Portela GT, Wang SV, Suissa S
… +1 more, Feldman WB
JAMA Intern Med
· 2026 Apr · PMID 41729543
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IMPORTANCE: Dual bronchodilator therapy with a long-acting muscarinic antagonist (LAMA) and a long-acting β2-agonist (LABA) is recommended for most patients with symptomatic chronic obstructive pulmonary disease (COPD)....IMPORTANCE: Dual bronchodilator therapy with a long-acting muscarinic antagonist (LAMA) and a long-acting β2-agonist (LABA) is recommended for most patients with symptomatic chronic obstructive pulmonary disease (COPD). Fixed-dose LAMA-LABA therapies are available in metered-dose, dry powder, and soft mist inhalers. However, metered-dosed inhalers are associated with greater greenhouse gas emissions than either dry powder or soft mist inhalers, and questions persist about potential intraclass differences among LAMA-LABAs given variability in their active ingredients, dosing schedules, and delivery devices. OBJECTIVE: To evaluate the comparative effectiveness and safety of once-daily umeclidinium-vilanterol dry powder inhalers, twice-daily glycopyrrolate-formoterol metered-dosed inhalers, and once-daily tiotropium-olodaterol soft mist inhalers. DESIGN, SETTING, AND PARTICIPANTS: This observational active-comparator study analyzed claims of patients (≥40 years) newly treated with LAMA-LABA inhalers and continuously enrolled in a large commercial health insurance or Medicare Advantage plan during the 183-day baseline period. Patients were propensity score matched 1:1 into 3 cohorts with index dates ranging from May 1, 2016, to February 28, 2025. Data were analyzed from July to August 2025. EXPOSURES: Patients treated with umeclidinium-vilanterol, glycopyrrolate-formoterol, or tiotropium-olodaterol fixed-dose inhalers. MAIN OUTCOMES AND MEASURES: Time to the first moderate or severe COPD exacerbation, major adverse cardiovascular event, urinary tract infection, and pneumonia hospitalization. RESULTS: The cohorts included 9479 matched pairs of patients receiving umeclidinium-vilanterol vs glycopyrrolate-formoterol (mean age, 68.9 [SD, 9.0] years; 10 319 women [54.4%]; 8636 men [45.6%]), 9598 receiving tiotropium-olodaterol vs glycopyrrolate-formoterol (mean age, 69.2 [SD, 8.7] years; 10 513 women [54.8%]; 8680 men [45.2%]), and 36 740 receiving umeclidinium-vilanterol vs tiotropium-olodaterol (mean age, 71.5 [SD, 8.4] years; 39 429 women [53.7%]; 34 044 men [46.3%]). Umeclidinium-vilanterol was associated with a 14% lower hazard of a first moderate or severe COPD exacerbation than glycopyrrolate-formoterol (hazard ratio [HR], 0.86; 95% CI, 0.81-0.91; number needed to treat [NNT], 17) and was associated with a 3% lower hazard than tiotropium-olodaterol (HR, 0.97; 95% CI, 0.94-0.99; NNT, 100). Tiotropium-olodaterol was associated with a 6% lower hazard of a first moderate or severe COPD exacerbation than glycopyrrolate-formoterol (HR, 0.94; 95% CI, 0.89-1.00). Similar risks of first major adverse cardiovascular event, urinary tract infection, and pneumonia hospitalization were observed among patients in all 3 cohorts. CONCLUSIONS AND RELEVANCE: This cohort study found that umeclidinium-vilanterol was associated with improved clinical outcomes compared with glycopyrrolate-formoterol and tiotropium-olodaterol. Patients, prescribers, and health systems may consider once-daily umeclidinium-vilanterol dry powder inhalers over alternatives among new users of LAMA-LABA therapy.
Ibounig T, Järvinen TLN, Raatikainen S
… +15 more, Härkänen T, Sillanpää N, Bensch F, Haapamäki V, Toivonen P, Björkenheim R, Ryösä A, Kanto K, Lepola V, Joukainen A, Paavola M, Koskinen S, Rämö L, Buchbinder R, Taimela S
JAMA Intern Med
· 2026 Apr · PMID 41697693
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IMPORTANCE: Shoulder pain is a common musculoskeletal complaint often attributed to rotator cuff (RC) abnormalities. Diagnostic imaging is frequently used, but the association between RC abnormalities and shoulder sympto...IMPORTANCE: Shoulder pain is a common musculoskeletal complaint often attributed to rotator cuff (RC) abnormalities. Diagnostic imaging is frequently used, but the association between RC abnormalities and shoulder symptoms remains uncertain. OBJECTIVE: To determine the prevalence of RC abnormalities in a general population sample and their association with shoulder symptoms. DESIGN, SETTING, AND PARTICIPANTS: Population-based cross-sectional study in a nationally representative random sample of adults aged 41 to 76 years who underwent standardized clinical assessment and bilateral 3-Tesla magnetic resonance imaging (MRI) of the shoulders conducted from February 2023 to April 2024 in Finland. Eligibility criteria included ability to undergo MRI and absence of previous shoulder replacement surgery. EXPOSURES: Structured interviews, standardized questionnaires, clinical shoulder tests, and shoulder MRI. MAIN OUTCOMES AND MEASURES: RC tendon status was classified on MRI as normal, tendinopathic, partial-thickness tear (PTT), or full-thickness tear (FTT). Shoulder symptoms were defined as pain or dysfunction in the preceding week. The prevalence of RC abnormalities was compared across age groups and between symptomatic and asymptomatic shoulders, adjusting for demographic factors, concurrent MRI findings, and clinical examination. RESULTS: Among 602 participants (median age, 58 [range, 41-76] years; 52% female), RC abnormalities on MRI were found in 595 (98.7%; 95% CI, 97.5%-99.5%): 25% tendinopathy, 62% PTT, and 11% FTT. The prevalence and severity of abnormalities increased with age but did not differ between sexes. RC abnormalities were present in 96% of asymptomatic shoulders (1039 of 1076) and 98% of symptomatic shoulders (126 of 128). Only FTTs were more prevalent in symptomatic shoulders (14.6%) than in asymptomatic shoulders (6.5%), but this difference diminished after adjustment (absolute difference, 0.8%; 95% CI, -3.4% to 6.0%). CONCLUSIONS AND RELEVANCE: In this population-based study, RC abnormalities were nearly universal after age 40 years and showed poor concordance with shoulder symptoms. These findings suggest that RC abnormalities often represent normal age-related changes rather than disease and call into question the clinical value of routine imaging for atraumatic shoulder pain.
Drake C, Buckman C, Brucker A
… +10 more, McPeek Hinz E, Pignone M, Shaikha H, Rader A, Granados I, Goldstein BA, Chamorro C, Hoeffler S, Wirth C, Spratt SE
JAMA Intern Med
· 2026 Apr · PMID 41697676
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IMPORTANCE: Patients with diabetes and food insecurity are at greater risk of adverse health outcomes. Effective strategies to promote healthy food access are urgently needed. OBJECTIVE: To evaluate the effect of a produ...IMPORTANCE: Patients with diabetes and food insecurity are at greater risk of adverse health outcomes. Effective strategies to promote healthy food access are urgently needed. OBJECTIVE: To evaluate the effect of a produce prescription (PRx) program on cardiometabolic health outcomes and health care utilization among patients with diabetes who were at risk of food insecurity. DESIGN, SETTING, AND PARTICIPANTS: This 2-arm, pragmatic, randomized clinical trial was conducted in an integrated academic health system in the southeastern US, and patients were recruited from June to August 2023 and followed up for 12 months. Patients were randomly assigned to be offered a PRx (treatment group) or continued to receive usual care (comparison group). Inclusion criteria included a diabetes diagnosis and being at risk for food insecurity. Randomization was stratified by mean hemoglobin A1c (HbA1c) level during the past year (≥8% vs <8%). Data were analyzed from October 2024 to April 2025. INTERVENTION: The PRx arm received a debit card loaded with $80 monthly for up to 12 months. The card was valid to purchase eligible fresh, frozen, or canned fruits, vegetables, and legumes from grocery retailers. Both arms received diabetes self-management educational materials. MAIN OUTCOMES AND MEASURES: Primary outcomes were HbA1c levels and emergency department visits at 12 months following randomization. Secondary outcomes included body mass index, blood pressure, and inpatient visits. RESULTS: Of 9608 patients assessed for eligibility, 2155 provided consent and were randomized and studied. The mean (SD) age was 56 (14) years, 1524 (71%) were female, 112 (5.3%) were Hispanic, 1272 (61%) were non-Hispanic Black, 663 (32%) were non-Hispanic White, and mean (SD) baseline HbA1c levels were 7.48% (1.77%; to convert to the proportion of total hemoglobin, multiply by 0.01). Benefit use was moderate, with only 433 participants (30%) using 80% or more per month. At 12 months, the treatment (n = 1450) and usual care comparison arm (n = 705) participants had an adjusted between-arm difference in HbA1C levels of 0.20 percentage points (95% CI, 0.05%-0.35%), favoring usual care. There were no significant between-group differences in emergency department visits, blood pressure, body mass index, and inpatient visits. Results were similar in the subgroup (n = 651) with elevated HbA1c levels (≥8%). CONCLUSIONS AND RELEVANCE: This randomized clinical trial found that the PRx program did not improve cardiometabolic health or health care utilization at 12 months. A produce prescription subsidy alone did not improve outcomes among patients with diabetes at risk for food insecurity. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05896644.
JAMA Intern Med
· 2026 Apr · PMID 41661627
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IMPORTANCE: On May 12, 2023, the Medicare program reinstated the long-standing 3-day hospitalization rule for skilled nursing facility (SNF) care after it had been waived for more than 2 years during the COVID-19 pandemi...IMPORTANCE: On May 12, 2023, the Medicare program reinstated the long-standing 3-day hospitalization rule for skilled nursing facility (SNF) care after it had been waived for more than 2 years during the COVID-19 pandemic. This abrupt policy change offers a natural opportunity to assess the contemporary impact of the rule on inpatient and postacute care. OBJECTIVE: To evaluate changes in inpatient length of stay, SNF utilization, spending, and short-term health outcomes among traditional Medicare beneficiaries following reinstatement of the 3-day hospitalization requirement. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study of traditional Medicare beneficiaries with acute care hospitalizations included data from January and November 2023. A regression discontinuity design was used to examine changes in outcomes after the 3-day rule's reinstatement. Data were analyzed from June to November 2025. EXPOSURES: Hospitalizations before vs on or after May 12, 2023. MAIN OUTCOMES AND MEASURES: Primary outcomes were hospitalization for at least 3 days and SNF discharge. Secondary outcomes included 30-day rehospitalization, 30-day mortality, Medicare spending, and total SNF days. RESULTS: This study included 332 044 unexposed hospitalizations (178 547 female patients [53.8%]; mean [SD] age, 78.3 [8.3] years) and 338 375 exposed hospitalizations (182 049 female patients [53.8%]; mean [SD] age, 78.2 [8.3] years) for traditional Medicare beneficiaries in 2023. Reinstatement of the 3-day rule was associated with a 1.13 percentage point (95% CI, 0.61-1.66; P < .001; relative change, 1.9%) increase in the likelihood of an inpatient stay lasting at least 3 days. Among patients discharged to SNFs, 3-day rule reinstatement increased the probability of an at least 3-day hospitalization by 5.57 percentage points (95% CI, 4.91-6.24; P < .001; relative change, 6.4%). No significant changes were observed in the overall probability of SNF discharge, 30-day rehospitalization, 30-day mortality, Medicare spending, or total SNF days. Subgroup analyses showed greater increases in at least 3-day stays among patients hospitalized for hip fractures and patients with dementia. CONCLUSIONS AND RELEVANCE: In this cohort study, reinstating Medicare's 3-day hospitalization requirement was associated with longer inpatient stays without decreases in SNF utilization or improvements in short-term health outcomes. These findings suggest that the policy imposes additional costs on hospitals while failing to lower Medicare spending on hospitalized patients. More generally, results raise questions regarding the value and continued relevance of a broadly applicable 3-day inpatient stay rule in the traditional Medicare program.
Collins SA, Geynisman-Tan J, Petito LC
… +7 more, Song J, Brown T, Lee JY, Syed G, Kennedy O, Persell SD, Kenton K
JAMA Intern Med
· 2026 Apr · PMID 41661564
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IMPORTANCE: Urinary incontinence (UI) in women is common and diminishes quality of life. While treatable, it is underreported. OBJECTIVE: To evaluate whether use of an automated UI screening and Identify, Teach, and Trea...IMPORTANCE: Urinary incontinence (UI) in women is common and diminishes quality of life. While treatable, it is underreported. OBJECTIVE: To evaluate whether use of an automated UI screening and Identify, Teach, and Treat (IT2) educational initiative in primary care is associated with changes in incident UI diagnosis and rates of referral for pelvic floor therapy and subspecialty care. DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study was conducted at a regional academic health system. Electronic health record (EHR) data were obtained for women who presented for annual visits at 1 of 43 primary care practices before and after implementation of an automated UI screening and IT2 initiative (January 1, 2023, to December 1, 2024). INTERVENTION: IT2 automated screening and education workflows for UI in primary care practices. Women received a UI screening question electronically before or in person at their routine annual visits. Those patients with screening responses indicating bothersome UI and desiring more information were offered an online module about UI and its treatments. Primary care clinicians electronically received module results and an EHR alert and order set for interventions, including medications and physical therapy or subspecialty care referrals. MAIN OUTCOMES AND MEASURES: Interrupted time-series analysis with segmented linear regression was used to model practice-level rates of UI diagnosis and treatments to compare preimplementation and postimplementation rates. RESULTS: A total of 72 009 women (median [IQR] age, 54 [38-67] years) were included in the analysis. IT2 was implemented at 43 primary care practices, and 72 009 screening responses were collected. Bothersome UI symptoms and the desire for more information were identified in 6578 women (9.1%). The mean (SD) clinic-level rate of UI diagnosis per 100 encounters was 4.2 (1.1) at baseline. At intervention start, there was an immediate step increase in UI diagnoses by 0.51 (95% CI, 0.12-0.91 per 100 encounters (P = .01), and the annual rate of diagnoses per 100 encounters continued to increase an additional 0.55 (95% CI, 0.05-1.05; P = .03) per 100 encounters. Pelvic floor physical therapy referrals followed a similar pattern, with an initial step increase of 0.38 (95% CI, 0.23-0.53) referrals per 100 encounters (P < .001), and an annual rate increase per 100 encounters of 0.31 (95% CI, 0.12-0.50; P = .001). At baseline, the rate of referral to subspecialty services was a mean (SD) of 0.5 (0.2) per 100 encounters and initially increased by a mean of 0.29 (95% CI, 0.16-0.41) per 100 encounters (P < .001) after IT2 implementation but thereafter remained constant. The rate of new prescriptions of UI medication did not change after IT2 implementation. CONCLUSIONS AND RELEVANCE: Findings of this study suggest that implementation of a large-scale, automated UI screening and education program is feasible and could be used to increase awareness and promote treatment of this condition among patients.