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- Insulin vs Sulfonylureas for Second-Line Diabetes Treatment. [JOURNAL ARTICLE]
- JAMA 2014 Oct 22; 312(16):1693.
- Presence of Banned Drugs in Dietary Supplements Following FDA Recalls. [JOURNAL ARTICLE]
- JAMA 2014 Oct 22; 312(16):1691-1693.
- Tests for Urinary Tract Infection in Nursing Home Residents. [JOURNAL ARTICLE]
- JAMA 2014 Oct 22; 312(16):1687-1688.
- Treatment of Generalized War-Related Health Concerns: Placing TBI and PTSD in Context. [JOURNAL ARTICLE]
- JAMA 2014 Oct 22; 312(16):1685-1686.
- Diagnosis and Management of Urinary Tract Infections in the Outpatient Setting: A Review. [JOURNAL ARTICLE]
- JAMA 2014 Oct 22; 312(16):1677-1684.
Urinary tract infection is among the most common reasons for an outpatient visit and antibiotic use in adult populations. The increasing prevalence of antibacterial resistance among community uropathogens affects the diagnosis and management of this clinical syndrome.To define the optimal approach for treating acute cystitis in young healthy women and in women with diabetes and men and to define the optimal approach for diagnosing acute cystitis in the outpatient setting.Evidence for optimal treatment regimens was obtained by searching PubMed and the Cochrane database for English-language studies published up to July 21, 2014.Twenty-seven randomized clinical trials (6463 patients), 6 systematic reviews, and 11 observational studies (252 934 patients) were included in our review. Acute uncomplicated cystitis in women can be diagnosed without an office visit or urine culture. Trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days), nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5-7 days), and fosfomycin trometamol (3 g in a single dose) are all appropriate first-line therapies for uncomplicated cystitis. Fluoroquinolones are effective for clinical outcomes but should be reserved for more invasive infections. β-Lactam agents (amoxicillin-clavulanate and cefpodoxime-proxetil) are not as effective as empirical first-line therapies. Immediate antimicrobial therapy is recommended rather than delayed treatment or symptom management with ibuprofen alone. Limited observational studies support 7 to 14 days of therapy for acute urinary tract infection in men. Based on 1 observational study and our expert opinion, women with diabetes without voiding abnormalities presenting with acute cystitis should be treated similarly to women without diabetes.Immediate antimicrobial therapy with trimethoprim-sulfamethoxazole, nitrofurantoin, or fosfomycin is indicated for acute cystitis in adult women. Increasing resistance rates among uropathogens have complicated treatment of acute cystitis. Individualized assessment of risk factors for resistance and regimen tolerability is needed to choose the optimum empirical regimen.
- Association Between Availability of Health Service Prices and Payments for These Services. [JOURNAL ARTICLE]
- JAMA 2014 Oct 22; 312(16):1670-1676.
Recent governmental and private initiatives have sought to reduce health care costs by making health care prices more transparent.To determine whether the use of an employer-sponsored private price transparency platform was associated with lower claims payments for 3 common medical services.Payments for clinical services provided were compared between patients who searched a pricing website before using the service with patients who had not researched prior to receiving this service. Multivariable generalized linear model regressions with propensity score adjustment controlled for demographic, geographic, and procedure differences. To test for selection bias, payments for individuals who used the platform to search for services (searchers) were compared with those who did not use the platform to search for services (nonsearchers) in the period before the platform was available. The exposure was the use of the price transparency platform to search for laboratory tests, advanced imaging services, or clinician office visits before receiving care for that service.Medical claims from 2010-2013 of 502 949 patients who were insured in the United States by 18 employers who provided a price transparency platform to their employees.The primary outcome was total claims payments (the sum of employer and employee spending for each claim) for laboratory tests, advanced imaging services, and clinician office visits.Following access to the platform, 5.9% of 2 988 663 laboratory test claims, 6.9% of 76 768 advanced imaging claims, and 26.8% of 2 653 227 clinician office visit claims were associated with a prior search on the price transparency platform. Before having access to the price transparency platform, searchers had higher claims payments than nonsearchers for laboratory tests (4.11%; 95% CI, 1.87%-6.41%), higher payments for advanced imaging services (5.57%; 95% CI, 1.83%-9.44%), and no difference in payments for clinician office visits (0.26%; 95% CI; 0.53%-0.005%). Following access to the price transparency platform, relative claim payments for searchers were lower for searchers than nonsearchers by 13.93% (95% CI, 10.28%-17.43%) for laboratory tests, 13.15% (95% CI, 9.49%-16.66%) for advanced imaging, and 1.02% (95% CI, 0.57%-1.47%) for clinician office visits. The absolute payment differences were $3.45 (95% CI, $1.78-$5.12) for laboratory tests, $124.74 (95% CI, $83.06-$166.42) for advanced imaging services, and $1.18 (95% CI, $0.66-$1.70) for clinician office visits.Use of price transparency information was associated with lower total claims payments for common medical services. The magnitude of the difference was largest for advanced imaging services and smallest for clinical office visits. Patient access to pricing information before obtaining clinical services may result in lower overall payments made for clinical care.
- Total Expenditures per Patient in Hospital-Owned and Physician-Owned Physician Organizations in California. [JOURNAL ARTICLE]
- JAMA 2014 Oct 22; 312(16):1663-1669.
Hospitals are rapidly acquiring medical groups and physician practices. This consolidation may foster cooperation and thereby reduce expenditures, but also may lead to higher expenditures through greater use of hospital-based ambulatory services and through greater hospital pricing leverage against health insurers.To determine whether total expenditures per patient were higher in physician organizations (integrated medical groups and independent practice associations) owned by local hospitals or multihospital systems compared with groups owned by participating physicians.Data were obtained on total expenditures for the care provided to 4.5 million patients treated by integrated medical groups and independent practice associations in California between 2009 and 2012. The patients were covered by commercial health maintenance organization (HMO) insurance and the data did not include patients covered by commercial preferred provider organization (PPO) insurance, Medicare, or Medicaid.Total expenditures per patient annually, measured in terms of what insurers paid to the physician organizations for professional services, to hospitals for inpatient and outpatient procedures, to clinical laboratories for diagnostic tests, and to pharmaceutical manufacturers for drugs and biologics.Annual expenditures per patient were compared after adjusting for patient illness burden, geographic input costs, and organizational characteristics.Of the 158 organizations, 118 physician organizations (75%) were physician-owned and provided care for 3 065 551 patients, 19 organizations (12%) were owned by local hospitals and provided care for 728 608 patients, and 21 organizations (13%) were owned by multihospital systems and provided care for 693 254 patients. In 2012, physician-owned physician organizations had mean expenditures of $3066 per patient (95% CI, $2892 to $3240), hospital-owned physician organizations had mean expenditures of $4312 per patient (95% CI, $3768 to $4857), and physician organizations owned by multihospital systems had mean expenditures of $4776 (95% CI, $4349 to $5202) per patient. After adjusting for patient severity and other factors over the period, local hospital-owned physician organizations incurred expenditures per patient 10.3% (95% CI, 1.7% to 19.7%) higher than did physician-owned organizations (adjusted difference, $435 [95% CI, $105 to $766], P = .02). Organizations owned by multihospital systems incurred expenditures 19.8% (95% CI, 13.9% to 26.0%) higher (adjusted difference, $704 [95% CI,$512 to $895], P < .001) than physician-owned organizations. The largest physician organizations incurred expenditures per patient 9.2% (95% CI, 3.8% to 15.0%, P = .001) higher than the smallest organizations (adjusted difference, $130 [95% CI, $-32 to $292]).From the perspective of the insurers and patients, between 2009 and 2012, hospital-owned physician organizations in California incurred higher expenditures for commercial HMO enrollees for professional, hospital, laboratory, pharmaceutical, and ancillary services than physician-owned organizations. Although organizational consolidation may increase some forms of care coordination, it may be associated with higher total expenditures.
- Physician Practice Competition and Prices Paid by Private Insurers for Office Visits. [JOURNAL ARTICLE]
- JAMA 2014 Oct 22; 312(16):1653-1662.
Physician practice consolidation could promote higher-quality care but may also create greater economic market power that could lead to higher prices for physician services.To assess the relationship between physician competition and prices paid by private preferred provider organizations (PPOs) for 10 types of office visits in 10 prominent specialties.Retrospective study in 1058 US counties in urbanized areas, representing all 50 states, examining the relationship between measured physician competition and prices paid for office visits in 2010 and the relationship between changes in competition and prices between 2003 and 2010, using regression analysis to control for possible confounding factors.Variation in the mean Hirschman-Herfindahl Index (HHI) of physician practices within a county by specialty (HHIs range from 0, representing maximally competitive markets, to 10 000 in markets served by a single [monopoly] practice).Mean price paid by county to physicians in each specialty by private PPOs for intermediate office visits with established patients (Current Procedural Terminology [CPT] code 99213) and a price index measuring the county-weighted mean price for 10 types of office visits with new and established patients (CPT codes 99201-99205, 99211-99215) relative to national mean prices.In 2010, across all specialties studied, HHIs were 3 to 4 times higher in the 90th-percentile county than the 10th-percentile county (eg, for family practice: 10th percentile HHI = 1023 and 90th percentile HHI = 3629). Depending on specialty, mean price for a CPT code 99213 visit was between $70 and $75. After adjustment for potential confounders, depending on specialty, prices at the 90th-percentile HHI were between $5.85 (orthopedics; 95% CI, $3.46-$8.24) and $11.67 (internal medicine; 95% CI, $9.13-$14.21) higher than at the 10th percentile. Including all types of office visits, price indexes at the 90th-percentile HHI were 8.3% (orthopedics; 95% CI, 5.0%-11.6%) to 16.1% (internal medicine; 95% CI, 12.8%-19.5%) higher. Between 2003 and 2010, there were larger price increases in areas that were less competitive in 2002 than in initially more competitive areas.More competition among physicians is related to lower prices paid by private PPOs for office visits. These results may inform work on policies that influence practice competition.
- Association Between Hospital Conversions to For-Profit Status and Clinical and Economic Outcomes. [JOURNAL ARTICLE]
- JAMA 2014 Oct 22; 312(16):1644-1652.
An increasing number of hospitals have converted to for-profit status, prompting concerns that these hospitals will focus on payer mix and profits, avoiding disadvantaged patients and paying less attention to quality of care.To examine characteristics of US acute care hospitals associated with conversion to for-profit status and changes following conversion.Retrospective cohort study conducted among 237 converting hospitals and 631 matched control hospitals. Participants were 1 843 764 Medicare fee-for-service beneficiaries at converting hospitals and 4 828 138 at control hospitals.Conversion to for-profit status, 2003-2010.Financial performance measures, quality process measures, mortality rates, Medicare volume, and patient population for the 2 years prior and the 2 years after conversion, excluding the conversion year, assessed using difference-in-difference models.Hospitals that converted to for-profit status were more often small or medium in size, located in the south, in an urban or suburban location, and were less often teaching institutions. Converting hospitals improved their total margins (ratio of net income to net revenue plus other income) more than controls (2.2% vs 0.4% improvement; difference in differences, 1.8% [ 95% CI, 0.5% to 3.1%]; P = .007). Converting hospitals and controls both improved their process quality metrics (6.0% vs 5.6%; difference in differences, 0.4% [95% CI, -1.1% to 2.0%]; P = .59). Mortality rates did not change at converting hospitals relative to controls for Medicare patients overall (increase of 0.1% vs 0.2%; difference in differences, -0.2% [95% CI, -0.5% to 0.2%], P = .42) or for dual-eligible or disabled patients. There was no change in converting hospitals relative to controls in annual Medicare volume (-111 vs -74 patients; difference in differences, -37 [95% CI, -224 to 150]; P = .70), Disproportionate Share Hospital Index (1.7% vs 0.4%; difference in differences, 1.3% [95% CI, -0.9% to 3.4%], P = .26), the proportion of patients with Medicaid (-0.2% vs 0.4%; difference in differences, -0.6% [95% CI, -2.0% to 0.8%]; P = .38) or the proportion of patients who were black (-0.4% vs -0.1%; difference in differences, -0.3% [95% CI, -1.9% to 1.3%]; P = .72) or Hispanic (0.1% vs -0.1%; difference in differences, 0.2% [95% CI, -0.3% to 0.7%]; P = .50).Hospital conversion to for-profit status was associated with improvements in financial margins but not associated with differences in quality or mortality rates or with the proportion of poor or minority patients receiving care.
- Health Care Price Transparency and Economic Theory. [JOURNAL ARTICLE]
- JAMA 2014 Oct 22; 312(16):1642-1643.