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In This Issue of JAMA Internal Medicine |

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JAMA Intern Med. 2014;174(5):657-659. doi:10.1001/jamainternmed.2013.10650.
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Most smokers do not receive evidence-based tobacco cessation treatments that include both behavioral counseling and pharmacotherapy. Fu and coauthors conducted a pragmatic randomized clinical trial testing the effect of a proactive tobacco cessation care model compared with usual care among a population-based electronic registry of 6400 current smokers in the Department of Veterans Affairs health care system. They found that proactive care increased the reach of evidence-based treatments and resulted in a 2.6% absolute increase in the population-level cessation rate. Pletcher and coauthors comment on the issue of informed consent in an Editorial.

Data on hypoglycemic episodes and complications of insulin therapy can help clarify the risks of insulin treatment to inform treatment guidelines and individualized treatment decisions. Geller and coauthors used nationally representative public health surveillance data from the Centers for Disease Control and Prevention to estimate numbers and rates of emergency department (ED) visits and hospitalizations for insulin-related hypoglycemia and errors among US patients with insulin-treated diabetes. Based on data from 2007 through 2011, an estimated 97 648 ED visits for insulin-related hypoglycemia and errors occurred annually, almost two-thirds (60.6%) of which involved serious neurologic signs and/or symptoms and almost one-third (29.3%) of which resulted in hospitalization. An estimated 1 in 49 older adults (age ≥65 years) with insulin-treated diabetes presented to the ED for insulin-related hypoglycemia during this period. In an Invited Commentary, Lee places the findings in clinical context.

Little is known about the trends in anemia care in patients approaching end-stage renal disease (ESRD). In a closed cohort study of 466 803 older US patients nearing ESRD, Winkelmayer and coauthors found that erythropoiesis-stimulating agents and intravenous iron use increased 10-fold between 1995 and 2010; however, the proportion of patients transfused prior to ESRD did not decline but rather doubled during that time. Coyne examines the history of erythropoiesis-stimulating agent research and use in an Invited Commentary.

Unanswered clinical questions may lead to suboptimal patient care decisions. Del Fiol and coauthors conducted a systematic review and meta-analysis of the frequency and nature of clinical questions raised by clinicians in the course of patient care. They found that of 20 patients seen in a typical primary care practice, clinicians raise approximately 12 questions, pursue answers to 6 of these questions, and meet 5 of the questions they pursue. Although 11 studies have shown a positive impact of information retrieval technology on clinicians’ decisions, the rate of unanswered questions has remained relatively stable over time. Carnahan evaluates the clinical impact of information’s increasing accessibility for physicians in an Invited Commentary.

Management of human immunodeficiency virus (HIV) in correctional settings is logistically feasible, but HIV-related outcomes before release have not recently been systematically examined. In a retrospective cohort study of 882 HIV-infected prisoners receiving antiretroviral therapy, Meyer and coauthors found that mean HIV-1 RNA level decreased by 1.1 log10 and CD4 lymphocyte count increased by 98 cells/µL during incarceration, with a higher proportion achieving viral suppression by release compared with entry (70.0% vs 29.8%) and with few regimen changes. After adjusting for baseline HIV-1 RNA, prerelease viral suppression correlated with female sex and lower psychiatric disorder severity but not race/ethnicity, incarceration duration, antiretroviral regimen or dosing strategy, or receipt of directly observed therapy. In an Invited Commentary, Puisis considers the future of prison health care.

There is little empirical data to understand the impact of hospitalist workload on the efficiency and quality of inpatient care. In a retrospective cohort study of 20 241 inpatient hospital admissions cared for by a private hospitalist group at a large academic community hospital system between February 1, 2008, and January 31, 2011, Elliott and coauthors found a clinically meaningful increase in length of stay (LOS) as workload increased, particularly at lower hospital occupancy. For hospital occupancies less than 75%, LOS increased from 5 to 7 days across the range of workload. Adjusted costs also increased across the range of workload, even after controlling for LOS. Wachter reports on the real-life impact of hospitalist workload in an Invited Commentary.

Prescription opioids contribute to thousands of deaths each year: from 1999 to 2010, the number of US drug poisoning deaths involving any opioid analgesic more than quadrupled. Using prescription data from the Tennessee controlled substances monitoring program, Baumblatt and coauthors conducted a matched case-control study to investigate the contribution of certain opioid prescribing patterns to the risk for opioid analgesic–related overdose death. Increased risk for opioid analgesic–related overdose death was associated with receiving prescription opioids from 4 or more prescribers, filling opioid prescriptions at 4 or more pharmacies, and receiving a mean daily dosage greater than 100 morphine milligram equivalents, and persons with 1 or more risk factors accounted for 55% of all opioid analgesic–related overdose deaths.

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