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Trends in the Overuse of Ambulatory Health Care Services in the United States
Policy makers are increasingly interested in identifying waste in our health care system. Kale et al performed a comparative analysis using data from the 1999 and 2009 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey to examine the performance of outpatient quality measures. They found that of 9 underuse measures, 6 improved, while of 11 overuse indicators, only 2 improved. The limited improvements in the overuse measures may reflect a national quality mission that is hampered by a lack of incentives and performance measures that support the reduction of inappropriate care.
Association of Blood Transfusion With Increased Mortality in Myocardial Infarction
Chatterjee et al performed a systematic literature search of studies comparing blood transfusion with no transfusion or a liberal vs restricted transfusion strategy. Analyses of transfusion in myocardial infarction (MI) revealed increased all-cause mortality with a strategy of transfusion during MI, with a weighted absolute risk increase of 12% and a number needed to harm of 8. A higher risk with transfusion compared with no or restrictive transfusion was noted for subsequent MI rates as well. A strategy of blood transfusion or liberal blood transfusion compared with no or restricted blood transfusion was associated with a higher incidence of all-cause mortality. A practice of routine or liberal blood transfusion in MI should not be encouraged but requires investigation in a large trial with low risk for bias.
Translating the Diabetes Prevention Program Lifestyle Intervention for Weight Loss Into Primary Care
Ma et al conducted a primary care–based, randomized controlled trial of 2 Diabetes Prevention Program–based, technology-supported lifestyle interventions, one delivered by a lifestyle coach and the other by self-directed DVD. Participants were overweight or obese adult primary care patients who had prediabetes and/or metabolic syndrome. Over a 15-month period, both interventions, compared with usual care, led to clinically significant reductions in body weight, accompanied by improvements in waist circumference and fasting plasma glucose level.
Risk-Reducing Salpingo-oophorectomy and Ovarian Cancer Screening in 1077 Women After BRCA Testing
Mannis et al surveyed a large cohort of women after BRCA testing to identify the prevalence and posttest predictors of risk-reducing and screening interventions, with a particular focus on the many women who receive uninformative test results. A median of 3.7 years after BRCA testing, 1077 women who received genetic counseling and BRCA testing at 2 hospital sites were surveyed to identify predictors of risk-reducing salpingo-oophorectomy (RRSO), screening transvaginal ultrasonography (TVUS), and screening serum CA-125. The authors found that of the 72% of women who received uninformative results after BRCA testing, 12% subsequently underwent RRSO, 36% reported ever having undergone screening serum CA-125 since BRCA testing, and 39% reported ever having undergone screening TVUS since BRCA testing. The results highlight the need for evidence-based guidelines to guide post– BRCA test risk-reducing and screening practices in women who test negative for a known deleterious BRCA mutation.
Integrating Technology Into Standard Weight Loss Treatment
Spring et al tested whether the outcome of clinician-directed weight loss treatment can be improved by adding mobile technology that transmits data to a telephone coach. Seventy adults were randomly assigned to either standard-of-care group treatment alone (standard group) or to the standard plus connective mobile technology system (+mobile group). +Mobile participants received a personal digital assistant for self-monitoring diet and activity, and they uploaded their data to a coach. A longitudinal intent-to-treat analysis indicated that the +mobile group lost a mean of 3.9 kg more than the standard group at each postbaseline time point. Compared with the standard group, the +mobile group had significantly greater odds of having lost 5% or more of their baseline weight at each postbaseline time point (odds ratio, 6.5; 95% CI, 2.5-18.6).
In This Issue of JAMA Internal Medicine. JAMA Intern Med. 2013;173(2):89. doi:10.1001/jamainternmed.2013.2686
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