Journal of General Internal Medicine最新文献

Background: Neighborhood disadvantage has been associated with potentially preventable acute care utilization among Medicare beneficiaries, but this association has not been studied in a Medicaid population, which is important for informing more equitable care and policies for this population.

Objective: To describe the association between Area Deprivation Index (ADI) and acute care utilization (including potentially preventable utilization) among Medicaid beneficiaries in Washington State.

Design: Retrospective cohort study of 100% Medicaid claims. Mixed effects logistic regression was applied to estimate the association between state-level ADI decile and acute care utilization, adjusting for age, sex, self-identified race and ethnicity, Charlson Comorbidity Index, primary spoken language, individual Federal Poverty Level, homelessness, and rurality. Standard errors were clustered at the Census block group level.

Participants: 1.5 million unique adult Medicaid beneficiaries enrolled for at least 11 months of a calendar year during the period 2017-2021.

Main measures: Binary measures denoting receipt of ED visits, low-acuity ED visits, hospitalizations in a calendar year.

Key results: Increasing levels of neighborhood socioeconomic disadvantage (by ADI decile) were associated with greater odds of any ED visits (adjusted odds ratio (aOR) 1.07, 95% confidence interval (CI) 1.06-1.07), low-acuity ED visits (aOR 1.08, CI 1.08-1.08), and any hospitalizations (aOR 1.02, CI 1.02-1.02).

Conclusions: Among Medicaid beneficiaries, greater neighborhood socioeconomic disadvantage was associated with increased acute care utilization, including potentially preventable utilization. These findings signal potential barriers to outpatient care access that could be amenable to future intervention by health systems and payers.

Background: Despite more women entering medicine, substantial gender disparities remain in various medical disciplines. This study explores the extent of these disparities in Canadian academic internal medicine, particularly in academic ranks, leadership positions, and research productivity.

Design: Cross-sectional.

Subjects: Faculty physicians within internal medicine and subspecialties.

Main measures: Data on faculty physicians with Medical Doctorate (MD), Doctor of Osteopathic Medicine (DO), or Bachelor of Medicine, Bachelor of Surgery (MBBS) degrees were compiled from 17 internal medicine programs listed in the Canadian Resident Matching Service (CaRMS). Research metrics were obtained using Elsevier's Scopus, and analyses were performed with Stata v14.2.

Key results: Among 5099 physician faculty members in internal medicine, 34% were women, and 66% were men. Among the faculty members holding leadership positions, 68% were men, and 32% were women. There was a significant difference in h-index between men and women physician faculty members (p ≤ 0.001), with men having a higher research output. Across all academic ranks, men faculty had higher median h-index values: Assistant Professor (12 vs. 9), Associate Professor (20 vs. 16), and Professor (40 vs. 30). Women were underrepresented in the procedural specialties, while only a few internal medicine subspecialties, such as palliative medicine and geriatrics, had a women predominance.

Conclusions: Our study underscores existing gender disparity within academic internal medicine in Canada, aligning with global trends. Women remain disproportionately underrepresented in academic ranks, leadership positions, and research productivity. Addressing these disparities necessitates a systemic and multifaceted approach, encompassing policy reforms, mentorship, and fostering an inclusive work environment.

In 1960, Dr. William Dock, visiting professor at Yale, discussed the case of a young girl with an unknown liver disease. Dock recommended biopsy, invoking bank robber Willie Sutton's words "that's where the money is." Drs. Petersdorf and Beeson, in attendance that day, included the following in their 1961 publication on fever of unexplained origin, "We are indebted to Dr. William Dock for the term Sutton's Law. It recommends proceeding immediately to the diagnostic test most likely to provide a diagnosis, and deplores the tendency to carry out a battery of 'routine' examinations in conventional sequence." Thereafter, Sutton's Law became an acclaimed aphorism advocating pursuit of tissue, because of its specificity for achieving diagnostic certainty. However, its popularity was fleeting, as formal medical decision-analysis (FMDA) became the standard. In the 1940s and 1950s, pioneers in the field laid the groundwork, and by the 1980s, clinician researchers had introduced the science into everyday clinical practice. The original version of Sutton's Law neglected the reality that FMDA is more than specificity, tissue, and absolute certainty. The newer version encourages clinicians to employ and prioritize their "routine" interview questions, physical examination assessments, and laboratory tests that provide clarity to differentiate between disease and no disease, to influence favorably the patient's management, and to discard those evaluations more likely to provide misleading results. Dock, Petersdorf, and Beeson may not have spoken the language of FMDA, but they were adept at applying its principles. Without them, and the unknown medical student who made the diagnosis of schistosomiasis, there would be no Sutton's Law. For many, it is an obsolete and apocryphal aphorism valuable solely for touting the importance of specificity in tissue diagnosis. For others, it has evolved, remaining relevant as an authentic lesson in decision-analysis, past and present.

Background: Incarcerated individuals in carceral facilities demonstrate an elevated prevalence of chronic disease conditions which are likely to persist post-release. Healthcare providers may not be trained on how exposure to incarceration may influence patient health outcomes and patient-provider communication.

Objective: To examine the self-perceived preparedness of healthcare providers to interview patients regarding history of incarceration and the potential related health consequences.

Design: This cross-sectional study consisted of a web-based self-administered questionnaire distributed via email to a random sample of healthcare providers in the Department of Medicine at Brigham and Women's Hospital.

Participants: In total, 400 healthcare providers were invited to participate; 114 respondents completed the survey, of which 26% were medical doctors (n=30), 41% were physician assistants (n=47), and 32% were nurse practitioners (n=37).

Main measures: Understanding healthcare provider training in caring for formerly incarcerated patients, current treatment practices and confidence caring for patients who have experienced incarceration, and implications for clinical care.

Key results: Of 114 respondents, 73% reported that they currently care for formerly incarcerated patients. However, only 8% received specialized training for the care of formerly incarcerated patients. While most respondents did not ask their patients about prior history of incarceration (81%), when asked about comfortability in doing so, 60% reported low levels of comfort. Most providers (77%) reported high agreement that incarceration impacted health, with 54% reporting that it led to significant healthcare access barriers, but 64% reported low confidence levels in addressing the needs of formerly incarcerated patients.

Conclusions: Healthcare workers recognized incarceration as a detrimental health exposure. However, providers reported low levels of confidence in understanding and addressing the unique needs of patients who experienced incarceration. Findings support the need for further training regarding how to address the needs of formerly incarcerated patients, which would support efforts towards achieving equitable healthcare.

Background and aims: Severity of fibrosis is the driver of liver-related outcomes in metabolic dysfunction-associated steatotic liver disease (MASLD), and non-invasive testing such as fibrosis-4 (FIB-4) score is utilized for risk stratification. We aimed to determine if primary care patients at risk for MASLD and advanced fibrosis were evaluated with subsequent testing. A secondary aim was to determine if at-risk patients with normal aminotransferases had advanced fibrosis.

Methods: Primary care patients at increased risk for MASLD with advanced fibrosis (n = 91,914) were identified using previously established criteria. Patients with known alternative/concomitant etiology of liver disease or cirrhosis were excluded. The study cohort included patients with calculated FIB-4 score in 2020 (n = 52,006), and stratified into low, indeterminate, and high likelihood of advanced fibrosis. Among those at indeterminate/high risk, rates of subsequent testing were measured.

Results: Risk stratification with FIB-4 characterized 77% (n = 40,026) as low risk, 17% (n = 8847) as indeterminate, and 6% (n = 3133) as high risk. Among indeterminate/high-risk patients (n = 11,980), 78.7% (n = 9433) had aminotransferases within normal limits, 0.95% (n = 114) had elastography, and 8.2% (n = 984) were referred for subspecialty evaluation.

Conclusion: In this cohort of primary care patients at risk for MASLD with fibrosis, the FIB-4 score identified a substantial proportion of indeterminate/high-risk patients, the majority of which had normal aminotransferase levels. Low rates of subsequent testing were observed. These data suggest that a majority of patients at increased risk for liver-related outcomes remain unrecognized and highlight opportunities to facilitate their identification.

Background: In the USA, multiple organizations rate hospitals based on quality and patient safety data, but few studies have analyzed and compared the rating results.

Objective: Compare the results of different US hospital-rating organizations.

Design: Observational data analysis of US acute care hospital ratings.

Participants: Four rating organizations: Hospital Compare® (HC), Healthgrades® (HG), The Leapfrog Group® (Leapfrog), and US News and World Report® (USN).

Main measures: We analyzed the level of concordance (similar ranking), discordance (difference of 1 or more rankings), and severe discordance (difference of two or more rankings), as well as differences and correlations between the scores.

Key results: From Feb 1 to Oct 3, 2023, we analyzed data from 2,384 hospitals. In Leapfrog, there were 688 hospitals (29%) with Grade A, 652 (27.3%) with B, 885 (37.1%) with C, 153 (6.4%) with D, and 6 (0.3%) with F. For HC, 333 hospitals (14%) had five stars, 676 (28.4%) four, 695 (29.2%) three, 502 (21.4%) two, and 171 (7.2%) one-star. In ratings between HC and Leapfrog, discordance was 70%, and severe discordance was 25.1%. USN ranked 469 hospitals (19.7%). Within the USN-ranked hospital group, there was a 62% discordance and 19.8% severe discordance between HC and Leapfrog. The analysis of orthopedic procedures from HG and USN showed discordance ranging from 48 to 61.2%.

Conclusion: The rating organizations' reported metrics were highly discordant. A hospital's ranking by one organization frequently did not correspond to a similar ranking by another. The methodology and included timeline and patient population can help explain the differences. However, the discordant ratings may confuse patients and customers.