Journal of general internal medicine
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Multicenter Study
Making housing first happen: organizational leadership in VA's expansion of permanent supportive housing.
While most organizational literature has focused on initiatives that transpire inside the hospital walls, the redesign of American health care increasingly asks that health care institutions address matters outside their walls, targeting the health of populations. The US Department of Veterans Affairs (VA)'s national effort to end Veteran homelessness represents an externally focused organizational endeavor. ⋯ Key organizational practices correlated with more successful implementation of HF for homeless Veterans. Medical Center directors substantively influenced the success of this endeavor through their actions to foster impetus, demonstrate commitment and support alignment and integration.
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Comparative Study Observational Study
Comparing patient outcomes of academician-preceptors, hospitalist-preceptors, and hospitalists on internal medicine services in an academic medical center.
Patient outcomes with hospitalist care have been studied in many settings, yet little is known about how hospitalist care interacts with trainee care to affect patient outcomes in teaching hospitals. ⋯ Preceptor-led medicine services were associated with more readmissions within 30 days, shorter lengths of stay, and lower index admission-associated costs. However, when considering cumulative hospitalization costs, patients discharged by academician-preceptors incurred the highest cost and hospitalist-preceptors incurred the lowest cost.
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Pain is the most common presenting problem in primary care. Opioid therapy (OT) for chronic pain has increased dramatically over the past decade, as have related negative outcomes. Despite the development and dissemination of policy and clinical practice guidelines for pain management and OT, adoption has been variable. The Veterans Health Administration (VHA) has established a Stepped Care Model of Pain Management (SCM-PM) as an evidence-based framework and single standard of pain care to promote guideline-concordant care, but to date its adoption and related outcomes have not been systematically examined. ⋯ We demonstrate improvements in the management of veterans receiving OT that are consistent with the SCM-PM and published practice guidelines. We highlight how partnerships among funders, researchers, clinicians, and administrators contributed to the project's design and implementation, and to the dissemination strategy and future directions for improving opioid management and pain care.
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Observational Study
Chronic opioid therapy urine drug testing in primary care: prevalence and predictors of aberrant results.
Urine drug tests (UDTs) are recommended for patients on chronic opioid therapy (COT). Knowledge of the risk factors for aberrant UDT results could help optimize their use. ⋯ In this primary care setting, results were aberrant for 30% of UDTs of COT patients, largely because of prescribed opioid non-detection and THC. Aberrant results of almost all types were more likely among patients under the age of 45. Other risk factors varied across aberrancies, but commonly included current smoking and prior substance use disorder diagnosis.