In high-risk outpatients with COVID-19, neither colchicine nor aspirin reduced disease progression or death at 45 d.

SOURCE CITATION: Eikelboom JW, Jolly SS, Belley-Cote EP, et al. Colchicine and aspirin in community patients with COVID-19 (ACT): an open-label, factorial, randomised, controlled trial. Lancet Respir Med. 2022;10:1160-8. 36228639.

In non-low back musculoskeletal injuries, NSAIDs and acetaminophen reduce acute pain.

SOURCE CITATION: Busse JW, Sadeghirad B, Oparin Y, et al. Management of acute pain from non-low back, musculoskeletal injuries: a systematic review and network meta-analysis of randomized trials. Ann Intern Med. 2020;173:730-8. 32805127.

Vitamin d and the risk of uterine fibroids.

BACKGROUND: Uterine leiomyomata (also known as fibroids) are benign tumors of uterine smooth muscle that are characterized by overproduction of extracellular matrix. Fibroids are the leading indication for hysterectomy in the United States. The active metabolite of vitamin D has been shown to inhibit cell proliferation and extracellular matrix production in fibroid tissue culture and to reduce fibroid volume in the Eker rat. No previous study has examined whether vitamin D is related to fibroid status in women. METHODS: The National Institute of Environmental Health Sciences Uterine Fibroid Study enrolled randomly selected 35- to 49-year-old women who were members of an urban health plan during 1996-1999. Fibroid status was determined by ultrasound screening of premenopausal women (620 blacks, 416 whites). Vitamin D status was assessed in stored plasma by radioimmunoassay of 25-hydroxyvitamin D (25(OH)D) and questionnaire data on sun exposure. Associations were evaluated with logistic regression, controlling for potential confounders. RESULTS: Only 10% of blacks and 50% of whites had levels of 25(OH)D regarded as sufficient (>20 ng/ml). Women with sufficient vitamin D had an estimated 32% lower odds of fibroids compared with those with vitamin D insufficiency (adjusted odds ratio [aOR] = 0.68, 95% confidence interval [CI] = 0.48-0.96). The association was similar for blacks and whites. Self-reported sun exposure ≥ 1 hour per day (weather permitting) was also associated with reduced odds of fibroids (aOR = 06. [0.4-0.9]), with no evidence of heterogeneity by ethnicity. CONCLUSIONS: The consistency of findings for questionnaire and biomarker data, the similar patterns seen in blacks and whites, and the biological plausibility provide evidence that sufficient vitamin D is associated with a reduced risk of uterine fibroids.

Uterine leiomyomata in relation to insulin-like growth factor-I, insulin, and diabetes.

BACKGROUND: Insulin-like growth factor-I (IGF-I) and insulin stimulate cell proliferation in uterine leiomyoma (fibroid) tissue. We hypothesized that circulating levels of these proteins would be associated with increased prevalence and size of uterine fibroids. METHODS: Participants were 35-49-year-old, randomly selected members of an urban health plan who were enrolled in the study in 1996-1999. Premenopausal participants were screened for fibroids with ultrasound. Fasting blood samples were collected. Associations between fibroids and diabetes, plasma IGF-I, IGF binding protein 3 (BP3), and insulin were evaluated for blacks (n = 585) and whites (n = 403) by using multiple logistic regression. RESULTS: IGF-I showed no association with fibroids in blacks, but in whites the adjusted odds ratios (aORs) for both mid and upper tertiles compared with the lowest tertile were 0.6 (95% confidence intervals [CI] = 0.3-1.0 and 0.4-1.1, respectively). Insulin and diabetes both tended to be inversely associated with fibroids in blacks. The insulin association was with large fibroids; aOR for the upper insulin tertile relative to the lowest was 0.4 (0.2-0.9). The aOR for diabetes was 0.5 (0.2-1.0). Associations of insulin and diabetes with fibroids were weak for whites. Binding protein 3 showed no association with fibroids. CONCLUSIONS: Contrary to our hypothesis, high circulating IGF-I and insulin were not related to increased fibroid prevalence. Instead, there was suggestion of the opposite. The inverse association with diabetes, although based on small numbers, is consistent with previously reported findings. Future studies might investigate vascular dysfunction as a mediator between hyperinsulinemia or diabetes and possible reduced risk of fibroids.

Appointment adherence and disparities in outcomes among patients with diabetes.

BACKGROUND: Successful control of diabetes mellitus requires lifelong adherence to multiple self-management activities in close collaboration with health professionals. We examined the association of such control with appointment keeping behavior in a rural health system. METHODS: Among 4,253 predominantly lower socioeconomic status patients with diabetes, the association of metabolic control (most recent A1c <7% or >9% in two models of respectively 'good' and 'poor' control) with 'missed appointment rate' over a 3-year period was examined using multiple logistic regression. MAIN RESULTS: For each 10% increment in missed appointment rate, the odds of good control decreased 1.12x (p < 0.001) and the odds of poor control increased 1.24x (p < 0.001). The missed appointment rate was substantially higher among African-American patients (15.9% vs. 9.3% for white patients, p < 0.001). Controlling for the missed appointment rate and insurance status in multivariate analysis attenuated the racial association with good control, and the racial association with poor control was no longer significant. Older, white patients with health insurance tended to have significantly better metabolic control. There was no independent association of metabolic control with patient income, gender, or number of primary care visits. CONCLUSION: Adherence to appointments, independent of visit frequency, was a strong predictor of diabetes metabolic control. We hypothesize that missed appointment behavior may serve as an indicator for other diabetes adherence behaviors and associated barriers that serve to undermine successful diabetes self-management.

Physician perception of hospital safety and barriers to incident reporting.

BACKGROUND: Despite increased attention to patient safety in recent years, physician involvement in hospital safety activities appears to have remained limited. METHODS: An anonymous survey of internal medicine housestaff and faculty physicians at an academic medical center assessed safety reporting behavior and witnessed adverse events or near misses. RESULTS: Although 65% of the 120 physicians responding (56% response rate) had not made any adverse event or near miss reports in the prior year, 60% had witnessed at least three adverse events or near misses. Uncertainty about reporting needs and mechanisms, concern about time required, perceived clinical import of the event in question, and lack of physician involvement in the system were all important reasons for failure to report. Concern about being blamed or judged less competent or similar consequences to others were considered less important barriers to reporting. The perceived degree of reporting barriers (p = .01) and number of witnessed adverse events or near misses (p = .005) were independently negatively associated with respondents' perception of safety. Most (58%) physicians expressed willingness to participate in the hospital safety process actively if requested. DISCUSSION: Physicians' barriers to safety reporting in an academic medical center are negatively associated with their perception of hospital safety. These barriers are remediable, and most physicians appear amenable to increased participation in the hospital safety process.

The Clinical Health Economics System Simulation (CHESS): a teaching tool for systems- and practice-based learning.

Academic medical centers face barriers to training physicians in systems- and practice-based learning competencies needed to function in the changing health care environment. To address these problems, at the University of Virginia School of Medicine the authors developed the Clinical Health Economics System Simulation (CHESS), a computerized team-based quasi-competitive simulator to teach the principles and practical application of health economics. CHESS simulates treatment costs to patients and society as well as physician reimbursement. It is scenario based with residents grouped into three teams, each team playing CHESS using differing (fee-for-service or capitated) reimbursement models. Teams view scenarios and select from two or three treatment options that are medically justifiable yet have different potential cost implications. CHESS displays physician reimbursement and patient and societal costs for each scenario as well as costs and income summarized across all scenarios extrapolated to a physician's entire patient panel. The learners are asked to explain these findings and may change treatment options and other variables such as panel size and case mix to conduct sensitivity analyses in real time. Evaluations completed in 2003 by 68 (94%) CHESS resident and faculty participants at 19 U.S. residency programs preferred CHESS to a traditional lecture-and-discussion format to learn about medical decision making, physician reimbursement, patient costs, and societal costs. Ninety-eight percent reported increased knowledge of health economics after viewing the simulation. CHESS demonstrates the potential of computer simulation to teach health economics and other key elements of practice- and systems-based competencies.

Ultrasound guidance during central venous catheterization: a survey of use by house staff physicians.

PURPOSE: The objective of this study is to explore the attitudes, knowledge, and behavior of house staff physicians regarding the use of ultrasound guidance (UG) during central venous catheter placement (CP). MATERIALS AND METHODS: A questionnaire-based study was used to survey house staff in multiple training programs at an academic tertiary care center. RESULTS: Fifteen percent of the respondents reported using UG on at least 60% of CP attempts. Those house staff physicians who agreed that UG is faster, easier, and more convenient than the landmark method reported more frequent use. Agreement that UG reduces the number of mechanical complications and placement failures was also associated with increased use. Respondents reporting the most CP experience were least likely to use UG. Most agreed that UG is useful in patients without good landmarks or when the landmark method failed, but these attitudes were not associated with the frequency of UG use. Most respondents were not aware of controlled trials demonstrating the benefits of UG. CONCLUSIONS: The use of UG during CP is infrequent despite the demonstrated benefits of this technology. Multiple knowledge and attitudinal barriers to the greater use of UG during CP must be addressed in the design of an effective UG implementation strategy.

Determinants of physician use of an ambulatory prescription expert system.

PURPOSE: To determine whether physician experience with and attitude towards computers is associated with adoption of a voluntary ambulatory prescription writing expert system. METHODS: A prescription expert system was implemented in an academic internal medicine residency training clinic and physician utilization was tracked electronically. A physician attitude and behavior survey (response rate=89%) was conducted six months after implementation. RESULTS: There was wide variability in system adoption and degree of usage, though 72% of physicians reported predominant usage (> or =50% of prescriptions) of the expert system six months after implementation. Self-reported and measured technology usage were strongly correlated (r=0.70, p<0.0001). Variation in use was strongly associated with physician attitude toward issues of system efficiency and effect on quality, but not with prior computer experience, level of training, or satisfaction with their primary care practice. Non-adopters felt that electronic prescribing was more time consuming and also more likely to believe that their patients preferred hand-written prescriptions. CONCLUSION: A voluntary electronic prescription system was readily adopted by a majority of physicians who believed it would have a positive impact on the quality and efficiency of care. However, dissatisfaction with system capabilities among both adopters and non-adopters suggests the importance of user education and expectation management following system selection.

The association between diabetes metabolic control and drug adherence in an indigent population.

OBJECTIVE: Studies of the association between diabetes metabolic control and adherence to drug therapy have yielded conflicting results. Because low socioeconomic and minority populations have poorer diabetes outcomes and greater barriers to adherence, we examined the relationship between adherence and diabetes metabolic control in a large indigent population. RESEARCH DESIGN AND METHODS: The study population consisted of patients receiving medical care from a university-based internal medicine clinic serving a low-income population in rural central Virginia. The sample comprised 810 patients with type 2 diabetes who received oral diabetes medications from the clinic pharmacy and had at least one HbA(1c) determination during the study period. Multiple linear regression was used to examine the association of HbA(1c) level as well as change in HbA(1c) level with medication adherence, demographic, and clinical characteristics. RESULTS: Better metabolic control was independently associated with greater medication adherence, increasing age, white (versus African-American) race, and lower intensity of drug therapy. For each 10% increment in drug adherence, HbA(1c) decreased by 0.16% (P < 0.0001). Controlling for other demographic and clinical variables, the mean HbA(1c) of African-Americans was 0.29% higher than that of whites (P = 0.04). Additionally, the intensity of diabetes drug therapy for African-Americans was lower, as was their measured adherence to it. There was no association between metabolic control and gender, income, encounter frequency, frequency of HbA(1c) testing, or continuity of care. CONCLUSIONS: Adherence to medication regimens for type 2 diabetes is strongly associated with metabolic control in an indigent population; African-Americans have lower adherence and worse metabolic control. Greater efforts are clearly needed to facilitate diabetes self-management behaviors of low-income populations and foster culturally sensitive and appropriate care for minority groups.

Repeated-measures modeling improved comparison of diagnostic tests in meta-analysis of dependent studies.

OBJECTIVE: Current methods for meta-analysis of diagnostic tests do not allow utilizing all the information from papers in which several tests have been studied on the same patient sample. We demonstrate how to combine several studies of diagnostic tests, where each study reports on more than one test and some tests (but not necessarily all of them) are shared with other papers selected for the meta-analysis. We adopt statistical methodology for repeated measurements for the purpose of meta-analysis of diagnostic tests. STUDY DESIGN AND SETTING: The method allows for missing values of some tests for some papers, takes into account different sample sizes of papers, adjusts for background and confounding factors including test-specific covariates and paper-specific covariates, and accounts for correlations of the repeated measurements within each paper. It does not need individual-level data, although it can be modified to use them, and uses the two-by-two table of test results vs. gold standard. RESULTS: The results are translated from diagnostic odds ratios (DOR) to more clinically useful measures such as predictive values, post-test probabilities, and likelihood ratios. Models to capture between-study variation are introduced. The fit and influence of specific studies on the regression can be evaluated. Furthermore, model-based tests for homogeneity of DORs across papers are presented. CONCLUSION: The use of this new method is illustrated using a recent meta-analysis of the D-dimer test for the diagnosis of deep venous thrombosis.

Self-reported heavy bleeding associated with uterine leiomyomata.

OBJECTIVE: To characterize the relationship between self-reported bleeding symptoms and uterine leiomyoma size and location. METHODS: The leiomyoma status of a randomly selected sample of women aged 35-49 in the Washington, DC, area was determined using abdominal and transvaginal ultrasound to measure size and location of leiomyomata found at screening. Women were asked about symptoms of heavy bleeding (gushing-type bleeding, long menses, pad/tampon use) in a telephone interview. Using multivariable regression, we examined the relationships between leiomyoma characteristics and heavy bleeding symptoms among 910 premenopausal women. RESULTS: Women with leiomyomata (n = 596) were more likely to report gushing-type bleeding than women without leiomyomata; risk increased with leiomyoma size. Adjusted relative risks with 95% confidence intervals (CI) for women in each leiomyoma size category compared with the reference category (women without leiomyomata) were as follows: adjusted relative risk of 1.4 (95% CI 1.1, 1.9) for diffuse only, adjusted relative risk of 1.4 (95% CI 1.1, 1.8) for small leiomyomata (less than 2 cm), adjusted relative risk of 1.6 (95% CI 1.3, 2.0) for medium leiomyomata (2-5 cm), and adjusted relative risk of 1.9 (95% CI 1.5, 2.5) for large leiomyomata (greater than 5 cm). Reported use of eight or more pads/tampons on the heaviest days of menstrual bleeding increased with leiomyoma size, with a nearly 2.5-fold risk for women with large leiomyomata compared with women without leiomyomata (adjusted relative risk of 2.4; 95% CI 1.8, 3.1). Nonsubmucosal leiomyomata were associated with essentially the same increase in heavy bleeding as submuscosal leiomyomata of similar size. CONCLUSION: Small leiomyomata were associated with increased risk of heavy bleeding, and risk increased with size. Contrary to published articles, nonsubmucosal leiomyomata were associated with heavy bleeding to the same extent as submucosal leiomyomata.

Can prescription refill feedback to physicians improve patient adherence?

BACKGROUND: Although adherence to long-term drug therapy is an important issue, the means to facilitate its assessment and improvement in clinical practice remain a challenge. OBJECTIVE: To evaluate the impact of prescription refill feedback and adherence education provided to primary care physicians. METHODS: We provided 83 resident and attending physicians at a university-based general internal medicine practice with refill adherence reports on each of 340 diabetic patients. An educational session on adherence assessment and improvement techniques was held, and all physicians received a written outline on this topic. Physician attitude toward the intervention and 6-month change in refill adherence (doses filled/doses prescribed) of their patient panels were assessed. A nonrandomized comparison group of patients receiving hypertension medications for whom the physicians did not receive feedback was also evaluated. RESULTS: The overall improvement in mean refill adherence was not significant (83.9% vs 86.0%, P=0.18). The educational session was attended by 53% of the physicians. The patient refill adherence of physicians attending the educational session improved by 5.0% (P<0.0009) with no significant change among patients of physicians not attending the session. There was no adherence change among patients for whom physicians did not receive refill feedback data, regardless of educational session attendance. CONCLUSIONS: Patients of physicians that received refill feedback and attended an educational session improved their refill adherence. After replication of these results in a randomized trial, broad implementation of this approach could have substantial impact from a public health perspective, given the ubiquity of prescription claims data.

The effect of physician feedback and an action checklist on diabetes care measures.

The objective was to evaluate whether physician feedback accompanied by an action checklist improved diabetes care process measures. Eighty-three physicians in an academic general medicine clinic were provided a single feedback report on the most recent date and result of diabetes care measures (glycosylated hemoglobin [A1c], urine microalbumin, serum creatinine, lipid levels, retinal examination) as well as recent diabetes medication refills with calculated dosing and adherence on 789 patients. An educational session regarding the feedback and adherence information was provided. The physicians were asked to complete a checklist accompanying the feedback on each of their patients, indicating requested actions with respect to follow-up, testing, and counseling. The physicians completed 82% of patient checklists, requesting actions consistent with patient needs on the basis of the feedback. Of the physicians, 93% felt the patient information and intervention format to be useful. The odds of urine microalbumin testing, serum creatinine, lipid profile, A1c, and retinal examination increased in the 6 months after the feedback. The increase was sustained at 1 year only for microalbumin and retinal exams. There was no significant change in refill adherence for the group overall after the feedback, although adherence did improve among patients of physicians attending the educational session. No significant change was noted in lipid or A1c levels during the study period. In conclusion, a simple physician feedback tool with action checklist can be both helpful and popular for improving rates of diabetes care guideline adherence. More complex interventions are likely required to improve diabetes outcomes.

The association of health literacy and socio-demographic factors with medication knowledge.

OBJECTIVE: To compare patient demographics and Rapid Estimate of Adult Literacy in Medicine (REALM) scores with respect to their ability to predict medication comprehension. METHODS: A survey was conducted of 100 patients presenting for follow-up at an academic primary care clinic serving a low socio-economic status population. The Medication Knowledge Score (MKS) consisted of knowledge of drug name, dose, indication, and a potential side effect for each of their medications and then averaged. The REALM (Rapid Estimate of Adult Literacy in Medicine) was administered and socio-demographic characteristics were recorded. The association of REALM score and patient characteristics with MKS was evaluated by univariate and multivariable regression analysis. RESULTS: The subjects' mean age was 62 with an average of 9.8 years of schooling and 5.9 prescription medications. Participants identified a correct indication for 78.8% of their medications and correct dosage for 93.4%. However, they could provide the name for only 55.8% of medications and a known side effect for only 11.7%. On multivariate analysis without including REALM score, younger age (p=.01), highest grade completed (p=.001), and female sex (p=.004) remained positively associated with MKS. When the model included REALM, REALM (p<.0001), age (p=.001), and sex (p=.04) remained independently associated with MKS. CONCLUSION: REALM score predicts medication knowledge as assessed by the MKS. However, age, last grade completed, and sex were also independently associated with mean MKS with a similar strength of association to that of REALM. This suggests that simpler cues to screen for medication knowledge deficits may also be useful. Since the MKS incorporates knowledge of medication indications and side effects, it may also be useful for quality and safety purposes.

Changing conversations: teaching safety and quality in residency training.

Improving patient safety and quality in health care is one of medicine's most pressing challenges. Residency training programs have a unique opportunity to meet this challenge by training physicians in the science and methods of patient safety and quality improvement (QI).With support from the Health Resources and Services Administration, the authors developed an innovative, longitudinal, experiential curriculum in patient safety and QI for internal medicine residents at the University of Virginia. This two-year curriculum teaches the critical concepts and skills of patient safety and QI: systems thinking and human factors analysis, root cause analysis (RCA), and process mapping. Residents apply these skills in a series of QI and patient safety projects. The constructivist educational model creates a learning environment that actively engages residents in improving the quality and safety of their medical practice.Between 2003 and 2005, 38 residents completed RCAs of adverse events. The RCAs identified causes and proposed useful interventions that have produced important care improvements. Qualitative analysis demonstrates that the curriculum shifted residents' thinking about patient safety to a systems-based approach. Residents completed 237 outcome assessments during three years. Results indicate that seminars met predefined learning objectives and were interactive and enjoyable. Residents strongly believe they gained important skills in all domains.The challenge to improve quality and safety in health care requires physicians to learn new knowledge and skills. Graduate medical education can equip new physicians with the skills necessary to lead the movement to safer and better quality of care for all patients.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Association of physical activity with development of uterine leiomyoma.

The relation between physical activity and uterine leiomyomata (fibroids) has received little study, but exercise is protective for breast cancer, another hormonally mediated tumor. Participants in this study were randomly selected members of a health plan based in Washington, DC, aged 35-49 years (734 African Americans, 455 Whites) enrolled between 1996 and 1999. Fibroid status was based on ultrasound screening. Physical activity was based on detailed interview questions. Logistic regression with adjustment for body mass index and other risk factors showed that women in the highest category of physical activity were significantly less likely to have fibroids (odds ratio = 0.6, 95% confidence interval = 0.4, 0.9 for the highest vs. the lowest category (equivalent to approximately > or =7 hours/week vs <2 hours/week)). There was a dose-response pattern; a significant trend was seen for both African-American and White women. A multistate Bayesian analysis indicated that exercise was associated with tumor onset more strongly than with tumor growth. When data for women who reported major fibroid-related symptoms were excluded, results remained essentially unchanged, suggesting that the observed association could not be attributed to reverse causation (fibroids preventing exercise). The authors concluded that regular exercise might help women prevent fibroids.