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Dabigatran is approved for use in atrial fibrillation. This analysis estimated quality-adjusted survival, costs, and cost-effectiveness of dabigatran versus adjusted-dose warfarin for preventing ischemic stroke in patients aged 65 years or older with nonvalvular atrial fibrillation. Incremental cost-effectiveness ratios compared with warfarin were $51 229 per quality-adjusted life-year (QALY) for low-dose dabigatran and $45 372 per QALY for high-dose dabigatran. The model was sensitive to the cost of dabigatran but relatively insensitive to other inputs, suggesting that dabigatran may be a cost-effective alternative to warfarin.
Tonelli and colleagues developed a new staging system for chronic kidney disease (CKD) that incorporates estimated glomerular filtration rate (eGFR) and proteinuria to predict which patients will develop worsening CKD. Compared with staging based on eGFR alone, the new system was more likely to correctly reclassify persons who did not develop worsening CKD than those who did. Using a staging system that considers proteinuria in combination with eGFR may reduce unnecessary referrals for care but delay referral for some patients who will develop kidney failure.
The degree of protection against colorectal cancer (CRC) that colonoscopy can achieve in a population setting is uncertain. In this study from Germany, colonoscopy in the preceding 10 years was associated with 77% lower risk for CRC. Strong risk reduction was observed for almost all cancer stages and ages. Risk reduction increased over time in both the right and the left colon.
In this series, 28 patients with retroperitoneal fibrosis received prednisone, 40 mg/d, tapered over 6 months, and mycophenolate mofetil, 1000 mg twice daily, for a mean of 24.3 months. Systemic symptoms resolved in all patients; 89% had a 25% or greater reduction in periaortic mass. Elevated erythrocyte sedimentation rate and serum creatinine level and decreased hemoglobin level normalized in all patients, and disease recurred in 2 patients.
KRAS mutations have been investigated as predictive biomarkers for treatment of advanced CRC with anti–epidermal growth factor receptor (EGFR) antibodies. This review assessed whether KRAS mutation status modifies effects of anti-EGFR–based treatments for advanced CRC and whether KRAS status predicts clinical outcomes. No significant benefit was found for overall or progression-free survival from anti-EGFR therapy versus best supportive care or cytotoxic chemotherapy among KRAS-positive patients. However, evidence favors anti-EGFR therapy among KRAS wild-type patients.
Research suggests that evidence from prior trials is often not accounted for in reports of subsequent randomized, controlled trials (RCTs). This review of 227 meta-analyses published in 2004 that combined 4 or more trials assessed whether the published report of each trial included in the meta-analyses cited trials that preceded it by more than 1 year. Fewer than one quarter of relevant trials were cited. Of the 1101 RCTs for which there were 5 or more relevant prior trials, 23% cited none and 23% cited only 1. Research is needed to explore the explanations for and consequences of this lack of citation of relevant prior research.
Physicians often fail to recognize substance use disorders and, as a result, provide inadequate patient care. To address this deficit, the Betty Ford Institute convened a meeting of experts who developed 5 recommendations focused on improving training in substance abuse in primary care residency programs.
The recent American College of Physicians (ACP) position paper on the patient-centered medical home neighbor (PCMH-N) outlines policies for how patient-centered medical homes (PCMHs) should interact with subspecialty practices to improve delivery of health care. This issue introduces 2 commentaries on the ACP PCMH-N position paper, one from a general internist and one from a subspecialist.
Dr. Sinsky believes that PCMH-Ns move us toward improved care for complex patients. However, effective transformation of the U.S. health care system around personalized PCMHs embedded in functional PCMH-Ns will require better staffing models; more robust electronic information tools; aligned incentives for quality and efficiency within payment and regulatory policies; and a culture of greater engagement of patients, their families, and communities.
Dr. Yee views PCMH-Ns as a significant step toward improving care coordination and quality. Yet, construction of a well-functioning medical neighborhood will require some refinements. The proposed interaction typology between PCMHs and PCMH-Ns must be expanded to include innovative forms of interaction that do not depend on traditional office visits, the recommended care coordination agreements must be better standardized, and genuine dialogue between PCMH and PCMH-N practices must be realized.
In this issue, Tonelli and colleagues compared a new classification for patients with CKD that incorporates eGFR and proteinuria with the current system that considers only eGFR. The editorialists conclude that adding proteinuria to GFR stages enables better description of CKD prognosis, but further study is needed on whether use of prognostic instruments improves CKD management and patient outcomes.
Brenner and colleagues' study in this issue offers reassurance that colonoscopy can provide substantial protection against right- and left-sided CRC. The editorialist discusses why these findings differ from recent studies showing lower-than-expected rates of protection against CRC and comments on the role of quality of endoscopy in detection and prevention of cancer.