Journal of General Internal Medicine最新文献

Background: Federally Qualified Health Centers (FQHCs) play a critical role in delivering preventive care, including cancer screening, to underserved populations in the United States. Despite widespread adoption of screening, disparities persist, particularly among socioeconomically disadvantaged patients. How neighborhood-level social risk contributes to variation in cancer screening across FQHCs remains unclear.

Objective: To examine the association between average patient social risk-measured using patients' ZIP code-level overall and domain-specific Social Vulnerability Index (SVI)-and cancer screening rates across FQHCs.

Design: Retrospective cross-sectional study using 2022 Uniform Data System (UDS) data.

Participants: 1,312 FQHCs with complete data, serving 29.8 million patients across 50 states and Washington, DC.

Main measures: FQHC-level social risk was calculated as the patient volume-weighted average SVI score across all patient ZIP codes served by the FQHC. Outcomes were FQHC-level breast, cervical, and colorectal cancer screening rates as defined by 2022 UDS clinical quality measure specifications. Linear regression models adjusted for FQHC characteristics, including patient volume, demographics, chronic condition prevalence, government funding, rurality, and Medicaid expansion status.

Results: Compared with FQHCs serving the least vulnerable communities, those serving the most socially vulnerable neighborhoods had cancer screening rates that were 7.8 percentage points (pp) lower for cervical cancer, 10.9 pp lower for breast cancer, and 15.3 pp lower for colorectal cancer (all p < 0.001). Disparities were largest for colorectal cancer and were most pronounced for the socioeconomic status SVI subdomain. Differences were larger in non-Medicaid expansion states and among larger FQHCs. Findings were consistent across sensitivity analyses.

Conclusion: Substantial disparities in cancer screening persist across FQHCs and are closely linked to the socioeconomic characteristics of the communities they serve. Targeted interventions, sustained funding, and tailored resource allocation for FQHCs serving socially vulnerable populations may help improve screening uptake, reduce preventable disparities, and advance national cancer prevention goals.

Background: Results from blood pressure (BP) control interventional trials can inform clinicians and health systems pursuing better BP control, but they must be interpreted cautiously.

Objective: Deconstruct the observed drop in systolic BP (SBP) into components attributable to increased adherence to previously prescribed medications, regression to the mean, and initiation of new medications.

Design: Secondary analysis of BP Home, a pragmatic randomized controlled trial.

Participants: Patients owning a smartphone who reported uncontrolled BP at their last clinic visit (> 145 mmHg) and a desire to lower their BP by > 10 mmHg.

Interventions: In BP Home, participants were randomly assigned to receive one of two devices for self-measurement of BP and followed for up to 24 months via electronic health records (EHR).

Approach: The primary outcome was EHR-recorded office SBP. We fit SBP trajectories for each participant using linear mixed models, and estimated the contributions of medication adjustments, and increased adherence to pre-existing BP medications due to their enrollment in a research study (i.e., a Hawthorne effect). Regression to the mean was calculated for each participant as the difference between their last measured pre-enrollment SBP and their modeled SBP trajectory at enrollment.

Key results: Among participants taking BP medications at enrollment, we estimated an average immediate drop in SBP of -4.2 mmHg (95% CI, -5.1 to -3.3; p < 0.001) at enrollment, explainable by increased medication adherence following study enrollment. Starting a new medication class post-enrollment resulted in an SBP drop of -4.1 mmHg (95% CI, -5.3 to -2.8; p < 0.001). The average expected regression to the mean was -3.9 (95% CI, -4.4 to -3.3; p < 0.001).

Conclusions: A significant portion of BP reductions in trials may stem from increased adherence to pre-existing medications arising from enrollment in a research study and enhanced awareness of their elevated BP.

Nih trial registry number: NCT03796689 (registered on 2019-01-04).

Background: Despite federal mandates requiring qualified interpreter use, ad hoc interpreters, untrained individuals such as family members or bilingual staff, continue to be used in clinical care for patients with non-English language preference (NELP). Prior studies rely primarily on self-report or administrative data, leaving gaps in our understanding of how and when ad hoc interpretation is documented in real-world practice.

Objective: To characterize the frequency, documentation, and contextual factors associated with untrained ad hoc interpreter use in inpatient medicine settings.

Methods: We conducted a retrospective cohort study of adults with NELP admitted to a general medicine service at a large academic medical center between 2019 and 2023. We analyzed clinical notes using a large language model-based approach to identify documentation of interpreter use. Ad hoc interpretation cases were manually validated and categorized by interpretive role and documented rationale.

Results: Among 23,245 clinical notes from 2176 admissions involving 1379 patients with NELP, professional interpreter services were documented in 5921 notes (25.5% of notes). Ad hoc interpreter use was explicitly documented in 600 notes (2.6% of notes), across 324 admissions (14.9% of admissions) and 223 patients (16.2% of patients). Most ad hoc interpreter documentation involved family members (64.7%), and 7.7% occurred in conjunction with professional interpreters. Admissions with documented ad hoc interpreter use involved older patients, longer hospital stays, and higher comorbidity burden. Documented ad hoc interpreter use was more prevalent among non-Spanish language groups and increased with length of stay; nearly 75% of ad hoc interpreter notes lacked a documented rationale.

Conclusion: Ad hoc interpreter use was relatively common among inpatients with NELP, particularly for less common languages and longer lengths of stay, and was most often provided by family members. Gaps in documented rationales for ad hoc interpreter use reveal systemic issues in language access workflows and underscore the need for improved access to professional interpretation, standardized documentation, and greater use of qualified bilingual staff to ensure equitable, policy-compliant communication for all language groups.

Background: Providing quality care for individuals with multimorbidity requires the integration of care across health and social care systems; however, the two systems often work in silos, resulting in information asymmetry, fragmented care, and the duplication of services.

Aim: To describe a model integrating health and social care for individuals with complex care needs.

Setting: A public primary care organization in Singapore.

Participants: Individuals with poorly controlled diabetes mellitus and complex psychosocial needs.

Program description: PACE-It (PrimAry CarE based Integrated community care Team) program comprising an integrated multidisciplinary team and a technology-enabled secure communication platform.

Program evaluation: A pilot randomized controlled trial (n = 41) was conducted between December 2020 and February 2022. Individuals enrolled in the PACE-It program had better clinical outcomes than those receiving usual care, with more achieving HbA1c < 7.5% (22.2% vs 9.1%) and LDL < 2.6 mmol/L (80.0% vs 57.1%) at 12 months. They also reported greater patient activation and medication adherence from baseline (PAM score 3 and 4, 43.8% vs 23.3%; MARS-5 ≥ 20, 9.5% vs 4.4%).

Discussion: Preliminary findings show improved clinical and patient-reported outcomes. Additionally, the co-development of PACE-It led to stronger relationships and collaboration between health and social care workers.

Background: Structured Interdisciplinary Rounds (SIDRs) aim to improve communication, care coordination, and discharge planning by bringing multidisciplinary teams together for structured bedside discussions. Although widely promoted, few multisite evaluations have assessed their association with key hospital performance metrics compared with traditional rounding models.

Objective: To evaluate the association of SIDRs with hospital efficiency, safety, and patient experience across a multi‑hospital health system.

Design: Retrospective cohort study comparing SIDR and traditional care units across four hospitals.

Participants: A total of 11,334 inpatient discharges between July 1, 2023, and October 31, 2024.

Interventions: Daily structured interdisciplinary rounds conducted by physicians, nurses, case managers, pharmacists, and rehabilitation staff.

Main measures: Length of stay (LOS), observed‑to‑expected LOS (O/E LOS), case mix index (CMI)‑adjusted LOS, 30‑day readmissions, safety outcomes (falls, pressure injuries, medication errors per 1000 patient‑days), patient experience (HCAHPS communication and care‑transition domains), and complaints per 1000 patient‑days.

Key results: SIDR units had lower O/E LOS compared with traditional units (1.35 vs 1.50; Δ - 0.15, 95% CI - 0.22 to - 0.05; p = 0.004). Unadjusted LOS was higher in SIDR units, whereas CMI‑adjusted LOS favored SIDR among moderate‑ and high‑complexity patients. Thirty‑day readmissions and patient‑experience scores did not differ significantly. Safety event rates were low in both groups, with no significant differences, although medication‑error reporting was likely under‑captured due to voluntary reporting systems. Unit‑level sensitivity analyses demonstrated site‑level heterogeneity but were directionally consistent with patient‑level findings, with risk‑adjusted advantages for SIDR most pronounced at one hospital.

Conclusions: SIDRs were associated with lower risk‑adjusted LOS without differences in readmissions, safety events, or patient‑experience scores. Benefits were greatest among higher‑complexity patients, suggesting that structured interdisciplinary communication may be particularly impactful for patients requiring intensive coordination. Further research should incorporate broader safety indicators, process‑of‑care measures, and patient‑reported experience tools to more fully characterize the effects of SIDRs across diverse inpatient environments.

Background: Medical debt burdens an estimated 20 million Americans and may contribute to unmet needs for healthcare.

Objective: To examine if medical, mental health, or dental needs are differentially sensitive to medical debt and if this varies by type of health insurance.

Design: Cross-sectional, nationally representative survey.

Participants: U.S. adult participants in the 2023 National Health Interview Survey.

Main measures: Self-reported medical financial hardship ("medical debt") and probability of deferred care in the past year for (a) medical, (b) mental health, and (c) dental needs, among adults with medical debt, compared to adults without medical debt.

Key results: The overall prevalence of past-year medical debt was 10.7% [95% CI: 10.3, 11.2] and was high across all insurance market segments: 19.5% [17.5, 21.8] among uninsured adults, 12.6% [11.3, 14.1] among adults with Medicaid, 9.3% [8.8, 9.9] among adults with commercial insurance, and 8.1% [7.2, 9.2] among adults with Medicare. Medical debt was associated with a 24.6 [22.4, 26.8] percentage point (pp) increase in the probability of deferred dental care, 17.6 pp [15.9, 19.4] increase in the probability of deferred medical care, and 9.3 pp [7.9, 10.7] increase in the probability of deferred mental healthcare. Associations were largely consistent by health insurance category, although the association between medical debt and deferred medical care was significantly higher (P = 0.008) among uninsured adults (32.5 pp [25.6, 39.4]) than adults covered by commercial insurance (16.9 [14.7, 19.1]).

Conclusions: Medical debt was consistently associated with deferred care, with dental care most commonly deferred, followed by medical care and then mental healthcare. This association remained mostly consistent across all types of health insurance. Policy interventions that aim to address financial barriers to care and the accompanying burden of medical debt may mitigate the health and economic consequences of delayed and forgone care.