Journal of General Internal Medicine最新文献

{"title":"Approach to Estimating Adherence to Heart Failure Medications Using Linked Electronic Health Record and Pharmacy Data.","authors":"Saul Blecker, Yunan Zhao, Xiyue Li, Ian M Kronish, Amrita Mukhopadhyay, Tyrel Stokes, Samrachana Adhikari","doi":"10.1007/s11606-024-09216-5","DOIUrl":"https://doi.org/10.1007/s11606-024-09216-5","url":null,"abstract":"<p><strong>Background: </strong>Medication non-adherence, which is common in chronic diseases such as heart failure, is often estimated using proportion of days covered (PDC). PDC is typically calculated using medication fill information from pharmacy or insurance claims data, which lack information on when medications are prescribed. Many electronic health records (EHRs) have prescription and pharmacy fill data available, enabling enhanced PDC assessment that can be utilized in routine clinical care.</p><p><strong>Objective: </strong>To describe our approach to calculating PDC using linked EHR-pharmacy data and to compare to PDC calculated using pharmacy-only data for patients with heart failure.</p><p><strong>Methods: </strong>We performed a retrospective cohort study of adult patients with heart failure who were prescribed guideline-directed medical therapy (GDMT) and seen in a large health system. Using linked EHR-pharmacy data, we estimated medication adherence by PDC as the percent of days in which a patient possessed GDMT based on medication pharmacy fills over the number of days the prescription order was active. We also calculated PDC using pharmacy-only data, calculated as medications possessed over days with continued medication fills. We compared these two approaches for days observed and PDC using a paired t-test.</p><p><strong>Results: </strong>Among 33,212 patients with heart failure who were prescribed GDMT, 2226 (6.7%) never filled their medications, making them unavailable in the assessment of PDC using pharmacy-only data (n = 30,995). Linked EHR-pharmacy data had slightly longer days observed for PDC assessment (164.7 vs. 163.4 days; p < 0.001) and lower PDC (78.5 vs. 90.6, p < 0.001) as compared to assessment using pharmacy-only data.</p><p><strong>Conclusions: </strong>Linked EHR-pharmacy data can be used to identify patients who never fill their prescriptions. Estimating adherence using linked EHR-pharmacy data resulted in a lower mean PDC as compared to estimates using pharmacy-only data.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":""},"PeriodicalIF":4.3,"publicationDate":"2024-11-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142710394","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Private Equity Penetration in Behavioral Health in the United States, 2010-2022.","authors":"Yashaswini Singh, Jonathan Cantor, Erin Fuse Brown, Christopher Whaley","doi":"10.1007/s11606-024-09218-3","DOIUrl":"https://doi.org/10.1007/s11606-024-09218-3","url":null,"abstract":"","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":""},"PeriodicalIF":4.3,"publicationDate":"2024-11-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142709542","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Identifying Demographic Trends in the Use of Audio-Video and Audio-Only Telehealth by Arizona Medicaid Beneficiaries Before and During the COVID-19 Pandemic.","authors":"Shreyas Hallur, Sara Salek, Sohail Daulat, Pamela Garcia-Filion","doi":"10.1007/s11606-024-09196-6","DOIUrl":"https://doi.org/10.1007/s11606-024-09196-6","url":null,"abstract":"<p><strong>Introduction: </strong>For the first time, our study tracked disparities in the utilization of audio-video and audio-only telehealth for outpatient visits before and during the COVID-19 pandemic.</p><p><strong>Methods: </strong>Using a dataset of de-identified claims corresponding to telehealth and in-person visits, a retrospective cohort study was conducted for all beneficiaries continuously enrolled in Arizona Medicaid between October 2019 and November 2020. Our definition of telehealth only covered outpatient services delivered remotely via the audio-video or audio-only modality. Outcomes of interest were indicators of telehealth (vs. in-person) service delivery and audio-video (vs. audio-only) delivery of a telehealth service. Multivariate models evaluated the association between each outcome and demographic factors, including age, urban/rural location, sex, and race/ethnicity.</p><p><strong>Results: </strong>In this cohort study of 1,799,537 beneficiaries, age over 75, male sex, Asian race, Black race, Hispanic ethnicity, and Native American race were associated with reduced odds of telehealth use for outpatient visits pre-pandemic. These deficits persisted for all groups except the Black race after the pandemic's onset. Throughout the study period, older age and Native American race were correlated with greater audio-video use while Black race indicated reduced odds of audio-video use. Hispanic ethnicity indicated lower odds of audio-video use only during the pandemic. Rural members exhibited greater odds of both overall telehealth and audio-video use for outpatient visits prior to the pandemic but both trends reversed as a rural-urban divide emerged during the pandemic. Spearman correlations between broadband access and audio-video uptake yielded no significant results pre-pandemic but a strong correlation emerged during the pandemic.</p><p><strong>Discussion: </strong>Pandemic-era telehealth expansions reduced but did not eliminate pre-existing disparities in telehealth and audio-video utilization for outpatient visits, indicating a need for health systems to better engage minority, elderly, and rural populations and continue to support audio-only telehealth.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":""},"PeriodicalIF":4.3,"publicationDate":"2024-11-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142709240","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Discussing Weight with Patients in Primary Care in Australia: A Mixed Methods Experimental Study.","authors":"Madeline L West, Joanne A Rathbone, Maria Bilal, Anne Nileshni Fernando, Gemma Sharp","doi":"10.1007/s11606-024-09202-x","DOIUrl":"https://doi.org/10.1007/s11606-024-09202-x","url":null,"abstract":"<p><strong>Background: </strong>Weight bias is characterised by negative attitudes towards people with a higher weight and is widespread in healthcare. Primary care professionals sometimes avoid discussing weight with patients due to concerns about upsetting them, insufficient training, resources, or referral pathways. There is, however, a responsibility for primary care professionals to address the health needs of patients, which may require discussing weight.</p><p><strong>Objective: </strong>The current study aimed to understand primary care professionals and trainee perceptions of the appropriateness of weight-centric, weight-inclusive/holistic, and avoidant approaches for discussing weight with higher weight individuals when patients were and were not seeking weight management advice.</p><p><strong>Design: </strong>Mixed methods design.</p><p><strong>Participants: </strong>Primary care professionals and trainees (N = 112) within Australia.</p><p><strong>Approach: </strong>Participants first completed an online survey and provided demographic data and completed measures of implicit and explicit weight bias. Secondly, participants viewed simulated patient consultations, reflecting each of the three approaches (weight-centric, weight-inclusive/holistic, and avoidant) in a weight-related and non-weight related context. Participants then evaluated the appropriateness of the language and strategies used.</p><p><strong>Key results: </strong>The participants showed, on average, low to moderate levels of explicit weight bias but high levels of implicit weight bias. For the consultations, language and strategies of the holistic approach were considered the most appropriate in both contexts. In the weight-related consultation, language used in the weight-centric and avoidant approaches were deemed equally inappropriate. However, weight-centric strategies were considered more appropriate than avoidant strategies. In the non-weight related consultation, the language and strategies of the avoidant approach were considered more appropriate than those of the weight-centric approach.</p><p><strong>Conclusions: </strong>Primary care professionals and trainees favoured the holistic approach to discussing weight when patients presented with weight-related or non-weight related concerns. These findings have potential practical implications for health professional education.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":""},"PeriodicalIF":4.3,"publicationDate":"2024-11-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142687253","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Association of Observation Stays with Clinical Outcomes and Costs in Medicare: An Instrumental Variable Analysis.","authors":"Kevin I Duan, Canada Parrish, Anirban Basu, Brad Wright, Joshua M Liao, Karen E Joynt Maddox, William Kreuter, Amber K Sabbatini","doi":"10.1007/s11606-024-09215-6","DOIUrl":"https://doi.org/10.1007/s11606-024-09215-6","url":null,"abstract":"<p><strong>Background: </strong>Observation stays in Medicare have grown over the last 15 years, yet limited research exists on how observation may impact outcomes for older adults.</p><p><strong>Objective: </strong>To examine the relationship of an observation stay with 30-day hospital returns, total acute care days post-discharge, mortality, and out-of-pocket costs, compared to an inpatient admission.</p><p><strong>Design: </strong>Retrospective cohort study using instrumental variable analysis.</p><p><strong>Participants: </strong>A 20% sample of US Medicare beneficiaries admitted to acute care with a length of stay < 5 days between 2009 and 2019.</p><p><strong>Interventions: </strong>Observation stay vs inpatient admission.</p><p><strong>Main measures: </strong>Unplanned hospital return within 30 days, total 30-day post-discharge acute care days, 30-day mortality, and 30-day acute care out-of-pocket spending.</p><p><strong>Key results: </strong>A total of 3,958,377 hospitalizations met study criteria, of which 1,656,631 (42%) were observation stays and 2,301,746 (58%) were inpatient admissions. Compared to inpatient admissions, observation stays were associated with a 4.39 percentage point (95% confidence interval [CI] 3.56%, 5.22%) higher rate of 30-day unplanned hospital returns, but no difference in total 30-day post-discharge acute care days (difference - 0.02 days; 95% CI - 0.08, 0.03), no difference in 30-day mortality (difference 0.20 percentage points; 95% CI 0.00, 0.40), and lower 30-day out-of-pocket costs (difference - $552; 95% CI - $561, - $542).</p><p><strong>Conclusions: </strong>Among Medicare beneficiaries hospitalized for fewer than 5 days, observation stay was associated with higher rates of 30-day unplanned hospital returns compared to inpatient admission. However, we simultaneously observed lower out-of-pocket costs among those hospitalized under an observation stay. The mixed results suggest that additional research and engagement with relevant parties is needed to optimize observation stay policy.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":""},"PeriodicalIF":4.3,"publicationDate":"2024-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142681906","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Master Adaptive Clinician Educator: A Framework for Future Educational Leaders in Academic Medicine.","authors":"Laura K Snydman, Milad Memari, Aditi Puri, Elisa M Sottile, Katherine Killian, David Callender, Anna K Donovan, Meghan Kiefer, Tanya Nikiforova, Mamta Singh, Wei Wei Lee, Danielle Jones, Craig Noronha","doi":"10.1007/s11606-024-09199-3","DOIUrl":"https://doi.org/10.1007/s11606-024-09199-3","url":null,"abstract":"<p><p>Medical education continues to evolve with technologic advances, cultural changes, and progress in the application of learning theories. One example is Cutrer's concept of the Master Adaptive Learner (MAL), where the trainee self-directs learning and innovates to maintain a level of expertise in a domain. We suggest that this concept can be applied alongside ideas of adaptive and teacher expertise to represent the medical educator of the future-the Master Adaptive Clinician Educator (MACE). The MACE is a clinician-educator leader who has specific medical education training, actively engages in ongoing education-focused skills development, and creates innovative approaches to teaching. The MACE reflects and continuously develops an educational toolbox, applies lessons from learning theories, and appropriately adapts to various learning environments. In this manuscript, we build upon recent publications outlining roles and competencies of clinician-educators by applying the MAL model; we propose a dynamic, adaptable, and well-trained expert educator who is best poised to lead future generations of medical trainees. We challenge institutional leaders and national societies to take the lead in creating structures to support the growth and promotion of MACEs with the goal of positively reshaping medical education and the clinician educator.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":""},"PeriodicalIF":4.3,"publicationDate":"2024-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142681945","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Empagliflozin in Diuretic-Refractory Ascites (DRAin-Em): Results of a Single-Center Feasibility Study.","authors":"Kelly Hu, Aparna Goel, Branden Tarlow, XingXing Cheng, Sun Kim, W Ray Kim, Paul Kwo","doi":"10.1007/s11606-024-09191-x","DOIUrl":"10.1007/s11606-024-09191-x","url":null,"abstract":"","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":""},"PeriodicalIF":4.3,"publicationDate":"2024-11-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142668142","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Leveraging Health Policy Solutions to Address Obesity in Rural America.","authors":"Perisa Ashar, Faraan O Rahim, Huda Haque, Humna Anzaar, Urvish Jain, Shivam Singh, Sandeep Palakodeti","doi":"10.1007/s11606-024-09207-6","DOIUrl":"10.1007/s11606-024-09207-6","url":null,"abstract":"<p><p>Rural America faces an alarming obesity crisis, with residents experiencing significantly higher rates of obesity due to socioeconomic disparities, limited access to healthcare, and structural challenges such as food deserts and insufficient healthcare infrastructure. This perspective addresses these pressing issues by proposing targeted, evidence-based interventions to reduce obesity in rural communities. Our recommendations include (1) increasing the number of multidisciplinary healthcare professionals in rural areas through initiatives such as the Rural Medical Scholars Program, the Rural Community Loan Repayment Program, and the Conrad 30 Waiver Program; (2) expanding coverage for essential obesity services via H.R. 1577, the Treat and Reduce Obesity Act, to alleviate financial barriers to treatment, including intensive behavioral therapy and pharmacotherapy; and (3) leveraging community-based programs, including the National Rural Obesity and Chronic Disease Initiative, the CDC's High Obesity Program, and the Delta Body and Soul initiative, to improve access to healthy foods and promote physical activity through local collaborations, education, and infrastructure enhancements. By implementing these comprehensive strategies, we aim to make obesity treatments and healthy lifestyle choices more accessible, ultimately reducing obesity rates, improving health outcomes, and enhancing the overall quality of life for rural residents across the USA.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":""},"PeriodicalIF":4.3,"publicationDate":"2024-11-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142668175","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Using Risk Assessment to Improve Screening for Albuminuria among US Adults without Diabetes.","authors":"Jennifer L Bragg-Gresham, Surekha Annadanam, Brenda Gillespie, Yiting Li, Neil R Powe, Rajiv Saran","doi":"10.1007/s11606-024-09185-9","DOIUrl":"10.1007/s11606-024-09185-9","url":null,"abstract":"<p><strong>Background: </strong>Guidelines currently recommend annual screening for albuminuria only among persons with diabetes mellitus (DM). There is no guidance about albuminuria screening in those with other important risk factors for chronic kidney disease (CKD), such as hypertension and/or family history of kidney disease. We sought to create a risk score that predicts the likelihood of albuminuria in adults without diabetes to prompt earlier detection and management of CKD.</p><p><strong>Methods: </strong>Data from 44,322 participants without diabetes, aged 18 + years from the National Health and Nutrition Examination Surveys 1999-2020 were analyzed. Survey-weighted logistic regression was used to assess associations between individual characteristics and presence of albuminuria (urinary albumin to creatinine ratio [UACR] ≥ 30 mg/g), including interaction terms, in three separate models. The sample was divided equally into development and validation data sets. C-statistics were used to assess model fit.</p><p><strong>Results: </strong>The prevalence of albuminuria was 9.7% in the US adult population. Higher odds of albuminuria among the non-diabetic population were observed in females, non-Hispanic Black, and smokers, as well as those with low eGFR, hypertension, cardiovascular disease, prediabetes, low HDL cholesterol, and high uric acid levels. Age showed a J-shaped relationship with albuminuria, with lowest odds for ages 25-64 years. The C-statistic was 0.756 for the developmental and 0.752 for the validation set of the final model. Using this model, screening individuals with a predicted probability of ≥ 5% would capture 85% of individuals with albuminuria.</p><p><strong>Conclusions: </strong>These results suggest that it may be helpful to use a risk score framework for albuminuria screening in people without DM to encourage earlier detection and management of CKD. Longitudinal studies are warranted to confirm this approach along with evaluation of its cost effectiveness.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":""},"PeriodicalIF":4.3,"publicationDate":"2024-11-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142668192","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Physician Documentation of Social Determinants of Health: Results from Two National Surveys.","authors":"Bradley E Iott, Vaishali Patel, Chelsea Richwine","doi":"10.1007/s11606-024-09184-w","DOIUrl":"10.1007/s11606-024-09184-w","url":null,"abstract":"<p><strong>Objective: </strong>We measured physicians' (1) perceived importance of having access to social determinants of health (SDOH) data received from external providers in the electronic health record (EHR); (2) internal SDOH documentation practices in the EHR, including whether physicians document SDOH in a structured format that may facilitate use; and (3) use of EHR SDOH data to identify community resources and make referrals on behalf of patients.</p><p><strong>Approach: </strong>We conducted a secondary analysis of two national physician surveys.</p><p><strong>Participants: </strong>Respondents from the American Board of Family Medicine Recertification Survey (ABFM, n = 4040), a survey of family physicians fielded 2021-2022, and the National Physician Health IT Survey (NPHIT, n = 3006), a survey of outpatient physicians across specialty areas fielded in 2022.</p><p><strong>Key results: </strong>Under half of physicians felt that SDOH data were very important (ABFM: 44.8%, NPHIT: 30.8%). Although most physicians documented SDOH in the EHR (ABFM: 72%, NPHIT: 63.3%), fewer used structured documentation methods (ABFM: 56.3%, NPHIT: 33.2%). In both surveys, physicians who participated in value-based care initiatives, those for whom > 10% of their patient population was considered vulnerable, and those who felt that their clinic had the resources to address patients' social needs had higher likelihood of documenting SDOH. Sixty-two percent of family physicians reported using SDOH data for identifying resources and making referrals.</p><p><strong>Conclusions: </strong>In 2022, most physicians documented SDOH data in their EHR, yet fewer used structured methods, limiting data exchange opportunities to address patients' social needs. Under half of physicians considered access to external SDOH data to be \"very\" important, suggesting greater reliance on data collected internally and missed opportunities to identify patients who need support. Variation in perceived importance of SDOH data access and SDOH documentation by physician characteristics indicate opportunities to support adoption of structured documentation tools facilitating SDOH data capture and exchange to improve patient-centered care.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":""},"PeriodicalIF":4.3,"publicationDate":"2024-11-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142668179","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}