Search Results for: "chronic back pain management"

Federal public reporting and payment programs have increasingly emphasized the measurement of outcomes (such as readmission, health care–associated infections, and mortality). Yet, the criteria for assessing whether outcome measures are accurate and valid enough to use for public reporting, payment, and accreditation are not well-defined. An outcome measure should be used only if the outcome can be influenced substantially by providers (that is, a strong process–outcome link exists) and statistical adjustment can be made for differences in patient populations across providers so that differences in outcomes are truly attributable to differences in the care provided. Validly distinguishing differences in quality of care across providers requires precision in both the design of the outcome measure and the actual recording of all the measure's elements. Four criteria are proposed to assess outcome measures. First, strong evidence should exist that good medical care leads to improvement in the outcome within the time period for the measure. Second, the outcome should be measurable with a high degree of precision. Third, the risk-adjustment methodology should include and accurately measure the risk factors most strongly associated with the outcome. Fourth, implementation of the outcome measure must have little chance of inducing unintended adverse consequences. These criteria were applied to 10 outcome measures currently used or proposed for accountability programs. Three measures met all 4 criteria; 5, including all 4 claims-based 30-day mortality measures, failed to meet 1 or more criteria. Patient-reported outcome measures are problematic, because low response rates may cause bias. These findings raise concerns and suggest the need for a national dialogue about how to judge outcome measures currently in use or proposed for the future.

Individualized Glycemic Control for U.S. Adults With Type 2 Diabetes: A Cost-Effectiveness Analysis: Annals of Internal Medicine: Vol 168, No 3

Background: Intensive glycemic control in type 2 diabetes (glycated hemoglobin [HbA1c] level <7%) is an established, cost-effective standard of care. However, guidelines recommend individualizing goals on the basis of age, comorbidity, diabetes duration, and complications. Objective: To estimate the cost-effectiveness of individualized control versus uniform intensive control (HbA1c level <7%) for the U.S. population with type 2 diabetes. Design: Patient-level Monte Carlo–based Markov model. Data Sources: National Health and Nutrition Examination Survey 2011–2012. Target Population: The approximately 17.3 million persons in the United States with diabetes diagnosed at age 30 years or older. Time Horizon: Lifetime. Perspective: Health care sector. Intervention: Individualized versus uniform intensive glycemic control. Outcome Measures: Average lifetime costs, life-years, and quality-adjusted life-years (QALYs). Results of Base-Case Analysis: Individualized control saved $13 547 per patient compared with uniform intensive control ($105 307 vs. $118 854), primarily due to lower medication costs ($34 521 vs. $48 763). Individualized control decreased life expectancy (20.63 vs. 20.73 years) due to an increase in complications but produced more QALYs (16.68 vs. 16.58) due to fewer hypoglycemic events and fewer medications. Results of Sensitivity Analysis: Individualized control was cost-saving and generated more QALYs compared with uniform intensive control, except in analyses where the disutility associated with receiving diabetes medications was decreased by at least 60%. Limitation: The model did not account for effects of early versus later intensive glycemic control. Conclusion: Health policies and clinical programs that encourage an individualized approach to glycemic control for U.S. adults with type 2 diabetes reduce costs and increase quality of life compared with uniform intensive control. Additional research is needed to confirm the risks and benefits of this strategy. Primary Funding Source: National Institute of Diabetes and Digestive and Kidney Diseases.

Functional Impairment and Decline in Middle Age: A Cohort Study: Annals of Internal Medicine: Vol 167, No 11

Background: Difficulties with daily functioning are common in middle-aged adults. However, little is known about the epidemiology or clinical course of these problems, including the extent to which they share common features with functional impairment in older adults. Objective: To determine the epidemiology and clinical course of functional impairment and decline in middle age. Design: Cohort study. Setting: The Health and Retirement Study. Participants: 6874 community-dwelling adults aged 50 to 56 years who did not have functional impairment at enrollment. Measurements: Impairment in activities of daily living (ADLs), defined as self-reported difficulty performing 1 or more ADLs, assessed every 2 years for a maximum follow-up of 20 years, and impairment in instrumental ADLs (IADLs), defined similarly. Data were analyzed by using multistate models that estimate probabilities of different outcomes. Results: Impairment in ADLs developed in 22% of participants aged 50 to 64 years, in whom further functional transitions were common. Two years after the initial impairment, 4% (95% CI, 3% to 5%) of participants had died, 9% (CI, 8% to 11%) had further ADL decline, 50% (CI, 48% to 52%) had persistent impairment, and 37% (CI, 35% to 39%) had recovered independence. In the 10 years after the initial impairment, 16% (CI, 14% to 18%) had 1 or more episodes of functional decline and 28% (CI, 26% to 30%) recovered from their initial impairment and remained independent throughout this period. The pattern of findings was similar for IADLs. Limitation: Functional status was self-reported. Conclusion: Functional impairment and decline are common in middle age, as are transitions from impairment to independence and back again. Because functional decline in older adults has similar features, current interventions used for prevention in older adults may hold promise for those in middle age. Primary Funding Source: National Institute on Aging and National Center for Advancing Translational Sciences through the University of California, San Francisco, Clinical and Translational Sciences Institute.

Benefits and Harms of Plant-Based Cannabis for Posttraumatic Stress Disorder: A Systematic Review: Annals of Internal Medicine: Vol 167, No 5

Background: Cannabis is available from medical dispensaries for treating posttraumatic stress disorder (PTSD) in many states of the union, yet its efficacy in treating PTSD symptoms remains uncertain. Purpose: To identify ongoing studies and review existing evidence regarding the benefits and harms of plant-based cannabis preparations in treating PTSD in adults. Data Sources: MEDLINE, the Cochrane Library, and other sources from database inception to March 2017. Study Selection: English-language systematic reviews, trials, and observational studies with a control group that reported PTSD symptoms and adverse effects of plant-based cannabis use in adults with PTSD. Data Extraction: Study data extracted by 1 investigator was checked by a second reviewer; 2 reviewers independently assessed study quality, and the investigator group graded the overall strength of evidence by using standard criteria. Data Synthesis: Two systematic reviews, 3 observational studies, and no randomized trials were found. The systematic reviews reported insufficient evidence to draw conclusions about benefits and harms. The observational studies found that compared with nonuse, cannabis did not reduce PTSD symptoms. Studies had medium and high risk of bias, and overall evidence was judged insufficient. Two randomized trials and 6 other studies examining outcomes of cannabis use in patients with PTSD are ongoing and are expected to be completed within 3 years. Limitation: Very scant evidence with medium to high risk of bias. Conclusion: Evidence is insufficient to draw conclusions about the benefits and harms of plant-based cannabis preparations in patients with PTSD, but several ongoing studies may soon provide important results. Primary Funding Source: U.S. Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative. (PROSPERO: CRD42016033623)

Diagnosis of Venous Thromboembolism: 20 Years of Progress

Many guidelines suggest incorporating clinical assessment, imaging, and D-dimer testing into diagnostic algorithms in patients with suspected deep venous thrombosis (DVT) and pulmonary embolism (PE). This special article reviews the evidence supporting the use of algorithms and their individual components for diagnosis of upper- and lower-extremity DVT and PE in adults, including pregnant women. The authors identified evidence through several electronic database searches to April 2017, evaluated the robustness of selected evidence, assessed whether diagnostic approaches that do not use algorithms are acceptable, and identified knowledge gaps that require further research.

Update in Women's Health: Evidence Published in 2016

Presence of Human Hepegivirus-1 in a Cohort of People Who Inject Drugs

Background: Next-generation metagenomic sequencing (NGMS) has opened new frontiers in microbial discovery but has been clinically characterized in only a few settings. Objective: To explore the plasma virome of persons who inject drugs and to characterize the sensitivity and accuracy of NGMS compared with quantitative clinical standards. Design: Longitudinal and cross-sectional studies. Setting: A clinical trial (ClinicalTrials.gov: NCT01285050) and a well-characterized cohort study of persons who have injected drugs. Participants: Persons co-infected with hepatitis C virus (HCV) and HIV. Measurements: Viral nucleic acid in plasma by NGMS and quantitative polymerase chain reaction (PCR). Results: Next-generation metagenomic sequencing generated a total of 600 million reads, which included the expected HIV and HCV RNA sequences. HIV and HCV reads were consistently identified only when samples contained more than 10 000 copies/mL or IU/mL, respectively, as determined by quantitative PCR. A novel RNA virus, human hepegivirus-1 (HHpgV-1), was also detected by NGMS in 4 samples from 2 persons in the clinical trial. Through use of a quantitative PCR assay for HHpgV-1, infection was also detected in 17 (10.9%) of 156 members of a cohort of persons who injected drugs. In these persons, HHpgV-1 viremia persisted for a median of at least 4538 days and was associated with detection of other bloodborne viruses, such as HCV RNA and SEN virus D. Limitation: The medical importance of HHpgV-1 infection is unknown. Conclusion: Although NGMS is insensitive for detection of viruses with relatively low plasma nucleic acid concentrations, it may have broad potential for discovery of new viral infections of possible medical importance, such as HHpgV-1. Primary Funding Source: National Institutes of Health.

Should We Prescribe Antibiotics to This Patient With Persistent Upper Respiratory Symptoms?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 166, No 3

The American College of Physicians (ACP) and the Centers for Disease Control and Prevention (CDC) recently published advice for high-value care on the appropriate use of antibiotics for acute respiratory tract infections. They conducted a narrative literature review of evidence for antibiotic use in this setting that included recent clinical guidelines from professional societies supplemented by randomized, controlled trials; meta-analyses; and systematic reviews. They concluded that clinicians should reserve antibiotic treatment for acute rhinosinusitis in patients with persistent symptoms for more than 10 days, high fever and purulent nasal discharge or facial pain lasting for at least 3 consecutive days, or worsening symptoms after a typical viral illness that lasted 5 days and had initially improved (“double-sickening”). In this Grand Rounds, 2 prominent clinicians debate whether to initiate antibiotic treatment in a 62-year-old man with a history of recurrent sinusitis who presents with persistent upper respiratory symptoms. They review the data on which the ACP/CDC recommendations are based and discuss the potential benefits and risks, as well as the challenges and controversies, of prescribing antibiotic therapy in this setting.

Safety-Net Hospitals, Neighborhood Disadvantage, and Readmissions Under Maryland's All-Payer Program: An Observational Study: Annals of Internal Medicine: Vol 171, No 2

Background: Safety-net hospitals have higher-than-expected readmission rates. The relative roles of the mean disadvantage of neighborhoods the hospitals serve and the disadvantage of individual patients in predicting a patient's readmission are unclear. Objective: To examine the independent contributions of the patient's neighborhood and the hospital's service area to risk for 30-day readmission. Design: Retrospective observational study. Setting: Maryland. Participants: All Maryland residents discharged from a Maryland hospital in 2015. Measurements: Predictors included the disadvantage of neighborhoods for each Maryland resident (area disadvantage index) and the mean disadvantage of each hospital's discharged patients (safety-net index). The primary outcome was unplanned 30-day hospital readmission. Generalized estimating equations and marginal modeling were used to estimate readmission rates. Results were adjusted for clinical readmission risk. Results: 13.4% of discharged patients were readmitted within 30 days. Patients living in neighborhoods at the 90th percentile of disadvantage had a readmission rate of 14.1% (95% CI, 13.6% to 14.5%) compared with 12.5% (CI, 11.8% to 13.2%) for similar patients living in neighborhoods at the 10th percentile. Patients discharged from hospitals at the 90th percentile of safety-net status had a readmission rate of 14.8% (CI, 13.4% to 16.1%) compared with 11.6% (CI, 10.5% to 12.7%) for similar patients discharged from hospitals at the 10th percentile of safety-net status. The association of readmission risk with the hospital's safety-net index was approximately twice the observed association with the patient's neighborhood disadvantage status. Limitations: Generalizability outside Maryland is unknown. Confounding may be present. Conclusion: In Maryland, residing in a disadvantaged neighborhood and being discharged from a hospital serving a large proportion of disadvantaged neighborhoods are independently associated with increased risk for readmission. Primary Funding Source: National Institute on Minority Health and Health Disparities and Maryland Health Services Cost Review Commission.

The Veterans Affairs Pharmacy System: Perfectly Designed to Achieve the Outcomes It Gets

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