WRITING GROUP MEMBERS Emelia J. Benjamin, MD, SCM, FAHA Michael J. Blaha, MD, MPH Stephanie E. Chiuve, ScD Mary Cushman, MD, MSc, FAHA Sandeep R. Das, MD, MPH, FAHA Rajat Deo, MD, MTR Sarah D. de Ferranti, MD, MPH James Floyd, MD, MS Myriam Fornage, PhD, FAHA Cathleen Gillespie, MS Carmen R. Isasi, MD, PhD, FAHA Monik C. Jiménez, ScD, SM Lori Chaffin Jordan, MD, PhD Suzanne E. Judd, PhD Daniel Lackland, DrPH, FAHA Judith H. Lichtman, PhD, MPH, FAHA Lynda Lisabeth, PhD, MPH, FAHA Simin Liu, MD, ScD, FAHA Chris T. Longenecker, MD Rachel H. Mackey, PhD, MPH, FAHA Kunihiro Matsushita, MD, PhD, FAHA Dariush Mozaffarian, MD, DrPH, FAHA Michael E. Mussolino, PhD, FAHA Khurram Nasir, MD, MPH, FAHA Robert W. Neumar, MD, PhD, FAHA Latha Palaniappan, MD, MS, FAHA Dilip K. Pandey, MBBS, MS, PhD, FAHA Ravi R. Thiagarajan, MD, MPH Mathew J. Reeves, PhD Matthew Ritchey, PT, DPT, OCS, MPH Carlos J. Rodriguez, MD, MPH, FAHA Gregory A. Roth, MD, MPH Wayne D. Rosamond, PhD, FAHA Comilla Sasson, MD, PhD, FAHA Amytis Towfighi, MD Connie W. Tsao, MD, MPH Melanie B. Turner, MPH Salim S. Virani, MD, PhD, FAHA Jenifer H. Voeks, PhD Joshua Z. Willey, MD, MS John T. Wilkins, MD Jason HY. Wu, MSc, PhD, FAHA Heather M. Alger, PhD Sally S. Wong, PhD, RD, CDN, FAHA Paul Muntner, PhD, MHSc On behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee Heart Disease and Stroke Statistics—2017 Update

Heart Disease and Stroke Statistics—2017 Update: A Report From the American Heart Association

The 11th edition of Harrison's Principles of Internal Medicine welcomes Anthony Fauci to its editorial staff, in addition to more than 85 new contributors. While the organization of the book is similar to previous editions, major emphasis has been placed on disorders that affect multiple organ systems. Important advances in genetics, immunology, and oncology are emphasized. Many chapters of the book have been rewritten and describe major advances in internal medicine. Subjects that received only a paragraph or two of attention in previous editions are now covered in entire chapters. Among the chapters that have been extensively revised are the chapters on infections in the compromised host, on skin rashes in infections, on many of the viral infections, including cytomegalovirus and Epstein-Barr virus, on sexually transmitted diseases, on diabetes mellitus, on disorders of bone and mineral metabolism, and on lymphadenopathy and splenomegaly. The major revisions in these chapters and many

Harrison's Principles of Internal Medicine

March 5, 2019 e1 WRITING GROUP MEMBERS Emelia J. Benjamin, MD, ScM, FAHA, Chair Paul Muntner, PhD, MHS, FAHA, Vice Chair Alvaro Alonso, MD, PhD, FAHA Marcio S. Bittencourt, MD, PhD, MPH Clifton W. Callaway, MD, FAHA April P. Carson, PhD, MSPH, FAHA Alanna M. Chamberlain, PhD Alexander R. Chang, MD, MS Susan Cheng, MD, MMSc, MPH, FAHA Sandeep R. Das, MD, MPH, MBA, FAHA Francesca N. Delling, MD, MPH Luc Djousse, MD, ScD, MPH Mitchell S.V. Elkind, MD, MS, FAHA Jane F. Ferguson, PhD, FAHA Myriam Fornage, PhD, FAHA Lori Chaffin Jordan, MD, PhD, FAHA Sadiya S. Khan, MD, MSc Brett M. Kissela, MD, MS Kristen L. Knutson, PhD Tak W. Kwan, MD, FAHA Daniel T. Lackland, DrPH, FAHA Tené T. Lewis, PhD Judith H. Lichtman, PhD, MPH, FAHA Chris T. Longenecker, MD Matthew Shane Loop, PhD Pamela L. Lutsey, PhD, MPH, FAHA Seth S. Martin, MD, MHS, FAHA Kunihiro Matsushita, MD, PhD, FAHA Andrew E. Moran, MD, MPH, FAHA Michael E. Mussolino, PhD, FAHA Martin O’Flaherty, MD, MSc, PhD Ambarish Pandey, MD, MSCS Amanda M. Perak, MD, MS Wayne D. Rosamond, PhD, MS, FAHA Gregory A. Roth, MD, MPH, FAHA Uchechukwu K.A. Sampson, MD, MBA, MPH, FAHA Gary M. Satou, MD, FAHA Emily B. Schroeder, MD, PhD, FAHA Svati H. Shah, MD, MHS, FAHA Nicole L. Spartano, PhD Andrew Stokes, PhD David L. Tirschwell, MD, MS, MSc, FAHA Connie W. Tsao, MD, MPH, Vice Chair Elect Mintu P. Turakhia, MD, MAS, FAHA Lisa B. VanWagner, MD, MSc, FAST John T. Wilkins, MD, MS, FAHA Sally S. Wong, PhD, RD, CDN, FAHA Salim S. Virani, MD, PhD, FAHA, Chair Elect On behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee

Heart Disease and Stroke Statistics—2019 Update: A Report From the American Heart Association

Each chapter listed in the Table of Contents (see next page) is a hyperlink to that chapter. The reader clicks the chapter name to access that chapter.

Each chapter listed here is a hyperlink. Click on the chapter name to be taken to that chapter. 

Each year, the American Heart Association (AHA), in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together in a single document the most up-to-date statistics related to heart disease, stroke, and the cardiovascular risk factors listed in the AHA’s My Life Check - Life’s Simple 7 (Figure1), which include core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure [BP], and glucose control) that contribute to cardiovascular health. The Statistical Update represents …

Heart Disease and Stroke Statistics-2018 Update: A Report From the American Heart Association.

Background: The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovas...

Heart Disease and Stroke Statistics—2020 Update: A Report From the American Heart Association

Air pollution is harmful to human health, but little is known about the costs of pollution-related health care. If such care imposes a significant burden on insurance companies and employers, they would have substantial stakes in improving air quality. Reduced medical spending could also benefit public programs such as Medicare and Medicaid. This study estimated the amount of medical spending by private health insurers and public purchasers, such as Medicare, that is related to air pollution. Specifically, the authors determined how much failing to meet air quality standards cost various purchasers of hospital care in California over 2005-2007. The results indicate that substantial reductions in hospital spending can be achieved through reductions in air pollution.

/pdf/the-impact-of-air-quality-on-hospital-spending-2hgzouey96.pdf

The Impact of Air Quality on Hospital Spending

Objective: To determine the association between inhaled corticosteroid (ICS) use and the risk of pneumonia among Medicare patients with chronic obstructive pulmonary disease (COPD). Methods: A nested case control analysis was performed to study the relationship between ICS use and pneumonia risk in a cohort of Medicare Advantage members with COPD. Patients were identified through a medical and pharmacy claims database. A case was designated as patient’s first inpatient or outpatient pneumonia episode. Cases were matched to controls who entered the COPD cohort at the same time, but had not yet developed pneumonia by the case’s index date. The association between ICS use and pneumonia was estimated using logistic regression. Adjusted models controlled for age, sex, race, use of other COPD medications, markers of COPD severity, receipt of the pneumococcal vaccine, and comorbidities. Analyses were also stratified by current or past ICS use, as well as dosage (low, medium, or high). Results: Out of a COPD cohort of 83,455 members, 13,778 pneumonia episodes were identified; these cases were matched to 36,767 controls. Adjusting for covariates, having used any ICS during the past year was associated with increased risk of a pneumonia episode (OR 1.11, 95% CI: 1.05–1.18). Pneumonia risk was highest for current ICS users (OR 1.26, 95% CI: 1.16–1.36) and current high-dose users (OR 1.55, 95% CI: 1.25–1.92), compared to non-users. Conclusion: As a retrospective claims analysis, this study had inherent limitations. The pneumonia diagnosis could not be confirmed, smoking history and other health confounders were not included. However, given the large study sample size and extensive number of available controls, the results remain persuasive and confirm previous studies’ findings that ICS use, particularly current use and high-dose use, is associated with increased pneumonia risk.

Original article Inhaled corticosteroids and the risk of pneumonia in Medicare patients with COPD

Medicare Part D Represents a bold experiment to publicly fund, but privately sell and administer, prescription drug insurance. Part D is only a relatively small part of the overall Medicare program; Medicare spent $432 billion overall in 2007, of which Part D accounted for only 11.6% ($50 billion).1 However, the Medicare program is so large that Part D alone should account for 1% of the entire economy in less than 2 decades.1 Furthermore, there is little room for more spending, given the trustees’ recent forecast of $12 trillion in unfunded liabilities over the next 75 years—a debt just slightly smaller than the entire US economy.1 So much appears to be riding on Part D’s success or failure, including possible models for the provision of health insurance to the currently uninsured. Two articles2,3 in this issue of JAMA raise important concerns about the program, but must be rightly viewed in this larger context.

Before the introduction of Part D, officials were justifiably concerned that the program would not appeal to all types of beneficiaries or entice a sufficient number of health plans to offer a benefit. Failing to attract a broad distribution of beneficiaries could induce adverse selection, which could have jeopardized the long-term viability of the program. Similarly, failing to attract a sufficient number of plan sponsors could diminish competition, which was rightly viewed as a cornerstone of a successful program. At the same time, consumer advocacy groups were concerned that low-income beneficiaries, particularly those with both Medicaid and Medicare, would be worse off under Part D.

More than 2 years into the program, Part D has broad appeal to beneficiaries and plan sponsors. Policies to protect plans from excessive losses in the first few years (through reinsurance and risk corridors) as well as efforts to educate beneficiaries about plan choices led to a large number of sponsors and a wide array of options that beneficiaries can choose from. In particular, low users of prescription drugs could select a drug plan with little or no annual premium in most parts of the country, mitigating the financial risk of enrollment. As a result, approximately 40 million Medicare beneficiaries now have prescription drug coverage at least as generous as the Standard Part D benefit.4 Depending on where they live, beneficiaries have a choice of at least 45 standalone prescription drug plans that offer coverage for prescription drugs only or they can choose to obtain drug coverage from Medicare Advantage plans that offer the drug benefit in addition to other Medicare benefits.

Although most enrollees rate their Part D plans favorably, many express concerns over increasing co-payments or premiums and having to switch medications.5 Many participants recall the complex process of choosing a plan when they first enrolled in Part D for 2006 and would rather “make do” with their current plan rather than revisit that decision.5 Such inertia may reduce competition over time if beneficiaries are reluctant to switch into lower-cost or more appropriate plans. In fact, as Hsu and colleagues2 report in this issue of JAMA, enrollees in a large Medicare Advantage plan have limited knowledge of the plan’s cost-sharing requirements. For example, only 40% of beneficiaries surveyed in early 2007 were aware that their Part D drug plan in 2006 included a coverage gap. Although this lack of knowledge is a concern, similar knowledge gaps have been widely observed in non–Part D plans and should diminish over time. Nonetheless, this observation underscores one of the tradeoffs associated with offering beneficiaries a wide array of plan options and benefit designs.

After the Medicare Modernization Act was signed, but before Part D was implemented, there was a very public discussion that the 10-year cost of the program would be substantially greater than original Congressional Budget Office estimates. But soaring costs have not materialized. According to the 2007 Medicare Trustees report, the average 2007 plan bid was about 10% lower than in 2006.6 These savings likely reflect a variety of factors, including vigorous plan competition, increased generic drug use, and a general slowing of spending relative to earlier in the decade. Initial studies using 2006 claims data indicated that Part D was associated with a 16% decrease in out-of-pocket spending for prescription drugs and a 6.5% increase in the number of prescriptions filled in 2006, and these changes were concentrated among low-income beneficiaries.7–9

Still, cost appears to be an issue for some. In their article in this issue of JAMA, Madden and colleagues3 use responses from the Medicare Current Beneficiary Survey from 2004 to 2006 to assess the association of Part D with cost-related medication nonadherence (CRN). The authors find only small reductions in CRN overall in 2006, and no change among those beneficiaries in poor health or with multiple morbidities. Some of the discrepancy may be a “first-year” effect, particularly because many beneficiaries were only enrolled in a Part D plan for part of the year.

One key policy question is whether the doughnut hole, a well-known gap in the standard benefit under Part D, is driving some of this nonadherence. In 2008, beneficiaries have drug coverage up to $2510 in drug costs, then coverage suddenly stops, at which time beneficiaries pay all of their drug costs up to a certain level ($5726 or $4050 in “true out-of-pocket” costs). Insurance coverage then resumes at a higher level. As a result, beneficiaries with moderate to high drug expenses will pay a substantial fraction of their costs out-of-pocket.

Little data on the effect of the doughnut hole exist, but in other private insurance plans pharmacy benefit caps have been associated with higher rates of medication discontinuation—nearly 25% for individuals taking cardiac drugs (15% for those taking antihyperlipidemic agents)—and only a minority of those discontinuing reinitiated therapy when coverage resumed.10 This nonadherence is associated with more emergency department use and more nonelective hospitalizations.11,12 However, a recent report from IMS Health using retail pharmacy claims suggests that the “doughnut hole” affected only 6% of Part D participants in 2006.9 Low-income and dual-eligible beneficiaries, 61% of Part D enrollees, were unaffected by the coverage gap (because there is no gap in coverage for them), and 33% of enrollees did not reach $2250 in drug spending over the year and thus never reached the coverage gap. Of those beneficiaries who did enter the gap, a substantial fraction entered in the last days of the year. Among those who entered the gap earlier in the year, many continued through the gap allowing them to be insured at the low, catastrophic rate.

More generally, poor adherence underscores a fundamental problem with Part D. Stand-alone prescription drug plans have little incentive to improve medication adherence, because this means more prescription drug use. Any long-term savings in the form of reduced hospitalizations or less emergency department use accrue to the other parts of Medicare rather than the plan. Medicare Advantage plans, on the other hand, do face these incentives, and it will be important to monitor medication adherence in both types of plans and to evaluate how benefit design develops across these 2 types of products.

The primary objective of the Medicare Modernization Act was to provide seniors with affordable coverage for their prescription medications. This goal has been largely achieved, as more than 90% of Medicare beneficiaries now have prescription drug coverage at least as generous as the Standard Part D benefit.4 The fact that average premiums are substantially lower than initial projections provides some evidence that the market is working. The articles by Hsu et al2 and by Madden et al3 document beneficiary confusion and problems with adherence—issues that are not likely to be endemic but still must be monitored. It may be that some features of the Part D benefit, especially the dreaded doughnut hole, are ripe for redesign.

/pdf/medicare-part-d-a-successful-start-with-room-for-improvement-26f5jualxc.pdf

Medicare Part D: A Successful Start With Room for Improvement

This paper uses data from a unique, nationally representative sample of HIV-infected adults receiving medical care, to describe the relationship between disease progression and insurance coverage in the United States. The authors find that public insurance is the predominant source of coverage for those in care for HIV, and that coverage increases as disease progresses.

Insurance Status of HIV-Infected Adults in the Post-Haart Era: Evidence from the United States

Despite the goal of comparative effectiveness research (CER) to inform patient-centered care, most studies fail to account for the patient-centeredness of care that already exist in practice, which we denote as passive personalization (PP). Because CER studies describe the average effectiveness of treatments rather than heterogeneity in how individual patients respond to therapies, clinical or coverage policies that respond to CER results may undermine PP in clinical practice and generate worse outcomes. We study this phenomenon empirically in the context of use of antipsychotic drugs in Medicaid patients with schizophrenia using novel instrumental variable methods. We find strong support for PP in clinical practice and demonstrate that the average effects from a CER study cannot be replicated in practice because of the presence of PP. In contrast, providing physicians with evidence to further personalize treatment can produce significant benefits.

/pdf/heterogeneity-in-action-the-role-of-passive-personalization-4gc9knnxkz.pdf

Dana P. Goldman

Papers

The Impact of Air Quality on Hospital Spending

Original article Inhaled corticosteroids and the risk of pneumonia in Medicare patients with COPD

Medicare Part D: A Successful Start With Room for Improvement

Insurance Status of HIV-Infected Adults in the Post-Haart Era: Evidence from the United States

Heterogeneity in action: the role of passive personalization in comparative effectiveness research.