The American journal of managed care
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Randomized Controlled Trial
Testing of a tethered personal health record framework for early end-of-life discussions.
The process of planning for end-of life decisions, also known as advance care planning (ACP), is associated with numerous positive outcomes, including improved patient satisfaction with care and improved patient quality of life in terminal illness. In this study, we sought to test a novel personal health record (PHR)-delivered ACP framework through a small-scale randomized trial of usual care practices versus PHR-delivered ACP. ⋯ Tethered PHR use as an initial ACP communication tool can improve outpatient documentation rates and quality. Future studies obtaining patient feedback on a revised framework and testing in a larger setting are needed to determine reproducibility of findings.
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Three modalities have a role in the primary management of diabetic macular edema (DME): laser photocoagulation, intravitreal vascular endothelial growth factor (VEGF) inhibitors, and intravitreal corticosteroid implants. Intravitreal VEGF inhibitors are most commonly used for center-involved DME, but laser photocoagulation and intravitreal corticosteroids also have an important role in DME management. Until recently, the selection of a VEGF inhibitor for a patient was complicated by a lack of comparative data and a much lower cost for bevacizumab compared with other agents. ⋯ However, aflibercept and ranibizumab were more effective than bevacizumab for patients with worse baseline visual acuity. A higher rate of nonfatal stroke and vascular death with ranibizumab in the Protocol T trial has raised concern in the community and needs to be investigated further. Emerging drugs for DME include VEGF inhibitors with less-frequent dosing intervals, and new agents that target other pathologic processes that contribute to vascular leakage and angiogenesis in DME.
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To study the association between cost sharing for diabetes medications, adherence, hospitalization rates, and healthcare costs, with relationship to patient risk. ⋯ Increased cost sharing for T2D medication was associated with reductions in pharmacy costs, but higher total costs for patients with T2D. This problem is particularly acute for patients with 1 or more cardiovascular comorbidities. The results suggest that increased diabetes cost sharing may hamper efforts to lower the total cost of diabetes care.
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Comprehensive lifestyle interventions, including nutrition, physical activity, and behavioral therapy, are the foundation for clinical obesity management. New tools and treatment approaches help clinicians provide these interventions and support weight management in the primary care setting. ⋯ This article provides a review of obesity treatment in primary care and managed care settings. Principles of lifestyle changes for weight management, behavioral counseling, and options for pharmacotherapy, medical devices, and bariatric surgery are discussed.