Importance:Vaccine effectiveness (VE) estimates are needed to determine the effectiveness of respiratory syncytial virus (RSV) vaccinations during their first season of availability among populations at high risk for severe RSV. Objective:To assess RSV VE against RSV-associated outcomes for nursing home residents. Design, Setting, and Participants:This retrospective cohort study of Medicare fee-for-service beneficiaries used electronic medical claims data from September 10, 2023, to March 30, 2024. A cohort was created for each outcome: an RSV-associated hospitalization cohort; an RSV-associated death cohort; a severe RSV-associated outcome cohort; and an RSV-associated thromboembolic event cohort. To be eligible for inclusion in a cohort, a Medicare fee-for-service beneficiary must be aged 65 years or older, reside in a US nursing home during the study period for at least 1 day, have continuous enrollment in Medicare Parts A and B (365 days prior to the index date), and have continuous enrollment in Part D (beginning on June 21, 2023). Exposure:RSV vaccination. Main Outcomes and Measures:Outcomes were RSV-associated hospitalization, RSV-associated death, severe RSV-associated outcomes (intensive care unit or critical care unit admission, medical ventilator use, or RSV-associated death), and RSV-associated thromboembolic event. RSV diagnoses and outcome definitions were based on claims with relevant International Classification of Diseases and Related Health Problems, Tenth Revision codes. RSV vaccine doses were determined from Medicare Part D claims using the National Drug Code Directory. Hazard ratios (HRs) from multivariable Cox proportional hazards models compared the times to first outcomes among RSV vaccinated beneficiaries and unvaccinated beneficiaries. VE was calculated as (1-HR) × 100%. Results:Of 597 430 included Medicare beneficiaries (66% female; median age, 82 [IQR, 75-88] years), RSV VE against RSV-associated hospitalizations was 73% (95% CI, 65%-79%). Among beneficiaries aged 65 to 74 years VE was 60% (95% CI, 35%-76%), 75% (95% CI, 67%-82%) among beneficiaries 75 years or older, 67% (95% CI, 55%-76%) among short-stay residents (<100 cumulative days), and 80% (95% CI, 68%-87%) among long-stay residents (≥100 cumulative days). VE against RSV-associated death was 56% (95% CI, 39%-69%), VE against severe RSV-associated outcomes was 59% (95% CI, 44%-70%), and VE against RSV-associated thromboembolic events was 66% (95% CI, 44%-79%). Conclusions and Relevance:In this study, in the first season of availability, RSV vaccines were associated with improved RSV-associated outcomes among US Medicare beneficiaries residing in nursing homes.
Importance Patients with prostate cancer have a high burden of cardiovascular risk factors, often suboptimally controlled, and adverse cardiovascular outcomes. Objective To determine whether the routine referral of patients with prostate cancer to a cardiovascular specialist to implement a systematic risk factor strategy is more likely to reduce adverse cardiovascular outcomes and improve risk factor control than usual care. Design, Settings, and Participants This randomized clinical trial included patients with prostate cancer from 55 sites in 8 countries between 2015 and 2025. Eligible patients were diagnosed with prostate cancer during the past 12 months; had received treatment with androgen deprivation therapy (ADT) for the first time within the past 6 months; or planned to start ADT in the next month. Patients taking a statin with a systolic blood pressure of 130 mm Hg or lower were ineligible. Data were analyzed from May 25 to August 7, 2026. Intervention Patients were allocated in a 1:1 ratio to receive usual care alone or usual care plus routine referral to an internist or cardiologist. The specialists provided a systematic intervention, including a target of systolic blood pressure of 130 mm Hg or lower and a statin medication, irrespective of the patient’s cholesterol levels (even if not usual or guideline-driven practice); encourage smoking cessation; and provide guidance on diet and exercise. Main Outcomes and Measures Hierarchical composite of cardiovascular death, myocardial infarction, stroke, heart failure, suboptimal cholesterol (total cholesterol, >155 mg/dL [to convert to mmol/L, multiply by 0.0259]) and suboptimal blood pressure (systolic blood pressure, >130 mm Hg) as evaluated by the win ratio. Results The analysis included 2487 patients with prostate cancer (mean [SD] age, 68 [8] years). During median (IQR) follow-up of 5.8 (2.7-8.2) years, the win ratio in favor of the intervention was 1.60 (95% CI, 1.42-1.81), mostly attributable to lower cholesterol in the intervention group (mean difference, 12 mg/dL; 95% CI, 9-15 mg/dL) as a consequence of greater protocol-mandated statin use. Mean (SD) close-out systolic blood pressure values were 131.1 (16.9) mm Hg in the intervention group and 132.9 (18.3) mm Hg in the control group. There was no difference in time to cardiovascular death, myocardial infarction, stroke, or heart failure between groups (subdistribution hazard ratio, 1.08; 95% CI, 0.79-1.49). Conclusions and Relevance In this randomized clinical trial, routine referral of patients with prostate cancer to a cardiovascular specialist lead to improved outcomes, specifically through better cholesterol control. However, it is uncertain whether this reduced clinical cardiovascular events. Trial Registration ClinicalTrials.gov Identifier: NCT03127631
Importance:Patients with prostate cancer have a high burden of cardiovascular risk factors, often suboptimally controlled, and adverse cardiovascular outcomes. Objective:To determine whether the routine referral of patients with prostate cancer to a cardiovascular specialist to implement a systematic risk factor strategy is more likely to reduce adverse cardiovascular outcomes and improve risk factor control than usual care. Design, Settings, and Participants:This randomized clinical trial included patients with prostate cancer from 55 sites in 8 countries between 2015 and 2025. Eligible patients were diagnosed with prostate cancer during the past 12 months; had received treatment with androgen deprivation therapy (ADT) for the first time within the past 6 months; or planned to start ADT in the next month. Patients taking a statin with a systolic blood pressure of 130 mm Hg or lower were ineligible. Data were analyzed from May 25 to August 7, 2026. Intervention:Patients were allocated in a 1:1 ratio to receive usual care alone or usual care plus routine referral to an internist or cardiologist. The specialists provided a systematic intervention, including a target of systolic blood pressure of 130 mm Hg or lower and a statin medication, irrespective of the patient's cholesterol levels (even if not usual or guideline-driven practice); encourage smoking cessation; and provide guidance on diet and exercise. Main Outcomes and Measures:Hierarchical composite of cardiovascular death, myocardial infarction, stroke, heart failure, suboptimal cholesterol (total cholesterol, >155 mg/dL [to convert to mmol/L, multiply by 0.0259]) and suboptimal blood pressure (systolic blood pressure, >130 mm Hg) as evaluated by the win ratio. Results:The analysis included 2487 patients with prostate cancer (mean [SD] age, 68 [8] years). During median (IQR) follow-up of 5.8 (2.7-8.2) years, the win ratio in favor of the intervention was 1.60 (95% CI, 1.42-1.81), mostly attributable to lower cholesterol in the intervention group (mean difference, 12 mg/dL; 95% CI, 9-15 mg/dL) as a consequence of greater protocol-mandated statin use. Mean (SD) close-out systolic blood pressure values were 131.1 (16.9) mm Hg in the intervention group and 132.9 (18.3) mm Hg in the control group. There was no difference in time to cardiovascular death, myocardial infarction, stroke, or heart failure between groups (subdistribution hazard ratio, 1.08; 95% CI, 0.79-1.49). Conclusions and Relevance:In this randomized clinical trial, routine referral of patients with prostate cancer to a cardiovascular specialist lead to improved outcomes, specifically through better cholesterol control. However, it is uncertain whether this reduced clinical cardiovascular events. Trial Registration:ClinicalTrials.gov Identifier: NCT03127631.
Importance:Serologic immunity to hepatitis A virus (HAV) and hepatitis B virus (HBV) protects against acute infection and severe outcomes among high-risk groups; however, contemporary data on population-level immunity remain limited, especially in high-risk populations. Objective:To estimate the prevalence and factors associated with serologic immunity in the overall population and across high-risk subgroups, including those with chronic liver disease (CLD), chronic kidney disease, diabetes, and immunosuppression and pregnant people. Design, Setting, and Participants:This cross-sectional study used data from the National Health and Nutrition Examination Survey from January 2017 to August 2023 and included adults aged 20 years or older with available HAV and HBV serologic test results. Data were analyzed from January 3 to May 10, 2026. Main Outcomes and Measures:The primary outcomes were the prevalence of serologic immunity to HAV, defined by hepatitis A antibody positivity, and HBV, defined by hepatitis B surface antibody positivity, with vaccine-derived immunity specifically identified by surface antibody positivity in the absence of hepatitis B core antibodies. Data were weighted to generate nationally representative estimates of the US adult population. Multivariable survey-weighted logistic regression models were used to identify independent factors associated with viral hepatitis immunity. Results:Among 13 514 individuals, representing an estimated 226.1 million US adults (mean [SE] age, 48.65 [0.40] years; 51.76% female), 39.5% (95% CI, 37.7%-41.3%) demonstrated serologic immunity to hepatitis A, corresponding to approximately 89.4 million individuals. For HBV, 27.1% (95% CI, 25.8%-28.4%) demonstrated serologic immunity, corresponding to approximately 61.3 million individuals, while vaccine-derived immunity was present in 25.2% (95% CI, 23.9%-26.5%). In adjusted models, HAV immunity was associated with younger age (eg, 20-29 vs ≥65 years: adjusted odds ratio [AOR], 0.51; 95% CI, 0.44-0.60); lower educational attainment (eg, <grade 9 vs college graduate or above: AOR, 0.32; 95% CI, 0.24-0.42); non-Hispanic Black (AOR, 1.67; 95% CI, 1.34-2.09), Mexican American (AOR, 4.22; 95% CI, 3.42-5.21), other Hispanic (AOR, 2.01; 95% CI, 1.60-2.54), non-Hispanic Asian (AOR, 3.03; 95% CI, 2.45-3.76), and multiracial or other (AOR, 1.36; 95% CI, 1.04-1.79) race and ethnicity; being born outside the US (AOR, 4.54; 95% CI, 3.74-5.52); and liver disease awareness (OR, 1.65; 95% CI, 1.29-2.09). Obesity was associated with lower odds of HAV immunity (AOR, 0.83; 95% CI, 0.72-0.96). Vaccine-derived HBV immunity was associated with younger age (eg, 20-29 vs ≥65 years: AOR, 0.18; 95% CI, 0.15-0.23), female sex (AOR, 1.36; 95% CI, 1.18-1.56), non-Hispanic Asian (AOR, 1.47; 95% CI, 1.17-1.86) and non-Hispanic Black (AOR, 1.15; 95% CI, 1.00-1.32) race and ethnicity, and higher educational attainment (eg, <grade 9 vs college graduate or above: AOR, 3.29; 95% CI, 2.35-4.61). In high-risk subgroups, HAV immunity ranged from 26.7% (95% CI, 18.9%-34.4%) for metabolic dysfunction-associated alcohol-related liver disease to 63.7% (95% CI, 50.0%-77.4%) for chronic HBV infection, while HBV vaccine-derived immunity ranged from 14.0% (95% CI, 11.3%-16.6%) for chronic kidney disease to 38.6% (95% CI, 28.0%-49.1%) for pregnancy. Conclusions and Relevance:This cross-sectional study found that population-level serologic immunity to HAV and HBV was suboptimal and substantial susceptibility persisted across high-risk clinical subgroups. These findings highlight persistent gaps in viral hepatitis protection and support targeted, systematic vaccination strategies for HAV and HBV, especially among high-risk populations.
This Viewpoint explores the distinction between analytical and diagnostic performance measures.
This case report describes the electrocardiogram findings of a patient in their 40s with dizziness and presyncope after hematemesis and multiple black stools.
This cross-sectional study examines mortality from radiation-related and non–radiation-related cancers among aircrew members and other aviation workers in the US.
Importance Shoulder pain is a common and disabling condition most often managed in primary care. This review provides an evidence-based update on the diagnosis and management of shoulder pain to support clinical decision-making and improve patient outcomes. Observations Shoulder pain arises from benign, self-limiting soft-tissue disorders or rare but serious causes. In primary care, most cases are nontraumatic and involve periarticular soft tissues. The subacromial region is the most frequent source of pain, and the term subacromial pain is preferred over overlapping and inconsistently defined labels such as rotator cuff tendinopathy or tear , impingement syndrome , or subacromial bursitis . Less commonly, pain originates from the glenohumeral joint, as in glenohumeral osteoarthritis or adhesive capsulitis. Assessment should focus on a detailed history and physical examination to assess pain patterns and movement limitation and to exclude serious causes, such as infection, malignant neoplasm, or nonshoulder referred pain. Once these are excluded, first-line treatment is similar for most patients and aligns with recommended care for other regional musculoskeletal concerns: education about the favorable natural history, symptom relief and activity modification if needed, and watchful waiting. Early imaging is not indicated in the absence of significant trauma or suspicious features, such as fever, unexplained weight loss, or history of malignant neoplasm, as structural abnormalities often do not correlate with symptoms, rarely alter management, and may lead to overdiagnosis and overtreatment. Specialist referral should be reserved for suspected serious pathology, such as infection, malignant neoplasm, fracture, or dislocation; significant functional or neurologic deficit; features suggestive of systemic inflammatory disease; or persistent or worsening pain and debility. High-certainty evidence indicates that subacromial pain does not benefit from surgical intervention. Conclusions and Relevance Shoulder pain is the third most common musculoskeletal presentation in primary care. Although causes vary, the initial management is largely the same once serious conditions have been excluded. Most patients with subacromial pain will fully recover with minimal intervention and can be safely treated with supportive care. Imaging and referral to surgical subspecialists should be reserved for rare and carefully selected cases to avoid unnecessary intervention.
Importance:For more than 10 years, the US Preventive Services Task Force has recommended annual lung cancer screening (LCS), but adherence to annual screening remains low. Objective:To test 2 multilevel, patient-centered interventions to increase adherence to guideline-concordant annual LCS. Design, Setting, and Participants:A pragmatic 2 × 2 factorial randomized clinical trial was conducted at Kaiser Permanente Washington among patients who completed LCS with normal findings from November 21, 2022, to April 5, 2024. The date of last follow-up was July 4, 2025. Data were analyzed from July to December 2025. Interventions:The 4 arms included usual care, health communication, Stepped Reminders, or both interventions. The health communication intervention addressed patient screening knowledge barriers with print and video messaging. The Stepped Reminders intervention pended LCS scan orders for primary care physicians (PCPs) and sent outreach to patients to remind them to schedule scans. Both interventions were facilitated by a system-level LCS coordinator with electronic health record registry to deliver interventions. Main Outcomes and Measures:The primary outcome was completion of screening low-dose computed tomography (LDCT) or chest CT 9 to 15 months after index LDCT. All participants eligible for annual screening were included in the modified intent-to-treat analysis. Participants were censored due to lung cancer diagnosis, death, early LDCT or chest CT, or disenrollment from the health plan. Results:Among 1837 trial participants, the mean (SD) age was 66.3 (6.5) years; 897 (48.8%) were female and 940 (51.2%) were male; 17 (1.0%) were American Indian or Alaska Native, 47 (2.7%) were Asian, 55 (3.1%) were Black, 10 (0.6%) were Native Hawaiian or Other Pacific Islander, 1560 (88.7%) were White, 37 (2.1%) were multiracial, and 32 (1.8%) were another race; and 875 (47.6%) were currently using tobacco. A total of 459 were randomized to the usual care group, 460 to the health communication group, 460 to the Stepped Reminders group, and 458 to the both interventions group. Adherence to annual screening was 4.7 percentage points lower in those who received the health communication intervention relative to those who did not (59.2% [476 of 804] vs 63.3% [516 of 815]; relative risk, 0.93; 95% CI, 0.86-1.00; P = .04) and 27.7 percentage points higher in those who received the Stepped Reminders intervention relative to those who did not (75.5% [604 of 800] vs 47.4% [388 of 819]; relative risk, 1.59; 95% CI, 1.47-1.72; P < .001). The Stepped Reminders intervention improved screening rates significantly more among participants currently using tobacco (received Stepped Reminders, 281 [73.0%]; did not receive Stepped Reminders, 160 [41.2%]; risk difference, 32.3 percentage points; 95% CI, 25.9-38.8) compared with former users (received Stepped Reminders, 323 [77.8%]; did not receive Stepped Reminders, 228 [52.9%]; risk difference, 24.1 percentage points; 95% CI, 18.1-30.0) (P for interaction = .03). Conclusions and Relevance:In this randomized clinical trial, appropriately timed multilevel reminders directed to PCPs to order and patients to schedule LDCT scans were effective at improving annual LCS adherence in programs led by PCPs. Trial Registration:ClinicalTrials.gov Identifier: NCT05747443.
Importance:Medicare Advantage (MA) costs 22% more than original Medicare (OM) for a given individual ($83 billion in annual excess public costs). However, MA may improve type 2 diabetes (T2D) outcomes compared with OM by providing financial protections (eg, annual out-of-pocket spending caps) and supplemental benefits (eg, healthy food assistance) that OM cannot. Objective:To determine whether MA coverage is associated with better T2D outcomes than OM. Design, Setting, and Participants:A longitudinal cohort study using target trial emulation principles for design and analysis in adults aged 18 years or older receiving OM or MA with T2D, followed up before and after Medicare coverage in community-based health centers (January 2021 to June 2024) across 44 states. Analyses were conducted from September 2025 to May 2026. Exposures:MA or OM coverage. Main Outcomes and Measures:Hemoglobin A1c (HbA1c) (primary outcome), systolic blood pressure (SBP) and diastolic blood pressure (DBP), low-density lipoprotein (LDL) cholesterol, food insecurity, housing instability, and transportation barriers at 12 months after Medicare coverage (primary time point) and at 6, 18, and 24 months. Statistical analysis accounted for pre-Medicare coverage factors that may influence selection of MA vs OM using targeted minimum loss estimation. Covariates were age, sex, race and ethnicity, comorbidities, income, Social Vulnerability Index, pre-Medicare insurance, Medicaid coverage, and pre-Medicare coverage values for HbA1c, SBP, DBP, LDL cholesterol, body mass index, food insecurity, housing instability, and transportation barriers. Results:In this study in 34 648 adults (19 054 in OM, 15 594 in MA) with T2D, followed up before and after Medicare coverage, the mean (SD) age was 65.24 (9.73) years and 53.42% were women. Twelve months after Medicare coverage, MA was not associated with better HbA1c (mean difference, 0.01; 95% CI, -0.04 to 0.05, P = .74), SBP (-0.15; 95% CI, -0.54 to 0.24; P = .44), DBP (0.06; 95% CI, -0.15 to 0.27; P = .58), or LDL cholesterol (-0.41; 95% CI, -1.24 to 0.42; P = .33), with similar results at other time points. MA was also not associated with a lower risk of food insecurity (relative risk [RR], 1.00; 95% CI, 0.94-1.05), housing instability (RR, 1.00; 95% CI, 0.91-1.09), or transportation barriers (RR, 1.00; 95% CI, 0.93-1.07) at 12 months or any other time point. Conclusions and Relevance:In this study, when accounting for factors that may drive MA selection, MA was not associated with better T2D outcomes or fewer health-related social needs than OM. Given substantially higher spending for MA, it is important to ensure this spending is being used effectively to improve health.
This cohort study explores the prevalence of diabetes medication adjustment based on health status and hemoglobin A 1c level among patients 65 years or older.
