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In This Issue of JAMA Internal Medicine
August 2016

Highlights

JAMA Intern Med. 2016;176(8):1047-1049. doi:10.1001/jamainternmed.2015.4894
Research

In this randomized clinical trial, Zhang and colleagues assigned 220 adults with abdominal obesity and nonalcoholic fatty liver disease to 1 of 3 groups: vigorous-moderate exercise, moderate exercise, or no-exercise control. Intrahepatic triglyceride content was reduced in the moderate exercise groups compared with the no-exercise control in the 6-month and 12-month interventions. Changes in intrahepatic triglyceride content were not significantly different between vigorous-moderate and moderate exercise groups over the 6-month or 12-month interventions. This trial indicated that vigorous and moderate exercise were equally effective in reducing intrahepatic triglyceride content in patients with nonalcoholic fatty liver disease.

Invited Commentary

Dewland and colleagues performed a secondary analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) to evaluate whether the antifibrotic and anti-inflammatory properties of angiotensin-converting enzyme inhibitors and treatments for hyperlipidemia reduce incident cardiac conduction disease risk. A total of 21 004 participants were randomly assigned to receive amlodipine, lisinopril, or chlorthalidone. Individuals with elevated fasting low-density lipoprotein cholesterol levels were also randomized to pravastatin vs usual care. Serial electrocardiograms were used to assess for incident conduction abnormalities, including left and right bundle branch block. Compared with chlorthalidone, randomization to lisinopril was associated with a significant reduction in conduction abnormalities. Treatment with amlodipine, however, was not associated with a significant difference in conduction outcome events. Similarly, pravastatin was not associated with a reduced adjusted risk of incident disease compared with usual hyperlipidemia treatment. Further studies are warranted to determine if pharmacologic treatment affects conduction abnormality outcomes, including pacemaker implantation.

Invited Commentary

Author Audio Interview

Wachterman and colleagues compared the quality of end-of-life care provided to veterans with different serious illnesses within all 146 inpatient facilities in the Veteran Affairs health system and found that family-reported quality of end-of-life care was significantly better for patients with cancer and dementia than for patients with end-stage renal disease, congestive heart failure, chronic obstructive pulmonary disease, or frailty, largely owing to higher rates of palliative care consultation and do-not-resuscitate orders and fewer deaths in the intensive care unit among patients with cancer and dementia.

Invited Commentary

DeJong and colleagues linked records of pharmaceutical industry payments to physicians from the US Sunshine Act’s Open Payments Program with physician-level prescribing data from Medicare Part D and found that receipt of a single industry-sponsored meal with an average value under $20 was positively associated with the rate that physicians prescribed the promoted drug over alternatives within the drug class. Analyses were adjusted for prescribing volume, physician specialty, practice setting, and demographic characteristics. The association was dose dependent, with additional meals and costlier meals associated with greater increases in relative prescribing rates. These findings inform ongoing efforts to develop evidence-based policy approaches to physician-industry relationships.

Continuing Medical Education

Editor’s Note

Wang and colleagues examined the associations of specific dietary fats with total and cause-specific mortality in 126 233 participants from 2 prospective cohort studies and found that higher saturated and trans-fat intakes were associated with higher mortality, whereas dietary polyunsaturated and monounsaturated fat intakes were inversely associated with mortality. Replacing saturated fats with polyunsaturated and/or monounsaturated fats was associated with a significantly lower risk of total mortality and cause-specific mortality owing to several major chronic diseases. Intake of linoleic acid, the most abundant n-6 polyunsaturated fatty acid, showed strong inverse associations with total and most cause-specific mortality. These findings support current dietary recommendations to replace saturated and trans-fat with unsaturated fats.

Related Article

Continuing Medical Education

Sweden has one of the most equitable health care systems worldwide, and all patients with type 2 diabetes are followed in a nationwide registry, with the purpose of identifying groups in need of intensified and targeted interventions. In this study, Rawshani and colleagues examined 217 364 patients younger than 70 years from the Sweden National Diabetes Register with type 2 diabetes, and after adjustment was made for well-recognized risk factors, socioeconomic status remained a strong predictor of all 10 outcomes studied. The risk of death, cardiovascular death, and diabetes-related death was almost doubled due to low income, and risk of death from cancer was elevated by 30%. Immigrants displayed a 30% to 60% lower risk of all-cause, cardiovascular, and diabetes-related death, and non-Western immigrants also had 30% lower risk of death from cancer. New approaches, beyond traditional risk factor management, are warranted to reduce socioeconomic disparities.

Related Article

Accountable care contracts hold physician groups financially responsible for the quality and cost of health care delivered to patients, yet little is known about the association of these new payment contracts with changes in spending and utilization, or which groups might benefit most from accountable care. In this study, Colla and colleagues estimated the effect of Medicare accountable care organization (ACO) contracts on spending and high-cost institutional use for all Medicare beneficiaries and for clinically vulnerable beneficiaries. A difference-in-difference estimation shows that Medicare ACO programs are associated with modest reductions in spending and utilization, which were realized through reductions in use of institutional settings in clinically vulnerable patients.

Clinical Review & Education

Percutaneous coronary intervention (PCI) continues to be performed frequently in patients with stable ischemic heart disease (SIHD) despite uncertain effectiveness. Individual randomized trial data and meta-analyses have not demonstrated that PCI in addition to optimal medical therapy reduces the incidence of death or myocardial infarction in SIHD. Percutaneous coronary intervention is also expensive, and the value to society of PCI for SIHD has also not been demonstrated. Future research should better define the role of PCI with a clear focus on patient-centered outcomes. Until such research can show that PCI for SIHD can reduce cardiovascular events, a strategy of optimal medical therapy first, with PCI reserved for unrelieved angina or the development of acute coronary syndromes, is safe, effective, and evidence-based.

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