Journal of General Internal Medicine

Murphy, Caleb J.; Williams, Andrew E.; Martinez, Maylyn S.

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08398-8pmid: 37698725

Matthias, Marianne S.; Bolla, Arya L.; Bair, Sophia M.; Adams, Jasma; Eliacin, Johanne; Burgess, Diana J.; Hirsh, Adam T.

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08410-1

BackgroundRacial inequities in pain treatment are well-documented and persist despite national priorities focused on health equity. The COOPERATE (Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity) intervention was a patient-centered, tailored intervention aimed at improving health equity by targeting patient activation—the knowledge and confidence to manage one’s health. COOPERATE led to significant and sustained increases in patient activation, significant short-term increases in communication self-efficacy (confidence to communicate with clinicians), and more intervention participants experienced clinically significant (≥ 30%) reductions in pain at 3 months than control group participants.ObjectiveTo understand how participants experienced the intervention, including their perspectives on its effects on their health and healthcare experiences.DesignSemi-structured qualitative interviews.ParticipantsBlack veterans with chronic pain who participated in the COOPERATE intervention.Key ResultsParticipants described acquiring new tools and cultivating skills to use in their clinic visits, including preparing for their visit (writing an agenda, listing questions); asking focused, effective questions; and expressing concerns and communicating goals, values, and preferences. Participants indicated that by putting these tools to use, they felt more confident and able to take ownership of their own pain care; for some, this led to better pain management and improved pain. Participants expressed mixed views of disparities in pain care, with some believing race and racism did not play a role in their care, while others valued being part of an intervention that helped equip them with tools to exercise autonomy over their healthcare.ConclusionsBlack patients with chronic pain described gaining greater confidence to self-manage and communicate with their clinicians after participating in the COOPERATE intervention. With its focus on empowering individuals, the COOPERATE intervention represents a promising approach to help advance equity in pain care.

Chua, Isaac S.; Khinkar, Roaa M.; Wien, Matthew; Kerrissey, Michaela; Lipsitz, Stuart; Cheung, Yvonne Y.; Mort, Elizabeth A.; Desai, Sonali; Morris, Charles A.; Pearson, Madelyn; Eappen, Sunil; Rozenblum, Ronen; Mendu, Mallika

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08393-z

BackgroundToxic work culture contributes to healthcare worker burnout and attrition, but little is known about how healthcare organizations can systematically create and promote a culture of civility and collegiality.ObjectiveTo analyze peer-to-peer positive feedback collected as part of a systematized mortality review survey to identify themes and recognition dynamics that can inform positive organizational culture change.DesignConvergent mixed-methods study design.ParticipantsA total of 388 physicians, 212 registered nurses, 64 advanced practice providers, and 1 respiratory therapist at four non-profit hospitals (2 academic and 2 community).InterventionProviding optional positive feedback in the mortality review survey.Main MeasuresKey themes and subthemes that emerged from positive feedback data, associations between key themes and positive feedback respondent characteristics, and recognition dynamics between positive feedback respondents and recipients.Key ResultsApproximately 20% of healthcare workers provided positive feedback. Three key themes emerged among responses with free text comments: (1) providing extraordinary patient and family-centered care; (2) demonstrating self-possession and mastery; and (3) exhibiting empathic peer support and effective team collaboration. Compared to other specialties, most positive feedback from medicine (70.2%), neurology (65.2%), hospice and palliative medicine (64.3%), and surgery (58.8%) focused on providing extraordinary patient and family-centered care (p = 0.02), whereas emergency medicine (59.1%) comments predominantly focused on demonstrating self-possession and mastery (p = 0.06). Registered nurses (40.2%) provided multidirectional positive feedback more often than other clinician types in the hospital hierarchy (p < 0.001).ConclusionsAnalysis of positive feedback from a mortality review survey provided meaningful insights into a health system’s culture of teamwork and values related to civility and collegiality when providing end-of-life care. Systematic collection and sharing of positive feedback is feasible and has the potential to promote positive culture change and improve healthcare worker well-being.

Ambrose, Nalini; Amin, Alpesh; Anderson, Brian; Bertagnolli, Monica; Campion, Francis; Chow, Dan; Danan, Risa; D’Arinzo, Lauren; Drews, Ashley; Erlandson, Karl; Fitzgerald, Kristin; Gaspar, Fraser; Gong, Carlene; Hanna, George; Hawley, Heather; Jones, Stephen; Lopansri, Bert; Mullen, Ty; Musser, James; O’Horo, John; Piantadosi, Steven; Pritt, Bobbi; Razonable, Raymund; Rele, Shyam; Roberts, Seth; Sandmeyer, Suzanne; Stein, David; Te, Jerez; Vahidy, Farhaan; Webb, Brandon; Welch, Nathan; Wood, Alexander; Yttri, Jennifer

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08324-ypmid: 37715096

BackgroundLimited research has studied the influence of social determinants of health (SDoH) on the receipt, disease risk, and subsequent effectiveness of neutralizing monoclonal antibodies (nMAbs) for outpatient treatment of COVID-19.ObjectiveTo examine the influence of SDoH variables on receiving nMAb treatments and the risk of a poor COVID-19 outcome, as well as nMAb treatment effectiveness across SDoH subgroups.DesignRetrospective observational study utilizing electronic health record data from four health systems. SDoH variables analyzed included race, ethnicity, insurance, marital status, Area Deprivation Index, and population density.ParticipantsCOVID-19 patients who met at least one emergency use authorization criterion for nMAb treatment.Main MeasureWe used binary logistic regression to examine the influence of SDoH variables on receiving nMAb treatments and risk of a poor outcome from COVID-19 and marginal structural models to study treatment effectiveness.ResultsThe study population included 25,241 (15.1%) nMAb-treated and 141,942 (84.9%) non-treated patients. Black or African American patients were less likely to receive treatment than white non-Hispanic patients (adjusted odds ratio (OR) = 0.86; 95% CI = 0.82–0.91). Patients who were on Medicaid, divorced or widowed, living in rural areas, or living in areas with the highest Area Deprivation Index (most vulnerable) had lower odds of receiving nMAb treatment, but a higher risk of a poor outcome. For example, compared to patients on private insurance, Medicaid patients had 0.89 (95% CI = 0.84–0.93) times the odds of receiving nMAb treatment, but 1.18 (95% CI = 1.13–1.24) times the odds of a poor COVID-19 outcome. Age, comorbidities, and COVID-19 vaccination status had a stronger influence on risk of a poor outcome than SDoH variables. nMAb treatment benefited all SDoH subgroups with lower rates of 14-day hospitalization and 30-day mortality.ConclusionDisparities existed in receiving nMAbs within SDoH subgroups despite the benefit of treatment across subgroups.

Shannon, Evan M.; Haderlein, Taona P.; Neil Steers, W.; Wong, Michelle S.; Washington, Donna L.

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08430-xpmid: 37740169

Nguyen, Binh; Zhao, Chenyue; Bailly, Eric; Chi, Winnie

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08383-1pmid: 37670069

BackgroundThe COVID-19 pandemic exacerbated access barriers for patients with opioid use disorder. Telehealth presents an opportunity to improve access, treatment quality, and patient outcomes.ObjectiveTo determine patient characteristics associated with initiating buprenorphine treatment via telehealth and to examine how telehealth initiation is associated with access, treatment quality, and health outcomes.Design and ParticipantsThis cross-sectional study used deidentified insurance claims to identify opioid use disorder adult patients initiating buprenorphine treatment between March 1, 2020, and November 30, 2021. Multivariable logistic regression assessed determinants of telehealth initiation. Propensity score matching addressed observed differences between in-person and telehealth initiators.Main MeasuresTreatment quality outcomes included initiation within 14 days of diagnosis, engagement (at least 2 opioid use disorder-related visits), and any buprenorphine refill during the study period. Health outcomes included opioid overdose and opioid use disorder-related emergency department and inpatient visits.Key ResultsWe identified 23,565 adult buprenorphine initiators, including 3314 (14.1%) patients using telehealth. Younger patients (OR 0.91 to 0.77), females (OR 1.18), South (OR 1.63) and Midwest (OR 1.27) regions, rural area (OR 1.12), and higher-income (OR 1.16) neighborhood residents were more likely to use telehealth. Telehealth patients were more likely than in-person patients (54.5% vs. 48.4%; adjusted odds ratio (AOR), 1.29; 95% CI, 1.19–1.40) to stay engaged with opioid use disorder treatment, and more likely to refill buprenorphine during the study period (83.6% vs. 79.0%, AOR 1.37; 95% CI, 1.23–1.52). Telehealth initiation of buprenorphine was associated with 36% lower overdose rate than in-person initiation (adjusted incidence rate ratio 0.64; 95% CI, 0.45–0.94). The two groups evidenced no significant differences in opioid use disorder-related ED visit and hospitalization.ConclusionsOur findings suggest that telehealth-initiated buprenorphine treatment is associated with reduced opioid overdose rate and improved patient engagement. Our findings strengthen the case for extending telehealth exemptions and prescribing flexibilities for treatment.

Eliacin, Johanne; Patterson, Scott M.; Mendez, Diana M.; Burgess, Diana J.; Traylor, Morgan H.; Borden, Maria Y.; Slaven, James E.; Matthias, Marianne S.

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08387-xpmid: 37723366

BackgroundSocial isolation is a global public health threat. Veterans are particularly at risk for social isolation due to high rates of comorbid physical and mental health problems. Yet, effective interventions are limited.ObjectivesOur primary objective was to assess the feasibility and acceptability of CONNECTED, a novel, transdiagnostic intervention to reduce social isolation that includes individual and group components and is delivered by peers via telehealth. Secondary objectives were to identify appropriate outcome measures and explore preliminary intervention effects.MethodsThis was a two-phase study. In Phase 1, to evaluate study feasibility, we surveyed 200 veterans to assess prevalence of social isolation and their interest in social connectedness interventions. In Phase 2, we employed a mixed-methods, pre-post study design in which we piloted CONNECTED with 19 veterans through 2 successive cohorts to further assess feasibility, to evaluate acceptability, and to explore preliminary effectiveness. Quantitative analyses involved descriptive and bivariate analyses as well as multivariate modeling. Qualitative interviews were analyzed using thematic analysis.ResultsFor Phase 1, 39% of veterans surveyed were socially isolated. Participants who were ≤ 55 years old, caregivers, and those who experienced unmet social needs were more likely to report social isolation. Over 61% expressed interest in VA programs to reduce social isolation. For Phase 2, the pilot intervention, recruitment rate was 88% and the enrollment rate was 86%. Retention rates for the two cohorts were 80% and 50%, respectively, and satisfaction rates among intervention completers were 100%. Results also showed statistically significant improvements in social isolation (+ 5.91, SD = 4.99; p = .0028), social support (+ 0.74, SD = 1.09; p = .03), anxiety (-3.92, SD = 3.73; p = .003), and depression (-3.83, SD = 3.13; p = .001). Results for the other measures were not statistically significant.ConclusionCONNECTED is a feasible and acceptable intervention and is likely to be an effective tool to intervene on social isolation among veterans.

Deeds, Stefanie; Schuttner, Linnaea; Wheat, Chelle; Gunnink, Eric; Geyer, John; Beste, Lauren; Chen, Anders; Dominitz, Jason A.; Nelson, Karin; Reddy, Ashok

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08409-8

BackgroundThe Veterans Affairs (VHA) is working to establish a population-based colorectal cancer screening program for average-risk patients using mailed fecal immunochemical testing (FIT). However, low response rates to mailed FIT may hinder success. Key features of mailed FIT programs, including the use of reminders, differ among various national programs, with limited evidence among veterans.ObjectiveWe sought to test whether using reminders, either via telephone call or text message, was effective in improving mailed FIT response rates.DesignWe conducted a prospective, randomized quality improvement trial (ClinicalTrials.gov NCT05012007). Veterans who had not returned a FIT within 2 weeks of receiving the kit were randomized to one of three groups: (1) control (no reminder); (2) an automated telephone call reminder; or (3) an automated text message reminder.ParticipantsA total of 2658 veterans enrolled at VA Puget Sound Health Care System who were aged 45–75 and had an average risk of colorectal cancer.InterventionsA single automated telephone call or text message reminder prompting veterans to return the FIT kit.Main MeasuresOur primary outcome was FIT return at 90 days and our secondary outcome was FIT return at 180 days.Key ResultsParticipant average age was 62 years, 88% were men, and 66% White. At 90 days, both the phone and text reminder interventions had higher FIT return rates compared to control (intention-to-treat results (ITT): control 28%, phone 39%, text 38%; p<0.001). At 180 days, FIT kit return remained higher in the reminder interventions (ITT: control 32%, phone 42%, text 40%; p<0.001).ConclusionsAutomated reminders increased colorectal cancer screening completion among average-risk veterans. An automated phone call or text message was equally effective. VHA facilities seeking to implement a mailed FIT program should consider using phone or text reminders, depending on available resources.

Patel, Roshni; Marquis, Timothy J.; Cook, Aliza; Gielissen, Katherine

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08406-xpmid: 37698722

BackgroundThe Primary Care Exception (PCE) is a billing rule from the Centers for Medicare and Medicaid Services (CMS) that allows supervising physicians to bill for ambulatory care provided by a resident without their direct supervision. There has been increased focus on entrustment as a method to assess readiness for unsupervised practice.ObjectiveTo understand the factors influencing attending physicians’ use of the PCE in ambulatory settings and identify common themes defining what motivates faculty preceptors to use the PCE.ApproachThis was a qualitative exploratory study. Participants were interviewed one-on-one using a semi-structured template informed by the entrustment literature. Analysis was conducted using a thematically framed, grounded theory-based approach to identify major themes and subthemes.ParticipantsTwenty-seven internal medicine teaching faculty took part in a multi-institutional study representing four residency training programs across two academic medical centers in Connecticut.Key ResultsFour predominant categories of themes influencing PCE use were identified: (1) clinical environment factors, (2) attending attitudes, (3) resident characteristics, and (4) patient attributes. An attending’s “internal rules” drawn from prior experiences served as a significant driver of PCE non-use regardless of the trainee, patient, or clinical context. A common conflict existed between using the PCE to promote resident autonomy versus waiving the PCE to promote safety.ConclusionsThe PCE can serve as a tool to support resident autonomy, confidence, and overall clinical efficiency. Choice of PCE use by attendings involved complex internal decision-making schema balancing internal, patient, resident, and environmental-related factors. The lack of standardized processes in competency evaluation may increase susceptibility to biases, which could be mitigated by applying standardized modes of assessment that encompass shared principles.

Anderson, Daniela; Lien, Katie; Agwu, Chibueze; Ang, Phillip S.; Abou Baker, Nabil

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08392-0pmid: 37698721

Sickle cell disease (SCD) is the most common monogenetic condition in the United States (US) and one that has been subjected to a history of negative bias. Since SCD was first described approximately 120 years ago, the medical establishment has, directly and indirectly, harmed patients by reinforcing biases and assumptions about the disease. Furthermore, negative biases and stigmas have been levied upon patients with SCD by healthcare providers and society, researchers, and legislators. This article will explore the historical context of SCD in the US; discuss specific issues in care that lead to biases, social and self-stigma, inequities in access to care, and research funding; and highlight interventions over recent years that address racial biases and stigma.

Balmuth, Evan A.; Scammell, Thomas E.

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08414-xpmid: 37740167

Harriet Tubman, a hero of the abolitionist movement and early civil rights advocate, suffered a head injury in childhood and subsequently developed sleep attacks associated with visions that were extensively documented in historical accounts. Her contemporaries perceived these visions together with unpredictable and unavoidable urges to sleep as manifestations of her deep faith, rather than as symptoms of an illness. While religious perspectives remain crucial to understanding Tubman’s sleep-related experiences, some may consider them insufficient in view of modern medical advances. We propose the parallel explanation that her sleep attacks, usually attributed to temporal lobe epilepsy, actually represent a hypersomnia that is most consistent with the modern diagnosis of post-traumatic narcolepsy. Using historical analysis as well as current understandings of sleep medicine, we aim to shed light on this under-recognized aspect of Tubman’s life. In addition, this case study allows us to review the potential long-term effects of severe traumatic brain injuries; consider a differential for excessive daytime sleepiness and hypnagogic hallucinations; and familiarize readers with the pathophysiology, diagnosis, and treatment of narcolepsy. Whether her symptoms are viewed through the lens of the past or measured against current biomedical standards, Tubman demonstrated an inspiring ability to persevere despite intrusive sleep episodes and to realize her dreams for the betterment of others.

Jain, Rajesh K.; Weiner, Mark; Polley, Eric; Iwamaye, Amy; Huang, Elbert; Vokes, Tamara

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08347-5pmid: 37715097

BackgroundOsteoporotic fracture prediction calculators are poorly utilized in primary care, leading to underdiagnosis and undertreatment of those at risk for fracture. The use of these calculators could be improved if predictions were automated using the electronic health record (EHR). However, this approach is not well validated in multi-ethnic populations, and it is not clear if the adjustments for race or ethnicity made by calculators are appropriate.ObjectiveTo investigate EHR-generated fracture predictions in a multi-ethnic population.DesignRetrospective cohort study using data from the EHR.SettingAn urban, academic medical center in Philadelphia, PA.Participants12,758 White, 7,844 Black, and 3,587 Hispanic patients seeking routine care from 2010 to 2018 with mean 3.8 years follow-up.InterventionsNone.MeasurementsFRAX and QFracture, two of the most used fracture prediction tools, were studied. Risk for major osteoporotic fracture (MOF) and hip fracture were calculated using data from the EHR at baseline and compared to the number of fractures that occurred during follow-up.ResultsMOF rates varied from 3.2 per 1000 patient-years in Black men to 7.6 in White women. FRAX and QFracture had similar discrimination for MOF prediction (area under the curve, AUC, 0.69 vs. 0.70, p=0.08) and for hip fracture prediction (AUC 0.77 vs 0.79, p=0.21) and were similar by race or ethnicity. FRAX had superior calibration than QFracture (calibration-in-the-large for FRAX 0.97 versus QFracture 2.02). The adjustment factors used in MOF prediction were generally accurate in Black women, but underestimated risk in Black men, Hispanic women, and Hispanic men.LimitationsSingle center design.ConclusionsFracture predictions using only EHR inputs can discriminate between high and low risk patients, even in Black and Hispanic patients, and could help primary care physicians identify patients who need screening or treatment. However, further refinements to the calculators may better adjust for race-ethnicity.

O’Brien, Matthew J.; Bailey, Stacy C.; Gregory, Dyanna L.; Owen, Andrew L.; Khan, Sadiya S.; Ackermann, Ronald T.; Hassan, Amro; Mohanty, Nivedita; Bowen, Michael E.

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08402-1

BackgroundIn 2021, the U.S. Preventive Services Task Force (USPSTF) recommended screening for prediabetes and diabetes among adults aged 35–70 years with overweight or obesity. Studying dysglycemia screening in federally qualified health centers (FQHCs) that serve vulnerable patient populations is needed to understand health equity implications of this recommendation.ObjectiveTo investigate screening practices among FQHC patients who would be eligible according to the 2021 USPSTF recommendation.DesignRetrospective cohort study analyzing electronic health records from a national network of 282 FQHC sites.ParticipantsWe included 183,329 patients without prior evidence of prediabetes or diabetes, who had ≥ 1 office visit from 2018–2020.Main MeasuresScreening eligibility was based on age and measured body mass index (BMI). The primary outcome, screening completion, was ascertained using hemoglobin A1c or fasting plasma glucose results from 2018–2020.Key ResultsAmong 89,543 patients who would be eligible according to the 2021 USPSTF recommendation, 53,263 (59.5%) were screened. Those who completed screening had higher BMI values than patients who did not (33.0 ± 6.7 kg/m2 vs. 31.9 ± 6.2 kg/m2, p < 0.001). Adults aged 50–64 years had greater odds of screening completion relative to younger patients (OR 1.13, 95% CI: 1.10–1.17). Patients from racial and ethnic minority groups, as well as those without health insurance, were more likely to complete screening than White patients and insured patients, respectively. Clinical risk factors for diabetes were also associated with dysglycemia screening. Among patients who completed screening, 23,588 (44.3%) had values consistent with prediabetes or diabetes.ConclusionsOver half of FQHC patients who would be eligible according to the 2021 USPSTF recommendation were screened. Screening completion was higher among middle-aged patients, those with greater BMI values, as well as vulnerable groups with a high risk of developing diabetes. Future research should examine adoption of the 2021 USPSTF screening recommendation and its impact on health equity.

Hryciw, Brett N.; Rodic, Stefan; Selim, Shehab; Wang, Chuqi; Lepage, Melissa-Fay; Nguyen, Long Hoai; Goyal, Vineet; van Walraven, Carl

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08407-wpmid: 37723368

BackgroundKnowing the probability that patients have a bloodstream infection (BSI) could influence the ordering of blood cultures and interpretation of their preliminary results. Many previous BSI probability models have limited applicability and accuracy. This study used currently recommended modeling techniques and a large sample to derive and validate the Ottawa BSI Model.MethodsAt a tertiary care teaching hospital, we retrieved a random sample of 4180 adults having blood cultures in our emergency department or during the initial 48 h of the encounter. Variable selection was based on clinical experience and a systematic review of previous model performance. Model performance was measured in a temporal external validation group of 4680 patients.ResultsA total of 327 derivation patients had a BSI (8.0%). BSI risk increased with increased number of culture sets (2 sets: adjusted odds ratio [aOR] 1.52 [1.10–2.11]; 3 sets: 1.99 [0.86–4.58]); with indwelling catheter (aOR 2.07 [1.34–3.20); with increasing temperature, heart rate, and neutrophil–lymphocyte ratio; and with decreasing systolic blood pressure, platelet count, urea-creatinine ratio, and estimated glomerular filtration rate. In the temporal external validation group, model discrimination was good (c-statistic 0.71 [0.69–0.74]) and calibration was very good (integrated calibration index .016 [.010–.024]). Exclusion of validation patients with acute SARS-CoV-2 infection improved discrimination slightly (c-statistic 0.73 [0.69–0.76]).ConclusionsThe Ottawa BSI Model uses commonly available data to return an expected BSI probability for acutely ill patients. However, it cannot exclude BSI and its complexity requires computational assistance to use.

Azenkot, Tali; Aronowitz, Paul B.

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08396-wpmid: 37723367

Cresswell, Kathrin; Anderson, Stuart; Montgomery, Catherine; Weir, Christopher J.; Atter, Marek; Williams, Robin

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08405-ypmid: 37715095

Evaluating healthcare digitalisation, where technology implementation and adoption transforms existing socio-organisational processes, presents various challenges for outcome assessments. Populations are diverse, interventions are complex and evolving over time, meaningful comparisons are difficult as outcomes vary between settings, and outcomes take a long time to materialise and stabilise. Digitalisation may also have unanticipated impacts. We here discuss the limitations of evaluating the digitalisation of healthcare, and describe how qualitative and quantitative approaches can complement each other to facilitate investment and implementation decisions. In doing so, we argue how existing approaches have focused on measuring what is easily measurable and elevating poorly chosen values to inform investment decisions. Limited attention has been paid to understanding processes that are not easily measured even though these can have significant implications for contextual transferability, sustainability and scale-up of interventions. We use what is commonly known as the McNamara Fallacy to structure our discussions. We conclude with recommendations on how we envisage the development of mixed methods approaches going forward in order to address shortcomings.

Gunderman, David J.; Fricker, Gabrielle E.; Kondury, Kasyap; Moe, Sharon M.; Al-Makki, Akram

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08350-w

Johnson, Lacey; Liss, David T.; Carcamo, Paula; Goel, Mita Sanghavi; Magner, Bridget G.; Yang, Ta-Yun; Llaneza, Josephine

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08404-zpmid: 37715098

BackgroundPrograms to screen for social and economic needs (SENs) are challenging to implement.AimTo describe implementation of an SEN screening program for patients obtaining care at a federally qualified health center (FQHC).SettingLarge Chicago-area FQHC where many patients are Hispanic/Latino and insured through Medicaid.Program DescriptionIn the program’s phase 1 (beginning April 2020), a prescreening question asked about patients’ interest in receiving community resources; staff then called interested patients. After several refinements (e.g., increased staffing, tailored reductions in screening frequency) to address challenges such as a large screening backlog, program phase 2 began in February 2021. In phase 2, a second prescreening question asked about patients’ preferred modality to learn about community resources (text/email versus phone calls).Program EvaluationDuring phase 1, 8925 of 29,861 patients (30%) expressed interest in community resources. Only 40% of interested patients were successfully contacted and screened. In phase 2, 5781 of 21,737 patients (27%) expressed interest in resources; 84% of interested patients were successfully contacted by either text/email (43%) or phone (41%).DiscussionUnder one-third of patients obtaining care at an FQHC expressed interest in community resources for SENs. After program refinements, rates of follow-up with interested patients substantially increased.

Hernandez, Inmaculada; Wright, Davene R.; Guo, Jingchuan; Shrank, William H.

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08416-9pmid: 37715099

When the Medicare Part D benefit was constructed, drugs for weight loss were explicitly excluded from coverage, as the limited effectiveness and unfavorable safety profile of medications available at the time failed to justify coverage of drugs perceived to be used for cosmetic purposes. In recent years, drugs activating the glucagon-like peptide-1 receptor (GLP-1R) pathway have proved to achieve significant reductions in body weight with a favorable safety profile. The effectiveness of GLP-1R agonists in reducing weight and improving the metabolic profile warrants the reconsideration of the historical exclusion of weight loss drugs from Part D coverage. In this perspective, we outline policy options to enable Part D coverage of GLP-1R agonists. These include legislative change through the passage of the Treat and Reduce Obesity Act and evaluation of coverage policies under the waiver authority of the Center for Medicare and Medicaid Innovation.

Thompson, Trevor; Stathi, Sofia; Buckley, Francesca; Shin, Jae Il; Liang, Chih-Sung

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08401-2pmid: 37698724

BackgroundDespite initiatives to eradicate racial inequalities in pain treatment, there is no clear picture on whether this has translated to changes in clinical practice.ObjectiveTo determine whether racial disparities in the receipt of pain medication in the emergency department have diminished over a 22-year period from 1999 to 2020.DesignWe used data from the National Hospital Ambulatory Medical Care Survey, an annual, cross-sectional probability sample of visits to emergency departments of non-federal general and short-stay hospitals in the USA.PatientsPain-related visits to the ED by Black or White patients.Main MeasuresPrescriptions for opioid and non-opioid analgesics.Key ResultsA total of 203,854 of all sampled 625,433 ED visits (35%) by Black or White patients were pain-related, translating to a population-weighted estimate of over 42 million actual visits to US emergency departments for pain annually across 1999–2020. Relative risk regression found visits by White patients were 1.26 (95% CI, 1.22–1.30; p<0.001) times more likely to result in an opioid prescription for pain compared to Black patients (40% vs. 32%). Visits by Black patients were also 1.25 (95% CI, 1.21–1.30; p<0.001) times more likely to result in non-opioid analgesics only being prescribed. Results were not substantively altered after adjusting for insurance status, type and severity of pain, geographical region, and other potential confounders. Spline regression found no evidence of meaningful change in the magnitude of racial disparities in prescribed pain medication over 22 years.ConclusionsInitiatives to create equitable healthcare do not appear to have resulted in meaningful alleviation of racial disparities in pain treatment in the emergency department.

Egede, Leonard E.; Walker, Rebekah J.; Williams, Joni S.

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08426-7pmid: 37740168

Significant national discourse has focused on the idea of structural inequalities and structural racism within a variety of societal sectors, including healthcare. This perspective provides an understanding of the historic and pervasive nature of structural inequalities and structural racism; uses well-known frameworks in health equity research for conceptualizing structural inequality and structural racism; offers a summary of the consequences of structural inequalities and structural racism on modern-day health outcomes; and concludes with strategies and suggestions for a way forward. Recommended strategies across different sectors of influence include (a) employment and economic empowerment sector: creating capacity for individuals to earn livable wages; (b) education sector: developing new funding structures to ensure equal opportunities are offered to all; (c) healthcare sector: prioritizing universal access to high-quality health care, including mental health treatment; (d) housing sector: improving access to affordable, safe housing through public–private partnerships; (e) criminal justice sector: focusing reform on restorative justice that is people-centric instead of punitive; and (f) environmental sector: creating sustainable systems that alleviate downstream consequences of climate change. The recommended strategies account for the mutually reinforcing and pervasive nature of structural inequalities/structural racism and target key sectors of influence to enhance overall health outcomes and achieve equity regardless of race, ethnicity, or socioeconomic status.

Everson, Jordan; Besaw, Robert J.; Whitmore, Christine C.; Joseph Mattingly, T.; Sinaiko, Anna D.; Keating, Nancy L.; Everson, Nicole Senft; Dusetzina, Stacie B.

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08388-w

BackgroundMedication cost conversations occur less frequently than patients prefer, and it is unclear whether patients have positive experiences with them when they do occur.ObjectiveTo describe patients’ experiences discussing their medication costs with their health care team.DesignCross-sectional survey.SettingNationally representative survey fielded in the United States in 2022 (response rate = 48.5%).Patients1020 adults over age 65.MeasurementsPrimary measures were adapted from Clinician and Group Consumer Assessment of Healthcare Providers Survey visit survey v4.0 and captured patients’ experiences of medication cost conversations. Additional measures captured patients’ interest in future cost conversations, the type of clinicians with whom they would be comfortable discussing costs, and sociodemographic characteristics.ResultsAmong 1020 respondents who discussed medication prices with their health care team, 39.3% were 75 or older and 78.6% were non-Hispanic White. Forty-three percent of respondents indicated that their prior medication cost conversation was not easy to understand; 3% indicated their health care team was not respectful and 26% indicated their health care team was somewhat respectful during their last conversation; 48% indicated that there was not enough time. Those reporting that their prior discussion was not easy to understand or that their clinician was not definitely respectful were less likely to be interested in future discussions. Only 6% and 10% of respondents indicated being comfortable discussing medication prices with financial counselors or social workers, respectively. Few differences in responses were observed by survey participant characteristics.LimitationsThis cross-sectional survey of prior experiences may be subject to recall bias.ConclusionAmong older adults who engaged in prior medication cost conversations, many report that these conversations are not easy to understand and that almost one-third of clinicians were somewhat or not respectful. Efforts to increase the frequency of medication cost conversations should consider parallel interventions to ensure the discussions are effective at informing prescribing decisions and reducing cost-related medication nonadherence.

Weinstein, Amy R.; Ratcliffe, Temple A.; Duca, Nicholas S.; Harris, Linda; Alexandraki, Irene

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08366-2pmid: 37670072

Rotenstein, Lisa S.; Melnick, Edward R.; Jeffery, Molly; Zhang, Jianyi; Sinsky, Christine A.; Gitomer, Richard; Bates, David W.

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08417-8

Kane, Julia; Munn, Lindsay; Kane, Shawn F.; Srulovici, Einav

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08322-0pmid: 37670070

BackgroundCommunication issues have been shown to contribute to healthcare errors. For years healthcare professionals have been told to “speak up.” What “speak up” means is unclear, as it has been defined and operationalized in many ways. Thus, this study aimed to systematically review the literature regarding definitions and measurements of speaking up in the healthcare system and to develop a single, comprehensive definition and operationalization of the concept.MethodsPubMed, CINAHL, PsychoInfo, and Communication/Mass Media Complete databases were searched from 1999 to 2020. Publications were included if they mentioned speaking up for patient safety or any identified synonyms. Articles that used the term speaking up concerning non-health-related topics were excluded. This systematic review utilized Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.ResultsA total of 294 articles met the inclusion criteria, yet only 58 articles focused on speaking up. While the most common synonym terms identified were “speak up” and “raise concern,” only 43 articles defined speaking up. Accordingly, a modified definition was developed for speaking up—A healthcare professional identifying a concern that might impact patient safety and using his or her voice to raise the concern to someone with the power to address it.DiscussionSpeaking up is considered important for patient safety. Yet, there has been a lack of agreement on the definition and operationalization of speaking up. This review demonstrates that speaking up should be reconceptualized to provide a single definition for speaking up in healthcare.

Ortega, Pilar; Gregorich, Steven E.; Karliner, Leah; González, Javier; Pérez-Cordón, Cristina; Iñiguez, Reniell X.; Izquierdo, Karen; Diamond, Lisa C.

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08391-1pmid: 37670071

BackgroundThe lack of a standardized language assessment process for medical students and physicians communicating in a non-English language threatens healthcare quality and safety.ObjectiveTo evaluate the validity of a new rating tool, the Physician Oral Language Observation Matrix (POLOM)™, in assessing medical students’ oral communication with Spanish-speaking standardized patients (SPs).DesignPOLOM scores were compared to measures of student medical Spanish proficiency to examine convergent validity and to measures of clinical performance to examine concurrent/criterion validity.ParticipantsForty-two students at two schools completed SP encounters between January 2021 and April 2022, and POLOM raters scored the videorecorded performances between January and June 2022.Main MeasuresTwo approaches to generating POLOM total scores were investigated: rater average and strict consensus. Convergent validity was examined via the POLOM’s correlations with (1) the phone-based Clinician Cultural and Linguistic Assessment (CCLA) and (2) the self-rated Interagency Language Roundtable scale for healthcare (ILR-H). Concurrent/criterion validity was examined via correlations with (1) the Comunicación y Habilidades Interpersonales (CAI) scale, (2) a checklist completed by the SP, and (3) a faculty rating of the student’s post-encounter clinical note. Pearson’s correlations of r ≥ 0.5 and r ≥ 0.2 were considered evidence of convergent validity and concurrent/criterion validity, respectively.Key ResultsBoth rater average and strict consensus POLOM scores were strongly correlated with ILR-H (r = 0.72) and CCLA (r ≥ 0.60), providing evidence of convergent validity. The POLOM was substantially correlated with the CAI (r ≥ 0.29), the SP Checklist (r = 0.32), and the faculty scoring of the student’s clinical note (r ≥ 0.24), providing concurrent/criterion validity evidence.ConclusionsThe POLOM has demonstrated evidence of convergent and concurrent/criterion validity as a measure of medical students’ Spanish proficiency during SP encounters. Additional research is needed to evaluate how the POLOM can be implemented with resident and practicing physicians, applied to other health professions, and adapted to other languages.

Satish, Priyanka; Khetan, Aditya; Shah, Dharav; Srinivasan, Shuba; Balakrishnan, Rojith; Padmanandan, Arun; Hejjaji, Vittal; Hull, Leland; Samuel, Reema; Josephson, Richard

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08413-ypmid: 37723365

Herbst, Ellen; Hoggatt, Katherine J.; Leonard, Samuel; Purcell, Natalie; Rossi, Nathan; Bialous, Stella

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08381-3pmid: 37715093

Boyer, Taylor L.; Wolfe, Hill L.; Littman, Alyson J.; Shipherd, Jillian C.; Kauth, Michael R.; Blosnich, John R.

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08389-9pmid: 37670068

BackgroundTransgender and gender diverse (TGD) veterans have a greater prevalence of suicide morbidity and mortality than cisgender veterans. Gender-affirming surgery (GAS) has been shown to improve mental health for TGD veterans. In 2021, the Veterans Health Administration (VHA) announced the initiation of a rulemaking process to cover GAS for TGD patients.ObjectiveThis study explores patients’ and providers’ perspectives about access to GAS and other gender-affirming medical interventions not offered in the VHA including barriers, facilitators, and clinical and policy recommendations.ParticipantsTGD patients (n = 30) and VHA providers (n = 22).ApproachSemi-structured telephone interviews conducted from August 2019 through January 2020. Two TGD analysts used conventional and directed content analysis to code transcribed data.Key ResultsVHA policy exclusions were the most cited barrier to GAS. Additional barriers included finding information about GAS, traveling long distances to non-VHA surgeons, out-of-pocket expenses, post-surgery home care, and psychological challenges related to the procedure. Factors facilitating access included surgical care information from peers and VHA providers coordinating care with non-VHA GAS providers. Pre- and post-operative care through the VHA also facilitated receiving surgery; however, patients and providers indicated that knowledge of these services is not widespread. Respondents recommended disseminating information about GAS-related care and resources to patients and providers to help patients navigate care. Additional recommendations included expanding access to TGD mental health specialists and establishing referrals to non-VHA GAS providers through transgender care coordinators. Finally, transfeminine patients expressed the importance of facial GAS and hair removal.ConclusionsA policy change to include GAS in the VHA medical benefits package will allow the largest integrated healthcare system in the United States to provide evidence-based GAS services to TGD patients. For robust and consistent policy implementation, the VHA must better disseminate information about VHA-provided GAS-related care to TGD patients and providers while building capacity for GAS delivery.

Todd, Hannah; Carmody, J. Bryan; Nguemeni Tiako, Max Jordan

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08421-ypmid: 37735327

Kaplan, Jonathan; Rado, Jeffrey; Laiteerapong, Neda

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08394-ypmid: 37698723

Calcaterra, Susan L.; Saunders, Scott; Grimm, Eric; Maki-Gianani, Emma; Keniston, Angela; Wold, Angi; Bonaguidi, Angela

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08411-0pmid: 37715094

IntroductionMethadone ameliorates opioid withdrawal among hospitalized patients with opioid use disorder (OUD). To continue methadone after hospital discharge, patients must enroll in an opioid treatment program (OTP) per federal regulations. Uncontrolled opioid withdrawal is a barrier to linkage from hospital to OTP.AimDescribe a federally compliant In-Hospital Methadone Enrollment Team (IN-MEET) that enrolls hospitalized patients with OUD into an OTP with facilitated hospital to OTP linkage.SettingSeven hundred-bed university hospital in Aurora, CO.Program DescriptionA physician dually affiliated with a hospital’s addiction consultation service and a community OTP completes an in-hospital, face-to-face medical assessment required by federal law and titrates methadone to comfort. An OTP-affiliated nurse with hospital privileges completes a psychosocial evaluation and provides case management by arranging transportation and providing weekly telephone check-ins.Program Evaluation MetricsIN-MEET enrollments completed, hospital to OTP linkage, and descriptive characteristics of patients who completed IN-MEET enrollments compared to patients who completed community OTP enrollments.ResultsBetween April 2019 and April 2023, our team completed 165 IN-MEET enrollments. Among a subset of 73 IN-MEET patients, 56 (76.7%) presented to the OTP following hospital discharge. Compared to community OTP enrolled patients (n = 1687), a higher percentage of IN-MEET patients were older (39.7 years, standard deviation [SD] 11.2 years vs. 36.1 years, SD 10.6 years) and were unhoused (n = 43, 58.9% vs. n = 199, 11.8%). Compared to community OTP enrolled patients, a higher percentage of IN-MEET patients reported heroin or fentanyl as their primary substance (n = 53, 72.6% vs. n = 677, 40.1%), reported methamphetamine as their secondary substance (n = 27, 37.0% vs. n = 380, 22.5%), and reported they injected their primary substance (n = 46, 63.0% vs. n = 478, 28.3%).ConclusionIN-MEET facilitates hospital to OTP linkage among a vulnerable population. This model has the potential to improve methadone access for hospitalized patients who may not otherwise seek out treatment.

Stark, Jennifer E.; Cole, Jennifer

2023 Journal of General Internal Medicine

doi: 10.1007/s11606-023-08390-2pmid: 37670067

BackgroundDiversity, equity, and inclusion (DEI) are at the core of publication ethics, and language around DEI has been shown to affect patient outcomes. Inclusive language is an important piece of effective communication and is one way to demonstrate and foster a welcoming, respectful, and accessible environment. Non-inclusive terminology in research may represent implicit bias, which is not typically corrected through introspection; thus, a systematic approach is needed in scientific writing. The prevalence of inclusive language guidance in leading medical journals is currently unknown.ObjectiveInvestigators assess the prevalence and quality of inclusive language guidelines in author instructions in highly cited English language medical journals.DesignA cross-sectional review of author instructions from a convenience sample of 100 highly cited medical journals was completed in January 2023.SubjectsEach journal’s author instructions were reviewed for presence of inclusive language guidelines for manuscript submissions.Main MeasuresGuidelines that included specific examples of inclusive language were defined as “strong.” Author instructions were also reviewed for the Sex and Gender Equity in Research (SAGER) checklist, and each journal’s publisher and impact factor (IF) were recorded.Key ResultsThe 100 journals reviewed had an IF range of 3.0–202.7 with a median IF = 19.5 (IQR 11.95, 38.68), and 28 unique publishers were represented. Inclusive language guidance was provided in 23% of medical journals reviewed. Of those, 20 (86.9%) provided strong guidance. Seven journals also recommended use of the SAGER checklist.ConclusionSignificant gaps still exist in ensuring use of inclusive language in medical journals.