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In This Issue of JAMA Internal Medicine
December 9/23, 2013


JAMA Intern Med. 2013;173(22):2021-2023. doi:10.1001/jamainternmed.2013.6343


The Food and Drug Administration allows manufacturers to determine whether additives to food are “generally recognized as safe” (GRAS) without notifying the agency. Neltner and coauthors evaluated 451 notices voluntarily submitted by additive manufacturers to the agency for review from 1997 to 2012. They found that 22.4% of the safety assessments were made by an employee of a manufacturer, 13.3% by an employee of a consulting firm selected by a manufacturer, and 64.3% by an expert panel selected by either a consulting firm or a manufacturer. At least 1 of the 10 individuals with the most frequent service was a member of 225 of the panels (78%), and 1 person served on 128 panels (44%). In an Invited Commentary, Nestle considers the study’s public health implications.

Invited Commentary

Health care–associated infections account for a large proportion of the harms caused by health care and are associated with high costs. Zimlichman and coauthors estimated costs associated with 5 significant and targetable health care–associated infections. On a per-case basis, central line–associated blood stream infections were found to be the most costly at $45 814, followed by (in descending order) ventilator associated pneumonia, surgical site infections, Clostridium difficile infection, and catheter-associated urinary tract infection. The total annual costs for the 5 major infections were $9.8 billion, with surgical site infections comprising the largest contribution to overall costs (33.7% of total), followed by (in descending order) ventilator associated pneumonia, central line–associated bloodstream infection, Clostridium difficile infection, and catheter-associated urinary tract infection. In an Editor’s Note, Katz explains the import of cost considerations for improved patient care.

Editor’s Note

Continuing Medical Education

Health Care Reform

Nursing home residents with advanced dementia commonly experience burdensome and costly hospitalizations that may not extend survival or improve the quality of life. Goldfeld and coauthors compared patterns of care and quality outcomes for nursing home residents with advanced dementia covered by managed care with those covered by traditional fee-for-service Medicare. Using Medicare claims data linked with data from a prospective cohort study that followed 323 nursing home residents with advanced dementia, the authors compared survival, symptoms related to comfort, presence of a do-not-hospitalize order, hospitalizations for acute illness, and primary care visits. They found that those enrolled in managed care had more primary care visits, had higher prevalence of do-not-hospital orders, and were less likely to be admitted to the hospital for acute illness, yet had no differences in survival and comfort. In an Invited Commentary, Hall situates the findings in context for clinicians.

Invited Commentary

Medicare expenditures continue to grow rapidly, but the reasons are uncertain. To compare expenditures in 1998-1999 and 2008 for Medicare beneficiaries hospitalized for acute myocardial infarction, Likosky and colleagues conducted a cross-sectional analysis of a random 20% sample of fee-for-service Medicare beneficiaries admitted with acute myocardial infarction during 1998-1999 (n = 105 074) and a 100% sample for 2008 (n = 212 329). Compared with the subjects in 1998-1999, although there was a 19% decline in the rate of hospitalizations for acute myocardial infarction, overall expenditures per patient increased by 16% (absolute difference, $6094). Expenditures for skilled nursing facilities, hospice, home health, durable medical equipment, and outpatient care nearly doubled 31 to 365 days after admission. Jha calls for new quality measures and better stewardship of Medicare in an Invited Commentary.

Invited Commentary

Author Audio Interview

Despite attention given to high-impact inpatient cases, there is increasing awareness that malpractice in the outpatient setting, particularly in primary care, is a major contributor to malpractice risk and claims. Schiff and coauthors studied primary care malpractice types, causes, and outcomes as part of a Massachusetts ambulatory malpractice risk and safety improvement project. Pooling claims data of 2 leading malpractice carriers for a 5-year period identified 551 primary care claims; more than 70% of these claims alleged failure or delays in diagnosis particularly for colorectal, breast, lung, and prostate cancer, each with its own pattern of problems. Hyman and Sage examine the difference between inpatient and outpatient malpractice claims and call for additional research in an Invited Commentary.

Invited Commentary

Author Video Interview

To investigate the quality of supportive cancer care in the Veterans Affairs Health System, Walling and coauthors measured the quality of symptom management and information and care planning using previously validated process indicators in a national sample of veterans diagnosed as having advanced colorectal, lung, and pancreatic cancers. Using medical chart abstraction methods, they identified many patient- and family-centered supportive care gaps that reflect important targets for improvement; for example, early goals of care discussions are infrequent despite recent evidence suggesting that they might be helpful. In an Invited Commentary, Aldridge and Meier explain the implications of the findings for the palliative care field.

Invited Commentary