Perspectives of internal medicine residency clinics: A national survey of US medical directors.

Background: Ambulatory training is an integral component of internal medicine residency programs, yet details regarding operational processes in resident continuity clinics remain limited. Methods: We surveyed a convenience sample of medical directors of residency practices between 2015 and 2019 (n = 222) to describe and share operational and scheduling processes in internal medicine resident continuity clinics in the US. Results: Among residency practices, support for the medical director role ranged substantially, but was most commonly reported at 11%-20% full-time-equivalent support. By the end of the survey period, the majority of programs (65.1%) reported obtaining patient-centered medical home (PCMH) certification (level 1-3). For new patient appointments, 34.9% of programs reported a 1-7 day wait and 25.8% reported an 8-14 day wait. Wait times for new appointments were generally shorter for PCMH certified practices (P = 0.029). No-show rates were most commonly 26%-50% for new patients and 11%-25% for established patients. Most programs reported that interns see 3-4 patients per ½-day and senior residents see 5-6 patients per ½-day. Most interns and residents maintain a panel size of 51-120 patients. Discussion: Creating high-performing residency clinics requires a focus on core building blocks and operational processes. Based on the survey results and consensus opinion, we provide five summary recommendations related to (1) support for the medical director leadership role, (2) patient-centered and coordinated models of care, (3) support for patient scheduling, (4) recommended visit lengths, and (5) ancillary support, such as social work.

Innovations in Human Immunodeficiency Virus (HIV) Care Delivery During the Coronavirus Disease 2019 (COVID-19) Pandemic: Policies to Strengthen the Ending the Epidemic Initiative-A Policy Paper of the Infectious Diseases Society of America and the HIV Medicine Association.

The goal of the Ending the HIV Epidemic Initiative is to reduce new infections in the United States by 90% by 2030. Success will require fundamentally changing human immunodeficiency virus (HIV) prevention and care delivery to engage more persons with HIV and at risk of HIV in treatment. While the coronavirus disease 2019 (COVID-19) pandemic reduced in-person visits to care facilities and led to concern about interruptions in care, it also accelerated growth of alternative options, bolstered by additional funding support. These included the use of telehealth, medication delivery to the home, and increased flexibility facilitating access to Ryan White HIV/AIDS Program services. While the outcomes of these programs must be studied, many have improved accessibility during the pandemic. As the pandemic wanes, long-term policy changes are needed to preserve these options for those who benefit from them. These new care paradigms may provide a roadmap for progress for those with other chronic health issues as well.

A review of opioid prescribing practices and associations with repeat opioid prescriptions in a contemporary outpatient HIV clinic.

OBJECTIVES: Among persons in current HIV outpatient care, data on opioid prescribing are lacking. This study aims to evaluate predictors of repeat opioid prescribing and to characterize outpatient opioid prescribing practices. METHODS: Retrospective cross-sectional study of persons ≥18 years in HIV outpatient care who completed an annual behavioral assessment between June 2008 and June 2009. Persons were grouped by ≤1 and ≥2 opioid prescriptions (no-repeat-opioid and repeat-opioids, respectively). Independent predictors for repeat-opioids were evaluated. Opioid prescribing practices were characterized in a sub-study of persons prescribed any opioid. RESULTS: Overall, 659 persons were included, median age 43 years, 70% men, and 68% African American. Independent predictors of repeat-opioids (88 [13%] persons) included opportunistic illnesses (both current and previous), depression, peripheral neuropathy, and hepatitis C coinfection (P<0.05). In the subgroup, 140 persons received any opioid prescription (96% short-acting, 33% tramadol). Indications for opioid prescribing were obtained in 101 (72%) persons, with 97% for noncancer-related pain symptoms. Therapeutic response was documented on follow-up in 67 (48%) persons, with no subjective relief of symptoms in 63%. Urine drug screens were requested in 6 (4%) persons, and all performed were positive for illicit drugs. CONCLUSIONS: Advanced HIV disease and greater medical and neuropsychiatric comorbidity predict repeat opioid prescribing, and these findings reflect the underlying complexities in managing pain symptoms in this population. We also highlight multiple deficiencies in opioid prescribing practices and nonadherence to guidelines, which are of concern as effective and safe pain management for our HIV-infected population is an optimal goal.

Red clover (Trifolium pratense) monograph: a clinical decision support tool.

Red clover, a legume resembling soy is used by man as a phytoestrogen. Other uses include asthma, pertussis, cancer and gout. The authors systematically review this herb in terms of pharmacology, efficacy, safety, side effects, standardization, dosing, toxicology as well as other parameters.

Shark cartilage monograph: a clinical decision support tool.

The use, adverse effects, mechanism of action, pharmacology, interactions and supporting evidence of shark cartilage is presented. Dosage, toxicology and safety parameters are also discussed.