Also Appearing in This Issue of JAMA


Study Examines Rate of Antipsychotic Use Among Nursing Home Residents

“The prescribing of antipsychotic medications persists at high levels in U.S. nursing homes (NHs) despite extensive data demonstrating marginal clinical benefits and serious adverse effects, including death. However, imprecise and outdated data have limited the understanding of the current state of antipsychotic medication prescribing in NHs,” writes Becky A. Briesacher, Ph.D., of the University of Massachusetts Medical School, Worcester, Mass., and colleagues.

As reported in a Research Letter, the authors conducted a study to assess the current level of antipsychotic use in NHs. The researchers analyzed September 2009 through August 2010 prescription dispensing data from a large, long-term care pharmacy that serves 48 states and half of all NH residents in the United States. Data elements included state location, patients’ sex, age, and enrollment dates, and national drug codes for all drugs dispensed regardless of payer (e.g., Medicare Part D, private insurance, and out of pocket). Overall and state-level annual prevalence of antipsychotic use was calculated as the percentage of NH residents receiving at least 1 antipsychotic drug.

“Of the overall sample of 1,402,039 NH residents, 308,449 (22.0 percent) received 1 or more prescriptions of antipsychotics. Prevalence of antipsychotic drug prescribing in NHs varied significantly, with the highest quintile [one of five groups] states (28.1 percent) located in the central south and the lowest quintile states (17.2 percent) located mostly in the west. Of 4,338,723 antipsychotic prescriptions in NHs, the majority (68.6 percent) were for the atypical agents quetiapine fumarate, risperidone, and olanzapine (n = 2,988,573).”

The authors note that their “finding that 22.0 percent of NH residents received antipsychotics in 2009-2010 is within the lower range of rates that were documented 25 years earlier before the passage of the Omnibus Budget Reconciliation Act of 1987, which instituted regulations on the appropriate use of antipsychotics in NHs.” They add that the extended duration of use (median duration, 30 to 77 days) raises “concerns about the care of frail elders residing in NHs.”

(JAMA. 2013;309[5]:440-442. Available pre-embargo to the media at


Viewpoints in This Issue of JAMA

Enhanced Tracking of Tissue for Transplantation

“The U.S. Food and Drug Administration (FDA) estimates that tissue banks provide 1.5 million tissue grafts annually, often supplying hospitals in several different states or even countries with tissue from a single donor. Tissue allografts have become a vitally important global industry. Nevertheless, tracking mechanisms that exist in other medical contexts have notable deficiencies with respect to tracking tissues,” writes John S. DePaolo, B.A., and James M. Barbeau, M.D., J.D., of the Louisiana State University School of Medicine, New Orleans.

In this Viewpoint, the authors discuss the deficiencies and provide suggestions for improving tracking of tissue.

(JAMA. 2013;309[5]:443-444. Available pre-embargo to the media at


FDA Regulation of Off-label Drug Promotion Under Attack

Aaron S. Kesselheim, M.D., J.D., M.P.H., of Brigham and Women’s Hospital and Harvard Medical School, Boston, and colleagues examine the issue of regulating off-label drug promotion, and cite a recent Court of Appeals decision that “signals that courts’ evolving views of protecting corporations’ commercial speech may prove incompatible with regulating drug promotion.”

“Courts’ seemingly inexorable drift toward greater protection of commercial speech at the expense of rigorous science directly threatens the FDA’s standing as the nation’s arbiter of which drugs are safe and effective. The existing approach to governing drug promotion, honed by enormous clinical and regulatory experience, is scientifically and legally justifiable and has benefitted patients and practitioners for decades. It should not be abandoned now.”

(JAMA. 2013;309[5]:445-446. Available pre-embargo to the media at


The European Working Time Directive

“A large-scale, uncontrolled experiment in medical care and education is in progress in the European community with important implications for the quality of medical care and education. Working hours for physicians in training are now limited to 48 hours per week, a fact that—to our knowledge—is little known to most U.S. physicians,” writes Lloyd Axelrod, M.D., of the Massachusetts General Hospital and Harvard Medical School, Boston, and colleagues.

In this Viewpoint, the authors discuss the European Working Time Directive that led to this reform, the effect of this directive on European medical care and education, and the important implications for graduate training reform in the United States.

(JAMA. 2013;309[5]:447-448. Available pre-embargo to the media at


Improving Population Health in U.S. Cities

Nicholas W. Stine, M.D., of the New York City Health and Hospitals Corporation, New York, and colleagues describe in a Viewpoint the challenges and opportunities to improving population health in U.S. cities.

“While the diversity and fragmentation of services within cities pose formidable organizational challenges, there are several key attributes of urban settings, if harnessed strategically, that offer opportunities for potentially effective population health strategies.”

(JAMA. 2013;309[5]:449-450. Available pre-embargo to the media at

Editor’s Note: Please see the articles for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

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