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Articles 
Wesley Yin, Anirban Basu, James X. Zhang, Atonu Rabbani, David O. Meltzer, and G. Caleb Alexander The authors analyzed prescriptions from a random sample of pharmacy customers to estimate changes in utilization and out-of-pocket expenditures due to the Medicare Part D prescription benefit program. During the enrollment period, average monthly drug utilization by all Part D–eligible beneficiaries—regardless of whether they enrolled in Part D—increased by 1.1% and out-of-pocket expenditures decreased by 8.8%. After enrollment stabilized, average monthly drug utilization increased by 5.9% and expenditures decreased by 13.1%. Overall, the drug benefit saved people about $9 a month and provided an extra 14 days of pills.
R. Scott Braithwaite, Mark S. Roberts, Chung Chou H. Chang, Matthew Bidwell Goetz, Cynthia L. Gibert, Maria C. Rodriguez-Barradas, Steven Shechter, Andrew Schaefer, Kimberly Nucifora, Robert Koppenhaver, and Amy C. Justice Controversy continues about the optimal CD4 cell count or viral load at which to start HIV treatment. The authors used a validated computer simulation to weigh harms and benefits of starting antiretroviral therapy at a relatively high CD4 cell count in a mostly male cohort with newly diagnosed chronic HIV infection. Although the simulation tended to underestimate benefits of treating early in the natural history of the disease, earlier treatment increased life expectancy and quality-adjusted life-years at age 30 years regardless of viral load and at age 40 years if viral loads were at least 30 000 copies/mL.
Rehan Qayyum, M. Rizwan Khalid, Jurga Adomaityte, Stylianos P. Papadakos, and Frank C. Messineo Qayyum and associates performed a systematic review of 10 randomized trials to compare the effects of managing all patients with non–ST-segment elevation acute coronary syndrome invasively or selectively. Of 10 648 patients, 15.9% of those assigned to a routine invasive strategy died or had nonfatal myocardial infarction, compared with 17.5% of those assigned to a selective invasive strategy. The trial evidence does not establish the superiority of routine invasive management over a selective approach.
Reviews
Catherine MacLean, Sydne Newberry, Margaret Maglione, Maureen McMahon, Veena Ranganath, Marika Suttorp, Walter Mojica, Martha Timmer, Alicia Alexander, Melissa McNamara, Sheetal B. Desai, Annie Zhou, Susan Chen, Jason Carter, Carlo Tringale, Di Valentine, Breanne Johnsen, and Jennifer Grossman This systematic review of 76 randomized trials and 24 meta-analyses found good evidence that several agents, including alendronate, zoledronic acid, and estrogen, reduced the risk for vertebral and hip fractures more than placebo. Harms included increased risk for thromboembolic events with raloxifene and estrogen and esophageal symptoms with bisphosphonates. No large trials directly compared 2 or more agents. The available evidence on the relative benefits and harms of various therapies for osteoporosis is inadequate.
Perspectives
Allen Jeremias and Ajay Kirtane Some cardiologists have questioned the safety of drug-eluting stents because of an apparent increase in late stent thrombosis. However, the current evidence seems to say that the net clinical benefit of drug-eluting stents may outweigh their risks. Patients who are candidates for drug-eluting stents should be screened for their ability to tolerate uninterrupted antiplatelet therapy for longer than is necessary with bare-metal stents, and all patients should take antiplatelet and other optimal medical therapies. Full assessment of the net clinical effects of drug-eluting stents compared with bare-metal stents will require randomized trials that are larger than past studies.
Clinical Guidelines
U.S. Preventive Services Task Force In this update of a 2001 recommendation, the U.S. Preventive Services Task Force explains why it recommends against screening for bacterial vaginosis in pregnant women at low risk for preterm delivery. Even in pregnant women at high risk for preterm delivery, current evidence is insufficient to assess the balance of benefits and harms of screening.
Peggy Nygren, Rongwei Fu, Michele Freeman, Christina Bougatsos, Mark Klebanoff, and Jeanne-Marie Guise To support the updated U.S. Preventive Services Task Force recommendation in this issue, Nygren and colleagues performed a systematic review and meta-analysis of information from 7 new randomized, controlled treatment trials and 2001 report data. They found no benefit of treating women with low- or average-risk pregnancies for asymptomatic bacterial vaginosis. More research is needed to better understand the conditions under which treatment can be harmful or helpful.
Editorials
Bruce Stuart The Centers for Medicare & Medicaid Services (CMS) have collected prescription drug claims data from all Medicare Part D plans since 2006, but these data are used only for limited purposes. Therefore, private researchers have sought alternative sources of information to study the operation of the drug benefit. Yin and colleagues' study in this issue is an innovative example. Although their findings seem to indicate that Part D has had only a small effect relative to its cost, their data on average changes in pill-days and out-of-pocket payments are based on all Medicare beneficiaries, not just Part D enrollees. The results indicate that Part D has accomplished much of what it set out to do.
On Being a Doctor
William J. Hall A woman of about 50 years of age waits in the examining room. She leans forward to present her medical records, inadvertently revealing the keloid formation along her inner arms, an almost certain sign of thermal injury.
Letters Ampicillin plus Ceftriaxone for High-Level Aminoglycoside-Resistant Enterococcus faecalis Endocarditis
Pitfalls in Linking Cost Sharing to Value
The Effect of a Primary Care Practice–Based Depression Intervention on Mortality in Older Adults
Joseph J. Gallo, Knashawn Morales, Edward Post, Hillary Bogner, Julia Lin, and Martha Bruce—RESPONSE Repair of Unruptured Abdominal Aortic Aneurysm
Translation of Genetic Discoveries into Clinical Therapies
Correction: Diagnosis and Treatment of Low Back Pain
Correction: Recommendations for Screening for Carotid Artery Stenosis
This issue provides a clinical overview of colorectal cancer screening, focusing on risk factors, diagnosis, practice improvement, and patient information. Readers can complete the accompanying CME quiz for 1.5 credits. | ||||||||||||||||||||||||||||||||||||||||
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