Journal of General Internal Medicine最新文献

{"title":"\"I Am Reluctant to Continue, Yet Know She Could Go into Withdrawal\": A Qualitative Analysis of Clinician Requests for eConsults in Opioid Management in the Ambulatory Setting.","authors":"Laila Khalid, Sharon Rikin, Dana Watnick, Tiffany Y Lu, Gianni Carrozzi, Ana Valle, Joanna L Starrels","doi":"10.1007/s11606-025-09811-0","DOIUrl":"https://doi.org/10.1007/s11606-025-09811-0","url":null,"abstract":"<p><strong>Background: </strong>Electronic consultations (eConsults) allow clinicians to submit questions through the electronic health records (EHR) to request specialist input about individual patients' care, but there is paucity of literature describing eConsult programs specifically for opioid management.</p><p><strong>Objectives: </strong>1. To understand clinicians' reasons for seeking eConsults for opioid management. 2. To describe characteristics of clinicians' questions that can be addressed through eConsults without requiring in-person specialist visits.</p><p><strong>Design: </strong>Retrospective qualitative study of eConsults for opioid management in the ambulatory setting.</p><p><strong>Participants: </strong>Clinicians who submitted an eConsult request for opioid management.</p><p><strong>Approach: </strong>We conducted a qualitative content analysis of eConsult requests and responses. First, a priori codes were developed and applied to textual data. Through iterative discussion and memoing, thematic codes were identified and applied to the dataset. Subsequently, breadth and depth of codes were explored, collapsed, and redefined, and relationships between codes were discussed. Following theme development, matrix analysis was used to compare eConsults that resulted with or without a recommendation for an in-person specialist visit.</p><p><strong>Key results: </strong>Forty eConsults were requested by 30 unique referring clinicians mostly from general internal medicine (53%) or family medicine (27%). We identified four themes: (1) clinicians were motivated to reduce harm, (2) clinicians had difficulty labeling opioid misuse and use disorder (OUD), (3) clinicians had difficulty articulating discrete questions, and (4) clinician questions revealed knowledge gaps in opioid management. In-person specialist visits were recommended when clinicians needed help with labeling opioid misuse or OUD or when questions were vague and around complex topics.</p><p><strong>Conclusion: </strong>Clinicians have unease and discomfort in treating chronic pain and managing opioids. eConsults are most helpful for low-complexity, discrete questions from clinicians focused on reducing harm. eConsult implementation should integrate EHR enhancements and clinician training in assessing opioid misuse and OUD and articulating discrete questions.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":""},"PeriodicalIF":4.2,"publicationDate":"2025-09-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144956853","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":"Intravenous to Subcutaneous Opioid Prescribing in Hospitalized Medicine Patients.","authors":"Barry J Wu, Rebecca Spear, Margaret Doyle, Noelle Gallant, Andrea Rink, Adam L Ackerman, Richard Marottoli","doi":"10.1007/s11606-025-09834-7","DOIUrl":"10.1007/s11606-025-09834-7","url":null,"abstract":"","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":""},"PeriodicalIF":4.2,"publicationDate":"2025-09-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144956794","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":"Continuous Glucose Monitoring in Primary Care: A Survey of Primary Care Providers.","authors":"Kailyn E Sitter, Ben Kragen, Alison J Leibowitz, Jolie B Wormwood, Bo Kim, Varsha G Vimalananda","doi":"10.1007/s11606-025-09741-x","DOIUrl":"https://doi.org/10.1007/s11606-025-09741-x","url":null,"abstract":"","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":""},"PeriodicalIF":4.2,"publicationDate":"2025-09-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144956844","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":"Estimating Health Condition Prevalence Among a Statewide Cohort with Recent Homelessness or Incarceration.","authors":"Lucas Zellmer, Renee Van Siclen, Peter Bodurtha, Paul E Drawz, Stephen C Waring, Alanna M Chamberlain, Behnam Sabayan, Steven G Johnson, Karen Margolis, Rebecca Rossom, Katherine Diaz Vickery, Tyler N A Winkelman","doi":"10.1007/s11606-025-09814-x","DOIUrl":"10.1007/s11606-025-09814-x","url":null,"abstract":"<p><strong>Background: </strong>Public health data systems have limited ability to provide timely, population-level information for people with severe and multiple disadvantages, such as individuals with recent homelessness or incarceration.</p><p><strong>Objective: </strong>To generate prevalence estimates for physical health, mental health, and substance use conditions in a statewide cohort that included individuals with recent incarceration or homelessness.</p><p><strong>Design: </strong>This observational cohort analysis was completed in July 2025 and used linked statewide electronic health record (EHR) and administrative data through the Minnesota Electronic Health Record Consortium (MNEHRC) and its Health Trends Across Communities project.</p><p><strong>Participants: </strong>Adults with an encounter at a MNEHRC-participating health system between 2021-2023.</p><p><strong>Main measures: </strong>Statewide directly standardized, age and sex-adjusted, prevalence rates of 22 health conditions chosen by public health, healthcare, and research leaders in Minnesota, stratified by recent homelessness, jail incarceration, or prison incarceration.</p><p><strong>Key results: </strong>This cohort included 4,362,645 individuals (53% female, 73% white), including 20,139 individuals with recent homelessness, 51,470 individuals with recent jail incarceration, and 4,889 individuals with recent prison incarceration. Individuals with recent homelessness or jail or prison incarceration had a higher prevalence of asthma (14.9%, 9.6%, 10.1% respectively, vs. 7.1%) and COPD (10.5%, 6.1%, 5.5%, respectively, vs. 3.0%) compared to the general population. Individuals with recent homelessness had the highest rates of mental health disorders compared to other included groups; recently homeless Black individuals had the highest recorded rates of psychotic disorder diagnoses (18.7%) across racial and ethnic groups experiencing homelessness. Substance use disorders among individuals with recent homelessness or jail or prison incarceration, including opioid use disorder (13.9%, 10.6%, and 13.6%, respectively, vs. 1.4%), were higher compared to the general population.</p><p><strong>Conclusions: </strong>Our findings highlight widespread disparities among people with recent homelessness or incarceration, particularly related to mental health and substance use conditions. Payment and delivery models that account for high levels of co-occurring health and social complexity are needed.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":""},"PeriodicalIF":4.2,"publicationDate":"2025-09-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144956861","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":"Inequities in Opioid Administration by Race and Ethnicity for Hospitalized Patients With and Without Substance Use Disorders.","authors":"Aksharananda Rambachan, Margaret C Fang","doi":"10.1007/s11606-025-09514-6","DOIUrl":"10.1007/s11606-025-09514-6","url":null,"abstract":"<p><strong>Background: </strong>Adequate pain management is challenging in patients with substance use disorders, particularly those from racial/ethnic minority groups who face intersecting biases.</p><p><strong>Objective: </strong>To investigate inequities in pain management for racial/ethnic minority groups with and without concurrent substance use disorders.</p><p><strong>Design: </strong>Retrospective cohort study from 2021 to 2022 on an acute care general medicine service at UCSF Medical Center.</p><p><strong>Participants: </strong>All adults ≥ 18 years old.</p><p><strong>Exposures: </strong>Primary exposure was the patient's self-identified race/ethnicity (Asian, Black or African American, Latino, Multi-Race/Ethnicity, Native American or Alaska Native, Native Hawaiian or Pacific Islander, Southwest Asian or North African, White, Other, and Unknown/Declined).</p><p><strong>Main outcome and measures: </strong>The primary outcome was average daily inpatient opioids received (morphine milligram equivalents, MME). Multivariable negative binomial regression assessed the relationship between self-reported race/ethnicity and opioid administration, adjusting for demographics, clinical factors, substance use disorders, and pain characteristics. The subgroup analyses focused on patients with substance use disorders and on patients without any buprenorphine or methadone prescriptions.</p><p><strong>Key results: </strong>In the overall cohort of 13,058 hospitalizations (mean age 62.7 years, 51.2% male, 31.3% with substance use disorder), patients from racial/ethnic minority groups received significantly fewer opioids than White patients in adjusted analyses: Asian (- 61.3 MME/day), Black (- 44.9 MME/day), Latino (- 48.8 MME/day), Native American/Alaska Native (- 80.4 MME/day), and Native Hawaiian/Pacific Islander (- 72.9 MME/day). Similar, significant disparities were present in both subgroups. Notably, in the substance use disorder-only subgroup (n = 4446), larger disparities persisted for Asian (- 124.4 MME/day), Black (- 68.7 MME/day), and Latino (- 110.8 MME/day) patients compared to White patients.</p><p><strong>Conclusions: </strong>Substantial racial/ethnic inequities in inpatient opioid prescribing for pain control were observed, particularly among patients with concurrent substance use disorders. These findings highlight the need for interventions promoting equitable, culturally competent pain management for marginalized populations facing intersecting biases and stigma.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":"2944-2952"},"PeriodicalIF":4.2,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12463787/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143995946","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Primary Care Patient and Clinician Perspectives on Safer Use Strategies for Opioids and/or Stimulants: A Mixed-Method Study.","authors":"Brittany E Blanchard, Elizabeth J Austin, Erin Chase, Julien Rouvere, Vinita Sharma, Morgan Johnson, Nichole Sams, Florence Williams, Madeline C Frost, Sarah Leyde, Judith I Tsui, Susan E Collins, John C Fortney","doi":"10.1007/s11606-025-09418-5","DOIUrl":"10.1007/s11606-025-09418-5","url":null,"abstract":"<p><strong>Introduction: </strong>Safer use strategies (SUS) are behaviors before, during, and after drug use to moderate use and/or mitigate unwanted consequences. As treatment of substance use disorders becomes more common in primary care, offering SUS in primary care merits exploration.</p><p><strong>Method: </strong>We explored acceptability and use of SUS in primary care using a convergent parallel mixed-method design consisting of patient and clinician semi-structured interviews and surveys. Participants were recruited from primary care clinics involved in a multi-state practice research network. Patients with lifetime stimulant and/or opioid and any SUS use were eligible. All clinicians were eligible. Qualitative data were analyzed using a rapid assessment procedure. Quantitative data were analyzed descriptively.</p><p><strong>Results: </strong>Participants included patients (n = 10) and clinicians (n = 12) from multiple disciplines. More than half of patients indicated that every SUS surveyed should be offered in primary care. Patients reported using multiple SUS to stay safer, reduce consequences, and limit use. Clinicians reported that offering SUS to primary care patients is acceptable and supported SUS use by sharing informational resources (e.g., safer injection practices) and tangible resources (e.g., naloxone, medication for opioid use disorder [MOUD]). Some strategies recommended by patients were not currently being systematically offered (e.g., fentanyl test strips). Several clinicians expressed willingness to discuss SUS with patients but wanted more training and resources to facilitate SUS discussions to support patient goals.</p><p><strong>Conclusion: </strong>Offering SUS to primary care patients is acceptable to patients and clinicians. Clinicians supported some SUS use, though more SUS and harm reduction training and resources were desired. Providing SUS to patients who use stimulants and/or opioids could enhance patient-centered primary care, especially in clinics offering MOUD. More research is needed to optimize SUS support in primary care settings.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":"2953-2961"},"PeriodicalIF":4.2,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12463806/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143557002","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"\"Just Be Relentless,\" Lessons Learned from In-Hospital Addiction Consult Service Implementation.","authors":"Beth E Williams, Alisa Patten, Linda Peng, Honora Englander","doi":"10.1007/s11606-024-09263-y","DOIUrl":"10.1007/s11606-024-09263-y","url":null,"abstract":"<p><strong>Background: </strong>Hospitalization is a \"reachable\" moment to engage people in addiction care. Addiction consult services (ACSs) have been shown to improve outcomes for hospitalized patients with substance use disorders (SUDs). Despite this, most hospital systems do not provide hospital-based addiction care or have an ACS.</p><p><strong>Objective: </strong>Characterize implementation barriers, lessons learned, and opportunities for future support of ACS implementation.</p><p><strong>Design and participants: </strong>Semi-structured qualitative interviews with 17 \"champions\" leading ACS implementation at 11 institutions across the U.S.</p><p><strong>Approach: </strong>Interviews explored evolution of ACSs, including staffing, service delivery, strategic planning, and barriers and facilitators to implementation. Reflexive thematic analysis was applied to identify emergent themes.</p><p><strong>Key results: </strong>Five dominant themes characterize ACS implementation: (1) how champions obtain buy-in from hospital leadership. Participants described the impression that ACSs are not revenue-generators as a barrier to implementation and found ways to capture monetary and non-monetary outcomes to demonstrate value; (2) specific attributes are common to ACS champions including persistence, good communication, and leadership skills. ACS champions described needing to communicate strategically with multiple stakeholders across their institution and often pitched their case multiple times before obtaining funding; (3) reliance on external resources. This included informal coaching from other ACS leaders and formal tools such as telementoring networks and published literature to learn to engage leadership and present a business case; (4) ACSs are important drivers of cultural change within institutions in the face of significant stigma and; (5) planning for sustainability. This included demonstrating improved quality of care and patient and provider satisfaction to obtain ongoing support for ACS.</p><p><strong>Conclusions: </strong>Barriers to ACS implementation are common and significant and the process of obtaining leadership support for implementation is often long and iterative. Broad adoption of ACSs will require support from hospital systems and policymakers including incentives, funding, and infrastructure to support clinical champions.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":"2916-2925"},"PeriodicalIF":4.2,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12463784/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142950141","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Fentanyl Initiation Rate Following the Requirement for Specialist Approval.","authors":"Oren Miron, Yael Wolff-Sagy, Mark Levin, Esti Lubich, Jordan Lewinski, Maya Shpunt, Wiessam Abu Ahmad, Ilya Borochov, Doron Netzer, Gil Lavie","doi":"10.1007/s11606-024-09160-4","DOIUrl":"10.1007/s11606-024-09160-4","url":null,"abstract":"<p><strong>Background: </strong>Healthcare organizations attempt to address unwarranted fentanyl use, which often leads to increased risk of addiction and overdose.</p><p><strong>Objective: </strong>To assess the impact of a requirement for a specialist's approval on fentanyl initiation for non-oncological pain.</p><p><strong>Design: </strong>A retrospective cohort study based on observational data.</p><p><strong>Participants: </strong>All 4.4 million non-oncological members of Clalit Health Services were included, from July 20, 2021, to July 19, 2023.</p><p><strong>Main measures: </strong>The rate of fentanyl initiation was assessed before and after the implementation of the requirement for specialist's approval, which was introduced on July 2022, and expanded 6 months later for continued use. A sub-group analysis by age group was performed, and patient characteristics and indications were assessed. We also compared total opioid dispensation in the 6th and 12th months after the implementation with the predicted rate based on pre-implementation rates.</p><p><strong>Key results: </strong>Fentanyl initiation rate in the year before the requirement was 711 per million capita, which decreased following the requirement by - 81% (95% CI: - 77%; - 85%). The decrease attenuated with age. The prevalence of diagnosis with substance abuse disorders at the time of fentanyl initiation decreased from 6 to 3%. In the 6th and 12th months after the requirement was implemented, the morphine milligram equivalent (MME) from dispensation of total opioids was lower than predicted based on pre-implementation rates by 7% and 26%, respectively.</p><p><strong>Conclusions: </strong>Requiring specialist approval for fentanyl initiation for non-oncological chronic pain was associated with a decrease in fentanyl prescription initiations, especially among non-elderly patients. A decrease also occurred gradually in total opioid dispensations, further decreasing following the extension of the requirement to continuous fentanyl. The requirement for specialist approval upon fentanyl initiation and continuous fentanyl may present an effective tool for limiting the use of fentanyl and total opioids in healthcare systems.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":"3097-3103"},"PeriodicalIF":4.2,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12508242/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142568788","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Baseline Housing Stability Positively Impacts the Effect of an Ambulatory Intensive Care Unit on Decreasing Hospitalization Rates.","authors":"Anna Geduldig, Priya Srikanth, Meg Devoe, Richard Bruno, Samuel T Edwards, Somnath Saha, Brian Chan","doi":"10.1007/s11606-025-09361-5","DOIUrl":"10.1007/s11606-025-09361-5","url":null,"abstract":"","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":"3263-3266"},"PeriodicalIF":4.2,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12508312/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143449317","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Impact of COVID-19 on US Academic Medical Centers: Implications for General Medicine Service Lines.","authors":"Natalie Caylor, David W Walsh, Ding Xie, Jennifer L Waller, Thad Wilkins","doi":"10.1007/s11606-025-09439-0","DOIUrl":"10.1007/s11606-025-09439-0","url":null,"abstract":"","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":"3273-3275"},"PeriodicalIF":4.2,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12508353/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143501678","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}