Journal of General Internal Medicine最新文献

Background: Veterans experiencing homelessness have a high burden of cardiovascular disease (CVD). Identifying approaches that can improve the health of this population is crucial.

Objective: The Department of Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) provides permanent supportive housing (PSH) assistance. We examined whether obtaining PSH through HUD-VASH was associated with changes in outcomes among Veterans with CVD experiencing homelessness.

Design: Using a difference-in-differences (DID) approach, outcomes among Veterans who received a HUD-VASH voucher and moved into PSH within one month (early group) were compared with those who received a voucher but remained unhoused for at least six months (delayed group).

Participants: Veterans ≥ 18 years of age with CVD (coronary artery disease, heart failure, peripheral arterial disease, ischemic stroke/cerebrovascular disease, or atrial fibrillation) who experienced ≥ 6 months of homelessness and received a HUD-VASH voucher in 2016 to 2019.

Intervention: Entering PSH after receiving a HUD-VASH voucher.

Main measures: Six-month probability of a cardiovascular ED visit or hospitalization.

Key results: Among 970 Veterans with CVD experiencing homelessness, 845 were in the early and 125 in the delayed PSH group. There was a significant decrease in the 6-month probability of cardiovascular ED visits or hospitalizations (16.3% [95% CI 13.9% - 18.7%] to 11.9% [95% CI 9.8% - 14.0%]) among Veterans who received a voucher and moved into PSH within one month, but no statistically significant change among Veterans who did not move into PSH for at least 6 months (13.4% [95% CI 8.0% - 18.8%] to 18.1% [95% CI 11.4% - 24.8%]) for a DID estimate of -9.1 (95% CI -17.7 - -0.5) percentage points, p = 0.04.

Conclusions: Obtaining PSH through HUD-VASH was associated with a significant decrease in the probability of CVD related ED visits or hospitalizations among Veterans with chronic CVD experiencing homelessness.

Background: The Department of Veterans Affairs (VA) refers patients to affiliated legal clinics to assist with health-related social needs like housing and benefits. However, little is known about the prevalence of various types of civil legal needs (CLNs) among VA patients and sociodemographic/clinical correlates. This limits the VA's ability to tailor medical-legal collaborations to patients' needs and identify subpopulations most likely to experience these needs.

Objective: To estimate the prevalence of eight types of CLNs (housing, family, wills/inheritance, VA benefits, non-VA benefits, finance, military discharge upgrade, and employment) among VA patients and test CLN associations with sociodemographic and clinical characteristics.

Design: We administered an online survey to a stratified random sample of VA patients and linked responses with VA administrative data. We calculated CLN prevalence, the proportion of participants who received help with CLNs, and correlations among CLNs. We used logistic regression to examine bivariate associations with sociodemographic and clinical characteristics.

Participants: A random race/ethnicity- and rurality-stratified sample of VA healthcare patients was invited to participate (n = 19,714). Those who answered CLN questions were included (n = 1,858; participation rate = 9.42%).

Main measures: Modeled measures included CLNs reported by ≥ 10% of the sample and a combined measure of any (versus no) CLNs.

Key results: The most prevalent CLNs were for wills/inheritance (30.52%), VA benefits (24.92%), finance (13.08%), family (10.82%), and housing (10.23%). In bivariate models examining sociodemographic and clinical correlates, financial strain was significantly associated with all individually modeled needs and any CLNs (ORs 1.23-3.32, p < 0.01-0.03). Education beyond high school was significant for all CLNs except housing (ORs = 1.46-2.38, p < 0.01-0.04).

Conclusions: CLNs are prevalent, and financially strained VA patients and those with higher education are more likely to report these needs. The VA should explore and evaluate tailored modes of screening and outreach to identify Veterans who could benefit from free or low-cost civil legal services.

Background: Studies on prescribing buprenorphine before and after buprenorphine training and the elimination of the X-waiver among hospitalists are limited.

Objective: This study aims to determine hospitalists' medication for opioid use disorder (MOUD) knowledge and beliefs before buprenorphine training and to assess MOUD prescribing patterns captured in the electronic medical record (EMR) pre-buprenorphine training, after training, and after elimination of the X-waiver.

Design: Quantitative cohort survey study and quantitative retrospective medical record review.

Participants: Hospitalists without an X-waiver before August 2022 (n = 70) at an academic hospital with a dedicated addiction consult service.

Main measures: For the survey, average composite scores of knowledge (higher score = more knowledge); for the EMR, MOUD inpatient, at discharge and ordering clinician specialty.

Key results: Fifty-four of 70 invited physicians (77.14%) completed the pre-training survey. The majority of participants provided counseling on MOUD (72.22%) before training, but only 46.3% initiated buprenorphine-naloxone, and 29.6% initiated methadone on patients with opioid use disorder (OUD) who were MOUD-naïve. The odds of a patient receiving an MOUD prescription at discharge post-training were higher than pre-training (OR = 1.69, [1.04, 2.70], p = 0.03). Having participated in the buprenorphine training was associated with greatly increased odds of prescribing buprenorphine at discharge (OR = 91.85, [28.17, 299.47], p < 0.001). The proportion of inpatient encounters with MOUD on their pre-hospitalization outpatient medication list that did not experience disruption of their MOUD during hospitalization increased over the three periods (82.05 to 83.64 to 93.33%; p < 0.001).

Conclusions: Among a hospitalist group with high baseline MOUD knowledge, targeted buprenorphine training was associated with greater odds of prescribing buprenorphine. Fewer disruptions of the MOUD care continuum were observed over time which may reflect a combined impact of providing targeted education, changing federal policy change and having a dedicated addiction consult service.

Background: Remote patient monitoring (RPM) for hypertension is effective for lowering blood pressure (BP), but it is unknown whether engagement in RPM is equal for diverse populations or whether engagement impacts achievement of BP targets.

Objective: To determine how participant characteristics are associated with level of RPM engagement and examine whether RPM engagement impacts achievement of BP < 140/90 mmHg at six months.

Design: Retrospective cohort study from January 1, 2022 to August 31, 2023.

Participants: Adults with hypertension, referred to RPM by their primary care clinician with the opportunity to be enrolled for least six months of enrollment at an urban academic health center.

Main measures: The primary outcome was a high level of engagement, defined as measuring BP more than half the days of the month for at least two of the three first months of participation, versus a low level of engagement. The secondary outcome was BP control < 140/90 mmHg by six months.

Key results: A total of 835 patients were enrolled in RPM. There were 521 (62.40%) participants with a high level of engagement. Older age (aOR = 1.03, 95% CI [1.01, 1.04]) and lower baseline average systolic BP (aOR = 0.98, 95% CI [0.97, 0.99]) were associated with increased odds of a high level of engagement. Gender, race/ethnicity, and preferred language were not associated with level of engagement. Among all participants, 478 (62.65%) achieved BP control by six months. Those with a high level of engagement, adjusted for age, gender, race/ethnicity, and baseline average systolic BP, had 83% higher odds of achieving BP control compared to those with a low level of engagement (aOR = 1.83, 95% CI [1.24, 2.69]).

Conclusions: RPM engagement was feasible in a diverse patient population and was similar across demographic groups. A higher level of engagement was associated with achieving BP control.

Introduction: Point-of-care ultrasound (POCUS) use during cardiac arrest (PDCA) is important as it has shown promising results in emergency medicine. Given its increase in use within internal medicine as well, this quality improvement (QI) project was devised to create such a protocol for PDCA within inpatient medicine, determine the current prevalence of PDCA, and survey attitudes regarding its clinical value.

Methods: We conducted Plan, Do, Study, Act (PDSA) cycles. Inclusion criteria were admitted adult patients who underwent Advanced Cardiovascular Life Support (ACLS) due to cardiac arrest. All data were collected through retrospective chart review and interviewing. Pre-intervention prevalence of PDCA was determined, and a protocol for PDCA was created and implemented. Data collected included the frequency of PDCA, the degree to which the protocol was followed, and code leaders' opinions on implementation and clinical utility.

Results: From November 2023 to November 2024, 117 code blue activations were reviewed. Eighty-six met inclusion criteria. Code leaders felt PDCA had clinical utility 57% of the time. The reasons PDCA was not utilized included code brevity (25%), delay in delivery of ultrasound to bedside (25%), lack of knowledge of PDCA utility (25%), and lack of proficiency to perform PDCA despite desiring to utilize it (21%). PDCA prevalence was 21%, 10%, 47%, and 23% respectively for each quarter compared to 13% pre-intervention. When combined into 6-month study periods, PDCA was 16% and 35%, respectively.

Conclusion: Code leaders felt that PDCA was useful because it often provided them helpful information and changed management. There is potential for improvement regarding several barriers to PDCA, including difficulty in image acquisition, user knowledge gaps, and physical machine presence, accounting for 95% of reasons PDCA was not utilized.