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The article reports on a policy paper about the future of funding and care of patients with human immunodeficiency virus (HIV) in the U.S. The paper was developed by the Ryan White Medical Providers Coalition (RWMPC) and the HIV Medicine Association (HIVMA). The paper highlighted concerns about the future of HIV care and funding as health care and economic situations in the country change. The Ryan White HIV/AIDS Program has been providing HIV-related services.

A call for papers for the annual theme issue of the "Journal of the American Medical Association" on violence and human rights in 2012 is presented.

Opinion. Presents a position paper from the Surgical Section of the National Medical Association. Financial aspects of caring for injured victims of violence; Viewing the issue from a public health perspective; Organizations which have addressed the issue of injury prevention.

Importance: Recent discussion has focused on questions related to the repeal and replacement of portions of the Affordable Care Act (ACA). However, issues central to the future of health and health care in the United States transcend the ACA provisions receiving the greatest attention. Initiatives directed to certain strategic and infrastructure priorities are vital to achieve better health at lower cost.Objectives: To review the most salient health challenges and opportunities facing the United States, to identify practical and achievable priorities essential to health progress, and to present policy initiatives critical to the nation's health and fiscal integrity.Evidence Review: Qualitative synthesis of 19 National Academy of Medicine-commissioned white papers, with supplemental review and analysis of publicly available data and published research findings.Findings: The US health system faces major challenges. Health care costs remain high at $3.2 trillion spent annually, of which an estimated 30% is related to waste, inefficiencies, and excessive prices; health disparities are persistent and worsening; and the health and financial burdens of chronic illness and disability are straining families and communities. Concurrently, promising opportunities and knowledge to achieve change exist. Across the 19 discussion papers examined, 8 crosscutting policy directions were identified as vital to the nation's health and fiscal future, including 4 action priorities and 4 essential infrastructure needs. The action priorities-pay for value, empower people, activate communities, and connect care-recurred across the articles as direct and strategic opportunities to advance a more efficient, equitable, and patient- and community-focused health system. The essential infrastructure needs-measure what matters most, modernize skills, accelerate real-world evidence, and advance science-were the most commonly cited foundational elements to ensure progress.Conclusions and Relevance: The action priorities and essential infrastructure needs represent major opportunities to improve health outcomes and increase efficiency and value in the health system. As the new US administration and Congress chart the future of health and health care for the United States, and as health leaders across the country contemplate future directions for their programs and initiatives, their leadership and strategic investment in these priorities will be essential for achieving significant progress. [ABSTRACT FROM AUTHOR]

Editorial. Comments on the aging of the population and the implications for medical care and health care systems. How the demographic trend will affect health care and society; Specific problems that the U.S. faces which are related to aging; Invitation to authors to submit manuscripts on topics such as disease interventions, dementia, incontinence, diabetes, cancer and others.

A list of books submitted to the "Journal of the American Medical Association" is presented, including: "Thieme Atlas of Anatomy: Neck and Internal Organs," by Michael Schuenke, Erik Schulte and Udo Schumacher; "A Personal History of Nuclear Medicine," by Henry N. Wagner Jr.; "The Biology of Cancer," by Robert A. Weinberg; "Crash Course: Immunology," by Robert Novak and James Griffin; "Glaucoma," edited by Franz Grehn and Robert Stamper; "On Call Pediatrics," by James J. Nocton; and many others.

The article presents a call for papers to be published in a special October, 2008 issue devoted to the health of the U.S. Preference will be given to papers describing original research that presents new scientific understanding backed by solid data. Any topic related to the nation's health is eligible, including national health status, the composition of the health care work force, econometric analysis of health care reform, and comparative analyses with health care systems in other countries.

A list of books received by the "Journal of the American Medical Association" for review is presented. Titles include "Prostate Cancer: Principles and Practice," "Pain: New Essays on Its Nature and the Methodology of Its Study," "Faces of Osteoporosis and the Stories Behind Them," 'Frantz Fanon: A Portrait" and "AJCC Cancer Staging Atlas." Books on medical topics such as immunology, infectious diseases, otolaryngology, pediatrics, pathology and sports exercise are also listed.

The article discusses the health care crisis in the United States and invites those who are serious scholars in the field of medical care to submit manuscripts on topics dealing with health care for a March 2007 special thematic issue of the "Journal of the American Medical Association." The article encourages papers to focus on access to health care as well as the economic ramifications associated with potential solutions. The author writes that the amount of people in the U.S. who are unable to receive adequate medical care is on the rise.

The author reflects on the achievements as well as the possible future of the Affordable Care Act (ACA) legislation. The author referred to the challenges faced by the legislation prior to implementation including that from the Supreme Court as well as the U.S. Congress with the slim majority Senate approval. The author applauded the innovative thrusts of ACA despite the shortcomings on truly making health care more affordable with mention of the accountable care organization (ACO) system.

Presents the author's response to letters to the editor regarding a study of computerized physician order entry systems and medication errors, published in the March 10, 2005 edition of the "Journal of American Medical Association."

Presents a letter to the editor in response to a study of computerized physician order entry systems and medication errors, published in the March 10, 2005 edition of the "Journal of American Medical Association."

Presents a letter to the editor in response to a study of computerized physician order entry systems and medication errors, published in the March 10, 2005 edition of the "Journal of American Medical Association."

Assesses the concerns raised regarding the launching of a federal program to vaccinate a half million U.S. health care workers with the smallpox vaccine. Who will receive the vaccination; Mandatory immunization of 500,000 military personnel; Questions about compensation raised by an expert panel convened by the Institute of Medicine; Lack of compensation provisions for those individuals who are harmed by the vaccine; Expert panel urges more deliberation, analysis and evaluation by the government; Report that a number of hospitals across the country are declining to participate in the program because of concerns such as the vaccine's potential adverse effects, worker's compensation issues, and the possibility of inadvertant exposure of vulnerable individuals to vaccinia shed by vaccinated volunteers.

In the article, the author discusses the need for medical practitioners to determine what is best for their practice rather than follow the trends in medicine as of November 1895. He claims that the trends where physicians and surgeons allow reporters during their operations and daily bulletins of cases should not be the focus of rational or state medicine. He also talks about the importance of preventive medicine in health care.

This paper examines market justice health care in the United States which is based on the principles of self-interest, personal effort and voluntary behavior and compares it to social justice of medicine which stems from the principles of a shared community and offers services to all equally. The commercialization of medical care and how that changed the medical profession itself is presented along why there is little incentive to change the system despite the need.

Importance: Meta-analyses have suggested that initiating pulmonary rehabilitation after an exacerbation of chronic obstructive pulmonary disease (COPD) was associated with improved survival, although the number of patients studied was small and heterogeneity was high. Current guidelines recommend that patients enroll in pulmonary rehabilitation after hospital discharge.Objective: To determine the association between the initiation of pulmonary rehabilitation within 90 days of hospital discharge and 1-year survival.Design, Setting, and Patients: This retrospective, inception cohort study used claims data from fee-for-service Medicare beneficiaries hospitalized for COPD in 2014, at 4446 acute care hospitals in the US. The final date of follow-up was December 31, 2015.Exposures: Initiation of pulmonary rehabilitation within 90 days of hospital discharge.Main Outcomes and Measures: The primary outcome was all-cause mortality at 1 year. Time from discharge to death was modeled using Cox regression with time-varying exposure to pulmonary rehabilitation, adjusting for mortality and for unbalanced characteristics and propensity to initiate pulmonary rehabilitation. Additional analyses evaluated the association between timing of pulmonary rehabilitation and mortality and between number of sessions completed and mortality.Results: Of 197 376 patients (mean age, 76.9 years; 115 690 [58.6%] women), 2721 (1.5%) initiated pulmonary rehabilitation within 90 days of discharge. A total of 38 302 (19.4%) died within 1 year of discharge, including 7.3% of patients who initiated pulmonary rehabilitation within 90 days and 19.6% of patients who initiated pulmonary rehabilitation after 90 days or not at all. Initiation within 90 days was significantly associated with lower risk of death over 1 year (absolute risk difference [ARD], -6.7% [95% CI, -7.9% to -5.6%]; hazard ratio [HR], 0.63 [95% CI, 0.57 to 0.69]; P < .001). Initiation of pulmonary rehabilitation was significantly associated with lower mortality across start dates ranging from 30 days or less (ARD, -4.6% [95% CI, -5.9% to -3.2%]; HR, 0.74 [95% CI, 0.67 to 0.82]; P < .001) to 61 to 90 days after discharge (ARD, -11.1% [95% CI, -13.2% to -8.4%]; HR, 0.40 [95% CI, 0.30 to 0.54]; P < .001). Every 3 additional sessions was significantly associated with lower risk of death (HR, 0.91 [95% CI, 0.85 to 0.98]; P = .01).Conclusions and Relevance: Among fee-for-service Medicare beneficiaries hospitalized for COPD, initiation of pulmonary rehabilitation within 3 months of discharge was significantly associated with lower risk of mortality at 1 year. These findings support current guideline recommendations for pulmonary rehabilitation after hospitalization for COPD, although the potential for residual confounding exists and further research is needed. [ABSTRACT FROM AUTHOR]

The article focuses on the role of U.S. newspapers in creating awareness among U.S. people regarding public health and medical care. It cites various medical incidents that were published in several newspapers including "Enquirer," "Ledger," and "Chronicle." It mentions that newspapers reports about various meetings on topics including perpetual eclampsia, chronic intestinal nephritis and hydrated mole.

The article discusses the role of precision medicine in U.S. health care services. Topics include the need for randomized clinical trial (RCT) evidence on the effectiveness of precision medicine, the use of genomic information as part of electronic health records (EHRs), and drug development in relation to precision medicine.

The article discusses the notion of democratizing health care in the U.S. Topics include the integration of behavioral health and social services with health care provision, the use of technology to promote the sharing of health information, and changing economic incentives to involve patients in their own health.

The article discusses U.S. health care access for people with mental health and substance abuse problems. Topics include problems with the fragmented delivery of medical care and social services, the use of videoconferencing for mental health care, and the possibility of improved payment models for integrating services.

The article discusses transparency in health care systems regarding outcomes, health care quality, medical safety, and the costs of care. Topics include the factors causing errors in the measurement of health care outcomes, the relation of the nonprofit Financial Accounting Standards Board (FASB) in promoting transparency in financial reporting, and the need for standards for health data in the U.S.

Importance: Bundled payments are an increasingly common alternative payment model for Medicare, yet there is limited evidence regarding their effectiveness.Objective: To report interim outcomes from the first year of implementation of a bundled payment model for lower extremity joint replacement (LEJR).Design, Setting, and Participants: As part of a 5-year, mandatory-participation randomized trial by the Centers for Medicare & Medicaid Services, eligible metropolitan statistical areas (MSAs) were randomized to the Comprehensive Care for Joint Replacement (CJR) bundled payment model for LEJR episodes or to a control group. In the first performance year, hospitals received bonus payments if Medicare spending for LEJR episodes was below the target price and hospitals met quality standards. This interim analysis reports first-year data on LEJR episodes starting April 1, 2016, with data collection through December 31, 2016.Exposure: Randomization of MSAs into the CJR bundled payment model group (75 assigned; 67 included) or to the control group without the CJR model (121 assigned; 121 included). Instrumental variable analysis was used to evaluate the relationship between inclusion of MSAs in the CJR model and outcomes.Main Outcomes and Measures: The primary outcome was share of LEJR admissions discharged to institutional postacute care. Secondary outcomes included the number of days in institutional postacute care, discharges to other locations, Medicare spending during the episode (overall and for institutional postacute care), net Medicare spending during the episode, LEJR patient volume and patient case mix, and quality-of-care measures.Results: Among the 196 MSAs and 1633 hospitals, 131 285 eligible LEJR procedures were performed during the study period (mean volume, 110 LEJR episodes per hospital) among 130 343 patients (mean age, 72.5 [SD, 0.91] years; 65% women; 90% white). The mean percentage of LEJR admissions discharged to institutional postacute care was 33.7% (SD, 11.2%) in the control group and was 2.9 percentage points lower (95% CI, -4.95 to -0.90 percentage points) in the CJR group. Mean Medicare spending for institutional postacute care per LEJR episode was $3871 (SD, $1394) in the control group and was $307 lower (95% CI, -$587 to -$27) in the CJR group. Mean overall Medicare spending per LEJR episode was $22 872 (SD, $3619) in the control group and was $453 lower (95% CI, -$909 to $3) in the CJR group, a statistically nonsignificant difference. None of the other secondary outcomes differed significantly between groups.Conclusions and Relevance: In this interim analysis of the first year of the CJR bundled payment model for LEJR among Medicare beneficiaries, MSAs covered by CJR, compared with those that were not, had a significantly lower percentage of discharges to institutional postacute care but no significant difference in total Medicare spending per LEJR episode. Further evaluation is needed as the program is more fully implemented.Trial Registration: ClinicalTrials.gov Identifier: NCT03407885; American Economic Association Registry Identifier: AEARCTR-0002521. [ABSTRACT FROM AUTHOR]

The article emphasizes the importance of preparedness and infection control policies for dealing with potentially dangerous infectious diseases in the U.S. Topics discussed include the confirmation of cases of Middle East respiratory syndrome coronavirus (MERS-Cov) infection in the country, the continued emergence of new pathogens around the world, and person-to-person transmission of the virus in health care settings.

Importance: Health care spending in the United States increased substantially from 1995 to 2015 and comprised 17.8% of the economy in 2015. Understanding the relationship between known factors and spending increases over time could inform policy efforts to contain future spending growth.Objective: To quantify changes in spending associated with 5 fundamental factors related to health care spending in the United States: population size, population age structure, disease prevalence or incidence, service utilization, and service price and intensity.Design and Setting: Data on the 5 factors from 1996 through 2013 were extracted for 155 health conditions, 36 age and sex groups, and 6 types of care from the Global Burden of Disease 2015 study and the Institute for Health Metrics and Evaluation's US Disease Expenditure 2013 project. Decomposition analysis was performed to estimate the association between changes in these factors and changes in health care spending and to estimate the variability across health conditions and types of care.Exposures: Change in population size, population aging, disease prevalence or incidence, service utilization, or service price and intensity.Main Outcomes and Measures: Change in health care spending from 1996 through 2013.Results: After adjustments for price inflation, annual health care spending on inpatient, ambulatory, retail pharmaceutical, nursing facility, emergency department, and dental care increased by $933.5 billion between 1996 and 2013, from $1.2 trillion to $2.1 trillion. Increases in US population size were associated with a 23.1% (uncertainty interval [UI], 23.1%-23.1%), or $269.5 (UI, $269.0-$270.0) billion, spending increase; aging of the population was associated with an 11.6% (UI, 11.4%-11.8%), or $135.7 (UI, $133.3-$137.7) billion, spending increase. Changes in disease prevalence or incidence were associated with spending reductions of 2.4% (UI, 0.9%-3.8%), or $28.2 (UI, $10.5-$44.4) billion, whereas changes in service utilization were not associated with a statistically significant change in spending. Changes in service price and intensity were associated with a 50.0% (UI, 45.0%-55.0%), or $583.5 (UI, $525.2-$641.4) billion, spending increase. The influence of these 5 factors varied by health condition and type of care. For example, the increase in annual diabetes spending between 1996 and 2013 was $64.4 (UI, $57.9-$70.6) billion; $44.4 (UI, $38.7-$49.6) billion of this increase was pharmaceutical spending.Conclusions and Relevance: Increases in US health care spending from 1996 through 2013 were largely related to increases in health care service price and intensity but were also positively associated with population growth and aging and negatively associated with disease prevalence or incidence. Understanding these factors and their variability across health conditions and types of care may inform policy efforts to contain health care spending. [ABSTRACT FROM AUTHOR]

Importance: US health care spending has continued to increase, and now accounts for more than 17% of the US economy. Despite the size and growth of this spending, little is known about how spending on each condition varies by age and across time.Objective: To systematically and comprehensively estimate US spending on personal health care and public health, according to condition, age and sex group, and type of care.Design and Setting: Government budgets, insurance claims, facility surveys, household surveys, and official US records from 1996 through 2013 were collected and combined. In total, 183 sources of data were used to estimate spending for 155 conditions (including cancer, which was disaggregated into 29 conditions). For each record, spending was extracted, along with the age and sex of the patient, and the type of care. Spending was adjusted to reflect the health condition treated, rather than the primary diagnosis.Exposures: Encounter with US health care system.Main Outcomes and Measures: National spending estimates stratified by condition, age and sex group, and type of care.Results: From 1996 through 2013, $30.1 trillion of personal health care spending was disaggregated by 155 conditions, age and sex group, and type of care. Among these 155 conditions, diabetes had the highest health care spending in 2013, with an estimated $101.4 billion (uncertainty interval [UI], $96.7 billion-$106.5 billion) in spending, including 57.6% (UI, 53.8%-62.1%) spent on pharmaceuticals and 23.5% (UI, 21.7%-25.7%) spent on ambulatory care. Ischemic heart disease accounted for the second-highest amount of health care spending in 2013, with estimated spending of $88.1 billion (UI, $82.7 billion-$92.9 billion), and low back and neck pain accounted for the third-highest amount, with estimated health care spending of $87.6 billion (UI, $67.5 billion-$94.1 billion). The conditions with the highest spending levels varied by age, sex, type of care, and year. Personal health care spending increased for 143 of the 155 conditions from 1996 through 2013. Spending on low back and neck pain and on diabetes increased the most over the 18 years, by an estimated $57.2 billion (UI, $47.4 billion-$64.4 billion) and $64.4 billion (UI, $57.8 billion-$70.7 billion), respectively. From 1996 through 2013, spending on emergency care and retail pharmaceuticals increased at the fastest rates (6.4% [UI, 6.4%-6.4%] and 5.6% [UI, 5.6%-5.6%] annual growth rate, respectively), which were higher than annual rates for spending on inpatient care (2.8% [UI, 2.8%-2.8%] and nursing facility care (2.5% [UI, 2.5%-2.5%]).Conclusions and Relevance: Modeled estimates of US spending on personal health care and public health showed substantial increases from 1996 through 2013; with spending on diabetes, ischemic heart disease, and low back and neck pain accounting for the highest amounts of spending by disease category. The rate of change in annual spending varied considerably among different conditions and types of care. This information may have implications for efforts to control US health care spending. [ABSTRACT FROM AUTHOR]

In this article, the author reflects on the current status of electronic health records (EHR) framework in the U.S. He discusses the history of electronic health records and mentions several advantages of this system in improving health care quality. He further emphasizes on the significance of improvements in medical documentation.

Presents a letter to the editor in response to an editorial on computer technology and clinical trial work in the March 9, 2005 edition of the "Journal of the American Medical Association."

Importance: There is increasing interest in using price transparency tools to decrease health care spending.Objective: To measure the association between offering a health care price transparency tool and outpatient spending.Design, Setting, and Participants: Two large employers represented in multiple market areas across the United States offered an online health care price transparency tool to their employees. One introduced it on April 1, 2011, and the other on January 1, 2012. The tool provided users information about what they would pay out of pocket for services from different physicians, hospitals, or other clinical sites. Using a matched difference-in-differences design, outpatient spending among employees offered the tool (n=148,655) was compared with that among employees from other companies not offered the tool (n=295,983) in the year before and after it was introduced.Exposure: Availability of a price transparency tool.Main Outcomes and Measures: Annual outpatient spending, outpatient out-of-pocket spending, use rates of the tool.Results: Mean outpatient spending among employees offered the tool was $2021 in the year before the tool was introduced and $2233 in the year after. In comparison, among controls, mean outpatient spending changed from $1985 to $2138. After adjusting for demographic and health characteristics, being offered the tool was associated with a mean $59 (95% CI, $25-$93) increase in outpatient spending. Mean outpatient out-of-pocket spending among those offered the tool was $507 in the year before introduction of the tool and $555 in the year after. Among the comparison group, mean outpatient out-of-pocket spending changed from $490 to $520. Being offered the price transparency tool was associated with a mean $18 (95% CI, $12-$25) increase in out-of-pocket spending after adjusting for relevant factors. In the first 12 months, 10% of employees who were offered the tool used it at least once.Conclusions and Relevance: Among employees at 2 large companies, offering a price transparency tool was not associated with lower health care spending. The tool was used by only a small percentage of eligible employees. [ABSTRACT FROM AUTHOR]

This Viewpoint characterizes correctional health care as a separate health system in the US responsible for the lives of 2 million citizens, but largely neglected by the quality improvement movement, and discusses ways to improve care, outcomes, and health care value for incarcerated individuals and populations. [ABSTRACT FROM AUTHOR]

The author presents an assessment on the possible future of the Affordable Care Act (ACA) legislation and provides suggestions on revisions. Topics discussed include the reference to the reduction in the number of uninsured Americans as reported by President Barack Obama, the label "Medicaid Expansion Act" and the Congressional Budget Office (CBO). The author suggests federal law experimentation notwithstanding the size of the U.S. health system as comparable to a large world economy.

This section offers news briefs about medical care in the U.S. including the Food and Drug Administration's (FDA) withdrawal of Avastin for the treatment of metastatic breast cancer, launch of a Web-based tool for better informing patients about health care, and research about schizophrenia risk.

A reprint of articles related to medicine that were published in the September 17, 1910 issue of the "Journal of the American Medical Association" is presented. An article written by Young highlighted the health-related efforts of the U.S. government. The author claims that such article deserves careful and critical study in order to fully understand its claims on the national department of health. The issues surrounding less expensive forms of food as the cost of living increases are also discussed.

Two brief articles which originally appeared in the August 18, 1906 issue of the "Journal of the American Medical Association" are presented. The first deals with whether the interaction between medical history and broader social issues have been adequately addressed by writers on the topic. William Browning suggests that a wider context of medicine in society needs to be seen. The second article explores evidence suggesting that surgery results were better and mortality rates lower in lake cities in the United States than in river or port cities.

Presents an excerpt from the "Journal of the American Medical Association" from the April 9, 1904 issue. Reference to an article printed in the "Century Magazine" for April 1904, by Gary N. Calkin, discussing the protozoa in disease.

This Viewpoint discusses differences that complicate cross-country comparisons of health and social services and proposes a framework for assessing the appropriateness of those comparisons to help researchers improve their investigations and help readers critically appraise them. [ABSTRACT FROM AUTHOR]

The article offers information on a study conducted to compare the effect of rotation of physicians shift hours during two versus four week period on the number of patients visit. It highlights that duty shift rotations of shorter duration have disruptive affect on patient and doctor relationship. The methodologies applied for the study consists of evaluation parameters for the residents medical physicians on the basis of their four weeks of inpatients service. The performances of the physicians were also analyzed on the basis of repeated number of visits of the patients and their health outcomes.

The author examines the President's Emergency Plan for AIDS Relief (PEPFAR) program and its effects on global health improvement efforts. The program is focused on countries chosen for their high rates of human immunodeficiency virus (HIV) and AIDS. He claims that PEPFAR was a success based on two metrics, the size of its budget and the number of antiretroviral therapy (ART) recipients. He cites a study that examines whether PEPFAR actually reduced mortality and prolonged lives.

The article presents a reprint of the article "Eliminating Waste in US Health Care,"by Donald M. Berwick and Andrew D. Hackbarth, which appeared in the online issue of the "Journal of the American Medical Association" (JAMA) on March 14, 2012. The article emphasizes the urgent need to bring U.S. health care costs into a sustainable range for both public and private payers. Examples of programs to contain costs are cited. Also mentioned are the six categories of waste.

The article discusses a systematic review of studies of models for predicting the risk of hospital readmission. A total of 7843 citations were reviewed, but only 30 studies of 26 models qualified for the inclusion criteria. Most studies were based on health care data in the U.S. and some data were from Australia, England, Ireland, Switzerland and Canada. The models evaluated were divided in different categories including models based on retrospective administrative data, models relying on real-time administrative data and models that incorporate primary data collection. The authors conclude that most readmission risk prediction models designed for comparative or clinical purposes have poor performance.

The article discusses waste in the U.S. health care delivery system, which is described as unsafe, ineffective, inefficient, inequitable, untimely, and not patient-centered. The Dept. of Veterans Affairs' reforms in the 1990s are cited as exemplary at the macrosystem level. Other positive initiatives cited are the Leapfrog Group's agenda to reduce preventable medical errors and the Institute for Healthcare Improvement's 5 Million Lives Campaign, which is engaging U.S. hospitals to improve patient care and prevent avoidable deaths.

This article presents a study detailing the effect of physical therapy on stroke victims during the first three to nine months of recovery. Each year, hundreds of thousands of Americans experience a new or recurrent stroke, which results in health care costs totalling billions of dollars. Though traditional methods for rehabilitation among patients have shown to be effective in controlled studies, approaches that involve repetitive training of the upper extremities resulted in statistically significant and clinically relevant improvements in arm mobility and use among stroke victims.

Context: Modifiable behavioral risk factors are leading causes of mortality in the United States. Quantifying these will provide insight into the effects of recent trends and the implications of missed prevention opportunities. Objectives: To identify and quantify the leading causes of mortality in the United States. Design: Comprehensive MEDLINE search of English-language articles that identified epidemiological, clinical, and laboratory studies linking risk behaviors and mortality. The search was initially restricted to articles published during or after 1990, but we later included relevant articles published in 1980 to December 31, 2002. Prevalence and relative risk were identified during the literature search. We used 2000 mortality data reported to the Centers for Disease Control and Prevention to identify the causes and number of deaths. The estimates of cause of death were computed by multiplying estimates of the cause-attributable fraction of preventable deaths with the total mortality data. Main Outcome Measures: Actual causes of death. Results: The leading causes of death in 2000 were tobacco (435 000 deaths; 18.1% of total US deaths), poor diet and physical inactivity (400 000 deaths; 16.6%), and alcohol consumption (85 000 deaths; 3.5%). Other actual causes of death were microbial agents (75 000), toxic agents (55 000), motor vehicle crashes (43 000), incidents involving firearms (29 000), sexual behaviors (20 000), and illicit use of drugs (17 000). Conclusions: These analyses show that smoking remains the leading cause of mortality. However, poor diet and physical inactivity may soon overtake tobacco as the leading cause of death. These findings, along with escalating health care costs and aging population, argue persuasively that the need to establish a more preventive orientation in the US health care and public health systems has become more urgent. [ABSTRACT FROM AUTHOR]

This article—the first in a series on primary care—outlines the daunting challenges facing primary care today. Most people in the United States desire a primary care "home" to provide for and coordinate their health care needs. Yet primary care is endangered by physician stress, inadequate performance in managing chronic illness, and inability to provide prompt access and reliable continuity of care. Fundamental redesign is needed to improve access to and quality of care while easing physicians' workload without causing major increases in health care costs. [ABSTRACT FROM AUTHOR]

Reports statistical data on graduate medical education (GME) in the United States for 2000-2001. Numbers of residents and programs; Average on-duty hours for residents; Number of primary care physicians needed to meet health care needs in the U.S.; Methods used to compile statistics for the National GME Census of the American Medical Association.

Comments on health care in the United States and on the opinion of the Supreme Court in Pegram versus Herdrich, which proclaimed that health care was a matter of national policy. Background on federal law and physician incentives; Details on the Employee Retirement Income Security Act (ERISA); Why actions taken by the Supreme Court proved to be disappointing.

Objective: The American College of Physicians-American Society of Internal Medicine (ACP-ASIM) End-of-Life Care Consensus Panel was convened in 1997 to identify clinical, ethical, and policy problems in end-of-life care, to analyze critically the available evidence and guidelines, and to offer consensus recommendations on how to improve care of the dying. Topic selection and content presentation were carefully debated to maximize the project's focus on providing practical clinical and other guidance to clinicians who are not specialists in palliative care. This statement examines current legal myths, realities, and grains of truth in end-of-life care.Participants: The Consensus Panel comprises 13 medical and bioethics experts, clinicians, and educators in care at the end of life selected by the Ethics and Human Rights Committee, College leadership, and the Center for Ethics and Professionalism at the ACP-ASIM.Evidence: A literature review including a MEDLINE search of articles from 1970-1998 and review of end-of-life care literature and organizational bibliographies was conducted. Unpublished sources were also identified by participants, as was anecdotal clinical experience.Consensus Process: The draft statement was debated by panel members over a series of 3 to 4 meetings. For this statement, the initial draft and subsequent revised drafts were discussed in 1998-1999. The statement then underwent external peer review and revision before panel approval and the journal peer review process.Conclusions: Legal myths about end-of-life care can undermine good care and ethical medical practice. In addition, at times ethics, clinical judgment, and the law conflict. Patients (or families) and physicians can find themselves considering clinical actions that are ethically appropriate, but raise legal concerns. The 7 major legal myths regarding end-of-life care are: (1) forgoing life-sustaining treatment for patients without decision-making capacity requires evidence that this was the patient's actual wish; (2) withholding or withdrawing of artificial fluids and nutrition from terminally ill or permanently unconscious patients is illegal; (3) risk management personnel must be consulted before life-sustaining medical treatment may be terminated; (4) advance directives must comply with specific forms, are not transferable between states, and govern all future treatment decisions; oral advance directives are unenforceable; (5) if a physician prescribes or administers high doses of medication to relieve pain or other discomfort in a terminally ill patient, resulting in death, he/she will be criminally prosecuted; (6) when a terminally ill patient's suffering is overwhelming despite palliative care, and he/she requests a hastened death, there are no legally permissible options to ease suffering; and (7) the 1997 Supreme Court decisions outlawed physician-assisted suicide. Many legal barriers to end-of-life care are more mythical than real, but sometimes there is a grain of truth. Physicians must know the law of the state in which they practice. JAMA. 2000;284:2495-2501. [ABSTRACT FROM AUTHOR]

Presents several letters to the editor dealing with medical issues. Discussion of barriers to patients seeking emergency care for acute coronary heart disease; Analysis of the United States health care system; Concern over the Institute of Medicine's report on the number of deaths in the U.S. as a result of medical errors; Others.

Although the US health care system is often touted as one of the best in the world, disparities exist in quality of care received by different populations, in different regions, and across different institutions and clinicians. Initiatives to provide access to health insurance have been a major policy tool to ensure that Americans receive high-quality health care. However, availability of insurance coverage does not automatically lead to high-quality care. This article explores points of vulnerability in the US health care system at which the potential to achieve high-quality care can be lost: (1) access to insurance coverage; (2) enrollment in available insurance plans; (3) access to covered services, clinicians, and health care institutions; (4) choice of plans, clinicians, and health care institutions; (5) access to a consistent source of primary care; (6) access to referral services; and (7) delivery of high-quality health care services. Ensuring high-quality health care requires that each of these "voltage drops" be recognized and addressed. JAMA. 2000;284:2100-2107. [ABSTRACT FROM AUTHOR]

Discusses how information about the performance of hospitals, health professionals and health care organizations has been made public in the United States for more than a decade. Study to summarize the empirical evidence concerning public disclosure of performance date, relate the results to the potential gains, and identify areas requiring further research; Data sources; Study selection; Data extraction and synthesis; Conclusions.