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In This Issue of JAMA Internal Medicine |

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JAMA Intern Med. 2013;173(13):1161-1163. doi:10.1001/jamainternmed.2013.6298.
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Long-acting inhaled β-agonists and anticholinergics, first-line medications for chronic obstructive pulmonary disease (COPD), have both been associated with adverse cardiovascular events. When choosing between the two, patients and physicians would benefit from knowing which has the least cardiovascular risk. Gershon et al conducted a retrospective cohort study of older patients with COPD who were new users of one of these medications to compare their risks of cardiovascular hospitalizations and emergency department visits. They found that new use of long-acting β-agonists and long-acting anticholinergics were associated with similar increased risk of cardiovascular events. A commentary by Woodruff follows.

To investigate whether hospitals with high case survival rates are effective at preventing cardiac arrest, Chen and colleagues examined a large national registry using multivariable hierarchical regression. They found that hospitals with exceptional rates of survival for in-hospital cardiac arrest are also better at preventing cardiac arrests, even after adjusting for patient case-mix. This relationship was partially mediated by measured hospital attributes.

Patient participation in decision making has been hypothesized to decrease excess resource utilization but might increase resource use when health care providers have incentives to decrease use. On the basis of 21 754 admissions at the University of Chicago Medical Center between 2003 and 2011, Tak and colleagues investigated the effect of patient preference for participation in medical decisions on hospital length of stay and costs. While 96.3% of patients preferred to receive information about their conditions and treatment options, only 28.9% of patients preferred to participate in decisions about their care, and compared with patients with a strong desire to delegate decisions to their physician, patients who preferred to participate had a greater length of stay and higher total hospital costs. Patient preference to participate in medical decisions may increase resource use in contexts such as hospital care where health care providers have incentives to decrease use. In a commentary, Lipkin discusses shared decision making.

This study by Wachterman and colleagues analyzed data collected from 62 in-person interviews with seriously ill hemodialysis patients and their nephrologists to compare patient and health care provider expectations about prognosis and transplant candidacy. Patients were significantly more optimistic than their nephrologists about 1-year and 5-year survival and were more likely to think they were transplant candidates. While patients’ expectations about 1-year survival were more accurate than their nephrologists’, their longer-term survival expectations dramatically underestimated even their 2-year survival rates. In a commentary, Lipkin discusses shared decision making. A podcast with Lipkin and Wachterman discussing this topic is available online.

To learn how patients describe the decision-making process for 10 common medical decisions, Fowler and colleagues surveyed a national sample of more than 2500 adults 40 years or older. They measured patients’ perceptions of the extent to which the pros and cons of the interventions were discussed with their physicians, whether the patients were told they had a choice, and whether the patients were asked for their input. Of these 10 decisions, the reported decision-making processes were the most patient centered for surgery for back or knee pain and the least for breast and prostate cancer screening. Discussions about these common tests, medications, and procedures as reported by patients do not reflect a high level of shared decision making, particularly for 5 of the decisions most often made in primary care. In a commentary, Lipkin discusses shared decision making.

Stender and colleagues investigate the association between bilirubin and gallstone disease using a genetic variant in UGT1A1 to assess a causal relationship. Their findings suggest a causal effect of elevated plasma bilirubin level with increased risk of symptomatic gallstones. In an Editor’s Note, Katz describes the clinical and methodological value of this innovative study.

Orlich and colleagues examined the association of vegetarian dietary patterns with all-cause and cause-specific mortality among 73 308 members of the Adventist Health Study 2, a North American cohort with a large proportion of vegetarians. Vegetarian diets were associated with significant reductions in cardiovascular mortality, noncardiovascular noncancer mortality, renal mortality (particularly from renal failure), and endocrine mortality (particularly from diabetes mellitus). Associations in men were larger and more often significant compared with those in women. In a commentary, Baron considers the vegetarian diet.

In some cases, advance directives may conflict with what the physician or surrogate view as the patient’s best interest. These conflicts can place substantial emotional and moral burdens on physicians and surrogates, and there is little practical guidance for how to address them. In a Special Communication, Smith and colleagues describe a 5-question framework for untangling the conflict between previous directives and best interests of a patient with a surrogate decision maker, using 2 clinical cases with contrasting outcomes to demonstrate how this framework can help resolve common dilemmas.




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