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Original Research | 
Yftach Gepner, MPH; Rachel Golan, RD, PhD; Ilana Harman-Boehm, MD; Yaakov Henkin, MD; Dan Schwarzfuchs, MD; Ilan Shelef, MD; Ronen Durst, MD; Julia Kovsan, MSc; Arkady Bolotin, PhD; Eran Leitersdorf, MD; Shoshana Shpitzen, MA; Shai Balag, MD; Elad Shemesh, MD; Shula Witkow, RD, MPH; Osnat Tangi-Rosental, BA; Yoash Chassidim, PhD; Idit F. Liberty, MD; Benjamin Sarusi, MSc; Sivan Ben-Avraham, RD, MPH; Anders Helander, PhD; Uta Ceglarek, PhD; Michael Stumvoll, MD; Matthias Blüher, MD; Joachim Thiery, MD; Assaf Rudich, MD, PhD; Meir J. Stampfer, MD, DrPH; and Iris Shai, RD, PhD
Background:Recommendations for moderate alcohol consumption remain controversial, particularly in type 2 diabetes mellitus (T2DM). Long-term randomized, controlled trials (RCTs) are lacking. Objective:To assess cardiometabolic effects of initiating moderate alcohol intake in persons with T2DM and whether the type of wine matters. Design:2-year RCT (CASCADE [CArdiovaSCulAr Diabetes & Ethanol] trial). (ClinicalTrials.gov: NCT00784433) Setting:Ben-Gurion University of the Negev–Soroka Medical Center and Nuclear Research Center Negev, Israel. Patients:Alcohol-abstaining adults with well-controlled T2DM. Intervention:Patients were randomly assigned to 150 mL of mineral water, white wine, or red wine with dinner for 2 years. Wines and mineral water were provided. All groups followed a Mediterranean diet without caloric restriction. Measurements:Primary outcomes were lipid and glycemic control profiles. Genetic measurements were done, and patients were followed for blood pressure, liver biomarkers, medication use, symptoms, and quality of life. Results:Of the 224 patients who were randomly assigned, 94% had follow-up data at 1 year and 87% at 2 years. In addition to the changes in the water group (Mediterranean diet only), red wine significantly increased high-density lipoprotein cholesterol (HDL-C) level by 0.05 mmol/L (2.0 mg/dL) (95% CI, 0.04 to 0.06 mmol/L [1.6 to 2.2 mg/dL]; P < 0.001) and apolipoprotein(a)1 level by 0.03 g/L (CI, 0.01 to 0.06 g/L; P = 0.05) and decreased the total cholesterol–HDL-C ratio by 0.27 (CI, −0.52 to −0.01; P = 0.039). Only slow ethanol metabolizers (alcohol dehydrogenase alleles [ADH1B*1] carriers) significantly benefited from the effect of both wines on glycemic control (fasting plasma glucose, homeostatic model assessment of insulin resistance, and hemoglobin A1c) compared with fast ethanol metabolizers (persons homozygous for ADH1B*2). Across the 3 groups, no material differences were identified in blood pressure, adiposity, liver function, drug therapy, symptoms, or quality of life, except that sleep quality improved in both wine groups compared with the water group (P = 0.040). Overall, compared with the changes in the water group, red wine further reduced the number of components of the metabolic syndrome by 0.34 (CI, −0.68 to −0.001; P = 0.049). Limitation:Participants were not blinded to treatment allocation. Conclusion:This long-term RCT suggests that initiating moderate wine intake, especially red wine, among well-controlled diabetics as part of a healthy diet is apparently safe and modestly decreases cardiometabolic risk. The genetic interactions suggest that ethanol plays an important role in glucose metabolism, and red wine's effects also involve nonalcoholic constituents. Primary Funding Source:European Foundation for the Study of Diabetes.
Topics: diabetes mellitus, type 2, alcohol drinking, biological markers, ethanol, wine, alcohol intervention, metabolic risk factors, glucose control, high density lipoprotein cholesterol, diabetes mellitus, lipids, metabolic syndrome x, mineral waters
Summaries for Patients | 
Topics: diabetes mellitus, type 2, wine
Original Research | 
Shuo-Ming Ou, MD; Chia-Jen Shih, MD; Pei-Wen Chao, MD; Hsi Chu, MD; Shu-Chen Kuo, MD, PhD; Yi-Jung Lee, MD; Shuu-Jiun Wang, MD; Chih-Yu Yang, MD, PhD; Chih-Ching Lin, MD, PhD; Tzeng-Ji Chen, MD, PhD; Der-Cherng Tarng, MD, PhD; Szu-Yuan Li, MD, PhD; and Yung-Tai Chen, MD
Background:Recent studies concluded that dipeptidyl peptidase-4 (DPP-4) inhibitors provide glycemic control but also raised concerns about the risk for heart failure in patients with type 2 diabetes mellitus (T2DM). However, large-scale studies of the effects on cardiovascular outcomes of adding DPP-4 inhibitors versus sulfonylureas to metformin therapy remain scarce. Objective:To compare clinical outcomes of adding DPP-4 inhibitors versus sulfonylureas to metformin therapy in patients with T2DM. Design:Nationwide study using Taiwan's National Health Insurance Research Database. Setting:Taiwan. Patients:All patients with T2DM aged 20 years or older between 2009 and 2012. A total of 10 089 propensity score–matched pairs of DPP-4 inhibitor users and sulfonylurea users were examined. Measurements:Cox models with exposure to sulfonylureas and DPP-4 inhibitors included as time-varying covariates were used to compare outcomes. The following outcomes were considered: all-cause mortality, major adverse cardiovascular events (MACEs) (including ischemic stroke and myocardial infarction), hospitalization for heart failure, and hypoglycemia. Patients were followed until death or 31 December 2013. Results:DPP-4 inhibitors were associated with lower risks for all-cause death (hazard ratio [HR], 0.63 [95% CI, 0.55 to 0.72]), MACEs (HR, 0.68 [CI, 0.55 to 0.83]), ischemic stroke (HR, 0.64 [CI, 0.51 to 0.81]), and hypoglycemia (HR, 0.43 [CI, 0.33 to 0.56]) compared with sulfonylureas as add-on therapy to metformin but had no effect on risks for myocardial infarction and hospitalization for heart failure. Limitation:Observational study design. Conclusion:Compared with sulfonylureas, DPP-4 inhibitors were associated with lower risks for all-cause death, MACEs, ischemic stroke, and hypoglycemia when used as add-ons to metformin therapy. Primary Funding Source:None.
Topics: metformin, diabetes mellitus, type 2, sulfonylurea compounds, dipeptidyl-peptidase iv inhibitors, occipital nerve stimulation, heart failure, treatment outcome, hospitalization, hypoglycemia, ischemic stroke, myocardial infarction
Original Research | 
Prachi Sanghavi, PhD; Anupam B. Jena, MD, PhD; Joseph P. Newhouse, PhD; and Alan M. Zaslavsky, PhD
Includes: Supplemental Content
Background:Most Medicare patients seeking emergency medical transport are treated by ambulance providers trained in advanced life support (ALS). Evidence supporting the superiority of ALS over basic life support (BLS) is limited, but some studies suggest ALS may harm patients. Objective:To compare outcomes after ALS and BLS in out-of-hospital medical emergencies. Design:Observational study with adjustment for propensity score weights and instrumental variable analyses based on county-level variations in ALS use. Setting:Traditional Medicare. Patients:20% random sample of Medicare beneficiaries from nonrural counties between 2006 and 2011 with major trauma, stroke, acute myocardial infarction (AMI), or respiratory failure. Measurements:Neurologic functioning and survival to 30 days, 90 days, 1 year, and 2 years. Results:Except in cases of AMI, patients showed superior unadjusted outcomes with BLS despite being older and having more comorbidities. In propensity score analyses, survival to 90 days among patients with trauma, stroke, and respiratory failure was higher with BLS than ALS (6.1 percentage points [95% CI, 5.4 to 6.8 percentage points] for trauma; 7.0 percentage points [CI, 6.2 to 7.7 percentage points] for stroke; and 3.7 percentage points [CI, 2.5 to 4.8 percentage points] for respiratory failure). Patients with AMI did not exhibit differences in survival at 30 days but had better survival at 90 days with ALS (1.0 percentage point [CI, 0.1 to 1.9 percentage points]). Neurologic functioning favored BLS for all diagnoses. Results from instrumental variable analyses were broadly consistent with propensity score analyses for trauma and stroke, showed no survival differences between BLS and ALS for respiratory failure, and showed better survival at all time points with BLS than ALS for patients with AMI. Limitation:Only Medicare beneficiaries from nonrural counties were studied. Conclusion:Advanced life support is associated with substantially higher mortality for several acute medical emergencies than BLS. Primary Funding Source:National Science Foundation, Agency for Healthcare Research and Quality, and National Institutes of Health.
Topics: ambulances, hospitals, respiratory insufficiency, wounds and injuries, advanced life support, ischemic stroke, basic life support
Original Research | 
Oluwaseun Falade-Nwulia, MD, MPH; Eric C. Seaberg, PhD; Anna E. Snider; Charles R. Rinaldo, PhD; John Phair, MD; Mallory D. Witt, MD; and Chloe L. Thio, MD
Background:Men who have sex with men (MSM) are at high risk for hepatitis B virus (HBV) infection. Data on the effect of highly active antiretroviral therapy (HAART) on incident HBV infection in HIV-infected and HIV-uninfected MSM are limited. Objective:To determine predictors of incident HBV infection in MSM during pre-HAART and HAART periods. Design:Observational cohort study. Setting:Cohort of MSM who have, or are at risk for, HIV infection. Patients:2375 HBV-uninfected MSM in the Multicenter AIDS Cohort Study. Measurements:Poisson regression was used to compare incidence rates of HBV infection in the pre-HAART and HAART eras and to identify factors associated with incidence of HBV infection. Results:In 25 322 person-years of follow-up, 244 incident HBV infections occurred. The unadjusted incidence rate was higher in HIV-infected MSM than in HIV-uninfected MSM (incidence rate ratio [IRR], 1.9 [95% CI, 1.5 to 2.4]) and was significantly lower in the HAART era than in the pre-HAART era among HIV-infected (IRR, 0.2 [CI, 0.1 to 0.4]) and HIV-uninfected (IRR, 0.3 [CI, 0.2 to 0.4]) MSM. Age younger than 40 years (IRR, 2.3 [CI, 1.7 to 3.0]), more than 1 recent sexual partner (IRR, 3.1 [CI, 2.3 to 4.2]), and HIV infection (IRR, 2.4 [CI, 1.8 to 3.1]) were independently associated with higher incidence of HBV infection, whereas HBV vaccination was protective (IRR, 0.3 [CI, 0.2 to 0.4]). Highly active antiretroviral therapy with HIV RNA levels less than 400 copies/mL was associated with protection (IRR, 0.2 [CI, 0.1 to 0.5]), but HAART in those with HIV RNA levels of 400 copies/mL or greater was not. Limitation:The observational nature limits inferences about causality. Conclusion:Effective HAART is associated with lower incidence of HBV infection; however, even in the HAART era, incidence of HBV infection remains high among MSM. Primary Funding Source:National Institute of Allergy and Infectious Diseases.
Topics: hiv, antiretroviral therapy, highly active, hepatitis b, men who have sex with men, hepatitis b virus
Editorials | 
Comilla Sasson, MD, PhD; and Jason S. Haukoos, MD, MSc
In this issue, Sanghavi and colleagues used national data to compare patient outcomes associated with the dispatch of advanced versus basic life support after a 911 call for a medical emergency. The editorialists argue that the results indicate the need to further evaluate how to best target advanced life support services.
Topics: advanced life support
Reviews | 
Daichi Shimbo, MD; Marwah Abdalla, MD; Louise Falzon; Raymond R. Townsend, MD; and Paul Muntner, PhD
Hypertension, a common risk factor for cardiovascular disease, is usually diagnosed and treated based on blood pressure readings obtained in the clinic setting. Blood pressure may differ considerably when measured inside versus outside of the clinic setting. Over the past several decades, evidence has accumulated on the following 2 approaches for measuring blood pressure outside of the clinic: ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM). Both of these methods have a stronger association with cardiovascular disease outcomes than clinic blood pressure measurement. Controversy exists about whether ABPM or HBPM is superior for estimating risk for cardiovascular disease and under what circumstances these methods should be used in clinical practice for assessing blood pressure outside of the clinic. This review describes ABPM and HBPM procedures, the blood pressure phenotypic measurements that can be ascertained, and the evidence that supports the use of each approach to measuring blood pressure outside of the clinic. It also describes barriers to the successful implementation of ABPM and HBPM in clinical practice, proposes core competencies for the conduct of these procedures, and highlights important areas for future research.
Topics: blood pressure monitoring, ambulatory, blood pressure monitoring, hypertension, blood pressure
In this issue, Ou and colleagues study a well-defined and clinically relevant decision: whether to add medication to metformin in the treatment of type 2 diabetes. The editorialist discusses the strengths and limitations of the study and how it can inform physician–patient discussions about diabetes therapy.
Topics: diabetes mellitus
Clinical Guidelines | 
Albert L. Siu, MD, MSPH, on behalf of the U.S. Preventive Services Task Force*
Description:Update of the 2007 U.S. Preventive Services Task Force (USPSTF) reaffirmation recommendation statement on screening for high blood pressure in adults. Methods:The USPSTF reviewed the evidence on the diagnostic accuracy of different methods for confirming a diagnosis of hypertension after initial screening and the optimal rescreening interval for diagnosing hypertension. Population:This recommendation applies to adults aged 18 years or older without known hypertension. Recommendation:The USPSTF recommends screening for high blood pressure in adults aged 18 years or older. (A recommendation) The USPSTF recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment.
Topics: hypertension, blood pressure determination, blood pressure monitoring, ambulatory
Topics: hypertension
Ideas and Opinions | 
Mark S. Lachs, MD, MPH; and S. Duke Han, PhD
Some older adults have difficulty managing their finances and are vulnerable to financial exploitation. Certain persons with this difficulty have a dementing illness, but others are cognitively intact. The question is whether we should assign these older adults to a specific condition.
Topics: public health medicine, emotional vulnerability, elderly
Position Papers | 
Hilary Daniel, BS; and Shari Erickson, BA, MPH, for the Medical Practice and Quality Committee of the American College of Physicians*
Retail health clinics are walk-in clinics located in retail stores or pharmacies that are typically staffed by nurse practitioners or physician assistants. When they entered the marketplace in the early 2000s, retail clinics offered a limited number of services for low-acuity conditions that were paid for out of pocket by the consumer. Over the past decade, business models for these clinics have evolved to accept public and private health insurance, and some are expanding their services to include diagnosis, treatment, and management of chronic conditions. Retail health clinics are one of several methods of health care delivery that challenge the traditional primary care delivery model. The positions and recommendations offered by the American College of Physicians in this paper are intended to establish a framework that underscores patient safety, communication, and collaboration among retail health clinics, physicians, and patients.
Topics: health clinic, retail setting, american college of physicians
Topics: pulmonary embolism, pulmonary embolism, massive, acute, clinical practice guideline, american college of physicians, best practice
Clinical Guidelines | 
Ali S. Raja, MD; Jeffrey O. Greenberg, MD; Amir Qaseem, MD, PhD, MHA; Thomas D. Denberg, MD, PhD; Nick Fitterman, MD; and Jeremiah D. Schuur, MD, MHS, for the Clinical Guidelines Committee of the American College of Physicians*
Description:Pulmonary embolism (PE) can be a severe disease but is also difficult to diagnose, given its nonspecific signs and symptoms. Because of this, testing of patients with suspected acute PE has risen drastically. However, the overuse of some tests, particularly computed tomography (CT) and plasma d-dimer, may not improve care while potentially leading to patient harm and unnecessary expense. Methods:The literature search encompassed studies indexed by MEDLINE (1966–2014; English-language only) and included all clinical trials and meta-analyses on diagnostic strategies, decision rules, laboratory tests, and imaging studies for the diagnosis of PE. This document is not based on a formal systematic review, but instead seeks to provide practical advice based on the best available evidence and recent guidelines. The target audience for this paper is all clinicians; the target patient population is all adults, both inpatient and outpatient, suspected of having acute PE. Best Practice Advice 1:Clinicians should use validated clinical prediction rules to estimate pretest probability in patients in whom acute PE is being considered. Best Practice Advice 2:Clinicians should not obtain d-dimer measurements or imaging studies in patients with a low pretest probability of PE and who meet all Pulmonary Embolism Rule-Out Criteria. Best Practice Advice 3:Clinicians should obtain a high-sensitivity d-dimer measurement as the initial diagnostic test in patients who have an intermediate pretest probability of PE or in patients with low pretest probability of PE who do not meet all Pulmonary Embolism Rule-Out Criteria. Clinicians should not use imaging studies as the initial test in patients who have a low or intermediate pretest probability of PE. Best Practice Advice 4:Clinicians should use age-adjusted d-dimer thresholds (age × 10 ng/mL rather than a generic 500 ng/mL) in patients older than 50 years to determine whether imaging is warranted. Best Practice Advice 5:Clinicians should not obtain any imaging studies in patients with a d-dimer level below the age-adjusted cutoff. Best Practice Advice 6:Clinicians should obtain imaging with CT pulmonary angiography (CTPA) in patients with high pretest probability of PE. Clinicians should reserve ventilation–perfusion scans for patients who have a contraindication to CTPA or if CTPA is not available. Clinicians should not obtain a d-dimer measurement in patients with a high pretest probability of PE.
Topics: pulmonary embolism, massive, acute, diagnostic imaging, pretest probability of disease, dimers, best practice, american college of physicians, clinical practice guideline
Ideas and Opinions | 
Tarig Elraiyah, MBBS, MSc; Michael R. Gionfriddo, PharmD; Victor M. Montori, MD, MSc; and Mohammad Hassan Murad, MD, MPH
Black box warnings (BBWs) are the highest-level warnings issued by the U.S. Food and Drug Administration for medications. Despite their potential importance, BBWs have been the subject of controversy, due in part to their opaque connection to the underlying body of evidence. In this article, the authors propose a new structure for presenting BBWs that takes into consideration the fundamental principles of evidence-based medicine.
Topics: black box warning
Ideas and Opinions | 
Alison Bateman-House, PhD, MPH, MA; Laura Kimberly, MSW, MBE; Barbara Redman, PhD, MBE; Nancy Dubler, LLB; and Arthur Caplan, PhD
Some terminally ill patients want to use drugs and devices that are too early in their development to be approved by the U.S. Food and Drug Administration. As a result, some states have recently passed “right-to-try” laws that authorize patients to request these treatments from the manufacturer. Several other states are considering similar legislation. What is uncertain is whether these laws provide the benefits they promise.
Topics: statutes and laws, double effect
Reviews | 
Jennifer Pillay, BSc; Marni J. Armstrong, PhD, RCEP; Sonia Butalia, MD, MSc; Lois E. Donovan, MD; Ronald J. Sigal, MD, MPH; Pritam Chordiya, BDS, MSc; Sanjaya Dhakal, MBBS, MPH; Ben Vandermeer, MSc; Lisa Hartling, PhD; Megan Nuspl, BSc; Robin Featherstone, MLIS; and Donna M. Dryden, PhD
Background:Whether behavioral approaches for self-management programs benefit individuals with type 1 diabetes is unclear. Purpose:To determine the effects of behavioral programs for patients with type 1 diabetes on behavioral, clinical, and health outcomes and to investigate factors that might moderate effect. Data Sources:6 electronic databases (1993 to June 2015), trial registries and conference proceedings (2011 to 2014), and reference lists. Study Selection:35 prospective controlled studies involving participants of any age group that compared behavioral programs with usual care, active controls, or other programs. Data Extraction:One reviewer extracted and another verified data. Two reviewers assessed quality and strength of evidence (SOE). Data Synthesis:Moderate SOE showed reduction in glycated hemoglobin (HbA1c) at 6 months after the intervention compared with usual care (mean difference, −0.29 [95% CI, −0.45 to −0.13]) percentage points and compared with active controls (−0.44 [CI, −0.69 to −0.19]) percentage points. At end of intervention and 12 months' follow-up or longer, there were no statistically significant differences in HbA1c (low SOE) for comparisons with usual care or active control. Compared with usual care, generic quality of life at program completion did not differ (moderate SOE). Other outcomes had low or insufficient SOE. Adults appeared to benefit more for glycemic control at program completion (−0.28 [CI, −0.57 to 0.01]) percentage points than did youth (−0.12 [CI, −0.43 to 0.19]) percentage points. Program intensity appeared not to influence effectiveness; some individual delivery appears beneficial. Limitations:All studies had medium or high risk of bias. There was scarce evidence for many outcomes. Conclusion:Behavioral programs for type 1 diabetes offer some benefit for glycemic control, at least at short-term follow-up, but improvement for other outcomes has not been shown. Primary Funding Source:Agency for Healthcare Research and Quality.
Topics: diabetes mellitus, type 1, follow-up, hemoglobin a, glycosylated, glucose control, diabetes mellitus, type 2, diabetes mellitus
Original Research | 
Jane J. Kim, PhD; Nicole G. Campos, PhD; Stephen Sy, MS; Emily A. Burger, PhD; Jack Cuzick, PhD; Philip E. Castle, PhD, MPH; William C. Hunt, MS; Alan Waxman, MD, MPH; Cosette M. Wheeler, PhD, on behalf of the New Mexico HPV Pap Registry Steering Committee
Background:Studies suggest that cervical cancer screening practice in the United States is inefficient. The cost and health implications of nonadherence in the screening process compared with recommended guidelines are uncertain. Objective:To estimate the benefits, costs, and cost-effectiveness of current cervical cancer screening practice and assess the value of screening improvements. Design:Model-based cost-effectiveness analysis. Data Sources:New Mexico HPV Pap Registry; medical literature. Target Population:Cohort of women eligible for routine screening. Time Horizon:Lifetime. Perspective:Societal. Intervention:Current cervical cancer screening practice; improved adherence to guidelines-based screening interval, triage testing, diagnostic referrals, and precancer treatment referrals. Outcome Measures:Reductions in lifetime cervical cancer risk, quality-adjusted life-years (QALYs), lifetime costs, incremental cost-effectiveness ratios, and incremental net monetary benefits (INMBs). Results of Base-Case Analysis:Current screening practice was associated with lower health benefit and was not cost-effective relative to guidelines-based strategies. Improvements in the screening process were associated with higher QALYs and small changes in costs. Perfect adherence to screening every 3 years with cytologic testing and adherence to colposcopy/biopsy referrals were associated with the highest INMBs ($759 and $741, respectively, at a willingness-to-pay threshold of $100 000 per QALY gained); together, the INMB increased to $1645. Results of Sensitivity Analysis:Current screening practice was inefficient in 100% of simulations. The rank ordering of screening improvements according to INMBs was stable over a range of screening inputs and willingness-to-pay thresholds. Limitation:The effect of human papillomavirus vaccination was not considered. Conclusions:The added health benefit of improving adherence to guidelines, especially the 3-year interval for cytologic screening and diagnostic follow-up, may justify additional investments in interventions to improve U.S. cervical cancer screening practice. Primary Funding Source:U.S. National Cancer Institute.
Topics: cervical cancer, human papillomavirus, new mexico, cost-effectiveness analysis, cervical cancer screening, cytology, biopsy, guidelines, colposcopy, cancer
Reviews | 
Jennifer Pillay, BSc; Marni J. Armstrong, PhD, RCEP; Sonia Butalia, MD, MSc; Lois E. Donovan, MD; Ronald J. Sigal, MD, MPH; Ben Vandermeer, MSc; Pritam Chordiya, BDS, MSc; Sanjaya Dhakal, MBBS, MPH; Lisa Hartling, PhD; Megan Nuspl, BSc; Robin Featherstone, MLIS; and Donna M. Dryden, PhD
Includes: Supplemental Content
Background:Behavioral programs may improve outcomes for individuals with type 2 diabetes, but there is a large diversity of behavioral interventions and uncertainty about how to optimize the effectiveness of these programs. Purpose:To identify factors moderating the effectiveness of behavioral programs for adults with type 2 diabetes. Data Sources:6 databases (1993 to January 2015), conference proceedings (2011–2014), and reference lists. Study Selection:Duplicate screening and selection of 132 randomized, controlled trials evaluating behavioral programs compared with usual care, active controls, or other behavioral programs. Data Extraction:One reviewer extracted and another verified data. Two reviewers independently assessed risk of bias. Data Synthesis:Behavioral programs were grouped on the basis of program content and delivery methods. A Bayesian network meta-analysis showed that most lifestyle and diabetes self-management education and support programs (usually offering ≥11 contact hours) led to clinically important improvements in glycemic control (≥0.4% reduction in hemoglobin [Hb] A1c), whereas most diabetes self-management education programs without added support—especially those offering 10 or fewer contact hours—provided little benefit. Programs with higher effect sizes were more often delivered in person than via technology. Lifestyle programs led to the greatest reductions in body mass index. Reductions in HbA1c seemed to be greater for participants with a baseline HbA1c level of 7.0% or greater, adults younger than 65 years, and minority persons (subgroups with ≥75% nonwhite participants). Limitations:All trials had medium or high risk of bias. Subgroup analyses were indirect, and therefore exploratory. Most outcomes were reported immediately after the interventions. Conclusion:Diabetes self-management education offering 10 or fewer hours of contact with delivery personnel provided little benefit. Behavioral programs seem to benefit persons with suboptimal or poor glycemic control more than those with good control. Primary Funding Source:Agency for Healthcare Research and Quality. (PROSPERO registration number: CRD42014010515)
Topics: diabetes mellitus, type 2, hemoglobin a, glycosylated, diabetes mellitus
Ideas and Opinions | 
John R. Ball, MD, JD; and Erin Balogh, MPH
To date, reduction of diagnostic error has not been emphasized in efforts to improve patient safety in health care. Recognizing this, the Institute of Medicine assembled a panel to evaluate the existing knowledge about diagnostic error and to propose solutions. This commentary highlights key points from the resulting September 2015 report, “Improving Diagnosis in Health Care”.
Topics: diagnostic errors, engineering, institute of medicine (u.s.)
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