Mallen et al investigated the use of a core set of generic prognostic indicators, administered at the point of care, to determine the outcome for common musculoskeletal conditions. They found that easy-to-obtain pieces of information (duration of present pain episode, pain interference with daily activities, and the presence of multiple-site pain), followed by the systematic recording of the general practitioners' prognostic judgment, provide a simple assessment of prognosis in older persons presenting with musculoskeletal problems in primary care. Such an assessment offers a common foundation for investigating the usefulness of prognostic stratification for guiding management in the consultation across a range of common painful conditions.
The characteristics of attending rounds in the current era of duty hour regulations, increased throughput pressures, and higher patient acuity have not been well described. Stickrath et al performed a cross-sectional observational study of internal medicine attending rounds. They found that rounds take place at the bedside infrequently and that teams discuss patient care plans and test results most of the time but fail to discuss many items that may be of significant value, including specific areas of patient care, interprofessional communication, and learner-centered education.
The need to control rising health care costs has become widely acknowledged, but how costs are considered in the development of professional clinical guidance documents has received little analysis. A cross-sectional study of guidance documents from the 30 largest US physician specialty societies found that 57% of societies explicitly integrated costs as part of guidance development, and 35% of the guidance documents produced by these societies made 1 or more specific statements on how costs could be addressed. These findings suggest the need for more transparency and greater dialogue on the role of guidance documents in cost containment.
Hermann et al examined the yield of provocative and invasive testing in 4181 subjects over 6 years. Using an accelerated diagnostic protocol that included serial biomarkers followed by stress testing in all patients and selective coronary angiography among those with abnormal initial test findings, the authors describe the confirmed true-positive rate (diagnostic yield) of provocative testing and the rate of anatomical findings potentially amenable to coronary intervention (therapeutic yield). Overall, 470 patients (13%) were noted to have abnormal initial results, while 123 went on to coronary angiography. Among these 123 patients, 63 were found to have obstructive disease and 28 had findings consistent with potential benefit from revascularization. Thus, the diagnostic and therapeutic yield of provocative testing in this large data set of patients with biomarker-negative chest pain was 1.5% and 0.7%, respectively. The yield of provocative testing after serial biomarkers are negative in acute chest pain may be extremely low.
Health funding bodies frequently use cost-utility economic analyses to guide decision making on new technologies. These analyses require robust estimates of quality of life. Hogg et al interviewed 216 patients with a history of venous thromboembolism to evaluate the effect of acute pulmonary embolism, deep vein thrombosis, intracranial bleeding, and gastrointestinal tract bleeding on quality of life. Using the standard gamble technique, the authors found that the results were widely distributed. A single summary value will not fully reflect true quality of life in these health states, and future economic models should incorporate the parameter distributions.
Visual aid for standard gamble with which patients rate their severe stroke health state.
In This Issue of JAMA Internal Medicine. JAMA Intern Med. 2013;173(12):1045. doi:10.1001/jamainternmed.2013.69