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1.
Ann Intern Med ; 176(1): 29-38, 2023 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-36534976

RESUMO

BACKGROUND: Older patients with advanced chronic kidney disease (CKD) face difficult decisions about managing kidney failure, frequently experiencing decisional conflict, regret, and treatment misaligned with preferences. OBJECTIVE: To assess whether a decision aid about kidney replacement therapy improved decisional quality compared with usual care. DESIGN: Multicenter, randomized, controlled trial. (ClinicalTrials.gov: NCT03522740). SETTING: 8 outpatient nephrology clinics associated with 4 U.S. centers. PARTICIPANTS: English-fluent patients, 70 years and older with nondialysis CKD stages 4 to 5 recruited from 2018 to 2020. INTERVENTION: DART (Decision-Aid for Renal Therapy) is an interactive, web-based decision aid for older adults with CKD. Both groups received written education about treatments. MEASUREMENTS: Change in the decisional conflict scale (DCS) score from baseline to 3, 6, 12, and 18 months. Secondary outcomes included change in prognostic and treatment knowledge and change in uncertainty. RESULTS: Among 400 participants, 363 were randomly assigned: 180 to usual care, 183 to DART. Decisional quality improved with DART with mean DCS declining compared with control (mean difference, -8.5 [95% CI, -12.0 to -5.0]; P < 0.001), with similar findings at 6 months, attenuating thereafter. At 3 months, knowledge improved with DART versus usual care (mean difference, 7.2 [CI, 3.7 to 10.7]; P < 0.001); similar findings at 6 months were modestly attenuated at 18 months (mean difference, 5.9 [CI, 1.4 to 10.3]; P = 0.010). Treatment preferences changed from 58% "unsure" at baseline to 28%, 20%, 23%, and 14% at 3, 6, 12, and 18 months, respectively, with DART, versus 51% to 38%, 35%, 32%, and 18% with usual care. LIMITATION: Latinx patients were underrepresented. CONCLUSION: DART improved decision quality and clarified treatment preferences among older adults with advanced CKD for 6 months after the DART intervention. PRIMARY FUNDING SOURCE: Patient-Centered Outcomes Research Institute (PCORI).


Assuntos
Técnicas de Apoio para a Decisão , Insuficiência Renal Crônica , Humanos , Idoso , Insuficiência Renal Crônica/terapia , Prognóstico , Pacientes , Tomada de Decisões
2.
JAMA ; 328(19): 1945-1950, 2022 11 15.
Artigo em Inglês | MEDLINE | ID: mdl-36378202

RESUMO

Importance: Current prevalence of obstructive sleep apnea (OSA) in the US is not well established; however, based on cohort and survey data, in 2007-2010 the estimated prevalence of at least mild OSA (defined as an apnea-hypoxia index [AHI] ≥5) plus symptoms of daytime sleepiness among adults aged 30 to 70 years was 14% for men and 5% for women, and the estimated prevalence of moderate to severe OSA (defined as AHI ≥15) was 13% for men and 6% for women. Severe OSA is associated with increased all-cause mortality. Other adverse health outcomes associated with untreated OSA include cardiovascular disease and cerebrovascular events, type 2 diabetes, cognitive impairment, decreased quality of life, and motor vehicle crashes. Objective: To update its 2017 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for OSA in adults. Population: Asymptomatic adults (18 years or older) and adults with unrecognized symptoms of OSA. Evidence Assessment: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for OSA in the general adult population. Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for OSA in the general adult population. (I statement).


Assuntos
Programas de Rastreamento , Apneia Obstrutiva do Sono , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Comitês Consultivos , Diabetes Mellitus Tipo 2/etiologia , Programas de Rastreamento/efeitos adversos , Programas de Rastreamento/métodos , Prevalência , Qualidade de Vida , Medição de Risco , Apneia Obstrutiva do Sono/complicações , Apneia Obstrutiva do Sono/diagnóstico , Apneia Obstrutiva do Sono/epidemiologia , Apneia Obstrutiva do Sono/mortalidade , Estados Unidos/epidemiologia
3.
Am J Clin Nutr ; 2022 Nov 30.
Artigo em Inglês | MEDLINE | ID: mdl-36446403

RESUMO

BACKGROUND: Whole-grain (WG) foods are defined by the Dietary Guidelines for Americans (DGA), FDA, AHA, American Association of Cereal Chemists International (AACCI), and Whole Grains Council (WGC) in different ways with diverse focuses on grain components only, whole foods, or nutrient contents. OBJECTIVES: We aimed to compare estimated WG food intake among US adults using different definitions. METHODS: For each definition, we estimated the mean intake and trends of WG food consumption using survey-weighted 24-h dietary recalls from nationally representative samples of 39,755 US adults aged 20+ y from 8 cycles (2003-2018) of the NHANES. This is an observational study that used deidentified and publicly available datasets. RESULTS: The estimated mean consumption of WG foods (ounces equivalents/2000 kcal/d, oz. eq./d) varied by definition. In 2017-2018, the AHA (mean [SEM]: 1.05 [0.07] oz. eq./d) and WGC (0.95 [0.07]) definitions yielded the highest amounts, followed by the DGA (0.81 [0.06]), AACCI (0.73 [0.05]), and FDA (0.53 [0.04]). Using all definitions except for WGC, US adults increased WG food intake from 2003-2004 to 2017-2018 with the largest increase (61.5%) using the AHA (from 0.65 to 1.05 oz. eq./d), followed by DGA (0.50 to 0.81) and AACCI (0.51 to 0.73) definitions. For each definition, the main sources of WG foods consumed by US adults were ready-to-eat cereals, cooked grains and cereals, and breads (including rolls and tortillas). For all definitions except the AHA, non-Hispanic White adults and individuals with college degrees or above consumed higher levels of WG foods than non-Hispanic Blacks and those with lower levels of education. CONCLUSIONS: Different definitions affect the determination of WG foods, estimated intakes, and associated trends in WG food consumption among US adults. These findings call for a standardized definition of WG foods to guide consumers, industry, and policymakers in promoting WG intake in the US.Clinical Trial Registration: Not Applicable.

4.
Nat Commun ; 13(1): 7066, 2022 Nov 22.
Artigo em Inglês | MEDLINE | ID: mdl-36414619

RESUMO

The Food Compass is a nutrient profiling system (NPS) to characterize the healthfulness of diverse foods, beverages and meals. In a nationally representative cohort of 47,999 U.S. adults, we validated a person's individual Food Compass Score (i.FCS), ranging from 1 (least healthful) to 100 (most healthful) based on cumulative scores of items consumed, against: (a) the Healthy Eating Index (HEI) 2015; (b) clinical risk factors and health conditions; and (c) all-cause mortality. Nationally, the mean (SD) of i.FCS was 35.5 (10.9). i.FCS correlated highly with HEI-2015 (R = 0.81). After multivariable-adjustment, each one SD (10.9 point) higher i.FCS associated with more favorable BMI (-0.60 kg/m2 [-0.70,-0.51]), systolic blood pressure (-0.69 mmHg [-0.91,-0.48]), diastolic blood pressure (-0.49 mmHg [-0.66,-0.32]), LDL-C (-2.01 mg/dl [-2.63,-1.40]), HDL-C (1.65 mg/d [1.44,1.85]), HbA1c (-0.02% [-0.03,-0.01]), and fasting plasma glucose (-0.44 mg/dL [-0.74,-0.15]); lower prevalence of metabolic syndrome (OR = 0.85 [0.82,0.88]), CVD (0.92 [0.88,0.96]), cancer (0.95 [0.91,0.99]), and lung disease (0.92 [0.88,0.96]); and higher prevalence of optimal cardiometabolic health (1.24 [1.16,1.32]). i.FCS also associated with lower all-cause mortality (HR = 0.93 [0.89,0.96]). Findings were similar by age, sex, race/ethnicity, education, income, and BMI. These findings support validity of Food Compass as a tool to guide public health and private sector strategies to identify and encourage healthier eating.


Assuntos
Doenças Cardiovasculares , Dieta Saudável , Adulto , Humanos , Alimentos , Bebidas , Nutrientes , Doenças Cardiovasculares/epidemiologia
5.
JAMA Netw Open ; 5(11): e2243449, 2022 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-36413364

RESUMO

Importance: Delivering low-value care can lead to unnecessary follow-up services and associated costs, and such care cascades have not been well examined in common clinical scenarios. Objective: To evaluate the utilization and costs of care cascades of prostate-specific antigen (PSA) tests for prostate cancer screening, as the routine use of which among asymptomatic men aged 70 years and older is discouraged by multiple guidelines. Design, Setting, and Participants: This cross-sectional study included men aged 70 years and older without preexisting prostate conditions enrolled in a Medicare Advantage plan during January 2016 to December 2018 with at least 1 outpatient visit. Medical billing claims data from the deidentified OptumLabs Data Warehouse were used. Data analysis was conducted from September 2020 to August 2021. Exposures: At least 1 claim for low-value PSA tests for prostate cancer screening during the observation period. Main Outcomes and Measures: Utilization of and spending on low-value PSA cancer screening and associated care cascades and the difference in overall health care utilization and spending among individuals receiving low-value PSA cancer screening vs those who did not, adjusting for observed characteristics using inverse probability of treatment weighting. Results: Of 995 442 men (mean [SD] age, 78.0 [5.6] years) aged 70 years or older in a Medicare Advantage plan included in this study, 384 058 (38.6%) received a low-value PSA cancer screening. Utilization increased for each subsequent cohort from 2016 to 2018 (49 802 of 168 951 [29.4%] to 134 404 of 349 228 [38.5%] to 199 852 of 477 203 [41.9%]). Among those receiving initial low-value PSA cancer screening, 241 188 of 384 058 (62.8%) received at least 1 follow-up service. Repeated PSA testing was the most common, and 27 268 (7.1%) incurred high-cost follow-up services, such as imaging, radiation therapy, and prostatectomy. Utilization and spending associated with care cascades also increased from 2016 to 2018. For every $1 spent on a low-value PSA cancer screening, an additional $6 was spent on care cascades. Despite avoidable care cascades, individuals who received low-value PSA cancer screening were not associated with increased overall health care utilization and spending during the 1-year follow-up period compared with an unscreened population. Conclusions and Relevance: In this cross-sectional study, low-value PSA tests for prostate cancer screening remained prevalent among Medicare Advantage plan enrollees and were associated with unnecessary expenditures due to avoidable care cascades. Innovative efforts from clinicians and policy makers, such as payment reforms, to reduce initial low-value care and avoidable care cascades are warranted to decrease harm, enhance equity, and improve health care efficiency.


Assuntos
Medicare Part C , Neoplasias da Próstata , Masculino , Idoso , Humanos , Estados Unidos , Idoso de 80 Anos ou mais , Detecção Precoce de Câncer , Antígeno Prostático Específico , Neoplasias da Próstata/epidemiologia , Estudos Transversais , Aceitação pelo Paciente de Cuidados de Saúde
6.
JAMA ; 328(17): 1740-1746, 2022 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-36318127

RESUMO

Importance: Menopause is defined as the cessation of a person's menstrual cycle. It is defined retrospectively, 12 months after the final menstrual period. Perimenopause, or the menopausal transition, is the few-year time period preceding a person's final menstrual period and is characterized by increasing menstrual cycle length variability and periods of amenorrhea, and often symptoms such as vasomotor dysfunction. The prevalence and incidence of most chronic diseases (eg, cardiovascular disease, cancer, osteoporosis, and fracture) increase with age, and US persons who reach menopause are expected on average to live more than another 30 years. Objective: To update its 2017 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of systemic (ie, oral or transdermal) hormone therapy for the prevention of chronic conditions in postmenopausal persons and whether outcomes vary by age or by timing of intervention after menopause. Population: Asymptomatic postmenopausal persons who are considering hormone therapy for the primary prevention of chronic medical conditions. Evidence Assessment: The USPSTF concludes with moderate certainty that the use of combined estrogen and progestin for the primary prevention of chronic conditions in postmenopausal persons with an intact uterus has no net benefit. The USPSTF concludes with moderate certainty that the use of estrogen alone for the primary prevention of chronic conditions in postmenopausal persons who have had a hysterectomy has no net benefit. Recommendation: The USPSTF recommends against the use of combined estrogen and progestin for the primary prevention of chronic conditions in postmenopausal persons. (D recommendation) The USPSTF recommends against the use of estrogen alone for the primary prevention of chronic conditions in postmenopausal persons who have had a hysterectomy. (D recommendation).


Assuntos
Doença Crônica , Estrogênios , Terapia de Reposição Hormonal , Hormônios , Pós-Menopausa , Progestinas , Feminino , Humanos , Doença Crônica/prevenção & controle , Estrogênios/efeitos adversos , Estrogênios/uso terapêutico , Prevenção Primária , Progestinas/efeitos adversos , Progestinas/uso terapêutico , Terapia de Reposição Hormonal/efeitos adversos , Terapia de Reposição Hormonal/métodos , Hormônios/efeitos adversos , Hormônios/uso terapêutico
7.
JAMA Netw Open ; 5(10): e2236898, 2022 10 03.
Artigo em Inglês | MEDLINE | ID: mdl-36251292

RESUMO

Importance: Medically tailored meals (MTMs) are associated with lower health care utilization among patients with complex diet-related diseases but are not a covered benefit in Medicare or Medicaid. The potential impact of extending insurance coverage for MTMs nationally remains unknown. Objective: To estimate 1- and 10-year potential changes in annual hospitalizations, potential changes in annual health care expenditures, and overall policy cost-effectiveness associated with national MTM coverage for US patients with diet-related disease and limited instrumental activities of daily living who have Medicaid, Medicare, or private insurance. Design, Setting, and Participants: In this economic evaluation, conducted from January 2021 to February 2022, a nationally representative sample from the 2019 Medical Expenditure Panel Survey was used to create a population-level cohort policy simulation model that estimated changes in annual hospitalizations and health care expenditures associated with coverage of MTMs. Participants were 6 309 998 US adults aged 18 years or older who had Medicare, Medicaid, or private payer insurance and at least 1 diet-sensitive condition and 1 limitation in instrumental activities of daily living. Interventions: Ten nutritionally tailored MTMs per week for a mean of 8 months in each year of intervention. Main Outcomes and Measures: The main outcomes were total hospitalizations, program costs, health care expenditures, and net policy costs. One thousand Monte Carlo simulations for each of 10 years (2019-2028) jointly incorporated uncertainty in model inputs for effect sizes, hospitalizations, health care expenditures, and program costs. Results: At the 2019 baseline, an estimated 6 309 998 US adults were eligible to receive MTMs. Mean (SD) age was 68.1 (16.6) years; most were female (63.4%), were non-Hispanic White (66.7%), and had Medicare and/or Medicaid (76.5%). The most common eligibility diagnoses were cardiovascular diseases (70.6%), diabetes (44.9%), and cancer (37.2%). If all eligible individuals received MTMs, an estimated 1 594 000 hospitalizations (95% uncertainty interval [UI], 1 297 000-1 912 000) and $38.7 billion (95% UI, $24.9 billion to $53.9 billion) in health care expenditures could potentially be averted in 1 year. Program costs were $24.8 billion (95% UI, $23.1 billion to $26.8 billion), for an associated net savings of $13.6 billion (95% UI, $0.2 billion to $28.5 billion) from a health care perspective. In 2019 dollars, 10 years of the MTM intervention was anticipated to cost $298.7 billion (95% UI, $279.7 billion to $317.4 billion) and to potentially be associated with 18 257 000 averted hospitalizations (95% UI, 14 690 000-22 109 000) and reductions in health care expenditures of $484.5 billion (95% UI, $310.2 billion to $678.4 billion), for net savings of $185.1 billion (95% UI, $12.9 billion to $377.8 billion). Findings were robust in multiple sensitivity analyses. Conclusions and Relevance: The findings suggest that national implementation of MTMs for patients with diet-sensitive conditions and activity limitations could potentially be associated with approximately 1.6 million averted hospitalizations and net cost savings of $13.6 billion annually. The results may inform US state, federal, and private-payer interest in expanding insurance coverage for MTMs among patients with diet-related chronic illness.


Assuntos
Gastos em Saúde , Medicare , Atividades Cotidianas , Adulto , Idoso , Feminino , Hospitalização , Humanos , Cobertura do Seguro , Masculino , Refeições , Estados Unidos
8.
JAMA ; 328(14): 1438-1444, 2022 10 11.
Artigo em Inglês | MEDLINE | ID: mdl-36219403

RESUMO

Importance: Anxiety disorder, a common mental health condition in the US, comprises a group of related conditions characterized by excessive fear or worry that present as emotional and physical symptoms. The 2018-2019 National Survey of Children's Health found that 7.8% of children and adolescents aged 3 to 17 years had a current anxiety disorder. Anxiety disorders in childhood and adolescence are associated with an increased likelihood of a future anxiety disorder or depression. Objective: The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for anxiety disorders in children and adolescents. This is a new recommendation. Population: Children and adolescents 18 years or younger who do not have a diagnosed anxiety disorder or are not showing recognized signs or symptoms of anxiety. Evidence Assessment: The USPSTF concludes with moderate certainty that screening for anxiety in children and adolescents aged 8 to 18 years has a moderate net benefit. The USPSTF concludes that the evidence is insufficient on screening for anxiety in children 7 years or younger. Recommendation: The USPSTF recommends screening for anxiety in children and adolescents aged 8 to 18 years. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for anxiety in children 7 years or younger. (I statement).


Assuntos
Transtornos de Ansiedade , Programas de Rastreamento , Adolescente , Comitês Consultivos , Transtornos de Ansiedade/diagnóstico , Criança , Humanos , Programas de Rastreamento/métodos , Serviços Preventivos de Saúde , Medição de Risco , Estados Unidos
9.
JAMA ; 328(15): 1534-1542, 2022 10 18.
Artigo em Inglês | MEDLINE | ID: mdl-36219440

RESUMO

Importance: Depression is a leading cause of disability in the US. Children and adolescents with depression typically have functional impairments in their performance at school or work as well as in their interactions with their families and peers. Depression can also negatively affect the developmental trajectories of affected youth. Major depressive disorder (MDD) in children and adolescents is strongly associated with recurrent depression in adulthood; other mental disorders; and increased risk for suicidal ideation, suicide attempts, and suicide completion. Suicide is the second-leading cause of death among youth aged 10 to 19 years. Psychiatric disorders and previous suicide attempts increase suicide risk. Objective: To update its 2014 and 2016 recommendations, the US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening, accuracy of screening, and benefits and harms of treatment of MDD and suicide risk in children and adolescents that would be applicable to primary care settings. Population: Children and adolescents who do not have a diagnosed mental health condition or are not showing recognized signs or symptoms of depression or suicide risk. Evidence Assessment: The USPSTF concludes with moderate certainty that screening for MDD in adolescents aged 12 to 18 years has a moderate net benefit. The USPSTF concludes that the evidence is insufficient on screening for MDD in children 11 years or younger. The USPSTF concludes that the evidence is insufficient on the benefit and harms of screening for suicide risk in children and adolescents owing to a lack of evidence. Recommendation: The USPSTF recommends screening for MDD in adolescents aged 12 to 18 years. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for MDD in children 11 years or younger. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for suicide risk in children and adolescents. (I statement).


Assuntos
Transtorno Depressivo Maior , Criança , Humanos , Adolescente , Adulto , Transtorno Depressivo Maior/diagnóstico , Transtorno Depressivo Maior/etiologia , Depressão/diagnóstico , Programas de Rastreamento/efeitos adversos , Programas de Rastreamento/normas , Comitês Consultivos , Suscetibilidade a Doenças
10.
Health Aff (Millwood) ; 41(9): 1281-1290, 2022 09.
Artigo em Inglês | MEDLINE | ID: mdl-36067429

RESUMO

Low-value care is a major source of health care inefficiency in the US. Our analysis of 2009-19 administrative claims data from OptumLabs Data Warehouse found that low-value care and associated spending remain prevalent among commercially insured and Medicare Advantage enrollees. The aggregated prevalence of twenty-three low-value services was 1,920 per 100,000 eligible enrollees, which amounted to $3.7 billion in wasteful expenditures during the study period. State-level variation in spending was greater than variation in utilization, and much of the variation in spending was driven by differences in average procedure prices. If the average price for twenty-three low-value services among the top ten states in spending were set to the national average, their spending would decrease by 19.8 percent (from $735,000 to $590,000 per 100,000 eligible enrollees). State-level actions to improve the routine measurement and reporting of low-value care could identify sources of variation and help design state-specific policies that lead to better patient-centered outcomes, enhanced equity, and more efficient spending.


Assuntos
Medicare Part C , Idoso , Atenção à Saúde , Gastos em Saúde , Humanos , Cuidados de Baixo Valor , Estados Unidos
11.
JAMA ; 328(10): 963-967, 2022 09 13.
Artigo em Inglês | MEDLINE | ID: mdl-36098719

RESUMO

Importance: The Centers for Disease Control and Prevention estimates that 210 000 children and adolescents younger than 20 years had diabetes as of 2018; of these, approximately 23 000 had type 2 diabetes. Youth with type 2 diabetes have an increased prevalence of associated chronic comorbid conditions, including hypertension, dyslipidemia, and nonalcoholic fatty liver disease. Data indicate that the incidence of type 2 diabetes is rising; from 2002-2003 to 2014-2015, incidence increased from 9.0 cases per 100 000 children and adolescents to 13.8 cases per 100 000 children and adolescents. Objective: The US Preventive Services Task Force (USPSTF) commissioned a review of the evidence on screening for prediabetes and type 2 diabetes in asymptomatic, nonpregnant persons younger than 18 years. This is a new recommendation. Population: Children and adolescents younger than 18 years without known diabetes or prediabetes or symptoms of diabetes or prediabetes. Evidence Assessment: The USPSTF concludes that the evidence is insufficient to assess the balance of benefits and harms of screening for type 2 diabetes in children and adolescents. There is a lack of evidence on the effect of screening for, and early detection and treatment of, type 2 diabetes on health outcomes in youth, and the balance of benefits and harms cannot be determined. Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for type 2 diabetes in children and adolescents. (I statement).


Assuntos
Diabetes Mellitus Tipo 2 , Programas de Rastreamento , Estado Pré-Diabético , Adolescente , Comitês Consultivos , Criança , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/epidemiologia , Humanos , Programas de Rastreamento/efeitos adversos , Programas de Rastreamento/métodos , Estado Pré-Diabético/diagnóstico , Estado Pré-Diabético/epidemiologia , Serviços Preventivos de Saúde , Medição de Risco
12.
JAMA ; 328(12): 1243-1249, 2022 09 27.
Artigo em Inglês | MEDLINE | ID: mdl-36166020

RESUMO

Importance: Syphilis is a sexually transmitted infection that can progress through different stages (primary, secondary, latent, and tertiary) and cause serious health problems if left untreated. Reported cases of primary and secondary syphilis in the US increased from a record low of 2.1 cases per 100 000 population in 2000 and 2001 to 11.9 cases per 100 000 population in 2019. Men account for the majority of cases (83% of primary and secondary syphilis cases in 2019), and rates among women nearly tripled from 2015 to 2019. Objective: To reaffirm its 2016 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a reaffirmation evidence update focusing on targeted key questions evaluating the performance of risk assessment tools and the benefits and harms of screening for syphilis in nonpregnant adolescents and adults. Population: Asymptomatic, nonpregnant adolescents and adults who have ever been sexually active and are at increased risk for syphilis infection. Evidence Assessment: Using a reaffirmation process, the USPSTF concludes with high certainty that there is a substantial net benefit of screening for syphilis infection in nonpregnant persons who are at increased risk for infection. Recommendation: The USPSTF recommends screening for syphilis infection in persons who are at increased risk for infection. (A recommendation).


Assuntos
Programas de Rastreamento , Sífilis , Adolescente , Adulto , Comitês Consultivos , Feminino , Humanos , Masculino , Programas de Rastreamento/efeitos adversos , Programas de Rastreamento/métodos , Serviços Preventivos de Saúde , Infecções Sexualmente Transmissíveis/diagnóstico , Infecções Sexualmente Transmissíveis/epidemiologia , Sífilis/diagnóstico , Sífilis/epidemiologia , Estados Unidos/epidemiologia
13.
JAMA ; 328(8): 746-753, 2022 08 23.
Artigo em Inglês | MEDLINE | ID: mdl-35997723

RESUMO

Importance: Cardiovascular disease (CVD) is the leading cause of morbidity and death in the US and is the cause of more than 1 of every 4 deaths. Coronary heart disease is the single leading cause of death and accounts for 43% of deaths attributable to CVD in the US. In 2019, an estimated 558 000 deaths were caused by coronary heart disease and 109 000 deaths were caused by ischemic stroke. Objective: To update its 2016 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a review of the evidence on the benefits and harms of statins for reducing CVD-related morbidity or mortality or all-cause mortality. Population: Adults 40 years or older without a history of known CVD and who do not have signs and symptoms of CVD. Evidence Assessment: The USPSTF concludes with moderate certainty that statin use for the prevention of CVD events and all-cause mortality in adults aged 40 to 75 years with no history of CVD and who have 1 or more CVD risk factors (ie, dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year CVD event risk of 10% or greater has at least a moderate net benefit. The USPSTF concludes with moderate certainty that statin use for the prevention of CVD events and all-cause mortality in adults aged 40 to 75 years with no history of CVD and who have 1 or more of these CVD risk factors and an estimated 10-year CVD event risk of 7.5% to less than 10% has at least a small net benefit. The USPSTF concludes that the evidence is insufficient to determine the balance of benefits and harms of statin use for the primary prevention of CVD events and mortality in adults 76 years or older with no history of CVD. Recommendation: The USPSTF recommends that clinicians prescribe a statin for the primary prevention of CVD for adults aged 40 to 75 years who have 1 or more CVD risk factors (ie, dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year CVD risk of 10% or greater. (B recommendation) The USPSTF recommends that clinicians selectively offer a statin for the primary prevention of CVD for adults aged 40 to 75 years who have 1 or more of these CVD risk factors and an estimated 10-year CVD risk of 7.5% to less than 10%. The likelihood of benefit is smaller in this group than in persons with a 10-year risk of 10% or greater. (C recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of initiating a statin for the primary prevention of CVD events and mortality in adults 76 years or older. (I statement).


Assuntos
Doenças Cardiovasculares , Dislipidemias , Inibidores de Hidroximetilglutaril-CoA Redutases , Prevenção Primária , Adulto , Comitês Consultivos , Idoso , Doenças Cardiovasculares/etiologia , Doenças Cardiovasculares/prevenção & controle , Dislipidemias/complicações , Dislipidemias/tratamento farmacológico , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/efeitos adversos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Hipertensão/complicações , Hipertensão/diagnóstico , Programas de Rastreamento , Pessoa de Meia-Idade , Serviços Preventivos de Saúde , Medição de Risco , Estados Unidos
14.
Med Care ; 60(12): 888-894, 2022 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-36038520

RESUMO

BACKGROUND: In 2012, the US Preventive Service Task Force revised its recommendations for prostate-specific antigen (PSA) screening from "insufficient evidence" to "do not recommend" for men aged 70-74 while maintaining "do not recommend" for men aged 75+. METHODS: Using the difference-in-difference approach, we evaluated whether the rate of change in the use of low-value PSA screening differed between the control group (men aged 75+, N=7,856,204 person-years) and the intervention group (men aged 70-74, N=5,329,192 person-years) enrolling in the Medicare Advantage plan without a history of prostate cancer within the OptumLabs Data Warehouse claims data (2009-2019). A generalized estimating equation logistic model was specified with independent variables: an intervention group indicator, a pre- and post-period (after 2012 Q2) indicator, index time, and interaction terms. We assumed a 12-month dissemination period. RESULTS: Before the revised recommendation in 2012, the trends did not significantly differ between the 2 age groups with the odds of receiving PSA screening decreasing by 1.2% (95% confidence interval [1.0, 1.4%]) per quarter. However, the odds of receiving PSA screening increased by 3.0% [2.8, 3.2%] per quarter across both groups since the revision. There was no significant additional change in the trend for those aged 70-74 (0.1% [-0.2, 0.5%]). CONCLUSIONS: Although the 2012 US Preventive Service Task Force's recommendations were expected to only change behaviors among men aged 70-74, our analysis found that men aged 70-74 and aged 75+ exhibited similar trends from 2009 to 2019, including the increased use of low-value PSA screening since 2016. Multifaceted efforts to discourage low-value PSA screening would be important for a sustained impact.


Assuntos
Medicare Part C , Neoplasias da Próstata , Masculino , Idoso , Humanos , Estados Unidos , Antígeno Prostático Específico , Detecção Precoce de Câncer , Fatores Etários , Programas de Rastreamento , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/prevenção & controle
15.
J Am Coll Cardiol ; 80(2): 138-151, 2022 07 12.
Artigo em Inglês | MEDLINE | ID: mdl-35798448

RESUMO

BACKGROUND: Few studies have assessed U.S. cardiometabolic health trends-optimal levels of multiple risk factors and absence of clinical cardiovascular disease (CVD)-or its impact on health disparities. OBJECTIVES: The purpose of this study was to investigate U.S. trends in optimal cardiometabolic health from 1999 to 2018. METHODS: We assessed proportions of adults with optimal cardiometabolic health, based on adiposity, blood glucose, blood lipids, blood pressure, and clinical CVD; and optimal, intermediate, and poor levels of each component among 55,081 U.S. adults in the National Health and Nutrition Examination Survey. RESULTS: In 2017-2018, only 6.8% (95% CI: 5.4%-8.1%) of U.S. adults had optimal cardiometabolic health, declining from 1999-2000 (P trend = 0.02). Among components of cardiometabolic health, the largest declines were for adiposity (optimal levels: 33.8%-24.0%; poor levels: 47.7%-61.9%) and glucose (optimal levels: 59.4%-36.9%; poor levels: 8.6%-13.7%) (P trend <0.001 for each). Optimal levels of blood lipids increased from 29.9%-37.0%, whereas poor decreased from 28.3%-14.7% (P trend <0.001). Trends over time for blood pressure and CVD were smaller. Disparities by age, sex, education, and race/ethnicity were evident in all years, and generally worsened over time. By 2017-2018, prevalence of optimal cardiometabolic health was lower among Americans with lower (5.0% [95% CI: 2.8%-7.2%]) vs higher education (10.3% [95% CI: 7.6%-13.0%]); and among Mexican American (3.2% [95% CI: 1.4%-4.9%]) vs non-Hispanic White (8.4% [95% CI: 6.3%-10.4%]) adults. CONCLUSIONS: Between 1999 and 2000 and 2017 and 2018, U.S. cardiometabolic health has been poor and worsening, with only 6.8% of adults having optimal cardiometabolic health, and disparities by age, sex, education, and race/ethnicity. These novel findings inform the need for nationwide clinical and public health interventions to improve cardiometabolic health and health equity.


Assuntos
Doenças Cardiovasculares , Adulto , Pressão Sanguínea , Estudos Transversais , Humanos , Americanos Mexicanos , Inquéritos Nutricionais , Obesidade , Fatores de Risco , Estados Unidos/epidemiologia
16.
JAMA ; 328(4): 367-374, 2022 07 26.
Artigo em Inglês | MEDLINE | ID: mdl-35881115

RESUMO

Importance: Cardiovascular disease (CVD), which includes heart disease, myocardial infarction, and stroke, is the leading cause of death in the US. A large proportion of CVD cases can be prevented by addressing modifiable risk factors, including smoking, obesity, diabetes, elevated blood pressure or hypertension, dyslipidemia, lack of physical activity, and unhealthy diet. Adults who adhere to national guidelines for a healthy diet and physical activity have lower rates of cardiovascular morbidity and mortality than those who do not; however, most US adults do not consume healthy diets or engage in physical activity at recommended levels. Objective: To update its 2017 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a review of the evidence on the benefits and harms of behavioral counseling interventions to promote healthy behaviors in adults without CVD risk factors. Population: Adults 18 years or older without known CVD risk factors, which include hypertension or elevated blood pressure, dyslipidemia, impaired fasting glucose or glucose tolerance, or mixed or multiple risk factors such as metabolic syndrome or an estimated 10-year CVD risk of 7.5% or greater. Evidence Assessment: The USPSTF concludes with moderate certainty that behavioral counseling interventions have a small net benefit on CVD risk in adults without CVD risk factors. Recommendation: The USPSTF recommends that clinicians individualize the decision to offer or refer adults without CVD risk factors to behavioral counseling interventions to promote a healthy diet and physical activity. (C recommendation).


Assuntos
Terapia Comportamental , Doenças Cardiovasculares , Dieta Saudável , Exercício Físico , Promoção da Saúde , Adulto , Comitês Consultivos , Doenças Cardiovasculares/prevenção & controle , Tomada de Decisão Clínica , Aconselhamento , Dislipidemias/terapia , Glucose , Humanos , Hipertensão , Medicina de Precisão , Intervenção Psicossocial , Fatores de Risco , Estados Unidos
17.
JAMA ; 327(23): 2326-2333, 2022 06 21.
Artigo em Inglês | MEDLINE | ID: mdl-35727271

RESUMO

Importance: According to National Health and Nutrition Examination Survey data, 52% of surveyed US adults reported using at least 1 dietary supplement in the prior 30 days and 31% reported using a multivitamin-mineral supplement. The most commonly cited reason for using supplements is for overall health and wellness and to fill nutrient gaps in the diet. Cardiovascular disease and cancer are the 2 leading causes of death and combined account for approximately half of all deaths in the US annually. Inflammation and oxidative stress have been shown to have a role in both cardiovascular disease and cancer, and dietary supplements may have anti-inflammatory and antioxidative effects. Objective: To update its 2014 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a review of the evidence on the efficacy of supplementation with single nutrients, functionally related nutrient pairs, or multivitamins for reducing the risk of cardiovascular disease, cancer, and mortality in the general adult population, as well as the harms of supplementation. Population: Community-dwelling, nonpregnant adults. Evidence Assessment: The USPSTF concludes with moderate certainty that the harms of beta carotene supplementation outweigh the benefits for the prevention of cardiovascular disease or cancer. The USPSTF also concludes with moderate certainty that there is no net benefit of supplementation with vitamin E for the prevention of cardiovascular disease or cancer. The USPSTF concludes that the evidence is insufficient to determine the balance of benefits and harms of supplementation with multivitamins for the prevention of cardiovascular disease or cancer. Evidence is lacking and the balance of benefits and harms cannot be determined. The USPSTF concludes that the evidence is insufficient to determine the balance of benefits and harms of supplementation with single or paired nutrients (other than beta carotene and vitamin E) for the prevention of cardiovascular disease or cancer. Evidence is lacking and the balance of benefits and harms cannot be determined. Recommendation: The USPSTF recommends against the use of beta carotene or vitamin E supplements for the prevention of cardiovascular disease or cancer. (D recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the use of multivitamin supplements for the prevention of cardiovascular disease or cancer. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the use of single- or paired-nutrient supplements (other than beta carotene and vitamin E) for the prevention of cardiovascular disease or cancer. (I statement).


Assuntos
Doenças Cardiovasculares , Suplementos Nutricionais , Minerais , Neoplasias , Vitaminas , Adulto , Comitês Consultivos , Doenças Cardiovasculares/prevenção & controle , Suplementos Nutricionais/efeitos adversos , Humanos , Programas de Rastreamento , Minerais/efeitos adversos , Minerais/uso terapêutico , Neoplasias/prevenção & controle , Inquéritos Nutricionais , Medição de Risco , Vitamina E/efeitos adversos , Vitaminas/efeitos adversos , Vitaminas/uso terapêutico , beta Caroteno/efeitos adversos
18.
Clin J Am Soc Nephrol ; 17(7): 957-965, 2022 07.
Artigo em Inglês | MEDLINE | ID: mdl-35672037

RESUMO

BACKGROUND AND OBJECTIVES: Coronavirus disease 2019 (COVID-19) disrupted medical care across health care settings for older patients with advanced CKD. Understanding how shared decision making for kidney treatment decisions was influenced by the uncertainty of an evolving pandemic can provide insights for supporting shared decision making through the current and future public health crises. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We performed thematic and narrative analyses of semistructured interviews with patients (CKD stages 4 and 5, age 70+), care partners, and clinicians from Boston, Portland (Maine), San Diego, and Chicago from August to December 2020. RESULTS: We interviewed 76 participants (39 patients, 17 care partners, and 20 clinicians). Among patient participants, 13 (33%) patients identified as Black, and seven (18%) had initiated dialysis. Four themes with corresponding subthemes emerged related to treatment decision making and the COVID-19 pandemic: (1) adapting to changed educational and patient engagement practices (patient barriers to care and new opportunities for telemedicine); (2) reconceptualizing vulnerability (clinician awareness of illness severity increased and limited discussions of patient COVID-19 vulnerability); (3) embracing home-based dialysis but not conservative management (openness to home-based modalities and limited discussion of conservative management and advanced care planning); and (4) satisfaction and safety with treatment decisions despite conditions of uncertainty. CONCLUSIONS: Although clinicians perceived greater vulnerability among older patients CKD and more readily encouraged home-based modalities during the COVID-19 pandemic, their discussions of vulnerability, advance care planning, and conservative management remained limited, suggesting areas for improvement. Clinicians reported burnout caused by the pandemic, increased time demands, and workforce limitations, whereas patients remained satisfied with their treatment choices despite uncertainty. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: Decision Aid for Renal Therapy (DART), NCT03522740.


Assuntos
COVID-19 , Falência Renal Crônica , Idoso , Tomada de Decisões , Humanos , Rim , Falência Renal Crônica/terapia , Pandemias , Pesquisa Qualitativa , Incerteza
19.
JAMA ; 327(21): 2123-2128, 2022 06 07.
Artigo em Inglês | MEDLINE | ID: mdl-35608838

RESUMO

Importance: Impairment of visual acuity is a serious public health problem in older adults. The number of persons 60 years or older with impaired visual acuity (defined as best corrected visual acuity worse than 20/40 but better than 20/200) was estimated at 2.91 million in 2015, and the number who are blind (defined as best corrected visual acuity of 20/200 or worse) was estimated at 760 000. Impaired visual acuity is consistently associated with decreased quality of life in older persons, including reduced ability to perform activities of daily living, work, and drive safely, as well as increased risk of falls and other unintentional injuries. Objective: To update its 2016 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for impaired visual acuity in older adults. Population: Asymptomatic adults 65 years or older who present in primary care without known impaired visual acuity and are not seeking care for vision problems. Evidence Assessment: The USPSTF concludes that the evidence is insufficient to assess the balance of benefits and harms of screening for impaired visual acuity in asymptomatic older adults. The evidence is lacking, and the balance of benefits and harms cannot be determined. More research is needed. Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for impaired visual acuity in older adults. (I statement).


Assuntos
Transtornos da Visão , Seleção Visual , Atividades Cotidianas , Comitês Consultivos , Idoso , Idoso de 80 Anos ou mais , Humanos , Programas de Rastreamento/métodos , Atenção Primária à Saúde/métodos , Qualidade de Vida , Medição de Risco , Transtornos da Visão/diagnóstico , Transtornos da Visão/etiologia , Transtornos da Visão/terapia , Seleção Visual/métodos , Acuidade Visual
20.
J Am Heart Assoc ; 11(11): e025192, 2022 06 07.
Artigo em Inglês | MEDLINE | ID: mdl-35583136

RESUMO

Background Heterozygous familial hypercholesterolemia (FH) is a common genetic disorder causing premature cardiovascular disease. Despite this, there is no national screening program in the United States to identify individuals with FH or likely pathogenic FH genetic variants. Methods and Results The clinical characteristics and FH variant status of 49 738 UK Biobank participants were used to develop a regression model to predict the probability of having any FH variants. The regression model and modified Dutch Lipid Clinic Network criteria were applied to 39 790 adult participants (aged ≥20 years) in the National Health and Nutrition Examination Survey to estimate the yield of FH screening programs using Dutch Lipid Clinic Network clinical criteria alone (excluding genetic variant status), genetic testing alone, or combining clinical criteria with genetic testing. The regression model accurately predicted FH variant status in UK Biobank participants (observed prevalence, 0.27%; predicted, 0.26%; area under the receiver-operator characteristic curve, 0.88). In the National Health and Nutrition Examination Survey, the estimated yield per 1000 individuals screened (95% CI) was 3.7 (3.0-4.6) FH cases with the Dutch Lipid Clinic Network clinical criteria alone, 3.8 (2.7-5.1) cases with genetic testing alone, and 6.6 (5.3-8.0) cases by combining clinical criteria with genetic testing. In young adults aged 20 to 39 years, using clinical criteria alone was estimated to yield 1.3 (95% CI, 0.6-2.5) FH cases per 1000 individuals screened, which was estimated to increase to 4.2 (95% CI, 2.6-6.4) FH cases when combining clinical criteria with genetic testing. Conclusions Screening for FH using a combination of clinical criteria with genetic testing may increase identification and the opportunity for early treatment of individuals with FH.


Assuntos
Hiperlipoproteinemia Tipo II , Testes Genéticos , Humanos , Hiperlipoproteinemia Tipo II/diagnóstico , Hiperlipoproteinemia Tipo II/epidemiologia , Hiperlipoproteinemia Tipo II/genética , Lipídeos , Programas de Rastreamento/métodos , Inquéritos Nutricionais , Adulto Jovem
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