Journal of General Internal Medicine最新文献

Background: EMBRACE was a practice-level cluster randomized trial of a multicomponent implementation strategy for increasing out-of-office blood pressure (BP) monitoring during hypertension screening. Key components included linking practices to ambulatory BP monitoring (ABPM), deploying electronic health record (EHR) tools to prompt and facilitate test ordering, and delivering educational presentations and reminder emails.

Objective: Understand why the implementation strategy modestly increased ABPM but not home BP monitoring (HBPM) versus usual care. DESIGN, SETTING, AND PARTICIPANTS: Clinicians from intervention and control practices were surveyed 1 year after implementation to compare attitudes toward out-of-office BP monitoring and recall of implementation strategies. A subsample was interviewed to gain a deeper understanding of survey results.

Key results: Of 142 eligible clinicians, 89 (63%) completed surveys (53 from intervention practices, 36 from control practices; 49% trainees). There was a pattern of clinicians from intervention practices having more favorable attitudes toward out-of-office BP monitoring generally (remember to order out-of-office BP testing) and ABPM specifically (aware of ABPM availability, know how to order/interpret ABPM, perceive ABPM to be affordable), but not HBPM. The implementation strategies most commonly recalled by intervention clinicians were the accessible ABPM testing service (recalled by 59%) and reminder emails (recalled by 48%). Only 38% and 24% of intervention clinicians recalled EHR tools for ABPM and HBPM, respectively. Key themes that emerged during interviews to explain modestly more favorable attitudes toward ABPM and no difference for HBPM included persistent logistical challenges with ABPM referrals when unavailable locally, low awareness of EHR tools to facilitate ABPM and HBPM ordering, and limited availability of nurses to offload HBPM training from clinicians.

Conclusions: Locally available ABPM testing, better designed EHR tools to prompt and facilitate test ordering, and increased nurse availability for HBPM teaching may be needed to substantially increase out-of-office BP monitoring as part of hypertension screening.

Trial registration: NCT03480217; http://clinicaltrials.gov/show/NCT03480217.

Background: Racial disparities in opioid prescriptions for pain are well documented. Evidence shows undertreated acute pain increases the risk of developing chronic pain, which puts patients at risk of long-term opioid use and misuse. We sought to determine the association between satisfaction with analgesia, unmet opioid preference, and opioid misuse risk by race in a diverse, longitudinal cohort.

Methods: We conducted a secondary analysis of participants with complete data in an RCT of 1301 patients who presented to the emergency department (E.D.) for acute kidney or back pain. Our primary outcome was opioid misuse risk quantified by the current opioid misuse measure (COMM), a self-report 17-item measure of risk of aberrant medication-related behavior among persons prescribed opioids for chronic pain, measured 90 days after the index E.D. visit. We used descriptive statistics and linear regressions to determine associations between satisfaction with analgesia (1-10, measured 1-day post-visit), unmet opioid preference, and opioid misuse risk by race, adjusting for age and sex.

Results: We analyzed 735 participants. The mean (SD) age was 39.6 (13.6), 58.9% (n = 432) were female, 46.4%(n = 341) were White, and 36.9%(n = 271) were Black. Unmet preference was more common among Black (21.8%, n = 59) vs. White (15%, n = 51) participants. Black (vs White) participants had a higher median (IQR) COMM (4 (1 - 12) vs 3 (1 - 6), P < 0.001, and lower median satisfaction (7 (4-10) vs 8 (5 - 10), P = 0.002). Adjusting for unmet preference and satisfaction, Black (vs. White) participants had higher COMM (β = 3.4, 95% CI 1.6-5.3, P = 0.01). Unmet preference was associated with higher COMM (β = 2.3, 95% CI 1.3-3.2, P < 0.001). Satisfaction was associated with lower COMM (β = - 0.5 pp, 95% CI - 0.7, - 0.2, P < 0.01). In a model with a triple interaction between satisfaction, unmet preference, and race, satisfaction was associated with lower COMM (- 0.3 pp, 95% CI - 0.5, - 0.1, P = 0.03) and mitigated the effect of unmet preference on Black participants' COMM (marginal effect β = - 1.3 pp, 95% CI - 1.9, - 0.7, P = 0.01).

Conclusion: Satisfaction with analgesia was protective against opioid misuse risk, especially among Black participants whose opioid preference was unmet. Addressing unmet preferences and understanding factors that shape patient satisfaction with analgesia could help reduce racial disparities in opioid misuse.

Background: Electronic consultations (eConsults) allow clinicians to submit questions through the electronic health records (EHR) to request specialist input about individual patients' care, but there is paucity of literature describing eConsult programs specifically for opioid management.

Objectives: 1. To understand clinicians' reasons for seeking eConsults for opioid management. 2. To describe characteristics of clinicians' questions that can be addressed through eConsults without requiring in-person specialist visits.

Design: Retrospective qualitative study of eConsults for opioid management in the ambulatory setting.

Participants: Clinicians who submitted an eConsult request for opioid management.

Approach: We conducted a qualitative content analysis of eConsult requests and responses. First, a priori codes were developed and applied to textual data. Through iterative discussion and memoing, thematic codes were identified and applied to the dataset. Subsequently, breadth and depth of codes were explored, collapsed, and redefined, and relationships between codes were discussed. Following theme development, matrix analysis was used to compare eConsults that resulted with or without a recommendation for an in-person specialist visit.

Key results: Forty eConsults were requested by 30 unique referring clinicians mostly from general internal medicine (53%) or family medicine (27%). We identified four themes: (1) clinicians were motivated to reduce harm, (2) clinicians had difficulty labeling opioid misuse and use disorder (OUD), (3) clinicians had difficulty articulating discrete questions, and (4) clinician questions revealed knowledge gaps in opioid management. In-person specialist visits were recommended when clinicians needed help with labeling opioid misuse or OUD or when questions were vague and around complex topics.

Conclusion: Clinicians have unease and discomfort in treating chronic pain and managing opioids. eConsults are most helpful for low-complexity, discrete questions from clinicians focused on reducing harm. eConsult implementation should integrate EHR enhancements and clinician training in assessing opioid misuse and OUD and articulating discrete questions.

Background: Few consensus guidelines exist regarding screening mammography recommendations for transgender and gender diverse (TGD) individuals.

Objective: Our study aimed to assess the utilization of screening mammograms in a large cohort of TGD individuals at a single institution and the factors influencing mammogram uptake.

Design: Retrospective cross-sectional study.

Participants: 800 TGD individuals actively engaged in care at a transgender medicine and surgery urban center.

Main measures: We conducted a retrospective analysis of a database of TGD patients (N = 4052) actively engaged in gender-affirming care in a specialized center for transgender health in a large urban healthcare system. We included all individuals who were age 40 or older at the time of data collection (N = 800) and conducted chart reviews on use of screening mammography and results.

Key results: Of the 800 TGD individuals over age 40, 532 were recorded male at birth, and 268 were recorded female at birth. Among those aged 50 and above, 136 out of 382 (36%) had a screening mammogram, whereas among those aged 40-49 years old, 72 out of 418 (17%) had a screening mammogram. Twenty-five percent (28/88) of those who underwent chest masculinization surgery had a screening mammogram, while 34.2% (94/275) of those who underwent chest feminizing surgery had a screening mammogram. Twenty-one out of the 208 (10%) of mammograms performed had a BI-RADS category greater than or equal to 3 or greater on diagnostic mammograms.

Conclusions: In our single-center large cohort of TGD individuals, we found a low percentage of screening mammography use. In those 50 and above, an age cohort with clear guidelines for screening, only 36% had any screening mammogram, and Hispanic ethnicity, chest masculinizing, and chest feminizing surgery were significant predictors for getting any screening mammograms. Our findings suggest the need for increased compliance with screening guidelines in TGD individuals, consistent with those for cisgender women.

Sustaining health equity work amid increasingly challenging political and institutional environments following executive orders and policy shifts during the second Trump administration requires strategic adaptation. In this perspective, we review recent targeted federal policies affecting healthcare and outline approaches to manage information effectively, sustain equity efforts, and foster constructive dialogue in divisive times. Given the rapid pace of change, developing structured strategies for information organization and consumption is critical to both clinician well-being and effectiveness. Institutions play a key role in this process by curating relevant information and supporting structured engagement. Additionally, preserving equity initiatives and identifying new opportunities for sustained advocacy are essential to counteract efforts to roll back civil rights and public health protections. By taking a deliberate and proactive approach, clinicians and healthcare leaders can uphold their commitment to equitable care despite external threats to progress.