Bringing the Team to the Video Visit: Best Practices and Practical Solutions

Make telemedicine more satisfying and effective for patients and physicians by mobilizing your practice team.

Telemedicine 201 Education Program: Moving Beyond Adoption to Optimal Integration Into Practice

Expand your skills and learn from experienced telemedicine educators in this series of free, one-hour webinars. Webinars will be recorded and reproduced as enduring material on this site after each event. Video Visits Beyond Simple Cases Watch the webinar (in short segments), and access video demonstrations of remote physical exam techniques from Johns Hopkins. Watch Videos

Remote Patient Monitoring | ACP

Patients with chronic medical conditions may benefit from remote patient monitoring. Learn how you can implement remote monitoring of your patients here.

ORCHA’s Assessment Process

Baseline AssessmentThe ORCHA Assessment Development Team have translated the DHAF evaluation criteria into a set of 350 objective questions that trained ORCHA Assessors are looking to answer. Questions are scored, earning the app positive points or negative points depending on the nature of the question and the response. Each Review Domain (set of questions) produces a Domain score. These Review Domain scores are then combined to create an overall DHAF percentage score.

About the Digital Health Assessment Framework (DHAF)

Seeking a common framework for assessing apps.

Library of Digital Health Apps for Patients

Are you keeping up with your patients’ interests in using digital health apps to monitor and manage chronic conditions and health? Recent surveys show 35-40% of adults use phone or tablet apps to manage their health.

Telehealthcare Guidance and Resources | Business Resources | ACP

ACP supports physicians use of telehealth to provide care to their patients from anywhere. Learn if it will work for your practice and the regulations here.

The Importance of Value Based Care

Success Story: Strategies to Reduce Inappropriate Antibiotic Prescribing

Success Story: Building a Team-based Care Approach

Epidemiology of Homebound Population Among Beneficiaries of a Large National Medicare Advantage Plan

Background: Interest in home-based care is increasing among Medicare Advantage (MA) plans. The epidemiology of homebound MA beneficiaries is unknown. Objective: To determine the prevalence, characteristics, predictors, health service use, and mortality outcomes of homebound beneficiaries of a large national MA plan. Design: Cross-sectional. Setting: National MA plan. Participants: Humana MA beneficiaries in 2022 (n = 2 435 519). Measurements: Homebound status was assessed via in-home assessment using previously defined categories: homebound (never or rarely left home in the past month), semihomebound (left home with assistance, had difficulty, or needed help leaving home), and not homebound. Demographic, clinical, health service use, and mortality outcomes were compared by homebound status. Results: In 2022, the overall prevalence of homebound beneficiaries was 22.0% (8.4% of beneficiaries were homebound, and 13.6% were semihomebound). In adjusted models, female sex (odds ratio [OR], 1.36 [95% CI, 1.35 to 1.37), low-income status or dual eligibility for Medicare and Medicaid (OR, 1.56 [CI, 1.55 to 1.57]), dementia (OR, 2.36 [CI, 2.33 to 2.39]), and moderate to severe frailty (OR, 4.32 [CI, 4.19 to 4.45]) were predictive of homebound status. In multivariable logistic regression, homebound status was associated with increased odds of any emergency department visit (OR, 1.14 [ CI, 1.14 to 1.15]), any inpatient hospital admission (OR, 1.44 [CI, 1.42 to 1.46]), any skilled-nursing facility admission (OR, 2.18 [CI, 2.13 to 2.23]), and death (OR, 2.55 [CI, 2.52 to 2.58]). Limitation: The study period overlapped the tail end of the COVID-19 pandemic, and data were derived from a single national MA plan, which limits generalizability. Conclusion: Overall homebound prevalence in a national MA plan was 22.0% and was independently associated with increased health service use and mortality. Study findings can inform strategic initiatives to identify and manage care for homebound beneficiaries. Primary Funding Source: Humana, under a collaborative research agreement with Johns Hopkins University.

Benefits and Risks Associated With Statin Therapy for Primary Prevention in Old and Very Old Adults: Real-World Evidence From a Target Trial Emulation Study: Annals of Internal Medicine: Vol 177, No 6

Background: There is little consensus on using statins for primary prevention of cardiovascular diseases (CVDs) and all-cause mortality in adults aged 75 years or older due to the underrepresentation of this population in randomized controlled trials. Objective: To investigate the benefits and risks of using statins for primary prevention in old (aged 75 to 84 years) and very old (aged ≥85 years) adults. Design: Sequential target trial emulation comparing matched cohorts initiating versus not initiating statin therapy. Setting: Territory-wide public electronic medical records in Hong Kong. Participants: Persons aged 75 years or older who met indications for statin initiation from January 2008 to December 2015 were included. Participants with preexisting diagnosed CVDs at baseline, such as coronary heart disease (CHD), were excluded from the analysis. Among 69 981 eligible persons aged 75 to 84 years and 14 555 persons aged 85 years or older, 41 884 and 9457 had history of CHD equivalents (for example, diabetes) in the respective age groups. Intervention: Initiation of statin therapy. Measurements: Incidence of major CVDs (stroke, myocardial infarction, or heart failure), all-cause mortality, and major adverse events (myopathies and liver dysfunction). Results: Of 42 680 matched person-trials aged 75 to 84 years and 5390 matched person-trials aged 85 years or older (average follow-up, 5.3 years), 9676 and 1600 of them developed CVDs in each age group, respectively. Risk reduction for overall CVD incidence was found for initiating statin therapy in adults aged 75 to 84 years (5-year standardized risk reduction, 1.20% [95% CI, 0.57% to 1.82%] in the intention-to-treat [ITT] analysis; 5.00% [CI, 1.11% to 8.89%] in the per protocol [PP] analysis) and in those aged 85 years or older (ITT: 4.44% [CI, 1.40% to 7.48%]; PP: 12.50% [CI, 4.33% to 20.66%]). No significantly increased risks for myopathies and liver dysfunction were found in both age groups. Limitation: Unmeasured confounders, such as lifestyle factors of diet and physical activity, may exist. Conclusion: Reduction for CVDs after statin therapy were seen in patients aged 75 years or older without increasing risks for severe adverse effects. Of note, the benefits and safety of statin therapy were consistently found in adults aged 85 years or older. Primary Funding Source: Health Bureau, the Government of Hong Kong Special Administrative Region, China, and National Natural Science Foundation of China.

Trends and Disparities in Ambulatory Follow-Up After Cardiovascular Hospitalizations: A Retrospective Cohort Study: Annals of Internal Medicine: Vol 177, No 9

Background: Timely follow-up after cardiovascular hospitalization is recommended to monitor recovery, titrate medications, and coordinate care. Objective: To describe trends and disparities in follow-up after acute myocardial infarction (AMI) and heart failure (HF) hospitalizations. Design: Retrospective cohort study. Setting: Medicare. Participants: Medicare fee-for-service beneficiaries hospitalized between 2010 and 2019. Measurements: Receipt of a cardiology visit within 30 days of discharge. Multivariable logistic regression models were used to estimate changes over time overall and across 5 sociodemographic characteristics on the basis of known disparities in cardiovascular outcomes. Results: The cohort included 1 678 088 AMI and 4 245 665 HF hospitalizations. Between 2010 and 2019, the rate of cardiology follow-up increased from 48.3% to 61.4% for AMI hospitalizations and from 35.2% to 48.3% for HF hospitalizations. For both conditions, follow-up rates increased for all subgroups, yet disparities worsened for Hispanic patients with AMI and patients with HF who were Asian, Black, Hispanic, Medicaid dual eligible, and residents of counties with higher levels of social deprivation. By 2019, the largest disparities were between Black and White patients (AMI, 51.9% vs. 59.8%, difference, 7.9 percentage points [pp] [95% CI, 6.8 to 9.0 pp]; HF, 39.8% vs. 48.7%, difference, 8.9 pp [CI, 8.2 to 9.7 pp]) and Medicaid dual-eligible and non–dual-eligible patients (AMI, 52.8% vs. 60.4%, difference, 7.6 pp [CI, 6.9 to 8.4 pp]; HF, 39.7% vs. 49.4%, difference, 9.6 pp [CI, 9.2 to 10.1 pp]). Differences between hospitals explained 7.3 pp [CI, 6.7 to 7.9 pp] of the variation in follow-up for AMI and 7.7 pp [CI, 7.2 to 8.1 pp]) for HF. Limitation: Generalizability to other payers. Conclusion: Equity-informed policy and health system strategies are needed to further reduce gaps in follow-up care for patients with AMI and patients with HF. Primary Funding Source: National Institute on Aging.

Understanding How Older Adults Use the U.S. Health Care System: From Measurement to Meaning

Quality Health Communication Is Critical to Optimal Adult Immunization

Beyond One-Size-Fits-All: Testing Insomnia Treatments in Special Populations

Excessive Alcohol Use and Alcohol Use Disorders: A Policy Brief of the American College of Physicians

Alcohol is used by more people in the United States than tobacco, electronic nicotine delivery systems, or illicit drugs. Several health conditions, including cancer, cardiovascular disease, and liver disease, are associated with excessive alcohol use and alcohol use disorder. Nearly 30 million people aged 12 years or older in the United States reported past-year alcohol use disorder in 2022, but—despite its prevalence—alcohol use disorder is undertreated. In this policy brief, the American College of Physicians outlines the health effects of excessive alcohol use and alcohol use disorder, calls for policy changes to increase the availability of treatment of alcohol use disorder and excessive alcohol use, and recommends alcohol-related public health interventions.

Diagnostic Strategy Using Color Doppler Ultrasound of Temporal Arteries in Patients With High Clinical Suspicion of Giant Cell Arteritis: A Prospective Cohort Study: Annals of Internal Medicine: Vol 177, No 6

Background: Giant cell arteritis (GCA) is the most prevalent systemic vasculitis in people older than 50 years. Any delay in diagnosis impairs patients' quality of life and can lead to permanent damage, particularly vision loss. Objective: To evaluate a diagnostic strategy for GCA using color Doppler ultrasound of the temporal artery as a first-line diagnostic test, temporal artery biopsy (TAB) as a secondary test, and physician expertise as the reference method. Design: Prospective multicenter study with a 2-year follow-up. (ClinicalTrials.gov: NCT02703922) Setting: Patients were referred by their general practitioner or ophthalmologist to a physician with extensive experience in GCA diagnosis and management in one of the participating centers: 4 general and 2 university hospitals. Patients: 165 patients with high clinical suspicion of GCA, aged 79 years (IQR, 73 to 85 years). Intervention: The diagnostic procedure was ultrasound, performed less than 7 days after initiation of corticosteroid therapy. Only ultrasound-negative patients underwent TAB. Measurements: Bilateral temporal halo signs seen on ultrasound were considered positive. Ultrasound and TAB results were compared with physician-diagnosed GCA based on clinical findings and other imaging. Results: Diagnosis of GCA was confirmed in 44%, 17%, and 21% of patients by ultrasound, TAB, and clinical expertise and/or other imaging tests, respectively. Their diagnosis remained unchanged at 1 month, and 2 years for those with available follow-up data. An alternative diagnosis was made in 18% of patients. The proportion of ultrasound-positive patients among patients with a clinical GCA diagnosis was 54% (95% CI, 45% to 62%). Limitation: Small sample size, no blinding of ultrasound and TAB results, lack of an objective gold-standard comparator, and single diagnostic strategy. Conclusion: By using ultrasound of the temporal arteries as a first-line diagnostic tool in patients with high clinical suspicion of GCA, further diagnostic tests for patients with positive ultrasound were avoided. Primary Funding Source: Tender “Recherche CH-CHU Poitou-Charentes 2014.”

Weighing In on the Body Mass Index: Addressing Criticisms and Embracing Purpose

Sensitivity and Specificity of Using GPT-3.5 Turbo Models for Title and Abstract Screening in Systematic Reviews and Meta-analyses

Background: Systematic reviews are performed manually despite the exponential growth of scientific literature. Objective: To investigate the sensitivity and specificity of GPT-3.5 Turbo, from OpenAI, as a single reviewer, for title and abstract screening in systematic reviews. Design: Diagnostic test accuracy study. Setting: Unannotated bibliographic databases from 5 systematic reviews representing 22 665 citations. Participants: None. Measurements: A generic prompt framework to instruct GPT to perform title and abstract screening was designed. The output of the model was compared with decisions from authors under 2 rules. The first rule balanced sensitivity and specificity, for example, to act as a second reviewer. The second rule optimized sensitivity, for example, to reduce the number of citations to be manually screened. Results: Under the balanced rule, sensitivities ranged from 81.1% to 96.5% and specificities ranged from 25.8% to 80.4%. Across all reviews, GPT identified 7 of 708 citations (1%) missed by humans that should have been included after full-text screening at the cost of 10 279 of 22 665 false-positive recommendations (45.3%) that would require reconciliation during the screening process. Under the sensitive rule, sensitivities ranged from 94.6% to 99.8% and specificities ranged from 2.2% to 46.6%. Limiting manual screening to citations not ruled out by GPT could reduce the number of citations to screen from 127 of 6334 (2%) to 1851 of 4077 (45.4%), at the cost of missing from 0 to 1 of 26 citations (3.8%) at the full-text level. Limitations: Time needed to fine-tune prompt. Retrospective nature of the study, convenient sample of 5 systematic reviews, and GPT performance sensitive to prompt development and time. Conclusion: The GPT-3.5 Turbo model may be used as a second reviewer for title and abstract screening, at the cost of additional work to reconcile added false positives. It also showed potential to reduce the number of citations before screening by humans, at the cost of missing some citations at the full-text level. Primary Funding Source: None.

MKSAP Quiz: Evaluation in the emergency department after chest discomfort

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Adding heart failure to chronic kidney disease affects transition to dialysis

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Observation stay patients more likely to return to hospital than admitted ones | ACP Hospitalist

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For BSI, seven days of antibiotics noninferior to 14 days, even in ICU patients | ACP Hospitalist

Pericardial Abscess in an Immunocompromised Patient | Annals of Internal Medicine: Clinical Cases

A 44-year-old woman treated with corticosteroids and methotrexate for mixed connective tissue disease was hospitalized for lower limb edema and chest pain. Imaging studies revealed a large pericardial abscess with spondylodiscitis. Blood cultures were positive for methicillin-sensitive Staphylococcus aureus (MSSA). Pairwise genomes comparison done on both the responsible strain and an MSSA strain isolated 3 months earlier in a context of catheter-related infraclinical blood stream infection revealed identical patterns, highlighting the probable silent evolution of an incompletely treated infection in a patient receiving corticosteroids.

Multiple Sclerosis–Specific Sign: Ependymal Dot–Dash Sign/Dawson Fingers/Central Vein Sign | Annals of Internal Medicine: Clinical Cases

Multiple sclerosis is most common inflammatory-demyelinating disease of the central nervous system, affecting the brain and spinal cord. Magnetic resonance imaging is the primary technique for identifying white matter lesions as demyelinating lesions involving the periventricular white matter and the corpus callosum and some specifics are Dawson fingers, ependymal dot-dash sign, and central vein sign.

Postzone Phenomenon: A False-Negative Cryptococcal Antigen Assay in a Patient With Cryptococcemia and Meningoencephalitis | Annals of Internal Medicine: Clinical Cases

Cryptococcal fungal infection is an invasive, well-known opportunistic infection in immunosuppressed patients with high mortality rates. Cryptococcus neoformans and Cryptococcus gattii are the major pathogens in humans, mostly affecting the central nervous system and pulmonary systems. Rapid diagnosis and early initiation of antifungal therapy effectively reduce cryptococcal infection-related mortality. The rapid cryptococcal antigen tests are used in current clinical practice to detect both species with more than 99% sensitivity and specificity. There are few case reports regarding false-negative results of rapid antigen tests. Therefore, clinicians should be aware of 1 of the reasons for false-negative results (postzone effect).

Foreign-Body Aspiration in an Older Patient | Annals of Internal Medicine: Clinical Cases

We present a case of a 68-year-old man with a history of heavy smoking and HIV infection, who displayed concerning symptoms. Initial imaging suggested a possible malignancy. This unique presentation underscores the significance of thorough patient history-taking in reaching accurate diagnoses, especially in complex cases that initially mimic more common conditions.

An Unusual Cause for Progressively Worsening Dyspnea | Annals of Internal Medicine: Clinical Cases

A 66-year-old female presented with progressive dyspnea and was found to have a large interatrial septal lipoma that grew to extend to the proximal superior vena cava (SVC), leading to extrinsic compression that caused the impedance of blood flow. The patient had operative removal of the lipoma with subsequent improvement in exercise tolerance.

Pure Red Cell Aplasia Associated With COVID-19 Infection: Case Report | Annals of Internal Medicine: Clinical Cases

A woman in her early seventies presented to the hospital with severe anemia requiring blood transfusions every 2 to 3 months after a SARS-CoV-2 infection. A bone marrow biopsy revealed a near-complete absence of erythropoiesis, with rare erythroid precursors. She was diagnosed with pure red cell aplasia (PRCA). With no clear association to other causes of PRCA, such as hematologic malignancy, thymoma, lymphoma, autoimmune, or drug-induced, we believe that this could be the third case report of PRCA associated with SARS-CoV-2. Clinicians should include PRCA in the differential diagnosis for patients post-SARS-CoV-2 once common causes have been excluded.

Atypical Case of Osteomyelitis Pubis due to Corynebacterium striatum in a Patient With End-Stage Renal Disease | Annals of Internal Medicine: Clinical Cases

We report the case of a 64-year-old woman who presented with progressively worsening right, mid-pelvic pain. Computed tomography images of the abdomen and pelvis were consistent with pubic symphysis osteomyelitis. Open decompression with culture grew Corynebacterium striatum. In the literature, Staphylococcus aureus is the most common organism that causes osteomyelitis. However, this does not rule out other, rarer causes. This example of unresolved osteomyelitis with an atypical pathogen underscores the importance of culturing the organism to ensure proper disease management.

Acute Exacerbation of Cold Agglutinin Disease by SARS-CoV-2 Infection: A Rural U.S. Hospital Experience | Annals of Internal Medicine: Clinical Cases

COVID-19 has been associated with profound hematologic disease processes, including cold agglutinin disease (CAD). We discuss a patient with preexisting stable CAD that was exacerbated by COVID-19. Management of this patient was complicated by the fact that rituximab, a known therapy for CAD, could not be used. Recent reports have shown poorer survival for patients with COVID-19 who received rituximab. In this report, we discuss the pathogenesis of CAD and its management in the context of SARS-CoV-2 infection. We aim to increase awareness of possible exacerbation of CAD by SARS-CoV-2 infection.

Drug-Induced Acute Dystonia After Sacubitril/Valsartan Combination | Annals of Internal Medicine: Clinical Cases

Adverse drug reaction by definition can be an unpleasant response due to a drug use that can adversely affect a person and may call for either treatment or withdrawal of the medication. We found classical dystonia in a young girl who presented with reduced systolic left ventricular function, had cardiac surgery, and was prescribed sacubitril/valsartan combination for reversal of remodeling of the heart. The dystonia did not reoccur after stoppage of this combination. Although being an effective drug for heart failure with reduced ejection fraction, newer indications will need further assessment for the different dose regimen and adverse drug reactions.

Acute Kidney Injury After the Concurrent Use of Checkpoint Inhibitors and Proton Pump Inhibitors | Annals of Internal Medicine: Clinical Cases

As the use of immune checkpoint inhibitors (CPIs) in cancer treatment has increased, so has the number of immune-related adverse events (irAEs), such as acute kidney injury (AKI). Proton pump inhibitors (PPIs) have also been associated with AKI, but PPIs are still consistently prescribed for acid reflux and are often administered to patients also receiving CPI therapy. We describe 3 patients who were each receiving both a CPI and PPI and had an AKI within 5 months of concurrent therapy. This suggests that clinicians should be cautious about prescribing CPIs in conjunction with PPIs.