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1.
Peter P. Reese Judd B. Kessler Jalpa A. Doshi Joelle Friedman Adam S. Mussell Caroline Carney Jingsan Zhu Wenli Wang Andrea Troxel Peinie Young Victor Lawnicki Swapnil Rajpathak Kevin Volpp 《Journal of general internal medicine》2016,31(4):402-410
Background
Medication nonadherence is an important obstacle to cardiovascular disease management.Objective
To improve adherence through real-time feedback based on theories of how social forces influence behavior.Design
Two randomized controlled pilot trials called PROMOTE and SUPPORT. Participants stored statin medication in wireless-enabled pill bottles that transmitted adherence data to researchers.Participants
Adults with diabetes and a history of low statin adherence based on pharmacy refills (i.e., Medication Possession Ratio [MPR] <80 % in the pre-randomization screening period).Intervention
In PROMOTE, each participant was randomized to 1) weekly messages in which that participant’s statin adherence was compared to that of other participants (comparison), 2) weekly summaries of that participant’s statin adherence (summary), or 3) control. In SUPPORT, each participant identified another person (the Medication Adherence Partner [MAP]) to receive reports about that participant’s adherence, and was randomized to 1) daily reports to MAP, 2) weekly reports to MAP, 3) reports to MAP only if dose was missed, or 4) control.Main Outcomes Measure
Adherence measured by pill bottle.Key Results
Among 45,000 health plan members contacted by mail, <1 % joined the trial. Participants had low baseline MPRs (median?=?60 %, IQR 41–72 %) but high pill-bottle adherence (90 % in PROMOTE, 92 % in SUPPORT) during the trial. In PROMOTE (n?=?201) and SUPPORT (n?=?200), no intervention demonstrated significantly better adherence vs. control. In a subgroup of PROMOTE participants with the lowest pre-study MPR, pill-bottle-measured adherence in the comparison arm (89 %) was higher than the control (86 %) and summary (76 %) arms, but differences were non-significant (p?=?0.10).Conclusions
Interventions based on social forces did not improve medication adherence vs. control over a 3-month period. Given the low percentage of invited individuals who enrolled, the studies may have attracted participants who required little encouragement to improve adherence other than study participation.2.
Christoph D. Spinner Christoph Boesecke Alexander Zink Heiko Jessen Hans-Jürgen Stellbrink Jürgen Kurt Rockstroh Stefan Esser 《Infection》2016,44(2):151-158
Purpose
Despite established HIV prevention strategies and broadly available diagnostic strategies in developed western countries, rates of HIV new infections remain high. Alternative strategies for HIV prevention, particularly among men who have sex with men (MSM), are crucial. HIV pre-exposure prophylaxis (PrEP) has been discussed as one additional option that this review seeks to explore.Methods
An online search identifying PrEP-relevant literature from 1st January 2010 to 1st August, 2015 was performed.Results
The iPrEx study, first published in 2010, demonstrated a reduction in relative risk (RRR) of HIV seroconversion of 44 % for continuous PrEP with tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) in MSM. The efficacy of PrEP has been confirmed for continuous PrEP in the PROUD study and for intermittent PrEP in the IPERGAY study (RRR = 86 % in both studies). The PrEP was well tolerated in all studies, and the evolution of HIV resistance has been low. Compensatory increased sexual risk behavior was not observed in recent studies. In contrast to the high efficacy of risk reduction for HIV transmission in MSM, the results of TDF PrEP and TDF/FTC PrEP studies using microbicidal agents or pills among heterosexual women were different (RRR 6–75 %).Conclusions
Continuous and intermittent PrEP demonstrated high efficacy in preventing HIV seroconversion, notably among MSM. PrEP was well tolerated. Adherence was critical for high efficacy in all studies. Further studies to evaluate implementation strategies and cost-effectiveness in different risk populations are needed as well as drug approval in Europe.3.
Background
Enhanced recovery after surgery (ERAS) pathway includes recovery goals requiring active participation of the patients; this may be perceived as “aggressive” care in older patients. The aim of the present study was to assess whether ERAS was feasible and beneficial in older patients.Methods
Since June 2011, all consecutive colorectal patients were included in an ERAS pathway and documented in a dedicated prospective database. This retrospective analysis included 513 patients, 311 younger patients (<70 years) and 202 older patients (≥70 years). Outcomes were adherence to the ERAS pathway, functional recovery, postoperative complications, and hospital stay.Results
Older patients had significantly more diabetes, malignancies, cardiac, and respiratory co-morbidities; both groups underwent similar surgical procedures. Overall adherence to the ERAS pathway was in median 78 % in younger and 74 % in older patients (P = 0.86). In older patients, urinary drains were kept longer (P = 0.001), and oral fluid intake was reduced from day 0 to day 3 (P < 0.001). There were no differences in mobilization and intake of nutritional supplements. Postoperative complications were similar for both comparative groups (51.5 vs. 46.6 %, P = 0.32). Median length of stay was 7 days (IQR 5–13) in older patients vs. 6 days (IQR 4–10) in the younger group (P = 0.001).Conclusion
Adherence to the ERAS pathway was equally high in older patients. Despite more co-morbidities, older patients did not experience more complications. Recovery was similar and hospital stay was only 1 day longer than in younger patients. ERAS pathway is of value for all patients and does not need any adaptation for the elderly.4.
Varsha G. Vimalananda Donald R. Miller Timothy P. Hofer Robert G. Holleman Mandi L. Klamerus Eve A. Kerr 《Journal of general internal medicine》2013,28(2):529-535
BACKGROUND
Women with diabetes have higher low-density lipoprotein (LDL) levels than men, resulting in apparent disparities between genders on quality indicators tied to LDL thresholds.OBJECTIVE
To investigate whether gender disparities persist when accounting for clinical action with statins or cardiovascular risk.DESIGN
Retrospective cohort study.PARTICIPANTS
Veterans Health Administration patients (21,780 women and 646,429 men) aged 50–75 with diabetes.MAIN MEASURES
Threshold measure: LDL < 100 mg/dL; clinical action measure: LDL < 100 mg/dL; or LDL ≥ 100 mg/dL and the patient was prescribed a moderate or high-dose statin at the time of the test; or LDL ≥ 100 mg/dL and the patient received other appropriate clinical action within 90 days; adherence: continuous multiple interval measure of gaps in dispensed medication (CMG).KEY RESULTS
Women were much less likely to have LDL < 100 mg/dL than were men (55 % vs. 68 %). This disparity narrowed from 13 % to 6 % for passing the clinical action measure (79 % vs. 85 %). These gender differences persisted among those with ischemic heart disease (IHD). Women had a lower odds of passing the clinical action measure (odds ratio 0.68, 95 % confidence interval 0.66–0.71). Among those with IHD, the gender gap increased with age. Differences in pass rates were explained by women’s higher LDL levels, but not by their slightly worse adherence (3 % higher CMG).CONCLUSIONS
Women and men veterans receive more similar quality of care for lipids in diabetes than previously indicated. Less reassuringly, the remaining gender differences appear to be as common in women at high cardiovascular risk as in those at low risk. Rather than focus on simply improving LDL levels in all women with diabetes, future efforts should ensure that patients with high cardiovascular risk are appropriately treated with statins when clinically indicated, feasible, and concordant with patient preferences.5.
Susan?P.?Bell Jeffrey?L.?Schnipper Kathryn?Goggins Aihua?Bian Ayumi?Shintani Christianne?L.?Roumie Anuj?K.?Dalal Terry?A.?Jacobson Kimberly?J.?Rask Viola?Vaccarino Tejal?K.?Gandhi Stephanie?A.?Labonville Daniel?Johnson Erin?B.?Neal Sunil?Kripalani for the Pharmacist Intervention for Low Literacy in Cardiovascular Disease Study Group 《Journal of general internal medicine》2016,31(5):470-477
Background
Reduction in 30-day readmission rates following hospitalization for acute coronary syndrome (ACS) and acute decompensated heart failure (ADHF) is a national goal.Objective
The aim of this study was to determine the effect of a tailored, pharmacist-delivered, health literacy intervention on unplanned health care utilization, including hospital readmission or emergency room (ER) visit, following discharge.Design
Randomized, controlled trial with concealed allocation and blinded outcome assessorsSetting
Two tertiary care academic medical centersParticipants
Adults hospitalized with a diagnosis of ACS and/or ADHFIntervention
Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after dischargeMain Measures
The primary outcome was time to first unplanned health care event, defined as hospital readmission or an ER visit within 30 days of discharge. Pre-specified analyses were conducted to evaluate the effects of the intervention by academic site, health literacy status (inadequate versus adequate), and cognition (impaired versus not impaired). Adjusted hazard ratios (aHR) and 95 % confidence intervals (CI) are reported.Key Results
A total of 851 participants enrolled in the study at Vanderbilt University Hospital (VUH) and Brigham and Women’s Hospital (BWH). The primary analysis showed no statistically significant effect on time to first unplanned hospital readmission or ER visit among patients who received interventions compared to controls (aHR?=?1.04, 95 % CI 0.78-1.39). There was an interaction of treatment effect by site (p?=?0.04 for interaction); VUH aHR?=?0.77, 95 % CI 0.51-1.15; BWH aHR?=?1.44 (95 % CI 0.95-2.12). The intervention reduced early unplanned health care utilization among patients with inadequate health literacy (aHR 0.41, 95 % CI 0.17-1.00). There was no difference in treatment effect by patient cognition.Conclusion
A tailored, pharmacist-delivered health literacy-sensitive intervention did not reduce post-discharge unplanned health care utilization overall. The intervention was effective among patients with inadequate health literacy, suggesting that targeted practice of pharmacist intervention in this population may be advantageous.6.
Ian M. Kronish Nathalie Moise Thomas McGinn Yan Quan William Chaplin Benjamin D. Gallagher Karina W. Davidson 《Journal of general internal medicine》2016,31(11):1294-1300
BACKGROUND
To appropriately manage uncontrolled hypertension, clinicians must decide whether blood pressure (BP) is above goal due to a need for additional medication or to medication nonadherence. Yet, clinicians are poor judges of adherence, and uncertainty about adherence may promote inertia with respect to medication modification.OBJECTIVE
We aimed to determine the effect of sharing electronically-measured adherence data with clinicians on the management of uncontrolled hypertension.DESIGN
This was a cluster randomized trial.PARTICIPANTS
Twenty-four primary care providers (12 intervention, 12 usual care; cluster units) and 100 patients with uncontrolled hypertension (65 intervention, 35 usual care) were included in the study.INTERVENTIONS
At one visit per patient, clinicians in the intervention group received a report summarizing electronically measured adherence to the BP regimen and recommended clinical actions. Clinicians in the control group did not receive a report.MAIN MEASURES
The primary outcome was the proportion of visits with appropriate clinical management (i.e., treatment intensification among adherent patients and adherence counseling among nonadherent patients). Secondary outcomes included patient-rated quality of care and communication during the visit.KEY RESULTS
The proportion of visits with appropriate clinical management was higher in the intervention group than the control group (45 out of 65; 69 %) versus (12 out of 35; 34 %; p?=?0.001). A higher proportion of adherent patients in the intervention group had their regimen intensified (p?=?0.01), and a higher proportion of nonadherent patients in the intervention group received adherence counseling (p?=?0.005). Patients in the intervention group were more likely to give their clinician high ratings on quality of care (p?=?0.05), and on measures of patient-centered (p?=?0.001) and collaborative communication (p?=?0.02).CONCLUSIONS
Providing clinicians with electronically-measured antihypertensive adherence reports reduces inertia in the management of uncontrolled hypertension.7.
8.
Oni J. Blackstock Janet P. Tate Kathleen M. Akgün Stephen Crystal Mona Duggal E. Jennifer Edelman Cynthia L. Gibert Kirsha S. Gordon David Rimland Maria C. Rodriguez-Barradas Emily A. Wang David A. Fiellin Amy C. Justice 《Journal of general internal medicine》2013,28(2):577-582
BACKGROUND
Whether sex disparities exist in overall burden of disease among human immunodeficiency virus (HIV)-infected individuals in the Veterans Affairs healthcare system (VA) is unknown.OBJECTIVE
To determine whether sex differences exist in overall burden of disease after 1 year of combined antiretroviral therapy (ART) among HIV-infected individuals in VA.DESIGN
Retrospective cohort study.PARTICIPANTS
Among patients in the Veterans Aging Cohort Study Virtual Cohort (VACS-VC), all ART-naïve HIV-infected Veterans who received VA-based HIV care between 1996 and 2009.MAIN MEASURES
Overall burden of disease was measured using the VACS Index, an index that incorporates HIV (e.g. CD4 cell count) and non-HIV biomarkers (e.g. hemoglobin) and is highly predictive of all-cause mortality. Possible scores range from 0 to 164, although scores typically range from 0 to 50 for 80 % of patients in VACS-VC. A higher score indicates greater burden of disease (each additional five points indicates approximately 20 % increased 5-year mortality risk). ART adherence was measured using pharmacy data.KEY RESULTS
Complete data were available for 227 women and 8,073 men. At ART initiation, compared with men, women were younger and more likely to be Black, less likely to have liver dysfunction, but more likely to have lower hemoglobin levels. Median VACS Index scores changed from ART initiation to 1 year after ART initiation: women’s scores went from 41 to 28 for women (13 point improvement) and men’s from 42 to 27 for men (15 point improvement). In multivariable regression, women had 3.6 point worse scores than men after 1 year on ART (p?=?0.002); this difference decreased to 3.2 points after adjusting for adherence (p?=?0.004).CONCLUSIONS
In VA, compared to men, women experienced less improvement in overall burden of disease after 1 year of HIV treatment. Further study is needed to elucidate the modifiable factors that may explain this disparity.9.
M. G. Pramateftakis P. Hatzigianni D. Kanellos G. Vrakas Th. Tsachalis I. Mantzoros I. Kanellos C. Lazaridis 《Techniques in coloproctology》2010,14(1):63-64
Aim
In this study, we present our patients with metachronous colorectal cancer.Patients and methods
In the period between 1990 and 2009, 670 patients with colorectal cancer were treated.Results
Metachronous cancer was developed in 4 (0.6%) patients. The time interval between index and metachronous cancer was 28 months to 22 years (mean 146 months).Conclusion
Metachronous colorectal cancer is a potential risk that proves the necessity of postoperative colonoscopic control of all patients with colorectal cancer.10.
Joseph J. Gallo Seungyoung Hwang Jin Hui Joo Hillary R. Bogner Knashawn H. Morales Martha L. Bruce Charles F. ReynoldsIII 《Journal of general internal medicine》2016,31(4):380-386
Background
Two-thirds of older adults have two or more medical conditions that often take precedence over depression in primary care.Objective
We evaluated whether evidence-based depression care management would improve the long-term mortality risk among older adults with increasing levels of medical comorbidity.Design
Longitudinal analyses of the practice-randomized Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT). Twenty primary care practices randomized to intervention or usual care.Patients
The sample included 1204 older primary care patients completing the Charlson Comorbidity Index (CCI) and other interview questions at baseline.Intervention
For 2 years, a depression care manager worked with primary care physicians to provide algorithm-based care for depression, offering psychotherapy, increasing the antidepressant dose if indicated, and monitoring symptoms, medication adverse effects, and treatment adherence.Main Measures
Depression status based on clinical interview, CCI to evaluate medical comorbidity, and vital status at 8 years (National Death Index).Key Results
In the usual care condition, patients with the highest levels of medical comorbidity and depression were at increased risk of mortality over the course of the follow-up compared to depressed patients with minimal medical comorbidity [hazard ratio 3.02 (95 % CI, 1.32 to 8.72)]. In contrast, in intervention practices, patients with the highest level of medical comorbidity and depression compared to depressed patients with minimal medical comorbidity were not at significantly increased risk [hazard ratio 1.73 (95 % CI, 0.86 to 3.96)]. Nondepressed patients in intervention and usual care practices had similar mortality risk.Conclusions
Depression management mitigated the combined effect of multimorbidity and depression on mortality. Depression management should be integral to optimal patient care, not a secondary focus.11.
A. Herold A. Ommer A. Fürst F. Pakravan D. Hahnloser B. Strittmatter T. Schiedeck F. Hetzer F. Aigner E. Berg M. Roblick D. Bussen A. Joos S. Vershenya 《Techniques in coloproctology》2016,20(8):585-590
Background
The aim of this prospective study was to determine the efficiency of the Gore Bio-A synthetic plug in the treatment of anal fistulas.Methods
A synthetic bioabsorbable anal fistula plug was implanted in 60 patients. All fistulas were transsphincteric and cryptoglandular in origin.Results
The healing rate after 1 year of follow-up was 52 % (31 out of 60 patients). No patient was lost to follow-up. The treatment had no effect on the incontinence score. The plug dislodgement rate was 10 % (6 out of 60 patients). Thirty-four per cent of the patients (16 out of 47) required reoperation. The average operating time was 32 ± 10.2 min, and the average length of hospital stay was 3.3 ± 1.8 days.Conclusions
Synthetic plugs may be an alternative to bioprosthetic fistula plugs in the treatment of transsphincteric anal fistulas. This method might have better success rates than treatment with bioprosthetic fistula plugs.12.
Dima Saab Rosane Nisenbaum Irfan Dhalla Stephen W. Hwang 《Journal of general internal medicine》2016,31(9):1011-1018
BACKGROUND
Hospital readmission rates are a widely used quality indicator that may be elevated in disadvantaged populations.OBJECTIVE
The objective of this study was to compare the hospital readmission rate among individuals experiencing homelessness with that of a low-income matched control group, and to identify risk factors associated with readmission within the group experiencing homelessness.DESIGN
We conducted a 1:1 matched cohort study comparing 30-day hospital readmission rates between homeless patients and low-income controls matched on age, sex and primary reason for admission. Multivariate analyses using generalized estimating equations were used to assess risk factors associated with 30-day readmission in the homeless cohort.PARTICIPANTS
This study examined a cohort of 1,165 homeless adults recruited at homeless shelters and meal programs in Toronto, Ontario, between 6 December 2004 and 20 December 2005.MAIN MEASURES
The primary outcome was the occurrence of an unplanned medical or surgical readmission within 30 days of discharge from hospital.KEY RESULTS
Between 6 December 2004 and 31 March 2009, homeless participants (N?=?203) had 478 hospitalizations and a 30-day readmission rate of 22.2 %, compared to 300 hospitalizations and a readmission rate of 7.0 % among matched controls (OR?=?3.79, 95 % CI 1.93-7.39). In the homeless cohort, having a primary care physician (OR?=?2.65, 95 % CI 1.05-6.73) and leaving against medical advice (OR?=?1.96, 95 % CI 0.99-3.86) were associated with an increased risk of 30-day readmission.CONCLUSIONS
Homeless patients had nearly four times the odds of being readmitted within 30-days as compared to low-income controls matched on age, sex and primary reason for admission to hospital. Further research is needed to evaluate interventions to reduce readmissions among this patient population.13.
Introduction
HIV infection is increasingly characterized as a chronic condition that can be managed through adherence to a healthy lifestyle, complex drug regimens, and regular treatment and monitoring. The location, quality, and/or affordability of a person’s housing can be a significant determinant of his or her ability to meet these requirements. The objective of this systematic review is to inform program and policy development and future research by examining the available empirical evidence on the effects of housing status on health-related outcomes in people living with HIV/AIDS.Methods
Electronic databases were searched from dates of inception through November 2005. A total of 29 studies met inclusion criteria for this review. Seventeen studies received a “good” or “fair” quality rating based on defined criteria.Results
A significant positive association between increased housing stability and better health-related outcomes was noted in all studies examining housing status with outcomes of medication adherence (n = 9), utilization of health and social services (n = 5), and studies examining health status (n = 2) and HIV risk behaviours (n = 1).Conclusions
Healthcare, support workers and public health policy should recognize the important impact of affordable and sustainable housing on the health of persons living with HIV.14.
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.15.
F. Breuckmann F. Remberg D. Böse M. Lichtenberg P. Kümpers H. Pavenstädt J. Waltenberger D. Fischer 《Herz》2016,41(2):151-158
Aim
This study aimed to analyze guideline adherence in the timing of invasive management for myocardial infarction without persistent ST-segment elevation (NSTEMI) in two exemplary German centers, comparing an urban university maximum care facility and a rural regional primary care facility.Methods
All patients diagnosed as having NSTEMI during 2013 were retrospectively enrolled in two centers: (1) site I, a maximum care center in an urban university setting, and (b) site II, a primary care center in a rural regional care setting. Data acquisition included time intervals from admission to invasive management, risk criteria, rate of intervention, and medical therapy.Results
The median time from admission to coronary angiography was 12.0 h (site I) or 17.5 h (site II; p?=?0.17). Guideline-adherent timing was achieved in 88.1?% (site I) or 82.9?% (site II; p?=?0.18) of cases. Intervention rates were high in both sites (site I—75.5?% vs. site II—75.3?%; p?=?0.85). Adherence to recommendations of medical therapy was high and comparable between the two sites.Conclusion
In NSTEMI or high-risk acute coronary syndromes without persistent ST-segment elevation, guideline-adherent timing of invasive management was achieved in about 85?% of cases, and was comparable between urban maximum and rural primary care settings. Validation by the German Chest Pain Unit Registry including outcome analysis is required.16.
Judith K. Ockene Rashelle B. Hayes Linda C. Churchill Sybil L. Crawford Denise G. Jolicoeur David M. Murray Abigail B. Shoben Sean P. David Kristi J. Ferguson Kathryn N. Huggett Michael Adams Catherine A. Okuliar Robin L. Gross Pat F. BassIII Ruth B. Greenberg Frank T. Leone Kola S. Okuyemi David W. Rudy Jonathan B. Waugh Alan C. Geller 《Journal of general internal medicine》2016,31(2):172-181
Background
Early in medical education, physicians must develop competencies needed for tobacco dependence treatment.Objective
To assess the effect of a multi-modal tobacco dependence treatment curriculum on medical students’ counseling skills.Design
A group-randomized controlled trial (2010–2014) included ten U.S. medical schools that were randomized to receive either multi-modal tobacco treatment education (MME) or traditional tobacco treatment education (TE).Setting/Participants
Students from the classes of 2012 and 2014 at ten medical schools participated. Students from the class of 2012 (N?=?1345) completed objective structured clinical examinations (OSCEs), and 50 % (N?=?660) were randomly selected for pre-intervention evaluation. A total of 72.9 % of eligible students (N?=?1096) from the class of 2014 completed an OSCE and 69.7 % (N?=?1047) completed pre and post surveys.Interventions
The MME included a Web-based course, a role-play classroom demonstration, and a clerkship booster session. Clerkship preceptors in MME schools participated in an academic detailing module and were encouraged to be role models for third-year students.Measurements
The primary outcome was student tobacco treatment skills using the 5As measured by an objective structured clinical examination (OSCE) scored on a 33-item behavior checklist. Secondary outcomes were student self-reported skills for performing 5As and pharmacotherapy counseling.Results
Although the difference was not statistically significant, MME students completed more tobacco counseling behaviors on the OSCE checklist (mean 8.7 [SE 0.6] vs. mean?8.0 [SE 0.6], p?=?0.52) than TE students. Several of the individual Assist and Arrange items were significantly more likely to have been completed by MME students, including suggesting behavioral strategies (11.8 % vs. 4.5 %, p?<?0.001) and providing information regarding quitline (21.0 % vs. 3.8 %, p?<?0.001). MME students reported higher self-efficacy for Assist, Arrange, and Pharmacotherapy counseling items (ps?≤0.05).Limitations
Inclusion of only ten schools limits generalizability.Conclusions
Subsequent interventions should incorporate lessons learned from this first randomized controlled trial of a multi-modal longitudinal tobacco treatment curriculum in multiple U.S. medical schools.NIH Trial Registry Number: NCT0190561817.
Lisandro D. Colantonio Shia T. Kent Lei Huang Ligong Chen Keri L. Monda Maria-Corina Serban Angelika Manthripragada Meredith L. Kilgore Robert S. Rosenson Paul Muntner 《Cardiovascular drugs and therapy / sponsored by the International Society of Cardiovascular Pharmacotherapy》2016,30(5):525-533
Purpose
To compare characteristics of patients with possible statin intolerance identified using different claims-based algorithms versus patients with high adherence to statins.Methods
We analyzed 134,863 Medicare beneficiaries initiating statins between 2007 and 2011. Statin intolerance and discontinuation, and high adherence to statins, defined by proportion of days covered ≥80 %, were assessed during the 365 days following statin initiation. Definition 1 of statin intolerance included statin down-titration or discontinuation with ezetimibe initiation, having a claim for a rhabdomyolysis or antihyperlipidemic event followed by statin down-titration or discontinuation, or switching between ≥3 types of statins. Definition 2 included beneficiaries who met Definition 1 and those who down-titrated statin intensity. We also analyzed beneficiaries who met Definition 2 of statin intolerance or discontinued statins.Results
The prevalence of statin intolerance was 1.0 % (n = 1320) and 5.2 % (n = 6985) using Definitions 1 and 2, respectively. Overall, 45,266 (33.6 %) beneficiaries had statin intolerance by Definition 2 or discontinued statins and 55,990 (41.5 %) beneficiaries had high adherence to statins. Compared with beneficiaries with high adherence to statins, those with statin intolerance and who had statin intolerance or discontinued statins were more likely to be female versus male, and black, Hispanic or Asian versus white. The multivariable adjusted odds ratio for statin intolerance by Definitions 1 and 2 comparing patients initiating high versus low/moderate intensity statins were 2.82 (95%CI: 2.42–3.29), and 8.58 (8.07–9.12), respectively, and for statin intolerance or statin discontinuation was 2.35 (2.25–2.45).Conclusions
Definitions of statin intolerance presented herein can be applied to analyses using administrative claims data.18.
Linda Y. Kim Danielle E. Rose Lynn M. Soban Susan E. Stockdale Lisa S. Meredith Samuel T. Edwards Christian D. Helfrich Lisa V. Rubenstein 《Journal of general internal medicine》2018,33(1):50-56
Background
The patient-centered medical home (PCMH) is a primary care delivery model predicated on shared responsibility for patient care among members of an interprofessional team. Effective task sharing may reduce burnout among primary care providers (PCPs). However, little is known about the extent to which PCPs share these responsibilities, and which, if any, of the primary care tasks performed independently by the PCPs (vs. shared with the team) are particularly associated with PCP burnout. A better understanding of the relationship between these tasks and their effects on PCP burnout may help guide focused efforts aimed at reducing burnout.Objective
To investigate (1) the extent to which PCPs share responsibility for 14 discrete primary care tasks with other team members, and (2) which, if any, of the primary care tasks performed by the PCPs (without reliance on team members) are associated with PCP burnout.Design
Secondary data analysis of Veterans Health Administration (VHA) survey data from two time periods.Participants
327 providers from 23 VA primary care practices within one VHA regional network.Main Measures
The dependent variable was PCP report of burnout. Independent variables included PCP report of the extent to which they performed 14 discrete primary care tasks without reliance on team members; team functioning; and PCP-, clinic-, and system-level variables.Key Results
In adjusted models, PCP reports of intervening on patient lifestyle factors and educating patients about disease-specific self-care activities, without reliance on their teams, were significantly associated with burnout (intervening on lifestyle: b = 4.11, 95% CI = 0.39, 7.83, p = 0.03; educating patients: b = 3.83, 95% CI = 0.33, 7.32, p = 0.03).Conclusions
Performing behavioral counseling and self-management education tasks without relying on other team members for assistance was associated with PCP burnout. Expanding the roles of nurses and other healthcare professionals to assume responsibility for these tasks may ease PCP burden and reduce burnout.19.