Tag: pubmed

JAMA Netw Open. 2025 Jun 2;8(6):e2517965. doi: 10.1001/jamanetworkopen.2025.17965.

ABSTRACT

IMPORTANCE: Prescriptions for potentially inappropriate medications are common and, by definition, may carry risks that outweigh benefits.

OBJECTIVE: To determine whether interventions to address potentially inappropriate prescribing for older primary care patients are associated with changes in the number of medications prescribed, drug-related harms, hospitalizations, and mortality.

DATA SOURCES: MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from inception to September 6, 2024.

STUDY SELECTION: Randomized clinical trials of interventions to address potentially inappropriate prescribing for older primary care patients (aged ≥65 years) residing in the community or in long-term care facilities, such as nursing homes or assisted-living facilities, were included.

DATA EXTRACTION AND SYNTHESIS: Two researchers independently screened the records and abstracted data using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline. Data were pooled using random-effects models.

MAIN OUTCOMES AND MEASURES: The planned outcomes were the number of medications, nonserious adverse drug reactions, injurious falls, quality of life, medical visits, emergency department visits, hospitalizations, and all-cause mortality. Random-effects meta-analyses were performed using the inverse variance method for similar studies, reporting risk ratios (RRs) or standardized mean differences (SMDs). Heterogeneity was assessed with I2 values, and publication bias was assessed with funnel plots and the Egger regression test.

RESULTS: Of the 14 649 records identified, 118 randomized clinical trials (comprising 417 412 patients) were included in this review. Interventions to address potentially inappropriate prescribing were associated with a reduction in the number of medications prescribed (SMD, -0.25 [95% CI, -0.38 to -0.13]), equivalent to approximately 0.5 fewer medications per patient. However, there were no substantial differences in the other outcomes, including nonserious adverse drug reactions (RR, 0.92 [95% CI, 0.58-1.46]), injurious falls (SMD, 0.01 [95% CI, -0.12 to 0.14]), quality of life (SMD, 0.09 [95% CI, -0.04 to 0.23]), medical visits (SMD, 0.02 [95% CI, -0.02 to 0.07]), emergency department admissions (RR, 1.02 [95% CI, 0.96-1.08]), hospitalizations (RR, 0.95 [95% CI, 0.89-1.02]), or all-cause mortality (RR, 0.94 [95% CI, 0.85-1.04]).

CONCLUSIONS AND RELEVANCE: In this systematic review and meta-analysis, interventions to address potentially inappropriate prescribing were associated with reductions in the number of medications prescribed, with no substantial change in other outcomes. These findings suggest that inappropriate prescribing interventions may be implemented to safely reduce the number of medications prescribed to older adults in the primary care setting. Future studies should continue to evaluate these interventions using standardized criteria and consistently report potential harms to support data synthesis and capture key outcomes such as quality of life, hospitalization, and mortality.

PMID:40577011 | DOI:10.1001/jamanetworkopen.2025.17965

JAMA Health Forum. 2025 Jun 7;6(6):e251467. doi: 10.1001/jamahealthforum.2025.1467.

ABSTRACT

IMPORTANCE: Many individuals in the US face a high risk of losing their health insurance coverage and experiencing insurance churn, especially those enrolled in Medicaid. Prior research has found that the risk of losing insurance coverage remains high in the US even after the Patient Protection and Affordable Care Act significantly reduced the number of uninsured individuals.

OBJECTIVE: To estimate whether the Families First Coronavirus Response Act (FFCRA) decreased insurance churn.

DESIGN, SETTING, AND PARTICIPANTS: This study used 2 quasi-experimental approaches: an interrupted time series approach and a difference-in-difference approach. Both approaches use individual-level data from the Medical Expenditure Panel Survey from January 2015 to December 2022. In the difference-in-difference analysis comparing individuals with Medicaid to individuals with private health insurance coverage, the probability that insured individuals aged 2 to 64 years lose insurance over the next 12 months before and after the FFCRA was estimated. Data were analyzed from January to November 2024.

MAIN OUTCOMES AND MEASURES: Primary outcome was the share of insured individuals who lost insurance coverage over the next 12 months. This measure was defined for all insured individuals and defined separately for individuals with Medicaid and for individuals with private insurance coverage.

RESULTS: The sample included 96 473 individuals. Of these, 46 779 (49.7%) were male, and the mean (SD) age was 31.9 (18.1) years. In the interrupted time series analysis, the FFCRA was associated with a reduction in insurance churn by 2.06 percentage points (β = -0.021; 95% CI, -0.024 to -0.018; P < .001). In the difference-in-difference analysis, the FFRCA reduced Medicaid churn by 5.51 percentage points (β = -0.055; 95% CI, -0.060 to -0.050; P < .001). Combining these estimates, 65.0% (95% CI, 54.8-75.3) of the reduction in insurance churn came from the reduction in Medicaid churn.

CONCLUSIONS AND RELEVANCE: In this study, the FFCRA was associated with a significantly decreased risk of losing health insurance. Without the FFCRA, an estimated 2.94 million individuals with Medicaid would have lost insurance coverage each year during the COVID-19 public health emergency.

PMID:40577007 | DOI:10.1001/jamahealthforum.2025.1467

JAMA Health Forum. 2025 Jun 7;6(6):e251630. doi: 10.1001/jamahealthforum.2025.1630.

ABSTRACT

IMPORTANCE: The American Rescue Plan of 2021 allowed states to expand pregnancy Medicaid coverage to 12 months post partum. How the new policy affects Medicaid coverage and health care utilization is largely unknown.

OBJECTIVES: To quantify insurance coverage and care utilization for postpartum individuals under Medicaid policies that extended postpartum coverage to 12 months after delivery from 60 days.

DESIGN, SETTING, AND PARTICIPANTS: A retrospective study of Medicaid coverage and utilization in North Carolina using Medicaid claims from March 2016 to December 2023 was conducted. All Medicaid-funded births in North Carolina from January 2017 through December 2022 were included.

EXPOSURE: A total of 3 periods were differentiated: before the COVID-19 public health emergency (PHE), during the PHE when there was a moratorium on Medicaid disenrollment, and after North Carolina adopted the 12-month postpartum extension through the American Rescue Plan of 2021.

MAIN OUTCOMES AND MEASURES: Length and type of postpartum Medicaid enrollment were evaluated. Utilization outcomes included indicators of (1) the receipt of at least 1 postpartum visit; (2) any contraceptive visit; (3) any primary care visit; (4) any outpatient mental health care, and (5) any outpatient substance use disorder (SUD) care.

RESULTS: There were 353 957 Medicaid-funded births in North Carolina from January 2017 through December 2022. During the postpartum extension, Medicaid recipients were more likely to have been continuously covered by comprehensive Medicaid at 12 months post partum (97.1% vs 26.5% pre-PHE). Beneficiaries in the extended coverage cohorts were substantially more likely to use Medicaid-financed care than those in the pre-PHE cohort for contraception (47.8% for the PHE cohort and 47.9% for the extension cohort vs 38.0% for the pre-PHE cohort), primary care (68.1% for the PHE cohort and 71.4% for the extension cohort vs 25.3% for the pre-PHE cohort), mental health (22.1% for the PHE cohort and 25.7% for the extension cohort vs 7.5% for the pre-PHE cohort) and substance use disorder visits (3.6% for the PHE cohort and 5.3% for the extension cohort vs 2.2%for the pre-PHE cohort) within 12 months, although there was evidence of delays in early postpartum and contraceptive visits.

CONCLUSIONS AND RELEVANCE: Results of this study suggest that extending Medicaid coverage for 12 months post partum was associated with expanded opportunities for greater access to Medicaid-financed medical and behavioral health care. Both prevention and ongoing treatment of chronic conditions may help mitigate key adverse outcomes. Findings may help policymakers and public health officials understand how extended coverage affects access to Medicaid-financed care.

PMID:40577006 | DOI:10.1001/jamahealthforum.2025.1630

Eur J Gen Pract. 2025 Dec;31(1):2520218. doi: 10.1080/13814788.2025.2520218. Epub 2025 Jun 27.

ABSTRACT

BACKGROUND: Emergency room (ER) utilisation by ambulatory patients with low urgency medical problems leads to ER-capacity use and long waiting times. Establishing General Practice (GP)-led urgent care practices (UCP) adjacent to ERs allows to triage patients from the ER to the UCP. However, patients may perceive themselves as ER-cases and expect ER-treatment including extensive diagnostics.

OBJECTIVES: To assess UCP-patients’ satisfaction compared to ambulatory ER-patients.

METHODS: Sub-analysis (11/2019-01/2020) of a prospective, monocentric observational study at the University Medical Centre Hamburg-Eppendorf ER and co-located UCP focusing on patient survey data including demographics, waiting time and diagnoses. Satisfaction, uncertainty and appropriateness of waiting time was assessed with 4-point Likert-scales.

RESULTS: Analysing 1196 UCP- and 597 ER-patients, patient satisfaction correlated positively with perceived appropriate waiting time in both groups. But more UCP-patients deemed their waiting time appropriate (76.7% vs. 70.4%; p = 0.004) and reported to be very satisfied with the treatment (64.7% vs. 55.8%; p < 0.001). Time until the first physician contact was nearly equal, but the entire length of stay was shorter in the UCP (104 ± 88.0 min vs. 179 ± 301 min; p < 0.001). In both groups, satisfaction was reduced by on-going uncertainty after the visit, but uncertainty was higher among UCP-patients (32% vs. 25%; p = 0.003). Age, gender or diagnosis had no influence on patients’ satisfaction. More UCP-patients stated that today’s problem could have been treated by a GP (57% vs. 15%; p < 0.001) and were advised to follow up in an outpatient setting.

CONCLUSIONS: Treating patients in an UCP does not lead to overall dissatisfaction.

PMID:40577002 | DOI:10.1080/13814788.2025.2520218

JMIR Med Inform. 2025 Jun 27;13:e65913. doi: 10.2196/65913.

ABSTRACT

BACKGROUND: The digitalization of health care has advanced significantly in recent years. Consequently, physicians have needed to increasingly adopt new digital health technologies such as electronic health record systems and other health information systems. Digitalization has changed physicians’ clinical work, work environment, management work, and use of tools for leadership. Many physician leaders have been critical of the capabilities of health information systems (HISs) to support leadership, management, and knowledge management.

OBJECTIVE: We aimed to examine the association between leadership position and perceived changes in clinical work due to digitalization among a nationally representative sample of Finnish physicians and physician leaders. In addition, we examined physician leaders’ perceptions of HISs as a support for management and whether their opinions differed based on their perceptions on changes in clinical work due to digitalization.

METHODS: Altogether 4630 Finnish physicians (2960/4586, 64% women) responded to a cross-sectional nation-wide web-based survey conducted in spring 2021. Perceptions of improved preventive work, facilitated access to patient information, progressed interprofessional collaboration, and accelerated clinical encounters were used as measures of changes due to digitalization. First, we examined with multivariable logistic regression analyses whether being in a leadership position was associated with perceived changes in work due to digitalization (improved preventive work, facilitated access to patient information, progressed interprofessional collaboration, and accelerated clinical encounters in separate analyses) in the total sample. Second, we examined with analyses of covariance whether the variables related to perceived changes in work due to digitalization were associated with perceived management support from HISs among those who had administrative or management responsibilities (n=817). All analyses were adjusted for gender, age, and sector.

RESULTS: Physician leaders had greater odds of agreeing that digitalization had improved preventive work (odds ratio [OR] 1.62, 95% CI 1.33-1.98), facilitated access to patient information (OR 1.28, 95% CI 1.09-1.51), progressed interprofessional collaboration (OR 1.81, 95% CI 1.53-2.14), and accelerated clinical encounters (OR 1.31, 95% CI 1.01-1.70) than those in nonleadership positions. Furthermore, leaders who perceived these changes in work due to digitalization positively also considered that health information systems supported their management work.

CONCLUSIONS: Physician leaders appeared to view the changes in work due to digitalization more positively than other physicians. In addition, those leaders who perceived these changes positively also perceived that HISs supported their management work. Thus, leaders should thoroughly evaluate and address physicians’ perceptions of their routine clinical work and its evolving nature. Doing so ensures access to up-to-date and accurate insights, enabling more effective planning of staffing, training programs, and future implementations. Furthermore, our results show that to guarantee positive views about digitalization among physician leaders, information systems should also support managerial work. This highlights the need to focus on the quality, utility, and usability of information systems.

PMID:40576972 | DOI:10.2196/65913

Phys Ther. 2025 Jun 18:pzaf083. doi: 10.1093/ptj/pzaf083. Online ahead of print.

ABSTRACT

IMPORTANCE: Conservative, non-pharmacological interventions are the recommended first-line treatment for hip and knee osteoarthritis (OA). Clinical practice guidelines (CPGs), such as those from the Osteoarthritis Research Society International (OARSI), guide evidence-based care by physical therapists. However, no studies in Germany have examined physical therapists’ treatment choices across patient cases and compared them with the latest evidence.

OBJECTIVE: The objective of this study was to investigate to what extent physical therapists meet the latest evidence when treating different type of people with hip or knee OA.

DESIGN AND SETTING: A cross-sectional vignette-based online survey was conducted among physical therapists working in outpatient practices.

PARTICIPANTS: Eligible participants had adequate German language skills, internet access, and recent experience treating patients with hip or knee OA.

MEASURES: The survey included 4 case vignettes of hip or knee OA, with and without comorbidities, and a list of treatment modalities from the OARSI guideline. Correct selections matched high-evidence recommendations. Descriptive statistics analyzed demographics and treatment choices; linear regression assessed the influence of professional degree and work experience on meeting the latest evidence.

RESULTS: Of 612 eligible therapists, 335 (54.7%) completed the survey (mean age 35.9 +/- 11.9 years; 60% female). Only 22% selected all recommended modalities across vignettes. Structured exercise (96%) and arthritis education (95%) were the most frequently chosen. However, many therapists also selected interventions with limited or conflicting evidence, such as massage and taping. Both professional degree and work experience significantly influenced the extent to which the latest evidence was met. Additionally, 49% were aware of at least 1 OA guideline.

CONCLUSIONS AND RELEVANCE: While many physical therapists aligned with evidence-based practices, inappropriate modality selection remained common. De-implementation is needed where evidence suggests a lack of benefit or potential safety concerns. Translating and implementing the OARSI guideline into various languages, specifically for physical therapists, is recommended to close knowledge gaps.

IMPACT STATEMENT: The study’s findings underscore the importance of understanding the treatment modalities used by physical therapists in managing hip or knee OA worldwide. This insight is crucial for addressing the evidence-to-practice gap and ensuring the effective implementation of high-quality physical therapy, a need that is equally relevant in other countries. Additionally, this knowledge is vital for developing targeted strategies, such as the creation and integration of (de-)implementation protocols into the education and ongoing professional development of physical therapists globally.

PMID:40576964 | DOI:10.1093/ptj/pzaf083

Int J Low Extrem Wounds. 2025 Jun 27:15347346251353684. doi: 10.1177/15347346251353684. Online ahead of print.

ABSTRACT

Diabetic foot osteomyelitis is the most frequent infection in diabetes-related foot ulcers, often associated with delayed healing, prolonged hospitalization, and increased risk of amputation. The contribution of microbiological factors to its clinical severity remains uncertain. While severe cases are often associated with soft tissue complications such as abscesses or necrotizing infections, it is unclear whether the bacterial profile influences infection severity. This study aimed to determine whether severe presentations are associated with a higher frequency of polymicrobial infections, multidrug-resistant organisms, or specific bacterial species. We conducted a secondary analysis of a prospective cohort of patients with moderate or severe diabetic foot infections confirmed to involve osteomyelitis through histopathological evaluation. Bacterial species isolated from bone biopsy cultures were compared between moderate and severe cases. Among 114 patients included, 73 were classified as moderate and 41 as severe. Bone cultures were positive in 101 cases, yielding 173 isolates. Staphylococcus aureus was the most frequently isolated species, followed by Enterococcus faecalis and Streptococcus agalactiae. No significant differences were found between severity groups in the distribution of individual species, polymicrobial cultures (46.6% in moderate vs 56.1% in severe; p = 0.435), or multidrug-resistant organisms (12.3% vs 12.2%; p = 1.000). A global comparison of species distribution also showed no statistical association with severity (p = 0.941). These findings suggest that severity is not explained by the microbiological profile identified through conventional aerobic cultures. Instead, host-related or anatomical factors may be more relevant, although the lack of anaerobic cultures may have underestimated microbial diversity.

PMID:40576955 | DOI:10.1177/15347346251353684

J Am Geriatr Soc. 2025 Jun 27. doi: 10.1111/jgs.19606. Online ahead of print.

ABSTRACT

BACKGROUND: Cost-effectiveness of family conferences on deprescribing with joint prioritization of treatment goals in primary care has not been investigated so far. We assessed cost-effectiveness in the cluster-randomized controlled COFRAIL trial conducted with general practitioners and 521 older frail patients with polypharmacy cared for at home in Germany.

METHODS: Hospital admissions averted and quality-adjusted life years (QALYs) gained were associated with costs from the German Social Insurance perspective. We applied adjusted GLM regressions with specified distributions to estimate group differences on imputed data, plotted bootstrap cost-outcome pairs by simulated resampling of the study population to illustrate uncertainty and calculate the probability of cost-effectiveness given a willingness-to-pay threshold, and assessed robustness in sensitivity analyses.

RESULTS: Intervention-related costs were €391 (US$459) per capita. On 100 people, the COFRAIL intervention had about 7 more hospital admissions (95% CI: -12; 26), 2 QALYs gained (95% CI: -1; 6), and additional costs of €117,681 (95% CI: -28,838; 264,201)/US$138,027 (95% CI: -33,824; 309,880) or €124,866 (95% CI: -12,649; 262,380)/US$146,455 (95% CI: -14,836; 307,745) without or with hospital costs, respectively, compared to usual care. By bootstrapping, we observed the COFRAIL intervention to have higher costs and more hospital admissions with a relative frequency of 28%-78%, or in terms of QALYs 57%-91%. The COFRAIL intervention had additional costs of €50,966 (US$59.778) per QALY gained with a 46% probability of being cost-effective at a willingness to pay of €45,000/QALY (≈US$50,000/QALY).

CONCLUSION: The COFRAIL intervention affected QALYs rather than hospital admissions after 12 months. The intervention tended to be associated with higher costs and QALYs but was less likely to be cost-effective than usual care at commonly used willingness-to-pay thresholds. Long-term cost-effectiveness should be assessed.

PMID:40576953 | DOI:10.1111/jgs.19606

Spine Deform. 2025 Jun 27. doi: 10.1007/s43390-025-01135-7. Online ahead of print.

ABSTRACT

INTRODUCTION: For early-onset scoliosis (EOS) patients with growth-friendly implants, posterior distraction is a known contributor to proximal junctional kyphosis (PJK). Rib-based proximal fixation is thought to potentially reduce the risk of PJK compared to spine-based anchors. However, the effect of revising proximal rib-based implants to rib vs. spine-based implants on PJK has not yet been investigated.

HYPOTHESES: (1) Patients converted from rib-based to spine-based proximal anchors (RTS) have a higher risk of PJK two years post-revision compared to those revised to rib-based anchors (RTR). (2) Revising the upper instrumented vertebra (UIV) to a lower level increases the risk of PJK at two years post-revision compared to revising to a higher or same level.

METHODS: In this retrospective cohort study of EOS patients with rib-based growing constructs undergoing revision surgery with a minimum 2-year follow-up, we assessed pre-revision, post-revision, and 2-year follow-up radiographs. We excluded patients lacking lateral radiographs and attachment data and conducted descriptive analyses.

RESULTS: 280 subjects were included, with an average age of 7.2 years at revision; RTS patients were slightly older (8.6y vs 7.2y), and 51% female. At 2 years, 32% of all patients developed PJK. This risk was higher in RTS patients compared to RTR patients (42.8% vs 30.2%, p = 0.17). RTS patients had a greater pre-revision total spine height (p = 0.02), a more negative sagittal balance at 2 years (p = 0.01) and were predominantly male (p = 0.08) compared to RTR. Of the factors associated with a greater risk of PJK, proximal anchor conversion from rib-to-spine had the highest predictive value of PJK development (OR 2.23, p = 0.04). While statistically significant, there was no clinical difference in risk at 2 years of developing PJK among patients revised to a lower level compared to those revised to a higher or same level (32.1% vs 32.5% vs 30.9%, respectively; p = 0.05).

CONCLUSION: 32% of all subjects developed PJK at a 2-year follow-up. The risk of PJK in RTS patients was 40% higher than in RTR patients. While this did not reach statistical significance to the 0.05 level, due to the associations of risk established by literature and replicated in this study, and the magnitude of this difference, we believe these results to be clinically significant. We intend to re-evaluate this population in the future as more data becomes available. With no demonstrated risk in revision levels, these results should guide providers in revision decision-making in growing rods.

PMID:40576947 | DOI:10.1007/s43390-025-01135-7

Updates Surg. 2025 Jun 27. doi: 10.1007/s13304-025-02206-0. Online ahead of print.

ABSTRACT

This study evaluates the impact of enhanced recovery after bariatric surgery (ERABS) on length of hospital stay (LoS), postoperative pain, postoperative nausea and vomiting (PONV), adherence to ERABS protocol, postoperative complications, and readmission rates via gradual stepwise implementation. Between January 2017 and December 2018, an observational, controlled, prospective study was performed, enrolling consecutively followed patients who underwent sleeve gastrectomy. Patients were divided into two groups treated with an ERABS protocol which was implemented in two steps. In 2017, this included 12 items (subgroup B1); in 2018, two more items were introduced (subgroup B2). These results were then compared retrospectively to a control group of patients who underwent the same procedure from 2015-2016 whilst adhering to the ‘traditional’ treatment approach (group A). 367 patients were included. 146 patients in group A, 99 in subgroup B1 and 122 in subgroup B2. The median LoS was 4.5 days in group A, 3.8 days in B1, and 2.3 days in B2. Postoperative pain was 35.7% in group A, 35.6% in B1, and 25% in B2 (p = 0.18). The PONV rate was significantly lower in group B than in group A. Adherence to the ERABS protocol increased from 67% in group B1 to 80% in B2. No statistical difference in terms of 30-day postoperative complications rate and 30-day readmission rate was found. ERABS protocol showed significant improvement in LoS, postoperative pain, and PONV without increasing postoperative complications and readmissions, showing progressively better outcomes with a stepwise implementation.

PMID:40576945 | DOI:10.1007/s13304-025-02206-0