Descripción del proyecto
Annals of Internal Medicine - recientes
Graham MM, Sessler DI, Parlow JL, et al.
Background:Uncertainty remains about the effects of aspirin in patients with prior percutaneous coronary intervention (PCI) having noncardiac surgery.
Objective:To evaluate benefits and harms of perioperative aspirin in patients with prior PCI.
Design:Nonprespecified subgroup analysis of a multicenter factorial trial. Computerized Internet randomization was done between 2010 and 2013. Patients, clinicians, data collectors, and outcome adjudicators were blinded to treatment assignment. (ClinicalTrials.gov: NCT01082874)
Setting:135 centers in 23 countries.
Patients:Adults aged 45 years or older who had or were at risk for atherosclerotic disease and were having noncardiac surgery. Exclusions were placement of a bare-metal stent within 6 weeks, placement of a drug-eluting stent within 1 year, or receipt of nonstudy aspirin within 72 hours before surgery.
Intervention:Aspirin therapy (overall trial, n = 4998; subgroup, n = 234) or placebo (overall trial, n = 5012; subgroup, n = 236) initiated within 4 hours before surgery and continued throughout the perioperative period. Of the 470 subgroup patients, 99.9% completed follow-up.
Measurements:The 30-day primary outcome was death or nonfatal myocardial infarction; bleeding was a secondary outcome.
Results:In patients with prior PCI, aspirin reduced the risk for the primary outcome (absolute risk reduction, 5.5% [95% CI, 0.4% to 10.5%]; hazard ratio [HR], 0.50 [CI, 0.26 to 0.95]; P for interaction = 0.036) and for myocardial infarction (absolute risk reduction, 5.9% [CI, 1.0% to 10.8%]; HR, 0.44 [CI, 0.22 to 0.87]; P for interaction = 0.021). The effect on the composite of major and life-threatening bleeding in patients with prior PCI was uncertain (absolute risk increase, 1.3% [CI, −2.6% to 5.2%]). In the overall population, aspirin increased the risk for major bleeding (absolute risk increase, 0.8% [CI, 0.1% to 1.6%]; HR, 1.22 [CI, 1.01 to 1.48]; P for interaction = 0.50).
Limitation:Nonprespecified subgroup analysis with small sample.
Conclusion:Perioperative aspirin may be more likely to benefit rather than harm patients with prior PCI.
Primary Funding Source:Canadian Institutes of Health Research.
Low Prevalence of Hepatitis B Vaccination Among Patients Receiving Medical Care for HIV Infection in the United States, 2009 to 201220/2/2018
Weiser J, Perez A, Bradley H, et al.
Background:Persons with HIV infection are at increased risk for hepatitis B virus infection. In 2016, the World Health Organization resolved to eliminate hepatitis B as a public health threat by 2030.
Objective:To estimate the prevalence of hepatitis B vaccination among U.S. patients receiving medical care for HIV infection (“HIV patients”).
Design:Nationally representative cross-sectional survey.
Participants:18 089 adults receiving HIV medical care who participated in the Medical Monitoring Project during 2009 to 2012.
Measurements:Primary outcomes were prevalence of 1) no documentation of hepatitis B vaccination or laboratory evidence of immunity or infection (candidates to initiate vaccination), and 2) initiation of vaccination among candidates, defined as documentation of at least 1 vaccine dose in a 1-year surveillance period during which patients received ongoing HIV medical care.
Results:At the beginning of the surveillance period, 44.2% (95% CI, 42.2% to 46.2%) of U.S. HIV patients were candidates to initiate vaccination. By the end of the surveillance period, 9.6% (CI, 8.4% to 10.8%) of candidates were vaccinated, 7.5% (CI, 6.4% to 8.6%) had no documented vaccination but had documented infection or immunity, and 82.9% (CI, 81.1% to 84.7%) remained candidates. Among patients at facilities funded by the Ryan White HIV/AIDS Program (RWHAP), 12.5% (CI, 11.1% to 13.9%) were vaccinated during the surveillance period versus 3.7% (CI, 2.6% to 4.7%) at facilities not funded by RWHAP. At the end of surveillance, 36.7% (CI, 34.4% to 38.9%) of HIV patients were candidates to initiate vaccination.
Limitation:The study was not designed to describe vaccine series completion or actual prevalence of immunity.
Conclusion:More than one third of U.S. HIV patients had missed opportunities to initiate hepatitis B vaccination. Meeting goals for hepatitis B elimination will require increased vaccination of HIV patients in all practice settings, particularly at facilities not funded by RWHAP.
Primary Funding Source:Centers for Disease Control and Prevention.
Roberts ET, Zaslavsky AM, McWilliams J.
Background:When risk adjustment is inadequate and incentives are weak, pay-for-performance programs, such as the Value-Based Payment Modifier (Value Modifier [VM]) implemented by the Centers for Medicare & Medicaid Services, may contribute to health care disparities without improving performance on average.
Objective:To estimate the association between VM exposure and performance on quality and spending measures and to assess the effects of adjusting for additional patient characteristics on performance differences between practices serving higher-risk and those serving lower-risk patients.
Design:Exploiting the phase-in of the VM on the basis of practice size, regression discontinuity analysis and 2014 Medicare claims were used to estimate differences in practice performance associated with exposure of practices with 100 or more clinicians to full VM incentives (bonuses and penalties) and exposure of practices with 10 or more clinicians to partial incentives (bonuses only). Analyses were repeated with 2015 claims to estimate performance differences associated with a second year of exposure above the threshold of 100 or more clinicians. Performance differences were assessed between practices serving higher- and those serving lower-risk patients after standard Medicare adjustments versus adjustment for additional patient characteristics.
Patients:Random 20% sample of beneficiaries.
Measurements:Hospitalization for ambulatory care–sensitive conditions, all-cause 30-day readmissions, Medicare spending, and mortality.
Results:No statistically significant discontinuities were found at the threshold of 10 or more or 100 or more clinicians in the relationship between practice size and performance on quality or spending measures in either year. Adjustment for additional patient characteristics narrowed performance differences by 9.2% to 67.9% between practices in the highest and those in the lowest quartile of Medicaid patients and Hierarchical Condition Category scores.
Limitation:Observational design and administrative data.
Conclusion:The VM was not associated with differences in performance on program measures. Performance differences between practices serving higher- and those serving lower-risk patients were affected considerably by additional adjustments, suggesting a potential for Medicare's pay-for-performance programs to exacerbate health care disparities.
Primary Funding Source:The Laura and John Arnold Foundation and National Institute on Aging.
Prognostic Accuracy of the Quick Sequential Organ Failure Assessment for Mortality in Patients With Suspected Infection A Systematic Review and Meta-analysis20/2/2018
Fernando SM, Tran A, Taljaard M, et al.
Background:The quick Sequential Organ Failure Assessment (qSOFA) has been proposed for prediction of mortality in patients with suspected infection.
Purpose:To summarize and compare the prognostic accuracy of qSOFA and the systemic inflammatory response syndrome (SIRS) criteria for prediction of mortality in adult patients with suspected infection.
Data Sources:Four databases from inception through November 2017.
Study Selection:English-language studies using qSOFA for prediction of mortality (in-hospital, 28-day, or 30-day) in adult patients with suspected infection in the intensive care unit (ICU), emergency department (ED), or hospital wards.
Data Extraction:Two investigators independently extracted data and assessed study quality using standard criteria.
Data Synthesis:Thirty-eight studies were included (n = 385 333). qSOFA was associated with a pooled sensitivity of 60.8% (95% CI, 51.4% to 69.4%) and a pooled specificity of 72.0% (CI, 63.4% to 79.2%) for mortality. The SIRS criteria were associated with a pooled sensitivity of 88.1% (CI, 82.3% to 92.1%) and a pooled specificity of 25.8% (CI, 17.1% to 36.9%). The pooled sensitivity of qSOFA was higher in the ICU population (87.2% [CI, 75.8% to 93.7%]) than the non-ICU population (51.2% [CI, 43.6% to 58.7%]). The pooled specificity of qSOFA was higher in the non-ICU population (79.6% [CI, 73.3% to 84.7%]) than the ICU population (33.3% [CI, 23.8% to 44.4%]).
Limitation:Potential risk of bias in included studies due to qSOFA interpretation and patient selection.
Conclusion:qSOFA had poor sensitivity and moderate specificity for short-term mortality. The SIRS criteria had sensitivity superior to that of qSOFA, supporting their use for screening of patients and as a prompt for treatment initiation.
Primary Funding Source:Canadian Association of Emergency Physicians. (PROSPERO: CRD42017075964)
O'Keeffe LM, Ramond A, Oliver-Williams C, et al.
Background:Long-term health risks for adults who donate kidneys are unclear.
Purpose:To summarize evidence about mid- and long-term health risks associated with living kidney donation in adults.
Data Sources:PubMed, Embase, Scopus, and PsycINFO without language restriction from April 1964 to July 2017.
Study Selection:Observational studies with at least 1 year of follow-up that compared health outcomes in adult living kidney donors versus nondonor populations.
Data Extraction:Two investigators independently extracted study data and assessed study quality.
Data Synthesis:52 studies, comprising 118 426 living kidney donors and 117 656 nondonors, were included. Average follow-up was 1 to 24 years. No evidence suggested higher risk for all-cause mortality, cardiovascular disease, hypertension, type 2 diabetes, or adverse psychosocial health outcomes in living kidney donors than in nondonor populations. Donors had higher diastolic blood pressure, lower estimated glomerular filtration rates, and higher risk for end-stage renal disease (ESRD) (relative risk [RR], 8.83 [95% CI, 1.02 to 20.93]) and preeclampsia in female donors (RR, 2.12 [CI, 1.06 to 4.27]). Despite the increased RR, donors had low absolute risk for ESRD (incidence rate, 0.5 event [CI, 0.1 to 4.9 events] per 1000 person-years) and preeclampsia (incidence rate, 5.9 events [CI, 2.9 to 8.9 events] per 100 pregnancies).
Limitation:Generalizability was limited by selected control populations, few studies reported pregnancy-related outcomes, and few studies were from low- and middle-income countries.
Conclusion:Although living kidney donation is associated with higher RRs for ESRD and preeclampsia, the absolute risk for these outcomes remains low. Compared with nondonor populations, living kidney donors have no increased risk for other major chronic diseases, such as type 2 diabetes, or for adverse psychosocial outcomes.
Primary Funding Source:National Health Service Blood and Transplant and National Institute for Health Research. (PROSPERO: CRD42017072284)
Chronic traumatic encephalopathy has recently been the focus of extensive attention. This commentary addresses diagnosis, prevention, treatment, and financial compensation for patients with a history of head trauma and their families.
Cohen JB, Townsend RR.
The most notable recommendation in the 2017 American College of Cardiology and American Heart Association hypertension guidelines is the reduced threshold for the diagnosis of hypertension, from ≥140/90 mm Hg to ≥130/80 mm Hg in the general population. This commentary discusses the guidelines and why they create as many questions as they answer.
Low-Dose Aspirin to Reduce the Risk for Myocardial Infarction Among Patients With Coronary Stents Undergoing Noncardiac Surgery20/2/2018
Piccolo R, Windecker S.
Graham and colleagues' post hoc analysis of the POISE-2 trial compared outcomes when aspirin was continued in the subgroup of patients with a history of previous PCI who had noncardiac surgery. The editorialists discuss the implications of the findings for perioperative care of patients with prior PCI.
Frakt AB, Jha AK.
Roberts and colleagues found that the Medicare Value-Based Payment Modifier, which measures quality and costs among physician group practices and provides bonuses or levies penalties accordingly, had no beneficial effect on the quality or cost of care. The editorialists discuss why these findings show us that it is time to abandon stand-alone pay-for-performance programs as an approach to improve care.
Singer M, Shankar-Hari M.
Fernando and colleagues' review compared the prognostic accuracy of the quick Sequential Organ Failure Assessment (qSOFA) and the systemic inflammatory response syndrome (SIRS) criteria for identifying patients with sepsis. The editorialists discuss the confusion surrounding sepsis scores and note that neither qSOFA nor the SIRS criteria are diagnostic for infection or sepsis, but they do offer information on the host's inflammatory reaction to an insult and the degree of physiologic perturbation.
Poggio ED, Reese PP.
O'Keeffe and colleagues' meta-analysis concluded that living kidney donors face elevated relative risks for end-stage renal disease, preeclampsia, and high diastolic blood pressure. The editorialists discuss the findings and believe that, despite the important contributions of this analysis, the field is still a long way from offering precise estimates to individuals about the risks surrounding kidney donation.
Mafi and colleagues report the findings of a qualitative study on having patients contribute to writing the note that documents what occurred in a health care encounter. The editorialist discusses the implications for patient-centered care and shared decision making.
To many, this election seemed to be as much a referendum on civility as it was about the political future of our country. Civility lost. How would we as professionals respond?
Hermann B, Thabut D, Weiss N.
Rossfeld ZM, Wright NR.
Ensrud KE, Crandall CJ.
Barkin JA, Stollman N, Barkin JS.
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