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In This Issue of JAMA Internal Medicine
June 2018

Highlights

JAMA Intern Med. 2018;178(6):737-739. doi:10.1001/jamainternmed.2017.5214
Research

For this observational study, Ackerman and colleagues evaluated an intervention to reduce opioid exposure by switching from intravenous (IV) to oral or subcutaneous administration in medical inpatients. Over a total of 2459 patient-days, IV opioid dosing was reduced by 84%, with mean pain scores similar to those before implementation of the new standard, demonstrating that this intervention targeting the use of IV opioids may be associated with reduced opioid exposure while providing effective pain control to hospitalized adults.

Related Articles 1 and 2

For this randomized clinical trial, Lofwall and colleagues examined whether treatment involving novel weekly and monthly subcutaneous buprenorphine depot formulations is noninferior to a daily sublingual combination of buprenorphine hydrochloride and naloxone hydrochloride in the treatment of opioid use disorder. Results showed that compared with daily sublingual buprenorphine, sustained-release subcutaneous buprenorphine did not result in an inferior likelihood of being a responder or having urine test results negative for opioids and produced superior results on the cumulative distribution function of no illicit opioid use.

Related Articles 1 and 2

Continuing Medical Education

Berry and colleagues conducted a retrospective cohort study of 3083 nursing home residents with advanced dementia and hip fracture that examined outcomes, including survival, among this population according to whether they underwent surgical hip fracture repair. Surgical repair of a hip fracture was associated with lower mortality among nursing home residents with advanced dementia and should be considered together with the residents’ goals of care in treatment decisions. Pain and other adverse outcomes were common regardless of surgical treatment, suggesting the need for broad improvements in the quality of care provided to nursing home residents with advanced dementia and hip fracture. Mehr and colleagues provide the Invited Commentary.

Invited Commentary

Lee and colleagues conducted a qualitative study of 40 primary care physicians (PCP) to examine and understand PCP perceptions of the results of electronic consult systems for specialty requests (eConsult) initiation on PCP workflow, specialist access, and patient care. Qualitative interviews were conducted from December 1, 2016, to April 15, 2017, and it was found that, although they were associated with improved specialty care access, eConsult systems simultaneously created new challenges for PCPs, such as an increased burden of work in providing specialty care. Gleason and colleagues provide the Invited Commentary.

Invited Commentary

Wachterman and colleagues conducted a cross-sectional study of 770 191 deceased Medicare beneficiaries to examine the association between hospice length of stay and health care utilization and costs at the end of life among beneficiaries who had received maintenance hemodialysis. Overall, less than half of hospice enrollees who had been treated with hemodialysis for their end-stage renal disease entered hospice within 3 days of death. Although less likely to die in the hospital and to receive an intensive procedure, these patients were more likely than those not enrolled in hospice to be hospitalized and admitted to the intensive care unit, and they had similar Medicare costs. Without addressing barriers to more timely referral, greater use of hospice may not translate into meaningful changes in patterns of health care utilization, costs, and quality of care at the end of life in this population. Schwarze and colleagues provide the Invited Commentary.

Invited Commentary

Morawski and colleagues conducted a randomized clinical trial of 411 adults with poorly controlled hypertension to examine whether the Medisafe smartphone app improved self-reported medication adherence and blood pressure (BP) control. Patients were randomized 1:1, and intervention arm participants were instructed to download and use the Medisafe app, which included reminder alerts, adherence reports, and optional peer support. Results showed that among individuals with poorly controlled hypertension, patients randomized to use a smartphone app had a small improvement in self-reported medication adherence but no change in systolic blood pressure compared with controls. Logan and Jassal provide the Invited Commentary.

Invited Commentary

Freund and colleagues performed a cluster randomized crossover trial to examine the effect of the implementation of systematic cross-checking between emergency physicians. The systematic cross-checking was conducted 3 times per day and included a brief presentation of one physician’s case to another, followed by the second physician’s feedback to the first. Results showed that implementation of systematic cross-checking between emergency physicians was associated with a significant reduction in adverse events, mainly driven by a reduction in near misses.

For this meta-analysis of 6 studies, May and colleagues examined and estimated the association of palliative care consultation with direct hospital costs for adults with serious illness. Studies were selected because they included economic evaluations of interdisciplinary palliative care consultation for hospitalized adults with at least 1 of 7 illnesses (cancer; heart, liver, or kidney failure; chronic obstructive pulmonary disease; AIDS/HIV; or selected neurodegenerative conditions) in the hospital inpatient setting vs usual care only, controlling for a minimum list of confounders. Findings showed that the estimated association of early hospital palliative care consultation with hospital costs may vary according to baseline clinical factors. Estimates may be larger for primary diagnosis of cancer and more comorbidities compared with primary diagnosis of noncancer and fewer comorbidities. Increasing palliative care capacity to meet national guidelines may reduce costs for hospitalized adults with serious and complex illnesses.

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