Journal of General Internal Medicine最新文献

Background: Antidepressant augmentation with bupropion was recently demonstrated to increase fall risk in older adults, though specific subpopulations that may have increased risk have not yet been identified.

Objective: To determine risk factors for falls in older adults with Major Depressive Disorder (MDD) receiving bupropion augmentation.

Design: Older adults with major depression were followed for approximately ten weeks during a randomized controlled trial (RCT) with three treatment arms, including bupropion augmentation. Data from the bupropion augmentation arm, which had higher fall rates, were analyzed.

Participants: 194 older adults with MDD randomized to bupropion augmentation.

Main measures: Participants' report of falls during biweekly study visits.

Key results: The following baseline characteristics were significantly correlated (p < 0.05) with total number of falls: number of falls during the previous 6 months (r = 0.42), burden of physical illness measured with the Cumulative Illness Rating Scale-Geriatric (r = 0.26), physical function score on the Patient-Reported Outcomes Measurement Information System (r = -0.23), and baseline Patient Health Questionnaire-9 Score (r = 0.16). There were significant main effects of bupropion dosage level (low, medium, or high) (p = 0.04) and number of falls during the six months prior to study entry (p < 0.001). Study fall rates extrapolated out to the number of falls per year of treatment for subgroups distinguished by dosage level and prior falls ranged from 1.39 falls/year (no history of falls, low dosage bupropion) to 12.32 falls/year (3 + falls during the 6 months prior to study entry, high dosage bupropion).

Conclusions: The risk of falls during bupropion augmentation is a function of the patient's personal history of falls and the dosage of bupropion. Careful patient selection and personalization of dosing strategy might reduce the risk of falls in older depressed patients treated with bupropion.

Background: Entrustable professional activities (EPAs) have been proposed as a holistic approach to competency-based assessment. The 13 Core EPAs for Entering Residency (CEPAER) are essential tasks that a medical student should be trusted to perform with indirect supervision upon entering residency, based on demonstrated competence.

Objective: To study the validity and reliability of workplace-based assessments of the 13 core EPAs as measurements of medical student performance and growth over the Internal Medicine (IM) clerkship.

Design: Correlational-based population study.

Participants: A total of 398 third-year medical students at the University of Minnesota Medical School participated. Students were enrolled in a required 8-week IM clerkship during the 2023-2024 and 2024-2025 academic years. A total of 825 assessors provided EPA ratings with a mean number of 12 per assessor; SD = 15.08.

Main measures: There were 10,034 EPA-based assessments collected (mean per student = 25; SD = 6.1). The most frequently assessed EPAs were EPA 6 (Provide an oral presentation of a clinical encounter; n = 1866; mean per student = 4.69), EPA 5 (Document a clinical encounter in the patient record; n = 1662; mean per student = 4.18), and EPA 2 (Recommend and interpret common diagnostic and screening tests; n = 1421; mean per student = 3.57).

Key results: Regression analyses indicated statistically significant growth in entrustment scores for EPAs 1, 2, 3, 5, 6, 8, 10, and 12. Generalizability analysis showed that to achieve adequate reliability (Ep2 ≥ 0.80), at least 5 assessments were required to be conducted by 5 raters.

Conclusion: EPAs represent a valid and reliable measure for medical student growth during the IM clerkship, particularly for EPAs 1, 2, 3, 5, 6, 8, and 10.

Background: In intensive care units (ICUs), shared decision making (SDM) between clinicians and families is critical for evaluating complex tradeoffs of life-sustaining treatments and making patient-centered decisions, yet clinicians are less likely to engage in SDM with Black compared to White families.

Objective: To describe how Black compared to White family members experienced medical decision making about life-sustaining treatments for their critically ill loved ones.

Design: This study is a thematic analysis of semi-structured, audio-recorded interviews with primary surrogate decision makers. The codebook included recommended components of SDM and known mechanisms of communication disparities. Analysts were blinded to family member race during coding; then patterns between and within racial groups were analyzed to identify themes.

Participants: Black or White primary surrogate decision makers for patients mechanically ventilated for ≥ 48 h.

Main measures: Themes describing experiences of medical decision making.

Key results: In 43 interviews, both Black (n = 25, 58%) and White (n = 18, 42%) family members were middle aged (median [interquartile range, IQR]: 55 [15] years vs 58 [17] years) and had critically ill loved ones with similar lengths of ICU stay (median [IQR]: 18 [22] days vs 23 [18] days). Black family members disproportionately reported the following: (1) experiencing pressure to make decisions that aligned with the ICU team's recommendations and timeline, (2) needing to code-switch by modifying their communication and behavior to ensure their advocacy was welcomed rather than perceived as intrusive, (3) being disregarded by the medical team, which negatively impacted partnership towards shared decisions, and (4) trusting clinicians' competence but not necessarily their intentions for critically ill loved ones.

Conclusions: Compared to White family members, Black family members of critically ill patients experienced unique challenges relevant to SDM. These results may identify promising focus areas for future conceptual models and interventions to improve equity in ICU-based SDM.

Background: Prescription depressants, particularly benzodiazepines, gabapentinoids, and Z-drugs, pose overdose risk. Understanding their prevalence in overdose fatalities and co-involved substances is critical.

Objective: To identify latent substance classes in prescription depressant-involved overdose deaths.

Design: Retrospective cohort study PARTICIPANTS: All individuals whose fatal overdoses involved prescription depressants from 2000-2023 in Massachusetts, US (n = 8,665).

Main measures: Data were obtained from the Massachusetts Registry of Vital Records and Statistics. Substances were identified using ICD-10 codes. Literal text entries were available from 2015-2023. We conducted a latent class analysis to derive substance classes and a multinomial logistic regression to examine associated factors. We assessed the proportion of deaths these classes comprised over time.

Key results: Five latent classes emerged and were characterized based on the substances with highest conditional probabilities within and across classes: 1) antidepressants (21.2%); 2) fentanyl, cocaine, and benzodiazepines (34.4%); 3) antidepressants and antipsychotics (8.2%); 4) prescription opioids and benzodiazepines (19.5%); and 5) fentanyl and gabapentin or xylazine (16.7%). Over time, fentanyl-related classes came to dominate earlier prescription-only classes; deaths in Class 1 declined by 86.5%, while those in Class 5 rose from 9.6% to 45.1%. Compared to Class 2, all other classes were older, more likely female, married, educated, from rural areas, and overdosed at home. Classes 1, 3, and 5 were more likely non-White.

Conclusions: Thousands of Massachusetts overdose deaths have involved prescribed medications, suggesting missed opportunities for intervention. Over time, the demographic patterns of deaths involving antidepressants, antipsychotics, benzodiazepines, and prescription opioids persisted, reflecting longstanding trends in polypharmacy among older women and racial disparities in prescribing. Prescription monitoring, deprescribing, screening for illicit drug use, and discussion of diversion risks are all needed. Findings underscore the need for clinical and policy interventions to reduce overdose risks among women, older individuals, and racial minorities.

Background: Ethnic minorities appear to be at higher risk of long COVID. Our objective was to estimate ethnic differences in the burden of long COVID symptoms and their impact on daily life and occupational status.

Methods: Retrospective cohort study of adults (≥ 18 years) admitted to a Long COVID Clinic, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark, from February 2021 through November 2022. Data from symptom questionnaires were linked to clinical data from patient records and national register data. Using regression models, we calculated the burden and number of long COVID symptoms as well as the risk of certain symptom categories, of being on sick leave, of loss of independence, and of having returned to usual leisure activities.

Results: A total of 864 patients from the long COVID clinic were included; hereof 31.2% were ethnic minorities. Compared to patients of Danish origin, ethnic minorities had an 18.32% higher mean burden of long COVID symptoms (adjusted mean difference (MD_adj) 3.23, 95% confidence interval (CI): 1.67;4.78) and experienced 18.56% more long COVID symptoms on average (MD_adj 1.56, 95% CI: 0.86;2.26). Ethnic minorities were more likely to experience cardio-pulmonary, psychological, and gastrointestinal symptoms. However, compared to patients of Danish origin, ethnic minorities had lower odds of being on sick leave (adjusted odds ratio (OR_adj) 0.61, 95% CI: 0.40;0.94) and of having returned to usual leisure activities (OR_adj 0.68, 95% CI: 0.48;0.94).

Conclusions: Ethnic minorities experienced a higher number and symptom burden of long COVID symptoms along with a higher risk of certain symptom categories, notably psychological symptoms. However, ethnic minorities had lower odds of being on sick leave. Additional research is needed into the explanations of the disparities identified in this study.

Importance: International medical graduates (IMGs-physicians who graduated from a medical school outside the US) hold a significant role in the US healthcare system. Research suggests that clinicians' attitudes towards end-of-life (EOL) care may vary across countries.

Objective: To compare EOL care processes and outcomes for older adults treated by IMGs vs. US medical graduates (USMGs).

Design: Cross-sectional study.

Participants: A 20% random sample of Medicare fee-for-service beneficiaries aged 66 years or older who died in 2016-2019.

Main measures: Seven EOL care-related measures: (i) palliative care counseling or hospice enrollment in the last 180 days of life; (ii) emergency department visits, (iii) hospital admissions, (iv) intensive care unit admissions, (v) use of mechanical ventilation or cardiopulmonary resuscitation, or (vi) feeding tube placement in the last 30 days of life; and (vii) death in an acute care hospital. We adjusted for beneficiary- and physician-level confounders; P-values were adjusted using the Bonferroni-Holm method for multiple comparisons.

Results: Among 391,425 beneficiaries, 117,754 (30.1%) were attributed to IMGs and 273,671 (69.9%) to USMGs. We found no evidence that six of the seven measured EOL care processes and outcomes differ between IMGs and USMGs. Beneficiaries treated by IMGs were slightly less likely to have emergency department visits in the last 30 days of life (57.1% vs. 57.6%; adjusted difference, -0.5 pp; 95% CI, -0.9 to -0.2; P = 0.04) compared with those treated by USMGs. Subgroup analyses by beneficiaries with cancer or chronic heart failure showed no evidence that EOL care processes and outcomes differ by physician's country of medical school after adjustment for multiple comparisons.

Conclusions: EOL care processes and outcomes were similar for older adults treated by IMG and USMG physicians, despite potential differences in medical training during medical school.

Background: Despite the high prevalence of substance use disorder (SUD) in primary care and hospital settings, few easily deployable interventions exist to address stigma and empathy decline among general internists.

Aim: To develop and pilot the first patient-centered podcast to improve attitudes toward opioid use disorder (OUD) patients among internal medicine residents and faculty.

Setting: Academic Medical Center General Internal Medicine department.

Participants: Sixty participants in needs assessment; 15 participants enrolled in a non-controlled pre-post intervention study.

Program description: We developed a novel three-episode podcast series incorporating authentic lived experience with OUD and expert commentary using a collaborative co-creation methodology. Our systematic needs assessment informed deployment of this educational innovation.

Program evaluation: Pre-post measures included attitudes (Medical Condition Regard Scale), confidence in OUD competencies, and participant satisfaction. Statistical analysis used Wilcoxon signed-rank and McNemar tests.

Results: Participants demonstrated statistically significant improvement in attitude (p = 0.015), confidence with motivational interviewing and offering resources (p = 0.04).

Discussion: This innovation suggests podcasts using patient voices can potentially provide attainable and scalable means to improve attitudes while addressing SUD education gaps. Larger studies are needed.

Background: Mammography overscreening, defined as any routine screening in women ≥ 75 years, particularly with limited life expectancy, persists.

Objective: Identify preferences for de-implementing mammography overscreening among older women.

Design: A national survey using the NORC AmeriSpeak panel, a probability-based panel representative of US households. Informed by qualitative methods, we constructed a discrete choice experiment (DCE) based on a hypothetical patient activation de-implementation strategy (the Rethink Resource) for prompting patient/provider discussions about whether to stop getting mammograms.

Participants: Women ≥ 70 years old selected using sampling strata based on age, race/ethnicity, and education and without a breast cancer history.

Main measures: Attributes (levels) included modality (electronic, paper, in-person); context (reviewed with provider, group, on their own); content (mammography pros/cons, patient story/testimonial); frequency (once, yearly); and decision-making principles (age/health calculator, personal preferences/responsibilities checklist). We estimated a random utility model to quantify patient preferences and calculate importance scores.

Results: There were 673 eligible participants; the weighted mean age was 77.5 (standard deviation: 5.3); 72.0% were Non-Hispanic White, 10.5% Non-Hispanic Black, and 9.8% Hispanic; 69.3% had less than a college degree; 49.6% agreed with the idea of stopping mammography based on age and health. In order of importance, participants preferred (mean [standard error]) the Rethink Resource be reviewed: with their healthcare provider (1.52 [0.08]) or on their own (1.22 [0.07]), include pros/cons (0.79 [0.05]), and be delivered on paper (0.81 [0.07]) or electronically (0.60 [0.07]) on a yearly basis (0.34 [0.05]). There were no significant preferences for decision-making principles (-0.01 [0.05]).

Conclusions: In the first DCE for de-implementation strategies, we found that women express clear preferences for how and with whom information is relayed, but do not have strong preferences for calculators/checklists.

Background and objective: Polypharmacy is common in older adults due to multimorbidity and is associated with frailty, falls, decreased function, and mortality. However, the association between older age and polypharmacy has never been studied in the context of limited English proficiency (LEP). We investigated whether older adults with LEP were more likely to experience polypharmacy than older adults who are English proficient.

Design, participants, and main measures: We conducted a cross-sectional analysis of pooled 2013-2018 Medical Expenditure Panel Survey (MEPS), a nationally representative US household survey. Participants were community-dwelling adults aged 65 and older. Polypharmacy was defined as using five or more prescription medications. LEP was defined as participants who reported speaking English "not well" or "not at all" and spoke a non-English language at home. We used multivariable logistic regression models adjusted for demographic, socioeconomic, and health characteristics.

Key results: There were 27,697 MEPS respondents representing 50.5 million community-dwelling older adults. In total, 57.7% of participants were 65-74 years old; 55.2% female; 76.4% white; and 9.8% living below the federal poverty line. The median number of chronic conditions was 3 (IQR, 2-5). A total of 57.8% (95% CI, 56.7-58.9%) used five or more medications, and 4.6% (95% CI, 4.1-5.2%) had LEP. In unadjusted analyses, polypharmacy was less common among older adults with LEP than English-proficient adults (51.7% vs. 58.1%; p < 0.001), which remained significant after adjusting for demographic, socioeconomic, and health characteristics (aOR = 0.79, 95% CI 0.67-0.97; p = 0.03).

Conclusions: In a representative sample of community-dwelling older adults, older adults with LEP were less likely to experience polypharmacy compared to older adults who are English proficient. While polypharmacy is associated with safety concerns, lower prevalence among individuals with LEP may reflect barriers to care rather than better prescribing practices, underscoring the need for language-concordant interventions to improve medication adherence and accessibility while avoiding inappropriate medications.