JAMA Network Open最新文献

Importance: The Glasgow Outcome Scale-Extended (GOS-E), Quality of Life After Brain Injury-Overall Scale (QOLIBRI-OS), and Patient Health Questionnaire-9 (PHQ-9) are commonly used to evaluate recovery after traumatic brain injury (TBI), but they may not fully reflect the lived experiences of older adults (≥65 years). As the population of older adult survivors of TBI grows, understanding the factors that shape recovery becomes increasingly important.

Objective: To explore how older adults adapt to life in the first year after TBI and whether qualitative analysis of patient and caregiver interviews identifies aspects of recovery not captured by conventional outcome measures.

Design, setting, and participants: This qualitative study used multiple-methods combining standardized surveys and semistructured interviews and was conducted from October 2023 to January 2025 at a level I trauma center in the US. Adults aged 65 years and older hospitalized for TBI were recruited through the institutional trauma registry and interviewed approximately 1 year after hospitalization. Patients with cognitive limitations could participate if a consenting caregiver proxy was available. Recruitment continued until theoretical saturation.

Main outcomes and measures: The primary outcome was qualitative findings from thematic analysis of semistructured interviews. Secondary outcomes were health-related quality of life (QOLIBRI-OS); scale of 0 to 100 with higher scores indicating better perceived quality of life, functional status (GOS-E); scale of 8 levels with higher levels indicating good recovery, and depressive symptoms (PHQ-9); scale of 0 to 27 with higher scores indicating severe depression.

Results: A total of 29 patients (12 [41.4%] female; mean [SD] age, 77.4 [7.2] years) and 13 caregivers participated in interviews and surveys, with 21 (73%) classified as having good recovery on GOS-E. Mean (SD) QOLIBRI-OS score was 70.1 (18.8), and median (IQR) PHQ-9 score was 4 (1-6). Three themes emerged from analysis of interviews: (1) influence of support systems on independence and quality of life; (2) adapting to postinjury life through grief, acceptance, and gratitude; and (3) desire for more information and guidance on life postinjury.

Conclusions and relevance: In this study, older adults and their caregivers reported that their post-TBI recovery was impacted by physical and emotional adaptation, caregiving dynamics, and understanding of their clinical course-factors not entirely reflected in standard outcome scales. These findings suggest that clear discharge counseling, structured caregiver education to maximize safety and independence, and regular follow-up could improve quality of life for older adults post-TBI.

Importance: Equity, diversity, and inclusion (EDI) initiatives are politically polarizing and increasingly adopted in the health care setting. Their broader impact across different health care career types, career stages, and various levels of education remains largely unknown.

Objective: To assess EDI programs and their associated outcomes within health care institutions.

Data sources: A Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020-compliant systematic review searching PubMed, Scopus, Web of Science, CINAHL, and PsychINFO databases from January 2010 to December 2023.

Study selection: Two independent reviewers screened studies that assessed EDI programs or policies in health care institutions.

Data extraction and synthesis: Programs were categorized based on reported outcomes, including participant satisfaction, increased awareness of EDI-related topics, increases in the proportion of underrepresented minority individuals within medical education or the health care workforce, and overall program impact. Odds ratios (ORs) were pooled using a random-effects model. Analyses followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. Analysis was conducted June 2025.

Main outcomes and measures: Outcome measures included the proportion of diversity among the workforce, employee and patient satisfaction, and the proportion of employees recruited and retained after program implementation.

Results: In total, 43 studies incorporating more than 15 000 individuals involved in EDI programs were included. Interventions were multifaceted, including 14 career advancement and training programs, 16 diversity representation programs, 11 academia and research support initiatives, and the growth of 2 pipeline programs. Furthermore, interventions demonstrated consistent improvement in EDI initiatives, with perceived benefit in promoting underrepresented minority populations. Findings from the meta-analysis of 2 studies showed that minority representation in competitive medical residencies increased after implementation of 2 EDI interventions (OR, 1.73; 95% CI, 1.21-2.47). Among the 43 studies included in the Joanna Briggs Institute assessment of methodological quality, 7 (16.3%) were rated as high quality, 20 (46.5%) as moderate quality, and 16 (37.2%) as low quality.

Conclusions and relevance: In this systematic review and meta-analysis of EDI initiatives in health care institutions, programs were associated with an increased workforce diversity. These findings support the continued use of EDI initiatives to promote a more inclusive and equitable health care culture.

Importance: Despite strong guideline support, single maintenance and reliever therapy (SMART) for asthma is underused in the US. Limited insurance coverage of SMART-compatible inhalers remains a major barrier to its adoption.

Objective: To compare the annual asthma management costs of SMART vs traditional therapy from a US health care payer perspective.

Design, setting, and participants: This economic evaluation used a probabilistic decision-tree model with Monte Carlo simulations to compare the total asthma management costs for patients prescribed SMART vs traditional therapy, conducting analyses from September 1, 2024, to March 13, 2025. Input data were extracted through a systematic review of 6 randomized clinical trials as well as current asthma guidelines.

Exposures: SMART vs traditional therapy.

Main outcomes and measures: The main outcome was annual asthma-related costs to health care payers. Model inputs, including exacerbation rates and expected inhaler utilization, were extracted from prior randomized clinical trials. Morbidity data and medication costs were obtained from national databases and inflated to 2024 US dollars. Analyses used a 1-year time horizon and were repeated with and without quality-adjusted life-years (QALYs) considered.

Results: The model includes 11 988 individuals with moderate to severe asthma who participated in the randomized clinical trials. For patients prescribed SMART, the estimated total annual cost of asthma management was $2181 (95% CI, $1606-$2939) per patient compared with $2235 (95% CI, $1595-$3267) for traditional therapy. SMART was associated with an incremental gain of 0.0006 QALYs (95% CI, 0.0003-0.0011 QALYs) per patient. SMART was less costly in 57% of simulations when QALYs were excluded, was more cost-effective in 67% of simulations when QALYs were included, and produced a mean incremental net monetary benefit of $118 (95% CI, -$344 to $663) per patient per year.

Conclusions and relevance: The findings of this economic analysis suggest that SMART was associated with modest cost savings and improved health outcomes compared with traditional asthma therapy. Given its cost-effectiveness, demonstrated effectiveness, and strong guideline endorsement, expanding insurance coverage of SMART may reduce asthma-related morbidity while lowering costs to US health care payers.