Letters
after levothyroxine therapy initiation would have had to have been unrecognized by health professionals over several years and therefore is likely to represent only a small number of individuals. Jolobe is also right to draw attention to the risk of overreplacement with levothyroxine in precipitating a transition from paroxysmal to persistent atrial fibrillation, which would certainly outweigh the benefits of replacement therapy, especially when the hypothyroidism is subclinical and the patient is elderly. Peter N. Taylor, MSc, MRCP Onyebuchi E. Okosieme, MD, FRCP Colin M. Dayan, PhD, FRCP Author Affiliations: Thyroid Research Group, Institute of Molecular Medicine, Cardiff University School of Medicine, Cardiff, Wales.
seems greater in England than for Medicaid and uninsured patients in the United States. Because all residents of England can receive primary care without charge at the point of use, patients in this country also benefit from protection against unaffordable appointment costs and, theoretically, greater equity in appointment availability across socioeconomic groups. Thomas E. Cowling, MPH Matthew J. Harris, MBBS, DPhil Azeem Majeed, MD Author Affiliations: Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, England. Corresponding Author: Thomas E. Cowling, MPH, Department of Primary Care and Public Health, Imperial College London, St Dunstan’s Road, Reynolds Building, Third Floor, London W6 8RP, England ([email protected]).
Corresponding Author: Peter N. Taylor, MSc, MRCP, Thyroid Research Group Institute of Molecular and Experimental Medicine, C2 link corridor, UHW, Cardiff University School of Medicine, Heath Park, Cardiff CF14 4XN, Wales (taylorpn @cardiff.ac.uk).
Conflict of Interest Disclosures: None reported.
Conflict of Interest Disclosures: None reported.
2. Ipsos MORI. GP Patient Survey results—national reports and data. https:// gp-patient.co.uk/surveys-and-reports. Accessed April 24, 2014.
1. Furqan S, Haque NU, Islam N. Conversion of autoimmune hypothyroidism to hyperthyroidism. BMC Res Notes. 2014;7:489.
HEALTH CARE REFORM
Access to Primary Care in England To the Editor As in the United States, the availability of primary care appointments is prominent in current policy discourse in England. The United Kingdom government recently announced that approximately 14% of primary care practices in England, serving a population of 7.5 million, will begin to offer appointments from 8 AM to 8 PM, 7 days a week.1 This intervention has arisen owing in part to the perception that appointment availability is insufficient and could result in greater utilization of emergency departments. According to the GP Patient Survey 2012-2013, a national, validated survey of adults in England, 89% of patients were able to obtain a primary care appointment on their last attempt to do so. 2 Of these patients, 92% were offered a convenient appointment, and 85% saw a primary care physician or nurse within 1 week.2 However, availability varies considerably between primary care practices; the minimum and maximum percentages of patients who received an appointment on their last attempt were 40% and 100%, respectively.2 In 2012-2013, the GP Patient Survey obtained 0.97 million responses, corresponding to approximately 2% of the English population.3 Although the response rate was relatively low (35%), a weighting scheme was applied to the responses to account for the possibility of nonresponse bias and ensure representativeness of the eligible population.3 A simulated patient study similar in design to that reported by Rhodes et al4 has demonstrated the construct validity of measures of access derived from the GP Patient Survey.5 Compared with the results presented by Rhodes et al,4 wait times for appointments in England are typically shorter than in the sampled US states, for both privately insured and Medicaid patients. Furthermore, appointment availability jamainternalmedicine.com
1. Department of Health. Millions to benefit from improved GP care. https: //www.gov.uk/government/news/millions-to-benefit-from-improved-gp-care. Accessed April 14, 2014.
3. Ipsos MORI. Technical annex for the GP Patient Survey: 2012-2013 annual report. http://gp-survey-production.s3.amazonaws.com/archive/2013/June /June%202013%20Technical%20Annex.pdf. Accessed April 24, 2014. 4. Rhodes KV, Kenney GM, Friedman AB, et al. Primary care access for new patients on the eve of health care reform. JAMA Intern Med. 2014;174(6):861-869. 5. Campbell JL, Carter M, Davey A, Roberts MJ, Elliott MN, Roland M. Accessing primary care: a simulated patient study. Br J Gen Pract. 2013;63(608):e71-e76.
In Reply The letter from Cowling and colleagues underscores that ensuring timely access to care is a challenge for health systems around the world. The United Kingdom (UK) has received high marks for access to primary care in crossnational comparisons of health systems.1 This is confirmed by the GP Patient Survey, which found that patients in the UK are able to obtain primary care appointments in less than 1 week on average.2 Higher levels of access in the UK have been explained by several structural and organizational factors. First, while the United States and UK have a similar ratio of physicians per population, a much higher fraction of these physicians provide primary care in the UK compared with the United States.3 Second, the UK National Health Service assigns patients to a regular primary care clinicians—a practice that has historically been limited to managed care plans in the United States. Finally, the presence of a salaried clinician workforce operating within a universal insurance coverage scheme in the UK reduces financial barriers to care for patients and promotes higher supply of health care services in low-income communities. Considering the UK experience will be valuable for US policymakers, as the Patient Protection and Affordable Care Act has intensified pressure to reorganize primary care. For example, insurance plans are increasingly steering patients toward preferred clinicians using autoassignment and narrow networks. These strategies can streamline the care-seeking experience for patients and lower costs but may also limit choice. The increasing use of chronic disease management programs led by mid-level clinicians in the UK may also increase the ca(Reprinted) JAMA Internal Medicine March 2015 Volume 175, Number 3
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a New York University User on 05/29/2015
467
Letters
pacity of primary care physicians to schedule new patients but also creates challenges for care coordination.4 Accurate measurement of capacity remains essential in both the United States and UK. In the GP Patient Study, Cowling and colleagues note that patient-reported data provided high correspondence with simulated patient (audit) methodologies. In the US context, however, there are informative differences between these 2 approaches. Looking at data from the US National Health Interview Survey, our team found that adults enrolled in Medicaid experience comparable, or better, access to care than privately insured low-income adults, whereas simulated new adult patients were substantially less likely to receive appointments with Medicaid than private insurance in the audit.5 Discrepancies between patient surveys and audit data can emerge because of differences in how schedulers respond to new vs established patients, financial barriers to care because of copayments and deductibles, and differences in the use of autoassignment methods. Beyond measuring how long patients have to wait for appointments, future cross-national comparisons of primary care access will require researchers to accurately define and capture both the enabling resources (such as after-hours care and convenient scheduling portals) and barriers (such as out-of-network costs and geographic distance) patients encounter as they navigate increasingly more complicated primary care systems. Brendan Saloner, PhD Karin V. Rhodes, MD, MS Daniel Polsky, PhD, MPP Author Affiliations: Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Saloner); Department of Emergency Medicine, University of Pennsylvania, Philadelphia (Rhodes); Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (Rhodes, Polsky). Corresponding Author: Karin V. Rhodes, MD, MS, Director, Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, 34th & Spruce, First Floor Ravdin, Hospital of the University of Pennsylvania, Philadelphia, PA 19104 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Davis K, Schoen C, Stremikis K. Mirror, Mirror on the Wall: How the Performance of the US Health Care System Compares Internationally: 2010 Update. New York, NY: Commonwealth Fund; 2010. 2. Ipsos MORI. GP Patient Survey results—national reports and data. https:// gp-patient.co.uk/surveys-and-reports. Accessed September 18, 2014. 3. OECD Health Statistics. OECD Health Statistics 2014. http://www.oecd.org /els/health-systems/health-data.htm. Accessed September 18, 2014. 4. Ham C. Chronic care in the English National Health Service: progress and challenges. Health Aff (Millwood). 2009;28(1):190-201. 5. Kenney GM, Saloner B, Anderson N, Polsky D, Rhodes K. Access to Care for Low-Income Medicaid and Privately Insured Adults in 2012 in the National Health Interview Survey: A Context for Findings from a New Audit Study. Washington, DC: The Urban Institute; 2014.
Television Watching and Effects on Food Intake: Distress vs Eustress To the Editor In the September issue of JAMA Internal Medicine, we read with great interest the article by Tal et al.1 In this study, the authors demonstrated that students watching an action movie ate significantly more than the group that 468
watched an interview program. This effect was seen for both sexes. However, a previous study from our group demonstrated that female students ate less grams when watching a comedy program compared with food intake when watching a television (TV) documentary (+52% increase).2 In our view, one reason for these discrepant results between our study and the study by Tal et al1 might be differences in the emotional content of the presented TV program. Previous studies have shown that humans who play violent video games show clear signs of distress (ie, negative stress), comprising higher blood pressure as well as reports of less fullness and a tendency to prefer sweet food.3 With this result in mind, it could be hypothesized that watching scenes of an action movie may cause distress, a condition that can increase food intake in the absence of hunger.4 In contrast, watching an engaging comedy clip has been linked with decreasing tiredness, sadness, irritation, anxiety, and restlessness, while increasing relaxation and joy.5 Thus, watching a comedy clip may cause eustress (ie, positive stress), which, owing to its high rewarding property, may reduce an individual’s concomitant drive to eat. Taken together, when interpreting the study findings by Tal et al,1 it must be borne in mind that the way TV watching affects short-term food intake in humans may depend on the emotional content of the TV program that they watch. Despite that, it must be mentioned that watching television is typically a sedentary activity, and as such—independent of the TV program’s content—may shift an individual’s energy balance toward energy surplus. Christian Benedict, PhD Helgi B Schiöth, PhD Jonathan Cedernaes, MD, PhD Author Affiliations: Department of Neuroscience, Uppsala University, Uppsala, Sweden. Corresponding Author: Jonathan Cedernaes, MD, PhD, Department of Neuroscience, Uppsala University, BMC Box 593, Uppsala 751 24, Sweden ([email protected]). Conflict of Interest Disclosures: None reported. Funding/Support: The authors’ work is supported by the Swedish Research Council, the Swedish Brain Foundation, and the Novo Nordisk Foundation. Role of the Funder/Sponsor: The sponsor had no role in the preparation, review, or approval of the manuscript or the decision to submit the manuscript for publication. 1. Tal A, Zuckerman S, Wansink B. Watch what you eat: action-related television content increases food intake. JAMA Intern Med. 2014;174(11):1842-1843. 2. Chapman CD, Nilsson VC, Thune HA, et al. Watching TV and food intake: the role of content. PLoS One. 2014;9(7):e100602. 3. Siervo M, Sabatini S, Fewtrell MS, Wells JC. Acute effects of violent video-game playing on blood pressure and appetite perception in normal-weight young men: a randomized controlled trial. Eur J Clin Nutr. 2013; 67(12):1322-1324. 4. Dallman MF. Stress-induced obesity and the emotional nervous system. Trends Endocrinol Metab. 2010;21(3):159-165. 5. Ragonesi AJ, Antick JR. Physiological responses to violence reported in the news. Percept Mot Skills. 2008;107(2):383-395.
In Reply Does what you watch on television (TV) determine how much you eat? In our study reported in the September issue of JAMA Internal Medicine,1 94 participants were randomly as-
JAMA Internal Medicine March 2015 Volume 175, Number 3 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a New York University User on 05/29/2015
jamainternalmedicine.com
after levothyroxine therapy initiation would have had to have been unrecognized by health professionals over several years and therefore is likely to represent only a small number of individuals. Jolobe is also right to draw attention to the risk of overreplacement with levothyroxine in precipitating a transition from paroxysmal to persistent atrial fibrillation, which would certainly outweigh the benefits of replacement therapy, especially when the hypothyroidism is subclinical and the patient is elderly. Peter N. Taylor, MSc, MRCP Onyebuchi E. Okosieme, MD, FRCP Colin M. Dayan, PhD, FRCP Author Affiliations: Thyroid Research Group, Institute of Molecular Medicine, Cardiff University School of Medicine, Cardiff, Wales.
seems greater in England than for Medicaid and uninsured patients in the United States. Because all residents of England can receive primary care without charge at the point of use, patients in this country also benefit from protection against unaffordable appointment costs and, theoretically, greater equity in appointment availability across socioeconomic groups. Thomas E. Cowling, MPH Matthew J. Harris, MBBS, DPhil Azeem Majeed, MD Author Affiliations: Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, England. Corresponding Author: Thomas E. Cowling, MPH, Department of Primary Care and Public Health, Imperial College London, St Dunstan’s Road, Reynolds Building, Third Floor, London W6 8RP, England ([email protected]).
Corresponding Author: Peter N. Taylor, MSc, MRCP, Thyroid Research Group Institute of Molecular and Experimental Medicine, C2 link corridor, UHW, Cardiff University School of Medicine, Heath Park, Cardiff CF14 4XN, Wales (taylorpn @cardiff.ac.uk).
Conflict of Interest Disclosures: None reported.
Conflict of Interest Disclosures: None reported.
2. Ipsos MORI. GP Patient Survey results—national reports and data. https:// gp-patient.co.uk/surveys-and-reports. Accessed April 24, 2014.
1. Furqan S, Haque NU, Islam N. Conversion of autoimmune hypothyroidism to hyperthyroidism. BMC Res Notes. 2014;7:489.
HEALTH CARE REFORM
Access to Primary Care in England To the Editor As in the United States, the availability of primary care appointments is prominent in current policy discourse in England. The United Kingdom government recently announced that approximately 14% of primary care practices in England, serving a population of 7.5 million, will begin to offer appointments from 8 AM to 8 PM, 7 days a week.1 This intervention has arisen owing in part to the perception that appointment availability is insufficient and could result in greater utilization of emergency departments. According to the GP Patient Survey 2012-2013, a national, validated survey of adults in England, 89% of patients were able to obtain a primary care appointment on their last attempt to do so. 2 Of these patients, 92% were offered a convenient appointment, and 85% saw a primary care physician or nurse within 1 week.2 However, availability varies considerably between primary care practices; the minimum and maximum percentages of patients who received an appointment on their last attempt were 40% and 100%, respectively.2 In 2012-2013, the GP Patient Survey obtained 0.97 million responses, corresponding to approximately 2% of the English population.3 Although the response rate was relatively low (35%), a weighting scheme was applied to the responses to account for the possibility of nonresponse bias and ensure representativeness of the eligible population.3 A simulated patient study similar in design to that reported by Rhodes et al4 has demonstrated the construct validity of measures of access derived from the GP Patient Survey.5 Compared with the results presented by Rhodes et al,4 wait times for appointments in England are typically shorter than in the sampled US states, for both privately insured and Medicaid patients. Furthermore, appointment availability jamainternalmedicine.com
1. Department of Health. Millions to benefit from improved GP care. https: //www.gov.uk/government/news/millions-to-benefit-from-improved-gp-care. Accessed April 14, 2014.
3. Ipsos MORI. Technical annex for the GP Patient Survey: 2012-2013 annual report. http://gp-survey-production.s3.amazonaws.com/archive/2013/June /June%202013%20Technical%20Annex.pdf. Accessed April 24, 2014. 4. Rhodes KV, Kenney GM, Friedman AB, et al. Primary care access for new patients on the eve of health care reform. JAMA Intern Med. 2014;174(6):861-869. 5. Campbell JL, Carter M, Davey A, Roberts MJ, Elliott MN, Roland M. Accessing primary care: a simulated patient study. Br J Gen Pract. 2013;63(608):e71-e76.
In Reply The letter from Cowling and colleagues underscores that ensuring timely access to care is a challenge for health systems around the world. The United Kingdom (UK) has received high marks for access to primary care in crossnational comparisons of health systems.1 This is confirmed by the GP Patient Survey, which found that patients in the UK are able to obtain primary care appointments in less than 1 week on average.2 Higher levels of access in the UK have been explained by several structural and organizational factors. First, while the United States and UK have a similar ratio of physicians per population, a much higher fraction of these physicians provide primary care in the UK compared with the United States.3 Second, the UK National Health Service assigns patients to a regular primary care clinicians—a practice that has historically been limited to managed care plans in the United States. Finally, the presence of a salaried clinician workforce operating within a universal insurance coverage scheme in the UK reduces financial barriers to care for patients and promotes higher supply of health care services in low-income communities. Considering the UK experience will be valuable for US policymakers, as the Patient Protection and Affordable Care Act has intensified pressure to reorganize primary care. For example, insurance plans are increasingly steering patients toward preferred clinicians using autoassignment and narrow networks. These strategies can streamline the care-seeking experience for patients and lower costs but may also limit choice. The increasing use of chronic disease management programs led by mid-level clinicians in the UK may also increase the ca(Reprinted) JAMA Internal Medicine March 2015 Volume 175, Number 3
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a New York University User on 05/29/2015
467
Letters
pacity of primary care physicians to schedule new patients but also creates challenges for care coordination.4 Accurate measurement of capacity remains essential in both the United States and UK. In the GP Patient Study, Cowling and colleagues note that patient-reported data provided high correspondence with simulated patient (audit) methodologies. In the US context, however, there are informative differences between these 2 approaches. Looking at data from the US National Health Interview Survey, our team found that adults enrolled in Medicaid experience comparable, or better, access to care than privately insured low-income adults, whereas simulated new adult patients were substantially less likely to receive appointments with Medicaid than private insurance in the audit.5 Discrepancies between patient surveys and audit data can emerge because of differences in how schedulers respond to new vs established patients, financial barriers to care because of copayments and deductibles, and differences in the use of autoassignment methods. Beyond measuring how long patients have to wait for appointments, future cross-national comparisons of primary care access will require researchers to accurately define and capture both the enabling resources (such as after-hours care and convenient scheduling portals) and barriers (such as out-of-network costs and geographic distance) patients encounter as they navigate increasingly more complicated primary care systems. Brendan Saloner, PhD Karin V. Rhodes, MD, MS Daniel Polsky, PhD, MPP Author Affiliations: Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Saloner); Department of Emergency Medicine, University of Pennsylvania, Philadelphia (Rhodes); Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (Rhodes, Polsky). Corresponding Author: Karin V. Rhodes, MD, MS, Director, Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, 34th & Spruce, First Floor Ravdin, Hospital of the University of Pennsylvania, Philadelphia, PA 19104 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Davis K, Schoen C, Stremikis K. Mirror, Mirror on the Wall: How the Performance of the US Health Care System Compares Internationally: 2010 Update. New York, NY: Commonwealth Fund; 2010. 2. Ipsos MORI. GP Patient Survey results—national reports and data. https:// gp-patient.co.uk/surveys-and-reports. Accessed September 18, 2014. 3. OECD Health Statistics. OECD Health Statistics 2014. http://www.oecd.org /els/health-systems/health-data.htm. Accessed September 18, 2014. 4. Ham C. Chronic care in the English National Health Service: progress and challenges. Health Aff (Millwood). 2009;28(1):190-201. 5. Kenney GM, Saloner B, Anderson N, Polsky D, Rhodes K. Access to Care for Low-Income Medicaid and Privately Insured Adults in 2012 in the National Health Interview Survey: A Context for Findings from a New Audit Study. Washington, DC: The Urban Institute; 2014.
Television Watching and Effects on Food Intake: Distress vs Eustress To the Editor In the September issue of JAMA Internal Medicine, we read with great interest the article by Tal et al.1 In this study, the authors demonstrated that students watching an action movie ate significantly more than the group that 468
watched an interview program. This effect was seen for both sexes. However, a previous study from our group demonstrated that female students ate less grams when watching a comedy program compared with food intake when watching a television (TV) documentary (+52% increase).2 In our view, one reason for these discrepant results between our study and the study by Tal et al1 might be differences in the emotional content of the presented TV program. Previous studies have shown that humans who play violent video games show clear signs of distress (ie, negative stress), comprising higher blood pressure as well as reports of less fullness and a tendency to prefer sweet food.3 With this result in mind, it could be hypothesized that watching scenes of an action movie may cause distress, a condition that can increase food intake in the absence of hunger.4 In contrast, watching an engaging comedy clip has been linked with decreasing tiredness, sadness, irritation, anxiety, and restlessness, while increasing relaxation and joy.5 Thus, watching a comedy clip may cause eustress (ie, positive stress), which, owing to its high rewarding property, may reduce an individual’s concomitant drive to eat. Taken together, when interpreting the study findings by Tal et al,1 it must be borne in mind that the way TV watching affects short-term food intake in humans may depend on the emotional content of the TV program that they watch. Despite that, it must be mentioned that watching television is typically a sedentary activity, and as such—independent of the TV program’s content—may shift an individual’s energy balance toward energy surplus. Christian Benedict, PhD Helgi B Schiöth, PhD Jonathan Cedernaes, MD, PhD Author Affiliations: Department of Neuroscience, Uppsala University, Uppsala, Sweden. Corresponding Author: Jonathan Cedernaes, MD, PhD, Department of Neuroscience, Uppsala University, BMC Box 593, Uppsala 751 24, Sweden ([email protected]). Conflict of Interest Disclosures: None reported. Funding/Support: The authors’ work is supported by the Swedish Research Council, the Swedish Brain Foundation, and the Novo Nordisk Foundation. Role of the Funder/Sponsor: The sponsor had no role in the preparation, review, or approval of the manuscript or the decision to submit the manuscript for publication. 1. Tal A, Zuckerman S, Wansink B. Watch what you eat: action-related television content increases food intake. JAMA Intern Med. 2014;174(11):1842-1843. 2. Chapman CD, Nilsson VC, Thune HA, et al. Watching TV and food intake: the role of content. PLoS One. 2014;9(7):e100602. 3. Siervo M, Sabatini S, Fewtrell MS, Wells JC. Acute effects of violent video-game playing on blood pressure and appetite perception in normal-weight young men: a randomized controlled trial. Eur J Clin Nutr. 2013; 67(12):1322-1324. 4. Dallman MF. Stress-induced obesity and the emotional nervous system. Trends Endocrinol Metab. 2010;21(3):159-165. 5. Ragonesi AJ, Antick JR. Physiological responses to violence reported in the news. Percept Mot Skills. 2008;107(2):383-395.
In Reply Does what you watch on television (TV) determine how much you eat? In our study reported in the September issue of JAMA Internal Medicine,1 94 participants were randomly as-
JAMA Internal Medicine March 2015 Volume 175, Number 3 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a New York University User on 05/29/2015
jamainternalmedicine.com
