Mini But Mighty: Quick Wins for Positive Organizational Change

NOTE: MOC is not available for this activity. In this webinar, Well-being Champion Carrie Horwitch, MD, MPH, MACP, Associate Clinical Professor at Virginia Mason, discusses how one person can make a difference by identifying ways to improve thriving at work. Dr. Horwitch guides you though several attainable ways to drive positive change and secure leadership buy-in for your well-being efforts.

Metabolic Dysfunction–Associated Steatotic Liver Disease

Metabolic dysfunction–associated steatotic liver disease (MASLD) is the most common chronic liver disease in the United States. It is characterized by steatosis in the liver and is potentially reversible. Risk factors include obesity, type 2 mellitus, and other metabolic disorders. Metabolic dysfunction–associated steatohepatitis (MASH), a more severe form of MASLD, puts patients at risk for cirrhosis, liver decompensation, and liver cancer. Diet, exercise, and weight loss are the cornerstones of management.

Mental Health and Burnout, Part 2

We're closing out Mental Health Awareness Month with the 2nd part of our discussion of burnout. Join us as we learn from Dr. Anand Jagannath, a clinician-educator hospitalist who experienced burnout as an early career physician, and then learned strategies that individuals and institutions can implement to better recognize and combat burnout.

Mental Health and Burnout, Part 1

While there has been increased awareness of the concept of burnout in general, many Internal Medicine physicians may have gaps in their knowledge as to what burnout is and how they may be affected by it. Given that over 50% of physicians have experienced symptoms of burnout at some point during their careers (with rates significantly increasing during the COVID-19 pandemic), it is imperative that they understand the signs and the physical and mental consequences burnout can have. This includes increased rates of medical errors, depression, suicide, and leaving the medical field.

Mediterranean Diet in the Management of Irritable Bowel Syndrome

In this episode of Annals On Call, Dr. Centor discusses dietary interventions for patients with irritable bowel syndrome with Dr. Imran Aziz.First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.

Medication Abortion in 2024: What Internal Medicine Physicians Need to Know

Video captured from Internal Medicine Meeting 2024. Cynthia Chuang, MD, MSc, FACP, Alexandra Bachorik, MD, EdM, Adelaide McClintock, MD, and Mindy Sobota, MD, MS, Mphil, address prevalence of early abortion and current restrictions that impede equity in access in the United States. They’ll also advise on how internal medicine physicians can serve as a resource to their patients by diagnosing pregnancy, prescribing pills, referring to other trusted clinicians, and/or sharing reliable Internet resources for tele-abortion care.

Medical Marijuana

In this episode of Annals On Call, Dr. Centor discusses medical marijuana with Dr. Davis Bradford. First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.

Measuring Body Temperature: A Hot Topic?

The Annals Consult Guys discuss the measurement of body temperature and the history of defining normal body temperature.

Mastering the Art of Storytelling: A Leadership Technique to Engage, Inspire, and Influence

This activity equips physicians and healthcare leaders to enhance their leadership and communication through storytelling. With engaging videos, real-world examples, and a reflective workbook, participants will learn to craft impactful stories that build trust, inspire action, and support well-being in today’s complex healthcare environment.

Management of Sepsis in Hospitalized Patients

Sepsis is the leading cause of death worldwide. Mortality has improved in the past few decades but remains high, and survivors frequently have long-term complications. Initial diagnostic evaluation focuses on risk stratification and source and pathogen identification. Treatment includes intravenous fluids, vasopressors, steroids if shock is present, antimicrobial therapy targeting the most likely source of infection, and source control. Patients with shock or high-risk organ failure syndromes should be admitted early to an intensive care unit.

How the Gender Wage Gap for Primary Care Physicians Differs by Compensation Approach: A Microsimulation Study: Annals of Internal Medicine: Vol 175, No 8

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.

Quantifying Individual-Level Inaccuracy in Glomerular Filtration Rate Estimation: A Cross-Sectional Study: Annals of Internal Medicine: Vol 175, No 8

Background: Although the population-level differences between estimated glomerular filtration rate (eGFR) and measured glomerular filtration rate (mGFR) are well recognized, the magnitude and potential clinical implications of individual-level differences are unknown. Objective: To quantify the magnitude and consequences of the individual-level differences between mGFRs and eGFRs. Design: Cross-sectional study. Setting: Four U.S. community-based epidemiologic cohort studies with mGFR. Patients: 3223 participants in 4 studies. Measurements: The GFRs were measured using urinary iothalamate and plasma iohexol clearance; the eGFR was calculated from serum creatinine concentration alone (eGFRCR) and with cystatin C. All GFR results are presented as mL/min/1.73 m2. Results: The participants' mean age was 59 years; 32% were Black, 55% were women, and the mean mGFR was 68. The population-level differences between mGFR and eGFRCR were small; the median difference (mGFR − eGFR) was −0.6 (95% CI, −1.2 to −0.2); however, the individual-level differences were large. At an eGFRCR of 60, 50% of mGFRs ranged from 52 to 67, 80% from 45 to 76, and 95% from 36 to 87. At an eGFRCR of 30, 50% of mGFRs ranged from 27 to 38, 80% from 23 to 44, and 95% from 17 to 54. Substantial disagreement in chronic kidney disease staging by mGFR and eGFRCR was present. Among those with eGFRCR of 45 to 59, 36% had mGFR greater than 60 whereas 20% had mGFR less than 45; among those with eGFRCR of 15 to 29, 30% had mGFR greater than 30 and 5% had mGFR less than 15. The eGFR based on cystatin C did not provide substantial improvement. Limitation: Single measurement of mGFR and serum markers without short-term replicates Conclusion: A substantial individual-level discrepancy exists between the mGFR and the eGFR. Laboratories reporting eGFR should consider including the extent of this uncertainty to avoid misinterpretation of eGFR as an mGFR replacement. Primary Funding Source: National Institutes of Health.

Heterogeneity in Obesity Prevalence Among Asian American Adults

Background: Obesity increases the risk for metabolic and cardiovascular disease, and this risk occurs at lower body mass index (BMI) thresholds in Asian adults than in White adults. The degree to which obesity prevalence varies across heterogeneous Asian American subgroups is unclear because most obesity estimates combine all Asian Americans into a single group. Objective: To quantify obesity prevalence in Asian American subgroups among U.S. adults using both standard BMI categorizations and categorizations tailored to Asian populations. Design: Cross-sectional. Setting: United States, 2013 to 2020. Participants: The analytic sample included 2 882 158 adults aged 18 years or older in the U.S. Behavioral Risk Factor Surveillance System surveys (2013 to 2020). Participants self-identified as non-Hispanic White ([NHW] n = 2 547 965); non-Hispanic Black ([NHB] n = 263 136); or non-Hispanic Asian ([NHA] n = 71 057), comprising Asian Indian (n = 13 916), Chinese (n = 11 686), Filipino (n = 11 815), Japanese (n = 12 473), Korean (n = 3634), and Vietnamese (n = 2618) Americans. Measurements: Obesity prevalence adjusted for age and sex calculated using both standard BMI thresholds (≥30 kg/m2) and BMI thresholds modified for Asian adults (≥27.5 kg/m2), based on self-reported height and weight. Results: Adjusted obesity prevalence (by standard categorization) was 11.7% (95% CI, 11.2% to 12.2%) in NHA, 39.7% (CI, 39.4% to 40.1%) in NHB, and 29.4% (CI, 29.3% to 29.5%) in NHW participants; the prevalence was 16.8% (CI, 15.2% to 18.5%) in Filipino, 15.3% (CI, 13.2% to 17.5%) in Japanese, 11.2% (CI, 10.2% to 12.2%) in Asian Indian, 8.5% (CI, 6.8% to 10.5%) in Korean, 6.5% (CI, 5.5% to 7.5%) in Chinese, and 6.3% (CI, 5.1% to 7.8%) in Vietnamese Americans. The prevalence using modified criteria (BMI ≥27.5 kg/m2) was 22.4% (CI, 21.8% to 23.1%) in NHA participants overall and 28.7% (CI, 26.8% to 30.7%) in Filipino, 26.7% (CI, 24.1% to 29.5%) in Japanese, 22.4% (CI, 21.1% to 23.7%) in Asian Indian, 17.4% (CI, 15.2% to 19.8%) in Korean, 13.6% (CI, 11.7% to 15.9%) in Vietnamese, and 13.2% (CI, 12.0% to 14.5%) in Chinese Americans. Limitation: Body mass index estimates rely on self-reported data. Conclusion: Substantial heterogeneity in obesity prevalence exists among Asian American subgroups in the United States. Future studies and public health efforts should consider this heterogeneity. Primary Funding Source: National Heart, Lung, and Blood Institute.

Maternal, Infant, and Child Health Outcomes Associated With the Special Supplemental Nutrition Program for Women, Infants, and Children: A Systematic Review: Annals of Internal Medicine: Vol 175, No 10

Background: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is intended to improve maternal and child health outcomes. In 2009, the WIC food package changed to better align with national nutrition recommendations. Purpose: To determine whether WIC participation was associated with improved maternal, neonatal–birth, and infant–child health outcomes or differences in outcomes by subgroups and WIC enrollment duration. Data Sources: Search (January 2009 to April 2022) included PubMed, Embase, CINAHL, ERIC, Scopus, PsycInfo, and the Cochrane Central Register of Controlled Trials. Study Selection: Included studies had a comparator of WIC-eligible nonparticipants or comparison before and after the 2009 food package change. Data Extraction: Paired team members independently screened articles for inclusion and evaluated risk of bias. Data Synthesis: We identified 20 observational studies. We found: moderate strength of evidence (SOE) that maternal WIC participation during pregnancy is likely associated with lower risk for preterm birth, low birthweight infants, and infant mortality; low SOE that maternal WIC participation may be associated with a lower likelihood of inadequate gestational weight gain, as well as increased well-child visits and childhood immunizations; and low SOE that child WIC participation may be associated with increased childhood immunizations. We found low SOE for differences in some outcomes by race and ethnicity but insufficient evidence for differences by WIC enrollment duration. We found insufficient evidence related to maternal morbidity and mortality outcomes. Limitation: Data are from observational studies with high potential for selection bias related to the choice to participate in WIC, and participation status was self-reported in most studies. Conclusion: Participation in WIC was likely associated with improved birth outcomes and lower infant mortality, and also may be associated with increased child preventive service receipt. Primary Funding Source: Agency for Healthcare Research and Quality. (PROSPERO: CRD42020222452)

Does Stopping Aspirin Differ Fundamentally From Not Starting Aspirin in the Primary Prevention of Cardiovascular Disease Among Older Adults?

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Promoting Safety, Transparency, and Quality in Xenotransplantation

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.

Comparative Effectiveness and Safety Between Apixaban, Dabigatran, Edoxaban, and Rivaroxaban Among Patients With Atrial Fibrillation: A Multinational Population-Based Cohort Study: Annals of Internal Medicine: Vol 175, No 11

Background: Current guidelines recommend using direct oral anticoagulants (DOACs) over warfarin in patients with atrial fibrillation (AF), but head-to-head trial data do not exist to guide the choice of DOAC. Objective: To do a large-scale comparison between all DOACs (apixaban, dabigatran, edoxaban, and rivaroxaban) in routine clinical practice. Design: Multinational population-based cohort study. Setting: Five standardized electronic health care databases, which covered 221 million people in France, Germany, the United Kingdom, and the United States. Participants: Patients who were newly diagnosed with AF from 2010 through 2019 and received a new DOAC prescription. Measurements: Database-specific hazard ratios (HRs) of ischemic stroke or systemic embolism, intracranial hemorrhage (ICH), gastrointestinal bleeding (GIB), and all-cause mortality between DOACs were estimated using a Cox regression model stratified by propensity score and pooled using a random-effects model. Results: A total of 527 226 new DOAC users met the inclusion criteria (apixaban, n = 281 320; dabigatran, n = 61 008; edoxaban, n = 12 722; and rivaroxaban, n = 172 176). Apixaban use was associated with lower risk for GIB than use of dabigatran (HR, 0.81 [95% CI, 0.70 to 0.94]), edoxaban (HR, 0.77 [CI, 0.66 to 0.91]), or rivaroxaban (HR, 0.72 [CI, 0.66 to 0.79]). No substantial differences were observed for other outcomes or DOAC–DOAC comparisons. The results were consistent for patients aged 80 years or older. Consistent associations between lower GIB risk and apixaban versus rivaroxaban were observed among patients receiving the standard dose (HR, 0.72 [CI, 0.64 to 0.82]), those receiving a reduced dose (HR, 0.68 [CI, 0.61 to 0.77]), and those with chronic kidney disease (HR, 0.68 [CI, 0.59 to 0.77]). Limitation: Residual confounding is possible. Conclusion: Among patients with AF, apixaban use was associated with lower risk for GIB and similar rates of ischemic stroke or systemic embolism, ICH, and all-cause mortality compared with dabigatran, edoxaban, and rivaroxaban. This finding was consistent for patients aged 80 years or older and those with chronic kidney disease, who are often underrepresented in clinical trials. Primary Funding Source: None.

Rethinking Professionalism Assessments in Medical Education

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Screening for latent TB may miss higher-risk patients

MKSAP Quiz: 2-week history of heat intolerance in pregnancy

Testosterone may not decrease fracture risk in hypogonadism

Sickle cell gene therapy cost-effective if less than $2 million per person

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Early Bird savings for Internal Medicine Meeting 2024 end on Jan. 31

Best practice advisory boosted primary aldosteronism screening

MKSAP Quiz: Evaluation for increasingly frequent angina

Combined use of ED drugs, nitrates linked with worse outcomes in patients with CAD

Algorithms for suspected myocardial infarction perform worse in falling troponin pattern | ACP Hospitalist

Review finds no significant difference between IV fluid strategies in sepsis | ACP Hospitalist

Recommendations on preventing surgical-site infections updated | ACP Hospitalist

Readmission project failed to reduce readmissions or mortality, Swiss study finds | ACP Hospitalist

New commandments for consults | ACP Hospitalist

Intervention successful in decreasing routine vitamin D testing | ACP Hospitalist

ACP advises on improving transitions of care | ACP Hospitalist

Procalcitonin algorithm reduced antibiotic use in COVID-19 inpatients | ACP Hospitalist

Pearls on diabetes meds in periop care | ACP Hospitalist

New consult service dramatically increased use of medication for alcohol use disorder | ACP Hospitalist