Optimizing Home Oxygen Therapy. An Official American Thoracic Society Workshop Report

Jacobs SS, Lederer DJ, Garvey CM, et al. Ann Am Thorac Soc. 2018 Dec;15(12):1369-81. [CrossRef] [PubMed]

The system of delivering supplemental oxygen to the more than 1.5 million people in the U.S. who rely on it is broken concluded a convened at the ATS International Conference in 2017. The panel unanimously found that the implementation of competitive bidding for durable medical equipment, including home oxygen, nearly a decade ago by the Centers for Medicare and Medicaid Services (CMS) has led to the crisis. A 2017 survey of nearly 2,000 supplemental oxygen users, conducted by the ATS Nursing Assembly, addressed some specific issues related to home oxygen delivery. The survey found that half of all respondents reported problems with their oxygen, including equipment malfunction, and being too heavy to manage physically and lack of portability, especially when traveling. Also, 70% reported having no more than 4 hours of portable oxygen, while 81% said they required more than 5 hours' supply. Beginning Jan. 1, 2019, CMS will suspend the durable medical equipment competitive bidding program for 2 years to assess it, but it is not clear what this means for liquid oxygen and other supplemental oxygen availability.

FDA Approves First Treatment for Lambert-Eaton Myasthenic Syndrome, A Rare Autoimmune Disorder

FDA News Release. November 28, 2018. Available at: https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm627093.htm (accessed 12/4/18).

The US Food and Drug Administration (FDA) has approved amifampridine (Firdapse) tablets as the first ever treatment of the rare autoimmune disorder Lambert-Eaton myasthenic syndrome (LEMS) in adults (1).

In LEMS, the immune system attacks the neuromuscular junction and disrupts the ability of nerve cells to send signals to muscle cells. LEMS may be associated with other autoimmune diseases, but more commonly occurs in patients with cancer such as small cell lung cancer, where its onset precedes or coincides with the diagnosis of cancer. The prevalence of LEMS is estimated to be three per million individuals worldwide.

The efficacy of amifampridine was studied in a pair of clinical trials involved 64 adult patients administered either amifampridine or placebo. Using the 13-item, physician-rated categorial Quantitative Myasthenia Gravis scale to assess for muscle weakness, as well as the seven-point, patient-rated Subject Global Impression, investigators assessed the therapy’s benefit for LEMS’ most prevalent symptoms. For both measures, patients treated with amifampridine reported greater benefits than those administered placebo.

In a statement included with the announced approval, Billy Dunn, MD, director of the Division of Neurology Products in the FDA’S Center for Drug Evaluation and Research, noted the burdens faced by the 3 million-patient population. “There has been a long-standing need for a treatment for this rare disorder,” Dunn said. “Patients with LEMS have significant weakness and fatigue that can often cause great difficulties with daily activities.”

The most common side effects experienced by patients in the clinical trials were burning or prickling sensation (paresthesia), upper respiratory tract infection, abdominal pain, nausea, diarrhea, headache, elevated liver enzymes, back pain, hypertension and muscle spasms. Seizures have been observed in patients without a history of seizures. Because it affects voltage-gated ion channels, it is contraindicated in people with long QT syndrome and in people taking a drug that might prolong QT like sultopride, disopyramide, cisapride, domperidone, rifampicin or ketoconazole. It is also contraindicated in people with epilepsy or badly controlled asthma.

Does Point-of-Care Ultrasonography Improve Clinical Outcomes in Emergency Department Patients with Undifferentiated Hypotension?

Atkinson PR, Milne J, Diegelmann L, et al. Ann Emerg Med. 2018 Oct;72(4):478-89. [CrossRef] [PubMed]

Point-of-care ultrasonography protocols are commonly used in the initial management of patients with undifferentiated hypotension in the emergency department (ED) or the intensive care unit (ICU). However, there is little published evidence for any mortality benefit. The authors compared a point-of-care ultrasonography protocol versus standard care without point-of-care ultrasonography for survival and clinical outcomes. Follow-up was completed for 270 of 273 patients. The most common diagnosis in more than half the patients was occult sepsis. No important differences between the two groups for 30-day survival. There were no important differences in rates of computed tomography (CT) scanning, inotrope or intravenous fluid use, and ICU or total length of stay. The authors conclude that addition of a point-of-care ultrasonography protocol to standard care may not translate into benefits in survival, length of stay, rates of CT scanning, inotrope use, or fluid administration.

E-cigarette Use and Subsequent Smoking Frequency Among Adolescents

Barrington-Trimis JL, Kong G, Leventhal AM, et al. Pediatrics. November 05, 2018. [Epub ahead of print] [CrossRef] [PubMed]

Electronic cigarette (e-cigarette) use is associated with cigarette initiation among adolescents. However, it is unclear whether e-cigarette use is associated with more frequent cigarette use after initiation. The authors pooled data from 3 prospective cohort studies in California and Connecticut (baseline: 2013–2014; follow-up: 2014–2016; N = 6258). Among baseline never smokers, e-cigarette users had greater odds of subsequent experimental (odds ratio [OR] = 4.58; 95% confidence interval [CI]: 3.56–5.88), infrequent (OR = 4.27; 95% CI: 2.75–6.62) or frequent (OR = 3.51; 95% CI: 1.97–6.24) cigarette use. Baseline past-30-day exclusive cigarette use was associated with higher odds at follow-up of exclusive cigarette or dual product use than of exclusive e-cigarette use. The authors conclude that tobacco control policy to reduce adolescent use of both e-cigarettes and cigarettes is needed to prevent progression to more frequent tobacco use patterns.

Changes in Prevalence of Health Care-Associated Infections in U.S. Hospitals

Magill SS, O'Leary E, Janelle SJ, et al. N Engl J Med. 2018 Nov 1;379(18):1732-1744. [CrossRef] [PubMed]

Health care-associated infections (HCAI) have been associated with poorer outcomes including increased mortality. Programs have been initiated by Centers for Medicare and Medicaid Services (CMS) to reduce reimbursement to hospitals based on their HCAI rate. The authors conducted a point-prevalence self-reported survey of selected US hospitals and compared it to 2011 data. The results showed that 3.2% of hospitalized patients had HACI in 2015 which was significantly lower than the 4.0% reported in 2011. However, mortality did not differ. The results suggest that the hospital-reported HACI has declined but was not associated with the dramatic reduction in mortality claimed by CMS.

Benefits and Harms of Antihypertensive Treatment in Low-Risk Patients with Mild Hypertension

Sheppard JP, Stevens S, Stevens R, Martin U, Mant J, Hobbs FDR, McManus RJ. JAMA Intern Med. October 29, 2018. [CrossRef]

Evidence to support initiation of pharmacologic treatment in low-risk patients with mild hypertension is inconclusive, with previous trials underpowered to demonstrate benefit. Clinical guidelines across the world are contradictory. In this longitudinal cohort study, data were extracted from the Clinical Practice Research Datalink, from January 1, 1998, through September 30, 2015, for patients aged 18 to 74 years who had mild hypertension (untreated blood pressure of 140/90-159/99 mm Hg) and no previous treatment. A total of 19,143 treated patients were matched to 19,143 similar untreated patients. During a median follow-up period of 5.8 years, no evidence of an association was found between antihypertensive treatment and mortality. Treatment was associated with an increased risk of adverse events, including hypotension, syncope, electrolyte abnormalities, and acute kidney injury. The authors found no evidence to support guideline recommendations that encourage initiation of treatment in patients with low-risk mild hypertension but an increased risk of adverse events.

Prevalence of Financial Conflicts of Interest Among Authors of Clinical Guidelines Related to High-Revenue Medications/Evaluation of Industry Relationships Among Authors of Clinical Practice Guidelines in Gastroenterology

Khan R, Scaffidi MA, Rumman A, Grindal AW, Plener IS, Grover SC.  JAMA Intern Med. 2018 Oct 29. [CrossRef]

Combs TR, Scott J, Jorski A, Heavener T, Vassar M. JAMA Intern Med. 2018 Oct 29. [CrossRef]

Two studies appeared in JAMA Internal Medicine in yesterday’s JAMA Internal Medicine on conflict of interest amongst guideline writing committees. The first study examined financial conflicts of interest of authors writing clinical practice guidelines recommending high-priced medications. Of the 160 authors, 50 (31.3%) declared payment from companies marketing the medication recommended in the guideline. An additional 41 authors (25.6%) received, but did not disclose, payments from the marketers. In the second study, payments disclosed in gastroenterology clinical guidelines often differed from those reported by the Centers for Medicare & Medicaid Services (CMS). 44 of 83 (53%) authors received industry payments but only 16 (19%) fully disclosed their financial conflicts of interest. Various organizations, including the Institute of Medicine, recommends that guideline development teams be composed of at most 50% authors who have financial relationships to disclose, and recommends abstaining from financial conflicts for a period of 1 year following guideline publication. These studies would seem to indicate that those writing clinical practice guidelines are not adhering to these policies.

Baloxavir Marboxil for Uncomplicated Influenza in Adults and Adolescents

Hayden FG, Sugaya N, Hirotsu N, et al. N Engl J Med. 2018 Sep 6;379(10):913-23. [CrossRef] [PubMed]

Baloxavir marboxil is a selective inhibitor of influenza cap-dependent endonuclease and has shown therapeutic activity in preclinical models of influenza A and B virus infections, including strains resistant to current antiviral agents. The authors conducted two randomized, double-blind, controlled trials involving otherwise healthy outpatients with acute uncomplicated influenza. A dose-ranging (10 to 40 mg) phase 1 placebo-controlled trial was initially conducted. This was followed by a phase 3 trial comparing baloxavir and the neuraminidase inhibitor, oseltamivir, in a single dose during the 2016-7 season. The primary efficacy end point was the time to alleviation of influenza symptoms in the intention-to-treat infected population. In the phase 2 trial, the median time to alleviation of influenza symptoms was 23.4 to 28.2 hours shorter in the baloxavir groups than in the placebo group (P<0.05). In the phase 3 trial, the intention-to-treat infected population included 1064 patients; 84.8 to 88.1% of patients in each group had influenza A(H3N2) infection. The time to alleviation of symptoms was similar with baloxavir and oseltamivir. Baloxavir was associated with greater reductions in viral load 1 day after initiation of the regimen than placebo or oseltamivir. Adverse events did not differ in the placebo, oseltamivir and baloxair groups. The emergence of polymerase acidic protein variants with I38T/M/F substitutions conferring reduced susceptibility to baloxavir occurred in 2.2% and 9.7% of baloxavir recipients in the phase 2 trial and phase 3 trial, respectively. The authors conclude that single-dose baloxavir was without evident safety concerns, was superior to placebo in alleviating influenza symptoms, and was superior to both oseltamivir and placebo in reducing the viral load 1 day after initiation of the trial regimen in patients with uncomplicated influenza. Based on this study, The US Food and Drug Administration (FDA) approved baloxavir marboxil tablets (Xofluza, Shionogi) for the treatment of acute uncomplicated influenza in people age 12 years and older who have been symptomatic for no more than 48 hours.

Assessment of Industry Data on Pulmonary and Immunosuppressive Effects of IQOS

Moazed F, Chun L, Matthay MA, Calfee CS, Gotts J.. Tob Control. 2018 Aug 29. pii: tobaccocontrol-2018-054296. [Epub ahead of print] [CrossRef] [PubMed]

Philip Morris International has submitted a modified risk tobacco product (MRTP) application to the US Food and Drug Administration in 2016 in which it purports that its heated tobacco product, I-Quit-Ordinary-Smoking (IQOS), is associated with reduced harm compared with conventional cigarettes. The authors reviewed Philip Morris International’s MRTP application to assess the pulmonary and immune toxicities associated with IQOS use in both animal and human studies. Among rats exposed to IQOS, there was evidence of pulmonary inflammation and immunomodulation. In human users, there was no evidence of improvement in pulmonary inflammation or pulmonary function in cigarette smokers who were switched to IQOS. The authors conclude that IQOS is associated with significant pulmonary and immunomodulatory toxicities with no detectable differences between conventional cigarette smokers and those who were switched to IQOS in Philip Morris International’s studies. Based on the limited available data to date, IQOS use does not appear to significantly differ from conventional cigarettes in causing pulmonary and immunomodulatory harm.

Effect of Aspirin on All-Cause Mortality in the Healthy Elderly

McNeil JJ, Nelson MR, Woods RL, et al. N Engl J Med. 2018 Sep 16. [Epub ahead of print] [CrossRef] [PubMed] 

Previous studies have suggested that daily aspirin may improve mortality from cardiovascular disease and cancer. The authors conducted the Aspirin in Reducing Events in the Elderly (ASPREE) trial which was a placebo-controlled trial of aspirin in older, healthy adults. Of the 19,114 persons who were enrolled, 9525 were assigned to receive aspirin and 9589 to receive placebo. The risk of death from any cause was 12.7 events per 1000 person-years in the aspirin group and 11.1 events per 1000 person-years in the placebo group (hazard ratio, 1.14; 95% confidence interval [CI], 1.01 to 1.29). Cancer was the major contributor to the higher mortality in the aspirin group, accounting for 1.6 excess deaths per 1000 person-years. In the context of previous studies, this result was unexpected and should be interpreted with caution.

Improved Empirical Antibiotic Treatment of Sepsis After an Educational Intervention: The ABISS-Edusepsis Study

Ferrer R, Martínez ML, Gomà G, et al. Crit Care. 2018 Jun 22;22(1):167. [CrossRef] [PubMed]

Early appropriate antibiotic treatment is essential in sepsis. The authors evaluated the impact of a multifaceted educational intervention to improve antibiotic treatment. They prospectively studied all 2628 consecutive patients with sepsis/septic shock admitted to 72 intensive care units (ICUs) throughout Spain in two 4-month periods (before and immediately after the 3-month intervention). In the postintervention cohort, the mean (SD) time from sepsis onset to empirical antibiotic therapy was lower (2.0 (2.7) vs. 2.5 (3.6) h; p = 0.002), the proportion of inappropriate empirical treatments was lower (6.5% vs. 8.9%;p = 0.024), and the proportion of patients in whom antibiotic treatment was de-escalated was higher (20.1% vs. 16.3%; p = 0.004); the expected reduction in mortality did not reach statistical significance (29.4% in the postintervention cohort vs. 30.5% in the preintervention cohort; p = 0.544). The educational intervention is poorly described and the gains in time to empirical antibiotic therapy and inappropriate antibiotic are modest and did not result in an improvement in mortality. These make the authors’ conclusions that “educational interventions can still improve the delivery of care” uncertain.

Effect of Azithromycin on Airflow Decline-Free Survival After Allogeneic Hematopoietic Stem Cell Transplant: The ALLOZITHRO Randomized Clinical Trial

Bergeron A, Chevret S, Granata A, et al. JAMA 2017;318(6):557-566. [CrossRef] [PubMed]

Bronchiolitis obliterans syndrome has been associated with increased morbidity and mortality after allogeneic hematopoietic stem cell transplant (HSCT). Previous studies have suggested that azithromycin may reduce the incidence of post-lung transplant bronchiolitis obliterans syndrome presumably through an anti-inflammatory effect. The ALLOZITHRO parallel-group trial conducted in 19 French academic transplant centers and involving participants who had undergone allogeneic HSCT for a hematological malignancy. Patients were randomly assigned to receive 3 times a week either 250 mg of azithromycin (n = 243) or placebo (n = 237) for 2 years, starting at the time of the conditioning regimen. Thirteen months after enrollment, the independent data and safety monitoring board stopped the trial. At the time of data cutoff, 104 patients (22%; 54 azithromycin vs 50 placebo) had experienced an airflow decline; 138 patients (30%) died (78 azithromycin vs 60 placebo). The azithromycin group had increased mortality, with a 2-year survival of 56.6% (95% CI, 50.2%-63.7%) vs 70.1% (95% CI, 64.2%-76.5%) in the placebo group (unadjusted HR, 1.5; 95% CI, 1.1-2.0; P = .02). In a post hoc analysis, the 2-year cumulative incidence of hematological relapse was 33.5% (95% CI, 27.3%-39.7%) with azithromycin vs 22.3% (95% CI, 16.4%-28.2%) with placebo (unadjusted cause-specific HR, 1.7; 95% CI, 1.2-2.4; P = .002). The FDA recently issued a warning against using chronic azithromycin therapy in HSCT.

Depression, Antidepressant Use, and Risk of Venous Thromboembolism: Systematic Review and Meta-Analysis Of Published Observational Evidence

Kunutsor SK Seidu S, Khunti K. Ann Med. 2018 Jul 12:1-17. [CrossRef] [PubMed]

The authors conducted a systematic review and meta-analysis of published observational studies evaluating the associations of depression and antidepressant use with venous thromboembolism (VTE) risk. Eight observational studies with data on 960,113 non-overlapping participants and 9027 VTE cases were included. The pooled RR (95% CI) for VTE comparing antidepressant use with no antidepressant use was 1.27 (1.06-1.51). Tricyclic antidepressants, selective serotonin reuptake inhibitors and other antidepressants were each associated with an increased VTE risk; 1.16 (1.06-1.27), 1.12 (1.02-1.23), and 1.59 (1.21-2.09) respectively. In pooled analysis of three studies that compared patients with depression versus individuals without depression, the RR for VTE was 1.31 (1.13-1.53). The authors conclude that pooled observational evidence suggests that depression and use of antidepressants are each associated with an increased VTE risk. The effect of antidepressant drugs on VTE may be a class effect. The mechanistic pathways underlying these associations deserve further evaluation.

Electronic Health Records Associated with Lower Hospital Mortality After Systems Have Time to Mature

Lin SC, Jha AK, Adler-Milstein J. Health Aff (Millwood). 2018 Jul;37(7):1128-1135. [CrossRef] [PubMed]

The effect of electronic health record (EHR) adoption on mortality is mixed. The authors used data for the period 2008–13 to assess the relationship between EHR adoption and thirty-day mortality rates. They found that baseline adoption was associated with a 0.11-percentage-point higher rate per function. Over time, maturation of the baseline functions was associated with a 0.09-percentage-point reduction in mortality rate per year per function. Each new function adopted in the study period was associated with a 0.21-percentage-point reduction in mortality rate per year per function. They observed effect modification based on size and teaching status, with small and nonteaching hospitals realizing greater gains. Importantly, US hospitals that adopted EHRs had improved 30-day mortality rates compared to those hospitals that did not adopt EHRs. These findings suggest that implementation of EHRs lowers mortality but achieving a reduction in mortality will take time.

Sodium Bicarbonate Therapy for Patients with Severe Metabolic Acidaemia in the Intensive Care Unit (BICAR-ICU): A Multicentre, Open-Label, Randomised Controlled, Phase 3 Trial

Jaber S, Paugam C, Futier E, et al. Lancet. 2018 Jun 14. pii: S0140-6736(18)31080-8. [CrossRef] [PubMed]

Acute acidemia is frequently observed during critical illness. Sodium bicarbonate (bicarb) infusion for the treatment of severe metabolic acidemia is a possible treatment option but remains controversial and is not routinely recommended after cardiac arrest. The authors performed a multicenter, open-label, randomized controlled, phase 3 trial of bicarb in adult patients with severe acidemia (pH ≤7.20, PaCO2 ≤45 mm Hg) and with a total Sequential Organ Failure Assessment score of 4 or more or an arterial lactate concentration of 2 mmol/L or more. The primary outcome was a composite of death from any cause by day 28 and the presence of at least one organ failure at day 7. Death occurred in 138 (71%) of 194 patients in the control group and 128 (66%) of 195 in the bicarbonate group (p=0.24). However, in an a-priori defined group of patients with acute kidney injury the Kaplan-Meier method estimate of survival by day 28 between the control group and bicarbonate group was significantly improved (63% vs 46%; p=0.0283). The authors conclude that in patients with severe metabolic acidemia, sodium bicarbonate had no effect on mortality but improved the day 28 mortality in patients with acute kidney injury.

Combined Analysis of Asthma Safety Trials of Long-Acting β2-Agonists

Busse WW, Bateman ED, Caplan AL, Kelly HW, O'Byrne PM, Rabe KF, Chinchilli VM. N Engl J Med. 2018 Jun 28;378(26):2497-2505. [CrossRef] [PubMed]

Safety concerns regarding long-acting β2-agonists (LABAs) in asthma management were initially identified in the 2006 SMART trial in which the risk of death was increased. In 2010, the Food and Drug Administration (FDA) mandated that the four companies marketing LABAs for asthma perform prospective, randomized, controlled trials comparing the safety of combination therapy with a LABA plus an inhaled glucocorticoid with that of an inhaled glucocorticoid alone. In conjunction with the FDA, the manufacturers harmonized their trial methods to allow an independent joint oversight committee to provide a final combined analysis of the four trials. The joint oversight committee performed a combined analysis of the four trials comparing an inhaled glucocorticoid plus a LABA (combination therapy) with an inhaled glucocorticoid alone. The primary outcome was a composite of asthma-related intubation or death. Post hoc secondary outcomes included serious asthma-related events and asthma exacerbations. Among the 36,010 patients in the intention-to-treat study, combination therapy with a LABA plus an inhaled glucocorticoid did not result in a significantly higher risk of serious asthma-related events than treatment with an inhaled glucocorticoid alone but resulted in significantly fewer asthma exacerbations.

Continuity of Care with Doctors-A Matter of Life and Death? A Systematic Review of Continuity of Care and Mortality

Pereira Gray D, Sidaway-Lee K, White E, Thorne A, Evans PH. BMJ Open. 2018 Jun 28;8(6):e021161. [CrossRef] [PubMed]

There have been many reported benefits to continuity of care including increased patient satisfaction, increased take-up of health promotion, greater adherence to medical advice and decreased use of hospital services. The authors examined whether there is also a relationship between continuity of doctor care and mortality. The authors search for peer-reviewed primary research articles, published in English which reported measured continuity of care received by patients from any kind of doctor, in any setting, in any country, related to measured mortality of those patients. Of the 726 articles identified in searches, 22 fulfilled the eligibility criteria. These studies came from nine countries with very different cultures and health systems. The authors found such heterogeneity of continuity and mortality measurement methods and time frames that it was not possible to combine the results of studies. However, 18 (81.8%) high-quality studies reported statistically significant reductions in mortality, with increased continuity of care. Sixteen of these were with all-cause mortality. According to the authors, this first systematic review reveals that increased continuity of care by doctors is associated with lower mortality rates.

Minimally Invasive Lung Cancer Surgery Performed by Thoracic Surgeons as Effective as Thoracotomy

Boffa DJ, Kosinski AS, Furnary AP, et al. J Clin Oncol. 2018 May 23:JCO2018778977. [Epub ahead of print] [CrossRef] [PubMed]

The prevalence of minimally invasive lung cancer surgery using video-assisted thoracic surgery (VATS) has increased dramatically over the past decade, yet recent studies have suggested that the lymph node evaluation during VATS lobectomy is inadequate. We hypothesized that the minimally invasive approach to lobectomy for stage I lung cancer resulted in a longitudinal outcome that was not inferior to thoracotomy. Patients > 65 years of age who had undergone lobectomy for stage I lung cancer between 2002 and 2013 were analyzed within the Society of Thoracic Surgeons General Thoracic Surgery Database, which had been linked to Medicare data, as part of a retrospective-cohort, noninferiority study. A total of 10,597 patients with clinical stage I lung cancer who underwent lobectomy were evaluated (4,448 patients underwent thoracotomy, and 6,149 underwent VATS). VATS patients had a more favorable distribution of all health-related variables, including pulmonary function (59% of VATS patients had intact spirometry v 51% of thoracotomy patients; P < .001). Kaplan-Meier survival estimates of 2,901 propensity-matched VATS-thoracotomy pairs demonstrated that the 4-year survival associated with VATS (68.6%) was modestly superior to thoracotomy (64.8%; P = .003). The analyses detailed above were replicated in a separate cohort of pathologic stage I patients with similar findings.

Serotonergic Antidepressant Use and Morbidity and Mortality Among Older Adults with COPD

Vozoris NT, Wang X, Austin PC, et al. Eur Respir J  2018 Jun 26. [Epub ahead of print] [CrossRef]

The authors evaluated the relationship between new selective serotonin reuptake inhibitor (SSRI) or serotonin norepinephrine reuptake inhibitor (SNRI) drug use and respiratory-related morbidity and mortality among older adults with chronic obstructive pulmonary disease (COPD). This was retrospective, population-based, cohort study using Ontario, Canada, heath administrative data. Individuals ages 66 years of age and older, with validated, physician-diagnosed COPD (n=131,718) were included. New SSRI/SNRI users were propensity score matched 1:1 to controls on 40 relevant covariates to minimize potential confounding. Among propensity-scored matched community-dwelling individuals, new SSRI/SNRI users compared to non-users had significantly higher rates of hospitalization for COPD or pneumonia (hazard ratio [HR] 1.15; 95% confidence interval [CI] 1.05–1.25), ER visits for COPD or pneumonia (HR 1.13; 95% CI 1.03–1.24), COPD or pneumonia-related mortality (HR 1.26; 95% CI 1.03–1.55) and all-cause mortality (HR 1.20; 95% CI 1.11–1.29). Respiratory-specific and all-cause mortality rates were also higher among long term care home residents newly starting SSRI/SNRI drugs versus controls. New use of serotonergic antidepressants was associated with small, but significant, increases in rates of respiratory-related morbidity and mortality among older adults with COPD. Further research is needed to clarify if the observed associations are causal or instead reflect unresolved confounding, however, a recent publication in the SWJPCC found no relationship between depression scores and 30-day readmission for exacerbation of COPD.

Associations Between American Board of Internal Medicine Maintenance of Certification Status and Performance on a Set of Healthcare Effectiveness Data and Information Set Process Measures

Gray B, Vandergrift J, Landon B, Reschovsky J, Lipner R. Ann Intern Med. 2018 Jun 12. [Epub ahead of print] [CrossRef] [PubMed]

The authors assessed whether the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) is associated with performance on selected Healthcare Effectiveness Data and Information Set (HEDIS) process measures. 1260 general internists who were initially certified in 1991 were evaluated. 786 maintained their certification from 1991 to 2012 and 474 did not. The percentage of physicians whose diabetic patients completed semiannual hemoglobin A1c, low-density lipoprotein (LDL) cholesterol measurement and biennial eye examinations were examined along with LDL cholesterol testing in patients with coronary heart disease (CAD LDL) and biennial mammography. The results demonstrate that maintaining certification was positively associated with physician performance scores on a set of HEDIS process measures (Figure 1).

Figure 1. Percentage of patients who completed HEDIS process measures.

An accompanying editorial by Lee Goldman points out that the changes are very modest, only mammography was associated with better outcomes (2.4 deaths per 100,000 patient-years) and MOC is expensive ($17,000 per general internist and $5.7 billion in total over 10 years).