Carrie Horwitch

Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care

Unsustainable rising health care costs in the United States have made reducing costs while maintaining high-quality health care a national priority. The overuse of some screening and diagnostic tests is an important component of unnecessary health care costs. More judicious use of such tests will improve quality and reflect responsible awareness of costs. Efforts to control expenditures should focus not only on benefits, harms, and costs but on the value of diagnostic tests-meaning an assessment of whether a test provides health benefits that are worth its costs or harms. To begin to identify ways that practicing clinicians can contribute to the delivery of high-value, cost-conscious health care, the American College of Physicians convened a workgroup of physicians to identify, using a consensus-based process, common clinical situations in which screening and diagnostic tests are used in ways that do not reflect high-value care. The intent of this exercise is to promote thoughtful discussions about these tests and other health care interventions to promote high-value, cost-conscious care.

Cardiac screening with electrocardiography, stress echocardiography, or myocardial perfusion imaging: advice for high-value care from the American College of Physicians.

BACKGROUND Cardiac screening in adults with resting or stress electrocardiography, stress echocardiography, or myocardial perfusion imaging can reveal findings associated with increased risk for coronary heart disease events, but inappropriate cardiac testing of low-risk adults has been identified as an important area of overuse by several professional societies. METHODS Narrative review based on published systematic reviews; guidelines; and articles on the yield, benefits, and harms of cardiac screening in low-risk adults. RESULTS Cardiac screening has not been shown to improve patient outcomes. It is also associated with potential harms due to false-positive results because they can lead to subsequent, potentially unnecessary tests and procedures. Cardiac screening is likely to be particularly inefficient in adults at low risk for coronary heart disease given the low prevalence and predictive values of testing in this population and the low likelihood that positive findings will affect treatment decisions. In this patient population, clinicians should focus on strategies for mitigating cardiovascular risk by treating modifiable risk factors (such as smoking, diabetes, hypertension, hyperlipidemia, and overweight) and encouraging healthy levels of exercise. HIGH-VALUE CARE ADVICE Clinicians should not screen for cardiac disease in asymptomatic, low-risk adults with resting or stress electrocardiography, stress echocardiography, or stress myocardial perfusion imaging.

Factors that complicate the treatment of tuberculosis in HIV-infected patients.

Treatment of tuberculosis (TB) in persons coinfected with HIV has become increasingly complex during the past decade. We describe the factors that complicate anti-TB therapy in a large observational cohort of HIV-infected persons in the United States. Among 367 HIV-infected patients with 372 episodes of culture-confirmed TB, 44.1% had injection drug use as a mode of HIV transmission. Hepatic disease was present at the time of TB diagnosis or during anti-TB therapy for 91 episodes (24.5%). Elevation at least twice the upper limits of normal of aminotransaminases was observed during the first month of anti-TB therapy in 116 (31.2%) of the episodes. The most commonly reported adverse effects occurring during therapy were rash (27.8%), nausea (26.2%), leukopenia or neutropenia (20.2%), diarrhea (19.3%), vomiting (18.5%), and elevated temperature (>101.5°F [38.6°C], 16.9%). Prescription of a rifamycin and a medication known to interact with rifamycins occurred during 270 (72.6%) episodes. Because HIV-infected patients with TB often have underlying complicating conditions, such as hepatic disease, and are treated with medications that may have toxicities and cause drug-drug interactions, we recommend that clinicians pay careful attention to these factors when treating coinfected patients.

Hemoglobin A1c targets for glycemic control with pharmacologic therapy for nonpregnant adults with type 2 diabetes mellitus: A guidance statement update from the American college of physicians

Diabetes mellitus is a leading cause of death in the United States and is associated with microvascular and macrovascular complications. Approximately 29.1 million persons, or 9.3% of the U.S. population, have type 2 diabetes (1). In 2012, the total direct and indirect costs associated with diabetes in the United States were

Transmission Cluster of Multiclass Highly Drug-Resistant HIV-1 Among 9 Men Who Have Sex With Men in Seattle/King County, WA, 2005−2007

245 billion (1). Markedly elevated glucose levels can result in subacute symptoms, such as polyuria, polydipsia, weight loss, and dehydration. Over time, the metabolic derangements associated with diabetes may lead to vision loss, painful neuropathy or sensory loss, foot ulcers, amputations, myocardial infarctions, strokes, and end-stage renal disease. Lowering blood glucose may decrease risk for complications, but lowering strategies come with harms, patient burden, and costs. Blood glucose can be measured in various ways, including the hemoglobin A1c (HbA1c; also called glycosylated or glycated hemoglobin) level, which approximates average blood glucose control over about 3 months. As with all laboratory tests, HbA1c measurements are associated with variability (2) and can vary further with race and ethnicity (35). Guidelines have historically recommended initiation or intensification of pharmacologic therapy to achieve specific HbA1c targets, depending on the population in question. The ideal target that optimally balances benefits and harms remains uncertain. Guidance Statement Focus and Target Population The purpose of this American College of Physicians (ACP) guidance statement is to critically review the available guidelines from various organizations and the evidence included therein to assist clinicians in making decisions about targets when using pharmacologic therapy in adults with type 2 diabetes. Recent data suggesting that newer agents reduce cardiovascular morbidity and mortality in high-risk patients with type 2 diabetes have prompted calls for a fundamental shift in diabetes management. Some anticipate that treatment decisions will eventually be based more on cardiovascular risk than achievement of specific HbA1c targets, analogous to recent changes in lipid management. However, for the foreseeable future, glycemic targets will continue to influence management decisions by front-line clinicians (6). This statement focuses on the benefits and harms of targeting lower versus higher HbA1c levels and does not cover use of specific medications outside of their use to achieve HbA1c targets. The intended audience is all clinicians, and the target population is nonpregnant adults with type 2 diabetes. Methods The Clinical Guidelines Committee (CGC) of ACP develops guidance statements on topics where several conflicting guidelines are available. We provide clinicians with a rigorous review of the guidelines and the evidence they include. We then adopt the clinical recommendations if we agree with their evaluation of benefits and harms or adapt them if changes are needed based on our assessment of the recommendations and evidence. Data Sources and Guideline Selection We searched the National Guideline Clearinghouse and the Guidelines International Network library (May 2017) for guidelines on recommended HbA1c targets in the treatment of type 2 diabetes in nonpregnant outpatient adults. We included guidelines that were developed by national organizations, were published in English, and targeted the correct population. We reviewed titles and abstracts and excluded guidelines that were modified or adapted from other organizations or addressed specific populations (such as pregnant women or patients with kidney disease). Our search yielded guidelines from the National Institute for Health and Care Excellence (NICE) (7) and the Institute for Clinical Systems Improvement (ICSI) (8). On the basis of the knowledge and expertise of ACP CGC members, we also selected the following 4 guidelines not identified in either database at the time of the search but commonly used in clinical practice: the American Association of Clinical Endocrinologists and American College of Endocrinology (AACE/ACE) guideline (9), the American Diabetes Association (ADA) guideline (10), the Scottish Intercollegiate Guidelines Network (SIGN) guideline (11), and the U.S. Department of Veterans Affairs and Department of Defense (VA/DoD) guideline (12). Quality Assessment Six coauthors independently reviewed and assessed each guideline using the AGREE II (Appraisal of Guidelines for Research and Evaluation II) instrument (13). This instrument asks 23 questions in the following 6 domains: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. The authors scored each guideline independently, and the scores were compared (Appendix Figure and Appendix Table 1). Authors then provided a summary determination of whether they would recommend this guideline for use by recording yes, no, or yes with modifications. Appendix Figure. Mean AGREE II scores for items in each domain across the 6 reviewers. Each question was rated on a Likert scale with a minimum of 1 point and a maximum of 7 points. The scores were averaged for each of the 6 reviewers. Error bars represent calculated standard deviation. AACE/ACE = American Association of Clinical Endocrinologists and American College of Endocrinology; ADA = American Diabetes Association; AGREE II = Appraisal of Guidelines for Research and Evaluation II; GDG = guideline development group; ICSI = Institute for Clinical Systems Improvement; NICE = National Institute for Health and Care Excellence; SIGN = Scottish Intercollegiate Guidelines Network; VA/DoD = U.S. Department of Veterans Affairs and Department of Defense. Appendix Table 1. Scaled AGREE II Domain Scores for Each Guideline and Overall Assessment Peer Review The draft guidance statement was peer-reviewed through Annals of Internal Medicine and was posted online for comments from ACP Regents and Governors, who represent ACP members at the regional level. The final guidance statement incorporated comments from peer reviewers and ACP Regents and Governors. Public Panel Review The development of this guidance statement also included perspectives, values, and preferences of 2 CGC members who represent the public and a 7-member public panel. Summary of Evaluated Guidelines Using the AGREE II Instrument We reviewed and rated 6 guidelines (AACE/ACE [9], ADA [10], ICSI [8], NICE [7], SIGN [11], and VA/DoD [12]), focusing solely on sections addressing HbA1c targets in patients with type 2 diabetes. Appendix Table 1 shows the detailed scaled domain scores and average quality ratings for each guideline, and the Appendix Figure shows average AGREE II scores for each item in each of the 6 domains. The fundamental difference between high- and low-scoring guidelines was methodology. The 2 lowest-scoring guidelines, AACE/ACE and ADA, scored lowest on stakeholder involvement, applicability, editorial independence, and scientific rigor. A systematic review is the backbone for any trustworthy guideline, but some guidelines might not be based on a systematic review or may not have made the review publicly available (14, 15). Several factors were important in considering guideline quality. For example, although many guidelines described benefits, adverse effects, and the strength and limitations of evidence or linked the evidence to the recommendation, they often inadequately described how they had considered or weighted these factors in developing the final recommendations. The guidelines frequently relied on selective reporting of studies or outcomes and focused on relative versus absolute effects and asymptomatic surrogate measures rather than patient-centered health outcomes. All of the reviewed guidelines recommend individualizing HbA1c targets on the basis of patient characteristics, such as comorbid conditions and risk for hypoglycemia (Appendix). The ADA and SIGN guidelines recommend a target of 7% for the general population, whereas AACE/ACE recommends 6.5% (if it can be achieved safely). The NICE guideline specifies 6.5% or 7%, depending on the patients treatment regimen. Both ICSI and VA/DoD recommend target ranges. The ICSI guideline recommends less than 7% to less than 8% based on patient factors, whereas the VA/DoD recommends the following target ranges based on life expectancy and comorbid conditions: 6% to 7% for patients with a life expectancy greater than 10 to 15 years and no or mild microvascular complications; 7% to 8.5% for those with established microvascular or macrovascular disease, comorbid conditions, or a life expectancy of 5 to 10 years; and 8% to 9% for those with a life expectancy less than 5 years, significant comorbid conditions, advanced complications of diabetes, or difficulties in self-management attributable to mental status, disability, or other factors (12). All guidelines recognize that HbA1c targets can be higher in patients with comorbid conditions and limited life expectancy. We looked into the evidence presented in these guidelines, specifically 5 large, long-term randomized trials with a treat-to-target strategy and corresponding reports on extended follow-up (1623). We summarize below the individual studies and resulting benefits and harms. Note that recent studies evaluating the effectiveness and safety of several newer diabetes drugs (for example, recently approved sodiumglucose cotransporter-2 inhibitors, dipeptidyl peptidase-4 inhibitors, and glucagon-like peptide-1 receptor agonists) were not considered in guideline sections pertaining to HbA1c targets because these studies were not designed to evaluate treat-to-target strategies. Therefore, their findings are not described here. Benefits and Harms of Lower HbA1c Targets: Evidence From Clinical Trials Five large, long-term randomized controlled trials investigated intensive (achieved HbA1c levels, 6.3% to 7.4%) versus less intensive (achieved HbA1c levels, 7.3% to 8.4%) t

International distance-learning outreach: the APEC EINet experience

Background:From 2005 through 2007, Seattle health care providers identified cases of primary multiclass drug-resistant (MDR) HIV-1 with common patterns of resistance to antiretrovirals (ARVs). Through surveillance activities and genetic analysis, the local Health Department and the University of Washington identified phylogenetically linked cases among ARV treatment-naive and -experienced individuals. Methods:HIV-1 pol nucleotide consensus sequences submitted to the University of Washington Clinical Virology Laboratory were assessed for phylogenetically related MDR HIV. Demographic and clinical data collected included HIV diagnosis date, ARV history, and laboratory results. Results:Seven ARV-naive men had phylogenetically linked MDR strains with resistance to most ARVs; these were linked to 2 ARV-experienced men. All 9 men reported methamphetamine use and multiple anonymous male partners. Primary transmissions were diagnosed for more than a 2-year period, 2005-2007. Three, including the 2 ARV-experienced men, were prescribed ARVs. Conclusions:This cluster of 9 men with phylogenetically related highly drug-resistant MDR HIV strains and common risk factors but without reported direct epidemiologic links may have important implications to public health. This cluster demonstrates the importance of primary resistance testing and of collaboration between the public and private medical community in identifying MDR outbreaks. Public health interventions and surveillance are needed to reduce transmission of MDR HIV-1.

The Asian Pacific Economic Cooperation Emerging Infections Network

BACKGROUND The Emerging Infections Network is a mature electronic network that links Public Health professionals in the Asia Pacific through regular e-mail bulletins and an extensive Web site (http://www.apec.org/infectious). Emerging infections is a new area of study; learning materials help foster education. Our objective is to quantify the response of the network to the introduction of distance-learning materials on the Web site. METHODS Distance-learning materials, developed by the University of Washington School of Public Health, were field tested and launched on the site. Publicity was carried out prior to the launch of the materials. Access was tracked prospectively using server counts of page downloads. RESULTS Web access increased substantially during the month after the materials were launched, especially among Asia based computers. The effect was isolated to the distance-learning pages, and not general to the site. CONCLUSIONS This Web site appears to be responsive to the advertisement and to the materials. Prospective Web-site monitoring proved useful.

Ethical Implications of the Electronic Health Record: In the Service of the Patient

ISSUE The Asia Pacific Economic Cooperation (APEC) has undertaken an initiative in emerging infections. PROJECT The APEC Emerging Infections Network project uses collaborative telecommunications tools such as e-mail and a World Wide Web site to bridge the broad geographic expanse and diversity of APEC. Scientists and policymakers share information to effectively combat emerging infectious disease (EID) through surveillance, prevention, research, and control measures. RESULTS In the projects first year, site visits compiled information on Internet access in selected economies. Information sharing via electronic lists has been successful; feedback suggests that these strategies will become increasingly useful. The Emerging Infections Network (EINet) Web site includes project information, library access, surveillance data, prevention guidelines, and distance learning resources. A pilot effort to promote the secure electronic exchange of surveillance data demonstrated that informal communications may be both preferable and more feasible during the early stages of this project. LESSONS LEARNED Human networking is as important as technology-based networking in addressing emerging infections. Internet technology in some APEC economies is barely adequate, but is becoming more reliable and accessible. Numerous member economies are eager to be included in project activities.

Hemoglobin A1c targets for nonpregnant adults with type 2 diabetes mellitus

Electronic health records (EHRs) provide benefits for patients, physicians, and clinical teams, but also raise ethical questions. Navigating how to provide care in the digital age requires an assessment of the impact of the EHR on patient care and the patient–physician relationship. EHRs should facilitate patient care and, as an essential component of that care, support the patient–physician relationship. Billing, regulatory, research, documentation, and administrative functions determined by the operational requirements of health care systems, payers, and others have resulted in EHRs that are better able to satisfy such external functions than to ensure that patient care needs are met. The profession has a responsibility to identify and address this mismatch. This position paper by the American College of Physicians (ACP) Ethics, Professionalism and Human Rights Committee does not address EHR design, user variability, meaningful use, or coding requirements and other government and payer mandates per se; these issues are discussed in detail in ACP’s Clinical Documentation policy. This paper focuses on EHRs and the patient–physician relationship and patient care; patient autonomy, privacy and confidentiality; and professionalism, clinical reasoning and training. It explores emerging ethical challenges and concerns for and raised by physicians across the professional lifespan, whose ongoing input is crucial to the development and use of information technology that truly serves patients.Electronic health records (EHRs) provide benefits for patients, physicians, and clinical teams, but also raise ethical questions. Navigating how to provide care in the digital age requires an assessment of the impact of the EHR on patient care and the patient–physician relationship. EHRs should facilitate patient care and, as an essential component of that care, support the patient–physician relationship. Billing, regulatory, research, documentation, and administrative functions determined by the operational requirements of health care systems, payers, and others have resulted in EHRs that are better able to satisfy such external functions than to ensure that patient care needs are met. The profession has a responsibility to identify and address this mismatch. This position paper by the American College of Physicians (ACP) Ethics, Professionalism and Human Rights Committee does not address EHR design, user variability, meaningful use, or coding requirements and other government and payer mandates per se; these issues are discussed in detail in ACP’s Clinical Documentation policy. This paper focuses on EHRs and the patient–physician relationship and patient care; patient autonomy, privacy and confidentiality; and professionalism, clinical reasoning and training. It explores emerging ethical challenges and concerns for and raised by physicians across the professional lifespan, whose ongoing input is crucial to the development and use of information technology that truly serves patients.

Emailing Test Results to Patients

Who developed these recommendations? The American College of Physicians (ACP) developed these recommendations. The ACP is a professional organization for internal medicine doctors, who specialize in health care for adults. What is the problem and what is known about it so far? Type 2 diabetes is a common disease that makes it difficult for the body to use sugar and store energy from food. Common symptoms include urinating often and increased thirst, but diabetes often has no symptoms. Over time, high blood sugar levels can lead to health problems, including blindness, kidney failure, nerve damage, heart attack, stroke, and the need to amputate certain body parts (such as fingers and toes). Treatment to control blood sugar levels includes eating healthy food, regular exercise, and medicines. Doctors measure sugar with a blood test called hemoglobin A1c (HbA1c) to diagnose and control the disease. Different organizations define good control with different HbA1c levels. The ACP reviewed guidelines for HbA1c targets in nonpregnant adults with type 2 diabetes to develop guidance to help doctors and patients decide what levels to aim for. How did the ACP develop these recommendations? The ACP Clinical Guidelines Committee reviewed 6 guidelines to rate their quality. They used this information to develop recommendations for HbA1c targets that ACP believes would be best for nonpregnant adults with type 2 diabetes. An HbA1c level below 7% can reduce the chances of diabetes complications. However, this level can be difficult to achieve and can be associated with weight gain and life-threatening episodes of low blood sugar. What does the ACP suggest that patients and doctors do? Doctors and patients should work together to create goals for diabetes control. These goals should consider the benefits and harms of diabetes medicines, patient preferences and general health, and costs of treatment. For most patients, HbA1c levels should be between 7% and 8%. Doctors and patients should consider decreasing the dose or stopping diabetes medicines if HbA1c levels fall below 6.5%. If a patient has type 2 diabetes and is not expected to live longer than 10 years, lower HbA1c levels might cause more harm than benefit. These patients include people older than 80 years; people who live in a nursing home; and people who have serious health conditions, such as dementia, cancer, kidney disease, severe chronic obstructive pulmonary disease, or heart failure. Questions you may want to ask your doctor What is HbA1c, and how often should I have this test? How do I measure my blood sugar at home and how often? What HbA1c level is best for me? What can I do to get my HbA1c to this level? What is the best diet for me? How much should I exercise? What symptoms might mean that my blood sugar is too high or too low? What should I do if I have symptoms of low blood sugar?