EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, FEBRUARY 28, 2017

Media Advisory: To contact Kenneth D. Mandl, M.D., M.P.H., email Keri Stedman at Keri.Stedman@childrens.harvard.edu.

To place an electronic embedded link to this study in your story  This link will be live at the embargo time: https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2016.19579

JAMA

The total payments insurance companies pay for knee and hip implants were twice as high as the average selling prices at which hospitals purchased the implants from manufacturers, resulting in hundreds of millions of dollars of additional insurance claims, according to a study appearing in the February 28 issue of JAMA.

Total knee arthroplasty (TKA; replacement) and total hip arthroplasty (THA) are common procedures with charges ranking first and eighth among all procedures in the United States. The cost of the implant device is typically the largest expense associated with these procedures, but insurance companies pay without knowledge of either price or even the device model.

Yi-Ju Tseng, Ph.D., and Kenneth D. Mandl, M.D., M.P.H., of Boston Children’s Hospital, conducted a study that included 40,372 patients with primary TKAs and 23,570 patients with primary THAs in 2011-2015. The patients were younger than 65 years of age. The average selling price (ASP; paid from surgical centers to manufacturers) was $5,023 for knee implants and the average insurance payment was $10,605. The ASP was $5,620 for hip implants and the average insurance payment was $11,751.

Based on the differences between the ASP and the average insurance payments, the cumulative differences in payment for patients in this insurance database were estimated at $225.3 million for total knee replacement and $199.7 million for total hip replacement.

“Insurance companies pay for implants without knowing the brand or model, and device pricing by manufacturers is not publicly reported. Availability of such information would allow price negotiation between insurance companies, hospitals, and manufacturers and may lower implant prices,” the authors write.

(doi:10.1001/jama.2016.19579; the study is available pre-embargo at the For the Media website)

Editor’s Note: Please see the article for additional information, including financial disclosures, funding and support, etc.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, FEBRUARY 21, 2017

Media Advisory: To contact Simon Gilbody, Ph.D., email Rachel Richardson at rachelrichardson1@gmail.com.
To place an electronic embedded link to this study in your story  This link will be live at the embargo time: https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2017.0130

JAMA

Among older adults with subthreshold depression (insufficient levels of depressive symptoms to meet diagnostic criteria), collaborative care compared with usual care resulted in an improvement in depressive symptoms after four months, although it is of uncertain clinical importance, according to a study appearing in the February 21 issue of JAMA.

Depression is the second leading cause of disability worldwide, and one in seven older people meet criteria for depression.  Effective therapeutic strategies are needed in older people with depressive symptoms. Simon Gilbody, Ph.D., of the University of York, England, and colleagues randomly assigned 705 adults age 65 years or older with subthreshold depression to collaborative care (n=344) or usual primary care (control; n=361). Collaborative care was coordinated by a case manager who assessed functional impairments relating to mood symptoms. Participants were offered behavioral activation and completed an average of six weekly sessions.

Collaborative care resulted in lower scores vs usual care at 4-month follow-up on measures of self-reported depression severity. The proportion of participants meeting criteria for depression were lower for collaborative care (17.2 percent) than usual care (23.5 percent) at 4-month follow-up, and at 12-month follow-up (15.7 percent vs 27.8 percent).

“Although differences persisted through 12 months, findings are limited by attrition, and further research is needed to assess longer-term efficacy,” the authors write.

(doi:10.1001/jama.2017.0130; the study is available pre-embargo at the For the Media website)

Editor’s Note: This project was funded by the UK National Institute of Health Research Health Technology Assessment Programme. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, FEBRUARY 21, 2017

Media Advisory: To contact Tara Lagu, M.D., M.P.H., email Brendan Monahan at Brendan.Monahan@baystatehealth.org.

To place an electronic embedded link to this study in your story  This link will be live at the embargo time: https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2016.18553

JAMA

An analysis of 28 commercial physician-rating websites finds that search mechanisms are cumbersome, and reviews scarce, according to a study appearing in the February 21 issue of JAMA.

Patients are increasingly seeking information about physicians online. Nearly 60 percent report that online reviews are important when choosing a physician. Because publicly reported quality data are not reported at the physician level, patients must consult physician-rating websites to find such reviews. Tara Lagu, M.D., M.P.H., of Baystate Medical Center, Springfield, Mass., and colleagues identified 28 physician-rating websites that met criteria for inclusion in the study. The researchers then used publicly available lists of registered and active physicians to identify a random sample of 600 physicians from three metropolitan areas (Boston, Portland, Ore.; and Dallas) and searched each website for reviews and calculated average and median number of reviews per physician per site.

The authors found that few sites allowed the user to search by clinical condition, sex of physician, hospital affiliation, languages spoken, or insurance accepted. Across the 28 websites, there were 8,133 quantitative reviews for the 600 physicians. Among physicians with at least one review on any site, the median number was 7 reviews per physician across all sites. One-third of sampled physicians did not have a review on any site.

The researchers write that despite certain study limitations, “these results demonstrate that it is difficult for a prospective patient to find (for any given physician on any commercial physician-rating website) a quantity of reviews that would accurately relay the experience of care with that physician.”

“Methods that use systematic data collection (e.g., surveys) may have a greater chance of amassing a sufficient quantity and quality of reviews to allow patients to make inferences about patient experience of care.”

(doi:10.1001/jama.2016.18553; the study is available pre-embargo at the For the Media website)

Editor’s Note: This work is supported by grants from the National Heart, Lung, and Blood Institute and from the National Institute of Child Health and Development of the National Institutes of Health. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, FEBRUARY 21, 2017

JAMA

An article in the Arts and Medicine section of JAMA reports the experience of a tattoo artist who works with women to design imagery to conceal their mastectomy scars. The article is available here, and images of a postmastectomy tattoo and the application process are below.

Botanical imagery in a tattoo after mastectomy and surgical
reconstruction.

Stages of tattoo application process after bilateral mastectomy and deep inferior epigastric artery perforator flap reconstruction.

EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, FEBRUARY 14, 2017

Media Advisory: To contact Julie Nangia, M.D., email Allison Huseman at Allison.Huseman@bcm.edu. To contact Hope S. Rugo, M.D., email Elizabeth Fernandez at Elizabeth.Fernandez@ucsf.edu.

Related material: Images of scalp cooling and photographic results of two patients treated with scalp cooling are available below.

To place an electronic embedded link to these studies in your story  These links will be live at the embargo time: https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2016.20939  https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2016.21038

JAMA

Two studies in the February 14 issue of JAMA examine hair loss among women with breast cancer who received scalp cooling before, during and after chemotherapy.

Chemotherapy may result in hair loss (alopecia), which women rate as one of the most distressing adverse effects of chemotherapy. Scalp cooling is hypothesized to reduce blood flow to hair follicles and reduce uptake of chemotherapeutic agents. Modern methods to prevent hair loss use devices that circulate fluid in a cooling cap using refrigeration. A cap is placed on the patient prior to chemotherapy and does not have to be changed or removed until the treatment is completed. Although scalp cooling devices have been used to prevent alopecia, efficacy has not been assessed in a randomized clinical trial.

In one study, Julie Nangia, M.D., of the Baylor College of Medicine, Houston, and colleagues randomly assigned 182 women with breast cancer undergoing chemotherapy to scalp cooling (n = 119) or control (n = 63). Scalp cooling was done 30 minutes prior to and during and 90 minutes after each chemotherapy infusion. Hair preservation was assessed at the end of four cycles of chemotherapy. One interim analysis was planned to allow the study to stop early for efficacy.

At the time of the interim analysis, 142 participants were evaluable. The researchers found that patients who received scalp cooling were significantly more likely than patients who did not receive scalp cooling to have less than 50 percent hair loss (with 51 percent of those in the scalp cooling group retaining their hair, compared with 0 percent of those in the control group). There were no significant differences in changes in any of the measures of quality of life between the groups. Only adverse events related to device use were collected; 54 adverse events were reported in the cooling group, none serious.

“Further research is needed to assess longer-term efficacy and adverse effects,” the authors write.

In another study, Hope S. Rugo, M.D., of the University of California, San Francisco, and colleagues included women with breast cancer receiving chemotherapy (106 patients in the scalp cooling group and 16 in the control group; 14 matched by both age and chemotherapy regimen). Scalp cooling was initiated 30 minutes prior to each chemotherapy cycle, with scalp temperature maintained at 3°C (37°F) throughout chemotherapy and for 90 minutes to 120 minutes afterward.

Image of scalp cooling:

From Rugo et al article, photographic results of two patients treated with scalp cooling (details available in paper):

Although scalp cooling has been available for several decades in Europe, use has been limited in the United States because of several factors, including insufficient prospective efficacy data with current chemotherapy regimens.

Among the 122 patients in the study, the average duration of chemotherapy was 2.3 months. Hair loss of 50 percent or less was seen in 67 of 101 patients (66 percent) evaluable for alopecia in the scalp cooling group vs 0 of 16 patients (0 percent) in the control group. Three of five quality-of-life measures were significantly better one month after the end of chemotherapy in the scalp cooling group. Of patients who underwent scalp cooling, 27 percent reported feeling less physically attractive compared with 56 percent of patients in the control group. Of the 106 patients in the scalp cooling group, four (3.8 percent) experienced the adverse event of mild headache and three (2.8 percent) discontinued scalp cooling due to feeling cold.

“Further research is needed to assess outcomes after patients receive anthracycline [a class of drugs used in chemotherapy] regimens, longer-term measures of alopecia, and adverse effects,” the authors write.

Editor’s Note for Nangia et al study: This work was supported by Paxman Coolers Ltd., which contracted with Baylor College of Medicine to conduct the study. Dr. Lacouture is supported in part by a grant from the National Cancer Institute. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.

Editor’s Note for Rugo et al study: The study was funded partially by Dignitana AB, the Lazlo Tauber Family Foundation, the Anne Moore Breast Cancer Research Fund, and the Friedman Family Foundation. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, FEBRUARY 14, 2017

Media Advisory: To contact Sekar Kathiresan, M.D., email Julie Cunningham at julie.cunningham@mgh.harvard.edu.

To place an electronic embedded link to this study in your story  This link will be live at the embargo time: https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2016.21042

JAMA

A genetic predisposition to higher waist-to-hip ratio adjusted for body mass index (a measure of abdominal adiposity [fat]) was associated with an increased risk of type 2 diabetes and coronary heart disease, according to a study appearing in the February 14 issue of JAMA.

Obesity, typically defined on the basis of body mass index (BMI), is a leading cause of type 2 diabetes and coronary heart disease (CHD). However, for any given BMI, body fat distribution can vary substantially; some individuals store proportionally more fat around their visceral organs (abdominal adiposity) than on their thighs and hip. In observational studies, abdominal adiposity has been associated with type 2 diabetes and CHD. Whether these associations represent causal relationships remains uncertain.

Sekar Kathiresan, M.D., of Massachusetts General Hospital, Harvard Medical School, Boston, and colleagues examined whether a genetic predisposition to increased waist-to-hip ratio adjusted for BMI was associated with cardiometabolic quantitative traits (i.e., lipids, insulin, glucose, and systolic blood pressure), type 2 diabetes and CHD.

Estimates for cardiometabolic traits were based on a combined data set consisting of summary results from 4 genome-wide association studies conducted from 2007 to 2015, including up to 322,154 participants, as well as individual-level, cross-sectional data from the UK Biobank collected from 2007-2011, including 111,986 individuals.

The researchers found that genetic predisposition to higher waist-to-hip ratio adjusted for BMI was associated with increased levels of quantitative risk factors (lipids, insulin, glucose, and systolic blood pressure) as well as a higher risk for type 2 diabetes and CHD.

“These results permit several conclusions. First, these findings lend human genetic support to previous observations associating abdominal adiposity with cardiometabolic disease,” the authors write. “Second, these results suggest that body fat distribution, beyond simple measurement of BMI, could explain part of the variation in risk of type 2 diabetes and CHD noted across individuals and subpopulations. … Third, waist-to-hip ratio adjusted for BMI might prove useful as a biomarker for the development of therapies to prevent type 2 diabetes and CHD.”

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

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, FEBRUARY 14, 2017

Media Advisory: To contact Stephen R. Durham, M.D., email s.durham@imperial.ac.uk.

To place an electronic embedded link to this study in your story  This link will be live at the embargo time: https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2016.21040

JAMA

Among patients with moderate to severe seasonal allergic rhinitis, two years of immunotherapy tablets was not significantly different from placebo in improving nasal symptoms at 3-year follow-up, according to a study appearing in the February 14 issue of JAMA.

The prevalence of allergic rhinitis in the United States has been estimated at 15 percent based on physician diagnosis and at 30 percent based on self-reported nasal symptoms. Rhinitis has major effects on quality of life, sleep, and work and school performance. Three years of continuous treatment with subcutaneous (injection) immunotherapy and sublingual (tablets) immunotherapy has been shown to improve symptoms for at least two years following discontinuation of treatment. It is unknown whether a shorter course of immunotherapy provides long-term benefits, while reducing overall costs, patient inconvenience, and adverse events.

Stephen R. Durham, M.D., of Imperial College London, and colleagues randomly assigned 106 adults with moderate to severe seasonal allergic rhinitis to receive two years of sublingual immunotherapy (n=36; daily tablets containing 15 µg of major allergen Phleum p 5 and monthly placebo injections); subcutaneous immunotherapy (n=36; monthly injections containing 20 µg of Phleum p 5 and daily placebo tablets); matched double-placebo (n=34). Nasal allergen challenge was performed before treatment, at one and two years of treatment, and at three years (1 year after treatment discontinuation).

Among 106 randomized participants, 92 completed the study at three years. The researchers found that treatment for two years with grass pollen sublingual immunotherapy was not sufficient to achieve an allergic response improvement at 3-year follow-up.

“International guidelines regarding immunotherapy recommend a minimum of 3 years of treatment with both delivery methods [subcutaneous, sublingual]. If a 2-year regimen had demonstrated long-term benefits in addition to efficacy, this could have represented cost savings in terms of clinical resources and improved convenience for the patient. Because this was not observed, clinicians should be advised to follow established guidelines that recommend at least 3 years treatment,” the authors write.

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

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, FEBRUARY 7, 2017

Media Advisory: To contact Mary E. Lacy, M.P.H., email David Orenstein at david_orenstein@brown.edu.

To place an electronic embedded link to this study in your story  This link will be live at the embargo time: https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2016.21035

JAMA

Using standard hemoglobin A_1c criteria resulted in identifying 40 percent fewer cases of prediabetes and 48 percent fewer cases of diabetes among African Americans with sickle cell trait compared with those without, while glucose-based methods resulted in a similar prevalence regardless of sickle cell trait status, according to a study in the February 7 issue of JAMA.

Hemoglobin A_1c (HbA_1c) reflects past glucose concentrations, but this relationship may differ between those with sickle cell trait (SCT) and those without it. Sickle cell trait is a condition in which a person has only one copy of the gene for sickle cell but does not have sickle cell disease (which requires two copies of the sickle cell gene). Correct interpretation of HbA_1c values in individuals with SCT is important because it directly affects efforts that use HbA_1c for screening, diagnosis, and monitoring of diabetes and prediabetes. Sickle cell trait is the most common hemoglobin variant in the United States, with 8 to 10 percent of black people affected by SCT compared with less than one percent of white people.

Mary E. Lacy, M.P.H., of the Brown University School of Public Health, Providence, R.I., and colleagues evaluated the association between SCT and HbA_1c for given levels of fasting or 2-hour glucose levels among African Americans using data collected from 7,938 participants in two community-based cohorts, the Coronary Artery Risk Development in Young Adults (CARDIA) study and the Jackson Heart Study (JHS).

The analytic sample included 4,620 participants (367 [7.9 percent] with SCT). The researchers found that at the same fasting or 2-hour glucose concentration, HbA_1c was significantly lower among participants with vs without SCT. Also, differences in HbA_1c concentration by SCT status were greater at higher glucose concentrations. The prevalence of prediabetes and diabetes was significantly lower among participants with SCT when defined using HbA_1c values (29 percent vs 49 percent for prediabetes and 3.8 percent vs 7.3 percent for diabetes).

“These results could have clinically significant implications. As a screening tool, an HbA_1c value that systematically underestimates long-term glucose levels may result in a missed opportunity for intervention,” the authors write. “Because black people typically have a higher prevalence of diabetes and experience a number of diabetic complications at higher rates than white people, the cost of inaccurately assessing risk and treatment response is high.”

(doi:10.1001/jama.2016.21035; the study is available pre-embargo at the For the Media website)

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

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, FEBRUARY 7, 2017

Media Advisory: To contact Allison W. Kurian, M.D., M.Sc., email Krista Conger at kristac@stanford.edu.

To place an electronic embedded link to this study in your story  This link will be live at the embargo time: https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2016.16918

JAMA

In a study appearing in the February 7 issue of JAMA, Allison W. Kurian, M.D., M.Sc., of the Stanford University School of Medicine, Stanford, Calif., and colleagues examined the use of genetic counseling and testing among patients with newly diagnosed breast cancer.

Testing of two breast cancer-associated genes, BRCA1 and BRCA2, has been available for 20 years but new technology and less restrictive patent laws have made certain tests available at much lower costs, yet little is known about recent patient experience with genetic testing and counseling. This study included women ages 20 through 79 years, diagnosed with stages 0 to II breast cancer, who were mailed surveys two months after surgical operation. Survey questions addressed how much patients wanted genetic testing (not at all, a little bit, somewhat, quite a bit, very much); and whether patients talked about testing with any “doctor or other health professional,” had a session with a genetic counseling expert, or had testing.

A total of 2,529 women (71 percent) responded to the survey. Among the findings: most patients (66 percent) reported wanting genetic testing and 29 percent reported having it. Yet only 40 percent of all high-risk women and 62 percent of tested high-risk women reported having a genetic counseling session. Only 53 percent of high-risk patients had a genetic test, “representing a missed opportunity to prevent ovarian and other cancer deaths among mutation carriers and their families,” the authors write.

They add that clinical need for genetic testing may not be adequately recognized by physicians. High-risk patients reported lack of a physician’s recommendation, not expense, as their primary reason for not testing.

High-risk patients most vulnerable to under-testing included Asians and older women, despite evidence that many such patients carry mutations.

“The findings emphasize the importance of cancer physicians in the genetic testing process. Priorities include improving physicians’ communication skills and assessments of patients’ risk and desire for testing, and optimizing triage to genetic counselors.”

(doi:10.1001/jama.2016.16918; the study is available pre-embargo at the For the Media website)

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

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, JANUARY 24, 2017

Media Advisory: To contact Christopher J. L. Murray, M.D., D.Phil., email Kayla Albrecht at albrek7@uw.edu.

To place an electronic embedded link to this study in your story  This link will be live at the embargo time: https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2016.20324

JAMA

The overall rate of death from cancer declined about 20 percent between 1980 and 2014; however, there are distinct clusters of counties in the U.S. with particularly high cancer mortality rates, according to a study in the January 24/31 issue of JAMA

Cancer is the second leading cause of death in the United States and globally. Most previous reports on geographic differences in cancer mortality in the U.S. have focused on variation by state, with less information available at the county level. There is a value for data at the county level because public health programs and policies are mainly designed and implemented at the local level. Moreover, local information can also be useful for health care clinicians to understand community needs for care and aid in identifying cancer hot spots that need more investigation to understand the root causes.

Christopher J. L. Murray, M.D., D.Phil., of the Institute for Health Metrics and Evaluation, University of Washington, Seattle, and colleagues estimated mortality rates by U.S. county from 29 cancers using death records from the National Center for Health Statistics (NCHS) and population counts from the Census Bureau, the NCHS, and the Human Mortality Database from 1980 to 2014.

The researchers found that cancer mortality decreased by 20.1 percent between 1980 and 2014, from 240 to 192 deaths per 100,000 population. A total of 19,511,910 cancer deaths were recorded in the United States during this period, including:

• 7 million due to tracheal, bronchus, and lung cancer;
• 5 million due to colon and rectum cancer;
• 6 million due to breast cancer;
• 2 million due to pancreatic cancer;
• 1 million due to prostate cancer.

For many cancers, there were distinct clusters of counties with especially high mortality. The location of these clusters varied by type of cancer and were spread in different regions of the United States. Clusters of breast cancer were present in the southern belt and along the Mississippi River, while liver cancer was high along the Texas-Mexico border, and clusters of kidney cancer were observed in North and South Dakota and counties in West Virginia, Ohio, Indiana, Louisiana, Oklahoma, Texas, Alaska, and Illinois.

“The study was able to identify clusters of high rates of change among U.S. counties, which is important for providing data to inform the debate on prevention, access to care, and appropriate treatment. Indeed, monitoring cancer mortality at the county level can help identify worsening incidence, inadequate access to quality treatment, or potentially other etiological factors involved,” the authors write.

(doi:10.1001/jama.2016.20324; the study is available pre-embargo at the For the Media website)

Editor’s Note: This work was funded by the Robert Wood Johnson Foundation, the National Institute on Aging and John W. Stanton and Theresa E. Gillespie. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, JANUARY 24, 2017

Media Advisory: To contact Roy W. Beck, M.D., Ph.D., email rbeck@Jaeb.org. To contact Marcus Lind, M.D., Ph.D., email lind.marcus@telia.com.

To place an electronic embedded link to these studies in your story  These links will be live at the embargo time. This is the link to the 1^st study: https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2016.19975  This is the link to the 2^nd study:  https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2016.19976

JAMA

Two studies in the January 24/31 issue of JAMA find that use of a sensor implanted under the skin that continuously monitors glucose levels resulted in improved levels in patients with type 1 diabetes who inject insulin multiple times a day, compared to conventional treatment.

In one study, Roy W. Beck, M.D., Ph.D., of the Jaeb Center for Health Research, Tampa, Fla., and colleagues randomly assigned 158 adults with type 1 diabetes who were using multiple daily insulin injections and had elevated hemoglobin A_1c (HbA_1c) levels of 7.5 percent to 9.9 percent to continuous glucose monitoring (n = 105) or usual care (control group; n = 53).

Only approximately 30 percent of individuals with type 1 diabetes meet the American Diabetes Association goal of HbA_1c level of 7.5 percent for children and 7.0 percent for adults, indicating the need for better approaches to diabetes management. Continuous glucose monitoring (CGM) with glucose measurements as often as every five minutes, plus low and high glucose level alerts and glucose trend information, has the capability of better informing diabetes management decisions than blood glucose meter testing performed several times a day. Only a small proportion of individuals with type 1 diabetes who inject insulin use CGM. Continuous glucose monitoring systems include a sensor underneath the skin with a transmitter attached and continuous reporting of glucose levels and trends to the patient by a handheld monitor.

In this study in the CGM group, 93 percent used CGM six days/week or more in month six. Average HbA_1c reduction from baseline was 1.1 percent at 12 weeks and 1.0 percent at 24 weeks in the CGM group and 0.5 percent and 0.4 percent, respectively, in the control group. Median duration of hypoglycemia was 43 minutes/day in the CGM group vs 80 minutes/day in the control group. Severe hypoglycemia events occurred in 2 participants in each group.

“Among adults with type l diabetes who used multiple daily insulin injections, the use of CGM compared with usual care resulted in a greater decrease in HbA_1c level during 24 weeks. Further research is needed to assess longer-term effectiveness, as well as clinical outcomes and adverse effects,” the authors write.

(doi:10.1001/jama.2016.19975; the study is available pre-embargo at the For the Media website)

Editor’s Note: Dexcom Inc. provided funding for the trial to each investigator’s institution. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.

In another study, Marcus Lind, M.D., Ph.D., of the University of Gothenburg, Sweden, and colleagues randomly assigned 161 individuals with type 1 diabetes and HbA_1c of at least 7.5 percent treated with multiple daily insulin injections to receive treatment using a CGM system or conventional treatment for 26 weeks, separated by a washout period of 17 weeks. The goal of the study was to analyze the effect of CGM on glycemic control, hypoglycemia, well-being, and glycemic variability.

The researchers found that average HbA_1c was 7.92 percent during CGM use and 8.35 percent during conventional treatment. Of 19 other outcomes comprising psychosocial and various glycemic measures, six met statistical significance, favoring CGM compared with conventional treatment. Five patients in the conventional treatment group and one patient in the CGM group had severe hypoglycemia.

“In this crossover study of persons with type 1 diabetes treated with multiple daily insulin injections, CGM was associated with a mean HbA_1c level that was 0.43 percent less than conventional treatment. Moreover, glycemic variability was reduced by CGM. Subjective well-being and treatment satisfaction were greater during CGM than conventional therapy,” the authors write. “Further research is needed to assess clinical outcomes and longer-term adverse effects.”

(doi:10.1001/jama.2016.19976; the study is available pre-embargo at the For the Media website)

Editor’s Note: The trial was sponsored by the NU Hospital Group, Trollhattan and Uddevalla, Sweden. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, JANUARY 24, 2017

Media Advisory: To contact the U.S. Preventive Services Task Force, email the Media Coordinator at Newsroom@USPSTF.net or call 202-572-2044.

To place an electronic embedded link to this report in your story  This link will be live at the embargo time: https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2016.20325

JAMA

The U.S. Preventive Services Task Force (USPSTF) has concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for obstructive sleep apnea in asymptomatic adults (including adults with unrecognized symptoms). The report appears in the January 24/31 issue of JAMA.

This is an I statement, indicating that evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

Based on data from the 1990s, the estimated prevalence of obstructive sleep apnea (OSA) in the United States is 10 percent for mild OSA and 3.8 percent to 6.5 percent for moderate to severe OSA. Current prevalence may be higher, given the increasing prevalence of obesity. Severe OSA is associated with an increased risk of death, cardiovascular disease and cerebrovascular events, diabetes, cognitive impairment, decreased quality of life and motor vehicle crashes. The proportion of persons with OSA who are asymptomatic or have unrecognized symptoms is unknown. To issue a new recommendation on screening for OSA, the USPSTF reviewed the evidence on the accuracy, benefits and potential harms of screening for OSA in asymptomatic adults seen in primary care, including those with unrecognized symptoms. The USPSTF also evaluated the evidence on the benefits and harms of treatment of OSA on intermediate and final health outcomes.

The USPSTF is an independent, volunteer panel of experts that makes recommendations about the effectiveness of specific preventive care services such as screenings, counseling services, and preventive medications.

Detection

Evidence on the use of validated screening questionnaires in asymptomatic adults (or adults with unrecognized symptoms) to accurately identify who will benefit from further testing for OSA is inadequate. The USPSTF identified this as a critical gap in the evidence.

Benefits of Early Detection and Intervention or Treatment

The USPSTF found inadequate direct evidence on the benefit of screening for OSA in asymptomatic populations. The USPSTF found no studies that evaluated the effect of screening for OSA on health outcomes. The USPSTF found at least adequate evidence that treatment with continuous positive airway pressure (CPAP) and mandibular advancement devices (MADs) can improve intermediate outcomes (e.g., the apnea-hypopnea index, Epworth Sleepiness Scale score, and blood pressure) in populations referred for treatment. However, the applicability of this evidence to screen-detected populations is limited.

The USPSTF found evidence that treatment with CPAP can improve general and sleep-related quality of life in populations referred for treatment, but the applicability of this evidence to screen-detected populations is unknown. The USPSTF found inadequate evidence on whether treatment with CPAP or MADs improves other health outcomes (mortality, cognitive impairment, motor vehicle crashes, and cardiovascular or cerebrovascular events). The USPSTF also found inadequate evidence on the effect of treatment with various surgical procedures in improving intermediate or health outcomes.

Harms of Early Detection and Intervention or Treatment

The USPSTF found inadequate evidence on the direct harms of screening for OSA. The USPSTF found adequate evidence that the harms of treatment of OSA with CPAP and MADs are small. The USPSTF found inadequate evidence on the harms of surgical treatment of OSA.

Summary

The USPSTF found insufficient evidence on screening for or treatment of OSA in asymptomatic adults or adults with unrecognized symptoms. Therefore, the USPSTF was unable to determine the magnitude of the benefits or harms of screening for OSA or whether there is a net benefit or harm to screening.

(doi:10.1001/jama.2016.20325; the full report is available pre-embargo to the media at the For the Media website)

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

Note: More information about the U.S. Preventive Services Task Force, its process, and its recommendations can be found on the newsroom page of its website.

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EMBARGOED FOR RELEASE: 2:30 P.M. (ET) SUNDAY, JANUARY 22, 2017

Media Advisory: To contact Sachin Yende, M.D., M.S., email Allison Hydzik at hydzikam@upmc.edu.

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JAMA

Sepsis hospitalizations account for a higher proportion of unplanned 30-day readmissions than hospitalizations for heart attack, heart failure, COPD, and pneumonia in the United States, according to a study published online by JAMA. The study is being released to coincide with its presentation at the Society of Critical Care Medicine’s 46th Critical Care Congress.

The Centers for Medicare & Medicaid Services (CMS) uses 30-day readmission rates to measure quality of care and guide pay-for-performance. The CMS tracks readmissions following hospitalizations for acute myocardial infarction (AMI; heart attack), heart failure, chronic obstructive pulmonary disease (COPD), and pneumonia because hospitalizations for these conditions are frequent and account for a large proportion of readmissions. The proportion and cost of unplanned readmissions following sepsis hospitalizations are not known.

Sachin Yende, M.D., M.S., of the VA Pittsburgh Healthcare System, and colleagues analyzed data from the 2013 Nationwide Readmissions Database, which aggregates acute care hospitalizations from 21 states and represents inpatient use for 49 percent of the U.S. population. Among 14,325,172 hospitalizations, the researchers identified 1,187,697 index admissions for medical reasons that were associated with an unplanned 30-day readmission. Of those, 12.2 percent had a diagnosis of sepsis; 6.7 percent, heart failure; 5 percent, pneumonia; 4.6 percent, COPD; and 1.3 percent, AMI.

The average length of stay for unplanned readmissions following sepsis hospitalization was longer than readmissions following AMI, heart failure, COPD, and pneumonia. The estimated average cost per readmission was highest for sepsis compared with the other diagnoses.

“Adding sepsis to the Hospital Readmission Reduction Program may lead to development of new interventions to reduce unplanned readmissions and associated costs,” the authors write.

(doi:10.1001/jama.2016.20468; the study is available pre-embargo at the For the Media website)

Editor’s Note: Dr. Yende was supported by grants from the National Institute of General Medical Sciences. The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Yende reported receiving grants from Bristol-Myers Squibb. No other disclosures were reported.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) THURSDAY, JANUARY 19, 2017

Media Advisory: To contact Daniel Grossman, M.D., email Jason Harless at harless.jason@ucsf.edu.

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JAMA

In Texas counties without an abortion facility in 2014, an increase in distance to the nearest facility was associated with a decline in abortions between 2012 and 2014, according to a study published online by JAMA.

Texas House Bill 2, enacted in 2013, was one of the most restrictive abortion laws in the country before the U.S. Supreme Court ruled in June 2016 that two provisions were unconstitutional. Following introduction and passage of the bill, the number of Texas facilities providing abortions declined, from 41 in 2012 to 17 in June 2016. Women whose nearest clinic closed traveled farther to access abortion services than those whose nearest clinic remained open. Overall, abortions declined 14 percent in Texas between 2013 and 2014.

Daniel Grossman, M.D., of the University of California-San Francisco, and colleagues examined whether the decline in abortions would be greater as the change in distance to the nearest open facility increased. County-level data on abortions received by Texas residents both in and out of state in 2012 and 2014 were obtained from the website of the Department of State Health Services. The distance from the center of each Texas county to the nearest open facility providing abortions in 2012 and 2014 was calculated.

In 2012, 66,098 abortions were performed among Texas residents (97 out of state). In 2014, 53,882 abortions were performed among Texas residents (754 out of state). Of 254 counties, there were 41 facilities in 17 counties in 2012 and there were 21 facilities in 6 counties in 2014. The average change in distance to a facility was 51 miles and the median change was 13 miles.

Counties that had an open facility in 2014 (all in large metropolitan areas) had minimal distance changes (0-5 miles) and a 16 percent decline in abortions. Among counties without an open facility in 2014, the decline in abortions increased as the distance change to the nearest facility increased. Counties with no facility in 2014 but no change in distance to a facility between 2012 and 2014 had a 1.3 percent decline in abortions. When the change in distance was 100 miles or more, the number of abortions decreased 50 percent.

The authors write that the decline in abortions among women in counties with an open facility in 2014 indicates that there were other factors related to the decrease, such as limited capacity to meet demand for services. “In counties with no facility and no change in distance, the decline in abortion was minimal. Many of these counties were in East Texas where family planning services were disrupted, likely leading to increased demand for abortion that offset the increased capacity barriers women faced.”

(doi:10.1001/jama.2016.17026; the study is available pre-embargo at the For the Media website)

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

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, JANUARY 17, 2017

Media Advisory: To contact Shawn D. Aaron, M.D., email Amelia Buchanan at ambuchanan@ohri.ca.

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JAMA

Among adults with a previous physician diagnosis of asthma, a current diagnosis could not be established in about one-third who were not using daily asthma medications or had medications weaned, according to a study appearing in the January 17 issue of JAMA. The researchers speculate that the failure to confirm the diagnosis could be because of spontaneous remission or misdiagnosis.

Diagnosis of asthma in the community can be difficult. Various types have been identified, all of which potentially have different triggers and clinical presentations. Asthma can be episodic or can follow a relapsing and remitting course, which further complicates attempts to arrive at a diagnosis based on a single patient-physician encounter. Although asthma is a chronic disease, the expected rate of spontaneous remissions of adult asthma and the stability of diagnosis are unknown.

Shawn D. Aaron, M.D., of the Ottawa Hospital Research Institute, University of Ottawa, Canada, and colleagues conducted a study that included 701 adults who reported a history of physician-diagnosed asthma established within the past five years. All participants were assessed with home peak flow and symptom monitoring, spirometry (measures lung function), and bronchial challenge tests, and those participants using daily asthma medications had their medications gradually tapered off over four study visits. Participants in whom a diagnosis of current asthma was ultimately ruled out were followed up clinically with repeated bronchial challenge tests over one year.

Of 701 participants, 613 completed the study and could be conclusively evaluated for a diagnosis of current asthma, which was ruled out in 203 of 613 study participants (33 percent). Twelve participants (2 percent) were found to have serious cardiorespiratory conditions that had been previously misdiagnosed as asthma in the community. After an additional 12 months of follow-up, 181 participants (30 percent) continued to exhibit no clinical or laboratory evidence of asthma. Participants in whom current asthma was ruled out, compared with those in whom it was confirmed, were less likely to have undergone testing for airflow limitation in the community at the time of initial diagnosis (44 percent vs 56 percent, respectively). More than 90 percent of participants in whom asthma was ruled out had asthma medications safely stopped for an additional one-year period.

“Two phenomena may account for failure to ultimately confirm current asthma in 33.1 percent of the study cohort: (1) spontaneous remission of previously active asthma; and (2) misdiagnosis of asthma in the community. At least 24 of 203 participants (11.8 percent) in whom current asthma was ruled out had undergone pulmonary function tests in the community that had been previously diagnostic of asthma. These participants presumably experienced spontaneous remission of their asthma at some time between their initial community diagnosis and entry into the study,” the authors write.

“This study also suggests that misdiagnosis of asthma may occasionally occur in the community. In 2.0 percent of study participants, a serious untreated cardiorespiratory condition was identified that may have been previously misdiagnosed as asthma. In addition, the study demonstrated that failure to consistently use objective testing at the time of initial diagnosis of asthma was associated with failure to confirm current asthma. These results suggest that whenever possible, physicians should order objective tests, such as prebronchodilator and postbronchodilator spirometry, serial peak flow measurements, or bronchial challenge tests, to confirm asthma at the time of initial diagnosis.”

(doi:10.1001/jama.2016.19627; the study is available pre-embargo at the For the Media website)

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

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, JANUARY 17, 2017

Media Advisory: To contact Zhengming Chen, D.Phil., email zhengming.chen@ctsu.ox.ac.uk or call (Oxford, UK) +44-1865-743-743, mobile: +44-791-777-1693. To contact Liming Li, M.P.H., email lmlee@vip.163.com or call (Beijing) +86-139-0121-3570.

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JAMA

Among adults in China, those with diabetes diagnosed in middle age lose, on average, nine years of life compared with those without diabetes, according to new research published in the January 17 issue of JAMA.

Most previous studies of diabetes have been in high-income countries where individuals with diabetes are generally well managed. In China the prevalence of diabetes has quadrupled in recent decades, with an estimated 100 million adults now affected. Because the increase in diabetes prevalence in China is only recent, the full eventual effect on mortality is unknown. Zhengming Chen, D.Phil., of the University of Oxford, England, Liming Li, M.P.H., of Peking University, Beijing, and colleagues examined the association of diabetes with mortality in China. The study included 512,869 adults ages 30 to 79 years from 10 (five rural and five urban) areas scattered throughout China, who were recruited between 2004 and 2008 and followed up for cause-specific mortality until 2014.

Among the participants, 6 percent had diabetes (4 percent in rural areas, 8 percent in urban areas; 3 percent had been previously diagnosed, and 3 percent were detected by screening). The researchers found that, compared with adults without diabetes, individuals with diabetes had twice the risk of dying during the follow-up period, and the increase was higher in rural areas than in urban areas. Diabetes was associated with increased mortality from ischemic heart disease, stroke, chronic kidney disease, chronic liver disease, infection, and cancer of the liver, pancreas and female breast. The risk of dying from inadequately treated acute complications of diabetes (diabetic ketoacidosis or coma) was much greater in rural areas than in urban areas, and was much higher than in high-income countries.

The researchers estimated that the 25-year probability of death would be 69 percent among those diagnosed with diabetes at age 50 years compared with 38 percent among otherwise similar individuals without diabetes, corresponding to a loss of about nine years of life (10 years in rural areas and eight years in urban areas).

The risk increased with increased time since diagnosis of diabetes. “As the prevalence of diabetes in young adults increases and the adult population grows, the annual number of deaths related to diabetes is likely to continue to increase, unless there is substantial improvement in prevention and management,” the authors write.

(doi:10.1001/jama.2016.19627; the study is available pre-embargo at the For the Media website)

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

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, JANUARY 17, 2017

Media Advisory: To contact Ge Bai, Ph.D., C.P.A., email Stephanie Desmon at sdesmon1@jhu.edu.

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JAMA

Nearly all physicians charge more than the Medicare program actually pays (“excess charges”), with complete discretion to determine the amount charged. Ge Bai, Ph.D., C.P.A., and Gerard F. Anderson, Ph.D., of Johns Hopkins University, Baltimore, conducted a study to understand the extent and variation of physician excess charges. The study appears in the January 17 issue of JAMA.

High excess charges can impose financial burdens on uninsured patients and privately insured patients using out-of-network physicians. Although some out-of-network physicians may offer discounts from their full charges, many patients receive unexpected medical bills. For this study, the researchers examined Medicare physician use and payment data, including payment and submitted charges for U.S. physicians who provided services to Medicare beneficiaries and submitted Medicare Part B claims in 2014. Physician excess charges were defined as total charges divided by total Medicare allowable amount for medical services (i.e., the charge-to-Medicare payment ratio) for each physician. Specialty and geographic distribution of physicians with high excess charges were defined as physicians with median charge-to-Medicare payment ratios in the top 2.5 percent.

Data from 429,273 individual physicians across 54 medical specialties were included in the study. The researchers found that the median physician charges were 2.5 times higher than what Medicare pays. The authors note that the charge-to-Medicare payment ratio represents the upper limit of each physician’s actual excess charge, and may not be what a patient actually pays. The ratio varied across specialties, with anesthesiology having the highest median and general practice having the lowest. Of the 10,730 physicians with high excess charges, 55 percent were anesthesiologists and 3 percent were in general practice, internal medicine, or family practice.

There were also regional differences in excess charges. Two neighboring states (Wisconsin and Michigan) had different median excess charges (3.8 vs 2.0, respectively). About one-third of physicians with high excess charges practiced in only 10 hospital referral regions.

“As the health insurance market shifts toward more restrictive physician networks and high-deductible plans, protecting uninsured and out-of-network patients from high medical bills should be a policy priority. For example, a recent law in New York restricts out-of-network physicians from charging patients excessive unexpected amounts,” the authors write.

(doi:10.1001/jama.2016.16230; the study is available pre-embargo at the For the Media website)

Editor’s Note: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, JANUARY 10, 2017

Media Advisory: To contact Christopher J. L. Murray, D.Phil., email Kayla Albrecht at albrek7@uw.edu.

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JAMA

An analysis that included 8.7 million participants finds that the rate of elevated systolic blood pressure (SBP) increased substantially globally between 1990 and 2015, and that in 2015 an estimated 3.5 billion adults had systolic blood pressure of at least 110 to 115 mm Hg, and 874 million adults had SBP of 140 mm Hg or higher, according to a study appearing in the January 10 issue of JAMA.

Systolic blood pressure of at least 110 mm Hg has been related to multiple cardiovascular and kidney outcomes, including ischemic heart disease, cerebrovascular disease and chronic kidney disease. The global obesity epidemic may further increase SBP in some populations. Quantifying the levels of SBP is important to guide prevention policies and interventions. Christopher J. L. Murray, D.Phil., of the Institute for Health Metrics and Evaluation, University of Washington, Seattle, and colleagues estimated the association between SBP of at least 110 to 115 mm Hg and SBP of 140 mm Hg or higher and the burden of different causes of death and disability by age and sex, based on 844 studies from 154 countries (published 1980-2015) of 8.69 million participants.

The researchers found that the rate of elevated SBP (110-115 or greater and 140 mm Hg or greater) increased substantially between 1990 and 2015, and disability-adjusted life-years (DALYs) and deaths associated with elevated SBP also increased. Systolic blood pressure of at least 110 to 115 mm Hg was associated with more than 10 million deaths and more than 212 million DALYs in 2015, a 1.4-fold increase since 1990. Compared with all other specific risks quantified in a 2015 study, SBP of at least 110 to 115 mm Hg was the leading global contributor to preventable death in 2015.

“These estimates are concerning given that in 2015, an estimated 3.5 billion individuals had an SBP level of at least 110 to 115 mm Hg,” the authors write.

The largest numbers of SBP-related deaths were caused by ischemic heart disease (4.9 million), hemorrhagic stroke (2 million), and ischemic stroke (1.5 million).

Five countries accounted for more than half of global DALYs associated with SBP of at least 110 to 115 mm Hg: China, India, Russia, Indonesia, and the United States. “Both the projected number and prevalence rate of SBP of at least 110 to115 mm Hg are likely to continue to increase globally. These findings support increased efforts to control the burden of SBP of at least 110 to 115 mm Hg to reduce disease burden,” the researchers write.

(doi:10.1001/jama.2016.19043; the study is available pre-embargo at the For the Media website)

Editor’s Note: This research was supported by funding from the Bill and Melinda Gates Foundation. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, JANUARY 10, 2017

Media Advisory: To contact the U.S. Preventive Services Task Force, email the Media Coordinator at Newsroom@USPSTF.net or call 202-572-2044.

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Folic Acid Supplementation Recommended for Prevention of Neural Tube Defects

The U.S. Preventive Services Task Force (USPSTF) recommends that all women who are planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400-800 µg) of folic acid. The report appears in the January 10 issue of JAMA.

This is an A recommendation, indicating that there is high certainty that the net benefit is substantial.

Neural tube defects are major birth defects of the brain and spine that occur early in pregnancy due to improper closure of the embryonic neural tube, which may lead to a range of disabilities or death. Daily folic acid supplementation in the periconceptional period (occurring around the time of conception) can prevent neural tube defects. However, most women do not receive the recommended daily intake of folate from diet alone. Data from 2003 to 2006 suggest that 75 percent of nonpregnant women ages 15 to 44 years do not consume the recommended daily intake of folic acid for preventing neural tube defects. To update its 2009 recommendation, the USPSTF assessed new evidence on the benefits and harms of folic acid supplementation in women of childbearing age.

The USPSTF is an independent, volunteer panel of experts that makes recommendations about the effectiveness of specific preventive care services such as screenings, counseling services, and preventive medications.

Recognition of Risk Status

Women who have a personal or family history of a pregnancy affected by a neural tube defect are at increased risk of having an affected pregnancy. However, most cases occur in the absence of any personal or family history. Some factors increase the risk of neural tube defects, including use of particular anti-seizure medications, maternal diabetes, obesity, and mutations in folate-related enzymes.

Benefits of Preventive Medication

The USPSTF found convincing evidence that folic acid supplementation in the periconceptional period provides substantial benefits in reducing the risk of neural tube defects in the developing fetus. The USPSTF found inadequate evidence on how the benefits of folic acid supplementation may vary by dosage, timing relative to pregnancy, duration of therapy, or race/ethnicity.

Harms of Preventive Medication

The USPSTF found adequate evidence that the harms to the mother or infant from folic acid supplementation taken at the usual doses are no greater than small.

Timing

The critical period for supplementation starts at least 1 month before conception and continues through the first 2 to 3 months of pregnancy.

Summary

The USPSTF concludes with high certainty that the net benefit of daily folic acid supplementation to prevent neural tube defects in the developing fetus is substantial for women who are planning or capable of pregnancy.

(doi:10.1001/jama.2016.19438; the full report is available pre-embargo to the media at the For the Media website)

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

Note: More information about the U.S. Preventive Services Task Force, its process, and its recommendations can be found on the newsroom page of its website.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, JANUARY 3, 2017

Media Advisory: To contact Andrew L. Himelstein, M.D., email Bill Schmitt at wschmitt@christianacare.org or call 302-327-3318.

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JAMA

Among patients with bone metastases due to breast cancer, prostate cancer, or multiple myeloma, use of the bisphosphonate drug zoledronic acid every 12 weeks compared with the standard dosing interval of every 4 weeks did not result in an increased risk of skeletal events over 2 years, according to a study appearing in the January 3 issue of JAMA.

Bone involvement in metastatic cancer is a common clinical problem. Zoledronic acid administered intravenously every 3 to 4 weeks reduces pain and the incidence of skeletal-related events, including clinical fracture, spinal cord compression, radiation to bone, and surgery to bone by 25 to 40 percent. Bisphosphonates are generally well tolerated, but are associated with toxic effects, including osteonecrosis (severe bone disease that results from disrupted blood supply) of the jaw, toxicity in the kidneys, and abnormally low levels of calcium in the blood. The optimal dosing interval for zoledronic acid has not been determined. In this study, Andrew L. Himelstein, M.D., of the Helen F. Graham Cancer Center & Research Institute, Newark, Del., and colleagues randomly assigned 1,822 patients with metastatic breast cancer, metastatic prostate cancer, or multiple myeloma who had at least 1 site of bone involvement to receive zoledronic acid administered intravenously every 4 weeks (n = 911) vs every 12 weeks (n = 911) for 2 years.

Among the patients who were randomized, 795 completed the study at 2 years. A total of 260 patients (29.5 percent) in the zoledronic acid every 4-week dosing group and 253 patients (28.6 percent) in the every 12-week dosing group experienced at least 1 skeletal-related event (defined as clinical fracture, spinal cord compression, radiation to bone, or surgery involving bone) within 2 years of randomization. The proportions of skeletal-related events did not differ significantly between groups. Pain scores, incidence of jaw osteonecrosis, and kidney dysfunction also did not differ significantly between the treatment groups.

“This longer interval may be an acceptable treatment option,” the authors write.

(doi:10.1001/jama.2016.19425; the study is available pre-embargo at the For the Media website)

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

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, JANUARY 3, 2017

Media Advisory: To contact David E. Stark, M.D., M.S., email Sasha Walek at sasha.walek@mssm.edu or call 917-471-4578.

Related material: JAMA Internal Medicine is publishing five articles on firearm violence, including two original investigations, two commentaries and an editorial. The articles are available at the For The Media website.

Previously published material: Other JAMA Network articles on firearm violence are available here.

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JAMA

In a study appearing in the January 3 issue of JAMA, David E. Stark, M.D., M.S., of the Icahn School of Medicine at Mount Sinai, New York, and Nigam H. Shah, M.B.B.S., Ph.D., of the Stanford University School of Medicine, Stanford, Calif., examined whether funding and publication of gun violence research are disproportionately low relative to the rate of death from gun violence.

The United States has the highest rate of gun-related deaths among industrialized countries, with more than 30,000 fatalities annually. To date, research on gun violence has been limited. A 1996 congressional appropriations bill stipulated that “none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention [CDC] may be used to advocate or promote gun control.” Similar restrictions were subsequently extended to other agencies (including the National Institutes of Health), and although the legislation does not ban gun-related research outright, it has been described as casting a pall over the research community.

For this study, CDC mortality statistics were accessed from 2004 to 2014 (the most recent year available) and the top 30 causes of death were determined. For each cause of death, MEDLINE was queried for the total number of publications between 2004 and 2015. Research funding data from 2004 to 2015 (all years available) were accessed from Federal RePORTER, a database of projects funded by U.S. federal agencies. To determine how research funding and publication volume correlated with mortality, analyses were performed using mortality rate as a predictor and funding or publication count as outcomes.

The researchers found that compared with other leading causes of death, gun violence was associated with less funding and fewer publications than predicted based on mortality rate. Gun violence had 1.6 percent of the funding predicted ($1.4 billion predicted, $22 million observed) and had 4.5 percent of the volume of publications predicted (38,897 predicted, 1,738 observed) from the analyses. Gun violence killed about as many individuals as sepsis. However, funding for gun violence research was about 0.7 percent of that for sepsis and publication volume about 4 percent. In relation to mortality rates, gun violence research was the least-researched cause of death and the second-least funded cause of death after falls.

“Injury research has been generally undersupported—a finding replicated in the present study,” the authors write. “Gun violence had less funding and fewer publications than comparable injury-related causes of death including motor vehicle accidents and poisonings. Given that gun violence disproportionately affects the young and inflicts many more nonfatal injuries than deaths, it is likely that the true magnitude of research funding disparity, when considering years of potential life lost or lived with disability, is even greater.”

(doi:10.1001/jama.2016.16215; the study is available pre-embargo at the For the Media website)

Editor’s Note: This work was supported by a grant from the National Library of Medicine of the National Institutes of Health. Both authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, JANUARY 3, 2017

Media Advisory: To contact Jian-Meng Liu, M.D., Ph.D., email liujm@pku.edu.cn.

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JAMA

Between 2008 and 2014, the overall annual rate in China of cesarean deliveries increased from 29 percent to 35 percent, although rates were declining in some of the largest urban areas, according to a study appearing in the January 3 issue of JAMA.

Overuse of cesarean delivery can jeopardize maternal and child health. Since 2002, reducing the cesarean rate has been a national priority in China. Prior estimates of China’s cesarean rate have been based on surveys with limited geographic coverage. Jian-Meng Liu, M.D., Ph.D., of the Peking University Health Science Center, Beijing, China and colleagues examined the overall rate and change in rate of cesarean deliveries and geographic variation in cesarean use in China. The study, covering every county (n = 2,865) in mainland China’s 31 provinces, used county-level aggregated information on the number of live births, cesarean deliveries, maternal deaths, and perinatal deaths. The information was collected by the Office for National Maternal & Child Health Statistics of China from 2008 through 2014.

Over the study period, there were 100,873,051 live births, of which 32,947,229 (33 percent) were by cesarean delivery. In 2008, 29 percent of live births were by cesarean delivery; in 2014, that figure was 35 percent. Rates varied markedly by province, from 4 percent to 63 percent in 2014. Despite the overall increase, by 2014 rates of cesarean deliveries in 14 of the nation’s 17 “super cities” (population 5 million or more) had declined by 4.1 to 17.5 percentage points from their earlier peak values. In 4 super cities with the largest decreases, there was no increase in maternal or perinatal mortality.

The authors note that the 2014 cesarean rate of 35 percent is more comparable with that of the United States (32 percent in 2014) than rates reported for such middle-income countries as Brazil (56 percent).

(doi:10.1001/jama.2016.18663; the study is available pre-embargo at the For the Media website)

Editor’s Note: This study was funded by grants from the National Health and Family Planning Commission of China, from the National Natural Science Foundation of China, and from the Beijing Young Talent Program. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, DECEMBER 27, 2016

Media Advisory: To contact Joseph L. Dieleman, Ph.D., email Kayla Albrecht at albrek7@uw.edu or call 206-897-3792. To contact editorial author Ezekiel J. Emanuel, M.D., Ph.D., email Katie Delach at Katharine.Delach@uphs.upenn.edu.

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JAMA

Estimates of U.S. spending on personal health care and public health showed substantial increases from 1996 through 2013, with spending on diabetes, ischemic heart disease, and low back and neck pain accounting for the highest amounts of spending by disease category, according to a study appearing in the December 27 issue of JAMA.

Health care spending in the United States is greater than in any other country in the world. According to estimates, spending on health care accounted for more than 17 percent of the U.S. economy in 2014. Between 2013 and 2014 alone, spending on health care increased 5.3 percent. Despite the resources spent on health care, much remains unknown about how much is spent for each condition, or how spending on these conditions differs across ages and time. Understanding how health care spending varies can help health system researchers and policy makers identify which conditions, age and sex groups, and types of care are driving spending increases.

Joseph L. Dieleman, Ph.D., of the Institute for Health Metrics and Evaluation, University of Washington, Seattle, and colleagues estimated U.S. spending on personal health care and public health, according to condition (i.e., disease or health category), age and sex group, and type of care. Government budgets, insurance claims, facility surveys, household surveys, and official U.S. records from 1996 through 2013 were collected and combined. In total, 183 sources of data were used to estimate spending for 155 conditions (including cancer, which was disaggregated [to divide into parts] into 29 conditions).

From 1996 through 2013, $30.1 trillion of personal health care spending was disaggregated by 155 conditions, age and sex group, and type of care. Among these conditions, diabetes had the highest health care spending in 2013, with an estimated $101.4 billion in spending, including 57.6 percent spent on pharmaceuticals and 23.5 percent spent on ambulatory care. Ischemic heart disease accounted for the second-highest amount of health care spending in 2013, with estimated spending of $88.l billion, and low back and neck pain accounted for the third-highest amount, with estimated health care spending of $87.6 billion.

The conditions with the highest spending levels varied by age, sex, type of care, and year. Personal health care spending increased for 143 of the 155 conditions from 1996 through 2013. Spending on low back and neck pain and on diabetes increased the most over the 18 years, by an estimated $57.2 billion and $64.4 billion, respectively. From 1996 through 2013, spending on emergency care and retail pharmaceuticals increased at the fastest rates (6.4 percent and 5.6 percent annual growth rate, respectively), which were higher than annual rates for spending on inpatient care (2.8 percent) and nursing facility care (2.5 percent).

The treatment of 2 risk factors, hypertension and hyperlipidemia, were also among the top 20 conditions incurring spending. Spending for these conditions has collectively increased at more than double the rate of total health spending, and together led to an estimated $135.7 billion in spending in 2013.

“The rate of change in annual spending varied considerably among different conditions and types of care. This information may have implications for efforts to control U.S. health care spending,” the authors write.

(doi:10.1001/jama.2016.16885; the study is available pre-embargo at the For the Media website)

Editor’s Note: This research was supported by a grant from the National Institute on Aging of the National Institutes of Health and by the Vitality Institute. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Editorial: How Can the United States Spend Its Health Care Dollars Better?

“In many walks of life-such as government, business, and even crime-it is always a good idea to ‘follow the money,’ although ‘pursuing the money’ may not be optimal. Dieleman et al have ‘followed’ the health care money, and the trail has led to important findings that could ultimately compel the United States to change how it spends its trillions of dollars in health care,” writes Ezekiel J. Emanuel, M.D., Ph.D., of the University of Pennsylvania, Philadelphia, in an accompanying editorial.

“At the very least, the data suggest that the United States needs to pay more attention to and provide higher-quality care for behavioral health and management of physical pain (such as low back, hip, and knee pain). There should also be an increased public health focus on lifestyle interventions and injury prevention. Finally, the findings by Dieleman et al suggest that the United States needs better strategies for nursing home care and for control of pharmaceutical costs. Initiatives in all of these areas are both necessary and timely. As the nation engages the quadrennial reexamination of national priorities that occurs with every new administration, these important suggestions will hopefully have the chance to both be considered and, ultimately, influence national policies and practices.”

(doi:10.1001/jama.2016.16739; the study is available pre-embargo at the For the Media website)

Editor’s Note: Please see the article for additional information, including financial disclosures, funding and support, etc.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, DECEMBER 27, 2016

Media Advisory: To contact Matthew M. Churpek, M.D., M.P.H., Ph.D., email John Easton (John.Easton@uchospitals.edu) and Matthew Wood (Matthew.Wood@uchospitals.edu).

To place an electronic embedded link to this study in your story  This link will be live at the embargo time: https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2016.15505

JAMA

In a study appearing in the December 27 issue of JAMA, Matthew M. Churpek, M.D., M.P.H., Ph.D., of the University of Chicago, and colleagues examined the risk to hospital ward occupants associated with patients on the same ward experiencing critical illness.

Major critical illness events, such as cardiopulmonary arrest and intensive care unit (ICU) transfer, disrupt workflow in a hospital ward. Other patients on the same ward may receive inadequate attention, especially if their care team is distracted by the emergency. This study of adult admissions (2009-2013) at the University of Chicago Medicine where rapid-response teams were used included 13 medical-surgical wards that were geographically distinct areas, had patient-nurse ratios of 4:1 on average and 1 charge nurse, and had approximately 20 beds per ward. Physician teams consisted of 1 attending and 2 to 3 resident trainees or a hospitalist. The researchers examined the number of patients on the same ward experiencing a critical illness event (cardiac arrest, ICU transfer, or death) anytime during the prior 6 hours.

Of 83,723 admissions, 4,286 experienced the primary outcome (179 cardiac arrests and 4,107 ICU transfers). The likelihood of cardiac arrest or ICU transfer within the next 6 hours was greater when 1 event (5.0 per 1,000-patient 6-hour blocks) or more than 1 event (7.1 per 1,000-patient 6-hour blocks) occurred during the prior 6 hours compared with no event (3.6 per 1,000-patient 6-hour blocks). In the fully adjusted model, when 1 or more patients developed critical illness, other ward patients’ risks for cardiac arrest or ICU transfer increased over the next 6 hours (1 event: adjusted absolute risk increase of 0.6 per 1,000-patient 6-hour blocks); greater than 1 event: adjusted absolute risk increase of 1.9 per 1,000-patient 6-hour blocks). Critical illness events were also associated with a decrease in other patients being discharged from the hospital within the next 6 hours.

“Although the absolute increased risk was small, these events were associated with high morbidity and mortality,” the authors write.

“The association may be explained by the diversion of resources to critically ill patients, which may result in caregivers being less attentive to other ward patients.”

(doi:10.1001/jama.2016.15505; the study is available pre-embargo at the For the Media website)

Editor’s Note: Dr. Churpek is supported by a career development award from the National Heart, Lung, and Blood Institute. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, DECEMBER 27, 2016

Media Advisory: To contact Leora I. Horwitz, M.D., M.H.S., email Elaine Meyer at Elaine.Meyer@nyumc.org.

To place an electronic embedded link to this study in your story  This link will be live at the embargo time: https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2016.18533

JAMA

Medicare fee-for-service patients at hospitals subject to penalties for excess readmissions had greater reductions in readmission rates compared with those at nonpenalized hospitals, particularly for targeted conditions, according to a study appearing in the December 27 issue of JAMA.

The Hospital Readmission Reduction Program (HRRP), enacted under the Patient Protection and Affordable Care Act, imposed financial penalties beginning in October 2012 for hospitals with higher-than-expected readmissions for acute myocardial infarction (AMI; heart attack), congestive heart failure (CHF), and pneumonia among their fee-for-service Medicare beneficiaries. Since the program’s inception, thousands of hospitals have been subjected to penalties now totaling nearly $1 billion. It is not known whether trends in readmission rates overall, as well as specifically for target and nontarget conditions, differed based on whether a hospital was subject to penalties under the HRRP.

Leora I. Horwitz, M.D., M.H.S., of the NYU School of Medicine, New York, and colleagues compared trends in readmission rates for target and nontarget conditions among Medicare fee-for-service beneficiaries older than 64 years discharged between January 1, 2008 and June 30, 2015, from 2,214 hospitals that were penalized and 1,283 hospitals that were not penalized under the HRRP.

The study included 48,137,102 hospitalizations of 20,351,161 Medicare beneficiaries. Between January 2008 and March 2010, prior to HRRP announcement, readmission rates were stable across hospitals (except AMI at nonpenalty hospitals). Following announcement of HRRP (March 2010), readmission rates for both target and nontarget conditions declined significantly faster for patients at hospitals later subject to financial penalties compared with those at nonpenalized hospitals (for AMI, additional decrease of -1.24 percentage points per year relative to nonpenalty discharges; for HF, -1.25; for pneumonia, -1.37; and for nontarget conditions, -0.27). For penalty hospitals, readmission rates for target conditions declined significantly faster compared with nontarget conditions (for AMI, additional decline of -0.49 percentage points per year relative to nontarget conditions; for HF,-0.90;and for pneumonia, -0.57), “which suggests that these hospitals specifically focused efforts to improve readmission outcomes for patients admitted for these target conditions,” the authors write.

In contrast, among nonpenalty hospitals, readmissions for target conditions declined similarly or more slowly compared with nontarget conditions. After HRRP implementation in October 2012, the rate of change for readmission rates plateaued, with the greatest relative change observed among hospitals subject to financial penalty.

“These findings may have implications for future policy programs aimed at reducing readmissions and may provide insight into the effect of external incentives.”

(doi:10.1001/jama.2016.18533; the study is available pre-embargo at the For the Media website)

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

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, DECEMBER 27, 2016

Media Advisory: To contact Dixon Chibanda, M.D., email dichi@zol.co.zw.

To place an electronic embedded link to this study in your story  This link will be live at the embargo time: https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2016.19102

JAMA

Among individuals screening positive for common mental disorders in Zimbabwe, lay health worker-administered, primary care-based problem-solving therapy with education and support compared with enhanced usual care resulted in improved symptoms at 6 months, according to a study appearing in the December 27 issue of JAMA.

Depression and anxiety are the most common mental disorders globally and major causes of disease burden in sub-Saharan Africa. Few people with common mental disorders in low-income settings have access to effective treatments. Task-shifting of mental health care to lay health workers (LHWs) might decrease the treatment gap. In this study, Dixon Chibanda, M.D., of the Zimbabwe AIDS Prevention Project-University of Zimbabwe Department of Community Medicine, Harare, Zimbabwe, and colleagues randomly assigned 24 clinics in Harare to an intervention or enhanced usual care (control). Study participants were clinic attenders 18 years or older who screened positive for common mental disorders (such as depression, generalized anxiety). The intervention comprised 6 sessions of individual problem-solving therapy delivered by trained, supervised LHWs plus an optional 6-session peer support program. The control group received standard care plus information, education, and support on common mental disorders.

Among 573 randomized patients, 86 percent were women, median age was 33 years, 42 percent were human immunodeficiency virus positive, and 91 percent completed follow-up at 6 months. Intervention group participants had fewer symptoms than control group participants on measures of common mental disorders. Intervention group participants also had lower risk of symptoms of depression (14 percent vs 50 percent).

“Scaled-up primary care integration of this intervention should be evaluated,” the authors write.

(doi:10.1001/jama.2016.19102; the study is available pre-embargo at the For the Media website)

Editor’s Note: This study was funded by Grand Challenges Canada. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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Embargoed for Release: 11 a.m. ET Monday, December 19, 2016

Media Advisory: To contact Deborah S. Hasin, Ph.D., email Stephanie Berger at sb2247@columbia.edu. To contact Wilson M. Compton, M.D., M.P.E., email the NIDA Press Office at media@nida.nih.gov.

To place an electronic embedded link to these studies in your story  These links will be live at the embargo time: https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2016.17383

https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2016.18900

JAMA

Two studies published online by JAMA examine trends in marijuana use among pregnant and nonpregnant women of reproductive age, and use for medical purposes among adults in the United States.

In one study, Deborah S. Hasin, Ph.D., Qiana L. Brown, Ph.D., M.P.H., L.C.S.W., of Columbia University, New York, and colleagues used data from women ages 18 through 44 years from the annual National Survey on Drug Use and Health from 2002 through 2014 to determine whether marijuana use has changed over time among pregnant and nonpregnant reproductive-aged women.

Between 2001 and 2013, marijuana use among U.S. adults more than doubled, many states legalized marijuana use, and attitudes toward marijuana became more permissive.  In aggregated 2007-2012 data, 3.9 percent of pregnant women and 7.6 percent of nonpregnant reproductive-aged women reported past-month marijuana use. Although the evidence is mixed, human and animal studies suggest that prenatal marijuana exposure may be associated with poor offspring outcomes (e.g., low birth weight, impaired neurodevelopment). The American College of Obstetricians and Gynecologists recommends that pregnant women and women contemplating pregnancy be screened for and discouraged from using marijuana  and  other substances.

Of the 200,510 women analyzed, 29.5 percent were ages 18 through 25 years and 70.5 percent were ages 26 through 44 years; 5.3 percent (n = 10,587) were pregnant. Among all pregnant women, the prevalence of past-month marijuana use increased from 2.4 percent in 2002 to 3.9 percent in 2014, an increase of 62 percent. The prevalence of past-month marijuana use was highest among those ages 18 to 25 years, reaching 7.5 percent in 2014, significantly higher than among those ages 26 to 44 years (2.1 percent). However, increases over time did not differ by age. Past-year use was higher overall, reaching 11.6 percent in 2014, with similar trends over time. In nonpregnant women, prevalences of past-month use (2014: 9.3 percent) and past-year use (2014: 16 percent) were higher overall, with similar trends over time. Increases over time in past-month marijuana use did not differ by pregnancy status.

“These results offer an important step toward understanding trends in marijuana use among women of reproductive age. Although the prevalence of past-month use among pregnant women (3.85 percent) is not high, the increases over time and potential adverse consequences of prenatal marijuana exposure suggest further monitoring and research are warranted. To ensure optimal maternal and child health, practitioners should screen and counsel pregnant women and women contemplating pregnancy about prenatal marijuana use,” the authors write.

(doi:10.1001/jama.2016.17383; the study is available pre-embargo at the For the Media website)

Editor’s Note: This work was supported by grants from the National Institute on Drug Abuse and the New York State Psychiatric Institute. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

In another study, Wilson M. Compton, M.D., M.P.E., of the National Institute on Drug Abuse, Bethesda, Md., and colleagues examined differences between medical and nonmedical marijuana users across all U.S. states.

By 2014, 23 states and the District of Columbia had legalized medical marijuana use, suggesting a need for information about national rates of marijuana use for medical purposes. Although 17 percent of past-year marijuana users reported use for medical purposes in states with medical marijuana legalization, physicians might recommend medical marijuana use to patients regardless of their residing states.

For this study, the researchers used data from adults 18 years and older who participated in the 2013-2014 National Survey on Drug Use and Health, which provides representative data on marijuana and other substance use among the U.S. population. Based on 96,100 respondents, 13 percent of U.S. adults had past-year marijuana use (nonmedical use only, 12 percent, medical use only, 0.8 percent, combined use, 0.5 percent). Among past-year adult marijuana users, 90 percent used nonmedically only, 6.2 percent used medically only, and 3.6 percent used medically and nonmedically. Of medical marijuana users, 79 percent resided in states where medical marijuana was legal, and 21 percent resided in other states.

“Using nationally representative data, 9.8 percent of adult marijuana users in the United States reported use for medical purposes. Although the prevalence of medical use was higher in states that had legalized medical marijuana, 21.2 percent of medical marijuana users resided in states that had not, suggesting physicians might recommend medical marijuana use regardless of legalization,” the authors write.

“Similarities in correlates of medical and nonmedical users, especially co-occurrence with psychiatric conditions and other substance use, suggest that some marijuana users may access medical marijuana without medical need. However, medical-only marijuana users differed from nonmedical-only users in ways that are consistent with use to address medical problems.”

(doi:10.1001/jama.2016.18900; the study is available pre-embargo at the For the Media website)

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

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, DECEMBER 20, 2016

Media Advisory: To contact Eyal Cohen, M.D., M.Sc., email Caitlin Johannesson at caitlin.johannesson@sickkids.ca.

To place an electronic embedded link to this study in your story  This link will be live at the embargo time: https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2016.18425

JAMA

In Denmark, having a child with a major congenital anomaly was associated with a small but statistically significant increased risk of death in the mother compared with women without an affected child, according to a study appearing in the December 20 issue of JAMA. A major congenital anomaly is a structural change (such as cleft palate) that has significant medical, social or cosmetic consequences for the affected individual; this type of anomaly typically requires medical intervention.

Major structural or genetic congenital anomalies affect approximately 2 percent to 5 percent of all births in the United States and Europe. Mothers of children born with major congenital anomalies face serious challenges such as high financial pressures, as well as the burden of providing care to a child with complex needs within the home setting, which can impair a mother’s health. Little is known about the long-term health consequences for the mother.

Eyal Cohen, M.D., M.Sc., of the Hospital for Sick Children, University of Toronto, Toronto, and colleagues assessed whether the birth of an infant with a major congenital anomaly was subsequently associated with an increased risk of death of the infant’s mother. The population-based study (n = 455,250 women) used individual-level linked Danish registry data for mothers who gave birth to an infant with a major congenital anomaly between 1979 and 2010, with follow-up until December 31, 2014. A comparison group was constructed by randomly sampling, for each mother with an affected infant, up to 10 mothers matched on maternal age, parity (the number of children a woman has given birth to), and year of infant’s birth.

Mothers in both groups were an average age of 29 years at delivery. After a median follow-up of 21 years, there were 1,275 deaths (1.60 per 1,000 person-years) among 41,508 mothers of a child with a major congenital anomaly vs 10,112 deaths (1.27 per 1,000 person-years) among 413,742 mothers in the comparison group. Mothers with affected infants were more likely to die of cardiovascular disease, respiratory disease, and other natural causes.

“The birth of a child with major congenital anomalies was associated with a small increased risk of death of mothers. This elevated risk was noted both during the first 10 years after the child’s birth, when the mother was likely caring for a dependent child with substantial health needs, and after longer follow-up. No single cause of death explained this association,” the authors write.

The researchers note that the clinical importance of this association is uncertain.

(doi:10.1001/jama.2016.18425; the study is available pre-embargo at the For the Media website)

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

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, DECEMBER 20, 2016

Media Advisory: To contact Roger Zemek, M.D., email Adrienne Vienneau at avienneau@cheo.on.ca.

Video Content: There is a JAMA Report video for this study, and it will be available under embargo at this link at 2 p.m. ET Friday, December 16, and include broadcast-quality downloadable video files, B-roll, scripts and other images. Please email JAMAReport@synapticdigital.com with any questions.

To place an electronic embedded link to this study in your story  This link will be live at the embargo time: https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2016.17396

JAMA

Among children and adolescents who experienced a concussion, physical activity within 7 days of injury compared with no physical activity was associated with reduced risk of persistent postconcussive symptoms at 28 days, according to a study appearing in the December 20 issue of JAMA.

Rest has long been considered the cornerstone of concussion management, and pediatric guidelines universally recommend an initial period of physical rest following a concussion until symptoms have resolved. No clear evidence has determined that avoiding physical activity expedites recovery. Roger Zemek, M.D., of Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada, and colleagues conducted a study that included 3,063 children and adolescents with acute concussion from 9 Pediatric Emergency Research Canada network emergency departments. Physical activity participation and postconcussive symptom severity were rated using standardized questionnaires in the emergency department and at days 7 and 28 postinjury. Persistent postconcussive symptoms (PPCS) were assessed at 28 days postenrollment.

The final study group included 2,413 participants, of whom PPCS at 28 days occurred in 733 (30 percent); 1,677 (70 percent) participated in physical activity within 7 days, primarily with light aerobic exercise. Of the patients who engaged in early physical activity, 31 percent were symptom free and 48 percent had at least 3 persistent or worsening postconcussive symptoms at day 7. Of those reporting engaging in no physical activity at day 7, 80 percent had at least 3 persistent or worsening postconcussive symptoms at day 7. Resumption of physical activity within 7 days postconcussion was associated with a lower risk of PPCS as compared with no physical activity. This finding was consistent across analytic approaches and intensity of exercise.

“Early physical activity could mitigate the undesired effects of physical and mental deconditioning associated with prolonged rest. Regardless of potential benefit, caution in the immediate postinjury period is prudent; participation in activities that might introduce risk for collision (e.g., resumption of contact sports) or falls (e.g., skiing, skating, bicycling) should remain prohibited until clearance by a health professional to reduce the risk for a potentially more serious second concussion during a period of increased vulnerability,” the authors write.

“A well-designed randomized clinical trial is needed to determine the benefits of early physical activity following concussion.”

(doi:10.1001/jama.2016.17396; the study is available pre-embargo at the For the Media website)

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

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, DECEMBER 20, 2016

Media Advisory: To contact the U.S. Preventive Services Task Force, email the Media Coordinator at Newsroom@USPSTF.net or call 202-572-2044.

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JAMA

The U.S. Preventive Services Task Force (USPSTF) recommends against routine serologic screening (via a blood test) for genital herpes simplex virus infection in asymptomatic adolescents and adults, including those who are pregnant. The report appears in the December 20 issue of JAMA.

This is a D recommendation, indicating that there is moderate or high certainty that the screening has no net benefit or that the harms outweigh the benefits.

Genital herpes is a prevalent sexually transmitted infection in the United States; the Centers for Disease Control and Prevention estimates that almost 1 in 6 persons ages 14 to 49 years have genital herpes. Genital herpes infection is caused by 2 subtypes of herpes simplex virus (HSV), HSV-1 and HSV-2. Unlike other infections for which screening is recommended, HSV infection may not have a long asymptomatic period during which screening, early identification, and treatment may alter its course. Antiviral medications may provide symptomatic relief from outbreaks; however, these medications do not cure HSV infection. Although transmission of HSV can occur between an infected pregnant woman and her infant during vaginal delivery, interventions can help reduce transmission.

To update its 2005 recommendation on screening for genital herpes, the USPSTF reviewed the evidence on the accuracy, benefits, and harms of serologic screening for HSV-2 infection in asymptomatic persons, including those who are pregnant, as well as the effectiveness and harms of preventive medications and behavioral counseling interventions to reduce future symptomatic episodes and transmission to others.

The USPSTF is an independent, volunteer panel of experts that makes recommendations about the effectiveness of specific preventive care services such as screenings, counseling services, and preventive medications.

Detection

In the past, most cases of genital herpes in the United States have been caused by infection with HSV-2. Adequate evidence suggests that the most widely used, currently available serologic screening test for HSV-2 approved by the U.S. Food and Drug Administration is not suitable for population-based screening, based on its low specificity, the lack of widely available confirmatory testing, and its high false-positive rate. Rates of genital herpes due to HSV-1 infection in the United States may be increasing. While HSV-1 infection can be identified by serologic tests, the tests cannot determine if the site of infection is oral or genital; thus, these serologic tests are not useful for screening for asymptomatic genital herpes resulting from HSV-1 infection.

Benefits of Early Detection and Intervention

Based on limited evidence from a small number of trials on the potential benefit of screening and interventions in asymptomatic populations and an understanding of the natural history and epidemiology of genital HSV infection, the USPSTF concluded that the evidence is adequate to bound the potential benefits of screening in asymptomatic adolescents and adults, including those who are pregnant, as no greater than small.

Harms of Early Detection and Intervention

Based on evidence on potential harms from a small number of trials, the high false-positive rate of the screening tests, and the potential anxiety and disruption of personal relationships related to diagnosis, the USPSTF found that the evidence is adequate to bound the potential harms of screening in asymptomatic adolescents and adults, including those who are pregnant, as at least moderate.

Summary

Based on the natural history of HSV infection, its epidemiology, and the available evidence on the accuracy of serologic screening tests, the USPSTF concluded that the harms outweigh the benefits of serologic screening for genital HSV infection in asymptomatic adolescents and adults, including those who are pregnant.

(doi:10.1001/jama.2016.16776; the full report is available pre-embargo to the media at the For the Media website)

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

Note: More information about the U.S. Preventive Services Task Force, its process, and its recommendations can be found on the newsroom page of its website.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, DECEMBER 20, 2016

Media Advisory: To contact Anna Wald, M.D., M.P.H., email Susan Gregg at sghanson@uw.edu.

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JAMA

In a study appearing in the December 20 issue of JAMA, Anna Wald, M.D., M.P.H., of the University of Washington & Fred Hutchinson Cancer Research Center, Seattle, and colleagues compared the medications pritelivir and valacyclovir for reducing genital herpes simplex virus shedding and lesions in persons with recurrent genital herpes.

The treatment for genital herpes simplex virus (HSV) infections relies on the nucleoside analogues acyclovir, valacyclovir, or famciclovir administered either for each recurrence or daily to prevent recurrences. In addition, valacyclovir, when taken daily has been shown to reduce the risk of HSV-2 transmission to susceptible partners. However, the protection is only partial (approximately 50 percent), likely because these drugs neither completely inhibit genital viral shedding (when the virus is active and potentially transmissible to sexual partners). Alternative agents to treat HSV infections are needed.

For this crossover study, 91 participants (adults with 4 to 9 annual genital HSV-2 recurrences) were randomly assigned, 45 to receive pritelivir first, a different class of medication for genital herpes, and 46 to receive valacyclovir first. Participants took the first drug for 28 days followed by 28 days of washout before taking the second drug for 28 days. Throughout treatment, the participants collected genital swabs 4 times daily for HSV testing. The U.S. Food and Drug Administration placed the trial on clinical hold based on findings in a concurrent nonclinical toxicity study, and the sponsor terminated the study.

Of the 91 randomized participants, 56 had completed both treatment periods at the time of the study’s termination. In intent-to-treat analyses, HSV shedding was detected in 2.4 percent of swabs during pritelivir treatment compared with 5.3 percent during valacyclovir treatment. Genital lesions were present on 1.9 percent of days in the pritelivir group vs 3.9 percent in the valacyclovir group. The frequency of shedding episodes did not differ by group. Quantity of virus shed was decreased significantly during pritelivir treatment compared with valacyclovir treatment. The frequency of pain was reduced in the pritelivir group compared to the valacyclovir group.

Treatment-emergent adverse events occurred in 62 percent of participants in the pritelivir group and 69 percent of participants in the valacyclovir group.

“Further research is needed to assess longer-term efficacy and safety,” the authors write.

(doi:10.1001/jama.2016.18189; the study is available pre-embargo at the For the Media website)

Editor’s Note: This study was supported by AiCuris GmbH & Co KG. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.

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RELEASED: DECEMBER 13, 2016

Media Advisory: To contact Margaret A. Honein, Ph.D., email Belsie Gonzalez at Media@cdc.gov.

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JAMA

Among pregnant women in the United States with completed pregnancies and laboratory evidence of possible recent Zika infection, 6 percent overall had a fetus or infant with evidence of a Zika-related birth defect, and among women with first-trimester Zika infection, 11 percent had a fetus or infant with a birth defect, findings that support the importance of screening pregnant women for Zika virus exposure, according to a study published online by JAMA.

Zika virus infection during pregnancy can cause microcephaly and brain abnormalities; however, the magnitude of risk is unknown. Understanding the risk of birth defects may help guide communication, prevention, and planning efforts. Margaret A. Honein, Ph.D., of the Centers for Disease Control and Prevention, Atlanta, and colleagues estimated the preliminary proportion of fetuses or infants with birth defects after maternal Zika virus infection by trimester of infection and maternal symptoms. The study included completed pregnancies with maternal, fetal, or infant laboratory evidence of possible recent Zika virus infection and outcomes reported in the continental United States and Hawaii from January 15 to September 22, 2016, in the U.S. Zika Pregnancy Registry (USZPR), a collaboration between the CDC and state and local health departments.

Among 442 completed pregnancies in women (median age, 28 years) with laboratory evidence of possible recent Zika virus infection, birth defects potentially related to Zika virus were identified in 26 (6 percent) fetuses or infants. There were 21 infants with birth defects among 395 live births and 5 fetuses with birth defects among 47 pregnancy losses. Birth defects were reported for 16 of 271 (6 percent) pregnant asymptomatic women and 10 of 167 (6 percent) symptomatic pregnant women.

Of the 26 affected fetuses or infants, 4 had microcephaly and no reported neuroimaging, 14 had microcephaly and brain abnormalities, and 4 had brain abnormalities without microcephaly. Infants with microcephaly (18/442) represent 4 percent of completed pregnancies. Birth defects were reported in 9 of 85 (11 percent) completed pregnancies with maternal symptoms or exposure exclusively in the first trimester (or periconceptional period), with no reports of birth defects among fetuses or infants with prenatal exposure to Zika virus infection only in the second or trimesters.

The authors write that based on data from population-based birth defects surveillance programs for 2009-2013, the median prevalence of microcephaly in the United States was approximately 7 per 10,000 live births.  Among completed pregnancies in the USZPR, 4 percent had a finding of microcephaly, a prevalence that is substantially higher than the background prevalence of microcephaly.

The researchers add that the findings in this report emphasize the need for pregnant women to avoid travel to areas with active Zika virus transmission and consistently and correctly use condoms to prevent sexual transmission throughout pregnancy if their partner has recently traveled to an area of active Zika virus transmission.

The CDC’s guidelines recommend “Zika virus testing for all women with possible exposure during pregnancy, regardless of symptoms. The findings that there were similar proportions with birth defects among those with symptomatic and asymptomatic maternal infections supports the importance of screening all pregnant women for Zika virus exposure and testing in accordance with CDC guidance,” the authors write.

(doi:10.1001/jama.2016.19006; the study is available pre-embargo at the For the Media website)

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

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, DECEMBER 13, 2016

Media Advisory: To contact Christopher J. L. Murray, M.D., D.Phil., email Kayla Albrecht at albrek7@uw.edu.

Video Content: There is a JAMA Report video for this study, and it will be available under embargo at this link at 2 p.m. ET Friday, December 9, and include broadcast-quality downloadable video files, B-roll, scripts and other images. Please email JAMAReport@synapticdigital.com with any questions.

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JAMA

In an analysis of U.S. cause-specific county-level mortality rates from 1980 through 2014, there were large between-county differences for every cause of death, although geographic patterns varied substantially by cause of death, according to a study appearing in the December 13 issue of JAMA.

Among counties within the United States, relatively little is known about geographic patterns and inequalities in mortality by underlying cause of death. Information about variation in cause-specific mortality could provide important insights into geographic inequalities and divergent trends in life expectancy.

Christopher J. L. Murray, M.D., D.Phil., of the Institute for Health Metrics and Evaluation, University of Washington, Seattle, and colleagues used death registration data from the National Vital Statistics System to estimate annual county-level mortality rates for 21 causes of death. These estimates were raked (scaled along multiple dimensions) to ensure consistency between causes and with existing national-level estimates. Geographic patterns in the age-standardized mortality rates in 2014 and in the change in the age-standardized mortality rates between 1980 and 2014 for the 10 highest-burden causes were determined.

A total of 80,412,524 deaths were recorded from January 1, 1980, through December 31, 2014, in the United States. Of these, 19.4 million deaths were assigned garbage codes (implausible or insufficiently specific cause of death codes). Mortality rates were analyzed for 3,110 counties or groups of counties. Large between-county disparities were evident for every cause, with the gap in age-standardized mortality rates between counties in the 90th and 10th percentiles varying from 14 deaths per 100,000 population (cirrhosis and chronic liver diseases) to 147 deaths per 100,000 population (cardiovascular diseases). Geographic regions with elevated mortality rates differed among causes: for example, cardiovascular disease mortality tended to be highest along the southern half of the Mississippi River, while mortality rates from self-harm and interpersonal violence were elevated in southwestern counties, and mortality rates from chronic respiratory disease were highest in counties in eastern Kentucky and western West Virginia.

Counties also varied widely in terms of the change in cause-specific mortality rates between 1980 and 2014. For most causes (e.g., neoplasms, neurological disorders, and self-harm and interpersonal violence), both increases and decreases in county-level mortality rates were observed.

“Geographic patterns differed significantly across causes, underscoring the importance of considering cause-specific mortality in addition to measures of all-cause mortality such as life expectancy. For some causes (e.g., cardiovascular diseases), counties in the south and Appalachia had elevated mortality, while counties in western states had mortality much lower than average, a pattern that, broadly speaking, has also been documented in maps of life expectancy as well as maps of risk factors such as smoking, physical inactivity, and obesity. However, other causes had very different geographic patterns. Moreover, for some causes (e.g., mental and substance use disorders), there were striking clusters of counties with very high mortality rates. Geographic patterns in changes over time were similarly variable among causes,” the authors write.

“There are a number of potential uses for these estimates: state and county health departments could use county-level mortality estimates to identify pressing local needs and to tailor policies and programs accordingly; physicians could use these estimates to better understand the health concerns of the populations they serve; researchers could identify counties that have done unexpectedly well or poorly with regard to a particular cause of death and that warrant additional study to identify factors driving these trends; and communities can use these estimates as evidence when advocating for change. Further, for causes of death for which effective treatments are available, variation in mortality rates can highlight where access to treatment or quality of care is a pressing problem.”

(doi:10.1001/jama.2016.13645; the study is available pre-embargo at the For the Media website)

Editor’s Note: This work was funded by a grant from the Robert Wood Johnson Foundation and the National Institute on Aging, and a philanthropic gift from John W. Stanton and Theresa E. Gillespie. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, DECEMBER 6, 2016

Media Advisory: To contact Douglas A. Mata, M.D., M.P.H., email Elaine St. Peter at estpeter@partners.org.

To place an electronic embedded link to this study in your story  This link will be live at the embargo time: https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2016.17324

JAMA

A review and analysis of nearly 200 studies involving 129,000 medical students in 47 countries found that the prevalence of depression or depressive symptoms was 27 percent, that 11 percent reported suicidal ideation during medical school, and only about 16 percent of students who screened positive for depression reportedly sought treatment, according to a study appearing in the December 6 issue of JAMA, a medical education theme issue.

Studies have suggested that medical students experience high rates of depression and suicidal ideation; however, prevalence estimates vary across studies. Reliable estimates of depression and suicidal ideation prevalence during medical training are important for informing efforts to prevent, treat, and identify causes of emotional distress among medical students, especially in light of recent work revealing a high prevalence of depression in resident physicians.

Douglas A. Mata, M.D., M.P.H., of Brigham and Women’s Hospital and Harvard Medical School, Boston, and colleagues conducted a systematic review and meta-analysis of published studies of depression, depressive symptoms, and suicidal ideation in undergraduate medical trainees. The researchers identified 195 studies that met criteria for inclusion in the analysis.

Depression or depressive symptom prevalence data were extracted from 167 cross-sectional studies (n = 116,628) and 16 longitudinal studies (n = 5,728) from 43 countries. The overall pooled crude prevalence of depression or depressive symptoms was 27 percent (37,933/122,356 individuals). Summary prevalence estimates ranged across assessment methods from 9 percent to 56 percent. Depressive symptom prevalence remained relatively constant over the period studied (baseline survey year range of 1982-2015). In the 9 longitudinal studies that assessed depressive symptoms before and during medical school, the median absolute increase in symptoms was 14 percent. Prevalence estimates did not significantly differ between studies of only preclinical students and studies of only clinical students (23.7 percent vs 22.4 percent). The percentage of medical students screening positive for depression who sought psychiatric treatment was 16 percent (110/954 individuals).

Suicidal ideation prevalence data were extracted from 24 cross-sectional studies (n = 21,002) from 15 countries. The overall pooled crude prevalence of suicidal ideation was 11 percent (2,043/21,002 individuals). Summary prevalence estimates ranged across assessment methods from 7 percent to 24 percent.

“The present analysis builds on recent work demonstrating a high prevalence of depression among resident physicians, and the concordance between the summary prevalence estimates (27.2 percent in students vs 28.8 percent in residents) suggests that depression is a problem affecting all levels of medical training. Taken together, these data suggest that depressive and suicidal symptoms in medical trainees may adversely affect the long-term health of physicians as well as the quality of care delivered in academic medical centers,” the authors write.

“Possible causes of depressive and suicidal symptomatology in medical students likely include stress and anxiety secondary to the competitiveness of medical school. Restructuring medical school curricula and student evaluations might ameliorate these stresses. Future research should also determine how strongly depression in medical school predicts depression during residency and whether interventions that reduce depression in medical students carry over in their effectiveness when those students transition to residency. Furthermore, efforts are continually needed to reduce barriers to mental health services, including addressing the stigma of depression.”

“Further research is needed to identify strategies for preventing and treating these disorders in this population,” the researchers conclude.

(doi:10.1001/jama.2016.17324; the study is available pre-embargo at the For the Media website)

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

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, DECEMBER 6, 2016

Media Advisory: To contact Joshua L. Denson, M.D., email David Kelly at david.kelly@ucdenver.edu.

To place an electronic embedded link to this study in your story  This link will be live at the embargo time: https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2016.17424

JAMA

Among patients admitted to internal medicine services in 10 Veterans Affairs hospitals, end-of-rotation transition in care was associated with significantly higher in-hospital mortality in an unrestricted analysis that included most patients, but not in an alternative restricted analysis, according to a study appearing in the December 6 issue of JAMA, a medical education theme issue.

A handoff is defined as the transition of patient care to another clinician through the transfer of information, responsibility, and authority. Increasing evidence indicates shift-to-shift handoffs are a source of adverse events and errors, and conversely, that interventions to improve such handoffs may have meaningful benefits to patient safety. However, the association between end-of-rotation transition and adverse events is uncertain.

Joshua L. Denson, M.D., of the University of Colorado School of Medicine, Aurora, and colleagues examined the association of end-of-rotation house staff transitions with mortality among hospitalized patients. The study included patients admitted to internal medicine services at 10 university-affiliated U.S. Veterans Health Administration hospitals (2008-2014). Transition patients (defined as those admitted prior to an end-of-rotation transition who died or were discharged within 7 days following transition) were stratified by type of transition (intern only, resident only, or intern + resident) and compared with all other discharges (control). An alternative analysis comparing admissions within 2 days before transition with admissions on the same 2 days 2 weeks later was also conducted.

Among 230,701 patient discharges (average age, 66 years; median length of stay, 3 days), overall mortality was 2.2 percent in-hospital, 9.5 percent at 30 days, and 14 percent at 90 days. Adjusted hospital mortality was significantly greater in transition vs control patients for the intern-only and intern + resident groups, but not for the resident-only group. Adjusted 30-day and 90-day mortality rates were greater in all transition vs control comparisons. Accreditation Council for Graduate Medical Education (ACGME) duty-hour changes (limiting first-year residents [interns] to 16 continuous hours of work) was associated with greater adjusted hospital mortality for transition patients in the intern-only and intern + resident groups than for controls. The alternative analyses did not demonstrate any significant differences in mortality between transition and control groups. There were no significant associations with readmission rates.

“Together, these results showed that end-of­ rotation transitions in care were associated with increased mortality; however, this increased risk may be limited to longer-stay, complex patients with greater comorbidities or those discharged soon after the transition,” the authors write.

(doi:10.1001/jama.2016.17424; the study is available pre-embargo at the For the Media website)

Editor’s Note: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, DECEMBER 6, 2016

Media Advisory: To contact Charlie M. Wray, D.O., M.S., email Matthew Coulson at Matthew.Coulson@va.gov.

To place an electronic embedded link to this study in your story  This link will be live at the embargo time: https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2016.17786

JAMA

Survey responses from internal medicine residency program directors reported large variation in implementation of recommended handoff techniques and educational strategies to teach handoffs in internal medicine training programs, according to a study appearing in the December 6 issue of JAMA, a medical education theme issue.

National organizations have recommended specific strategies to improve resident handoffs, such as dedicated time and space to perform handoffs, standardized templates, and supervision by senior physicians. How these best-practice recommendations are implemented across programs is unknown. Charlie M. Wray, D.O., M.S., of the San Francisco Veterans Affairs Medical Center, and colleagues examined internal medicine residency program directors’ responses to the 2014 Association of Program Directors in Internal Medicine electronic survey, in which they were asked to report implementation of handoff strategies within 3 domains: properties of verbal handoffs (i.e., dedicated time), properties of written handoffs (i.e., use of electronic health records [EHRs]), and educational resources (i.e., didactic lectures).

Among all programs, 234 of 361 (65 percent) responded to the survey. Most program directors (61 percent) were very or somewhat satisfied with the handoff strategies used at their institutions. Implementation of handoff strategies ranged from 6 percent to 67 percent, with the most frequent strategies being dedicated time (67 percent), didactic lectures (64 percent), overlapping shifts (61 percent), ward-based teaching by residents (61 percent), and allowing the receiver access to patient records (60 percent).

Statistically significant differences in the proportion of program directors who were satisfied were observed for those implementing vs not implementing 4 strategies: having a dedicated room, supervision by a senior resident, EHR-enabled handoff, and receiver given written copy of sign out. Implementation ranged between 47 percent (EHR-enabled handoff) and 59 percent (receiver given written copy of sign out), with 12 percent implementing all 4 strategies.

“Discordance between low implementation and high program director satisfaction may indicate confusion regarding which practices are best for their setting because of the lack of strong or consistent evidence,” the authors write. “Also, program directors may want to implement these handoff strategies but face significant barriers, such as an EHR unable to facilitate shift handoffs or lack of local expertise to lead interactive workshops.”

“Future work to disseminate and implement recommended handoff strategies is warranted.”
(doi:10.1001/jama.2016.17786; the study is available pre-embargo at the For the Media website)

Editor’s Note: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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EMBARGOED FOR RELEASE: 11 A.M. (ET) TUESDAY, DECEMBER 6, 2016

Media Advisory: To contact Lisa M. Meeks, Ph.D., email Laura Kurtzman at Laura.Kurtzman@ucsf.edu.

To place an electronic embedded link to this study in your story  This link will be live at the embargo time: https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2016.10544

JAMA

New research has identified a higher prevalence of disability among students in U.S. allopathic medical schools (2.7 percent) than prior studies (0.3 percent to 0.6 percent), according to a study appearing in the December 6 issue of JAMA, a medical education theme issue.

Studying the performance of medical students with disabilities requires a better understanding of the prevalence and categories of disabilities represented. It remains unclear how many medical students have disabilities; prior estimates are out-of-date and psychological, learning, and chronic health disabilities have not been evaluated. For this study, Lisa M. Meeks, Ph.D., of the University of California, San Francisco School of Medicine, and Kurt R. Herzer, Ph.D., M.Sc., of the Johns Hopkins School of Medicine, Baltimore, assessed the prevalence of all disabilities and the accommodations in use at allopathic medical schools in the United States.

From December 2014 through February 2016, an electronic, web-based survey was sent to institutionally designated disability administrators at eligible allopathic medical schools who have a federally mandated duty to assist qualified students with disabilities. The survey was designed by experts in medical school disability administration based on provisions of the Americans with Disabilities Act and prior research. The survey assessed the following domains: (1) total number of self-disclosed or registered students with disabilities receiving accommodations, (2) demographic characteristics of students with disabilities, (3) categories of disabilities, and (4) approved accommodations.

One hundred forty-five schools were identified; 12 were excluded. Of the 133 eligible schools, 91 completed the survey (68 percent) and 89 reported complete data and were included in the analysis. Respondents identified 1,547 students with disabilities (43 percent male), representing 2.7 percent of the total enrollment and ranging from 0 percent to 12 percent. Of these students, 98 percent received accommodations. Attention-deficit/hyperactivity disorder (ADHD) was the most common disability (34 percent), followed by learning disabilities (22 percent) and psychological disabilities (20 percent). Mobility and sensory disabilities were less common. School-based testing accommodations were most frequently used (98 percent); clinical accommodations were less frequently used.

“These results underscore the limitations of studying isolated subtypes of disabilities (i.e., only mobility impairments), which may underestimate this population. The preponderance of students with ADHD, learning disabilities, and psychological disabilities suggests that these disability subtypes should be included in future research efforts, such as studies assessing the performance of appropriately accommodated students,” the authors write.

(doi:10.1001/jama.2016.10544; the study is available pre-embargo at the For the Media website)

Editor’s Note: This work was supported by a grant from the National Institute of General Medical Sciences’ Medical Scientist Training Program and from the National Institute on Aging. Both authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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