The Effects of the Medicare Modernization Act on Dual Eligible Medicare Beneficiary Drug Benefits

(FY) 2014 302(b) allocation to the Labor, HHS, Education and Related Agencies Appropriations Subcommittee

Universal Coverage: Renewing the Call to Action

Understanding and Addressing Disparities and Discrimination in Education and in the Physician Workforce

Racial and Ethnic Disparities in Healthcare

Promoting Transparency and Alignment in Medicare Advantage

Understanding and Addressing Disparities and Discrimination Affecting Health and Health Care of Persons and Populations at Highest Risk

Reducing Waste, Fraud and Abuse Without Increasing the Hassle Factor for Physicians and Their Patients

The Hassle Factor: America's Health Care System Strangling in Red Tape

Linking Physician Payments to Quality Care

The Safety of Outpatient Health Care: Review of Electronic Health Records: Annals of Internal Medicine: Vol 177, No 6

Background: Despite considerable emphasis on delivering safe care, substantial patient harm occurs. Although most care occurs in the outpatient setting, knowledge of outpatient adverse events (AEs) remains limited. Objective: To measure AEs in the outpatient setting. Design: Retrospective review of the electronic health record (EHR). Setting: 11 outpatient sites in Massachusetts in 2018. Patients: 3103 patients who received outpatient care. Measurements: Using a trigger method, nurse reviewers identified possible AEs and physicians adjudicated them, ranked severity, and assessed preventability. Generalized estimating equations were used to assess the association of having at least 1 AE with age, sex, race, and primary insurance. Variation in AE rates was analyzed across sites. Results: The 3103 patients (mean age, 52 years) were more often female (59.8%), White (75.1%), English speakers (90.8%), and privately insured (70.4%) and had a mean of 4 outpatient encounters in 2018. Overall, 7.0% (95% CI, 4.6% to 9.3%) of patients had at least 1 AE (8.6 events per 100 patients annually). Adverse drug events were the most common AE (63.8%), followed by health care–associated infections (14.8%) and surgical or procedural events (14.2%). Severity was serious in 17.4% of AEs, life-threatening in 2.1%, and never fatal. Overall, 23.2% of AEs were preventable. Having at least 1 AE was less often associated with ages 18 to 44 years than with ages 65 to 84 years (standardized risk difference, −0.05 [CI, −0.09 to −0.02]) and more often associated with Black race than with Asian race (standardized risk difference, 0.09 [CI, 0.01 to 0.17]). Across study sites, 1.8% to 23.6% of patients had at least 1 AE and clinical category of AEs varied substantially. Limitation: Retrospective EHR review may miss AEs. Conclusion: Outpatient harm was relatively common and often serious. Adverse drug events were most frequent. Rates were higher among older adults. Interventions to curtail outpatient harm are urgently needed. Primary Funding Source: Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions.

Xylazine Adulteration of the Heroin–Fentanyl Drug Supply: A Narrative Review: Annals of Internal Medicine: Vol 176, No 10

Xylazine is an animal sedative, approved by the U.S. Food and Drug Administration, that is commonly used in veterinary medicine and is not approved for human use. Since 2016, xylazine has consistently appeared in the illicitly manufactured fentanyl supply and has significantly increased in prevalence, likely due to its low cost, easy availability, and presumed synergistic psychoactive effect. Clinical experience along with the available pertinent research were used to review xylazine adulteration of the drug supply and provide guidance on the care of patients exposed to xylazine. This review discusses xylazine pharmacology, animal and human clinical effects, and what is known to date about care of patients experiencing acute overdose, xylazine–fentanyl withdrawal, and xylazine-associated wounds.

The Pendulum Swings on Glucocorticoids in Rheumatoid Arthritis

Lessons Learned While Grieving

Clinical Effectiveness of Cognitively Enhanced Tai Ji Quan Training on Global Cognition and Dual-Task Performance During Walking in Older Adults With Mild Cognitive Impairment or Self-Reported Memory Concerns: A Randomized Controlled Trial: Annals of Internal Medicine: Vol 176, No 11

Background: Mild cognitive impairment (MCI) negatively impacts cognition and dual-task abilities. A physical–cognitive integrated treatment approach could mitigate this risk for dementia. Objective: To compare the effectiveness of cognitively enhanced tai ji quan versus standard tai ji quan or stretching exercise in improving global cognition and reducing dual-task walking costs in older adults with MCI or self-reported memory concerns. Design: 3-group, randomized (1:1:1), superiority trial. (ClinicalTrials.gov: NCT04070703) Setting: Community residential homes. Participants: 318 older adults with self-reported memory decline or concern and a Clinical Dementia Rating (CDR) global score of 0.5 or lower at baseline. Intervention: Cognitively enhanced tai ji quan (n = 105), standard tai ji quan (n = 107), or stretching (n = 106). All groups exercised at home via real-time videoconferencing, 1 hour semiweekly for 24 weeks. Measurements: The co–primary endpoints were change in Montreal Cognitive Assessment (MoCA; range, 0 to 30) and dual-task walking costs (difference between single- and dual-task gait speed, expressed in percentage) from baseline to 24 weeks. Secondary outcomes included CDR–Sum of Boxes (CDR-SB), Trail Making Test B, Digit Span Backward (DSB), and physical performance tests. Outcomes were assessed at 16, 24 (primary endpoint), and 48 weeks (6 months after intervention). Results: A total of 304 participants (96%) completed the 24-week assessment. Cognitively enhanced tai ji quan outperformed standard tai ji quan and stretching with a greater improvement in MoCA score (mean difference, 1.5 points [98.75% CI, 0.7 to 2.2 points] and 2.8 points [CI, 2.1 to 3.6 points], respectively) and in dual-task walking (mean difference, 9.9% [CI, 2.8% to 16.6%] and 22% [CI, 13% to 31%], respectively). The intervention effects persisted at 48-week follow-up. Limitation: There was no nonexercise control group; participants had subjective or mild cognitive impairment. Conclusion: Among community-dwelling older adults with MCI, cognitively enriched tai ji quan therapy was superior to standard tai ji quan and stretching exercise in improving global cognition and reducing dual-task gait interference, with outcomes sustained at 48 weeks. Primary Funding Source: National Institute on Aging.

Addressing Viral Medical Rumors and False or Misleading Information

The rapid spread of medical rumors and false or misleading information on social media during times of uncertainty is a vexing challenge that threatens public health. Understanding the information ecosystem, social media networks, and the scope of incentives that drive users and social media platforms can provide critical insights for strong coordination between stakeholders and funders to address this challenge. The COVID-19 pandemic created an opportunity to demonstrate the role of media monitoring and counter-messaging efforts in responding to dangerous medical rumors, misinformation, and disinformation. It also highlighted the challenges. The efforts of ThisIsOurShot and VacunateYa to spread accurate health information about COVID-19 and COVID-19 vaccines are described and lessons learned are discussed. These lessons include the need for substantial financial investments at the local and national levels to sustain and scale these types of programs. Examples in other fields that offer a path forward include Information Sharing and Analysis Centers and Public Health Emergency Operations Centers. Understanding the scale and scope of what it takes to address viral medical rumors, misinformation, and disinformation in a networked information environment should inspire elected leaders to consider policy and regulatory reforms. Our transformed information ecosystem requires new public health infrastructure to address information that threatens personal safety and population health.

Suspected Bronchiectasis and Mortality in Adults With a History of Smoking Who Have Normal and Impaired Lung Function: A Cohort Study: Annals of Internal Medicine: Vol 176, No 10

Background: Bronchiectasis in adults with chronic obstructive pulmonary disease (COPD) is associated with greater mortality. However, whether suspected bronchiectasis—defined as incidental bronchiectasis on computed tomography (CT) images plus clinical manifestation—is associated with increased mortality in adults with a history of smoking with normal spirometry and preserved ratio impaired spirometry (PRISm) is unknown. Objective: To determine the association between suspected bronchiectasis and mortality in adults with normal spirometry, PRISm, and obstructive spirometry. Design: Prospective, observational cohort. Setting: The COPDGene (Genetic Epidemiology of Chronic Obstructive Pulmonary Disease) study. Participants: 7662 non-Hispanic Black or White adults, aged 45 to 80 years, with 10 or more pack-years of smoking history. Participants who were former and current smokers were stratified into normal spirometry (n = 3277), PRISm (n = 986), and obstructive spirometry (n = 3399). Measurements: Bronchiectasis identified by CT was ascertained using artificial intelligence–based measurements of an airway-to-artery ratio (AAR) greater than 1 (AAR >1), a measure of bronchial dilatation. The primary outcome of “suspected bronchiectasis” was defined as an AAR >1 of greater than 1% plus 2 of the following: cough, phlegm, dyspnea, and history of 2 or more exacerbations. Results: Among the 7662 participants (mean age, 60 years; 52% women), 1352 (17.6%) had suspected bronchiectasis. During a median follow-up of 11 years, 2095 (27.3%) died. Ten-year mortality risk was higher in participants with suspected bronchiectasis, compared with those without suspected bronchiectasis (normal spirometry: difference in mortality probability [Pr], 0.15 [95% CI, 0.09 to 0.21]; PRISm: Pr, 0.07 [CI, −0.003 to 0.15]; obstructive spirometry: Pr, 0.06 [CI, 0.03 to 0.09]). When only CT was used to identify bronchiectasis, the differences were attenuated in the normal spirometry (Pr, 0.04 [CI, −0.001 to 0.08]). Limitations: Only 2 racial groups were studied. Only 1 measurement was used to define bronchiectasis on CT. Symptoms of suspected bronchiectasis were nonspecific. Conclusion: Suspected bronchiectasis was associated with a heightened risk for mortality in adults with normal and obstructive spirometry. Primary Funding Source: National Heart, Lung, and Blood Institute.

Fatal Drug Overdose Risks of Health Care Workers in the United States: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 176, No 8

Background: Despite an unprecedented increase in drug overdose deaths in the United States, the risks faced by U.S. health care workers, who often have access to controlled prescription drugs, are not known. Objective: To estimate risks for drug overdose death among health care workers relative to non–health care workers. Design: Prospective cohort study. Setting: United States. Participants: Health care workers (n = 176 000) and non–health care workers (n = 1 662 000) aged 26 years or older surveyed in 2008 and followed for cause of death through 2019. Measurements: Age- and sex-standardized drug overdose deaths were determined for 6 health care worker groups (physicians, registered nurses, other treating or diagnosing health care workers, health technicians, health care support workers, and social or behavioral health workers) and non–health care workers. Adjusted drug overdose death hazards (and 95% CIs) were also evaluated, with adjustment for age, sex, race/ethnicity, marital status, education, income, urban or rural residence, and region. Results: Approximately 0.07% of our study sample died of a drug overdose during follow-up. Among health care workers, annual standardized rates of drug overdose death per 100 000 persons ranged from 2.3 (95% CI, 0 to 4.8) for physicians to 15.5 (CI, 9.8 to 21.2) for social or behavioral health workers. Compared with those for non–health care workers, the adjusted hazards of total drug overdose death were significantly increased for social or behavioral health workers (adjusted hazard ratio, 2.55 [CI, 1.74 to 3.73]), registered nurses (adjusted hazard ratio, 2.22 [CI, 1.57 to 3.13]), and health care support workers (adjusted hazard ratio, 1.60 [CI, 1.19 to 2.16]), but not for physicians (adjusted hazard ratio, 0.61 [CI, 0.19 to 1.93]), other treating or diagnosing health care workers (adjusted hazard ratio, 0.93 [CI, 0.44 to 1.95]), or health technicians (adjusted hazard ratio, 1.13 [CI, 0.75 to 1.68]). Results were generally similar for opioid-related overdose deaths and unintentional overdose deaths. Limitation: Unmeasured confounding, uncertain validity of cause of death, and one-time assessment of occupation. Conclusion: Registered nurses, social or behavioral health workers, and health care support workers were at increased risk for drug overdose death, suggesting the need to identify and intervene on those at high risk. Primary Funding Source: National Heart, Lung, and Blood Institute.

How Would You Manage This Patient With Clostridioides difficile Infection?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 176, No 8

The Infectious Diseases Society of America/Society for Healthcare Epidemiology of America and the American College of Gastroenterology recently released updated guidelines on management of patients with Clostridioides difficile infection. Although these 2 guidelines generally agree, there are a few important differences in their advice to clinicians. In these rounds, 2 experts, an infectious diseases specialist and a gastroenterologist, discuss antibiotic treatment options for nonsevere disease, the role of fecal microbiota transplantation for fulminant disease, and the use of bezlotoxumab to prevent recurrence in the context of Ms. C, a 48-year-old woman with fulminant C difficile infection.

Chronotype, Unhealthy Lifestyle, and Diabetes Risk in Middle-Aged U.S. Women: A Prospective Cohort Study: Annals of Internal Medicine: Vol 176, No 10

Background: Evening chronotype may promote adherence to an unhealthy lifestyle and increase type 2 diabetes risk. Objective: To evaluate the role of modifiable lifestyle behaviors in the association between chronotype and diabetes risk. Design: Prospective cohort study. Setting: Nurses’ Health Study II. Participants: 63 676 nurses aged 45 to 62 years with no history of cancer, cardiovascular disease, or diabetes in 2009 were prospectively followed until 2017. Measurements: Self-reported chronotype using a validated question from the Morningness-Eveningness Questionnaire. The lifestyle behaviors that were measured were diet quality, physical activity, alcohol intake, body mass index (BMI), smoking, and sleep duration. Incident diabetes cases were self-reported and confirmed using a supplementary questionnaire. Results: Participants reporting a “definite evening” chronotype were 54% (95% CI, 49% to 59%) more likely to have an unhealthy lifestyle than participants reporting a “definite morning” chronotype. A total of 1925 diabetes cases were documented over 469 120 person-years of follow-up. Compared with the “definite morning” chronotype, the adjusted hazard ratio (HR) for diabetes was 1.21 (CI, 1.09 to 1.35) for the “intermediate” chronotype and 1.72 (CI, 1.50 to 1.98) for the “definite evening” chronotype after adjustment for sociodemographic factors, shift work, and family history of diabetes. Further adjustment for BMI, physical activity, and diet quality attenuated the association comparing the “definite evening” and “definite morning” chronotypes to 1.31 (CI, 1.13 to 1.50), 1.54 (CI, 1.34 to 1.77), and 1.59 (CI, 1.38 to 1.83), respectively. Accounting for all measured lifestyle and sociodemographic factors resulted in a reduced but still positive association (HR comparing “definite evening” vs. “definite morning” chronotype, 1.19 [CI, 1.03 to 1.37]). Limitations: Chronotype assessment using a single question, self-reported data, and homogeneity of the study population. Conclusion: Middle-aged nurses with an evening chronotype were more likely to report unhealthy lifestyle behaviors and had increased diabetes risk compared with those with a morning chronotype. Accounting for BMI, physical activity, diet, and other modifiable lifestyle factors attenuated much but not all of the increased diabetes risk. Primary Funding Source: National Institutes of Health.