JAMA Internal Medicine最新文献

Importance: Most individuals attempting smoking cessation relapse, even with evidence-based treatment. Mobile interventions offer a potential but largely untested strategy to sustain cessation.

Objective: To test the effectiveness of mobile chat messaging for relapse prevention among individuals who recently quit smoking.

Design, setting, and participants: This randomized clinical trial was conducted from March 14, 2023, to August 15, 2024, at 2 clinic-based smoking cessation services in Hong Kong. Participants were adults who smoked daily and had abstained for 3 to 30 days; they were randomly assigned to an intervention group or a control group.

Interventions: All participants received usual smoking cessation treatment from the services. The intervention group additionally received 3 months of mobile relapse prevention intervention, including chat-based support delivered by a live counselor and access to a supportive chatbot via a messaging app. The control group received 8 text messages on generic smoking cessation advice over 3 months as a contact control.

Main outcomes and measures: The primary outcome was biochemically validated tobacco abstinence at 6 months after randomization, defined by an exhaled carbon monoxide level of less than 5 ppm or a negative salivary cotinine test result. Secondary outcomes at 6 months included self-reported prolonged abstinence, 7-day point prevalence abstinence, and relapse (7 consecutive days of smoking) rate. Intention-to-treat analyses were conducted, assuming participants with missing outcomes relapsed.

Results: Of 590 participants, 465 (78.8%) were male, and the mean (SD) age was 47.1 (11.2) years; 294 were randomized to the intervention group and 296 were randomized to the control group. The retention rate at 6-month follow-up was 98.0% (n = 578). Biochemically validated abstinence at 6 months was significantly higher in the intervention group than in the control group (45.9% [135 of 294] vs 35.5% [105 of 296]; relative risk [RR], 1.29; 95% CI, 1.06-1.58; P = .01). The intervention group also reported significantly higher prolonged abstinence (57.5% [169 of 294] vs 47.6% [141 of 296]; RR, 1.21; 95% CI, 1.03-1.41; P = .02), higher 7-day point prevalence abstinence (65.6% [193 of 294] vs 54.7% [162 of 296]; RR, 1.20; 95% CI, 1.05-1.37; P = .007), and lower relapse rate (33.0% [97 of 294] vs 44.9% [133 of 296]; RR, 0.73; 95% CI, 0.60-0.90; P = .003) at 6 months.

Conclusions and relevance: This randomized clinical trial found that mobile chat messaging for smoking relapse prevention increased validated abstinence by approximately 30%, offering a scalable approach to sustain abstinence among individuals who recently quit smoking.

Trial registration: ClinicalTrials.gov Identifier: NCT05370352.

Importance: Approximately 25% to 40% of hospitalized adults are discharged to receive postacute care (PAC) either at home through home health (HH) or in skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), or long-term acute care hospitals (LTACHs). An overview of various PAC settings is needed to help hospital-based clinicians collaborate most effectively with patients, caregivers, and an interdisciplinary care team to promote high-quality PAC and facilitate better PAC transitions.

Observations: PAC settings vary in their eligibility requirements and in the intensity and complexity of services they provide. HH provides intermittent in-home support for homebound individuals with skilled needs. SNFs provide housing, daily nursing care, rehabilitative services, and medical supervision, although the medical care provided is often a dramatic step down from hospital-based acute care. IRFs provide intensive rehabilitation, most commonly for individuals with specific diagnoses (eg stroke, hip fracture, or spinal cord injury). LTACHs care for patients with medically complex conditions who require prolonged hospital-level care for services (eg, ventilator weaning, complex wound management). Discharge planning to PAC should be guided by clinical needs, caregiver support, and the values and preferences of patients and caregivers; yet it is often opaque and influenced by external factors such as insurance coverage and geography. Clinicians should proactively recognize PAC needs, advocate for specific PAC settings for targeted situations, and assist on selecting an appropriate PAC facility, especially for patients with insurance restrictions. Moreover, PAC admissions frequently represent a pivotal time period for individuals with serious illness, during which a subsequent poor prognosis becomes clear. Therefore, PAC stays represent an opportunity for clinicians to revisit prognosis with patients and caregivers, engage in goals of care conversations, and clarify plans for the future.

Conclusions and relevance: To provide patient-centered care and help facilitate better transitions for patients and caregivers, hospital-based clinicians have a responsibility to understand the different types of PAC settings and actively participate in discharge planning.

Importance: Skilled nursing facilities (SNFs) are the primary provider of institutional postacute care. Following the COVID-19 pandemic, there have been reports of SNFs reducing their capacity, affecting access to care and disrupting hospital discharges, yet little empirical evidence exists.

Objective: To describe changes in SNF capacity after 2020 and assess whether changes were associated with staffing shortages and hospital discharge outcomes.

Design, setting, and participants: In this cross-sectional study, data from the 2018-2024 Centers for Medicare & Medicaid Services Payroll-Based Journal on patient censuses in US skilled nursing facilities were assessed. Descriptive analyses characterized trends in SNF capacity from 2018 to 2024.

Main outcomes and measures: Main outcomes were SNF licensed bed count and estimated operating capacity. Secondary outcomes included SNF staffing shortages, mean hospital length of stay, percentage of hospital admissions lasting 28 days or more, and the median distance traveled to admitting SNFs. County-level regression analyses examined the association between changes in SNF capacity and the frequency of SNF staffing shortages. Hospital-level regressions examined the association between changes in nearby SNF capacity and discharge outcomes.

Results: Among US skilled nursing facilities, the number of licensed SNF beds declined by 2.5% between 2019 and 2024, while operating capacity declined by 5.0% over the same time period. There was substantial geographic variation-1 in 4 counties experienced operating capacity declines of 15.1% or more, with the largest declines being more common among rural counties. SNF capacity declines were larger in counties with more frequent reports of SNF staffing shortages-a 1-percentage point decline in county SNF capacity was associated with a 0.20-percentage point (95% CI, 0.11-0.29) increase in the frequency of reported shortages. Additionally, hospitals that experienced larger declines in nearby SNF capacity experienced greater increases in mean length of stay, percentage of stays lasting 28 or more days, and median distance traveled to admitting SNFs.

Conclusions and relevance: Results of this study suggest that SNF operating capacity declined following the pandemic and these declines were larger than the observed declines in licensed SNF bed counts, potentially because of staffing shortages. Greater loss of SNF capacity was associated with longer hospital stays and increased travel distances to SNFs, suggesting that declines in operating capacity may be impairing access to care.

Importance: Annual influenza vaccination reduces burden of disease for older adults, but rates remain suboptimal.

Objective: To evaluate if a multicomponent nudge intervention to clinicians and patients increases vaccine completion during primary care visits.

Design, setting, and participants: The pragmatic BE IMMUNE (Behavioral Economics to Improve and Motivate Vaccination in Primary Care Using Nudges Through the Electronic Health Record) randomized clinical trial took place across 48 primary care clinics through Penn Medicine (Philadelphia, Pennsylvania) and UW Medicine (Seattle, Washington). Patients 50 years and older who were scheduled for a primary care visit and were due for an influenza vaccine within the active intervention period (September 25, 2023, to February 20, 2024) were included.

Interventions: Clinics were randomized in a 2:1 ratio to receive (1) previsit text message reminders to patients, (2) an automatic pended order, and (3) monthly comparisons of panel vaccination rates to peer clinicians, or usual care. Additionally, patients in the intervention arm who were identified as high risk for noncompletion were individually randomized 1:1 to receive previsit bidirectional text messaging or a standard text reminder.

Main outcomes and measures: The primary outcome was influenza vaccination during the visit.

Results: Among 80 039 patients across 47 clinics, the mean (SD) age was 65.8 (10.2) years, and 56.0% were female while 43.6% were male. The adjusted odds ratio (AOR) for vaccine completion comparing intervention to usual care was 1.28 (97.5% CI, 1.13-1.45; adjusted P < .001). The probability of completion in the intervention was 31.4% compared to 26.4% under usual care, with a risk difference of 5.1 percentage points (97.5% CI, 2.6-7.5 percentage points; adjusted P < .001). The adjusted odds ratio comparing bidirectional vs standard text messaging among high-risk patients was not statistically significant (1.00; 97.5% CI, 0.98-1.02; adjusted P = .92).

Conclusions and relevance: In this randomized clinical trial, the multicomponent nudge resulted in a statistically significant higher rate of influenza vaccination during the primary care visit, but the bidirectional text messaging did not further increase vaccination in the high-risk group.

Trial registration: ClinicalTrials.gov Identifier: NCT06057727.