Tag: pubmed

JAMA Netw Open. 2025 Jun 2;8(6):e2513285. doi: 10.1001/jamanetworkopen.2025.13285.

ABSTRACT

IMPORTANCE: Integrating artificial intelligence (AI) technologies into gatekeeping holds significant potential, as it efficiently handles repetitive tasks and can process large amounts of information quickly.

OBJECTIVE: To develop and assess the accuracy of an AI model that enhances the gatekeeping process for referrals to specialized care.

DESIGN, SETTING, AND PARTICIPANTS: This diagnostic study comprised referrals from primary care to endocrinology, gastroenterology, proctology, rheumatology, and urology from a retrospective administrative database of patients in Brazil between June 2016 and April 2019. Analysis was performed between December 2022 and July 2024.

MAIN OUTCOMES AND MEASURES: The algorithm’s development and testing comprised 2 stages. Multiple AI models were initially evaluated to train and test the algorithm for categorizing referrals as authorizing or requiring additional information. Subsequently, the model’s performance was assessed against an independent set of referrals. Additionally, the current (human) evaluations of gatekeepers were evaluated against the standard. The reference standard was the consensus of 2 physicians with extensive experience. Accuracy, sensitivity, specificity, and area under the receiver operating characteristic curve (AUC-ROC) were assessed.

RESULTS: The electronic system retrieved 45 039 eligible referrals for the development stage (mean [SD] patient age, 51.9 [15.8] years; 25 458 women [56.5%]). An algorithm utilizing word embeddings and a neural network proved the most effective. In the second phase, 1750 referrals (350 for each specialty) showed a 32% authorization rate according to the reference standard. The AI model achieved an overall accuracy of 0.716 (95% IC, 0.694-0.737), with a sensitivity of 0.542 (95% CI, 0.501 to 0.582) and specificity of 0.801 (95% CI, 0.777 to 0.822). Regarding individual specialties, rheumatology exhibited the highest accuracy (0.811; 95% IC, 0.767-0.849), while proctology had the lowest (0.649; 95% IC, 0.597-0.697). The overall AUC-ROC was 0.765 (95% IC, 0.742-0.788). When compared against the consensus standard, the AI model had higher accuracy and specificity and lower sensitivity than the current approach.

CONCLUSIONS AND RELEVANCE: In this diagnostic study of referral data, a novel AI model effectively distinguished between referrals that warranted immediate authorization and those that required further information with moderate accuracy; it had higher specificity and lower sensitivity than gatekeepers decisions. Implementing this AI model in the gatekeeping process should combine human judgment and AI support to optimize the referral process.

PMID:40459894 | DOI:10.1001/jamanetworkopen.2025.13285

JAMA Netw Open. 2025 Jun 2;8(6):e2513366. doi: 10.1001/jamanetworkopen.2025.13366.

ABSTRACT

IMPORTANCE: Transcatheter closure of the patent ductus arteriosus (PDA) has increasingly been adopted in extremely preterm infants as a method to definitively close the PDA while avoiding the inherent risks of surgical ligation. Differences in respiratory outcomes after transcatheter closure compared with surgical ligation have not been substantiated, particularly in the context of timing of the intervention.

OBJECTIVE: To characterize respiratory outcomes in extremely preterm infants with PDA treated with transcatheter device closure compared with surgical ligation.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study assessed data from preterm infants born at less than 29 weeks’ gestation or with birth weight less than 1000 g who underwent definitive PDA closure in neonatal intensive care units participating in the Neonatal Research Network’s Generic Database between January 1, 2016, and December 31, 2020. Data were analyzed from October 2021 to February 2024.

EXPOSURES: PDA treatment with transcatheter device closure or with surgical ligation.

MAIN OUTCOMES AND MEASURES: The primary outcome was total days of mechanical ventilation.

RESULTS: Of 3806 included infants with a PDA diagnosis, 202 underwent transcatheter PDA closure (median [IQR] gestational age, 25.4 [24.1-27.1] weeks; 114 [56%] female) and 359 underwent surgical ligation (median [IQR] gestational age, 24.9 [24.0-25.9] weeks; 187 [52%] female). Infant age at transcatheter closure was older than at surgical ligation (mean [SD], 58.7 [28.4] vs 33.6 [16.7] days; P < .001). After adjustment of analyses for center, birth year, gestational age, age at PDA intervention, and prior pharmacologic treatment, infants with transcatheter closure compared with surgical ligation had comparable respiratory outcomes, including total days of mechanical ventilation (adjusted median difference, -2.65 [95% CI, -8.36 to 3.07] days; P = .36).

CONCLUSIONS AND RELEVANCE: In this cohort study of extremely preterm infants who underwent transcatheter closure compared with surgical ligation for treatment of PDA, respiratory outcomes did not differ, although the transcatheter closure group had a longer duration of PDA exposure. Future research evaluating outcomes after transcatheter PDA closure should assess the optimal timing of definitive intervention.

PMID:40459893 | DOI:10.1001/jamanetworkopen.2025.13366

JAMA Netw Open. 2025 Jun 2;8(6):e2513394. doi: 10.1001/jamanetworkopen.2025.13394.

ABSTRACT

IMPORTANCE: The role of supplemental coverage (eg, Medigap) in Medicare enrollment and disenrollment is understudied among beneficiaries with cancer. Understanding the association between initially selecting a supplement and switching plans is necessary to ensure adequate and affordable coverage for beneficiaries with high-cost health conditions.

OBJECTIVE: To evaluate Medicare plan switching by initial plan selection and history of cancer.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study used data from the Health and Retirement Study, from 2008 to 2020. Respondents were aged 65 or 66 years at initial Medicare plan selection and completed 2 consecutive surveys. Analyses were conducted from November 2023 to October 2024.

EXPOSURES: Self-reported initial Medicare plan selection (traditional Medicare [TM] without supplemental coverage, TM plus supplemental coverage, or Medicare Advantage [MA]) and history of cancer.

MAIN OUTCOMES AND MEASURES: The primary outcome was self-reported Medicare plan switching in the 2 years after initial plan selection. Modified Poisson regression was used to assess the association between initial Medicare plan selection and plan switching. Models adjusted for baseline sociodemographic and health-related characteristics and were stratified by a history of cancer.

RESULTS: Among 2852 respondents aging into Medicare (1113 male [39.02%]), 1511 (52.98%) initially selected TM plus supplemental coverage and 358 (12.55%) reported a history of cancer. Less than one-third of beneficiaries (786 beneficiaries without a history of cancer [31.52%] and 106 beneficiaries with a history of cancer [29.61%]) switched coverage in the 2 years after initial plan selection. Most beneficiaries switched from TM without supplemental coverage to benefits with greater financial protections; 131 of 227 beneficiaries without a history of cancer (57.71%) switched to MA, and 18 of 27 beneficiaries with a history of cancer (66.67%) switched to TM plus supplemental coverage. Among beneficiaries without a history of cancer, initial selection of MA (adjusted risk ratio [aRR], 0.55; 95% confidence limit [CL], 0.47-0.64) or TM plus supplemental coverage (aRR, 0.63; 95% CL, 0.55-0.72) was associated with a lower probability of switching coverage compared with initial selection of TM without supplemental coverage. Findings were similar for beneficiaries with a history of cancer.

CONCLUSIONS AND RELEVANCE: In this cohort study of older adults with and without a history of cancer, initial selection of MA or TM plus supplemental coverage was associated with a low likelihood of switching coverage. Given that benefits with greater financial protections may meet beneficiaries’ evolving needs and preferences, policymakers should consider improving the adequacy of TM.

PMID:40459892 | DOI:10.1001/jamanetworkopen.2025.13394

JAMA Netw Open. 2025 Jun 2;8(6):e2513527. doi: 10.1001/jamanetworkopen.2025.13527.

ABSTRACT

IMPORTANCE: National statistics about regionalization and access to hospitals’ pediatric services have been derived from different datasets with differing sampling frames, sizes, and designs, generating conflicting estimates about pediatric service accessibility.

OBJECTIVE: To calculate test characteristics for the provision of pediatric hospital-based inpatient services in 3 national datasets and explore models for improving service identification in a merged dataset.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study analyzed pediatric services in 3114 US hospitals common across the American Hospital Association Annual Survey (AHA), Centers for Medicare & Medicaid Services Provider of Service File (POS), and National Pediatric Readiness Project (NPRP) in 2021. Analysis was conducted June 2024 to March 2025.

EXPOSURE: Provision of 4 pediatric services-newborn, neonatal intensive care, general pediatric inpatient care, and pediatric intensive care.

MAIN OUTCOMES AND MEASURES: Test characteristics and model performance were calculated and reported as F1 scores, a machine learning evaluation metric that calculates the harmonic mean of precision and recall within a model, for the provision of services as reported in the AHA and POS relative to the NPRP, this study’s benchmark for pediatric service reporting. Logistic regression, random forest, gradient-boosted trees, and rule-based models were tested to estimate pediatric service provision using a merged dataset.

RESULTS: Of 3114 hospitals, NPRP identified 2742 providing newborn care (88.1%), 1375 with neonatal intensive care (44.2%), 2204 offering general pediatric care (70.8%), and 450 with pediatric intensive care (14.5%). For newborn care, AHA data showed 95.7% agreement with NPRP (F1 = 0.97; 95% CI, 0.96-0.97), while POS showed 89.4% (F1 = 0.62; 95% CI, 0.60-0.64). For neonatal intensive care, agreement was 89.8% for AHA (F1 = 0.86; 95% CI, 0.85-0.88) and 72.9% for POS (F1 = 0.75; 95% CI, 0.74-0.77). General pediatric care showed lower agreement, with AHA showing 65.6% agreement (F1 = 0.69; 95% CI, 0.67-0.71) and POS showing 69.7% agreement (F1 = 0.79; 95% CI, 0.77-0.80). For pediatric intensive care, AHA agreement was 81.5% (F1 = 0.91; 95% CI, 0.90-0.93) while POS was 78.3% (F1 = 0.49; 95% CI, 0.46-0.51). Merging datasets modestly improved service identification accuracy.

CONCLUSIONS AND RELEVANCE: In this cross-sectional study of commonly used datasets, reporting of pediatric service provision varied significantly. As these datasets inform pediatric health care policy, these results may guide approaches to optimize service line definitions.

PMID:40459891 | DOI:10.1001/jamanetworkopen.2025.13527

JAMA Netw Open. 2025 Jun 2;8(6):e2513537. doi: 10.1001/jamanetworkopen.2025.13537.

ABSTRACT

IMPORTANCE: The US has the highest incarceration rates in the developed world. The harms of incarceration have long-term health implications, including increased mortality. Existing studies of incarceration-related mortality are limited by data sources and design.

OBJECTIVE: To examine the associations between both individual- and area-level incarceration rates with all-cause and overdose mortality in the US.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study used data from the Mortality Disparities in American Communities (MDAC) study, linking over 3 million 2008 American Community Survey (ACS) respondents to National Death Index data from the respondents’ 2008 interview date through December 31, 2019, or their date of death, and county incarceration data from the Vera Institute of Justice. The sample included US adults 18 years or older, representing individuals in group quarters such as prisons and jails but excluding those in counties lacking jail incarceration rate data. Data were analyzed from July 5, 2023, to November 10, 2024.

EXPOSURE: Individual incarceration status at the time of the ACS survey and county jail incarceration rates.

MAIN OUTCOMES AND MEASURES: The outcomes of interest were all-cause mortality and overdose mortality, assessed through time-to-event analyses. Cox proportional hazard models were used to estimate mortality risks, adjusting for individual- and county-level characteristics. ACS survey weights were applied so that the final sample represents the US adult population.

RESULTS: The study includes a total of 3 255 000 individuals (51.3% female), of whom 45 000 (0.93%) were incarcerated at the time of the 2008 ACS administration. The mean (SD) county jail incarceration rate was 372 (358) per 100 000 people. During the study period, 431 000 individuals (11.6%) died from any cause, and 5500 (0.2%) died from overdoses. Incarcerated individuals had a higher risk of all-cause mortality (hazard rate [HR], 1.39 [95% CI, 1.33-1.45]) and an increased risk of overdose mortality (HR, 3.08 [95% CI, 2.70-3.52]) compared with nonincarcerated individuals. A 10% increase in county jail incarceration rates was associated with 4.6 (95% CI, 3.8-5.5) additional all-cause deaths per 100 000 people.

CONCLUSIONS AND RELEVANCE: In this cohort study of 3.26 million individuals in the US, results highlighted the dual burden of incarceration on health outcomes. Individuals who were incarcerated faced significantly higher risks of death, particularly from overdoses, and elevated county incarceration rates exacerbated individual-level mortality risks. These findings suggest the need for reforms in criminal justice and public health policies to address these elevated risks and their widespread implications.

PMID:40459890 | DOI:10.1001/jamanetworkopen.2025.13537

JAMA Netw Open. 2025 Jun 2;8(6):e2513578. doi: 10.1001/jamanetworkopen.2025.13578.

ABSTRACT

IMPORTANCE: Given that nearly one-third of US births are cesarean deliveries, subsequent births after a cesarean delivery are common. Racial and ethnic disparities in severe maternal morbidity (SMM) have been well-documented, and prior studies have identified differences in birth mode after prior cesarean delivery by race and ethnicity.

OBJECTIVE: To examine variation by race and ethnicity in the association between SMM and birth mode for individuals with a prior cesarean delivery.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used Massachusetts linked birth certificate and hospital discharge data from 2012 to 2021. The analytic sample was limited to births to individuals with 1 prior cesarean delivery. Data were analyzed from August 23, 2024, to March 31, 2025.

EXPOSURES: Race and ethnicity and birth mode (vaginal birth after cesarean delivery, planned repeat cesarean delivery, and unplanned repeat cesarean delivery).

MAIN OUTCOME AND MEASURES: SMM was measured using Centers for Disease Control and Prevention indicators. Associations of race and ethnicity and birth mode with SMM were calculated using logistic regression, then an interaction term was added between race and ethnicity and birth mode. Models controlled for covariates.

RESULTS: The study population included 72 836 individuals (mean [SD] age, 32.40, [5.03] years), of whom 8022 (11.0%) were Black, 14 664 (20.1%) were Latinx, and 41 350 (56.8%) were White. Approximately one-third of individuals were born outside the US (25 119 individuals [34.5%]). In adjusted analyses, Black individuals had higher odds of SMM compared with White individuals (adjusted odds ratio [AOR], 1.60; 95% CI, 1.25-2.05). Odds of SMM were higher for unplanned repeat cesarean birth (AOR, 3.05; 95% CI, 2.23-4.18) compared with vaginal birth after cesarean delivery, and higher for planned repeat cesarean birth compared with vaginal birth after cesarean delivery (AOR, 1.57; 95% CI, 1.20-2.06). Including an interaction term identified variation in the association between birth mode and SMM by race and ethnicity. Planned repeat cesarean birth vs VBAC was associated with an increase in the likelihood of SMM of 0.56 (95% CI, 0.21-0.90) percentage points (P = .001) among Black birthing people and 0.46 (95% CI, 0.16-0.76) percentage points (P = .003) among Latinx birthing people, while among White individuals, the likelihood of SMM did not differ between planned repeat cesarean birth and VBAC.

CONCLUSIONS AND RELEVANCE: In this cross-sectional study of births among individuals with a prior cesarean birth, patterns of SMM by birth mode varied by race and ethnicity, with elevated rates of SMM among those from marginalized racial and ethnic groups with planned cesarean births. Future work should identify interventions to improve quality of care and promote equity for this population.

PMID:40459888 | DOI:10.1001/jamanetworkopen.2025.13578

Am J Hosp Palliat Care. 2025 Jun 3:10499091251346479. doi: 10.1177/10499091251346479. Online ahead of print.

ABSTRACT

BackgroundPhysicians’ unpreparedness to conduct conversations around serious illness creates a barrier to initiating effective goals of care conversations. Teaching primary palliative care communication skills in medical school is paramount to overcome this barrier.ObjectiveTo evaluate the effectiveness of an innovative, immersive primary palliative care communication skills workshop for fourth-year medical students and to incorporate professional actors with teaching experience into the medical school curriculum.MethodsAn interactive, scenario-based, day-long workshop utilizing professional actors as faculty was developed and conducted multiple times annually for 4 years. Students completed online surveys before, immediately after, and 3-6 months after the workshop. Likert scales assessed student self-perceived comfort with skills learned and short response queries evaluated student experiences. Descriptive statistics and one-way ANOVA repeated measures test were used. Qualitative data was double coded and thematically analyzed.Results226 students participated in the workshop; 100%. Responded to the pre-survey, 170 (75.2%) responded to the post-survey, and 133 (58.8%) responded to the post-3-6 months survey. The mean self-perceived comfort between the pre-survey and both post- and post-3-6 months surveys was statistically significant (P < 0.05) for all skills taught. Students reported integrating learned skills and found subjective success in their improved approaches to communication with patients.ConclusionAn innovative primary palliative care communication skills workshop using trained professional actors improved and maintained fourth-year medical students’ self-perceived primary palliative care communication skills. Widespread education of primary palliative care communication skills to medical students with trained actors as faculty could improve physician-patient communication around goals of care.

PMID:40459857 | DOI:10.1177/10499091251346479

Traffic Inj Prev. 2025 Jun 3:1-6. doi: 10.1080/15389588.2025.2458589. Online ahead of print.

ABSTRACT

OBJECTIVE: Despite the mandatory use of seatbelts in Korea, their prevalence remains comparatively low. This study examines whether DUIA, a leading risk factor for road traffic injuries, predicts seatbelt usage by analyzing the prevalence of seatbelt use among individuals who have experienced DUIA compared to those who have not.

METHODS: This cross-sectional study utilized data from 9,227 driver’s license holders aged 20 years or older from the Korea National Health and Nutrition Examination Survey (KHANES) conducted between 2019 and 2021. Multivariable logistic regression analysis was conducted to investigate the association between experience of DUIA and seatbelt use while adjusting for individual-level covariates. A stratified analysis was conducted based on sociodemographic variables. Finally, a subgroup analysis was performed to examine the association between experience of DUIA and frequency of seatbelt use in each seat type (the driver’s seat, the front passenger seat, and the rear seat).

RESULTS: This study showed that having an experience of DUIA is significantly associated with not wearing seatbelts. (aOR, 3.53 [95% CI, 2.55-4.88]). Stratification based on sociodemographic variables showed that one’s job type (pink collar: aOR, 5.67 [95% CI, 2.03-15.88]; blue collar: aOR, 5.35 [95% CI, 3.03-9.47]), and smoking status (current smokers: aOR, 5.67 [95% CI, 2.72-11.82]) increase the prevalence of experience of DUIA. Furthermore, experience of DUIA was associated with an increased prevalence of not wearing seatbelts in all seat types.

CONCLUSION: The prevalence of experience of DUIA can be established as a statistically significant independent predictor of seatbelt usage among Korean adults.

PMID:40459850 | DOI:10.1080/15389588.2025.2458589

Eur Arch Paediatr Dent. 2025 Jun 3. doi: 10.1007/s40368-025-01056-z. Online ahead of print.

ABSTRACT

OBJECTIVES: Given the prevalence of physical abuse toward the head and face, dental care settings are frequently the first point of contact for victims of violence. Dentists, like other medical practitioners, have a primary responsibility to safeguard patient health and life, hence they can be crucial in identifying and reporting violent victims. Therefore, this study was directed to assess the attitudes and perceptions of Palestinian dentists regarding child abuse and to investigate professional characteristics associated with the identification of suspected child abuse.

MATERIALS AND METHODS: A questionnaire was sent to the 745 dentists of Palestine and 380 (51.0%) were returned. Demographic data, profiles of dentists, information regarding their knowledge and attitudes concerning child abuse, and the obstacles that may stop them from reporting abuse cases were collected. Descriptive analysis was performed, and associations were tested by chi-square and Fisher’s exact tests.

RESULTS: Most dentists were general practitioners (88.9%), nine of whom were boarded paediatric dentists. 217 (58.2%) considered themselves fit to identify signs of abuse even so, 93.5% do not report the abuse cases. A statistically higher proportion of specialist dentists, working in the public sector, having more practice and who have children had suspected cases of child abuse.

CONCLUSIONS: Although dentists considered themselves able to identify cases of child maltreatment, a high proportion of them do not report the abuse cases, this is related to many factors, such as less experience, little information, no training, and less confidence to report child abuse. Improved training in forensic and legal dentistry is needed, together with the establishment of detection and reporting protocols.

PMID:40459842 | DOI:10.1007/s40368-025-01056-z

Bull Math Biol. 2025 Jun 3;87(7):90. doi: 10.1007/s11538-025-01458-6.

ABSTRACT

Melanoma progression can be effectively modeled through mathematical frameworks, making it a pivotal focus for enhancing our understanding of cancer dynamics and informing personalized treatment strategies. The present research investigates the growth dynamics of melanoma by analyzing 16 individual melanoma cell lines, utilizing in vivo clinical data that spans a range of metastatic stages from primary melanoma to stage IV. The study estimates growth rates across these cell lines by implementing a power law model through nonlinear least squares, uncovering distinct mathematical patterns linked to melanoma stages. Furthermore, the research evaluates the efficacy of various treatment strategies tailored to each disease stage through a chemoimmunotherapy mathematical model. For primary and early-stage melanoma, where tumors are localized, surgical excision is identified as the most effective intervention, often enhanced by CD4⁺T cell immunotherapy. In cases of low to moderately metastatic melanoma, a combination of low-dose chemotherapy with CD8⁺T cell immunotherapy effectively targets metastatic lesions, reducing systemic toxicity while promoting a strong immune response. For highly metastatic melanoma, which presents significant treatment challenges, a combination therapy involving both CD8⁺T and CD4⁺T cell immunotherapy is recommended. This dual approach utilizes the direct tumor-killing effects of CD8⁺T cells alongside the supportive actions of CD4⁺T cells, resulting in improved treatment efficacy and survival outcomes. Overall, this research provides a comprehensive analysis of melanoma cell lines at various stages, integrating mathematical modeling with treatment efficacy to enhance personalized treatment strategies in melanoma management.

PMID:40459814 | DOI:10.1007/s11538-025-01458-6