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Guideline-Concordant Care and Clinician and Clinic Characteristics for Patients With Schizophrenia
No full textImportance: Guideline-concordant care of schizophrenia remains low despite available evidence-based treatments. Primary care providers (PCPs; primary care clinicians) and psychiatric advanced practice practitioners (APPs) increasingly deliver specialty mental health care, but whether care quality differs by clinician or clinic type or patient mix is unclear.
Objective: To assess whether clinician or clinic specialty and higher schizophrenia caseload intensity are associated with receipt of guideline-concordant schizophrenia care.
Design, setting, and participants: This cross-sectional study (January 1, 2014, to December 31, 2021) used multivariable logistic regression to assess associations between clinician or clinic specialty and guideline-concordant care, adjusting for patient and zip code characteristics. Some models included interactions between specialty and a high schizophrenia caseload intensity indicator to examine associations within specialties. Insured individuals aged 18 to 64 years with schizophrenia from the Massachusetts All Payer Claims Database were studied. Analysis was completed between August 1, 2024, and September 25, 2025.
Exposures: Clinician or clinic specialty and schizophrenia caseload intensity.
Main outcomes and measures: Binary indicators of high medication adherence, any receipt of psychosocial services, routine receipt of psychotherapy, high inpatient use, and receipt of antipsychotic-related diabetes screening.
Results: The final analytic sample included 29 713 person-year observations (18 772 [63.2%] male; 5569 [63.2%] aged 35-64 years). Among these, 12 104 (40.7%) were attributed to psychiatrists, 3144 (10.6%) to psychiatric APPs, 6626 (22.3%) to mental health clinics, and 7839 (26.4%) to PCPs. In adjusted regressions, patients of psychiatric APPs or mental health clinics had higher probabilities of receiving psychosocial services (APP vs psychiatrist: 80.1% vs 72.1%, P \u3c .001; mental health clinic vs psychiatrist: 87.1% vs 72.1%, P \u3c .001) and routine psychotherapy (APP vs psychiatrist: 30.4% vs 24.0%, P \u3c .001; mental health clinic vs psychiatrist: 35.2% vs 24.0%, P \u3c .001) than patients of psychiatrists; antipsychotic adherence was similar or higher. In contrast, those with PCPs were less likely to receive psychosocial services (-15.85 percentage points [pp]; 95% CI, -18.40 to -13.30 pp) or routine psychotherapy (-16.42 pp; 95% CI, -17.80 to -15.05 pp) but more likely to receive antipsychotic-related diabetes screening (5.66 pp; 95% CI, 4.02-7.30 pp). High inpatient use did not significantly differ. Attribution to PCPs with higher schizophrenia caseload intensity was not consistently associated with improved outcomes across specialties.
Conclusions and relevance: In this cross-sectional study, guideline-concordant care was similar for patients of psychiatric APPs, mental health clinics, and psychiatrists, but patients of PCPs were less likely to receive psychosocial or psychotherapy services, although higher schizophrenia caseload intensity may mitigate this gap. Strategies to improve care across specialties are needed because overall rates remain low
Comparative Analysis of Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting in Left Main Disease Stratification by Angiographic SYNTAX Score
No full textUsing the SYNTAX score (SS) for decision-making between percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) for left main coronary artery (LMCA) revascularization is under scrutiny. This study investigated the clinical outcomes of LMCA revascularization stratified by SS. This multicenter study included 2138 patients recruited between 2015 and 2020 who underwent LMCA disease revascularization using PCI or CABG and were categorized based on their SS into three groups: low (≤22), intermediate (23-32), and high (≥33). Patients with a high SS compared with those with an intermediate SS experienced increased hospital mortality (Odds ratio: 1.99; P = .026) and Major Adverse Cardiac and Cerebrovascular Event (MACCE; OR: 2.17; P = .006). With an average follow-up of 24.7 months, no substantial differences emerged in MACCE (Hazard ratio: 1.23; P = .52) or mortality (HR: 3.26; P = .073] between patients with high and intermediate SSs. A significant interaction between the SS category (low vs intermediate) and LMCA revascularization modality was observed for hospital MACCEs, favoring PCI over CABG (OR: 0.32; P = .033). However, no noteworthy interactions between SS categories and revascularization modalities were noted concerning hospital or follow-up mortality or follow-up MACCEs. These findings raise doubts about the utility of SS alone in selecting left-main revascularization modalities for LMCA disease.
Keywords: CABG; MACCE; PCI; SYNTAX score; left-main coronary artery disease; mortality
Addressing Note Bloat: Solutions for Effective Clinical Documentation
No full textClinical documentation in the United States has grown longer and more difficult to read, a phenomenon described as note bloat. This issue is especially pronounced in emergency medicine, where high diagnostic uncertainty and brief evaluations demand focused, efficient chart review to inform decision-making. Note bloat arises from multiple factors: efforts to enhance billing, mitigate malpractice risk, and leverage electronic health record tools that improve speed and completeness. We discuss best practices based on available evidence and expert opinion to improve note clarity and concision. Recent E/M coding reforms aim to streamline documentation by prioritizing medical decision-making over details of historical and physical examination, though implementation varies. New technologies such as generative artificial intelligence present opportunities and challenges for documentation practices. Addressing note bloat will require ongoing effort from clinical leadership, electronic health record vendors, and professional organizations.
Keywords: clinical informatics; documentation; electronic medical records; reimbursement
A systematic review on the assessment of pregnancy-specific psychological trauma during pregnancy: A call to action
No full textObjective: Psychological trauma negatively impacts maternal and infant health during the perinatal period. A history of traumatic experiences related to previous pregnancies and births (termed pregnancy-specific psychological trauma or PSPT) increases the risk of a host of psychological disorders. It can impede women\u27s/the pregnant individual\u27s relationship with the healthcare system and their developing child. There are, however, no guidelines or agreed-upon validated screening measures to assess PSPT during the perinatal period. To build a knowledge base to develop future measure(s) of PSPT, we conducted a systematic review to understand how and when PSPT has been measured during pregnancy.
Data sources: Searches were run in July 2021 on the following databases: Ovid MEDLINE (In-Process & Other Non-Indexed Citations and Ovid MEDLINE 1946 to Present), Ovid EMBASE (1974 to present), Scopus, Web of Science, PsycInfo, and Cochrane. Updated searches and reference searching/snow-balling were conducted in September 2023.
Study eligibility criteria: The search strategy included all appropriate controlled vocabulary and keywords for psychological trauma and pregnancy.
Methods: This systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Two independent researchers screened abstracts and, subsequently, full-texts of abstracts for appropriateness, with conflicts resolved via a third independent reviewer. A secondary analysis was performed on studies measuring PSPT during pregnancy.
Results: Of the 576 studies examining psychological trauma in pregnancy, only 15.8% (n=91) had a measure of PSPT. Of these 91 studies, 53 used a measure designed by the research team to assess PSPT. Critically, none of the measurements used screened for PSPT comprehensively.
Conclusion: It is time to screen for and study PSPT in all perinatal individuals. Recognition of PSPT should promote trauma-informed care delivery by obstetrics and neonatology/pediatric teams during the perinatal period.
Keywords: perinatal; pregnancy; pregnancy complications; pregnancy loss; psychological trauma; traumatic delivery
Sexual identity, sexual behavior, and drug use behaviors among people who use drugs in the rural U.S
No full textIntroduction: People who use drugs (PWUD) are at risk of HIV infection, but the frequency and distribution of transmission-associated behaviors within rural communities is not well understood. Further, while interventions designed to more explicitly affirm individuals\u27 sexual orientation and behaviors may be more effective, descriptions of behavior variability by orientation are lacking. We sought to describe how disease transmission behaviors and overdose risk vary by sexual orientation and activity among rural PWUD.
Methods: From 01/2018-03/2020, rural PWUD participating in the Rural Opioid Initiative were surveyed across 8 sites. Collected data included: demographics; experiences with drug use, overdose, and healthcare; stigma; gender identity; and sexual orientation and partners. Participants were categorized as: monosexual by orientation and behavior (Mono-only), monosexual by orientation but behaviorally bisexual (Mono/Bi), and bisexual by orientation (Bi+). Analyses included descriptive summaries, bivariate examination (chi-square), and logistic regression (relative risk [RR] and 95 % confidence interval [CI]).
Results: The 1455 participants were 84.8 % Mono-only, 3.2 % Mono/Bi, and 12.0 % Bi+. Compared to Mono-only men, Mono/Bi and Bi+ men had greater risk of transactional sex (RR = 9.71, CI = 6.66-14.2 and RR = 5.09, CI = 2.79-9.27, respectively) and sharing syringes for injection (RR = 1.58, CI = 1.06-2.35 and RR = 1.85, CI = 1.38-2.47). Compared to Mono-only women, Mono-Bi and Bi+ women had greater risk of transactional sex (RR = 4.47, CI = 2.68-7.47 and RR = 2.63, CI = 1.81-3.81); and Bi+ women had greater risk of sharing syringes for injection (RR = 1.49, CI = 1.23-1.81), sharing syringes to mix drugs (RR = 1.44, CI = 1.23-1.69), and experiencing an overdose (RR = 1.32, CI = 1.12-1.56). Bi+ men and women both more frequently reported selling sex as a source of income (versus Mono-only, both p \u3c 0.050) and measures of perceived stigma (all p \u3c 0.050).
Conclusions: Rural PWUD who are bisexual by orientation or behavior are significantly more likely to engage in behaviors associated with infectious disease transmission and to experience stigma and drug overdose. Given the growing recognition of bisexuality as a distinct orientation that warrants individualized consideration, interventions that are specifically acknowledging and affirming to the circumstances of this group are needed.
Keywords: Infectious Disease; Overdose; People who use drugs; Rural
Ventilator-Associated Pneumonia After Cardiac Arrest and Prevention Strategies: A Narrative Review
No full textBackground and Objectives: Ventilator-associated pneumonia (VAP) poses a significant threat to the clinical outcomes and hospital stays of mechanically ventilated patients, particularly those recovering from cardiac arrest. Given the already elevated mortality rates in cardiac arrest cases, the addition of VAP further diminishes the chances of survival. Consequently, a paramount focus on VAP prevention becomes imperative. This review endeavors to comprehensively delve into the nuances of VAP, specifically in patients requiring mechanical ventilation in post-cardiac arrest care. The overarching objectives encompass (I) exploring the etiology, risk factors, and pathophysiology of VAP, (II) delving into available diagnostic modalities, and (III) providing insights into the management options and recent treatment guidelines. Methods: A literature search was conducted using PubMed, MEDLINE, and Google Scholar databases for articles about VAP and Cardiac arrest. We used the MeSH terms VAP , Cardiac arrest , postcardiac arrest syndrome , and postcardiac arrest syndrome . The clinical presentation, diagnostic, and management strategies of VAP were summarized, and all authors reviewed the selection and decided which studies to include. Key Content and Findings: The incidence and mortality rates of VAP exhibit significant variability, yet a recurring pattern emerges, marked by prolonged hospitalization and exacerbated clinical outcomes. This pattern is attributed to the elevated incidence of drug-resistant infections and the delayed initiation of antimicrobial treatment. This review focuses on VAP, aiming to offer valuable insights into the efficient identification and management of this fatal complication in post-cardiac arrest patients. Conclusion: The prognosis for survival after cardiac arrest is already challenging, and the outlook becomes even more daunting when complicated by VAP. The timely diagnosis of VAP and initiation of antibiotics pose considerable challenges, primarily due to the invasive nature of obtaining high-quality samples and the time required for speciation and identification of antimicrobial sensitivity. The controversy surrounding prophylactic antibiotics persists, but promising new strategies have been proposed; however, they are still awaiting well-designed clinical trials.
Keywords: cardiac arrest; hospital-acquired pneumonia (HAP); ventilator-associated pneumonia (VAP)
Safety and efficacy of transcranial direct current stimulation in addition to constraint-induced movement therapy for post-stroke motor recovery (TRANSPORT2): a phase 2, multicentre, randomised, sham-controlled triple-blind trial
No full textBackground: Motor impairments contribute substantially to long-term disability following stroke. Studies of transcranial direct current stimulation (tDCS), combined with various rehabilitation therapies, have shown promising results in reducing motor impairment. We aimed to evaluate the safety and efficacy of three doses of tDCS in combination with modified constraint-induced movement therapy (mCIMT) in people who have had their first ischaemic stroke in the preceding 1-6 months.
Methods: We conducted a phase 2, multicentre, randomised, triple-blind, sham-controlled study with a blinded centrally scored primary outcome. The trial was conducted at 15 medical centres in the USA. Eligible participants were enrolled between 1 month and 6 months after their first ischaemic stroke. Inclusion criteria required participants to have a persistent motor deficit, defined as a Fugl-Meyer Upper-Extremity (FM-UE) score of 54 or lower (out of 66), and two consecutive baseline visits (separated by 7-14 days) with an absolute difference of 2 or fewer points on the FM-UE scale. Participants were randomly assigned to treatment groups by an adaptive randomisation algorithm hosted on the TRANSPORT2 WebDCU study website. Participants received either sham, 2 mA, or 4 mA of bi-hemispheric tDCS for the first 30 min and mCIMT with 120 min of active therapy time per session, administered over ten sessions during a 2-week period. The primary endpoint was the change in FM-UE score from baseline to day 15, which was analysed in all participants who have data both at baseline and post-baseline (modified intention-to-treat group). Safety outcomes were analysed in all participants. TRANSPORT2 is registered at clinicaltrials.gov (NCT03826030) and its status is completed.
Findings: 129 participants were recruited between Sept 9, 2019, and June 14, 2024, and 43 participants were randomly assigned to each group. 54 (42%) of 129 participants were female, and 69 (53%) were White. Two participants in the sham plus mCIMT group withdrew consent before the day 15 assessment and were excluded from the primary analysis. The median baseline FM-UE score was 39·0 (IQR 30·0-46·0) in the sham plus mCIMT group, 39·0 (27·0-48·0) in the 2 mA plus mCIMT group, and 40·0 (27·0-48·0) in the 4 mA plus mCIMT group. For the primary outcome, the adjusted mean change from baseline to day 15 in FM-UE was 4·91 (3·00-6·82) for sham plus mCIMT, 3·87 (2·00-5·74) for 2 mA plus mCIMT, and 5·53 (3·64-7·42) for 4 mA plus mCIMT (p=0·39). No clinically important adverse events were observed in any group and no deaths were reported.
Interpretation: tDCS at doses of 2 mA or 4 mA, in addition to mCIMT, did not lead to further reduction in motor impairment in patients 1-6 months after stroke, but it was safe, well tolerated, and feasible for clinical practice. tDCS at higher doses (ie, \u3e4 mA) might be a consideration for future trials in addition to balancing known covariates affecting stroke recovery during the group allocation.
Funding: National Institute of Neurological Disorders and Stroke
Escalation and De-escalation of Temporary Mechanical Circulatory Support: Joint Consensus Report of the PeriOperative Quality Initiative and the Enhanced Recovery After Surgery Cardiac Society
No full textBackground: Temporary mechanical circulatory support (tMCS) for cardiogenic shock (CS) is increasing despite knowledge gaps and variations in management practices. This document was created to provide clinicians with guidance regarding initiation, escalation and de-escalation of tMCS in patients with CS.
Methods: An interdisciplinary, international expert panel utilizing a structured literature appraisal and modified Delphi method derived consensus statements regarding triggers for prompt patient assessment and initiating tMCS in CS, assessing adequacy of support, readiness for tMCS weaning and next steps in non-recovery. Individual statements were graded based on the quality of available evidence.
Results: The panel addressed four main questions aimed at initiation, escalation and de-escalation of tMCS. Based on available literature review and expert consensus, 11 recommendations were formulated. Key principles included recognition of the need for CS patients with ongoing hemodynamic compromise, tissue hypoperfusion, and metabolic derangements to be considered for early tMCS initiation. An interdisciplinary shock team should be involved in management with early referral when patient conditions require care beyond center capabilities. Discussions providing anticipatory guidance should be performed with patients and decision makers prior to initiating tMCS. Management of tMCS involves frequent, timely hemodynamic and tissue perfusion reassessments to determine the need for escalation or weaning. For patients unable to wean from tMCS, evaluation should include interdisciplinary assessment for advanced therapies with palliation included as a consideration in care discussions.
Conclusions: A practical guide to initiation, escalation, and de-escalation of temporary MCS is provided. Center-specific approaches based on local capabilities should be implemented
