ACP Comments on Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program and Medicare Prescription Drug Benefit Program Proposed Rule

ACP Comments on CMS" CY23 Medicare Advantage (Part C) and Medicare Prescription Drug Benefit (Part D) Programs Proposed Rule

ACP's Comments on Draft CDC Guideline on Use of Opioids for Chronic Pain

ACP Comments on Contract Year 2027 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, and Medicare Cost Plan Program Proposed Rule

ACP Comment Letter on 2020 Medicare Physician Fee Schedule Final Rule

Joint ACO Working Group Letter on Senate Finance Committee Chronic Care Policy Options

ACP Comments on CY 2013 Medicare Physician Fee Schedule proposed rule

ACP Comment Letter to CMS Regarding the Physician Fee Schedule Final Rule for CY 2016

ACP Comments on Proposed 2021 Medicare Physician Fee Schedule (PFS) Rule

ACP Comments on 2021 Final Physician Fee Schedule and Quality Payment Program Rule

Annals Clinical Decision Making: Incorporating Perspective Into Clinical Decisions

Risk for Subdeltoid Bursitis After Influenza Vaccination: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 173, No 4

Background: Subdeltoid bursitis has been reported as an adverse event after intramuscular vaccination in the deltoid muscle. Most published case reports involved influenza vaccine. Objective: To estimate the risk for subdeltoid bursitis after influenza vaccination. Design: Retrospective cohort study. Setting: The Vaccine Safety Datalink, which contains health encounter data for 10.2 million members of 7 U.S. health care organizations. Patients: Persons who received an inactivated influenza vaccine during the 2016–2017 influenza season. Measurements: Potential incident cases were identified by searching administrative data for persons with a shoulder bursitis diagnostic code within 180 days after receiving an injectable influenza vaccine in the same arm. The date of reported bursitis symptom onset was abstracted from the medical record. A self-controlled risk interval analysis was used to calculate the incidence rate ratio of bursitis in a risk interval of 0 to 2 days after vaccination versus a control interval of 30 to 60 days, which represents the background rate. The attributable risk was also estimated. Results: The cohort included 2 943 493 vaccinated persons. Sixteen cases of symptom onset in the risk interval and 51 cases of symptom onset in the control interval were identified. The median age of persons in the risk interval was 57.5 years (range, 24 to 98 years), and 69% were women. The incidence rate ratio was 3.24 (95% CI, 1.85 to 5.68). The attributable risk was 7.78 (CI, 2.19 to 13.38) additional cases of bursitis per 1 million persons vaccinated. Limitation: The results may not be generalizable to vaccinations done in other types of health care settings. Conclusion: Although an increased risk for bursitis after vaccination was present, the absolute risk was small. Primary Funding Source: Centers for Disease Control and Prevention.

Health Care Administrative Costs in the United States and Canada, 2017

Background: Before Canada's single-payer reform, its payment system, health costs, and number of health administrative personnel per capita resembled those of the United States. By 1999, administration accounted for 31% of U.S. health expenditures versus 16.7% in Canada. No recent comprehensive analyses of those costs are available. Objective: To quantify 2017 spending for administration by insurers and providers. Design: Analyses of government reports, accounting data that providers file with regulators, surveys of physicians, and census-collected data on employment in health care. Setting: United States and Canada. Measurements: Insurance overhead; administrative expenditures of hospitals, physicians, nursing homes, home care agencies, and hospices. Results: U.S. insurers and providers spent $812 billion on administration, amounting to $2497 per capita (34.2% of national health expenditures) versus $551 per capita (17.0%) in Canada: $844 versus $146 on insurers' overhead; $933 versus $196 for hospital administration; $255 versus $123 for nursing home, home care, and hospice administration; and $465 versus $87 for physicians' insurance-related costs. Of the 3.2–percentage point increase in administration's share of U.S. health expenditures since 1999, 2.4 percentage points was due to growth in private insurers' overhead, mostly because of high overhead in their Medicare and Medicaid managed-care plans. Limitations: Estimates exclude dentists, pharmacies, and some other providers; accounting categories for the 2 countries differ somewhat; and methodological changes probably resulted in an underestimate of administrative cost growth since 1999. Conclusion: The gap in health administrative spending between the United States and Canada is large and widening, and it apparently reflects the inefficiencies of the U.S. private insurance–based, multipayer system. The prices that U.S. medical providers charge incorporate a hidden surcharge to cover their costly administrative burden. Primary Funding Source: None.

Linked Color Imaging Focused on Neoplasm Detection in the Upper Gastrointestinal Tract: A Randomized Trial: Annals of Internal Medicine: Vol 174, No 1

Background: Linked color imaging (LCI) is a new image-enhanced endoscopy technique that allows users to recognize slight differences in mucosal color. Objective: To compare the performance of LCI with white light imaging (WLI) in detecting neoplastic lesions in the upper gastrointestinal tract. Design: A controlled, multicenter trial with randomization using minimization. (University Hospital Medical Information Network Clinical Trials Registry: UMIN000023863) Setting: 16 university hospitals and 3 tertiary care hospitals in Japan. Patients: 1502 patients with known previous or current cancer of the gastrointestinal tract and undergoing surveillance for gastrointestinal cancer. Intervention: WLI followed by LCI examination (WLI group) or LCI followed by WLI examination (LCI group). Measurements: Diagnosis of 1 or more neoplastic lesions in the pharynx, esophagus, or stomach in the first examination (primary outcome) and 1 or more neoplastic lesions overlooked in the first examination (secondary outcome). Results: 752 patients were assigned to the WLI group and 750 to the LCI group. The percentage of patients with 1 or more neoplastic lesions diagnosed in the first examination was higher with LCI than with WLI (60 of 750 patients or 8.0% [95% CI, 6.2% to 10.2%] vs. 36 of 752 patients or 4.8% [CI, 3.4% to 6.6%]; risk ratio, 1.67 [CI, 1.12 to 2.50; P = 0.011]). The proportion with overlooked neoplasms was lower in the LCI group than in the WLI group (5 of 750 patients or 0.67% [CI, 0.2% to 1.6%] vs. 26 of 752 patients or 3.5% [CI, 2.3% to 5.0%]; risk ratio, 0.19 [CI, 0.07 to 0.50]). Limitation: Endoscopists were not blinded. Conclusion: LCI is more effective than WLI for detecting neoplastic lesions in the pharynx, esophagus, and stomach. Primary Funding Source: Fujifilm Corporation.

Declining Use of Primary Care Among Commercially Insured Adults in the United States, 2008–2016

Background: Primary care is known to improve outcomes and lower health care costs, prompting recent U.S. policy efforts to expand its role. Nonetheless, there is early evidence of a decline in per capita primary care visit rates, and little is understood about what is contributing to the decline. Objective: To describe primary care provider (PCP) visit trends among adults enrolled with a large, national, commercial insurer and assess factors underlying a potential decline in PCP visits. Design: Descriptive repeated cross-sectional study using 100% deidentified claims data from the insurer, 2008–2016. A 5% claims sample was used for Poisson regression models to quantify visit trends. Setting: National, population-based. Participants: Adult health plan members aged 18 to 64 years. Measurements: PCP visit rates per 100 member-years. Results: In total, 142 million primary care visits among 94 million member-years were examined. Visits to PCPs declined by 24.2%, from 169.5 to 134.3 visits per 100 member-years, while the proportion of adults with no PCP visits in a given year rose from 38.1% to 46.4%. Rates of visits addressing low-acuity conditions decreased by 47.7% (95% CI, −48.1% to −47.3%). The decline was largest among the youngest adults (−27.6% [CI, −28.2% to −27.1%]), those without chronic conditions (−26.4% [CI, −26.7% to −26.1%]), and those living in the lowest-income areas (−31.4% [CI, −31.8% to −30.9%]). Out-of-pocket cost per problem-based visit rose by $9.4 (31.5%). Visit rates to specialists remained stable (−0.08% [CI, −0.56% to 0.40%]), and visits to alternative venues, such as urgent care clinics, increased by 46.9% (CI, 45.8% to 48.1%). Limitation: Data were limited to a single commercial insurer and did not capture nonbilled clinician–patient interactions. Conclusion: Commercially insured adults have been visiting PCPs less often, and nearly one half had no PCP visits in a given year by 2016. Our results suggest that this decline may be explained by decreased real or perceived visit needs, financial deterrents, and use of alternative sources of care. Primary Funding Source: None.

Rethinking Opioid Dose Tapering, Prescription Opioid Dependence, and Indications for Buprenorphine

Ready or Not, We Live in an Age of Health Information Transparency

Comparative Accuracy of Focused Cardiac Ultrasonography and Clinical Examination for Left Ventricular Dysfunction and Valvular Heart Disease: A Systematic Review and Meta-analysis: Annals of Internal Medicine: Vol 171, No 4

Background: Incorporating focused cardiac ultrasonography (FoCUS) into clinical examination could improve the diagnostic yield of bedside patient evaluation. Purpose: To compare the accuracy of FoCUS-assisted clinical assessment versus clinical assessment alone for diagnosing left ventricular dysfunction or valvular disease in adults having cardiovascular evaluation. Data Sources: English-language searches of MEDLINE, Embase, and Web of Science from 1 January 1990 to 23 May 2019 and review of reference citations. Study Selection: Eligible studies were done in patients having cardiovascular evaluation; compared FoCUS-assisted clinical assessment versus clinical assessment alone for the diagnosis of left ventricular systolic dysfunction, aortic or mitral valve disease, or pericardial effusion; and used transthoracic echocardiography as the reference standard. Data Extraction: Three study investigators independently abstracted data and assessed study quality. Data Synthesis: Nine studies were included in the meta-analysis. The sensitivity of clinical assessment for diagnosing left ventricular dysfunction (left ventricular ejection fraction <50%) was 43% (95% CI, 33% to 54%), whereas that of FoCUS-assisted examination was 84% (CI, 74% to 91%). The specificity of clinical assessment was 81% (CI, 65% to 90%), and that of FoCUS-assisted examination was 89% (CI, 85% to 91%). The sensitivities of clinical assessment and FoCUS-assisted examination for diagnosing aortic or mitral valve disease (of at least moderate severity) were 46% (CI, 35% to 58%) and 71% (CI, 63% to 79%), respectively. Both the clinical assessment and the FoCUS-assisted examination had a specificity of 94% (CI, 91% to 96%). Limitation: Evidence was scant, persons doing ultrasonography had variable skill levels, and most studies had unclear or high risk of bias. Conclusion: Clinical examination assisted by FoCUS has greater sensitivity, but not greater specificity, than clinical assessment alone for identifying left ventricular dysfunction and aortic or mitral valve disease; FoCUS-assisted examination may help rule out cardiovascular pathology in some patients, but it may not be sufficient for definitive confirmation of cardiovascular disease suspected on physical examination. Primary Funding Source: None. (PROSPERO: CRD42019124318)

Health-Related Values and Preferences Regarding Meat Consumption: A Mixed-Methods Systematic Review: Annals of Internal Medicine: Vol 171, No 10

This article has been corrected. The original version (PDF) is appended to this article as a Supplement. Background: A person's meat consumption is often determined by their values and preferences. Purpose: To identify and evaluate evidence addressing health-related values and preferences regarding meat consumption. Data Sources: MEDLINE, EMBASE, Web of Science, Centre for Agriculture and Biosciences Abstracts, International System for Agricultural Science and Technology, and Food Science and Technology Abstracts were searched from inception to July 2018 without language restrictions. Study Selection: Pairs of reviewers independently screened search results and included quantitative and qualitative studies reporting adults' health-related values and preferences regarding meat consumption. Data Extraction: Pairs of reviewers independently extracted data and assessed risk of bias. Data Synthesis: Data were synthesized into narrative form, and summaries were tabulated and certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Of 19 172 initial citations, 41 quantitative studies (38 addressed reasons for meat consumption and 5 addressed willingness to reduce meat consumption) and 13 qualitative studies (10 addressed reasons for meat consumption and 4 addressed willingness to reduce meat consumption) were eligible for inclusion. Thirteen studies reported that omnivores enjoy eating meat, 18 reported that these persons consider meat an essential component of a healthy diet, and 7 reported that they believe they lack the skills needed to prepare satisfactory meals without meat. Omnivores are generally unwilling to change their meat consumption. The certainty of evidence was low for both “reasons for meat consumption” and “willingness to reduce meat consumption in the face of undesirable health effects.” Limitation: Limited generalizability of findings to lower-income countries, low-certainty evidence for willingness to reduce meat consumption, and limited applicability to specific types of meat (red and processed meat). Conclusion: Low-certainty evidence suggests that omnivores are attached to meat and are unwilling to change this behavior when faced with potentially undesirable health effects. Primary Funding Source: None. (PROSPERO: CRD42018088854)

How Would You Manage This Patient With Nonalcoholic Fatty Liver Disease?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 171, No 3

Nonalcoholic fatty liver disease (NAFLD), a common diagnosis in the United States and other developed countries, has been increasing in prevalence. The American Association for the Study of Liver Diseases recently published updated practice guidelines for diagnosing and managing NAFLD, including the following recommendations: Routine screening for NAFLD in high-risk groups is not advised because of uncertainties surrounding test and treatment options, along with a lack of knowledge about cost-effectiveness and long-term benefits. Noninvasive studies, including biomarkers from laboratory tests and liver stiffness measured through elastography, are clinically useful tools for identifying advanced fibrosis in patients with NAFLD. Liver biopsy should be considered in patients with NAFLD who are at increased risk for nonalcoholic steatohepatitis (NASH) or advanced fibrosis. Weight loss of at least 3% to 5% generally reduces NASH, but greater weight loss (7% to 10%) is needed to improve most histopathologic features, including fibrosis. Pharmacologic therapies (such as pioglitazone and vitamin E) should be considered only in patients with biopsy-proven NASH. Patients with NAFLD should not consume heavy amounts of alcohol, although insufficient data exist to provide advice about other levels of alcohol use. Here, 2 clinicians with expertise in this area debate whether to screen for NAFLD in primary care, how to monitor patients with NAFLD, and what interventions should be used to manage this condition.

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