Search Results for: "chronic back pain management"

Background: The physician gender wage gap may be due, in part, to productivity-based compensation models that undervalue female practice patterns. Objective: To determine how primary care physician (PCP) compensation by gender differs when applying existing productivity-based and alternative compensation models. Design: Microsimulation. Setting: 2016 to 2019 national clinical registry of 1222 primary care practices. Participants: Male and female PCPs matched on specialty, years since medical school graduation, practice site, and sessions worked. Measurements: Net annual, full-time-equivalent compensation for male versus female PCPs, under productivity-based fee-for-service, panel size–based capitation without or with risk adjustment, and hybrid payment models. Microsimulation inputs included patient and visit characteristics and overhead expenses. Results: Among 1435 matched male (n = 881) and female (n = 554) PCPs, female PCP panels included patients who were, on average, younger, had lower diagnosis-based risk scores, were more often female, and were more often uninsured or insured by Medicaid rather than by Medicare. Under productivity-based payment, female PCPs earned a median of $58 829 (interquartile range [IQR], $39 553 to $120 353; 21%) less than male PCPs. This gap was similar under capitation ($58 723 [IQR, $42 141 to $140 192]). It was larger under capitation risk-adjusted for age alone ($74 695 [IQR, $42 884 to $152 423]), for diagnosis-based scores alone ($114 792 [IQR, $49 080 to $215 326] and $89 974 [IQR, $26 175 to $173 760]), and for age-, sex-, and diagnosis-based scores ($83 438 [IQR, $28 927 to $129 414] and $66 195 [IQR, $11 899 to $96 566]). The gap was smaller and nonsignificant under capitation risk-adjusted for age and sex ($36 631 [IQR, $12 743 to $73 898]). Limitation: Panel attribution based on office visits. Conclusion: The gender wage gap varied by compensation model, with capitation risk-adjusted for patient age and sex resulting in a smaller gap. Future models might better align with primary care effort and outcomes. Primary Funding Source: None.

A Framework for the Development of Living Practice Guidelines in Health Care

Background: Living practice guidelines are increasingly being used to ensure that recommendations are responsive to rapidly emerging evidence. Objective: To develop a framework that characterizes the processes of development of living practice guidelines in health care. Design: First, 3 background reviews were conducted: a scoping review of methods papers, a review of handbooks of guideline-producing organizations, and an analytic review of selected living practice guidelines. Second, the core team drafted the first version of the framework. Finally, the core team refined the framework through an online survey and online discussions with a multidisciplinary international group of stakeholders. Setting: International. Participants: Multidisciplinary group of 51 persons who have experience with guidelines. Measurements: Not applicable. Results: A major principle of the framework is that the unit of update in a living guideline is the individual recommendation. In addition to providing definitions, the framework addresses several processes. The planning process should address the organization's adoption of the living methodology as well as each specific guideline project. The production process consists of initiation, maintenance, and retirement phases. The reporting should cover the evidence surveillance time stamp, the outcome of reassessment of the body of evidence (when applicable), and the outcome of revisiting a recommendation (when applicable). The dissemination process may necessitate the use of different venues, including one for formal publication. Limitation: This study does not provide detailed or practical guidance for how the described concepts would be best implemented. Conclusion: The framework will help guideline developers in planning, producing, reporting, and disseminating living guideline projects. It will also help research methodologists study the processes of living guidelines. Primary Funding Source: None.

Prescribing Nirmatrelvir–Ritonavir: How to Recognize and Manage Drug–Drug Interactions

Risks for Anaphylaxis With Intravenous Iron Formulations: A Retrospective Cohort Study: Annals of Internal Medicine: Vol 175, No 5

Background: The risks for anaphylaxis among intravenous (IV) iron products currently in use have not been assessed. Objective: To compare risks for anaphylaxis among 5 IV iron products that are used frequently. Design: Retrospective cohort study using a target trial emulation framework. Setting: Medicare fee-for-service data with Part D coverage between July 2013 and December 2018. Participants: Older adults receiving their first administration of IV iron. Measurements: The primary outcome was the occurrence of anaphylaxis within 1 day of IV iron administration, ascertained using a validated case definition. Analysis was adjusted for 40 baseline covariates using inverse probability of treatment weighting. The adjusted incidence rates (IRs) for anaphylaxis per 10 000 first administrations and odds ratios (ORs) were computed. Results: The adjusted IRs for anaphylaxis per 10 000 first administrations were 9.8 cases (95% CI, 6.2 to 15.3 cases) for iron dextran, 4.0 cases (CI, 2.5 to 6.6 cases) for ferumoxytol, 1.5 cases (CI, 0.3 to 6.6 cases) for ferric gluconate, 1.2 cases (CI, 0.6 to 2.5 cases) for iron sucrose, and 0.8 cases (CI, 0.3 to 2.6 cases) for ferric carboxymaltose. Using iron sucrose as the referent category, the adjusted ORs for anaphylaxis were 8.3 (CI, 3.5 to 19.8) for iron dextran and 3.4 (CI, 1.4 to 8.3) for ferumoxytol. When cohort entry was restricted to the period after withdrawal of high-molecular-weight iron dextran from the U.S. market in 2014, the risk for anaphylaxis associated with low-molecular-weight iron dextran (OR, 8.4 [CI, 2.8 to 24.7]) did not change appreciably. Anaphylactic reactions requiring hospitalizations were observed only among patients using iron dextran or ferumoxytol. Limitation: Generalizability to non-Medicare populations. Conclusion: The rates of anaphylaxis were very low with all IV iron products but were 3- to 8-fold greater for iron dextran and ferumoxytol than for iron sucrose. Primary Funding Source: None.

Historically High Excess Mortality During the COVID-19 Pandemic in Switzerland, Sweden, and Spain

Background: Excess mortality quantifies the overall mortality impact of a pandemic. Mortality data have been accessible for many countries in recent decades, but few continuous data have been available for longer periods. Objective: To assess the historical dimension of the COVID-19 pandemic in 2020 for 3 countries with reliable death count data over an uninterrupted span of more than 100 years. Design: Observational study. Setting: Switzerland, Sweden, and Spain, which were militarily neutral and not involved in combat during either world war and have not been affected by significant changes in their territory since the end of the 19th century. Participants: Complete populations of these 3 countries. Measurements: Continuous series of recorded deaths (from all causes) by month from the earliest available year (1877 for Switzerland, 1851 for Sweden, and 1908 for Spain) were jointly modeled with annual age group–specific death and total population counts using negative binomial and multinomial models, which accounted for temporal trends and seasonal variability of prepandemic years. The aim was to estimate the expected number of deaths in a pandemic year for a nonpandemic scenario and the difference in observed and expected deaths aggregated over the year. Results: In 2020, the number of excess deaths recorded per 100 000 persons was 100 (95% credible interval [CrI], 60 to 135) for Switzerland, 75 (CrI, 40 to 105) for Sweden, and 155 (CrI, 110 to 195) for Spain. In 1918, excess mortality was 6 to 7 times higher. In all 3 countries, the peaks of monthly excess mortality in 2020 were greater than most monthly excess mortality since 1918, including many peaks due to seasonal influenza and heat waves during that period. Limitation: Historical vital statistics might be affected by minor completeness issues before the beginning of the 20th century. Conclusion: In 2020, the COVID-19 pandemic led to the second-largest infection-related mortality disaster in Switzerland, Sweden, and Spain since the beginning of the 20th century. Primary Funding Source: Foundation for Research in Science and the Humanities at the University of Zurich, Swiss National Science Foundation, and National Institute of Allergy and Infectious Diseases.

Estimation of Breast Cancer Overdiagnosis in a U.S. Breast Screening Cohort

Background: Mammography screening can lead to overdiagnosis—that is, screen-detected breast cancer that would not have caused symptoms or signs in the remaining lifetime. There is no consensus about the frequency of breast cancer overdiagnosis. Objective: To estimate the rate of breast cancer overdiagnosis in contemporary mammography practice accounting for the detection of nonprogressive cancer. Design: Bayesian inference of the natural history of breast cancer using individual screening and diagnosis records, allowing for nonprogressive preclinical cancer. Combination of fitted natural history model with life-table data to predict the rate of overdiagnosis among screen-detected cancer under biennial screening. Setting: Breast Cancer Surveillance Consortium (BCSC) facilities. Participants: Women aged 50 to 74 years at first mammography screen between 2000 and 2018. Measurements: Screening mammograms and screen-detected or interval breast cancer. Results: The cohort included 35 986 women, 82 677 mammograms, and 718 breast cancer diagnoses. Among all preclinical cancer cases, 4.5% (95% uncertainty interval [UI], 0.1% to 14.8%) were estimated to be nonprogressive. In a program of biennial screening from age 50 to 74 years, 15.4% (UI, 9.4% to 26.5%) of screen-detected cancer cases were estimated to be overdiagnosed, with 6.1% (UI, 0.2% to 20.1%) due to detecting indolent preclinical cancer and 9.3% (UI, 5.5% to 13.5%) due to detecting progressive preclinical cancer in women who would have died of an unrelated cause before clinical diagnosis. Limitations: Exclusion of women with first mammography screen outside BCSC. Conclusion: On the basis of an authoritative U.S. population data set, the analysis projected that among biennially screened women aged 50 to 74 years, about 1 in 7 cases of screen-detected cancer is overdiagnosed. This information clarifies the risk for breast cancer overdiagnosis in contemporary screening practice and should facilitate shared and informed decision making about mammography screening. Primary Funding Source: National Cancer Institute.

When Only Words Are Left

How Would You Manage This Male Patient With Hypogonadism?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 174, No 8

Male hypogonadism is defined as an abnormally low serum testosterone concentration or sperm count. As men age, often in the context of obesity and other comorbid conditions, serum testosterone levels may decrease. Normalizing serum testosterone levels in male adults with hypogonadism may improve symptoms related to androgen deficiency, but controversies exist regarding the long-term benefits and risks of hormone supplementation in this setting. In 2020, the American College of Physicians published a clinical guideline for the use of testosterone supplementation in adult men based on a systematic review of available evidence. Among their recommendations were that clinicians discuss whether to initiate testosterone treatment in men with age-related low testosterone with sexual dysfunction who want to improve sexual function and not initiate testosterone treatment in men with age-related low testosterone to improve energy, vitality, physical function, or cognition. Here, two clinicians with expertise in this area, one a generalist and the other an endocrinologist, debate the management of a patient with sexual symptoms and a low serum testosterone level. They discuss the diagnosis of male hypogonadism, the indications for testosterone therapy, its potential benefits and risks, how it should be monitored, and how long it should be continued.

Comparative Effectiveness of an Automated Text Messaging Service for Monitoring COVID-19 at Home

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.

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.

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