Journal of General Internal Medicine最新文献

Background: How state opioid policy environments with multiple concurrent policies affect opioid prescribing to individuals with acute pain is unknown.

Objective: To examine how prescription drug monitoring programs (PDMPs), pain management clinic regulations, initial prescription duration limits, and mandatory continued medical education affected total and high-dose prescribing.

Design: A county-level multiple-policy difference-in-difference event study framework.

Subjects: A total of 2,425,643 individuals in a large national commercial insurance deidentified claims database (aged 12-64 years) with acute pain diagnoses and opioid prescriptions from 2007 to 2019.

Main measures: The total number of acute pain opioid treatment episodes and number of episodes containing high-dose (> 90 morphine equivalent daily dosage (MEDD)) prescriptions.

Key results: Approximately 7.5% of acute pain episodes were categorized as high-dose episodes. Prescription duration limits were associated with increases in the number of total episodes; no other policy was found to have a significant impact. Beginning five quarters after implementation, counties in states with pain management clinic regulations experienced a sustained 50% relative decline in the number of episodes containing > 90 MEDD prescriptions (95 CIs: (Q5: - 0.506, - 0.144; Q12: - 1.000, - 0.290)). Mandated continuing medical education regarding the treatment of pain was associated with a 50-75% relative increase in number of high-dose episodes following the first year-and-a-half of enactment (95 CIs: (Q7: 0.351, 0.869; Q12: 0.413, 1.107)). Initial prescription duration limits were associated with an initial relative reduction of 25% in high-dose prescribing, with the effect increasing over time (95 CI: (Q12: - 0.967, - 0.335). There was no evidence that PDMPs affected high-dose opioids dispensed to individuals with acute pain. Other high-risk prescribing indicators were explored as well; no consistent policy impacts were found.

Conclusions: State opioid policies may have differential effects on high-dose opioid dispensing in individuals with acute pain. Policymakers should consider effectiveness of individual policies in the presence of other opioid policies to address the ongoing opioid crisis.

Background: Patient-physician sex discordance (when patient sex does not match physician sex) has been associated with reduced clinical rapport and adverse outcomes including post-operative mortality and unplanned hospital readmission. It remains unknown whether patient-physician sex discordance is associated with "before medically advised" hospital discharge (BMA discharge; commonly known as discharge "against medical advice").

Objective: To evaluate whether patient-physician sex discordance is associated with BMA discharge.

Design: Retrospective cohort study using 15 years (2002-2017) of linked population-based administrative health data for all non-elective, non-obstetrical acute care hospitalizations from British Columbia, Canada.

Participants: All individuals with eligible hospitalizations during study interval.

Main measures: Exposure: patient-physician sex discordance.

Outcomes: BMA discharge (primary), 30-day hospital readmission or death (secondary).

Results: We identified 1,926,118 eligible index hospitalizations, 2.6% of which ended in BMA discharge. Among male patients, sex discordance was associated with BMA discharge (crude rate, 4.0% vs 2.9%; adjusted odds ratio [aOR] 1.08; 95%CI 1.03-1.14; p = 0.003). Among female patients, sex discordance was not associated with BMA discharge (crude rate, 2.0% vs 2.3%; aOR 1.02; 95%CI 0.96-1.08; p = 0.557). Compared to patient-physician sex discordance, younger patient age, prior substance use, and prior BMA discharge all had stronger associations with BMA discharge.

Conclusions: Patient-physician sex discordance was associated with a small increase in BMA discharge among male patients. This finding may reflect communication gaps, differences in the care provided by male and female physicians, discriminatory attitudes among male patients, or residual confounding. Improved communication and better treatment of pain and opioid withdrawal may reduce BMA discharge.

Background: Ethnically Chinese adults in Canada and the United States face multiple barriers in accessing equitable, culturally respectful care at the end-of-life. Palliative care (PC) is committed to supporting patients and families in achieving goal-concordant, high-quality serious illness care. Yet, current PC delivery may be culturally misaligned. Therefore, understanding ethnically Chinese patients' use of palliative care may uncover modifiable factors to sustained inequities at the end-of-life.

Objective: To compare the use and delivery of PC in the last year of life between ethnically Chinese and non-Chinese adults.

Design: Population-based cohort study.

Participants: All Ontario adults who died between January 1st, 2012, and October 31st, 2022, in Ontario, Canada.

Exposures: Chinese ethnicity.

Main measures: Elements of physician-delivered PC, including model of care (generalist; specialist; mixed), timing and location of initiation, and type of palliative care physician at initial consultation.

Key results: The final study cohort included 527,700 non-Chinese (50.8% female, 77.9 ± 13.0 mean age, 13.0% rural residence) and 13,587 ethnically Chinese (50.8% female, 79.2 ± 13.6 mean age, 0.6% rural residence) adults. Chinese ethnicity was associated with higher likelihoods of using specialist (adjusted odds ratio [aOR] 1.53, 95%CI 1.46-1.60) and mixed (aOR 1.32, 95%CI 1.26-1.38) over generalist models of PC, compared to non-Chinese patients. Chinese ethnicity was also associated with a higher likelihood of PC initiation in the last 30 days of life (aOR 1.07, 95%CI 1.03-1.11), in the hospital setting (aOR 1.24, 95%CI 1.18-1.30), and by specialist PC physicians (aOR 1.33, 95%CI 1.28-1.38).

Conclusions: Chinese ethnicity was associated with a higher likelihood of mixed and specialist models of PC delivery in the last year of life compared to adults who were non-Chinese. These observed differences may be due to later initiation of PC in hospital settings, and potential differences in unmeasured needs that suggest opportunities to initiate early, community-based PC to support ethnically Chinese patients with serious illness.

Background: Alcohol use disorders (AUD) are prevalent and responsible for substantial morbidity and mortality; yet efficacious treatments are underused. Previous studies have identified demographic and clinical predictors of medication fills, yet these studies typically do not include patients who were prescribed a medication but did not fill it.

Objectives: To examine rates of and factors associated with prescription order and prescription fill for medications for AUD (MAUD) among individuals diagnosed with AUD in outpatient settings.

Design: In a cross-sectional analysis, we used multivariate logistic regression to identify factors associated with prescription order and fill.

Patients: We used data from the Optum Labs Data Warehouse that linked 2016-2021 de-identified claims and electronic health record (EHR) data, allowing us to observe prescription orders and whether they were filled. We identified 14,674 patients aged ≥ 18 who had an index outpatient encounter with an AUD diagnosis in the EHR.

Key measures: We computed the proportion for whom a MAUD prescription was ordered within 1 year of index visit, and for whom one was filled within 30 days of the order.

Key results: 5.8% of the sample had a MAUD prescription order within 1 year of their index visit. Among those with an order, 87% filled their MAUD prescription within 30 days of receipt (i.e., 5.1% of full sample). After multivariable adjustment, receipt of a MAUD prescription order was more likely for patients who were female (adjusted odds ratio (aOR) [95%CI] = 1.44 [1.24-1.67]), or had moderate or severe AUD (1.74 [1.50-2.01]). Patients receiving an order were more likely to fill it if they had a comorbid mental disorder (1.64 [1.09-2.49]).

Conclusions: The low rate of prescription orders was notable. Low use of MAUD appears to result chiefly from prescription order decisions, rather than from prescription fill decisions made by patients.

Background: Artificial intelligence (AI) algorithms are increasingly used to target patients with elevated mortality risk scores for goals-of-care (GOC) conversations.

Objective: To evaluate the association between the presence or absence of AI-generated mortality risk scores with GOC documentation.

Design: Retrospective cross-sectional study at one large academic medical center between July 2021 and December 2022.

Participants: Hospitalized adult patients with AI-defined Serious Illness Risk Indicator (SIRI) scores indicating > 30% 90-day mortality risk (defined as "elevated" SIRI) or no SIRI scores due to insufficient data.

Intervention: A targeted intervention to increase GOC documentation for patients with AI-generated scores predicting elevated risk of mortality.

Main measures: Odds ratios comparing GOC documentation for patients with elevated or no SIRI scores with similar severity of illness using propensity score matching and risk-adjusted mixed-effects logistic regression.

Key results: Among 13,710 patients with elevated (n = 3643, 27%) or no (n = 10,067, 73%) SIRI scores, the median age was 64 years (SD 18). Twenty-five percent were non-White, 18% had Medicaid, 43% were admitted to an intensive care unit, and 11% died during admission. Patients lacking SIRI scores were more likely to be younger (median 60 vs. 72 years, p < 0.0001), be non-White (29% vs. 13%, p < 0.0001), and have Medicaid (22% vs. 9%, p < 0.0001). Patients with elevated versus no SIRI scores were more likely to have GOC documentation in the unmatched (aOR 2.5, p < 0.0001) and propensity-matched cohorts (aOR 2.1, p < 0.0001).

Conclusions: Using AI predictions of mortality to target GOC documentation may create differences in documentation prevalence between patients with and without AI mortality prediction scores with similar severity of illness. These finding suggest using AI to target GOC documentation may have the unintended consequence of disadvantaging severely ill patients lacking AI-generated scores from receiving targeted GOC documentation, including patients who are more likely to be non-White and have Medicaid insurance.

Background: Patients hospitalized with COVID-19 can clinically deteriorate after a period of initial stability, making optimal timing of discharge a clinical and operational challenge.

Objective: To determine risks for post-discharge readmission and death among patients hospitalized with COVID-19.

Design: Multicenter retrospective observational cohort study, 2020-2021, with 30-day follow-up.

Participants: Adults admitted for care of COVID-19 respiratory disease between March 2, 2020, and February 11, 2021, to one of 180 US hospitals affiliated with the HCA Healthcare system.

Main measures: Readmission to or death at an HCA hospital within 30 days of discharge was assessed. The area under the receiver operating characteristic curve (AUC) was calculated using an internal validation set (33% of the HCA cohort), and external validation was performed using similar data from six academic centers associated with a hospital medicine research network (HOMERuN).

Key results: The final HCA cohort included 62,195 patients (mean age 61.9 years, 51.9% male), of whom 4704 (7.6%) were readmitted or died within 30 days of discharge. Independent risk factors for death or readmission included fever within 72 h of discharge; tachypnea, tachycardia, or lack of improvement in oxygen requirement in the last 24 h; lymphopenia or thrombocytopenia at the time of discharge; being ≤ 7 days since first positive test for SARS-CoV-2; HOSPITAL readmission risk score ≥ 5; and several comorbidities. Inpatient treatment with remdesivir or anticoagulation were associated with lower odds. The model's AUC for the internal validation set was 0.73 (95% CI 0.71-0.74) and 0.66 (95% CI 0.64 to 0.67) for the external validation set.

Conclusions: This large retrospective study identified several factors associated with post-discharge readmission or death in models which performed with good discrimination. Patients 7 or fewer days since test positivity and who demonstrate potentially reversible risk factors may benefit from delaying discharge until those risk factors resolve.

Background: Despite rising hospitalizations for opioid use disorder (OUD), rates of inpatient medications for OUD (MOUD) initiation are low. Addiction consult services (ACSs) facilitate inpatient MOUD initiation and linkage to post-discharge MOUD, but few studies have rigorously examined ACS OUD outcomes.

Objective: To determine the association between ACS consultation and inpatient MOUD initiation, discharge MOUD provision, and post-discharge MOUD linkage.

Design: Retrospective study comparing admissions that received an ACS consult and propensity score-matched historical control admissions.

Subjects: One hundred admissions with an OUD-related diagnosis, of patients not currently receiving MOUD who received an ACS consult, and 100 matched historical controls.

Intervention: Consultation from an interprofessional ACS offering expertise in MOUD initiation and linkage to post-discharge MOUD.

Main measures: The primary outcome was inpatient MOUD initiation (methadone or buprenorphine). Secondary outcomes were inpatient buprenorphine initiation, inpatient methadone initiation, discharge prescription for buprenorphine, linkage to post-discharge MOUD (buprenorphine prescription within 60 days and new methadone administration at a methadone program within 30 days after discharge), patient-directed discharge, 30-day readmission, and 30-day emergency department (ED) visit.

Key results: Among 200 admissions with an OUD-related diagnosis, those that received an ACS consultation were significantly more likely to have inpatient MOUD initiation (OR 2.57 [CI 1.44-4.61]), inpatient buprenorphine initiation (OR 5.50 [2.14-14.15]), a discharge prescription for buprenorphine (OR 17.22 [3.94-75.13]), a buprenorphine prescription within 60 days (22.0% vs. 0.0%, p < 0.001; of those with inpatient buprenorphine initiation: 84.6% vs. 0.0%), and new methadone administration at a methadone program within 30 days after discharge (7.0% vs. 0.0%, p = 0.007; of those with inpatient methadone initiation: 19.4% vs. 0.0%). There were no significant differences in other secondary outcomes.

Conclusions: There was a strong association between ACS consultation and inpatient MOUD initiation and linkage to post-discharge MOUD. ACSs promote the delivery of evidence-based care for patients with OUD.