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News from Annals of Internal Medicine Dec. 8, 2014

December 08, 2014

1. Breast density notification laws substantially increase costs yet save few lives

Laws requiring women to be notified of their breast density so that they may discuss supplemental screening options, including ultrasound, with their health care providers would substantially increase costs and save relatively few lives, according to an article published in Annals of Internal Medicine. More than 40 percent of women between the ages of 40 and 74 have dense breast tissue, which puts them at increased risk for breast cancer and affects how well a mammogram can detect abnormalities. As such, at least 19 states have enacted breast density notification laws so that women can make informed decisions about supplemental screening. With similar legislation being considered at a national level, researchers sought to determine the benefits, harms, and cost-effectiveness of supplemental ultrasound screening for women with dense breasts. Three validated simulation models predicted that supplemental ultrasound screening after a negative mammogram for women with dense breasts would result in limited health gains and substantially increased expenses. According to model estimates, supplemental screening for women with dense breasts and a negative mammogram would save 0.36 additional breast cancer deaths, gain 1.7 quality adjusted life years (QALYs), and result in 354 false-positive ultrasound biopsy recommendations per 1,000 women with dense breasts compared to biennial screening by mammography alone. The cost-effectiveness ratio was $325,000 per QALY gained, but costs could be improved by restricting supplemental ultrasound screening to women with extremely dense breasts.

Note: The URL for this story will be live when embargo lifts. For a PDF, please contact Megan Hanks. To interview the lead author, please contact Sarah Keblin at sarah.keblin@med.uvm.edu or 802-656-3099.

2. Institute of Medicine 'Dying in America' report sparks discussion and debate

Four commentaries published in Annals of Internal Medicine discuss the recent report from the Institute of Medicine (IOM) titled "Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life." Each commentary offers a different perspective on the topic of end-of-life care.
  • IOM Committee on Approaching Death co-chair, Philip A Pizzo, MD, discusses the importance of compassionate care that is respectful of patients' end-of-life preferences. He suggests that physicians, such as oncologists who care for seriously ill patients, should be open and honest with patients when discussing their treatment options and should remain fully present after palliative or hospice care has begun. Note: To interview Dr. Pizzo, please contact Ruthann Richter at richter1@stanford.edu or 650-725-8047.

  • Drs. Scott Halpern and Ezekiel Emanuel from the Department of Medical Ethics & Health Policy at the Perelman School of Medicine at the University of Pennsylvania recognize that sweeping overhauls in the delivery of end-of-life care are greatly needed. However, reimbursing physicians for engaging patients in advance care planning may not be the best approach. They explain some of the opportunities outside of physician incentives to improve the quality of end-of-life care. Note: To interview Dr. Halpern, please contact Emily Kane at emkane@exchange.upenn.edu or 215-898-0861. To interview Dr. Emanuel, please contact Beth Dunn at bethwalk@upenn.edu or 215-573-9384.

  • Debra L Ness, MS, from the National Partnership for Women and Families and Beverley H. Johnson, BSN, from the Institute for Patient- and Family-Centered Care, applaud the IOM for initiating a national conversation about end-of-life care. However, they argue that the report needs an authentic patient-and family-centered approach that focuses on working with rather than for patients and families. Note: To reach Debra Ness, please contact Cindy Romero at cromero@nationalpartnership.org or 202-986-2600.

  • Annals of Internal Medicine Deputy Editor, Jaya K. Rao, MD, MHS, praises the IOM report for suggesting that end-of-life care is a public health issue, a concept she championed while working for the Centers for Disease Control and Prevention (CDC) from 2000 to 2008. According to Dr. Rao, end-of-life care meets the criteria to be a public health priority. She hopes that members of the IOM Committee and health professionals will build on the report recommendations to educate and engage the public about this serious issue. Note: To interview Dr. Rao, please contact Angela Collom at acollom@acponline.org or 215-351-2653.

    American College of Physicians

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