JAMA Internal Medicine Online First

Symptom Number and Severity as a Sign of Emotional Distress in Patients With Cardiovascular Disease Comment on: “Somatic Symptoms in Patients With Coronary Heart Disease” Symptom Number and Severity as a Sign of Distress

O’Malley PG. — Mon, 17 Jun 2013 00:00:00 GMT

The study by Kohlmann et al corroborates the finding that somatic symptom burden (defined as the number and severity of symptoms) is high in a population of patients with chronic disease and that such burden is associated with substantial quality-of-life impairment, largely from emotional health problems (anxiety and depression). In this case, they focused their study on only patients with coronary heart disease. This population is already at higher risk for depression and anxiety disorders and also at high risk for excessive testing. Given physician distress associated with treating patients with high symptom burden that, in turn, often leads to unnecessary diagnostic testing, clinicians should use the somatic symptom burden more as a “sed rate” for emotional distress, and treat accordingly, rather than as a sign of anatomic disease requiring further testing.

Changes in Red Meat Consumption and Subsequent Risk of Type 2 Diabetes Mellitus Three Cohorts of US Men and Women Red Meat Consumption and Type 2 Diabetes Risk

Pan A, Sun Q, Bernstein AM, et al. — Mon, 17 Jun 2013 00:00:00 GMT

Importance

Red meat consumption has been consistently associated with an increased risk of type 2 diabetes mellitus (T2DM). However, whether changes in red meat intake are related to subsequent T2DM risk remains unknown.

Objective

To evaluate the association between changes in red meat consumption during a 4-year period and subsequent 4-year risk of T2DM in US adults.

Design and Setting

Three prospective cohort studies in US men and women.

Participants

We followed up 26 357 men in the Health Professionals Follow-up Study (1986-2006), 48 709 women in the Nurses' Health Study (1986-2006), and 74 077 women in the Nurses' Health Study II (1991-2007). Diet was assessed by validated food frequency questionnaires and updated every 4 years. Time-dependent Cox proportional hazards regression models were used to calculate hazard ratios with adjustment for age, family history, race, marital status, initial red meat consumption, smoking status, and initial and changes in other lifestyle factors (physical activity, alcohol intake, total energy intake, and diet quality). Results across cohorts were pooled by an inverse variance–weighted, fixed-effect meta-analysis.

Main Outcomes and Measures

Incident T2DM cases validated by supplementary questionnaires.

Results

During 1 965 824 person-years of follow-up, we documented 7540 incident T2DM cases. In the multivariate-adjusted models, increasing red meat intake during a 4-year interval was associated with an elevated risk of T2DM during the subsequent 4 years in each cohort (all P < .001 for trend). Compared with the reference group of no change in red meat intake, increasing red meat intake of more than 0.50 servings per day was associated with a 48% (pooled hazard ratio, 1.48; 95% CI, 1.37-1.59) elevated risk in the subsequent 4-year period, and the association was modestly attenuated after further adjustment for initial body mass index and concurrent weight gain (1.30; 95% CI, 1.21-1.41). Reducing red meat consumption by more than 0.50 servings per day from baseline to the first 4 years of follow-up was associated with a 14% (pooled hazard ratio, 0.86; 95% CI, 0.80-0.93) lower risk during the subsequent entire follow-up through 2006 or 2007.

Conclusions and Relevance

Increasing red meat consumption over time is associated with an elevated subsequent risk of T2DM, and the association is partly mediated by body weight. Our results add further evidence that limiting red meat consumption over time confers benefits for T2DM prevention.

ω-3 Fatty Acid Supplements for Secondary Prevention of Cardiovascular Disease: From “No Proof of Effectiveness” to “Proof of No Effectiveness”

Messori A, Fadda V, Maratea D, et al. — Mon, 17 Jun 2013 00:00:00 GMT

In patients who have experienced cardiovascular events, ω-3 fatty acid supplements do not seem to be beneficial. However, there is not universal agreement on this conclusion. On the one hand, after examining the data of 14 randomized placebo-controlled studies, the meta-analysis by Kwak et al found no reduction in cardiovascular events (risk ratio, 0.99; 95% CI, 0.89-1.09) as well as no improvement in other relevant end points. On the other hand, the aforementioned meta-analysis has been criticized because 2 positive randomized studies were excluded owing to their open-label design and no administration of placebo; furthermore, a query of clinicaltrials.gov (run on March 5, 2013) indicates that 8 trials, registered on this website, are presently under way, thus confirming that the effectiveness of ω-3 fatty acid supplements is still thought to be an open question.

The Effect of Treatment History on Therapeutic Outcome: An Experimental Approach

Kessner S, Wiech K, Forkmann K, et al. — Mon, 17 Jun 2013 00:00:00 GMT

Therapeutic context can critically determine treatment outcome. Prior experience with a treatment is an important contextual factor that has been shown to modulate treatment efficacy. To date, this influence of prior treatment experience has been studied only within the same treatment approach. However, in clinical practice, treatments are often changed, particularly in case of failure. The aim of this study was therefore to investigate whether the effects of treatment history carry over from one treatment approach to another.

Somatic Symptoms in Patients With Coronary Heart Disease: Prevalence, Risk Factors, and Quality of Life

Kohlmann S, Gierk B, Hümmelgen M, et al. — Mon, 17 Jun 2013 00:00:00 GMT

Abroad spectrum of somatic symptoms is common in primary care, and more than half of medical visits are due to nonspecific symptoms (eg, nausea, headache, dizziness). Patients with frequent somatic symptoms show increased health care use, functional impairment, and a decreased quality of life. Although patients with coronary heart disease (CHD) might present with more than only cardiac symptoms (such as angina pectoris), research on the prevalence of somatic symptoms and their burden on health is rare and historic. Numerous studies showing that the somatic-affective component of depression predicts worse cardiac outcomes underpin the importance of examining somatic symptom severity in CHD.

Differences in Human Immunodeficiency Virus Care and Treatment Among Subpopulations in the United States HIV Care and Treatment in the United States

Hall H, Frazier EL, Rhodes P, et al. — Mon, 17 Jun 2013 00:00:00 GMT

Importance

Early diagnosis of human immunodeficiency virus (HIV) infection, prompt linkage to and sustained care, and antiretroviral therapy are associated with reduced individual morbidity, mortality, and transmission of the virus. However, levels of these indicators may differ among population groups with HIV. Disparities in care and treatment may contribute to the higher incidence rates among groups with higher prevalence of HIV.

Objective

To examine differences between groups of persons living with HIV by sex, age, race/ethnicity, and transmission category at essential steps in the continuum of care.

Design and Setting

We obtained data from the National HIV Surveillance System of the Centers for Disease Control and Prevention to determine the number of persons living with HIV who are aware and unaware of their infection using back-calculation models. We calculated the percentage of persons linked to care within 3 months of diagnosis on the basis of CD4 level and viral load test results. We estimated the percentages of persons retained in care, prescribed antiretroviral therapy, and with viral suppression using data from the Medical Monitoring Project, a surveillance system of persons receiving HIV care in select areas representative of all such persons in the United States.

Participants

All HIV-infected persons in the United States.

Main Outcomes and Measures

Percentage of persons living with HIV who are aware of their infection, linked to care, retained in care, receiving antiretroviral therapy, and achieving viral suppression.

Results

Of the estimated 1 148 200 persons living with HIV in 2009 in the United States, 81.9% had been diagnosed, 65.8% were linked to care, 36.7% were retained in care, 32.7% were prescribed antiretroviral therapy, and 25.3% had a suppressed viral load (≤200 copies/mL). Overall, 857 276 persons with HIV had not achieved viral suppression, including 74.8% of male, 79.0% of black, 73.9% of Hispanic/Latino, and 70.3% of white persons. The percentage of blacks in each step of the continuum was lower than that for whites, but these differences were not statistically significant. Among persons with HIV who were 13 to 24 years of age, only 40.5% had received a diagnosis and 30.6% were linked to care. Persons aged 25 to 34, 35 to 44, and 45 to 54 years were all significantly less likely to achieve viral suppression than were persons aged 55 to 64 years.

Conclusions and Relevance

Significant age disparities exist at each step of the continuum of care. Additional efforts are needed to ensure that all persons with HIV receive a diagnosis and optimal care to reduce morbidity, mortality, disparities in care and treatment, and ultimately HIV transmission. Ensuring that people stay in care and receive treatment will increase the proportion of HIV-infected individuals who achieve and maintain a suppressed viral load.

Delivery System Integration and Health Care Spending and Quality for Medicare Beneficiaries Medicare Integration, Spending, and Quality

McWilliams J, Chernew ME, Zaslavsky AM, et al. — Mon, 17 Jun 2013 00:00:00 GMT

Importance

The Medicare accountable care organization (ACO) programs rely on delivery system integration and health care provider risk sharing to lower spending while improving quality of care.

Objective

To compare spending and quality between larger and smaller provider groups and examine how size-related differences vary by 2 factors considered central to ACO performance: group primary care orientation and financial risk sharing by health care providers.

Evidence Review

Using 2009 Medicare claims and linked American Medical Association Group Practice data, we assigned 4.29 million beneficiaries to health care provider groups based on primary care use. We categorized group size according to eligibility thresholds for the Shared Savings (≥5000 assigned beneficiaries) and Pioneer (≥15 000) ACO programs and distinguished hospital-based from independent groups. We assessed the primary care orientation of larger groups' specialty mix and used health maintenance organization market penetration and data from the Community Tracking Study to measure the extent of financial risk accepted by different types of provider groups in different areas for managed care patients. We estimated linear regression models comparing spending and quality between larger and smaller health care provider groups, allowing size-related differences to vary by measures of group primary care orientation and risk sharing. Spending and quality measures included total medical spending, spending by type of service, 5 process measures of quality, and 30-day readmissions, all adjusted for sociodemographic and clinical characteristics.

Findings

Compared with smaller groups, larger hospital-based groups had higher total per-beneficiary spending in 2009 (mean difference, +$849), higher 30-day readmission rates (+1.3 percentage points), and similar performance on 4 of 5 process measures of quality. In contrast, larger independent physician groups performed better than smaller groups on all process measures and exhibited significantly lower per-beneficiary spending in counties where risk sharing by these groups was more common (−$426). Among all groups sufficiently large to participate in ACO programs, a strong primary care orientation was associated with lower spending, fewer readmissions, and better quality of diabetes care.

Conclusions and Relevance

Spending was lower and quality of care better for Medicare beneficiaries served by larger independent physician groups with strong primary care orientations in environments where health care providers accepted greater risk.

Epidemiology of Community-Associated Clostridium difficile Infection, 2009 Through 2011 Community-Associated Clostridium difficile

Chitnis AS, Holzbauer SM, Belflower RM, et al. — Mon, 17 Jun 2013 00:00:00 GMT

Importance

Clostridium difficile infection (CDI) has been increasingly reported among healthy individuals in the community. Recent data suggest that community-associated CDI represents one-third of all C difficile cases. The epidemiology and potential sources of C difficile in the community are not fully understood.

Objectives

To determine epidemiological and clinical characteristics of community-associated CDI and to explore potential sources of C difficile acquisition in the community.

Design and Setting

Active population-based and laboratory-based CDI surveillance in 8 US states.

Participants

Medical records were reviewed and interviews performed to assess outpatient, household, and food exposures among patients with community-associated CDI (ie, toxin or molecular assay positive for C difficile and no overnight stay in a health care facility within 12 weeks). Molecular characterization of C difficile isolates was performed. Outpatient health care exposure in the prior 12 weeks among patients with community-associated CDI was a priori categorized into the following 3 levels: no exposure, low-level exposure (ie, outpatient visit with physician or dentist), or high-level exposure (ie, surgery, dialysis, emergency or urgent care visit, inpatient care with no overnight stay, or health care personnel with direct patient care).

Main Outcomes and Measures

Prevalence of outpatient health care exposure among patients with community-associated CDI and identification of potential sources of C difficile by level of outpatient health care exposure.

Results

Of 984 patients with community-associated CDI, 353 (35.9%) did not receive antibiotics, 177 (18.0%) had no outpatient health care exposure, and 400 (40.7%) had low-level outpatient health care exposure. Thirty-one percent of patients without antibiotic exposure received proton pump inhibitors. Patients having CDI with no or low-level outpatient health care exposure were more likely to be exposed to infants younger than 1 year (P = .04) and to household members with active CDI (P = .05) compared with those having high-level outpatient health care exposure. No association between food exposure or animal exposure and level of outpatient health care exposure was observed. North American pulsed-field gel electrophoresis (NAP) 1 was the most common (21.7%) strain isolated; NAP7 and NAP8 were uncommon (6.7%).

Conclusions and Relevance

Most patients with community-associated CDI had recent outpatient health care exposure, and up to 36% would not be prevented by reduction of antibiotic use only. Our data support evaluation of additional strategies, including further examination of C difficile transmission in outpatient and household settings and reduction of proton pump inhibitor use.

Oxygen-Carrying Proteins in Meat and Risk of Diabetes Mellitus Comment on “Changes in Red Meat Consumption and Subsequent Risk of Type 2 Diabetes Mellitus: Three Cohorts of US Men and Women” Oxygen-Carrying Proteins in Meat and Diabetes Risk

Evans WJ. — Mon, 17 Jun 2013 00:00:00 GMT

The article by Pan et al confirms previous observations that the consumption of so-called red meat is associated with an increased risk of type 2 diabetes mellitus (T2DM). While previous studies have been cross-sectional in nature, the present study demonstrated that a relatively short-term (4-year) increase in red meat consumption is associated with subsequent risk, even in individuals who initially consumed low amounts of red meat. The authors demonstrated that consuming more red meat is also associated with weight gain, and a statistical adjustment for change in body weight attenuates but does not eliminate the risk, indicating that increased weight is not the only cause of a greater risk of T2DM associated with red meat consumption. The data in this article are valuable for those considering strategies to decrease the risk of developing T2DM.

Clostridium difficile Leaves the Hospital—What's Next? Comment on “Epidemiology of Community-Associated Clostridium difficile Infection, 2009 Through 2011” Clostridium difficile Leaves the Hospital

Sepkowitz KA. — Mon, 17 Jun 2013 00:00:00 GMT

Since their introduction after World War II, antibiotics have been known to cause gastrointestinal problems, including nausea and diarrhea. By the late 1970s, Clostridium difficile was put forward as the cause of a large proportion of cases of diarrhea, and the hunt began for an optimal control strategy. At first, control of the situation seemed easy: clindamycin, an agent with potent anaerobic activity, was implicated, a connection that made biologic sense and was supported by the newly developed hamster model. Better yet, less clindamycin use resulted in less C difficile, at least early on, and the problem briefly came under control.

Overcoming the Human Immunodeficiency Virus Obstacle Course Comment on “Differences in Human Immunodeficiency Virus Care and Treatment Among Subpopulations in the United States” Overcoming the HIV Obstacle Course

Christopoulos KA, Havlir DV. — Mon, 17 Jun 2013 00:00:00 GMT

Approximately 50 000 new human immunodeficiency virus (HIV) infections develop in the United States each year. How many of these people know of their HIV infection? How many are engaged in HIV care? How many are successfully treated with antiretroviral therapy (ART)? Surprisingly, until very recently, the answers to these simple questions regarding HIV care were unknown.

Promoting Delivery System Integration to Foster Higher Value Care: Slow Progress Ahead Comment on “Delivery System Integration and Health Care Spending and Quality for Medicare Beneficiaries” Delivery System Integration for Higher Value Care

Epstein AM. — Mon, 17 Jun 2013 00:00:00 GMT

While most people think of the Affordable Care Act (ACA) as designed primarily to expand insurance coverage, the roughly 900-page bill establishes numerous additional programs promising to change the delivery structure of American medicine. Most notably, the ACA provides clear impetus for hospitals to establish closer relations, if not integration, with medical groups providing ambulatory care and health care providers responsible for post–acute care.