JAMA internal medicine
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JAMA internal medicine · Mar 2015
Comparative StudyOut-of-hospital mortality among patients receiving methadone for noncancer pain.
Growing methadone use in pain management has raised concerns regarding its safety relative to other long-acting opioids. Methadone hydrochloride may increase the risk for lethal respiratory depression related to accidental overdose and life-threatening ventricular arrhythmias. ⋯ The increased risk of death observed for patients receiving methadone in this retrospective cohort study, even for low doses, supports recommendations that it should not be a drug of first choice for noncancer pain.
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JAMA internal medicine · Mar 2015
Comparative StudyThe effect of emergency department copayments for Medicaid beneficiaries following the Deficit Reduction Act of 2005.
High unemployment during the 2007-2009 Great Recession and eligibility expansions have increased the size and cost of Medicaid. To provide states with flexibility in administering the program while containing costs, the Deficit Reduction Act of 2005 (DRA) gave states the authority to impose cost-sharing strategies, including emergency department (ED) copayments for nonurgent visits. To our knowledge, there has been no previous longitudinal analysis of the effect of the DRA on health care utilization outcomes for Medicaid beneficiaries. ⋯ Granting states permission to collect copayments for nonurgent visits under the DRA did not significantly change ED or outpatient medical provider use among Medicaid beneficiaries.
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JAMA internal medicine · Mar 2015
Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study.
Many medications have anticholinergic effects. In general, anticholinergic-induced cognitive impairment is considered reversible on discontinuation of anticholinergic therapy. However, a few studies suggest that anticholinergics may be associated with an increased risk for dementia. ⋯ Higher cumulative anticholinergic use is associated with an increased risk for dementia. Efforts to increase awareness among health care professionals and older adults about this potential medication-related risk are important to minimize anticholinergic use over time.
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JAMA internal medicine · Mar 2015
Comparative StudyComparative effectiveness of diagnostic testing strategies in emergency department patients with chest pain: an analysis of downstream testing, interventions, and outcomes.
Patients presenting to the emergency department (ED) with chest pain whose evaluation for ischemia demonstrates no abnormalities receive further functional or anatomical studies for coronary artery disease; however, comparative evidence for the various strategies is lacking and multiple testing options exist. ⋯ Patients with chest pain evaluated in the ED who do not have an MI are at very low risk of experiencing an MI during short- and longer-term follow-up in a cohort of privately insured patients. This low risk does not appear to be affected by the initial testing strategy. Deferral of early noninvasive testing appears to be reasonable.
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JAMA internal medicine · Mar 2015
Potential overtreatment of diabetes mellitus in older adults with tight glycemic control.
In older adults with multiple serious comorbidities and functional limitations, the harms of intensive glycemic control likely exceed the benefits. ⋯ Although the harms of intensive treatment likely exceed the benefits for older patients with complex/intermediate or very complex/poor health status, most of these adults reached tight glycemic targets between 2001 and 2010. Most of them were treated with insulin or sulfonylureas, which may lead to severe hypoglycemia. Our findings suggest that a substantial proportion of older adults with diabetes were potentially overtreated.