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In This Issue of JAMA Internal Medicine
Jan 14, 2013

In This Issue of JAMA Internal Medicine

JAMA Intern Med. 2013;173(1):5. doi:10.1001/jamainternmed.2013.2680

Whereas treatment duration for urinary tract infection (UTI) in ambulatory women is well defined, the optimal treatment duration for male UTI is unknown. In this observational study of more than 33 000 outpatient subjects using Veterans Affairs administrative data, treatment with antimicrobials for more than 7 days was not associated with a decrease in early or late recurrence, compared with 7 days or less of treatment. These findings question the role of longer-duration treatment for male UTI in the outpatient setting.

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Primary medication adherence to cholesterol-lowering drugs can be increased using automated outreach. In a randomized trial, a telephone call followed by a letter 1 week later was used to increase adherence in patients who had not had their medication dispensed up to 2 weeks after the prescription date. Adherence rates increased from 26% (usual care control group) to 42% in the intervention group (relative risk, 1.63; 95% CI, 1.50-1.76). It is difficult to change patient adherence behavior. The reasonable cost and suitability for outreach to large populations makes this an attractive strategy to help reduce the numbers of patients with primary nonadherence and better target those who remain nonadherent with more resource-intensive programs.

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In January 2010, Medicare eliminated consultation payments from the Part B Physician Fee Schedule in an effort to curb the overbilling of consultations and redistribute payments from specialists to primary care physicians. Consultations were required to be billed as office visits, amounting to a fee cut for physicians who commonly bill for consultations. At the same time, office visit fees were increased slightly in a projected budget-neutral manner, representing a fee increase for physicians who bill frequently for office visits. Using an interrupted time-series design, Song et al found that the policy was associated with a 6.5% increase in spending on all physician encounters in 2010, largely explained by the increase in office visit fees and higher complexity (coding) of visits. Approximately 58% of the increased spending was for primary care physician encounters and 42% for specialist encounters.

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Among 44 167 adults patients in an integrated care setting who were recently treated for hypertension, Adams et al explore the role of health system factors in explaining and addressing racial and ethnic differences in medication adherence and persistence. Adams et al found evidence that health system factors such as medication choice, copayment, and mail-order pharmacy may play important roles as both mediators and modifiers of racial and ethnic differences in medication-taking behavior. Unlike socioeconomic and psychosocial determinants that can be difficult to change, health system factors are potentially modifiable through system-level intervention and have the potential to attenuate persistent gaps in adherence.

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Lazzarino et al evaluated 66 518 individuals representative of the general population in England for psychological distress. These individuals were categorized according to their socioeconomic status (SES) at baseline and followed up over 8 years for all-cause mortality. After adjustment for age, sex, smoking, body mass index, physical activity, hypertension, and diabetes, both psychological distress and low SES were associated with increased mortality rates. However, the association of psychological distress with mortality differed according to SES, with the strongest associations being observed in the lowest SES categories. The detrimental effect of psychological distress on mortality is amplified by low SES, and people in higher SES categories have lower mortality rates even when they report high levels of psychological distress.

Figure. Age- and sex-adjusted hazard ratios (HRs) for all-cause mortality as a function of psychological distress for each stratum of SES.

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