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In This Issue of JAMA Internal Medicine
August 12/26, 2013


JAMA Intern Med. 2013;173(15):1389-1391. doi:10.1001/jamainternmed.2013.6308


The latest generation of benchtop DNA sequencing platforms can provide an accurate whole-genome sequence for a broad range of bacteria in less than a day; this technology may more effectively contain the spread of multidrug-resistant pathogens. This laboratory-based study from the United Kingdom defines the utility of whole-genome sequencing using a series of case studies. Reuter and coauthors investigate 2 putative nosocomial outbreaks, one caused by vancomycin-resistant Enterococcus faecium and the other by carbapenem-resistant Enterobacter cloacae. They found that whole-genome sequencing accurately discriminated between outbreak and nonoutbreak isolates and was superior to conventional typing methods. The speed, accuracy, and depth of information provided by whole-genome sequencing platforms to confirm or refute outbreaks, as well as to accurately define transmission of multidrug-resistant and other organisms, represents an important advance. In an Invited Commentary, Ehrlich and Post address the clinical significance of whole-genome sequencing.

Invited Commentary

Rheumatoid arthritis (RA) has been estimated to incur annual costs of $11 billion because of work loss in the United States. While the introduction of tumor necrosis factor inhibitors have increased the drug costs considerably, work loss remains the largest cost driver, and there has been hope that the high cost of tumor necrosis factor inhibitors would be offset by reduced work loss. Eriksson and coauthors investigated this question in a randomized trial of patients with early RA, in whom methotrexate therapy had failed. They found considerable improvement in work ability over 21 months in both the biological and the conventional combination treatment arm, but with no difference in work loss between the arms at 21 months. The radiological superiority of biological agents did not translate into better work ability compared with the less-expensive combination treatment with nonbiological disease-modifying drugs. In an Invited Commentary, Yelin sets the authors’ findings in the context of current standards of treatment for RA.

Invited Commentary

In patients with immune-mediated chronic inflammatory conditions treated with biological agents, development of blocking and no-blocking antibodies have been associated with diminution of drug concentration, loss of efficacy, and changes in safety profile. In a systematic review and meta-analysis, Maneiro and coauthors summarize the published information on the association of the development of these antibodies with efficacy and safety. Results of this review showed that in rheumatoid arthritis the presence of antibodies against tumor necrosis factor monoclonal antibodies relates to a higher risk of drug therapy discontinuation for any reason. In rheumatoid arthritis and other immune-mediated inflammatory conditions such as inflammatory bowel disease and psoriasis, these antibodies conveyed higher risk of hypersensitivity reactions. The combined use of biological agents with disease-modifying antirheumatic drugs or immunosuppressors such as azathioprine reduces the development of antibodies and subsequent risks.

Postmenopausal hormone therapy with conjugated equine estrogens may adversely affect older women’s cognitive function; it is not known whether this extends to younger women. Espeland and coauthors examine the long-term effects of postmenopausal hormone therapy prescribed to 1326 women aged 50 to 55 years, who had participated in a randomized clinical trial over a mean of 7 years. Active therapies consisted of conjugated equine estrogens, with or without medroxyprogesterone acetate depending on hysterectomy status. Seven years after the trial ended, no overall long-lasting benefits or harms from prior hormone therapy on women’s cognitive function were found; however, there was some evidence for small treatment-related deficits in verbal fluency for women with prior hysterectomy. Grodstein provides an Invited Commentary.

Invited Commentary Author Audio Interview

Health Care Reform

Understanding the frequency and correlates of redundant lipid testing could identify areas for quality improvement initiatives aimed at improving the efficiency of cholesterol care in patients with coronary heart disease (CHD). Virani and colleagues report on the frequency and correlates of repeat lipid testing in patients with CHD who have attained guideline-recommended low-density lipoprotein cholesterol levels of lower than 100 mg/dL and received no further treatment intensification. Of 27 947 patients with a low-density lipoprotein cholesterol level lower than 100 mg/dL, 9200 (32.9%) received additional lipid testing by 11 months following an index lipid panel. Patients with concomitant diabetes, hypertension, and higher illness burden and those receiving more frequent primary care visits were more likely to undergo repeat lipid testing. This study demonstrates a high prevalence of redundant lipid testing in patients with CHD and highlights areas for future quality improvement initiatives aimed at improving health care efficiency and reducing health care costs. Drozda discusses the impact of this study on the existing literature on physician performance measures in an Invited Commentary, and Covinsky provides an Editor’s Note.

Invited Commentary, Editor’s Note

Clinical Review & Education

Health Care Reform

The Medicare accountable care organization (ACO) programs rely on delivery system integration and provider risk sharing to lower spending while improving quality of care. McWilliams and coauthors examined health care spending and quality of care for 4.29 million Medicare beneficiaries served by various types of health care provider groups, investigating how size-related differences in spending and quality varied by 2 factors considered central to ACO performance: group primary care orientation and provider risk sharing. Compared with smaller groups, larger hospital-based groups had substantially higher total per-beneficiary spending, higher 30-day readmission rates, and similar performance on 4 of 5 process measures of quality, despite minimal differences in clinical case mix. In contrast, larger independent physician groups performed better than smaller groups on all process measures and exhibited significantly lower per-beneficiary spending in counties where risk sharing by these groups was more common. Among all groups sufficiently large to participate in ACO programs (hospital based or not), a strong primary care orientation was associated with lower spending, fewer readmissions, and better quality of diabetes care. In an Invited Commentary, Epstein outlines the progress of improving care through greater accountability.

Invited Commentary