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Embargoed for release until 5:00 p.m. ET on Monday 24 April 2023
Annals of Internal Medicine Tip Sheet
@Annalsofim
Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.
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1. Growing number of states provide coverage for outpatient hemodialysis for undocumented immigrants
Abstract: https://www.acpjournals.org/doi/10.7326/M23-0202
Editorial: https://www.acpjournals.org/doi/10.7326/M23-0838
URL goes live when the embargo lifts
A brief research report has found that, due to increased advocacy and awareness of outcomes, a growing number of states have implemented policies that provide statewide coverage for undocumented persons with kidney failure to receive outpatient hemodialysis. The report is published in Annals of Internal Medicine.
Currently, undocumented immigrants cannot receive federal health insurance and most state Medicaid programs. In many states, undocumented immigrants with kidney failure rely on emergency hemodialysis (dialysis only after presenting critically ill to an emergency department) as mandated by the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA), which requires hospitals to provide emergency care regardless of ability to pay. Emergency hemodialysis is associated with a 14-fold higher mortality rate at 5 years and increased psychosocial burden for patients, caregivers, and clinicians. In 2019, only 12 states and the District of Columbia provided statewide coverage of outpatient hemodialysis by including kidney failure as a qualifying condition under Emergency Medicaid.
Researchers from the University of Colorado and University of California San Francisco assessed policy between March and October 2022 by 1) review of state Medicaid and Emergency Medicaid policy manuals for covered diagnosis codes “kidney failure,” “dialysis,” and “transplantation” and inclusion of undocumented immigrants and 2) brief interviews with clinicians with experience working with undocumented immigrants in every state. The authors found that as of 2022, twenty states and Washington, DC provide statewide coverage for standard outpatient hemodialysis for undocumented immigrants. Seventeen of those states provide outpatient hemodialysis through Emergency Medicaid, the remainder through Medicaid or state insurance pools. Five states also provide coverage for kidney transplantation. According to the authors, the expansion of dialysis coverage may be due to increasing awareness of poor outcomes with emergency hemodialysis and heightened advocacy efforts.
An accompanying editorial by authors from Harvard Medical School highlights the significant burden of lack of access to kidney replacement therapy care faced by undocumented residents experiencing kidney failure. The authors call for a humane national solution to abandon emergency dialysis as the only option for undocumented immigrants and instead pursue a move toward covering outpatient dialysis in all 50 states. They also call on legislators and policymakers to support a pathway for non-U.S. citizens living in the United States, including undocumented immigrants, to be able to purchase affordable insurance.
Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Katherine Rizzolo, MD, please email Katherine.rizzolo@cuanschutz.edu.
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2. A cash transfer temporarily alleviates functional impairments for older adults
Abstract: https://www.acpjournals.org/doi/10.7326/M22-2496
URL goes live when the embargo lifts
A randomized controlled trial of more than 1,100 people aged 55 years and older found that among older people living alone, a small cash transfer was effective in alleviating short-term functional impairment, but the effects were not sustained after 3 months. The findings are published in Annals of Internal Medicine.
As many as 16 percent of older adults worldwide live alone, and the proportion is expected to grow over time. The resulting isolation is of significant policy concern, as loneliness is associated with depression, cognitive decline, and reduced well-being. Given the low number of trained therapists in developing countries and the financial constraints their governments face, delivery of cognitive behavioral therapy (CBT) over the phone could be a promising intervention to improve the well-being of older persons living alone. Similarly, cash transfers could have a direct impact on food security and could also affect mental health or day-to-day functioning.
Researchers from Dartmouth College, MIT, Sangath, and IIT Madras studied 1,120 adults living alone in Tamil Nadu, India aged 55 and older to determine whether phone-based CBT or a cash transfer reduce functional impairment, depression, or food insecurity in this population. Participants received phone-based CBT, a one-time cash transfer of 1,000 rupees ($12 USD), or both. The outcomes were measured at baseline and at 2 rounds of follow-up phone surveys, 3 weeks and 3 months after the end of CBT. Overall, the small cash transfer reduced short-term (3 weeks) functional impairment and resulted in a small but not clinically or statistically significant reduction in depression in the short term. Cash had no effect on short-term food security. There were no short-term effects from CBT or the 2 interventions together. None of the interventions showed any effect at 3 months.
Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Esther Duflo, please email eduflo@mit.edu.
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3. Hypotensive-avoidance strategies not associated with decrease in postoperative hypotension or adverse outcomes
Abstract: https://www.acpjournals.org/doi/10.7326/M22-3157
Editorial: https://www.acpjournals.org/doi/10.7326/M23-0745
URL goes live when the embargo lifts
A randomized trial of more than 7,000 people found that hypotension-avoidance strategies were not associated with a decrease in postoperative hypotension or adverse outcomes compared with hypertension-avoidance strategies. The findings are published in Annals of Internal Medicine.
Hypotension is common during and after noncardiac surgery. It is also associated with an increased risk for death and cardiovascular complications at 30 days after noncardiac surgery. Similarly, postoperative hypertension is associated with vascular complications after noncardiac surgery. Half of adults having major noncardiac surgery have a history of hypertension, and most use antihypertension medication. Uncertainty remains about what intraoperative blood pressure to target and how to manage long-term antihypertensive medications perioperatively.
Researchers from Population Health Research Institute conducted a partial factorial randomized trial of 7,490 people using two perioperative blood pressure management strategies. Patients using the hypotension-avoidance strategy did not take angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin-receptor blockers (ARBs) from the night before surgery through postoperative day 2, resuming them 3 days after surgery. Patients using the hypertension-avoidance strategy received all their usual antihypertensives preoperatively, including on the morning of surgery, and postoperatively. The authors found that fewer patients using the hypotensive-avoidance strategy experienced clinically significant hypotension compared with patients using the hypertensive-avoidance strategy. However, there was no difference between strategies related to vascular death and nonfatal myocardial injury, stroke, or cardiac arrest. According to the authors, further research is needed to identify and evaluate perioperative interventions that can modify hemodynamics to an extent and in the direction that will lead to a favorable effect on major clinical outcomes.
An accompanying editorial from authors at the University of Nebraska Medical Center and Cleveland Clinic Lerner College of Medicine highlights that the decision about whether to hold selected antihypertensive medications for surgery remains a nuanced, individualized decision. They emphasize that the degree and possibly the duration of hypotension experienced by patients in this study may have been inadequate to affect the outcomes that were studied. The authors also call for future studies to examine both intraoperative and postoperative management strategies, identify other patient risk factors for poor outcomes, and ensure the clarity of surrogate versus patient-relevant clinical outcomes.
Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author P.J. Devereaux, MD, PhD, please email PJ.Devereaux@phri.ca.
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Also published in this issue:
Infectious Diseases: What You May Have Missed in 2022
Rand Al Ohaly, MBBS*; Marie-Eve Benoit, MD*; and Mindy Schuster, MD, MSCE
Special Article
Abstract: https://www.acpjournals.org/doi/10.7326/M23-0757
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