Search

Background: Older adults may experience a significant digital divide and need support with using technology to transition to telehealth. This study examines the role of social support for telehealt...

While left ventricular assist devices (LVADs) increase survival for patients with advanced heart failure (HF), racial and sex access and outcome inequities remain and are poorly understood.To assess risk-adjusted inequities in access and outcomes for both Black and female patients and to examine heterogeneity in treatment decisions among patients for whom clinician discretion has a more prominent role.This retrospective cohort study of 12 310 Medicare beneficiaries used 100% Medicare Fee-for-Service administrative claims. Included patients had been admitted for heart failure from 2008 to 2014. Data were collected from July 2007 to December 2015 and analyzed from August 23, 2020, to May 15, 2022.Beneficiary race and sex.The propensity for LVAD implantation was based on clinical risk factors from the 6 months preceding HF admission using XGBoost and the synthetic minority oversampling technique. Beneficiaries with a 5% or greater probability of receiving an LVAD were included. Logistic regression models were estimated to measure associations of race and sex with LVAD receipt adjusting for clinical characteristics and social determinants of health (eg, distance from LVAD center, Medicare low-income subsidy, neighborhood deprivation). Next, 1-year mortality after LVAD was examined.The analytic sample included 12 310 beneficiaries, of whom 22.9% (n = 2819) were Black and 23.7% (n = 2920) were women. In multivariable models, Black beneficiaries were 3.0% (0.2% to 5.8%) less likely to receive LVAD than White beneficiaries, and women were 7.9% (5.6% to 10.2%) less likely to receive LVAD than men. Individual poverty and worse neighborhood deprivation were associated with reduced use, 2.9% (0.4% to 5.3%) and 6.7% (2.9% to 10.5%), respectively, but these measures did little to explain observed disparities. The racial disparity was concentrated among patients with a low propensity score (propensity score0.52). One-year survival by race and sex were similar on average, but Black patients with a low propensity score experienced improved survival (7.2% [95% CI, 0.9% to 13.5%]).In this cohort study of Medicare beneficiaries hospitalized for HF, disparities in LVAD use by race and sex existed and were not explained by clinical characteristics or social determinants of health. The treatment and post-LVAD survival by race were equivalent among the most obvious LVAD candidates. However, there was differential use and outcomes among less clear-cut LVAD candidates, with lower use but improved survival among Black patients. Inequity in LVAD access may have resulted from differences in clinician decision-making because of systemic racism and discrimination, implicit bias, or patient preference.

Background Electronic medical record–based interventions such as best practice alerts, or reminders, have been proposed to improve evidence‐based medication prescribing. Formal implementation evaluation including long‐term sustainment are not commonly reported. Preprocedural medication management is often a complex issue for patients taking antithrombotic medications. Methods We implemented a best practice alert (BPA) that recommended referral to an anticoagulation clinic before outpatient elective gastrointestinal (GI) endoscopies. Eligible patients were taking an oral anticoagulant (warfarin or direct oral anticoagulant [DOAC]) and/or antiplatelet medications. Patients referred to the anticoagulation clinic were compared to those managed by the ordering provider. Outcomes assessed included guideline‐adherent drug management before endoscopy, documentation of a medication management plan, guideline‐adherent rates of bridging for high‐risk patients taking warfarin, and evaluation for sustained use of BPA. Results Eighty percent of patients (553/691) were referred to the anticoagulation clinic during the initial 13‐month study period. Most referrals came from gastroenterologists (397/553; 71.8%) followed by primary care providers (127/554; 22.9%). Patients referred had improved rates of guideline‐adherent medication management compared to those who were not referred (97.4% vs 91.0%; P = .001). Documentation of medication plan was significantly higher in the referred group (99.1% vs 59.4%; P ≤ .001). There were no differences in rates of appropriate bridging for patients taking warfarin. Implementation of the BPA also resulted in sustained, consistent use over an additional 18 months following the initial study period. Conclusion Implementation of a BPA before elective outpatient GI endoscopies was associated with improved rates of guideline‐adherent medication management and documented management plan, while streamlining preprocedural medication management.

Background As opioid use disorder (OUD) incidence and its associated deaths continue to persist at elevated rates, the development of novel treatment modalities is warranted. Recent strides in this therapeutic area include novel anti-opioid vaccine approaches. This work compares logistical and ethical considerations surrounding currently available interventions for opioid use disorder with an anti-opioid vaccine approach. Methods The opinions of student pharmacists and practicing pharmacists assessing knowledge, perceptions, and attitudes toward current and future OUD management strategies were characterized using a staged, multi-modal research approach incorporating a focus group, pilot survey development and refinement, and final survey deployment. Survey responses were assessed using one- and two-way parametric and non-parametric analyses where appropriate, and multi-dimensional matrix profiles were compared using z-tests following an exhaustive combinatorial sum of differences calculation between items within each compared matrix. Results Focus group content analysis revealed a high level of agreeableness among participants regarding anti-opioid vaccine technology and a sense of shared ownership regarding solutions to the opioid epidemic at large. Pilot survey results demonstrated subject ability to consider both pragmatic and ethical considerations related to current therapeutics and novel interventions in a single instrument, with high endurance amongst engaged subjects. Access inequality was the most concerning ethical consideration identified for anti-opioid vaccines. Support for anti-opioid vaccine implementation across various clinical scenarios was strongest for voluntary use amongst individuals in recovery, and lowest for mandatory use in at-risk individuals. Conclusions Ethical and logistical concerns surrounding anti-opioid vaccines were largely similar to those for current OUD therapeutics overall. Anti-opioid vaccines were endorsed as helpful potential additions to current OUD therapeutic approaches, particularly for voluntary use in the later stages of clinical progression.

Within mycobacteria, polysaccharide chain length determines periplasm size and modulates antibiotic susceptibility., Bacteria control the length of their polysaccharides, which can control cell viability, physiology, virulence, and immune evasion. Polysaccharide chain length affects immunomodulation, but its impact on bacterial physiology and antibiotic susceptibility was unclear. We probed the consequences of truncating the mycobacterial galactan, an essential linear polysaccharide of about 30 residues. Galactan covalently bridges cell envelope layers, with the outermost cell wall linkage point occurring at residue 12. Reducing galactan chain length by approximately half compromises fitness, alters cell morphology, and increases the potency of hydrophobic antibiotics. Systematic variation of the galactan chain length revealed that it determines periplasm size. Thus, glycan chain length can directly affect cellular physiology and antibiotic activity, and mycobacterial glycans, not proteins, regulate periplasm size.

On July 20, 2005, the US government provided an unprecedented and relatively uncharacteristic act by passing an “Opening Doors to Foreign Students Act.” The event that had spurred this addition to an amendment was an alarming sudden decrease in international student enrollment in the US in the years 2004–2005. This was the first time the US government had ever directly addressed the need for an active promotion of welcoming foreign students into the United States. The goal of this paper is to understand this change through a historical analysis of government’s actions on international education since World War II. In this understanding, the second goal is to explore how this sheds light to the occurrence of declining international students in the US today and the US government’s contribution to this trend. Through the exploration, the research has led to three conclusions: First, the US government has historically overlooked the international student community because politically and publicly the community had a nonthreatening nature and was systematically benefiting the US. Second, the September 11 attack was an event that caught both the public and government attention on the foreign students. The attention was dual in nature: the international student community became a potential threatening entity as well as an integral part of the US academic, economic, and political system. Third, while the very act of government’s oversight is what has allowed the international student community to become a presence to be acknowledged, moving forward, despite the Open Doors Act, regulation has been the main concern as opposed to support and “opening doors.”

Although frequent attendance at religious services is associated with healthier behaviors and improved health outcomes, this relationship is confounded to the extent that attending religious services requires and displays a certain degree of health. This study surveyed patients over multiple hospitalizations at a large urban academic medical center to test the hypothesis that changes in health status would be accompanied by parallel changes in religious attendance but not with self-rated religiosity and spirituality. Study data confirmed the hypothesis, suggesting that cross-sectional associations between religious attendance and good health outcomes reflect, to some degree, the way changes in health status impact one’s ability to attend religious services.

Decisions to withhold or withdraw life-sustaining treatment (LST) precede the majority of ICU deaths. Although professional guidelines generally treat the two as ethically equivalent, evidence suggests withdrawing LST is often more psychologically difficult than withholding it. The aim of the experiment was to investigate whether physicians are more supportive of withholding LST than withdrawing it and to assess how physicians' opinions are shaped by their religious characteristics, specialty, and experience caring for dying patients. In 2010, a survey was mailed to 2016 practicing US physicians. Physicians were asked whether physicians should always comply with a competent patient's request to withdraw LST, whether withdrawing LST is more psychologically difficult than withholding it, and whether withdrawing LST is typically more ethically problematic than withholding it. Of 1880 eligible physicians, 1156 responded to the survey (62%); 93% agreed that physicians should always comply with a competent patient's request to withdraw LST. More than half of the physicians reported that they find withdrawing LST more psychologically difficult than withholding it (61%), and that withdrawing LST is typically more ethically problematic (59%). Physician religiosity was associated with finding withdrawal more ethically problematic, but not with finding it more psychologically difficult. Physicians working in an end-of-life specialty and physicians with more experience caring for dying patients were less likely to endorse either a psychological or an ethical distinction between withdrawing and withholding LST. Most US physicians find withdrawing LST not only more psychologically difficult, but also more ethically problematic than withholding such treatment. Physicians' opinions are to some extent shaped by their religious characteristics, specialty, and levels of experience caring for dying patients.

Prior studies suggest that terminally ill patients who use religious coping are less likely to have advance directives and more likely to opt for heroic end-of-life measures. Yet, no study to date has examined whether end-of-life practices are associated with measures of religiosity and spirituality.To assess the relationship between general measures of patient religiosity and spirituality and patients' preferences for care at the end of life.We examined data from the University of Chicago Hospitalist Study, which gathers sociodemographic and clinical information from all consenting general internal medicine patients at the University of Chicago Medical Center. Primary outcomes were whether the patient had an advance directive, a do-not-resuscitate (DNR) order, a durable power of attorney for health care, and an informally designated decision maker. Primary predictors were religious attendance, intrinsic religiosity, and self-rated spirituality.The sample population (n=8308) was predominantly African American (73%) and female (60%). In this population, 1.5% had advance directives and 10.4% had DNR orders. Half (51%) of the patients had specified a decision maker. White patients were more likely than African American patients to have an advance directive (odds ratio [OR] 2.1; 95% CI 1.1-4.0) and a DNR order (OR 1.7; 95% CI 1.0-2.9). Patients reporting high intrinsic religiosity were more likely to have specified a decision maker than those reporting low intrinsic religiosity (OR 1.3; 95% CI 1.1-1.6). The same was true for those with high compared with low spirituality (OR 1.3; 95% CI 1.1-1.5). Religious characteristics were not significantly associated with having an advance directive or DNR order.Among general medicine inpatients at an urban academic medical center, those who were highly religious and/or spiritual were more likely to have a designated decision maker to help with end-of-life decisions but did not differ from other patients in their likelihood of having an advance directive or DNR order.

Objective The purpose of this study was to assess obstetrician-gynecologists' regarding their beliefs about when pregnancy begins and to measure characteristics that are associated with believing that pregnancy begins at implantation rather than at conception. Study Design We mailed a questionnaire to a stratified, random sample of 1800 practicing obstetrician-gynecologists in the United States. The outcome of interest was obstetrician-gynecologists' views of when pregnancy begins. Response options were (1) at conception, (2) at implantation of the embryo, and (3) not sure. Primary predictors were religious affiliation, the importance of religion, and a moral objection to abortion. Results The response rate was 66% (1154/1760 physicians). One-half of US obstetrician-gynecologists (57%) believe pregnancy begins at conception. Fewer (28%) believe it begins at implantation, and 16% are not sure. In multivariable analysis, the consideration that religion is the most important thing in one's life (odds ratio, 0.5; 95% confidence interval, 0.2–0.9) and an objection to abortion (odds ratio, 0.4; 95% confidence interval, 0.2–0.9) were associated independently and inversely with believing that pregnancy begins at implantation. Conclusion Obstetrician-gynecologists' beliefs about when pregnancy begins appear to be shaped significantly by whether they object to abortion and by the importance of religion in their lives.

Little is known about how often patients desire and experience discussions with hospital personnel regarding R/S (religion and spirituality) or what effects such discussions have on patient satisfaction. OBJECTIVE, DESIGN AND PARTICIPANTS: We examined data from the University of Chicago Hospitalist Study, which gathers sociodemographic and clinical information from all consenting general internal medicine patients at the University of Chicago Medical Center.Primary outcomes were whether or not patients desired to have their religious or spiritual concerns addressed while hospitalized, whether or not anyone talked to them about religious and spiritual issues, and which member of the health care team spoke with them about these issues. Primary predictors were patients' ratings of their religious attendance, their efforts to carry their religious beliefs over into other dealings in life, and their spirituality.Forty-one percent of inpatients desired a discussion of R/S concerns while hospitalized, but only half of those reported having such a discussion. Overall, 32% of inpatients reported having a discussion of their R/S concerns. Religious patients and those experiencing more severe pain were more likely both to desire and to have discussions of spiritual concerns. Patients who had discussions of R/S concerns were more likely to rate their care at the highest level on four different measures of patient satisfaction, regardless of whether or not they said they had desired such a discussion (odds ratios 1.4-2.2, 95% confidence intervals 1.1-3.0).These data suggest that many more inpatients desire conversations about R/S than have them. Health care professionals might improve patients' overall experience with being hospitalized and patient satisfaction by addressing this unmet patient need.

BACKGROUND: Although medical ethicists and educators emphasise patient-centred decision-making, previous studies suggest that patients often prefer their doctors to make the clinical decisions. OBJECTIVE: To examine the associations between a preference for physician-directed decision-making and patient health status and sociodemographic characteristics. METHODS: Sociodemographic and clinical information from all consenting general internal medicine patients at the University of Chicago Medical Center were examined. The primary objectives were to (1) assess the extent to which patients prefer an active role in clinical decision-making, and (2) determine whether religious service attendance, the importance of religion, self-rated spirituality, Charlson Comorbidity Index, self-reported health, Vulnerable Elder Score and several demographic characteristics were associated with these preferences. RESULTS: Data were collected from 8308 of 11 620 possible participants. Ninety-seven per cent of respondents wanted doctors to offer them choices and to consider their opinions. However, two out of three (67%) preferred to leave medical decisions to the doctor. In multiple regression analyses, preferring to leave decisions to the doctor was associated with older age (per year, OR=1.019, 95% CI 1.003 to 1.036) and frequently attending religious services (OR=1.5, 95% CI 1.1 to 2.1, compared with never), and it was inversely associated with female sex (OR=0.6, 95% CI 0.5 to 0.8), university education (OR=0.6, 95% CI 0.4 to 0.9, compared with no high school diploma) and poor health (OR=0.6, 95% CI 0.3 to 0.9). CONCLUSIONS: Almost all patients want doctors to offer them choices and to consider their opinions, but most prefer to leave medical decisions to the doctor. Patients who are male, less educated, more religious and healthier are more likely to want to leave decisions to their doctors, but effects are small.