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Displaying 381 - 390 of 1307 in Annals of Internal Medicine
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Comparison of Initial Artificial Intelligence (AI) and Final Physician Recommendations in AI-Assisted Virtual Urgent Care Visits
Background: Whether artificial intelligence (AI) assistance is associated with quality of care is uncertain. Objective: To compare initial AI recommendations with final recommendations of physicians who had access to the AI recommendations and may or may not have viewed them. Design: Retrospective cohort study. Setting: Cedars-Sinai Connect, an AI-assisted virtual urgent care clinic with intake questions via structured chat. When confidence is sufficient, AI presents diagnosis and management recommendations (prescriptions, laboratory tests, and referrals). Patients: 461 physician-managed visits with AI recommendations of sufficient confidence and complete medical records for adults with respiratory, urinary, vaginal, eye, or dental symptoms from 12 June to 14 July 2024. Measurements: Concordance of diagnosis and management recommendations of initial AI recommendations and final physician recommendations. Physician adjudicators scored all nonconcordant and a sample of concordant recommendations as optimal, reasonable, inadequate, or potentially harmful. Results: Initial AI and final physician recommendations were concordant for 262 visits (56.8%). Among the 461 weighted visits, AI recommendations were more frequently rated as optimal (77.1% [95% CI, 72.7% to 80.9%]) compared with treating physician decisions (67.1% [CI, 62.9% to 71.1%]). Quality scores were equal in 67.9% (CI, 64.8% to 70.9%) of cases, better for AI in 20.8% (CI, 17.8% to 24.0%), and better for treating physicians in 11.3% (CI, 9.0% to 14.2%), respectively. Limitations: Single-center retrospective study. Adjudicators were not blinded to the source of recommendations. It is unknown whether physicians viewed AI recommendations. Conclusion: When AI and physician recommendations differed, AI recommendations were more often rated better quality. Findings suggest that AI performed better in identifying critical red flags and supporting guideline-adherent care, whereas physicians were better at adapting recommendations to changing information during consultations. Thus, AI may have a role in assisting physician decision making in virtual urgent care. Primary Funding Source: K Health.
How Would You Manage This Patient With Gastroesophageal Reflux Symptoms? Grand Rounds Discussion From Beth Israel Deaconess Medical Center
Gastroesophageal reflux disease (GERD) is a common medical condition presenting with heartburn, regurgitation, cough, hoarseness, and/or wheezing. Patients with classic GERD symptoms often do not require diagnostic studies before empirical treatment is initiated. However, if atypical features are present, including alarm symptoms for malignancy, or if symptoms do not respond to conventional treatment, upper endoscopy may be necessary. The optimal management of GERD, which is the subject of debate, depends on the frequency and severity of symptoms. In 2021, the American College of Gastroenterology published updated recommendations for diagnosis and management of GERD. In addition to histamine-2 receptor antagonist or proton-pump inhibitor therapy, which may be prescribed as needed or continuously, lifestyle and dietary modification are often advised. Here, 2 physicians, a primary care practitioner and a gastroenterologist, debate how to manage a patient with GERD symptoms. They discuss the diagnosis of this condition, its initial management, indications for upper endoscopy, and how to care for the patient whose condition does not respond to empirical therapy.
Incorporating Economic Evidence in Clinical Guidelines: A Framework From the Clinical Guidelines Committee of the American College of Physicians
In recognition of accelerating health care spending and alignment with the American College of Physicians (ACP) principles of promoting high-value care, the ACP Clinical Guidelines Committee (CGC) developed a framework to standardize its approach to identifying, appraising, and considering economic evidence in the development of ACP clinical guidelines. This article presents the CGC’s process for incorporating economic evidence, which encompasses cost-effectiveness analyses, economic outcomes in randomized controlled trials, and resource utilization (intervention cost) data. Economic evidence is one component of ACP recommendations. The CGC first and foremost assesses the certainty of evidence for clinical net benefit of interventions; it then considers patient values and preferences, and only then considers economic evidence to develop recommendations.
How Would You Manage This Patient With Obesity? Grand Rounds Discussion From Beth Israel Deaconess Medical Center
In 2022, 1 in 8 people in the world were living with obesity, and lifestyle interventions that include diet, exercise, and behavioral modification have been the foundation for management of obesity. Recently, pharmacologic therapies have been developed for management of obesity, the newest of these being glucagon-like peptide 1 receptor agonists. With the development of new pharmacologic options, the American Gastroenterological Association developed a guideline in 2022 to provide evidence-based recommendations for the pharmacologic management of obesity in adults and recommended, for adults with obesity or overweight with weight-related complications who have had an inadequate response to lifestyle interventions, adding pharmacologic agents to lifestyle interventions over continuing lifestyle interventions alone. In this article, 2 experts review the available evidence to answer the following questions: How effective are lifestyle interventions for the treatment of obesity? How effective are pharmacologic interventions for the treatment of obesity? Given these options, how do you engage in a shared decision-making discussion to develop a mutually agreed-on treatment plan?
Effectiveness of Synchronous Postdischarge Contacts on Health Care Use and Patient Satisfaction: A Systematic Review and Meta-analysis: Annals of Internal Medicine: Vol 178, No 2
Background: Postdischarge contacts (PDCs) after hospitalization are common practice, but their effectiveness in reducing use of acute care after discharge remains unclear. Purpose: To assess the effects of PDC on 30-day emergency department (ED) visits, 30-day hospital readmissions, and patient satisfaction. Data Sources: MEDLINE, Embase, and CINAHL searched from 2012 to 25 May 2023. Study Selection: Randomized and nonrandomized trials of PDC within 7 days. Data Extraction: Two investigators independently screened articles and assessed risk of bias (ROB). Single reviewers extracted data, with verification by second investigators. Random-effects meta-analyses were done on outcomes shared by at least 3 studies, and the certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. Data Synthesis: Of 13 included studies (11 randomized trials [RTs]), 12 delivered PDCs via telephone. Three of 11 RTs were rated as having low ROB, with 1 rated high. Most PDC interventions (n = 10) consisted of single telephone contacts, often within 3 days. Eight studies focused on patients identified as higher-risk by the authors. There were no differences in 30-day ED use (5 RTs; 3054 patients; risk difference, 0.00 [95% CI, −0.02 to 0.03]; moderate certainty) or 30-day hospital readmissions (7 RTs; 7075 patients; risk difference, 0.00 [CI, −0.02 to 0.02]; moderate certainty) with PDC. Limitation: Adherence and fidelity to PDC interventions were poorly described, and only 1 study investigated nontelephone PDC. Conclusion: Postdischarge contacts within 7 days of discharge were not associated with reductions in 30-day ED use or readmissions compared with usual care. Health systems should reconsider the utility of universal PDCs because multifaceted interventions targeting higher-risk patients may be necessary to reduce use of acute care after discharge. Primary Funding Source: Department of Veterans Affairs. (PROSPERO: CRD42023465675)
How Would You Treat This Inpatient With Type 2 Diabetes Mellitus? Grand Rounds Discussion From Beth Israel Deaconess Medical Center
Management of hospitalized patients with type 2 diabetes mellitus (T2DM) presents unique challenges. Two recently released guidelines, one from the American Diabetes Association and the other from the Endocrine Society, provide useful recommendations and evidence review to inform the care of medical inpatients with T2DM. These guidelines mostly agree, although there are slight differences in their recommendations. In these rounds, 2 expert diabetologists discuss their approach to inpatient management of T2DM, specifically regarding inpatient glycemic goals on the medical ward, the use of noninsulin antihyperglycemic medications, and patient safety strategies for patients receiving long-acting insulin. They conclude with recommendations for Mr. D, a real patient with T2DM admitted with a recurrent foot infection.
Association of Work Control With Burnout and Career Intentions Among U.S. Physicians: A Multi-institution Study: Annals of Internal Medicine: Vol 178, No 1
Background: Physician control over their clinical work is hypothesized to be associated with both burnout and career intentions. Objective: To assess the association of perceived work control with burnout and career intentions. Design: A multi-institution study. Setting: Cross-sectional survey. Participants: A sample of U.S. physicians between November 2022 and December 2023. Measurements: A novel multicomponent measure of work control, Mini-Z single-item burnout measure, intent to reduce clinical hours (ITR), and intent to leave the current practice. Results: Among respondents, 61.4% (1318 of 2144) reported adequate control over patient load, 60.6% (1301 of 2144) adequate control over membership of their clinical team, and 61.3% (1434 of 2339) adequate control over workload. Adequate control over hiring of staff and clinical schedule were reported by 49.0% (772 of 1574) and 74.6% (1175 of 1574), respectively. Most respondents (58.3% [692 of 1186]) reported that they had sufficient authority/autonomy over that for which they are accountable. On multivariable analyses adjusting for personal and professional characteristics, poor control over patient load, team composition, clinical schedule, domains for which the physician is accountable, and workload were independently associated with burnout. Poor control over patient load and workload were each independently associated with ITR. Limitation: This is a cross-sectional study, so causation cannot be determined, and it is a convenience sample of practices with more than 100 physicians, so it may not be representative of all U.S. physicians. Conclusion: In this large, cross-sectional study, poor control over specific aspects of work was associated with burnout and intentions to reduce clinical effort or leave one’s organization. Efforts to reduce burnout and improve retention should consider how to provide physician control over appropriate aspects of their clinical work environment. Primary Funding Source: American Medical Association.
Comparison of Semaglutide or Dulaglutide Versus Empagliflozin for Risk for Death and Cardiovascular Outcomes Among Patients With Type 2 Diabetes: Two Target Trial Emulation Studies: Annals of Internal Medicine: Vol 178, No 7
Background: Reduction of premature death and adverse cardiovascular outcomes is a key goal in type 2 diabetes management. Objective: To compare mortality and cardiovascular event risks in patients treated with semaglutide versus empagliflozin and, secondarily, dulaglutide versus empagliflozin. Design: Target trial emulation studies from observational data comparing semaglutide- or dulaglutide-treated patients with propensity score–matched patients treated with empagliflozin. Setting: Health care system of 703 academic and community clinical practices. Participants: Patients aged 45 years or older with type 2 diabetes treated from 1 January 2019 to 31 December 2024 with semaglutide, dulaglutide, or empagliflozin. Intervention: Initial treatment with semaglutide, dulaglutide, or empagliflozin. At baseline, concomitant treatment with other diabetes medication was permitted, excluding other glucagon-like peptide-1 receptor agonists or sodium–glucose cotransporter-2 inhibitors. Measurements: A composite of death, myocardial infarction (MI), or stroke was the primary outcome, and secondary composite outcomes included death or MI, MI or stroke, and individual cardiac events. Results: Patients treated with semaglutide (n = 7899) versus empagliflozin (n = 7899) were followed for a median of 2.2 years; the respective rates of the composite of death, MI, or stroke were 3.7% versus 4.5% at 2 years and 5.9% versus 6.9% at 3 years. Corresponding incidence rates for the composite outcome were 20.99 versus 23.56 per 1000 person-years, with a hazard ratio (HR) of 0.89 (95% CI, 0.78 to 1.02). The HRs for the individual outcomes were 0.97 (CI, 0.81 to 1.15) for death, 0.85 (CI, 0.68 to 1.05) for MI, and 0.62 (CI, 0.43 to 0.89) for stroke. Risks for dulaglutide- and empagliflozin-treated patients were similar for the composite outcome (HR, 1.03 [CI, 0.90 to 1.16]) and for death, MI, and stroke separately. Limitation: Observational study design, lack of data on cause-specific mortality, and residual confounding. Conclusion: Semaglutide treatment seems to confer some advantage over empagliflozin. This advantage was not observed for dulaglutide. Primary Funding Source: American Heart Association.
Assessing the Risk for Falls in Older Adults After Initiating Gabapentin Versus Duloxetine
Background: The evidence informing the harms of gabapentin use are at risk of bias from comparing users with nonusers. Objective: To describe the risk for fall-related outcomes in older adults starting treatment with gabapentin versus duloxetine. Design: New user, active comparator study using a target trial emulation framework. Setting: MarketScan (IBM) commercial claims between January 2014 and December 2021. Participants: Adults aged 65 years or older with diabetic neuropathy, postherpetic neuralgia, or fibromyalgia and without depression, anxiety, seizures, or cancer in the 365 days before cohort entry. Intervention: New initiation of treatment with gabapentin or duloxetine (comparator). Measurements: The primary outcome was the hazard of experiencing any fall-related visit in the 6 months after initiating gabapentin or duloxetine until discontinuation of treatment. Secondary outcomes were hazard of severe fall-related events defined as a fall associated with hip fracture or emergency department visit or hospitalization associated with a fall. Stabilized inverse probability of treatment weighting was used to adjust for baseline characteristics. Results: Our analytic cohort included 57 086 older adults with a diagnosis of interest initiating treatment with gabapentin (n = 52 152) or duloxetine (n = 4934). Overall median follow-up duration was 30 days (IQR, 30 to 90 days). Weighted cumulative incidence of a fall-related visit per 1000 person-years at 30, 90, and 180 days was 103.60, 90.44, and 84.44 for gabapentin users and 203.43, 177.73, and 158.21 for duloxetine users, respectively. At 6-month follow-up, incident gabapentin users had lower hazard of falls (hazard ratio, 0.52 [95% CI, 0.43 to 0.64]), but there was no difference in the hazards of experiencing severe falls. Results were similar across sensitivity and subgroup analyses. Limitation: Claims may contain fewer frail adults and undercount falls. Conclusion: Compared with incident use of duloxetine, incident use of gabapentin was not associated with increased fall-related visits. Primary Funding Source: None.
Clinical Tools to Assess Functional Capacity During Risk Assessment Before Elective Noncardiac Surgery: A Scoping Review: Annals of Internal Medicine: Vol 178, No 1
Background: Functional capacity is critical to preoperative risk assessment, yet guidance on its measurement in clinical practice remains lacking. Purpose: To identify functional capacity assessment tools studied before surgery and characterize the extent of evidence regarding performance, including in populations where assessment is confounded by noncardiopulmonary reasons. Data Sources: MEDLINE, EMBASE, and EBM Reviews (until July 2024). Study Selection: Studies evaluating performance of functional capacity assessment tools administered before elective noncardiac surgery to stratify risk for postoperative outcomes. Data Extraction: Study details, measurement properties, pragmatic qualities, and/or clinical utility metrics. Data Synthesis: 6 categories of performance-based tests and 5 approaches using patient-reported exercise tolerance were identified. Cardiopulmonary exercise testing (CPET) was the most studied tool (132 studies, 32 662 patients) followed by field walking tests (58 studies, 9393 patients) among performance-based tests. Among patient-reported assessments, the Duke Activity Status Index (14 studies, 3303 patients) and unstructured assessments (19 studies, 28 520 patients) were most researched. Most evidence focused on predictive validity (92% of studies), specifically accuracy in predicting cardiorespiratory complications. Several tools lacked evidence on reliability (test consistency across similar measurements), pragmatic qualities (feasibility of implementation), or concurrent criterion validity (correlation to gold standard). Only CPET had evidence on clinical utility (whether administration improved postoperative outcomes). Older adults (≥65 years) were well represented across studies, whereas there were minimal data in patients with obesity, lower-limb arthritis, and disability. Limitation: Synthesis focused on reported data without requesting missing information. Conclusion: Though several tools for preoperative functional capacity assessment have been studied, research has overwhelmingly focused on CPET and only 1 aspect of validity (predictive validity). Important evidence gaps remain among vulnerable populations with obesity, arthritis, and physical disability. Primary Funding Source: None. (Open Science Framework: https://osf.io/ah7u5)