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In This Issue of JAMA Internal Medicine
December 2019


JAMA Intern Med. 2019;179(12):1613-1615. doi:10.1001/jamainternmed.2018.5526


In this randomized clinical trial of 602 overweight and obese adults from 40 states across the United States, Patel and colleagues assessed the effectiveness of support, collaboration, and competition within a behaviorally designed gamification intervention to increase physical activity. Participants used a wearable device to track daily steps, established a baseline, selected a step goal increase, were randomly assigned to a control or to 1 of 3 gamification interventions, and were remotely monitored. Results showed that the gamification arm had the greatest increase in physical activity from baseline during the intervention; during the 12-week follow-up, physical activity was lower among the cohort but remained greater in the gamification arm.

Weiner and colleagues performed this cohort study to examine whether insulin treatment is used less frequently and discontinued more often among older individuals with poor health compared with those in good health. The cohort included individuals with type 2 diabetes who were followed for up to 4 years starting at age 75 years. Health status was defined as good (<2 comorbid conditions or 2 comorbidities but physically active), intermediate (>2 comorbidities or 2 comorbidities and no self-reported weekly exercise), or poor (having end-stage pulmonary, cardiac, or renal disease; diagnosis of dementia; or metastatic cancer). Insulin use was most prevalent among those in poor health, whereas subsequent insulin discontinuation after age 75 years was most likely in healthier patients.

This cohort study by Demb and colleagues identified factors associated with radiation dose variation occurring during computed tomography (CT) screening scans for lung cancer. Lung cancer screening dose metrics were collected from US institutions in the University of California, San Francisco International Dose Registry, and institution-level factors were collected through baseline survey. Results showed wide dose variation across institutions performing CT scans. Institutions with protocol creation limited to lead radiologists or medical physicists and collaborating internal medical physicists had lower doses, whereas institutions where any radiologists could establish protocols had higher doses.

Continuing Medical Education

In this randomized clinical trial, Possin and colleagues examined the effects of the Care Ecosystem, a program for collaborative dementia care delivered over the telephone and internet by a trained care team navigator, on key outcomes for persons with dementia and their caregivers compared with usual care. The Care Ecosystem is a model for delivering care from centralized hubs across broad geographic areas to caregivers and persons with dementia independently of their health system affiliations. During study follow-up, it was shown that the Care Ecosystem improved quality of life of persons with dementia, reduced emergency department visits, and decreased caregiver depression and burden. Tjia provides the Invited Commentary.

Invited Commentary and Related Article

Hajduk and colleagues performed this cohort study to evaluate the association of mobility impairment, measured during hospitalization, as a risk marker for functional decline among older patients with acute myocardial infarction. Mobility was evaluated during hospitalization using the Timed “Up and Go,” with scores categorized as preserved mobility, mild impairment, moderate impairment, and severe impairment. Self-reported function in activities of daily living and walking was assessed at baseline and 6 months after discharge. Results demonstrated that more than half of the cohort demonstrated mobility impairment during hospitalization for acute myocardial infarction and that an easy-to-administer mobility assessment may be useful to identify older patients with acute myocardial infarction who are at risk for functional decline.

This qualitative study by Wheeler and colleagues assessed how a convenience sample of physicians and trainees perceived and responded to encounters with biased patients. Data were collected from hospitalist attending physicians, internal medicine residents, and medical students during focus groups. Participants used their own definition of biased patient behavior. Reported behavior ranged from patient refusal of care and explicit racist, sexist, or homophobic remarks to belittling compliments or jokes. Targeted physicians reported an emotional toll that included exhaustion, self-doubt, and cynicism. Cooper and colleagues provide an Invited Commentary.

Invited Commentary

Author Audio Interview

This nonrandomized clinical trial by Tinetti and colleagues compared self-reported patient outcomes and burden of unwanted care among older adults with multiple chronic conditions who received either patient priorities–based care or usual care. Patient priorities care was defined as an approach to decision-making that includes patients identifying their health priorities and clinicians aligning their decision-making to achieve these health priorities. Although there was no difference in perception of whether their care was goal-directed or coordinated, participants receiving patient priorities care vs usual care reported a greater reduction in treatment burden. Hargraves and Montori provide the Invited Commentary.

Invited Commentary

In this observational study using Medicare claims data, Masoudi and colleagues quantified trends in differential Medicare fee-for-service (FFS) payments for noninvasive cardiac tests performed in hospital-based and provider-based settings, and determined the association between the hospital-based outpatient testing to provider-based office testing payment ratio and the proportion of hospital-based noninvasive cardiac tests. Results showed that the Medicare payment ratio of FFS hospital-based outpatient testing to provider-based office testing increased over a decade, and the FFS hospital-based outpatient testing proportion increased over an 8-year period and was correlated with the payment ratio. Figueroa and Joynt Maddox provide the Invited Commentary.

Invited Commentary