Shorter physician encounters associated with antibiotic prescribing

1. Shorter physician encounters associated with antibiotic prescribing

Abstract: http://annals.org/aim/article/doi/10.7326/M18-2042

URLs go live when the embargo lifts

Patients who received antibiotics for respiratory tract infections had significantly shorter telemedicine encounters than those in which nonantibiotics were prescribed. A brief research report is published in Annals of Internal Medicine.

Outpatient respiratory tract infections rarely require antibiotics, yet these agents are frequently prescribed. Physicians may think that prescribing antibiotics is quicker and easier than explaining to patients why antibiotics are not warranted.

Researchers from Cleveland Clinic reviewed telemedicine encounters for 13,438 patients diagnosed with respiratory tract infections completed on the Online Care Group (American Well) telemedicine system to assess the association between prescription outcome and length of encounter. The researchers found that encounters resulting in nothing being prescribed were about 33 seconds longer than those resulting in antibiotic prescriptions. Those resulting in prescriptions of nonantibiotics were 1.12 minutes longer.

According to the researchers, this finding may highlight physician's difficulty explaining to patients why respiratory tract infections do not require antibiotics.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Kathryn Martinez, PhD, MPH, please contact Hope Buggey at buggeyh@ccf.org.

2. Screening programs based on fecal immunochemical tests may have suboptimal efficacy for preventing right-sided colon cancers

Abstract: http://annals.org/aim/article/doi/10.7326/M18-0855

Editorial: http://annals.org/aim/article/doi/10.7326/M18-2444

URLs go live when the embargo lifts

Screening programs based on the fecal immunochemical test (FIT) may have suboptimal efficacy for preventing right-sided colorectal cancers (CRC) as patients age. Findings from a retrospective cohort study are published in Annals of Internal Medicine.

Available evidence suggests that FIT-based CRC screening may reduce cancer mortality through both speed of diagnosis and the detection and removal of advanced adenomas during post-FIT colonoscopy. When considering biennial FIT for a screening program, the long-term efficacy of screening may be assessed by calculating the cumulative detection of both advanced adenoma and CRC. Studies have shown that FIT-based programs were less sensitive in detecting right-sided, versus left-sided CRC; however, no data was reported from repeat-FIT programs on how the cancer location might affect test sensitivity. With regard to cancer location (right side vs left side), it is also relevant that a shift to the right is seen in persons older than 60.

Researchers from Veneto Tumour Registry, Azienda Zero, Padova studied a fixed cohort of 123,347 persons who completed up to 6 rounds of biennial FIT between 2002 and 2015 in a screening program in Italy to assess the long-term detection rates for advanced adenoma and CRC, according to anatomical location. They found that the significant long-term reduction in detection rate for left-sided advanced neoplasia paralleled a much smaller reduction in detection of right-sided advanced neoplasia. At the same time, a higher proportional interval cancer rate was observed for right-sided versus left-sided cancer.

According to the researchers, the modest reduction in long-term detection rates for right-sided neoplasia, particularly invasive CRC, with repeated FIT and the hither proportional interval cancer rate in the right colon indicate that FIT-based programs have suboptimal efficacy in preventing the age-related rightward shift of CRC.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Manuel Zorzi, MD, MSc, please contact him directly at manuel.zorzi@azero.veneto.it.

3. High costs persist over 3 years for more than half of high-cost patients dually eligible for Medicare and Medicaid

Cost-saving efforts should focus on long-term care

Abstract: http://annals.org/aim/article/doi/10.7326/M18-0085

URLs go live when the embargo lifts

A substantial majority of high-cost dual-eligible beneficiaries had persistently high costs over 3 years, with most of the cost related to long-term care. Findings from an observational study are published in Annals of Internal Medicine.

More than 11 million Americans are dually-eligible, or covered by both Medicare and Medicaid. Because they are generally sicker, have lower incomes, and have high levels of comorbidity and disability, these patients are particularly expensive to treat. While there is substantial policy interest in reducing spending for these patients, little is known about the drivers of and even less is known about the drivers of spending over time.

Researchers from Harvard School of Public Health, Brigham and Women's Hospital, and Harvard Medical School studied 1,928,340 dually-eligible patients over 3 years to determine what proportion of this population had persistently high costs. Medicare and Medicaid payments for these beneficiaries were calculated for each year and the patients were categorized as high-cost for a given year if their spending was in the top 10 percent for that year. In the first year, 192,835 patients were high cost and more than half (54.8 percent remained high-cost across all 3 years). Spending in persistently high-cost patients was largely attributable to long-term care use, as patients were younger and much more likely to have intellectual and cognitive disabilities while very little (less than 1 percent of costs) were related to potentially preventable hospitalizations.

According to the researchers, strategies to control costs in dual-eligible beneficiaries may be more effective if they focus on reducing spending in long-term care rather than on reducing potentially preventable acute care use.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Ashish K. Jha, MD, MPH, please contact Stacy Evans at stacy_evans@harvard.edu.

4. Doctors debate supplemental screening for a patients with dense breasts

Clinicians go 'Beyond the Guidelines' to debate breast cancer screening for a woman who has dense breasts

Abstract: http://annals.org/aim/article/doi/10.7326/M18-1822

URLs go live when the embargo lifts

Breast cancer is the second leading cause of cancer death among U.S. women, and women with denser breasts are at an increased risk for breast cancer. Both the U.S. Preventative Services Task Force (USPSTF) and American College of Radiology (ACR) have issued guidelines for breast cancer screening among women with dense breasts, but the evidence for supplemental screening is insufficient to make a clear recommendation.

A general internist and a radiologist, both from Beth Israel Deaconess Medical Center (BIDMC), debate the role of supplemental breast cancer screening, including breast ultrasonography or magnetic resonance imaging (MRI) for a 47-year-old woman with dense breasts whose radiologist recommended additional screening. This multicomponent educational article is being published in Annals of Internal Medicine.

Radiologist Dr. Christoph I. Lee recommends the patient continue receiving routine mammography or digital breast tomosynthesis (DBT) screening, and that the patient may select additional cancer screening methods if she chooses. Internist Dr. Joann Elmore points out that the patient's lifetime risk for breast cancer is 10 percent (The ACR recommends MRI screening for women with a lifetime risk greater than 10 percent). She recommends educating the patient on potential benefits of screening while cautioning her about the risk for false-positives. Overall, Dr. Elmore advises against supplemental imaging.

All 'Beyond the Guidelines' papers are based on the Department of Medicine Grand Rounds at BIDMC in Boston and include print, video, and educational components. A list of topics is available at http://www.annals.org/grandrounds.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To speak with someone regarding BIDMC Beyond the Guidelines, please contact Jennifer Kritz at jkritz@bidmc.harvard.edu.

Also new in this issue:

Reconciling the Discrepancies in Medicine's Relationship to Medical Marijuana

Ilana Braun, MD; James Tulsky, MD

Ideas and Opinions

Abstract: http://annals.org/aim/article/doi/10.7326/M18-1883

Ten Principles for More Conservative, Careful Diagnosis

Gordon D. Schiff, MD; Stephen A. Martin, MD, EdM; David H. Eidelman, MD; Lynn A. Volk, MHS; Elise Ruan, BS; Christine Cassel, MD; William Galanter, MD; Mark Johnson, MD, MS; Annemarie Jutel, PhD; Kurt Kroenke, MD; Bruce L. Lambert, PhD; Joel Lexchin, MSc, MD; Sara Myers, BA; Alexa Miller, MA; Stuart Mushlin, MD; Lisa Sanders, MD; Aziz Sheikh, M

Ideas and Opinions

Abstract: http://annals.org/aim/article/doi/10.7326/M18-1468

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