JAMA Network Open最新文献

Importance: Online review platforms offer valuable insights into patient satisfaction and the quality of health care services, capturing content and trends that traditional metrics might miss. The COVID-19 pandemic has disrupted health care services, influencing patient experiences.

Objective: To examine health care facility numerical ratings and patient experience reported on an online platform by facility type and area demographic characteristics after the COVID-19 pandemic (ie, post-COVID).

Design, setting, and participants: All reviews of US health care facilities posted on one online platform from January 1, 2014, to December 31, 2023, were obtained for this cross-sectional study. Analyses focused on facilities providing essential health benefits, which are service categories that health insurance plans must cover under the Affordable Care Act. Facility zip code tabulation area level demographic data were obtained from US census and rural-urban commuting area codes.

Main outcomes and measures: The primary outcome was the change in the percentage of positive reviews (defined as reviews with ≥4 of 5 stars) before and post-COVID. Secondary outcomes included the association between positive ratings and facility demographic characteristics (race and ethnicity and urbanicity), and thematic analysis of review content using latent Dirichlet allocation.

Results: A total of 1 445 706 reviews across 151 307 facilities were included. The percent of positive reviews decreased from 54.3% to 47.9% (P < .001) after March 2020. Rural areas, areas with a higher proportion of Black residents, and areas with a higher proportion of White residents experienced lower positive ratings post-COVID, while reviews in areas with a higher proportion of Hispanic residents were less negatively impacted (P < .001 for all comparisons). For example, logistic regression showed that rural areas had significantly lower odds of positive reviews post-COVID compared with urban areas (odds ratio, 0.77; 95% CI, 0.72-0.83). Latent Dirichlet allocation identified themes such as billing issues, poor customer service, and insurance handling that increased post-COVID among certain communities. For instance, areas with a higher proportion of Black residents and areas with a higher proportion of Hispanic residents reported increases in insurance and billing issues, while areas with a higher proportion of White residents reported increases in wait time among negative reviews.

Conclusions and relevance: This serial cross-sectional study observed a significant decrease in positive reviews for health care facilities post-COVID. These findings underscore a disparity in patient experience, particularly in rural areas and areas with the highest proportions of Black and White residents.

Importance: Chronic back and lower extremity pain is one of the leading causes of disability worldwide. Spinal cord stimulation (SCS) aims to improve symptoms and quality of life.

Objective: To evaluate the efficacy of SCS therapies compared with conventional medical management (CMM).

Data sources: MEDLINE, Embase, and Cochrane Library were systematically searched from inception to September 2, 2022.

Study selection: Selected studies were randomized clinical trials comparing SCS therapies with sham (placebo) and/or CMM or standard treatments for adults with chronic back or leg pain who had not previously used SCS.

Data extraction and synthesis: Evidence synthesis estimated odds ratios (ORs) and mean differences (MDs) and their associated credible intervals (CrI) through bayesian network meta-analysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline for network meta-analyses was followed.

Main outcomes and measures: The primary outcomes were pain-related end points, including pain intensity (measured by visual analog scale) and proportion of patients achieving at least 50% pain relief (responder rate) in the back or leg. Quality of life (measured by EQ-5D index score) and functional disability (measured by the Oswestry Disability Index score) were also considered.

Results: A total of 13 studies of 1561 patients were included in the network meta-analysis comparing conventional and novel SCS therapies with CMM across the 6 outcomes of interest at the 6-month follow-up. Both conventional and novel SCS therapies were associated with superior efficacy compared with CMM in responder rates in back (conventional SCS: OR, 3.00; 95% CrI, 1.49 to 6.72; novel SCS: OR, 8.76; 95% CrI, 3.84 to 22.31), pain intensity in back (conventional SCS: MD, -1.17; 95% CrI, -1.64 to -0.70; novel SCS: MD, -2.34; 95% CrI, -2.96 to -1.73), pain intensity in leg (conventional SCS: MD, -2.89; 95% CrI, -4.03 to -1.81; novel SCS: MD, -4.01; 95% CrI, -5.31 to -2.75), and EQ-5D index score (conventional SCS: MD, 0.15; 95% CrI, 0.09 to 0.21; novel SCS: MD, 0.17; 95% CrI, 0.13 to 0.21). For functional disability, conventional SCS was superior to CMM (MD, -7.10; 95% CrI, -10.91 to -3.36). No statistically significant differences were observed for other comparisons.

Conclusions and relevance: This systematic review and network meta-analysis found that SCS therapies for treatment of chronic pain in back and/or lower extremities were associated with greater improvements in pain compared with CMM. These findings highlight the potential of SCS therapies as an effective and valuable option in chronic pain management.

Importance: Although intensive follow-up of patients after curative surgery for colorectal cancer is common in clinical practice, evidence for a long-term survival benefit of more frequent testing is limited.

Objective: To examine overall and colorectal cancer-specific mortality rates in patients with stage II or III colorectal cancer who underwent curative surgery and underwent high-frequency or low-frequency follow-up testing.

Design, setting, and participants: This randomized clinical trial with posttrial prespecified follow-up was performed in 23 centers in Sweden and Denmark. The original study enrolled 2509 patients with stage II or III colorectal cancer from Sweden, Denmark, and Uruguay (1 center) who received treatment from January 1, 2006, through December 31, 2010, and were followed up for up to 5 years. The participants from Sweden and Denmark were then followed up for 10 years through population-based health registries. The 53 patients from Uruguay were not included in the posttrial follow-up. Statistical analysis was performed from March to June 2024.

Interventions: Patients were randomly allocated to follow-up testing with computed tomography (CT) scans and serum carcinoembryonic antigen (CEA) screening at 6, 12, 18, 24, and 36 months after surgery (high-frequency group; 1227 patients), or at 12 and 36 months after surgery (low-frequency group, 1229 patients).

Main outcomes and measures: The outcomes were 10-year overall mortality and colorectal cancer-specific mortality rates. Both intention-to-treat and per-protocol analyses were performed.

Results: Of the 2555 patients who were randomly allocated, 2509 were included in the intention-to-treat analysis, of whom 2456 (97.9%) were included in this posttrial analysis (median age, 65 years [IQR, 59-70 years]; 1355 male patients [55.2%]). The 10-year overall mortality rate for the high-frequency group was 27.1% (333 of 1227; 95% CI, 24.7%-29.7%) compared with 28.4% (349 of 1229; 95% CI, 26.0%-31.0%) in the low-frequency group (risk difference, 1.3% [95% CI, -2.3% to 4.8%]). The 10-year colorectal cancer-specific mortality rate in the high-frequency group was 15.6% (191 of 1227; 95% CI, 13.6%-17.7%) compared with 16.0% (196 of 1229; 95% CI, 14.0%-18.1%) in the low-frequency group (risk difference, 0.4% [95% CI, -2.5% to 3.3%]). The same pattern resulted from the per-protocol analysis.

Conclusions and relevance: Among patients with stage II or III colorectal cancer, more frequent follow-up testing with CT scans and CEA testing did not result in a significant reduction in 10-year overall mortality or colorectal cancer-specific mortality. The results of this trial should be considered as the evidence base for updating clinical guidelines.

Trial registration: ClinicalTrials.gov Identifier: NCT00225641.

Importance: The use of antipsychotics, antidepressants, and benzodiazepines may influence the risk of mortality in people with schizophrenia. However, many observational studies have not accounted for immortal time bias (ITB), which occurs when there is a period during which patients in the exposed group are necessarily alive and misclassified as exposed (the period between start of follow-up and initiation of drug). Ignoring ITB may lead to misinterpretation of the association between these drugs and mortality.

Objectives: To examine whether the cumulative dose of antipsychotics, antidepressants, and benzodiazepines is associated with mortality risk in patients with schizophrenia and discuss the potential impacts of ignoring ITB.

Design, setting, and participants: This cohort study used administrative data from Québec, Canada, including patients aged 17 to 64 years diagnosed with schizophrenia between January 1, 2002, and December 31, 2012. Data analysis was performed from June 22, 2022, to September 30, 2024.

Main outcomes and measures: The primary outcome was all-cause mortality, with follow-up from January 1, 2013, to December 31, 2017, or until death. Mortality risk was assessed for low, moderate, and high exposure to antipsychotics, antidepressants, and benzodiazepines. Cox proportional hazards regression models with time-fixed exposure (not controlling for ITB) and time-dependent exposure (controlling for ITB) were performed.

Results: The cohort included 32 240 patients (mean [SD] age, 46.1 [11.6] years; 19 776 [61.3%] men), of whom 1941 (6.0%) died during follow-up. No dose-response association was found for antipsychotics with mortality using the time-fixed method. However, high-dose antipsychotic use was associated with increased mortality after correcting for ITB (adjusted hazard ratio [AHR], 1.28; 95% CI, 1.07-1.55; P = .008). Antidepressants showed a reduced mortality risk using the time-fixed method, but only at high doses when correcting for ITB (AHR, 0.86; 95% CI, 0.74-1.00; P = .047). Benzodiazepines were associated with increased mortality risk regardless of the method.

Conclusions and relevance: The findings of this study do not dispute the known efficacy of antipsychotics in schizophrenia, but they call into question the magnitude of long-term mortality benefits.