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In This Issue of JAMA Internal Medicine
August 2014


JAMA Intern Med. 2014;174(8):1209-1211. doi:10.1001/jamainternmed.2013.10665

Because guidelines often fail to consider treatment burden, many patients with type 2 diabetes mellitus may be overtreated. Vijan and coauthors used a Markov simulation model to estimate the effects of hemoglobin A1c level reduction on diabetes outcomes and overall quality-adjusted life years. They found that for many patients, the burdens and adverse effects of treatment outweigh the benefits from reduction of diabetes complications. Patients and clinicians should consider this information when deciding on treatments to lower hemoglobin A1c, and health care organizations should reconsider how they define quality of care for diabetes, since current guidelines and quality measures may provide incentives to deliver care that causes more harm than benefit.

Expanded use of fecal occult blood testing (FOBT) has been proposed as a strategy to reduce disparities in colorectal cancer screening; however, it is unclear whether it is possible to achieve the high level of adherence to annual FOBT necessary to reduce colorectal cancer mortality. In a randomized comparative effectiveness study, Baker and coauthors assessed whether a multifaceted intervention could achieve higher adherence to annual FOBT compared with usual care in a network of community health centers. The intervention achieved high levels of adherence (82.2% completion within 6 months of the due date), which was much higher than that for usual care (37.3%). Green and Coronado consider the challenges of FOBT screening in underserved populations in an Invited Commentary.

Invited Commentary

The increased risk of hemorrhage associated with anticoagulant therapy following traumatic brain injury (TBI) creates a dilemma for medical management of older patients with TBI: should anticoagulant therapy be resumed after injury, and if so, when? Albrecht and coauthors conducted a retrospective longitudinal analysis of 10 782 anticoagulated Medicare beneficiaries hospitalized with TBI during 2006 through 2009 to estimate the risk of thrombotic and hemorrhagic events associated with resumption of warfarin therapy following hospital discharge. During the year following hospital discharge for TBI, warfarin resumption was associated with increased risk of hemorrhagic events and decreased risk of thrombotic events, regardless of timing of resumption. Resumption of warfarin therapy was associated with decreased risk of hemorrhagic and ischemic stroke.

Continuing Medical Education

Muscle pain, fatigue, and weakness are common adverse effects of statin medications and may decrease physical activity in older men. In a prospective cohort study of community-dwelling men 65 years and older from the Osteoporotic Fractures in Men Study, Lee and coauthors studied the cross-sectional and longitudinal association between statin use and physical activity. Physical activity was measured by a validated self-administered questionnaire at baseline, 4.6 years, and 6.9 years (n = 3039). At the last follow-up visit, physical activity was also measured by an accelerometer worn by the participants (n = 3079). They found that statin use was associated with modestly less physical activity, even after accounting for medical history and other potentially confounding factors. In an Invited Commentary, Golomb sets the findings in clinical context.

Invited Commentary

Outcomes after hip fracture among long-term nursing home residents are not well studied. In a retrospective cohort study of 60 111 US long-term nursing home residents between 2005 and 2009, Neuman and coauthors found increased mortality and decreased independence after hospitalization for hip fracture. In adjusted analyses, marked increases in the risk of adverse outcomes after hip fracture were seen among nursing home residents who received nonoperative hip fracture care, patients older than 90 years, patients with multiple comorbidities, and patients with severe cognitive impairment. In an Invited Commentary, Ko and Morrison examine the implications of the findings for the practice of palliative care.

Invited Commentary

Little is known about how pharmaceutical sales representatives affect trainees’ knowledge about pharmaceutical prescribing. To determine whether there is an association between medical trainees’ interactions with pharmaceutical promotion and their medication use preferences, Austad and coauthors conducted a national survey of medical students and residents from all US-based allopathic medical schools. The authors developed an “industry relations index” that graded trainees’ perceptions of the value of pharmaceutical promotion and frequency of accepting gifts and free meals from industry marketing representatives. In common clinical scenarios involving drug prescribing, respondents with higher industry relations scores were less likely to make evidence-based prescribing recommendations and more likely to pick brand-name drugs over equally effective generic alternatives. Ross provides pedagogical context in an Editor’s Note.

Editor’s Note

An increased risk of high-grade disease among users of 5α-reductase inhibitors (5ARIs) has been detected, leading to a Food and Drug Administration warning about using 5ARIs for chemoprevention of prostate cancer. To investigate whether 5ARI use was associated with high-grade or lethal prostate cancer, Preston and coauthors conducted a prospective cohort study of 38 058 men in the Health Professional’s Follow-up Study, assessing their exposure to 5ARIs every 2 years. They found that 5ARI use was not associated with risk of high-grade or lethal prostate cancer, while it was associated with a significant reduction in risk of low-grade, Gleason sum 7, and overall prostate cancer. However, the study cannot exclude the possibility of an increased risk of high-grade or lethal disease because the number of exposed cases was low and confidence intervals were wide.

Bonica and coauthors conducted multiple regression analyses of campaign contributions from 1991 through 2012 to explore the partisan differences in contributions by women compared with men, by those practicing in for-profit compared with nonprofit health care organizations, and by medical specialization. They found that physicians’ political preferences are increasingly polarized by sex, specialty, and nonprofit vs for-profit employment. Physician contributors have shifted from majority Republican to majority Democratic, less because of changes in individual physicians than new physician contributors, especially women and practitioners not in solo or small group practices. The gaps, sharply increasing over time, are large compared with similar distinctions among general voters. Relman contributes an Invited Commentary.

Invited Commentary

Author Audio Interview