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In This Issue of JAMA Internal Medicine
April 2014


JAMA Intern Med. 2014;174(4):489-491. doi:10.1001/jamainternmed.2013.10645

How for-profit and nonprofit hospices differ in activities beyond service delivery is unknown. Aldridge and coauthors examined the impact of for-profit hospice ownership on the provision of community benefits, the setting and timing of the hospice population served, and community outreach using results from a cross-sectional survey of a national random sample of Medicare-certified hospices. They found that for-profit were less likely than nonprofit hospices to provide community benefits including serving as training sites, conducting research, and providing charity care. For-profit were more likely than nonprofit hospices to engage in community outreach and less likely to partner with oncology centers. Johnson considers the impact of the growth in for-profit hospices in the United States on quality of and access to hospice in an Invited Commentary.

Invited Commentary

To create a “top-five” list for emergency medicine, Schuur and coauthors conducted a multistep project using a modified Delphi process. A technical expert panel of 9 emergency physicians reviewed tests, treatments, and disposition decisions to identify low-value items that are amenable to standardization and are actionable by emergency medicine clinicians. They surveyed 283 emergency medicine physicians, physicians’ assistants, and nurse practitioners about potential benefit or harm and actionability. The final top-five list includes 3 computed tomography examinations, 1 magnetic resonance imaging examination, and 1 blood test. An Editorial from Grady and colleagues discusses the development of top-five lists.

Related Editorial

Many studies have suggested that higher added sugar intake was associated with several adverse health outcomes; however, few studies have examined the relationship between added sugar intake and cardiovascular disease (CVD) mortality. Using a series of National Health and Nutritional Examination Surveys and a prospective cohort study of a nationally representative sample of US adults, Yang and coauthors found that after adjusting for CVD risk factors, higher consumption of added sugar was associated with significantly increased risk of CVD mortality. In addition, regular consumption of sugar-sweetened beverages, a main source of added sugar, was associated with CVD mortality. Schmidt considers the public policy implications in an Invited Commentary.

Invited Commentary

Despite the documented prevalence and clinical ramifications of physician distress, few rigorous studies have tested interventions to address the problem. West and coauthors conducted a single-center randomized clinical trial of a 9-month intervention involving a facilitated small group curriculum for 74 practicing physicians at a large academic medical center, with protected time for participants provided by the institution. They found improved meaning and engagement in work and reduced depersonalization in the intervention group, with sustained results at 12 months after the study. Goitein situates the findings in the context of other research in an Invited Commentary.

Invited Commentary, Continuing Medical Education

Current guidelines allow substantial discretion in the use of noninvasive cardiac imaging for patients without acute myocardial infarction who are being evaluated for ischemia, and imaging may have an impact on downstream testing and outcomes. In a cross-sectional study of 549 078 patients at 224 hospitals, using 2010 administrative data from Premier Inc, Safavi and coauthors aimed to characterize hospital variation in the use of noninvasive cardiac imaging and the association of imaging use with downstream testing, interventions, and outcomes. They found substantial variation across hospitals in the use of noninvasive cardiac imaging for patients with suspected cardiac ischemia. Hospitals with higher rates of imaging were more likely to admit a patient for inpatient hospitalization and perform downstream coronary angiography. The rates of same hospital readmission for myocardial infarction were the same. An Invited Commentary from Amsterdam and Aman and an Editor’s Note from Redberg accompany the study.

Invited Commentary, Editor’s Note

Continuing Medical Education

Hypertension is the leading risk factor for death in sub-Saharan Africa, but lack of affordability of treatment and poor-quality health care compromises antihypertensive treatment coverage and outcomes. Hendriks and coauthors evaluated the impact of a community-based health insurance program that included quality improvement of health facilities on blood pressure in the adult population with hypertension in rural Nigeria. They found that increased access to health care and improvement of the quality of health care through the insurance program were associated with a significant decrease in blood pressure.

The stronger acid suppression effect of proton pump inhibitors may reduce the rate of stress-related gastrointestinal tract bleeding associated with critical illness but enhance the occurrence of infectious complications, specifically pneumonia and Clostridium difficile infection, when compared with histamine-2 receptor antagonists. In a retrospective pharmacoepidemiological cohort study, MacLaren and coauthors assessed 35 312 adult patients requiring mechanical ventilation for 24 hours or more using propensity score–adjusted multivariate regression models. They found that the odds ratios of gastrointestinal tract hemorrhage, pneumonia, and Clostridium difficile infection were all greater with proton pump inhibitors. Similar results were obtained in propensity-matched models of 8799 patients in each cohort. Kim and Goss give the findings clinical and academic context in an Invited Commentary.

Invited Commentary

Bereavement has been reported to increase the risk of cardiovascular events, but this risk is not well described. In a United Kingdom study using primary care data, Carey and coauthors compared the risk of myocardial infarction and stroke in 30 447 individuals who had experienced partner bereavement, with an age- and sex-matched control group whose partner was still alive. They found that in the immediate 30-day period following bereavement, the risk of myocardial infarction and stroke was doubled The increased risk was seen in both bereaved men and women and attenuated after 30 days.