Primary Care Medical Practices Research Articles

Results of an Initiative to Charge for Previously Uncompensated Care in an Academic Primary Care Practice

Increasing clinical workload with dwindling compensation has challenged primary care medical practices over the past decade. This has led to more physicians leaving and fewer medical trainees entering primary care. In an effort to make primary care practices viable, many groups routinely charge for providing care that was uncompensated in the past. We initiated a program in our practice that charged for certain after-hour and electronic communications, completion of forms outside of office visits, and failure to show for appointments. We assessed the effect on workload, patient adherence to appointments, and financial outcomes. This initiative decreased our physicians' workload, increased physicians' satisfaction, and produced a modest increase in revenues.

Association between underweight and hospitalization, emergency room visits, and mortality among patients in community medical homes

BackgroundIn older adults, underweight (body mass index [BMI] <18.5) has been associated with increased mortality. This increased mortality risk may be associated with increased health care utilization. We evaluated the relationship between underweight and hospitalization, emergency room visits, and mortality.MethodsAn analysis of a retrospective cohort study was conducted at a multisite academic primary care medical practice in Minnesota. The patients were ≥60 years of age, impaneled within primary care on January 1, 2011, and had a BMI measurement recorded between January 1, 2011, and December 31, 2011. Individuals were excluded if they refused review of their medical record. The primary measurement was BMI, which was categorized as underweight (BMI < 18.5) or normal and obese (BMI ≥ 18.5). The outcomes were hospitalization, emergency room visits, and mortality in the 2011 calendar year. Associations between underweight and each outcome were calculated using logistic regression. Interactions between underweight and gender were assessed in the logistic regression models. The final results were adjusted for age, gender, comorbid health conditions, and single living status.ResultsThe final cohort included 21,019 patients, of whom 220 (1%) were underweight. Underweight patients had a higher likelihood of hospitalization compared with patients with higher BMI (adjusted odds ratio [OR] 1.64; 95% confidence interval [CI] 1.21–2.22). Underweight patients were also more likely to visit the emergency room (adjusted OR 1.70; 95% CI 1.28–2.25) or to die (adjusted OR 3.64; 95% CI 2.33–5.69). Men with a BMI < 18.5 compared with those having a BMI ≥ 18.5 had the highest odds of hospitalization (OR 3.45; 95% CI 1.59–7.48).ConclusionUnderweight older adults, especially men, have higher odds of hospitalization, emergency room visits, and mortality. Future work on underweight might involve improving weight status, which may reduce the risk of hospitalization, emergency room visits, and mortality.

Are characteristics of the medical home associated with diabetes care costs?

To examine the relationship between primary care medical home clinical practice systems corresponding to the domains of the Chronic Care Model and annual diabetes-related health care costs incurred by members of a health plan with type-2 diabetes and receiving care at one of 27 Minnesota-based medical groups. Cross-sectional analysis of the relation between patient-level costs and Patient-Centered Medical Home (PCMH) practice systems as measured by the Physician Practice Connections Readiness Survey. Multivariate regressions adjusting for patient demographics, health status, and comorbidities estimated the relationship between the use of PCMH clinical practice systems and 3 annual cost outcomes: total costs of diabetes-related care, outpatient medical costs of diabetes-related care, and inpatient costs of diabetes-related care (ie, inpatient and emergency care). Overall PCMH scores were not significantly related to any annual cost outcome; however, 2 of 5 subdomains were related. Health Care Organization scores were related to significantly lower total (P=0.04) and inpatient costs (P=0.03). Clinical Decision Support was marginally related to a lower total cost (P=0.06) and significantly related to lower inpatient costs (P=0.02). A detailed analysis of the Health Care Organization domain showed that compared with medical groups with only quality improvement, those with performance measurement and individual provider feedback averaged $245/patient less. Medical groups with clinical reminders for counseling averaged $338/patient less. Certain PCMH practice systems were related to lower costs, but these effects are small compared with total costs. Further research about how these and other PCMH domains affect costs over time is needed.

Ethics for the Pediatrician: Bioethics Education and Resources

Ethics education based upon everyday ethical dilemmas can help trainees place themselves within the situation and encourage them to reflect on their role and responsibility in reaching its resolution.• Three elements can help augment the bioethics teaching experience: (a) identifying the ethical dilemma, (b) employing methods of ethical analysis, and(c) having knowledge of additional bioethics resources.An increasing number of bioethics resources are available to clinicians, including clinical ethics consultation (CEC) and print and Web-based resources.

Deletion diagnostics for alternating logistic regressions.

Deletion diagnostics are introduced for the regression analysis of clustered binary outcomes estimated with alternating logistic regressions, an implementation of generalized estimating equations (GEE) that estimates regression coefficients in a marginal mean model and in a model for the intracluster association given by the log odds ratio. The diagnostics are developed within an estimating equations framework that recasts the estimating functions for association parameters based upon conditional residuals into equivalent functions based upon marginal residuals. Extensions of earlier work on GEE diagnostics follow directly, including computational formulae for one-step deletion diagnostics that measure the influence of a cluster of observations on the estimated regression parameters and on the overall marginal mean or association model fit. The diagnostic formulae are evaluated with simulations studies and with an application concerning an assessment of factors associated with health maintenance visits in primary care medical practices. The application and the simulations demonstrate that the proposed cluster-deletion diagnostics for alternating logistic regressions are good approximations of their exact fully iterated counterparts.

The impact of childhood acute rotavirus gastroenteritis on the parents’ quality of life: prospective observational study in European primary care medical practices

BackgroundRotavirus (RV) is the commonest cause of acute gastroenteritis in infants and young children worldwide. A Quality of Life study was conducted in primary care in three European countries as part of a larger epidemiological study (SPRIK) to investigate the impact of paediatric rotavirus gastroenteritis (RVGE) on affected children and their parents.MethodsA self-administered questionnaire was linguistically validated in Spanish, Italian and Polish. The questionnaire was included in an observational multicentre prospective study of 302 children aged <5 years presenting to a general practitioner or paediatrician for RVGE at centres in Spain, Italy or Poland. RV infection was confirmed by polymerase chain reaction (PCR) testing (n = 264). The questionnaire was validated and used to assess the emotional impact of paediatric RVGE on the parents.ResultsQuestionnaire responses showed that acute RVGE in a child adversely affects the parents’ daily life as well as the child. Parents of children with RVGE experience worry, distress and impact on their daily activities. RVGE of greater clinical severity (assessed by the Vesikari scale) was associated with higher parental worries due to symptoms and greater changes in the child’s behaviour, and a trend to higher impact on parents’ daily activities and higher parental distress, together with a higher score on the symptom severity scale of the questionnaire.ConclusionsParents of a child with acute RVGE presenting to primary care experience worry, distress and disruptions to daily life as a result of the child’s illness. Prevention of this disease through prophylactic vaccination will improve the daily lives of parents and children.

Talking about smoking in primary care medical practice—Results of experimental studies from the US, UK and Germany

ObjectiveTo analyse effects of patient and physician characteristics on questions and advice about smoking in primary care practice and to examine country differences. MethodsWe conducted a factorial experiment, employing filmed scenarios in which actors played the role of patients with symptoms of coronary heart disease (CHD) or type 2 diabetes. Versions were filmed with patient–actors of different gender, age, race, and socioeconomic status. The videotapes were presented to primary care physicians in the US, UK and Germany. Physicians were asked whether they would ask questions about smoking or give cessation advice. ResultsFemale and older CHD patients are less likely to be asked or get advice about smoking in all three countries. Effects of physician attributes are weak and inconsistent. Compared to physicians in the US and the UK, German doctors are least likely to ask questions or give advice. ConclusionsAlthough all physicians viewed the same cases their questioning and advice giving differed according to patient attributes and country. Due to the experimental design external validity of the study may be limited. Practice implicationsFindings have implications for medical education and professional training of physicians as well as for the organization and financing of health care.

Abstract 223: Innovations in Quality Improvement

Innovative Medical Platform Optimizing Research and Technology (IMPORT)&gt; Background: A medical group, pharmaceutical company, and data harvesting and integration company collaborated to test an innovative approach to quality improvement (QI) that utilizes clinical expertise, advanced outcomes analytics, electronic medical records (EMR), and a cloud technology data harvesting platform. The objective of this project was to measure the ability of this collaborative project to effectively and efficiently identify quality improvement opportunities. Methods: This was a retrospective EMR analysis which utilized Solution for Quality Improvement (SQI) platform on an advanced electronic medical record system. All patients in one primary care medical practice seen from 7/1/2009 - 7/31/2011 were included. The primary outcomes were effectiveness of the platform to integrate data, measured by data density of diabetes laboratory and clinical quality performance values from structured EMR fields and unstructured physician notes; and efficiency, measured as the time period from SQI data mapping to final results analysis. A secondary outcome was the ability of the project to identify and target meaningful QI opportunities. Results: SQI collected data from 9,294 patient records, including 73,706 office visits and 35,602 physician dictated visit notes. Of these records, 6,251 cardiovascular patients were identified with diabetic patients accounting for 1,561 (25%) of these. Values and measurement dates for A1c, LDL, and blood pressure values were harvested in 83%, 75%, and 96% of these diabetic patients, respectively. The collection of other diabetic preventive services performance indicators was relatively low. Additional QI is being done to ensure complete capture of data. The time period for analysis, including 3 iterative rounds of expanded data identification, was 15 weeks total. Through this project, 3 specific areas of QI were prioritized: improve dictation/documentation of preventative diabetes care recommendations; implement diabetes panel management; and develop electronic diabetes patient reported outcomes screening tools. Conclusion: This collaboration led to an efficient and effective QI analysis in diabetes care. Results of the analysis have led to development and implementation of meaningful QI initiatives. Future implications include the use of this project’s approach to rapidly re-measure performance after implementation of the QI initiatives and expansion of the collaboration from a 4 physician practice to the network of 100 primary care physicians.

US and global efforts to expand the use of electronic health records

PurposeThis paper seeks to analyze attempts, in the USA and globally, to create new and improved methods used to manage patient health information: electronic medical records (EHRs). This new system of records management is to be examined to determine the possible benefits for patients, providers, insurers, employers, and others, as well as barriers to the use of EHRs, particularly in those embedded in US law.Design/methodology/approachIn the USA, and in various other jurisdictions, new laws have been enacted to incentivize the use of EHRs, and the paper examines the regulations and provisions incentivizing the adoption of this type of integrated system for lifelong tracking of health‐related information. There are issues to be dealt with, such as cost, privacy, and legality, but each of these can and must be overcome to effectively manage and communicate health care informationFindingsThe use of EHRs is increasing in the USA and globally, both in acute care hospitals and in primary care medical practices, largely accomplished through positive incentives, and penalties for non‐compliance. There are also various countries well on the way to wide‐spread use of electronic health records management.Social implicationsThe use of EHRs creates a societal benefit, initially one on an individual level, but one which over time could rise to a level positively affecting health care on a national, even global level.Originality/valueThe paper is based on an analysis of relevant laws/regulations, best practices, and anecdotal/observational evidence. No empirical evidence survey or study was conducted, primarily because the process of implementation of EHRs is too new. It is of value to practitioners, policy makers, and interested public parties.

Interdisciplinary Prenatal Group Visits as a Significant Learning Experience

Group visits offer documented benefit to patients and clinicians. They also provide an excellent venue to teach residents interdisciplinary care and group facilitation skills. Third-year residents received experiential training to provide prenatal care through group visits rather than one-on-one visits. A descriptive study is used to illustrate the effectiveness of various facets of resident skill acquisition and patient-centered prenatal care. Evaluation methods included feedback from patients, team members, learner self-reflection, and observation by a behavioral health clinician. Residents collaboratively provide prenatal care in a group model during a 6-month period. Interdisciplinary team members explicitly teach and model biopsychosocial whole-person care and effective communication. This inventive experience has increased resident competency-based skills in facilitation and effective team collaboration as measured through observation. These skills are directly applicable in future primary care medical home practice. Using a group visit model benefits patients and clinicians, and promotes enriching and effective resident education. Our model can easily be implemented in other programs.

How Eight Primary Care Practices Initiated and Maintained Quality Monitoring and Reporting

Primary care medical practices increasingly are asked by payers, employers, and government agencies to report quality data, but the process of doing so is not well delineated. Providers and office staff in a diverse sample of eight primary care practices in North Carolina comprised this study population. Interviews were conducted and self-administered questionnaires were disseminated in practices that were successfully reporting data to one or more of 4 reporting programs. Our measures included responses to open-ended and Likert scale questions about experiences and potential facilitators and barriers, as well as subscales of the Practice Assessment tool and the Culture of Group Practices instrument. Study practices had stronger change histories, higher information and quality emphases, and lower business emphases than historical comparison practices. Motivation to participate, a leader who catalyzes the process, and establishment of new systems characterized successful practices. Staff time, information technology challenges, and resistance from some providers were common barriers. Practices achieve a sustainability state when numerous barriers have been successfully overcome and tangible results achieved from the process. Implementing and sustaining quality reporting requires a complex set of motivators, facilitators, and strategies to overcome inherent barriers that can present themselves in practices that seek to implement changes in this direction.

Creating Safety in Primary Care Practice with Electronic Medical Records Requires the Consideration of System Dynamics

Improvement in quality and safety in health care often depends on eliminating errors. Using examples from our research on the medical testing processes in primary care medical practices, we argue that designing safer systems requires moving beyond frameworks that focus exclusively on error elimination to consider the broader system dynamics including information loops that can be critical to the overall stability of the system. We focus on describing the nature of information coupling in relation to the constructs of essential friction, autonomation, and ecological interface design and how these can lead to more resilient systems. With the recent push in the United States to move towards electronic medical records (EMR), we conclude with suggestions for improving EMR systems based on these concepts.

Characteristics and Acute Care Use Patterns of Patients in a Senior Living Community Medical Practice

Primary care medical practices dedicated to the needs of older adults who dwell in independent and assisted living residences in senior living communities (SLCs) have been developed. To date, the demographic and acute medical care use patterns of patients in these practices have not been described. A descriptive study using a 6-month retrospective record review of adults enrolled in a medical primary care practice that provides on-site primary medical care in SLCs. Greater Rochester, New York. Participants were 681 patients residing in 19 SLCs. Demographic and clinical data were collected. Use of acute medical care by patients in the SLC program, including phone consultation, provider emergent/urgent in-home visit, emergency department (ED) visit, and hospital admissions, were recorded. ED visit and hospital admissions at the 2 primary referral hospitals for the practice were reviewed for chief complaint and discharge plan. A total of 635 (93%) of 681 records were available. The median age was 85 years (interquartile range [IQR] 77, 89). Patients were predominantly female (447, 70%) and white (465, 73%). Selected chronic medical diseases included dementia/cognitive impairment (367, 58%), cardiac disease (271, 43%), depression (246, 39%), diabetes (173, 27%), pulmonary disease (146, 23%), renal disease (118, 19%), cancer (115, 18%), and stroke/TIA (93,15%). The median Mini Mental State Examination score was 25 (IQR 19, 28; n= 446). Patients took a median of 10 medications (IQR 7, 12). Important medication classes included cardiovascular (512, 81%), hypoglycemics (117, 18%), benzodiazepines (71, 11%), dementia (194, 31%), and anticoagulants (51, 8%). Patients received acute care 1876 times (median frequency 3, IQR 2, 6) for 1504 unique medical issues. Falls were the most common complaint (399, 20%). Of these 1876 episodes, patients accessed acute care via telephone (1071, 57%), provider visit at the SLC (417, 22%), and ED visit (388, 21%). Of the cases conducted via telephone, 693 (67%) were resolved by phone, 253 (24%) required home visits, 15 (1%) required subspecialist follow-up, and 81 (8%) required ED evaluation. Of the cases prompting a home visit by a medical provider, 399 (96%) were resolved duringthe visit, 13 (3%) required subspecialist follow-up, and 4 (1%) required ED evaluation. Of the 389 cases conducted via ED visit, 164 (42%) were admitted to the hospital and 2 (0.5%) died. SLC primary care medical practices serve a population that is older, has significant medical comorbidity, and frequently accesses acute medical care. Although many acute care issues for this population are handled via phone, home visits and/or ED use is common. Understanding the acute care health utilization patterns of SLC dwellers is critical to designing systems to optimally address the acute care needs of aging older adults.

A randomized controlled trial of telemonitoring in older adults with multiple chronic conditions: the Tele-ERA study

BackgroundOlder adults with multiple chronic illnesses are at risk for worsening functional and medical status and hospitalization. Home telemonitoring may help slow this decline. This protocol of a randomized controlled trial was designed to help determine the impact of home telemonitoring on hospitalization. The specific aim of the study reads as follows: to determine the effectiveness of home telemonitoring compared with usual care in reducing the combined outcomes of hospitalization and emergency department visits in an at-risk population 60 years of age or older.Methods/DesignTwo-hundred patients with the highest 10% Mayo Clinic Elder Risk Assessment scores will be randomly assigned to one of two interventions. Home telemonitoring involves the use of a computer device, the Intel Health Guide, which records biometric and symptom data from patients in their homes. This information is monitored by midlevel providers associated with a primary care medical practice. Under the usual care scenario, patients make appointments with their providers as problems arise and use ongoing support such as a 24-hour nurse line.Patients will have initial evaluations of gait and quality of life using instruments such as the SF-12 Health Survey, the Kokmen Short Test of Mental Status, and the PHQ-9 health questionnaire. Patients will be followed for 1 year for primary outcomes of hospitalizations and emergency department visits. Secondary analysis will include quality of life, compliance with the device, and attitudes about telemonitoring. Sample size is based on an 80% power to detect a 36% difference between the two groups. The primary analysis will involve Cox proportional time-to-event analysis. Secondary analysis will use t-test comparisons for continuous variables and the chi square test for proportional analysis.DiscussionPatients randomized to home telemonitoring will have daily assessments of their health status using the device. Registered nurse monitoring will assess any change in status followed by videoconferencing by a mid-level provider. We obtained trial registration and Institutional Review Board approval.Trial registrationTrial registration number through http://www.clinicaltrials.gov: NCT01056640.

Barriers to the Adoption and Implementation of Preventive Dental Services in Primary Medical Care

To determine the barriers to adopting preventive oral health procedures in medical primary care. Medical providers who participated in a Medicaid demonstration in North Carolina completed questionnaires reporting their experiences with providing preventive dental services for children from birth to 3 years of age. Eleven factors were established as possible obstacles to the adoption of an oral health program. After 12 months of participation in the Into the Mouths of Babes training program, providers (N = 231) from 49 pediatric practices and 28 family physician practices reported if any of the 11 factors had been an obstacle to adoption and, if so, whether these obstacles were overcome. Program adoption and implementation, defined as providing all of the services on a regular basis, were predicted by using logistic regression to analyze the responses from providers who reported 1 or more barriers, the number of barriers identified (knowledge, attitudes, and external factors), and the number that were overcome. Program-adoption rates were high, with 70.3% of the participants providing dental services on a routine basis. Attitude and external factors were positively associated with adoption, particularly with difficulty in applying the varnish, integration of the dental procedures into practice, resistance among staff and colleagues, and dentist referral difficulties. From 40.4% to 61.5% of providers overcame these 4 most common barriers. Those who reported external barriers and were unable to overcome them were less likely to provide the services, compared with those providers who reported no barriers (odds ratio: 0.08 [95% confidence interval: 0.01-0.44]). The number of barriers to adopting preventive dental procedures in primary care medical practices is associated with implementation. A large proportion of these barriers can be overcome, leading to high adoption rates in a short amount of time. The barriers to adoption are similar to those identified in the literature on changing patient care, with the unique aspects of fluoride application to teeth. Interventions to promote preventive dental care in medical settings should rely heavily on empirical literature. Training physicians in preventive dentistry should identify and target potential barriers with information and options for introducing office-based systems to improve the chances of adoption.

Demographics and Acute Medical Needs of Assisted Living Facility Residents

Introduction/Objective: Background. Increasing numbers of older adults live in assisted living residences (ALRs). Primary care medical practices focusing on the care of older adults who dwell in ALR are developing to meet these patient's special needs. To our knowledge, the types of patients in an ALR medical practice and the use of acute medical care by ALR dwellers have not been previously characterized. Objectives: To characterize the patients participating in an ALR primary care program and their use of acute medical care services.

The effectiveness of the McKenzie method in addition to first-line care for acute low back pain: a randomized controlled trial.

BackgroundLow back pain is a highly prevalent and disabling condition worldwide. Clinical guidelines for the management of patients with acute low back pain recommend first-line treatment consisting of advice, reassurance and simple analgesics. Exercise is also commonly prescribed to these patients. The primary aim of this study was to evaluate the short-term effect of adding the McKenzie method to the first-line care of patients with acute low back pain.MethodsA multi-centre randomized controlled trial with a 3-month follow-up was conducted between September 2005 and June 2008. Patients seeking care for acute non-specific low back pain from primary care medical practices were screened. Eligible participants were assigned to receive a treatment programme based on the McKenzie method and first-line care (advice, reassurance and time-contingent acetaminophen) or first-line care alone, for 3 weeks. Primary outcome measures included pain (0-10 Numeric Rating Scale) over the first seven days, pain at 1 week, pain at 3 weeks and global perceived effect (-5 to 5 scale) at 3 weeks. Treatment effects were estimated using linear mixed models.ResultsOne hundred and forty-eight participants were randomized into study groups, of whom 138 (93%) completed the last follow-up. The addition of the McKenzie method to first-line care produced statistically significant but small reductions in pain when compared to first-line care alone: mean of -0.4 points (95% confidence interval, -0.8 to -0.1) at 1 week, -0.7 points (95% confidence interval, -1.2 to -0.1) at 3 weeks, and -0.3 points (95% confidence interval, -0.5 to -0.0) over the first 7 days. Patients receiving the McKenzie method did not show additional effects on global perceived effect, disability, function or on the risk of persistent symptoms. These patients sought less additional health care than those receiving only first-line care (P = 0.002).ConclusionsWhen added to the currently recommended first-line care of acute low back pain, a treatment programme based on the McKenzie method does not produce appreciable additional short-term improvements in pain, disability, function or global perceived effect. However, the McKenzie method seems to reduce health utilization although it does not reduce patient's risk of developing persistent symptoms.Trial RegistrationAustralian New Zealand Clinical Trials Registry: ACTRN12605000032651

Itʼs About Time: Physiciansʼ Perceptions of Time Constraints in Primary Care Medical Practice in Three National Healthcare Systems

Itʼs About Time: Physiciansʼ Perceptions of Time Constraints in Primary Care Medical Practice in Three National Healthcare Systems

Er representativiteten til det nasjonale skaderegisteret god nok?

A new national injury register in Norway provides injury statistics based on injuries treated at hospitals and emergency care clinics in Oslo, Bergen and Trondheim. The aim of the study is to investigate whether the national register is adequately representative, by estimating the proportion of injuries in the municipality of Trondheim that are treated by regular general practitioners (GPs) in Trondheim. Eight primary care medical practices were invited to record information about injuries treated by GPs in their practice; seven practices completed the recording. An electronic injury recording system, WinMed, was used. The study population comprises 22.5 % of patients registered in GP lists in Trondheim. The GPs at the seven practices treated 142 injuries in April 2008. Provided that these practices are representative, the GPs in Trondheim treated 631 injuries in April 2008, i.e. 29.4 % of all injuries treated by physicians in Trondheim that month. The annual incidence of injuries in Trondheim, based on data from the injury register for the period 1986-2008, showed a decreasing trend after 1992. By including estimated data for injuries treated by GPs in general practice the trend increased in the same period. Data from the National injury register at hospitals and emergency care clinics in Trondheim do not provide reliable information about the incidence of injuries.

Aspirin and Secondary Prevention in Peripheral Artery Disease

LOWER EXTREMITY PERIPHERAL ARTERY DISEASE (PAD) is common among older men and women in developed countries and will become increasingly prevalent as populations survive longer with chronic disease. Recent estimates in the United States indicate that 1 in 16 men and women 40 years or older have PAD. In primary care medical practices in the United States, nearly 30% of men and women who are either 70 years or older or aged 50 to 69 years with a history of diabetes or smoking have an ankle-brachial index (ABI) of less than 0.90, consistent with PAD. Multiple epidemiological studies completed during the past 20 years consistently demonstrate increased rates of cardiovascular morbidity and mortality among men and women with PAD compared with those without PAD even after adjusting for cardiovascular disease risk factors and history of cardiovascular events. Therefore, preventing cardiovascular events is a major therapeutic goal for clinicians treating patients with PAD. Current clinical practice guidelines from the American Heart Association and the American College of Cardiology recommend low-dose aspirin (75 to 325 mg/d) to reduce the high risk of cardiovascular morbidity and mortality in patients with PAD. Clopidogrel is recommended as an alternative antiplatelet medication for secondary prevention in PAD. In this issue of JAMA, Berger et al report results of a metaanalysis of 18 randomized controlled clinical trials assessing the effect of aspirin therapy, alone or with dipyridamole, on the risk of cardiovascular events in 5269 patients with PAD. Overall, compared with a control group, aspirin therapy was associated with a 12% relative risk reduction in the primary outcome measure of cardiovascular events (nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death). However, this 12% risk reduction did not achieve statistical significance. For secondary outcomes, aspirin therapy was associated with a statistically significant reduction in nonfatal stroke but was not associated with significant reductions in nonfatal myocardial infarction, cardiovascular mortality, or all-cause mortality. Several characteristics of this meta-analysis must be considered when interpreting the results. First, the sample size is small. The authors report that a sample size of 5000 participants provided 88% power to detect a 25% difference and 70% power to detect a 20% difference between the aspirin and control groups for the primary outcome measure. Therefore, themeta-analysis lacks statisticalpower fordemonstratingclinically meaningful differences of 20% or less between the aspirin and control groups. Second, of the 5269 participants included in the meta-analysis, more than 25% were from 2 studies that included only PAD participants with diabetes mellitus, which is a major risk factor for and is common among those with PAD. However, patients with diabetes mellitus may derive less benefit from aspirin than those without diabetes mellitus, as suggested by results of the Antithrombotic Trialists’ Collaboration meta-analysis and other recent clinical trial data. Third, of the 18 trials included in the meta-analysis, 15 were published prior to 1995; however, the diagnosis and recognition of PAD has changed dramatically in the past 10 years. Although PAD was previously considered synonymous with intermittent claudication, it is now known that most patients with PAD are asymptomatic or present with leg symptoms other than classic intermittent claudication. The results of aspirin clinical trials that enrolled patients with PAD during earlier decades may have limited generalizability to patients with PAD treated by clinicians in the 21st century. Fourth, given the heterogeneity of results, subset analyses stratified by patient characteristics such as age, sex, and diabetes would be informative. However, individual data were not available for these comparisons. The current guideline-recommended dose of 75 to 325 mg ofaspirin forpatientswithPADisderived fromtheAntithrombotic Trialists’ Collaboration meta-analysis of 287 studies involving135 000patientsathighriskofvascularevents. Among all patients, the Antithrombotic Trialists’ Collaboration metaanalysis demonstrated that proportional reductions in vascular events were 19% for daily aspirin doses of 500 to 1500 mg, 26% for aspirin doses of 160 to 325 mg, 32% for aspirin doses