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Trends in Physician Referrals in the United States, 1999-2009
Physician referrals are central to ambulatory care in the United States, yet little is known about national trends in referrals over the past decade. In an analysis of over 800 000 nationally representative ambulatory visits from 1993 to 2009, Barnett et al found that from 1999 to 2009, the probability that an ambulatory visit to a physician resulted in a referral to another physician almost doubled. Combined with a national trend of increasing numbers of ambulatory visits per 1000 persons, this led to a 159% increase in the absolute number of visits resulting in a physician referral nationally. More research is necessary to understand the contribution of rising referral rates to increasing costs of care.

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Nocturnal Leg Cramps and Prescription Use That Precedes Them
Nocturnal leg cramps are common in the geriatric population and they can be difficult to treat. This pharmacoepidemiologic analysis of a large Canadian health care database used a novel analytic method (sequence symmetry) and uncovered a strong link between cramp treatment and the use of inhaled long-acting β₂-agonists, potassium-sparing diuretics, and thiazidelike diuretics. Use of one or more of these drugs was common in patients experiencing nocturnal leg cramps, raising the possibility that dose reduction or therapeutic substitution of these medications might be a potential treatment option when complaints of leg cramps are raised.

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Statin Use and Risk of Diabetes in Postmenopausal Women
Using the Women's Health Initiative data, Culver et al investigated whether the incidence of new-onset diabetes is associated with statin use among postmenopausal women. At baseline, 7.04% reported taking statin medication. There were 10 242 incident cases of self-reported diabetes over 1 million person-years of follow-up. Statin use at baseline was associated with an increased risk of diabetes (hazard ratio, 1.71; 95% CI, 1.61-1.83). This association remained after adjusting for other potential confounders (multivariable adjusted hazard ratio, 1.48; 95% CI, 1.38-1.59) and was observed for all types of statin medications. Subset analyses evaluating the association of self-reported diabetes with longitudinal measures of statin use in 125 575 women confirmed these findings. Statin medication use in postmenopausal women is associated with an increased risk for diabetes. This may be a medication class effect.

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Factors Associated With 30-Day Readmission Rates After Percutaneous Coronary Intervention
Percutaneous coronary interventions (PCIs) are among the most common procedures performed in the United States, and 30-day readmission rates have become a publicly reported performance measure for quality of PCIs. Khawaja et al identified 15 498 PCIs (elective or for acute coronary syndromes) from January 1998 to June 2008 at Saint Marys Hospital, Rochester, Minnesota, including Medicare and other payer types. Overall, nearly 1 in 10 patients were readmitted within 30-days after PCI, and the majority (69%) of readmissions were related to a cardiac reason. After multivariable analysis, female sex, Medicare insurance, less than a high school education, unstable angina, stroke or transient ischemic attack, moderate to severe renal disease, chronic obstructive pulmonary disease, peptic ulcer disease, metastatic cancer, and a length of stay longer than 3 days were associated with an increased risk of 30-day readmission after PCI. Patients who were readmitted within 30 days of discharge were at an increased risk of 1-year mortality compared with those who were not readmitted (adjusted hazard ratio, 1.38; 95% CI, 1.08-1.75 [P = .009]).

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