Effects on Abstinence of Nicotine Patch Treatment Before Quitting Smoking: Parallel, Two Arm, Pragmatic Randomised Trial

The preloading investigators. BMJ. 2018 Jun 13;361:k2164. [CrossRef] [PubMed]

The authors examined the effectiveness of a nicotine patch worn for four weeks before a quit attempt in a randomized controlled open label trial. There were 1792 adults who were daily smokers with tobacco dependence. 899 were allocated to the preloading arm and 893 to the control arm. Biochemically validated abstinence at six months was achieved by 157/899 (17.5%) participants in the preloading arm and 129/893 (14.4%) in the control arm: difference 3.0% (95% confidence interval −0.4% to 6.4%), odds ratio 1.25 (95% confidence interval 0.97 to 1.62, P=0.08). There was an imbalance between arms in the frequency of varenicline use as post-cessation treatment, and planned adjustment for this gave an odds ratio for the effect of preloading of 1.34 (95% confidence interval 1.03 to 1.73), P=0.03). The authors conclude that although evidence was insufficient to confidently show that nicotine preloading increases subsequent smoking abstinence, a beneficial effect seems to have been masked by a concurrent reduction in the use of varenicline in people using nicotine preloading.  

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. June 11, 2018. [Epub ahead of print] [CrossRef]

The value of the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program has been questioned as a marker of physician quality. The authors evaluated whether MOC status is associated with performance of 1260 general internists who were initially certified in 1991 and provided care for 85,931 Medicare patients between 2009 and 2012. Among the 1260 physicians, 786 maintained their certification from 1991 to 2012 and 474 did not. The mean annual percentage of HEDIS-eligible diabetic patients who completed semiannual hemoglobin A1c testing and low-density lipoprotein (LDL) cholesterol measurement, measures for LDL cholesterol testing in patients with coronary heart disease and biennial mammography were higher in patients of physicians who maintained certification. Only in biennial eye examinations was there no significant difference between physicians who maintained certification and those who did not. The authors conclude that maintaining certification was positively associated with physician performance scores on a set of process measures. 

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. June 11, 2018. [Epub ahead of print] [CrossRef]

The value of the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program has been questioned as a marker of physician quality. The authors evaluated whether MOC status is associated with performance of 1260 general internists who were initially certified in 1991 and provided care for 85,931 Medicare patients between 2009 and 2012. Among the 1260 physicians, 786 maintained their certification from 1991 to 2012 and 474 did not. The mean annual percentage of HEDIS-eligible diabetic patients who completed semiannual hemoglobin A1c testing and low-density lipoprotein (LDL) cholesterol measurement, measures for LDL cholesterol testing in patients with coronary heart disease and biennial mammography were higher in patients of physicians who maintained certification. Only in biennial eye examinations was there no significant difference between physicians who maintained certification and those who did not. The authors conclude that maintaining certification was positively associated with physician performance scores on a set of process measures.

Impact of Primary Care Intensive Management on High-Risk Veterans' Costs and Utilization: A Randomized Quality Improvement Trial

Yoon J, Chang E, Rubenstein LV, Park A, Zulman DM, Stockdale S, Ong MK, Atkins D, Schectman G, Asch SM. Ann Intern Med. 2018 Jun 5. [Epub ahead of print] [CrossRef] [PubMed]

The authors assessed whether augmenting usual primary care with team-based intensive management lowers utilization and costs in patients at high risk for hospitalization. Locally tailored intensive management programs were created providing care coordination, goals assessment, health coaching, medication reconciliation, and home visits through an interdisciplinary team. 2210 patients were randomly assigned, 1105 to intensive management and 1105 to usual care. Patients had a mean age of 63 years and an average of 7 chronic conditions; 90% were men. From the pre- to post-randomization periods, mean inpatient costs decreased more for the intensive management than the usual care group (-$2164 [95% CI, -$7916 to $3587]). However, outpatient costs increased more for the intensive management than the usual care group ($2636 [CI, $524 to $4748]), driven by greater use of primary care, home care, telephone care, and telehealth. After adjustment for patient demographic factors and health conditions diagnosed during the year before randomization, total healthcare costs for patients in the intervention group were $471 higher than in the control group. Limitations of the study were that sites took up to several months to contact eligible patients, limiting the time between treatment and outcome assessment and it is unclear whether all costs were assessed, such as personnel costs. The authors conclude that high-risk patients with access to an intensive management program received more outpatient care but may actually modestly increase costs.  

Effect of Increased Inpatient Attending Physician Supervision on Medical Errors, Patient Safety, and Resident Education: A Randomized Clinical Trial

Finn KM, Metlay JP, Chang Y, Nagarur A, Yang S, Landrigan CP, Iyasere C. JAMA Intern Med. 2018 Jun 4 [Epub ahead of print] [CrossRef] [PubMed]

Most of us have assumed that greater supervision of residents would lead to improved outcomes. However, little research has evaluated the role of attending physician supervision on patient safety. The authors conducted a randomized clinical trial of 22 attending physicians each providing 2 different levels of supervision, either (1) increased direct supervision in which attending physicians joined work rounds on previously admitted patients or (2) standard supervision in which attending physicians were available but did not join work rounds. The primary safety outcome was rate of medical errors. Resident education was evaluated via a time-motion study to assess resident participation on rounds and via surveys to measure resident and attending physician educational ratings. A total of 1259 patients (5772 patient-days) were included in the analysis. The medical error rate was not significantly different between standard vs increased supervision (107.6; 95% CI, 85.8-133.7 vs 91.1; 95% CI, 76.9-104.0 per 1000 patient-days; P = .21). Time-motion analysis of 161 work rounds found no difference in mean length of time spent discussing established patients in the 2 models (202; 95% CI, 192-212 vs 202; 95% CI, 189-215 minutes; P = .99). Interns spoke less when an attending physician joined rounds (64; 95% CI, 60-68 vs 55; 95% CI, 49-60 minutes; P = .008). In surveys, interns reported feeling less efficient (41 [55%] vs 68 [73%]; P = .02) and less autonomous (53 [72%] vs 86 [91%]; P = .001) with an attending physician present and residents felt less autonomous (11 [58%] vs 30 [97%]; P < .001). Conversely, attending physicians rated the quality of care higher when they participated on work rounds (20 [100%] vs 16 [80%]; P = .04). The authors conclude that increased direct attending physician supervision did not significantly reduce the medical error rate. They suggested that residency programs should reconsider their balance of patient safety, learning needs, and resident autonomy when designing morning work rounds,