American Journal of Medicine最新文献

Purpose: VA's Clinical Resource Hubs (CRH) are well-positioned to fill pain care gaps experienced by rural-dwelling patients through regional hub-and-spoke models. We examined how CRHs integrated Whole Health approaches to expand access to this care for chronic pain.

Methods: Qualitative interviews conducted with employees in 4 CRHs were rapidly analyzed to examine how CRHs organized and delivered Whole Health care.

Results: CRH's delivered Whole Health care in interdisciplinary pain, stand-alone Whole Health, and primary care clinics. All offered varied Whole Health services (Whole Health coaching, complementary and integrative health therapies, and Whole Health groups), and incorporated key elements of person-centered communication to ensure care aligned with what mattered most to patients. Considerations unique to CRH delivery included multiple referral pathways, orienting patients to this short-term centralized care model, obtaining medical clearance, ensuring care continuity upon discharge, and telehealth adaptations. Participants perceived multiple benefits of Whole Health in CRHs for the healthcare system and patients.

Conclusions: Whole Health care can be successfully integrated into innovative centralized health system models like CRHs, enhancing accessibility. Replicating these models requires establishment of clear entry and discharge processes, and attention to virtual care delivery.

Over 40% of patients are discharged to post-acute care services which serve predominantly older adults with cardiovascular or cerebrovascular disease and substantial age-related complexity. Post-acute care settings are often siloed from the broader healthcare system, creating care gaps, suboptimal outcomes, and higher-than-average readmission rates. As value-based care models increasingly emphasize holistic, equitable care for an aging population, Post-acute care represents a major opportunity for improvement, including the use of preventive strategies and standardized, evidence-based processes. Certification programs in post-acute care could strengthen patient and family engagement in prevention and wellness, integrate routine geriatric assessments, and promote consistent application of personalized clinical practice guidelines following cardiovascular events and stroke. The American Heart Association (AHA)/American Stroke Association (ASA) is well suited to lead this effort, with a strong history of building registries, accreditation frameworks, and recognition programs that elevate guideline-recommended heart and stroke care. Leveraging new tools and data systems, the AHA/ASA is generating the evidence needed to support widespread post-acute care certification, with the goal of improving care quality and long-term outcomes for patients transitioning from acute hospitalization.

Renin-angiotensin-aldosterone system (RAAS) antagonists are essential in managing heart failure, hypertension, chronic kidney disease, and atherosclerotic cardiovascular disease. However, their perioperative use remains controversial due to concerns about intraoperative hypotension and vasoplegia. This review offers an updated synthesis of guideline recommendations, mechanistic insights, and clinical trial evidence, including POISE-3, STOP-OR-NOT, and SPACE, along with a practical decision-making framework for internists. We examine the physiological basis for holding or continuing RAAS antagonists amidst anesthetic interactions, fluid shifts, and cardiovascular risks. Evidence indicates that continuing RAAS antagonists until the day of surgery may raise the risk of intraoperative hypotension but does not consistently worsen major postoperative outcomes. Discontinuation might be suitable for patients with low cardiovascular risk or those undergoing high-risk procedures. We also discuss when and how to resume therapy, incorporate biomarkers like NT-proBNP for risk stratification, and explore emerging approaches such as ARNIs and pharmacogenomics. This review advocates for an individualized, evidence-based approach to RAAS management across surgical contexts.