Medical Care最新文献

Background: PRECIDENTD (PRevention of CardIovascular and DiabEtic KidNey Disease in Type 2 Diabetes) is a PCORnet® Study evaluating 2 classes of medications, SGLT2 inhibitors and GLP-1 receptor agonists, among people with type 2 diabetes. Participants obtain their assigned medication through their health insurance and complete semi-annual study assessments.

Objective: We engaged multiple partners to develop a centralized text message-based program to facilitate adherence and retention in PRECIDENTD and evaluated its performance from April 2024 to April 2025.

Methods: The PRECIDENTD study team applied best practices in digital health tool design and built the program with technology company MEMOTEXT. Patient partners identified program goals, co-wrote message content, and completed internal testing. We then deployed the program to PRECIDENTD participants and analyzed responses.

Measures: We assessed response rate to interactive text messages, proportion of messages flagging participants needing additional support, and the adherence problems identified.

Results: The text messaging program includes interactive messages querying if participants are taking the study medication, as well as one-way study timeline messages. During the first year, 450 PRECIDENTD participants across 20 sites received texts. Interactive message response rate was 80%, and 25% of responses identified problems (ie, trouble getting fills/refills and experiencing a health concern or side effect), prompting an outreach call.

Conclusions: We co-designed a digital tool that engaged participants and helped identify study participants needing assistance obtaining and adhering to study medications. Collaborative development of similar centralized tools may augment the capacity of national studies to answer important comparative effectiveness research questions.

Background: The Veterans Health Administration (VHA) greatly expanded the proportion of health care services it purchases from community providers over the last decade, which could impact the quality of care and create care fragmentation. Continuity of care between inpatient and outpatient care delivery systems is critical for high-quality mental health care.

Objective: To compare rates of outpatient follow-up visits between VHA-purchased and VHA-delivered psychiatric hospitalizations, overall and by VHA facility.

Methods: Using VHA electronic medical records and community care claims data, we compared 7-day and 30-day outpatient follow-up rates across VHA-purchased and VHA-delivered settings. We estimated follow-up rates and comparisons overall as well as separately for 4 diagnosis groups and separately across VHA facilities.

Results: Our sample included 64,784 hospitalizations; more than 30% were VHA-purchased as opposed to VHA-delivered. Compared with VHA-delivered hospitalizations, follow-up rates were 30.1 (95% CI: 27.8-32.5) percentage points lower at 7 days and 22.5 (95% CI: 20.8-24.1) percentage points lower at 30 days for VHA-purchased hospitalizations. Lower follow-up rates occurred for neurocognitive disorder discharges for both VHA-purchased and delivered care. Follow-up rates at 30 days were significantly lower for VHA-purchased hospitalizations at 121 out of 128 facilities and significantly higher at no facility.

Conclusions: VHA enrollees seeking mental health care and VHA program managers could benefit from data on psychiatric care quality differences between community providers and VHA providers. From a system perspective, VHA-purchased care quality reports and value-based purchasing contracts could include outpatient follow-up quality measures to incentivize higher quality care.

Background: There is a significant shortage of psychiatrists compared with the demand for their services. We studied Medicare Part D claims of psychiatrists and similar clinician prescribers to identify possible shifts in medication prescribing to address this gap.

Objective: This pharmacoepidemiology study aimed to identify prescribing patterns among psychiatrists, family physicians, internists, physician associates/assistants (PAs), and nurse practitioners (NPs), as well as trends.

Design: An observational, retrospective cohort study of Medicare Part D claims from 2013 to 2022 was conducted. Psychiatrists' prescription patterns were compared with those of non-psychiatrists, using the National Provider Identifier (NPI). Diagnosis information was not available in the dataset.

Participants: In 2022, more than 32,400 psychiatrists' prescriptions were submitted for more than 36.6 million Medicare Part D claims for various medications.

Main measures: Prescribers and medication claim counts were analyzed to determine the most commonly prescribed drugs by psychiatrists. Total psychiatrist prescription counts and trends were compared with those of primary care physicians, PAs, and NPs.

Key results: Family practice physicians wrote more than 55 million prescriptions in 2022, nearly twice the number written by psychiatrists. From 2013 to 2022, prescriptions written by PAs and NPs showed a strong upward trend. In 2020, prescription claims by NPs surpassed psychiatrists, and by 2022, they had exceeded those of internal medicine physicians.

Conclusions: Claims by NPs increased from 8.6% to 24.8%, whereas psychiatrists' claims decreased from 24.4% to 18.0%. As of 2023, NPs and PAs comprise a significant portion of the workforce that addresses gaps in mental health medication care for Medicare patients.

Objective: To examine changes in persistent emergency department (ED) use by adult frequent ED (FED) users over time comparing prepandemic versus peripandemic periods, and to identify distinct characteristics of individuals who remained FED users over time during the pandemic versus the prepandemic era.

Methods: We conducted a retrospective, secondary, longitudinal analysis in Texas, following 2 cohorts of ED users over 36 months (cohort 1: March 2017-February 2020; cohort 2: March 2019-February 2022). The main outcomes were whether a baseline FED (≥9 ED visits/12 mo) user remained a FED user persistently over the next 24 months and whether they were persistent FED users prepandemic or peripandemic. Multivariable regressions estimated changes in persistent FED use across cohorts and assessed differences between individuals who remained persistent FED users during the pandemic compared with the prepandemic period.

Setting: All-payer Texas Hospital ED Research Data File from 2016 to 2022.

Results: About 1 million individuals had at least one ED visit in the baseline years, totaling 4.6 million visits. Overall, FED users accounted for 8% of all ED users but over 40% of visits. Although more than half of FED users at baseline exhibited persistent FED use over the next 24 months, there was a 7% decline in the proportion of return FED users after the onset of COVID-19 which was statistically significant (AOR=0.82; 95% CI=0.80-0.84), and this effect was more pronounced when patients with any COVID-19-related ED visit during the study period were excluded (AOR=0.10; 95% CI=0.09-0.11). Individuals aged 45 years or older, those with congestive heart failure and diabetes with complications, and those with public insurance (when COVID-19-related visits were excluded) had higher odds of remaining persistent FED users during the pandemic.

Conclusions: Many FED users will seek ED care for multiple years, given their medical complexity. Future research should identify heterogeneous subgroups among persistent FED users to tailor interventions towards their needs.

Background: To identify patients at the highest risk for acute care utilization, health care systems have developed "hot spotter" programs. Homelessness is a robust social determinant of acute care utilization.

Objectives: To describe the prevalence, patterns, and correlates of meeting criteria for a hot spotter program among housing-insecure adults in the US Veterans Health Administration (VHA).

Research design: Among veterans on the VHA Homeless Registry in Fiscal Years 2018-2022 (N=1,469,893), we identified those who met criteria for a Hot Spotter Report [ie, ≥1 hospital admissions and/or ≥2 emergency department (ED) visits in at least one quarter], described their patterns of acute care use, and examined differences in patient characteristics and outpatient service use between those who met report criteria in multiple quarters (vs. one).

Results: Thirty percent (N=446,974) met report criteria in at least one quarter; most (56%) met report criteria in ≥2 quarters. Diagnoses of depression (58%) and/or a substance use disorder (51%) were common; however, the rate of hospitalization in an acute medical setting during the cohort period was twice that of being hospitalized in an acute mental health setting (50% vs. 25%). Being on the Hot Spotter Report in multiple quarters (vs. one) was associated with more chronic conditions (M=5.08 vs. 3.29), higher rates of suicidality (23.7% vs. 11.7%), and higher likelihood of all types of outpatient care (P<0.0001).

Conclusions: Given rates of chronic medical conditions and medical hospitalizations, it may behoove hot spotter programs to increase care coordination with medical respite programs to support patients in the postacute phase.

Background: Chronic conditions affect over 60% of US adults and drive nearly 90% of the nation's $4.9 trillion in annual health care costs. Nurse practitioners (NPs), particularly in Full Practice Authority (FPA) states, may be critical to improving outcomes and reducing health care burdens.

Objectives: To evaluate whether nurse practitioner FPA reduces hospital readmissions and emergency department visits related to chronic conditions across the United States.

Research design: A secondary data analysis using restricted Medical Expenditure Panel Survey (MEPS) data (2010-2019) was performed on site at the Agency of Health Research and Quality. We applied incidence rate ratios (IRRs) and difference-in-difference (DiD) models.

Measures: Primary outcomes included readmission and emergency visit rates for five chronic conditions: high cholesterol (n=33,409), high blood pressure (n=38,858), diabetes (n=13,075), emphysema (n=2,509), and asthma (n=17,018). Covariates included county-level socioeconomic factors and rurality.

Results: States with FPA had modestly lower IRRs for high cholesterol (0.9863), high blood pressure (0.9758), diabetes (0.9746), and asthma (0.9710) compared with restricted states. DiD models showed inconsistent effects, with most FPA*Post coefficients lacking statistical significance. However, rural FPA counties frequently showed significantly lower readmission rates, notably for diabetes and high cholesterol.

Conclusions: NP FPA is associated with slight reductions in chronic condition readmissions, particularly in rural areas. While DiD models showed limited policy-specific impact, IRR findings support FPA as a promising strategy to enhance chronic disease management and access to care. Future research should address model limitations and explore causal pathways.

Introduction: Burn pit smoke exposure (BPSE) during military deployment has been linked to long-term cardiorespiratory conditions, but its relationship with sleep apnea (SA) remains unclear. This study examines the association between BPSE and SA using Veterans Health Administration (VHA) electronic medical records (EMR) and the Airborne Hazards and Open Burn Pit Registry (AHOBPR).

Methods: We conducted a retrospective cohort study of veterans from AHOBPR with VHA sleep study data. BPSE was classified into quartiles based on the duration of exposure, and SA severity was measured using the Apnea-Hypopnea Index (AHI). Logistic regression models and Cox proportional hazards models were used to evaluate the association between BPSE and SA, adjusting for confounders such as age, body mass index, smoking status, post-traumatic stress disorder (PTSD), and comorbid disease burden.

Results: The study included 17,064 veterans (mean age 40.2 y; 89.6% male; 58.3% with PTSD). Veterans in the highest BPSE quartile (≥245 d) had an unadjusted OR of 1.13 for SA, which became nonsignificant after adjustment (aOR: 1.10, P=0.058). The median time to SA diagnosis was 8.8 years in the highest BPSE group versus 11.1 years in the lowest. The adjusted Hazard Ratio for earlier SA diagnosis in the highest BPSE quartile was 1.16 (95% CI: 1.10, 1.22).

Discussion: Although BPSE was not associated with SA prevalence, it was linked to earlier diagnosis. BPSE-related airway inflammation or increased health care use among exposed veterans may explain this pattern. Findings support early surveillance and screening for SA in highly exposed veterans.

Background: First-year registered nurses (RNs) have the highest turnover rate of all hospital-based RNs, and often face various challenges during their transition to practice. RN transition-to-practice programs (RNTTPs) can potentially alleviate critical RN staffing shortages and support the development of the nursing workforce's future.

Objectives: To (1) capture and critically appraise the landscape of existing synthesis efforts on RNTTPs and (2) synthesize included reviews' findings to assess the potential benefits of RNTTPs for organizational, nursing, and patient outcomes and descriptions of RNTTPs.

Research design: We conducted a systematic review of reviews to identify published evidence syntheses evaluating RNTTPs for newly graduated RNs.

Results: Nineteen evidence reviews were included. Despite having similar scopes, there was little overlap in their included literature, and no single review included the majority of identified original research studies. Two reviews with high methodological rigor and high topical relevance emphasized the methodological issues in the available evidence, which used a mix of methodological approaches, and indicated a connection between RNTTPs and increased critical thinking, competency, and retention. Published reviews suggest program lengths between 6 and 12 months, but evidence for optimal program length was inconclusive or unsupported.

Conclusions: RNTTPs that have been piloted and implemented in recent years deserve more rigorous evaluation to answer critical questions about their role in organizational, nurse, and patient outcomes. However, before best practices can be ascertained to support scaling and sustainment, their potential benefits must first be verified.

Background: Environmental exposures are common, may impact health, and may cause concerns. There have been calls to improve clinical care for exposure concerns through an "informed care" approach, which designs care in consideration of the patient's experiences with the concern. Understanding Veterans' experiences and concerns about military environmental exposures through an "informed care" approach may help with care; however, there is a need to better define the core components of this model of care.

Objectives: The current project aimed to define the core components of "exposure-informed care" using a modified Delphi quality improvement study.

Research design: Delphi methodology utilizes expert opinion in a series of rounds and is appropriate to use when there is incomplete knowledge, uncertainty, or lack of evidence on a specific topic.

Results: Experts in military environmental exposures (n=35) provided their feedback on the definition of "exposure-informed care." After 4 rounds of rating, 20 statements were agreed upon as core components of exposure-informed care. Accepted statements about the core components of exposure-informed care were coded into a 6-part framework: (1) use concordant communication, (2) build trust, (3) provide resources and support, (4) assess and document, (5) take professional responsibility, and (6) integrate into care.

Conclusions: The 6-part exposure-informed care framework represents experts' definition of the core components of "exposure-informed care." Future implementation of exposure-informed care and the impact of each theme are discussed.