Partial Resumption of Economic, Health Care and Other Activities While Mitigating COVID-19 Risk and Expanding System Capacity

Achieving Affordable Health Insurance Coverage for All Within Seven Years

It's Time to Build Capacity to Meet Mounting Health Needs

Sign-On Letter to the PTAC in Response to Request for Public Input

Sign-On Letter to CMS on Payment Concerns Regarding Telephone Calls During COVID-19 Pandemic

Comments to PCORI on National Priorities for Research and Research Agenda

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

Letter to Senate Leaders Expressing ACP Opposition to Revised Better Care Reconciliation Act (BCRA)

Letter to CMS regarding the New Mexico Centennial Care Medicaid Waiver

Letter to CMS regarding the Kansas KanCare 2.0 1115 Medicaid Waiver

How Would You Manage This Patient With Osteoporosis?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 168, No 11

Osteoporosis is a skeletal disorder characterized by reduced bone strength that increases the risk for fracture. Approximately 10 million men and women in the United States have osteoporosis, and more than 2 million osteoporosis-related fractures occur annually. In 2016, the American Association of Clinical Endocrinologists issued the “Clinical Practice Guideline for the Diagnosis and Treatment of Postmenopausal Osteoporosis,” and in 2017, the American College of Physicians issued the guideline “Treatment of Low Bone Density or Osteoporosis to Prevent Fracture in Men and Women.” Both guidelines agree that patients diagnosed with osteoporosis should be treated with an antiresorptive agent, such as alendronate, that has been shown to reduce hip and vertebral fractures. However, there is no consensus on how long patients with osteoporosis should be treated and whether bone density should be monitored during and after the treatment period. In this Beyond the Guidelines, 2 experts discuss management of osteoporosis in general and for a specific patient, the role of bone density monitoring during and after a 5-year course of alendronate, and treatment recommendations for a patient whose bone density decreases during or after a 5-year course of alendronate.

Clinicians' Perspectives on Providing Emergency-Only Hemodialysis to Undocumented Immigrants: A Qualitative Study: Annals of Internal Medicine: Vol 169, No 2

Background: In the United States, nearly half of undocumented immigrants with end-stage kidney disease receive hemodialysis only when they are evaluated in an emergency department and are found to have life-threatening renal failure (“emergency-only hemodialysis” [EOHD]). These patients experience psychosocial distress and much higher mortality than patients receiving regularly scheduled hemodialysis, but little is known about how providing EOHD affects the clinicians involved. Objective: To understand clinicians' experiences providing EOHD. Design: Qualitative study using semistructured interviews. Setting: A safety-net hospital in Denver, Colorado, and a safety-net system in Houston, Texas. Participants: Fifty interdisciplinary clinicians experienced in providing EOHD. Measurements: Interviews were analyzed using thematic analysis. Outcomes included themes and subthemes. Results: Four themes and 13 subthemes (in parentheses) were identified: 1) drivers of professional burnout (emotional exhaustion from witnessing needless suffering and high mortality, jeopardizing patient trust, detaching from patients, perceived lack of control over EOHD criteria, and physical exhaustion from overextending to bridge care), 2) moral distress from propagating injustice (altered care based on nonmedical factors, focus on volume at the expense of quality, and need to game the system), 3) confusing and perverse financial incentives (wasting resources, confusing financial incentives, and concerns about sustainability), and 4) inspiration toward advocacy (deriving inspiration from patients and strengthened altruism). Limitation: Whether the findings apply to other settings is unknown, and social desirability response bias might have reduced reporting of negative perceptions and experiences. Conclusion: Clinicians in safety-net settings who provide EOHD to undocumented patients describe experiencing moral distress and being driven toward professional burnout. The burden of EOHD on clinicians should inform discussions of systemic approaches to support provision of adequate care based on medical need. Primary Funding Source: Robert Wood Johnson Foundation and Doris Duke Charitable Foundation.

Should This Patient Receive Prophylactic Medication to Prevent Delirium?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 168, No 7

In 2015, the American Geriatrics Society released recommendations for prevention and management of postoperative delirium, based on a systematic literature review and evaluation of nonpharmacologic and pharmacologic approaches by an expert panel. The guidelines recommend an interdisciplinary focus on nonpharmacologic measures (reorientation, medication management, early mobility, nutrition, and gastointestinal motility) for prevention and consideration of this strategy for acute management. They also recommend optimizing nonopioid medication as a means to manage pain and avoiding benzodiazepines other than to treat substance withdrawal. The authors concluded that evidence to recommend antipsychotics for prevention of delirium is insufficient but that these drugs may be considered for short-term treatment in the setting of imminent harm to the patient or caregivers or severe distress due to agitation. Patients should be given the lowest possible dose for the shortest duration when other nonpharmacologic measures have failed. In this Beyond the Guidelines, a psychiatrist and a geriatrician debate whether Mr. W, a 79-year-old man at high risk for postoperative delirium, should receive prophylactic antipsychotics with his next surgery. They review risk factors, appropriate evaluation, and potential benefits and harms of the various medications often used in this setting.

Annals for Hospitalists Inpatient Notes - Why Should Hospitalists Use Point-of-Care Ultrasound?

Value-Based Health Care Meets Cost-Effectiveness Analysis

Value-based health care (VBHC) has recently emerged as a prominent movement within health care. Value-based health care focuses on maximizing outcomes achieved per dollar spent. As such, it bears many similarities to a well-established method, cost-effectiveness analysis (CEA), which provides a framework for comparing the relative value of different diagnostic or treatment interventions. Both approaches address “bang for the health care buck,” but although they overlap in many ways, VBHC and CEA differ with regard to their main applications, their perspective, and the types of costs and outcomes they consider. For example, CEA generally considers costs and benefits from the societal or health care sector perspectives, whereas VBHC is intended to adopt the patient perspective. As such, CEA is intended to inform coverage decisions at a group or population level and VBHC is intended to be implemented at the level of clinician–patient interactions. Meanwhile, value-based payment has emerged as a visible component of VBHC and is gaining a foothold in the United States in various forms, particularly bundled payments and accountable care organizations, in an effort to reward high-value care and disincentivize low-value care. Differences aside, as the worlds of VBHC and CEA begin to intersect, each discipline can learn from the other.

Cost-Effectiveness of Buprenorphine–Naloxone Versus Extended-Release Naltrexone to Prevent Opioid Relapse

Background: Not enough evidence exists to compare buprenorphine–naloxone with extended-release naltrexone for treating opioid use disorder. Objective: To evaluate the cost-effectiveness of buprenorphine–naloxone versus extended-release naltrexone. Design: Cost-effectiveness analysis alongside a previously reported randomized clinical trial of 570 adults in 8 U.S. inpatient or residential treatment programs. Data Sources: Study instruments. Target Population: Adults with opioid use disorder. Time Horizon: 24-week intervention with an additional 12 weeks of observation. Perspective: Health care sector and societal. Interventions: Buprenorphine–naloxone and extended-release naltrexone. Outcome Measures: Incremental costs combined with incremental quality-adjusted life-years (QALYs) and incremental time abstinent from opioids. Results of Base-Case Analysis: Use of the health care sector perspective and a willingness-to-pay threshold of $100 000 per QALY showed buprenorphine–naloxone to be preferable to extended-release naltrexone in 97% of bootstrap replications at 24 weeks and in 85% at 36 weeks. Similar results were obtained with incremental time abstinent from opioids as an outcome and with use of the societal perspective. Results of Sensitivity Analysis: The base-case results were sensitive to the cost of the 2 treatments and the success of randomized treatment initiation. Limitation: Relatively short follow-up for a chronic condition, substantial missing data, no information on patient out-of-pocket and social service costs. Conclusion: Buprenorphine–naloxone is preferred to extended-release naltrexone as first-line treatment when both options are clinically appropriate and patients require detoxification before initiating extended-release naltrexone. Primary Funding Source: National Institute on Drug Abuse, National Institutes of Health.

Principles for Patient and Family Partnership in Care: An American College of Physicians Position Paper

In this position paper, the American College of Physicians (ACP) examines the rationale for patient and family partnership in care and reviews outcomes associated with this concept, including greater adherence to care plans, improved satisfaction, and lower costs. The paper also explores and acknowledges challenges associated with implementing patient- and family-centered models of care. On the basis of a comprehensive literature review and a multistakeholder vetting process, the ACP's Patient Partnership in Healthcare Committee developed a set of principles that form the foundation for authentic patient and family partnership in care. The principles position patients in their rightful place at the center of care while acknowledging the importance of partnership between the care team and patient in improving health care and reducing harm. The principles state that patients and families should be treated with dignity and respect, be active partners in all aspects of their care, contribute to the development and improvement of health care systems, and be partners in the education of health care professionals. This paper also recommends ways to implement these principles in daily practice.

Cranial Electrical Stimulation: What Is It, and Should We Use It in Practice?

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.

Opportunities and Challenges in Genomic Sequencing for Precision Cancer Care