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In This Issue of JAMA Internal Medicine
May 27, 2013

In This Issue of JAMA Internal Medicine

JAMA Intern Med. 2013;173(10):845. doi:10.1001/jamainternmed.2013.57

Implantable cardioverter-defibrillators (ICDs) have revolutionized the approach to the prevention of sudden cardiac death and are now commonly used in a wide range of high-risk patients, including the large population of patients with severe left ventricular systolic dysfunction. The benefit from these devices derives from its therapies, including both antitachycardia pacing and high-energy shocks. Although these therapies may be life saving, the devices can also deliver inappropriate shocks. Borne et al review data to describe the epidemiology, health outcomes, and therapeutic approaches to ICD shocks.

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Saint et al identified practices currently used to prevent catheter-associated urinary tract infection (CAUTI) and compared practice use and CAUTI standardized infection ratios for a national sample of US hospitals with hospitals in Michigan, which launched a CAUTI prevention initiative in 2007 (known as the “Bladder Bundle”). Michigan hospitals more frequently participated in collaboratives to reduce health care–associated infection and used bladder scanners, as well as catheter reminders or stop orders and/or nurse-initiated discontinuation. More frequent use of these practices coincided with a 25% reduction in CAUTI rates in Michigan, a significantly greater reduction than the 6% overall decrease observed in the rest of the United States.

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As dementia progresses, patients experience functional deficits, which ultimately progress to disabilities. In a randomized clinical trial with 2 intervention arms (home-based exercise and group-based exercise) and 1 control group (usual community care), Pitkälä et al investigated the effectiveness of exercise on the physical functioning in patients with Alzheimer disease. Findings showed that intensive and long-term exercise program had beneficial effects on physical functioning in patients with Alzheimer disease and decreased the number of falls without increasing the total costs of health and social services.

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To spur cost-consciousness and resource stewardship, Feldman et al examined whether they could decrease the number of tests ordered by presenting inpatient care providers with laboratory test fees at the time of order entry in a tertiary care hospital. They randomly assigned 61 diagnostic laboratory tests to an “active” arm (fee displayed) or to a control arm (fee not displayed). They compared the number of tests ordered and total charges during a 6-month intervention period when they displayed fees for active tests only to a baseline period when no fees were displayed. For the active arm, there was an 8.59% reduction in tests ordered per patient-day compared with a 5.64% increase in the control group (P < .001). Presenting fee data to providers at the time of order entry resulted in a modest decrease in test ordering.

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This study provides frequencies of downstream outcomes during the 5 years following an abnormal screening prostate-specific antigen (PSA) result among men 65 years and older in clinical practice. The percentage of men with a screening PSA level above 4 ng/mL increased with age, but only one-third of men underwent biopsy. Receipt of biopsy decreased with advancing age and comorbidity, whereas biopsy detection of prostate cancer increased with age. Most men with biopsy-detected cancer received immediate treatment, regardless of advancing age, poor health, or low-risk cancer. Among those treated, 5-year survival was high but decreased with advancing age and comorbidity, whereas deaths from nonprostate cancer causes increased. Decisions to pursue PSA screening should include discussion about when to pursue biopsy and treatment and the likely outcomes of these interventions according to baseline characteristics to better individualize these decisions.

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