Annals of Internal Medicine最新文献

Background: Urinary albumin-creatinine ratio (UACR) and urinary protein-creatinine ratio (UPCR) are both used in clinical practice to diagnose and monitor chronic kidney disease (CKD). Which measure exhibits stronger associations with clinical outcomes and whether this varies by patient characteristics are unknown.

Objective: To assess and compare the performance of UACR and UPCR across CKD-related clinical outcomes.

Design: Individual patient-level meta-analysis.

Setting: 38 research and clinical cohorts.

Participants: 148 994 participants with same-day measurements of UACR and UPCR.

Measurements: We quantified the associations of UACR and UPCR with subsequent clinical outcomes, including kidney failure and cardiovascular events, using Cox proportional hazards regression. Analyses were done in each cohort, followed by random-effects meta-analysis. Subgroups included those based on severity of proteinuria, type 2 diabetes, estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m², and glomerular disease.

Results: There were 148 994 participants and 9773 kidney failure events during a median of 3.8 years of follow-up. Higher UACR and UPCR both had a log-linear association with increased risk for kidney failure. The association with kidney failure was somewhat stronger for UACR (adjusted hazard ratio [HR] per SD increment, 2.55 [95% CI, 2.36 to 2.74]) than UPCR (HR, 2.40 [CI, 2.28 to 2.53]; P for comparison<0.001). Results were consistent to slightly stronger in subgroups with UACR greater than 30 mg/g, UPCR greater than 500 mg/g, eGFR less than 60 mL/min/1.73 m², diabetes, and glomerular disease. Associations between UACR and UPCR were generally similar for cardiovascular outcomes but favored UACR in subgroups with moderately to severely elevated UACR.

Limitation: Assessment of UACR and UPCR in spot urine samples.

Conclusion: Overall, UACR was more strongly associated with kidney failure than UPCR (particularly in subgroups with higher UACR), supporting the use of UACR rather than UPCR to diagnose and risk-stratify patients.

Primary funding source: National Kidney Foundation and National Institute of Diabetes and Digestive and Kidney Diseases.

Background: Advance care planning (ACP) can improve communication of patients' preferences but is underutilized in health systems.

Objective: To compare approaches to increase ACP.

Design: Pragmatic, 24-month, comparative, cluster randomized trial. (ClinicalTrials.gov: NCT04012749).

Setting: Fifty clinics in 3 University of California health systems.

Participants: All seriously ill primary care patients without an advance directive (AD) or a Physician Orders for Life-Sustaining Treatment (POLST) form in the electronic health record (EHR).

Intervention: Three ACP interventions, timed to primary care visits. The group 1 intervention included a letter with an AD sent via the EHR portal and mail. The interventions in groups 2 and 3 additionally included a link to PrepareForYourCare.org and a mailed pamphlet, and the group 3 intervention also included health navigator outreach. Clinicians received ACP training.

Measurements: Presence of AD or POLST form in the EHR at 12 and 24 months (primary outcome); documented ACP discussions and utilization (secondary outcomes).

Results: Among 5810 seriously ill patients (mean age, 71 years; 48% female; 50% in a racial or ethnic minority), by 24 months, 13.7% (95% CI, 12.1% to 15.3%) of patients in group 1, 12.7% (CI, 11.2% to 14.1%) in group 2, and 19.8% (CI, 18.1% to 21.5%) in group 3 had a documented AD or POLST form. After adjustment for patient and site factors, group 3 patients were more likely to have an AD or a POLST form compared with group 1 (adjusted difference [aDiff], 4.6% [CI, 0.8% to 8.4%]) and group 2 (aDiff, 5.5% [CI, 0.8% to 10.2%]); groups 1 and 2 did not differ significantly. Documented ACP discussions were higher in group 3 than group 1 (aDiff, 4.7% [CI, 1.4% to 7.9%]) and group 2 (aDiff, 4.2% [CI, 1.1% to 7.2%]); groups 1 and 2 did not differ. Utilization did not differ by group.

Limitations: Academic health centers; no control group.

Conclusion: Health system implementation of automated ACP interventions with clinician training and mailed materials increases ACP documentation and is enhanced with navigator outreach.

Primary funding source: Patient-Centered Outcomes Research Institute.

Background: There is limited evidence of the strategies to mitigate burnout among all health care professionals (HCPs).

Purpose: To evaluate the effectiveness of all interventions to mitigate burnout among HCPs.

Data sources: PubMed and Scopus (up to 14 May 2025).

Study selection: Independent study selection (2 people) of randomized controlled trials (RCTs) and cluster RCTs of interventions to mitigate burnout (vs. no active intervention) among HCPs.

Data extraction: Independent extraction with validation by second reviewer. Continuous data for burnout outcomes extracted for emotional exhaustion (EE), depersonalization, personal accomplishment (PA), and single-concept burnout measurement. Separate random-effects models were stratified by role.

Data synthesis: 93 RCTs and 6 cluster RCTs evaluating individual-level interventions were included (9330 participants). Among physicians, professional coaching was probably effective in reducing some aspects of burnout (EE standardized mean difference [SMD], -0.37 [95% CI, -0.62 to -0.13], low certainty; and depersonalization SMD, -0.30 [CI, -0.42 to -0.19], moderate certainty), but mindfulness-based interventions may not be effective (EE SMD, -0.46 [CI, -1.28 to 0.35], very low certainty; depersonalization SMD, -0.09 [CI, -0.30 to 0.12], moderate certainty). However, mindfulness-based interventions may reduce burnout among nurses and midwives (EE SMD, -0.90 [CI,-1.46 to -0.34], low certainty) and among a mixture of HCP roles (EE SMD, -0.40 [-0.65 to -0.16], low certainty; depersonalization SMD, -0.36 [CI, -0.58 to -0.14], low certainty; and PA SMD, 0.48 [CI, 0.29 to 0.67], moderate certainty). Mindfulness-based and professional coaching interventions were generally more than 4 weeks in duration.

Limitations: Most trials were unblinded with subjective outcomes. There was substantial heterogeneity among interventions and populations despite stratifying by role.

Conclusion: Although mindfulness-based interventions may reduce burnout in nurses and midwives and among a mixture of HCPs, professional coaching probably reduces burnout among physicians, particularly when sustained for more than 4 weeks.

Primary funding source: Barts Charity. (PROSPERO: CRD42024552385).