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In This Issue of JAMA Internal Medicine
October 2016


JAMA Intern Med. 2016;176(10):1419-1421. doi:10.1001/jamainternmed.2015.4906

In this prospective cohort study of 85 013 women from the Nurses’ Health Study and 46 329 men from the Health Professionals Follow-up Study, Song and colleagues found that higher animal protein intake was associated with increased cardiovascular mortality, whereas higher plant protein intake was associated with decreased mortality. These associations were confined to participants with at least 1 of the unhealthy lifestyle factors based on smoking, heavy alcohol drinking, overweight or obesity, and physical inactivity, but not evident among those without any of these risk factors. Substitution of plant protein for animal protein, especially from processed red meat, was associated with lower mortality, suggesting the importance of protein source.

Author Video Interview

Continuing Medical Education

Using the United Kingdom Clinical Practice Research Datalink linked with the Hospital Episodes Statistics database, Faillie and colleagues performed a population-based cohort study aimed to assess whether the use of dipeptidyl-peptidase–4 (DPP-4) inhibitors and glucagon-like peptide 1 (GLP-1) analogs are associated with an increased risk of incident bile duct and gallbladder disease in patients with type 2 diabetes. Among 71 369 patients initiating antidiabetic drugs between 2007 and 2014, 853 patients were hospitalized for bile duct and gallbladder disease. Compared with current use of at least 2 oral antidiabetic drugs, current use of DPP-4 inhibitors was not associated with an increased risk of bile duct and gallbladder disease. In contrast, the use of GLP-1 analogs was associated with an increased risk, as well as an increased risk of cholecystectomy.

Related Article


Using Medical Expenditure Panel Survey data, Olfson and colleagues found that approximately 8.4% of adults in the United States screened positive for depression and only a portion of those screened received any treatment for depression in a year. Among patients with serious psychological distress who were treated for depression, most received treatment exclusively from general medical professionals with fewer receiving any treatment from psychiatrists or other mental health professionals. These national patterns reveal gaps in depression care including challenges with access to specialized mental health services, even for the most distressed patients.

In this study, Chang and Shapiro examined the patterns of intensive care unit (ICU) utilization for 4 common medical conditions from 94 hospitals in Washington state and Maryland using the State Inpatient Database from the Agency for Healthcare Research and Quality. They found large variability in hospital-level ICU admission rates for each condition and significant correlations in patterns of ICU utilization for these medical conditions among hospitals. Furthermore, hospitals that utilized ICUs more frequently were more likely to perform invasive studies and have higher hospital costs with no improvement in mortality for each medical condition.

Invited Commentary

Author Audio Interview

Under the Affordable Care Act, 30 states and the District of Columbia have expanded Medicaid, with several states using private insurance to expand. Sommers and colleagues conducted a 3-year study to evaluate the effect of 2 alternative expansion approaches—Kentucky’s traditional Medicaid expansion and Arkansas’ private option—compared with nonexpansion in Texas, for low-income adults living in those 3 states and found that the effect of the coverage expansions was considerably larger in the second year of the policy (2015) compared with the first year (2014). Additionally, insurance expansion led to significant improvements in access to care, affordability, use of preventive services, and health care quality, with reduced reliance on emergency department care.

Invited Commentary

Pulakka and colleagues used 2 Finnish longitudinal cohorts to examine associations between increasing distance from home to the nearest tobacco outlet and quitting smoking or smoking relapse. Among the 8349 baseline smokers, increase in distance to a tobacco outlet increased odds of quitting smoking. Change in distance was not associated with smoking relapse among the 12 380 baseline ex-smokers.

Invited Commentary

In this this cohort study of 168 133 Medicare patients who survived a hip, wrist, or upper arm fracture, Munson and colleagues examine the use of prescription drugs known to increase the risk of fracture in the time periods prior to and following the index fracture. In this study population, 76% of patients were using at least 1 drug that increases fracture risk in the months leading up to their initial fracture. While a small minority of patients stopped taking these drugs after fracture, an equal or greater number of patients initiated a high-risk drug. Use of drugs that decrease fracture risk was uncommon at the time of fragility fracture and increased only slightly in the postfracture period. Taken as a whole, these results suggest that a fragility fracture does not consistently alter prescribing practices for drugs that could potentially modify the risk of a subsequent fracture.

Invited Commentary

In this retrospective study using population-based SEER-Medicare data, Lipitz-Snyderman and colleagues assessed the extent of physician variation regarding services that tend to be overused in cancer care. There was significant unexplained variation in service use between physicians. Whether a physician ordered a service for a patient was highly predictive of whether the physician would order the same service for the next patient. Physicians’ utilization of nonrecommended services exhibit patterns that suggest consistent behavior more than personalized patient-care decisions. Reducing overuse may require understanding the cognitive drivers of repetitive inappropriate decisions.

Invited Commentary