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In This Issue of JAMA Internal Medicine
Feb 11, 2013

In This Issue of JAMA Internal Medicine

JAMA Intern Med. 2013;173(3):176. doi:10.1001/jamainternmed.2013.2692

Although 8 statins are presently available, few head-to-head comparisons exist. The recent release of generic atorvastatin eliminated any residual justification for using branded statins, as no branded statin can claim greater potency than its best generic alternative. The equivalence of generic and branded statins has been studied and proven; except when branded prices fall to or below generic prices, generics should be used exclusively. This includes transitioning all but the rarest patients (with unique contraindications) to generic regimens and always starting therapy with generics for new patients. Widespread adoption of generic statins may save more than $5 billion with no negative impact on care.

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Gross et al identified a cohort of women who had no history of breast cancer on January 1, 2006, and assessed costs associated with breast cancer screening and postscreening evaluations. They found that the Medicare fee-for-service program is spending more than $1 billion per year on breast cancer screening and related workup services. Women residing in high screening + workup–cost hospital referral regions (HRRs) were more likely to be diagnosed as having early-stage cancer (incidence rate ratio, 1.43; 95% CI, 1.14-1.81). There was no significant difference in the cost of cancer treatment between highest and lowest screening+ workup–cost HRRs ($115 vs $151; P = .96).

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Using a sample of patients starting antiepileptic drug therapy, Kesselheim et al designed a nested case-control study to evaluate whether changes in pill color or shape were more likely to precede lengthy gaps in medication refilling. The authors found that the odds of color discordance occurring immediately before an episode of nonpersistence was 27% greater than in controls for whom no interruption in therapy was observed (adjusted odds ratio, 1.27; 95% CI, 1.04-1.55). Among the subset of patients with a known seizure disorder, the odds were even higher (adjusted odds ratio, 1.53; 95% CI, 1.07-2.18). Changes in pill shape were also more common before cases of nonpersistence, but the difference was not statistically significant. The finding that patients who experience changes in pill color have an increased risk of nonpersistence in their use of essential medications supports reconsidering current regulatory policy that permits wide variation in the appearance of bioequivalent drugs.

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In a cross-sectional study of a racially and ethnically diverse primary care population of 9377 persons with diabetes, poor patient ratings of health care provider communication were independently associated with objectively measured, inadequate cardiometabolic medication adherence using pharmacy claims. For each 10-point decrease in Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS) score, the adjusted prevalence of poor adherence increased by 0.9%. Low ratings for shared decision making and trust were associated with a 4%- to 6%-increased adjusted prevalence of poor adherence. Oral hypoglycemic medications had higher rates of poor refill adherence and stronger associations with patient-provider communication, compared with lipid-lowering and antihypertensive medications.

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Baggett et al examined mortality rates and causes of death among 28 033 adults seen at Boston Health Care for the Homeless Program from 2003 through 2008 and compared their findings with individuals seen at the program from 1988 through 1993. Drug overdose, primarily involving opioids, was the leading cause of death in 2003 through 2008 and accounted for one-third of deaths among adults younger than 45 years. Cancer and heart disease were the major causes of death among adults 45 years and older. Compared with the Massachusetts general population, all-cause mortality rates were approximately 9-fold higher in 25- to 44-year-old individuals and 4.5-fold higher in 45- to 64-year-old individuals. Compared with homeless persons in 1988 through 1993, reductions in deaths due to human immunodeficiency virus were offset by increases in deaths due to drug overdose and substance use disorders, resulting in no change in overall mortality.

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