Journal of general internal medicine
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Comparative Study Observational Study
Prescription Medications for the Treatment of Insomnia and Risk of Suicide Attempt: a Comparative Safety Study.
Guidelines for the pharmacological treatment of chronic insomnia in adults recognize that trazodone and other off-label medications are commonly prescribed despite poor evidence. The Department of Veterans Health Affairs (VA) fills high volumes of inexpensive, over-the-counter sedating antihistamines and older antidepressants in addition to benzodiazepines and zolpidem. Yet little is known about the comparative safety of these agents with regard to suicidal behavior. ⋯ Compared to zolpidem, hazard of suicide attempt was 61% higher with trazodone (< 200 mg). No significant differences in suicide attempt risk were identified between benzodiazepines or sedating antihistamines and zolpidem, respectively. These findings provide the first comparative effectiveness evidence against the use of trazodone for insomnia.
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In a prior study, we found patient satisfaction was associated with mortality. However, that study included few deaths, yielding wide confidence intervals, was criticized for possible morbidity under-adjustment, and lacked power to explore sociodemographic moderation. ⋯ The association of higher patient satisfaction with clinicians with higher short-term mortality was evident only after CAHPS-recommended adjustment, was not attenuated by further morbidity adjustment, and was evident in women but not men. The findings suggest that characteristics among women who are more satisfied with their clinicians may be associated with increased mortality risk.
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Communication about priorities and goals improves the value of care for patients with serious illnesses. Resource constraints necessitate targeting interventions to patients who need them most. ⋯ When used in combination with a high-risk algorithm, the 2-year version of the SQ captured the majority of patients who died, demonstrating better than expected performance as a screening tool for a serious illness communication intervention in a heterogeneous primary care population.
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Dense breast tissue increases breast cancer risk and lowers mammography sensitivity, but the value of supplemental imaging for dense breasts remains uncertain. Since 2009, 37 states and Washington DC have passed legislation requiring patient notification about breast density. ⋯ As breast density notification laws are considered, policymakers and clinicians should expect increases in breast imaging/biopsies. Additional research is needed on these laws' effects on cost and patient outcomes.
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The international project "Choosing Wisely" aims to target unnecessary and potentially harmful examinations and treatments. ⋯ This Top-5 list provides an opportunity to discuss appropriate use of health care practices in internal medicine.