JAMA Network Open最新文献

Importance: Accurate patient understanding of prognosis is essential for informed decision-making to pursue therapies for advanced heart failure (HF).

Objectives: To evaluate (1) patient characteristics associated with overestimating survival with HF and (2) whether overestimation is associated with mortality.

Design, setting, and participants: This prospective cohort study was an exploratory secondary analysis of data from the multicenter US Registry Evaluation of Vital Information for Ventricular Assist Devices (VADs) in Ambulatory Life (REVIVAL) study. Participants were high-risk ambulatory patients with HF with reduced ejection fraction enrolled from July 2015 to June 2016. Data were analyzed from December 1, 2024, to December 16, 2025.

Exposures: Patient characteristics (eg, age) and estimation index (EI), defined as the ratio of patient-estimated life expectancy to Seattle Heart Failure Model (SHFM)-estimated mean survival (EI <0.5, discordantly pessimistic; 0.5 to <1.5, concordant; and ≥1.5, discordantly optimistic).

Main outcomes and measures: Primary outcomes were EI and 2-year all-cause mortality. Factors associated with EI were estimated using ordered logistic regression. Association between EI and mortality was assessed using a cause-specific Cox proportional hazards regression model with VAD and heart transplant as censoring events.

Results: A total of 296 high-risk, ambulatory patients with chronic HF were included; 223 (75.3%) were male, and mean (SD) age was 60.1 (11.5) years. The median SHFM-estimated survival was 8.2 years (IQR, 5.1-12.1 years), and median patient-estimated life expectancy was 7.0 years (IQR, 5.0-10.0 years). In all, 98 patients (33.1%) were discordantly optimistic. Increasing EI was associated with increased mortality in the univariable model, which was attenuated with multivariable adjustment (adjusted hazard ratio [AHR] for concordant optimism, 1.21 [95% CI, 0.49-2.99] and for discordant optimism, 2.23 [95% CI, 0.94-5.33] vs discordant pessimism). Compared with discordantly pessimistic or concordantly optimistic estimates (EI <1.5), discordant optimism was associated with increased hazard of 2-year mortality (AHR, 1.98; 95% CI, 1.04-3.77) but a similar hazard for a VAD or heart transplant compared with discordant pessimism (HR, 1.24; 95% CI, 0.64-2.41) in a post hoc analysis.

Conclusions: In this cohort study, discordant optimism regarding life expectancy compared with model estimates was common and associated with mortality that was not due to a lower probability of receiving a heart transplant or VAD. The findings suggest clinicians should objectively evaluate HF risk when considering advanced therapies, rather than relying primarily on patient-reported symptoms.

Importance: Hospital-based opioid treatment (HBOT) can improve outcomes for patients with opioid use disorder, but little is known about specific attributes and supports needed for clinical champions to successfully implement HBOT.

Objective: To identify characteristics and supports of effective clinical champions implementing HBOT in US hospitals.

Design, setting, and participants: Qualitative study using postimplementation semistructured interviews conducted with individuals highly involved in HBOT implementation, including champions and hospital staff at 12 US community hospitals randomized to the high-intensity group of the Exemplar Hospital Initiation Trial to Enhance Treatment Engagement, a national implementation trial comparing low- and high-intensity HBOT implementation strategies. Interviews explored implementation experiences over 24 months from December 2021 to December 2023. Interviews were audio recorded, transcribed, and coded. The framework method and in-depth thematic analysis were used to explore the role of champions.

Interventions: All hospitals received a best-practices manual, video webinar series, and hub team support for questions, while hospitals randomized to the high-intensity group also received monthly practice facilitation, telementoring, and 10% effort funding for a local champion. Champions led HBOT implementation with support from regional hubs with HBOT expertise.

Measures: Effective champions were defined as those perceived by staff to successfully lead HBOT implementation. Open-ended questions and thematic analysis explored participants' perspectives on attributes of effective champions and how they overcame implementation barriers.

Results: A total of 31 hospital staff (15 physicians, 5 executives, 5 pharmacists, 2 nurse practitioners, 2 social workers, 1 nurse, and 1 addiction counselor) were interviewed. Effective champions were perceived as respected hospital "insiders" with institutional influence, persistence, and systems change skills. They built multidisciplinary teams, developed standard workflows, and used emotionally resonant strategies (eg, patient narratives) to overcome stigma and engage hospital leadership. Champions could be effective without addiction medicine expertise, particularly when provided with protected time, hospital leadership support, and external practice facilitation from addiction experts.

Conclusions and relevance: This multisite qualitative study underscores the vital role of champions in expanding hospital-based opioid care. To ensure HBOT expansion, hospitals should invest in champions, protected time, leadership backing, and external supports that legitimize and routinize evidence-based addiction care.

Importance: Private equity investment in US health care, including substance use disorder treatment, has grown. However, the implications of private equity acquisition of substance use disorder treatment facilities for buprenorphine access and quality of care are unknown.

Objective: To examine the associations of private equity acquisition of substance use disorder treatment facilities and buprenorphine prescribing patterns.

Design, setting, and participants: In this cross-sectional study using difference-in-differences analysis, aggregate prescription claims from an analytical dataset for buprenorphine from acquired substance use disorder treatment facilities were compared with those from nonacquired facilities from 2019 quarter 3 through 2021 quarter 2. Prescriptions for buprenorphine filled by adult individuals (aged >18 years) were included in the analyses. An event study difference-in-differences design was used to assess changes in buprenorphine prescribing characteristics at facilities from 4 quarters before to 4 quarters after acquisition using a linear model adjusted for facility, year, and treatment cohort characteristics. Analyses were performed from January 2025 to December 2025.

Main outcomes and measures: Patient volume, prescription volume, payer mix, and treatment retention duration.

Results: In a sample of 90 acquired facilities and 2374 never-acquired facilities, private equity acquisition was associated with increases in patient volumes. Acquisition was associated with a mean increase of 65.66 (95% CI, 30.57-100.76; P < .001) patients receiving buprenorphine per facility quarter. Similarly, acquisition was associated with a mean increase of 163.90 (95% CI, 47.07-280.73; P = .006) buprenorphine prescriptions per facility quarter. Acquisition was associated with an increase of 0.73 (95% CI, 0.07-1.40; P = .03) percentage points in prescriptions paid with cash compared with the control group. Other payer types were not associated with acquisition. Measures of treatment episode duration decreased after acquisition, with decreases of 6.24 (95% CI, -11.47 to -1.00; P = .02) percentage points in 90-day retention and 7.91 (95% CI, -13.96 to -1.86; P = .01) percentage points in 180-day retention.

Conclusion and relevance: In this study, the volume of patients treated with buprenorphine increased after private equity acquisition, with minimal changes in the payer mix among these patients. However, the quality of treatment, in terms of buprenorphine retention duration, decreased after acquisition. These results underscore the need for oversight mechanisms and continued research to ensure incentives for private investment in addiction care align with delivery of high-quality evidence-based treatment.