Oral and Topical Treatment of Painful Diabetic Polyneuropathy: Practice Guideline Update Summary: Report of the AAN Guideline Subcommittee.

OBJECTIVE: To update the 2011 American Academy of Neurology (AAN) guideline on the treatment of painful diabetic neuropathy (PDN) with a focus on topical and oral medications and medical class effects. METHODS: The authors systematically searched the literature from January 2008 to April 2020 using a structured review process to classify the evidence and develop practice recommendations using the AAN 2017 Clinical Practice Guideline Process Manual. RESULTS: Gabapentinoids (standardized mean difference [SMD] 0.44; 95% confidence interval [CI], 0.21-0.67), serotonin-norepinephrine reuptake inhibitors (SNRIs) (SMD 0.47; 95% CI, 0.34-0.60), sodium channel blockers (SMD 0.56; 95% CI, 0.25-0.87), and SNRI/opioid dual mechanism agents (SMD 0.62; 95% CI, 0.38-0.86) all have comparable effect sizes just above or just below our cutoff for a medium effect size (SMD 0.5). Tricyclic antidepressants (TCAs) (SMD 0.95; 95% CI, 0.15-1.8) have a large effect size, but this result is tempered by a low confidence in the estimate. RECOMMENDATIONS SUMMARY: Clinicians should assess patients with diabetes for PDN (Level B) and those with PDN for concurrent mood and sleep disorders (Level B). In patients with PDN, clinicians should offer TCAs, SNRIs, gabapentinoids, and/or sodium channel blockers to reduce pain (Level B) and consider factors other than efficacy (Level B). Clinicians should offer patients a trial of medication from a different effective class when they do not achieve meaningful improvement or experience significant adverse effects with the initial therapeutic class (Level B) and not use opioids for the treatment of PDN (Level B).

A view from Cheyenne Mountain: Generation III's perspective of Keystone III.

In October 2000 the family of family medicine convened the Keystone III conference at Cheyenne Mountain Resort. Keystone III participants included members of Generation I (entered practice before 1970), Generation II (entered 1970-1990), and Generation III (entered after 1990). They represented a wide range of family physicians, from medical students to founders of the discipline, and from small-town solo practice to academic medicine. During the conference, the three generations worked together and separately thinking about the past, present, and future of family medicine, our roles in it, and how the understanding of a family physician and our discipline had and would continue to evolve. After the conference, the 10 Generation III members wrote the article published here, reflecting on our experiences as new physicians and physicians in training, and the similarities and differences between our experiences and those of physicians in Generations I and II. Key similarities included commitment to whole-person care, to a wide scope of practice, to community health, and to ongoing engagement with our discipline. Key differences included our understanding of availability, the need for work-life balance, the role of technology in the physician-patient relationship, and the perceptions of the relationship between medicine and a range of outside forces such as insurance and government. This article, presented with only minor edits, thus reflects accurately our perceptions in late 2000. The accompanying editorial reflects our current perspective.

Value-driven health care: proceed with caution.

Given the context of continually increasing health care expenditures, value-driven health care is a concept that is gaining attention. Optimizing quality and efficiency provides greatest value, and aligning financial incentives through, for example, pay-for-performance programs, is a strategy growing in popularity. Such programs lack evidence of effectiveness for improving health outcomes and may have the potential limitations of opportunity costs and further disenfranchisement of vulnerable populations. However our current health care system is unsustainable, and fundamental reform is indicated. Financial incentives may prove to be an effective strategy for improving quality and efficiency and deserve exploration, but pay-for-performance programs warrant further evaluation, with attention directed to identify and respond to any adverse unintended effects of these programs.

Efficacy and safety analysis of epoetin alfa in patients with small-cell lung cancer: a randomized, double-blind, placebo-controlled trial.

PURPOSE: This randomized, double-blind, placebo-controlled trial (N93-004) evaluated the effects of epoetin alfa on tumor response to chemotherapy and survival in patients with small-cell lung cancer (SCLC). PATIENTS AND METHODS: Adult patients with hemoglobin < or = 14.5 g/dL starting chemotherapy received epoetin alfa 150 U/kg or placebo subcutaneously 3 times weekly until 3 weeks after completion of chemotherapy. Survival was assessed for 3 years. The primary end point was the proportion of patients with complete or partial response after three chemotherapy cycles. RESULTS: The trial was terminated prematurely after 224 of a projected 400 patients were accrued. Baseline characteristics were similar between groups. Epoetin alfa and placebo patients (n = 109 and n = 115, respectively) had mean baseline hemoglobin of 12.8 g/dL and 13.0 g/dL, respectively. Overall tumor response was similar between the epoetin alfa and placebo groups after three chemotherapy cycles (72% and 67%, respectively; 95% CI of difference, -6% to 18%) and after completion of chemotherapy (60% and 56%, respectively; 95% CI of difference, -9% to 17%). Epoetin alfa and placebo groups had similar median overall survival (10.5 and 10.4 months, respectively) and overall mortality (91.7% and 87.8%, respectively; hazard ratio, 1.172; 95% CI, 0.887 to 1.549; P = .264). Hemoglobin was maintained in the prechemotherapy range in epoetin alfa patients, but decreased substantially in placebo patients. Fewer epoetin alfa patients than placebo patients required transfusion. CONCLUSION: These results suggest that in newly diagnosed patients with SCLC epoetin alfa does not affect tumor response to chemotherapy or survival. However, the early trial closure makes these conclusions preliminary.

Better information for better health care: the Evidence-based Practice Center program and the Agency for Healthcare Research and Quality.

To provide decision makers with the best available evidence, the Agency for Healthcare Research and Quality established a network of Evidence-based Practice Centers across North America. The centers perform systematic reviews on important questions posed by partner organizations about clinical, organizational, and policy interventions in healthcare. The Agency works closely with partners and other decision maker s to help translate that evidence into practice or policy. In this paper, we review important lessons we have learned over the past 7 years about how to increase the efficiency and impact of systematic reviews. Lessons concern selecting the right topics and scope, working effectively with partners, and balancing consistency and flexibility in methods. We examine continuing evolutions of the program and the impact of planned work on comparative effectiveness performed as part of the Medicare Modernization Act of 2003.

Changing prescribing patterns and increasing prescription expenditures in Medicaid.

PURPOSE: Prescription drug expenditures are the most rapidly growing component of total health care expenditures and particularly affect state Medicaid programs. We determined the extent to which increasing prescription price and changing prescribing patterns contribute to rising prescription expenditures in Medicaid. METHODS: We conducted a claims-based analysis comparing annual prescription drug expenditures and prescribing patterns. Prescription drug and outpatient visit claims for all North Carolina Medicaid enrollees from 1998 through 2000 were included. We analyzed drugs individually by combining all prescriptions and expenditures for the same drug formulation, and we calculated the number of units dispensed per person-year of enrollment. RESULTS: Prescription drug coverage for 1 person-year cost 503 dollars in 1998 and 759 dollars in 2000, for an annual increase of 22.8%. The average number of prescriptions filled per person-year increased from 13.0 in 1998 to 15.5 in 2000. Increased prescribing for 6 drugs accounted for more than 25% of the total increase in expenditures. The price for the 15 most expensive drugs increased an average of 4.1% annually. CONCLUSIONS: Prices for existing drugs increased slightly during the study period, but the major cause of the increase in drug costs was an increase in the number of prescriptions for new and more expensive medications. Prescribing patterns in Medicaid differ somewhat from those in the private sector and partly reflect the population with low socioeconomic status and high health care needs that it serves. To help control rising prescription drug expenditures, efforts should be undertaken to improve appropriate and cost-effective prescribing.

International medical graduates and the primary care workforce for rural underserved areas.

The proportion of international medical graduates (IMGs) serving as primary care physicians in rural underserved areas (RUAs) has important policy implications. We analyzed the 2000 American Medical Association Masterfile and Area Resource File to calculate the percentage of primary care IMGs, relative to U.S. medical graduates (USMGs), working in RUAs. We found that 2.1 percent of both primary care USMGs and IMGs were in RUAs, where USMGs were more likely to be family physicians but less likely to be internists or pediatricians. IMGs appear to have been no more likely than USMGs were to practice primary care in RUAs, but the distribution by specialty differs.