Journal of General Internal Medicine最新文献

{"title":"Effectiveness of a Population Health Intervention on Disparities in Hypertension Control: A Stepped Wedge Cluster Randomized Clinical Trial.","authors":"Andrew S Hwang, Yuchiao Chang, Sarah Matathia, Suzanne Brodney, Michael J Barry, Daniel M Horn","doi":"10.1007/s11606-024-08839-y","DOIUrl":"10.1007/s11606-024-08839-y","url":null,"abstract":"<p><strong>Background: </strong>Disparities in hypertension control across race, ethnicity, and language have been a long-standing problem in the United States.</p><p><strong>Objective: </strong>To assess whether a multi-pronged intervention can improve hypertension control for a target population and reduce disparities.</p><p><strong>Design: </strong>This stepped wedge cluster randomized trial was conducted at 15 adult primary care clinics affiliated with Massachusetts General Hospital. PCPs were randomized to receive the intervention in twelve groups.</p><p><strong>Participants: </strong>The target population was patients who met one of the following criteria based on self-identification: (1) Asian, Black, Indigenous, multi-racial, or other race; (2) Hispanic ethnicity; or (3) preferred language other than English. Reference population was White, English-speaking patients.</p><p><strong>Interventions: </strong>PCPs were given access to an online equity dashboard that displays disparities in chronic disease management and completed an equity huddle with population health coordinators (PHCs), which involved reviewing target patients whose hypertension was not well controlled. In addition, community health workers (CHWs) were available in some practices to offer additional support.</p><p><strong>Main measures: </strong>The primary outcome was change in the proportion of target patients meeting the hypertension control goal when comparing intervention and control periods.</p><p><strong>Key results: </strong>Of the 365 PCPs who were randomized, 311 PCPs and their 10,865 target patients were included in the analysis. The intervention led to an increase in hypertension control in the target population (RD 0.9%; 95% CI [0.3,1.5]) and there was a higher intervention effect in the target population compared to the reference population (DiD 2.1%; 95% CI [1.1, 3.1]).</p><p><strong>Conclusions: </strong>Utilizing data on disparities in quality outcome measures in routine clinical practice augmented by clinical support provided by PHCs and CHWs led to modest, but statistically significant, improvement in hypertension control among BIPOC, Hispanic, and LEP patients.</p><p><strong>Trial registration: </strong>ClinicalTrials.gov Identifier: NCT05278806.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":"3028-3034"},"PeriodicalIF":4.3,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11576672/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141306116","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":"Leisure-Time Physical Activity, Time Spent Sitting and Risk of Non-alcoholic Fatty Liver Disease: A Cross-Sectional Study in Puglia.","authors":"Isabella Franco, Antonella Bianco, Caterina Bonfiglio, Ritanna Curci, Angelo Campanella, Alberto Rubén Osella","doi":"10.1007/s11606-024-08804-9","DOIUrl":"10.1007/s11606-024-08804-9","url":null,"abstract":"<p><strong>Background: </strong>Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in the world. The increasingly sedentary lifestyle in recent years may have accelerated the development of NAFLD, independent of the level of physical activity.</p><p><strong>Objective: </strong>The purpose of this cross-sectional study was to determine the association between leisure-time physical activity (LTPA) and time spent sitting (TSS) and the likelihood of developing NAFLD in a sample of men and women aged 18-64 years, from southern Italy.</p><p><strong>Design: </strong>The study is based on two cohort studies, a randomized clinical trial and an observational cost-benefit study.</p><p><strong>Participants: </strong>A total of 1269 participants (51.5% women) drawn from 3992 eligible subjects were enrolled in this study.</p><p><strong>Exposures: </strong>Leisure-time physical activity (LTPA) and time spent sitting (TSS) were assessed using the Italian long form of the International Physical Activity Questionnaire (IPAQ-LF), designed for administration to adults aged 18 to 65 years.</p><p><strong>Main measures: </strong>The association of exposures with the probability of belonging to a certain NAFLD degree of severity.</p><p><strong>Key results: </strong>The probability of having mild, moderate, and severe NAFLD tends to decrease with increasing LTPA and decreasing TSS levels. We selected a combination of participants aged 50 years and older stratified by gender. Men had a statistically significant difference in the probability of developing moderate NAFLD if they spent 70 h per week sitting and had low LTPA, while among women there was a statistically significant difference in the probability of developing mild or moderate NAFLD if they had moderate LPTA and spent 35-70 h/week sitting.</p><p><strong>Conclusions: </strong>The study thus showed that the amount of LTPA and the amount of TSS are associated with development and progression of NAFLD, but this relationship is not a linear one-especially in women aged ≥ 50 years old.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":"2788-2796"},"PeriodicalIF":4.3,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11534907/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141161840","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":"Barriers and Unmet Educational Needs Regarding Implementation of Medication Adherence Management Across Europe: Insights from COST Action ENABLE.","authors":"Gaye Hafez, Emma Aarnio, Sara Mucherino, Maria Kamusheva, Miriam Qvarnström, Ines Potočnjak, Indre Trečiokiene, Jovan Mihajlović, Marie Ekenberg, Job F M van Boven, Francisca Leiva-Fernández","doi":"10.1007/s11606-024-08851-2","DOIUrl":"10.1007/s11606-024-08851-2","url":null,"abstract":"<p><strong>Background: </strong>Medication adherence is essential for the achievement of therapeutic goals. Yet, the World Health Organization estimates that 50% of patients are nonadherent to medication and this has been associated with 125 billion euros and 200,000 deaths in Europe annually.</p><p><strong>Objective: </strong>This study aimed to unravel barriers and unmet training needs regarding medication adherence management across Europe.</p><p><strong>Design: </strong>A cross-sectional study was conducted through an online survey. The final survey contained 19 close-ended questions.</p><p><strong>Participants: </strong>The survey content was informed by 140 global medication adherence experts from clinical, academic, governmental, and patient associations. The final survey targeted healthcare professionals (HCPs) across 39 European countries.</p><p><strong>Main measures: </strong>Our measures were barriers and unmet training needs for the management of medication adherence across Europe.</p><p><strong>Key results: </strong>In total, 2875 HCPs (pharmacists, 40%; physicians, 37%; nurses, 17%) from 37 countries participated. The largest barriers to adequate medication adherence management were lack of patient awareness (66%), lack of HCP time (44%), lack of electronic solutions (e.g., access to integrated databases and uniformity of data available) (42%), and lack of collaboration and communication between HCPs (41%). Almost all HCPs pointed out the need for educational training on medication adherence management.</p><p><strong>Conclusions: </strong>These findings highlight the importance of addressing medication adherence barriers at different levels, from patient awareness to health system technology and to fostering collaboration between HCPs. To optimize patient and economic outcomes from prescribed medication, prerequisites include adequate HCP training as well as further development of digital solutions and shared health data infrastructures across Europe.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":"2917-2926"},"PeriodicalIF":4.3,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11576669/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141468520","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":"Some Perceptions Differ, Match Outcomes Do Not: A Multisite Retrospective Cross-Sectional Comparison of Virtual vs. In-Person Recruitment.","authors":"Anjali J Das, Anisha S Das, Scott D Rothenberger, Rachel A Bonnema, Kyle J Kent, Jennifer A Corbelli","doi":"10.1007/s11606-024-08723-9","DOIUrl":"10.1007/s11606-024-08723-9","url":null,"abstract":"<p><strong>Background: </strong>Virtual interviewing for residency provides considerable savings. Its impact on match outcomes remains unclear.</p><p><strong>Objective: </strong>Evaluate the impact of virtual residency recruitment on program and applicant assessment and match outcomes.</p><p><strong>Design: </strong>Cross-sectional survey, September 2020-July 2021 PARTICIPANTS: Faculty interviewers and 2019 and 2020 PGY-1 classes at three academic internal medicine residencies.</p><p><strong>Main measures: </strong>Survey items rating effectiveness of interview format, preference for future interview format, and perceived impact on diversity.</p><p><strong>Key results: </strong>A total of 247/436 faculty (57%) interviewers responded. Faculty perceived that in-person interviews enhanced applicant assessment (3.23 ± 0.38, p < 0.01) and recruitment of the most qualified applicants (p < 0.01) but did not impact recruitment of a racially or gender diverse class (3.03 ± 0.99, p = 0.95 and 3.09 ± 0.76, p = 0.14 respectively). They also did not demonstrate a preference for future interview formats. A total of 259/364 matched applicants responded, corresponding to a 76% response rate in the in-person cohort and a 66% response rate for virtual. Trainees were equally likely to match at their top choice when interviewing virtually vs. in-person (p = 0.56), and racial/ethnic and gender composition of the incoming class also did not differ (p = 0.81 and p = 0.19 respectively). Trainees perceived many aspects of the institution were better assessed in-person, though the impact varied according to assessment domain. Trainees who interviewed in-person preferred in-person formats. Of those who interviewed virtually, 47% preferred virtual and 54% preferred in-person. There were no predictors of virtual preference for future interview formats.</p><p><strong>Conclusions: </strong>Faculty and applicants who experienced virtual recruitment had no preference for future recruitment format. Virtual recruitment had no impact on the racial/gender diversity of matched classes or on applicants matching at their top-ranked institution. Institutions should consider the potential non-inferiority of virtual interviews with financial and other benefits when making decisions about future interview formats.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":"2910-2916"},"PeriodicalIF":4.3,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11576668/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141492310","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":"Disparities in Use of Novel Diabetes Medications by Insurance: A Nationally Representative Cohort Study.","authors":"Lurit Bepo, Oanh K Nguyen, Anil N Makam","doi":"10.1007/s11606-024-08961-x","DOIUrl":"10.1007/s11606-024-08961-x","url":null,"abstract":"<p><strong>Background: </strong>Minority racial and ethnic populations have the highest prevalence of type 2 diabetes mellitus but lower use of sodium-glucose co-transporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1ra), novel medications that reduce morbidity and mortality. Observed disparities may be due to differences in insurance coverage, which have variable cost-sharing, prior authorization, and formulary restrictions that influence medication access.</p><p><strong>Objective: </strong>To assess whether racial/ethnic differences in SGLT2i and GLP1ra use differ by payer.</p><p><strong>Design: </strong>Cross-sectional analysis of 2018 and 2019 Medical Expenditure Panel Survey data.</p><p><strong>Participants: </strong>Adults ≥ 18 years old with diabetes.</p><p><strong>Main measures: </strong>We defined insurance as private, Medicare, or Medicaid using ≥ 7 months of coverage in the calendar year. We defined race/ethnicity as White (non-Hispanic) vs non-White (including Hispanic). The primary outcome was use of ≥ 1 SGLT2i or GLP1ra medication. We used multivariable logistic regression to assess the interaction between payer and race/ethnicity adjusted for cardiovascular, socioeconomic, and healthcare access factors.</p><p><strong>Key results: </strong>We included 4997 adults, representing 24.8 million US adults annually with diabetes (mean age 63.6 years, 48.8% female, 38.8% non-White; 33.5% private insurance, 56.8% Medicare, 9.8% Medicaid). In our fully adjusted model, White individuals with private insurance had significantly more medication use versus non-White individuals (16.1% vs 8.3%, p < 0.001), which was similar for Medicare beneficiaries but more attenuated (14.7% vs 11.0%, p = 0.04). Medication rates were similar among Medicaid beneficiaries (10.0% vs 9.0%, p = 0.74).</p><p><strong>Conclusions: </strong>Racial/ethnic disparities in novel diabetes medications were the largest among those with private insurance. There was no disparity among Medicaid enrollees, but overall prescription rates were the lowest. Given that disparities vary considerably by payer, differences in insurance coverage may account for the observed disparities in SGLT2i and GLP1ra use. Future studies are needed to assess racial/ethnic differences in novel diabetes use by insurance formulary restrictions and out-of-pocket cost-sharing.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":"2987-2994"},"PeriodicalIF":4.3,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11576692/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141860026","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":"Decision Support and Behavioral Health for Reducing High-Dose Opioids in Comorbid Chronic Pain, Depression and Anxiety: Stepped-Wedge Cluster Randomized Trial.","authors":"Eboni G Price-Haywood, Jeffrey H Burton, Jewel Harden-Barrios, Alessandra Bazzano, Lizheng Shi, John Lefante, Robert N Jamison","doi":"10.1007/s11606-024-08965-7","DOIUrl":"10.1007/s11606-024-08965-7","url":null,"abstract":"<p><strong>Background: </strong>High prevalence of depression or anxiety with opioid use for chronic pain complicates co-management and may influence prescribing behaviors.</p><p><strong>Objective: </strong>Compare clinical effectiveness of electronic medical record clinical decision support (EMR-CDS) versus additional behavioral health (BH) care management for reducing rates of high-dose opioid prescriptions.</p><p><strong>Design: </strong>Type 2 effectiveness-implementation hybrid stepped-wedge cluster randomized trial in 35 primary care clinics within a health system in LA, USA.</p><p><strong>Participants: </strong>Patients aged 18+ receiving chronic opioid therapy for non-cancer pain with depression or anxiety and matched controls.</p><p><strong>Intervention: </strong>EMR-CDS included opioid risk mitigation procedures. BH care included cognitive behavioral therapy; depression or anxiety medication adjustments; and case management.</p><p><strong>Main measures: </strong>Outcomes of interest included difference-in-difference (DID) estimate of changes in probability for prescribing high-dose morphine equivalent daily dose (MEDD ≥50 mg/day and MEDD ≥90), average MEDD, and rates of hospitalization, emergency department use, and opioid risk mitigation.</p><p><strong>Key results: </strong>Most participants were female with 3+ pain syndromes. Data analysis included 632 patients. Absolute risk differences for MEDD≥50 and ≥90 decreased post-index compared to pre-index (DID of absolute risk difference [95%CI]: -0.036 [-0.089, 0.016] and -0.029 [-0.060, 0.002], respectively). However, these differences were not statistically significant. The average MEDD decreased at a higher rate for the BH group compared to EMR-CDS only (DID rate ratio [95%CI]: 0.85 [0.77, 0.93]). There were no changes in hospitalization and emergency department utilization. The BH group had higher probabilities of new specialty referrals and prescriptions for naloxone and antidepressants.</p><p><strong>Conclusions: </strong>Incorporation of a multidisciplinary behavioral health care team into primary care did not decrease high-dose prescribing; however, it improved adherence to clinical guideline recommendations for managing chronic opioid therapy for non-cancer pain.</p><p><strong>Trial registration: </strong>ClinicalTrials.gov ID NCT03889418.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":"2952-2960"},"PeriodicalIF":4.3,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11576687/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141878816","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":"National Comparison of Ambulatory Physician Electronic Health Record Use Across Specialties.","authors":"A Jay Holmgren, Christine A Sinsky, Lisa Rotenstein, Nate C Apathy","doi":"10.1007/s11606-024-08930-4","DOIUrl":"10.1007/s11606-024-08930-4","url":null,"abstract":"","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":"2868-2870"},"PeriodicalIF":4.3,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11534958/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141558917","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":"A Sip of Hot Chocolate.","authors":"Chloe O Zimmerman, Benjamin R Doolittle","doi":"10.1007/s11606-023-08453-4","DOIUrl":"10.1007/s11606-023-08453-4","url":null,"abstract":"","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":"2866-2867"},"PeriodicalIF":4.3,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11535115/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141579907","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":"Shortages of Essential Generic Drugs with Limited Competition.","authors":"Matthew J Martin, Benjamin N Rome, Aaron S Kesselheim, Hussain S Lalani","doi":"10.1007/s11606-024-08937-x","DOIUrl":"10.1007/s11606-024-08937-x","url":null,"abstract":"","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":"2871-2874"},"PeriodicalIF":4.3,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11534946/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141723761","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":"Complexities of Physician Workforce Projection: Call for a Unified National Healthcare Workforce Policy.","authors":"Amirala S Pasha, Meredith A Niess, David C Parish, Tracey Henry, V Ram Krishnamoorthi, Robert B Baron, Shaowei Wan","doi":"10.1007/s11606-024-08966-6","DOIUrl":"10.1007/s11606-024-08966-6","url":null,"abstract":"<p><p>Ensuring an adequate supply of physicians is paramount in securing the future of healthcare. To do so, accurate physician workforce predictions are needed to inform policymakers. However, the United States lacks such predictions from reliable sources. Several non-governmental organizations have actively been involved in attempting to quantify workforce needs, but they often employ opaque methodologies and are deeply conflicted, leading to potentially unreliable or biased results. Moreover, while federal and state entities invest approximately $15 billion annually in graduate medical education (GME) payments, they have very little control over how the funding is used to shape the future physician workforce. In this article, we review physician workforce predictions from both an international and a domestic perspective and finally discuss how the creation of an apolitical, data-driven, expert-led panel at the federal level with sufficient authority to influence broader workforce policy is the optimal solution for ensuring an adequate supply of physicians for generations to come.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":"3077-3081"},"PeriodicalIF":4.3,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11576690/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141792595","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}