Journal of General Internal Medicine最新文献

Background: Hospital readmissions are a key metric of healthcare quality and cost. Pain has been implicated as a predictor of readmissions, yet its role in internal medicine remains underexplored.

Objective: To investigate the association between in-hospital pain assessment at different timepoints and subsequent hospital readmissions in internal medicine patients.

Design: Retrospective cross-sequential cohort study.

Participants: 7277 patients admitted to the Internal Medicine Department of a Swiss network of public hospitals from 2020 to 2023.

Measures: Pain intensity was assessed using the Visual Analogue Scale (VAS) at admission, during hospitalisation, and at discharge. Admissions and readmissions were analysed as all-cause hospitalisations, because only the main diagnosis is routinely recorded, which may not accurately reflect pain-related causes. Severity-related factors such as cost weight and hospital length of stay were included as covariates to control for case-mix differences. Multivariate logistic regression models were used to examine predictors of readmission at 18 and 30 days, and 3, 6, and 9 months post-discharge.

Key results: The mean VAS score significantly decreased from 4.7 at admission to 1.9 at discharge. Readmission rates were 1.1% at 18 days, 10% at 3 months, 14.4% at 6 months, and 17.8% at 9 months. Pain at admission, peak pain during hospitalisation, and pain at discharge were each associated with increased readmission risk, though with different temporal patterns. Pain at discharge (VAS) was an independent predictor of readmissions, with odds ratios of 1.10 (95% CI:1.01-1.19) at 30 days, 1.06 (95% CI: 1.01-1.13) at 3 months and 1.05 (95% CI: 1.00-1.10) at 6 months. Subgroup analysisshowed that pain at discharge was associated with a 31% increase in the risk of 18-day readmission among older adults (≥65 years) and a 26% increase in the risk of 30-day unplanned readmission among younger patients (≤65 years).

Conclusions: Although all three timepoints provide prognostic value, pain at discharge is a significant predictor of readmissions, emphasising the need for comprehensive pain management during hospitalisation and discharge planning. Targeted interventions for high-risk groups may improve outcomes and reduce healthcare utilisation.

The Designated Institutional Official (DIO) is a necessary but uncommon role in medical education. Every sponsoring institution (SI) in the USA that trains residents or fellows is required to have a DIO. Nationally, there are slightly more than 900 SIs. DIOs may oversee small-, medium-, or large-sized graduate medical education (GME) institutions. Based on size and complexity, the DIO may be the main person who orchestrates the day-to-day functions of GME or may manage a team who undertakes the work. Many of the DIO's responsibilities are prescribed by the Accreditation Council for Graduate Medical Education (ACGME), but how these responsibilities are completed is variable. At its essence, the role of the DIO is to ensure every resident and fellow receives a good educational experience and meets requirements for board certification. In addition, DIOs may take on roles as a human resource expert, as a strategic content expert for GME, as a developer of educational sites and curriculum, and a quality assurance person evaluating GME programs. The DIO role is likely to increase in scope and complexity as GME evolves, and the DIO is positioned to think strategically about larger topics pertinent to GME.

Background: To examine the prospective association between device-measured sedentary behavior and risk of emergency department (ED) or hospital readmission among patients with suspected acute coronary syndrome (ACS), independent of moderate to vigorous physical activity (MVPA).

Methods: 536 patients who were evaluated for suspected ACS were enrolled between September 2016 and March 2020. Sedentary behavior and MVPA were measured via wrist-worn GENEActiv accelerometer for 30-days post-discharge. ED and hospital readmissions between 30 and 365 days after discharge were ascertained by chart review and patient contact.

Results: Over 1-year follow-up, 198 patients were readmitted. Sedentary behavior was associated with an increased risk of ED or hospital readmission after adjusting for covariates and MVPA [Tertile 1: REF, Tertile 2: HR = 0.89 (95% CI: 0.60-1.32), Tertile 3: HR = 1.73 (95% CI: 1.16-2.58), P-trend = 0.003]. In joint association analyses, high sedentary behavior in combination with low MVPA was associated with the greatest risk of ED or hospital readmission [HR = 2.36 (95%: CI: 1.52-3.68)] compared to the referent group (low sedentary behavior/high moderate to vigorous physical activity).

Conclusions: Sedentary behavior was associated with an increased risk of ED or hospital readmission between 30 and 365 days after discharge among patients with suspected ACS, independent of MVPA. These findings suggest reducing sedentary behavior should be considered as a modifiable therapeutic target to reduce subsequent ED or hospital readmission in patients following a suspected ACS.

Background: The GRADE (Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study) trial assessed the effectiveness of four glucose-lowering medication classes in reducing hemoglobin A1c (HbA1c) in individuals with type 2 diabetes mellitus (T2DM) on metformin monotherapy but did not include sodium-glucose cotransporter-2 inhibitors (SGLT-2is).

Objective: To replicate and extend GRADE findings by emulating a modified trial including SGLT-2is in a GRADE-eligible population, i.e., with low-to-moderate cardiovascular risk.

Design: A 4-arm target trial emulation-an observational design that mimics a randomized trial- comparing SGLT-2is, sulfonylureas (SUs), glucagon-like peptide-1 receptor agonists (GLP-1RAs), and dipeptidyl peptidase 4 inhibitors (DPP-4is) in a modified GRADE trial framework, excluding insulin. Optum's de-identified Clinformatics® Data Mart, a commercial claims database in the US, from January 01, 2014-August 31, 2023 was used.

Participants: GRADE-eligible patients (T2DM, age ≥ 30 years, on metformin monotherapy, no recent cardiovascular events, baseline HbA1c 6-9%).

Interventions: Incident use of SGLT-2i, SU, GLP-1RA or DPP-4i.

Main measures: The primary outcome was the first occurrence of HbA1c ≥ 7.0%. Propensity score weights emulated random treatment assignment; hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated using Cox regression models.

Key results: The weighted cohort included 2,065 SGLT-2i, 2,015 SU, 2,006 GLP-1RA, and 2,006 DPP-4i initiators. GLP-1RAs had a lower risk of HbA1c ≥ 7.0% vs. SUs (HR 0.73; 95% CI 0.68-0.78) and DPP-4is (HR 0.65; 95% CI 0.60-0.70). SGLT-2is had risk of HbA1c ≥ 7.0% comparable to DPP-4is (HR 1.04; 95% CI 0.97-1.10) but higher than GLP-1RAs (HR 1.60; 95% CI 1.48-1.72) and SUs (HR 1.17; 95% CI 1.11-1.23). Subgroups and sensitivity analyses showed consistent results.

Conclusions: In this target trial emulation, GLP-1RAs were most effective for glycemic control, aligning with GRADE, and superior to SGLT-2is in combination with metformin for T2DM in patients with low-to-moderate cardiovascular risk.

Background: High-quality primary care is paramount for health equity and cost containment, yet many individuals lack access to a usual source of care. Since 2017, Covered California, the ACA Marketplace, has required all health plans to match enrollees with a PCP to serve as a first point of contact to promote high-value primary care.

Objective: To understand primary care and overall healthcare utilization patterns for enrollees on ACA marketplace plans.

Design: This study analyzed primary care utilization patterns across 1.1 million Covered California enrollees in 2022 under this policy and examined differences in usage of assigned and non-assigned PCPs across product types.

Participants: In total, 1,112,292 Covered California enrollees aged 18 years or older in 2022.

Main measures: Our main measures included utilization rates for assigned primary care providers (PCPs), utilization rates of other PCPs, utilization of all non-primary care services, and rates of non-utilization of healthcare services.

Key results: Results indicated that while enrollees in PPO or EPO plans had higher overall rates of PCP utilization, differences in PCP usage disappeared after correcting for demographic and clinical differences between enrollees in HMO and PPO/EPO plans. However, visits to non-assigned PCPs are common in all plan types. And, 43% of adult enrollees with 12-months continuous enrollment did not have any primary care visits.

Conclusions: We recommend that policy makers promote consistent utilization of any PCP regardless of PCP assignment, as we found that many people use other-than-assigned PCPs even when current policies intend to proactively steer them towards one main point of contact.