Quality Indicators for Screening and Surveillance of Colorectal Cancer in Adults: A Review of Performance Measures by the American College of Physicians

Colorectal cancer is the second leading cause of cancer-related deaths for both men and women. Screening for colorectal cancer is an effective strategy to reduce morbidity and mortality, but uptake remains suboptimal. Several performance measures for colorectal cancer screening and surveillance are currently used in pay-for-performance, public reporting, and/or accountability programs. The American College of Physicians (ACP) embraces performance measurement as a means to improve quality of care. The ACP believes that a performance measure must be methodologically sound and evidence-based to be considered for inclusion in payment, accountability, or reporting programs. These principles are critical given the potential effect to physician administrative work and reputation and reimbursement and to prevent unintended consequences on patient care. The ACP’s Performance Measurement Committee (PMC) reviews performance measures using a validated process to recognize high-quality performance measures, address gaps and areas for improvement in performance measures, and help reduce reporting burden. This article aims to present a review of current performance measures for colorectal cancer screening and surveillance to inform physicians, payers, and policymakers in their selection and use of performance measures and make recommendations for measures that could be developed. The PMC appreciates the importance of colorectal cancer screening in the prevention and early detection of colorectal cancer and supports performance measures based on strong recommendations. The PMC reviewed 5 performance measures for colorectal cancer screening relevant to internal medicine and supports 1 performance measure (“Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy”) for use.

Annals for Educators - March 2025

Medical Cannabis Certifications After Pennsylvania Added Anxiety Disorders as a Qualifying Condition

Care of the Patient With Asthma

Nearly 8% of the U.S. population is diagnosed with asthma, leading to more than 5 million office visits and 1 million emergency department visits annually. Both outpatient and inpatient internal medicine clinicians treat asthma frequently, but nuances in diagnosis and management have emerged. This article highlights many of these developments.

The Role of Medical Experts in Transgender Legal Advocacy: A Historical Perspective on Kantaras v. Kantaras

This article examines the ethical challenges that medical experts have navigated when mobilizing biological and psychological evidence to advocate for transgender patients in legal proceedings across a quarter of a century. In 2002, clinicians from a private clinic in Galveston, Texas, testified on behalf of Michael Kantaras, a transgender male patient, during his divorce and custody trial. Presenting gender identity as an innate product of neuroendocrine development, medical experts in Kantaras v. Kantaras challenged portrayals of gender dysphoria as a psychological illness resulting from sociocultural factors. Although this biological argument was key to destigmatizing transgender identity and convincing the judge to rule in Michael's favor, transgender advocates have argued that such claims strengthen medical authority over transgender identities. The article draws parallels with L.W. v. Skrmetti, a 2023 case heard by the U.S. Supreme Court concerning bans on gender-affirming care for transgender minors, to analyze how physician experts have referenced neuroimaging and genetic-sequencing studies to support the biological foundations of transgender identity. Transgender advocates have similarly expressed concerns about the medicalization of their identities, criticizing these studies as limited with regard to capturing the diversity and complexity of transgender experiences. Through analysis of historical and contemporary court cases, this article identifies shifting evidence-based methods for studying sex, understanding gender identity, and evaluating gender-affirming care, as well as the rising prominence of patient-centered approaches that seek to move beyond medicalized conceptions of gender identity as key themes clinicians should consider in their advocacy for their transgender patients.

Identifying Core Clinical Topics and Recommending Core Performance Measures for Internal Medicine Physicians: A Position Paper From the American College of Physicians

Internal medicine physicians are specialists who promote health, emphasize disease prevention, manage complex acute and chronic conditions in adults, and receive extensive training in the diagnosis and treatment of diseases affecting all systems of the human body. As a result, internal medicine performance measures (PMs) target several topics. Many PMs are not based on high-certainty evidence of at least moderate net benefit and are burdensome, with low or no value to patient care. The American College of Physicians (ACP) wants to provide a national focus to improve the quality of health care in the United States. The ACP is a leader in the evidence-based world, being the only physician organization designated as a GRADE (Grading of Recommendations Assessment, Development and Evaluation) Center, an Appraisal of Guidelines for Research and Evaluation (AGREE) Center, and a member of the Cochrane U.S. Network. Using a structured, stepwise, evidence-based approach, ACP identified the most important clinical topics evaluated and treated by internal medicine physicians. The ACP is also actively working toward recommending essential PMs for each core clinical topic that can be used to evaluate and improve patient care. This position paper describes ACP’s method and results of identifying core clinical topics. It also offers a blueprint for defining core PMs and illustrating the principals through application to 2 core clinical topics. The ACP plans to apply this method on PMs for other core clinical topics.

Glucagon-Like Peptide-1 Receptor Agonists and Risk for Ischemic Optic Neuropathy: A Target Trial Emulation: Annals of Internal Medicine: Vol 0, No 0

Background: There are few data evaluating the association between glucagon-like peptide-1 receptor agonists (GLP-1RAs) and nonarteritic anterior ischemic optic neuropathy (NAION), which constitutes approximately 75% of ischemic optic neuropathy (ION) cases in adults. Objective: To estimate the effect of GLP-1RAs versus sodium–glucose cotransporter-2 inhibitors (SGLT2is) and dipeptidyl peptidase-4 inhibitors (DPP4is) on risk for ION. Design: Observational emulation of a target trial. Setting: Large U.S.-based commercial claims database (January 2017 to December 2022). Participants: Patients aged 18 to 65 years with type 2 diabetes initiating a GLP-1RA, an SGLT2i, or a DPP4i. Measurements: The primary outcome was incident ION as a proxy for NAION. Analyses adjusted for more than 80 covariates using inverse probability of treatment weights, and 18-month cumulative incidence and risk differences (RDs) per 10 000 patients were estimated. Results: The 18-month risk for ION was 8.5 versus 5.5 per 10 000 among GLP-1RA users versus SGLT2i users (RD, 3.0 [95% CI, 0.4 to 5.7]) and 7.8 versus 4.2 per 10 000 among GLP-1RA users versus DPP4i users (RD, 3.6 [CI, 1.1 to 6.1]). Corresponding numbers needed to harm were 3333 and 2778, respectively. Among GLP-1RA users, 69 (85.2%) of the 81 ION events occurred in persons older than 50 years and 57 (70.3%) occurred in men. Risk differences were attenuated among metformin monotherapy users (2.0 and 4.1) compared with users of 2 or more diabetes medications (5.7 and 4.0) versus SGLT2is and DPP4is, respectively. Risk differences were higher in men, patients aged 50 years or older, and those with cardiovascular disease or ophthalmic conditions, with minimal differences in women and those younger than 50 years. Limitations: Diagnostic codes specifically for NAION were lacking. Missing data on key clinical factors (such as body mass index and type 2 diabetes duration) may contribute to residual confounding, leaving uncertainty about whether the observed association is causal. Conclusion: Use of GLP-1RAs was associated with higher 18-month risk for ION than use of SGLT2is and DPP4is, although absolute risk remained very low. Observed differences may reflect residual confounding. Primary Funding Source: National Institutes of Health.

Artificial Intelligence–Assisted Data Extraction With a Large Language Model: A Study Within Reviews

Background: Data extraction is a critical but error-prone and labor-intensive task in evidence synthesis. Unlike other artificial intelligence (AI) technologies, large language models (LLMs) do not require labeled training data for data extraction. Objective: To compare an AI-assisted versus a traditional, human-only data extraction process. Design: Study within reviews (SWAR) using a prospective, parallel-group comparison with blinded data adjudicators. Setting: Workflow validation within 6 ongoing systematic reviews of interventions under real-world conditions. Intervention: Initial data extraction using an LLM (Claude, versions 2.1, 3.0 Opus, and 3.5 Sonnet) verified by a human reviewer. Measurements: Concordance, time on task, accuracy, sensitivity, positive predictive value, and error analysis. Results: The 6 systematic reviews in the SWAR yielded 9341 data elements from 63 studies. Concordance between the 2 methods was 77.2% (95% CI, 76.3% to 78.0%). Compared with the reference standard, the AI-assisted approach had an accuracy of 91.0% (CI, 90.4% to 91.6%) and the human-only approach an accuracy of 89.0% (CI, 88.3% to 89.6%). Sensitivities were 89.4% (CI, 88.6% to 90.1%) and 86.5% (CI, 85.7% to 87.3%), respectively, with positive predictive values of 99.2% (CI, 99.0% to 99.4%) and 98.9% (CI, 98.6% to 99.1%). Incorrect data were extracted in 9.0% (CI, 8.4% to 9.6%) of AI-assisted cases and 11.0% (CI, 10.4% to 11.7%) of human-only cases, with corresponding proportions of major errors of 2.5% (CI, 2.2% to 2.8%) versus 2.7% (CI, 2.4% to 3.1%). Missed data items were the most frequent error type in both approaches. The AI-assisted method reduced data extraction time by a median of 41 minutes per study. Limitations: Assessing concordance and classifying errors required subjective judgment. Consistently tracking time on task was challenging. Conclusion: Data extraction assisted by AI may offer a viable, more efficient alternative to human-only methods. Primary Funding Source: Agency for Healthcare Research and Quality and RTI International.

Projected Effects of Proposed Cuts in Federal Medicaid Expenditures on Medicaid Enrollment, Uninsurance, Health Care, and Health

In January 2025, the Republican majority in the House of Representatives’ Budget Committee offered a list of possible spending reductions to offset revenue losses from proposed tax cuts. In May, the Committee advanced a bill incorporating several reductions on the list. The Committee estimated that the 6 largest potential Medicaid cuts (for example, work requirements for some Medicaid enrollees) would each reduce the federal government’s Medicaid outlays by at least $100 billion over 10 years. On the basis of the Committee’s estimates of savings; Congressional Budget Office analyses; and peer-reviewed studies of the coverage, financial, and health impacts of past Medicaid expansions and contractions, the authors project the likely effects of each option and of the House bill advanced by the Budget Committee in May. Each option individually would reduce federal Medicaid outlays by between $100 billion and $900 billion over a decade, increase the ranks of the uninsured by between 600 000 and 3 900 000 and the annual number of persons forgoing needed medical care by 129 060 to 838 890, and result in 651 to 12 626 medically preventable deaths annually. Enactment of the House bill advanced in May would increase the number of uninsured persons by 7.6 million and the number of deaths by 16 642 annually, according to a mid-range estimate. These figures exclude harms from lowering provider payments and shrinking benefits, as well as possible repercussions from states increasing taxes or shifting expenditures from other needs to make up for shortfalls in federal Medicaid funding. Policy makers should weigh the likely health and financial harms to patients and providers of reducing Medicaid expenditures against the desirability of tax reductions, which would accrue mostly to wealthy Americans.

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