In This Issue of Archives of Internal Medicine

This population-based nested case-control study investigated the relationship between opioid dose and related mortality among Ontario, Canada, residents with nonmalignant pain eligible for public drug funding. Gomes et al found that a high daily dose of opioids is associated with large relative and absolute increases in opioid-related mortality. In particular, doses exceeding 200 mg of morphine (or equivalent) were associated with a nearly 3-fold risk compared with lower doses (<20 mg of morphine or equivalent). These findings have important implications, largely because the majority of opioid deaths were avoidable and occurred in young people (aged 43 years at death, on average).

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Teamwork is essential to providing safe hospital care, yet few studies have evaluated efforts on general medical patient care units. O’Leary et al conducted a controlled trial of an intervention, Structured Inter-Disciplinary Rounds (SIDR), implemented on 1 of 2 similar medical teaching units in a tertiary care academic hospital. The intervention combined a structured format for communication with a forum for regular interdisciplinary meetings. A retrospective review of 555 medical records, using both a concurrent and historic control, found a significant reduction in the adjusted rate of adverse events (adjusted rate ratio, 0.54 [P = .005] and 0.51 [P = .001], respectively). The authors conclude that SIDR is an effective strategy to improve patient safety on general medical patient care units.

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Early aggressive treatment in rheumatoid arthritis (RA) improves outcomes but carries increased risk. This study examined the incremental cost-effectiveness of adding magnetic resonance imaging (MRI) to standard risk stratification in early RA. Using a decision analysis model, the authors estimated 1-year and lifetime quality-adjusted life-years, RA-related costs, and incremental cost-effectiveness ratios (“with MRI” compared with “without”) for patients with RA with fewer than 12 months of disease and no baseline radiographic erosions. The authors report that under plausible clinical conditions, adding MRI to standard risk stratification is unlikely to be considered a cost-effective addition to currently available tests according to commonly cited cost-effectiveness thresholds.

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Screening reduces colorectal cancer mortality, but effective screening tests remain underused. Sequist et al conducted a randomized controlled trial of electronic patient messages for 1103 patients in 14 ambulatory health centers. Patients aged 50 to 75 years who were overdue for screening were randomly assigned to receive a single electronic message within a personal health record that highlighted their overdue screening status and provided a link to an online tool to assess their personal risk of colorectal cancer. Screening rates were higher at 1 month for patients who received electronic messages compared with those who did not (8.3% vs 0.2%; P < .001), but this difference was no longer significant at 4 months (15.8% vs 13.1%; P = .18). Among 552 patients randomized to receive the intervention, 296 (54%) viewed the message, and 47 (9%) used the Web-based risk assessment tool. One-fifth of patients (19%) using the risk assessment tool were estimated to have above-average risk for colorectal cancer.

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Suppose you faced a choice between 2 treatments, one of which gave you a better chance of surviving a potentially fatal disease but at the cost of several very unpleasant adverse effects. Would you opt for this treatment? What if you were a physician recommending a treatment to a patient. Would you recommend the same treatment you chose for yourself? This national physician survey shows that in these kinds of situations, physicians recommend different treatments to their patients than they would choose for themselves.

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