Journal of General Internal Medicine最新文献

Background: Some who suffer traumatic/adverse life events experience positive change or posttraumatic growth (PTG) from those events. Research suggests that minority populations may experience greater PTG than non-minorities, but factors contributing to these differences are unclear. The COVID-19 pandemic provides an opportunity to assess PTG in diverse populations.

Objective: To investigate PTG among COVID-19 survivors, compare PTG between Hispanic and non-Hispanic survivors, and ascertain factors that contribute to PTG.

Participants and design: A cross-sectional study of 239 adults with a history of COVID-19 infection were surveyed from December 2020 to September 2021 in San Antonio, TX. PTG was measured by the CAIR Pandemic Impact Questionnaire (C-PIQ), addressing five domains scored on a scale of 0-4: strengthened relationships, new possibilities, personal strength, spiritual change, and appreciation of life, with higher scores corresponding to greater PTG. Data related to pandemic-related social determinants of health stressors and Patient-Reported Outcomes Measurement Information System (PROMIS) health status domains were also collected. Multivariable linear regression analysis examined factors associated with PTG, including interactions between PTG scores and Hispanic ethnicity.

Results: The sample was predominantly female (69%) and Hispanic (84%). The mean (SD) age was 43.7 (14.7) years, and the mean (SD) time between COVID-19 diagnosis to survey completion was 8.1 (3.2) months. The mean (SD, range) total PTG score for all respondents was 7.7 (4.7, 0-20); Hispanic respondents had higher scores than non-Hispanic respondents (8.1 [4.7] vs 5.7 [4.7]), respectively (p = 0.003). Multivariable regression analyses indicated higher PTG scores were positively associated with Hispanic ethnicity, older age, anxiety, and caring for sick/aging family members and negatively associated with depression (R² = 0.14).

Conclusions: Many survivors of COVID-19 infection experience PTG. Hispanic individuals with a history of COVID-19 infection experienced greater total PTG scores than non-Hispanic individuals. Older age, anxiety, and caring for sick/aging family members may contribute to greater PTG.

The Agency for Healthcare Research and Quality encouraged a re-examination of the concept, process, and measurement of shared decision-making (SDM) in 2016. Progress, however, has been slow. One illustrative example is SDM's relationship with the concept of equipoise: there remains little consensus on what equipoise means in the context of SDM, creating confusion about when SDM is and is not indicated. In this paper, we describe the ways in which this focus on equipoise in SDM is counter-productive and argue that equipoise is neither a necessary nor sufficient criterion in determining the need for SDM. Moreover, we suggest that what is needed to move the field of SDM forward is a shift away from focusing on when SDM is needed to instead focusing on how best to accomplish SDM across a variety of contexts by advancing the science of SDM implementation.

Background: Graduate medical education is a critical period for fostering self-directed learning (SDL). This study introduced an academic coaching program to support SDL among internal medicine (IM) residents, leveraging Gallimore and Tharp's four-stage model as a scaffolding framework.

Objective: To assess the impact of academic coaching on residents' performance, including Internal Medicine In-Training Examination (IM-ITE) scores, individualized learning plans (ILPs), and attitudinal changes. The study also explored how coaching influenced SDL within the residency program.

Design and participants: A mixed-methods case study was conducted in a mid-sized university's IM residency program. Quantitative measures included pre- and post-coaching surveys, ILP analysis, and IM-ITE score evaluation. Semi-structured interviews provided qualitative insights into participant experiences. Of 77 eligible residents, 40 enrolled in the coaching program, and 27 (18 post-graduate year (PGY) 1 and PGY2) completed at least one session. Baseline IM-ITE scores guided enrollment for mandatory participants.

Key results: Of the 77 residents, 51 had complete IM-ITE data and individualized learning plans (ILPs) from 2022 and 2023. Residents attending one coaching session demonstrated significant improvement in IM-ITE percentile scores (p = .022), while those with two or more sessions showed significant gains in both percent correct (p = .015) and percentile scores (p = .003). No significant differences were observed in ILPs or attitudinal surveys. Qualitative analyses of resident participant interviews highlight coaching's positive influence on SDL, organized into input, process, and output domains.

Conclusions: Sustained coaching, defined as two or more coaching meetings, is associated with improved IM-ITE performance. Qualitative findings underscore the program's role in enhancing residents' SDL.

Background: Millions of Americans remain infected with hepatitis C (HCV). Innovation in care delivery is required to achieve the goal of national elimination.

Aim: Develop a low-threshold HCV treatment program.

Setting: Free clinic with mobile unit providing transitional care to people leaving jails and prisons across Alabama.

Participants: Formerly incarcerated persons, many of whom are uninsured and live in rural areas.

Program description: We utilized point-of-care diagnostics to condense the HCV screening and pre-treatment evaluation into a single encounter. Patient assistance programs were used to obtain medications for uninsured patients. Clinical support was provided through in-person and telehealth care.

Program evaluation: From January 2023 to December 2024, 369 patients were screened for HCV; 104 (28.1%) were HCV antibody positive, and 71 (19.2%) were viremic. Of these patients, 70 completed pre-treatment diagnostics, 54 started treatment, 41 confirmed completion, 20 had SVR12 collected, with 19 achieving cure (94% cure rate). The median time from diagnosis to treatment initiation was 27 days.

Discussion: It is possible to both diagnose HCV and complete the entire pre-treatment evaluation in a single encounter and initiate treatment within 1 month, even for predominantly uninsured populations in rural areas.

Background: Long-acting injectable cabotegravir (CAB-LA), approved in 2021, is a more effective HIV prevention method than daily oral PrEP. CAB-LA expansion addresses key HIV prevention gaps, especially in the Southern United States (U.S.), to support national Ending the HIV Epidemic (EHE) goals. However, complex implementation requirements hinder CAB-LA expansion, highlighting the need for real-world data to guide effective and equitable scale-up.

Objective: Describe the implementation and early outcomes of implementing CAB-LA in a large safety-net primary care center in the Southern U.S.

Design: We described the integration of CAB-LA into an existing oral PrEP program. We manually abstracted individual sociodemographic and clinical data. We developed a CAB-LA care continuum and reported early outcomes among CAB-LA initiators.

Participants: Individuals referred to the CAB-LA program from 12/1/2022 to 8/1/2023, with outcomes assessed through 12/1/2023.

Main measures: Development of a CAB-LA care continuum from linkage, eligibility assessment, program enrollment, initiation, and persistence. We reported the sociodemographic and clinical characteristics of individuals referred for and initiated on CAB-LA, the total number and timing of injections administered, self-reported adverse events, CAB-LA discontinuations, and HIV seroconversions.

Key results: Integration of CAB-LA into an existing oral PrEP program required multidisciplinary team adaptation, protocol development for drug procurement and care coordination, and adapting an existing population health registry to the CAB-LA workflow to monitor and track individuals. Of 221 referred individuals, 77 (35%) initiated CAB-LA. Initiation barriers included program intake scheduling delays (29%), individuals declining CAB-LA (19%), and delayed medication procurement (16%). Among CAB-LA initiators, 275 injections were administered, 94% were administered on time, six individuals (8%) reported adverse effects, and eight (10%) discontinued CAB-LA. No HIV seroconversions occurred.

Conclusions: We successfully implemented a CAB-LA PrEP program in a safety-net primary care center in the U.S. South, using an approach designed to address structural barriers to PrEP uptake and persistence.

Nocturnists are the principal means by which hospital medicine groups currently ensure continuous overnight coverage of hospitalized patients within academic medical centers and community hospitals. Yet despite their involvement in most aspects of overnight care, a comprehensive review of the impact of nocturnists in the hospital is absent. Here we examine the physiologic effects of overnight work on clinicians, the quality of medical care delivered by nocturnists in floor and intensive care units, the impact of nocturnist presence on trainee supervision and graduated autonomy in academic settings, and prevalent staffing models. Nocturnists serve diverse roles across institutions, including performing overnight admissions and consultations, managing patients, supervising trainees, and participating in rapid response activations. Physiologically, nocturnists may experience circadian misalignment and sleep deprivation, which can impact cognitive function and results in potential long-term health risks to those working overnight. Studies show mixed results of nocturnist impact on patient outcomes, with comparative observational analyses revealing no significant differences in mortality, readmissions, or length of stay, despite perceived benefits. Nocturnist presence has been shown to enhance resident supervision and educational value of overnight rotations without compromising decision-making autonomy, though trainees' fear of revealing knowledge gaps persists. Overnight staffing models vary, with some institutions employing dedicated nocturnists and others using hybrid models; the heterogeneity of nocturnist responsibilities across institutions makes determining ideal models difficult. Compensation is typically greater for nocturnists, but the role's sustainability and impact on overall group retention remain unknown. Nocturnist programs are essential to provide continuous care of hospitalized patients and meet trainee supervision mandates, yet their full impact on patient and educational outcomes requires further investigation. Future research should aim to optimize staffing models to enhance patient care, trainee education, and clinician well-being.

Background: Poor quality communication and language barriers lead to worse care experiences and inferior health care outcomes for those with limited English proficiency. Fewer than one-third of outpatient providers regularly use professional interpreters when communicating with non-English preferring patients. Effective strategies to address language barriers in primary care are lacking and in demand.

Objective: Examine provider perspectives on providing in-person care to Spanish-preferring patients.

Design: Partnered with a large, urban Federally Qualified Health Center predominantly caring for Spanish-preferring Hispanic patients, we identified primary care providers who (1) were language-concordant (provider and patient speak same language); (2) used qualified interpreters; and (3) used informal strategies for interpretation/communication.

Participants: We interviewed 24 providers (10 language-concordant, 9 who used qualified interpreters, 5 who used informal interpreters and other strategies; response-rate 23%).

Approach: We established codes using systematic, inductive procedures to generate insights from responses and identified themes using content analysis.

Results: Providers-both language-concordant and those using interpreters-preferred to speak the same language as the patient, employed varying communication strategies, and required more time to care for Spanish-preferring patients for differing reasons. Using interpreters did not always improve communication because using qualified interpreters requires more time for initiating interpretation, connectivity issues, and conducting consecutive interpretation; using any interpreter requires provider-interpreter clarification or staff to translate, and sometimes interpreters had difficulty with medical content/terminology. Provider-patient visits also qualitatively differed based on language spoken and interpreter use in eliciting concerns, topics covered, patient comprehension, and time spent on rapport-building and patient education.

Conclusions: Providers described barriers that organizations need to address to facilitate effective communication and language interpretation when caring for Spanish-preferring patients. Research is needed that identifies and tests language support strategies for providers and clinics and structural changes that preserve time during patient visits for providers and patients to spend on health care needs.

Background: Medicare Advantage (MA) includes incentives to reduce health care spending and insures over half of Medicare eligible adults. Substance use disorders (SUD) are common in this population.

Objective: To compare clinical outcomes between MA and traditional Medicare beneficiaries hospitalized with SUD.

Design: Retrospective cohort.

Patients: Medicare beneficiaries hospitalized for alcohol withdrawal or opioid overdose from 2016 to 2021.

Measures: Primary outcomes included mortality and all-cause readmissions within 30 days of discharge. Secondary outcomes included use of SUD medications.

Results: Of 104,833 beneficiaries hospitalized for alcohol withdrawal (mean age 62.1 [SD 11.5] years, 71.8% male) and 75,463 hospitalized for opioid overdose (mean age 64.5 [SD 12.5] years, 40.8% male), 36.4% and 37.3% were enrolled in MA, respectively. Adjusted rates of 30-day mortality were lower in MA for alcohol withdrawal (unadjusted 2.5% in MA vs 2.4% in traditional Medicare; adjusted difference -0.27 pp [95% CI -0.47, -0.08]) but similar for opioid overdose (7.8% in MA vs 7.9% in traditional Medicare; adjusted difference -0.13 pp [-0.54, 0.27]). Rates of 30-day readmissions were lower in MA for both alcohol withdrawal (12.3% in MA vs 13.7% in traditional Medicare; adjusted difference -1.01 pp [95% CI -1.44, -0.59]) and opioid overdose (14.8% in MA vs 17.6% in traditional Medicare; adjusted difference -1.93 pp [95% CI -2.49, -1.37]). Enrollment in MA was associated with lower use of medications for alcohol use disorder (unadjusted 9.6% in MA vs 11.3% in traditional Medicare; adjusted difference -1.66 pp [95% CI -2.72, -0.60]) but higher use of medications for opioid use disorder (unadjusted 4.9% in MA vs 4.2% in traditional Medicare; adjusted difference, 0.82 pp [95% CI 0.08, 1.57]).

Conclusions: Compared to traditional Medicare, MA was associated with modestly lower 30-day mortality after alcohol withdrawal, lower 30-day readmission rates after alcohol withdrawal and opioid overdose hospitalizations, and mixed findings on medication use.