JAMA Network Open最新文献

{"title":"Availability of Evidence for Predictive Machine Learning Algorithms in Primary Care","authors":"Margot M. Rakers, Marieke M. van Buchem, Sergej Kucenko, Anne de Hond, Ilse Kant, Maarten van Smeden, Karel G. M. Moons, Artuur M. Leeuwenberg, Niels Chavannes, María Villalobos-Quesada, Hendrikus J. A. van Os","doi":"10.1001/jamanetworkopen.2024.32990","DOIUrl":"https://doi.org/10.1001/jamanetworkopen.2024.32990","url":null,"abstract":"ImportanceThe aging and multimorbid population and health personnel shortages pose a substantial burden on primary health care. While predictive machine learning (ML) algorithms have the potential to address these challenges, concerns include transparency and insufficient reporting of model validation and effectiveness of the implementation in the clinical workflow.ObjectivesTo systematically identify predictive ML algorithms implemented in primary care from peer-reviewed literature and US Food and Drug Administration (FDA) and Conformité Européene (CE) registration databases and to ascertain the public availability of evidence, including peer-reviewed literature, gray literature, and technical reports across the artificial intelligence (AI) life cycle.Evidence ReviewPubMed, Embase, Web of Science, Cochrane Library, Emcare, Academic Search Premier, IEEE Xplore, ACM Digital Library, MathSciNet, AAAI.org (Association for the Advancement of Artificial Intelligence), arXiv, Epistemonikos, PsycINFO, and Google Scholar were searched for studies published between January 2000 and July 2023, with search terms that were related to AI, primary care, and implementation. The search extended to CE-marked or FDA-approved predictive ML algorithms obtained from relevant registration databases. Three reviewers gathered subsequent evidence involving strategies such as product searches, exploration of references, manufacturer website visits, and direct inquiries to authors and product owners. The extent to which the evidence for each predictive ML algorithm aligned with the Dutch AI predictive algorithm (AIPA) guideline requirements was assessed per AI life cycle phase, producing evidence availability scores.FindingsThe systematic search identified 43 predictive ML algorithms, of which 25 were commercially available and CE-marked or FDA-approved. The predictive ML algorithms spanned multiple clinical domains, but most (27 [63%]) focused on cardiovascular diseases and diabetes. Most (35 [81%]) were published within the past 5 years. The availability of evidence varied across different phases of the predictive ML algorithm life cycle, with evidence being reported the least for phase 1 (preparation) and phase 5 (impact assessment) (19% and 30%, respectively). Twelve (28%) predictive ML algorithms achieved approximately half of their maximum individual evidence availability score. Overall, predictive ML algorithms from peer-reviewed literature showed higher evidence availability compared with those from FDA-approved or CE-marked databases (45% vs 29%).Conclusions and RelevanceThe findings indicate an urgent need to improve the availability of evidence regarding the predictive ML algorithms’ quality criteria. Adopting the Dutch AIPA guideline could facilitate transparent and consistent reporting of the quality criteria that could foster trust among end users and facilitating large-scale implementation.","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":null,"pages":null},"PeriodicalIF":13.8,"publicationDate":"2024-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142188585","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Kidney Outcomes Following Angiotensin Receptor-Neprilysin Inhibitor vs Angiotensin-Converting Enzyme Inhibitor/Angiotensin Receptor Blocker Therapy for Thrombotic Microangiopathy","authors":"Jianbo Li, Qinghua Liu, Xingji Lian, Shicong Yang, Rong Lian, Wenchuan Li, Jianwen Yu, Fengxian Huang, Wenfang Chen, Feng He, Wei Chen","doi":"10.1001/jamanetworkopen.2024.32862","DOIUrl":"https://doi.org/10.1001/jamanetworkopen.2024.32862","url":null,"abstract":"ImportanceThrombotic microangiopathy (TMA) on kidney biopsy is a pattern of endothelial injury commonly seen in malignant hypertension (mHTN), but treatment strategies are not well established.ObjectiveTo evaluate the kidney outcomes of angiotensin receptor-neprilysin inhibitor (ARNI), specifically sacubitril/valsartan, vs angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) therapy for patients with mHTN-associated TMA.Design, Setting, and ParticipantsThis single-center cohort study enrolled consecutive patients in China diagnosed with mHTN-associated TMA through kidney biopsy from January 2008 to June 2023. Follow-up was conducted until the conclusion of the study period. Data were analyzed in September 2023.ExposuresTreatment with sacubitril/valsartan or ACEI/ARBs during hospitalization and after discharge.Main Outcomes and MeasuresThe primary outcome was a composite of kidney recovery: a 50% decrease in serum creatinine level, decrease in serum creatinine levels to the reference range, or kidney survival free from dialysis for more than 1 month. The secondary and tertiary outcomes were a 15% increase in the estimated glomerular filtration rate (eGFR) relative to baseline and kidney survival free from dialysis, respectively. Propensity score matching (PSM) and Cox proportional hazards regression analysis were used to evaluate the association between sacubitril/valsartan and ACEI/ARB therapy with kidney recovery outcomes.ResultsAmong the 217 patients (mean [SD] age, 35.9 [8.8] years; 188 men [86.6%]) included in the study, 66 (30.4%) received sacubitril/valsartan and 151 (69.6%) received ACEI/ARBs at baseline. Sacubitril/valsartan treatment was associated with shorter time to the primary outcome compared with ACEI/ARB treatment (20 of 63 [31.7%] vs 38 of 117 [32.5%]; adjusted hazard ratio [aHR], 1.85; 95% CI, 1.05-3.23). Sacubitril/valsartan treatment was independently associated with shorter time to a 15% increase in eGFR (15 of 46 [32.6%] vs 46 of 83 [55.4%]; aHR, 2.13; 95% CI, 1.09-4.17) and kidney survival free from dialysis (11 of 23 [47.8%] vs 16 of 57 [28.1%]; aHR, 2.63; 95% CI, 1.15-5.88) compared with ACEI/ARB treatment. These differences remained significant in the PSM comparison.Conclusions and RelevanceIn this cohort study, sacubitril/valsartan treatment was associated with a potential kidney function benefit in patients with mHTN-associated TMA compared with ACEI/ARB treatment. The findings suggested that sacubitril/valsartan could be a superior therapeutic approach for managing this serious condition in terms of kidney recovery.","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":null,"pages":null},"PeriodicalIF":13.8,"publicationDate":"2024-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142188602","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Automated Analysis of Stereotypical Movements in Videos of Children With Autism Spectrum Disorder","authors":"Tal Barami, Liora Manelis-Baram, Hadas Kaiser, Michal Ilan, Aviv Slobodkin, Ofri Hadashi, Dor Hadad, Danel Waissengreen, Tanya Nitzan, Idan Menashe, Analya Michaelovsky, Michal Begin, Ditza A. Zachor, Yair Sadaka, Judah Koler, Dikla Zagdon, Gal Meiri, Omri Azencot, Andrei Sharf, Ilan Dinstein","doi":"10.1001/jamanetworkopen.2024.32851","DOIUrl":"https://doi.org/10.1001/jamanetworkopen.2024.32851","url":null,"abstract":"ImportanceStereotypical motor movements (SMMs) are a form of restricted and repetitive behavior, which is a core symptom of autism spectrum disorder (ASD). Current quantification of SMM severity is extremely limited, with studies relying on coarse and subjective caregiver reports or laborious manual annotation of short video recordings.ObjectiveTo assess the utility of a new open-source AI algorithm that can analyze extensive video recordings of children and automatically identify segments with heterogeneous SMMs, thereby enabling their direct and objective quantification.Design, Setting, and ParticipantsThis retrospective cohort study included 241 children (aged 1.4 to 8.0 years) with ASD. Video recordings of 319 behavioral assessments carried out at the Azrieli National Centre for Autism and Neurodevelopment Research in Israel between 2017 and 2021 were extracted. Behavioral assessments included cognitive, language, and autism diagnostic observation schedule, 2nd edition (ADOS-2) assessments. Data were analyzed from October 2020 to May 2024.ExposuresEach assessment was recorded with 2 to 4 cameras, yielding 580 hours of video footage. Within these extensive video recordings, manual annotators identified 7352 video segments containing heterogeneous SMMs performed by different children (21.14 hours of video).Main outcomes and measuresA pose estimation algorithm was used to extract skeletal representations of all individuals in each video frame and was trained an object detection algorithm to identify the child in each video. The skeletal representation of the child was then used to train an SMM recognition algorithm using a 3 dimensional convolutional neural network. Data from 220 children were used for training and data from the remaining 21 children were used for testing.ResultsAmong 319 behavioral assessment recordings from 241 children (172 [78%] male; mean [SD] age, 3.97 [1.30] years), the algorithm accurately detected 92.53% (95% CI, 81.09%-95.10%) of manually annotated SMMs in our test data with 66.82% (95% CI, 55.28%-72.05%) precision. Overall number and duration of algorithm-identified SMMs per child were highly correlated with manually annotated number and duration of SMMs (<jats:italic>r</jats:italic> = 0.8; 95% CI, 0.67-0.93; <jats:italic>P</jats:italic> &amp;amp;lt; .001; and <jats:italic>r</jats:italic> = 0.88; 95% CI, 0.74-0.96; <jats:italic>P</jats:italic> &amp;amp;lt; .001, respectively).Conclusions and relevanceThis study suggests the ability of an algorithm to identify a highly diverse range of SMMs and quantify them with high accuracy, enabling objective and direct estimation of SMM severity in individual children with ASD.","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":null,"pages":null},"PeriodicalIF":13.8,"publicationDate":"2024-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142188581","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Prescription Drug Costs Among People With Alzheimer Disease and Related Dementias","authors":"Seyeon Jang, Rozalina G. McCoy, Jie Chen","doi":"10.1001/jamanetworkopen.2024.33026","DOIUrl":"https://doi.org/10.1001/jamanetworkopen.2024.33026","url":null,"abstract":"This cross-sectional study examines the association of Alzheimer disease and related dementias with prescription drug expenditures across cost distributions.","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":null,"pages":null},"PeriodicalIF":13.8,"publicationDate":"2024-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142188580","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Hospitalization Trends for Airway Infections and In-Hospital Complications in Cleft Lip and Palate","authors":"Rahel Laager, Claudia Gregoriano, Stephanie Hauser, Henrik Koehler, Philipp Schuetz, Beat Mueller, Alexander Kutz","doi":"10.1001/jamanetworkopen.2024.28077","DOIUrl":"https://doi.org/10.1001/jamanetworkopen.2024.28077","url":null,"abstract":"ImportanceCleft lip or palate is a prevalent birth defect, occurring in approximately 1 to 2 per 1000 newborns and often necessitating numerous hospitalizations. Specific rates of hospitalization and complication are underexplored.ObjectiveTo assess the rates of airway infection–associated hospitalization, overall hospital admissions, in-hospital complications, and mortality among children with a cleft lip or palate.Design, Setting, and ParticipantsThis nationwide, population-based cohort study used in-hospital claims data from the Federal Statistical Office in Switzerland between 2012 and 2021. Participants included newborns with complete birth records born in a Swiss hospital. Data were analyzed from March to November 2023.ExposurePrevalent diagnosis of a cleft lip or palate at birth.Main Outcomes and MeasuresOutcomes of interest were monthly hospitalization rates for airway infections and any cause during the first 2 years of life in newborns with cleft lip or palate. In-hospital outcomes and mortality outcomes were also assessed, stratified by age and modality of surgical intervention.ResultsOf 857 806 newborns included, 1197 (0.1%) had a cleft lip and/or palate, including 170 (14.2%) with a cleft lip only, 493 (41.2%) with a cleft palate only, and 534 (44.6%) with cleft lip and palate. Newborns with cleft lip or palate were more likely to be male (55.8% vs 51.4%), with lower birth weight (mean [SD] weight, 3135.6 [650.8] g vs 3284.7 [560.7] g) and height (mean [SD] height, 48.6 [3.8] cm vs 49.3 [3.2] cm). During the 2-year follow-up, children with a cleft lip or palate showed higher incidence rate ratios (IRRs) for hospitalizations due to airway infections (IRR, 2.33 [95% CI, 1.98-2.73]) and for any reason (IRR, 3.72 [95% CI, 3.49-3.97]) compared with controls. Additionally, children with cleft lip or palate had a substantial increase in odds of mortality (odds ratio [OR], 17.97 [95% CI, 11.84-27.29]) and various complications, including the need for intubation (OR, 2.37 [95% CI, 1.95-2.87]), extracorporeal membrane oxygenation (OR, 2.89 [95% CI, 1.81-4.63]), cardiopulmonary resuscitation (OR, 3.25 [95% CI, 2.21-4.78]), and respiratory support (OR, 1.94 [95% CI, 1.64-2.29]).Conclusions and RelevanceIn this nationwide cohort study, the presence of cleft lip or palate was associated with increased hospitalization rates for respiratory infections and other causes, as well as poorer in-hospital outcomes and greater resource use.","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":null,"pages":null},"PeriodicalIF":13.8,"publicationDate":"2024-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142188579","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Economic Evaluation of Population-Based BRCA1 and BRCA2 Testing in Canada","authors":"Li Sun, Xia Wei, Caitlin T. Fierheller, Lesa Dawson, Samuel Oxley, Ashwin Kalra, Jacqueline Sia, Fabio Feldman, Stuart Peacock, Kasmintan A. Schrader, Rosa Legood, Janice S. Kwon, Ranjit Manchanda","doi":"10.1001/jamanetworkopen.2024.32725","DOIUrl":"https://doi.org/10.1001/jamanetworkopen.2024.32725","url":null,"abstract":"ImportancePopulation-based <jats:italic>BRCA</jats:italic> testing can identify many more <jats:italic>BRCA</jats:italic> carriers who will be missed by the current practice of <jats:italic>BRCA</jats:italic> testing based on family history (FH) and clinical criteria. These carriers can benefit from screening and prevention, potentially preventing many more breast and ovarian cancers and deaths than the current practice.ObjectiveTo estimate the incremental lifetime health outcomes, costs, and cost-effectiveness associated with population-based <jats:italic>BRCA</jats:italic> testing compared with FH-based testing in Canada.Design, Setting, and ParticipantsFor this economic evaluation, a Markov model was developed to compare the lifetime costs and outcomes of <jats:italic>BRCA1/BRCA2</jats:italic> testing for all general population women aged 30 years compared with FH-based testing. <jats:italic>BRCA</jats:italic> carriers are offered risk-reducing salpingo-oophorectomy to reduce their ovarian cancer risk and magnetic resonance imaging (MRI) and mammography screening, medical prevention, and risk-reducing mastectomy to reduce their breast cancer risk. The analyses were conducted from both payer and societal perspectives. This study was conducted from October 1, 2022, to February 20, 2024.Main Outcomes and MeasuresOutcomes of interest were ovarian cancer, breast cancer, additional heart disease deaths, and incremental cost-effectiveness ratio ICER per quality-adjusted life-year (QALY). One-way and probabilistic-sensitivity-analyses (PSA) were undertaken to explore the uncertainty.ResultsIn the simulated cohort of 1 000 000 women aged 30 years in Canada, the base case ICERs of population-based <jats:italic>BRCA</jats:italic> testing were CAD $32 276 (US $23 402.84) per QALY from the payer perspective or CAD $16 416 (US $11 903.00) per QALY from the societal perspective compared with FH-based testing, well below the established Canadian cost-effectiveness thresholds. Population testing remained cost-effective for ages 40 to 60 years but not at age 70 years. The results were robust for multiple scenarios, 1-way sensitivity, and PSA. More than 99% of simulations from payer and societal perspectives were cost-effective on PSA (5000 simulations) at the CAD $50 000 (US $36 254.25) per QALY willingness-to-pay threshold. Population-based <jats:italic>BRCA</jats:italic> testing could potentially prevent an additional 2555 breast cancers and 485 ovarian cancers in the Canadian population, corresponding to averting 196 breast cancer deaths and 163 ovarian cancer deaths per 1 000 000 population.Conclusions and RelevanceIn this economic evaluation, population-based <jats:italic>BRCA</jats:italic> testing was cost-effective compared with FH-based testing in Canada from payer and societal perspectives. These findings suggest that changing the genetic testing paradigm to population-based testing could prevent thousands of breast and ovarian cancers.","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":null,"pages":null},"PeriodicalIF":13.8,"publicationDate":"2024-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142188582","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Active Visual Art Therapy and Health Outcomes","authors":"Ronja Joschko, Caroline Klatte, Weronika A. Grabowska, Stephanie Roll, Anne Berghöfer, Stefan N. Willich","doi":"10.1001/jamanetworkopen.2024.28709","DOIUrl":"https://doi.org/10.1001/jamanetworkopen.2024.28709","url":null,"abstract":"ImportanceArt therapy has a long-standing tradition in patient treatment. As scientific interest in its use has recently grown, a comprehensive assessment of active visual art therapy is crucial to understanding its potential benefits.ObjectiveTo assess the association of active visual art therapy with health outcomes across patient groups and comparators.Data SourcesThe systematic literature search included the Cochrane Library, Embase, MEDLINE, CINAHL, ERIC, American Psychological Association PsycArticles, American Psychological Association PsycInfo, PSYNDEX, the German Clinical Trials Register, and ClinicalTrials.gov. No filters regarding language were applied. The search covered all dates before March 2021. Data analysis was conducted from April 24 to September 8, 2023.Study SelectionRandomized clinical trials with any type of patient population comparing the intervention with any control not using active visual art therapy were included. Two researchers independently screened the abstracts and full texts.Data Extraction and SynthesisData extraction followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and study quality was evaluated using the Cochrane Risk of Bias tool. Data were synthesized using narrative summaries, forest plots, and random effects meta-analyses.Main Outcome and MeasuresIn line with the protocol, all outcome measures of the included studies were extracted.ResultsThe search identified 3104 records, of which 356 outcomes of 69 studies were included, with a total of approximately 4200 participants, aged 4 to 96 years, in the review. The meta-analyses included 50 studies and 217 outcomes of 2766 participants. Treatment indications included mental, neurological, and other somatic disorders, and prevention. Most outcome measures focused on depression, anxiety, self-esteem, social adjustment, and quality of life. Art therapy was associated with an improvement in 18% of the 217 outcomes compared with the controls (1%), while 81% showed no improvement. The standardized mean difference in the change from baseline of the meta-analyses of 0.38 (95% CI, 0.26-0.51) and posttest analysis of 0.19 (95% CI, 0.12-0.26) also indicated an improvement of outcomes associated with art therapy. Overall study quality was low.Conclusions and RelevanceIn this systematic review and meta-analysis of randomized clinical trials, visual art therapy was associated with therapeutic benefits for some outcomes, although most studies were of low quality. Further good-quality studies are needed to provide additional insights for its best possible integration into routine care.","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":null,"pages":null},"PeriodicalIF":13.8,"publicationDate":"2024-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142188583","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Mortality and Function After Widowhood Among Older Adults With Dementia, Cancer, or Organ Failure","authors":"Rebecca Rodin, Alexander K. Smith, Edie Espejo, Siqi Gan, W. John Boscardin, Lauren J. Hunt, Katherine A. Ornstein, R. Sean Morrison","doi":"10.1001/jamanetworkopen.2024.32979","DOIUrl":"https://doi.org/10.1001/jamanetworkopen.2024.32979","url":null,"abstract":"ImportanceThe widowhood effect, in which mortality increases and function decreases in the period following spousal death, may be heightened in older adults with functional impairment and serious illnesses, such as cancer, dementia, or organ failure, who are highly reliant on others, particularly spouses, for support. Yet there are limited data on widowhood among people with these conditions.ObjectiveTo determine the association of widowhood with function and mortality among older adults with dementia, cancer, or organ failure.Design, Setting, and ParticipantsThis longitudinal cohort study used population-based, nationally representative data from the Health and Retirement Study database linked to Medicare claims from 2008 to 2018. Participants were married or partnered community-dwelling adults aged 65 years and older with and without cancer, organ failure, or dementia and functional impairment (function score &amp;amp;lt;9 of 11 points), matched on widowhood event and with follow-up until death or disenrollment. Analyses were conducted from September 2021 to May 2024.ExposureWidowhood.Main Outcomes and MeasuresFunction score (range 0-11 points; 1 point for independence with each activity of daily living [ADL] or instrumental activity of daily living [IADL]; higher score indicates better function) and 1-year mortality.ResultsAmong 13 824 participants (mean [SD] age, 70.1 [5.5] years; 6416 [46.4%] female; mean [SD] baseline function score, 10.2 [1.6] points; 1-year mortality: 0.4%) included, 5732 experienced widowhood. There were 319 matched pairs of people with dementia, 1738 matched pairs without dementia, 95 matched pairs with cancer, 2637 matched pairs without cancer, 85 matched pairs with organ failure, and 2705 matched pairs without organ failure. Compared with participants without these illnesses, widowhood was associated with a decline in function immediately following widowhood for people with cancer (change, −1.17 [95% CI, −2.10 to −0.23] points) or dementia (change, −1.00 [95% CI, −1.52 to −0.48] points) but not organ failure (change, −0.84 [95% CI, −1.69 to 0.00] points). Widowhood was also associated with increased 1-year mortality among people with cancer (hazard ratio [HR], 1.08 [95% CI, 1.04 to 1.13]) or dementia (HR, 1.14 [95% CI, 1.02 to 1.27]) but not organ failure (HR, 1.02 [95% CI, 0.98 to 1.06]).Conclusions and RelevanceThis cohort study found that widowhood was associated with increased functional decline and increased mortality in older adults with functional impairment and dementia or cancer. These findings suggest that persons with these conditions with high caregiver burden may experience a greater widowhood effect.","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":null,"pages":null},"PeriodicalIF":13.8,"publicationDate":"2024-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142188606","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Medicare Advantage Enrollment Following the 21st Century Cures Act in Adults With End-Stage Renal Disease","authors":"Kevin H. Nguyen, Eunhae G. Oh, David J. Meyers, Maricruz Rivera-Hernandez, Daeho Kim, Rajnish Mehrotra, Amal N. Trivedi","doi":"10.1001/jamanetworkopen.2024.32772","DOIUrl":"https://doi.org/10.1001/jamanetworkopen.2024.32772","url":null,"abstract":"ImportanceIn January 2021, under the 21st Century Cures Act, Medicare beneficiaries with end-stage renal disease (ESRD) were permitted to enroll in private Medicare Advantage (MA) plans for the first time. In the first year of the Cures Act, there was a 51% increase in MA enrollment among beneficiaries with ESRD.ObjectiveTo examine changes in MA enrollment among Medicare beneficiaries with ESRD in the first 2 years of the Cures Act and, among beneficiaries newly enrolled in MA in 2021, to assess the proportion of beneficiaries who switched MA contracts and how the characteristics of contracts changed.Design, Setting, and ParticipantsThis cross-sectional, population-based time-trend study was conducted from January 2020 to December 2022. Eligible participants included Medicare beneficiaries with ESRD. Data analysis was conducted from August 2023 to March 2024.ExposureEnrollment in Medicare during the first 2 years of the 21st Century Cures Act.Main Outcomes and MeasuresThe primary outcomes were enrollment in MA, switching between traditional Medicare (TM) and MA, and switching between MA contracts from 2021 to 2022.ResultsThere were 718 252 unique Medicare beneficiaries with ESRD between 2020 and 2022 (1 659 652 beneficiary-years). In 2022, there were 583 203 beneficiaries with ESRD (mean [SD] age, 64.9 [14.1] years, 245 153 female (42.0%); 197 988 Black [34.0%]; 47 912 Hispanic [8.2%]). The proportion of beneficiaries with ESRD who were enrolled in MA increased from 25.1% (118 601 of 472 234 beneficiaries) in January 2020 to 43.1% (211 896 of 491 611 beneficiaries) in December 2022. Increases in MA enrollment were larger in the first year of the Cures Act (12.6 percentage points [pp]; 95% CI 12.3-12.8 pp) compared with the second year (5.7 pp; 95% CI, 5.5-5.9 pp). Changes between December 2020 and December 2022 ranged between 49.3% for Asian or Pacific Islander beneficiaries (difference = 13.0 pp; 95% CI, 12.2-13.8 pp) and 207.2% for American Indian or Alaska Native beneficiaries (difference = 17.0 pp; 95% CI, 15.3-18.7 pp). Changes were high among partial dual-eligible (difference = 35.5 pp; 95% CI, 34.9-36.1 pp; 134.7% increase) and fully dual-eligible beneficiaries (difference = 22.8 pp, 95% CI, 22.5-23.1 pp; 98.0% increase). Among 53 366 beneficiaries enrolled in MA in 2021, 37 439 (70.2%) remained in their contract, 11 730 (22.0%) switched contracts, and 4197 (7.9%) switched to TM in 2022. Compared with the characteristics of MA enrollees with ESRD in 2021, those in 2022 were more likely to be in contracts with lower premiums and with a rating of 4.5 stars or higher.Conclusions and RelevanceIn this cross-sectional time-trend study of Medicare beneficiaries with ESRD, MA enrollment continued to increase in the second year of the Cures Act, particularly among racially or ethnically minoritized individuals and dual eligible populations. These findings suggest need to monitor the equity of care for beneficiaries with ESRD as they enroll in manag","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":null,"pages":null},"PeriodicalIF":13.8,"publicationDate":"2024-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142188584","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Persistent Lymph Node Metastases After Neoadjuvant Chemoradiotherapy for Rectal Cancer","authors":"Markus Diefenhardt, Daniel Martin, Ralf-Dieter Hofheinz, Michael Ghadimi, Emmanouil Fokas, Claus Rödel, Maximilian Fleischmann","doi":"10.1001/jamanetworkopen.2024.32927","DOIUrl":"https://doi.org/10.1001/jamanetworkopen.2024.32927","url":null,"abstract":"ImportancePatients with locally advanced rectal cancer and persistent lymph node metastases (PLNM) after neoadjuvant treatment are at high risk of developing locoregional and distant metastasis, yet optimal postsurgical treatment of these patients is limited.ObjectiveTo analyze the association of PLNM with pretreatment clinical parameters, intensity of neoadjuvant treatment, and long-term oncological outcomes.Design, Setting, and ParticipantsThis cohort study is a post-hoc analysis of 3 randomized clinical trials (Surgical Oncology Working Group of Germany [CAO], Radiological Oncology Working Group of Germany [ARO], and Working Group for Internal Oncology in the German Cancer Society [AIO]) conducted in Germany in 1994, 2004, and 2012 that included 1948 patients with locally advanced rectal cancer recruited between February 1995 and January 2018. Statistical analysis was conducted between September 2023 and February 2024.ExposuresReceiving preoperative fluorouracil-based chemoradiotherapy (CRT, comprising the preoperative group of CAO/ARO/AIO-94 and the control group of CAO/ARO/AIO-04), fluorouracil-based CRT plus oxaliplatin (experimental group of CAO/ARO/AIO-04), or total neoadjuvant treatment (TNT) with fluorouracil-based CRT plus oxaliplatin with induction or consolidation leucovorin calcium (folinic acid), fluorouracil, and oxaliplatin chemotherapy within the CAO/ARO/AIO-12 trial.Main Outcome and MeasuresThe associations of PLNM with clinical parameters, intensity of neoadjuvant treatment, and cumulative incidences of LR, DM, and overall survival were assessed.ResultsA total of 1888 patients (1333 male participants [70.6%]; median [range] age, 62 [19-84] years) with locally advanced rectal adenocarcinoma (clinical tumor stage 3 to 4 and/or clinically node-positive) treated within 3 consecutive clinical trials were analyzed. A total of 522 (29%) experienced PLNM; 378 had lymph node stage (ypN) 1 (20%) after neoadjuvant treatment (ypN) 1 (20%), and 174 had ypN2 (9%). Age, clinical T-stage, N-stage, grading, carcinoembryonic antigen levels, and time interval from completion of CRT to surgery were significantly associated with PLNM, whereas sex and tumor location were not. The percentage of patients with ypN2 stage was almost halved after TNT (18 of 293 patients [6%]) compared with patients treated with fluorouracil-based CRT (114 of 1009 patients [11.3%]; χ&lt;jats:sup&gt;2&lt;/jats:sup&gt;&lt;jats:sub&gt;6&lt;/jats:sub&gt; = 16.693; &lt;jats:italic&gt;P&lt;/jats:italic&gt; = .01). After a median (IQR) follow-up of 54 (37-62) months, 5-year overall survival was 86.1% (95% CI, 83.9%-88.4%) for ypN0, 74.0% (95% CI, 83.9%-88.4%) for ypN1, and 43% for ypN2 (95% CI, 35.4%-52.2%) (&lt;jats:italic&gt;P&lt;/jats:italic&gt; &amp;amp;lt; .001). The 5-year cumulative incidences of locoregional and distant metastases were, respectively, 3% (95% CI, 2.1%-4.2%) and 20% (95% CI, 18%-23%) for ypN0, 6% (95% CI, 3.4%-8.8%) and 40% (95% CI, 34%-46%) for ypN1, and 19% (95% CI, 13%-26%) and 72% (95% CI, 63%-79%)","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":null,"pages":null},"PeriodicalIF":13.8,"publicationDate":"2024-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142188586","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}