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Risk Model–Based Lung Cancer Screening: A Cost-Effectiveness Analysis: Annals of Internal Medicine: Vol 176, No 3

Background: In their 2021 lung cancer screening recommendation update, the U.S. Preventive Services Task Force (USPSTF) evaluated strategies that select people based on their personal lung cancer risk (risk model–based strategies), highlighting the need for further research on the benefits and harms of risk model–based screening. Objective: To evaluate and compare the cost-effectiveness of risk model–based lung cancer screening strategies versus the USPSTF recommendation and to explore optimal risk thresholds. Design: Comparative modeling analysis. Data Sources: National Lung Screening Trial; Surveillance, Epidemiology, and End Results program; U.S. Smoking History Generator. Target Population: 1960 U.S. birth cohort. Time Horizon: 45 years. Perspective: U.S. health care sector. Intervention: Annual low-dose computed tomography in risk model–based strategies that start screening at age 50 or 55 years, stop screening at age 80 years, with 6-year risk thresholds between 0.5% and 2.2% using the PLCOm2012 model. Outcome Measures: Incremental cost-effectiveness ratio (ICER) and cost-effectiveness efficiency frontier connecting strategies with the highest health benefit at a given cost. Results of Base-Case Analysis: Risk model–based screening strategies were more cost-effective than the USPSTF recommendation and exclusively comprised the cost-effectiveness efficiency frontier. Among the strategies on the efficiency frontier, those with a 6-year risk threshold of 1.2% or greater were cost-effective with an ICER less than $100 000 per quality-adjusted life-year (QALY). Specifically, the strategy with a 1.2% risk threshold had an ICER of $94 659 (model range, $72 639 to $156 774), yielding more QALYs for less cost than the USPSTF recommendation, while having a similar level of screening coverage (person ever-screened 21.7% vs. USPSTF's 22.6%). Results of Sensitivity Analyses: Risk model–based strategies were robustly more cost-effective than the 2021 USPSTF recommendation under varying modeling assumptions. Limitation: Risk models were restricted to age, sex, and smoking-related risk predictors. Conclusion: Risk model–based screening is more cost-effective than the USPSTF recommendation, thus warranting further consideration. Primary Funding Source: National Cancer Institute (NCI).

Total Ankle Replacement Versus Arthrodesis for End-Stage Ankle Osteoarthritis: A Randomized Controlled Trial: Annals of Internal Medicine: Vol 175, No 12

Background: End-stage ankle osteoarthritis causes severe pain and disability. There are no randomized trials comparing the 2 main surgical treatments: total ankle replacement (TAR) and ankle fusion (AF). Objective: To determine which treatment is superior in terms of clinical scores and adverse events. Design: A multicenter, parallel-group, open-label randomized trial. (ISRCTN registry number: 60672307) Setting: 17 National Health Service trusts across the United Kingdom. Patients: Patients with end-stage ankle osteoarthritis, aged 50 to 85 years, and suitable for either procedure. Intervention: Patients were randomly assigned to TAR or AF surgical treatment. Measurements: The primary outcome was change in Manchester–Oxford Foot Questionnaire walking/standing (MOXFQ-W/S) domain scores between baseline and 52 weeks after surgery. No blinding was possible. Results: Between 6 March 2015 and 10 January 2019, a total of 303 patients were randomly assigned; mean age was 68 years, and 71% were men. Twenty-one patients withdrew before surgery, and 281 clinical scores were analyzed. At 52 weeks, the mean MOXFQ-W/S scores improved for both groups. The adjusted difference in the change in MOXFQ-W/S scores from baseline was −5.6 (95% CI, −12.5 to 1.4), showing that TAR improved more than AF, but the difference was not considered clinically or statistically significant. The number of adverse events was similar between groups (109 vs. 104), but there were more wound healing issues in the TAR group and more thromboembolic events and nonunion in the AF group. The symptomatic nonunion rate for AF was 7%. A post hoc analysis suggested superiority of fixed-bearing TAR over AF (−11.1 [CI, −19.3 to −2.9]). Limitation: Only 52-week data; pragmatic design creates heterogeneity of implants and surgical techniques. Conclusion: Both TAR and AF improve MOXFQ-W/S and had similar clinical scores and number of harms. Total ankle replacement had greater wound healing complications and nerve injuries, whereas AF had greater thromboembolism and nonunion, with a symptomatic nonunion rate of 7%. Primary Funding Source: National Institute for Health and Care Research Heath Technology Assessment Programme.

Characteristics of Persons Screened for Lung Cancer in the United States: A Cohort Study: Annals of Internal Medicine: Vol 175, No 11

Background: Lung cancer screening (LCS) with low-dose computed tomography (LDCT) was recommended by the U.S. Preventive Services Task Force (USPSTF) in 2013, making approximately 8 million Americans eligible for screening. The demographic characteristics and adherence of persons screened in the United States have not been reported at the population level. Objective: To define sociodemographic characteristics and adherence among persons screened and entered into the American College of Radiology's Lung Cancer Screening Registry (LCSR). Design: Cohort study. Setting: United States, 2015 to 2019. Participants: Persons receiving a baseline LDCT for LCS from 3625 facilities reporting to the LCSR. Measurements: Age, sex, and smoking status distributions (percentages) were computed among persons who were screened and among respondents in the 2015 National Health Interview Survey (NHIS) who were eligible for screening. The prevalence between the LCSR and the NHIS was compared with prevalence ratios (PRs) and 95% CIs. Adherence to annual screening was defined as having a follow-up test within 11 to 15 months of an initial LDCT. Results: Among 1 159 092 persons who were screened, 90.8% (n = 1 052 591) met the USPSTF eligibility criteria. Compared with adults from the NHIS who met the criteria (n = 1257), screening recipients in the LCSR were older (34.7% vs. 44.8% were aged 65 to 74 years; PR, 1.29 [95% CI, 1.20 to 1.39]), more likely to be female (41.8% vs. 48.1%; PR, 1.15 [CI, 1.08 to 1.23]), and more likely to currently smoke (52.3% vs. 61.4%; PR, 1.17 [CI, 1.11 to 1.23]). Only 22.3% had a repeated annual LDCT. If follow-up was extended to 24 months and more than 24 months, 34.3% and 40.3% were adherent, respectively. Limitations: Underreporting of LCS and missing data may skew demographic characteristics of persons reported to be screened. Underreporting of adherence may result in underestimates of follow-up. Conclusion: Approximately 91% of persons who had LCS met USPSTF eligibility criteria. In addition to continuing to target all eligible adults, men, those who formerly smoked, and younger eligible patients may be less likely to be screened. Adherence to annual follow-up screening was poor, potentially limiting screening effectiveness. Primary Funding Source: None.

How the Gender Wage Gap for Primary Care Physicians Differs by Compensation Approach: A Microsimulation Study: Annals of Internal Medicine: Vol 175, No 8

Background: The physician gender wage gap may be due, in part, to productivity-based compensation models that undervalue female practice patterns. Objective: To determine how primary care physician (PCP) compensation by gender differs when applying existing productivity-based and alternative compensation models. Design: Microsimulation. Setting: 2016 to 2019 national clinical registry of 1222 primary care practices. Participants: Male and female PCPs matched on specialty, years since medical school graduation, practice site, and sessions worked. Measurements: Net annual, full-time-equivalent compensation for male versus female PCPs, under productivity-based fee-for-service, panel size–based capitation without or with risk adjustment, and hybrid payment models. Microsimulation inputs included patient and visit characteristics and overhead expenses. Results: Among 1435 matched male (n = 881) and female (n = 554) PCPs, female PCP panels included patients who were, on average, younger, had lower diagnosis-based risk scores, were more often female, and were more often uninsured or insured by Medicaid rather than by Medicare. Under productivity-based payment, female PCPs earned a median of $58 829 (interquartile range [IQR], $39 553 to $120 353; 21%) less than male PCPs. This gap was similar under capitation ($58 723 [IQR, $42 141 to $140 192]). It was larger under capitation risk-adjusted for age alone ($74 695 [IQR, $42 884 to $152 423]), for diagnosis-based scores alone ($114 792 [IQR, $49 080 to $215 326] and $89 974 [IQR, $26 175 to $173 760]), and for age-, sex-, and diagnosis-based scores ($83 438 [IQR, $28 927 to $129 414] and $66 195 [IQR, $11 899 to $96 566]). The gap was smaller and nonsignificant under capitation risk-adjusted for age and sex ($36 631 [IQR, $12 743 to $73 898]). Limitation: Panel attribution based on office visits. Conclusion: The gender wage gap varied by compensation model, with capitation risk-adjusted for patient age and sex resulting in a smaller gap. Future models might better align with primary care effort and outcomes. Primary Funding Source: None.

The Incidence of SARS-CoV-2 Reinfection in Persons With Naturally Acquired Immunity With and Without Subsequent Receipt of a Single Dose of BNT162b2 Vaccine: A Retrospective Cohort Study: Annals of Internal Medicine: Vol 175, No 5

Background: There is insufficient evidence regarding the magnitude and durability of protection conferred by a combined effect of naturally acquired immunity after SARS-CoV-2 infection and vaccine-induced immunity. Objective: To compare the incidence rate of SARS-CoV-2 reinfection in previously infected persons to that of previously infected persons who subsequently received a single dose of BNT162b2 messenger RNA vaccine. Design: A retrospective cohort study emulating a randomized controlled target trial through a series of nested trials. Setting: Nationally centralized database of Maccabi Healthcare Services, Israel. Participants: Persons with documented SARS-CoV-2 infection who did not receive subsequent SARS-CoV-2 vaccination were compared with persons with documented SARS-CoV-2 infection who received a single dose of the BNT162b2 vaccine at least 3 months after infection. Intervention: Forty-one randomized controlled trials were emulated, in which 107 413 Maccabi Healthcare Services' members aged 16 years and older were eligible for at least 1 trial. Measurements: SARS-CoV-2–related outcomes of infection, symptomatic disease, hospitalization, and death, between 2 March and 13 December 2021. Results: A statistically significant decreased risk (hazard ratio, 0.18 [95% CI, 0.15 to 0.20]) for reinfection was found among persons who were previously infected and then vaccinated versus those who were previously infected but remained unvaccinated. In addition, there was a decreased risk for symptomatic disease (hazard ratio, 0.24 [CI, 0.20 to 0.29]) among previously infected and vaccinated persons compared with those who were not vaccinated after infection. No COVID-19–related mortality cases were found. Limitation: Hybrid protection against non-Delta variants could not be inferred. Conclusion: Persons previously infected with SARS-CoV-2 gained additional protection against reinfection and COVID-19 from a subsequent single dose of the BNT162b2 vaccine. Nonetheless, even without a subsequent vaccination, reinfection appeared relatively rare. Primary Funding Source: None.

Video Teleconferencing for Disease Prevention, Diagnosis, and Treatment: A Rapid Review: Annals of Internal Medicine: Vol 175, No 2

Background: Video teleconferencing (VTC) as a substitute for in-person health care or as an adjunct to usual care has increased in recent years. Purpose: To assess the benefits and harms of VTC visits for disease prevention, diagnosis, and treatment and to develop an evidence map describing gaps in the evidence. Data Sources: Systematically searched PubMed, EMBASE, Web of Science, and the Cochrane Library from 1 January 2013 to 3 March 2021. Study Selection: Two investigators independently screened the literature and identified 38 randomized controlled trials (RCTs) meeting inclusion criteria. Data Extraction: Data abstraction by a single investigator was confirmed by a second investigator; 2 investigators independently rated risk of bias. Data Synthesis: Results from 20 RCTs rated low risk of bias or some concerns of bias show that the use of VTC for the treatment and management of specific diseases produces largely similar outcomes when used to replace or augment usual care. Nine of 12 studies where VTC was intended to replace usual care and 5 of 8 studies where VTC was intended to augment usual care found similar effects between the intervention and control groups. The remaining 6 included studies (3 intended to replace usual care and 3 intended to augment usual care) found 1 or more primary outcomes that favored the VTC group over the usual care group. Studies comparing VTC with usual care that did not involve in-person care were more likely to favor the VTC group. No studies evaluated the use of VTC for diagnosis or prevention of disease. Studies that reported harms found no differences between the intervention and control groups; however, many studies did not report harms. No studies evaluated the effect of VTC on health equity or disparities. Limitations: Studies that focused on mental health, substance use disorders, maternal care, and weight management were excluded. Included studies were limited to RCTs with sample sizes of 50 patients or greater. Component analyses were not conducted in the studies. Conclusion: Replacing or augmenting aspects of usual care with VTC generally results in similar clinical effectiveness, health care use, patient satisfaction, and quality of life as usual care for areas studied. However, included trials were limited to a handful of disease categories, with patients seeking care for a limited set of purposes. Primary Funding Source: Patient-Centered Outcomes Research Institute.

Trends in Depressive Symptoms and Associated Factors During Residency, 2007 to 2019: A Repeated Annual Cohort Study: Annals of Internal Medicine: Vol 175, No 1

Background: Efforts to address the high depression rates among training physicians have been implemented at various levels of the U.S. medical education system. The cumulative effect of these efforts is unknown. Objective: To assess how the increase in depressive symptoms with residency has shifted over time and to identify parallel trends in factors that have previously been associated with resident physician depression. Design: Repeated annual cohort study. Setting: U.S. health care organizations. Participants: First-year resident physicians (interns) who started training between 2007 and 2019. Measurements: Depressive symptoms (9-item Patient Health Questionnaire [PHQ-9]) assessed at baseline and quarterly throughout internship. Results: Among 16 965 interns, baseline depressive symptoms increased from 2007 to 2019 (PHQ-9 score, 2.3 to 2.9; difference, 0.6 [95% CI, 0.3 to 0.8]). The prevalence of baseline predictors of greater increase in depressive symptoms with internship also increased across cohorts. Despite the higher prevalence of baseline risk factors, the average change in depressive symptoms with internship decreased 24.4% from 2007 to 2019 (change in PHQ-9 score, 4.1 to 3.0; difference, −1.0 [CI, −1.5 to −0.6]). This change across cohorts was greater among women (4.7 to 3.3; difference, −1.4 [CI, −1.9 to −0.9]) than men (3.5 to 2.9; difference, −0.6 [CI, −1.2 to −0.05]) and greater among nonsurgical interns (4.1 to 3.0; difference, −1.1 [CI, −1.6 to −0.6]) than surgical interns (4.0 to 3.2; difference, −0.8 [CI, −1.2 to −0.4]). In parallel to the decrease in depressive symptom change, there were increases in sleep hours, quality of faculty feedback, and use of mental health services and a decrease in work hours across cohorts. The decrease in work hours was greater for nonsurgical than surgical interns. Further, the increase in mental health treatment across cohorts was greater for women than men. Limitation: Data are observational and subject to biases due to nonrandom sampling, missing data, and unmeasured confounders, limiting causal conclusions. Conclusion: Although depression during physician training remains high, the average increase in depressive symptoms associated with internship decreased between 2007 and 2019. Primary Funding Source: National Institute of Mental Health.

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.

Changes in Dialysis Center Quality Associated With the End-Stage Renal Disease Quality Incentive Program: An Observational Study With a Regression Discontinuity Design: Annals of Internal Medicine: Vol 174, No 8

Background: In 2012, the Centers for Medicare & Medicaid Services started levying performance-based financial penalties against outpatient dialysis centers under the mandatory End-Stage Renal Disease Quality Incentive Program. Objective: To determine whether penalization was associated with improvement in dialysis center quality. Design: Leveraging the threshold for penalization (total performance score < 60), a regression discontinuity design was used to examine the effect of penalization on quality over 2 years. Publicly available Medicare data from 2015–2018 were used. The effect of penalization at dialysis centers with different characteristics (for example, size or chain affiliation) was also examined. Setting: United States. Participants: Outpatient dialysis centers (n = 5830). Measurements: Dialysis center total performance scores (a composite metric ranging from 0 to 100 based on clinical quality and adherence to reporting requirements) and individual measures that contribute to the total performance score. Results: There were 1109 (19.0%) outpatient dialysis centers that received penalties in 2017 on the basis of performance in 2015. Penalized centers were located in ZIP codes with a higher average proportion of non-White residents (36.4% vs. 31.2%; P < 0.001) and residents with lower median income ($49 290 vs. $51 686; P < 0.001). Penalization was not associated with improvement in total performance scores in 2017 (0.4 point [95% CI, −2.5 to 3.2 points]) or 2018 (0.3 point [CI, −2.8 to 3.4 points]). This was consistent across dialysis centers with different characteristics. There was also no association between penalization and improvement in specific measures. Limitation: The study could not account for how centers respond to penalization. Conclusion: Penalization under the End-Stage Renal Disease Quality Incentive Program was not associated with improvement in the quality of outpatient dialysis centers. Primary Funding Source: None.

Comparison of Knowledge and Information-Seeking Behavior After General COVID-19 Public Health Messages and Messages Tailored for Black and Latinx Communities: A Randomized Controlled Trial: Annals of Internal Medicine: Vol 174, No 4

Background: The paucity of public health messages that directly address communities of color might contribute to racial and ethnic disparities in knowledge and behavior related to coronavirus disease 2019 (COVID-19). Objective: To determine whether physician-delivered prevention messages affect knowledge and information-seeking behavior of Black and Latinx individuals and whether this differs according to the race/ethnicity of the physician and tailored content. Design: Randomized controlled trial. (Registration: ClinicalTrials.gov, NCT04371419; American Economic Association RCT Registry, AEARCTR-0005789) Setting: United States, 13 May 2020 to 26 May 2020. Participants: 14 267 self-identified Black or Latinx adults recruited via Lucid survey platform. Intervention: Participants viewed 3 video messages regarding COVID-19 that varied by physician race/ethnicity, acknowledgment of racism/inequality, and community perceptions of mask wearing. Measurements: Knowledge gaps (number of errors on 7 facts on COVID-19 symptoms and prevention) and information-seeking behavior (number of web links demanded out of 10 proposed). Results: 7174 Black (61.3%) and 4520 Latinx (38.7%) participants were included in the analysis. The intervention reduced the knowledge gap incidence from 0.085 to 0.065 (incidence rate ratio [IRR], 0.737 [95% CI, 0.600 to 0.874]) but did not significantly change information-seeking incidence. For Black participants, messages from race/ethnicity-concordant physicians increased information-seeking incidence from 0.329 (for discordant physicians) to 0.357 (IRR, 1.085 [CI, 1.026 to 1.145]). Limitations: Participants' behavior was not directly observed, outcomes were measured immediately postintervention in May 2020, and online recruitment may not be representative. Conclusion: Physician-delivered messages increased knowledge of COVID-19 symptoms and prevention methods for Black and Latinx respondents. The desire for additional information increased with race-concordant messages for Black but not Latinx respondents. Other tailoring of the content did not make a significant difference. Primary Funding Source: National Science Foundation; Massachusetts General Hospital; and National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases.

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