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In This Issue of JAMA Internal Medicine
August 2017


JAMA Intern Med. 2017;177(8):1069-1071. doi:10.1001/jamainternmed.2016.6159


For the HPTN 065 randomized clinical trial, El-Sadr and colleagues offered financial incentives at 37 human immunodeficiency virus (HIV) test sites and 39 HIV care sites across the Bronx, New York, and Washington, DC, with the goals to enhance linkage to care for individuals who test positive for HIV and to encourage patients with HIV to take their antiretroviral therapy regularly to achieve and maintain viral suppression. Half of these test and care sites were randomized to offer financial incentives, while the other half offered the standard of care. Findings demonstrate that financial incentives increased viral suppression and regular clinic attendance among patients who are HIV positive. Financial incentives offer promise for achieving individual and societal benefits of antiretroviral therapy through motivating adherence to HIV treatment and sustaining viral suppression.

For this randomized clinical trial, Sudore and colleagues compared the effectiveness of an interactive, patient-centered, advance care planning website (https://prepareforyourcare.org) plus an easy-to-read advance directive with an advance directive alone on advance care planning documentation for 414 older veterans with serious and chronic illnesses. Results demonstrate that the PREPARE website plus an easy-to-read advance directive resulted in higher advance care planning documentation compared with an advance directive alone in the absence of additional clinical or health care system input.

Related Article

In a systematic review assessing the diagnostic accuracy of fecal immunochemical tests (FIT) for screening of patients at increased risk for colorectal cancer (CRC), Katsoula et al synthesized data from 12 studies with 6204 patients with personal or familial history of CRC, using colonoscopy as reference standard. Average sensitivity and specificity for CRC and advanced neoplasia were 93% and 91%, and 48% and 93%, respectively. Quantitative FIT with cutoff between 15 to 25 μg Hb/g feces provided the best combination of sensitivity and specificity for diagnosis of CRC. FIT is the best alternative noninterventional screening strategy for patients at increased risk for CRC who refuse colonoscopy, hence enabling patient-centered screening tailored to individual preferences and values. Leontiadis provides the Invited Commentary.

Invited Commentary

Continuing Medical Education

For this semistructured interview study, Schoenborn and colleagues explored the perspectives of community-dwelling older adults about stopping cancer screening when life expectancy is limited, as well as preferences for how clinicians should communicate recommendations to cease cancer screening. Although many participants supported using age and health status to individualize cancer screening decisions, they did not often understand that life expectancy is directly related to age and health status. Participants preferred discussions on screening cessation to be framed around age, health status, and helping people live longer, and views were divided on whether life expectancy should be discussed in the screening context. As research and clinical practice guidelines increasingly recommend using life expectancy to inform cancer screening, patient-centered approaches to discussion of screening cessation when life expectancy is limited is an important next step. Torke provides the Invited Commentary.

Invited Commentary

For the DUMAS (Dutch Unique Method for Antimicrobial Stewardship) Study, a multicenter intervention study, Sikkens and colleagues used a participatory approach based on behavioral insights to improve antimicrobial appropriateness in 2 Dutch hospitals. Physicians prescribing systemic antimicrobial drugs for any indication for patients admitted to the participating departments were included, and appropriateness of antimicrobial prescriptions was determined using a validated approach based on guideline adherence and motivated guideline deviation and measured with repeated point prevalence surveys. The approach was associated with a significant increase in antimicrobial prescribing appropriateness. The approach is cheap and could be easily transferable to various health care environments.

For this data analysis, Xu and colleagues analyzed Medicare billing records from 2707 hospitals for 2013 and found that emergency departments charge up to 12.6 times what Medicare reimburses for care. Hospitals often increase charges in the emergency department relative to internal medicine. These findings underscore the need for further legislation to protect uninsured and out-of-network patients from excess charges in the emergency department.

Clinical Review & Education

In this Special Communication, Dusetzina and colleagues examined rebates for prescription medications billed through Medicare Part D plans and identified potentially problematic consequences for spending by patients and the Federal Medicare Part D program. Although rebates reduce prices paid for drugs by Medicare Part D plan sponsors, these savings are not shared directly with patients and increase patient out-of-pocket and Medicare spending.

In this Special Communication, Lee and Curfman examined the controversial Florida law that prohibited physicians from speaking with their patients about firearm safety. To provide the highest-quality medical care, physicians must be able to communicate openly with their patients and provide advice that conforms with professional standards of care. The US Court of Appeals for the Eleventh Circuit recently struck down key provisions of a Florida law that prohibited physicians from speaking with their patients about firearm safety as a violation of the First Amendment. In Wollschlaeger v Governor, Florida, the court concluded that the Florida law restricted content-based and speaker-focused speech and did not pass constitutional muster.