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In This Issue of JAMA Internal Medicine |

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JAMA Intern Med. 2013;173(18):1665-1667. doi:10.1001/jamainternmed.2013.6323.
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Low 25-hydroxyvitamin D (25OHD) levels have been associated with higher blood pressure (BP) and with future cardiovascular events. Witham and coauthors conducted a randomized clinical trial of high-dose, intermittent, oral vitamin D3 supplementation in 159 patients 70 years and older with isolated systolic hypertension, the commonest type of hypertension in older people. Despite significant increases in circulating 25OHD levels in the intervention group, no effect on office BP or 24-hour ambulatory BP was evident; surrogate markers of vascular function, including measures of arterial stiffness and endothelial function, also failed to improve with vitamin D3 supplementation. In an Invited Commentary, Giovannucci looks at the evidence base for vitamin D3 supplementation for isolated systolic hypertension and calls for further research.

Little is known about the long-term effect of diet on the incidence and progression of early-stage diabetic chronic kidney disease (CKD). Dunkler and coauthors examined the association between healthy diet measured with the modified Alternative Healthy Eating Index, alcohol consumption, protein and sodium intake, and the incidence or progression of CKD among 6213 participants with diabetes from the ONTARGET trial. They found that a healthy diet and moderate intake of alcohol may decrease incidence or progression of CKD among individuals with diabetes. High protein and sodium intake, often cited as modifiable risk factors for the progression of renal disease, were not associated with incidence and progression of CKD in this high-risk population. Kramer and Chang discuss the future of dietary diabetes management in an Invited Commentary.

Previous evaluations of the patient-centered medical home (PCMH) model of care suggest that the model holds promise for increasing patient and provider satisfaction, improving quality of care, and in certain circumstances, reducing inappropriate emergency department and hospital utilization. Hochman and coauthors extend these findings by reporting on a primary care reform effort guided by PCMH principles at a safety-net clinic with resident physician providers. As a result of the intervention, the clinic’s score on the National Committee for Quality Assurance’s PCMH certification tool improved from 35 to 53 of 100 possible points, although the clinic did not achieve all must-pass elements to qualify as a PCMH. The intervention did not result in a reduction in either emergency department or hospital utilization in the intervention clinic vs controls. The PCMH model holds promise for improving patient and resident physician satisfaction in a teaching setting and may have educational benefits for clinical trainees. In an Invited Commentary, Margolius evaluates the current state of the PCMH movement.

The conflicting recommendations for prostate cancer screening and the mixed messages communicated to the public about screening effectiveness make it critical to assist men in making informed decisions. Taylor and coauthors conducted a randomized clinical trial to assess the effectiveness of a print- and a web-based decision aid compared with usual care in helping men make informed decisions about prostate cancer screening. Both decision aids significantly improved patients’ informed decision making about prostate cancer screening but did not affect actual screening, up to 13-months after randomization. Reuland and Pignone set the findings in the context of the ongoing conversation about prostate cancer screening in an Invited Commentary.

Colorectal cancer screening participation rates are low among underserved populations, and knowledge of effective approaches for screening the underserved, including the best test type to offer, is limited. Gupta and coauthors conducted a randomized clinical trial of the effectiveness of fecal immunochemical test (FIT) outreach, colonoscopy outreach, and usual care for increasing colorectal cancer screening in a racially/ethnically diverse underserved population cared for by a large safety-net health system. The FIT outreach tripled and the colonoscopy outreach doubled screening rates compared with usual care, and FIT was superior to colonoscopy outreach for increasing colorectal cancer screening.

Health Care Reform

Historically, US physicians have been paid more for performing costly procedural care that drives up spending and less for cognitive services that may conserve costs and promote population health. To explore the differences between reimbursement to physicians for cognitive and procedural care for patients covered by Medicare, Sinsky and Dugdale modeled hourly revenue for common office visit evaluation and management codes, screening colonoscopy, and cataract removal. Their calculations demonstrated that the revenue for physician time spent on screening colonoscopy and cataract extraction was 368% and 486%, respectively, of the revenue for a similar amount of physician time spent on cognitive care. In an Invited Commentary, Ginsburg addresses the discrepancies in Medicare policies.





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