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Background: Although most patients with SARS-CoV-2 infection can be safely managed at home, the need for hospitalization can arise suddenly. Objective: To determine whether enrollment in an automated remote monitoring service for community-dwelling adults with COVID-19 at home (“COVID Watch”) was associated with improved mortality. Design: Retrospective cohort analysis. Setting: Mid-Atlantic academic health system in the United States. Participants: Outpatients who tested positive for SARS-CoV-2 between 23 March and 30 November 2020. Intervention: The COVID Watch service consists of twice-daily, automated text message check-ins with an option to report worsening symptoms at any time. All escalations were managed 24 hours a day, 7 days a week by dedicated telemedicine clinicians. Measurements: Thirty- and 60-day outcomes of patients enrolled in COVID Watch were compared with those of patients who were eligible to enroll but received usual care. The primary outcome was death at 30 days. Secondary outcomes included emergency department (ED) visits and hospitalizations. Treatment effects were estimated with propensity score–weighted risk adjustment models. Results: A total of 3488 patients enrolled in COVID Watch and 4377 usual care control participants were compared with propensity score weighted models. At 30 days, COVID Watch patients had an odds ratio for death of 0.32 (95% CI, 0.12 to 0.72), with 1.8 fewer deaths per 1000 patients (CI, 0.5 to 3.1) (P = 0.005); at 60 days, the difference was 2.5 fewer deaths per 1000 patients (CI, 0.9 to 4.0) (P = 0.002). Patients in COVID Watch had more telemedicine encounters, ED visits, and hospitalizations and presented to the ED sooner (mean, 1.9 days sooner [CI, 0.9 to 2.9 days]; all P < 0.001). Limitation: Observational study with the potential for unobserved confounding. Conclusion: Enrollment of outpatients with COVID-19 in an automated remote monitoring service was associated with reduced mortality, potentially explained by more frequent telemedicine encounters and more frequent and earlier presentation to the ED. Primary Funding Source: Patient-Centered Outcomes Research Institute.

Rapid Assessment and Containment of Candida auris Transmission in Postacute Care Settings—Orange County, California, 2019

Background: Candida auris, a multidrug-resistant yeast, can spread rapidly in ventilator-capable skilled-nursing facilities (vSNFs) and long-term acute care hospitals (LTACHs). In 2018, a laboratory serving LTACHs in southern California began identifying species of Candida that were detected in urine specimens to enhance surveillance of C auris, and C auris was identified in February 2019 in a patient in an Orange County (OC), California, LTACH. Further investigation identified C auris at 3 associated facilities. Objective: To assess the prevalence of C auris and infection prevention and control (IPC) practices in LTACHs and vSNFs in OC. Design: Point prevalence surveys (PPSs), postdischarge testing for C auris detection, and assessments of IPC were done from March to October 2019. Setting: All LTACHs (n = 3) and vSNFs (n = 14) serving adult patients in OC. Participants: Current or recent patients in LTACHs and vSNFs in OC. Intervention: In facilities where C auris was detected, PPSs were repeated every 2 weeks. Ongoing IPC support was provided. Measurements: Antifungal susceptibility testing and whole-genome sequencing to assess isolate relatedness. Results: Initial PPSs at 17 facilities identified 44 additional patients with C auris in 3 (100%) LTACHs and 6 (43%) vSNFs, with the first bloodstream infection reported in May 2019. By October 2019, a total of 182 patients with C auris were identified by serial PPSs and discharge testing. Of 81 isolates that were sequenced, all were clade III and highly related. Assessments of IPC identified gaps in hand hygiene, transmission-based precautions, and environmental cleaning. The outbreak was contained to 2 facilities by October 2019. Limitation: Acute care hospitals were not assessed, and IPC improvements over time could not be rigorously evaluated. Conclusion: Enhanced laboratory surveillance and prompt investigation with IPC support enabled swift identification and containment of C auris. Primary Funding Source: Centers for Disease Control and Prevention.

Symptoms After COVID-19 Vaccination in Patients With Persistent Symptoms After Acute Infection: A Case Series

Comparative Implementation of a Brief App-Directed Protocol for Delirium Identification by Hospitalists, Nurses, and Nursing Assistants: A Cohort Study: Annals of Internal Medicine: Vol 175, No 1

Background: Systematic screening improves delirium identification among hospitalized older adults. Little data exist on how to implement such screening. Objective: To test implementation of a brief app-directed protocol for delirium identification by physicians, nurses, and certified nursing assistants (CNAs) in real-world practice relative to a research reference standard delirium assessment (RSDA). Design: Prospective cohort study. Setting: Large urban academic medical center and small rural community hospital. Participants: 527 general medicine inpatients (mean age, 80 years; 35% with preexisting dementia) and 399 clinicians (53 hospitalists, 236 nurses, and 110 CNAs). Measurements: On 2 study days, enrolled patients had an RSDA. Subsequently, CNAs performed an ultra-brief 2-item screen (UB-2) for delirium, whereas physicians and nurses performed a 2-step protocol consisting of the UB-2 followed in those with a positive screen result by the 3-Minute Diagnostic Assessment for the Confusion Assessment Method. Results: Delirium was diagnosed in 154 of 924 RSDAs (17%) and in 114 of 527 patients (22%). The completion rate for clinician protocols exceeded 97%. The CNAs administered the UB-2 in a mean of 62 seconds (SD, 51). The 2-step protocols were administered in means of 104 seconds (SD, 99) by nurses and 106 seconds (SD, 105) by physicians. The UB-2 had sensitivities of 88% (95% CI, 72% to 96%), 87% (CI, 73% to 95%), and 82% (CI, 65% to 91%) when administered by CNAs, nurses, and physicians, respectively, with specificities of 64% to 70%. The 2-step protocol had overall accuracy of 89% (CI, 83% to 93%) and 87% (CI, 81% to 91%), with sensitivities of 65% (CI, 48% to 79%) and 63% (CI, 46% to 77%) and specificities of 93% (CI, 88% to 96%) and 91% (CI, 86% to 95%), for nurses and physicians, respectively. Two-step protocol sensitivity for moderate to severe delirium was 78% (CI, 54% to 91%). Limitation: Two sites; limited diversity. Conclusion: An app-directed protocol for delirium identification was feasible, brief, and accurate, and CNAs and nurses performed as well as hospitalists. Primary Funding Source: National Institute on Aging.

Developing Treatment Guidelines During a Pandemic Health Crisis: Lessons Learned From COVID-19

The development of the National Institutes of Health (NIH) COVID-19 Treatment Guidelines began in March 2020 in response to a request from the White House Coronavirus Task Force. Within 4 days of the request, the NIH COVID-19 Treatment Guidelines Panel was established and the first meeting took place (virtually—as did subsequent meetings). The Panel comprises 57 individuals representing 6 governmental agencies, 11 professional societies, and 33 medical centers, plus 2 community members, who have worked together to create and frequently update the guidelines on the basis of evidence from the most recent clinical studies available. The initial version of the guidelines was completed within 2 weeks and posted online on 21 April 2020. Initially, sparse evidence was available to guide COVID-19 treatment recommendations. However, treatment data rapidly accrued based on results from clinical studies that used various study designs and evaluated different therapeutic agents and approaches. Data have continued to evolve at a rapid pace, leading to 24 revisions and updates of the guidelines in the first year. This process has provided important lessons for responding to an unprecedented public health emergency: Providers and stakeholders are eager to access credible, current treatment guidelines; governmental agencies, professional societies, and health care leaders can work together effectively and expeditiously; panelists from various disciplines, including biostatistics, are important for quickly developing well-informed recommendations; well-powered randomized clinical trials continue to provide the most compelling evidence to guide treatment recommendations; treatment recommendations need to be developed in a confidential setting free from external pressures; development of a user-friendly, web-based format for communicating with health care providers requires substantial administrative support; and frequent updates are necessary as clinical evidence rapidly emerges.

Trends in Depressive Symptoms and Associated Factors During Residency, 2007 to 2019: A Repeated Annual Cohort Study: Annals of Internal Medicine: Vol 175, No 1

Background: Efforts to address the high depression rates among training physicians have been implemented at various levels of the U.S. medical education system. The cumulative effect of these efforts is unknown. Objective: To assess how the increase in depressive symptoms with residency has shifted over time and to identify parallel trends in factors that have previously been associated with resident physician depression. Design: Repeated annual cohort study. Setting: U.S. health care organizations. Participants: First-year resident physicians (interns) who started training between 2007 and 2019. Measurements: Depressive symptoms (9-item Patient Health Questionnaire [PHQ-9]) assessed at baseline and quarterly throughout internship. Results: Among 16 965 interns, baseline depressive symptoms increased from 2007 to 2019 (PHQ-9 score, 2.3 to 2.9; difference, 0.6 [95% CI, 0.3 to 0.8]). The prevalence of baseline predictors of greater increase in depressive symptoms with internship also increased across cohorts. Despite the higher prevalence of baseline risk factors, the average change in depressive symptoms with internship decreased 24.4% from 2007 to 2019 (change in PHQ-9 score, 4.1 to 3.0; difference, −1.0 [CI, −1.5 to −0.6]). This change across cohorts was greater among women (4.7 to 3.3; difference, −1.4 [CI, −1.9 to −0.9]) than men (3.5 to 2.9; difference, −0.6 [CI, −1.2 to −0.05]) and greater among nonsurgical interns (4.1 to 3.0; difference, −1.1 [CI, −1.6 to −0.6]) than surgical interns (4.0 to 3.2; difference, −0.8 [CI, −1.2 to −0.4]). In parallel to the decrease in depressive symptom change, there were increases in sleep hours, quality of faculty feedback, and use of mental health services and a decrease in work hours across cohorts. The decrease in work hours was greater for nonsurgical than surgical interns. Further, the increase in mental health treatment across cohorts was greater for women than men. Limitation: Data are observational and subject to biases due to nonrandom sampling, missing data, and unmeasured confounders, limiting causal conclusions. Conclusion: Although depression during physician training remains high, the average increase in depressive symptoms associated with internship decreased between 2007 and 2019. Primary Funding Source: National Institute of Mental Health.

Has the Medicare Sepsis Performance Measure (SEP-1) Catalyzed Better Outcomes for Patients With Sepsis?

Trends in Outpatient Care for Medicare Beneficiaries and Implications for Primary Care, 2000 to 2019

This article has been corrected. The original version (PDF) is appended to this article as a Supplement. Background: Despite the central role of primary care in improving health system performance, there are little recent data on how use of primary care and specialists has evolved over time and its implications for the range of care coordination needed in primary care. Objective: To describe trends in outpatient care delivery and the implications for primary care provider (PCP) care coordination. Design: Descriptive, repeated, cross-sectional study using Medicare claims from 2000 to 2019, with direct standardization used to control for changes in beneficiary characteristics over time. Setting: Traditional fee-for-service Medicare. Patients: 20% sample of Medicare beneficiaries. Measurements: Annual counts of outpatient visits and procedures, the number of distinct physicians seen, and the number of other physicians seen by a PCP's assigned Medicare patients. Results: The proportion of Medicare beneficiaries with any PCP visit (66.1% in 2000 to 75.8% in 2019) or specialist visit (68.9% to 76.1%) annually increased. The mean annual number of primary care office visits per beneficiary changed little from 2009 to 2019 (3.25 to 3.48; 7.1% increase), although the mean number of PCPs seen increased from 0.96 to 1.41 (46.9% increase). In contrast, the mean annual number of visits to specialists increased 28.3% from 4.42 to 5.67, whereas the mean number of unique specialists seen increased 43.5% from 1.77 to 2.54. The proportion of beneficiaries seeing 5 or more physicians annually increased from 19.1% to 35.1%. In 2000, a PCP’s Medicare patient panel saw a median of 52 other physicians (interquartile range, 23 to 87), increasing to 95 (interquartile range, 40 to 164) in 2019. Limitation: Data were limited to Medicare beneficiaries and, because of the use of a 20% sample, may underestimate the number of other physicians seen across a PCP's entire panel. Conclusion: Outpatient care for Medicare beneficiaries has shifted toward more specialist care received from more physicians with modestly increased primary care contact. This represents a substantial expansion of the coordination burden faced by PCPs. Primary Funding Source: National Institute on Aging.

Adding a New Medication Versus Maximizing Dose to Intensify Hypertension Treatment in Older Adults: A Retrospective Observational Study: Annals of Internal Medicine: Vol 174, No 12

Background: There are 2 approaches to intensifying antihypertensive treatment when target blood pressure is not reached, adding a new medication and maximizing dose. Which strategy is better is unknown. Objective: To assess the frequency of intensification by adding a new medication versus maximizing dose, as well as the association of each method with intensification sustainability and follow-up systolic blood pressure (SBP). Design: Large-scale, population-based, retrospective cohort study. Observational data were used to emulate a target trial with 2 groups, new medication and maximizing dose, who underwent intensification of their drug regimen. Setting: Veterans Health Administration (2011 to 2013). Patients: Veterans aged 65 years or older with hypertension, an SBP of 130 mm Hg or higher, and at least 1 antihypertensive medication at less than the maximum dose. Measurements: The following 2 intensification approaches were emulated: adding a new medication, defined as a total dose increase with new medication, and maximizing dose, defined as a total dose increase without new medication. Inverse probability weighting was used to assess the observational effectiveness of the intensification approach on sustainability of intensified treatment and follow-up SBP at 3 and 12 months. Results: Among 178 562 patients, 45 575 (25.5%) had intensification by adding a new medication and 132 987 (74.5%) by maximizing dose. Compared with maximizing dose, adding a new medication was associated with less intensification sustainability (average treatment effect, −15.2% [95% CI, −15.7% to −14.6%] at 3 months and −15.1% [CI, −15.6% to −14.5%] at 12 months) but a slightly larger reduction in mean SBP (−0.8 mm Hg [CI, −1.2 to −0.4 mm Hg] at 3 months and −1.1 mm Hg [CI, −1.6 to −0.6 mm Hg] at 12 months). Limitation: Observational data; largely male population. Conclusion: Adding a new antihypertensive medication was less frequent and was associated with less intensification sustainability but slightly larger reductions in SBP. Trials would provide the most definitive support for our findings. Primary Funding Source: National Institute on Aging and Veterans Health Administration.

A Primary Care–Based Cognitive Behavioral Therapy Intervention for Long-Term Opioid Users With Chronic Pain: A Randomized Pragmatic Trial: Annals of Internal Medicine: Vol 175, No 1

Background: Chronic pain is common, disabling, and costly. Few clinical trials have examined cognitive behavioral therapy (CBT) interventions embedded in primary care settings to improve chronic pain among those receiving long-term opioid therapy. Objective: To determine the effectiveness of a group-based CBT intervention for chronic pain. Design: Pragmatic, cluster randomized controlled trial. (ClinicalTrials.gov: NCT02113592) Setting: Kaiser Permanente health care systems in Georgia, Hawaii, and the Northwest. Participants: Adults (aged ≥18 years) with mixed chronic pain conditions receiving long-term opioid therapy. Intervention: A CBT intervention teaching pain self-management skills in 12 weekly, 90-minute groups delivered by an interdisciplinary team (behaviorist, nurse, physical therapist, and pharmacist) versus usual care. Measurements: Self-reported pain impact (primary outcome, as measured by the PEGS scale [pain intensity and interference with enjoyment of life, general activity, and sleep]) was assessed quarterly over 12 months. Pain-related disability, satisfaction with care, and opioid and benzodiazepine use based on electronic health care data were secondary outcomes. Results: A total of 850 patients participated, representing 106 clusters of primary care providers (mean age, 60.3 years; 67.4% women); 816 (96.0%) completed follow-up assessments. Intervention patients sustained larger reductions on all self-reported outcomes from baseline to 12-month follow-up; the change in PEGS score was −0.434 point (95% CI, −0.690 to −0.178 point) for pain impact, and the change in pain-related disability was −0.060 point (CI, −0.084 to −0.035 point). At 6 months, intervention patients reported higher satisfaction with primary care (difference, 0.230 point [CI, 0.053 to 0.406 point]) and pain services (difference, 0.336 point [CI, 0.129 to 0.543 point]). Benzodiazepine use decreased more in the intervention group (absolute risk difference, −0.055 [CI, −0.099 to −0.011]), but opioid use did not differ significantly between groups. Limitation: The inclusion of only patients with insurance in large integrated health care systems limited generalizability, and the clinical effect of change in scores is unclear. Conclusion: Primary care–based CBT, using frontline clinicians, produced modest but sustained reductions in measures of pain and pain-related disability compared with usual care but did not reduce use of opioid medication. Primary Funding Source: National Institutes of Health.

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