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ACP recommendations for treating chronic insomnia

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1. ACP recommends cognitive behavioral therapy over drugs for treating chronic insomnia
Soundbites: HD video soundbites of ACP's president discussing management of chronic insomnia disorder in adults are available to download at http://www.dssimon.com/MM/ACP-insomnia-guideline/.

Free content:
Recommendation: http://www.annals.org/article.aspx?doi=10.7326/M15-2175
Evidence Review: http://www.annals.org/article.aspx?doi=10.7326/M15-1781
Evidence Review: http://www.annals.org/article.aspx?doi=10.7326/M15-1782
Editorial: http://www.annals.org/article.aspx?doi=10.7326/M16-0359
Paper URLs go live when the embargo lifts

Cognitive behavioral therapy for insomnia (CBT-I) should be the first-line treatment for adults with chronic insomnia, according to the American College of Physicians (ACP). The new evidence-based clinical practice guideline is published in Annals of Internal Medicine.

CBT-I consists of a combination of treatments that include cognitive therapy around sleep, behavioral interventions such as sleep restriction and stimulus control, and education such as sleep hygiene (habits for a good night's sleep). A review of published evidence found that CBT-I is an effective treatment and can be initiated in a primary care setting. While the reviewers found insufficient evidence to directly compare CBT-I and drug treatment, CBT-I is likely to have fewer harms than sleep medications, which are associated with significant side effects.

If CBT-I alone is unsuccessful, ACP recommends that doctors use a shared-decision making approach with their patients to decide whether drug therapy should be added to treatment. This should include discussing the benefits, harms, and costs of medications.

Note: For an embargoed PDF, please contact Cara Graeff. To interview someone from ACP, please contact Steve Majewski at [email protected] or 215-351-2514.

2. ICDs associated with high risk for long-term complications
Implantation at a younger age, female sex, and black race associated with the greatest long-term risks
Abstract: http://www.annals.org/article.aspx?doi=10.7326/M15-2732
URL goes live when the embargo lifts

Implantable cardioverter-defibrillator (ICD) implantation is associated with a high risk of long-term complications and reoperation, especially for younger patients, females, and blacks. The observational cohort study is published in Annals of Internal Medicine.

ICDs are highly efficacious in preventing sudden cardiac death and reducing mortality in select populations, yet early complications are common. Less is known about the long-term risks of ICDs and how patient and device characteristics at implantation affect outcomes.

Using data from the National Cardiovascular Data Registry ICD registry and Medicare claims, researchers assessed the long-term nonfatal risks for ICD-related complications among patients with first-time implantations. Based on data from more than 114,000 patients at 1,437 centers, ICDs were associated with a high risk for complications and reoperations in the years after implantation. Increasing complexity of the implanted device (particularly CRT-D devices), younger age at implantation, female sex, and black race were associated with the greatest long-term hazards for complications. The researchers suggest that these findings be considered during the decision-making process before implantation.

Note: For an embargoed PDF, please contact Cara Graeff. To interview an author, please contact Karen Peart at [email protected] or 203-432-1326.

3. Scientific community seeks answers about explosive Zika outbreak
Abstract: http://www.annals.org/article.aspx?doi=10.7326/M16-0617
URL goes live when the embargo lifts

The explosive nature of recent Zika virus epidemics and links to Guillain-Barre syndrome and microcephaly, have scientists concerned, according to an article published in Annals of Internal Medicine. Poor understanding of the transmission and pathogenesis of Zika virus presents an enormous challenge in responding to the rapidly emerging threat to human health.

Zika was identified in 1947 and for decades caused only sporadic cases of mild human disease. However, the recent Zika epidemic that began in Brazil in 2015 has spread rapidly to more than 30 countries in the Americans and the Caribbean and shows no signs of slowing. Answers are needed to inform vaccine development and also to properly advise those living in or traveling to Zika-endemic areas.

While the contribution of Zika infection to the total increase in microcephaly cases being observed relative to other unidentified causes remains unknown, blood evidence suggests that Zika infection at any stage of pregnancy could increase risk for microcephaly, intrauterine growth restriction, and fetal death. As such, pregnant women in unaffected areas are currently advised to postpone travel to Zika-endemic regions, if possible.

Pregnant women are also advised to avoid sex with males who have traveled to Zika-endemic regions. Zika virus is detectable in semen for at least two months following infection and multiple cases of suspected sexual transmission of Zika are currently under investigation in the United States. The relative importance of sexual transmission with regard to the overall burden of Zika transmission and risk for microcephaly is unknown.

At present, there is no specific antiviral and no vaccine for Zika, though vaccines are in development. Providers should maintain a high level of suspicion for Zika infection in any patient presenting with rash and either a personal history of recent travel to an area with active Zika transmission or a history of travel in a sexual partner.

Note: For an embargoed PDF, please contact Cara Graeff. For an interview with the lead author, Dr. Kathryn Anderson, please contact Caroline Marin at [email protected] or 612-624-5680.

4. Internists Recommend Ways to Better Align Graduate Medical Education Financing with Workforce Needs
Abstract: http://www.annals.org/article.aspx?doi=10.7326/M15-2917
URL goes live when the embargo lifts

The Alliance for Academic Internal Medicine (AAIM) and the American College of Physicians (ACP) call for changes that better align funding for Graduate Medical Education (GME) with the nation's health care workforce needs. The paper, Financing U.S. Graduate Medical Education, is published in Annals of Internal Medicine.

GME is the process by which graduated medical students progress to become competent practitioners in a particular field of medicine. GME programs, referred to as residencies and fellowships, allow trainees to develop the knowledge, skills, and attitudes required for independent practice. GME plays a major role in addressing the nation's workforce needs, as GME is the ultimate determinant of the output of physicians.

Under the current system, GME is funded through a combination of sources. The federal government, which is the largest source of GME financing, provides GME funding to teaching hospitals through Medicare. States fund GME through Medicaid, but the level of funding varies greatly by state. Private payers pay higher rates to teaching hospitals compared with other hospitals to fund GME, though they do not explicitly contribute to GME. And finally, GME receives funding from private sources, such as hospitals, universities, and gifts or grants from industry, though the amount can vary significantly.

According to authors from the AAIM and ACP, the current system of GME financing does not consider physician workforce needs on the local, regional, or national level. They recommend changes to better align GME with the nation's health care workforce needs. These recommendations include using Medicare GME funds to meet policy goals to ensure an adequate supply, specialty mix, and site of training; spreading the costs of financing GME across the health care system; evaluating the true cost of training a resident and establishing a single per resident amount; increasing transparency and innovation; and ensuring that primary care residents receive training in well-functioning ambulatory settings that are financially supported for their training roles.

Note: For an embargoed PDF, please contact Cara Graeff. To interview someone from ACP, please contact Jacquelyn Blaser at [email protected] or 202-261-4572.

Also new in this issue:
Living on Benefits: How cancer screening is portrayed in the UK national press
Jack W. Bedeman, BM, BSc, MSc; Susanne F. Meisel, PhD; and Nora Pashayan, MD, PhD
Annals Graphic Medicine
Free content: http://www.annals.org/article.aspx?doi=10.7326/G15-0019

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Media Contact

Cara Graeff
[email protected]
215-351-2513
@ACPinternists

http://www.acponline.org

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