Occupational and Environmental Medicine: The Internist's Role

Nurse Practitioners in Primary Care

Medical Liability Reform: Innovative Solutions for a New Health Care System

Inner-City Health Care

Home Health Care

Documentation Guidelines for Evaluation and Management Services and Resource-Based Practice Expense Project, and Physician Supervision of Allied Health Professionals. Statement given before the Practicing Physicians Advisory Council.

Federal Trade Commission and the Medical Profession. Statement of the American College of Physicians given before the House Energy and Commerce Subcommittee on Commerce, Transportation, and Tourism, March 11, 1983.

EHR-based Quality Measurement and Reporting Initiatives: Critical for Meaningful Use and Healthcare Improvement

Assuring Appropriate Patient Care Under Capitation Arrangements

Joint Letter Regarding FDA’s Premarket Tobacco Product Applications Proposed Rule

When Epidemics Collide: Coronavirus Disease 2019 (COVID-19) and the Opioid Crisis

An Epidemic in the Midst of a Pandemic: Opioid Use Disorder and COVID-19

Should You Recommend Inhaled Corticosteroids for This Patient With Chronic Obstructive Pulmonary Disease?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 172, No 11

Approximately 12 million adults in the United States receive a diagnosis of chronic obstructive pulmonary disease (COPD) each year, and it is the fourth leading cause of death. Chronic obstructive pulmonary disease refers to a group of diseases that cause airflow obstruction and a constellation of symptoms, including cough, sputum production, and shortness of breath. The main risk factor for COPD is tobacco smoke, but other environmental exposures also may contribute. The GOLD (Global Initiative for Chronic Obstructive Lung Disease) 2020 Report aims to provide a nonbiased review of the current evidence for the assessment, diagnosis, and treatment of patients with COPD. To date, no conclusive evidence exists that any existing medications for COPD modify mortality. The mainstay of treatment for COPD is inhaled bronchodilators, whereas the role of inhaled corticosteroids is less clear. Inhaled corticosteroids have substantial risks, including an increased risk for pneumonia. Here, 2 experts, both pulmonologists, reflect on the care of a woman with severe COPD, a 50–pack-year smoking history, frequent COPD exacerbations, and recurrent pneumonia. They consider the indications for inhaled corticosteroids in COPD, when inhaled corticosteroids should be withdrawn, and what other treatments are available.

Supporting Clinicians During the COVID-19 Pandemic

Knowledge and Perceptions of COVID-19 Among the General Public in the United States and the United Kingdom: A Cross-sectional Online Survey

How Should U.S. Hospitals Prepare for Coronavirus Disease 2019 (COVID-19)?

Developing Primary Care–Based Recommendations for Social Determinants of Health: Methods of the U.S. Preventive Services Task Force

The purpose of the U.S. Preventive Services Task Force (USPSTF) is to provide evidence-based recommendations on primary care screening, behavioral counseling, and preventive medications. A person's health is strongly influenced by social determinants of health, such as economic and social conditions; therefore, preventive recommendations that address these determinants would be ideal. However, differing social determinants have been proposed by a wide range of agencies and organizations, little prevention evidence is available, and responsible parties are in competition, all of which make the creation of evidence-based prevention recommendations for social determinants of health challenging. This article highlights social determinants already included in USPSTF recommendations and proposes a process by which others may be considered for primary care preventive recommendations. In many ways, incorporating social determinants of health into evidence-based recommendations is an evolving area. By reviewing the evidence on the effects of screening and interventions on social determinants relevant to primary care, the USPSTF will continue to provide recommendations on clinical preventive services to improve the health of all Americans.

Distinguishing High-Performing Health Systems Using a Composite of Publicly Reported Measures of Ambulatory Care

Background: Payers and policymakers are rewarding high-performing health care providers on the basis of summaries of overall quality performance, and the methods they use for measuring performance are increasingly important. Objective: To develop and evaluate a measure that ranks health care systems by ambulatory care quality. Design: Systems were ranked using a composite model that summarizes individual measures of quality, accounts for their correlation, and does not require health care systems to report every measure. The composite measure's suitability was evaluated by examining whether it captured the quality indicated by component measures (validity), whether differences in rank between health care systems were larger than statistical noise (reliability), and whether year-to-year changes in rank were small (stability). Setting: California and Minnesota, 2014 to 2016. Participants: 55 health care systems. Measurements: Publicly reported measures of ambulatory care quality. Results: The composite measure was valid in that it was broadly representative of the component measures and was not dominated by any single measure. The measure was reliable because the ranks for 93% of California systems and 80% of Minnesota systems were unlikely to be more than 2 places lower or higher. The measure was stable because fewer than half of systems changed ranks by more than 2 ranks from year to year. Limitation: The analysis is limited to available measures of ambulatory care quality and includes only 2 states. Conclusion: This composite measure uses publicly reported data to produce valid, reliable, and stable ranks of ambulatory care quality for health care systems in Minnesota and California, and this approach could be used in other applications. Primary Funding Source: Agency for Healthcare Research and Quality.

Screening for Anxiety in Adolescent and Adult Women: A Recommendation From the Women's Preventive Services Initiative

Description: The Women's Preventive Services Initiative (WPSI), a national coalition of women's health professional organizations and patient representatives, developed a recommendation on screening for anxiety in adolescent and adult women to improve detection; achieve earlier diagnosis and treatment; and improve health, function, and well-being. The WPSI's recommendations are intended to guide clinical practice and coverage of services for the Health Resources and Services Administration and other stakeholders. The target audience for this recommendation includes all clinicians providing preventive health care to women, particularly in primary care settings. This recommendation applies to women and adolescent girls aged 13 years or older who are not currently diagnosed with anxiety disorders, including pregnant and postpartum women. Methods: The WPSI developed this recommendation after evaluating results of a systematic review of the effectiveness of screening, accuracy of screening instruments, and benefits and harms of treatments in adolescent girls and adult women. No studies directly evaluated the overall effectiveness or harms of screening for anxiety. Twenty-seven screening instruments and their variations were moderately to highly accurate in identifying anxiety (33 individual studies and 2 systematic reviews; 171 studies total). Symptoms improved and relapse rates decreased with psychological therapies (246 randomized controlled trials [RCTs] in 5 systematic reviews) and with selective serotonin reuptake inhibitors or selective serotonin and norepinephrine reuptake inhibitors (126 RCTs in 3 systematic reviews). The WPSI also considered the effect of screening on symptom progression and identification of associated and underlying conditions, as well as implementation factors. Recommendation: The WPSI recommends screening for anxiety in women and adolescent girls aged 13 years or older who are not currently diagnosed with anxiety disorders, including pregnant and postpartum women. Optimal screening intervals are unknown, and clinical judgment should be used to determine frequency. When screening suggests the presence of anxiety, further evaluation is necessary to establish the diagnosis and determine appropriate treatment and follow-up.

Screening for Anxiety in Adolescent and Adult Women: A Systematic Review for the Women's Preventive Services Initiative: Annals of Internal Medicine: Vol 173, No 1

Background: Anxiety disorders are infrequently recognized during routine health care even though they are common in adolescent girls and adult women. Purpose: To evaluate evidence on the effectiveness of screening for anxiety disorders in primary care in improving symptoms, function, and quality of life; harms of screening; accuracy of screening instruments; and effectiveness and harms of treatments. Data Sources: English-language searches of Ovid MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Health and Psychosocial Instruments (1 January 1996 to 4 November 2019); ClinicalTrials.gov (November 2019); and reference lists of studies and reviews. Study Selection: Studies that enrolled adolescent girls and adult women not currently diagnosed with anxiety disorders, including pregnant or postpartum women, and compared clinical outcomes and harms between women who were and were not screened; diagnostic accuracy studies of screening instruments; and systematic reviews of randomized trials of behavioral and pharmacologic treatments. Data Extraction: Dual extraction and quality assessment of individual studies. Data Synthesis: No studies evaluated the overall effectiveness or harms of screening. Thirty-three studies and 2 systematic reviews (171 studies; 112 574 participants) evaluated the diagnostic accuracy of 27 screening instruments and their variations against a clinical diagnosis or other instruments. Most demonstrated moderate to high accuracy for adults (Generalized Anxiety Disorder scale: sensitivity, 70% to 97%; specificity, 50% to 89%), pregnant and postpartum women (Edinburgh Postnatal Depression Scale: sensitivity, 74%; specificity, 64%), and adolescents (Screen for Child Anxiety Related Emotional Disorders: sensitivity, 64% to 74%; specificity, 64% to 73%). Anxiety symptoms improved with cognitive behavioral therapy (246 randomized controlled trials; 17 209 participants) and antianxiety medications (126 randomized controlled trials; 8225 participants). Limitation: Limited data on long-term harms of treatment and no treatment trials in pregnant or postpartum women. Conclusion: Evidence on the overall effectiveness and harms of screening for anxiety is insufficient. Most screening instruments are moderately to highly accurate. Behavioral therapies and antianxiety medications effectively improve anxiety symptoms. Primary Funding Source: Health Resources and Services Administration.

Demystifying the diagnosis of PCOS

Preventing suicide in primary care

Maximizing recovery after cardiac events

EpiPen expiration date extended, first generic approved

Increasing rates of chronic pain found among those who die by suicide

Large valsartan recall, new warnings for fluoroquinolones

Conversing about cancer at ASCO conference

Big data offers information, but as yet few answers

MKSAP Quiz: Follow-up evaluation of Alzheimer disease

‘Wearables' warrant wary expectations

Working up inpatient psychosis | ACP Hospitalist

Care management, attending supervision, and more | ACP Hospitalist

Cases from the University of Wisconsin | ACP Hospitalist

Linking severe sepsis and hyperlactatemia | ACP Hospitalist

Medicine's #MeToo movement | ACP Hospitalist

Thrombectomy window and note templates | ACP Hospitalist

Cases from Emory Division of Hospital Medicine | ACP Hospitalist

Morbid fascination | ACP Hospitalist

A new drug and more on the way for sickle cell disease | ACP Hospitalist

Speed of sepsis care, early feeding for mild pancreatitis, and more | ACP Hospitalist