1
|
Becker B. Primary Care: Its Pokemon Moment. Am J Med 2024:S0002-9343(24)00166-9. [PMID: 38556037 DOI: 10.1016/j.amjmed.2024.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/08/2024] [Accepted: 03/08/2024] [Indexed: 04/02/2024]
Abstract
Primary care in the United States is undergoing bursts of evolution in response to health system stresses, changing demographics, and expansion of risk and value-based reimbursement structures. The impact of primary care remains substantive and associated with improved population health. However, the spectrum of services, the nature of the physicians involved and new ways of including the patient in her, or his own care suggests that a new definition of primary care be considered, and patient expectations be heeded and understood. Evolutionary bursts yield new traits and in primary care, they are spawning new care models with significant implications for general internal medicine, internal medicine/pediatrics trained individuals and medicine subspecialties given the focus of these models on Medicare Advantage. Ultimately, changes in reimbursement and creative incentives will be two factors among many that will solidify the next stage of primary care in the United States.
Collapse
Affiliation(s)
- Bryan Becker
- Department of Medicine, Anne Burnett Marion School of Medicine, Texas Christian University, Fort Worth, Tex.
| |
Collapse
|
2
|
Wingo MT, Andersen CA, Bornstein SL, Huber JM, Szostek JH, Wieland ML. Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2023. Am J Med 2024:S0002-9343(24)00099-8. [PMID: 38403180 DOI: 10.1016/j.amjmed.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 02/27/2024]
Abstract
The expansive scope of internal medicine can make it challenging for clinicians to stay informed about new literature that changes practice. Guideline updates and synthesis of relevant evidence can facilitate incorporation of advancements into clinical practice. The titles and abstracts from the seven general medicine journals with highest impact factors and relevance to outpatient internal medicine were reviewed by six internal medicine physicians. Coronavirus disease 19 research was excluded. The New England Journal of Medicine (NEJM), The Lancet, Journal of the American Medical Association (JAMA), The British Medical Journal (BMJ), Annals of Internal Medicine, JAMA Internal Medicine, and Mayo Clinic Proceedings were reviewed. Additionally, article synopsis collections and databases were evaluated: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster ACCESSSS/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on clinical relevance to outpatient internal medicine, potential impact on practice, and strength of evidence. Article qualities and importance were debated until consensus was reached. Clusters of articles pertinent to the same topic were considered together. In total, seven practice-changing articles were included.
Collapse
Affiliation(s)
- Majken T Wingo
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, MN.
| | - Carl A Andersen
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Shari L Bornstein
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Jill M Huber
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Jason H Szostek
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Mark L Wieland
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
3
|
Schönenberger N, Meyer-Massetti C. Risk factors for medication-related short-term readmissions in adults - a scoping review. BMC Health Serv Res 2023; 23:1037. [PMID: 37770912 PMCID: PMC10536731 DOI: 10.1186/s12913-023-10028-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 09/12/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Hospital readmissions due to medication-related problems occur frequently, burdening patients and caregivers emotionally and straining health care systems economically. In times of limited health care resources, interventions to mitigate the risk of medication-related readmissions should be prioritized to patients most likely to benefit. Focusing on general internal medicine patients, this scoping review aims to identify risk factors associated with drug-related 30-day hospital readmissions. METHODS We began by searching the Medline, Embase, and CINAHL databases from their inception dates to May 17, 2022 for studies reporting risk factors for 30-day drug-related readmissions. We included all peer-reviewed studies, while excluding literature reviews, conference abstracts, proceeding papers, editorials, and expert opinions. We also conducted backward citation searches of the included articles. Within the final sample, we analyzed the types and frequencies of risk factors mentioned. RESULTS After deduplication of the initial search results, 1159 titles and abstracts were screened for full-text adjudication. We read 101 full articles, of which we included 37. Thirteen more were collected via backward citation searches, resulting in a final sample of 50 articles. We identified five risk factor categories: (1) patient characteristics, (2) medication groups, (3) medication therapy problems, (4) adverse drug reactions, and (5) readmission diagnoses. The most commonly mentioned risk factors were polypharmacy, prescribing problems-especially underprescribing and suboptimal drug selection-and adherence issues. Medication groups associated with the highest risk of 30-day readmissions (mostly following adverse drug reactions) were antithrombotic agents, insulin, opioid analgesics, and diuretics. Preventable medication-related readmissions most often reflected prescribing problems and/or adherence issues. CONCLUSIONS This study's findings will help care teams prioritize patients for interventions to reduce medication-related hospital readmissions, which should increase patient safety. Further research is needed to analyze surrogate social parameters for the most common drug-related factors and their predictive value regarding medication-related readmissions.
Collapse
Affiliation(s)
- N Schönenberger
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland.
| | - C Meyer-Massetti
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Healthcare (BIHAM), University of Bern, Bern, Switzerland
| |
Collapse
|
4
|
Huber JM, Wieland ML, Bornstein SL, Mauck KF, Szostek JH, Post JA, Wingo MT. Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2022. Am J Med 2023; 136:869-873. [PMID: 37245787 DOI: 10.1016/j.amjmed.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 05/11/2023] [Indexed: 05/30/2023]
Abstract
It can be difficult for clinicians to stay updated on practice-changing articles. Synthesis of relevant articles and guideline updates can facilitate staying informed on important new data impacting clinical practice. The titles and abstracts from the 7 general internal medicine outpatient journals with highest impact factors and relevance were reviewed by 8 internal medicine physicians. Coronavirus disease 2019 research was excluded. The New England Journal of Medicine (NEJM), The Lancet, the Journal of the American Medical Association, The British Medical Journal (BMJ), the Annals of Internal Medicine, JAMA Internal Medicine, and Public Library of Science Medicine were reviewed. Additionally, article synopsis collections and databases were reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on clinical relevance to outpatient internal medicine, potential impact on practice, and strength of evidence. Article qualities and importance were debated until consensus was reached. Clusters of articles pertinent to the same topic were considered together. In total, 5 practice-changing articles were included, along with a highlight of key guideline updates.
Collapse
Affiliation(s)
- Jill M Huber
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, Minn.
| | - Mark L Wieland
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Shari L Bornstein
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Karen F Mauck
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Jason H Szostek
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Jason A Post
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Majken T Wingo
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, Minn
| |
Collapse
|
5
|
Affiliation(s)
- Paul Sebo
- University Institute for Primary Care (IuMFE), University of Geneva, Geneva, Switzerland.
| |
Collapse
|
6
|
Roeser A, Vanjak A, Mettler C, Gramont B, Azoyan L, Oziol E, Le Moigne E, Bouillet L, Durieu I, Bourgarit A. [Place of internal medicine specialists in inpatient unprogrammed care of adult patients in France: A survey of in training and senior internal medicine specialists]. Rev Med Interne 2022; 43:524-527. [PMID: 35989195 DOI: 10.1016/j.revmed.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 06/27/2022] [Accepted: 07/10/2022] [Indexed: 10/15/2022]
Abstract
INTRODUCTION French internal medicine specialists are trained in clinical immunology and rare diseases as well as frequent ones. The latest activity is rarely highlighted by practitioners themselves and their representative authorities. Frequent diseases care in French hospitals are also the tasks of physicians without internal medicine specialty, mostly trained in general medicine, who practice in departments carrying various names. METHODS We conducted a survey to estimate the part of frequent diseases' care and unplanned hospital medicine in the practice of specialists and residents in internal medicine in France, and its designation, through two surveys released by the "Collège National Professionnel de Médecine Interne" (for the internal medicine specialists), and the "Amicale des Jeunes Internists" (for the internal medicine residents). RESULTS A total of 180 and 247 responses were obtained among the residents and the specialists, respectively, representing 31.3% and 24.8% of the internal medicine specialist's workforce. The most suitable qualifier for frequent diseases' care and unplanned hospital medicine, primarily post-emergency, was "general hospital medicine" for 48.9% of the residents and "general internal medicine" for 35.6% of the specialists. Unplanned hospital medicine was considered to represent a large part of the internal medicine activity by 66.7% and 64.7% of residents and specialists, respectively. A 50% and more hourly part of the activity devoted to it was reported by 71.4% of the residents and 76.1% of the specialists. General hospital medicine was reported to be distinct from internal medicine-clinical immunology by 46.1% of the residents and 47.4% of the specialists. CONCLUSION French internists devote a large part of their activities to frequent diseases' care and unscheduled medicine, the name of which was not consensual. However, their work could not be summarized to it, often involving a specific activity named internal medicine - clinical immunology.
Collapse
Affiliation(s)
- A Roeser
- Amicale des jeunes internistes, 15, rue de l'École-de-Médecine, 75005 Paris, France.
| | - A Vanjak
- Amicale des jeunes internistes, 15, rue de l'École-de-Médecine, 75005 Paris, France
| | - C Mettler
- Amicale des jeunes internistes, 15, rue de l'École-de-Médecine, 75005 Paris, France
| | - B Gramont
- Service de médecine interne, CHU de Saint-Étienne, Saint-Étienne, France
| | - L Azoyan
- Amicale des jeunes internistes, 15, rue de l'École-de-Médecine, 75005 Paris, France
| | - E Oziol
- Service de médecine interne, centre hospitalier de Béziers, Béziers, France
| | - E Le Moigne
- Département de médecine interne, médecine vasculaire et pneumologie, centre hospitalier universitaire de Brest, Brest, France
| | - L Bouillet
- Service de médecine interne et immunologie clinique, centre hospitalier universitaire de Grenoble, Grenoble, France
| | - I Durieu
- Service de médecine interne et pathologie vasculaire, groupement hospitalier Sud, hospices civils de Lyon, université Claude-Bernard Lyon 1, Lyon, France
| | - A Bourgarit
- Service de médecine interne, hôpital Jean-Verdier, Assistance-Publique Hôpitaux-de-Paris, Bondy, France
| |
Collapse
|
7
|
Wingo MT, Huber JM, Bornstein SL, Sundsted KK, Mauck KF, Szostek JH, Post JA, Wieland ML. Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2021. Am J Med 2022; 135:1069-1074. [PMID: 35367181 DOI: 10.1016/j.amjmed.2022.02.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 02/21/2022] [Indexed: 11/19/2022]
Abstract
It can be challenging to identify new evidence that may shift clinical practice within internal medicine. Synthesis of relevant articles and guideline updates can facilitate staying informed of these changes. The titles and abstracts from the 7 general internal medicine outpatient journals with highest impact factors and relevance were reviewed by 8 internal medicine physicians. Coronavirus disease 2019 research was excluded. The New England Journal of Medicine (NEJM), The Lancet, Journal of the American Medical Association (JAMA), The British Medical Journal (BMJ), Annals of Internal Medicine, JAMA Internal Medicine, and Public Library of Science Medicine were reviewed. Additionally, article synopsis collections and databases were reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on clinical relevance to outpatient internal medicine, potential impact on practice, and strength of evidence. Article qualities and importance were debated until consensus was reached. Clusters of articles pertinent to the same topic were considered together. In total, 8 practice-changing articles were included.
Collapse
Affiliation(s)
- Majken T Wingo
- Division of Community Internal Medicine, Geriatrics and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, Minn.
| | - Jill M Huber
- Division of Community Internal Medicine, Geriatrics and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Shari L Bornstein
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Karna K Sundsted
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Karen F Mauck
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Jason H Szostek
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Jason A Post
- Division of Community Internal Medicine, Geriatrics and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Mark L Wieland
- Division of Community Internal Medicine, Geriatrics and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, Minn
| |
Collapse
|
8
|
Wingo MT, Huber JM, Szostek JH, Bornstein SL, Post JA, Mauck KF, Wieland ML. Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2020. Am J Med 2021; 134:854-9. [PMID: 33773973 DOI: 10.1016/j.amjmed.2021.01.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 01/26/2021] [Indexed: 11/23/2022]
Abstract
In a time of rapidly shifting evidence-based medicine, it is challenging to stay informed of research that modifies clinical practice. To enhance knowledge of practice-changing literature, a group of 7 internists reviewed titles and abstracts in 7 internal medicine journals with the highest impact factors and relevance to outpatient general internal medicine. Coronavirus disease-19 research was purposely excluded to highlight practice changes beyond the pandemic. New England Journal of Medicine (NEJM), The Lancet, Annals of Internal Medicine, Journal of the American Medical Association (JAMA), JAMA Internal Medicine, British Medical Journal (BMJ), and Public Library of Science (PLoS) Medicine were reviewed. The following collections of article synopses and databases were also reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on relevance to outpatient internal medicine, impact on practice, and strength of evidence. Clusters of articles pertaining to the same topic were considered together. In total, 7 practice-changing articles were included.
Collapse
|
9
|
Abstract
This piece discusses an internal medicine trainee's attempt to process the untimely death of a patient seen in primary clinic by suicide. More specifically, it explores the role mental health may have played in the patient's care, and the possibility of the symptoms which were labeled as functional having been manifestations of underlying psychiatric illness. The piece also attempts to explore the unique challenges facing veterans within the healthcare system.
Collapse
|
10
|
Sawatsky AP, Halvorsen AJ, Daniels PR, Bonnes SL, Issa M, Ratelle JT, Stephenson CR, Beckman TJ. Characteristics and quality of rotation-specific resident learning goals: a prospective study. Med Educ Online 2020; 25:1714198. [PMID: 31941433 PMCID: PMC7006652 DOI: 10.1080/10872981.2020.1714198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/23/2019] [Accepted: 01/02/2020] [Indexed: 06/10/2023]
Abstract
Background: Residents are expected to develop the skills to set learning goals. Setting learning goals is part of self-regulated learning, setting the foundation for creating a learning plan, deploying learning strategies, and assessing their progress to those goals. While effective goal setting is essential to resident self-regulated learning, residents struggle with setting learning goals and desire faculty assistance with goal setting.Objective: We aimed to characterize the topics and quality of residents' rotation-specific learning goals.Design: We conducted a prospective study of 153 internal medicine residents, assessing 455 learning goals for general medicine inpatient rotations. We coded learning goal themes, competencies, and learning domains, and assessed quality using the validated Learning Goal Scoring Rubric. We compared topic categories, competencies, learning domains, and quality between the first and second months of postgraduate (PGY)-1 residents and between PGY-1 and PGY-3 residents. We assessed factors associated with learning goal completion.Results: The overall response rate was 80%. The top three learning goal categories were patient management, specific diseases related to general medicine, and teaching skills. There were no changes in learning goal characteristics between PGY-1 months (p ≥ 0.04). There were differences between PGY-1 and PGY-3 residents' learning goals in patient management (28% vs 6%; p < .001), specific disease conditions (19% vs 3%; p < .001), and teaching skills (2% vs 56%; p < .001). There was no difference in learning goal quality between PGY-1 months (1.63 vs. 1.67; p = 0.82). The PGY-3 learning goals were of higher quality than PGY-1 learning goals for the 'specific goal' item (1.38 vs. 0.98, p = 0.005), but not for other items or overall (all p ≥ 0.02). Residents reported 85% (297/347) learning goal completion.Conclusions: Resident rotation-specific learning goals reflect a broad array of topics. Residents' learning goal quality was low and residents may benefit from guidance to support residents' learning goals.
Collapse
Affiliation(s)
- Adam P. Sawatsky
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Paul R. Daniels
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sara L. Bonnes
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Meltiady Issa
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - John T. Ratelle
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Thomas J. Beckman
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
11
|
Kawahigashi T, Teshima S, Tanaka E. Intravascular lymphoma with hypopituitarism: A case report. World J Clin Oncol 2020; 11:673-678. [PMID: 32879852 PMCID: PMC7443836 DOI: 10.5306/wjco.v11.i8.673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 05/07/2020] [Accepted: 06/27/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Intravascular lymphoma (IVL) is a rare subtype of lymphoma involving the growth of lymphoma cells within the vessel lumina without lymphadenopathy. Because of various modes of presentation and its rarity, IVL is often diagnosed postmortem. Herein, we report a case of intravascular B-cell lymphoma with hypopituitarism, an extremely rare complication, that was successfully treated with chemotherapy.
CASE SUMMARY An 80-year-old Japanese woman presented with a 7-mo history of a tingling sensation in the lower limbs. She also presented with various other symptoms such as pancytopenia, high fever daily, and unconsciousness with hypoglycemia. Although the doctor who previously treated her diagnosed hypoglycemia as being due to hypopituitarism, the cause of the other symptoms remained uncertain despite a 7-mo evaluation period. We performed bone marrow aspiration to evaluate pancytopenia and found that she had hemophagocytic lymphohistiocytosis (HLH). On the basis of a random skin biopsy for assessing the cause of HLH, she was diagnosed with intravascular B-cell lymphoma. HLH and hypopituitarism were considered secondary to IVL. All her clinical findings matched the presentations of IVL. She was immediately treated with chemotherapy and achieved complete response. She was relapse free two years after treatment.
CONCLUSION IVL should be included in the differential diagnosis of hypopituitarism, which although life-threatening, is treatable through prompt diagnosis and appropriate chemotherapy.
Collapse
Affiliation(s)
- Teiko Kawahigashi
- Department of General Internal Medicine, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Shinichi Teshima
- Department of Histopathology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Eri Tanaka
- Department of Hematology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| |
Collapse
|
12
|
Wingo MT, Bornstein SL, Szostek JH, Mauck KF, Post JA, Wieland ML. Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2019. Am J Med 2020; 133:789-794. [PMID: 32247820 DOI: 10.1016/j.amjmed.2020.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 02/13/2020] [Accepted: 02/16/2020] [Indexed: 10/24/2022]
Abstract
Clinicians are challenged to stay informed of new and changing medical literature. To facilitate knowledge updates and synthesis of practice-changing information, a group of 6 internists reviewed the titles and abstracts in the 7 outpatient general internal medicine journals with the highest impact factors and relevance to outpatient internal medicine physicians: New England Journal of Medicine (NEJM), Lancet, Annals of Internal Medicine, Journal of the American Medical Association (JAMA), JAMA Internal Medicine, British Medical Journal (BMJ), and Public Library of Science (PLoS) Medicine. The following collections of article synopses and databases were also reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on clinical relevance to outpatient internal medicine, potential impact on practice, and strength of evidence. Article qualities and importance were debated until consensus was reached. Clusters of articles pertaining to the same topic were considered together. In total, 7 practice-changing articles were included.
Collapse
Affiliation(s)
- Majken T Wingo
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn.
| | - Shari L Bornstein
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Jason H Szostek
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Karen F Mauck
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Jason A Post
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Mark L Wieland
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn
| |
Collapse
|
13
|
Flaegel K, Brandt B, Goetz K, Steinhaeuser J. Which procedures are performed by general internists practicing primary care in Germany? - a cross-sectional study. BMC Fam Pract 2020; 21:73. [PMID: 32349681 PMCID: PMC7191754 DOI: 10.1186/s12875-020-01136-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 04/02/2020] [Indexed: 11/25/2022]
Abstract
Background Due to differences of residency training programs’ emphases – inpatient vs office-based – internal medicine and family medicine residents consistently reported differences in preparedness to care for common adult conditions. Study’s aim was to add knowledge about procedures that a) are performed by general internists working in primary care and b) should be learned during residency in general internists’ appraisal. Methods A cross-sectional postal survey was carried out by using a questionnaire that comprised 90 procedures relevant in primary care. Each procedure implied the two questions “Do you perform this procedure in your own practice?” and “How important do you think it is to learn this procedure during residency?” The final questionnaire was sent to 1002 general internists working in primary care in Germany in May 2015. Data analysis was performed using SPSS Version 24.0 (SPSS inc., IBM). Next to descriptive statistics subgroup analyses were performed using cross tabulation and Chi-square tests for evaluation of differences in the performance of most frequently performed procedures in urban or rural areas as well as by male or female physicians. Results Twenty-eight percent of sent questionnaires (276/1002) could be included in analysis. Mean age of participants was 52 years with 13 years of practice experience; 40% were female. Twenty-nine (32%) of 90 given procedures were performed by at least half of the participants, foremost technical diagnostics, punctures, procedures of the integument and resuscitation. After Bonferroni correction, five of those procedures were performed by more male than female physicians and two procedures by more physicians working in a rural practice than physicians practicing in an urban location. Moreover, 46 (51%) procedures were assessed as important to learn during residency by at least 50% of participants. Conclusions General internists working in German primary care perform a narrow scope of procedures offered by primary care physicians. In order to provide best ambulatory care for patients, residency training programs must ensure training in procedures that are necessary for providing high quality care. Therefore, a consensus aligned with patients’ and health-systems’ needs on procedures required for working as a general internist in primary care is necessary.
Collapse
Affiliation(s)
- Kristina Flaegel
- Institute of Family Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Bettina Brandt
- Department of General Practice/Primary Care, Hamburg University Medical School, Martinistraße 52, 20246, Hamburg, Germany
| | - Katja Goetz
- Institute of Family Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Jost Steinhaeuser
- Institute of Family Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| |
Collapse
|
14
|
Strumann C, Emcke T, Flägel K, Steinhäuser J. [Regional differences between general practitioners and general internal medicine physicians in primary care]. Z Evid Fortbild Qual Gesundhwes 2020; 150-152:88-95. [PMID: 32115385 DOI: 10.1016/j.zefq.2020.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 01/17/2020] [Accepted: 01/20/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE In many places in Germany, the need for primary care physicians has been steadily increasing for several years, especially in rural areas. It is hypothesized that physicians are more likely to practice in rural areas if they have received a broad education and vocational training. Differences between general practitioners (GPs) and physicians in general internal medicine (GIM) in the breadth of their vocational training are created by the underlying distinct training schemes. The aim of the analysis was to test whether GPs and GIM physicians differ in their distribution between urban and rural regions of Schleswig-Holstein and whether there are differences in the rate and frequency of performing home visits. METHODS Based on invoicing data of the Association of Statutory Health Insurance Physicians in the federal state of Schleswig-Holstein (Northern Germany) covering the years 2015 up to the third quarter (Q3) of 2018, we analysed differences between GPs and GIM physicians in their regional distribution. Furthermore, we looked at differences between both specialties regarding the application rate and the number of home visits performed and unforeseen physician visits. In addition to bivariate approaches, we also used multivariate regression analysis. RESULTS Between 2017 (Q4) and 2018 (Q3), 1,378 GPs and 585 GIM physicians provided medical services in Schleswig-Holstein. While 27.5 % of the GPs had practices in rural areas, the share of GIM physicians was 14.5 % (p < 0.001). Home visits were performed by 97.8 % of the GPs and 93.2 % of the GIM physicians (p < 0.001). This difference was even more pronounced in rural areas (99.5 % vs. 94.1 % (p = 0.002)). Significant differences have also been found in the number of billed home visits. GPs made 36 % more home visits than GIM physicians. In rural areas, the difference was 60 %. CONCLUSION The analysis revealed significant differences between GPs and GIM physicians regarding the type of region where they work, the application rate and the number of performed home visits. The findings could foster a discussion about how GIM physicians can be better prepared to provide primary care, especially in rural areas.
Collapse
Affiliation(s)
- Christoph Strumann
- Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Institut für Allgemeinmedizin, Lübeck, Deutschland.
| | - Timo Emcke
- Kassenärztliche Vereinigung Schleswig-Holstein, Bad Segeberg, Deutschland
| | - Kristina Flägel
- Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Institut für Allgemeinmedizin, Lübeck, Deutschland
| | - Jost Steinhäuser
- Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Institut für Allgemeinmedizin, Lübeck, Deutschland
| |
Collapse
|
15
|
Bai AD, Dai C, Srivastava S, Smith CA, Gill SS. Risk factors, costs and complications of delayed hospital discharge from internal medicine wards at a Canadian academic medical centre: retrospective cohort study. BMC Health Serv Res 2019; 19:935. [PMID: 31801590 PMCID: PMC6894295 DOI: 10.1186/s12913-019-4760-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 11/20/2019] [Indexed: 11/13/2022] Open
Abstract
Background Hospitalized patients are designated alternate level of care (ALC) when they no longer require hospitalization but discharge is delayed while they await alternate disposition or living arrangements. We assessed hospital costs and complications for general internal medicine (GIM) inpatients who had delayed discharge. In addition, we developed a clinical prediction rule to identify patients at risk for delayed discharge. Methods We conducted a retrospective cohort study of consecutive GIM patients admitted between 1 January 2015 and 1 January 2016 at a large tertiary care hospital in Canada. We compared hospital costs and complications between ALC and non-ALC patients. We derived a clinical prediction rule for ALC designation using a logistic regression model and validated its diagnostic properties. Results Of 4311 GIM admissions, 255 (6%) patients were designated ALC. Compared to non-ALC patients, ALC patients had longer median length of stay (30.85 vs. 3.95 days p < 0.0001), higher median hospital costs ($22,459 vs. $5003 p < 0.0001) and more complications in hospital (25.5% vs. 5.3% p < 0.0001) especially nosocomial infections (14.1% vs. 1.9% p < 0.0001). Sensitivity analyses using propensity score and pair matching yielded similar results. In a derivation cohort, seven significant risk factors for ALC were identified including age > =80 years, female sex, dementia, diabetes with complications as well as referrals to physiotherapy, occupational therapy and speech language pathology. A clinical prediction rule that assigned each of these predictors 1 point had likelihood ratios for ALC designation of 0.07, 0.25, 0.66, 1.48, 6.07, 17.13 and 21.85 for patients with 0, 1, 2, 3, 4, 5, and 6 points respectively in the validation cohort. Conclusions Delayed discharge is associated with higher hospital costs and complication rates especially nosocomial infections. A clinical prediction rule can identify patients at risk for delayed discharge.
Collapse
Affiliation(s)
- Anthony D Bai
- Department of Medicine, Queen's University, Kingston, Ontario, Canada.,Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Cathy Dai
- Department of Medicine, Queen's University, Kingston, Ontario, Canada.,Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Siddhartha Srivastava
- Department of Medicine, Queen's University, Kingston, Ontario, Canada.,Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Christopher A Smith
- Department of Medicine, Queen's University, Kingston, Ontario, Canada.,Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Sudeep S Gill
- Department of Medicine, Queen's University, Kingston, Ontario, Canada. .,Kingston Health Sciences Centre, Kingston, Ontario, Canada. .,Providence Care Hospital, Kingston, 752 King St. West, Kingston, ON, K7L 4X3, Canada.
| |
Collapse
|
16
|
Wingo MT, Szostek JH, Sundsted KK, Post JA, Mauck KF, Wieland ML. Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2018. Am J Med 2019; 132:926-930. [PMID: 30853473 DOI: 10.1016/j.amjmed.2019.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 02/12/2019] [Accepted: 02/12/2019] [Indexed: 11/15/2022]
Abstract
The expansive scope of general internal medicine makes it difficult to identify practice-changing medical literature. Clinical updates can be facilitated by synthesizing relevant articles and implications for practice. Six internal medicine physicians reviewed the titles and abstracts in the 7 general internal medicine clinical outpatient journals with the highest impact factor and relevance to the internal medicine outpatient physician: New England Journal of Medicine (NEJM), Lancet, Annals of Internal Medicine, Journal of the American Medical Association (JAMA), JAMA-Internal Medicine, British Medical Journal (BMJ), and Public Library of Science (PLoS) Medicine. The following collections of article synopses and databases were also reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus on articles based on clinical relevance to outpatient Internal Medicine, potential impact on practice, and strength of evidence. Article qualities and importance were debated until consensus was reached. Clusters of articles pertinent to the same topic were considered together. In total, 7 practice-changing articles were included.
Collapse
Affiliation(s)
- Majken T Wingo
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn.
| | - Jason H Szostek
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Karna K Sundsted
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Jason A Post
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Karen F Mauck
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Mark L Wieland
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn
| |
Collapse
|
17
|
Strumann C, Flägel K, Emcke T, Steinhäuser J. Procedures performed by general practitioners and general internal medicine physicians - a comparison based on routine data from Northern Germany. BMC Fam Pract 2018; 19:189. [PMID: 30509221 PMCID: PMC6276264 DOI: 10.1186/s12875-018-0878-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 11/19/2018] [Indexed: 11/21/2022]
Abstract
Background In response to a rising shortage of general practitioners (GPs), physicians in general internal medicine (GIM) have become part of the German primary care physician workforce. Previous studies have shown substantial differences in practice patterns between both specialties. The aim of this study was to analyse and compare the application of procedures by German GPs and GIM physicians based on routine data. Methods The Association of Statutory Health Insurance Physicians in the federal state Schleswig-Holstein (Northern Germany) provided invoicing data of the first quarters of 2013 and 2015. Differences between GPs and GIM physicians in the implementation rate of 46 selected primary care procedures were examined by means of the Pearson χ2-test. The selection of procedures was based on international and own preliminary studies on primary care procedures. Results In the first quarter of 2013/2015 respectively, 1228/1227 GPs and 447/484 GIM physicians provided services in Schleswig-Holstein. Significant differences were found for 20 of the 46 procedures. GPs had higher application rates of procedures concerning health screening (e.g. adolescent health examination, well-child visits) and minor surgery. GIM physicians more often applied technology-oriented procedures, such as ultrasound scans, electrocardiograms (ECG), and 24-h ambulatory blood pressure measurements. The treatment patterns of both specialities did not vary much during the study period. Cardiac stress testing was the only significantly increased GP procedure in that time. Conclusions Our results suggest substantial differences in the application of procedures between GPs and GIM physicians with potential consequences for the overall primary healthcare provision. The findings could foster a discussion about training needs for procedures in primary care to ensure its comprehensiveness. The results reflect scope for changes in vocational training in the future for an effective and efficient re-allocation of primary healthcare.
Collapse
Affiliation(s)
- C Strumann
- Institute of Family Medicine, University Hospital Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23538, Luebeck, Germany.
| | - K Flägel
- Institute of Family Medicine, University Hospital Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23538, Luebeck, Germany
| | - T Emcke
- Association of Statutory Health Insurance Physicians of the Federal State of Schleswig-Holstein, Bismarckallee 1-6, 23795, Bad Segeberg, Germany
| | - J Steinhäuser
- Institute of Family Medicine, University Hospital Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23538, Luebeck, Germany
| |
Collapse
|
18
|
Kirsch JD, Duran A, Kaizer AM, Buum HT, Robiner WN, Weber-Main AM. Career-Focused Mentoring for Early-Career Clinician Educators in Academic General Internal Medicine. Am J Med 2018; 131:1387-1394. [PMID: 30076827 DOI: 10.1016/j.amjmed.2018.07.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 07/25/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Jonathan D Kirsch
- Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis.
| | - Alisa Duran
- Section of Women's Health and General Internal Medicine, Minneapolis VA Health Care System, Minn
| | - Alexander M Kaizer
- Department of Biostatistics and Informatics, University of Colorado School of Public Health, Aurora
| | - Heather Thompson Buum
- Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis
| | - William N Robiner
- Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis
| | - Anne Marie Weber-Main
- Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis
| |
Collapse
|
19
|
Wieland ML, Szostek JH, Wingo MT, Post JA, Mauck KF. Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2017. Am J Med 2018; 131:896-901. [PMID: 29496500 DOI: 10.1016/j.amjmed.2018.01.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 01/18/2018] [Accepted: 01/19/2018] [Indexed: 01/09/2023]
Abstract
Clinicians are challenged to identify new practice-changing articles in the medical literature. To identify the practice-changing articles published in 2017 most relevant to outpatient general internal medicine, 5 internists reviewed the following sources: 1) titles and abstracts from internal medicine journals with the 7 highest impact factors, including New England Journal of Medicine, Lancet, Journal of the American Medical Association, British Medical Journal, Public Library of Science Medicine, Annals of Internal Medicine, and JAMA Internal Medicine; 2) synopses and syntheses of individual studies, including collections in the American College of Physicians Journal Club, Journal Watch, and Evidence-Based Medicine; 3) databases of synthesis, including Evidence Updates and the Cochrane Library. Inclusion criteria were perceived clinical relevance to outpatient general medicine, potential for practice change, and strength of evidence. This process yielded 140 articles. Clusters of important articles around one topic were considered as a single-candidate series. A modified Delphi method was utilized by the 5 authors to reach consensus on 7 topics to highlight and appraise from the 2017 literature.
Collapse
Affiliation(s)
- Mark L Wieland
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, Mayo Clinic School of Medicine, Rochester, Minn.
| | - Jason H Szostek
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Mayo Clinic School of Medicine, Rochester, Minn
| | - Majken T Wingo
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, Mayo Clinic School of Medicine, Rochester, Minn
| | - Jason A Post
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, Mayo Clinic School of Medicine, Rochester, Minn
| | - Karen F Mauck
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Mayo Clinic School of Medicine, Rochester, Minn
| |
Collapse
|
20
|
Bai AD, Srivastava S, Tomlinson GA, Smith CA, Bell CM, Gill SS. Mortality of hospitalised internal medicine patients bedspaced to non-internal medicine inpatient units: retrospective cohort study. BMJ Qual Saf 2017; 27:11-20. [PMID: 29101293 DOI: 10.1136/bmjqs-2017-006925] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 10/06/2017] [Accepted: 10/20/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare inhospital mortality of general internal medicine (GIM) patients bedspaced to off-service wards with GIM inpatients admitted to assigned GIM wards. METHOD A retrospective cohort study of consecutive GIM admissions between 1 January 2015 and 1 January 2016 was conducted at a large tertiary care hospital in Canada.Inhospital mortality was compared between patients admitted to off-service wards (bedspaced) and assigned GIM wards using a Cox proportional hazards model and a competing risk model. Sensitivity analyses included propensity score and pair matching based on GIM service team, workload, demographics, time of admission, reasons for admission and comorbidities. RESULTS Among 3243 consecutive GIM admissions, more than a third (1125, 35%) were bedspaced to off-service wards with the rest (2118, 65%) admitted to assigned GIM wards. In hospital, 176 (5%) patients died: 88/1125 (8%) bedspaced patients and 88/2118 (4%) assigned GIM ward patients. Compared with assigned GIM wards patients, bedspaced patients had an HR of 3.42 (95% CI 2.23 to 5.26; P<0.0001) for inhospital mortality at admission, which then decreased by HR of 0.97 (95% CI 0.94 to 0.99; P=0.0133) per day in hospital. Competing risk models and sensitivity analyses using propensity scores and pair matching yielded similar results. CONCLUSIONS Bedspaced patients had significantly higher inhospital mortality than patients admitted to assigned GIM wards. The risk was highest at admission and subsequently declined. The results of this single centre study may not be generalisable to other hospitals and may be influenced by residual confounding. Despite these limitations, the relationship between bedspacing and patient outcomes requires investigation at other institutions to determine if this common practice represents a modifiable patient safety indicator.
Collapse
Affiliation(s)
- Anthony D Bai
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | | | | | | | - Chaim M Bell
- Department of Medicine, Sinai Health System and University of Toronto, Toronto, ON, Canada
| | - Sudeep S Gill
- Department of Medicine, Queen's University, Kingston, ON, Canada
| |
Collapse
|
21
|
Card SE, Clark HD, Elizov M, Kassam N. The Evolution of General Internal Medicine (GIM)in Canada: International Implications. J Gen Intern Med 2017; 32:576-581. [PMID: 27778214 PMCID: PMC5400753 DOI: 10.1007/s11606-016-3891-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 08/18/2016] [Accepted: 09/26/2016] [Indexed: 10/20/2022]
Abstract
General internal medicine (GIM), like other generalist specialties, has struggled to maintain its identity in the face of mounting sub-specialization over the past few decades. In Canada, the path to licensure for general internists has been through the completion of an extra year of training after three core years of internal medicine. Until very recently, the Royal College of Physicians and Surgeons of Canada (RCPSC) did not recognize GIM as a distinct entity. In response to a societal need to train generalist practitioners who could care for complex patients in an increasingly complex health care setting, the majority of universities across Canada voluntarily developed structured GIM training programs independent of RCPSC recognition. However, interest amongst trainees in GIM was declining, and the GIM workforce in Canada, like that in many other countries, was in danger of serious shortfalls. After much deliberation and consultation, in 2010, the RCPSC recognized GIM as a distinct subspecialty of internal medicine. Since this time, despite the challenges in the educational implementation of GIM as a distinct discipline, there has been a resurgence of interest in this field of medicine. This paper outlines the journey of the Canadian GIM to educational implementation as a distinct discipline, the impact on the discipline, and the implications for the international GIM community.
Collapse
Affiliation(s)
- Sharon E Card
- Division of General Internal Medicine, University of Saskatchewan, Department of Internal Medicine, Royal University Hospital, 103 Hospital Drive, Saskatoon, SK, Canada.
| | - Heather D Clark
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Michelle Elizov
- Department of Medicine, McGill University, Montréal, QC, Canada
| | - Narmin Kassam
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
22
|
Yarnell CJ, Shadowitz S, Redelmeier DA. Hospital Readmissions Following Physician Call System Change: A Comparison of Concentrated and Distributed Schedules. Am J Med 2016; 129:706-714.e2. [PMID: 26976386 DOI: 10.1016/j.amjmed.2016.02.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 02/16/2016] [Accepted: 02/17/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Physician call schedules are a critical element for medical practice and hospital efficiency. We compared readmission rates prior to and after a change in physician call system at Sunnybrook Health Sciences Centre. METHODS We studied patients discharged over a decade (2004 through 2013) and identified whether or not each patient was readmitted within the subsequent 28 days. We excluded patients discharged for a surgical, obstetrical, or psychiatric diagnosis. We used time-to-event analysis and time-series analysis to compare rates of readmission prior to and after the physician call system change (January 1, 2009). RESULTS A total of 89,697 patients were discharged, of whom 10,001 (11%) were subsequently readmitted and 4280 died. The risk of readmission was increased by about 26% following physician call system change (9.7% vs 12.2%, P <.001). Time-series analysis confirmed a 26% increase in the readmission rate after call system change (95% confidence interval, 22%-31%; P <.001). The increase in readmission rate after call system change persisted across patients with diverse ages, estimated readmission risks, and medical diagnoses. The net effect was equal to 7240 additional patient days in the hospital following call system change. A modest increase was observed at a nearby acute care hospital that did not change physician call system, and no increase in risk of death was observed with increased hospital readmissions. CONCLUSION We suggest that changes in physician call systems sometimes increase subsequent hospital readmission rates. Further reductions in readmissions may instead require additional resources or ingenuity.
Collapse
Affiliation(s)
- Christopher J Yarnell
- Department of Medicine, University of Toronto, Ont., Canada; Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ont., Canada
| | - Steven Shadowitz
- Department of Medicine, University of Toronto, Ont., Canada; Division of General Internal Medicine, University of Toronto, Ont., Canada
| | - Donald A Redelmeier
- Department of Medicine, University of Toronto, Ont., Canada; Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ont., Canada; Division of General Internal Medicine, University of Toronto, Ont., Canada; Institute of Clinical Evaluative Sciences (ICES) in Ontario, Toronto, Canada; Institute for Health Policy Management and Evaluation, Toronto, Ont., Canada.
| |
Collapse
|
23
|
Martens PJP, Daniels H, Delforge M. Lymphoproliferative associated type 1 cryoglobulinemia. Acta Clin Belg 2016; 71:120-1. [PMID: 26271811 DOI: 10.1179/2295333715y.0000000057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Affiliation(s)
- Pieter Jan P Martens
- a Internal Medicine Resident, Department of Internal Medicine, Katholieke Universiteit Leuven - Universitair Ziekenhuis Leuven , Belgium Belgium
| | - Hugo Daniels
- b Department of Geriatrics , Ziekenhuis Oost Limburg , Genk , Belgium
| | - Michel Delforge
- c Department of Hematology , University hospital UZ Leuven , Belgium
| |
Collapse
|
24
|
Lau D, Majumdar SR, McAlister FA. Patient isolation precautions and 30-day risk of readmission or death after hospital discharge: a prospective cohort study. Int J Infect Dis 2016; 43:74-76. [PMID: 26751237 DOI: 10.1016/j.ijid.2015.12.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 12/15/2015] [Accepted: 12/24/2015] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Concerns have been raised that isolation precautions may have unintended consequences. The relationship between patient isolation and the 30-day risk of readmission or death among patients discharged from a general medicine ward was examined. METHODS A prospective cohort study of adult patients discharged to the community from seven general internal medicine wards in Edmonton, Alberta, Canada, from October 2013 to November 2014, was performed. Patients under contact, respiratory, or droplet precautions were considered isolated. Covariates measured at discharge included the Charlson comorbidity score, LACE index, clinical frailty, depression, anxiety, health-related quality of life, and patient satisfaction. Outcomes were measured at 30 days by telephone follow-up and provincial electronic health record query. RESULTS Of 495 patients (mean age 62 years, 51% female), 75 (18%) were isolated during their admission. Isolated and non-isolated patients had similar lengths of stay (6.2 vs. 6.2 days), depression, anxiety, health-related quality of life, and satisfaction scores at discharge (all p-values non-significant). At 30 days, 85 (17.2%) patients had been readmitted or had died (20.0% of isolated patients vs. 16.7% of non-isolated patients; adjusted odds ratio 1.11, 95% confidence interval 0.57-2.18). CONCLUSIONS In-hospital isolation does not appear to have an adverse impact on outcomes once patients are discharged from hospital.
Collapse
Affiliation(s)
- Darren Lau
- Division of General Internal Medicine, 5-134C Clinical Sciences Building, University of Alberta, 11350 83 Avenue, Edmonton, Alberta, Canada T6G 2G3
| | - Sumit R Majumdar
- Division of General Internal Medicine, 5-134C Clinical Sciences Building, University of Alberta, 11350 83 Avenue, Edmonton, Alberta, Canada T6G 2G3
| | - Finlay A McAlister
- Division of General Internal Medicine, 5-134C Clinical Sciences Building, University of Alberta, 11350 83 Avenue, Edmonton, Alberta, Canada T6G 2G3; Patient Health Outcomes Research and Clinical Effectiveness Unit (PHORCE), University of Alberta, Edmonton, Alberta, Canada.
| |
Collapse
|
25
|
Lau D, Padwal RS, Majumdar SR, Pederson JL, Belga S, Kahlon S, Fradette M, Boyko D, McAlister FA. Patient-Reported Discharge Readiness and 30-Day Risk of Readmission or Death: A Prospective Cohort Study. Am J Med 2016; 129:89-95. [PMID: 26344631 DOI: 10.1016/j.amjmed.2015.08.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 08/11/2015] [Accepted: 08/14/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Early readmissions to hospital after discharge are common, and clinicians cannot accurately predict their occurrence. We examined whether patients who feel unready at the time of discharge have increased readmissions or death within 30 days. METHODS This was a prospective cohort study of adult patients discharged home from 2 tertiary care hospitals in Edmonton, Alberta, Canada, between October 2013 and November 2014. Patient-reported discharge readiness was measured with an 11-point Likert response scale, with scores <7 indicating subjective unreadiness. The primary outcome was readmission or death within 30 days. Logistic regression models were adjusted for age, sex, and a validated risk prediction score for postdischarge events (LACE index). RESULTS Of 495 patients (mean age 62 years, 51% female, mean Charlson comorbidity index 2.8), 112 (23%) reported being unready for discharge. Risk factors for being unready at discharge were cognitive impairment (mild vs none), low satisfaction with health care services, depression, lower education, previous hospital admissions (12 months), and persistent symptoms or disability. At 30 days, 85 patients (17%) had been readmitted or died, with no significant difference between patients who felt unready or ready (15% vs 18%, adjusted odds ratio 0.84, 95% confidence interval 0.46-1.54, P = .59). CONCLUSIONS Although nearly one-quarter of hospitalized medical patients reported being unready at the time of discharge, they did not experience any higher risk of readmission or death in the first 30 days after discharge, compared with patients who felt ready for discharge.
Collapse
Affiliation(s)
- Darren Lau
- Division of General Internal Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Raj S Padwal
- Division of General Internal Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sumit R Majumdar
- Division of General Internal Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jenelle L Pederson
- Division of General Internal Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sara Belga
- Division of General Internal Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sharry Kahlon
- Division of General Internal Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Miriam Fradette
- Epidemiology Coordinating and Research Centre (EPICORE), University of Alberta, Edmonton, Alberta, Canada
| | - Debbie Boyko
- Epidemiology Coordinating and Research Centre (EPICORE), University of Alberta, Edmonton, Alberta, Canada
| | - Finlay A McAlister
- Division of General Internal Medicine, University of Alberta, Edmonton, Alberta, Canada; Patient Health Outcomes Research and Clinical Effectiveness Unit (PHORCE), University of Alberta, Edmonton, Alberta, Canada.
| |
Collapse
|
26
|
Abstract
The Future Hospital Commission has highlighted the need for increased general medical skills in the medical workforce in order to meet the increasing demands on the NHS in terms of patients with increasing age, frailty and complex comorbidities. However there continues to be a lack of clarity around the concept of generalism and general internal medicine (GIM), with differing views on the physician's role in GIM. This survey sought to explore further the roles in which current physicians perceive they are practising GIM as well as views on training in GIM. The survey highlights three key points: (i) that consultant perception and practice of GIM continues to vary dependent on physician specialty; (ii) that the practice of GIM is not limited to the front door but includes the management of patients under the care of a specialty team with general medical needs, be that in an inpatient, outpatient or acute care setting; and (iii) that training in GIM needs to reflect this variation in roles and practice.
Collapse
Affiliation(s)
| | - Nina Newbery
- Medical Workforce Unit, Royal College of Physicians, London, UK
| | | |
Collapse
|
27
|
Sundsted KK, Wieland ML, Szostek JH, Post JA, Mauck KF. Update in outpatient general internal medicine: practice-changing evidence published in 2014. Am J Med 2015; 128:1065-9. [PMID: 26052025 DOI: 10.1016/j.amjmed.2015.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 04/13/2015] [Accepted: 04/13/2015] [Indexed: 11/17/2022]
Abstract
The practice of outpatient general internal medicine requires a diverse and evolving knowledge base. General internists must identify practice-changing shifts in the literature and reflect on their impact. Accordingly, we conducted a review of practice-changing articles published in outpatient general internal medicine in 2014. To identify high-quality, clinically relevant publications, we reviewed all titles and abstracts published in the following primary data sources in 2014: New England Journal of Medicine, Journal of the American Medical Association (JAMA), Annals of Internal Medicine, JAMA Internal Medicine, and the Cochrane Database of Systematic Reviews. All 2014 primary data summaries from Journal Watch-General Internal Medicine and ACP JournalWise also were reviewed. The authors used a modified Delphi method to reach consensus on inclusion of 8 articles using the following criteria: clinical relevance to outpatient internal medicine, potential for practice change, and strength of evidence. Clusters of important articles around one clinical question were considered as a single-candidate series. The article merits were debated until consensus was reached on the final 8, spanning a variety of topics commonly encountered in outpatient general internal medicine.
Collapse
Affiliation(s)
- Karna K Sundsted
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, Minn.
| | - Mark L Wieland
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, Minn
| | - Jason H Szostek
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, Minn
| | - Jason A Post
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, Minn
| | - Karen F Mauck
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, Minn
| |
Collapse
|
28
|
Abstract
OBJECTIVES Annually, millions of pairs of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) tests are ordered. These enzymes are highly correlated, and ALT is far more specific diagnostically than AST. To reduce AST testing, we suggest measuring AST only when ALT exceeds a predetermined limit. METHODS We derived the proportions of elevated ASTs that would not be measured based on 15 months of paired inpatient and outpatient ALT and AST data. RESULTS For inpatients, a 35 U/L ALT limit for initiating AST testing would reduce AST testing by 51%, missing only 3% and 7.5% of ASTs exceeding 50 U/L and 35 U/L, respectively. In outpatients, AST testing can be reduced by more than 65%, with fewer missed elevated ASTs (0.5% and 2% of the ASTs exceeding 50 U/L and 35 U/L, respectively). CONCLUSIONS Conservatively, $100 million could be saved annually in the US health care budget by selectively limiting AST testing in just the US outpatient environment.
Collapse
Affiliation(s)
- Qian Xu
- University of Alberta Hospital, Edmonton, Canada
| | | | - George S. Cembrowski
- Department of Laboratory Medicine and Pathology, University of Alberta Hospital, Edmonton, Canada
| |
Collapse
|