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In This Issue of JAMA Internal Medicine
June 2014


JAMA Intern Med. 2014;174(6):833-835. doi:10.1001/jamainternmed.2013.10655

Current measures of access to care may not accurately reflect the capacity of the primary care system to absorb new patients. To assess care appointment availability for new patients, Rhodes and coauthors conducted a simulated patient study in 10 states, calling primary care offices to request the first available new patient appointment for either routine care or an urgent health concern. Across the 10 states, 85% of privately insured and 58% of Medicaid callers received an appointment; appointment rates were 79% for uninsured with full cash payment but only 15% if payment required at the time of visit is restricted to $75 or less. Conditional on getting an appointment, median wait times were typically under 1 week (2 weeks in Massachusetts), with no differences by insurance status or urgency of health concern. In an Invited Commentary, Bindman and Coffman consider the policy implications of the study’s findings.

Invited Commentary, Editorial, and Related Articles 1 and 2

Guidelines for evaluating pulmonary nodules for cancer exist, but little is known about how potentially malignant pulmonary nodules are evaluated in the usual care setting. In this retrospective cohort study of 300 veterans with potentially malignant pulmonary nodules from 15 Department of Veterans Affairs hospitals, Wiener and coauthors found that substantial resources were used for pulmonary nodule evaluation, including 1044 imaging studies, 147 consultations, 76 biopsies, 13 resections, and 21 hospitalizations. Among the 197 patients with a nodule detected after release of the Fleischner Society guidelines, 55% of patients received guideline-consistent evaluation, 18% received more intensive evaluation than recommended by guidelines, and 27% received less intensive evaluation, including 15 patients who received no apparent purposeful nodule evaluation.

Foreign aid to the health sector is an important component of all health spending in many developing countries, but the extent to which this health aid has contributed to overall population health improvements remains unknown. In a cross-country panel data analysis of 140 aid-recipient countries between 1974 and 2010, Bendavid and Bhattacharya examined the relationship between health aid and changes in 2 measures of population health: life expectancy and under-five mortality (mortality of children younger than 5 years). They found that each 1% increase in health aid was associated with 0.24 months’ greater increase in life expectancy and 0.14 faster decline in the probability of under-5 deaths per 1000 live births. Mundel describes a stronger future for health aid in an Invited Commentary.

Invited Commentary

The effect of direct patient education to catalyze collaborative care for reducing inappropriate prescriptions remains unknown. In a cluster randomized trial of 303 adults aged 65 to 95 years, Tannenbaum and coauthors contrasted usual care with a deprescribing patient empowerment intervention describing the risks of benzodiazepine use and a stepwise tapering protocol. They found that receipt of direct-to-consumer education about drug harms yielded a 6-month benzodiazepine discontinuation rate of 27%, compared with 5% in the control group, and dose reduction occurred in an additional 11%.

Continuing Medical Education

Some policy observers have raised concerns that the increased demand for care generated by new Medicaid enrollees has the potential to erode access to care for individuals already enrolled in Medicaid prior to an expansion. Ndumele and coauthors conducted a quasiexperimental difference-in-differences study of 1714 adult Medicaid enrollees in 10 states that expanded Medicaid between 2000 and 2009 and 5089 Medicaid enrollees in 14 bordering control states that did not expand Medicaid over the same period. The study did not find evidence that expanding the number of individuals eligible for Medicaid coverage eroded perceived access to care or increased the use of emergency services among adult Medicaid enrollees. Katz addresses health care reform and primary care access in an Editorial.

Editorial and Related Articles 1 and 2

In a pragmatic randomized clinical trial of 183 patients, Huffman and coauthors sought to determine whether a low-intensity collaborative care management program for depression, generalized anxiety disorder, and/or panic disorder was associated with improvement in mental health-related quality of life and other outcomes among patients hospitalized for one of several acute cardiac conditions. They found superior improvements in treatment rates, function, and mental health-related quality of life at 24 weeks compared with enhanced usual care, although there were no between-group differences in some additional outcomes, including rates of cardiac readmission. In an Invited Commentary, Davidson and coauthors consider this intervention in light of the Affordable Care Act.

Invited Commentary

Fostering accountability in the Medicare accountable care organization (ACO) programs may be challenging because traditional Medicare beneficiaries have unrestricted choice of health care providers, are attributed to ACOs based on utilization, and often receive fragmented care. Using 2010-2011 Medicare claims and ACO physician rosters, McWilliams and coauthors measured stability of assignment from 2010 to 2011, leakage of outpatient care, and contract penetration. Of 524 246 beneficiaries hypothetically assigned to 1 of 145 ACOs in 2010 or 2011, 66.0% were consistently assigned in both years. Of Medicare spending on outpatient care billed by ACO physicians, only 37.9% was devoted to assigned beneficiaries, and this proportion was higher for ACOs with specialty mixes oriented more toward primary care. Ginsburg discusses the future of ACOs in an Invited Commentary.

Invited Commentary

Phosphodiesterase 5A expression by BRAF activation or sildenafil use increases the invasiveness of melanoma cells, which raises a link between sildenafil use and melanoma. Li and coauthors evaluated the association between sildenafil use and risk of incident melanoma in a prospective cohort study of 25 848 men (14 of 1378 users and 128 of 24 470 nonusers) with a 10-year follow-up. In that group, 142 melanomas occurred, and sildenafil use at baseline or ever use was associated with a significantly increased risk of melanoma. In contrast, sildenafil use was not associated with risk of nonmelanoma skin cancers. In an Invited Commentary, Robinson sets the findings in clinical context.

Invited Commentary