Journal of General Internal Medicine

Background: People with disabilities (PWD) represent over one-quarter of the US population and disproportionately experience chronic pain, yet limited research explores disparities they face in opioid use disorder (OUD) treatment. Objective: To examine disparities across disability status regarding opioid use disorder (OUD)-related outcomes and understand how chronic pain interacts with these associations. Methods: We completed a cross-sectional, secondary analysis of data from the All of Us Research Program, including 370,722 adults with electronic health record data available between January 2021-September 2023. We identified prevalence of disability, chronic pain, OUD, receipt of medications for OUD (MOUD), and OUD remission using diagnostic codes. We performed interaction analyses between chronic pain, disability subtype, and MOUD receipt in affecting OUD outcomes. Results: OUD was more common among individuals with physical (aOR: 2.74, 95% CI: 2.54-2.95), cognitive (2.19, 1.94-2.45), and multiple disabilities (2.43, 2.19-2.68), compared to those without disabilities. Among patients with OUD, those with physical disabilities were less likely to receive MOUD (0.81, 0.69-0.94). Compared to those without disabilities, chronic pain was associated with higher probabilities of OUD diagnosis and lower probabilities of MOUD and OUD remission across all subjects. These relationships were stronger for OUD diagnosis in cognitive disabilities, MOUD in multiple disabilities, and OUD remission in physical disabilities. Conclusions: Disability and chronic pain jointly shape disparities in OUD treatment and underscore the urgent need for care models that integrate OUD treatment with pain management and address the unique access challenges faced by people with disabilities.

Objectives Outpatient buprenorphine-naltrexone (bup-nx) treatment reduces overdose risk, yet many patients still return to use or disengage from treatment. We sought to understand how patients and prescribers experience and manage relapse risk, monitoring, and treatment agency in routine bup-nx treatment to identify gaps in current practice. Methods We conducted a qualitative needs assessment using semi structured, critical incident interviews with patients receiving outpatient bup-nx and prescribers who manage bup-nx treatment. Interviews examined situations involving relapse risk and empowerment in treatment decisions. We structured data collection and analysis using the Theoretical Domains Framework and COM B model to characterize determinants. Transcripts were coded deductively and inductively until code level saturation was reached. Results Participants (9 patients, 8 prescribers) described nine treatment needs mapped to the Capability, Opportunity, and Motivation components of the COM B model. These themes highlighted how patient agency in bup-nx treatment was constrained by physiologic and emotional states, with withdrawal, craving, pain, and distress often overriding longer term goals. Relapse vulnerability was experienced as dynamic and intensifying between visits, while clinical detection remained anchored to visit bound assessments, urine drug testing, refill patterns, and crisis driven contact, creating blind spots. Structural friction (pharmacy rules, insurance disruptions, transportation and housing instability), stigma from family and recovery communities, and motivational processes tied to fluctuating readiness and trust in monitoring further shaped engagement, disclosure, and dosing decisions; the same monitoring tools could either support honest disclosure or provoke concealment when perceived as punitive. Conclusions Relapse risk and agency in bup-nx treatment are negotiated as dynamic processes within structurally constrained and trust sensitive systems. Addressing the identified capability, opportunity, and motivation gaps will require patient centered, trust preserving approaches to monitoring and shared decision making.

Objective: To assess the efficacy of an executive peer coaching program, Charting Champions Program (CCP), in helping physicians manage their administrative workload, thereby improving time management, workflow and well-being. Findings: In this longitudinal survey study, physicians self-reported significant improvements in completing charting and administrative paperwork during their clinical day. Physicians reported significant improvements in mental, cognitive and emotional states after the program. Meaning: The Charting Champions Program is an effective intervention that supports physicians in problem-solving the administrative burden of their clinical day, improving workflow efficiency, completing administrative requirements during clinical hours, and enhancing work-life balance and personal satisfaction. Background: Physicians are subject to high levels of mental, physical, and emotional stress, partly due to increasing administrative burdens. Online coaching is a proven intervention to help physicians improve workflow efficiency, reduce administrative burden and improve job satisfaction. Design: This voluntary longitudinal survey took place between 2020 and 2023. Physicians were asked to complete a survey at program entry and again 30-90 days after program completion. The survey consisted of 14 Likert scale questions, and a final sample of 280 physicians completed both surveys. Intervention: CCP contains modules that teach workflow improvements for clinical days, including timely charting, administrative task workflow, managing patient consultations and reducing interruptions. Interventions include self-paced modules, live coaching, recordings and an online peer community. Results: Post-CCP physicians reported a significant decrease in hours spent charting (P<0.0001) and completing clinical paperwork outside of clinical hours (P<0.006). Physicians also reported a decrease in work-related dread (P<0.001), feelings of burnout (P<0.001), and thoughts of quitting due to administrative burdens (P<0.001). Physicians felt more focused at work (P<0.001), felt more in control of the clinical day (P<0.001), and rated their mental energy at work higher (P<0.001). The program did not affect the number of patients seen in a full clinical day (P > 0.918). Conclusion and Relevance: The CCP reduces the time physicians spend on tasks outside of clinical hours, increasing free time without decreasing the number of patients seen per day.

Introduction Postoperative analgesic management after minimally invasive cardiac surgery (MICS) should facilitate early recovery while providing adequate pain control. However, direct evidence comparing postoperative remifentanil- and fentanyl-based analgesic strategies after MICS remains limited. We compared these strategies and explored their associations with postoperative recovery, postoperative nausea and vomiting (PONV), and pain management. Methods This retrospective single-center observational cohort study included patients who underwent MICS via a right mini-thoracotomy between January 2023 and June 2026. Patients were categorized according to postoperative remifentanil- or fentanyl-based analgesia in the intensive care unit. Outcomes included time to extubation, PONV, postoperative pain assessed using the numerical rating scale (NRS), additional analgesic use, and intensive care unit length of stay. Multivariable logistic regression examined the association between postoperative opioid strategy and PONV, adjusting for age, sex, and smoking history. Results PONV occurred less frequently in the remifentanil group than in the fentanyl group (20.6% vs 45.0%, P = 0.004), and this association remained significant after adjustment (adjusted odds ratio, 0.23; 95% confidence interval, 0.10-0.56; P = 0.001). Time to extubation was shorter with remifentanil (median, 179 [interquartile range, 134-240.5] vs 247 [190.2-276.5] min; P < 0.001). In contrast, NRS pain scores on postoperative day 0 were higher with remifentanil (3 [1-6] vs 1 [0-2]; P < 0.001), and additional analgesics were used more frequently (80.6% vs 33.3%; P < 0.001). Pain scores on postoperative day 1 did not differ significantly between groups. Conclusion Postoperative remifentanil-based analgesia after MICS was associated with less PONV and earlier extubation but also with greater early postoperative pain and more frequent additional analgesic use than fentanyl-based analgesia. Appropriate transition to longer-acting analgesics with multimodal analgesia may help preserve the potential benefits of remifentanil while maintaining adequate postoperative pain control.

The forced displacement of medical students due to armed conflict presents a profound disruption to the global medical education continuum. Existing research predominantly evaluates individual psychological trauma, leaving a critical gap in measuring the structural and institutional friction displaced learners face when transitioning into host medical schools. This study details the development, structural refinement, and psychometric validation of the Displaced Medical Student Scale (DMSS), a novel 38-item instrument theoretically grounded in Pierre Bourdieus Theory of Practice. Utilising an exploratory sequential mixed-methods design adhering to COSMIN guidelines, initial qualitative items generated from a transnational cohort underwent content validation by an expert panel (Scale-Level Content Validity Index Average = 0.96) and pilot face validation (N = 29) to eliminate linguistic barriers. Subsequent psychometric testing with 156 displaced Gazan medical students confirmed a robust six-factor latent structure: Mechanisms of Conflict, Hysteresis and Dislocation, Agential Coping, The Agents Toolkit, The Institutional Field, and Transition Outcomes. Confirmatory factor analysis using diagonally weighted least squares demonstrated excellent model fit (, Comparative Fit Index = 0.925, Tucker-Lewis Index = 0.918, Root Mean Square Error of Approximation = 0.058, Standardised Root Mean Square Residual = 0.064) and exceptional internal consistency (Cronbachs , McDonalds ). Structural equation modelling proved that institutional symbolic violence negatively impacts transposed clinical capital () and that structural hysteresis mathematically mediates the path between symbolic violence and professional attrition fatigue (). Furthermore, agential coping significantly moderates identity crisis outcomes (). The DMSS provides medical faculties with an evidence-based metric to transition from deficit frameworks to targeted structural interventions that preserve displaced clinical capital.

Introduction: Shared medical appointments (SMAs) are medical visits where multiple individuals are seen together in a group setting. For patients with inherited cardiovascular disease, where multiple family members often require ongoing cardiac care and screening, family SMAs may be particularly valuable as a tool to facilitate family communication and comprehension of their condition. This research aimed to identify patient perspectives on the potential benefits and challenges of family SMAs in comparison to an existing individual clinic model. Methods: Qualitative semi-structured interviews were conducted with adult family representatives. Each family had at least one family member seen at the adult and pediatric inherited cardiovascular disease clinics. Interview recordings were transcribed verbatim and inductively coded using a content analysis approach. Results: Sixteen families were interviewed in this study. The mean age of the family representative interviewed was 43.4 years ({+/-} 9.3 SD), and they were followed at Stanford Health Care for a mean of 7.3 years ({+/-} 4.2 SD). 81.2% (13/16) of families said they would find family SMAs beneficial. For interested families who consented to recorded interviews (n=12), benefits and challenges fell into two major categories: care quality and access and logistics. Interested families thought family SMAs would provide an added care quality benefit by increasing understanding among adults, children, and providers (83.3%, 10/12). Six of twelve participants interested in having family SMA visits felt there would be logistical/access-based benefits to this new model (50%, 6/12). Families also identified possible challenges with this model, such as less individualized care, potential privacy concerns, and concerns regarding the smoothness of the clinic process in coordinating a family SMA. Conclusion: The majority of families believed a family SMA model would provide added benefit to families with inherited cardiovascular disease, but requires thoughtful implementation and should be tailored to families? unique needs.

Background: Mortality prediction models often combine early electronic health record data, but the relative prognostic value of baseline vulnerability, physiological severity, treatment exposure, and procedure burden remains unclear. Objective: To compare routinely available first-24-hour clinical domains for visit-level 30-day mortality prediction and assess whether domain-level patterns replicated in MIMIC-IV. Methods: We used CHoRUS, an OMOP-formatted acute-care dataset, with independent domain-level replication in MIMIC-IV. CHoRUS included 22,098 visits among 5,892 unique patients, with 1,004 30-day mortality events and 4.5% mortality prevalence. MIMIC-IV included 23,000 acute-care visits among 10,006 unique patients, with 819 events and 3.6% prevalence. Across both datasets, 45,098 visits and 15,898 unique patients were analyzed. Predictors were restricted to the first 24 hours after visit start. Performance was evaluated using AUPRC, AUROC, Brier score, calibration, sensitivity at 90% specificity, highest-risk 10% analyses, decision-curve analysis, and SHAP summaries. Because 30-day mortality was infrequent, the classification task was class-imbalanced. Accordingly, AUPRC was interpreted relative to the prevalence-based no-skill baseline, rather than as an absolute measure alone. Results and Conclusion: Physiological severity produced the largest improvement beyond baseline in CHoRUS, with median AUPRC 0.38 and median AUROC 0.86, and showed the same primary domain-level pattern in MIMIC-IV. Treatment exposure and procedure burden provided smaller gains. In CHoRUS, the best pairwise model combined baseline, physiological severity, and procedure burden features, with median AUPRC 0.41; the all-domain model was slightly lower, with median AUPRC 0.40 and median AUROC 0.86. In MIMIC-IV, the all-domain model had the highest median AUPRC, 0.25, only modestly above the best pairwise model. First-24-hour physiological severity features therefore provided the most consistent prognostic information across datasets, supporting parsimonious, clinically interpretable acute-care risk models centered on high-quality early physiological data.

Background To characterize Coronavirus disease 2019 (COVID-19) symptom severity, and recovery from pre-infection through one month, overall and by risk groups. Methods Symptomatic adults aged [&ge;]18 years with test-confirmed COVID-19 were enrolled from ambulatory care clinics within a national U.S. retail pharmacy network between 10/24/2024 and 08/29/2025 (NCT05160636). Adjusted mixed models for repeated measures estimated least-squares mean changes (LSE) and standard errors (SE) from pre-infection and on Days 1-7, 10, 14, and Week 4 from enrollment in composite symptom scores (sum of severity ratings (0-3) across 14 symptoms), counts of mild-to-severe, moderate-to-severe, and severe symptoms, overall and by age and clinical risk status. Effect sizes (ES) were defined as small (0.2-<0.5), medium ([&ge;]0.5), and large ([&ge;]0.8). Results The analysis included 608 adults. On Day 1, symptom severity rose sharply from pre-infection for the composite symptom score (LSE 14.2 [SE 0.3]; ES 2.22), mild-to-severe (7.6 [0.1]; 2.72), moderate-to-severe (5.0 [0.2]; 1.77); and severe (1.8 [0.1]; 0.92) (all p<0.001). By Week 4, composite score (0.7 [0.2]; 0.26), mild-to-severe (0.5 [0.1]; 0.23); moderate-to-severe symptoms (0.1 [0.1]; 0.17) and severe symptoms (0.2 [0.1]; 0.5) remained slightly above baseline (all p[&le;]0.025). Elevated severe symptom durations varied: high-risk adults (through Day 3), adults <50 years (through Day 7), and adults [&ge;]50 years (through Day 7). Conclusions COVID-19 was associated with notable acute symptoms in outpatients, followed by gradual improvement over time, although symptoms still persisted at four weeks. Improvement in severe symptoms varied by individual risk profile, reinforcing the importance risk-based follow-up and ongoing monitoring.

Introduction: In 2020, Oregon became the first US state to legalize state-regulated psilocybin services. This study aims to examine: 1) the clinical and demographic characteristics, 2) psilocybin use motivations, and 3) differences in preparedness among patients seeking care in a Oregon- based pilot consult service specializing in psilocybin risk reduction. Methods: This retrospective chart review abstracted sociodemographics, trauma history, and medical and psychiatric risks of patients (November 2023 - September 2025). The Psychedelic Preparedness Scale (PPS), a validated self-report questionnaire, measured preparedness. Two sample t-tests examined associations of PPS scores by insurance, consult motivations, and prior psychedelic use. Results: Patients (N=29) had a mean age of 47.14 years (SD=15.9), were majority female (55.2%); White (82.8%); and privately insured (62.1%). Patients mostly sought psilocybin to address only a psychiatric concern (75.9%); 27.6% anticipated naturalistic (non-state regulated) use. Most patients were deemed low risk for adverse events. Prevalence of prior challenging psychedelic experiences (CPE) was 17.2%; 58.6% reported lifetime psilocybin use. 86.2% endorsed >1 form of lifetime trauma. Of PPS completers (N=23, 79%), mean score was 91.3 (SD = 23.99). Scores did not significantly differ by insurance; consultation motivation; CPE; prior psilocybin or psychedelic use. Conclusion: Patients utilizing a novel consultation service demonstrate a high prevalence of trauma, prior psilocybin use, and baseline preparedness. While preliminary, this is among the first descriptions of patients seeking medical and psychiatric consultation when considering psilocybin and highlight the potential role of healthcare systems in providing evidence-based patient education and risk reduction as interest in psychedelics grows.

Objectives: To estimate the prevalence of Post-Exertional Malaise (PEM) among adults with prior COVID-19 and associated mental health and disability outcomes. Methods: We conducted a cross-sectional analysis of data from a survey of 9,620 adults with prior COVID-19 in New York City, collected May - June 2024. PEM was measured with the DePaul Symptom Questionnaire - Post Exertional Malaise, categorized by symptom duration (< 14 vs. [&ge;]14 hours). Weighted prevalence estimates were stratified by socio-demographic and clinical characteristics. Modified Poisson regression was used to assess the association of PEM with depression, anxiety, and disability. Results: The prevalence of PEM symptoms was 20.9% overall and 4.0% with symptom duration [&ge;]14 hours, representing over 800,000 New Yorkers affected and over 150,000 who meet a diagnostic criterion for ME/CFS. PEM prevalence was higher among women, transgender and non-binary adults, people of color, and lower educational attainment, chronic comorbidities, or disabilities. PEM was associated with 3 - 4 times higher prevalence of mental health outcomes and 4 - 5 times higher disability scores. Conclusions: PEM symptoms were common and strongly associated with disability and adverse mental health. Screening, pathways to care, and supportive policies are needed to mitigate long-term consequences, particularly among marginalized populations.

Purpose. Prognostic assessments after acute brain injury are largely narrative, and how prognostic language relates to subsequent care has not been measured at scale. We quantified where it is written and its association with a subsequent code-status limitation. Materials and Methods. Multidatabase observational study of adults with acute brain injury or a related neurologic emergency, using MIMIC-IV (2008-2019; discharge summaries and radiology reports) and a timestamped MIMIC-III cohort (notes and code-status orders). The exposure was documented prognostic language; outcomes were its association with a subsequent full-code-to-limitation transition, note-stream location, and completeness of documented command-following relative to structured Glasgow Coma Scale (GCS) motor scores. Results. Among 31,993 admissions (27,054 patients; median age, 69 years; 54.9% male), prognostic language in the timestamped cohort (MIMIC-III) was associated with a subsequent code-status limitation after multivariable adjustment (adjusted hazard ratio, 4.3; 95% CI, 2.9-6.5; unadjusted 14-day cumulative incidence, 40% vs 8.5%), including the comfort-measures component (3.9), a higher-risk subgroup (4.4), and after acute-physiology adjustment (4.1); the association was concentrated in the first 3 days. Non-prognostic severity language showed no comparable association (hazard ratios, 1.1-1.3). Prognostic language localized almost entirely to the narrative (4.9% of discharge summaries vs 0.015% of radiology reports); command-following was undocumented in 55.7% of summaries, and no final-24-hour GCS motor score was charted in 72.8%. Conclusions. Documented prognostic language after acute brain injury was written in the narrative, not structured fields, and was associated with a subsequent code-status limitation after multivariable adjustment. This observational association cannot establish causation but warrants prospective study.

Background: While critical care pharmacists (CCPs) are broadly associated with improvements in outcomes for critically ill patients, operationalizing staffing in the intensive care unit (ICU) requires further study. The purpose of this evaluation was to determine the relationship of a CCP on interprofessional rounds for weekday admissions of ICU patients on patient-centered outcomes. Methods: This post-hoc analysis of the Optimizing Pharmacist-Team Integration for ICU Patient Management (OPTIM) study included adults admitted to an ICU on a weekday in the multicenter observational study. The primary outcome was in-hospital mortality. The primary exposure was level of comprehensive medication management (CMM) during the first 24 hours of ICU stay. A secondary exposure was pharmacist-to-patient ratio. Multivariable generalized estimating equations (GEE) were used to estimate associations between mortality and patient, ICU, and institution variables. Fine-Gray sub-distribution hazards regression estimated hazard of discharge alive (HDA) from the ICU and hospital and hazard of extubation alive. Results: 21,835 patients met inclusion criteria, and 76.1% of patients had CMM delivered on interprofessional rounds. Patients who had no CMM on the first ICU day had an increased risk of mortality of 23% (Odds Ratio (OR) 1.23, 95% Confidence Interval (CI) 1.04-1.46, p=0.02) compared to those who received CMM on interprofessional rounds. Patients with no CMM also had decreased HDA from the ICU and hospital and decreased hazard of extubation alive. No difference was seen in any outcomes when comparing other levels of CMM (CMM delivered outside of interprofessional rounds or abbreviated CMM) compared to CMM delivered on rounds. Conclusions: Absence of pharmacist CMM on the first day of ICU stay for patients with weekday admission was associated with an increased risk of in-hospital mortality, but no difference was seen in other levels of CMM: this signal supports further investigation in prospective analysis.

Objectives: Healthcare data can reveal actionable opportunities to prevent asthma hospitalizations. Limited national-level data exist regarding social determinants of health (SDOH) and asthma hospitalizations. We examined SDOH-related International Classification of Diseases, Tenth Revision (ICD-10) Z-codes in national administrative data on asthma hospitalizations and described patient- and hospital-level characteristics associated with documented SDOH Z-codes. Methods: Pooled cross-sectional analysis of 2016-2022 Nationwide Inpatient Sample for 200,452 U.S. hospitalizations (all ages) with a primary diagnosis of asthma. Presence of SDOH Z-codes (codes Z55-Z65) assessed by descriptive statistics and multivariable logistic regression to calculate odds ratios (ORs) and 95% confidence intervals (95% CIs) for associations between SDOH Z-codes and patient- and hospital-level characteristics. Results: In unweighted analyses, 3,149 asthma hospitalizations had SDOH Z-codes (1.57%). The most common SDOH Z-codes were homelessness (Z59.0; n=942) and unemployment (Z56.0; n=349). Weighted chi-square analyses found all selected variables were associated with asthma hospitalization SDOH Z-code documentation. Logistic regression results varied; adjusted odds for SDOH Z-code documentation were higher for asthma hospitalizations involving male patients (aOR=1.51; 95% CI, 1.39-1.63; P < .001) compared to female patients. Asthma hospitalizations involving rural hospitals had lower odds of SDOH Z-codes documentation (aOR=0.57; 95% CI, 0.47-0.70; P < .001) compared to urban teaching hospitals. Conclusions: National 2016-2022 data indicate housing- and employment-related Z-codes were the most commonly documented SDOH within asthma hospitalizations. Future analyses could consider establishing causality and exploring how relationships between these SDOH may be used by public health practitioners and others to improve program interventions.

Indiana still faces significant health challenges, ranking among the least healthy U.S. states due to high obesity rates, mental health issues, and other chronic conditions. These disparities are closely linked to inequities in healthcare access, which are largely shaped by social determinants of health. Using data from the Social Vulnerability Index and County Health Rankings and Roadmaps, this study analyzes trends in obesity, mental health, and premature death across Indiana counties before, during, and after the COVID-19 pandemic. Descriptive statistics, correlation analyses, and Negative Binomial regression models were used to evaluate county-level disparities. In 2018, higher rates of uninsured, obese, and physically inactive populations were associated with increased premature death. In 2020, diabetes, smoking, and alcohol consumption were significant factors. By 2022, unemployment, education, obesity, insurance, exercise access, and mental health provider availability were associated with premature death. Findings indicate that socially vulnerable counties experienced amplified health impacts, with obesity rising most sharply where exercise infrastructure was limited and poor mental health days increasing across all counties. These results highlight persistent service gaps and the critical need for targeted investments in recreational infrastructure and mental healthcare. Future research should examine policy influences and causal relationships to inform equity-focused interventions.

Background Effective communication during consultations is facilitated by clinical empathy and realistic optimism, and can enhance patient satisfaction with care, alleviate symptoms, and improve quality of life. However, primary care systems are under significant strain and changing rapidly, which may affect practitioners' ability to communicate empathically and convey realistic optimism, with implications for the patient-practitioner relationship and patient outcomes. Understanding patients' perspectives of healthcare communication in the current clinical context is therefore important. We aimed to explore patients' experiences and perceptions of communication in UK primary care consultations, focussing on the communication of clinical empathy and realistic optimism. Methods A qualitative interview study was conducted as part of a multi-centre cluster-randomised trial of EMPathicO, a brief e-learning package for Primary Care Practitioners (PCPs) on communicating clinical empathy and realistic optimism. Participants were not aware whether their general practice had access to EMPathicO or not. Interviews were conducted within 7-14 days of participants' consultations, explored their views and experiences of clinical empathy and realistic optimism, and were transcribed verbatim. Interviews were analysed using Ritchie and Spencer's Framework Method. Results We conducted semi-structured audio-recorded qualitative telephone interviews with 71 participants from 29 primary care practices taking part in the EMPathicO trial. Following comprehensive mapping of data to the framework derived following initial analysis, four themes were agreed. Overall, most participants described positive empathic consultations with their PCPs, however, participants' experiences were shaped by wider systemic and contextual factors. They described a stretched and inefficient primary care system impacting empathy and optimism; the impact of PCP 'preparedness' as a marker for empathy; how consultation modality (i.e. in-person or telephone) shaped perceptions of empathy, and how PCPs sharing next steps in participants' treatment and management could foster realistic optimism. Conclusions While clinical empathy and realistic optimism may be experienced by patients during consultations with practitioners, the wider contextual challenges of accessing and navigating primary care systems can threaten overall perceptions of feeling cared for. Future primary care policy and workforce training must consider these system pressures to preserve effective communication in consultations and positive patient-practitioner encounters.

Perioperative safety checklists standardize critical actions, but reliable completion depends on the surrounding work system and team behavior. We conducted a prospective observational analytic study from April to May 2026 in the central surgical unit of a high-volume public teaching referral hospital in Indonesia to examine whether patient safety culture and teamwork were associated with directly observed perioperative safety compliance and whether teamwork mediated the culture-compliance relationship. Patient safety culture was measured with the Hospital Survey on Patient Safety Culture 2.0, teamwork with a 35-item TeamSTEPPS Teamwork Perceptions Questionnaire research adaptation, and compliance by direct role-based observation using a 45-item checklist derived from the AORN Comprehensive Surgical Checklist. Eighty of 92 recruited professionals contributed 240 person-operation observations across 50 operations. Overall compliance was 74.75%, with sign-out lowest at 70.68%. Patient safety culture was associated with teamwork ({beta} = 0.590; 95% CI 0.510-0.770) and directly with compliance ({beta} = 0.407; 95% CI 0.187-0.712). The teamwork-compliance coefficient was positive ({beta} = 0.285; p = 0.046), but the prespecified percentile 95% CI included zero (-0.045 to 0.517). The indirect effect through teamwork was not supported ({beta} = 0.168; p = 0.079). These findings support a system-level interpretation of perioperative safety and identify learning-oriented responses to error, situation monitoring, and sign-out fidelity as measurable targets for future improvement efforts.

Background Patient-reported satisfaction is a core tracer of health-system responsiveness in Universal Health Coverage (UHC) monitoring, yet its determinants in rural Sierra Leone are poorly characterised. We quantified overall and domain-specific satisfaction and identified modifiable predictors across three rural border districts. Methods We conducted a cross-sectional, population-based household survey in October 2024 in Kailahun, Kambia and Pujehun districts, using a two-stage cluster design (chiefdoms sampled with probability proportional to size; households sampled at random). A validated 29-item instrument measured overall satisfaction and eight patient-experience domains on five-point Likert scales. The primary outcome was the five-level single-item overall satisfaction rating. We fitted a multivariable proportional-odds ordinal logistic regression, with 95% confidence intervals (CIs) obtained by a cluster bootstrap resampling the 20 chiefdom clusters. Robustness was assessed with binary and composite-outcome sensitivity models. Results Of 750 respondents, 679 (90.5%) had used a formal health facility in the previous 12 months and formed the analytic sample (510 [75.1%] female; mean age 28.2 years [SD 13.8]). The instrument showed high internal consistency (Cronbach = 0.87 for the five core domains). Overall, 375/679 (55.2%) were satisfied or very satisfied, ranging from 185/244 (75.8%) in Kambia to 110/224 (49.1%) in Kailahun and 80/211 (37.9%) in Pujehun ({chi}{superscript 2} = 70.8; p<0.001). In the adjusted model, staff attitude was the strongest predictor of higher satisfaction (adjusted odds ratio [AOR] 2.74, 95% CI 2.03-3.70; p<0.001 per one-point increase), followed by waiting-time satisfaction (AOR 1.89, 1.39-2.46) and medicine availability (AOR 1.43, 1.16-2.10). Travel-time category, facility type and sex were not independently associated. Large district disparities persisted after adjustment: relative to Kambia, the AOR for higher satisfaction was 0.27 (0.15-0.50) in Kailahun and 0.33 (0.20-0.66) in Pujehun. Adjusted probabilities of high satisfaction were 0.72, 0.48 and 0.43, respectively. Conclusions Respectful provider behaviour, shorter waits and reliable medicine supply, all amenable to district-level management, were the dominant and actionable drivers of patient satisfaction, whereas geographic distance was not. Persistent between-district gaps call for tailored quality-improvement in Kailahun and Pujehun. Institutionalising routine patient-experience measurement would strengthen accountability for people-centred care and support equitable progress towards UHC.

Background: Hyperkalemia is a clinically relevant disorder across the cardiorenal continuum. In Central America and the Dominican Republic, there are no published systematic descriptions of real-world clinical practices or the degree of alignment of these practices with the most recent hyperkalemia management guidelines. Objective: To characterize physicians perceptions and therapeutic behaviors regarding hyperkalemia, including diagnostic thresholds, criteria for intervention and referral, management strategies, and access to potassium monitoring. Methods: A cross-sectional study was conducted using an online survey administered between April and June 2025 to physicians from multiple specialties across seven countries. Absolute and relative frequencies were calculated overall and stratified by specialty and country. Results: A total of 362 responses were collected. Participants were primarily from Costa Rica (32.3%), Honduras (27.9%), and Guatemala (21.0%). 37.8% of respondents reported hyperkalemia in 10% to 30% of their patients, with the most reported diagnostic threshold being serum potassium 5.5 mEq/L. Outpatient intervention was most frequently initiated at 5.5 mEq/L (55.2%), while referral to the emergency department was reported at a potassium level of 6.0 mEq/L (35.6%). Regarding management strategies, 67.0% favored an electrocardiogram prior to deciding on intervention; 93.0% reported reduction or discontinuation of drug causing hiperkalemia; and 74.0% prescribed therapies increasing potassium excretion. Access to potassium monitoring differed substantially by setting reported as 55.5% in the public versus 90.3% in the private sector. Among cardiologists, frequently used strategies for hyperkalemia in heart failure were reduction or discontinuation of mineralocorticoid receptor antagonists and increased use of loop diuretics. Nephrologists favored strict dietary modifications, loop diuretics, and the use of cation-exchange resins. Conclusions: Substantial heterogeneity was observed in hyperkalemia definitions, action thresholds, and referral criteria, along with frequent modification of renin-angiotensin-aldosterone inhibitors, and reduced access to potassium monitoring in the public sector.

Purpose: Lung cancer screening (LCS) with low-dose computed tomography (LDCT) reduces lung cancer mortality, yet screening participation remains low. We evaluated whether a brief informational video nudge delivered immediately before a scheduled clinical encounter increased LCS ordering and baseline LCS completion. Patients and Methods: We conducted a randomized feasibility trial within Kaiser Permanente Colorado from March through October 2025. LCS-eligible patients with an upcoming primary care or pulmonology appointment were assigned to intervention or usual care based on birth month. Intervention patients were split into two group, a group who received the LCS informational video nudge via text message within 24 hours of an eligible appointment; and second group who received the text plus a QR code video link during appointment rooming. Outcomes included LCS orders, baseline LCS-LDCT completion, and video engagement. Multivariable logistic regression was used to evaluate factors associated with LCS ordering. Results: Among 1,093 patients, 549 were assigned to intervention and 544 to usual care. Intervention patients were more likely to receive an LCS order within 1 day of their appointment (22.6% vs 16.4%; p=.010) and any time during follow-up (32.6% vs 24.1%; p=.002). Baseline LCS-LDCT completion was 51% higher in the intervention group, although the difference was not statistically significant (8.6% vs 5.7%; p=.078). Among the intervention group, 93 individuals (17%) viewed the video, generating 114 total views, and viewers watched an average of 79% of the video. Most views (82.5%) occurred through text-message delivery rather than QR codes. Conclusion: A brief, low-burden LCS informational video delivered immediately before a clinical encounter and integrated into existing workflows significantly increased LCS ordering and was associated with higher screening completion. Timely, scalable digital nudges may provide an effective strategy for improving LCS participation. Based on the observed effectiveness, feasibility, and efficiency of the intervention, KPCO incorporated the behavioral nudge into standard clinical care in February 2026.

Introduction: Risk of recurrent opioid use during buprenorphine-naloxone (bup-nx) treatment is dynamic and remains elevated after initiation, with vulnerability shaped in part by treatment intensity and gaps between visits, yet routine outpatient care relies on episodic encounters and retrospective data. This mismatch can delay recognition of emerging instability and limit timely treatment adjustments. This paper reports the development and specification of an intervention strategy to address this mismatch. Methods: We used a structured, multi-phase design process to specify and configure a measurement-based care (MBC) strategy for bup-nx treatment (Bup-MBC) in outpatient addiction clinics through three phases: (1) a systematic review of patient-reported outcome measures (PROMs) for substance use treatment; (2) a qualitative needs assessment using the Theoretical Domains Framework and COM-B (Capability, Opportunity, Motivation-Behavior) model to identify gaps in risk monitoring, agency, and trust; and (3) iterative co-design with multidisciplinary clinicians to refine workflow fit and trust-preserving use of data. Patients informed item and feedback content during the needs assessment but did not participate in the co-design cycles. Results: Bup-MBC integrates (1) brief between-visit PROMs (e.g., withdrawal, craving, adherence); (2) immediate non-punitive patient feedback; (3) clinician-facing summaries and non-directive prompts in the electronic health record (EHR); and (4) an opt-in between-visit outreach pathway with predefined safety triggers, all configured within existing EHR and patient portal infrastructure. It targets patient and clinician capability to recognize changes in risk, opportunity for action through structured monitoring and visit preparation, and trust and agency through non-punitive communication, without adding substantial burden. The full measure set, severity bands, and question-to-action map are provided as supplementary material. Key trade-offs included prioritizing single-item measures for feasibility, balancing opt-in outreach with safety overrides, and assuming routine clinician use of summaries. Conclusion: This development study specifies an EHR-integrated MBC strategy for outpatient bup-nx treatment. As single-center design work with co-design limited to clinicians and delivery contingent on portal or text-message access, its outputs are hypotheses about mechanism and fit rather than demonstrated effects. Feasibility studies are needed to evaluate uptake, acceptability, workflow fit, and effects on treatment.