Journal of General Internal Medicine最新文献

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.

Background: Despite guideline recommendations to offer continuous glucose monitoring (CGM) to all patients with diabetes using insulin, prescription rates for CGM remain low in primary care.

Objective: This quality improvement project aimed to improve access to CGM in primary care for patients with type 2 diabetes on insulin.

Design: This was a quality improvement project conducted by a joint endocrinology/primary care team at a single primary care community health clinic. After defining the problem through process mapping, driver diagrams, and Pareto charts, several interventions were trialed through Plan-Do-Study-Act (PDSA) cycles.

Participants: The study team consisted of four endocrinologists, two primary care providers (MD/NP), the lead primary care nurse, and the primary care population health specialist.

Interventions: Interventions included a directory for durable medical equipment (DME) suppliers, nursing education with device company representatives, a new electronic ordering system for DME, and a nursing outreach program to patients eligible for CGM.

Main measures: The primary outcome was percentage of eligible patients using CGM. Process measures included the number of CGM orders started weekly. Nursing comfort with CGM, knowledge of CGM, and perceptions of communication with DME suppliers were also measured.

Key results: The percentage of eligible patients using CGM increased from 28 to 42%, and the percentage of patients using CGM started in primary care increased from 8 to 14%. Weekly orders increased from 0.3 per week to 2.3 per week. Nursing reported feeling more comfortable and knowledgeable about CGM after the interventions and reported improved communication with DME suppliers.

Conclusions: CGM is known to improve outcomes for patients with diabetes but is an underutilized tool in primary care. Collaborative quality improvement projects between endocrinology and primary care can rapidly build capacity within primary care to prescribe CGM and expand access for patients with diabetes who do not have endocrinologists.

Background: Minoritized populations face many barriers to accessing evidence-based diabetes intervention.

Objectives: To evaluate the feasibility, acceptability, and potential efficacy of a social media-based intervention to improve glycemic control among Chinese Americans with type 2 diabetes.

Design: A pilot randomized controlled trial (RCT) with 3-month and 6-month follow-ups.

Participants: Chinese Americans (n = 60, mean age 54.3 years old) with limited education (70.0% with high school or less) and low income (50.0% with annual household income < $25,000), and 88.3% have limited English proficiency.

Intervention: Culturally and linguistically tailored diabetes videos (two videos/week for 12 weeks) delivered via social media and support calls from community health workers.

Main measures: Primary outcomes include feasibility (video watch rate, biweekly call completion rate, and retention rates), acceptability (patient satisfaction), and HbA1c. Secondary health-related outcomes include body weight, BMI, physical activity, and dietary intake. Video watch rate and biweekly call completion rate were assessed at baseline and 3 months, while others were measured at baseline, 3 months, and 6 months.

Results: We observed high feasibility and acceptability of the intervention, with retention rates over 87%, an 89% video watch rate, 80% biweekly phone call completion, and a satisfaction rating of 9 out of 10. The intervention group showed a significantly greater increase in fruit intake compared to the control group (0.15 cups vs. - 0.44 cups, adj_p = 0.023) at 3 months. While no significant differences in other outcomes were observed between the groups, the intervention group showed significant improvements in key outcomes, including reduced HbA1c levels (- 1.08%, adj_p < 0.001), weight loss (- 5.15 lbs, adj_p = 0.004), lower BMI (- 0.83, adj_p = 0.023), and reduced starchy food intake (- 0.33 cups, adj_p = 0.033) at 6 months.

Conclusions: The observed high feasibility and acceptability suggest the intervention's feasibility. However, due to the limited sample size, a larger-scale RCT is warranted to test the efficacy of the intervention.

Trial registration: ClinicalTrials.gov NCT03557697; https://clinicaltrials.gov/ct2/show/NCT03557697.

Introduction: Climate change is the twenty-first century's biggest threat to human health. Paradoxically, North American healthcare delivery is carbon intensive. Addressing low-value interventions stands to reduce healthcare's carbon footprint. In this position paper, we describe eight new climate focused Canadian Society of Internal Medicine (CSIM)-Choosing Wisely Canada (CWC) recommendations to help internists stop or reduce tests, treatments, and procedures that do not benefit patients and harm the environment.

Methods: The CSIM planetary health task force drafted 14 potential recommendations. This list was refined to eight final recommendations based on feedback from the CSIM membership via an online survey, an online seminar, and expert review by the CWC planetary health panel.

Recommendations: The eight recommendations are as follows: (1) Do not prescribe intravenous antibiotics for patients who can safely be treated with an oral option; (2) do not prescribe heparin or low molecular weight heparin when oral options are effective, preferred by the patient and felt to be safe by the prescriber; (3) do not prescribe greenhouse gas-intensive metered-dose inhalers where a greener alternative with comparable efficacy is available, technique is adequate, and patient preference has been considered; (4) do not recommend/order investigations or interventions before discussing patients' expected trajectory of health and life expectancy, and exploring their goals of care; (5) do not continue medications without confirming clinical indications, particularly for sedative medications, proton pump inhibitors, and inhalers; (6) do not order daily blood tests on hospitalized patients if it will not change management; (7) do not use non-sterile disposable gloves when hand hygiene is sufficient; (8) do not book in-person follow-up appointments when a virtual visit is clinically appropriate and is preferred by the patient.

Conclusion: Using a consensus process, the CSIM recommends eight evidenced-based practices that can feasibly be adopted by general internists to reduce the carbon footprint associated with low-value clinical care.