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Medicine and Public Issues | 
Ilana Graetz, PhD; Cameron M. Kaplan, PhD; Erin K. Kaplan, PhD; James E. Bailey, MD, MPH; and Teresa M. Waters, PhD
The Patient Protection and Affordable Care Act requires that individuals have health insurance or pay a penalty. Individuals are exempt from paying this penalty if the after-subsidy cost of the least-expensive plan available to them is greater than 8% of their income. For this study, premium data for all health plans offered on the state and federal health insurance marketplaces were collected; the after-subsidy cost of premiums for the least-expensive bronze plan for every county in the United States was calculated; and variations in premium affordability by age, income, and geographic area were assessed. Results indicated that—although marketplace subsidies ensure affordable health insurance for most persons in the United States—many individuals with incomes just above the subsidy threshold will lack affordable coverage and will be exempt from the mandate. Furthermore, young individuals with low incomes often pay as much as or more than older individuals for bronze plans. If substantial numbers of younger, healthier adults choose to remain uninsured because of cost, health insurance premiums across all ages may increase over time.
Topics: income, patient protection and affordable care act, health insurance exchanges, government subsidies, insurance premium
Original Research | 
Paul F. Pinsky, PhD; David S. Gierada, MD; William Hocking, MD; Edward F. Patz Jr., MD; and Barnett S. Kramer, MD, MPH
Background:The NLST (National Lung Screening Trial) showed reduced lung cancer mortality in high-risk participants (smoking history of ≥30 pack-years) aged 55 to 74 years who were randomly assigned to screening with low-dose computed tomography (LDCT) versus those assigned to chest radiography. An advisory panel recently expressed reservations about Medicare coverage of LDCT screening because of concerns about its performance in the Medicare-aged population, which accounted for only 25% of the NLST participants. Objective:To examine the results of the NLST LDCT group by age (Medicare-eligible vs. <65 years). Design:Secondary analysis of a group from a randomized trial (NCT00047385). Setting:33 U.S. screening centers. Patients:19 612 participants aged 55 to 64 years (under-65 cohort) and 7110 participants aged 65 to 74 years (65+ cohort) at randomization. Intervention:3 annual rounds of LDCT screening. Measurements:Demographics, smoking and medical history, screening examination adherence and results, diagnostic follow-up procedures and complications, lung cancer diagnoses, treatment, survival, and mortality. Results:The aggregate false-positive rate was higher in the 65+ cohort than in the under-65 cohort (27.7% vs. 22.0%; P < 0.001). Invasive diagnostic procedures after false-positive screening results were modestly more frequent in the older cohort (3.3% vs. 2.7%; P = 0.039). Complications from invasive procedures were low in both groups (9.8% in the under-65 cohort vs. 8.5% in the 65+ cohort). Prevalence and positive predictive value (PPV) were higher in the 65+ cohort (PPV, 4.9% vs. 3.0%). Resection rates for screen-detected cancer were similar (75.6% in the under-65 cohort vs. 73.2% in the 65+ cohort). Five-year all-cause survival was lower in the 65+ cohort (55.1% vs. 64.1%; P = 0.018). Limitation:The oldest screened patient was aged 76 years. Conclusion:NLST participants aged 65 years or older had a higher rate of false-positive screening results than those younger than 65 years but a higher cancer prevalence and PPV. Screen-detected cancer was treated similarly in the groups. Primary Funding Source:National Institutes of Health.
Topics: chest x-ray, lung cancer, chest ct, nlst, low-dose spiral ct, medicare
In this issue, Pinsky and colleagues present the results of their secondary analysis of data from the National Lung Screening Trial, in which they compared outcomes of screening with low-dose computed tomography between Medicare-eligible and younger participants. The editorialist discusses the findings and their implications for clinicians and policymakers.
Topics: lung cancer, elderly, lung cancer screening, nlst
Reviews | 
Carolyn J. Crandall, MD, MS; Sydne J. Newberry, PhD; Allison Diamant, MD, MSHS; Yee-Wei Lim, MD, PhD; Walid F. Gellad, MD, MPH; Marika J. Booth, MS; Aneesa Motala, BA; and Paul G. Shekelle, MD, PhD
Background:Osteoporosis is a major contributor to the propensity to fracture among older adults, and various pharmaceuticals are available to treat it. Purpose:To update a review about the benefits and harms of pharmacologic treatments used to prevent fractures in adults at risk. Data Sources:Multiple computerized databases were searched between 2 January 2005 and 4 March 2014 for English-language studies. Study Selection:Trials, observational studies, and systematic reviews. Data Extraction:Duplicate extraction and assessment of data about study characteristics, outcomes, and quality. Data Synthesis:From more than 52 000 titles screened, 294 articles were included in this update. There is high-strength evidence that bisphosphonates, denosumab, and teriparatide reduce fractures compared with placebo, with relative risk reductions from 0.40 to 0.60 for vertebral fractures and 0.60 to 0.80 for nonvertebral fractures. Raloxifene has been shown in placebo-controlled trials to reduce only vertebral fractures. Since 2007, there is a newly recognized adverse event of bisphosphonate use, atypical subtrochanteric femur fracture. Gastrointestinal side effects, hot flashes, thromboembolic events, and infections vary among drugs. Limitations:Few studies have directly compared drugs used to treat osteoporosis. Data in men are very sparse. Costs were not assessed. Conclusion:Good-quality evidence supports that several medications for bone density in osteoporotic range and/or preexisting hip or vertebral fracture reduce fracture risk. Side effects vary among drugs, and the comparative effectiveness of the drugs is unclear. Primary Funding Source:Agency for Healthcare Research and Quality and RAND Corporation.
Topics: osteoporosis, pharmacotherapy, fracture, teriparatide, comparative effectiveness research, osteoporotic fracture risk, adverse event, bisphosphonates, denosumab
In this issue, Crandall and colleagues report a systematic review of the comparative effectiveness of pharmacological treatments to prevent fractures. The editorialists believe that the review provides helpful information to guide clinical decision making but that clinicians and patients should be informed that the findings may not apply to patients aged 75 years or older, and especially not to those aged 80 years or older with nonskeletal risk factors for falls.
Topics: osteoporosis, pharmacotherapy, bisphosphonates, fracture, teriparatide, elderly, denosumab, adverse event, comparative effectiveness research, osteoporotic fracture risk
Description:Update of the 1996 U.S. Preventive Services Task Force (USPSTF) recommendation on aspirin prophylaxis in pregnancy. Methods:The USPSTF reviewed the evidence on the effectiveness of low-dose aspirin in preventing preeclampsia in women at increased risk and in decreasing adverse maternal and perinatal health outcomes, and assessed the maternal and fetal harms of low-dose aspirin during pregnancy. Population:This recommendation applies to asymptomatic pregnant women who are at increased risk for preeclampsia and who have no prior adverse effects with or contraindications to low-dose aspirin. Recommendation:The USPSTF recommends the use of low-dose aspirin (81 mg/d) as preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia. (B recommendation)
Topics: aspirin, pre-eclampsia, pregnancy, morbidity, mortality, prevention
Topics: aspirin, pre-eclampsia, pregnancy, preventive health services, morbidity, mortality
Topics: obesity, physical activity, cardiovascular diseases, diabetes mellitus, cardiovascular disease risk factors, diabetes mellitus, type 2, diet, behavior therapy, counseling, preventive health services, lifestyle changes, health outcomes, changes in diet, healthy diet, diabetes prevention, cardiovascular disease prevention
Description:Update and refinement of the 2003 U.S. Preventive Services Task Force (USPSTF) recommendation on dietary counseling for adults with risk factors for cardiovascular disease (CVD). Methods:The USPSTF reviewed the evidence on whether primary care–relevant counseling interventions for a healthful diet and physical activity modify self-reported behaviors, intermediate physiologic outcomes, diabetes incidence, and cardiovascular morbidity or mortality in adults with CVD risk factors, as well as the adverse effects of counseling interventions. Population:This recommendation applies to adults aged 18 years or older in primary care settings who are overweight or obese and have known CVD risk factors (hypertension, dyslipidemia, impaired fasting glucose, or the metabolic syndrome). Recommendation:The USPSTF recommends offering or referring adults who are overweight or obese and have additional CVD risk factors to intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention. (B recommendation)
Topics: diet, behavior therapy, preventive health services, lifestyle changes, health outcomes, changes in diet, healthy diet, diabetes prevention, cardiovascular disease prevention, physical activity, diabetes mellitus, cardiovascular disease risk factors, obesity, diabetes mellitus, type 2
Reviews | 
Jennifer S. Lin, MD, MCR; Elizabeth O'Connor, PhD; Corinne V. Evans, MPP; Caitlyn A. Senger, MPH; Maya G. Rowland, MPH; and Holly C. Groom, MPH
Includes: Supplemental Content
Background:Most Americans do not meet diet and physical activity recommendations despite known health benefits. Purpose:To systematically review the benefits and harms of lifestyle counseling interventions in persons with cardiovascular risk factors for the U.S. Preventive Services Task Force. Data Sources:MEDLINE, PsycINFO, the Database of Abstracts of Reviews of Effects, and the Cochrane Central Register of Controlled Trials (January 2001 to October 2013); experts; and existing systematic reviews. Study Selection:Two investigators independently reviewed 7218 abstracts and 553 articles against a set of inclusion and quality criteria. Data Extraction:Data from 74 trials were abstracted by one reviewer and checked by a second. Data Synthesis:At 12 to 24 months, intensive lifestyle counseling in persons selected for risk factors reduced total cholesterol levels by an average of 0.12 mmol/L (95% CI, 0.16 to 0.07 mmol/L) (4.48 mg/dL [CI, 6.36 to 2.59 mg/dL]), low-density lipoprotein cholesterol levels by 0.09 mmol/L (CI, 0.14 to 0.04 mmol/L) (3.43 mg/dL [CI, 5.37 to 1.49 mg/dL]), systolic blood pressure by 2.03 mm Hg (CI, 2.91 to 1.15 mm Hg), diastolic blood pressure by 1.38 mm Hg (CI, 1.92 to 0.83 mm Hg), fasting glucose levels by 0.12 mmol/L (CI, 0.18 to 0.05 mmol/L) (2.08 mg/dL [CI, 3.29 to 0.88 mg/dL]), diabetes incidence by a relative risk of 0.58 (CI, 0.37 to 0.89), and weight outcomes by a standardized mean difference of 0.25 (CI, 0.35 to 0.16). Behavioral changes in dietary intake and physical activity were generally concordant with changes in physiologic outcomes. Limitation:Sparse reporting of patient health outcomes, longer-term follow-up of outcomes, and harms. Conclusion:Intensive diet and physical activity behavioral counseling in persons with risk factors for cardiovascular disease resulted in consistent improvements across various important intermediate health outcomes up to 2 years. Primary Funding Source:Agency for Healthcare Research and Quality.
Topics: obesity, cardiovascular diseases, behavior therapy, counseling, preventive health services, lifestyle changes, changes in diet, healthy diet, diabetes prevention, cardiovascular disease prevention, cardiovascular disease risk factors, diet, diabetes mellitus, type 2, diabetes mellitus, health outcomes, physical activity
Ideas and Opinions | 
William A. Fischer II, MD; Noreen A. Hynes, MD, MPH; and Trish M. Perl, MD, MSc
The authors discuss how so many health care workers in West Africa could have become infected with Ebola virus disease despite the known effectiveness of barrier protection in blocking its transmission.
Topics: ebola virus, health personnel, hemorrhagic fever, ebola, personal protective equipment
Ideas and Opinions | 
Alison P. Galvani, PhD; Martial L. Ndeffo-Mbah, PhD; Natasha Wenzel, MPH; and James E. Childs, PhD
As an unprecedented Ebola epidemic continues to spread, the authors argue that vaccines not yet tested in humans should be deployed.
Topics: ebola virus, disease outbreaks, hemorrhagic fever, ebola, vaccination, epidemic, experimental treatment, ebola vaccines
Ideas and Opinions | 
Michael Klompas, MD, MPH; Daniel J. Diekema, MD; Neil O. Fishman, MD; and Deborah S. Yokoe, MD
On the basis of their review of evidence from prior Ebola outbreaks, the authors conclude that current recommendations from the Centers for Disease Control and Prevention to prevent transmission of the virus to health care workers are appropriate. They argue that additional measures, such as full-body hazardous material suits, may paradoxically increase the risk for transmission.
Topics: ebola virus, hemorrhagic fever, ebola, hospitals, protective clothing, infection prophylaxis
Ideas and Opinions | 
Carlos del Rio, MD; Aneesh K. Mehta, MD; G. Marshall Lyon III, MD; and Jeannette Guarner, MD
The possibility that a patient with Ebola hemorrhagic fever could travel to the United States has created unprecedented media coverage and widespread concern. It is important for clinicians to understand the epidemiology and pathogenesis of this once-obscure disease so they can serve as trusted experts to patients and the public.
Topics: epidemiology, ebola virus, disease outbreaks, hemorrhagic fever, ebola, epidemic, pathogenesis, epidemic control
Ideas and Opinions | 
Nancy Kass, ScD
Two U.S. aid workers with Ebola have been evacuated to the United States and treated with an extremely scarce and untested therapy. Given the hundreds of similarly stricken patients in Africa, whether it was ethical to single out the Americans for such heroic care is a matter of debate.
Topics: ethics, ebola virus, health personnel, hemorrhagic fever, ebola, public health medicine, epidemic, experimental treatment
Reviews | 
Erin D. Michos, MD, MHS; Lisa M. Wilson, ScM; Hsin-Chieh Yeh, PhD; Zackary Berger, MD, PhD; Catalina Suarez-Cuervo, MD; Sylvie R. Stacy, MD; and Eric B. Bass, MD, MPH
Includes: Supplemental Content
Background:Clinicians face uncertainty about the prognostic value of troponin testing in patients with chronic kidney disease (CKD) without suspected acute coronary syndrome (ACS). Purpose:To systematically review the literature on troponin testing in patients with CKD without ACS. Data Sources:MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through May 2014. Study Selection:Studies examining elevated versus normal troponin levels in patients with CKD without ACS. Data Extraction:Paired reviewers selected articles for inclusion, extracted data, and graded strength of evidence (SOE). Meta-analyses were conducted when studies had sufficient homogeneity of key variables. Data Synthesis:Ninety-eight studies met inclusion criteria. Elevated troponin levels were associated with all-cause and cardiovascular mortality among patients receiving dialysis (moderate SOE). Pooled hazard ratios (HRs) for all-cause mortality from studies that adjusted for age and coronary artery disease or a risk equivalent were 3.0 (95% CI, 2.4 to 4.3) for troponin T and 2.7 (CI, 1.9 to 4.6) for troponin I. The pooled adjusted HRs for cardiovascular mortality were 3.3 (CI, 1.8 to 5.4) for troponin T and 4.2 (CI, 2.0 to 9.2) for troponin I. Findings were similar for patients with CKD who were not receiving dialysis, but there were fewer studies. No study tested treatment strategies by troponin cut points. Limitation:Studies were heterogeneous regarding assays, troponin cut points, covariate adjustment, and follow-up. Conclusion:In patients with CKD without suspected ACS, elevated troponin levels were associated with worse prognosis. Future studies should focus on whether this biomarker is more appropriate than clinical models for reclassifying risk of patients with CKD and whether such classification can help guide treatment in those at highest risk for death. Primary Funding Source:Agency for Healthcare Research and Quality.
Topics: acute coronary syndromes, troponin, hemodialysis, kidney failure, chronic, troponin t, dialysis procedure, troponin i, cardiovascular death, cardiac troponin measurement
Reviews | 
Sylvie R. Stacy, MD, MPH*; Catalina Suarez-Cuervo, MD*; Zackary Berger, MD, PhD; Lisa M. Wilson, ScM; Hsin-Chieh Yeh, PhD; Eric B. Bass, MD, MPH; and Erin D. Michos, MD, MHS
Background:Patients with chronic kidney disease (CKD) have high prevalence of elevated serum troponin levels, which makes diagnosis of acute coronary syndrome (ACS) challenging. Purpose:To evaluate the utility of troponin in ACS diagnosis, treatment, and prognosis among patients with CKD. Data Sources:MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through May 2014. Study Selection:Studies examining elevated versus normal troponin levels in terms of their diagnostic performance in detection of ACS, effect on ACS management strategies, and prognostic value for mortality or cardiovascular events after ACS among patients with CKD. Data Extraction:Paired reviewers selected articles for inclusion, extracted data, and graded strength of evidence (SOE). Data Synthesis:Twenty-three studies met inclusion criteria. The sensitivity of troponin T for ACS diagnosis ranged from 71% to 100%, and specificity ranged from 31% to 86% (6 studies; low SOE). The sensitivity and specificity of troponin I ranged from 43% to 94% and from 48% to 100%, respectively (8 studies; low SOE). No studies examined how troponin levels affect management strategies. Twelve studies analyzed prognostic value. Elevated levels of troponin I or troponin T were associated with higher risk for short-term death and cardiac events (low SOE). A similar trend was observed for long-term mortality with troponin I (low SOE), but less evidence was found for long-term cardiac events for troponin I and long-term outcomes for troponin T (insufficient SOE). Patients with advanced CKD tended to have worse prognoses with elevated troponin I levels than those without them (moderate SOE). Limitation:Studies were heterogeneous in design and in ACS definitions and adjudication methods. Conclusion:In patients with CKD and suspected ACS, troponin levels can aid in identifying those with a poor prognosis, but the diagnostic utility is limited by varying estimates of sensitivity and specificity. Primary Funding Source:Agency for Healthcare Research and Quality.
Topics: troponin, hemodialysis, kidney failure, chronic, dialysis procedure, cardiovascular death, cardiac troponin measurement, troponin i, acute coronary syndromes, troponin t
Ideas and Opinions | 
Linda S. Kinsinger, MD, MPH; David Atkins, MD, MPH; Dawn Provenzale, MD, MS; Charles Anderson, MD, PhD; and Robert Petzel, MD
Whether community lung cancer screening programs will result in benefits and harms similar to those in a clinical trial is unknown. As policymakers debate about whether to adopt widespread screening or await further data, the Veterans Health Administration is initiating a demonstration project to assess initial experience in implementing a screening program at select sites and will assess the results to inform whether, and how, to proceed with broader implementation.
Topics: veterans, lung cancer, lung cancer screening, low-dose spiral ct
Editorials | 
William G. Kussmaul III, MD; and Ashwini R. Sehgal, MD
In this issue, Michos, Stacy, and colleagues report 2 systematic reviews that address the challenges of using troponin levels to diagnose cardiac disease in patients with chronic kidney disease. The editorialists discuss these findings and view them as a solid base for future research to optimize the renal and cardiac outcomes of patients with chronic kidney disease.
Topics: acute coronary syndromes, troponin, hemodialysis, kidney failure, chronic, dialysis procedure, troponin i, cardiovascular death, cardiac troponin measurement, troponin t
Ideas and Opinions | 
Scott H. Podolsky, MD
Two American missionary workers infected with the deadly Ebola virus have been administered a combination of preformed monoclonal antibodies directed against the virus and previously demonstrated to work only in monkeys. This commentary discusses the history of serotherapy in the United States and what lessons we can learn from it.
Topics: ebola virus, monoclonal antibodies, hemorrhagic fever, ebola, serotherapy
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