Wilt et al conducted a systematic review to evaluate efficacy, safety, and comparative effectiveness of pharmacologic treatments for primary restless legs syndrome (RLS) and found that dopamine agonists and calcium channel alpha-2-delta ligands reduced RLS symptoms and improved sleep outcomes and disease-specific quality of life. Adverse effects and treatment withdrawals due to adverse effects were common. There were no high-quality data on comparative effectiveness and harms nor effectiveness data on other interventions often used but lacking approval for RLS treatment.
White et al investigated how frequently different hospitals in California used vena cava filters (VCFs) in patients with acute deep-vein thrombosis or pulmonary embolism who were hospitalized between 2006 and 2010. After adjusting for potential indicators for VCF use, such as bleeding, undergoing surgery, presence of malignancy, the extent of variation in VCF use between different hospitals was extreme, from 0% to 39% of all patients. The authors conjecture that the principal explanation is likely because of cultural differences within different hospitals and/or the availability of interventional specialists, coupled with absence of evidence supporting any benefit.
Sarosiek et al report on the outcome of a large number of patients after inferior vena cava filter placement at a single institution. Their data include a high percentage of trauma patients, many of whom had filters inserted without evidence of thrombosis. They document low rates of “temporary” filter retrieval (8.5%) and a substantial risk of unsuccessful retrieval (18% of attempts). Many patients with a perceived contraindication to anticoagulation began therapeutic anticoagulation shortly after filter placement. Their data demonstrate high rates of thrombotic complications, including pulmonary embolism, often in patients who were not receiving anticoagulation and had no venous thromboembolism at the time of filter placement.
Wright et al examined compliance with guideline-based recommendations for febrile neutropenia (FN) treatment and analyzed how the use of guideline-based care affects outcomes. Among 25 231 patients admitted with FN, guideline-based antibiotics were administered to 79%, vancomycin to 37%, and granulocyte colony-stimulating factors (GCSF) to 63%. Vancomycin use increased from 17% in 2000 to 55% in 2010, whereas GCSF use only decreased from 73% to 55%. Among low-risk patients, prompt initiation of guideline-based antibiotics decreased discharge to a nursing facility and death.
Sheffield et al performed a retrospective cohort study of Medicare beneficiaries 70 years and older who received a colonoscopy in 2008-2009 to determine the frequency of potentially inappropriate colonoscopy and to examine variation across providers and geographic regions. They found that 23% of colonoscopies performed in older adults were potentially inappropriate because of age-based screening recommendations or previous screening. There was considerable variation across colonoscopy providers in the percentage of colonoscopies performed that were potentially inappropriate, ranging from 7% to 45%.
Map showing percentages of colonoscopies performed that were potentially inappropriate in Medicare beneficiaries aged 70 years or older in 2008-2009 for 306 hospital referral regions in the United States.
In This Issue of JAMA Internal Medicine. JAMA Intern Med. 2013;173(7):486. doi:10.1001/jamainternmed.2013.39