IMPORTANCE: Anxiety disorders and symptoms are prevalent and burdensome, and patients are most likely to seek treatment in primary care settings. However, anxiety is underdetected and undertreated. This narrative review...IMPORTANCE: Anxiety disorders and symptoms are prevalent and burdensome, and patients are most likely to seek treatment in primary care settings. However, anxiety is underdetected and undertreated. This narrative review details behavioral and pharmacological treatment options that are feasible and effective in primary care. OBSERVATIONS: Screening for anxiety is recommended for primary care patients younger than 65 years. Given that anxiety often involves somatic symptoms, assessment should include patient-reported symptom measures, clinical interview, physical examination, and appropriate laboratory tests. For subthreshold symptoms (those that do not meet diagnostic criteria for anxiety disorders) and adjustment-related anxiety, starting with self-help and behavioral treatment is recommended. When deciding between behavioral, pharmacological, or combined treatment for anxiety disorders, consider the presentation, patient preferences, potential adverse effects, and treatment history, and engage in shared decision-making. Cognitive-behavioral therapy (CBT) is the first-line behavioral treatment for anxiety. Brief CBT in primary care delivered by embedded behavioral health clinicians is effective. First-line pharmacotherapy for anxiety disorders includes several selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors, which tend to be well tolerated without considerable long-term adverse effects. The main decision for pharmacological treatment is between a daily medication and a short-acting medication taken as needed for intermittent symptoms or while awaiting the effect of a daily medication. Benzodiazepines are not recommended due to risk of adverse effects, especially with long-term use. The Collaborative Care Management model, which involves collaboration between primary care clinicians, consulting psychiatrists, and care managers who monitor patient progress and provide behavioral treatment, improves anxiety outcomes compared to usual primary care. CONCLUSIONS AND RELEVANCE: Clinicians should recognize common anxiety presentations and understand how to differentiate between anxiety and other psychiatric or medical conditions. Referring patients to behavioral health specialists for CBT and/or prescribing recommended pharmacotherapy with Collaborative Care Management can help to reduce patient morbidity and improve functioning.
Chen Z, Trivedi AN, Rooke-Ley H
… +2 more, Marr J, Meyers DJ
JAMA Intern Med
· 2026 Jul · PMID 42081205
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IMPORTANCE: Enrollment in Medicare Advantage (MA) plans continues to increase, now covering more than half of Medicare beneficiaries and receiving more than $494 billion in annual federal payment. Therefore, robust overs...IMPORTANCE: Enrollment in Medicare Advantage (MA) plans continues to increase, now covering more than half of Medicare beneficiaries and receiving more than $494 billion in annual federal payment. Therefore, robust oversight is essential to monitor plans' adherence to federal standards and initiate enforcement actions when necessary to ensure program integrity and protect beneficiaries. OBJECTIVE: To examine Centers for Medicare & Medicaid Services (CMS) enforcement actions against MA contracts and characteristics of contracts and beneficiaries involved with enforcement actions. DESIGN, SETTING, AND PARTICIPANTS: This is a cross-sectional study of CMS enforcement actions against MA contracts that were preferred provider organizations or health maintenance organizations from 2010 to 2023. Data were analyzed from May 2025 to January 2026. EXPOSURES: Enforcement actions, including civil money penalties, suspension of enrollment, and contract termination. MAIN OUTCOMES AND MEASURES: The outcomes of interest were number of enforcement actions and contracts affected and mean monetary penalties per MA enrollee. RESULTS: There were 1173 unique MA contracts and 844 enforcement actions from 2010 to 2023. A total of 493 unique MA contracts (42.0%) received an enforcement action during the study period. Most of enforcement actions originated from program audit (544 actions [64.5%]). Enforcement activity varied widely across years: in 2012, 100 contracts (19.2%) received monetary penalties, while only 5 contracts (0.9%) received such penalties in 2019. Most enforcement actions were monetary penalties (737 actions [87.3%]), with far fewer enrollment suspensions (99 actions [11.7%]) and contract terminations (8 actions [0.9%]). Financial penalties peaked at $6.50 per enrollee in 2019 and remained less than $3 in other years. Compared with contracts that did not receive enforcement actions, contracts that were terminated had lower star ratings (mean [SD], 2.5 [0.5] stars vs 3.6 [0.6] stars) and enrolled a much lower share of White beneficiaries (44.7% vs 68.7%); suspended contracts enrolled more dually eligible beneficiaries (28.9% vs 18.8%). CONCLUSIONS AND RELEVANCE: This cross-sectional study found that federal enforcement actions against MA plans were highly variable from year-to-year and imposed modest fines. Enforcement actions may be relatively modest in magnitude, raising concerns about their effectiveness in deterring nonadherence. The design of oversight and enforcement actions warrant further evaluation to determine what amount of enforcement actions are needed to protect patients and ensure plans meet federal standards.
JAMA Intern Med
· 2026 Jun · PMID 42043828
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IMPORTANCE: The Centers for Medicare & Medicaid Services Oncology Care Model (OCM) was an episode payment model for patients with cancer; episodes were triggered by receipt of systemic cancer therapy. OCM provided monthl...IMPORTANCE: The Centers for Medicare & Medicaid Services Oncology Care Model (OCM) was an episode payment model for patients with cancer; episodes were triggered by receipt of systemic cancer therapy. OCM provided monthly care management payments, and all practices were engaged in 1-sided risk in its early years. A concern about episode payment models triggered by use of a particular service is that they may prompt increases in episode volume. OBJECTIVE: To assess if OCM is associated with an increase in the likelihood of initiating systemic therapy for cancer. DESIGN, SETTING, AND PARTICIPANTS: This quasi-experimental study used matched difference-in-differences analysis of serial cross sections of Medicare beneficiaries with an index visit for cancer from January 2010 to December 2019 who were treated at OCM practices or matched practices not participating in the OCM and followed up for 1 year, comparing changes in outcomes before vs after OCM began in July 2016. Data were analyzed from October 2021 to November 2025. MAIN OUTCOMES AND MEASURES: Systemic therapy initiation in the year after an index visit for newly diagnosed (incident) or poor-prognosis cancer; a secondary outcome examined total Medicare payments in the year after the index visit. RESULTS: The study included 754 182 patient episodes (750 483 patients; mean [SD] age, 74.1 [9.0] years; 467 071 female [62.2%]) in the incident population and 517 858 patients (mean [SD] age, 72.4 [9.7] years; 270 416 female [52.2%]) in the poor prognosis cohort treated at 197 intervention and 197 comparison practices. There was no statistically significant differential change in the initiation of systemic therapy in the incident population (-0.9 percentage point difference; 95% CI, -2.2 to 0.3 percentage points; P = .14). Among patients with poor-prognosis cancers, there was a statistically significant differential decrease in the likelihood of systemic therapy initiation (1.5 percentage points, 95% CI, -2.8 to -0.2 percentage points; P = .03). Following OCM, there was a non-statistically significant relative decrease in spending (-$898.26; 95% CI, -$1890.31 to $93.80; P = .08) in the year after the index incident diagnosis and a statistically significant relative decrease (-$2192.15; 95% CI, -3559.66 to -833.63; P = .002) in the poor prognosis cohort. CONCLUSIONS AND RELEVANCE: Despite concerns about greater use of systemic therapy for patients with cancer under 1-sided risk, this study found that the OCM was not associated with an increase in the likelihood of initiating systemic therapy episodes among patients with incident cancers but was associated with less chemotherapy initiation and lower spending among patients with poor-prognosis cancers. By not examining changes in chemotherapy initiation, the OCM evaluation may have underestimated savings related to the model.
May FP, Brodney S, Tuan JJ
… +23 more, Syngal S, Chan AT, Glenn B, Johnson G, Chang Y, Drew DA, Moy B, Rodriguez NJ, Warner ET, Anyane-Yeboa A, Ukaegbu C, Davis AQ, Schoolcraft K, Regan S, Le Beaux K, Lee ET, Bhat R, Gordon A, Phan LK, Chirino AFC, Marotta CJ, Kindermann RGZ, Haas JS
JAMA Intern Med
· 2026 Jun · PMID 42043827
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IMPORTANCE: Colorectal cancer (CRC) is the second most common cause of cancer mortality in the US and disproportionately impacts individuals in underresourced settings. OBJECTIVE: To compare 2 mailed population outreach...IMPORTANCE: Colorectal cancer (CRC) is the second most common cause of cancer mortality in the US and disproportionately impacts individuals in underresourced settings. OBJECTIVE: To compare 2 mailed population outreach approaches to increase CRC screening uptake among screening-eligible adults in community health centers (CHCs). DESIGN, SETTING, AND PARTICIPANTS: This pragmatic cluster randomized clinical trial was conducted in 8 CHCs and an additional site in a nonrandomized parallel protocol. The CHCs were located in the greater Boston area in Massachusetts and Los Angeles County in California (randomized sites), and Rapid City, South Dakota (parallel site). Patients were enrolled in the trial between June 7, 2023, and October 24, 2023. English- or Spanish-speaking primary care patients aged 45 to 75 years, who were due for CRC screening, were eligible to participate. INTERVENTIONS: Patients received either mailed fecal immunochemical test (FIT) with automated text message outreach from study personnel or mailed FIT-DNA with the manufacturer's outreach protocol. Participants in Boston and Los Angeles (randomized sites) with an abnormal FIT or FIT-DNA result were offered standardized navigation to colonoscopy. MAIN OUTCOMES AND MEASURES: The primary outcome was CRC screening participation using any modality (FIT, FIT-DNA, or colonoscopy) within 90 days. Secondary outcomes were screening within 180 days and time to screening participation. The completion of follow-up colonoscopy within 180 days of an abnormal stool test result was also studied. RESULTS: Among 5127 participants in the RCT regions, 2435 (47.5%) were in the FIT group, and 2692 (52.5%) were in the FIT-DNA group. The mean (SD) age was 54.5 (8.1) years; 3018 (58.9%) were female, and 2109 (41.1%) were male. There were 3818 Hispanic individuals (74.5%), 369 non-Hispanic Black individuals (7.2%), 763 non-Hispanic White individuals (14.9%), and 58 individuals of another race (1.1%). A total of 3363 individuals (65.6%) preferred the Spanish language; 2540 (49.5%) were Medicaid insured, and 614 were (12.0%) uninsured. Screening participation was significantly higher in the FIT-DNA group vs the FIT group at 90 days (751 of 2692 [27.9%] vs 550 of 2435 [22.6%], respectively; P = .02) and 180 days (854 of 2692 [31.7%] vs 649 of 2435 [26.7%], respectively). In Boston, screening participation at 90 days was higher (628 of 2208 [28.4%]) than in Los Angeles (673 of 2919 [23.1%]). Findings were similar at 180 days. Among the 100 individuals with an abnormal stool test result, 36 (36.0%) completed a colonoscopy within 180 days. CONCLUSIONS AND RELEVANCE: In this cluster randomized clinical trial, CRC screening uptake was higher in the FIT-DNA group than in the FIT group and was higher in Boston compared to Los Angeles CHCs. The follow-up colonoscopy rate within 6 months was suboptimal, even with the availability of navigation. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05714644.
Fowler NR, Perkins AJ, Gao S
… +7 more, Bakas T, Head KJ, Higbie A, Baucco C, Callahan CM, Williams-Farrelly MM, Boustani MA
JAMA Intern Med
· 2026 Jun · PMID 42008257
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IMPORTANCE: Early detection of Alzheimer disease and related dementias (ADRD) may influence outcomes for both patients and their family members, yet the risks and benefits of screening for family members are not establis...IMPORTANCE: Early detection of Alzheimer disease and related dementias (ADRD) may influence outcomes for both patients and their family members, yet the risks and benefits of screening for family members are not established. OBJECTIVE: To evaluate the benefits and risks of ADRD screening for family members of older adults screened in primary care (PC). DESIGN, SETTING, AND PARTICIPANTS: This multisite randomized clinical trial was conducted in 29 PC clinics from October 2018 to September 2023. Dyads of patients aged 65 years and older and a family member were randomized into 1 of 3 groups: screening only, screening plus referral for diagnostic follow-up, and no-screening control. Data were collected at baseline and at 6, 12, 18, and 24 months. INTERVENTIONS: Cognitive screening was conducted in-person, by telephone, or secure video using the Mini-Cog, the Memory Impairment Screen Telephone version (MIS-T), or the MIS-T with the clock drawing test. MEASURES: The primary outcome was family member health-related quality of life at 24 months measured using the Short Form Health Survey (SF-36) physical and mental component summary scores. Secondary outcomes included family member depressive and anxiety symptoms, caregiver preparedness, and caregiving self-efficacy, as well as patient health-related quality of life and depressive and anxiety symptoms. RESULTS: A total of 1808 dyads completed baseline assessments. Mean (SD) patient age was 73.7 (5.7) years and 959 (53%) were female. Among family members, 1171 (64.8%) were spouses, 1224 (67.7%) were female, and mean [SD] age was 64.2 [12.9] years. Overall, 62 patients (5.1%) screened positive for cognitive impairment. Among dyads assigned to screen plus, 10 (35.7%) did not pursue diagnostic follow-up. There were no significant differences between the combined screening groups and no-screening group in SF-36 physical (24-month predicted difference, -0.21; 95% CI, -1.26-0.85) or mental (24-month predicted difference, 0.58; 95% CI, -0.18-1.33) component scores. No differences were observed in patient secondary outcomes at 24 months. DISCUSSION: This randomized clinical trial found that ADRD screening in PC was not associated with improvement in family member health-related quality of life, caregiver preparedness, or caregiving self-efficacy. Screening was also not associated with increased family member depression or anxiety. Low rates of positive screening and high rates of refusal for follow-up diagnostic assessment may help explain these findings. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03300180.
Narang H, Talukdar D, Kumar B
… +32 more, Mathur P, Ningombam A, Singh M, Bajaj A, Markandey M, Kalaivani M, Verma M, Kaur M, Bakshi S, Jana P, Jamdhade M, Bhardwaj N, Puraswani M, Ashita, Ahmed N, Goyal MK, Mubbunu M, Thomas DM, Mundhra S, Prasad S, Garg R, Gupta A, Shalimar, Gunjan D, Mahapatra SJ, Agarwal S, Saraya A, Garg P, Makharia G, Kedia S, Das B, Ahuja V
JAMA Intern Med
· 2026 Jun · PMID 42008253
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IMPORTANCE: Gut colonization by multidrug-resistant organisms (MDROs) is a risk factor for infection with these pathogens. There are no approved therapeutic interventions to combat it. OBJECTIVE: To assess the efficacy o...IMPORTANCE: Gut colonization by multidrug-resistant organisms (MDROs) is a risk factor for infection with these pathogens. There are no approved therapeutic interventions to combat it. OBJECTIVE: To assess the efficacy of fecal microbiota transplant (FMT) in causing MDRO decolonization and decreasing antimicrobial resistance (AMR) genes and its impact on gut microbiome, virome, and mycobiome composition in patients with gastrointestinal (GI) diseases. DESIGN, SETTING, AND PARTICIPANTS: This randomized, double-blind, sham-controlled clinical trial was conducted in a gastroenterology ward and intensive care unit at a tertiary care center in India. Participants were patients with GI diseases with persistent MDRO colonization. Patient recruitment occurred from July 2022 to June 2024, with follow-up completed in July 2024. Data were analyzed from October 1, 2024, to April 25, 2025. INTERVENTION: FMT via colonoscopy or sham intervention (sigmoidoscopy with saline injection). MAIN OUTCOMES AND MEASURES: Co-primary outcomes were MDRO decolonization rate and decrease in antimicrobial resistance genes (AMR) at 4 weeks after the intervention. Secondary outcomes included changes in stool microbiome (16S ribosomal RNA amplicon sequencing), virome (viruslike particles shotgun sequencing), and mycobiome (ITS2 sequencing); incidence of MDRO infections; and adverse events within 4 weeks. RESULTS: Of 114 randomized patients (mean [SD] age, 40.6 [12.5] years; 80 [70.2%] male; 52 patients [45.6%] with pancreatitis; 43 patients [37.7%] with cirrhosis; 19 patients [16.7%] with other GI disorders), 58 received FMT and 56 received the sham intervention. Most patients were colonized with carbapenem-resistant Enterobacteriaceae or extended-spectrum β-lactamase-producing Enterobacteriaceae at baseline (55 patients [94.8%] in the FMT group and 56 patients [100%] in the sham group). Five patients (2 in the FMT group, 3 in the sham group) were lost to follow-up. Intention-to-treat analysis showed no significant differences in MDRO decolonization (18 patients [31.0%] in the FMT group vs 17 patients [30.4%] in the sham group; absolute difference, 0.6% [95% CI, -16.2% to 17.6%]; P = .94) or AMR genes (median [IQR], 2.5 [1.2 to 3.0] genes in the FMT group vs 2.0 [1.0 to 3.0] genes in the sham group; P = .68), with comparable adverse events. Among 71 patients who underwent 16S ribosomal RNA gene sequencing at 4 to 6 weeks after the intervention, enrichment of bacteria capable of producing short-chain fatty acids was observed in the FMT group. These microbial alterations were not observed in the sham group. However, viral diversity remained unchanged after FMT. Mycobiome analysis revealed that FMT induced only modest, transient alterations in the gut mycobiome. CONCLUSIONS AND RELEVANCE: This randomized clinical trial found that while a single session of FMT did not significantly enhance MDRO decolonization or decrease AMR genes in patients with GI diseases, it modulated gut microbiome diversity and composition. TRIAL REGISTRATION: Clinical Trials Registry-India Registration No. 2022/07/043847.