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In This Issue of JAMA
September 27, 2016


JAMA. 2016;316(12):1233-1235. doi:10.1001/jama.2015.14497

The Bundled Payments for Care Improvement (BPCI) initiative, a voluntary initiative of the Centers for Medicare & Medicaid Services, is testing whether linking payments for services provided during an episode of care can reduce Medicare payments while maintaining or improving quality. In an analysis of Medicare claims for lower extremity joint replacement before (n = 29 441) and after (n = 31 700) the BPCI initiative took effect, Dummit and colleagues found that Medicare payments declined more in BCPI-participating hospitals than in comparison hospitals, without significant change in quality outcomes. In an Editorial, Fisher discusses bundled payments as one approach to Medicare payment reform.

Editorial and Related Article


In a meta-analysis of data from 5 randomized trials (1287 patients) of endovascular thrombectomy in the treatment of large-vessel ischemic stroke, Saver and colleagues examined the association between time-to-treatment and patient outcomes. The authors report that compared with medical therapy alone, earlier treatment with endovascular thrombectomy was associated with a lower degree of disability at 3 months. Greatest benefit was observed when the time between symptom onset and arterial puncture for thrombectomy was less than 2 hours. In an Editorial, Warach and Johnston discuss implications of early time-to-treatment strategies for ischemic stroke.


Author Video Interview

Although clinical benefits of lowering low-density lipoprotein cholesterol (LDL-C) levels with statin therapy are widely accepted, benefits of nonstatin therapies are less clear. In a meta-analysis of data from 49 randomized clinical trials (312 175 participants) of LDL-C lowering therapies, Silverman and colleagues evaluated the association between LDL-C reduction and relative cardiovascular risk reduction across different statin and nonstatin therapies. The authors report that statin or nonstatin therapies that act via up-regulation of LDL receptor expression were associated with similar lower relative risks of major vascular events per change in LDL-C levels.


Clinical Review & Education

Overly aggressive fluid resuscitation can adversely affect outcomes among hemodynamically unstable patients. This article in The Rational Clinical Examination series by Bentzer and colleagues examines predictors of fluid responsiveness—defined as an increase in cardiac output following intravenous fluid administration—among hemodynamically unstable adult patients with refractory hypotension, signs of organ hypoperfusion, or both. Based on a review of 50 prospective studies of the diagnostic accuracy of tests to predict fluid responsiveness in this patient population, the authors report that passive leg raising followed by measurement of cardiac output or related parameters may be the most useful test to predict fluid responsiveness in hemodynamically unstable adults.

Author Audio Interview and CME

Monitoring of blood carcinoembryonic antigen (CEA) levels to identify colorectal cancer recurrence is recommended after primary curative treatment. Further evaluation is recommended if the blood CEA level rises above a threshold level; however, there is substantial variation in the threshold applied. This JAMA Clinical Evidence Synopsis article summarizes a Cochrane diagnostic test accuracy review (52 studies; 9717 patients total) of the diagnostic performance of CEA at different thresholds. Associations of CEA thresholds with recurrences, missed recurrences, and unnecessary referrals are reported.

A 67-year-old man presented with a 2-week history of painless, nonpruritic blisters on his hands that were unrelated to trauma, irritants, or known contact dermatitis. He has a long history of heavy smoking and alcohol consumption and a history of hypertension, which is treated with lisinopril. Examination of the hands revealed tense and mildly hemorrhagic vesicles (0.2-cm to 0.6-cmdiameter) on the dorsal but not palmar surfaces, scattered pink scars, and milia. No mucosal changes were seen. What would you do next?