area (abdominal pain, gastrointestinal concerns, back pain, dermatologic concerns, musculoskeletal pain, routine care, hypertension or diabetes, and mental health). Results: Of 2 357 598 primary care visits, 50.8% used telemedicine (19.5% video and 31.3% telephone). After adjustment, medications were prescribed in 46.8% of office visits, 38.4% of video visits, and 34.6% of telephone visits. After the visit, 1.3% of in-person visits, 6.2% of video visits, and 7.6% of telephone visits had a 7-day return in-person primary care visit; 1.6% of in-person visits, 1.8% of video visits, and 2.1% of telephone visits were followed by an emergency department visit. Differences in follow-up office visits were largest after index office versus telephone visits for acute pain conditions and smallest for mental health. Limitations: In the study setting, telemedicine is fully integrated with ongoing EHRs and with clinicians, and the study examines an insured population during the late COVID-19 pandemic period. Observational comparison lacks detailed severity or symptom measures. Follow-up was limited to 7 days. Clinical area categorization uses diagnosis code rather than symptom. Conclusion: In-person return visits were somewhat higher after telemedicine compared with in-person primary care visits but varied by specific clinical condition. Primary Funding Source: Agency for Healthcare Research and Quality.

How Would You Manage This Patient With Recurrent Diverticulitis?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 176, No 6

Acute diverticulitis, which refers to inflammation or infection, or both, of a colonic diverticulum, is a common medical condition that may occur repeatedly in some persons. It most often manifests with left-sided abdominal pain, which may be associated with low-grade fever and other gastrointestinal symptoms. Complications may include abscess, fistula formation, perforation, and bowel obstruction. The American College of Physicians recently published practice guidelines on the diagnosis and management of acute diverticulitis, the role of colonoscopy after resolution, and interventions to prevent recurrence of this condition. Among the recommendations were the use of abdominal computed tomography (CT) scanning in cases where there was diagnostic uncertainty, initial management of uncomplicated cases in the outpatient setting without antibiotics, referral for colonoscopy after an initial episode if not performed recently, and discussion of elective surgery to prevent recurrent disease in patients with complicated diverticulitis or frequent episodes of uncomplicated disease. Here, 2 gastroenterologists with expertise in acute diverticulitis debate CT scanning for diagnosis, antibiotics for treatment, colonoscopy to screen for underlying malignancy, and elective surgery to prevent recurrent disease.

The Management of Major Depressive Disorder: Synopsis of the 2022 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline

Description: In February 2022, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline (CPG) for the management of major depressive disorder (MDD). This synopsis summarizes key recommendations. Methods: Senior leaders within the VA and the DoD assembled a team to update the 2016 CPG for the management of MDD that included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy CPGs. The guideline panel developed key questions, systematically searched and evaluated the literature, created two 1-page algorithms, and distilled 36 recommendations for care using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Select recommendations that were identified by the authors to represent key changes from the prior CPG are presented in this synopsis. Recommendations: The scope of the CPG is diverse; however, this synopsis focuses on key recommendations that the authors identified as important new evidence and changes to prior recommendations on pharmacologic management, pharmacogenomics, psychotherapy, complementary and alternative therapies, and the use of telemedicine.

How Would You Treat This Patient Hospitalized With Community-Acquired Pneumonia?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 174, No 12

Community-acquired pneumonia is a major cause of morbidity and mortality in the United States, leading to 1.5 million hospitalizations and at least 200 000 deaths annually. The 2019 American Thoracic Society/Infectious Diseases Society of America clinical practice guideline on diagnosis and treatment of adults with community-acquired pneumonia provides an evidence-based overview of this common illness. Here, 2 experts, a general internist who served as the co–primary author of the guidelines and a pulmonary and critical care physician, debate the management of a patient hospitalized with community-acquired pneumonia. They discuss disease severity stratification methods, whether to use adjunctive corticosteroids, and when to prescribe empirical treatment for multidrug-resistant organisms such as methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa.

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

Documented Pain Diagnoses in Adults Prescribed Opioids: Results From the National Ambulatory Medical Care Survey, 2006–2015

Patterns of Potential Opioid Misuse and Subsequent Adverse Outcomes in Medicare, 2008 to 2012

Background: Providers are increasingly being expected to examine their patients' opioid treatment histories before writing new opioid prescriptions. However, little evidence exists on how patterns of potential opioid misuse are associated with subsequent adverse outcomes nationally. Objective: To estimate how a range of patterns of potential opioid misuse relate to adverse outcomes during the subsequent year. Design: Observational study comparing outcomes for Medicare enrollees with potential opioid misuse patterns versus those for beneficiaries with no such patterns, adjusting for patient characteristics. Setting: Medicare, 2008 to 2012. Patients: A 5% sample of beneficiaries who had an opioid prescription without a cancer diagnosis. Measurements: Several measures for opioid misuse were defined on the basis of drug quantity, overlapping prescriptions, use of multiple prescribers or pharmacies, and use of out-of-state prescribers or pharmacies. The primary outcome was a diagnosis of opioid overdose in the year after a 6-month index period. Secondary outcomes included subsequent opioid-related or overall mortality. Results: Overall, 0.6% to 8.5% of beneficiaries fulfilled a misuse measure. Subsequent opioid overdose was positively associated with successively greater numbers of prescribers or pharmacies or higher opioid quantities during the index period. For example, patients who obtained opioids from 2, 3, or 4 prescribers were increasingly more likely to have an opioid overdose (adjusted absolute risk per 1000 beneficiary-years [aAR], 3.5 [95% CI, 3.3 to 3.7]; 4.8 [CI, 4.5 to 5.2]; or 6.4 [CI, 5.8 to 6.9], respectively) than those with a single prescriber (aAR, 1.9 [CI, 1.8 to 2.0]). Subsequent overdose risk increased meaningfully with any deviation in the single prescriber–single pharmacy opioid use pattern. All misuse measures examined had a positive association with subsequent opioid overdose and death. Limitation: Risk estimates provide measures of association and may not generalize to non-Medicare populations. Conclusion: To fully assess patients' opioid overdose risk, clinicians should examine a wide range of misuse patterns. Primary Funding Source: National Institutes of Health.

Persistent Hypoxemia on Home Sleep Apnea Testing Prompting Further Evaluation for Pulmonary Embolism: A Case Report | Annals of Internal Medicine: Clinical Cases

Obstructive sleep apnea is a condition characterized by recurrent upper airway collapse during sleep, which may be associated with sleep disruption and repetitive oxygen desaturations. It is diagnosed by nocturnal in-lab polysomnography or home sleep apnea testing. We present a case of an otherwise healthy individual who had home sleep apnea testing that revealed persistent, unexplained hypoxemia which, on further investigation, was found to be due to a saddle pulmonary embolism.

Beyond Uremia: Chronic Kidney Disease as a Cryptic Gateway for Opportunistic Neuroinvasion by John Cunningham Virus | Annals of Internal Medicine: Clinical Cases

Progressive multifocal leukoencephalopathy (PML), a devastating demyelinating central nervous system infection caused by John Cunningham virus (JCV) reactivation, typically occurs in profound immunosuppression. Chronic kidney disease (CKD) induces a state of “immunoparalysis” through uremic toxin-mediated T-cell dysfunction yet remains an underrecognized risk factor for PML. We present a 72-year-old man with end-stage renal disease who developed subacute expressive aphasia and confusion. Magnetic resonance imaging showed demyelinating white matter lesions, and cerebrospinal fluid confirmed JCV DNA, establishing PML. This case highlights CKD as a cryptic immunosuppressive state predisposing to PML and emphasizes the importance of considering PML in patients with CKD presenting with new, progressive neurologic deficits.

Insights Into a Hypercoagulable Case of Thyrocardiac Disease and Literature Overview | Annals of Internal Medicine: Clinical Cases

Hyperthyroidism is associated with a hypercoagulable state and has been described previously in case studies in the context of cerebral vein thrombosis and pulmonary emboli. In this case report, we present a middle-aged man with a rare combination of rheumatic mitral valve disease and thyroid storm complicated by enormous intracardiac thrombus burden. We aim to highlight the hypercoagulable state associated with thyrocardiac disease and to alert the physician to remain vigilant for not only this clinical entity but also for multiple disease states occurring in 1 patient.

Renovascular Hypertension: Unraveling a Case of Mixed Histiocytosis | Annals of Internal Medicine: Clinical Cases

Renovascular hypertension is a cause of secondary hypertension. Atherosclerotic renal artery stenosis and fibromuscular dysplasia are the main causes, but other rare entities can involve the renal arteries. Erdheim-Chester disease is a non-Langerhans cell histiocytosis with a heterogenous clinical presentation and prognosis. We report a case of a 63-year-old woman with a history of Langerhans cell histiocytosis presenting with difficult-to-treat hypertension. A literature review is presented, and owing to the pathophysiology and anatomical characteristics of the vascular attainment, we propose that angioplasty with stenting, as preconized for atherosclerotic renal artery stenosis, should be the preferred treatment approach.

Ivermectin-Clorsulon Overdose in Attempting Coronavirus Disease 2019 Prophylaxis: A Case Report | Annals of Internal Medicine: Clinical Cases

With aims of coronavirus disease 2019 (COVID-19) prophylaxis, a 60-year-old woman ingested a formulation of ivermectin and clorsulon, intended for veterinarian use, that contained 30 times the U.S. Food and Drug Administration–approved dose of ivermectin (5.4 mg/kg). She developed altered mental status requiring intubation. Symptoms were similar to other cases of supratherapeutic ivermectin ingestion. Misinformation propagated about COVID-19 prophylaxis and treatment has led to adverse effects both from misuse of medications and disregard of proven options.

Screening for breast, colorectal cancer rebounded after COVID-19

MKSAP Quiz: Discussing results of bone mineral density testing

U.S. statin use plateaued in 2013 to 2018

MKSAP Quiz: Risks of gender dysphoria treatment

MKSAP Quiz: Evaluation for risk of rheumatoid arthritis

MKSAP Quiz: Evaluation of lung cancer risk during a routine visit

COVID-19 research focused on anticoagulation, vaccine-induced thrombocytopenia

MKSAP Quiz: 2-month history of nonproductive cough

MKSAP Quiz: Evaluation of abnormal thyroid laboratory results

IDSA offers criteria on testing for COVID-19; new research looks at clots, treatments

Perfecting potassium management | ACP Hospitalist

Fast versus slow | ACP Hospitalist

POCUS training gets professional | ACP Hospitalist

At home with AI | ACP Hospitalist

Lateral positioning reduced hypoxemia in sedated patients, Chinese trial finds | ACP Hospitalist

The spark of contrast in the kidney | ACP Hospitalist

Parenteral, enteral, and malnutrition in the hospital | ACP Hospitalist

First rapid-acting insulin biosimilar approved | ACP Hospitalist

Improving interpretation for inpatients | ACP Hospitalist

Cases from LSU Health New Orleans | ACP Hospitalist