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This Week in JAMA
August 13, 2003

This Week in JAMA

JAMA. 2003;290(6):707. doi:10.1001/jama.290.6.707
Care of Previously Uninsured Adults After Medicare

Cross-sectional studies indicate that uninsured adults in the United States receive less appropriate care and have worse health outcomes than insured adults, but these studies are limited by unmeasured factors associated with insurance status. In this longitudinal study of adults before and after they became eligible for Medicare at age 65 years, McWilliams and colleaguesArticle found that differences in the use of cholesterol testing, mammography, and prostate examination between those who were continuously insured prior to Medicare eligibility and those who were continously uninsured were significantly reduced after Medicare eligibility. Among adults with arthritis or hypertension, however, differences in use of disease-specific medications between continuously uninsured and insured adults did not significantly diminish after Medicare eligibility. In an editorial, Bindman and HaggstromArticle suggest that major reform rather than incremental change is necessary to address the problem of uninsured Americans.

Guggulipid for Treatment of Hypercholesterolemia

Guggul, an extract from the resin of the mukul myrrh tree, is widely used in Asia to reduce cholesterol levels and is increasingly being used in the United States, where it is available as a dietary supplement. In this randomized trial among healthy adults with hypercholesterolemia eating a typical Western diet, Szapary and colleagues found that standardized guggul extract (guggulipid, containing 2.5% guggulsterones) was not effective in lowering cholesterol levels after 8 weeks of therapy. Low-density lipoprotein cholesterol levels increased 4% in the standard-dose guggulipid group and 5% in the high-dose guggulipid group, whereas they decreased 5% in the placebo group.

Predictors of Early Readmission After CABG Surgery

Early readmission following coronary artery bypass graft (CABG) surgery is an important adverse outcome of CABG surgery and may be a useful measure for quality assessment. Hannan and colleagues analyzed data from patients who underwent CABG surgery in New York State in 1999 and found that almost 13% of patients were readmitted within 30 days for reasons related to CABG surgery. Higher early readmission rates were associated with patient-level risk factors, including female sex, older age, and African American race, provider characteristics, and postoperative factors.

Addition of HPV Vaccine to Screening for Cervical Cancer

Vaccines for prevention of cervical infection with human papillomavirus (HPV) types that are associated with a high risk of cervical cancer may become available within the next 5 to 10 years. Kulasingam and Myers used mathematical modeling to identify potentially cost-effective strategies for adding vaccination to existing conventional cytology-based screening programs. Vaccination allowed the onset of screening to be delayed. Vaccination at age 12 years plus biennial screening delayed until age 24 years had the most attractive cost-effectiveness ratio. The cost-effectiveness of vaccination plus delayed screening depended on maintaining vaccine efficacy during the ages of peak incidence of oncogenic HPV infection.

Variations in End-of-Life Care in European ICUs

Sprung and colleaguesArticle conducted a prospective, observational cohort study to examine end-of-life practices in 37 intensive care units (ICUs) in 17 European countries. From January 1, 1999, to June 30, 2000, 9.8% of patients admitted to ICUs had limitations of life-sustaining therapy. The limitations and manner of dying varied substantially between countries. Limitation of therapy was associated with patient age, acute and chronic diagnoses, number of days in ICU, region, and physician religion. In an editorial, Rocker and CurtisArticle discuss factors that may contribute to geographic variation in end-of-life care.

A Piece of My Mind

"An eerie silence enveloped the trauma room, an event that frequently precedes a pediatric resuscitation." From "A Little Bit Longer."

Contempo Updates

Improvements in the care of serious burns.

Medical News & Perspectives

A program that allows physicians to offer in-office treatment to opiate-addicted patients has been hailed as a way to "de-ghettoize" treating such individuals. But few physicians have embraced the opportunity.

National Health Insurance

A proposal for a single-payer national health insurance program with universal, comprehensive coverage that would both expand access to care and reduce costs.

CLINICIAN'S CORNER

Excerpts of interviews with a 33-year-old man with advanced HIV infection, his aunt, and his physician illustrate the importance of a comprehensive treatment plan that integrates curative or disease-specific interventions and symptom palliation.

JAMA Patient Page

For your patients: Information about burn injuries.

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