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In This Issue of JAMA Internal Medicine
January 2015


JAMA Intern Med. 2015;175(1):1-3. doi:10.1001/jamainternmed.2014.5044


Veterans with dual VA and Medicare benefits have access to glucose test strips through both systems, raising the potential for overuse. Gellad and colleagues examined a national cohort of 363 996 VA patients 65 years and older with diabetes who received glucose test strips in 2009. Overall, 71.6% received test strips from the VA only, 22.8% from Medicare only, and 5.6% from both VA and Medicare (dual users). Dual users received 3 times as many test strips in a year as those receiving from VA only and 1.5 times as many as those receiving from Medicare only. Among patients taking no diabetes medications, for whom daily self-monitoring is rarely indicated, 55.4% of dual users received more than 1 test strip daily compared with 15.8% of VA only users. The odds of overuse were greater for dual users compared with both Medicare only and VA only users across all medication groups.

Researchers have worked with clinicians and administrators to integrate depression care management into the routine practice of medical nurses. In a cluster-randomized effectiveness trial conducted in 6 diverse agencies and using clinically informed research assessments of depression severity, Bruce and colleagues found no effect of this intervention in the full sample of patients who screened positive for depression. In the subset of patients with clinically significant symptoms, however, the intervention led to greater reduction in depressive symptoms than enhanced usual care. The effect in these patients was clinically meaningful, continued to grow over 1 year, and did not differ by whether patients were taking antidepressants. Lyketsos provides an Invited Commentary.

Invited Commentary

Cardiac biomarker testing is not indicated in emergency department (ED) patients without symptoms suggestive of acute coronary syndrome (ACS). Using the National Hospital Ambulatory Medical Care Surveys for 2009 and 2010, Makam and Nguyen found that 17% of all visits had biomarker testing, representing 28.6 million ED visits nationally. Nearly one-third of these individuals received biomarker testing despite having no symptoms of ACS. Among individuals subsequently hospitalized for any reason, biomarkers were collected in 47% of visits. The strongest predictor of biomarker testing was the number of other tests or services performed during the ED visit, independent of the presence of ACS symptoms. These findings suggest that cardiac biomarker testing in the ED is common, even among those without symptoms suggestive of ACS.

In clinical practice, it is customary to consider initiation of antiretroviral therapy (ART) as “early” vs “late,” depending on whether the CD4+ T-cell count is above or below a specific CD4+ threshold, not whether ART is initiated earlier vs later relative to HIV infection. In an observational analysis from a well-characterized chronic infection cohort, Okulicz and colleagues defined earlier vs later ART based on the time interval between seroconversion or study entry and commencement of ART. They report that initiation of ART after 12 months of seroconversion and/or study entry was associated with a significantly decreased likelihood and rate of normalization of CD4+ T-cell counts, increased AIDS risk, increased T-cell activation, and impaired in vivo functional immune responses. Schacker provides an Invited Commentary.

Invited Commentary

As advanced practice clinicians (APCs) are increasingly called on to relieve the shortage of primary care physicians (PCPs), little is known about their use of diagnostic testing relative to PCPs. Using logistic regression to conduct a retrospective analysis of 2010-2011 Medicare claims data, Hughes and colleagues found that APCs are associated with more imaging services following evaluation and management office visits than PCPs. Across all patient groups and imaging services, they found that the odds of an APC ordering diagnostic imaging was 28% higher than that of a PCP, with APCs ordering 0.3% more images per patient. While this slight increase in imaging may not have a substantial impact on individual patients, it has important ramifications on care and overall costs at the population level. Katz provides an Editor’s Note.

Editor’s Note

Home visitation by community health workers (CHWs) improves asthma control among children, but the effectiveness of this strategy for control among adults has not been evaluated. In a randomized clinical trial with 366 participants, Krieger and colleagues assessed whether CHW home visits that provided self-management support to low-income adults with uncontrolled asthma improved outcomes relative to usual care. Intervention group participants had clinically important and significantly greater increases in symptom-free days and asthma-related quality of life relative to the control group. Unscheduled health care use decreased similarly in both groups. Secondary outcomes generally improved more in the intervention group. Alter provides an Invited Commentary.

Invited Commentary

Clinical Review & Education

Overuse of medical care, consisting primarily of overdiagnosis and overtreatment, is a common clinical problem. Morgan and colleagues systematically reviewed the medical literature from 2013 to select the top 10 articles related to overuse. These articles, organized into “overdiagnosis,” “overtreatment,” and “methods to avoid overuse,” were reviewed and interpreted for their impact on clinical medicine. The authors conclude that overuse of testing causes false-positive results and overdiagnosis; negative test results do not appear to genuinely reassure patients; and overtreatment, with both medical therapies and procedural interventions, places patients at risk of unnecessary adverse events.

More than 80% of sudden deaths in sport in young athletes are attributed to cardiac disease. Both the American Heart Association and the European Society of Cardiology support preparticipation cardiac screening but differ in their approach. Sharma and colleagues review their recommendations and the literature, finding that the American model is insensitive, whereas the European model has an unacceptably false-positive rate. The authors conclude that cardiac screening should be voluntary and not mandatory and should be conducted by highly experienced physicians who fully understand the cardiovascular adaptation to exercise.