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Routine cancer screening has unproven net benefit for patients with limited life expectancy. Royce and coauthors conducted a study using data from the population-based National Health Interview Survey (NHIS). They found high rates of cancer screening in individuals with limited life expectancy: in individuals with 75% or higher risk of mortality within 9 years, 55% (prostate), 38% (breast), 31% (cervical), and 41% (colorectal) received recent cancer screening. On multivariate analysis, higher mortality risk was associated with less screening for prostate, breast, and cervical cancers, and there was less screening for prostate and cervical cancers in more recent years compared with 2000. The results from sensitivity analysis showed that screening was also common in individuals with a less than 5-year life expectancy. Gross contributes an Invited Commentary on this article and the article by Van Hees and coauthors.
Related Article and Invited Commentary
Many Medicare beneficiaries undergo more intensive colonoscopy screening than recommended. Van Hees and coauthors conducted a microsimulation modeling study to determine whether observed practices of more intensive colonoscopy screening than recommended are favorable for Medicare beneficiaries. They found that most of these practices are associated with a balance among benefits, burden, and harms that is unfavorable for Medicare beneficiaries. Gross contributes an Invited Commentary on this article and the article by Royce and coauthors.
Although hospitalized medical patients are at increased risk for venous thromboembolism (VTE), the extent to which quality improvement efforts focused on increasing hospital performance of pharmacologic prophylaxis delivery lead to reductions in VTE among this population is unclear. Using data from multiple hospitals throughout the state of Michigan, Flanders and colleagues found that, after accounting for patient-level factors, greater hospital-level rates of pharmacologic prophylaxis were not associated with reduced VTE. The findings imply that efforts to broadly increase rates of pharmacologic prophylaxis in medical patients may not yield significant reductions in hospital-associated VTE. Rothberg discusses the challenges of delivering appropriate care in an Invited Commentary.
The β-blockers carvedilol and metoprolol succinate both reduce mortality in patients with heart failure, but the comparative clinical effectiveness of these drugs is unknown. Using data from a national registry in Denmark, Pasternak and coauthors investigated the comparative clinical effectiveness of the β-blockers carvedilol and metoprolol succinate in patients with newly diagnosed heart failure with reduced ejection fraction. The cohort included approximately 6000 patients treated with carvedilol and 5600 treated with metoprolol, followed up for a median of 2.4 years. They found no significant differences between the drugs in the primary outcome of all-cause mortality and the secondary outcome of cardiovascular mortality.
Although percutaneous coronary intervention (PCI) does not reduce the risk of myocardial infarction or death for patients with stable coronary artery disease (CAD), patients believe that the procedure confers these benefits. In this qualitative study, Goff and coauthors explored how cardiologists’ presentation of information about PCI for stable CAD may affect patients’ beliefs about the procedure’s benefit. They analyzed 40 transcripts of patient-cardiologist interactions in which PCI was discussed as an option for a patient, finding that cardiologists may contribute to patients’ misperceptions through overstated benefit, understated risk, and limited use of shared decision-making techniques. Lin and Dudley contribute an Invited Commentary on this and 2 other related articles.
Related Articles 1 and 2 and Invited Commentary
Continuing Medical Education
Patients with stable angina pectoris often believe that percutaneous coronary intervention (PCI) prevents myocardial infarction (MI), despite evidence to the contrary. Rothberg and coauthors conducted a randomized trial in which they provided varying levels of information to 1257 participants recruited through the Internet. They found that in the hypothetical setting of mild, stable angina, 71% of people assume PCI prevents MI and are likely to choose it. Offering explicit information to the contrary reduces the proportion who hold that belief and who choose PCI. Explaining why PCI does not prevent MI was most effective in influencing beliefs but had little additional effect on decision making. Lin and Dudley contribute an Invited Commentary on this and 2 other related articles.
Understanding the relationship between patient selection for coronary angiography and percutaneous coronary intervention (PCI) appropriateness may inform strategies to minimize inappropriate procedures. To determine if hospitals that frequently perform coronary angiography in asymptomatic patients are more likely to perform inappropriate PCI, Bradley and coauthors conducted a multicenter observational study of 544 hospitals. They found that performing coronary angiography on asymptomatic patients was associated with higher rates of inappropriate PCI and lower rates of appropriate PCI. Lin and Dudley contribute an Invited Commentary on this and 2 other related articles.
Growing concern about the costs and harms of medical care has spurred interest in assessing physicians’ ability to avoid the provision of unnecessary care. To evaluate whether residency training influences this capability, Sirovich and coauthors developed a measure based on the American Board of Internal Medicine certifying examination. Selected examination questions allowed assessment of candidates’ ability to manage patients conservatively when a conservative approach is appropriate; they developed a similar measure to assess appropriately aggressive management capability. The authors found that, regardless of overall medical knowledge, internal medicine residents trained at programs characterized by lower-intensity practice patterns were more likely to choose a conservative approach when appropriate, while remaining capable of choosing an aggressive approach when indicated. In an Invited Commentary, Korenstein and Smith consider the challenges and benefits of training residents to practice conservatively.
Highlights. JAMA Intern Med. 2014;174(10):1533-1535. doi:10.1001/jamainternmed.2013.10676