Showing papers in "Journal of General Internal Medicine in 2014"
TL;DR: This study indicates that opportunities for suicide prevention exist in primary care and medical settings, where most individuals receive services prior to death, and may target improved identification of mental illness and suicidal ideation.
Abstract: BACKGROUND
Suicide prevention is a public health priority, but no data on the health care individuals receive prior to death are available from large representative United States population samples.
441 citations
TL;DR: To stimulate discussion of outmoded thinking regarding the conduct of research, a list of six misconceptions about research that persist long after their flaws have become apparent are listed.
Abstract: Scientific knowledge changes rapidly, but the concepts and methods of the conduct of research change more slowly. To stimulate discussion of outmoded thinking regarding the conduct of research, I list six misconceptions about research that persist long after their flaws have become apparent. The misconceptions are: 1) There is a hierarchy of study designs; randomized trials provide the greatest validity, followed by cohort studies, with case–control studies being least reliable. 2) An essential element for valid generalization is that the study subjects constitute a representative sample of a target population. 3) If a term that denotes the product of two factors in a regression model is not statistically significant, then there is no biologic interaction between those factors. 4) When categorizing a continuous variable, a reasonable scheme for choosing category cut-points is to use percentile-defined boundaries, such as quartiles or quintiles of the distribution. 5) One should always report P values or confidence intervals that have been adjusted for multiple comparisons. 6) Significance testing is useful and important for the interpretation of data. These misconceptions have been perpetuated in journals, classrooms and textbooks. They persist because they represent intellectual shortcuts that avoid more thoughtful approaches to research problems. I hope that calling attention to these misconceptions will spark the debates needed to shelve these outmoded ideas for good.
341 citations
TL;DR: Stakeholder engagement was more common in earlier (prioritization) than in later (implementation and dissemination) stages of research, and the roles and activities of stakeholders were highly variable across research and program reports.
Abstract: OBJECTIVES
We conducted a review of the peer-reviewed literature since 2003 to catalogue reported methods of stakeholder engagement in comparative effectiveness research and patient-centered outcomes research.
315 citations
TL;DR: The scope of crowdsourcing in health research is described and a taxonomy to characterize past uses of this methodology for health and medical research is created to provide clarity and comparability in methods is created.
Abstract: Objective
Crowdsourcing research allows investigators to engage thousands of people to provide either data or data analysis. However, prior work has not documented the use of crowdsourcing in health and medical research. We sought to systematically review the literature to describe the scope of crowdsourcing in health research and to create a taxonomy to characterize past uses of this methodology for health and medical research.
291 citations
TL;DR: There is substantial evidence that audit and feedback can effectively improve quality of care, but little evidence of progress in the field when investigators test quality improvement interventions that do not build upon, or contribute toward, extant knowledge.
Abstract: BACKGROUND
This paper extends the findings of the Cochrane systematic review of audit and feedback on professional practice to explore the estimate of effect over time and examine whether new trials have added to knowledge regarding how optimize the effectiveness of audit and feedback.
275 citations
TL;DR: The purpose of this review is to describe the A1c measurement, outline clinical scenarios or factors that may yield false results, and describe alternative laboratory biomarkers.
Abstract: Since the beginning of clinical use in the 1970s, hemoglobin A1c (A1c) has become the standard tool for monitoring glycemic control in patients with diabetes. The role of the A1c test was broadened in 2010, when the American Diabetes Association added A1c as a diagnostic criterion for diabetes. Because of hemoglobin A1c’s integral role in diagnosis and treatment, it is important to recognize clinical scenarios and interfering factors that yield false results. The purpose of this review is to describe the A1c measurement, outline clinical scenarios or factors that may yield false results, and describe alternative laboratory biomarkers.
187 citations
TL;DR: Global evidence for racism among healthcare providers from 1995 onwards is reviewed, as well as comparing existing measurement approaches to emerging best practice, it focuses on the assessment of interpersonal racism, rather than internalized or systemic/institutional racism.
Abstract: BACKGROUND
Although considered a key driver of racial disparities in healthcare, relatively little is known about the extent of interpersonal racism perpetrated by healthcare providers, nor is there a good understanding of how best to measure such racism.
185 citations
TL;DR: The addition of a highly partnered IF strategy to national level support resulted in greater Reach and Adoption of the mandated PC-MHI initiative, thereby increasing patient access to VA mental health care.
Abstract: BACKGROUND
Implementing new programs and practices is challenging, even when they are mandated. Implementation Facilitation (IF) strategies that focus on partnering with sites show promise for addressing these challenges.
164 citations
TL;DR: RD-Connect is a global infrastructure project initiated in November 2012 that links genomic data with registries, biobanks, and clinical bioinformatics tools to produce a central research resource for rare diseases.
Abstract: Research into rare diseases is typically fragmented by data type and disease Individual efforts often have poor interoperability and do not systematically connect data across clinical phenotype, genomic data, biomaterial availability, and research/trial data sets Such data must be linked at both an individual-patient and whole-cohort level to enable researchers to gain a complete view of their disease and patient population of interest Data access and authorization procedures are required to allow researchers in multiple institutions to securely compare results and gain new insights Funded by the European Union's Seventh Framework Programme under the International Rare Diseases Research Consortium (IRDiRC), RD-Connect is a global infrastructure project initiated in November 2012 that links genomic data with registries, biobanks, and clinical bioinformatics tools to produce a central research resource for rare diseases
162 citations
TL;DR: The high unsatisfactory sample prevalence among female-to-male (FTM) transgender patients is likely due to a combination of physical changes induced by testosterone therapy and provider/patient discomfort with the exam.
Abstract: BACKGROUND
Little is known about whether and how screening for cancers of natal reproductive structures, including cervical cancer, in female-to-male (FTM) transgender individuals differs from cancer screening among non-transgender females.
161 citations
TL;DR: The BHLS, administered by nurses during routine clinical care, demonstrates adequate reliability and validity to be used as a health literacy measure.
Abstract: BACKGROUND
The three-item Brief Health Literacy Screen (BHLS) has been validated in research settings, but not in routine practice, administered by clinical personnel.
TL;DR: SLower burnout may be achieved by medical home models that are appropriately staffed, emphasize participatory decision making, and increase the proportion of time team members spend working to the top of their competency level.
Abstract: BACKGROUND
A high proportion of the US primary care workforce reports burnout, which is associated with negative consequences for clinicians and patients. Many protective factors from burnout are characteristics of patient-centered medical home (PCMH) models, though even positive organizational transformation is often stressful. The existing literature on the effects of PCMH on burnout is limited, with most findings based on small-scale demonstration projects with data collected only among physicians, and the results are mixed.
TL;DR: How interactions among conditions result in clinical complexity and may affect quality of care is described, and how this comorbidity interrelatedness influences the value of existing quality guidelines and performance metrics is discussed.
Abstract: Multimorbidity—the presence of multiple chronic conditions in a patient—has a profound impact on health, health care utilization, and associated costs. Definitions of multimorbidity in clinical care and research have evolved over time, initially focusing on a patient’s number of comorbidities and the associated magnitude of required care processes, and later recognizing the potential influence of comorbidity characteristics on patient care and outcomes. In this article, we review the relationship between multimorbidity and quality of care, and discuss how this relationship may be mediated by the degree to which conditions interact with one another to generate clinical complexity (comorbidity interrelatedness). Drawing on established theoretical frameworks from cognitive engineering and biomedical informatics, we describe how interactions among conditions result in clinical complexity and may affect quality of care. We discuss how this comorbidity interrelatedness influences the value of existing quality guidelines and performance metrics, and describe opportunities to quantify this construct using data widely available through electronic health records. Incorporating comorbidity interrelatedness into conceptualizations of multimorbidity has the potential to enhance clinical and research efforts that aim to improve care for patients with multiple chronic conditions.
TL;DR: To combat burnout, organizations need to identify stress in its earlier stages, and choose programs to prevent burnout before it occurs, and following this quality improvement (QI) model for organizational self-care can produce a sustainable workplace for clinicians, with high quality and accessible care for patients.
Abstract: Physician burnout is an escalating problem receiving little attention from health care leaders. Burnout is a long-term stress reaction which includes emotional exhaustion, depersonalization, and a lack of sense of personal accomplishment. Physician burnout rates range from 30–65 % across medical specialties, with the highest rates experienced by those at the front line of care, including emergency medicine and general internal medicine.1 Recruitment of medical students into general internal medicine is worrisomely low, and may relate in part to the perceived stressfulness of a primary care career. Addressing burnout among general internists is a national imperative, as health care reform necessitates greater reliance on primary care.
Burnout poses problems for both health care organizations and patients. While burned-out physicians attempt to maintain quality of care at their own expense, work conditions that result in burnout are associated with poorer care quality.2 Burned out doctors are more likely to leave their practice, thus reducing access to care. Turnover sacrifices continuity, and replacement costs are at least $250,000 per primary care physician. Satisfied role models could make a difference in this steady drain on primary care, but it is getting harder to find them. The situation may be no better for hospitalist physicians, for whom burnout is also common.3 Women physicians in national surveys have a 60 % higher burnout rate than that seen in men, yet the workplace remains largely unmindful of gender as a predictor of burnout. And despite known work condition challenges that contribute to burnout in clinics serving minority patients, few if any changes have occurred to improve this situation. Finally, models to prevent physician burnout are not well documented.
We offer suggestions for addressing these challenges. The fact that burnout is a long-term stress reaction allows time to measure and intervene. To combat burnout, organizations need to identify stress in its earlier stages (Fig. 1), and choose programs to prevent burnout before it occurs. Following this quality improvement (QI) model for organizational self-care can produce a sustainable workplace for clinicians, with high quality and accessible care for patients (see Table 1).
Figure 1.
Conceptual model of Ql feedback loop to prevent stress, burnout and turnover.
Table 1
Ten Steps to Prevent Physician Burnoutᅟ
TL;DR: Pregnancy complication was more likely to attend primary care visits post-delivery compared to the comparison group, but overall visit rates were low and innovative models for preventive health services after delivery are needed to target women at higher risk for chronic disease development.
Abstract: BACKGROUND
Because pregnancy complications, including gestational diabetes mellitus (GDM) and hypertensive disorders in pregnancy, are risk factors for diabetes and cardiovascular disease, post-delivery follow-up is recommended.
Tufts University1, Johns Hopkins University School of Medicine2, Johns Hopkins University3, Tufts Medical Center4, University of California, Irvine5, McMaster University6, Wake Forest University7, Icahn School of Medicine at Mount Sinai8, University of Texas Health Science Center at San Antonio9, Duke University10, University of California, San Francisco11, University of Cambridge12
TL;DR: A list of issues and possible approaches for addressing important coexisting conditions in each step of the guideline development process, with a focus on considering relevant interactions between the conditions, their treatments and their outcomes, is drafted.
Abstract: Many patients of all ages have multiple conditions, yet clinicians often lack explicit guidance on how to approach clinical decision-making for such people. Most recommendations from clinical practice guidelines (CPGs) focus on the management of single diseases, and may be harmful or impractical for patients with multimorbidity. A major barrier to the development of guidance for people with multimorbidity stems from the fact that the evidence underlying CPGs derives from studies predominantly focused on the management of a single disease. In this paper, the investigators from the Improving Guidelines for Multimorbid Patients Study Group present consensus-based recommendations for guideline developers to make guidelines more useful for the care of people with multimorbidity. In an iterative process informed by review of key literature and experience, we drafted a list of issues and possible approaches for addressing important coexisting conditions in each step of the guideline development process, with a focus on considering relevant interactions between the conditions, their treatments and their outcomes. The recommended approaches address consideration of coexisting conditions at all major steps in CPG development, from nominating and scoping the topic, commissioning the work group, refining key questions, ranking importance of outcomes, conducting systematic reviews, assessing quality of evidence and applicability, summarizing benefits and harms, to formulating recommendations and grading their strength. The list of issues and recommendations was reviewed and refined iteratively by stakeholders. This framework acknowledges the challenges faced by CPG developers who must make complex judgments in the absence of high-quality or direct evidence. These recommendations require validation through implementation, evaluation and refinement.
TL;DR: In this sample of veterans with no recent (24-month) history of depression or opioid analgesic use, the risk of development of depression increased as the duration of opioid analgesics exposure increased.
Abstract: BACKGROUND
Prescription opioid analgesic use has quintupled recently. Evidence linking opioid use with depression emanates from animal models and studies of persons with co-occurring substance use and major depression. Little is known about depressogenic effects of opioid use in other populations.
TL;DR: Patients’ perceptions of their relationships with providers, including lack of shared decision-making or trust, demonstrated strong associations with antidepressant non-adherence, and interventions for healthcare providers and systems that foster shared decisions and trust might improve medication adherence.
Abstract: BACKGROUND
Depression and adherence to antidepressant treatment are important clinical concerns in diabetes care. While patient–provider communication patterns have been associated with adherence for cardiometabolic medications, it is unknown whether interpersonal aspects of care impact antidepressant medication adherence.
TL;DR: Hospitalized adult medical patients in an urban academic safety net hospital with lower levels of Patient Activation had a higher rate of post-discharge 30-day hospital utilization.
Abstract: Patient activation is linked to better health outcomes and lower rates of health service utilization. The role of patient activation in the rate of hospital readmission within 30 days of hospital discharge has not been examined. A secondary analysis using data from the Project RED-LIT randomized controlled trial conducted at an urban safety net hospital. Data from 695 English-speaking general medical inpatient subjects were analyzed. We used an adapted, eight-item version of the validated Patient Activation Measure (PAM). Total scores were categorized, according to standardized methods, as one of four PAM levels of activation: Level 1 (lowest activation) through Level 4 (highest activation). The primary outcome measure was total 30-day post-discharge hospital utilization, defined as total emergency department (ED) visits plus hospital readmissions including observation stays. Poisson regression was used to control for confounding. Of the 695 subjects, 67 (9.6 %) were PAM Level 1, 123 (17.7 %) were Level 2, 193 (27.8 %) were Level 3, and 312 (44.9 %) were Level 4. Compared with highly activated patients (PAM Level 4), a higher rate of 30-day post-discharge hospital utilization was observed for patients at lower levels of activation (PAM Level 1, incident rate ratio [IRR] 1.75, 95 % CI,1.18 to 2.60) and (PAM Level 2, IRR 1.50, 95 % CI 1.06 to 2.13). The rate of returning to the hospital among patients at PAM Level 3 was not statistically different than patients with PAM Level 4 (IRR 1.30, 95 % CI, 0.94 to 1.80). The rate ratio for PAM Level 1 was also higher compared with Level 4 for ED use alone (1.68(1.07 to 2.63)) and for hospital readmissions alone (1.93 [1.22 to 3.06]). Hospitalized adult medical patients in an urban academic safety net hospital with lower levels of Patient Activation had a higher rate of post-discharge 30-day hospital utilization.
TL;DR: Evidence is synthesized about engagement of patients and other stakeholders in research on rare diseases, including the role of rare disease organizations in facilitating patient-centered research and the most effective approaches to engagement have not been well defined.
Abstract: BACKGROUND
Patients with rare diseases have limited access to useful information to guide treatment decisions. Engagement of patients and other stakeholders in clinical research may help to ensure that research efforts in rare diseases address relevant clinical questions and patient-centered health outcomes. Rare disease organizations may provide an effective means to facilitate patient engagement in research. However, the effectiveness of patient-engagement approaches, particularly for the study of rare diseases, has not been well studied.
TL;DR: Results demonstrate that treatment for an alcohol use disorder can be delivered effectively within primary care, leading to greater rates of engagement in treatment and greater reductions in heavy drinking.
Abstract: BACKGROUND
Alcohol use disorder is one of the leading causes of disability worldwide. Despite the availability of efficacious treatments, few individuals with an alcohol use disorder are actively engaged in treatment. Available evidence suggests that primary care may play a crucial role in the identification of patients with an alcohol use disorder, delivery of interventions, and the success of treatment.
TL;DR: SSystematically collecting exercise information during outpatient visits is associated with small but significant changes in exercise-related clinical processes and outcomes, and represents a valuable first step towards addressing the problem of inadequate physical activity.
Abstract: BACKGROUND
Lack of regular physical activity is highly prevalent in U.S. adults and significantly increases mortality risk.
TL;DR: It is hypothesized that this goal misalignment leads to a cycle of low achievement and loss of self-efficacy that may underlie poor post-hospital outcomes among low-SES patients.
Abstract: BACKGROUND
Patients with low socioeconomic status (low-SES) are at risk for poor outcomes during the post-hospital transition. Few prior studies explore perceived reasons for poor outcomes from the perspectives of these high-risk patients.
TL;DR: The first national unplanned readmission results demonstrating declining rates for all three conditions between 2009–2012 are reported, with AMI mortality continued to decline, pneumonia mortality was stable, and HF mortality experienced a small increase.
Abstract: BACKGROUND
The Centers for Medicare & Medicaid Services publicly reports risk-standardized mortality rates (RSMRs) within 30-days of admission and, in 2013, risk-standardized unplanned readmission rates (RSRRs) within 30-days of discharge for patients hospitalized with acute myocardial infarction (AMI), heart failure (HF), and pneumonia. Current publicly reported data do not focus on variation in national results or annual changes.
TL;DR: Financial exploitation of older adults is a common and serious problem and Elders from groups traditionally considered to be economically, medically, and sociodemographically vulnerable are more likely to self-report financial exploitation.
Abstract: BACKGROUND
Financial exploitation is the most common and least studied form of elder abuse. Previous research estimating the prevalence of financial exploitation of older adults (FEOA) is limited by a broader emphasis on traditional forms of elder mistreatment (e.g., physical, sexual, emotional abuse/neglect).
TL;DR: This work describes the internal medicine residency curriculum and assessment system, which uses entrustment and mapping of observable practice activities (OPAs) for resident assessment, and created discrete OPAs for each resident rotation and learning experience.
Abstract: Entrustable Professional Activities (EPAs) and the Next Accreditation System reporting milestones reduce general competencies into smaller evaluable parts. However, some EPAs and reporting milestones may be too broad to use as direct assessment tools. We describe our internal medicine residency curriculum and assessment system, which uses entrustment and mapping of observable practice activities (OPAs) for resident assessment. We created discrete OPAs for each resident rotation and learning experience. In combination, these serve as curricular foundation and tools for assessment. OPA performance is measured via a 5-point entrustment scale, and mapped to milestones and EPAs. Entrustment ratings of OPAs provide an opportunity for immediate structured feedback of specific clinical skills, and mapping OPAs to milestones and EPAs can be used for longitudinal assessment, promotion decisions, and reporting. Direct assessment and demonstration of progressive entrustment of trainee skill over time are important goals for all training programs. Systems that use OPAs mapped to milestones and EPAs provide the opportunity for achieving both, but require validation.
TL;DR: SA daily lottery incentive worth $1.40 per day improved monitoring rates relative to control and had significantly better efficacy once incentives were removed than a higher incentive.
Abstract: BACKGROUND
Home wireless device monitoring could play an important role in improving the health of patients with poorly controlled chronic diseases, but daily engagement rates among these patients may be low.
TL;DR: There is strong validity evidence for several published tools assessing teamwork in internal medicine, however, few teamwork assessments have been directly linked to patient outcomes.
Abstract: OBJECTIVE
Valid teamwork assessment is imperative to determine physician competency and optimize patient outcomes. We systematically reviewed published instruments assessing teamwork in undergraduate, graduate, and continuing medical education in general internal medicine and all medical subspecialties.
TL;DR: SSRI use is associated with modest improvement in the severity and frequency of hot flashes but can also be associated with the typical profile of SSRI adverse effects.
Abstract: Background
Hot flashes are the most commonly reported vasomotor symptom during the peri- and early post-menopausal period.
TL;DR: African Americans and men were less likely to have considered bariatric surgery and were lesslikely to have been recommended surgery by their doctors, and differences in how obesity affects QOL appear to account for some of these variations.
Abstract: Bariatric surgery is one of few obesity treatments to produce substantial weight loss but only a small proportion of medically-eligible patients, especially men and racial minorities, undergo bariatric surgery To describe primary care patients’ consideration of bariatric surgery, potential variation by sex and race, and factors that underlie any variation Telephone interview of 337 patients with a body mass index or BMI > 35 kg/m2 seen at four diverse primary care practices in Greater-Boston Patients’ consideration of bariatric surgery Of 325 patients who had heard of bariatric surgery, 34 % had seriously considered surgery Men were less likely than women and African Americans were less likely than Caucasian patients to have considered surgery after adjustment for sociodemographics and BMI Comorbid conditions did not explain sex and racial differences but racial differences dissipated after adjustment for quality of life (QOL), which tended to be higher among African American than Caucasian patients Physician recommendation of bariatric surgery was independently associated with serious consideration for surgery [OR 495 (95 % CI 281–870)], but did not explain variation in consideration of surgery across sex and race However, if recommended by their doctor, men were as willing and African American and Hispanic patients were more willing to consider bariatric surgery than their respective counterparts after adjustment Nevertheless, only 20 % of patients reported being recommended bariatric surgery by their doctor and African Americans and men were less likely to receive this recommendation; racial differences in being recommended surgery were also largely explained by differences in QOL High perceived risk to bariatric surgery was the most commonly cited barrier; financial concerns were uncommonly cited Single geographic region; examined consideration and not who eventually proceeded with bariatric surgery African Americans and men were less likely to have considered bariatric surgery and were less likely to have been recommended surgery by their doctors Differences in how obesity affects QOL appear to account for some of these variations High perceived risk rather than financial barrier was the major deterrent for patients