Table of Contents

Although many older adults have HIV infection, national guidelines recommend screening only persons age 13 to 64 years. Using a decision model, Sanders and colleagues examined the costs and benefits of HIV screening in patients age 55 to 75 years. Screening is reasonably cost-effective when HIV prevalence is 0.1% or greater, the counseling process is streamlined, and the person has an at-risk partner. This information should inform decisions about expanding screening recommendations to older people.

Studies have examined the association between coffee consumption and a variety of specific diseases, but the relationship between coffee consumption and all-cause mortality remains unclear. This study followed 2 large cohorts of men and women who had provided data on coffee consumption, other behaviors, and health outcomes every 2 to 4 years over 2 decades. High coffee consumption was not related to increased mortality and may be associated with lower total and cardiovascular mortality, a finding that requires further investigation.

Mehrotra and colleagues helped 6 primary care practices implement open-access scheduling, in which patients receive an appointment at or near the time of their choosing. Five of the 6 practices substantially reduced waiting times for appointments, but none could consistently provide same-day access or sustain shorter waiting times. Patient and staff satisfaction did not change, no-show rates remained the same, and the practices differed too much to measure postimplementation changes in average waiting time.

Sequential provision of antibiotics may help overcome the declining efficacy of treatment for Helicobacter pylori. In their review and meta-analysis, Jafri and colleagues compared sequential therapy with standard triple therapy for H. pylori infection. Among 10 trials, evidence consistently favored sequential over standard triple therapy for H. pylori. However, most trials were performed in 1 country (Italy), 1 trial was performed in children only, and the investigators found strong evidence for publication bias.

Hydroxyurea has benefited some patients with sickle cell disease—an inherited blood disorder that affects 50 000 to 100 000 people in the United States—but several issues about its use are unresolved. To more closely examine this topic, the National Heart, Lung, and Blood Institute and the Office of Medical Applications of Research of the National Institutes of Health convened a Consensus Development Conference to assess the available scientific evidence. This article answers key questions about the evidence.

Lanzkron and colleagues synthesized the evidence on the efficacy, effectiveness, and toxicity of hydroxyurea for treating adults with sickle cell disease. They found that hydroxyurea increases fetal hemoglobin in adults with sickle cell disease and reduces the frequency of pain crises, hospital-days, and transfusions. They found far less evidence on hydroxyurea's effect on hospitalization, stroke, pain crises, the acute chest syndrome, and death outcomes. Limited evidence indicated that hydroxyurea treatment of sickle cell disease is not associated with leukemia or leg ulcers. The evidence was insufficient to estimate the risk for skin neoplasms.

The American College of Physicians recently highlighted the need for increased information on the comparative effectiveness of health care interventions and recommended the establishment of an adequately funded, trusted national entity to prioritize, sponsor, or produce both comparative clinical and cost-effectiveness data. This article addresses the need for the proposed entity to develop cost-effectiveness information. It examines the current reluctance to develop and use cost-effectiveness in the United States, arguing for the importance of this information for all health care stakeholders, and recommending how to disseminate and use this information.

In sequential therapy for H. pylori, more antibiotics are added to the treatment regimen in sequence rather than giving all 4 drugs together. In this issue, Jafri and colleagues' meta-analysis of clinical trials of sequential therapy convincingly confirms the efficacy of sequential therapy for H. pylori. Marshall describes several reasons why this therapeutic strategy makes sense.

Commenting on American College of Physicians' position paper, which contends that cost-effectiveness analysis should be linked to any study of clinical effectiveness, Garber discusses how comparative effectiveness research can fill part of the information void.

As a counterpoint to the College's position, Wilensky (despite general agreement that cost-effectiveness information should be used to develop smarter strategies of reimbursement) believes keeping comparative clinical effectiveness analysis and cost-effectiveness analysis separate from each other to be vitally important.