Mayo Clinic proceedings. Innovations, quality & outcomes最新文献

Age-related macular degeneration (AMD) is the leading cause of irreversible blindness in the Western world, with a higher prevalence among Europeans and North Americans than that in Africans, Hispanics, and Asians. Advanced AMD is categorized as atrophic (dry) or exudative (wet/neovascular age-related macular degeneration [nAMD]). Dry AMD is characterized by progressive geographic atrophy of the retinal pigment epithelium and outer retinal layers, whereas nAMD is characterized by new vessels that invade the subretinal and/or subretinal pigment epithelium spaces. Existing treatments delay the onset of advanced AMD and reverses vision loss for a couple of years before atrophy usually decreases central visual acuity. We searched PubMed and Medline databases from January 1, 1980, to December 1, 2023, using the following search terms: macular degeneration, choroidal neovascularization, geographic atrophy, drusen, age-related maculopathy, AMD, ARMD, and anti-VEGF. Relevant articles in English (or English translations) were retrieved and reviewed. Bibliographies of the identified manuscripts were also reviewed to identify relevant studies. Age-related macular degeneration most commonly affects people older than 55 years. Visual prognosis varies, with advanced lesions (nAMD and geographic atrophy) leading to rapid, progressive loss of central vision and contrast sensitivity. Although AMD is not a life-threatening disease, reduced vision profoundly compromises quality of life and necessitates living assistance for many patients. Over the past 2 decades, advances in prevention (vitamin supplementation) and therapy (antivascular endothelial growth factor and complement inhibitor drugs) have reduced vision loss and blindness. Further research is needed to decrease the incidence of blindness in patients with advanced disease.

Objective

To examine impacts of a structured mentorship committee program on academic promotion and participant perceptions because impacts of formal mentorship programs for clinical faculty are unknown.

Participants and Methods

This prospective cohort study at a Midwestern Veterans Affairs tertiary care system from December 17, 2019 to December 31, 2022 included clinical track faculty in the Medicine Service below the rank of Clinical Associate Professor. Mentoring meetings (mentee, committee chair, and mentors) were generally held twice annually. All participants were surveyed after each meeting (response rate: 100%).

Results

All 23 of 23 (100%) eligible faculty were enrolled as mentees, and 49 distinct meetings occurred. Three (13%) mentees were promoted, and the remaining 20 (87%) continued in the program. Mean scores (SD), scaled 1 (strongly disagree) to 5 (strongly agree), for mentors and mentees were 4.71 (0.51) and 4.80 (0.54) for “effective use of my time”; 4.58 (0.64) and 4.37 (0.49) for “appropriate progress since last meeting”; 4.52 (0.66) and 4.31 (0.64) for “program increased my work satisfaction”; and 4.07 (0.96) and 3.75 (0.92) for “program reduced my work burnout,” respectively.

Conclusion

Clinically oriented physicians viewed the program positively. It appeared to help junior faculty get promoted and led to improved work satisfaction and reduced burnout.

Objective

To examine the association of left atrial (LA) function with incident chronic kidney disease (CKD) and assess the clinical utility of adding LA function to a CKD risk prediction equation.

Patients and Methods

We included 4002 Atherosclerosis Risk in Communities study participants without prevalent CKD (mean ± SD age, 75±5 years; 58% female, 18% Black). Left atrial function (reservoir, conduit, and contractile strain) was evaluated by 2D-echocardiograms on 2011 to 2013. Chronic kidney disease was defined as greater than 25% decline in estimated glomerular filtration rate of less than 60 mL/min/1.73 m², end-stage kidney disease, or hospital records. Cox proportional hazards models were used. Risk prediction and decision curve analyses evaluated 5-year CKD risk by diabetes status.

Results

Median follow-up was 7.2 years, and 598 participants developed incident CKD. Incidence rate for CKD was 2.29 per 100 person-years. After multivariable adjustments, the lowest quintile of LA reservoir, conduit, and contractile strain (vs highest quintile) had a higher risk of CKD (hazard ratios [95% CIs]: 1.94 [1.42-2.64], 1.62 [1.19-2.20], and 1.49 [1.12-1.99]). Adding LA reservoir strain to the CKD risk prediction equation variables increased the C-index by 0.026 (95% CI: 0.005-0.051) and 0.031 (95% CI: 0.006-0.058) in participants without and with diabetes, respectively. Decision curve analysis found the model with LA reservoir strain had a higher net benefit than the model with CKD risk prediction equation variables alone.

Conclusion

Lower LA function is independently associated with incident CKD. Adding LA function to the CKD risk prediction enhances prediction and yields a higher clinical net benefit. These findings suggest that impaired LA function may be a novel risk factor for CKD.

Objective

To identify the characteristics that distinguish occupationally well outliers (OWO), a subset of academic psychiatrists and neurologists with consistently high professional fulfillment and low burnout, from their counterparts with lower levels of occupational well-being.

Participants and Methods

Participants included faculty physicians practicing psychiatry and neurology in academic medical centers affiliated with the Professional Well-being Academic Consortium. In this prospective, longitudinal study, a mixed qualitative and quantitative approach was used. Quantitative measures were administered to physicians in a longitudinal occupational well-being survey sponsored by the academic organizations where they work. Four organizations participated in the qualitative study. Psychiatrists and neurologists at these organizations who competed survey measures at 2 consecutive time points between 2019 and 2021 were invited to participate in an interview.

Results

Of 410 (213 psychiatrists and 197 neurologists) who completed professional fulfillment and burnout measures at 2 time points, 84 (20.5%) met OWO criteria. Occupationally well outliers psychiatrists and neurologists had more favorable scores on hypothesized determinants of well-being (values alignment, perceived gratitude, supportive leadership, peer support, and control of schedule). Ultimately, 31 psychiatrists (25% of 124 invited) and 33 neurologists (18.5% of 178 invited) agreed to participate in an interview. Qualitatively, OWO physicians differed from all others in 3 thematic domains: development of life grounded in priorities, ability to shape day-to-day work context, and professional relationships that provide joy and support.

Conclusion

A multilevel approach is necessary to promote optimal occupational well-being, targeting individual-level factors, organizational-level factors, and broader system-level factors.

Objective

To evaluate whether access to buprenorphine to treat opioid use disorder (OUD) was associated with the coronavirus disease pandemic, the relaxation of training requirements to obtain an X-Waiver to prescribe buprenorphine (April 2021), and the removal of the X-Waiver (December 2022).

Patients and Methods

The OptumLabs Data Warehouse, which includes claims from Commercial and Medicare Advantage enrollees, was used to evaluate trends in prescription fills from January 1, 2019, to June 30, 2023. We compared fill patterns of buprenorphine for OUD with acamprosate to treat alcohol use disorder and naltrexone to treat alcohol use disorder or OUD. We evaluated trends in the rate ratio (RR) of overall fills; RR by days supply; distribution of fills by daily dose; and distribution of fills by prescriber type.

Results

Coronavirus disease (RR, 1.06; 95% CI, 1.01-1.11) was associated with a slightly increased rate of fills for Commercial enrollees but not overall or for Medicare Advantage enrollees. There were also no significant increases (P>0.05) associated with the change in training requirements or removal of the X-Waiver. Over the study period, there was an increasing share of fills for 16+ mg for Commercial enrollees, and buprenorphine prescribers were more likely to be advanced practice nurses or physician assistants.

Conclusion

We did not find meaningful improvement in access in response to coronavirus disease or the changes in the X-Waiver. These findings suggest that interventions beyond removing the X-Waiver may be needed to improve buprenorphine access.

Objective

To evaluate the heterogeneity in treatment effect in posttraumatic stress disorder (PTSD) trials.

Patients and Methods

We downloaded data from a publicly available repository that captured PTSD trials published from January 1988 through February 2023. We applied restricted maximum-likelihood random-effect meta-analyses and meta-regression to explore potential moderators of treatment effect including methodologic study features (risk of bias domains and control group response rate), characteristics of the population, and intervention features following the theme, intensity, and platform framework.

Results

We included 199 PTSD trials that reported the outcomes of diagnosis resolution (122 trials, 8437 patients) and clinically meaningful improvement (133 trials, 9895 patients). Multiple treatments demonstrated effectiveness but with significant heterogeneity. Statistically significant moderators included risk of bias domains of randomization sequence and outcome measurement, control group response rate reflecting severity of PTSD in the enrolled population, and whether the psychotherapeutic approach was trauma focused (P values <0.05). There was no statistically significant effect for the frequency of treatments per week, format of the intervention (eg, individual vs group), duration of the intervention, or delivery method (in person vs not), (P values <0.05). Characteristics of the population such as sex, age, and military status did not appear to significantly affect the treatment effect (P values <0.05).

Conclusion

Trauma focused psychotherapies should be considered the first-line intervention to induce remission. Several patient characteristics or treatment context did not modify the treatment effect, which allows tailoring care based on patient values, preferences and logistics.

Objective

To reduce the frequency of insufficient overlap of intravenous (IV) and subcutaneous (SC) insulin during the treatment of diabetic ketoacidosis (DKA) as a quality improvement project.

Patients and Methods

Rates of insufficient IV and SC insulin overlap (< 2-hour overlap, SC insulin given after IV insulin discontinuation, or no SC insulin given after IV insulin discontinuation) were assessed in adults with DKA treated with IV insulin at a large tertiary care referral center in Rochester, Minnesota, from July 1, 2021, to March 15, 2023. After a preintervention analysis period, an electronic medical record–based best practice advisory was introduced to notify hospital providers discontinuing IV insulin if SC long-acting insulin had not been given in the previous 2-6 hours. Demographic characteristics and clinical outcomes before and after intervention were compared.

Results

A total of 352 patient encounters were included (251 in the preintervention phase and 101 in the postintervention phase). The rate of insufficient IV to SC insulin overlap decreased from (88 of 251) 35.1% before intervention to (20 of 101) 19.8% after intervention (P=.005). The rate of posttransition hypoglycemia (<70 mg/dL; to convert to mmol/L, multiply by 0.0259) decreased from (27 of 251) 10.7% to (4 of 101) 4% after intervention (P=.04). Rates of posttransition hyperglycemia (>250 mg/dL), rebound DKA, length of hospital stay, and duration of IV insulin therapy were similar before and after intervention.

Conclusion

Using quality improvement methodology, the rates of insufficient IV to SC insulin overlap during treatment of DKA in a large tertiary care referral center were measured and reduced through an electronic medical record–based best practice advisory targeting hospital providers.

Chronic diseases are the leading cause of death and disability in the United States, and much of this burden can be attributed to lifestyle and behavioral risk factors. Lifestyle medicine is an approach to preventing and treating lifestyle-related chronic disease using evidence-based lifestyle modification as a primary modality. NYC Health + Hospitals, the largest municipal public health care system in the United States, is a national pioneer in incorporating lifestyle medicine systemwide. In 2019, a pilot lifestyle medicine program was launched at NYC Health + Hospitals/Bellevue to improve cardiometabolic health in high-risk patients through intensive support for evidence-based lifestyle changes. Analyses of program data collected from January 29, 2019 to February 26, 2020 demonstrated feasibility, high demand for services, high patient satisfaction, and clinically and statistically significant improvements in cardiometabolic risk factors. This pilot is being expanded to 6 new NYC Health + Hospitals sites spanning all 5 NYC boroughs. As part of the expansion, many changes have been implemented to enhance the original pilot model, scale services effectively, and generate more interest and incentives in lifestyle medicine for staff and patients across the health care system, including a plant-based default meal program for inpatients. This narrative review describes the pilot model and outcomes, the expansion process, and lessons learned to serve as a guide for other health systems.

Coronary artery disease is the most common cause of heart failure, which is the leading cause of cardiovascular-related death worldwide. There are insufficient data to make strong recommendations for percutaneous coronary intervention (PCI) in patients with severe ischemic left ventricular systolic dysfunction (LVSD). In that context, we performed a meta-analysis to compare the outcomes of PCI with those of optimal medical therapy alone in patients with severe ischemic LVSD. A systematic search was conducted in PubMed, EMBASE, and ClinicalTrials.gov from inception to December 2023. Our outcome of interest was all-cause mortality in patients undergoing PCI vs medical therapy. We used random effects models to aggregate data and to calculate pooled incidence and relative risk with 95% CIs. Four studies including 2 randomized controlled trials with 2080 patients (PCI, 1082; optimal medical therapy, 998) were included. All-cause mortality did not differ significantly between the groups: 168 patients (15.5%) in the PCI group vs 200 patients (20.0%) in the optimal medical therapy group (relative risk, 0.88; 95% CI, 0.75-1.09; P=.25). In conclusion, the available evidence indicates that PCI does not improve all-cause mortality in patients with severe LVSD without lifestyle-limiting anginal symptoms. Further data are needed to identify subgroups of patients better served by each modality.