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In This Issue of JAMA Internal Medicine
February 2017


JAMA Intern Med. 2017;177(2):151-153. doi:10.1001/jamainternmed.2016.6129

The FAVOURED trial (Fish Oils and Aspirin in Vascular Access Outcomes in Renal Disease) is the first randomized clinical trial to determine whether fish oil or low-dose aspirin is effective in preventing failure of de novo arteriovenous fistulae (AVF) in patients requiring hemodialysis. In this trial that included 567 adults, the occurrence of fistula failure within 12 months of surgery was high (47%) and not reduced by fish oil (relative risk 1.03) or aspirin (relative risk 1.05) compared with placebo. Based on these results, neither fish oil nor aspirin can be recommended for prevention of AVF failure and additional strategies to reduce the high AVF failure rate are urgently required.

Editor’s Note

More than one-third of physicians at some point feel emotionally exhausted, have difficulty showing empathy, and undervalue their achievements. This is called burnout, and it has serious consequences such as job turnover and early retirement and may also lead to less appropriate care for patients. Panagioti et al carried out a systematic review and meta-analysis of studies that tested the effectiveness of interventions to reduce burnout. They also examined whether different types of interventions including changes to the health care organization (organization-directed interventions) and targeting individual physicians (physician-directed interventions) were more effective in reducing burnout. There were 2 main findings. First, the overall effectiveness of the interventions to reduce burnout was significant but low. Second, organization-directed interventions were more effective in reducing burnout but were rare compared with physician-directed interventions. These findings highlight the need for more effective models for mitigating burnout in physicians.


Continuing Medical Education

This study examines the association between physician sex and 30-day mortality and readmission rates of patients using nationally representative data of Medicare beneficiaries hospitalized with a medical condition from 2011 through 2014 and found that elderly hospitalized patients treated by female internists have lower mortality and readmissions compared with those cared for by male internists.


Audio Author Interview and Continuing Medical Education

Navathe et al analyzed changes in quality, internal hospital costs, and postacute care (PAC) spending for lower-extremity joint replacement bundled payment episodes encompassing hospitalization and 30 days of PAC. Between 2009 and 2015, average Medicare episode expenditures declined 20.8% for joint replacement without complications during a period in which Medicare payments increased 5% nationally. Quality of care was stable to improved. By 2015, 51.2% of overall hospital savings had come from internal cost reductions, and 48.8% from PAC spending reductions. Reductions in implant costs, down on average $1920.68 (30%) per case, contributed the greatest proportion of hospital savings. Average PAC spending declined largely from reductions in inpatient rehabilitation and skilled nursing facility spending, but only in Bundled Payments for Care Improvement when bundles included financial responsibility for PAC.

Invited Commentary

Mortality in patients with congenital heart disease (CHD) has markedly decreased during the last decades because of advancement in pediatric care. Nevertheless, there are limited data on survival trends in children and young adults with CHD compared with the general population. Mandalenakis et al linked data from the Swedish Patient and Cause of Death Registers to study all patients who were diagnosed with CHD and born between January 1, 1970, and December 31, 1993. The survivorship among children younger than 5 years was increased by two-thirds in those born in between 1990 and 1993 compared with those born between 1970 and 1979. Furthermore, the group of patients with the most severe complex defects had the highest risk for death (hazard ratio, 64.1; 95% CI, 53.4-76.9). The absolute and relative survival increased substantially, but mortality remains high in young patients with CHD compared with matched controls, in particular in CHD subsets of great complexity.

Using Veterans Health Administration databases, London et al analyzed associations of early perioperative statin exposure with 30-day mortality and a variety of complications in veterans undergoing major noncardiac surgery from 2005 to 2010. A significant association was found, with a reduction in 30-day all-cause mortality from 2.3% to 1.8%, in patients exposed to statins on the day of or following surgery along with several other aggregated complications. Higher-intensity statin dosing and continued use were also associated with significant reduction in the primary outcome. Analysis of potential selection biases were inconclusive, suggesting the need for further study.

Invited Commentary

Berkowitz et al evaluate the association between improvement in chronic cardiometabolic disease (CCD) management and enrollment in Health Leads, a program to screen for and address unmet basic resource needs. Basic resource needs include things like food, medications, housing, and transportation that may keep patients from getting the full benefit of medical care. Using a before-and-after screening difference-in-difference design, Berkowitz et al compare participants who screened positive for unmet basic resource needs and enrolled in Health Leads with those who screened positive and did not enroll in Health Leads. They found that enrollment in Health Leads was associated with improved blood pressure and cholesterol levels but not blood sugar levels.

Invited Commentary

In this study, Steinman et al used causal inference methods to evaluate the benefits and harms of β-blockers after acute myocardial infarction (MI) in a national observational cohort of older nursing home residents. They found that use of β-blockers after acute MI was associated with a 26% reduction in risk of death in the first 90 days after hospital discharge but a 14% increase in the odds of functional decline. Mortality benefits were observed across a range of patient subgroups. However, functional harms were observed only in people with poor cognitive or functional status at baseline. In these high-risk individuals, patients’ goals of care can help determine whether the reduction in mortality from β-blockers is worth the increased risk of functional decline that these drugs appear to cause.

Invited Commentary