Primecuts – This Week In The Journals

April 28, 2014

By Nicole Van Groningen, MD

Peer reviewed

NYU Langone made headlines in the New York Times this week with the re-opening of its emergency room, over 18 months after waters from the East River flooded the hospital during Hurricane Sandy [1]. Now triple its previous size, the emergency room is fully open for business, most notably to city ambulances – a rare sight in the post-Sandy era.

Many have suggested the opening of the emergency room has social implications – patient advocates have long accused NYU Langone of attempting to divert poorer patients to nearby Bellevue. Although NYU administrators have agreed to take more low-income patients, the Times cites that the percentage of outpatient visits to NYU Langone made by those with Medicare or no insurance is only 22% – the lowest of any full-service hospital in the city. Down the street at Bellevue, the proportion is 83%.

Conversations centered on Medicare spending, ever present in the media, again appeared in the journals this week, with a JAMA study that underscored a weakness of the current model of the Accountable Care Organization (ACO) – the failure of Medicare to concretely link beneficiaries to ACOs [2]. Investigators identified 524,246 Medicare beneficiaries attributed to 145 ACOs, and examined 3 related constructs to assess ACO’s capacity to manage care: stability of assignment between 2010 and 2011, leakage of outpatient care to outside the organization, and contract penetration, or the proportion of outpatient Medicare spending by the ACO devoted to its assigned patients. Importantly, data was obtained before the actual advent of ACOs, based on the rosters of physicians who would go on to participate in ACOs starting in 2012.

Stability of assignment to ACO was only 66% between 2010 and 2011. Although a portion of this instability was accounted for by beneficiaries with a low number of chronic diseases and overall low utilization of the ACO, it also disproportionately represented beneficiaries with in the top decile of total spending. Leakage of outpatient care occurred at a rate of 8.7% for primary care visits, but at a staggering 66.7% for specialist visits. Contract penetration was found to be low: of Medicare spending billed by ACO physicians, only 37.9% was devoted to the ACO’s attributed beneficiaries. The authors identify a key tradeoff across different types of ACOs: smaller ACOs had better contract penetration but more leakage of care, while larger ACOs had less leakage of care but worse contract penetration.

This illustrates the consequences of the fact that Medicare beneficiaries are offered no incentives to stay within an ACO, and ACOs have limited capability to keep beneficiaries within their networks. The phenomenon has led policy thinkers to refine Medicare ACO models to include incentives for both beneficiaries and organizations for enrollment in and maintenance in an Accountable Care Organization.

Although negative sequelae of false-positive results on screening mammography prompted the United States Preventive Service Task Force’s 2009 changes to breast cancer screening guidelines, the psychological harms of screening remain poorly defined [3]. To better characterize these, authors in JAMA Internal Medicine reported the findings of a Digital Mammographic Imaging Screening Trial (DMIST) sub-study focusing on the quality of life impact of false-positive cases [4]. The investigators conducted telephone interviews of women of eligible screening age (n= 1226) both during work-up of a positive mammogram and after the confirmation of a false-positive result. Their responses were then compared to women of similar age with negative mammograms. Questions specifically addressed personal anxiety (using a validated abbreviated questionnaire for general anxiety, the State-Trait Anxiety Inventory [STAI]-6), health utility (using the EuroQol [EQ]-5D, a validated questionnaire to reflect an individual’s overall health status), and attitudes toward future screening.

Women with false-positive results experienced a significantly higher level of anxiety during the work-up period, as indicated by a higher STAI-6 score. These effects were transient, however, with a statistically significant decrease in the score following confirmation of a false-positive result (-1.53, 95% confidence interval [CI], -2.70 to -0.35). EQ-5D scores, a surrogate measure of perceived overall health, did not differ significantly between women with false-positive and negative mammography results. With regard to future attitudes regarding screening, a false-positive result more than doubled a woman’s stated intention to use future screening (odds ratio [OR] 2.22, 95% CI 1.54-2.93).

Despite compelling results, the study remains limited by its use of a screening tool for generalized anxiety, as opposed to breast cancer-specific anxiety, which was not measured in this study and has been notably increased in false-positive mammography in previous studies [5]. Still, the findings indicate that the psychological burden of a false-positive mammogram may be less appreciable than some physicians fear. Additionally, women with a false-positive result may be more likely to undergo future screening.

Virtual autopsy, which employs post-mortem computed tomography (PMCT), was proposed almost a decade ago as an alternative to medical autopsy in determining cause of death among hospitalized patients. The technique has faltered in comparisons to the gold-standard medical autopsy, chiefly due to missed diagnoses of pulmonary embolism and major cardiac events – a direct result of the post-mortem cessation of circulation. A German study, published in the Annals of Internal Medicine this week, suggests that this well-known restriction of PMCT could be overcome by the use of multiphase PMCT angiography, which offers improved visualization of vasculature [6]. 50 hospitalized patients, who either died unexpectedly or within 48 hours of an event necessitating cardiopulmonary resuscitation, underwent both multiphase PMCT angiography and gold-standard medical autopsy. A total of 590 diagnoses were made by clinicians prior to death, virtual autopsy, or gold-standard medical autopsy. Of these, 519 (87%) were identified by virtual autopsy, including 73 that were detected solely by post-mortem angiography. Importantly, 51 of these were vascular diagnoses that would have been missed without PMCT angiography. Medical autopsy, on the other hand, identified 474 (80%) of all diagnoses.

The authors posit that these results indicate a promising role for virtual autopsy using multiphase PMCT angiography. The widespread use of the technique remains limited by several factors: cost, inconsistent levels of training and experience in employing the modality, as well as certain conditions in which virtual autopsy continues to fall short, including malignancy and metastases. Still, given the profile of accuracy in diagnosing a wide array of conditions presented in this study, further investigation of the virtual autopsy is warranted.

Last week, Primecuts reported on a NEJM study of patients with hepatitis C (HCV) who failed interferon and ribavirin therapy, and displayed staggeringly improved response rates with the use of ledipasvir and sofosbuvir – a transformative stride in improving our treatment in a disease historically ridden with treatment failure [7]. The New England Journal further revolutionized the landscape of HCV treatment this week, in its publication of a phase 3 trial examining the safety and efficacy of a novel, non-interferon based regimen using ABT-450 (an HCV non-structural (NS) 3/4A protease inhibitor), ritonavir (an inhibitor of cytochrome P450 3A4 and pharmacologic enhancer of ABT-450), ombitasavir (an HCV NS5A inhibitor), and dasabuvir (a nonnucleoside NS5B polymerase inhibitor) [8].

636 patients with HCV and, importantly, no cirrhosis were randomized in a 3:1 ratio to receive a 12-week course of the active regimen versus placebo. At 12 weeks, the rate of sustained virologic response, defined as HCV ribonucleic acid level <25 IU/mL, was 95.3% (95% CI, 93.0 to 97.6) in patients with HCV genotype 1a and 98.0% (95% CI, 95.8 to 100) among those with HCV genotype 1b, with an overall response rate of 96.2%. These rates soar above historical response rates of 72-80% in traditional peginterferon-based therapy. The rate of serious adverse events was 2.1%, with a rate of discontinuation due to adverse events of 0.6% – favorably low in comparison to serious adverse event rates of 9-12% and discontinuation rates due to adverse events of 10-15% in peginterferon-based therapy.

Other noteworthy reads:

The New England Journal of Medicine published a brief report of a Zaire Ebola Virus outbreak in Guinea that began in March 2014. Within 13 weeks, a suspected 111 cases have resulted in 79 deaths, translating to a 71% mortality rate [9].

Cognitive therapy may offer an alternative to pharmacologic treatment in patients with schizophrenia spectrum disorders who have chosen not to take antipsychotic drugs. A Lancet study found that cognitive therapy significantly reduced psychotic symptoms in people not on antipsychotic medication, when compared to usual care, which included supportive listening and crisis management [10].

Questions about the journal topics this week? Google may not be an inferior way to answer them, a study in the Journal of Academic Medicine suggests. The crossover study prompted 48 Internal Medicine interns to answer several clinical questions, and found that there were no significant differences in correct response rate or mean time to correct response in interns who used Google versus a summary resource (Like Elsevier’s First Consult) [11].

Dr. Nicole Van Groningen is a 1st year resident at NYU Langone Medical Center

Peer reviewed by Matthew Vorsanger, MD, Associate Editor, Clinical Correlations

References:

1. http://www.nytimes.com/2014/04/25/nyregion/nyu-langone-reopens-emergency-room-that-was-closed-by-hurricane-sandy.html?_r=0

2. McWIlliams et al. Outpatient Care Patterns and Organizational Accountability in Medicare. JAMA Internal Medicine 2014 Apr 21. doi:10.1001/jamainternmed.2014. https://archinte.jamanetwork.com/article.aspx?articleid=1861039

3. http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm

4. Tosteson et al. Consequences of False-Positive Screening Mammograms. JAMA Internal Medicine 2014 Apr 21. doi:10.1001/jamainternmed.2014.981. https://archinte.jamanetwork.com/article.aspx?articleid=1861037

5. Bond M, Pavey T, Welch K, et al. Systematic review of the psychological consequences of false-positive screening mammograms. Health Technol Assess. 2013;17(13):1-170, v-vi.

6. Wichman et al. Virtual Autopsy With Multiphase Postmortem Computed Tomographic Angiography Versus Traditional Medical Autopsy to Investigate Unexpected Deaths of Hospitalized Patients: A Cohort Study. Ann Intern Med. 2014;160(8):534-541. http://annals.org/article.aspx?articleid=1861131

7. http://www.clinicalcorrelations.org/?p=7635

8. Feld et al. Treatment of HCV with ABT-450/r–Ombitasvir and Dasabuvir with Ribavirin. N Engl J Med 2014; 370:1594-1603. http://www.nejm.org.ezproxy.med.nyu.edu/doi/full/10.1056/NEJMoa1315722?query=featured_home#t=abstract

9. Baize et al. Emergence of a Zaire Ebola Virus in Guinea – A Preliminary Report. http://www.nejm.org.ezproxy.med.nyu.edu/doi/full/10.1056/NEJMoa1315722?query=featured_home#t=abstract

10. Morrison et al. Cognitive therapy for people with schizophrenia spectrum disorders not taking antipsychotic drugs: a single-blind randomised controlled trial. The Lancet 2014 Apr 19; 383(9926): 1395-1403. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62246-1/abstract

11. Kim et al. Searching for Answers to Clinical Questions Using Google Versus Evidence-Based Summary Resources: A Randomized Controlled Crossover Study. Academic Medicne 2014 June; 89(6). http://journals.lww.com/academicmedicine/Abstract/publishahead/Searching_for_Answers_to_Clinical_Questions_Using.99108.aspx

 

 

 

 

2 Responses to Primecuts – This Week In The Journals

  1. Ephraim Mandel on April 29, 2014 at 12:01 am

    Great compilation and discussion of interesting and clinically cutting edge articles. Some weeks the Primecuts feature induces somnolence; this week’s synopsis and review creates wholly the opposite effect.Coax this reviewer to do it again.

  2. [...] NS5A inhibitor) and dasabuvir (nonnucleoside HCV NS5B RNA polymerase inhibitor) with ribavirin, in treatment-naive, non-cirrhotic, HCV patients in the SAPPHIRE-I study [...]

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