Insurance Reform in a Voluntary System: Implications for the Sick, the Well, and Universal Health Care

Health Care Financing Administration Conference on Resource-Based Practice Expenses.

Direct-to-Consumer Prescription Drug Advertising

Direct to Consumer Advertising for Prescription Drugs

The Acquired Immunodeficiency Syndrome (AIDS) and Infection with the Human Immunodeficiency Virus (HIV)

Summary and Results of CLIA Inspection Process Survey

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

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

Over-the-Counter Drugs: Proposed Labeling Requirements. Letter to Department of Health and Human Services.

Medicare Program; Negotiated Rulemaking Coverage and Administrative Policies for Clinical Diagnostic Laboratory Services. Letter to Health Care Financing Administration.

Fantasies of a Wounded Healer

Medical Schools as Racialized Organizations: A Primer

The year 2020 saw the largest social movement in response to the police killings of Black people and anti-Black racism in U.S. history. As a result, medical schools and professional societies such as the American Medical Association and the Association of American Medical Colleges are reckoning with their role in perpetuating racial inequality and the impact of structural racism on medical training. Whether these efforts will translate into meaningful change has yet to be determined. Success depends on a deep understanding of the fundamental role racism plays in how medical schools function and an acknowledgment that current organizational structures and processes often serve to entrench, not dismantle, racial inequities. Drawing on racialized organizations theory from the field of sociology, this article gives an overview of scholarship on race and racism in medical training to demonstrate how seemingly race-neutral processes and structures within medical education, in conjunction with individuals’ biases and interpersonal discrimination, serve to reproduce and sustain racial inequality. From entrance into medical school through the residency application process, organizational factors such as reliance on standardized tests to predict future success, a hostile learning climate, and racially biased performance metrics ultimately stunt the careers of trainees of color, particularly those from backgrounds underrepresented in medicine (URM). These compounding disadvantages contribute to URM trainees’ lower matching odds, steering into less competitive and lucrative specialties, and burnout and attrition from academic careers. In their commitment against structural racism in medical training and academic medicine, medical schools and larger organizations like the Association of American Medical Colleges should prioritize interventions targeted at these structural barriers to achieve equity.

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.

Health Information Privacy, Protection, and Use in the Expanding Digital Health Ecosystem: A Position Paper of the American College of Physicians

Technologic advancements and the evolving digital health landscape have offered innovative solutions to several of our health care system's issues as well as increased the number of digital interactions and type of personal health information that is generated and collected, both within and outside of traditional health care. This American College of Physicians' position paper discusses the state of privacy legislation and regulations, highlights existing gaps in health information privacy protections, and outlines policy principles and recommendations for the development of health information privacy and security protections that are comprehensive, transparent, understandable, adaptable, and enforceable. The principles and recommendations aim to improve on the privacy framework in which physicians have practiced for decades and expand similar privacy guardrails to entities not currently governed by privacy laws and regulations. The expanded privacy framework should protect personal health information from unauthorized, discriminatory, deceptive, or harmful uses and align with the principles of medical ethics, respect individual rights, and support the culture of trust necessary to maintain and improve care delivery.

Cross-sectional Assessment of COVID-19 Vaccine Acceptance Among Health Care Workers in Los Angeles

A Comprehensive Policy Framework to Understand and Address Disparities and Discrimination in Health and Health Care: A Policy Paper From the American College of Physicians

Racial and ethnic minority populations in the United States experience disparities in their health and health care that arise from a combination of interacting factors, including racism and discrimination, social drivers of health, health care access and quality, individual behavior, and biology. To ameliorate these disparities, the American College of Physicians (ACP) proposes a comprehensive policy framework that recognizes and confronts the many elements of U.S. society, some of which are intertwined and compounding, that contribute to poorer health outcomes. In addition to this framework, which includes high-level principles and discusses how disparities are interconnected, ACP offers specific policy recommendations on disparities and discrimination in education and the workforce, those affecting specific populations, and those in criminal justice practices and policies in its 3 companion policy papers. ACP believes that a cross-cutting approach that identifies and offers solutions to the various aspects of society contributing to poor health is essential to achieving its goal of good health care for all, poor health care for none.

Ethical and Professionalism Implications of Physician Employment and Health Care Business Practices: A Policy Paper From the American College of Physicians

The environment in which physicians practice and patients receive care continues to change. Increasing employment of physicians, changing practice models, new regulatory requirements, and market dynamics all affect medical practice; some changes may also place greater emphasis on the business of medicine. Fundamental ethical principles and professional values about the patient–physician relationship, the primacy of patient welfare over self-interest, and the role of medicine as a moral community and learned profession need to be applied to the changing environment, and physicians must consider the effect the practice environment has on their ethical and professional responsibilities. Recognizing that all health care delivery arrangements come with advantages, disadvantages, and salient questions for ethics and professionalism, this American College of Physicians policy paper examines the ethical implications of issues that are particularly relevant today, including incentives in the shift to value-based care, physician contract clauses that affect care, private equity ownership, clinical priority setting, and physician leadership. Physicians should take the lead in helping to ensure that relationships and practices are structured to explicitly recognize and support the commitments of the physician and the profession of medicine to patients and patient care.

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.

Clinician Perspectives on Caring for Dying Patients During the Pandemic: A Mixed-Methods Study: Annals of Internal Medicine: Vol 174, No 4

Background: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has affected the hospital experience for patients, visitors, and staff. Objective: To understand clinician perspectives on adaptations to end-of-life care for dying patients and their families during the pandemic. Design: Mixed-methods embedded study. (ClinicalTrials.gov: NCT04602520) Setting: 3 acute care medical units in a tertiary care hospital from 16 March to 1 July 2020. Participants: 45 dying patients, 45 family members, and 45 clinicians. Intervention: During the pandemic, clinicians continued an existing practice of collating personal information about dying patients and “what matters most,” eliciting wishes, and implementing acts of compassion. Measurements: Themes from semistructured clinician interviews that were summarized with representative quotations. Results: Many barriers to end-of-life care arose because of infection control practices that mandated visiting restrictions and personal protective equipment, with attendant practical and psychological consequences. During hospitalization, family visits inside or outside the patient's room were possible for 36 patients (80.0%); 13 patients (28.9%) had virtual visits with a relative or friend. At the time of death, 20 patients (44.4%) had a family member at the bedside. Clinicians endeavored to prevent unmarked deaths by adopting advocacy roles to “fill the gap” of absent family and by initiating new and established ways to connect patients and relatives. Limitation: Absence of clinician symptom or wellness metrics; a single-center design. Conclusion: Clinicians expressed their humanity through several intentional practices to preserve personalized, compassionate end-of-life care for dying hospitalized patients during the SARS-CoV-2 pandemic. Primary Funding Source: Canadian Institutes of Health Research and Canadian Critical Care Trials Group Research Coordinator Fund.

The Safety and Immunologic Effectiveness of the Live Varicella-Zoster Vaccine in Patients Receiving Tumor Necrosis Factor Inhibitor Therapy: A Randomized Controlled Trial: Annals of Internal Medicine: Vol 174, No 11

Background: The safety and effectiveness of live virus vaccines, such as the varicella-zoster vaccine, are unknown in patients with inflammatory diseases receiving immunomodulatory therapy such as tumor necrosis factor inhibitors (TNFis). Objective: To evaluate the safety and immunogenicity of the live attenuated zoster vaccine (ZVL) in patients receiving TNFis. Design: Randomized, blinded, placebo-controlled trial. (ClinicalTrials.gov: NCT02538341) Setting: Academic and community-based rheumatology, gastroenterology, and dermatology practices. Patients: Adults aged 50 years or older receiving TNFis for any indication. Intervention: Random assignment to ZVL versus placebo. Measurements: Glycoprotein enzyme-linked immunosorbent assay (gpELISA) and enzyme-linked immunosorbent spot (ELISpot) from serum and peripheral blood mononuclear cells measured at baseline and 6 weeks after vaccination. Suspected varicella infection or herpes zoster was clinically assessed using digital photographs and polymerase chain reaction on vesicular fluid. Results: Between March 2015 and December 2018, 617 participants were randomly assigned in a 1:1 ratio to receive ZVL (n = 310) or placebo (n = 307) at 33 centers. Mean age was 62.7 years (SD, 7.5); 66.1% of participants were female, 90% were White, 8.2% were Black, and 5.9% were Hispanic. The most common TNFi indications were rheumatoid arthritis (57.6%) and psoriatic arthritis (24.1%); TNFi medications were adalimumab (32.7%), infliximab (31.3%), etanercept (21.2%), golimumab (9.1%), and certolizumab (5.7%). Concomitant therapies included methotrexate (48.0%) and oral glucocorticoids (10.5%). Through week 6, no cases of confirmed varicella infection were found; cumulative incidence of varicella infection or shingles was 0.0% (95% CI, 0.0% to 1.2%). At 6 weeks, compared with baseline, the mean increases in geometric mean fold rise as measured by gpELISA and ELISpot were 1.33 percentage points (CI, 1.17 to 1.51 percentage points) and 1.39 percentage points (CI, 1.07 to 1.82 percentage points), respectively. Limitation: Potentially limited generalizability to patients receiving other types of immunomodulators. Conclusion: This trial informs safety concerns related to use of live virus vaccines in patients receiving biologics. Primary Funding Source: The National Institute of Arthritis and Musculoskeletal and Skin Diseases and the American College of Rheumatology.

Behavioral symptoms associated with poor outcomes in hospitalized patients with dementia | ACP Hospitalist

How much work is too much? | ACP Hospitalist

Having more hospitalists linked to better care value | ACP Hospitalist

Hospitalist information cards improved communication scores from patients | ACP Hospitalist

Mistreatment, discrimination more common for medical students in marginalized identity groups | ACP Hospitalist

Real-time clinical decision support associated with improved pneumonia care | ACP Hospitalist

Study finds higher thresholds of troponin I associated with death after cardiac surgery | ACP Hospitalist

Bedspacing not associated with adverse outcomes in general internal medicine patients | ACP Hospitalist

Discharge ed, doctor harassment, and more | ACP Hospitalist

Strategies for recruiting NPs and PAs | ACP Hospitalist