Methods  To assess the impact of consultation code elimination, 2 assessments were conducted. First, from June 1, 2008, to July 1, 2009, 500 consecutive referrals from primary care physicians to other specialists were reviewed and matched with claims for accuracy of coding and billing. Second, to evaluate the financial impact of this change, year 2007 data on outpatient consultations from the Centers for Medicare and Medicaid Services were reviewed.

Results  Of the 500 claims reviewed, 466 were appropriate for analysis. Overall, the coding error rate was 32.4%. When the requesting physician ordered a consultation, the error rate was 5.5%; however, with lower paid referral requests, the error rate was 78.0%. Changing ambulatory consultation codes to those for new patient visits would save Medicare $534.5 million per year.

Conclusions  Consultation codes are being billed erroneously at a high rate. Furthermore, the differential cost to Medicare of these codes over those for new patient evaluation and management codes is over half a billion dollars per year. With the growing needs for cost savings as well as encouraging payment parity for cognitive services for primary care physicians, it is time these codes are reevaluated.

Published online November 9, 2009 (doi:10.1001/archinternmed.2009.446).

Methods  We searched Cochrane Databases and MEDLINE (1957 through December 2008) for English-language articles on PMR treatment (randomized trials, prospective cohorts, case-control trials, and case series) that included 20 or more patients. All data on study design, PMR definition criteria, medical therapy, and disease outcomes were collected using a standardized protocol.

Results  Thirty studies (13 randomized trials and 17 observational studies) were analyzed. No meta-analyses or systematic reviews were found. The PMR definition criteria, treatment protocols, and outcome measures differed widely among the trials. Starting prednisone doses higher than 10 mg/d were associated with fewer relapses and shorter therapy than were lower doses; starting prednisone doses of 15 mg/d or lower were associated with lower cumulative glucocorticoid doses than were higher starting prednisone doses; and starting prednisone doses higher than 15 mg/d were associated with more glucocorticoid-related adverse effects. Slow prednisone dose tapering (<1 mg/mo) was associated with fewer relapses and more frequent glucocorticoid treatment cessation than faster tapering regimens. Initial addition of oral or intramuscular methotrexate provided efficacy at doses of 10 mg/wk or higher. Infliximab was ineffective as initial cotreatment.

Conclusions  The scarcity of randomized trials and the high level of heterogeneity of studies on PMR therapy do not allow firm conclusions to be drawn. However, PMR remission seems to be achieved with prednisone treatment at a dose of 15 mg/d in most patients, and reductions below 10 mg/d should preferably follow a tapering rate of less than 1 mg/mo. Methotrexate seems to exert glucocorticoid-sparing properties.

Methods  We reviewed clinical and experimental data on thiazide diuretics since their introduction in the late 1950s.

Results  The results of thiazide-based therapy in young and old are consistently positive despite concerns about some metabolic changes, eg, insulin resistance or hypokalemia, that may occur.

Conclusion  We conclude that these agents are safe, effective, and well tolerated and should continue to be used either as monotherapy or with other medications in the management of hypertension.

Methods  Using a stratified random sampling of 151 999 visits, representing 539 million ED visits from 1997 to 2006, we examined trends in the percentage of patients seen within the triage target time by triage category (emergent, urgent, semiurgent, and nonurgent), payer type, and race/ethnicity.

Results  The percentage of patients seen within the triage target time declined a mean of 0.8% per year, from 80.0% in 1997 to 75.9% in 2006 (P < .001). The percentage of patients seen within the triage target time declined 2.3% per year for emergent patients (59.2% to 48.0%; P < .001) compared with 0.7% per year for semiurgent patients (90.6% to 84.7%; P < .001). In 2006, the adjusted odds of being seen within the triage target time were 30% lower than in 1997 (odds ratio, 0.70; 95% confidence interval, 0.55-0.89). The adjusted odds of being seen within the triage target time were 87% lower (odds ratio, 0.13; 95% confidence interval, 0.11-0.15) for emergent patients compared with semiurgent patients. Patients of each payment type experienced similar decreases in the percentage seen within the triage target over time (P for interaction = .24), as did patients of each racial/ethnic group (P = .05).

Conclusions  The percentage of patients in the ED who are seen by a physician within the time recommended at triage has been steadily declining and is at its lowest point in at least 10 years. Of all patients in the ED, the most emergent are the least likely to be seen within the triage target time. Patients of all racial/ethnic backgrounds and payer types have been similarly affected.

Methods  We conducted a retrospective analysis of visits by adults 18 years or older to a nationally representative sample of office-based primary care physicians in the United States.

Results  Between 1997 and 2005, US adult primary care visits to physicians increased from 273 million to 338 million annually, or 10% on a per capita basis. The mean visit duration increased from 18.0 to 20.8 minutes (P < .001 for trend). Visit duration increased by 3.4 minutes for general medical examinations and for the 3 most common primary diagnoses of diabetes mellitus (4.2 minutes, P = .002 for trend), essential hypertension (3.7 minutes, P < .001 for trend), and arthropathies (5.9 minutes, P < .001 for trend). Comparing the early period (1997-2001) with the late period (2002-2005), quality of care improved for 1 of 3 counseling or screening indicators and for 4 of 6 medication indicators. Providing appropriate counseling or screening generally took 2.6 to 4.2 minutes. Providing appropriate medication therapy was not associated with longer visit duration.

Conclusions  Adult primary care visit frequency, quality, and duration increased between 1997 and 2005. Modest relationships were noted between visit duration and quality of care. Providing counseling or screening required additional physician time, but ensuring that patients were taking appropriate medications seemed to be independent of visit duration.

Methods  A total of 106 overweight and obese participants (mean [SE] age, 50.0 [0.8] years; mean [SE] body mass index [calculated as weight in kilograms divided by height in meters squared], 33.7 [0.4]) were randomly assigned either to an energy-restricted (approximately 1433-1672 kcal [to convert to kilojoules, multiply by 4.186]), planned isocaloric, very low-carbohydrate, high-fat (LC) diet or to a high-carbohydrate, low-fat (LF) diet for 1 year. Changes in body weight, psychological mood and well-being (Profile of Mood States, Beck Depression Inventory, and Spielberger State Anxiety Inventory scores), and cognitive functioning (working memory and speed of processing) were assessed.

Results  By 1 year, the overall mean (SE) weight loss was 13.7 (1.8) kg, with no significant difference between groups (P = .26). Over the course of the study, there were significant time x diet interactions for Spielberger State Anxiety Inventory, Beck Depression Inventory, and Profile of Mood States scores for total mood disturbance, anger-hostility, confusion-bewilderment, and depression-dejection (P < .05) as a result of greater improvements in these psychological mood states for the LF diet compared with the LC diet. Working memory improved by 1 year (P < .001 for time), but speed of processing remained largely unchanged, with no effect of diet composition on either cognitive domain.

Conclusions  Over 1 year, there was a favorable effect of an energy-restricted LF diet compared with an isocaloric LC diet on mood state and affect in overweight and obese individuals. Both diets had similar effects on working memory and speed of processing.

Trial Registration  anzctr.org.au Identifier: 12606000203550

Methods  A 6-item written survey was administered at 20 grand rounds presentations across the United States and by mail at 2 collaborating institutions. Respondents were asked to report 3 cases of diagnostic errors and to describe their perceived causes, seriousness, and frequency.

Results  A total of 669 cases were reported by 310 clinicians from 22 institutions. After cases without diagnostic errors or lacking sufficient details were excluded, 583 remained. Of these, 162 errors (28%) were rated as major, 241 (41%) as moderate, and 180 (31%) as minor or insignificant. The most common missed or delayed diagnoses were pulmonary embolism (26 cases [4.5% of total]), drug reactions or overdose (26 cases [4.5%]), lung cancer (23 cases [3.9%]), colorectal cancer (19 cases [3.3%]), acute coronary syndrome (18 cases [3.1%]), breast cancer (18 cases [3.1%]), and stroke (15 cases [2.6%]). Errors occurred most frequently in the testing phase (failure to order, report, and follow-up laboratory results) (44%), followed by clinician assessment errors (failure to consider and overweighing competing diagnosis) (32%), history taking (10%), physical examination (10%), and referral or consultation errors and delays (3%).

Conclusions  Physicians readily recalled multiple cases of diagnostic errors and were willing to share their experiences. Using a new taxonomy tool and aggregating cases by diagnosis and error type revealed patterns of diagnostic failures that suggested areas for improvement. Systematic solicitation and analysis of such errors can identify potential preventive strategies.

Methods  The study included a random sample of medical and surgical acute care adult patients in Massachusetts hospitals between April 1 and October 1, 2003. The unit of analysis was the AE, and multivariable regression analyses accounted for clustering at the patient level.

Results  Overall, 603 patients reported 845 AEs, and 40% of AEs were disclosed. The AEs that required additional treatment (odds ratio [OR], 1.64; 95% confidence interval [CI], 1.16-2.32) or affected patients who reported good health (OR, 2.04; 95% CI, 1.29-3.24) were more likely to be disclosed. Disclosure was less likely if the events were preventable (OR, 0.58; 95% CI, 0.41-0.83) or if the patients were still affected by the AE at the time of survey (OR, 0.49; 95% CI, 0.31-0.78). Higher-quality ratings were associated with disclosure (OR, 2.04; 95% CI, 1.39-2.99) of preventable and nonpreventable events and with patients who felt that they were able to protect themselves from AEs (OR, 1.98; 95% CI, 1.21-3.24). Lower-quality ratings were associated with events that were preventable (OR, 0.55; 95% CI, 0.40-0.76), with events that caused increased discomfort (OR, 0.62; 95% CI, 0.46-0.86), or with events that still adversely affected the patient at the time of the survey (OR, 0.68; 95% CI, 0.46-0.98).

Conclusions  Rates of disclosure of AEs by medical personnel remain low in hospitalized patients. Disclosure of some of these events is associated with higher ratings of quality by patients.

Methods  Cross-sectional, follow-up (20 years), and case-control analyses were undertaken in 3 independent populations. We analyzed gene-diet interactions between the APOA2 –265T>C polymorphism and saturated fat intake on BMI and obesity in 3462 individuals from 3 populations in the United States: the Framingham Offspring Study (1454 whites), the Genetics of Lipid Lowering Drugs and Diet Network Study (1078 whites), and Boston–Puerto Rican Centers on Population Health and Health Disparities Study (930 Hispanics of Caribbean origin).

Results  Prevalence of the CC genotype in study participants ranged from 10.5% to 16.2%. We identified statistically significant interactions between the APOA2 –265T>C and saturated fat regarding BMI in all 3 populations. Thus, the magnitude of the difference in BMI between the individuals with the CC and TT+TC genotypes differed by saturated fat. A mean increase in BMI of 6.2% (range, 4.3%-7.9%; P = .01) was observed between genotypes with high– (≥22 g/d) but not with low– saturated fat intake in all studies. Likewise, the CC genotype was significantly associated with higher obesity prevalence in all populations only in the high–saturated fat stratum. Meta-analysis estimations of obesity for individuals with the CC genotype compared with the TT+TC genotype were an odds ratio of 1.84 (95% confidence interval, 1.38-2.47; P < .001) in the high–saturated fat stratum, but no association was detected in the low–saturated fat stratum (odds ratio, 0.81; 95% confidence interval, 0.59-1.11; P = .18).

Conclusion  For the first time to our knowledge, a gene-diet interaction influencing BMI and obesity has been strongly and consistently replicated in 3 independent populations.

Methods  Adult patients scheduled to undergo diagnostic cardiac catheterization (n = 135) were randomized to receive details about the procedure using either standard institutional verbal and written information (SI) or interactive computerized information (ICI) preloaded on a laptop computer. Understanding was measured using semistructured interviews at baseline (ie, before information was given), immediately following cardiac catheterization (early understanding), and 2 weeks after the procedure (late understanding). The primary study outcome was the change from baseline to early understanding between groups.

Results  Subjects randomized to the ICI intervention had significantly greater improvement in understanding compared with those who received the SI (net change, 0.81; 95% confidence interval, 0.01-1.6). Significantly more subjects in the ICI group had complete understanding of the risks of cardiac catheterization (53.6% vs 23.1%) (P = .001) and options for treatment (63.2% vs 46.2%) (P = .048) compared with the SI group. Several predictors of improved understanding were identified, including baseline knowledge (P < .001), younger age (P = .002), and use of the ICI (P = .003).

Conclusions  Results suggest that an interactive computer-based information program for cardiac catheterization may be more effective in improving patient understanding than conventional written consent information. This technology, therefore, holds promise as a means of presenting understandable detailed information regarding a variety of medical treatments and procedures.

Methods  Demographic, military-specific, and outcome data were prospectively collected over a 2-week period at the Deployed Warrior Medical Management Center in Germany on 1410 consecutive soldiers medically evacuated out of theaters of combat operations for a primary diagnosis pertaining to back pain between 2004 and 2007. The 2-week period represents the maximal allowable time an evacuated soldier can spend in treatment before disposition (ie, return to theater or evacuate to United States) is rendered. Electronic medical records were then reviewed to examine the effect a host of demographic and clinical variables had on the categorical outcome measure, return to unit.

Results  The overall return-to-unit rate was 13%. Factors associated with a positive outcome included female sex, deployment to Afghanistan, being an officer, and a history of back pain. Trends toward not returning to duty were found for navy and marine service members, coexisting psychiatric morbidity, and not being seen in a pain clinic.

Conclusions  The likelihood of a service member medically evacuated out of theater with back pain returning to duty is low irrespective of any intervention(s) or characteristic(s). More research is needed to determine whether concomitant treatment of coexisting psychological factors and early treatment "in theater" can reduce attrition rates.