Resource-based Practice Expenses and Medicare Budget. Letter to Budget Conferees, U.S. House of Representatives.

Resource-based Practice Expenses. Letter to the Senate Finance, House Ways & Means, and House Commerce Committees.

Resource-based Practice Expenses. Letter to the Health Care Financing Administration

Resource-Based Practice Expenses. Letter to Finance Committee, U.S. Senate, and Ways and Means Committee, U.S. House of Representatives.

Resource-Based Practice Expenses. HR 3859. Letter to U.S. House of Representatives.

Resource-based Practice Expense, Balanced Budget Act of 1997. Letter to Ways and Means Committee, U.S. House of Representatives.

Resource-Based Physician Expenses. HR 3859. Letter to U.S. House of Representatives.

Resource-Based Down Payments, HCFA Budget 1997. Letter to United States Health Care Financing Administration.

Repeal SGR

Relief for Teaching Hospitals from Indirect Medical Education Reductions

Effect of the STAMP (Sharing and Talking About My Preferences) Intervention on Completing Multiple Advance Care Planning Activities in Ambulatory Care: A Cluster Randomized Controlled Trial: Annals of Internal Medicine: Vol 174, No 11

Background: Interventions with the potential for broad reach in ambulatory settings are necessary to achieve a life course approach to advance care planning. Objective: To examine the effect of a computer-tailored, behavioral health model–based intervention on the engagement of adults in advance care planning recruited from ambulatory care settings. Design: Cluster randomized controlled trial with participant-level analysis. (ClinicalTrials.gov: NCT03137459) Setting: 10 pairs of primary and selected specialty care practices matched on patient sociodemographic information. Participants: English-speaking adults aged 55 years or older; 454 adults at practices randomly assigned to usual care and 455 at practices randomly assigned to intervention. Intervention: Brief telephone or web-based assessment generating a mailed, individually tailored feedback report with a stage-matched brochure at baseline, 2 months, and 4 months. Measurements: The primary outcome was completion of the following 4 advance care planning activities at 6 months: identifying and communicating with a trusted person about views on quality versus quantity of life, assignment of a health care agent, completion of a living will, and ensuring that the documents are in the medical record—assessed by a blinded interviewer. Secondary outcomes were completion of individual advance care planning activities. Results: Participants were 64% women and 76% White. The mean age was 68.3 years (SD, 8.3). The predicted probability of completing all advance care planning activities in usual care sites was 8.2% (95% CI, 4.9% to 11.4%) versus 14.1% (CI, 11.0% to 17.2%) in intervention sites (adjusted risk difference, 5.2 percentage points [CI, 1.6 to 8.8 percentage points]). Prespecified subgroup analysis found no statistically significant interactions between the intervention and age, education, or race. Limitations: The study was done in a single region and excluded non–English speaking participants. No information was collected about nonparticipants. Conclusion: A brief, easily delivered, tailored print intervention increased participation in advance care planning in ambulatory care settings. Primary Funding Source: National Institute of Nursing Research and National Institute of Aging.

Management of Blood Pressure in Patients With Chronic Kidney Disease Not Receiving Dialysis: Synopsis of the 2021 KDIGO Clinical Practice Guideline

Description: The Kidney Disease: Improving Global Outcomes (KDIGO) 2021 clinical practice guideline for the management of blood pressure (BP) in patients with chronic kidney disease (CKD) not receiving dialysis is an update of the KDIGO 2012 guideline on the same topic and reflects new evidence on the risks and benefits of BP-lowering therapy among patients with CKD. It is intended to support shared decision making by health care professionals working with patients with CKD worldwide. This article is a synopsis of the full guideline. Methods: The KDIGO leadership commissioned 2 co-chairs to convene an international Work Group of researchers and clinicians. After a Controversies Conference in September 2017, the Work Group defined the scope of the evidence review, which was undertaken by an evidence review team between October 2017 and April 2020. Evidence reviews were done according to the Cochrane Handbook. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used to guide the development of the recommendations and rate the strength and quality of the evidence. Practice points were included to provide guidance when evidence was insufficient to make a graded recommendation. The guideline was revised after public consultation between January and March 2020. Recommendations: The updated guideline comprises 11 recommendations and 20 practice points. This synopsis summarizes key recommendations pertinent to the diagnosis and management of high BP in adults with CKD, excluding those receiving kidney replacement therapy. In particular, the synopsis focuses on recommendations for standardized BP measurement and a target systolic BP of less than 120 mm Hg, because these recommendations differ from some other guidelines.

Passing the Test: A Model-Based Analysis of Safe School-Reopening Strategies

Background: The COVID-19 pandemic has induced historic educational disruptions. In April 2021, about 40% of U.S. public school students were not offered full-time in-person education. Objective: To assess the risk for SARS-CoV-2 transmission in schools. Design: An agent-based network model was developed to simulate transmission in elementary and high school communities, including home, school, and interhousehold interactions. Setting: School structure was parametrized to reflect average U.S. classrooms, with elementary schools of 638 students and high schools of 1451 students. Daily local incidence was varied from 1 to 100 cases per 100 000 persons. Participants: Students, faculty, staff, and adult household members. Intervention: Isolation of symptomatic individuals, quarantine of an infected individual's contacts, reduced class sizes, alternative schedules, staff vaccination, and weekly asymptomatic screening. Measurements: Transmission was projected among students, staff, and families after a single infection in school and over an 8-week quarter, contingent on local incidence. Results: School transmission varies according to student age and local incidence and is substantially reduced with mitigation measures. Nevertheless, when transmission occurs, it may be difficult to detect without regular testing because of the subclinical nature of most children's infections. Teacher vaccination can reduce transmission to staff, and asymptomatic screening improves understanding of local circumstances and reduces transmission. Limitation: Uncertainty exists about the susceptibility and infectiousness of children, and precision is low regarding the effectiveness of specific countermeasures, particularly with new variants. Conclusion: With controlled community transmission and moderate mitigation, elementary schools can open safety, but high schools require more intensive mitigation. Asymptomatic screening can facilitate reopening at higher local incidence while minimizing transmission risk. Primary Funding Source: Centers for Disease Control and Prevention through the Council of State and Territorial Epidemiologists, National Institute of Allergy and Infectious Diseases, National Institute on Drug Abuse, and Facebook.

Associations of Serum Testosterone and Sex Hormone–Binding Globulin With Incident Cardiovascular Events in Middle-Aged to Older Men

Background: The influence of testosterone on risk for cardiovascular events in men is uncertain. Previous observational studies of sex hormones and incident cardiovascular disease in men have reported inconsistent findings, limited by cohort sizes and different selection criteria. Objective: To analyze associations of serum total testosterone and sex hormone–binding globulin (SHBG) with incident cardiovascular events in men. Design: Cohort study. Setting: UK Biobank prospective cohort. Participants: Community-dwelling men aged 40 to 69 years. Measurements: Testosterone and SHBG were assayed, and free testosterone was calculated. Cox proportional hazards regression was done, with outcomes of incident myocardial infarction (MI), hemorrhagic stroke (HS), ischemic stroke (IS), heart failure (HF), and major adverse cardiovascular events (MACE), adjusted for sociodemographic, lifestyle, and medical factors. Results: Of 210 700 men followed for 9 years, 8790 (4.2%) had an incident cardiovascular event. After adjustment for key variables, lower total testosterone concentrations (quintile 1 vs. quintile 5) were not associated with incident MI (fully adjusted hazard ratio [HR], 0.89 [95% CI, 0.80 to 1.00]), HS (HR, 0.94 [CI, 0.70 to 1.26]), IS (HR, 0.95 [CI, 0.82 to 1.10]), HF (HR, 1.15 [CI, 0.91 to 1.45]), or MACE (HR, 0.92 [CI, 0.84 to 1.00]). Men with lower calculated free testosterone values had a lower incidence of MACE (HR, 0.90 [CI, 0.84 to 0.97]). Lower SHBG concentrations were associated with higher incidence of MI (HR, 1.23 [CI, 1.09 to 1.38]) and lower incidence of IS (HR, 0.79 [CI, 0.67 to 0.94]) and HF (HR, 0.69 [CI, 0.54 to 0.89]), but not with HS (HR, 0.81 [CI, 0.57 to 1.14]) or MACE (HR, 1.01 [CI, 0.92 to 1.11]). Limitation: Observational study; single baseline measurement of testosterone and SHBG. Conclusion: Men with lower total testosterone concentrations were not at increased risk for MI, stroke, HF, or MACE. Calculated free testosterone may be associated with risk for MACE. Men with lower SHBG concentrations have higher risk for MI but lower risk for IS and HF, with causality to be determined. Primary Funding Source: Western Australian Health Translation Network, Medical Research Future Fund, and Lawley Pharmaceuticals.

Postdiagnosis Smoking Cessation and Reduced Risk for Lung Cancer Progression and Mortality: A Prospective Cohort Study: Annals of Internal Medicine: Vol 174, No 9

Background: Lung cancer is the leading cause of cancer death worldwide, and about one half of patients with lung cancer are active smokers at diagnosis. Objective: To determine whether quitting smoking after diagnosis of lung cancer affects the risk for disease progression and mortality. Design: Prospective study of patients with non–small cell lung cancer (NSCLC) who were recruited between 2007 and 2016 and followed annually through 2020. Setting: N.N. Blokhin National Medical Research Center of Oncology and City Clinical Oncological Hospital No. 1, Moscow, Russia. Patients: 517 current smokers who were diagnosed with early-stage (IA-IIIA) NSCLC. Measurements: Probabilities of overall survival, progression-free survival, and lung cancer–specific mortality and hazard ratios (HRs) for all-cause and cancer-specific mortality. Results: During an average of 7 years of follow-up, 327 (63.2%) deaths, 273 (52.8%) cancer-specific deaths, and 172 (33.7%) cases of tumor progression (local recurrence or metastasis) were recorded. The adjusted median overall survival time was 21.6 months higher among patients who had quit smoking than those who continued smoking (6.6 vs. 4.8 years, respectively; P = 0.001). Higher 5-year overall survival (60.6% vs. 48.6%; P = 0.001) and progression-free survival (54.4% vs. 43.8%; P = 0.004) were observed among patients who quit than those who continued smoking. After adjustments, smoking cessation remained associated with decreased risk for all-cause mortality (HR, 0.67 [95% CI, 0.53 to 0.85]), cancer-specific mortality (HR, 0.75 [CI, 0.58 to 0.98]), and disease progression (HR, 0.70 [CI, 0.56 to 0.89]). Similar effects were observed among mild to moderate and heavy smokers and patients with earlier and later cancer stages. Limitation: Exposure measurements were based on self-reported questionnaires. Conclusion: Smoking cessation after diagnosis materially improved overall and progression-free survival among current smokers with early-stage lung cancer. Primary Funding Source: International Agency for Research on Cancer.

Diabetes Screening by Race and Ethnicity in the United States: Equivalent Body Mass Index and Age Thresholds

Background: Racial/ethnic minority populations in the United States have increased rates of diabetes compared with White populations. The 2021 guidelines from the U.S. Preventive Services Task Force recommend diabetes screening for adults aged 35 to 70 years with a body mass index (BMI) of 25 kg/m2 or greater. Objective: To determine the BMI threshold for diabetes screening in major racial/ethnic minority populations with benefits and harms equivalent to those of the current diabetes screening threshold in White adults. Design: Cross-sectional study. Setting: NHANES (National Health and Nutrition Examination Survey), 2011 to 2018. Participants: Nonpregnant U.S. adults aged 18 to 70 years (n = 19 335). Measurements: A logistic regression model was used to estimate diabetes prevalence at various BMIs for White, Asian, Black, and Hispanic Americans. For each racial/ethnic minority group, the equivalent BMI threshold was defined as the BMI at which the prevalence of diabetes in 35-year-old persons in that group is equal to that in 35-year-old White adults at a BMI of 25 kg/m2. Ranges were estimated to account for the uncertainty in prevalence estimates for White and racial/ethnic minority populations. Results: Among adults aged 35 years with a BMI of 25 kg/m2, the prevalence of diabetes in Asian Americans (3.8% [95% CI, 2.8% to 5.1%]), Black Americans (3.5% [CI, 2.7% to 4.7%]), and Hispanic Americans (3.0% [CI, 2.1% to 4.2%]) was significantly higher than that in White Americans (1.4% [CI, 1.0% to 2.0%]). Compared with a BMI threshold of 25 kg/m2 in White Americans, the equivalent BMI thresholds for diabetes prevalence were 20 kg/m2 (range, <18.5 to 23 kg/m2) for Asian Americans, less than 18.5 kg/m2 (range, <18.5 to 23 kg/m2) for Black Americans, and 18.5 kg/m2 (range, <18.5 to 24 kg/m2) for Hispanic Americans. Limitation: Sample size limitations precluded assessment of heterogeneity within racial/ethnic groups. Conclusion: Among U.S. adults aged 35 years or older, offering diabetes screening to Black Americans and Hispanic Americans with a BMI of 18.5 kg/m2 or greater and Asian Americans with a BMI of 20 kg/m2 or greater would be equivalent to screening White adults with a BMI of 25 kg/m2 or greater. Using screening thresholds specific to race/ethnicity has the potential to reduce disparities in diabetes diagnosis. Primary Funding Source: Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology.

Should You Recommend Cannabinoids for This Patient With Painful Neuropathy?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 174, No 2

Cannabis includes 140 active cannabinoid compounds, the most important of which are tetrahydrocannabinol and cannabidiol (CBD). Tetrahydrocannabinol is primarily responsible for the intoxicating effects of cannabis; CBD has potential therapeutic effects, including reduction in chronic pain. Recent legislative changes have resulted in the legal availability of cannabinoids in all 50 states, as well as a marked increase in patients' interest in their use. Despite an abundance of data, albeit of varied quality, clinicians may feel poorly prepared to counsel patients seeking advice on the suitability of CBD products for various indications, particularly chronic neuropathic pain. In 2018, on the basis of a systematic review of the literature, a Canadian Evidence Review Group published a guideline with recommendations for clinicians on prescribing cannabinoids in primary care practice. The overall quality of evidence was low to very low. In a meta-analysis of 15 randomized trials of medical cannabis for treating chronic pain, 39% of patients achieved at least a 30% reduction in pain. The corresponding value for placebo-treated patients was 30%; the number needed to treat was 11. More evidence exists for neuropathic pain than for other types of noncancer pain. Here, a general internist with a focus on addiction medicine and an addiction psychiatrist discuss how they would apply the literature to make recommendations for a patient with painful diabetic neuropathy, including counseling on both potential benefits and harms.

Falls: To D or Not to D—That Is Not the (Only) Question!

Estimated Effect on Life Expectancy of Alleviating Primary Care Shortages in the United States

Background: Prior studies have reported that greater numbers of primary care physicians (PCPs) per population are associated with reduced population mortality, but the effect of increasing PCP density in areas of low density is poorly understood. Objective: To estimate how alleviating PCP shortages might change life expectancy and mortality. Design: Generalized additive models, mixed-effects models, and generalized estimating equations. Setting: 3104 U.S. counties from 2010 to 2017. Participants: Children and adults. Measurements: Age-adjusted life expectancy; all-cause mortality; and mortality due to cardiovascular disease, cancer, infectious disease, respiratory disease, and substance use or injury. Results: Persons living in counties with less than 1 physician per 3500 persons in 2017 had a mean life expectancy that was 310.9 days shorter than for persons living in counties above that threshold. In the low-density counties (n = 1218), increasing the density of PCPs above the 1:3500 threshold would be expected to increase mean life expectancy by 22.4 days (median, 19.4 days [95% CI, 0.9 to 45.6 days]), and all such counties would require 17 651 more physicians, or about 14.5 more physicians per shortage county. If counties with less than 1 physician per 1500 persons (n = 2636) were to reach the 1:1500 threshold, life expectancy would be expected to increase by 56.3 days (median, 55.6 days [CI, 4.2 to 105.6 days]), and all such counties would require 95 754 more physicians, or about 36.3 more physicians per shortage county. Limitation: Some projections are based on extrapolations of the actual data. Conclusion: In counties with fewer PCPs per population, increases in PCP density would be expected to substantially improve life expectancy. Primary Funding Source: None.

Effects of Tai Chi or Conventional Exercise on Central Obesity in Middle-Aged and Older Adults: A Three-Group Randomized Controlled Trial: Annals of Internal Medicine: Vol 174, No 8

Background: Central obesity is a major manifestation of metabolic syndrome, which is a common health problem in middle-aged and older adults. Objective: To examine the therapeutic efficacy of tai chi for management of central obesity. Design: Randomized, controlled, assessor-blinded trial. (ClinicalTrials.gov: NCT03107741) Setting: A single research site in Hong Kong between 27 February 2016 and 28 February 2019. Participants: Adults aged 50 years or older with central obesity. Intervention: 543 participants were randomly assigned in a 1:1:1 ratio to a control group with no exercise intervention (n = 181), conventional exercise consisting of aerobic exercise and strength training (EX group) (n = 181), and a tai chi group (TC group) (n = 181). Interventions lasted 12 weeks. Measurements: Outcomes were assessed at baseline, week 12, and week 38. The primary outcome was waist circumference (WC). Secondary outcomes were body weight; body mass index; high-density lipoprotein cholesterol (HDL-C), triglyceride, and fasting plasma glucose levels; blood pressure; and incidence of remission of central obesity. Results: The adjusted mean difference in WC from baseline to week 12 in the control group was 0.8 cm (95% CI, −4.1 to 5.7 cm). Both intervention groups showed reductions in WC relative to control (adjusted mean differences: TC group vs. control, −1.8 cm [CI, −2.3 to −1.4 cm]; P < 0.001; EX group vs. control: −1.3 cm [CI, −1.8 to −0.9 cm]; P < 0.001); both intervention groups also showed reductions in body weight (P < 0.05) and attenuation of the decrease in HDL-C level relative to the control group. The favorable changes in WC and body weight were maintained in both the TC and EX groups, whereas the beneficial effect on HDL-C was only maintained in the TC group at week 38. Limitations: High attrition and no dietary intervention. Conclusion: Tai chi is an effective approach to reduce WC in adults with central obesity aged 50 years or older. Primary Funding Source: Health and Medical Research Fund.