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Clinical leadership is a difficult balancing act

British Medical Journal - Jue, 14/04/2022 - 13:06
Kar writes about the challenges of NHS leadership.1 It takes a very special person to become a clinical leader if the role has a management component.In days gone by, clinicians’ requests for funding...

Covid-19: Health leaders accuse government of ignoring crisis in NHS

British Medical Journal - Jue, 14/04/2022 - 12:46
The BMA has accused the UK government of “burying its head in the sand” over current high levels of covid-19 and the threat they pose to health services and recovery plans.It warned that the...

The health community must resist the UK’s expansion of oil and gas

British Medical Journal - Jue, 14/04/2022 - 12:11
When it comes to the health impacts of the climate crisis, every degree matters. This fact has been keenly emphasised in the recent instalment of the sixth Intergovernmental Panel on Climate Change...

Measuring what counts to improve quality of care

British Medical Journal - Jue, 14/04/2022 - 11:51
In the US in 1961, Robert McNamara joined the Kennedy administration as secretary of defence, bringing with him a strong track record in the application of metrics to complex problems. During the...

Why the world has no universal biosafety standards

British Medical Journal - Jue, 14/04/2022 - 11:31
In late November 2021, after weeks of no confirmed community transmission of SARS-CoV-2, Taiwan’s Central Epidemic Command Center held a special evening press conference to announce an unusual...

Johnson’s bigger crime is failing to take the nation’s health seriously enough

British Medical Journal - Jue, 14/04/2022 - 11:26
The ideal of living longer and healthier has proved to be fool’s gold. Instead, people are living for longer but with chronic disease and a poor quality of life. The unwellness industry in older age...

Making Prescription Drugs More Affordable Under the Biden Administration

JAMA - Mar, 02/03/2021 - 02:00
This Viewpoint discusses policies the Biden administration can enact to reduce costs, including benchmarking Medicare Part B drug payments to the lowest price paid in similar countries, preventing Part D plans from negotiating confidential rebates with manufacturers, and patent reform to promote generic drug use.

Addressing Excess Health Care Pricing With Backstop Price Caps

JAMA - Mar, 02/03/2021 - 02:00
This Viewpoint reviews evidence that higher hospital prices reflect greater market power more than higher-quality services and proposes that backstop price caps can mitigate harms from the most excessive prices without constraining or distorting competitive health care markets.


JAMA - Mar, 02/03/2021 - 02:00

Diagnosis and Treatment of Irritable Bowel Syndrome

JAMA - Mar, 02/03/2021 - 02:00
This narrative review summarizes the epidemiology, pathophysiology, diagnosis, management, and prognosis of irritable bowel syndrome.

It’s Not Your Fault—Forgiveness in Illness and Death

JAMA - Mar, 02/03/2021 - 02:00
In this narrative medicine essay an infectious diseases physician shares the sense of forgiveness she brings to anyone possibly involved in COVID-19 transmission, having learned as a child the healing power of family absolution after she witnessed the death of a cousin.

Reason for Everything

JAMA - Mar, 02/03/2021 - 02:00
I will work. I will work without a mask. I will mask the work of courage. I will say there is a reason, bury my aunt, and say it again. I will walk on any street without a graveyard without a mask. I will let our children play there. I will see them share the sand. I will let them touch each other. I will see them slip in soil. I will remember I played dead. I will forget two hundred thousand bodies. I will sift anything but ash.

Effect of Blinatumomab vs Chemotherapy on Event-Free Survival in Children With High-Risk First Relapse of B-Cell ALL

JAMA - Mar, 02/03/2021 - 02:00
This randomized trial compares the effects of blinatumomab, an antibody construct that links CD3+ T cells to CD19+ leukemia cells, vs consolidation chemotherapy as a third consolidation block before allogeneic hematopoietic stem cell transplant (HST) on event-free survival in children with high-risk first-relapse B-cell acute lymphoblastic leukemia (B-ALL).

Consolidation With Blinatumomab vs Chemotherapy in First Relapse of B-Cell Acute Lymphoblastic Leukemia

JAMA - Mar, 02/03/2021 - 02:00
This randomized trial compares the effects of postreinduction therapy consolidation using blinatumomab, an antibody construct that links CD3+ T cells to CD19+ leukemia cells, vs chemotherapy on disease-free survival among children, adolescents, and young adults with first relapse of B-cell acute lymphoblastic leukemia (ALL).

Ticagrelor vs Clopidogrel for Patients With Acute Coronary Syndrome Undergoing Percutaneous Intervention—Reply

JAMA - Mar, 02/03/2021 - 02:00
In Reply Dr Kim and colleagues state that the results of our study are not comparable with those of PLATO and suggest that our findings may differ because patients enrolled in PLATO had a higher proportion of prior myocardial infarction. First, as we mention in our article, PLATO failed to show benefit in North America and included few Asian patients. It did show that ticagrelor reduced ischemic events and increased the rate of nonprocedural bleeding. However, several studies have demonstrated that high-risk patients with ACS do not have a net benefit with ticagrelor. For example, the SWEDEHEART registry showed that ticagrelor was associated with higher rates of bleeding and increased mortality in patents with ACS who were aged 80 years or older. A reduction in ischemic outcomes from ticagrelor was also not observed in this study. The open-label randomized clinical trial POPular AGE demonstrated that clopidogrel is favored for older patients with non–ST-elevation ACS, a high-risk subgroup. The TICA-KOREA trial showed that ticagrelor use was not associated with fewer ischemic events but was associated with increased risk of bleeding in Korean patients with ACS treated with PCI.

Antiretroviral Drug Recommendations for HIV Treatment and Prevention—Reply

JAMA - Mar, 02/03/2021 - 02:00
In Reply Our recommendations for initial antiretroviral therapy are based on evidence from randomized clinical trials demonstrating superiority of InSTI-based therapy vs comparators that included boosted protease inhibitors or efavirenz. Additional benefits of dolutegravir-based and bictegravir-based therapies include a low risk of treatment-emergent resistance, lack of need for pretreatment genotype results, few significant drug interactions, and a highly favorable tolerability profile, along with a very low rate of discontinuation due to adverse effects.

The De-Adoption of Low-Value Health Care—Reply

JAMA - Mar, 02/03/2021 - 02:00
In Reply We agree with Dr Donzelli that reforming health care payment is an essential step in reducing the delivery of low-value services. This is core to our argument around the economic forces that guide the de-adoption of low-value care. Within this realm of economic levers, Donzelli makes an important distinction between pay-for-performance and pay-for-health models, noting some inconsistent results from the former. Although there is evidence that targeted payment policies can reduce the provision of low-value care, we agree that more holistic value-based payment models are needed. Our understanding of how to best pay for health continues to evolve and requires precise measurement of and alignment around the definition of health. One approach raised by Donzelli is to move toward risk-adjusted capitated payments, an approach already used at scale within the Medicare Advantage program. There is also some evidence to suggest that other global payment structures influence the provision of low-value services. As the adoption of value-based payment continues to grow, it will be important to rigorously evaluate the impact on low-value care.

Ticagrelor vs Clopidogrel for Patients With Acute Coronary Syndrome Undergoing Percutaneous Intervention

JAMA - Mar, 02/03/2021 - 02:00
To the Editor A recent retrospective cohort analysis by Dr You and colleagues demonstrated that compared with clopidogrel, ticagrelor was not associated with better outcomes in patients from the US and South Korea with acute coronary syndrome (ACS) undergoing percutaneous intervention (PCI). However, there are several important discrepancies between this cohort analysis and the randomized Platelet Inhibition and Patient Outcomes (PLATO) trial.

Antiretroviral Drug Recommendations for HIV Treatment and Prevention

JAMA - Mar, 02/03/2021 - 02:00
To the Editor As HIV clinicians, we read with interest the new antiretroviral treatment guidelines published on behalf of the International Antiviral Society–USA. Nevertheless, we believe these guidelines failed to integrate emerging evidence and may have reflected implicit commercial bias.

The De-adoption of Low-Value Health Care

JAMA - Mar, 02/03/2021 - 02:00
To the Editor In their Viewpoint, Dr Powers and colleagues analyzed 3 forces governing de-adoption of low-value care: evidence, eminence, and economics. A common denominator underlies them: the interest and convenience of the health care producers, providers, and purchasers. Fee-for-service creates strong incentives to continue delivering low-value but profitable care and technological abuse. More generally, it incentivizes provision of services with a profitable differential between the production costs and the fee applied by purchasers. The production cost is physician- or hospital team–specific, based also on specific skills and preferences, whereas the applied fees are not hospital- or physician-specific, further limiting targeted tariff policies. Aligned with pressure from patients and induced by technology producers and professional societies, fee-for-service multiplies outputs, which translates into financial and career benefits for hospitals, physicians, and producers. Therefore, low-value care for patients and society can be of high value for the producers, hospitals, and physicians selling it. A distorted rewarding model for health players puts the health systems in structural conflict of interest with health.
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