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In This Issue of JAMA Internal Medicine |

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JAMA Intern Med. 2013;173(17):1565-1567. doi:10.1001/jamainternmed.2013.6318.
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Spinal complaints are common and significantly costly for the US health care system. Mafi and coauthors analyze a nationally representative database of ambulatory visits from 1999 through 2010. They found a 48% decline in guideline-concordant nonsteroidal anti-inflammatory drugs and acetaminophen use, accompanied by substantial growth in guideline-discordant care, including a 53% rise in narcotics, a 53% increase in computed tomography or magnetic resonance imaging examinations, and a 106% rise in referrals to other physicians. In an Invited Commentary, Casey discusses the implementation of clinical practice guidelines.

Health Care Reform

There is consensus that incorporating clinical decision support into electronic health records will improve quality of care, contain costs, and reduce overtreatment, but this potential has yet to be demonstrated in clinical trials. In a randomized clinical trial, McGinn and coauthors developed 2 well-validated clinical prediction rules into a clinical decision support tool. The intervention arm completed the integrated clinical prediction rule tool in 57.5% of visits, suggesting that the tool could have significant implications for informing the meaningful use strategy. Katz considers the implications for electronic health record use in an Editor’s Note.

Identification of structural heart disease in asymptomatic individuals could allow for early treatment. Lindekleiv and coauthors randomly assigned 6861 middle-aged participants of the population-based Tromsø Study in Norway to echocardiographic screening or control. The authors found that echocardiographic screening did not reduce all-cause or cardiac mortality during 15 years of follow-up. In an Invited Commentary, Michos and Abraham apply the findings to the current Appropriate Use Criteria consensus statement.

The widespread availability, negligible risk, and versatility of transthoracic echocardiography make it a powerful and appealing diagnostic tool. However, these same characteristics may encourage overuse. Matulevicius and coauthors report the proportion of transthoracic echocardiographies that affect clinical care in an academic medical center overall and in subgroups defined as appropriate and inappropriate by the Appropriate Use Criteria (AUC), and found that although most (92%) were appropriate by AUC, only 32% led to an active change in clinical care, 47% resulted in continuation of current care, and 21% resulted in no change in care. The proportion resulting in active change did not correlate with AUC classification. An Editor’s Note by Redberg supplements Invited Commentaries by Armstrong and Eagle and Ioannidis.

Invited Commentaries 1, 2Editor’s Note

Health care is constitutionally guaranteed in correctional facilities, but not on release, which could increase the risk of acute events. In a retrospective cohort study, Wang and coauthors investigated the risk of hospitalization for 110 419 fee-for-service beneficiaries who were released from a correctional facility from 2002 through 2010 and controls matched by age, sex, race, Medicare status, and residential zip code. They found that approximately 1 in 70 former inmates are hospitalized for an acute condition within 7 days of release and 1 in 12 by 90 days—a rate much higher than that in the general population.





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