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In This Issue of JAMA |

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JAMA. 2013;310(2):117-119. doi:10.1001/jama.2013.5196.
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To examine how different financial incentives between Medicare Advantage and Medicare fee-for-service (FFS) reimbursement structures might influence cardiovascular procedure use, Matlock and colleagues analyzed data from 878 339 Medicare Advantage patients and 5 013 650 Medicare FFS patients across 32 hospital referral regions in 12 states. The authors found that patients enrolled in Medicare Advantage programs had lower rates of angiography and percutaneous coronary intervention procedures than those enrolled in Medicare FFS. Substantial and similar geographic variation in procedure rates was observed among patients in both Medicare Advantage and Medicare FFS programs. In an Editorial, Krumholz discusses steps to ensure high-quality, patient-centered decision making.

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To examine whether differences in the per capita rates of cardiac catheterization in New York State and Ontario, Canada, are due to a difference in the burden of coronary artery disease (CAD) or a difference in patient selection for the procedure, Ko and colleagues analyzed registry data from 18 114 New York patients and 54 933 Ontario patients who underwent elective cardiac catheterization. The authors found that patients in Ontario were significantly more likely to have obstructive CAD than patients in New York and that a higher percentage of New York patients with a low predicted probability of CAD underwent catheterization.

Related Editorial

Observational data suggest there is an inverse association between soy consumption and prostate cancer risk. In a randomized, placebo-controlled trial that enrolled 177 men at high risk of prostate cancer recurrence after radical prostatectomy, Bosland and colleagues found that daily consumption of a soy protein–based supplement for 2 years after radical prostatectomy did not reduce or delay the rate of biochemical recurrence.

Low serum levels of 25-hydroxyvitamin D have been associated with increased risk of coronary heart disease (CHD) in white populations. Robinson-Cohen and colleagues analyzed data from 6436 participants in the Multi-Ethnic Study of Atherosclerosis who were free of known cardiovascular disease at baseline and found that lower serum vitamin D concentration was associated with an increased risk of incident CHD events among study participants who were white or Chinese but who were not black or Hispanic during a median 8.5 years’ follow-up. In an Editorial, Norris and Williams discuss the study findings and questions to explore in future research of the relationship between race, ethnicity, vitamin D and CHD.

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CLINICAL REVIEW & EDUCATION

Percutaneous coronary intervention (PCI) with stent placement is the most commonly performed coronary revascularization procedure. Brilakis and colleagues reviewed the contemporary literature on optimal medical therapy after PCI and found that dual antiplatelet therapy with aspirin and a P2Y12 inhibitor reduces the risk of stent thrombosis and subsequent cardiovascular events after PCI (number needed to treat 33-53) and is the current standard of care. Aspirin should be administered indefinitely, whereas the P2Y12 inhibitor is usually administered for 12 months. Adjustments in therapy are appropriate for patients at high risk of bleeding, such as patients who need warfarin. Routine platelet function or genetic testing is not recommended.

A 43-year-old Asian man reports a 6-month history of generalized nonpuritic, nonpainful papules and nodules. Microscopy of a biopsied lesion reveals foamy histiocytes with emperipolesis (engulfed lymphocytes) in the dermis. What would you do next?

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