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In This Issue of JAMA Internal Medicine
July 2015

Highlights

JAMA Intern Med. 2015;175(7):1077-1079. doi:10.1001/jamainternmed.2014.5074
Research

In a 4-year randomized clinical trial in older individuals at high risk of vascular disease, participants allocated to a Mediterranean diet were found to have significantly improved memory, frontal function, and global cognitive domains compared with those allocated to a control diet based on reduced dietary fat.

The Lariat device is widely used off-label for left atrial appendage occlusion. A systematic review of published literature and formal analytic review of the US FDA-MAUDE database were performed to assess safety of the device for this off-label indication. Significant risks of major adverse events were found, and controlled investigations into the safety and efficacy of the device for this indication are warranted. Varosy provides an Invited Commentary.

Invited Commentary

The Wells score to determine the pretest probability of deep vein thrombosis (DVT) was validated in outpatient settings, but it is unclear whether it applies to inpatients. In a prospective study performed in a quaternary care academic hospital, the Wells score performed only slightly better than chance for discrimination of risk for DVT in 1143 hospitalized patients, suggesting that this is not a sufficient model to exclude DVT or influence management decisions in the inpatient setting. Price and Minichiello provide an Invited Commentary.

Invited Commentary

To investigate the association between care continuity and the use of potentially unnecessary procedures, Romano et al conducted a retrospective cohort study using insurance claims for 1 208 250 Medicare fee-for-service patients older than 65 years. Continuity was quantified using the Bice-Boxerman continuity of care index, and overuse was measured using a previously validated set of 19 potentially overused procedures. Higher continuity was significantly associated with lower odds of 9 procedures and with increased overuse for 3 procedures. Increased continuity was associated with an overall decrease in overuse, suggesting a potential benefit of high-continuity care; however, the strength and direction of the association varied according to the specific procedure examined. Greyson and Detsky provide an Invited Commentary.

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Invited Commentary

Patients receiving warfarin for secondary prevention of venous thromboembolism (VTE) often need invasive surgical or diagnostic procedures that require warfarin interruption. Use of a short-acting anticoagulant (bridge therapy) during the periprocedural period has been suggested for patients at high risk of VTE recurrence. This study retrospectively identified 1812 invasive procedures in 1178 unique patients with a history of VTE who had their warfarin interrupted. Bridge therapy was prescribed in 555 procedures. Recurrent VTE was rare and not significantly different between groups. Bridge therapy was associated with an increased risk of bleeding during warfarin interruption for invasive procedures and is likely unnecessary for most of these patients. Brotman and Streiff provide an Invited Commentary.

Invited Commentary

The US Clean Air Act prohibits use of nonessential ozone-depleting substances. In 2005, the US FDA announced the ban of chlorofluorocarbon (CFC) albuterol inhalers by December 31, 2008. The policy resulted in the controversial replacement of generic CFC inhalers by more expensive, branded hydrofluoroalkane inhalers. Jena et al studied the impact of the FDA CFC ban on out-of-pocket costs and utilization of albuterol inhalers, as well as use of hospital services, among privately insured individuals during 2004 to 2010. The authors estimated that a $10 increase in out-of-pocket albuterol costs had a small negative impact on inhaler use and no impact on asthma-related hospitalizations, emergency department visits, and outpatient visits. The policy’s impact on individuals without insurance is unknown.

Editor’s Note

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Using a nationally representative sample of noninstitutionalized Medicare beneficiaries from the National Health and Aging Trends Study, the authors developed measures of the frequency of and ability to leave the home. In 2011, 5.6% of the elderly, community-dwelling Medicare population was completely or mostly homebound. Completely homebound individuals were more likely to be older, female, nonwhite, have less education and income, have more chronic conditions, and have been hospitalized in the past 12 months than the non–homebound population. Only 11.9% of completely homebound individuals reported receiving primary care services at home. These findings can inform improvements in clinical and social services for these often underserved individuals.

Patients with stable coronary disease undergoing angiogram potentially followed by percutaneous coronary intervention (angiogram/PCI) are frequently misinformed about the benefits of PCI, but it is unclear whether physicians’ explanations may contribute to patient misperceptions. This study reviewed 59 conversations between cardiologists and their patients who were considering angiogram/PCI. Using a 7-point framework to grade the quality of discussions, the authors found that only 3% of the conversations contained all 7 elements required for an informed decision, whereas 14% contained a more limited discussion of the procedure, alternatives, and risks. More complete discussions were associated with patients choosing not to undergo angiogram/PCI. The study highlights an important quality gap that may contribute to patients’ misunderstanding. Tulsky provides an Invited Commentary.

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Editorial

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