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Redefining Acute Virtual Care for Overburdened Health Systems. 为不堪重负的医疗系统重新定义急诊虚拟护理。
IF 10.5 1区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-11-04 DOI: 10.1001/jamanetworkopen.2024.47359
Michael J Maniaci, Richard D Rothman, Jessica A Hohman
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引用次数: 0
Telehealth Brief Cognitive Behavioral Therapy for Suicide Prevention: A Randomized Clinical Trial. 预防自杀的远程健康简短认知行为疗法:随机临床试验
IF 10.5 1区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-11-04 DOI: 10.1001/jamanetworkopen.2024.45913
Justin C Baker, Austin Starkey, Ennio Ammendola, Christina Rose Bauder, Samantha E Daruwala, Jaryd Hiser, Lauren R Khazem, Keelin Rademacher, Jarrod Hay, AnnaBelle O Bryan, Craig J Bryan
<p><strong>Importance: </strong>Suicide rates continue to increase in the US. Evidence-based treatments for suicide risk exist, but their effectiveness when delivered via telehealth remains unknown.</p><p><strong>Objective: </strong>To test the efficacy of brief cognitive behavioral therapy (BCBT) for reducing suicide attempts and suicidal ideation among high-risk adults when delivered via telehealth.</p><p><strong>Design, setting, and participants: </strong>This 2-group parallel randomized clinical trial comparing BCBT with present-centered therapy (PCT) was conducted from April 2021 to September 2023 with 1-year follow-up at an outpatient psychiatry and behavioral health clinic located in the midwestern US. Participants reporting suicidal ideation during the past week and/or suicidal behavior during the past month were recruited from clinic waiting lists, inpatient service, intermediate care, research match, and direct referrals from clinicians. A total of 768 participants were invited to participate, 112 were assessed for eligibility, and 98 were eligible and randomly assigned to a treatment condition. Data analysis was from April to September 2024.</p><p><strong>Interventions: </strong>Participants received either BCBT, an evidence-based suicide-focused treatment that teaches emotion regulation and reappraisal skills, or PCT, a goal-oriented treatment that helps participants identify adaptive responses to stressors. Participants were randomized using a computerized stratified randomization algorithm with 2 strata (sex and history of suicide attempts).</p><p><strong>Main outcomes and measures: </strong>The primary outcome was suicide attempts as measured by the Self-Injurious Thoughts and Behaviors Interview-Revised. The secondary outcome was severity of suicidal ideation as measured by the Scale for Suicide Ideation.</p><p><strong>Results: </strong>Participants included 96 adults (mean [SD] age, 31.8 [12.6] years; 64 female [66.7%] and 32 male [33.3%]), with 51 receiving BCBT and 45 receiving PCT. Of all participants, 85 (88.5%) completed at least 1 session. From baseline to 12 months, 12 participants receiving PCT (estimated percentage, 35.6%) made 56 suicide attempts and 11 participants receiving BCBT (estimated percentage, 30.0%) made 36 suicide attempts. Participants randomized to BCBT made significantly fewer suicide attempts than participants randomized to PCT (mean [range], 0.70 [0.00-8.00] attempts per participant vs 1.40 [0.00-10.00] per participant) and had a 41% reduced risk for suicide attempts (hazard ratio, 0.59; 95% CI, 0.36-0.96; P = .03). Severity of suicidal ideation significantly decreased in both treatments (F4,330 = 50.1; P < .001) but did not differ between groups (F4,330  = 0.2; P = .91).</p><p><strong>Conclusions and relevance: </strong>The findings of this randomized clinical trial suggest that BCBT delivered via video telehealth is effective for reducing suicide attempts among adults with recent suicidal thoughts and
重要性:美国的自杀率持续上升。目前已有针对自杀风险的循证疗法,但通过远程医疗提供这些疗法的效果仍不清楚:目的:测试简短认知行为疗法(BCBT)通过远程医疗方式减少高危成人自杀企图和自杀意念的疗效:这项两组平行随机临床试验比较了简短认知行为疗法(BCBT)和以现在为中心的疗法(PCT),试验于 2021 年 4 月至 2023 年 9 月在美国中西部的一家精神病学和行为健康门诊进行,随访 1 年。报告在过去一周内有自杀意念和/或在过去一个月内有自杀行为的参与者是从诊所候诊名单、住院服务、中间护理、研究匹配和临床医生直接转介中招募的。共有 768 人受邀参加,112 人通过资格评估,98 人符合条件并被随机分配到治疗条件中。数据分析时间为 2024 年 4 月至 9 月:干预措施:参与者接受BCBT或PCT治疗,前者是一种以自杀为重点的循证治疗,教授情绪调节和重新评估技能;后者是一种目标导向型治疗,帮助参与者识别对压力的适应性反应。采用计算机分层随机化算法对参与者进行随机化,其中包括两个分层(性别和自杀未遂史):主要结果和测量方法:主要结果是自杀未遂,通过自伤想法和行为访谈-修订版进行测量。次要结果是自杀意念的严重程度,采用自杀意念量表进行测量:参与者包括 96 名成年人(平均 [SD] 年龄为 31.8 [12.6] 岁;64 名女性 [66.7%] 和 32 名男性 [33.3%]),其中 51 人接受了 BCBT 治疗,45 人接受了 PCT 治疗。在所有参与者中,85 人(88.5%)至少完成了一次治疗。从基线到 12 个月期间,12 名接受 PCT 的参与者(估计比例为 35.6%)有 56 次自杀企图,11 名接受 BCBT 的参与者(估计比例为 30.0%)有 36 次自杀企图。随机接受 BCBT 的参与者自杀未遂的次数明显少于随机接受 PCT 的参与者(平均 [范围],0.70 [0.00-8.00] 次/人 vs 1.40 [0.00-10.00] 次/人),自杀未遂的风险降低了 41%(危险比,0.59;95% CI,0.36-0.96;P = .03)。两种治疗方法的自杀意念严重程度均显著降低(F4,330 = 50.1;P 结论及意义:这项随机临床试验的结果表明,通过视频远程保健提供的 BCBT 能够有效减少近期有自杀想法和/或行为的成年人的自杀企图:试验注册:ClinicalTrials.gov Identifier:NCT04844294。
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引用次数: 0
Language Preference, Surgical Wait Time, and Outcomes Among Older Adults With Hip Fracture. 髋部骨折老年人的语言偏好、手术等待时间和疗效。
IF 10.5 1区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-11-04 DOI: 10.1001/jamanetworkopen.2024.48010
Christina Reppas-Rindlisbacher, Alexa Boblitz, Sho Podolsky, Robert A Fowler, Lauren Lapointe-Shaw, Kathleen A Sheehan, Therese A Stukel, Nathan M Stall, Paula A Rochon

Importance: Patients with a non-English language preference served within English-dominant health care settings are at increased risk of adverse events that may be associated with communication barriers and inequitable access to care.

Objective: To investigate the association of non-English language preference with surgical wait time and postoperative outcomes in older patients undergoing hip fracture repair.

Design, setting, and participants: This population-based, retrospective cohort study was conducted using linked databases to measure surgical wait time and postoperative outcomes among older adults (aged ≥66 years) in Ontario, Canada, who underwent hip fracture surgery between January 1, 2017, and December 31, 2022. Propensity-based overlap weighting accounting for baseline patient characteristics was used to compare primary and secondary outcomes.

Exposure: Non-English language preference.

Main outcomes and measures: The primary outcome was surgical delay beyond 24 hours. Secondary outcomes included time to surgery, surgical delay beyond 48 hours, postoperative medical complications, length of stay, discharge destination, 30-day mortality, and 30-day hospital readmission.

Results: Among 35 238 patients who underwent hip fracture surgery, 28 815 individuals (81.8%) were English speakers (mean [SD] age, 84.4 [8.0] years; 19 965 female [69.3%]) and 6423 individuals (18.2%) were non-English speakers (mean [SD] age, 85.5 [7.0] years; 4556 female [70.9%]). The median (IQR) wait time for surgery was similar for English (24 [16-41] hours) and non-English (25 [16-42] hours) speakers. There was no significant difference in surgical delay beyond 24 hours between English-speaking and non-English-speaking patients (3321 patients [51.7%] vs 14 499 patients [50.3%]; adjusted relative risk [aRR], 1.00; 95% CI, 0.98-1.03). Compared with English speakers, patients with a non-English language preference had increased risk of delirium (4207 patients [14.6%] vs 1209 patients [18.8%]; aRR, 1.10; 95% CI, 1.03-1.17), myocardial infarction (150 patients [0.5%] vs 43 patients [0.7%]; aRR, 1.52; 95% CI, 1.04-2.22), longer length of stay (median [IQR], 10 [6-17] vs 11 [7-20] days; aRR per 1-day increase, 1.11; 95% CI, 1.06-1.15), and more frequent discharge to a nursing home (1814 of 26 673 patients surviving to discharge [6.8%] vs 413 of 5903 patients surviving to discharge [7.0%]; aRR, 1.13; 95% CI, 1.01-1.27).

Conclusions and relevance: In this study of older adults with hip fracture, non-English language preference was associated with increased risk of delirium, myocardial infarction, longer length of stay, and discharge to a nursing home. These findings suggest inequities in hip fracture care for patients with a non-English language preference.

重要性:在以英语为主的医疗环境中,非英语语言偏好患者发生不良事件的风险增加,这可能与沟通障碍和获得医疗服务的机会不平等有关:调查接受髋部骨折修补术的老年患者非英语语言偏好与手术等待时间和术后结果的关系:这项基于人群的回顾性队列研究使用链接数据库来测量加拿大安大略省在 2017 年 1 月 1 日至 2022 年 12 月 31 日期间接受髋部骨折手术的老年人(年龄≥66 岁)的手术等待时间和术后效果。在比较主要和次要结果时,采用了基于倾向的重叠加权法,并考虑了患者的基线特征:主要结果是手术延迟超过 24 小时。次要结果包括手术时间、手术延迟超过 48 小时、术后医疗并发症、住院时间、出院目的地、30 天死亡率和 30 天再入院率:在接受髋部骨折手术的 35 238 名患者中,28 815 人(81.8%)为英语使用者(平均 [SD] 年龄 84.4 [8.0] 岁;女性 19 965 [69.3%]),6423 人(18.2%)为非英语使用者(平均 [SD] 年龄 85.5 [7.0] 岁;女性 4556 [70.9%])。英语使用者(24 [16-41] 小时)和非英语使用者(25 [16-42] 小时)的手术等待时间中位数(IQR)相似。讲英语和不讲英语的患者在手术延迟超过 24 小时方面没有明显差异(3321 名患者 [51.7%] vs 14 499 名患者 [50.3%];调整后相对风险 [aRR],1.00;95% CI,0.98-1.03)。与讲英语的患者相比,偏好非英语语言的患者发生谵妄(4 207 名患者 [14.6%] vs 1209 名患者 [18.8%];aRR,1.10;95% CI,1.03-1.17)、心肌梗死(150 名患者 [0.5%] vs 43 名患者 [0.7%];aRR,1.52;95% CI,1.04-2.22)、住院时间更长(4 207 名患者 [14.6%] vs 14 499 名患者 [50.3%];aRR,1.00;95% CI,0.98-1.03)的风险更高。结论及相关性:在这项针对髋部骨折老年人的研究中,非英语语言偏好与谵妄、心肌梗死、住院时间延长以及出院后入住疗养院的风险增加有关。这些研究结果表明,髋部骨折患者在接受非英语语言护理时存在不公平现象。
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引用次数: 0
Workplace Violence in a Large Urban Emergency Department. 大型城市急诊室中的工作场所暴力。
IF 10.5 1区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-11-04 DOI: 10.1001/jamanetworkopen.2024.43160
Marla C Doehring, Megan Palmer, Ashley Satorius, Tabitha Vaughn, Bruck Mulat, Andrew Beckman, Kyra Reed, Theresa Spech Dos Santos, Benton R Hunter
<p><strong>Importance: </strong>Workplace violence (WPV) against health care workers (HCWs) is common and likely underreported. Reliable data on the incidence of WPV and its impact on victims are lacking.</p><p><strong>Objective: </strong>To prospectively define the frequency of WPV against HCWs in the emergency department (ED), examine whether HCW demographics are associated with increased risk, and explore the impact of these events on HCWs.</p><p><strong>Design, setting, and participants: </strong>This cross-sectional study was conducted over 2 months in 2023 (August 28 to October 22, 2023) in the ED of a large, urban, academic safety net hospital in the US. Participants included ED physicians, nurses, and other HCWs, who were asked to complete a brief so-called shift sheet for every ED shift worked during the study period.</p><p><strong>Exposure: </strong>WPV as recorded on shift sheets.</p><p><strong>Main outcomes and measures: </strong>The primary outcome was the number of events per shift. Events were coded for severity (types 1-5) and gender- or race and ethnicity-related bias. Shift sheets asked for the participant's demographics and whether they experienced verbal or physical abuse during the shift. If so, they were asked to provide a description; rate the impact the event had on them; and indicate whether they felt the event was sexist, racist, or otherwise biased. Perceived impact was recorded, and demographic characteristics associated with the likelihood of experiencing WPV were explored using multivariable logistic regression analysis.</p><p><strong>Results: </strong>Among 72 HCWs who participated in the study, 52 were female (72%). A total of 575 shift sheets were returned of an estimated 1250 possible (46%), with 155 events, including 77 type 1 events (50%; shouting, yelling, or insults), 29 type 2 events (19%; threats of physical or sexual violence, death threats, or use of slurs), and 39 type 3 events (25%; physical violence); there was a mean (SD) of 3.7 (1.9) shifts per 1 event. No type 4 or 5 events, which involve physical violence causing grievous injuries requiring medical attention and, in the case of type 5 events, permanent disability or death, were recorded. Ten events could not be coded. Sexist or racist bias occurred in 38 events (25%) and 11 events (7%), respectively. Participants reported how the event impacted them in 133 events. Of those, moderate or severe impact was reported in 32 (24%) and mild to no effect in 101 (76%). There was no association between self-reported impact and coded severity of events. In a multivariable logistic regression analysis, a higher likelihood of experiencing WPV on any given shift was independently associated with being in the nursing role (odds ratio, 3.1; 95% CI, 1.9-5.0) and being age 40 years or younger (odds ratio, 2.0; 95% CI, 1.2-3.5).</p><p><strong>Conclusions and relevance: </strong>In this cross-sectional study of HCWs in the ED, participants experienced WPV once every 3.
重要性:针对医护人员(HCWs)的工作场所暴力(WPV)很常见,但很可能未得到充分报告。目前还缺乏有关 WPV 发生率及其对受害者影响的可靠数据:前瞻性地确定急诊科(ED)中针对医护人员的 WPV 事件的发生频率,研究医护人员的人口统计学特征是否与风险增加有关,并探讨这些事件对医护人员的影响:这项横断面研究于 2023 年在美国一家大型城市学术安全网医院的急诊科进行,历时 2 个月(2023 年 8 月 28 日至 10 月 22 日)。参与者包括急诊科医生、护士和其他医护人员,他们被要求在研究期间的每一次急诊科轮班中填写一份简短的所谓轮班表:主要结果和测量方法:主要结果是每班发生的事件数量。对事件的严重程度(1-5 类)以及性别或种族和民族偏见进行编码。轮班表要求填写参与者的人口统计数据,以及他们在轮班期间是否遭受过言语或身体虐待。如果有,则要求他们提供描述;评价该事件对他们的影响;并指出他们是否认为该事件具有性别歧视、种族主义或其他偏见。记录所感受到的影响,并使用多变量逻辑回归分析探讨与遭遇 WPV 可能性相关的人口特征:在参与研究的 72 名医护人员中,52 人为女性(占 72%)。在估计可能发生的 1250 起事件中,共收回了 575 份轮班表(46%),发生了 155 起事件,其中包括 77 起 1 类事件(50%;大喊大叫或侮辱)、29 起 2 类事件(19%;身体或性暴力威胁、死亡威胁或使用污言秽语)和 39 起 3 类事件(25%;身体暴力);平均(标清)每发生 1 起事件需要轮班 3.7 次(1.9 次)。没有第 4 类和第 5 类事件的记录,第 4 类和第 5 类事件涉及身体暴力,造成严重伤害,需要就医,而第 5 类事件则造成终身残疾或死亡。有 10 起事件无法编码。性别歧视或种族主义偏见分别发生在 38 起事件(25%)和 11 起事件(7%)中。在 133 起事件中,参与者报告了事件对他们的影响。其中,32 人(24%)报告了中度或严重影响,101 人(76%)报告了轻度或无影响。自我报告的影响与事件的编码严重程度之间没有关联。在一项多变量逻辑回归分析中,在任何特定班次中经历 WPV 的可能性较高与护理角色(几率比为 3.1;95% CI,1.9-5.0)和年龄在 40 岁或以下(几率比为 2.0;95% CI,1.2-3.5)独立相关:在这项针对急诊室医护人员的横断面研究中,参与者每 3.7 个班次中就有一次感染 WPV 的经历。护理角色和年轻与风险增加有关。这些结果凸显了确定干预措施以支持和保护高危护理人员的迫切需要。
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引用次数: 0
Self-Injury, Substance Use, and Risk of Borderline Personality Disorder in Young Patients. 年轻患者的自伤、药物使用和边缘型人格障碍风险。
IF 10.5 1区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-11-04 DOI: 10.1001/jamanetworkopen.2024.44196
Khrista Boylan
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引用次数: 0
Modeling Health and Economic Outcomes of Eliminating Sex Disparities in Youth Physical Activity. 为消除青少年体育活动中的性别差异建立健康和经济成果模型。
IF 10.5 1区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-11-04 DOI: 10.1001/jamanetworkopen.2024.46775
Kosuke Tamura, Marie F Martinez, Yangyang Deng, Jessie Heneghan, Colleen Weatherwax, Kavya Velmurugan, Kevin L Chin, Breanna Rogers, Mohammad Moniruzzaman, Meredith Whitley, Sarah M Bartsch, Kelly J O'Shea, Alexis Dibbs, Sheryl Scannell, Bruce Y Lee

Importance: Sex disparities in physical activity (PA) and sports participation among US children and adolescents have been persistent. Quantifying the impact of reducing or eliminating these disparities may help determine how much to prioritize this problem and invest in interventions and policies to reduce them.

Objective: To quantify what might happen if existing PA and sports participation disparities were reduced or eliminated between male and female children and adolescents.

Design, setting, and participants: This simulation study used an agent-based model representing all children (aged 6 to 17 years) in the US, their PA and sports participation levels, and relevant physical and physiologic characteristics (eg, body mass index) as of 2023. Experiments conducted from April 5, 2024, to September 10, 2024, simulated what would happen during the lifetime of each cohort member if PA and sports participation levels for female participants were increased (to varying degrees) to match male participants in the same age group.

Main outcomes and measures: Health outcomes, such as body mass index, incidence of weight-related conditions (eg, stroke, coronary heart disease, type 2 diabetes, and cancer), and economic outcomes (eg, direct medical costs and productivity losses).

Results: This simulation study modeled 8 299 353 US children and adolescents (4 240 119 [51.1%] male and 4 059 234 [48.9%] female) aged 6 to 17 years. Eliminating PA sex disparities averted 28 061 (95% CI, 25 358-30 763) overweight and obesity cases per cohort by age 18 years, which in turn averted 4869 (95% CI, 4007-5732) weight-related disease cases during their lifetimes and resulted in recurring savings of $333.45 million (95% CI, $290.22 million to $376.68 million) in direct medical costs and $446.42 million (95% CI, $327.39 million to $565.44 million) in productivity losses (in 2024 US dollars) for every new cohort of 6- to 17-year-olds. Reducing PA disparities by 50% averted 9027 (95% CI, 6942-11 112) overweight and obesity cases. Eliminating sex disparities in sports participation averted 41 499 (95% CI, 37 874-45 125) cases of overweight and obesity and 8939 (95% CI, 8088-9790) weight-related disease cases during their lifetimes, generating recurring savings of $713.48 million (95% CI, $668.80 million to $758.16 million) in direct medical costs and $839.68 million (95% CI, $721.18 million to $958.18 million) in productivity losses.

Conclusions and relevance: In this simulation study of youth PA and sports participation, eliminating sex disparities could save millions of dollars for each new cohort of 6- to 17-year-olds, which could exceed the cost of programs and investments that could enable greater equity.

重要性:美国儿童和青少年在体育活动(PA)和运动参与方面的性别差异一直存在。量化减少或消除这些差异所产生的影响,有助于确定应优先解决这一问题的程度,并投资于减少这些差异的干预措施和政策:量化减少或消除男女儿童和青少年之间现有的体育锻炼和运动参与差距可能产生的影响:这项模拟研究使用了一个基于代理的模型,该模型代表了 2023 年美国的所有儿童(6 至 17 岁)、他们的体育锻炼和运动参与水平以及相关的身体和生理特征(如体重指数)。从 2024 年 4 月 5 日到 2024 年 9 月 10 日进行的实验模拟了如果女性参与者的体育锻炼和运动参与水平(不同程度)提高到与同年龄组男性参与者一致,那么每个队列成员在一生中会发生什么情况:健康结果,如体重指数、体重相关疾病(如中风、冠心病、2 型糖尿病和癌症)的发病率,以及经济结果(如直接医疗成本和生产力损失):这项模拟研究模拟了 8 299 353 名 6 至 17 岁的美国儿童和青少年(4 240 119 名[51.1%]男性和 4 059 234 名[48.9%]女性)。消除 PA 性别差异可使每个队列在 18 岁前避免 28 061 例(95% CI,25 358-30 763 例)超重和肥胖病例,进而在他们的一生中避免 4869 例(95% CI,4007-5732 例)与体重相关的疾病病例,并节省 3.33 亿美元的经常性开支。每新增一批 6 至 17 岁的儿童,可节省 4500 万美元(95% CI,2.9022 亿美元至 3.7668 亿美元)的直接医疗费用和 4.4642 亿美元(95% CI,3.2739 亿美元至 5.6544 亿美元)的生产力损失(按 2024 年美元计算)。将运动量差距缩小 50%,可避免 9027 例(95% CI,6942-11112 例)超重和肥胖病例。消除体育运动参与方面的性别差异可避免 41 499 例(95% CI,37 874-45 125 例)超重和肥胖病例以及 8939 例(95% CI,8088-9790 例)与体重相关的疾病病例,从而在直接医疗成本方面节省 7.1348 亿美元(95% CI,6.688 亿美元至 7.5816 亿美元),在生产力损失方面节省 8.3968 亿美元(95% CI,7.2118 亿美元至 9.5818 亿美元):在这项关于青少年体育锻炼和运动参与的模拟研究中,消除性别差异可为每一批新的 6 至 17 岁青少年节省数百万美元,这可能超过可实现更大程度公平的计划和投资成本。
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引用次数: 0
Decision Support Intervention and Anticoagulation for Emergency Department Atrial Fibrillation: The O'CAFÉ Stepped-Wedge Cluster Randomized Clinical Trial. 急诊科心房颤动的决策支持干预和抗凝治疗:O'CAFÉ阶梯式楔形群随机临床试验。
IF 10.5 1区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-11-04 DOI: 10.1001/jamanetworkopen.2024.43097
David R Vinson, E Margaret Warton, Edward J Durant, Dustin G Mark, Dustin W Ballard, Erik R Hofmann, Dana R Sax, Mamata V Kene, James S Lin, Luke S Poth, Meena S Ghiya, Anuradha Ganapathy, Patrick M Whiteley, Sean C Bouvet, Adina S Rauchwerger, Jennifer Y Zhang, Judy Shan, Daniel D DiLena, Bory Kea, Ashok P Pai, Jodi B Loyles, Matthew D Solomon, Alan S Go, Mary E Reed
<p><strong>Importance: </strong>Oral anticoagulation for adults with atrial fibrillation or atrial flutter (AFF) who are at elevated stroke risk reduces the incidence of ischemic stroke but remains underused. Efforts to increase anticoagulation initiation on emergency department (ED) discharge have yielded conflicting results.</p><p><strong>Objective: </strong>To evaluate the effectiveness of a multipronged intervention supporting anticoagulation initiation for eligible adult ED patients.</p><p><strong>Design, setting, and participants: </strong>The Clinical Decision Support to Optimize Care of Patients With Atrial Fibrillation or Flutter in the Emergency Department (O'CAFÉ) pragmatic, stepped-wedge cluster randomized clinical trial was conducted from July 1, 2021, through April 30, 2023, at 13 community medical centers (in 9 clusters) of an integrated health system in Northern California. The study included adult ED patients with primary AFF eligible for anticoagulation initiation when discharged home. Clusters were randomly assigned to staggered dates for 1-way crossover from the control phase (usual care) to the intervention phase.</p><p><strong>Intervention: </strong>Physician education, facility-specific audit and feedback, and access to decision support, which identified eligible patients and recommended shared decision-making, anticoagulation initiation (if suitable), and timely follow-up.</p><p><strong>Main outcomes and measures: </strong>The main outcome was a composite of anticoagulation on discharge or within 30 days. A primary intention-to-treat analysis (decision support access regardless of use) and a secondary per-protocol analysis (decision support use) were performed. Multivariable analyses adjusted for intervention and exposure months with random effects, accounting for clustering by facility and patient.</p><p><strong>Results: </strong>A total of 3388 eligible patients with atrial fibrillation were discharged home: 2185 (64.5%) were receiving pre-ED arrival anticoagulation and 1203 (35.5%) were eligible for anticoagulation. Among the 1203 patients with an initiation-eligible encounter, the median age was 74.0 (IQR, 68.0-82.0) years and approximately half (618 [51.4%]) were men. Among the 387 patients with an initiation-eligible control encounter, 244 (63.0%) received anticoagulation (190 [49.0%] at discharge and 54 [14.0%] within 30 days). Among the 816 patients with an initiation-eligible intervention encounter, 558 (68.4%) received anticoagulation (428 [52.5%] on discharge and 130 [15.9%] within 30 days). There was no statistically significant change in initiation of anticoagulation associated with the intervention (adjusted odds ratio, 1.33 [95% CI, 0.75-2.35]; P = .13). Decision support was used for 217 eligible case patients (26.6%) (per protocol) and was associated with a statistically significant change in anticoagulation initiation when compared with 599 patients for whom decision support was not used (164 [75.6%] vs 39
重要性:对中风风险较高的成人房颤或房扑患者进行口服抗凝治疗可降低缺血性中风的发病率,但目前仍未得到充分利用。在急诊科(ED)出院时增加抗凝治疗的努力产生了相互矛盾的结果:目的:评估支持符合条件的急诊科成人患者开始抗凝治疗的多管齐下干预措施的有效性:从 2021 年 7 月 1 日到 2023 年 4 月 30 日,在北加州一个综合医疗系统的 13 个社区医疗中心(9 个群组)开展了临床决策支持以优化急诊科心房颤动或扑动患者护理(O'CAFÉ)实用阶梯式群组随机临床试验。研究对象包括原发性 AFF 的成人急诊室患者,这些患者在出院回家时符合开始抗凝治疗的条件。各集群被随机分配到错开的日期,从对照阶段(常规护理)到干预阶段进行单向交叉:干预措施:医生教育、特定设施的审核和反馈以及决策支持,决策支持可识别符合条件的患者并建议共同决策、开始抗凝治疗(如果合适)和及时随访:主要结果为出院时或 30 天内的抗凝综合结果。进行了主要的意向治疗分析(无论是否使用决策支持)和次要的按方案分析(使用决策支持)。多变量分析对干预和暴露月份进行了随机效应调整,并考虑了设施和患者的聚类情况:共有 3388 名符合条件的心房颤动患者出院回家:2185名患者(64.5%)在出院前接受了抗凝治疗,1203名患者(35.5%)符合抗凝治疗条件。在 1203 名符合启动条件的患者中,中位年龄为 74.0(IQR,68.0-82.0)岁,约一半(618 [51.4%])为男性。在 387 名符合启动条件的对照组患者中,有 244 人(63.0%)接受了抗凝治疗(190 人[49.0%]在出院时接受了抗凝治疗,54 人[14.0%]在 30 天内接受了抗凝治疗)。在 816 名符合干预条件的患者中,558 人(68.4%)接受了抗凝治疗(出院时为 428 人 [52.5%],30 天内为 130 人 [15.9%])。干预后,开始抗凝治疗的人数没有明显变化(调整后的几率比为 1.33 [95% CI, 0.75-2.35];P = .13)。有 217 名符合条件的病例患者(26.6%)使用了决策支持(根据方案),与未使用决策支持的 599 名患者相比,抗凝治疗的启动率发生了统计学意义上的显著变化(164 [75.6%] vs 394 [65.8%]; P = .008):在这项试验中,为促进符合条件的急诊科 AFF 患者进行血栓预防而采取的多管齐下的干预措施并未显著提高抗凝治疗的启动率。有机会进一步改善原发性 AFF 急诊患者的卒中预防:试验注册:ClinicalTrials.gov Identifier:试验注册:ClinicalTrials.gov Identifier:NCT05009225。
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引用次数: 0
Obesity and Outcomes in Adoptive Cellular Therapy in Solid Tumors. 肥胖与实体瘤采纳细胞疗法的疗效
IF 10.5 1区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-11-04 DOI: 10.1001/jamanetworkopen.2024.47617
Derrick L Tao, Mirella Nardo, Cheuk Hong Leung, Heather Y Lin, Lei Kang, Hung Le, Ecaterina E Dumbrava, David S Hong
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引用次数: 0
Intensive Home Treatment-Clinical and Methodological Issues. 强化家庭治疗--临床和方法问题。
IF 10.5 1区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-11-04 DOI: 10.1001/jamanetworkopen.2024.45052
Neil Krishan Aggarwal
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引用次数: 0
Burnout Among Sexual and Gender Minority Physicians-From Recognition to Intervention. 少数性取向和性别少数群体医生的职业倦怠--从认识到干预。
IF 10.5 1区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-11-04 DOI: 10.1001/jamanetworkopen.2024.43891
Dovie L Watson
{"title":"Burnout Among Sexual and Gender Minority Physicians-From Recognition to Intervention.","authors":"Dovie L Watson","doi":"10.1001/jamanetworkopen.2024.43891","DOIUrl":"https://doi.org/10.1001/jamanetworkopen.2024.43891","url":null,"abstract":"","PeriodicalId":14694,"journal":{"name":"JAMA Network Open","volume":"7 11","pages":"e2443891"},"PeriodicalIF":10.5,"publicationDate":"2024-11-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142620975","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
期刊
JAMA Network Open
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