IMPORTANCE Little is known regarding the durability of clinical practice guideline recommendations over time. OBJECTIVE To characterize variations in the durability of class I (“procedure/treatment should be performed/administered”) American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations. DESIGN, SETTING, AND PARTICIPANTS Textual analysis by 4 independent reviewers of 11 guidelines published between 1998 and 2007 and revised between 2006 and 2013. MAIN OUTCOMES AND MEASURES We abstracted all class I recommendations from the first of the 2 most recent versions of each guideline and identified corresponding recommendations in the subsequent version. We classified recommendations replaced by less determinate or contrary recommendations as having been downgraded or reversed; we classified recommendations for which no corresponding item could be identified as having been omitted. We tested for differences in the durability of recommendations according to guideline topic and underlying level of evidence using bivariable hypothesis tests and conditional logistic regression. RESULTS Of 619 index recommendations, 495 (80.0%; 95%CI, 76.6%–83.1%) were retained in the subsequent guideline version, 57 (9.2%; 95%CI, 7.0%–11.8%) were downgraded or reversed, and 67 (10.8%; 95%CI, 8.4%–13.3%) were omitted. The percentage of recommendations retained varied across guidelines from 15.4%(95%CI, 1.9%–45.4%) to 94.1%(95%CI, 80.3%–99.3%; P < .001). Among recommendations with available information on level of evidence, 90.5%(95%CI, 83.2%–95.3%) of recommendations supported by multiple randomized studies were retained, vs 81.0% (95%CI, 74.8%–86.3%) of recommendations supported by 1 randomized trial or observational data and 73.7%(95% CI, 65.8%–80.5%) of recommendations supported by opinion (P = .001). After accounting for guideline-level factors, the probability of being downgraded, reversed, or omitted was greater for recommendations based on opinion (odds ratio, 3.14; 95%CI, 1.69–5.85; P < .001) or on 1 trial or observational data (odds ratio, 3.49; 95%CI, 1.45–8.41; P = .005) vs recommendations based on multiple trials. CONCLUSIONS AND RELEVANCE The durability of class I cardiology guideline recommendations for procedures and treatments promulgated by the ACC/AHA varied across individual guidelines and levels of evidence. Downgrades, reversals, and omissions were most common among recommendations not supported by multiple randomized studies.

BACKGROUND: It is widely hypothesized that improvement in transitions of care will reduce unplanned hospital readmissions. However, the association between the Care Transitions Measure, the national quality metric for transitions of care and readmission risk, has not been established. OBJECTIVE: We aimed to determine the association between the Care Transition Measure and readmission. DESIGN: This was a single-center, prospective cohort study. PARTICIPANTS: Convenience sample of 2,963 patients enrolled in the BBridging the Divides^program, a longitudinal care management program for patients with coronary revascularization, from 2013 to 2014. Of these, 1594 (54 %) patients completed a post-discharge Care Transition Measure questionnaire. INTERVENTION: Care Transition Measure scores were collected by trained research staff blinded to study hypothesis, by telephone, within 30 days of discharge. Higher Care Transition Measure scores reflect a higher quality transition of care. MAIN MEASURES: 30-day readmission was measured. KEY RESULTS: Of the1594 patients that completed the Care Transition Measure survey, 1216 (76 %) received percutaneous coronary intervention and 378 (24 %) received coronary artery bypass grafting. Mean Care Transition Measure scores were significantly lower among patients who had a prior admission (77.2 vs. 82.1, p < 0.001) and those with ≥ 5 comorbidities (77 vs. 82.6 vs. 81.6, p < 0.001). Mean scores were significantly lower among patients who were readmitted within the percutaneous coronary intervention subgroup (73 vs. 80.9, p < 0.001) and the total study population (74.6 vs. 81.1, p < 0.001) compared to those who were not readmitted. This was not the case in the coronary artery bypass grafting subgroup (78.5 vs. 81.7, p = 0.29). After multivariable adjustment, every ten-point increase in the Care Transition Measure score was associated with a 14 % reduction in readmission risk (adjusted odds ratio 0.86, 95 % CI 0.78-0.95). CONCLUSIONS: The Care Transition Measure is strongly associated with readmissions, which strengthens its validity. However, its association with patient variables linked with readmission and its inconsistent association with readmission across clinical groups raises concerns that scores may be influenced by patient characteristics.

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Background There are currently no evidence-based guidelines that provide standardized criteria for the discharge of COVID-19 patients from the hospital. Objective To address this gap in practice guidance, we reviewed published guidance and collected discharge protocols and procedures to identify and synthesize common practices. Design Rapid review of existing guidance from US and non-US public health organizations and professional societies and qualitative review using content analysis of discharge documents collected from a national sample of US academic medical centers with follow-up survey of hospital leaders Setting and Participants We reviewed 65 websites for major professional societies and public health organizations and collected documents from 22 Academic Medical Centers (AMCs) in the US participating in the HOspital MEdicine Reengineering Network (HOMERuN). Results We synthesized data regarding common practices around 5 major domains: (1) isolation and transmission mitigation; (2) criteria for discharge to non-home settings including skilled nursing, assisted living, or homeless; (3) clinical criteria for discharge including oxygenation levels, fever, and symptom improvement; (4) social support and ability to perform activities of daily living; (5) post-discharge instructions, monitoring, and follow-up. Limitations We used streamlined methods for rapid review of published guidance and collected discharge documents only in a focused sample of US academic medical centers. Conclusion AMCs studied showed strong consensus on discharge practices for COVID-19 patients related to post-discharge isolation and transmission mitigation for home and non-home settings. There was high concordance among AMCs that discharge practices should address COVID-19-specific factors in clinical, functional, and post-discharge monitoring domains although definitions and details varied. Supplementary Information The online version contains supplementary material available at 10.1007/s11606-021-06711-x.

Poverty predicts high use of observation care. The poor or near poor may be at highest risk for high liability.

Medication substitution is prevalent in this sample of inner city primary care patients who receive care in the VA system. Cost of prescriptions and belief in the value of complementary and alternative approaches to care appear to be associated with this patient-driven treatment decision.

This may come as a surprise, but certain forms of insulin are-and always have been-available over the counter in the United States. When Congress established federal prescription drug regulation in 1951, the types of insulin available at that time, including neutral protamine Hagedorn (NPH) and Regular, now referred to as human insulins, were exempted. 1 By contrast, insulin analogs, which were developed much later, such as insulin glargine, insulin detemir, insulin degludec, insulin lispro, insulin aspart, or insulin glulisine, require a prescription. This little-known fact presents both opportunities and potential dangers to patients. It also poses a challenge to clinicians and the US Food and Drug Administration (FDA): is over-the-counter access to insulin an asset or a liability?Two recent news stories highlight the complexity of this dilemma. The first involved Kevin Houdeshell, a 36-year-old man from Ohio with type 1 diabetes. In 2014, he attempted to fill a prescription for insulin, but could not do so because the prescription had expired. Houdeshell was unable to contact his physician, whose office was closed for the New Year's holiday, and his condition worsened. When family members came to his house, Houdeshell did not let them in because he believed that he had the flu and he did not want to infect them. Several days later, Houdeshell died at home from diabetic ketoacidosis. 2,3 This story received national attention and led Ohio to pass "Kevin's Law," which allows pharmacists in the state to provide a 30-day refill on any essential life-sustaining medication if there is a prescription previously on file. 4 Since then, at least 8 other states have passed similar laws. 5 Even without these laws, Houdeshell's tragedy might have been averted if he had purchased insulin over the counter.The second news story involved Carmen Smith, a patient with type 2 diabetes taking insulin therapy, who lost her health insurance. National Public Radio reported that in 2009, Smith, who coincidentally was also from Ohio, could no longer afford to see a physician or pay for her prescription insulin analogs. Smith, however, found out that human insulin could be purchased at Walmart under the ReliOn brand (Novo Nordisk) for as little as $25 per vial, which is by far the least expensive insulin on the market (at roughly one-tenth the price of insulin analogs). 6 She purchased the insulin over the counter and-without any medical supervision-began to selftitrate based on the dose of insulin analog that she had taken in the past. 7 But the insulin formulations were different and she could not get the doses and timing quite right. She experienced both hypoglycemia and hyperglycemia, which ultimately necessitated several trips to the emergency department at a hospital near where she lived. In 2014, similar reports in Indiana led the state leg-VIEWPOINT

CAM approaches have broad appeal within this inner city cohort of veterans, particularly among African Americans, those that experience pain and those that expect greater benefit from CAM. These findings may inform the development of patient-centered integrative pain management for veterans.