ACP Comments on Proposed 2024 Physician Fee Schedule, Medicare Shared Savings Program, and Quality Payment Program Rule

ACP Comments on Proposed 2024 Physician Fee Schedule, Medicare Shared Savings Program, and Quality Payment Program Rule

ACP Response to SFC on Chronic Care Policies

Letter to Senate Leadership Emphasizing Opposition to Better Care Reconciliation Act of 2017

Letter to Senate Leaders Opposing Reported Senate AHCA Bill

ACP Letter to Secretary Azar in Prioritizing Relief Funds to Primary Care and Other Frontline Physician Practices

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 Regarding the Physician Fee Schedule Proposed Rule for CY 2016

Improving Payments for Undervalued Evaluation and Management and Care Management Srvices

ACP Comments on CY 2013 Medicare Physician Fee Schedule proposed rule

Evidence-Based Prescribing and Polypharmacy for Patients With Heart Failure

Prevalence of Symptoms More Than Seven Months After Diagnosis of Symptomatic COVID-19 in an Outpatient Setting

Background: With millions of SARS-CoV-2 infections worldwide, increasing numbers of patients are coming forward with long-term clinical effects of the disease lasting several weeks to months. Objective: To characterize symptoms 7 to 9 months after diagnosis of COVID-19. Design: Self-reported surveys and semistructured telephone interviews at enrollment and 30 to 45 days and 7 to 9 months from diagnosis. Setting: From 18 March to 15 May 2020, symptomatic persons who tested positive for SARS-CoV-2 at the Geneva University Hospitals were followed by CoviCare, a virtual, clinical, outpatient follow-up program. Persons were contacted again at 30 to 45 days and 7 to 9 months from diagnosis. Participants: Persons who were a part of the CoviCare program from 18 March to 15 May 2020. Measurements: A standardized interview of symptoms consistent with COVID-19, with grading of intensity. Results: Of the 629 participants in the study who completed the baseline interviews, 410 completed follow-up at 7 to 9 months after COVID-19 diagnosis; 39.0% reported residual symptoms. Fatigue (20.7%) was the most common symptom reported, followed by loss of taste or smell (16.8%), dyspnea (11.7%), and headache (10.0%). Limitation: Limitations include generalizability and missing data for 34.8% of participants. Conclusion: Residual symptoms after SARS-CoV-2 infection are common among otherwise young and healthy persons followed in an outpatient setting. These findings contribute to the recognition of long-term effects in a disease mostly counted by its death toll to date by promoting communication on postacute sequelae of SARS-CoV-2 and encouraging physicians to continue long-term monitoring of their patients. Primary Funding Source: None.

Postdiagnosis Smoking Cessation and Reduced Risk for Lung Cancer Progression and Mortality: A Prospective Cohort Study: Annals of Internal Medicine: Vol 174, No 9

Background: Lung cancer is the leading cause of cancer death worldwide, and about one half of patients with lung cancer are active smokers at diagnosis. Objective: To determine whether quitting smoking after diagnosis of lung cancer affects the risk for disease progression and mortality. Design: Prospective study of patients with non–small cell lung cancer (NSCLC) who were recruited between 2007 and 2016 and followed annually through 2020. Setting: N.N. Blokhin National Medical Research Center of Oncology and City Clinical Oncological Hospital No. 1, Moscow, Russia. Patients: 517 current smokers who were diagnosed with early-stage (IA-IIIA) NSCLC. Measurements: Probabilities of overall survival, progression-free survival, and lung cancer–specific mortality and hazard ratios (HRs) for all-cause and cancer-specific mortality. Results: During an average of 7 years of follow-up, 327 (63.2%) deaths, 273 (52.8%) cancer-specific deaths, and 172 (33.7%) cases of tumor progression (local recurrence or metastasis) were recorded. The adjusted median overall survival time was 21.6 months higher among patients who had quit smoking than those who continued smoking (6.6 vs. 4.8 years, respectively; P = 0.001). Higher 5-year overall survival (60.6% vs. 48.6%; P = 0.001) and progression-free survival (54.4% vs. 43.8%; P = 0.004) were observed among patients who quit than those who continued smoking. After adjustments, smoking cessation remained associated with decreased risk for all-cause mortality (HR, 0.67 [95% CI, 0.53 to 0.85]), cancer-specific mortality (HR, 0.75 [CI, 0.58 to 0.98]), and disease progression (HR, 0.70 [CI, 0.56 to 0.89]). Similar effects were observed among mild to moderate and heavy smokers and patients with earlier and later cancer stages. Limitation: Exposure measurements were based on self-reported questionnaires. Conclusion: Smoking cessation after diagnosis materially improved overall and progression-free survival among current smokers with early-stage lung cancer. Primary Funding Source: International Agency for Research on Cancer.

Addressing Mistrust About COVID-19 Vaccines Among Patients of Color

Clinical Practice Guidelines Registry: Toward Reducing Duplication, Improving Collaboration, and Increasing Transparency

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.

The Effect of Flat Flexible Versus Stable Supportive Shoes on Knee Osteoarthritis Symptoms: A Randomized Trial: Annals of Internal Medicine: Vol 174, No 4

Background: Experts recommend that persons with knee osteoarthritis wear stable supportive shoes; however, evidence suggests that flat flexible shoes may be more beneficial. Objective: To compare flat flexible with stable supportive shoes for knee osteoarthritis symptoms. Design: Participant- and assessor-blinded randomized trial. (Prospectively registered with the Australian New Zealand Clinical Trials Registry [ACTRN12617001098325]) Setting: Community. Participants: 164 patients with moderate to severe symptomatic radiographic medial knee osteoarthritis. Intervention: Flat flexible (n = 82) or stable supportive shoes (n = 82), worn for at least 6 hours a day for 6 months. Measurements: Primary outcomes were changes in walking pain (measured by an 11-point numerical rating scale) and physical function (as assessed by the Western Ontario and McMaster Universities Osteoarthritis Index subscale of 0 to 68 points) at 6 months. Secondary outcomes included additional pain and function measures, physical activity, and quality of life. Other measures included adverse events. Results: Of 164 participants recruited, 161 (98%) completed 6-month primary outcomes. No evidence was found that flat flexible shoes were superior to stable supportive shoes in primary outcomes. Evidence did show a between-group difference in change in pain favoring stable supportive shoes (mean difference, 1.1 units [95% CI, 0.5 to 1.8 units]; P = 0.001) but not function (mean difference, 2.3 units [CI, −0.9 to 5.5 units]; P = 0.167). Improvements in knee-related quality of life and ipsilateral hip pain favored stable supportive shoes (mean difference, −5.3 units [CI, −10.0 to −0.5 units] and 0.7 units [CI, 0.0 to 1.4 units], respectively). Flat flexible shoes were not superior to stable supportive shoes for any secondary outcome. Fewer participants reported adverse events with stable supportive shoes (n = 12 [15%]) compared with flat flexible shoes (n = 26 [32%]) (risk difference, −0.17 [CI, −0.30 to −0.05]). Limitation: No “usual shoes” control group and a select patient subgroup, which may limit generalizability. Conclusion: Flat flexible shoes were not superior to stable supportive shoes. Contrary to our hypothesis, stable supportive shoes improved knee pain on walking more than flat flexible shoes. Primary Funding Source: National Health and Medical Research Council.

Comparative Effectiveness and Harms of Antibiotics for Outpatient Diverticulitis: Two Nationwide Cohort Studies: Annals of Internal Medicine: Vol 174, No 6

Background: Outpatient diverticulitis is commonly treated with either a combination of metronidazole and a fluoroquinolone (metronidazole-with-fluoroquinolone) or amoxicillin–clavulanate alone. The U.S. Food and Drug Administration advised that fluoroquinolones be reserved for conditions with no alternative treatment options. The comparative effectiveness of metronidazole-with-fluoroquinolone versus amoxicillin–clavulanate for diverticulitis is uncertain. Objective: To determine the effectiveness and harms of metronidazole-with-fluoroquinolone versus amoxicillin–clavulanate for outpatient diverticulitis. Design: Active-comparator, new-user, retrospective cohort studies. Setting: Nationwide population-based claims data on U.S. residents aged 18 to 64 years with private employer-sponsored insurance (2000 to 2018) or those aged 65 years or older with Medicare (2006 to 2015). Participants: Immunocompetent adults with diverticulitis in the outpatient setting. Intervention: Metronidazole-with-fluoroquinolone or amoxicillin–clavulanate. Measurements: 1-year risks for inpatient admission, urgent surgery, and Clostridioides difficile infection (CDI) and 3-year risk for elective surgery. Results: In MarketScan (IBM Watson Health), new users of metronidazole-with-fluoroquinolone (n = 106 361) and amoxicillin–clavulanate (n = 13 160) were identified. There were no differences in 1-year admission risk (risk difference, 0.1 percentage points [95% CI, −0.3 to 0.6]), 1-year urgent surgery risk (risk difference, 0.0 percentage points [CI, −0.1 to 0.1]), 3-year elective surgery risk (risk difference, 0.2 percentage points [CI, −0.3 to 0.7]), or 1-year CDI risk (risk difference, 0.0 percentage points [CI, −0.1 to 0.1]) between groups. In Medicare, new users of metronidazole-with-fluoroquinolone (n = 17 639) and amoxicillin–clavulanate (n = 2709) were identified. There were no differences in 1-year admission risk (risk difference, 0.1 percentage points [CI, −0.7 to 0.9]), 1-year urgent surgery risk (risk difference, −0.2 percentage points [CI, −0.6 to 0.1]), or 3-year elective surgery risk (risk difference, −0.3 percentage points [CI, −1.1 to 0.4]) between groups. The 1-year CDI risk was higher for metronidazole-with-fluoroquinolone than for amoxicillin–clavulanate (risk difference, 0.6 percentage points [CI, 0.2 to 1.0]). Limitation: Residual confounding is possible, and not all harms associated with these antibiotics, most notably drug-induced liver injury, could be assessed. Conclusion: Treating diverticulitis in the outpatient setting with amoxicillin–clavulanate may reduce the risk for fluoroquinolone-related harms without adversely affecting diverticulitis-specific outcomes. Primary Funding Source: National Institutes of Health.

Public Health Interventions, Epidemic Growth, and Regional Variation of the 1918 Influenza Pandemic Outbreak in a Swiss Canton and Its Greater Regions

Public health interventions implemented during the coronavirus disease 2019 (COVID-19) pandemic are based on experience gained from past pandemics. The 1918 influenza pandemic is the most extensively researched historical influenza outbreak. All 9335 reports available in the State Archives on 121 152 cases of influenza-like illness from the canton of Bern from 473 of 497 municipalities (95.2%) were collected; the cases were registered between 30 June 1918 and 30 June 1919. The overall incidence rates of newly registered cases per week for the 9 greater regions of Bern for both the first and second waves of the pandemic were calculated. Relative incidence rate ratios (RIRRs) were calculated to estimate the change in the slope of incidence curves associated with public health interventions. During the first wave, school closures (RIRR, 0.16 [95% CI, 0.15 to 0.17]) and restrictions of mass gatherings (RIRR, 0.57 [CI, 0.54 to 0.61]) were associated with a deceleration of epidemic growth. During the second wave, in autumn 1918, cantonal authorities initially reacted hesitantly and delegated the responsibility to enact interventions to municipal authorities, which was associated with a lack of containment of the second wave. A premature relaxation of restrictions on mass gatherings was associated with a resurgence of the epidemic (RIRR, 1.18 [CI, 1.12 to 1.25]). Strikingly similar patterns were found in the management of the COVID-19 outbreak in Switzerland, with a considerably higher amplitude and prolonged duration of the second wave and much higher associated rates of hospitalization and mortality.

Effectiveness and Safety of Direct Oral Anticoagulants Versus Warfarin in Patients With Valvular Atrial Fibrillation: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 174, No 7

Background: Direct oral anticoagulants (DOACs) are increasingly used in place of warfarin, but evidence about their effectiveness and safety in patients with valvular atrial fibrillation (AF) remains limited. Objective: To assess the effectiveness and safety of DOACs compared with warfarin in patients with valvular AF. Design: New-user retrospective propensity score–matched cohort study. Setting: U.S.-based commercial health care database from 1 January 2010 to 30 June 2019. Participants: Adults with valvular AF who were newly prescribed DOACs or warfarin. Measurements: The primary effectiveness outcome was a composite of ischemic stroke or systemic embolism. The primary safety outcome was a composite of intracranial or gastrointestinal bleeding. Results: Among a total of 56 336 patients with valvular AF matched on propensity score, use of DOACs (vs. warfarin) was associated with lower risk for ischemic stroke or systemic embolism (hazard ratio [HR], 0.64 [95% CI, 0.59 to 0.70]) and major bleeding events (HR, 0.67 [CI, 0.63 to 0.72]). The results for the effectiveness and safety outcomes remained consistent for apixaban (HRs, 0.54 [CI, 0.47 to 0.61] and 0.52 [CI, 0.47 to 0.57], respectively) and rivaroxaban (HRs, 0.74 [CI, 0.64 to 0.86] and 0.87 [CI, 0.79 to 0.96], respectively); with dabigatran, results were consistent for the major bleeding outcome (HR, 0.81 [CI, 0.68 to 0.97]) but not for effectiveness (HR, 1.03 [CI, 0.81 to 1.31]). Limitation: Relatively short follow-up; inability to ascertain disease severity. Conclusion: In this comparative effectiveness study using practice-based claims data, patients with valvular AF who were new users of DOACs had lower risks for ischemic stroke or systemic embolism and major bleeding than new users of warfarin. These data may be used to guide risk–benefit discussions regarding anticoagulant choices for patients with valvular AF. Primary Funding Source: None.