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1.
Background
Frequent exacerbations of chronic obstructive pulmonary disease (COPD) have negative effects on quality of life and survival. Thus, factors related to exacerbations should be determined. We aimed to evaluate the effects of thyroid function on quality of life and exacerbation frequency in COPD patients.Methods
The study population (n?=?128) was divided into 3 groups (Group 1: COPD patients with hypothyroidism (n?=?44); Group 2: COPD patients with normal thyroid function tests (n?=?44); Group 3: Healthy subjects (n?=?40)). Pulmonary function tests, maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP) measurements were performed. Quality of life questionnaire (Short Form 36, SF-36) was carried out. Patients were followed up for one year and number of exacerbations was recorded.Results
FVC, FEV1/FVC, and FEF 25–75% measurements were statistically different between group 1 and 2 (p?=?0.041, p?=?0.001, p?=?0.009 respectively). Although MEP values were significantly different between group 1 and 2 (p?=?0.006), there was no significant difference in MIP values between groups (p?=?0.77). Quality of life scores in group 1 and 2 were significantly lower than control group. Exacerbation frequency was significantly higher in group 1 than in group 2 (p?=?0.017). TSH values and exacerbation frequency had positive correlation (p?<?0.0001; r?=?0.82).Conclusions
The results of the present study suggest that thyroid function has an effect in exacerbation frequency of COPD. Decrease in exacerbation numbers with early detection of impairment in thyroid function will have positive contribution on quality of life in COPD patients.2.
Travis I. Lovejoy Benjamin J. Morasco Michael I. Demidenko Thomas H. A. Meath Steven K. Dobscha 《Journal of general internal medicine》2018,33(1):24-30
Background
Little is known about pain care offered to patients discontinued from long-term opioid therapy (LTOT) by their prescriber due to aberrant behaviors versus other reasons.Objective
This study aimed to compare rates of non-opioid analgesic pharmacotherapy initiation and clinician referrals for non-pharmacologic pain treatment, complementary and integrative pain therapies, and specialty mental health and substance use disorder treatment between patients discontinued from opioid therapy due to aberrant behaviors versus other reasons.Design
The design included retrospective manual electronic health record review and administrative data abstraction.Participants
Patients were sampled from a national cohort of US Department of Veterans Affairs patients prescribed continuous opioid therapy in 2011 who subsequently discontinued opioid therapy in 2012. The study sample comprised 509 patients discontinued from LTOT by opioid-prescribing clinicians.Main Measures
The primary independent variable was reason for discontinuation of LTOT (aberrant behaviors versus other reasons). Pain care dichotomous outcomes included clinician use of an opioid taper; initiating new non-opioid analgesic pharmacotherapy; and referrals for non-pharmacologic pain treatment, complementary and integrative pain therapies, and specialty mental health and substance use disorder treatment.Key Results
We observed low rates of opioid taper (15% of patients), initiations of new or modifications of existing non-opioid analgesic pharmacotherapy (45% of patients), and clinician referrals for non-pharmacologic pain treatment (58% of patients) and complementary and integrative therapies (25% of patients). Patients discontinued due to aberrant behaviors, relative to patients discontinued for other reasons, were more likely to receive opioid tapers (adjusted OR?=?5.60, 95% CI?=?2.10–14.93), receive new non-opioid analgesic medications or dose changes to an existing non-opioid analgesic medications (adjusted OR?=?2.61, 95% CI?=?1.59–4.29), or be referred for specialty substance use disorder treatment (adjusted OR?=?7.39, 95% CI?=?3.76–14.53).Conclusions
These findings highlight the variability in referral rates for different types of non-opioid pain treatments and challenges accessing specific types of pain care.3.
Purpose
Acute severe colitis affects 25 % of patients with ulcerative colitis (UC). Up to 30–40 % of these patients are resistant to intensive steroid therapy and therefore require rescue therapy to prevent emergent colectomy. Data comparing rescue therapy using infliximab and cyclosporine are limited and equivocal. This study evaluates the outcomes of UC patients receiving infliximab or cyclosporine as rescue therapy in acute severe steroid-refractory exacerbations.Methods
Electronic databases (PubMed, EMBASE, and Cochrane database) were searched for studies directly comparing infliximab and cyclosporine in UC, and references of included studies were screened. Two independent reviewers identified relevant studies and extracted data. Meta-analyses were performed using the random effect model. Outcome measures included 3- and 12-month colectomy rates, adverse drug reactions, and postoperative complications.Results
Six retrospective cohort studies describing 321 patients met the inclusion criteria. The meta-analysis did not show significant differences between infliximab and cyclosporine in the 3-month colectomy rate (odds ratio (OR)?=?0.86, 95 % confidence interval (CI)?=?0.31–2.41, p?=?0.775), in the 12-month colectomy rate (OR?=?0.60, 95 % CI?=?0.19–1.89, p?=?0.381), in adverse drug reactions (OR?=?0.76, 95 % CI?=?0.34–1.70, p?=?0.508), and in postoperative complications (OR?=?1.66, 95 % CI?=?0.26–10.50, p?=?0.591). Funnel plot revealed no publication bias.Conclusions
Infliximab and cyclosporine are comparable when used as rescue therapy in acute severe steroid-refractory UC. Randomized trials are required to further evaluate these agents.4.
Sanja Percac-Lima Lydia E. Pace Kevin H. Nguyen Charis N. Crofton Katharine A. Normandin Sara J. Singer Meredith B. Rosenthal Alyna T. Chien 《Journal of general internal medicine》2018,33(4):415-422
Background
Rectal bleeding is a common, frequently benign problem that can also be an early sign of colorectal cancer. Diagnostic evaluation for rectal bleeding is complex, and clinical practice may deviate from available guidelines.Objective
To assess the degree to which primary care physicians document risk factors for colorectal cancer among patients with rectal bleeding and order colonoscopies when indicated, and the likelihood of physicians ordering and patients receiving recommended colonoscopies based on demographic characteristics, visit patterns, and clinical presentations.Design
Cross-sectional study using explicit chart abstraction methods.Participants
Three hundred adults, 40–80 years of age, presenting with rectal bleeding to 15 academically affiliated primary care practices between 2012 and 2016.Main Measures
1) The frequency at which colorectal cancer risk factors were documented in patients’ charts, 2) the frequency at which physicians ordered colonoscopies and patients received them, and 3) the odds of ordering and patients receiving recommended colonoscopies based on patient demographic characteristics, visit patterns, and clinical presentations.Key Results
Risk factors for colorectal cancer were documented between 9% and 66% of the time. Most patients (89%) with rectal bleeding needed a colonoscopy according to a clinical guideline. Physicians placed colonoscopy orders for 74% of these patients, and 56% completed the colonoscopy within a year (36% within 60 days). The odds of physicians ordering recommended colonoscopies were significantly higher in patients aged 50–64 years of age than in those aged 40–50 years (OR?=?2.23, 95% CI: 1.04, 4.80), and for patients whose most recent colonoscopy was 5 or more years ago (OR?=?4.04, 95% CI: 1.50, 10.83). The odds of physicians ordering and patients receiving recommended colonoscopies were significantly lower for each primary care visit unrelated to rectal bleeding (OR?=?0.85, 95% CI: 0.75, 0.96).Conclusions
Diagnostic evaluation of patients presenting to primary care with rectal bleeding may be suboptimal because of inadequate risk factor assessment and prioritization of patients’ other concurrent medical problems.5.
Ellen H. Chen David H. Thom Danielle M. Hessler La Phengrasamy Hali Hammer George Saba Thomas Bodenheimer 《Journal of general internal medicine》2010,25(4):610-614
Background
Team care can improve management of chronic conditions, but implementing a team approach in an academic primary care clinic presents unique challenges.Objectives
To implement and evaluate the Teamlet Model, which uses health coaches working with primary care physicians to improve care for patients with diabetes and/or hypertension in an academic practice.Design
Process and outcome measures were compared before and during the intervention in patients seen with the Teamlet Model and in a comparison patient group.Participants
First year family medicine residents, medical assistants, health workers, and adult patients with either type 2 diabetes or hypertension in a large public health clinic.Intervention
Health coaches, in coordination with resident primary care physicians, met with patients before and after clinic visits and called patients between visits.Measurements
Measurement of body mass index, assessment of smoking status, and formulation of a self-management plan prior to and during the intervention period for patients in the Teamlet Model group. Testing for LDL and HbA1C and the proportion of patients at goal for blood pressure, LDL, and HbA1C in the Teamlet Model and comparison groups in the year prior to and during implementation.Results
Teamlet patients showed improvement in all measures, though improvement was significant only for smoking, BMI, and self-management plan documentation and testing for LDL (p?=?0.02), with a trend towards significance for LDL at goal (p?=?0.07). Teamlet patients showed a greater, but non-significant, increase in the proportion of patients tested for HbA1C and proportion reaching goal for blood pressure, HgbA1C, and LDL compared to the comparison group patients. The difference for blood pressure was marginally significant (p?=?0.06). In contrast, patients in the comparison group were significantly more likely to have had testing for LDL (P?=?0.001).Conclusions
The Teamlet Model may improve chronic care in academic primary care practices.6.
Steven K. Dobscha Lauren M. Denneson Anne E. Kovas Alan Teo Christopher W. Forsberg Mark S. Kaplan Robert Bossarte Bentson H. McFarland 《Journal of general internal medicine》2014,29(4):853-860
BACKGROUND
Veterans receiving Veterans Affairs (VA) healthcare have increased suicide risk compared to the general population. Many patients see primary care clinicians prior to suicide. Yet little is known about the correlates of suicide among patients who receive primary care treatment prior to death.OBJECTIVE
Our aim was to describe characteristics of veterans who received VA primary care in the 6 months prior to suicide; and to compare these to characteristics of control patients who also received VA primary care.DESIGN
This was a retrospective case–control study.SUBJECTS
The investigators partnered with VA operations leaders to obtain death certificate data from 11 states for veterans who died by suicide in 2009. Cases were matched 1:2 to controls based on age, sex, and clinician.MAIN MEASURES
Demographic, diagnosis, and utilization data were obtained from VA’s Corporate Data Warehouse. Additional clinical and psychosocial context data were collected using manual medical record review. Multivariate conditional logistic regression was used to examine associations between potential predictor variables and suicide.KEY RESULTS
Two hundred and sixty-nine veteran cases were matched to 538 controls. Average subject age was 63 years; 97 % were male. Rates of mental health conditions, functional decline, sleep disturbance, suicidal ideation, and psychosocial stressors were all significantly greater in cases compared to controls. In the final model describing men in the sample, non-white race (OR?=?0.51; 95 % CI?=?0.27–0.98) and VA service-connected disability (OR?=?0.54; 95 % CI?=?0.36–0.80) were associated with decreased odds of suicide, while anxiety disorder (OR?=?3.52; 95 % CI?=?1.79–6.92), functional decline (OR?=?2.52; 95 % CI?=?1.55–4.10), depression (OR?=?1.82; 95 % CI?=?1.07–3.10), and endorsement of suicidal ideation (OR?=?2.27; 95 % CI?=?1.07–4.83) were associated with greater odds of suicide.CONCLUSIONS
Assessment for anxiety disorders and functional decline in addition to suicidal ideation and depression may be especially important for determining suicide risk in this population. Continued development of interventions that support identifying and addressing these conditions in primary care is indicated.7.
Fabienne Langlois Dawn Shao Ting Lim Chris G. Yedinak Isabelle Cetas Shirley McCartney Justin Cetas Aclan Dogan Maria Fleseriu 《Pituitary》2018,21(1):32-40
Purpose
Silent corticotroph adenomas (SCAs) are clinically silent and non-secreting, but exhibit positive adrenocorticotropic hormone (ACTH) immunostaining. We characterized a single center cohort of SCA patients, compared the SCAs to silent gonadotroph adenomas (SGAs), identified predictors of recurrence, and reviewed and compared the cohort to previously published SCAs cases.Methods
Retrospective review of SCA and SGA surgically resected patients over 10 years and 6 years, respectively. Definitions; SCA—no clinical or biochemical evidence of Cushing’s syndrome and ACTH positive immunostaining, and SGA—steroidogenic factor (SF-1) positive immunostaining. A systematic literature search was undertaken using Pubmed and Scopus.Results
Review revealed 814 pituitary surgeries, 39 (4.8%) were SCAs. Mean follow-up was 6.4 years (range 0.5–23.8 years). Pre-operative magnetic resonance imaging demonstrated sphenoid and/or cavernous sinus invasion in 44%, 33% were >?50% cystic, and 28% had high ACTH levels pre-operatively. Compared to SGAs (n?=?70), SCAs were of similar size and invasiveness (2.5 vs. 2.9 cm, p?=?0.2; 44 vs. 41%, p?=?0.8, respectively), but recurrence rate was higher (36 vs. 10%, p?=?0.001) and more patients received radiation therapy (18 vs. 3%, p?=?0.006). Less cystic tumors (0 vs. 50%, p?<?0.001) and higher pre-operative ACTH levels (54 vs. 28 pg/ml, p?=?0.04) were predictors of recurrence for SCAs.Conclusion
This review is unique; a strict definition of SCA was used, and single center SCAs were compared with SGAs and with SCAs literature reviewed cases. We show that SCAs are aggressive and identify predictors of recurrence. Accurate initial diagnosis, close imaging and biochemical follow up are warranted.8.
Mueez Waqar Robert McCreary Tara Kearney Konstantina Karabatsou Kanna K. Gnanalingham 《Pituitary》2017,20(4):441-449
Purpose
In pituitary apoplexy (PA), there are preliminary reports on the appearance of sphenoid sinus mucosal thickening (SSMT). SSMT is otherwise uncommon with an incidence of up to 7% in asymptomatic individuals. The aim of this study was to evaluate the incidence and clinical significance of SSMT in patients with PA and a control group of surgically treated non-functioning pituitary adenomas (NFPAs).Methods
Retrospective review of clinical and imaging variables in PA and NFPA patients. Sphenoid sinus mucosal thickness was measured on the presenting MRI scan by a blinded neuroradiologist. Pathological SSMT was defined as >1 mm adjacent to the pituitary fossa. Forward stepwise logistic regression was used to identify factors associated with SSMT.Results
There were 50 NFPA and 47 PA patients. PA patients were managed conservatively (N?=?11) or surgically (N?=?36). The median sphenoid sinus mucosal thickness was greater in the PA than NFPA groups (2.0 vs. 0.5 mm; p?<?0.001). In multivariate analysis of both the PA and NFPA groups, the presence of PA was the only factor associated with SSMT (OR 0.043, 95% CI 0.012–0.16; p?<?0.001). In multivariate analysis of the PA group alone, a shorter time from symptom onset to presenting MRI scan (OR 0.12, 95% CI 0.026–0.54; p?=?0.006) and a more severe grade of apoplexy (OR 7.29, 95% CI 1.10–48.40; p?=?0.04), were associated with SSMT.Conclusion
The incidence of SSMT is higher in patients with PA, especially during the acute phase of PA. The aetiology of SSMT in PA is unclear and may reflect inflammatory and/or infective changes.9.
Ethan A. Halm Elisabeth F. Beaber Dale McLerran Jessica Chubak Douglas A. Corley Carolyn M. Rutter Chyke A. Doubeni Jennifer S. Haas Bijal A. Balasubramanian 《Journal of general internal medicine》2016,31(10):1190-1197
Background
Population outreach strategies are increasingly used to improve colorectal cancer (CRC) screening. The influence of primary care on cancer screening in this context is unknown.Objective
To assess associations between primary care provider (PCP) visits and receipt of CRC screening and colonoscopy after a positive fecal immunochemical (FIT) or fecal occult blood test (FOBT).Design
Population-based cohort study.Participants
A total of 968,072 patients ages 50–74 years who were not up to date with CRC screening in 2011 in four integrated healthcare systems (three with screening outreach programs using FIT kits) in the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium.Measures
Demographic, clinical, PCP visit, and CRC screening data were obtained from electronic health records and administrative databases. We examined associations between PCP visits in 2011 and receipt of FIT/FOBT, screening colonoscopy, or flexible sigmoidoscopy (CRC screening) in 2012 and follow-up colonoscopy within 3 months of a positive FIT/FOBT in 2012. We used multivariable logistic regression and propensity score models to adjust for confounding.Results
Fifty-eight percent of eligible patients completed a CRC screening test in 2012, most by FIT. Those with a greater number of PCP visits had higher rates of CRC screening at all sites. Patients with ≥1 PCP visit had nearly twice the adjusted-odds of CRC screening (OR?=?1.88, 95 % CI: 1.86–1.89). Overall, 79.6 % of patients with a positive FIT/FOBT completed colonoscopy within 3 months. Patients with ≥1 PCP visit had 30 % higher adjusted odds of completing colonoscopy after positive FIT/FOBT (OR?=?1.30; 95 % CI: 1.22–1.40).Conclusions
Patients with a greater number of PCP visits had higher rates of both incident CRC screening and colonoscopy after positive FIT/FOBT, even in health systems with active population health outreach programs. In this era of virtual care and population outreach, primary care visits remain an important mechanism for engaging patients in cancer screening.10.
Michael G. Usher Christine Fanning Vivian W. Fang Madeline Carroll Amay Parikh Anne Joseph Dana Herrigel 《Journal of general internal medicine》2018,33(12):2078-2084
Background
Patients transferred between hospitals are at high risk of adverse events and mortality. The relationship between insurance status, transfer practices, and outcomes has not been definitively characterized.Objective
To identify the association between insurance coverage and mortality of patients transferred between hospitals.Design
We conducted a single-institution observational study, and validated results using a national administrative database of inter-hospital transfers.Setting
Three ICUs at an academic tertiary care center validated by a nationally representative sample of inter-hospital transfers.Patients
The single-institution analysis included 652 consecutive patients transferred from 57 hospitals between 2011 and 2012. The administrative database included 353,018 patients transferred between 437 hospitals.Measurements
Adjusted inpatient mortality and 24-h mortality, stratified by insurance status.Results
Of 652 consecutive transfers to three ICUs, we observed that uninsured patients had higher adjusted inpatient mortality (OR 2.67, p?=?0.021) when controlling for age, race, gender, Apache-II, and whether the patient was transferred from an ED. Uninsured were more likely to be transferred from ED (OR 2.3, p?=?0.026), and earlier in their hospital course (3.9 vs 2.0 days, p?=?0.002). Using an administrative dataset, we validated these observations, finding that the uninsured had higher adjusted inpatient mortality (OR 1.24, 95% CI 1.13–1.36, p?<?0.001) and higher mortality within 24 h (OR 1.33 95% CI 1.11–1.60, p?<?0.002). The increase in mortality was independent of patient demographics, referral patterns, or diagnoses.Limitations
This is an observational study where transfer appropriateness cannot be directly assessed.Conclusions
Uninsured patients are more likely to be transferred from an ED and have higher mortality. These data suggest factors that drive inter-hospital transfer of uninsured patients have the potential to exacerbate outcome disparities.11.
J. Daryl Thornton Catherine Sullivan Jeffrey M. Albert Maria Cedeño Bridget Patrick Julie Pencak Kristine A. Wong Margaret D. Allen Linda Kimble Heather Mekesa Gordon Bowen Ashwini R. Sehgal 《Journal of general internal medicine》2016,31(8):832-839
BACKGROUND
Low organ donation rates remain a major barrier to organ transplantation.OBJECTIVE
We aimed to determine the effect of a video and patient cueing on organ donation consent among patients meeting with their primary care provider.DESIGN
This was a randomized controlled trial between February 2013 and May 2014.SETTING
The waiting rooms of 18 primary care clinics of a medical system in Cuyahoga County, Ohio.PATIENTS
The study included 915 patients over 15.5 years of age who had not previously consented to organ donation.INTERVENTIONS
Just prior to their clinical encounter, intervention patients (n?=?456) watched a 5-minute organ donation video on iPads and then choose a question regarding organ donation to ask their provider. Control patients (n?=?459) visited their provider per usual routine.MAIN MEASURES
The primary outcome was the proportion of patients who consented for organ donation. Secondary outcomes included the proportion of patients who discussed organ donation with their provider and the proportion who were satisfied with the time spent with their provider during the clinical encounter.KEY RESULTS
Intervention patients were more likely than control patients to consent to donate organs (22 % vs. 15 %, OR 1.50, 95%CI 1.10–2.13). Intervention patients were also more likely to have donation discussions with their provider (77 % vs. 18 %, OR 15.1, 95%CI 11.1–20.6). Intervention and control patients were similarly satisfied with the time they spent with their provider (83 % vs. 86 %, OR 0.87, 95%CI 0.61–1.25).LIMITATION
How the observed increases in organ donation consent might translate into a greater organ supply is unclear.CONCLUSION
Watching a brief video regarding organ donation and being cued to ask a primary care provider a question about donation resulted in more organ donation discussions and an increase in organ donation consent. Satisfaction with the time spent during the clinical encounter was not affected.TRIAL REGISTRATION
clinicaltrials.gov Identifier: NCT0169713712.
Introduction
Several studies have shown a strong correlation between the serum vitamin D level and asthma severity and deficits in lung function.Objective
Study the relationship between vitamin D and the severity of asthma by targeting five SNPs of vitamin D metabolism gene pathway in a Tunisian adult asthmatics population.Methods
Our case–control study includes 154 adult asthmatic patients and 154 healthy Tunisian subjects. We genotyped many variants in three human genes encoding key components of the vitamin D metabolism, CYP2R1, CYP27B1, GC. The GC gene rs4588 and rs7041 polymorphisms were analysed using the PCR-RFLP method, while rs10741657 and rs12794714 for CYP2R1 gene and rs10877012 of CYP27B1 gene were investigated using TaqMan PCR genotyping techniques.Results
We found that the presence of at least one copy of the rs12794714 A, allele was associated with lower risk of developing asthma (OR 0.61). Further, the rs12794714 is a protector factor against asthma severity (OR 0.5). However, the presence of rs10877012 TG genotype is a risk factor related to asthma severity (OR 1.89). When we classified the population according to sex, our results showed that rs10877012 TT genotype was a risk factor for women subjects (OR 6.7). Moreover, the expression of TT genotype was associated with a higher risk of asthma in non-smoker patients (OR 7.13). We found a significant lower VD serum levels in asthmatics than controls but no impact of the polymorphisms on VD levels.Conclusions
We found that rs12794714 and rs10877012 SNPs were associated with asthma risk.13.
James S. Goodwin Kristin Sheffield Shuang Li Alai Tan 《Journal of general internal medicine》2016,31(11):1308-1314
Background
Obtaining cancer screening on patients with limited life expectancy has been proposed as a measure for low quality care for primary care physicians (PCPs). However, administrative data may underestimate life expectancy in patients who undergo screening.Objective
To determine the association between receipt of screening mammography or PSA and overall survival.Design
Retrospective cohort study from 1/1/1999 to 12/31/2012. Receipt of screening was assessed for 2001–2002 and survival from 1/1/2003 to 12/31/2012. Life expectancy was estimated as of 1/1/03 using a validated algorithm, and was compared to actual survival for men and women, stratified by receipt of cancer screening.Participants
A 5 % sample of Medicare beneficiaries aged 69–90 years as of 1/1/2003 (n?=?906,723).Interventions
Receipt of screening mammography in 2001–2002 for women, or a screening PSA test in 2002 for men.Main Measures
Survival from 1/1/2003 through 12/31/2012.Key Results
Subjects were stratified by life expectancy based on age and comorbidity. Within each stratum, the subjects with prior cancer screening had actual median survivals higher than those who were not screened, with differences ranging from 1.7 to 2.1 years for women and 0.9 to 1.1 years for men. In a Cox model, non-receipt of screening in women had an impact on survival (HR?=?1.52; 95 % CI?=?1.51, 1.54) similar in magnitude to a diagnosis of complicated diabetes or heart failure, and was comparable to uncomplicated diabetes or liver disease in men (HR?=?1.23; 1.22, 1.25).Conclusions
Receipt of cancer screening is a powerful marker of health status that is not captured by comorbidity measures in administrative data. Because life expectancy algorithms using administrative data underestimate the life expectancy of patients who undergo screening, they can overestimate the problem of cancer screening in patients with limited life expectancy.14.
15.
Anne C. Melzer Laura C. Feemster Margaret P. Collins David H. Au 《Journal of general internal medicine》2016,31(6):623-629
BACKGROUND
Many smokers admitted for chronic obstructive pulmonary disease (COPD) are not given smoking cessation medications at discharge. The reasons behind this are unclear, and may reflect an interplay of patient characteristics, health disparities, and the receipt of inpatient tobacco control processes.OBJECTIVES
We aimed to assess potential disparities in treatment for tobacco use following discharge for COPD, examined in the context of inpatient tobacco control processes.PARTICIPANTS
Smokers aged ≥ 40 years, admitted for treatment of a COPD exacerbation within the VA Veterans Integrated Service Network 20, identified using ICD-9 discharge codes and admission diagnoses from 2005–2012.MAIN MEASURES
The outcome was any tobacco cessation medication dispensed within 48 hours of discharge. We assessed potential predictors administratively up to 1 year prior to admission. We created the final logistic regression model using manual model building, clustered by site. Variables with p?<?0.2 in biviariate models were considered for inclusion in the final model.RESULTS
We identified 1511 subjects. 16.9 % were dispensed a medication at discharge. In the adjusted model, several predictors were associated with decreased odds of receiving medications: older age (OR per year older 0.96, 95 % CI 0.95–0.98), black race (OR 0.34, 95 % CI 0.12–0.97), higher comorbidity score (OR 0.89, 95 % CI 0.82–0.96), history of psychosis (OR 0.40, 95 % CI 0.31–0.52), hypertension (OR 0.75, 95 % CI 0.62–0.90), and treatment with steroids in the past year (OR 0.80, 95 % CI 0.70–0.90). Inpatient tobacco control processes were associated with increased odds of receiving medications: documented brief counseling at discharge (OR 3.08, 95 % CI 2.02–4.68) and receipt of smoking cessation medications while inpatient (OR 5.95, 95 % CI 3.19–11.10).CONCLUSIONS
Few patients were treated with tobacco cessation medications at discharge. We found evidence for disparities in treatment, but also potentially beneficial effects of inpatient tobacco control measures. Further focus should be on using novel processes of care to improve provision of medications and decrease the observed disparities.16.
Anita D. Misra-Hebert Bo Hu Glen Taksler Robert Zimmerman Michael B. Rothberg 《Journal of general internal medicine》2016,31(8):871-877
Background
Many employers offer worksite wellness programs, including financial incentives to achieve goals. Evidence supporting such programs is sparse.Objective
To assess whether diabetes and cardiovascular risk factor control in employees improved with financial incentives for participation in disease management and for attaining goals.Design
Retrospective cohort study using insurance claims linked with electronic medical record data from January 2008–December 2012.Participants
Employee patients with diabetes covered by the organization’s self-funded insurance and propensity-matched non-employee patient comparison group with diabetes and commercial insurance.Intervention
Financial incentives for employer-sponsored disease management program participation and achieving goals.Main Measures
Change in glycosylated hemoglobin (HbA1c), low-density lipoprotein (LDL), systolic blood pressure (SBP), and weight.Results
A total of 1092 employees with diabetes were matched to non-employee patients. With increasing incentives, employee program participation increased (7 % in 2009 to 50 % in 2012, p?<?0.001). Longitudinal mixed modeling demonstrated improved diabetes and cardiovascular risk factor control in employees vs. non-employees [HbA1c yearly change ?0.05 employees vs. 0.00 non-employees, difference in change (DIC) p <0.001]. In their first participation year, employees had larger declines in HbA1c and weight vs. non-employees (0.33 vs. 0.14, DIC p?=?0.04) and (2.3 kg vs. 0.1 kg, DIC p?<?0.001), respectively. Analysis of employee cohorts corresponding with incentive offerings showed that fixed incentives (years 1 and 2) or incentives tied to goals (years 3 and 4) were not significantly associated with HbA1c reductions compared to non-employees. For each employee cohort offered incentives, SBP and LDL also did not significantly differ in employees compared with non-employees (DIC p?>?0.05).Conclusions
Financial incentives were associated with employee participation in disease management and improved cardiovascular risk factors over 5 years. Improvements occurred primarily in the first year of participation. The relative impact of specific incentives could not be discerned.18.
Jennifer M. Polinski Tobias Barker Nancy Gagliano Andrew Sussman Troyen A. Brennan William H. Shrank 《Journal of general internal medicine》2016,31(3):269-275
Background
One-quarter of U.S. patients do not have a primary care provider or do not have complete access to one. Work and personal responsibilities also compete with finding convenient, accessible care. Telehealth services facilitate patients’ access to care, but whether patients are satisfied with telehealth is unclear.Objective
We assessed patients’ satisfaction with and preference for telehealth visits in a telehealth program at CVS MinuteClinics.Design
Cross-sectional patient satisfaction survey.Participants
Patients were aged ≥18 years, presented at a MinuteClinic offering telehealth in January–September 2014, had symptoms suitable for telehealth consultation, and agreed to a telehealth visit when the on-site practitioner was busy.Main Measures
Patients reported their age, gender, and whether they had health insurance and/or a primary care provider. Patients rated their satisfaction with seeing diagnostic images, hearing and seeing the remote practitioner, the assisting on-site nurse’s capability, quality of care, convenience, and overall understanding. Patients ranked telehealth visits compared to traditional ones: better (defined as preferring telehealth), just as good (defined as liking telehealth), or worse. Predictors of preferring or liking telehealth were assessed via multivariate logistic regression.Key results
In total, 1734 (54 %) of 3303 patients completed the survey: 70 % were women, and 41 % had no usual place of care. Between 94 and 99 % reported being “very satisfied” with all telehealth attributes. One-third preferred a telehealth visit to a traditional in-person visit. An additional 57 % liked telehealth. Lack of medical insurance increased the odds of preferring telehealth (OR?=?0.83, 95 % CI, 0.72–0.97). Predictors of liking telehealth were female gender (OR?=?1.68, 1.04–2.72) and being very satisfied with their overall understanding of telehealth (OR?=?2.76, 1.84–4.15), quality of care received (OR?=?2.34, 1.42–3.87), and telehealth’s convenience (OR?=?2.87, 1.09–7.94)Conclusions
Patients reported high satisfaction with their telehealth experience. Convenience and perceived quality of care were important to patients, suggesting that telehealth may facilitate access to care.19.
Julia McNabb-Baltar Shadeah L. Suleiman Peter A. Banks Darwin L. Conwell 《Digestive diseases and sciences》2018,63(11):2874-2879
Objectives
Chronic pancreatitis (CP) is a debilitating chronic illness. We sought to assess the most common reasons patients with CP visit the Emergency Department (ED), the disposition of ED visit [admission, discharge, death], and evaluate predictors of admission and discharge.Methods
Within the Health Care Utilization Project Nationwide Emergency Department Sample (NEDS), we focused on patients, 18 years and older, presenting to the emergency department with CP (ICD-9 code 577.1) (2006–2009). Model was fitted to predict the likelihood of admission.Results
Overall, a weighted sample of 638,310 patients visits for CP were identified, of which 399,559 (62.6%) were admitted, 228,523 (35.8%) were discharged from the ED, 5572 (0.9%) discharged against medical advice, and 4656 (0.7%) had an unknown destination. Of those admitted, 4370 (0.7%) died during the hospital episode. The most associated diagnoses for ED visit were diabetes (28.8%), abdominal pain (25.4%), acute pancreatitis (22.5%), cardiac complication (11.1%), infection (10.1%), and dehydration (8.8%). Multivariable analyses revealed that older (OR?=?1.02 P?<?0.001), sicker patients (Charlson Comorbidity Index?≥?3, OR?=?2.28 P?<?0.001), patients presenting with C. difficile colitis (OR?=?23.85 P?<?0.001), alcohol withdrawal (OR?=?6.71 P?<?0.001), and acute pancreatitis (OR?=?6.46 P?<?0.001) were associated with increased odds of hospitalization.Conclusions
In this national database, our study demonstrates that diabetes, followed by abdominal pain, acute pancreatitis and cardiac complication, were the most common diagnoses associated with ED visits in patients with chronic pancreatitis. Most patients were admitted following the ED visit. Although C. Difficile colitis was a rare associated diagnosis with an ED visit, it was the strongest predictor of admission.20.
Dima Saab Rosane Nisenbaum Irfan Dhalla Stephen W. Hwang 《Journal of general internal medicine》2016,31(9):1011-1018