Journal of General Internal Medicine

BackgroundLong-acting injectable buprenorphine (LAI-BUP) is safe and effective, however is dramatically underutilized in comparison to oral formulations. Little is known regarding how buprenorphine prescribers view LAI-BUP, and which medication attributes they prioritize when selecting treatment for opioid use disorder (OUD). MethodsA secondary analysis of a national, cross-sectional online survey of U.S. physicians who prescribe buprenorphine for OUD was conducted. Respondents reported OUD caseload, LAI-BUP use, and the importance of medication attributes relevant to treatment selection (e.g., efficacy, safety, ease of administration, ease of prescribing, and administrative requirements). Providers were categorized as no LAI-BUP use or, among LAI-BUP prescribers, Low vs High use based on a median split. Group comparisons used chi-square (or Fishers exact) tests for categorical variables and Jonckheere-Terpstra tests for ordinal responses. ResultsAmong 125 respondents, 39 (31.2%) reported no patients receiving LAI-BUP. The remaining 86 (68.8%) were LAI-BUP prescribers, split evenly into Low and High (ns=43; 34.4%) groups using a median cut of 23.2%. LAI-BUP use did not differ meaningfully by specialty, region, or practice setting. Greater LAI-BUP use was reported by providers with larger OUD panels. Ratings of key medication attributes were uniformly high. ConclusionsLAI-BUP remains underused, with uptake highest among clinicians managing larger OUD caseloads. Measured attitudes toward medication attributes did not explain these differences. Future work should assess clinic workflow, staffing, reimbursement, and REMS burden, testing targeted implementation strategies using mixed-methods trials. Identifying what shifts clinicians from no use to low and high use may guide scalable implementation interventions.

Importance Missed outpatient appointments, including no-shows and cancellations, may disrupt continuity of care and be associated with worse outcomes, but long-term system-wide patterns and clinical implications are not well characterized. Objective To characterize variation in missed appointment rates in the Veterans Health Administration (VHA) over time and by geographic location, visit modality, and preexisting conditions, and to evaluate associations between missed appointment rates and adverse outcomes among veterans with posttraumatic stress disorder (PTSD) or traumatic brain injury (TBI). Design Cohort study using VHA Corporate Data Warehouse outpatient appointment data from January 1, 2000, through December 31, 2024. Setting National integrated health care system of the VHA. Participants System analysis includes all scheduled outpatient appointments with a valid status, and outcome analysis includes veterans with PTSD (n = 1 429 890) or TBI (n = 554 553), diagnosed before 2023. Exposures For system -level analyses, missed appointment rates were calculated. In outcome analyses, 2023 missed appointment rates were categorized into tertiles within the cohort and appointment type. Main Outcomes and Measures One year risks of all-cause hospitalization, all-cause mortality, and hospitalization or death beginning January 1, 2024. Results Among 2,162,520,880 outpatient appointments from 2000 to 2024, 6.5% were no-shows and 25.4% were canceled. Across facilities, no-show rates ranged from 3.5% to 14.1%, patient-initiated cancellation rates from 9.7% to 26.0%, and clinic-initiated cancellation rates from 8.5% to 17.9%. In 2023, veterans with amputation, Parkinson disease, PTSD, or TBI had higher missed appointment rates than veterans without these conditions. Among veterans with PTSD, the highest no-show tertile, compared with none, was associated with higher mortality (HR, 1.91; 95% CI, 1.84-1.98) and hospitalization or death (HR, 1.07; 95% CI, 1.05-1.08). Among veterans with TBI, the highest no-show tertile was associated with hospitalization or death (HR, 1.65; 95% CI, 1.61-1.69). Conclusions and Relevance Missed outpatient appointments were common in the VHA and varied substantially across facilities and over time. Among veterans with PTSD or TBI, higher missed appointment rates, particularly no-shows, were associated with increased risks of hospitalization and mortality, suggesting that these patterns may help identify high-risk veterans for targeted outreach.

Purpose: High clinical workload is associated with worse patient and hospital outcomes and is a well-established driver of clinician burnout. Trainees may be particularly exposed, shouldering both clinical and educational responsibilities. Evidence-based work design offers a data-driven approach to healthcare work but relies on robust workload measurements. Trainee workload remains poorly characterized, as commonly used metrics (e.g., duty hours, patient census) overlook cognitive and contextual dimensions. This pilot evaluated the feasibility of combining survey-based and electronic health record (EHR) data to characterize internal medicine (IM) trainee workload. Methods: A pilot study was conducted including IM and Medicine-Pediatrics residents (postgraduate years 1-4) between March 31 and June 22, 2025. Participants completed daily surveys during a seven-day inpatient schedule assessing workload and work experience domains, including environment, professional fulfillment, psychological safety, autonomy, and rounding experience, using validated instruments where available. Concurrently, EHR data captured chart review, documentation, orders, and secure messaging activity. Associations between survey and EHR data were assessed. Results: Among 37 eligible residents, 28 (76%) participated in the pilot capturing 166 shifts. Trainees spent 4.4 +/- 1.6 (mean +/- SD) minutes completing daily surveys and 8.6 +/- 2.3 minutes completing the final survey. Trainees reported working 11.6 +/- 1.0 hours/day and a median census of 9.0 (IQR 6.0-11.0). NASA-TLX score was 50.8 +/- 12.6. Positive shift ratings were associated with lower NASA-TLX scores and perceived rounding length. First-to-last EHR login duration was 15 +/- 2 hours/day, and EHR data showed 204 +/- 46 active minutes/day. Login duration correlated with self-reported hours (r=0.43, p<0.0001), and notes signed correlated with self-reported team (r=0.19, p=0.013) and personal census (r=0.34, p<0.0001). Conclusions: Integrating survey-based and EHR-derived workload measures provides multidimensional insight into trainee work. This novel approach supports scalable measurement and evidence-based work design interventions to improve trainee well-being, education, and clinical efficiency.

ObjectivesEmergency Medical Services (EMS) demand is increasing, with a growing proportion of low-acuity encounters. Prior studies are limited by regional sampling, inconsistent definitions, narrow observation periods, and limited theoretical grounding. The objective of this study was to identify predisposing, enabling, and need-based factors associated with EMS transport among low-acuity emergency department (ED) patients, guided by Andersens Behavioral Model of Health Services Use. MethodsWe conducted a secondary, retrospective observational study using a 10% random sample of multicenter electronic health record (EHR) data from 21 emergency departments in the southeastern United States. To be eligible to be included in the analysis, the visit had to be for: (1) patient age >17 years of age, (2) occur between January 1, 2016, to April 29, 2025, (3) triaged as Emergency Severity Index (ESI) 4 or 5, and (4) ended in a final visit disposition of being discharged. The primary outcome was EMS utilization. Independent variables were categorized as predisposing, enabling, or need-based factors according to Andersens model. We used multivariable logistic regression to estimate adjusted odds ratios (aORs) with 95% confidence intervals. ResultsAmong 41,772 low-acuity ED encounters, 3,233 (7.7%) arrived by EMS. Increased odds of EMS use were associated with older age (per 10-year increase; aOR 1.30, 95% CI=1.27-1.33), male sex (aOR 1.20, 95% CI=1.12-1.30), being retired or disabled (aOR 3.60, 95% CI=3.15-4.10), being unemployed (aOR 2.26, 95% CI=2.04-2.52), having a nighttime presentation (aOR 1.63, 95% CI=1.51-1.76), and mental health diagnosis (aOR 1.76, 95% CI=1.62-1.90). Protective factors included White race (aOR=0.89, 95% CI=0.83-0.96), established primary care (aOR=0.57, 95% CI=0.57-0.62), weekend presentation (aOR 0.91; CI = 0.84-0.99), and visits during (aOR 0.63, 95% CI=0.55-0.71) or after (aOR 0.54, 95% CI=0.48-0.61) the COVID-19 period. Rurality, insurance, and primary language were not associated with EMS use. ConclusionsPredisposing and enabling factors were the predominant drivers of low-acuity EMS utilization in this sample. Expanding access to primary care and behavioral health services, especially for older patients, may reduce EMS use for low-acuity complaints while preserving EMS capacity for higher-acuity emergencies.

BackgroundClimate change is an escalating health crisis, yet its influence on medical students career decisions remains underexplored. ObjectiveThis study uses the "Six Americas" framework to assess students climate views and the impact on residency and career decisions. MethodsA survey was distributed to students at four North American medical schools from October 2024 to January 2025. The instrument assessed demographic information, climate change views utilizing the Six Americas Super Short Survey, and the impact of climate change on residency and career decisions. Respondents were classified as Alarmed, Concerned, Cautious, Disengaged, Doubtful, or Dismissive using the Six Americas framework. Associations between climate attitudes, training year, and intended specialty were analyzed using Kruskal-Wallis tests. ResultsA total of 105 medical students completed the survey. 93% agreed climate change is a major health threat, 66% valued residency program sustainability efforts, and 41% indicated commitment to sustainability influences their rank list. Most students were Alarmed (62%), Concerned (19%), or Cautious (12%). Climate attitudes did not vary by specialty interest. Training year was associated with Six Americas classification (p < 0.05), MS2s had the most Alarmed respondents. ConclusionsMedical students overwhelmingly view climate change as a serious health threat and expect residency programs to demonstrate commitment to sustainability. Nearly half consider environmental values when ranking programs. These findings suggest climate-conscious training environments may gain a competitive recruitment advantage. Given the high proportion of "Alarmed" students, embedding climate-resilient education and sustainable practices into residency programs may align with future physician priorities.

Importance: Sickle cell disease (SCD) affects approximately 100,000 people in the United States, causes life-threatening complications, and shortens life expectancy by decades. Adults with SCD routinely encounter undertreated pain, provider bias, and structural barriers in hospital settings. Objective: To describe patterns of leave against medical advice (LAMA) among adults hospitalized for SCD. Design, Setting, and Participants: Retrospective analysis of inpatient discharge records among adults ages 18 and older in New York City hospitals, 2022-2023, hospitalized for SCD or any reason. Main Outcomes and Measures: The primary outcome was hospital-level LAMA, measured by crude rates and rates adjusting for patient characteristics using Bayesian hierarchical models. The secondary outcome was 30-day all-cause readmissions, stratified by LAMA status. Results: LAMA discharges comprised 14% of SCD hospitalizations and 4% of all-cause hospitalizations. Adjusted hospital-level SCD LAMA ranged from under 5% to 30% (IQR: 10-20%) and was higher than all-cause LAMA in most facilities. Crude SCD LAMA rates exceeded 30% in several hospitals, including those with more than 100 SCD hospitalizations during the study period. Patients with 10 or more SCD hospitalizations accounted for 40% of total SCD volume. Sensitivity analyses accounting for this concentration showed attenuated but persistent variation in SCD LAMA. Over 50% of SCD LAMA discharges were followed by a 30-day readmission compared to 38% of non-LAMA discharges. LAMA was associated with higher adjusted odds of readmissions in both SCD and all-cause hospitalizations. Conclusions: Our findings challenge the assumption that patients are solely responsible for early departures. Leaving against medical advice should be monitored as a signal of unmet care needs in SCD.

BACKGROUNDDelirium is common in critically ill adults but often goes unrecognized and undertreated. Little is known about the perceptions of ICU nurse and physician leaders regarding ICU delirium detection and management and the potential role of objective continuous delirium monitoring to facilitate ICU delirium care. RESEARCH QUESTIONWhat are the perceptions of ICU leaders regarding the current challenges associated with delirium recognition and management and the potential benefits of continuous delirium monitoring? STUDY DESIGN AND METHODSWe conducted a blinded, cross-sectional, electronic survey of ICU leaders across the U.S., including physician directors and nursing managers with [&ge;]3 years of ICU leadership experience. We asked about perceptions of the effectiveness of current delirium clinical assessment tools, current delirium detection and management challenges, and how an objective, continuous delirium monitoring system might impact clinician practice and patient outcomes in their ICU. RESULTSAmong the 81 respondents (62 physicians, 19 nurses), most (76%) reported that recommended delirium assessment tools (CAM-ICU, ICDSC) are used in their ICUs, though there were mixed perceptions on how reliably they are conducted. A majority (63-90%) perceived that current bedside assessments delay and limit the recognition of ICU delirium. Nearly all (89%) agreed an objective delirium monitoring tool would be more clinically valuable than current delirium assessment tools and that it would support real-time, delirium management by clinicians. CONCLUSIONSICU leaders perceive that there are limitations to using clinical delirium assessment tools in ICU patients to effectively detect and manage ICU delirium. Most felt that an objective delirium monitor could facilitate delirium detection and potentially expedite appropriate delirium management in patients.

BackgroundThe self-management of type 2 diabetes (T2D) typically requires enacting various lifestyle changes, which can challenge people living with T2D. Clinical encounters between people with T2D and their clinicians, however, are often focused on metabolic management, leaving less time available for other self-management topics. The QBSAFE cards help patients articulate aspects of their experience with diabetes and prioritize issues for discussion. MethodsThis report details secondary outcomes of a randomized controlled trial; primary outcomes are reported elsewhere. All data was collected at Fair Haven Community Health Care, a federally qualified primary care clinic. 11 clinicians were randomly assigned to provide either usual care or usual care with QBSAFE cards to 155 of their patients with type 2 diabetes and hemoglobin A1c >8%. All patient encounters were video recorded for analysis. Patients and clinicians were not blinded to arm allocation but were kept unaware of the specific aims of the trial. Encounter video reviewers were blinded to arm allocation, but not to specific aims of the trial. The outcomes of interest for this report were the extent to which the QBSAFE cards were used as intended, their effect on the topics of discussion, and whether they enabled clinicians to notice and respond to each patients situation; comparisons between arms were conducted by a linear mixed model with fixed effect of arm and cluster effect of clinician, analyzed in both intent-to-treat and per-protocol populations. Findings12 patients were excluded post-randomization (A1c <8%). Of 143 eligible patients, 137 encounters (65 in the usual care arm, 72 in QBSAFE) yielded evaluable videos. QBSAFE was used as intended in 61 (85%) QBSAFE arm encounters. Conversations about burden of treatment related to non-pharmacological interventions (17 vs 33, p= 0{middle dot}04) and taking medications (11 vs 33, p= 0{middle dot}0008) and about the patients challenging environment (2 vs 10, p= 0{middle dot}04) were more prevalent in the QBSAFE group. There was no difference in the rate of conversations about metabolic management or of new care plans as a result of conversations between groups. InterpretationWhile there was a difference in the types of conversations observed between the two study arms, this difference was small and only apparent in a few domains. Future work could aim to modify the QBSAFE cards to more effectively stimulate patient-centered discussions and to further prepare clinicians to respond to a variety of issues raised during the clinical visit. FundingThis work was supported by funding from the National Institute of Diabetes and Digestive and Kidney Diseases (R01DK129616).

BACKGROUNDThis study evaluates the reach, scalability, and implementation of a large-scale, multi-site tele-buprenorphine program designed to treat opioid use disorder (OUD) within rural carceral settings. Given that individuals transition frequently between jails and the community, these facilities represent a critical window for OUD intervention, yet they often face significant provider shortages and logistical barriers. We conducted a retrospective chart review of 842 unique patients (1,321 treatment episodes) enrolled in the University of Marylands tele-buprenorphine program across six rural county jails between June 2020 and May 2025. Data extracted from jail records and electronic health records were used to analyze patient demographics, prescribing patterns, and program retention. RESULTSThe patient population was primarily male (71.1%) and White (75.7%), with a mean age of 35.4 years. Participants reported high-severity OUD, with an average of 12.6 years of opioid use. Reflecting broad admission criteria, 55.2% of participants were new treatment initiates not receiving MOUD prior to booking. Patients spent a mean of 35.6 days incarcerated before initiation and were retained in the program for an average of 66 days. Buprenorphine doses were titrated from a mean initiation dose of 8.8 mg to 16.2 mg at discharge. The program demonstrated a 99.5% adherence rate among retained patients. Only 3% of the total sample were discharged for medication diversion or hoarding. CONCLUSIONSTelemedicine is a highly feasible and scalable model for delivering evidence-based MOUD in rural jails. By utilizing a "liberal admission policy" that prioritizes both treatment initiation and maintenance, programs can successfully reach high-risk individuals who lack access to community-based care. These findings suggest that tele-buprenorphine can effectively bridge the treatment gap in underserved jurisdictions, potentially reducing the risk of overdose during the high-risk post-release period.

BackgroundThe physician assistant (PA) workforce has expanded rapidly in the United States, increasing the importance of effective physician-PA collaboration. Although PAs improve patient outcomes and access to care, the determinants of effective collaboration has not been well studied. North Carolina provides a relevant context due to its growing PA workforce and supervisory regulatory structure, in which physicians retain administrative responsibility for PA supervision across practice settings. This study examines determinants of effective physician-PA collaboration in ambulatory care settings in North Carolina. MethodsFour virtual focus groups were conducted with practicing physicians (n=7) and PAs (n=9) across multiple specialties in NC. Transcripts were analyzed using thematic analysis to identify facilitators and barriers to collaboration. ResultsThematic analysis identified six major themes reflecting relational, organizational, and systemic influences on teamwork. Findings demonstrate collaboration evolves over time through early-career mentorship, continuity of working relationships, and progressive trust development. Differences in professional identity, power dynamics, and misunderstanding of PA scope of practice influenced autonomy and delegation. Systemic factors such as reimbursement structures and organizational supervisory policies hindered efficient teamwork. LimitationsFindings are based on a small, purposive sample within a single state and may not be generalizable to all ambulatory settings or regulatory environments. Perspectives may also reflect self-selection bias among participants with strong views on collaboration. ConclusionsEffective physician-PA collaboration depends on intentional onboarding, role clarity, interprofessional education, and alignment of organizational policies with regulatory standards to support team-based care.

Background Therapeutic empathy improves patient and practitioner outcomes, yet existing measures are often lengthy, conceptually inconsistent, and cannot be easily compared across respondent groups. Brief, universal measures (usable by patients, practitioners, students, and observers) are lacking. We therefore developed a universal single-item scale and conducted psychometric testing of the patient-reported version. Methods Following best-practice, we used a three-phase approach: (1) item development; (2) pre-testing the scale by obtaining expert panel feedback (n=9) and conducting cognitive interviews with stakeholders (n=35); and (3) scale validation in an international patient sample (n=521) assessing convergent, discriminant, and known-groups validity. Validation involved assessing correlations with the Consultation and Relational Empathy (CARE) measure and clinical neutrality measure, and by assessing differences in scores by patient ethnicity. Results We developed two versions (pictorial and text-based) of each scale. Expert feedback and cognitive interviews confirmed content and face validity. Pictorial and text-based versions showed high convergent validity with the CARE measure (r=0.761 and r=0.838, both p<0.001), and discriminant validity with a clinical neutrality measure (r=0.131 and r=0.139, p=0.003 and p=0.001, respectively). Correlations with the CARE measure remained high (r>0.70) and statistically significant (p<0.001) across patient gender, ethnicity, and practitioner type. Ethnic minority patients rated practitioner empathy lower than White patients (pictorial p=0.057; text-based p=0.033), demonstrating known-groups validity. Patients rated doctors' empathy higher than other healthcare practitioners' (p=0.001 for both pictorial and text-based); there were no significant differences in empathy scores by patient gender. Conclusions We developed the first universal single-item therapeutic empathy measure and demonstrated validity for the patient-reported versions. The scale is brief, accessible, and applicable to clinical practice, education, and research. Further research should validate practitioner-, student-, and observer-reported versions, and assess predictive and cross-cultural validity. This robust tool can support patient-reported routine measurement of therapeutic empathy and contribute to improving patient and practitioner outcomes.

Background Persons experiencing homelessness (PEH) have a 2-3-fold greater risk for cardiovascular disease (CVD) mortality compared with domiciled counterparts. Evidence has repeatedly shown elevated chronic disease burden, reduced access to many types of care, and lower utilization of medication to control CVD risk factors in clinical settings dedicated to providing health care to PEH. There are federally funded health clinics targeting barriers to access for patient populations experiencing homelessness in place. These clinics are frequently overwhelmed and limited by their scope to primary care despite well documented burdens of co- and tri-morbid conditions. There is scarce evidence on differences between access, quality, and experiences of care delivered relative to other safety-net models. Method The 2022 Health Center Patient Survey (HCPS) was collected on behalf of the Health Resources and Services Administration (HRSA). The HCPS is a nationally representative, three-staged, sample-based survey collected via 1:1 interview with clinic patients. The survey assessed sociodemographics, health conditions and behaviors, access to and utilization of care, and patients? experiences with comprehensive services they received at HRSA-funded Federally Qualified Health Centers (FQHCs), including community health centers (CHC), healthcare for the homeless (HCH) clinics, and public housing primary care (PHPC) clinics. One hundred and three unique awardees and 318 health center sites were recruited, and 4,414 patient interviews were completed. Investigators analyzed patient characteristics and multiple survey items related to AHA?s Essential 8 metrics for differences between HCH and CHC patient responses. Results HCH clinics had fewer elderly patients (~7%) than CHCs (~17%). Reported 7-day physical activity measures, average sleep below 7 hours per day, and Lifetime smoking (>100 cigarettes; OR=4.2, p<0.001) were all greatest among HCH patients. Fewer HCH patients reported ever having or recent lipid tests (both p<0.001). HCH patients were more likely to report hypertension (p=0.003) but less likely to report receiving nutrition advice (all p<0.05). HCH patients were less likely to be taking medication even if it was prescribed (p<0.001). Adjustments for differences in age or CVD history were able to explain some observed differences but increased the magnitude of other disparities. Conclusions CVD burden differs across the various HRSA funding mechanisms for clinics, as do demographics and multiple metrics of health behaviors and biomarkers of cardiovascular health. Greater disease burden in HCH patients is likely compounded by increased risk factors and underperformance in providing health education interventions.

BackgroundCo-occurring substance use and mental health disorders (COD) represent a growing public health concern, yet healthcare utilization studies with a large sample size remain limited. This study examined healthcare utilization patterns and sociodemographic correlates among COD adults using data from the All of Us Research Program (2018-2023). MethodsElectronic health record data were analyzed for adults aged [&ge;]18 years with confirmed diagnoses of substance use and mental health disorders recorded on at least two occasions. Healthcare services were identified using the standardized Current Procedural Terminology and Healthcare Common Procedure Coding System codes and categorized into counseling and therapy, medication/somatic services, online or telehealth care, and other supportive modalities. Multivariable logistic regression was employed to assess sociodemographic and structural correlates of healthcare utilization. ResultsAmong 19,423 adults with COD, 57.1% received healthcare. Counseling and therapy accounted for the largest share of encounters, while online services surged in 2020 during the COVID-19 pandemic. Healthcare utilization was higher among older adults ([&ge;]65 years: aOR=1.52, 95%CI:1.29-1.78), males (aOR=1.19, 95%CI:1.12-1.26), individuals with disabilities (aOR=1.46, 95%CI:1.36-1.56), and those with employer-sponsored (aOR=1.22, 95%CI:1.10-1.36) or other private insurance (aOR=2.15, 95%CI:1.97-2.34). The level of healthcare utilization was lower among participants with lower income ([&le;]$25,000: aOR=0.75, 95%CI:0.69-0.81) or Medicaid coverage (aOR=0.83, 95%CI:0.77-0.89). ConclusionsDespite high clinical need, healthcare utilization among adults with COD remains suboptimal and is shaped by structural inequities across income and insurance lines. Findings highlight the need to expand integrated healthcare services, strengthen Medicaid coverage, and sustain telehealth infrastructure to promote equitable, long-term engagement in care. Highlights{o} Individuals with co-occurring disorders continue to face low healthcare utilization. {o} Counseling and therapy were the major mode of care, while telehealth peaked during COVID-19. {o} Lower income and Medicaid coverage were tied to lower healthcare utilization. {o} Older adults and people with disabilities were more likely to use healthcare services. {o} Findings highlight the needs to expand integrated, equitable behavioral care.

Background Rural populations face disproportionate barriers to healthcare access, often due to geographic isolation and limited provider availability. Prior studies have shown that increased travel time negatively affects appointment adherence. Telemedicine has emerged as a potential solution, but understanding its utilization in rural populations remains ongoing. Methods This retrospective cross-sectional observational study analyzed all scheduled appointments (n=5,548) from a single rural family medicine clinic in the Pacific Northwest United States during 2024. One-way travel times were calculated using the Google Maps Distance Matrix API and categorized into Short (<15 minutes), Medium (15-30 minutes), and Long (>30 minutes) commute groups. Proportions for utilization and cancellations of both telemedicine and in-person appointments were assessed across commute groups using chi-square tests (p < 0.05 considered significant). Results Overall, the proportion of cancellations were significantly higher among patients with Long commutes (36.2%) compared to Medium (31.0%) and Short (32.2%) commute groups (p < 0.001). Telemedicine utilization increased proportionately with commute time (7.7% for Long commute patients vs. 1.5% for Short; p < 0.001). However, telemedicine cancellation proportions did not significantly differ across groups (21.2% for Long, 13.3% for Medium, 17.0% for Short; p = 0.122), suggesting comparable telemedicine adherence regardless of distance. The proportions for in-person appointment utilization and cancellation were both greatest for the Short commute group. Conclusion Longer travel times are associated with increased appointment cancellations for rural patients, reinforcing travel burden as a key barrier to care. Telemedicine use increases with commute distance and demonstrates consistent adherence across groups, indicating its value as a tool to address rural healthcare gaps. These findings support the continued expansion of telehealth infrastructure to improve care for geographically isolated populations.

BackgroundAdvanced Practice Providers (APPs), including physician assistants and nurse practitioners, represent a growing proportion of the emergency medicine workforce, including in high-acuity community emergency departments (EDs). Despite this growth, many sites lack formal onboarding structures, particularly for new graduate or inexperienced APPs transitioning to practice. Unlike postgraduate residencies and fellowships, limited literature exists on structured onboarding models outside academic settings. This study evaluated the feasibility and perceived impact of a structured onboarding program for APPs in a non-academic community ED. MethodsThis mixed-methods feasibility study was conducted at a single-site community ED without an existing formal onboarding process. New graduate or inexperienced APPs hired within 12 months of program implementation completed a post-intervention survey assessing satisfaction across five domains derived from a conceptual framework of human resource practices and retention. Quantitative data was collected using 5-point Likert-scale items, and qualitative data was obtained through open responses. Leadership and preceptors completed a secondary survey evaluating feasibility and perceived impact. Descriptive statistics and thematic analysis were performed. ResultsFour new graduate APPs (100% response rate) completed the post-implementation survey. Mean scores across domains ranged from 3.33 to 5.00, with highest ratings observed in supervisor support (mean = 5.00), employee engagement (4.33), and alternative training via online modules (4.67). Qualitative themes included clear communication of expectations, value of asynchronous educational modules, and strong mentorship support. Fifteen leaders and preceptors reported that although the program required additional effort, it improved tracking of APP progress, preparedness for transition to practice (4.67), and was perceived as worthwhile to reduce attrition. ConclusionsA structured onboarding program for new graduate APPs in a community ED was feasible, well accepted, and perceived to support transition to practice. These findings support the need for further study of structured onboarding as a scalable strategy to enhance preparedness, engagement, and potential retention in high-acuity clinical settings.

BackgroundEffective interventions are needed to support co-creation of diabetes care plans that fit patients lives. We evaluated the QBSafe agenda-setting kit (14 conversation cards) for its impact on care fit and glycemic control when added to usual primary care. MethodsThis single-center, clinician-level cluster-randomized, open-label trial was conducted at a federally qualified health center in New Haven, Connecticut (ClinicalTrials.gov NCT05553912). Clinicians and their patients with type 2 diabetes and HbA1c >8% were randomized 1:1 to usual care with or without QBSafe cards. In the intervention arm, patients selected up to 3 cards highlighting concerns about life with diabetes prior to their visit. Primary outcomes were change at 6 months in care fit (Illness Intrusiveness Ratings Scale, IIRS) and HbA1c, analyzed by intention to treat. Secondary outcomes were treatment burden (Treatment Burden Questionnaire, TBQ) and diabetes distress (Diabetes Distress Scale, DDS), and satisfaction with visits. ResultsBetween February 2023 and July 2024, 143 participants (mean age 56 years; 61% female; 73% Hispanic; mean HbA1c 10%) were enrolled: 74 received usual care with QBSafe, 69 usual care alone. At 6 months, there were no significant between-arm differences in changes in IIRS (-3.9 [95% CI -10.4, 2.6]), HbA1c (-0.2% [95% CI -0.9, 0.5]), TBQ (1.0 [95% CI -16.6, 18.6]), or DDS (-0.1 [95% CI -0.4, 0.2]). Clinicians reported greater satisfaction when using QBSafe. Patient satisfaction was high and did not differ across arms. ConclusionsQBSafe cards improved clinician satisfaction but did not improve care fit or glycemic control. Future tools should focus on helping clinicians respond effectively to patient-identified challenges.

PurposeThe quality improvement (QI) initiative integrated the use of the Monk Skin Tone (MST) scale into routine nursing skin assessments to reduce hospital-acquired pressure injuries (HAPIs) among patients with dark skin tones (DST). The project addressed disparities in early detection of subtle skin changes, which are less visible in DST, and sought to advance equity in patient safety. Participants and SettingThe initiative was implemented in 900-bed, academic Level I trauma hospital in Los Angeles, California. Seventy-nine registered nurses (RNs) from the Medical Unit participated, excluding agency, float pool, and nurse residency program nurses. Implementation phase was from May to July 2025. ApproachGuided by the Plan-Do-Study-Act (PDSA) framework, the MST scale was embedded into comprehensive skin assessment protocols. RNs received structured training and education, laminated MST badge buddies, and documentation reinforcement within the electronic health record (EHR). Compliance was monitored through chart audits and electronic data capture documentation review. OutcomesPre-implementation HAPI incidence was 3.18 per 1,000 patient days. Post-implementation, incidence decreased to 0.18, representing a 94% reduction. Among DST patients, only 2% developed HAPIs. Nursing compliance with MST documentation reached 95%, surpassing the 60% benchmark. Implications for PracticeIntegration of the MST scale improved documentation accuracy, reduced disparities in PI detection, and enhanced nurse compliance in skin assessments and documentation. Sustained adoption requires embedding MST training into staff onboarding, continuous education, and EHR workflows. Expansion across inpatient and outpatient settings may further advance equity, patient safety, and organizational performance.

ObjectivesAlarm fatigue is a patient safety concern in ICUs, yet no validated instrument exists to assess alarm fatigue among healthcare professionals in non-Western settings. This study aimed to cross-culturally adapt the Charite Alarm Fatigue Questionnaire (CAFQa) into Japanese and evaluate its reliability and validity among ICU nurses and physicians. MethodsThe Japanese CAFQa was cross-culturally adapted following the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines, including forward translation, back-translation, expert panel review, and cognitive interviews. A multicenter cross-sectional validation study was performed across eight ICUs at five hospitals in Japan. A total of 129 participants (103 nurses and 26 physicians) completed the Japanese CAFQa, the NIOSH Brief Job Stress Questionnaire, and the Insomnia Severity Index (ISI). Structural validity, internal consistency, test-retest reliability (n = 102), convergent validity, and known-groups validity were assessed. ResultsCFA confirmed the two-factor structure with acceptable fit (CFI = 0.922, RMSEA = 0.041, SRMR = 0.076), with standardized factor loadings ranging from 0.33 to 0.82. The two factors were not correlated (r = 0.05). Cronbachs alpha was 0.688 for the overall scale, 0.805 for Alarm Stress, and 0.649 for Alarm Coping. Test-retest ICCs ranged from 0.616 to 0.753. The CAFQa total score correlated with the NIOSH total (r = 0.261) and the ISI total (r = 0.338). Healthcare professionals with [&ge;]4 years of ICU experience had higher Alarm Coping scores than those with 1-3 years (median 7.0 vs 6.5), and physicians scored higher on Alarm Coping than nurses (median 8.0 vs 7.0). ConclusionsThe Japanese CAFQa demonstrated acceptable structural validity, reliability, and convergent and known-groups validity, providing the first validated tool for quantitatively measuring alarm fatigue in Japan. Implications for Clinical PracticeThe Japanese CAFQa enables ICU managers to quantify alarm fatigue at individual and unit levels, identify high-risk staff, and evaluate the effectiveness of alarm management interventions.

Background and ObjectivesPatient portals have become essential infrastructure for healthcare delivery following the 21st Century Cures Act, yet adoption remains inequitable. Understanding demographic and geographic determinants of portal activation is critical for addressing digital health disparities, particularly among neurology patients who face unique access barriers. We examined the demographic, geographic, and neighborhood-level factors associated with patient portal activation among neurology patients at multiple geographic scales in the Washington, DC metropolitan area. MethodsWe conducted a retrospective cohort study of 72,417 adult neurology patients seen at two academic medical centers sharing an electronic health record in Washington, DC (February 2021-February 2026). We examined portal activation using multivariable logistic regression and geographic analysis at four nested scales: the metropolitan catchment area, DCs eight wards, individual census tracts (via geocoded patient addresses), and individual DC residents. ResultsPortal activation was 64.7% overall. Activation varied by race/ethnicity (Non-Hispanic White 76.1%, Non-Hispanic Black 57.0%, Non-Hispanic Asian 57.6%, Hispanic 55.0%) and geography (DC Ward 2: 82.0% vs. Ward 7: 48.0%). Ward-level educational attainment (r = 0.948), broadband access (r = 0.889), and income (r = 0.811) were strongly correlated with activation. Within individual wards, Non-Hispanic White patients activated at 84-91% while Non-Hispanic Black patients activated at 48-64%, demonstrating that neighborhood resources alone do not explain disparities. DiscussionPatient portal activation is shaped by demographic, socioeconomic, and geographic factors operating at multiple levels. Persistent within-ward racial disparities indicate that geographically targeted interventions must be paired with culturally tailored approaches to achieve digital health equity.

BackgroundThe 21st Century Cures Act (2017) expanded FDA flexibility in applying methodological standards for drug approval. To examine trends before and after implementation, we independently reviewed all novel drugs approved between 2016 and 2024. MethodsWe constructed a database of all novel FDA approvals from January 1, 2016, through December 31, 2024. Each study linked to an approved drug (N=6,763) was cataloged by study number, sponsorship, and timing of results reporting relative to completion. ResultsSince 2016, the number of studies supporting approval has steadily declined. Beginning in 2017, the modal number of studies per approval fell to one. Industry sponsorship increased while NIH-supported studies decreased. Average time to public posting of results exceeded the one-year statutory limit. ConclusionsAfter implementation of the Cures Act, FDA approvals have relied on fewer, increasingly industry-sponsored studies. Although this may accelerate access to new therapies, it raises concerns about the strength of evidence for safety and effectiveness.