Journal of General Internal Medicine最新文献

Background: Continuous glucose monitoring (CGM) may improve self-management and reduce hypoglycemia risk among individuals with diabetes. However, little is known about how older adults with insulin-treated type 2 diabetes (T2D) experience and incorporate this technology into their daily lives.

Objective: To explore experiences, preferences, barriers, and questions related to using CGM among older adults with insulin-treated T2D with and without experience using CGM.

Design: Qualitative focus group study.

Participants: English-speaking older adults with T2D in a large, integrated healthcare delivery system. Groups included either experienced CGM users or adults who had not previously used CGM. Recruitment efforts prioritized individuals ≥ 75 years of age.

Approach: Transcripts were analyzed using the Framework Method to identify perspectives on CGM. Specific thematic categories were hypoglycemia-related benefits, general benefits, usefulness and ease of use concerns, and CGM questions.

Key results: The study included 26 participants: 17 (65%) were experienced CGM users, 58% were female; median age was 74 (range 62-88) years. Participants perceived and anticipated these CGM benefits: informing behavior changes, reducing in-the-moment hypoglycemia risk, improving awareness and decision-making, and strengthening clinician collaboration. Perceived CGM barriers included challenges with wearability and reliability, burdens to others, distrust of technology, sensory and learning challenges, insufficient clinician support or engagement, and access and payer hurdles. Despite these downsides, experienced users perceived CGM as a worthwhile alternative to daily fingerstick glucose checks. Non-users were able to formulate many usability questions, providing a snapshot of informational needs for this age group.

Conclusions: Older adults with insulin-treated T2D experienced or anticipated benefits from CGM for diabetes management. Findings indicate a need for tailored education and self-management support for older adults to learn and gain maximal benefit from this technology.

Background: Highly prevalent and worsened by the COVID-19 pandemic, burnout is associated with more frequent self-reported medical errors, suboptimal patient care, staff attrition, and lower professional fulfillment. There is a growing call for "wellness-centered leaders" who model, integrate, and prioritize well-being within the practice environment.  OBJECTIVE: Having piloted a novel intervention called "The Practice" in one work unit with promising outcomes, we set out to implement and prospectively study the intervention more broadly at our institution.

Design: Departmental leaders were offered an opportunity for their team to participate. Within each interested departmental group, participants were trained in the core components of "The Practice": five daily well-being exercises taking less than 15 min. Biweekly facilitated group meetings to share challenges and successes of doing "The Practice" were integrated into departmental meetings for 3 months. Outcome measures included the WHO-5 Well-being Index, the Wong & Law Emotional Intelligence Scale (WLEIS), and the Professional Fulfillment Index (PFI), completed at baseline and months 3, 6, 9, and 12 after enrollment. Changes over time were analyzed using mixed models. Supplemental experience data were collected from a convenience sample and analyzed using the Framework approach.

Participants: From May 2021 through January 2022, 191 physicians and allied health staff from 14 clinical departments were enrolled. Participants were majority female (84%, n = 161) and White (83.2%, n = 159).

Key results: We observed significant improvements in scores from baseline compared to month 3 that were sustained at later time points for WHO-5, WLEIS, and three of four PFI scales (p < 0.05). Experience data reflected feelings of gratitude that the institution was invested in their well-being, "humanization" of leaders, and increased awareness of coworker's feelings.

Conclusion: "The Practice" may be an effective, integrated, departmental wellness program by which healthcare organizations can support the well-being of their staff.

Introduction: Safer use strategies (SUS) are behaviors before, during, and after drug use to moderate use and/or mitigate unwanted consequences. As treatment of substance use disorders becomes more common in primary care, offering SUS in primary care merits exploration.

Method: We explored acceptability and use of SUS in primary care using a convergent parallel mixed-method design consisting of patient and clinician semi-structured interviews and surveys. Participants were recruited from primary care clinics involved in a multi-state practice research network. Patients with lifetime stimulant and/or opioid and any SUS use were eligible. All clinicians were eligible. Qualitative data were analyzed using a rapid assessment procedure. Quantitative data were analyzed descriptively.

Results: Participants included patients (n = 10) and clinicians (n = 12) from multiple disciplines. More than half of patients indicated that every SUS surveyed should be offered in primary care. Patients reported using multiple SUS to stay safer, reduce consequences, and limit use. Clinicians reported that offering SUS to primary care patients is acceptable and supported SUS use by sharing informational resources (e.g., safer injection practices) and tangible resources (e.g., naloxone, medication for opioid use disorder [MOUD]). Some strategies recommended by patients were not currently being systematically offered (e.g., fentanyl test strips). Several clinicians expressed willingness to discuss SUS with patients but wanted more training and resources to facilitate SUS discussions to support patient goals.

Conclusion: Offering SUS to primary care patients is acceptable to patients and clinicians. Clinicians supported some SUS use, though more SUS and harm reduction training and resources were desired. Providing SUS to patients who use stimulants and/or opioids could enhance patient-centered primary care, especially in clinics offering MOUD. More research is needed to optimize SUS support in primary care settings.

Introduction: Myocardial infarction (MI) imposes a significant health burden to the Australian population. However, detailed economic implication of MI on the Australian healthcare system has not been exhaustively explored.

Objective: To estimate the current chronic management cost and project the future healthcare cost burden of MI, from the Australian healthcare system perspective.

Design: A generalized linear model with a gamma outcome distribution and negative inverse link function was used to estimate the current chronic management cost burden of MI while a dynamic multistate Markov model constructed to project the future healthcare cost burden of MI over 20 years (2019-2038). For all projected costs, 5% annual discounting was applied in the base case, as per Australian guidelines.

Participants: We identified all people, 59,260, aged ≥ 30 years discharged from a public or private hospital following MI between 2012 and 2017 from the Victorian Admitted Episode Dataset. We estimated annual chronic management cost of MI by age, sex, socioeconomic disadvantage and years of follow-up. We used these data to project the future healthcare cost burden of MI.

Main measure: Cost in Australian dollar (AUD).

Key results: The current annual chronic management cost of MI was estimated to be AUD 14,412 (95% confidence interval: AUD 14,282, AUD 14,542) per person. This cost was higher among advanced age group, male participants, during first year of follow-up and people in the most socioeconomically disadvantaged quintile. The projected total healthcare cost following MI was AUD 85.1 billion (95% uncertainty interval AUD 80.8 billion, AUD 89.8 billion) from 2019 to 2038.

Conclusion: Our projections suggest that MI will cost the Australian healthcare system over AUD 85 billion in the coming years. Cost estimates based on key sociodemographic characteristics and socioeconomic disadvantage are expected to inform future health economic modelling studies for MI prevention strategies and interventions.

Background: Multimorbidity with diabetes mellitus (DM and ≥ 1 chronic disease) presents challenges to maintaining adequate DM control.

Objective: This study evaluates the risk of DM-related complications associated with various multimorbidity/DM patterns for patients seen in community-based health centers (CHCs).

Design: Retrospective cohort study from the ADVANCE multi-state practice-based clinical data network.

Participants: Study included data from 132,765 patients age ≥ 45 years with DM seen in 2493 CHCs across 26 states from 10/01/2015 to 12/31/2019.

Main measures: We assessed accrual of conditions and risk of experiencing DM complications during follow-up. Primary outcome of DM complication was categorized into acute, microvascular, microvascular (end-stage), macrovascular, or other. Key exposures included mutually exclusive multimorbidity categories: (1) DM + cardiometabolic, (2) DM + other somatic, (3) DM + mental, (4) DM + mental + somatic.

Key results: At baseline, 17.2% of patients had DM only, 55.0% had DM + cardiometabolic multimorbidity, 2.3% had DM + other somatic multimorbidity, 3.0% had DM + mental multimorbidity, and 22.5% had DM + mental + somatic multimorbidity. Most DM-only patients (76.5%) developed multimorbidity with DM by study end. Compared with DM-only, adjusted risk differences of DM complications ranged from 1.4% (acute) to 8.8% (microvascular). DM + mental + somatic multimorbidity was associated with 13.4% (95%CI 12.8-14.1%) higher adjusted risk of experiencing any DM complication.

Conclusions: CHCs care for increasingly complex populations of patients with DM. Tailoring disease management strategies to address comorbid cardiovascular and/or mental health conditions may be important to prevent acute, microvascular, and macrovascular complications in these settings.

Background: Aligned with increasing organizational and policy focus on whole person care, particularly for patients with multimorbidity, health systems are operationalizing how to assess what patients find meaningful in life for personalized health planning. Few studies have examined how patients with multimorbidity at high risk of adverse events perceive connections between what is most important in life (i.e., personal values) and health, healthcare, and healthcare decisions. This knowledge is critical to optimizing how, when, and under what circumstances the topics are addressed in healthcare settings.

Objective: To understand how high-risk patients with multimorbidity perceive connections between personal values and health, healthcare, and healthcare decisions.

Design: Qualitative study.

Participants: Patients ≥ 75th percentile risk of hospitalization or mortality using a validated prediction score, with ≥ 2 diagnoses among depression, hypertension, chronic kidney disease, or diabetes, engaged in Veterans Health Administration primary care.

Approach: Individual semi-structured telephone interview, analyzed with content analysis.

Key results: Patients (N=27) averaged 68 years old; 17 (63%) were male. Three main themes emerged: (1) personal values were rarely discussed in healthcare settings or reflected in healthcare decision-making, sometimes given perceived lower relevance by patients; (2) when personal values were perceived as affecting health decisions, it was within specific contexts or circumstances (e.g., deciding on surgery); (3) eliciting personal values in healthcare settings could have positive or negative consequences, related to conditions of disclosure and resultant action taken in the care plan, and not all patients wanted to disclose values.

Conclusions: In this study, high-risk patients with multimorbidity reported rarely discussing values in healthcare settings, and if so, only perceived relevant connections between values and health in specific contexts. While some participants felt sharing values benefitted care, not all felt comfortable with disclosure. Patient preferences for eliciting and incorporating values are relevant to integrating patient personal values in healthcare settings.

Background: Delirium affects approximately a quarter of hospitalized adults and is associated with higher mortality, cognitive decline, and prolonged hospitalizations. Patient and caregiver education may improve outcomes. However, limited literature exists on the general public's current understanding of this condition.

Objective: To assess knowledge and attitudes toward delirium via an online convenience sample.

Design: Cross-sectional survey using Amazon's Mechanical Turk between October 2023 and January 2024.

Participants: Adults 18 years old and older, living in the USA, and fluent in English.

Main measures: We assessed delirium knowledge using a 15-question knowledge assessment covering three categories (risk factors, symptoms, and management). We compared mean scores between knowledge categories using one-way analysis of variance (ANOVA). We used univariate and multivariate logistic regression models to identify demographics associated with low delirium knowledge scores.

Key results: Among 397 respondents, 52% were male, 67% were White, and the median age was 44.6 (IQR 36-52). Participants reported living in 43 states. Participants answered 59% (SD 14.8) of knowledge questions correctly; respondents performed highest within the risk factor category (74%, SD 19.6) and lowest in management (47%, SD 21.1), p = <0.01. Few knew that bedrest is not recommended for delirium and that symptoms do not develop gradually (18% and 25%, respectively). Most (83%) agreed that more patient and caregiver education on delirium is needed. In multivariate analysis, individuals with higher incomes were less likely to score in the lowest quartile compared to those earning under $50K (e.g., OR 0.60 for persons earning $50-100K, 95% CI 0.29-0.91). Finally, low self-confidence in delirium knowledge was not associated with low knowledge scores.

Conclusions: Respondents had misconceptions about delirium that could be addressed in future educational initiatives, including the importance of early mobilization. Further work is needed to characterize what types of knowledge are valued by patients and caregivers and are critical to facilitating engagement.

Aims: To determine associations between suboptimal social determinants of health (SDoH) and diabetes distress in adults with diabetes on Medicaid.

Methods: We surveyed adults with type 2 diabetes covered by Alabama Medicaid. Diabetes distress was assessed using the Diabetes Distress Scale. Suboptimal SDoH included food or housing insecurity; having < high school degree; being unemployed; and household income < $10,000/year. Unadjusted associations between individual SDoH and diabetes distress were examined using logistic regression. We also examined the association between the number of suboptimal SDoH and distress. Multivariable models controlled for age, sex, race, marital status, rurality, diabetes duration, social support, and insulin use.

Results: In total, 433 patients participated (mean age, 50 years (SD 10.4); 80% female; 62% Black). Roughly 32% reported food insecurity, participants experienced a mean of 2 (SD, 0.9; range 0-5) suboptimal SDoH. There was increased odds of diabetes distress in participants who reported food insecurity (OR, 2.2; 95% CI, 1.36-3.65 and OR, 2.35; 95% CI, 1.40-3.93). For each additional suboptimal SDoH a patient experienced, they had increased odds of experiencing diabetes distress (OR, 1.50; CI, 1.15-2.01).

Conclusions: Participants with diabetes who reported food insecurity or experienced a higher number of suboptimal social determinants of health had an increased likelihood of experiencing diabetes distress.

MD/PhD programs have traditionally prioritized the biomedical sciences, training physician-scientists skilled at advancing medical knowledge. Yet, with health disparities increasingly traced to social determinants of health (SDOH), a broader approach-one that integrates "non-traditional" fields such as the social sciences and humanities (SSH)-is essential. Significant challenges persist at three levels: (1) at the structural and systemic levels, where funding mechanisms like the NIH's Medical Scientist Training Program (MSTP) prioritize biomedical fields, limiting support for SSH fields; (2) at the institutional level, where curricula and resources remain narrowly aligned with biomedical timelines, leaving SSH trainees without adequate support; and (3) at the individual level, where the demands of SSH research often clash with the broader structure of MD/PhD programs, creating unique hurdles. Addressing these barriers requires coordinated reforms, including expanding MSTP programs' eligibility to include SSH fields and partnering with funding agencies and foundations to establish dedicated SSH funding. Medical schools could further support these students by developing cross-departmental SSH-integrated tracks with dedicated mentorship from SSH departments. Additionally, SSH-specific mentorship and community-building initiatives could reduce isolation and nurture a shared identity among SSH trainees. Bridging these gaps is paramount to making MD/PhD training for SSH students more inclusive and effective.