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In This Issue of Archives of Internal Medicine
July 26, 2010

In This Issue of Archives of Internal Medicine

Arch Intern Med. 2010;170(14):1188. doi:10.1001/archinternmed.2010.240

Cardiac Function in 5-Year Survivors of Childhood Cancer

In this study, van der Pal et al evaluated cardiac function during long-term follow-up (median,15.4 years) in a large cohort of adult childhood cancer survivors (CCSs) treated with potentially cardiotoxic therapy (ie, anthracyclines, cardiac irradiation, high-dose cyclophosphamide, and/or ifosfamide). Of 601 eligible CCSs, 525 (87%) had an echocardiogram performed, of which 514 were evaluable for assessment of the left ventricular fractional shortening. A high percentage (27%) of young adult CCSs had an abnormal cardiac function, defined as a fractional shortening of less than 30%. The strongest predictors of subclinical cardiac dysfunction were anthracycline dose, cardiac irradiation, and younger age at diagnosis.

A Health Insurance Company–Initiated Multifaceted Intervention for Optimizing Acid-Suppressing Drug Prescriptions in Primary Care

In a cluster randomized controlled trial, half of 112 primary care physician (PCP) peer review groups (993 PCPs) received a guideline for long-term use of acid-suppressing drugs, a list of long-term users, and financial compensation for additional consultations. After 6 months, multilevel analyses of prescription data from the regional health insurance company of 23 433 patients demonstrated neither reduction of long term users (relative risk, 1.04; 95% confidence interval, 0.97 to 1.11) nor reduction in volume (β = 0.33 DDD; 95% confidence interval, −3.0 to 3.6) of acid-suppressing drugs in the intervention group compared with the control group. The authors concluded that practical tools and financial incentives did not alter prescription practice and that more tailored interventions are required to optimize acid-suppressing drug use.

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National Quality Forum Performance Measures for HIV/AIDS Care

In 2008, the National Quality Forum (NQF) first endorsed performance measures for human immunodeficiency virus (HIV)/AIDS care. In a retrospective analysis of 21 564 patients with HIV receiving Department of Veterans Affairs (VA) medical care in 2008, national rates for 6 performance measures were greater than 80%; the remaining measures and their rates were 54% for annual syphilis screening, 65% for tuberculosis screening, 72% for pneumocystis pneumonia prophylaxis, and 73% for HIV RNA control. National VA performance rates were generally high, but variation in rates across facilities revealed room for improvement. Both patient and resource factors had an impact on the likelihood of receipt of indicated care.

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Risk Profiles and Treatment Patterns Among Men Diagnosed as Having Prostate Cancer and a Prostate-Specific Antigen Level Below 4.0 ng/mL

Men with a prostate-specific antigen (PSA) level of 4.0 ng/mL or lower represent 14% of incident prostate cancer cases. These patients were less likely to have high-grade cancer, and more than half were classified as having low-risk cancer. Despite their lower risk of having clinically significant disease, treatment rates for men with PSA values of 4.0 ng/mL or lower were comparable to men presenting with PSA values of 4 to 20 ng/mL. Treatments were especially common among men with screen-detected cancer. The finding that men in low-risk groups were treated intensively raises the concern of overtreatment, especially among older patients. Lowering biopsy threshold, while lacking the ability to distinguish indolent cancers from aggressive cancers, may increase overdiagnosis and overtreatment.

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Geographic Variation in Carotid Revascularization Among Medicare Beneficiaries, 2003-2006

Little is known about patterns in the use of carotid revascularization since a 2004 Medicare national coverage decision supporting carotid artery stenting. In this analysis of elderly Medicare beneficiaries who underwent carotid revascularization between 2003 and 2006, the rate of endarterectomy declined from 3.2 to 2.7 per 1000 person-years. There was significant geographic variation in the use of both endarterectomy and stenting and in the imaging modalities used prior to revascularization. Moreover, men and patients with a prior diagnosis of peripheral vascular disease were more likely to undergo revascularization, and patients with a prior diagnosis of coronary artery disease or a prior carotid endarterectomy were more likely to undergo stenting. The findings highlight the need for consensus regarding diagnostic imaging criteria for the identification and management of carotid artery disease.

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