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BACKGROUND: Sodium consumption raises blood pressure, increasing the risk for heart attack and stroke. Several countries, including the United States, are considering strategies to decrease population sodium intake. OBJECTIVE: To assess the cost-effectiveness of 2 population strategies to reduce sodium intake: government collaboration with food manufacturers to voluntarily cut sodium in processed foods, modeled on the United Kingdom experience, and a sodium tax. DESIGN: A Markov model was constructed with 4 health states: well, acute myocardial infarction (MI), acute stroke, and history of MI or stroke. DATA SOURCES: Medical Panel Expenditure Survey (2006), Framingham Heart Study (1980 to 2003), Dietary Approaches to Stop Hypertension trial, and other published data. TARGET POPULATION: U.S. adults aged 40 to 85 years. TIME HORIZON: Lifetime. PERSPECTIVE: Societal. OUTCOME MEASURES: Incremental costs (2008 U.S. dollars), quality-adjusted life-years (QALYs), and MIs and strokes averted. RESULTS OF BASE-CASE ANALYSIS: Collaboration with industry that decreases mean population sodium intake by 9.5% averts 513 885 strokes and 480 358 MIs over the lifetime of adults aged 40 to 85 years who are alive today compared with the status quo, increasing QALYs by 2.1 million and saving $32.1 billion in medical costs. A tax on sodium that decreases population sodium intake by 6% increases QALYs by 1.3 million and saves $22.4 billion over the same period. RESULTS OF SENSITIVITY ANALYSIS: Results are sensitive to the assumption that consumers have no disutility with modest reductions in sodium intake. LIMITATION: Efforts to reduce population sodium intake could result in other dietary changes that are difficult to predict. CONCLUSION: Strategies to reduce sodium intake on a population level in the United States are likely to substantially reduce stroke and MI incidence, which would save billions of dollars in medical expenses. PRIMARY FUNDING SOURCE: Department of Veterans Affairs, Stanford University, and National Science Foundation. [ABSTRACT FROM AUTHOR]

Background: The Geriatric Evaluation and Management study was developed to assess the impact of a comprehensive geriatric assessment service on the care of the elderly.Objectives: We sought to evaluate the cost and clinical impact of inpatient units and outpatient clinics for geriatric evaluation and management.Research Design: We undertook a prospective, randomized, controlled trial using a 2x2 factorial design, with 1-year follow-up.Subjects: A total of 1388 participants hospitalized on either a medical or surgical ward at 11 participating Veterans Affairs medical centers were randomized to receive either inpatient geriatric unit (GEMU) or usual inpatient care (UCIP), followed by either outpatient care from a geriatric clinic (GEMC) versus usual outpatient care (UCOP).Measures: We measured health care utilization and costs.Results: Patients assigned to the GEMU had a significantly decreased rate of nursing home placement (odds ratio=0.65; P=0.001). Neither the GEMU nor GEMC had any statistically significant improvement effects on survival and only modest effects on health status. There were statistically insignificant mean cost savings of $1027 (P=0.29) per patient for the GEMU and $1665 (P=0.69) per patient for the GEMC.Conclusions: Inpatient or outpatient geriatric evaluation and management units didn't increase the costs of care. Although there was no effect on survival and only modest effects on SF-36 scores at 1-year follow-up, there was a statistically significant reduction in nursing home admissions for patients treated in the GEMU. [ABSTRACT FROM AUTHOR]

Background: Low rates of technology utilization in hospitals with high proportions of black inpatients may be a remediable cause of healthcare disparities.Objectives: Our objective was to determine how differences in technology utilization among hospitals contributed to racial disparity and if temporal reduction in hospital procedure rate variation resulted in decreased racial disparity for these technologies.Methods: We identified 2,348,952 elderly Medicare beneficiaries potentially eligible for 1 of 5 emerging medical technologies from 1989-2000 and determined if these patients had received the indicated procedure within 90 days of their qualifying hospital admission. Initial multivariate regression models adjusted for age, race, sex, admission year, clinical comorbidity, community levels of education and income, and academic/urban hospital admission. The inpatient racial composition of each patient's admitting hospital and time-race interactions were added as covariates to subsequent models.Results: Blacks had significantly lower adjusted rates (P < 0.001) compared with whites for tissue replacement of the aortic valve, internal mammary artery coronary bypass grafting, dual-chambered pacemaker implantation, and lumbar spinal fusion. Hospitals with > 20% black inpatients were less likely to perform these procedures on both white and black patients than hospitals with < 9% black inpatients, and racial disparity was greater in hospitals with larger black populations. There were no temporal reductions in racial disparities.Conclusions: Blacks may be disadvantaged in access to new procedures by receiving care at hospitals that have both lower procedure rates and greater racial disparity. Policies designed to ameliorate racial disparities in health care must address hospital variation in the provision of care. [ABSTRACT FROM AUTHOR]

Objective: Although an increasing fraction of Medicare beneficiaries die outside the hospital, the proportion of total Medicare expenditures attributable to care in the last year of life has not dropped. We sought to determine whether disproportionate increases in hospital treatment intensity over time among decedents are responsible for the persistent growth in end-of-life expenditures.Data Source: The 1985-1999 Medicare Medical Provider Analysis and Review (MedPAR) and Denominator files.Study Design: We sampled inpatient claims for 20 percent of all elderly fee-for-service Medicare decedents and 5 percent of all survivors between 1985 and 1999 and calculated age-, race-, and gender-adjusted per-capita inpatient expenditures and rates of intensive care unit (ICU) and intensive procedure use. We used the decedent-to-survivor expenditure ratio to determine whether growth rates among decedents outpaced growth relative to survivors, using the growth rate among survivors to control for secular trends in treatment intensity. Data Collection. The data were collected by the Centers for Medicare and Medicaid Services.Principal Findings: Real inpatient expenditures for the Medicare fee-for-service population increased by 60 percent, from $58 billion in 1985 to $90 billion in 1999, one-quarter of which were accrued by decedents. Between 1985 and 1999 the proportion of beneficiaries with one or more intensive care unit (ICU) admission increased from 30.5 percent to 35.0 percent among decedents and from 5.0 percent to 7.1 percent among survivors; those undergoing one or more intensive procedure increased from 20.9 percent to 31.0 percent among decedents and from 5.8 percent to 8.5 percent among survivors. The majority of intensive procedures in the United States were performed in the more numerous survivors, although in 1999 50 percent of feeding tube placements, 60 percent of intubations/tracheostomies, and 75 percent of cardiopulmonary resuscitations were in decedents. The proportion of beneficiaries dying in a hospital decreased from 44.4 percent to 39.3 percent, but the likelihood of being admitted to an ICU or undergoing an intensive procedure during the terminal hospitalization increased from 38.0 percent to 39.8 percent and from 17.8 percent to 30.3 percent, respectively. One in five Medicare beneficiaries who died in the hospital in 1999 received mechanical ventilation during their terminal admission.Conclusions: Inpatient treatment intensity for all fee-for-service beneficiaries increased between 1985 and 1999 regardless of survivorship status. Absolute changes in per-capita hospital expenditures, ICU admissions, and intensive inpatient procedure use were much higher among decedents. Relative changes were similar except for ICU admissions, which grew faster among survivors. The secular decline in in-hospital deaths has not resulted in decreased per capita utilization of expensive inpatient services in the last year of life. This could imply that net hospital expenditures for the dying might have been even higher over this time period if the shift toward hospice had not occurred. [ABSTRACT FROM AUTHOR]

Objective: To discuss and quantify the incentives that Medicare managed care plans have to avoid (through selective enrollment or disenrollment) people who are at risk for very high costs, focusing on Medicare beneficiaries in the last year of life-a group that accounts for more than one-quarter of Medicare's annual expenditures.Data Source: Medicare administrative claims for 1994 and 1995.Study Design: We calculated the payment a plan would have received under three risk-adjustment systems for each beneficiary in our 1995 sample based on his or her age, gender, county of residence, original reason for Medicare entitlement, and principal inpatient diagnoses received during any hospital stays in 1994. We compared these amounts to the actual costs incurred by those beneficiaries. We then looked for clinical categories that were predictive of costs, including costs in a beneficiary's last year of life, not accounted for by the risk adjusters.Data Extraction Methods: The analyses were conducted using claims for a 5 percent random sample of Medicare beneficiaries who died in 1995 and a matched group of survivors.Principal Findings: Medicare is currently implementing the Principal Inpatient Diagnostic Cost Groups (PIP-DCG) risk adjustment payment system to address the problem of risk selection in the Medicare+Choice program. We quantify the strong financial disincentives to enroll terminally ill beneficiaries that plans still have under this risk adjustment system. We also show that up to one-third of the selection observed between Medicare HMOs and the traditional fee-for-service system could be due to differential enrollment of decedents. A risk adjustment system that incorporated more of the available diagnostic information would attenuate this disincentive; however, plans could still use clinical information (not included in the risk adjustment scheme) to identify beneficiaries whose expected costs exceed expected payments.Conclusions: More disaggregated prospective risk adjustment methods and alternative payment systems that compensate plans for delivering care to certain classes of patients should be considered to ensure access to high-quality managed care for all beneficiaries. [ABSTRACT FROM AUTHOR]

Background: Low-molecular-weight heparins may simplify the management of deep venous thrombosis. A critical clinical issue is whether this more convenient therapy is as safe and effective as treatment with unfractionated heparin.Purpose: To compare the safety and efficacy of low-molecular-weight heparins with those of unfractionated heparin for treatment of acute deep venous thrombosis.Data Sources: Reviewers identified studies by searching MEDLINE, reviewing references from retrieved articles, scanning abstracts from conference proceedings, and contacting investigators and pharmaceutical companies.Study Selection: Randomized, controlled trials that compared a low-molecular-weight heparin preparation with unfractionated heparin for treatment of acute deep venous thrombosis.Data Extraction: Two reviewers extracted data independently. Reviewers evaluated study quality using a validated four-item instrument.Data Synthesis: Eleven of 37 studies met inclusion criteria for three major outcomes. Most studies used proper randomization procedures, but only one was double-blinded. Compared with unfractionated heparin, low-molecular-weight heparins reduced mortality rates over 3 to 6 months of patient follow-up (odds ratio, 0.71 [95% CI, 0.53 to 0.94]; P = 0.02). For major bleeding complications, the odds ratio favored low-molecular-weight heparins (0.57 [CI, 0.33 to 0.99]; P = 0.047), but the absolute risk reduction was small and not statistically significant (0.61% [CI, -0.04% to 1.26%]; P = 0.07). For preventing thromboembolic recurrences, low-molecular-weight heparins seemed as effective as unfractionated heparin (odds ratio, 0.85 [CI, 0.63 to 1.14]; P > 0.2).Conclusions: Low-molecular-weight heparin treatment reduces mortality rates after acute deep venous thrombosis. These drugs seem to be as safe as unfractionated heparin with respect to major bleeding complications and appear to be as effective in preventing thromboembolic recurrences. [ABSTRACT FROM AUTHOR]

Background: Low-molecular-weight heparins are effective for treating venous thrombosis, but their cost-effectiveness has not been rigorously assessed.Objective: To evaluate the cost-effectiveness of low-molecular-weight heparins compared with unfractionated heparin for treatment of acute deep venous thrombosis.Design: Decision model.Data Sources: Probabilities for clinical outcomes were obtained from a meta-analysis of randomized trials. Cost estimates were derived from Medicare reimbursement and other sources.Target Population: Two hypothetical cohorts of 60-year-old men with acute deep venous thrombosis.Time Horizon: Patient lifetime.Perspective: Societal.Intervention: Fixed-dose low-molecular-weight heparin or adjusted-dose unfractionated heparin.Outcome Measures: Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. An in-patient hospital setting was used for the base-case analysis. Secondary analyses examined outpatient treatment with low-molecular-weight heparin.Results Of Base-case Analysis: Total costs for inpatient treatment were $26,516 for low-molecular-weight heparin and $26,361 for unfractionated heparin. The cost of initial care was higher in patients who received low-molecular-weight heparin, but this was partly offset by reduced costs for early complications. Low-molecular-weight heparin treatment increased quality-adjusted life expectancy by approximately 0.02 years. The incremental cost-effectiveness of inpatient low-molecular-weight heparin treatment was $7820 per QALY gained. Treatment with low-molecular-weight heparin was cost saving when as few as 8% of patients were treated at home.Results Of Sensitivity Analysis: When late complications were assumed to occur 25% less frequently in patients who received unfractionated heparin, the incremental cost-effectiveness ratio increased to almost $75,000 per QALY gained. When late complications were assumed to occur 25% less frequently in patients who received low-molecular-weight heparin, this treatment resulted in a net cost savings. Inpatient low-molecular-weight heparin treatment became cost saving when its pharmacy cost was reduced by 31% or more, when it reduced the yearly incidence of late complications by at least 7%, when as few as 8% of patients were treated entirely as outpatients, or when at least 13% of patients were eligible for early discharge.Conclusions: Low-molecular-weight heparins are highly cost-effective for inpatient management of venous thrombosis. This treatment reduces costs when small numbers of patients are eligible for outpatient management. [ABSTRACT FROM AUTHOR]

Objective: To assess the role of serum lipid levels as screening tests in adults.Design: Pooled analysis of clinical trials, supplemented by analysis of data from the Framingham Heart Study, to estimate the effect of cholesterol reduction in patient groups stratified by cardiac risk.Study Selection: Published randomized controlled trials of cholesterol reduction, meta-analyses of such trials, prospective cohort studies of the association between cholesterol levels and morbidity and death related to coronary heart disease, and cost-effectiveness analyses of cholesterol reduction.Data Analysis: Two-stage logistic regression on cardiac risk factors and outcomes in the Framingham Heart Study. The first stage predicted the risk for death from coronary heart disease using standard risk factors but not cholesterol; the second stage predicted the risk for death from coronary heart disease and all causes as functions of age and cholesterol level, stratified by the risk predicted from the first stage.Results: Randomized clinical trials show that cholesterol reduction confers survival benefits in patients with symptomatic coronary disease. In asymptomatic middle-aged men, who are at lower risk for death from coronary disease, cholesterol reduction prevents coronary disease but has not been shown to prolong life. The risk model based on analysis of the data from the Framingham Heart Study is consistent with the randomized trial data and shows that in the demographic groups excluded from trials, the hypothetical benefits of cholesterol reduction are greatest when the underlying risk for coronary disease is greatest.Conclusions: Screening with total cholesterol levels is most likely to be useful when done in populations at high short-term risk for dying of coronary heart disease, such as survivors of myocardial infarction and middle-aged men with multiple cardiac risk factors. In these populations, cholesterol reduction appears to be both effective and cost-effective. In other populations, the benefits of reduction are much smaller or are uncertain. [ABSTRACT FROM AUTHOR]

Background: The Asymptomatic Carotid Atherosclerosis Study (ACAS) showed that carotid endarterectomy was beneficial for symptom-free patients with carotid stenosis of 60% or more. This finding raises the question of whether widespread screening to identify cases of asymptomatic carotid stenosis should be implemented.Objective: To determine whether a screening program to identify cases of asymptomatic carotid stenosis would be a cost-effective strategy for stroke prevention.Design: Cost-effectiveness analysis using published data from clinical trials.Setting: General population of asymptomatic 65-year-old men.Intervention: Patients who were screened for carotid disease with duplex Doppler ultrasonography were compared with patients who were not screened. If ultrasonography found significant carotid stenosis (> or = 60%), disease was confirmed by angiography before carotid endarterectomy was done.Measurements: Quality-adjusted life-years, costs, and marginal cost-effectiveness ratios.Results: When the conditions and results of ACAS were modeled and it was assumed that the survival advantage produced by endarterectomy would last for 30 years, the lifetime marginal cost-effectiveness of screening relative to no screening was $120,000 per quality-adjusted life-year. Sensitivity analysis showed that marginal cost-effectiveness decreased to $50,000 or less per quality-adjusted life-year only under implausible conditions (for example, if a free screening instrument with perfect test characteristics was used or an asymptomatic population with a 40% prevalence of carotid stenosis was found).Conclusions: Surgery offers a real but modest absolute reduction in the rate of stroke at a substantial cost. A program to identify candidates for endarterectomy by screening asymptomatic populations for carotid stenosis costs more per quality-adjusted life-year than is usually considered acceptable. [ABSTRACT FROM AUTHOR]

Published guidelines differ -- sharply, at times -- on whom, when, and how to screen for elevated cholesterol levels. At the heart of the controversy is the question of which strategy will target those most in need of cholesterol-lowering therapy. [ABSTRACT FROM AUTHOR]

An intensified focus on drug safety often leads to demands for more data collection prior to drug approval. Other approaches can be used, such as enhanced postmarketing surveillance. Many drug benefits and adverse effects are unlikely to become apparent before wide distribution among diverse patients. The best balance of pre- and postapproval data collection may vary by drug. The consequences of alternative strategies are complex and not always immediately apparent, so formal modeling offers the best approach to determine which strategy is optimal in each case. [ABSTRACT FROM AUTHOR]

Recent innovations in biomedicine seem poised to revolutionize medical practice. At the same time, disease and disability are increasing among younger populations. This paper considers how these confluent trends will affect the elderly's health status and health care spending over the next thirty years. Because healthier people live longer, cumulative Medicare spending varies little with a beneficiary's disease and disability status upon entering Medicare. On the other hand, ten of the most promising medical technologies are forecast to increase spending greatly. It is unlikely that a 'silver bullet' will emerge to both improve health and dramatically reduce medical spending [ABSTRACT FROM AUTHOR]

Motivation: Medical curricula improvement is an ongoing process to keep material relevant and improve the student's learning experience to better prepare them for patient care. Many programs utilize end-of-year evaluations, but these frequently have low response rates and lack actionable feedback. We hypothesized that student reflections written during a fourth year Sub-Internship could be used retrospectively to mine additional information as feedback for future curriculum adjustments. However, reflections contain a large amount of narrative content that would require a cumbersome and essentially infeasible manual review process for busy medical education faculty., Methods: We developed a Natural Language Processing (NLP) pipeline to automatically identify common themes and topics present in the set of reflective writings that could be used to improve the curriculum. The dataset contains required responses to a faculty issued question submitted between August 2016 and July 2018 about challenges experienced during the medical students fourth year Sub-Internship., Results: Eleven distinct topics were identified, with several being subsequently addressed in future iterations of the curriculum., Conclusion: Utilizing NLP on reflective writings was able to identify areas of curriculum improvement, and the NLP results provided a quick and easy way to explore the main themes and challenges expressed by students.

Background: The acting internship (AI) in internal medicine plays a key role in the transition from medical school to residency. While there have been recent changes in medical education including a pass/fail USMLE Step 1 and increasing use of competency-based assessment, there has not been a large survey of the state of the AI in many years., Objective: To assess the current landscape of the internal medicine AI and identify areas in need of standardization., Design: This was a voluntary online survey of medical schools in the United States (U.S.)., Participants: Course directors of the AI rotation at U.S. medical schools., Main Measures: Number of AI rotations required for graduation, length of AI rotation, types of services allowed for AI, clinical responsibilities of students, curricular components., Key Results: Response rate was 50.7% (71/140 LCME accredited schools). All responding institutions require at least one AI for graduation, with nearly all schools integrating students into resident teaching teams, and almost half also allowing AI students to work on hospitalist services. Students carry 3-4 patients per day on average with a maximum of 5-6 in most institutions. Students are responsible for most aspects of patient care including notes, orders, interprofessional communication, and transitions of care. Night call or night float responsibilities are infrequently required. The structured curriculum published by AAIM is used by only 41% of schools., Conclusions: The internal medicine AI continues to be a staple in the medical school experience, but there is variation in the structure, curriculum, and expectations on the rotation. Opportunities exist to improve standardization of the AI experience and expectations to better prepare medical students for the transition from medical school to residency., (© 2024. The Author(s).)

Background: Recognizing and attempting management of patients with urgent or emergent conditions is one of the Association of American Medical Colleges Core Entrustable Professional Activities (#10) and a skill desired of new interns. However, given the acuity of these patient conditions, medical students often struggle to gain experience in these situations. Virtual reality could help fill this void while lowering costs and resources compared with high-fidelity simulation., Methods: We converted a high-fidelity chest pain simulation case to virtual reality format utilizing short video clips filmed with a 360-degree camera and superimposed menus of options at decision points. This virtual reality simulation was offered to fourth-year medical students during their transition to residency course in the spring of 2023. Students were offered a post-survey on the simulation., Results: There were 47 fourth-year students that completed the virtual reality simulation; 41 completed the post-survey (response rate 87.2%). Over 90% of the students agreed or strongly agreed with the following statements: the virtual reality simulation was a valuable part of the transition to residency course, the virtual reality case was similar to what they will face as an intern, and they would like to have more virtual reality simulations earlier in the fourth year; 85.4% agreed or strongly agreed that the virtual reality simulation helped prepare them for the first few days of intern year., Conclusions: We demonstrated that virtual reality is an acceptable, cost-effective, and feasible modality to teach medical students how to recognize and attempt management of urgent clinical situations (Core Entrustable Professional Activity 10)., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: "Giving or receiving a patient handover to transition patient care responsibility" is one of the thirteen Core Entrustable Professional Activities (Core EPAs) for Entering Residency. However, implementing a patient handover curriculum in undergraduate medical education (UME) remains challenging. Educational leaders in the multi-institutional Core EPA8 pilot workgroup developed a longitudinal patient handover UME curriculum that was implemented at two pilot institutions., Materials and Methods: We utilized multi-school graduation questionnaire data to assess the association of our patient handover curriculum on self-reported frequency of observation/feedback and skill acquisition by comparing data from the shared curriculum schools to data from other Core EPA pilot schools (three schools with school-specific curriculum; five without a dedicated handover curriculum). Questionnaire data from 1,278 graduating medical students of the class of 2020 from all ten Core EPA pilot schools were analyzed., Results: Graduates from the two medical schools that implemented the shared patient handover curriculum reported significantly greater frequency of handover observation/feedback compared to graduates at the other schools (school-specific curriculum ( p  < .05) and those without a handover curriculum ( p  < .05)). Graduates from the two shared approach schools also more strongly agreed that they possessed the skill to perform handovers compared to graduates from the other eight pilot schools that did not implement this curriculum., Conclusion: The findings of this study suggest that the implementation of a multi-institutional Core EPA-based curricular model for teaching and assessing patient handovers was successful and could be implemented at other UME institutions., Competing Interests: Conflict of InterestThe authors declare no competing interests., (© The Author(s) under exclusive licence to International Association of Medical Science Educators 2022.)

Introduction: The Core Entrustable Professional Activities for Entering Residency (Core EPAs) are clinical activities all interns should be able to perform on the first day of residency with indirect supervision. The acting (sub) internship (AI) rotation provides medical students the opportunity to be assessed on advanced Core EPAs., Materials and Methods: All fourth-year AI students were taught Core EPA skills and performed these clinical skills under direct supervision. Formative feedback and direct observation data were provided via required workplace-based assessments (WBAs). Supervising physicians rated learner performance using the Ottawa Clinic Assessment Tool (OCAT). WBA and pre-post student self-assessment data were analyzed to assess student performance and gauge curriculum efficacy., Results: In the 2017-2018 academic year, 167 students completed two AI rotations at our institution. By their last WBA, 91.2% of students achieved a target OCAT supervisory scale rating for both patient handoffs and calling consults. Paired sample t tests of the student pre-post surveys showed statistically significant improvement in self-efficacy on key clinical functions of the EPAs., Discussion: This study demonstrates that the AI rotation can be structured to include a Core EPA curriculum that can assess student performance utilizing WBAs of directly observed clinical skills., Conclusions: Our clinical outcomes data demonstrates that the majority of fourth-year medical students are capable of performing advanced Core EPAs at a level acceptable for intern year by the conclusion of their AI rotations. WBA data collected can also aid in ad hoc and longitudinal summative Core EPA entrustment decisions., Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-021-01208-y., Competing Interests: Conflict of InterestThe authors declare that they have no conflict of interest., (© International Association of Medical Science Educators 2021.)

Introduction Medical students have been documenting notes in the electronic health records (EHR) for many years but often wrote separate notes from housestaff and faculty because licensed providers (LPs) could not bill the Centers for Medicare and Medicaid Services (CMS) for Evaluation and Management (E/M) services. However, in 2018, CMS updated its policy to allow LPs to simply verify any component of an E/M service under appropriate supervision, allowing LPs to bill a full medical student note. Methods At Virginia Commonwealth University Health Systems (VCUHS), a task force was formed to develop and pilot the One Note System (ONS), a system that incorporates the new CMS guidelines for certain note types. In June 2019, or 10 months after implementation of the ONS, the authors developed and distributed a survey that explored perceptions regarding the ONS among medical students, housestaff (residents and fellows), and faculty. Results The results showed that most participants were aware of the ONS and preferred email as the form of training. Overall, the ONS had a positive impact on faculty and housestaff workflow, improved self-reported faculty wellbeing, and increased meaning in student work. Only a minority reported barriers to implementing the ONS. Conclusions The One Note System was successfully implemented at VCUHS and positively received. Other outcomes to measure include impact of the ONS on student and trainee education, compliance and billing, quality and quantity of documentation, and faculty and housestaff burnout rates., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Safdar et al.)

Background Medical training relies on direct observations and formative feedback. After residency graduation, opportunities to receive feedback on clinical teaching diminish. Although feedback through learner evaluations is common, these evaluations can be untimely, non-specific, and potentially biased. On the other hand, peer feedback in a small group setting or lecture format has been shown to be beneficial to teaching behaviors, however, little is known if peer observation using a standardized tool followed by feedback results in improved teaching behaviors. Therefore, the objective of this study was to examine if feedback after peer observation results in improved inpatient teaching behaviors. Methods This study was conducted at a tertiary care hospital. Academic hospitalists in the Division of Hospital Medicine developed a standardized 28-item peer observation tool based on the Stanford Faculty Development Program to observe their peers during bedside teaching rounds and provide timely feedback after observation. The tool focused on five teaching domains (learning climate, control of session, promotion of understanding and retention, evaluation, and feedback) relevant to the inpatient teaching environment. Teaching hospitalists were observed at the beginning of a two-week teaching rotation, given feedback, and then observed at the end of the rotation. Furthermore, we utilized a post-observation survey to assess the teaching and observing hospitalists' comfort with observation and the usefulness of the feedback. We used mixed linear models with crossed design to account for correlations between the observations. Models were adjusted for gender, age, and years of experience. We tested the internal validity of the instrument with Cronbach's alpha. Results Seventy (range: one to four observations per faculty) observations were performed involving 27 teaching attendings. A high proportion of teachers were comfortable with the observation (79%) and found the feedback helpful (92%), and useful for their own teaching (88%). Mean scores in teaching behavior domains ranged from 2.1 to 2.7. In unadjusted and adjusted analysis, each teaching observation was followed by higher scores in learning climate (adjusted improvement = 0.09; 95% CI = 0.02-0.15; p = 0.007) and promotion of understanding and retention (adjusted improvement = 0.09; 95% CI = 0.02-0.17; p = 0.01). The standardized observation tool had Cronbach's alpha of 0.81 showing high internal validity. Conclusions Peer observation of bedside teaching followed by feedback using a standardized tool is feasible and results in measured improvements in desirable teaching behaviors. The success of this approach resulted in the expansion of peer observation to other Divisions within the Department of Internal Medicine at our Institution., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Pedram et al.)

Background: The acting (Sub)internship (AI) provides fourth-year medical students the opportunity to gain essential clinical experience, making it challenging to develop an effective curriculum without detracting from clinical time., Activity: This flipped classroom, asynchronous learning curriculum utilized a short online video, called a micro-lecture, to teach one to two key concepts, associated with online case-based questions., Results and Discussion: Over one academic year, 96% (64/67) of internal medicine AI students at our institution completed the online questions. The majority of students selected the single best response for both questions and preferred this online micro-lecture format over traditional methods., Competing Interests: Conflict of InterestThe authors declare that they have no conflict of interest., (© International Association of Medical Science Educators 2019.)

Background: The increase in applications to residency programs, known as "application inflation," creates challenges for program directors (PDs). Prior studies have shown that internal medicine (IM) PDs utilize criteria, such as United States Medical Licensing Examination (USMLE) Step examination performance, when reviewing applications. However, little is known about how early these filters are utilized in the application review cycle., Objective: This study sought to assess the frequency and types of filters utilized by IM PDs during initial residency application screening and prior to more in-depth application review., Methods: A web-based request for the 2016 Internal Medicine In-Training Examination (IM-ITE) PD Survey was sent to IM PDs. Responses from this survey were analyzed, excluding non-US programs., Results: With a 50% response rate (214 of 424), IM PDs responded that the most commonly used data points to filter applicants prior to in-depth application review were the USMLE Step 2 Clinical Knowledge score (32%, 67 of 208), USMLE Step 1 score (24%, 50 of 208), and medical school attended (12%, 25 of 208). Over half of US IM PD respondents (55%, 114 of 208) indicated that they list qualifying interview criteria on their program website, and 31% of respondents (50 of 160) indicated that more than half of their applicant pool does not meet the program's specified interview criteria., Conclusions: Results from the 2016 IM-ITE PD Survey indicate many IM PDs use filters for initial application screening, and that these filters, when available to applicants, do not affect many applicants' decisions to apply., Competing Interests: Conflict of interest: The authors declare they have no competing interests., (Accreditation Council for Graduate Medical Education 2019.)

Objectives: Low back pain (LBP) is a common and expensive clinical problem, resulting in tens of billions of dollars of direct medical expenditures in the United States each year. Although expensive imaging tests are commonly used, they do not improve outcomes when used in the initial management of idiopathic LBP. We estimated 1-year medical costs associated with early imaging of Medicare beneficiaries with idiopathic LBP., Study Design: We used a 5% random sample of Medicare fee-for-service enrollees between 2006 and 2010 to determine 12-month costs following a diagnosis of idiopathic LBP. We analyzed costs of care and patient outcomes according to whether or not the patients had been referred for early imaging following their initial diagnosis., Methods: We employed an instrumental variables analysis using risk-adjusted physician-level propensity to order imaging for patients without LBP as an instrument for imaging use among patients with LBP. We selected this approach to adjust for confounding by indication when estimating the relative costs of early imaging of LBP compared with conservative management., Results: Early imaging is strongly associated with increased costs of care in the first year following LBP diagnosis. Patients receiving an early magnetic resonance imaging scan accrued $2500 more in Medicare expenditures than conservatively managed patients, and patients who received computed tomography accrued $19,900 more., Conclusions: Medicare beneficiaries with low-risk LBP frequently receive early imaging studies. Early imaging was associated with greater long-term costs than a conservative diagnostic strategy; Medicare expenditures could be reduced by $362 million annually by managing newly diagnosed LBP in accordance with clinical guidelines.

Background: Randomized trials of left atrial appendage (LAA) closure with the Watchman device have shown varying results, and its cost effectiveness compared with anticoagulation has not been evaluated using all available contemporary trial data., Methods and Results: We used a Markov decision model to estimate lifetime quality-adjusted survival, costs, and cost effectiveness of LAA closure with Watchman, compared directly with warfarin and indirectly with dabigatran, using data from the long-term (mean 3.8 year) follow-up of Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation (PROTECT AF) and Prospective Randomized Evaluation of the Watchman LAA Closure Device in Patients With Atrial Fibrillation (PREVAIL) randomized trials. Using data from PROTECT AF, the incremental cost-effectiveness ratios compared with warfarin and dabigatran were $20 486 and $23 422 per quality-adjusted life year, respectively. Using data from PREVAIL, LAA closure was dominated by warfarin and dabigatran, meaning that it was less effective (8.44, 8.54, and 8.59 quality-adjusted life years, respectively) and more costly. At a willingness-to-pay threshold of $50 000 per quality-adjusted life year, LAA closure was cost effective 90% and 9% of the time under PROTECT AF and PREVAIL assumptions, respectively. These results were sensitive to the rates of ischemic stroke and intracranial hemorrhage for LAA closure and medical anticoagulation., Conclusions: Using data from the PROTECT AF trial, LAA closure with the Watchman device was cost effective; using PREVAIL trial data, Watchman was more costly and less effective than warfarin and dabigatran. PROTECT AF enrolled more patients and has substantially longer follow-up time, allowing greater statistical certainty with the cost-effectiveness results. However, longer-term trial results and postmarketing surveillance of major adverse events will be vital to determining the value of the Watchman in clinical practice., (© 2016 American Heart Association, Inc.)

We aimed to characterize the independent predictors of LVT following STEMI and the association with outcomes. The clinical predictors of left ventricular thrombus (LVT) formation after ST-segment elevation myocardial infarction (STEMI) are not well-defined in the contemporary era. We performed a retrospective analysis of STEMI patients at Duke from 2000 to 2011 who had a transthoracic echocardiogram within 90 days post-STEMI and compared patients with and without LVT (LVT+ vs. LVT-). Univariate Cox proportional hazards regression models of baseline characteristics were examined and significant variables were used in a multivariable model to assess adjusted relationships with LVT. A multivariable Cox PH survival model with covariate adjustments was used for assessment of LVT and long-term mortality. Of all eligible patients, 1734 patients met inclusion criteria and 4.3 % (N = 74) had a LVT. LVT+ patients tended to have a history of heart failure (HF) and higher initial troponin compared to LVT- patients. After adjustment, higher heart rate, non-white race, HF severity, and presence of left anterior descending artery (LAD) disease were independent predictors of LVT. There was a trend toward an association between LVT and increased all-cause mortality (HR 1.36; 95 % CI 0.84-2.21, P = 0.22), however this was not statistically significant. LVT was seen in over 4 % of this contemporary post-STEMI population. Several baseline characteristics were independently associated with LVT: Heart rate, HF severity, LAD disease, and non-white race. Prospective studies are warranted to determine whether anticoagulation in patients at increased risk for LVT improves outcomes.

Background: Vaccination for the 2009 pandemic did not occur until late in the outbreak, which limited its benefits. Influenza A (H7N9) is causing increasing morbidity and mortality in China, and researchers have modified the A (H5N1) virus to transmit via aerosol, which again heightens concerns about pandemic influenza preparedness., Objective: To determine how quickly vaccination should be completed to reduce infections, deaths, and health care costs in a pandemic with characteristics similar to influenza A (H7N9) and A (H5N1)., Design: Dynamic transmission model to estimate health and economic consequences of a severe influenza pandemic in a large metropolitan city., Data Sources: Literature and expert opinion., Target Population: Residents of a U.S. metropolitan city with characteristics similar to New York City., Time Horizon: Lifetime., Perspective: Societal., Intervention: Vaccination of 30% of the population at 4 or 6 months., Outcome Measures: Infections and deaths averted and cost-effectiveness., Results of Base-Case Analysis: In 12 months, 48 254 persons would die. Vaccinating at 9 months would avert 2365 of these deaths. Vaccinating at 6 months would save 5775 additional lives and $51 million at a city level. Accelerating delivery to 4 months would save an additional 5633 lives and $50 million., Results of Sensitivity Analysis: If vaccination were delayed for 9 months, reducing contacts by 8% through nonpharmaceutical interventions would yield a similar reduction in infections and deaths as vaccination at 4 months., Limitation: The model is not designed to evaluate programs targeting specific populations, such as children or persons with comorbid conditions., Conclusion: Vaccination in an influenza A (H7N9) pandemic would need to be completed much faster than in 2009 to substantially reduce morbidity, mortality, and health care costs. Maximizing non-pharmaceutical interventions can substantially mitigate the pandemic until a matched vaccine becomes available., Primary Funding Source: Agency for Healthcare Research and Quality, National Institutes of Health, and Department of Veterans Affairs.

Background: The choice of antiplatelet therapy after acute coronary syndrome (ACS) is complicated: Ticagrelor and prasugrel are novel alternatives to clopidogrel, patients with some genotypes may not respond to clopidogrel, and low-cost generic formulations of clopidogrel are available., Objective: To determine the most cost-effective strategy for dual antiplatelet therapy after percutaneous coronary intervention for ACS., Design: Decision-analytic model., Data Sources: Published literature, Medicare claims, and life tables., Target Population: Patients having percutaneous coronary intervention for ACS., Time Horizon: Lifetime., Perspective: Societal., Intervention: Five strategies were examined: generic clopidogrel, prasugrel, ticagrelor, and genotyping for polymorphisms of CYP2C19 with carriers of loss-of-function alleles receiving either ticagrelor (genotyping with ticagrelor) or prasugrel (genotyping with prasugrel) and noncarriers receiving clopidogrel., Outcome Measures: Direct medical costs, quality-adjusted life years(QALYs), and incremental cost-effectiveness ratios (ICERs)., Results of Base-Case Analysis: The clopidogrel strategy produced$179 301 in costs and 9.428 QALYs. Genotyping with prasugrel was superior to prasugrel alone, with an ICER of $35 800 per QALY relative to clopidogrel. Genotyping with ticagrelor was more effective than genotyping with prasugrel ($30 200 per QALY relative to clopidogrel). Ticagrelor was the most effective strategy($52 600 per QALY relative to genotyping with ticagrelor)., Results of Sensitivity Analysis: Stronger associations between genotype and thrombotic outcomes rendered ticagrelor substantially less cost-effective ($104 800 per QALY). Genotyping with prasugrel was the preferred therapy among patients who could not tolerate ticagrelor., Limitation: No randomized trials have directly compared genotyping strategies or prasugrel with ticagrelor., Conclusion: Genotype-guided personalization may improve the cost-effectiveness of prasugrel and ticagrelor after percutaneous coronary intervention for ACS, but ticagrelor for all patients may bean economically reasonable alternative in some settings.

Background: Transcatheter aortic valve replacement (TAVR) seems to improve the survival and quality of life of patients with aortic stenosis ineligible for surgical aortic valve replacement., Methods and Results: We used a decision analytic Markov model to estimate lifetime costs and benefits in a hypothetical cohort of patients with severe, symptomatic aortic stenosis who were ineligible for surgical aortic valve replacement. The model compared transfemoral TAVR with medical management and was calibrated to the Placement of Aortic Transcatheter Valves (PARTNER) trial. TAVR increased life expectancy from 2.08 to 2.93 years and quality-adjusted life expectancy from 1.19 to 1.93 years. TAVR also reduced subsequent hospitalizations by 1.40 but increased complications, particularly stroke (from 1% to 11% lifetime risk), and also increased lifetime costs from $83,600 to $169,100. The incremental cost-effectiveness of TAVR was $116,500 per quality-adjusted life-year gained ($99,900 per life-year gained). Results were robust to reasonable changes in individual variables but were sensitive to the level of annual healthcare costs caused by noncardiac diseases and to the projected life expectancy of medically treated patients., Conclusions: TAVR seems to be an effective but somewhat expensive alternative to medical management among patients with symptomatic aortic stenosis ineligible for surgery. TAVR is more cost-effective for patients with a lower burden of noncardiac disease.

With Medicare spending projected to increase to 24 percent of all federal spending and to equal 6 percent of the gross domestic product by 2037, policy makers are again considering ways to curb the program's spending growth. We used a microsimulation approach to estimate three scenarios: imposing a means-tested premium for Part A hospital insurance, introducing a premium support credit to purchase health insurance, and increasing the eligibility age to sixty-seven. We found that the scenarios would lead to reductions in cumulative Medicare spending in 2012-36 of 2.4-24.0 percent. However, the scenarios also would increase out-of-pocket spending for enrollees and, in some cases, cause millions of seniors not to enroll in the program and to be left without coverage. To achieve substantial cost savings without causing substantial lack of coverage among seniors, policy makers should consider benefit changes in combination with other options, such as some of those now being contemplated by the Obama administration and Congress.

Objectives: The authors sought to evaluate the cost-effectiveness of statins for primary prevention of myocardial infarction (MI) and stroke in patients with chronic kidney disease (CKD)., Background: Patients with CKD have an elevated risk of MI and stroke. Although HMG Co-A reductase inhibitors (“statins”) may prevent cardiovascular events in patients with non–dialysis-requiring CKD, adverse drug effects and competing risks could materially influence net effects and clinical decision-making., Methods: We developed a decision-analytic model of CKD and cardiovascular disease (CVD) to determine the cost-effectiveness of low-cost generic statins for primary CVD prevention in men and women with hypertension and mild-to-moderate CKD. Outcomes included MI and stroke rates, discounted quality-adjusted life years (QALYs) and lifetime costs (2010 USD), and incremental cost-effectiveness ratios., Results: For 65-year-old men with moderate hypertension and mild-to-moderate CKD, statins reduced the combined rate of MI and stroke, yielded 0.10 QALYs, and increased costs by $1,800 ($18,000 per QALY gained). For patients with lower baseline cardiovascular risks, health and economic benefits were smaller; for 65-year-old women, statins yielded 0.06 QALYs and increased costs by $1,900 ($33,400 per QALY gained). Results were sensitive to rates of rhabdomyolysis and drug costs. Statins are less cost-effective when obtained at average retail prices, particularly in patients at lower CVD risk., Conclusions: Although statins reduce absolute CVD risk in patients with CKD, the increased risk of rhabdomyolysis, and competing risks associated with progressive CKD, partly offset these gains. Low-cost generic statins appear cost-effective for primary prevention of CVD in patients with mild-to-moderate CKD and hypertension.

Comparative effectiveness research suggests that conservative management (CM) strategies are no less effective than active initial treatment for many men with localized prostate cancer. We estimate longer-term costs of initial management strategies and potential US health expenditure savings by increased use of conservative management for men with localized prostate cancer. Five-year total health expenditures attributed to initial management strategies for localized prostate cancer were calculated using commercial claims data from 1998 to 2006, and savings were estimated from a US population health-care expenditure model. Our analysis finds that patients receiving combinations of active treatments have the highest additional costs over conservative management at $63 500, followed by $48 550 for intensity-modulated radiation therapy, $37 500 for primary androgen deprivation therapy, and $28 600 for brachytherapy. Radical prostatectomy ($15 200) and external beam radiation therapy ($18 900) were associated with the lowest costs. The population model estimated that US health expenditures could be lowered by 1) use of initial CM over all active treatment ($2.9-3.25 billion annual savings), 2) shifting patients receiving intensity-modulated radiation therapy to CM ($680-930 million), 3) foregoing primary androgen deprivation therapy($555 million), 4) reducing the use of adjuvant androgen deprivation in addition to local therapies ($630 million), and 5) using single treatments rather than combination local treatment ($620-655 million). In conclusion, we find that all active treatments are associated with higher longer-term costs than CM. Substantial savings, representing up to 30% of total costs, could be realized by adopting CM strategies, including active surveillance, for initial management of men with localized prostate cancer.

Background: Inflammatory bowel diseases are costly chronic gastrointestinal diseases. We aimed to determine whether immediate colectomy with ileal pouch-anal anastamosis (IPAA) after diagnosis of severe ulcerative colitis (UC) was cost-effective compared to the standard medical therapy., Methods: We created a Markov model simulating 2 cohorts of 21-year-old patients with severe UC, following them until 100 years of age or death, comparing early colectomy with IPAA strategy to the standard medical therapy strategy. Deterministic and probabilistic analyses were performed., Results: Standard medical care accrued a discounted lifetime cost of $236,370 per patient. In contrast, early colectomy with IPAA accrued a discounted lifetime cost of $147,763 per patient. Lifetime quality-adjusted life-years gained (QALY-gained) for standard medical therapy was 20.78, while QALY-gained for early colectomy with IPAA was 20.72. The resulting incremental cost-effectiveness ratio (Δcosts/ΔQALY) was approximately $1.5 million per QALY-gained. Results were robust to one-way sensitivity analyses for all variables in the model. Quality-of-life after colectomy with IPAA was the most sensitive variable impacting cost-effectiveness. A low utility value of less than 0.7 after colectomy with IPAA was necessary for the colectomy with IPAA strategy to be cost-ineffective., Conclusions: Under the appropriate clinical settings, early colectomy with IPAA after diagnosis of severe UC reduces health care expenditures and provides comparable quality of life compared to exhaustive standard medical therapy.