Cover photograph by Shalinee Bhoobun, MD
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IN THIS ISSUE
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The U.S. government's meaningful use program incentivizes providers to use electronic health records to improve health care quality. This study compared electronic and manual chart documentation for 12 process-of-care measures in a single medical system and found that electronic reporting overestimated provision of some measures (cholesterol control in diabetic patients) and underestimated others (appropriate asthma medication and pneumococcal vaccination). Electronic health record platforms must facilitate accurate reporting by providers if they are to be a viable way to improve health care quality.
HIV treatment guidelines in the United States recommend first-line treatment with daily administration of a single pill that contains 3 branded drugs. In a mathematical simulation, daily administration of 3 pills (2 generic drugs and 1 branded drug) taken simultaneously dramatically reduced cost and only slightly reduced survival gain compared with the fully branded regimen. The use of first-line, generic-based HIV treatment in the United States could save nearly $1 billion a year.
d-Dimer testing is sensitive but not specific for diagnosing deep venous thrombosis (DVT). This trial compared d-dimer testing of all patients with testing based on clinical pretest probability among those with suspected first DVT. The latter strategy identified equal proportions of patients with DVT and substantially reduced the number of d-dimer assays and ultrasonographies performed. A d-dimer testing strategy based on probability of DVT is as safe as and more efficient than testing everyone.
This review examined the evidence on hepatitis C virus (HCV) screening in asymptomatic adults without known liver enzyme abnormalities. It found no direct evidence on the effects of HCV screening versus no screening on clinical outcomes or on the clinical effects of alternative screening strategies. Although screening tests can accurately identify adults with chronic HCV infection, targeted screening strategies based on the presence of risk factors misses some patients with HCV infection.
Mother-to-infant transmission is the leading cause of childhood HCV infection. This review synthesized evidence on the effects of mode of delivery, labor management strategies, and breastfeeding practices on risk for mother-to-infant transmission of HCV infection. No intervention clearly reduces risk for transmission. Avoidance of breastfeeding does not seem indicated to reduce transmission risk.
Chronic HCV infection is a leading cause of complications from chronic liver disease. This review assessed the comparative effectiveness of antiviral regimens in antiviral-naive patients but found no study that evaluated the comparative effectiveness of antiviral regimens on long-term clinical outcomes. However, sustained virologic response (SVR) rates for genotype 1 infection are higher with triple therapy that includes a protease inhibitor than with standard dual therapy. An SVR after antiviral therapy seems to be associated with improved clinical outcomes.
This article gauged consensus among U.S. state medical boards about the likelihood of investigations for violations of online professionalism by using 10 hypothetical vignettes. It found areas of high consensus of online behaviors in which physicians should never engage and others that provide useful contextual information about gray areas. Increased awareness of these specific behaviors may reduce investigations and improve online professionalism for physicians.
In this issue, Kern and colleagues provide important insight into the validity of electronic measures used in primary care practice. The editorialist calls for more implementation research to arrive at electronic accountability measures that we can use with confidence, as well as greater collaboration among key stakeholders, including clinicians, measure developers, vendors, and researchers.
Generic antiretroviral drugs have achieved remarkable results in the global HIV epidemic. In this issue, Walensky and colleagues mathematically model the effect of substituting generic efavirenz and lamivudine in all U.S. persons with HIV who were assumed to receive the branded coformulation of these drugs with tenofovir. The study should serve as a wake-up call to clinicians who care for people with HIV: The era of generic antiretrovirals in the United States has come.
Can patient-centeredness and quality measures coexist? As we strive to protect our patients, do we also dehumanize them?