ACP Letter to Congress in Support of the George Floyd Policing Act of 2021

ACP Comment Letter to CMS on the Patient Protection and Affordable Care Act Notice of Benefit and Payment Parameters for PY 2027

ACP Comment Letter on Senate Finance Committee Chronic Care Policy Options

ACP Comments to the Department of Treasury on Section 213 of the Internal Revenue Code

ACP Comments re CMS Episode-Based Cost Measure Development for MACRA/QPP

ACP Comments on Department of Health and Human Services (HHS) Proposed Rule to Update Section 1557

ACP Comment Letter to the Senate Finance Committee Regarding Tele-Mental Health Draft Legislation

ACP letter to CMS, regarding the CY 2014 Medicare Physician Fee Schedule

ACP Comment Letter on the Occupational Safety and Health Administration's Heat Injury and Illness Prevention in Outdoor and Indoor Work Settings Proposed Rule

Use of Intensive Insulin Therapy for the Management of Glycemic Control in Hospitalized Patients

Identifying Trends in Undiagnosed Diabetes in U.S. Adults by Using a Confirmatory Definition: A Cross-sectional Study: Annals of Internal Medicine: Vol 167, No 11

Background: A common belief is that one quarter to one third of all diabetes cases remain undiagnosed. However, such prevalence estimates may be overstated by epidemiologic studies that do not use confirmatory testing, as recommended by clinical diagnostic criteria. Objective: To provide national estimates of undiagnosed diabetes by using a confirmatory testing strategy, in line with clinical practice guidelines. Design: Cross-sectional study. Setting: National Health and Nutrition Examination Survey results from 1988 to 1994 and 1999 to 2014. Participants: U.S. adults aged 20 years and older. Measurements: Confirmed undiagnosed diabetes was defined as elevated levels of fasting glucose (≥7.0 mmol/L [≥126 mg/dL]) and hemoglobin A1c (≥6.5%) in persons without diagnosed diabetes. Results: The prevalence of total (diagnosed plus confirmed undiagnosed) diabetes increased from 5.5% (9.7 million adults) in 1988 to 1994 to 10.8% (25.5 million adults) in 2011 to 2014. Confirmed undiagnosed diabetes increased during the past 2 decades (from 0.89% in 1988 to 1994 to 1.2% in 2011 to 2014) but has decreased over time as a proportion of total diabetes cases. In 1988 to 1994, the percentage of total diabetes cases that were undiagnosed was 16.3%; by 2011 to 2014, this estimate had decreased to 10.9%. Undiagnosed diabetes was more common in overweight or obese adults, older adults, racial/ethnic minorities (including Asian Americans), and persons lacking health insurance or access to health care. Limitation: Cross-sectional design. Conclusion: Establishing the burden of undiagnosed diabetes is critical to monitoring public health efforts related to screening and diagnosis. When a confirmatory definition is used, undiagnosed diabetes is a relatively small fraction of the total diabetes population; most U.S. adults with diabetes (about 90%) have received a diagnosis of the condition. Primary Funding Source: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases and National Heart, Lung, and Blood Institute.

Treatment of Type 1 Diabetes: Synopsis of the 2017 American Diabetes Association Standards of Medical Care in Diabetes

Description: The American Diabetes Association (ADA) annually updates Standards of Medical Care in Diabetes to provide clinicians, patients, researchers, payers, and other interested parties with evidence-based recommendations for the diagnosis and management of patients with diabetes. Methods: For the 2017 Standards of Care, the ADA Professional Practice Committee did MEDLINE searches from 1 January 2016 to November 2016 to add, clarify, or revise recommendations on the basis of new evidence. The committee rated the recommendations as A, B, or C, depending on the quality of evidence, or E for expert consensus or clinical experience. The Standards of Care were reviewed and approved by the Executive Committee of the ADA Board of Directors, which includes health care professionals, scientists, and laypersons. Feedback from the larger clinical community informed revisions. Recommendation: This synopsis focuses on recommendations from the 2017 Standards of Care about monitoring and pharmacologic approaches to glycemic management for type 1 diabetes.

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.

Pharmacologic Therapy for Type 2 Diabetes: Synopsis of the 2017 American Diabetes Association Standards of Medical Care in Diabetes

Description: The American Diabetes Association (ADA) annually updates the Standards of Medical Care in Diabetes to provide clinicians, patients, researchers, payers, and other interested parties with evidence-based recommendations for the diagnosis and management of patients with diabetes. Methods: For the 2017 Standards, the ADA Professional Practice Committee updated previous MEDLINE searches performed from 1 January 2016 to November 2016 to add, clarify, or revise recommendations based on new evidence. The committee rates the recommendations as A, B, or C, depending on the quality of evidence, or E for expert consensus or clinical experience. The Standards were reviewed and approved by the Executive Committee of the ADA Board of Directors, which includes health care professionals, scientists, and laypersons. Feedback from the larger clinical community informed revisions. Recommendations: This synopsis focuses on recommendations from the 2017 Standards about pharmacologic approaches to glycemic treatment of type 2 diabetes.

Glycemic Therapy for Type 2 Diabetes: Choices Expand, Data Lag Behind

Balancing Primary Diabetes Care Quality and Services

Pioglitazone: An Addition to Our Toolbox for Patients With Diabetes and Nonalcoholic Steatohepatitis?

Should We Screen for Type 2 Diabetes?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 165, No 7

The prevalence of diabetes in the United States is rising. Twelve percent of U.S. adults have diabetes and another 37% have impaired fasting glucose or impaired glucose tolerance. Diabetes is a major risk factor for such outcomes as cardiovascular disease, blindness, chronic kidney disease, and limb amputation. An important consideration is whether screening for abnormal glucose levels or diabetes reduces cardiovascular or all-cause morbidity and mortality. In October 2015, the U.S. Preventive Services Task Force published recommendations on screening for abnormal blood glucose and concluded that intensive lifestyle interventions have a moderate benefit in reducing progression to diabetes in patients who have abnormal blood glucose levels detected by screening. It found inadequate evidence that such screening reduces cardiovascular or all-cause mortality and no evidence of psychological or other harms from screening. The Task Force recommends glucose screening every 3 years for adults aged 40 to 70 years who are overweight or obese and do not have symptoms of diabetes. In this article, we present the case of a man who meets these criteria and explore his preferences and concerns regarding screening. Two experts then debate screening merits and benefits, the significance of abnormal blood glucose levels and diabetes as cardiovascular risk factors, and application of the guidelines to this particular patient.

Primary Care Physician Volume and Quality of Diabetes Care: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 166, No 4

Background: A relationship between higher patient volume and both better quality of care and better outcomes has been shown for many acute care conditions. Whether a volume–quality relationship exists for the outpatient management of chronic diseases is uncertain. Objective: To explore the association between primary care physician volume and quality of diabetes care. Design: Cohort study. Setting: The study was conducted using linked population-based health care administrative data in Ontario, Canada. Patients: 1 018 647 adults with diabetes in 2011 who received care from 9014 primary care physicians. Two measures of volume were ascertained for each physician: overall ambulatory volume (representing time available to devote to chronic disease management during patient encounters) and diabetes-specific volume (representing disease-specific expertise). Measurements: Quality of care was measured over a 2-year period using 6 indicators: disease monitoring (eye examination, hemoglobin A1c testing, and low-density lipoprotein cholesterol testing), prescribing appropriate medications (angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers and statins), and adverse clinical outcomes (emergency department visits for hypoglycemia or hyperglycemia). Results: Higher overall ambulatory volume was associated with lower rates of appropriate disease monitoring and medication prescription. In contrast, higher diabetes-specific volume was associated with better quality of care across all 6 indicators. Limitation: Only a select set of quality indicators and potential confounders could be ascertained from available data. Conclusion: Primary care physicians with busier ambulatory patient practices delivered lower-quality diabetes care, but those with greater diabetes-specific experience delivered higher-quality care. These findings show that relationships between physician volume and quality can be extended from acute care to outpatient chronic disease care. Health policies or programs to support physicians with a low volume of patients with diabetes may improve care. Primary Funding Source: Canadian Institutes of Health Research.

“Nonfunctional” Adrenal Tumors and the Risk for Incident Diabetes and Cardiovascular Outcomes: A Cohort Study: Annals of Internal Medicine: Vol 165, No 8

Background: Benign adrenal tumors are commonly discovered on abdominal imaging. Most are classified as nonfunctional and are considered to pose no health risk, but some are considered functional because they secrete hormones that increase risk for metabolic and cardiovascular diseases. Objective: To evaluate the hypothesis that nonfunctional adrenal tumors (NFATs) increase risk for cardiometabolic outcomes compared with absence of adrenal tumors. Design: Cohort study. Setting: Integrated hospital system. Participants: Participants with benign NFATs (“exposed”; n = 166) and those with no adrenal tumor (“unexposed”; n = 740), with at least 3 years of follow-up. Measurements: Medical records were reviewed from the time of abdominal imaging for development of incident outcomes (hypertension, composite diabetes [prediabetes or type 2 diabetes], hyperlipidemia, cardiovascular events, and chronic kidney disease) (mean, 7.7 years). Primary analyses evaluated independent associations between exposure status and incident outcomes by using adjusted generalized linear models. Secondary analyses evaluated relationships between NFATs and cortisol physiology. Results: Participants with NFATs had significantly higher risk for incident composite diabetes than those without adrenal tumors (30 of 110 [27.3%] vs. 72 of 615 [11.7%] participants; absolute risk, 15.6% [95% CI, 6.9% to 24.3%]; adjusted risk ratio, 1.87 [CI, 1.17 to 2.98]). No significant associations between NFATs and other outcomes were observed. Higher “normal” postdexamethasone cortisol levels (≤50 nmol/L) were associated with larger NFAT size and higher prevalence of type 2 diabetes. Limitation: Potential bias in the selection of participants and ascertainment of outcomes. Conclusion: Participants with NFATs had a significantly higher risk for diabetes than those without adrenal tumors. These results should prompt a reassessment of whether the classification of benign adrenal tumors as “nonfunctional” adequately reflects the continuum of hormone secretion and metabolic risk they may harbor. Primary Funding Source: National Institutes of Health and Doris Duke Charitable Foundation.

What and Where Else: Hypervirulent Klebsiella pneumoniae With Pyogenic Liver Abscess and Disseminated Multifocal Osteomyelitis | Annals of Internal Medicine: Clinical Cases

Hypervirulent Klebsiella pneumoniae (hvKp), a pathotype of Klebsiella pneumoniae presents many clinical challenges. hvKp often causes disseminated, invasive disease in immunocompetent hosts. It is primarily associated with pyogenic liver abscesses, but also causes osteomyelitis, necrotizing fasciitis, endophthalmitis, and meningitis. The diagnosis of hvKp is largely clinical because many laboratories lack the ability to test for the associated biomarkers. To emphasize the need to assess for disseminated invasive infection in such patients, we present a patient with hvKp who had bacteremic and tibial osteomyelitis, but also pyogenic liver abscess and multifocal osteomyelitis with a pathologic fracture.

Medical Management of Emphysematous Gastritis | Annals of Internal Medicine: Clinical Cases

A 95-year-old man presented to the hospital with altered mental status, sepsis, and coffee-ground emesis. His chest radiograph showed gas along the lesser curvature of the stomach, prompting abdominal computed tomography, which demonstrated intramural gastric air. This patient's clinical presentation and computed tomography findings were suggestive of emphysematous gastritis (EG). He was successfully managed with an intravenous proton-pump inhibitor and broad-spectrum antibiotics. Details of the case are presented to encourage the early diagnosis of EG, which may make conservative management more successful.

Achromobacter Hepatic Abscess Several Months After Laparoscopic Cholecystectomy: A Case Report and Review of Literature | Annals of Internal Medicine: Clinical Cases

Achromobacter xylosoxidans is a rare pathogen that causes opportunistic and nosocomial infections in immune-compromised patients. After a cholecystectomy, dropped stones can serve as nidus for abscess formation. We describe a rare case of hepatic abscess caused by Achromobacter xylosoxidans in a 40-year-old immune-competent woman who had a laparoscopic cholecystectomy 9 months previously.

When Community-Acquired Pneumonia Guidelines Provide Misguided Guidance | Annals of Internal Medicine: Clinical Cases

Limited diagnostic testing and empirical antimicrobial therapy are recommended in practice guidelines for adults with community-acquired pneumonia (CAP). Although following CAP guidelines is cost-effective with high cure rates, consideration should be given to the possibility that CAP is caused by pathogens not effectively treated by the recommended antibiotic regimens. Expanding the differential diagnosis based on potential pathogen exposures and comorbid conditions can prevent delays in diagnosis and appropriate treatment. As an example, mucormycosis should be considered in a patient presenting with pneumonia in the setting of diabetic ketoacidosis.

A Case of Isolated Cardiac Sarcoidosis: An Underdiagnosed Disease With Little Diagnostic Consensus | Annals of Internal Medicine: Clinical Cases

Sarcoidosis is a rare cause of cardiomyopathy and can be missed when there is no pulmonary involvement. We present the case of a 55-year-old woman with isolated cardiac sarcoidosis who presented with symptoms of worsening intermittent dyspnea, weight gain, and lower extremity swelling. Cardiac evaluation showed a nonischemic cardiomyopathy secondary to an inflammatory cause. Cardiac magnetic resonance and positron emission tomography scans were performed that led to the diagnosis of isolated cardiac sarcoidosis. Recent updates in diagnostic criteria have allowed the use of imaging modalities alone to confirm the diagnosis in place of biopsy.

A Case of Emphysematous Cholecystitis | Annals of Internal Medicine: Clinical Cases

An 85-year-old man with no history of biliary intervention or cholecystenteric fistulas presented to the emergency department with right hypochondralgia. Imaging revealed pneumobilia and an emphysematous gallbladder wall, consistent with the presentation of emphysematous cholecystitis. Pneumobilia is a rare finding with emphysematous cholecystitis. Gas production by anaerobic bacteria in the biliary tract could be the cause of pneumobilia.

High Radial Nerve Palsy Resulting From Massage | Annals of Internal Medicine: Clinical Cases

Nerve palsies can lead to devastating outcomes that frighten patients. The limited availability in the published literature of information regarding nerve palsies can be disconcerting to patients and primary care physicians alike. This case report identifies this mechanism of injury and follows the path of recovery. A high radial nerve palsy resulting from a deep tissue massage about the shoulder recovered in 6 to 8 weeks. With the apparent increase of massage parlors in our society, the frequency of such events may increase. By providing references regarding such injuries, clinicians can better reassure patients as to expected outcomes.

Listeria monocytogenes–Associated Acute Cholecystitis: A Case Report and Review of the Literature | Annals of Internal Medicine: Clinical Cases

People who are pregnant, immunocompromised, or elderly are at risk for listeriosis, a life-threatening condition. Although Listeria monocytogenes may be asymptomatic or limited to uncomplicated gastroenteritis in healthy adults, it can cause invasive disease such as meningitis and bacteremia in susceptible individuals. Less commonly, L monocytogenes can cause a focal site of infection such as acute cholecystitis. In the literature, previous cases of L monocytogenes–associated acute cholecystitis were treated with antibiotics either provided or held and a cholecystectomy. We present an 80-year-old man who recovered from acute cholecystitis due to L monocytogenes with appropriate antibiotic coverage and a percutaneous cholecystostomy.

Three Cases of Atypical Cutaneous Ovarian Metastases: A Single-Center Case Series | Annals of Internal Medicine: Clinical Cases

Ovarian cancer rarely metastasizes to the skin, but when cutaneous metastases occur, the typical location is within the umbilicus, commonly known as a Sister Mary Joseph nodule. Extraabdominal cutaneous metastases from ovarian cancer are extremely rare. Here, we report a series of 3 patient cases at a single institution who presented with extraabdominal cutaneous ovarian metastases. We discuss the potential mechanisms for cutaneous involvement as well as histopathology, treatments, and outcomes in patients with extraabdominal cutaneous ovarian cancer metastases.

Prostate Adenocarcinoma With Atypical Immunohistochemistry Presenting With a Cheerio Sign | Annals of Internal Medicine: Clinical Cases

The most common cancer in men is prostate cancer. The Cheerio sign is the computed tomography finding of multiple pulmonary nodules with central lucency resembling the ring-shaped Cheerio breakfast cereal. Unlike bone metastasis, pulmonary involvement is less common. The Cheerio sign has malignant and benign etiologies. Thyroid transcription factor-1 (TTF-1) stain is commonly used in the diagnosis of primary lung cancer. TTF-1 positivity in cancers of prostate origin is rare, with only case reports and small case series available in the literature. Metastatic prostate cancer presenting with a Cheerio sign has not been reported in the literature.