This Week in JAMA FREE

Geographic variation in Medicare spending at the end of life is well documented. In an analysis of linked survey and Medicare claims data from 3302 participants in the Health and Retirement Study who died between 1998 and 2007, Nicholas and colleagues examined the relationship between treatment-limiting advance directive use and the cost and aggressiveness of end-of-life care in regions of the United States characterized by high, medium, and low average expenditures for end-of-life care. Among the authors' findings were that treatment-limiting advance directives were associated with lower levels of Medicare spending, lower rates of in-hospital death, and higher use of hospice care in regions characterized by higher levels of end-of-life spending. In an editorial, White and Arnold discuss the evolution of advance care planning.

ArticleArticleArticle (AUTHOR VIDEO INTERVIEW)

In a cross-sectional study that included 37 267 children with asthma exacerbations admitted to 30 children's hospitals in 2008-2010, Morse and colleagues examined hospital adherence with the 3 components of the Children's Asthma Care measure set—use of relievers, use of systemic corticosteroids, and provision of a written home management plan—and assessed the association of adherence with patient outcomes. The authors found high adherence with in-hospital use of relievers and systemic corticosteroids and moderate adherence with provision of a home management plan but found no association between adherence with home care plans and subsequent asthma-related readmissions or emergency department visits. In an editorial, Homer discusses the need to develop health care performance measures that are associated with important clinical and patient-centered outcomes.

Patients undergoing elective percutaneous coronary intervention (PCI) are generally observed overnight in the hospital; however, some data suggest same-day discharge may be safe. In an analysis of data from 107 018 low-risk Medicare beneficiaries who underwent elective PCI at 903 sites between November 2004 and December 2008, Rao and colleagues assessed the prevalence and outcomes of same-day discharge after PCI. The authors report that same-day discharge was rarely implemented for these Medicare patients. Compared with patients who were observed overnight, those discharged the day of PCI had similar rates of death or rehospitalization.

Article (AUTHOR AUDIO INTERVIEW)

Zweig and colleagues present the cases of 2 elderly individuals with multiple medical problems who are admitted to nursing homes when it is no longer possible for family members to care for them at home. The authors discuss the physician's role in planning for nursing home admission, participating as a team member in patients' ongoing assessment and care in the nursing home, and in guiding care at the end of life.

“Critical to successful teaching is cultivating relationship and relevance—this is the art and the challenge (and the fun).” From “Je Vais le Faire.”

Vaccine-related adverse events are rare and usually time-limited or reversible, an Institute of Medicine report has found.

Quality indicators for older adults

Time-limited trials near the end of life

Join Michael Paasche-Orlow, MD, MA, MPH, Wednesday, October 19, from 2 to 3 PM eastern time to discuss caring for patients with limited health literacy. To register, go to http://www.ihi.org/AuthorintheRoom.

Dr Bauchner summarizes and comments on this week's issue. Go to http://jama.ama-assn.org/misc/audiocommentary.dtl.

Ms J, a 46-year-old woman with a history of iron deficiency anemia and 3 miscarriages, was recently diagnosed with celiac disease. How would you treat her illness, and what follow-up would you recommend for Ms J and her family? Go to www.jama.com to read the case. Submit your response by October 9 for possible online posting.

For your patients: Information about irritable bowel syndrome.