JAMA Internal Medicine最新文献

{"title":"Implementation of Electronic Triggers to Identify Diagnostic Errors in Emergency Departments.","authors":"Viralkumar Vaghani, Ashish Gupta, Usman Mir, Li Wei, Daniel R Murphy, Umair Mushtaq, Dean F Sittig, Andrew J Zimolzak, Hardeep Singh","doi":"10.1001/jamainternmed.2024.6214","DOIUrl":"10.1001/jamainternmed.2024.6214","url":null,"abstract":"<p><strong>Importance: </strong>Missed diagnosis can lead to preventable patient harm.</p><p><strong>Objective: </strong>To develop and implement a portfolio of electronic triggers (e-triggers) and examine their performance for identifying missed opportunities in diagnosis (MODs) in emergency departments (EDs).</p><p><strong>Design, setting, and participants: </strong>In this retrospective medical record review study of ED visits at 1321 Veterans Affairs health care sites, rules-based e-triggers were developed and implemented using a national electronic health record repository. These e-triggers targeted 6 high-risk presentations for MODs in treat-and-release ED visits. A high-risk stroke e-trigger was applied to treat-and-release ED visits from January 1, 2016, to December 31, 2020. A symptom-disease dyad e-trigger was applied to visits from January 1, 2018, to December 31, 2019. High-risk abdominal pain, unexpected ED return, unexpected hospital return, and test result e-triggers were applied to visits from January 1, 2019, to December 31, 2019. At least 100 randomly selected flagged records were reviewed by physician reviewers for each e-trigger. Data were analyzed between January 2024 and April 2024.</p><p><strong>Exposures: </strong>Treat-and-release ED visits involving high-risk stroke, symptom-disease dyads, high-risk abdominal pain, unexpected ED return, unexpected hospital return, and abnormal test results not followed up after initial ED visit.</p><p><strong>Main outcomes and measures: </strong>Trained physician reviewers evaluated the presence/absence of MODs at ED visits and recorded data on patient and clinician characteristics, types of diagnostic process breakdowns, and potential harm from MODs.</p><p><strong>Results: </strong>The high-risk stroke e-trigger was applied to 8 792 672 treat-and-release ED visits (4 967 283 unique patients); the symptom-disease dyad e-trigger was applied to 3 692 454 visits (2 070 979 patients); and high-risk abdominal pain, unexpected ED return, unexpected hospital return, and test result e-triggers were applied to 1 845 905 visits (1 032 969 patients), overall identifying 203, 1981, 170, 116 785, 14 879, and 2090 trigger-positive records, respectively. Review of 625 randomly selected patient records (mean [SD] age, 62.5 [15.2] years; 553 [88.5%] male) showed the following MOD counts and positive predictive values (PPVs) within each category: 47 MODs (PPV, 47.0%) for stroke, 31 MODs (PPV, 25.8%) for abdominal pain, 11 MODs (PPV, 11.0%) for ED returns, 23 MODs (PPV, 23.0%) for hospital returns, 18 MODs (PPV, 18.0%) for symptom-disease dyads, and 55 MODs (PPV, 52.4%) for test results. Patients with MODs were slightly older than those without (mean [SD] age, 65.6 [14.5] vs 61.2 [15.3] years; P < .001). Reviewer agreement was favorable (range, 72%-100%). In 108 of 130 MODs (83.1%; excluding MODs related to the test result e-trigger), the most common diagnostic process breakdown involved the patient-clinic","PeriodicalId":14714,"journal":{"name":"JAMA Internal Medicine","volume":" ","pages":""},"PeriodicalIF":22.5,"publicationDate":"2024-12-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11612912/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142768980","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"High-Risk Medications in Persons Living With Dementia: A Randomized Clinical Trial.","authors":"Sonal Singh, Xiaojuan Li, Noelle M Cocoros, Mary T Antonelli, Ramya Avula, Sybil L Crawford, Inna Dashevsky, Hassan Fouayzi, Thomas P Harkins, Kathleen M Mazor, Ashley I Michnick, Lauren Parlett, Mark Paullin, Richard Platt, Paula A Rochon, Cassandra Saphirak, Mia Si, Yunping Zhou, Jerry H Gurwitz","doi":"10.1001/jamainternmed.2024.5632","DOIUrl":"10.1001/jamainternmed.2024.5632","url":null,"abstract":"<p><strong>Importance: </strong>Individuals with Alzheimer disease (AD) and Alzheimer disease-related dementias (ADRD) may be at increased risk for adverse outcomes relating to inappropriate prescribing of certain high-risk medications, including antipsychotics, sedative-hypnotics, and strong anticholinergic agents.</p><p><strong>Objective: </strong>To evaluate the effect of a patient/caregiver and prescriber-mailed educational intervention on potentially inappropriate prescribing to patients with AD or ADRD.</p><p><strong>Design, setting, and participants: </strong>This prospective, open-label, pragmatic randomized clinical trial, embedded in 2 large national health plans, was conducted from April 2022 to June 2023. The trial included patients with AD or ADRD and use of any of 3 drug classes targeted for deprescribing (antipsychotics, sedative-hypnotics, or strong anticholinergics).</p><p><strong>Interventions: </strong>Patients were randomized to 1 of 3 arms: (1) a mailing of educational materials specific to the medication targeted for deprescribing to both the patient and their prescribing clinician; (2) a mailing to the prescribing clinician only; or (3) a usual care arm.</p><p><strong>Main outcomes and measures: </strong>Analysis was performed using a modified intention-to-treat approach. The primary study outcome was the dispensing of the medication targeted for deprescribing during a 6-month study observation period. Secondary outcomes included changes in medication-specific mean daily dose and health service utilization.</p><p><strong>Results: </strong>Among 12 787 patients included in the modified intention-to-treat analysis, 8742 (68.4%) were female, and the mean (SD) age was 77.3 (9.4) years. The cumulative incidence of being dispensed a medication targeted for deprescribing was 76.7% (95% CI, 75.4-78.0) in the patient and prescriber mailing group, 77.9% (95% CI, 76.5-79.1) in the prescriber mailing only group, and 77.5% (95% CI, 76.2-78.8) in the usual care group. Hazard ratios were 0.99 (95% CI, 0.94-1.04) for the patient and prescriber group and 1.00 (95% CI, 0.96-1.06) for the prescriber only group compared with the usual care group. There were no differences between the groups for secondary outcomes.</p><p><strong>Conclusions and relevance: </strong>These findings suggest medication-specific educational mailings targeting patients with AD or ADRD and their clinicians are not effective in reducing the use of high-risk medications.</p><p><strong>Trial registration: </strong>ClinicalTrials.gov Identifier: NCT05147428.</p>","PeriodicalId":14714,"journal":{"name":"JAMA Internal Medicine","volume":" ","pages":"1426-1433"},"PeriodicalIF":22.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11581620/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142465849","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Reducing Lecanemab Waste Is Penny Wise, but Medicare Coverage May Be Pound Foolish.","authors":"Nathan M Stall, Kenneth E Covinsky","doi":"10.1001/jamainternmed.2024.5299","DOIUrl":"10.1001/jamainternmed.2024.5299","url":null,"abstract":"","PeriodicalId":14714,"journal":{"name":"JAMA Internal Medicine","volume":" ","pages":"1413-1414"},"PeriodicalIF":22.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142465852","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Competitive Bidding and Rate of Prescriptions for Home Oxygen.","authors":"Sneha Kannan, Ishani Ganguli","doi":"10.1001/jamainternmed.2024.5747","DOIUrl":"10.1001/jamainternmed.2024.5747","url":null,"abstract":"","PeriodicalId":14714,"journal":{"name":"JAMA Internal Medicine","volume":" ","pages":"1412-1413"},"PeriodicalIF":22.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142500727","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Guideline-Directed Medical Therapy Intolerance in Heart Failure.","authors":"Adeoluwa Ayoola, Alison Ohringer, Oanh Kieu Nguyen","doi":"10.1001/jamainternmed.2024.5159","DOIUrl":"10.1001/jamainternmed.2024.5159","url":null,"abstract":"","PeriodicalId":14714,"journal":{"name":"JAMA Internal Medicine","volume":" ","pages":"1468-1469"},"PeriodicalIF":22.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142500730","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Physicians, the Homelessness Crisis, and Public Health-All Hands on Deck.","authors":"Cary P Gross, Abbe R Gluck, Giselle Corbie","doi":"10.1001/jamainternmed.2024.5341","DOIUrl":"10.1001/jamainternmed.2024.5341","url":null,"abstract":"","PeriodicalId":14714,"journal":{"name":"JAMA Internal Medicine","volume":" ","pages":"1414-1416"},"PeriodicalIF":22.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142465851","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Reducing Wasteful Spending on Discarded Lecanemab in the US Medicare Program.","authors":"Frank F Zhou, Chi-Hong Tseng, Mei Leng, Benjo A Delarmente, Cheryl L Damberg, Catherine A Sarkisian, John N Mafi","doi":"10.1001/jamainternmed.2024.5292","DOIUrl":"10.1001/jamainternmed.2024.5292","url":null,"abstract":"","PeriodicalId":14714,"journal":{"name":"JAMA Internal Medicine","volume":" ","pages":"1477-1479"},"PeriodicalIF":22.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11581569/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142465853","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Clarifying the Risks of Consuming Edible Cannabis.","authors":"Donna M Lisi","doi":"10.1001/jamainternmed.2024.5014","DOIUrl":"10.1001/jamainternmed.2024.5014","url":null,"abstract":"","PeriodicalId":14714,"journal":{"name":"JAMA Internal Medicine","volume":" ","pages":"1479"},"PeriodicalIF":22.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142380893","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Electrocardiogram Intricacies in a Patient With Prostate Cancer-The Heart of the Matter.","authors":"Cuizhen Yuan, Linfeng Peng, Dandan Yang","doi":"10.1001/jamainternmed.2024.2282","DOIUrl":"10.1001/jamainternmed.2024.2282","url":null,"abstract":"","PeriodicalId":14714,"journal":{"name":"JAMA Internal Medicine","volume":" ","pages":"1472-1473"},"PeriodicalIF":22.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142500729","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Student Call for Gun Violence Education in Medical Schools.","authors":"Samuel E Okum","doi":"10.1001/jamainternmed.2024.3316","DOIUrl":"10.1001/jamainternmed.2024.3316","url":null,"abstract":"","PeriodicalId":14714,"journal":{"name":"JAMA Internal Medicine","volume":" ","pages":"1401-1402"},"PeriodicalIF":22.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142380891","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}