Journal of general internal medicine
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Comparative Study Observational Study
Prescription Medications for the Treatment of Insomnia and Risk of Suicide Attempt: a Comparative Safety Study.
Guidelines for the pharmacological treatment of chronic insomnia in adults recognize that trazodone and other off-label medications are commonly prescribed despite poor evidence. The Department of Veterans Health Affairs (VA) fills high volumes of inexpensive, over-the-counter sedating antihistamines and older antidepressants in addition to benzodiazepines and zolpidem. Yet little is known about the comparative safety of these agents with regard to suicidal behavior. ⋯ Compared to zolpidem, hazard of suicide attempt was 61% higher with trazodone (< 200 mg). No significant differences in suicide attempt risk were identified between benzodiazepines or sedating antihistamines and zolpidem, respectively. These findings provide the first comparative effectiveness evidence against the use of trazodone for insomnia.
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In a prior study, we found patient satisfaction was associated with mortality. However, that study included few deaths, yielding wide confidence intervals, was criticized for possible morbidity under-adjustment, and lacked power to explore sociodemographic moderation. ⋯ The association of higher patient satisfaction with clinicians with higher short-term mortality was evident only after CAHPS-recommended adjustment, was not attenuated by further morbidity adjustment, and was evident in women but not men. The findings suggest that characteristics among women who are more satisfied with their clinicians may be associated with increased mortality risk.
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Patient care ownership is essential to delivering high-quality medical care but appears to be eroding among trainees. The lack of an objective measure has limited the study of ownership in physicians. ⋯ We developed an instrument to quantify patient care ownership in residents. Our scale demonstrates good internal consistency and preliminary evidence of validity. With further validation, we expect this to be a valuable tool to evaluate interventions aimed at improving ownership.
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High-Need Patients' Goals and Goal Progress in a Veterans Affairs Intensive Outpatient Care Program.
Healthcare systems nationwide are implementing intensive outpatient care programs to optimize care for high-need patients; however, little is known about these patients' personal goals and factors associated with goal progress. ⋯ Among high-need patients participating in an intensive outpatient care program, patient goals were fairly evenly distributed across medical, behavioral, and social domains. Notably, individuals living alone with mental health conditions were least likely to attain progress. Future care coordination interventions might incorporate strategies to address this gap, e.g., broader integration of behavioral and social service components.