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Expanding patient access to multiple health systems may compromise safety

December 05, 2016

1. Policies that expand patient access to multiple health systems may compromise patient safety

URLs go live when the embargo lifts

Prescribing safety may be inadvertently compromised when national policies expand patient access to several poorly coordinated health systems. According to an article published in Annals of Internal Medicine, rates of potentially unsafe medication prescribing were significantly higher among veterans with dementia using more than one health system compared to those using the Department of Veterans Affairs (VA) only. Results of a national cohort study are published in Annals of Internal Medicine.

Dementia is a growing public health priority that affects all health care systems in the United States, including the VA. Dementia care is challenging for health care systems because the average dementia patient has four comorbid conditions and receives care from five different providers annually. Because the average patient also takes at least five different drugs, medication management is challenging. Using a greater number of medications and prescribers is a major risk factor for potentially unsafe medication prescribing, which makes it imperative for care to be highly coordinated. As such, recent federal policy changes attempting to expand veterans' access to providers outside the VA may thwart the VA's efforts to enhance care coordination.

Researchers sought to examine the prevalence and effect of dual use of VA and Part D medications on prescribing safety among a national cohort of more than 75,000 veteran outpatients with dementia who were eligible for both VA and Part D prescription benefits. Patient data revealed that the prevalence of potentially unsafe medication prescribing was high overall (44 percent), but was particularly high among dual users (59 percent) compared to VA-only users (39 percent). The authors suggest that policymakers consider implementing electronic health information exchanges and additional medication therapy management services across systems to protect vulnerable patients.

2. Prescribing antibiotics, narcotics, and opioids is common but little benefit for patients

American College of Physicians publishes survey results of internal medicine physicians
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A study by the American College of Physicians (ACP) found that physicians continue to prescribe treatments that offer little benefit to patients, despite the advice of clinical guidelines. Overuse of antibiotics, aggressive non-palliative treatment in patients with limited life expectancy, treatment of chronic pain, and dietary supplements may be the most frequently used low value treatment interventions used by doctors. The study is based on a random survey of 5,000 ACP member physicians asking them to identify two treatments frequently used by internists but unlikely to provide High Value Care to patients. The findings are published in Annals of Internal Medicine.

"While many current clinical guidelines recommend appropriate care, the results of this survey may reflect intrinsic motivations to err on the side of treatment rather than 'doing nothing,'" said lead author Amir Qaseem, MD, FACP, PhD, Vice President, Clinical Policy, ACP, and Chair of ACP's High Value Care Task Force. "However, as health care shifts to a value driven system, this study shows that doctors are willing to critically assess their own clinical practice."

ACP's High Value Care recommendations help doctors and patients understand the benefits, harms, and costs of tests and treatment options for diseases so they can pursue care together that improves health, avoids harms, and eliminates wasteful practices. Value is not merely cost. Some expensive tests and treatments have high value because they provide high benefit and low harm. Conversely, some inexpensive tests or treatments have low value because they do not provide enough benefit to justify even their low costs and might even be harmful.

3. Patient geography considered when debating whether or not to screen for vitamin D deficiency

Annals of Internal Medicine and Beth Israel Deaconess Medical Center go "Beyond the Guidelines" to discuss vitamin D screening
URLs go live when the embargo lifts

Should an asymptomatic 55 year-old woman be screened for vitamin D deficiency? An endocrinologist and primary care physician debate the topic in a multicomponent educational article being published in Annals of Internal Medicine.

The goal of vitamin D supplementation is to decrease mortality and prevent falls. However, the U.S. Preventive Services Task Force concluded that current evidence is insufficient to assess the benefits and harms of screening for vitamin D deficiency in asymptomatic adults. With no recommendation, physicians are left to make their own decisions on vitamin D screening based on individual patient characteristics. In this Beyond the Guidelines article, two internists debate the benefits and harms of screening for vitamin D deficiency in a postmenopausal 55 year-old woman who is generally healthy, but who lives in the Northeast where there is limited sunshine during winter months. Both doctors consider the patient's health history and geography when making their recommendations but come to differing conclusions as to whether screening is needed.

All Beyond the Guidelines papers are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center in Boston. Each session focuses on care of a patient who "falls between the cracks" in available evidence and for whom the optimal clinical management is unclear. Such situations include those in which a guideline finds evidence insufficient to make a recommendation, a patient does not fit criteria mapped out in recommendations, or different organizations provide conflicting recommendations. Debates are presented in a question and answer format, and include video interviews with the patient and physicians. A list of topics is available at
Also new in this issue:

Primary Care-Based Models for the Treatment of Opioid Use Disorder: A Scoping Review

P. Todd Korthuis, MD, MPH; Dennis McCarty, PhD; Melissa Weimer, DO, MCR; Christina Bougatsos, MPH; Ian Blazina, MPH; Bernadette Zakher, MBBS; Sara Grusing, BS; Beth Devine, PhD, PharmD, MBA; and Roger Chou, MD

Fight or Flight
William J. Doan, BA, MFA, PhD
Annals Graphic Medicine

American College of Physicians

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