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Annals of Internal Medicine Tip Sheet
January 24, 2017


Below is information about articles being published in Annals of Internal Medicine. The information is not intended to substitute for the full article as a source of information. Annals of Internal Medicine attribution is required for all coverage.


1. Obamacare increased coverage and access for the chronically ill, but many still face barriers to care

Abstract: http://annals.org/aim/article/doi/10.7326/M16-1256

The Patient Protection and Affordable Care Act (ACA) increased insurance coverage and access to care for patients with chronic medical conditions, but a year after the law took full effect, many remained without coverage and faced significant barriers to getting regular medical care. The findings are published in Annals of Internal Medicine.

About half of adults have more than one chronic medical condition and many of them are uninsured. Little is known about the extent to which the ACA increased coverage or access to care for these patients. Researchers analyzed nationally representative health data for more than 600,000 adults with at least one chronic disease in the year before and the year after the ACA was implemented to determine if the law was associated with expanded insurance coverage and access. They also assessed whether preexisting racial and ethnic disparities in these outcomes declined after ACA implementation, and whether these outcomes varied by state Medicaid expansion status.

The researchers found that about 5 percent of Americans with heart disease, cancer, asthma, or other common chronic conditions, gained insurance coverage in the first year of the law’s implementation. The data also showed that Americans with chronic diseases were less likely after the ACA to forgo a doctor visit due to cost, and were more likely to have a check-up in the last year. Coverage for the chronically ill increased the most in states that expanded Medicaid, from 83 percent to 89 percent. In states that declined to expand Medicaid under the ACA, coverage increased more modestly from 77 percent to 81 percent. However, nearly 1 in 7 of those with a chronic disease still lacked coverage, including 1 in 5 chronically ill Blacks and 1 in 3 chronically ill Hispanics.

According to the authors, their research suggests that repealing the ACA without an equivalent replacement would strip coverage from millions of chronically ill Americans, spelling disaster for many of them.

2. Home sleep testing as good as lab testing for informing management of obstructive sleep apnea

Abstract: http://annals.org/aim/article/doi/10.7326/M16-1301
Editorial: http://annals.org/aim/article/doi/10.7326/M16-2902

Outcomes for patients with suspected obstructive sleep apnea (OSA) were not inferior when managed with data from limited-channel sleep testing versus full laboratory-based polysomngraphy (PSG). The findings, published in Annals of Internal Medicine, suggest that data for informing OSA patient management can be obtained at home.

Demand for diagnostic sleep services has grown substantially due to the prevalence of OSA. Considered the gold standard for OSA evaluation, PSG can be labor-intensive, time-consuming and costly. In response, there has been a push for the adoption of limited-channel sleep studies, which record fewer physiologic signals than during PSG and are increasingly conducted at home, to diagnose suspected OSA. While previous studies have found that there are similar patient outcomes with limited-channel testing versus PSG, it is unclear whether they should be adopted in routine practice for a broad range of patients being evaluated for OSA.

In a randomized controlled trial, researchers separated patients into one of three groups, which determined the level of sleep study information to be disclosed to treating physicians: full polysomnographic data, cardiorespiratory data only, or oximetry and heart rate data only. Sleep study reports and data corresponding to the randomized groups were distributed to treating physicians to guide diagnosis and management. After review, a similar proportion of patients were diagnosed with moderate to severe OSA and received similar treatment recommendations in all groups.

Authors of an accompanying editorial say that these results are welcome news to health providers and other stakeholders interested in delivering cost-effective care options, like home sleep testing (HST). The lack of infrastructure required for HST allows for reduced wait times for testing, and the ability to expand access to underserved groups, such as rural populations. Professional medical societies will need to work with payers and other stakeholders to ensure an economically-sustainable strategy of replacing in-laboratory polysomnography with HST in order to provide high-value-care for patients with this common disease.

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