In this noninferiority randomized clinical trial, Heapy and colleagues found that cognitive behavioral therapy (CBT) for chronic back pain delivered by interactive telephone technology was not inferior to standard in-person CBT for pain reduction. Participants in both conditions also achieved statistically significant and clinically meaningful improvements in pain-related interference and sleep. An efficacious interactive technology-based CBT telephone intervention for back pain could provide a more convenient nonpharmacological option for patients and an alternative to solely pharmacological therapy for clinicians.
In this single-center, open-label, randomized, controlled clinical trial, Cowley and colleagues assessed the efficacy, safety and feasibility of antiviral prophylaxis to prevent cytomegalovirus reactivation in critically ill patients. Valganciclovir and valaciclovir both suppressed cytomegalovirus reactivation compared with no intervention, although the valaciclovir arm was stopped early because of higher mortality. Prophylaxis prevents cytomegalovirus reactivation in critically ill patients; further research is needed to determine clinical efficacy and safety.
In this systematic review and meta-analysis of 16 studies, Tariq and colleagues found that gastric acid suppression medications were associated with an increased risk of recurrent Clostridium difficile infection (CDI). Subgroup analysis including only studies that had adjusted for potential confounders confirmed an increased risk of recurrent CDI. These data should be interpreted with caution, because they may be confounded due to the observational nature of the individual studies. It may be reasonable to reevaluate the need for these medications in patients with CDI. Bauer and O’Malley provide an Editor’s Note.
In a systematic review and meta-analysis, Tsai and coauthors summarized published information comparing intensive blood pressure (BP) control (<130/80 mm Hg) with standard blood pressure control (<140/90 mm Hg) on major renal outcomes in patients with chronic kidney disease without diabetes. They found that targeting blood pressure below the current standard did not provide additional benefit for renal outcomes compared with standard treatment during a follow-up of 3.3 years. However, patients who are younger, who are nonblack race/ethnicity, or have higher levels of proteinuria might benefit from the intensive blood pressure lowering. The risk of adverse events are mostly similar among different patients undergoing blood pressure control.
Continuing Medical Education
In this before/after interventional study, Demb and colleagues assessed the impact of an institutional-level audit and collaborative efforts to share best practices on computed tomography (CT) radiation doses across the 5 University of California (UC) medical centers. Audit reports were shared with each medical center, and each medical center was invited to a 1.5-day in-person meeting to review reports and share best practices. As a result of this intervention, mean effective doses significantly decreased in chest CTs and abdominal CTs across all 5 UC medical centers. These findings indicate that reviewing institutional doses and sharing dose-optimization best practices can lower radiation doses and lead to more consistent radiation doses. Gonzales and colleagues provide the Invited Commentary.
The National Academy of Medicine and The Joint Commission endorse routine documentation of patient sexual orientation (SO) in health care settings to help understand the health status and needs of sexual-minority patients. However, patient preferences regarding collection of SO demographic information remain largely unexplored. In this exploratory, sequential, mixed-methods study—the EQUALITY Study—Haider and colleagues sought to identify an optimal patient-centered approach to collect SO data in the emergency department. Findings from qualitative interviews with patients and health care providers suggest that patients are willing to provide SO, especially if SO data is collected from all patients. Sexual-minority patients felt that routine collection provided normalization and recognition of sexual minorities. Results from a national survey corroborated this finding, suggesting that overall only 10.3% of patients would refuse to provide SO data. A national effort to collect SO data needs to be prioritized.
In this multiyear cross-sectional observational study, Barnett and colleagues examined rates of low-value care and high-value care received by patients without insurance or with Medicaid, and whether these rates depend on the treating physician. Using national survey data, Barnett and colleagues found that low-value care was delivered in 19.4% of eligible visits; patients without insurance or with Medicaid received higher or similar rates of low-value care compared with privately insured patients. Physicians providing care to a high proportion of patients without insurance or with Medicaid provided similar rates of low-value and high-value services as physicians serving fewer patients without insurance or with Medicaid. Overuse of low-value care is a potentially important focus for state Medicaid programs and safety-net institutions to pursue cost savings and improved health care quality.
Using nationally representative data on ambulatory visits, Mafi and colleagues found that hospital-based outpatient practices provide more low-value computed tomography, magnetic resonance imaging, radiography, and specialty referrals than community–based office practices for common conditions, particularly during visits with a clinician other than a primary care provider. In contrast, hospital ownership of community-based practices does not affect the use of low-value services. These findings suggest that location of primary care practices plays a larger role than practice ownership in the delivery of low-value care in the United States.
Highlights. JAMA Intern Med. 2017;177(6):753–755. doi:10.1001/jamainternmed.2016.6149