Journal of General Internal Medicine最新文献

Background: Chronic hyponatremia is a common electrolyte disturbance associated with adverse outcomes. The optimal rate of correction remains uncertain, with current guidelines emphasizing avoidance of overcorrection. This systematic review and meta-analysis aimed to synthesize the existing evidence on patient and healthcare utilization outcomes associated with overcorrection in adults with chronic hyponatremia.

Methods: This study followed a pre-registered protocol (PROSPERO CRD42024606516). Medline and EMBASE were searched from inception to May 2024. Eligible studies included original experimental or observational research. Included studies reported outcomes for adult patients with chronic hyponatremia who experienced overcorrection, and those who did not. The outcomes of interest were neurologic complications, acute care utilization (hospital and intensive care unit length of stay, re-admission) and mortality. Study quality was assessed using the Newcastle-Ottawa Quality Assessment Scale. Meta-analyses were performed using the Hartung-Knapp-Sidik-Jonkman random effects models when data allowed; otherwise, outcomes were synthesized narratively.

Results: Forty-three studies were included. Overcorrection of hyponatremia was associated with an increased odds of neurologic complications (OR 4.23, 95% CI 2.93 - 6.11, I² = 0%) but lower odds of mortality (OR of 0.67, 95% CI 0.47 - 0.97, I² = 82.3%). In sensitivity analyses restricted to studies at low risk of bias, the association between overcorrection and neurologic complications was no longer statistically significant (OR 3.22, 95% CI 0.40-25.83, I² = 25.4%). Given the observational nature of included studies, indirect evidence, and high risk of bias across studies, the certainty of evidence is very low.

Discussion: While sodium overcorrection appears to be associated with increased risk of neurologic complications but lower risk of mortality, the limitations of the current literature warrant cautious application of these findings. Given the potential risks of under- and overcorrection, a reframing of practice to achieve adequate correction, rather than focusing on overcorrection avoidance alone may be warranted.

Background: Patients in federally qualified health centers (FQHCs) are at risk of delay in or non-completion of follow-up colonoscopy (FC) after a positive fecal immunochemical test (FIT). Increased time to FC is associated with increased colorectal cancer (CRC) incidence, late-stage diagnosis, and mortality.

Objective: We evaluated the impact of centralized patient navigation on completion of FC and time to FC after a positive FIT.

Design: This survival analysis is a sub-analysis of a randomized clinical trial conducted in FQHC systems in North Carolina. Trial patients were randomly assigned to mailed FIT outreach and to centralized patient navigation for a positive FIT or to usual care alone.

Participants: RCT participants with a positive FIT.

Intervention: Intervention patients with a positive FIT were offered centralized telephone-based navigation to FC, including support with procedure scheduling, bowel preparation, and social needs. Patients in the control arm received usual care.

Main measures: We compared the restricted mean time to FC in an intention-to-screen survival analysis over 1 year of follow-up. We censored by last observation date when FC was not completed.

Key results: Among 4002 trial patients, 842 completed a FIT, of whom 89 (10.6%) tested positive and were included in this analysis. Forty-eight (53.9%) were female, 29 (32.6%) identified as Black, 53 (59.6%) identified as White, and 53 (59.6%) had no prior CRC screening. Fifty-eight (65.2%) were intervention patients, and 31 (34.8%) received usual care (control). Intervention patients were more likely to complete FC at 1 year than control patients (69.0% vs 38.7%, p = 0.006). The difference in mean time to FC between the arms was 80.4 days (95% CI 13.6-147.2, p = 0.018). As-screened sensitivity analyses showed that the difference in time to FC increased further with increasing levels of engagement with navigation.

Conclusions: Centralized patient navigation significantly increased FC completion and reduced the mean time to FC after a positive FIT among FQHC patients. Patient navigation is an important intervention to support the timely diagnostic resolution of positive CRC screening in under-resourced settings.

Trial registration: ClinicalTrials.gov Identifier: NCT04406714.

Background: Interhospital transfer (IHT), the movement of patients between acute care hospitals, has traditionally been based on the need to provide patients with care not available at the hospital to which they initially present. However, additional factors influencing medicine transfer decision-making and their interplay have not been described within a comprehensive framework.

Objective: The objective of the study is to characterize and integrate factors shaping IHT decision-making for medicine patients into a comprehensive conceptual model.

Design: This is a qualitative study using focus groups guided by clinical cases and semistructured discussion guides as part of the POINT Study ("Identification and Prevention of Potentially Inappropriate Inter-Hospital Transfer," AHRQ R01 HS028621). Data were analyzed using thematic analysis with deductive and inductive approaches.

Participants/setting: We used purposive convenience sampling to recruit patients/families, clinicians, and hospital leadership from 18 academic medical centers in the POINT Study and their affiliates. Patient/family representatives were recruited from a volunteer patient family advisory council.

Main outcomes and measures: IHT decision-making themes were identified through thematic analysis.

Key results: Seven 1-h focus groups included 39 participants from 13 tertiary hospitals and their affiliates. We grouped factors that shape IHT decision-making into themes and subthemes and describe their interactions. Specifically, we identified that medical necessity and contextual factors (e.g., hospital capacity) influence transfer decisions, with contextual factors playing a larger role than previously recognized. Participants also considered patient-, clinician-, and organization-level outcomes, as well as constraints imposed by IHT processes and the broader healthcare ecosystem. Based on these findings, we developed a conceptual model that captures the interrelationships among factors, potential IHT outcomes, and system constraints that influence IHT decision-making.

Conclusions: IHT decision-making reflects a complex interplay of medical necessity, contextual factors, anticipated outcomes, and system constraints. Our conceptual model provides a nuanced understanding of these dynamics and offers targets for improving transfer processes and supporting informed IHT decision-making.