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At least 19 recordsLinked to original sources
PubMed1978

The academic medical center: a stressed American institution.

In recent years, relations between academic medical centers and the government have become increasingly adversarial. Although the centers and the government were formerly partners in a number of health ventures, to the mutual benefit of both, the climate is now too often confrontational. It is a confrontation in which there will be no winners, but the larger society may be the loser. A number of pressures on academic centers have helped to contribute to this situation. The federal sector and academic medical institutions must understand one another better and rediscover effective ways to preserve the special strengths of academic medicine in this country.

Community Health Services↗
PubMed1978

Medical service plans in academic medical centers.

Medical service plans are of major importance to academic medical centers and are becoming increasingly so each year as evidenced by growing dependence of medical schools on resulting funds. How these funds are generated and used varies among schools. The procedures may affect the governance of the institution, modifying the authority of the central administration or the clinical departments. Recent developments in federal legislation, such as health maintenance organizations and amendments (Section 227) to the Social Security Act, and the future development of national health insurance will certainly have an effect on how academic medical centers organize their clinical activities. How successfully various medical schools deal with the dynamic problem may well determine their future survival.

Faculty, Medical↗
PubMed1978

Primary health care in an academic medical center.

In 1975-76 a one-year longitudinal study of the delivery of primary care services was carried out at all ambulatory institutional facilities in Durham County, North Carolina and in 47 of 50 community private practices covering the broad fields of surgery (including urology and orthopedics), medicine, pediatrics, and ob/gyn. The present paper focuses on the private and public clinics of Duke University Medical Center. Data were analyzed to document differentials in sociodemographic characteristics of patients attending these two systems of care. Results showed that patients attending the private clinics are predominantly white and covered by private insurance, while patients attending the public clinics are predominantly black and heavily dependent on Medicaid coverage. The potentially detrimental effects of a two-class system of care on the health of patients, as well as on the education of students, is discussed in the context of a scant medical literature on this subject.

Adolescent↗
PubMed1977

Emergency medicine as an academic discipline.

Because of an explosive increase in the use of emergency rooms in hospitals across the country, many hospitals have found it expedient to employ full-time emergency physicians. The demand for emergency physicians has prompted the development of training programs in emergency medicine in academic medical centers. The first such training program was instituted at The Medical College of Pennsylvania in 1970. The 32 current programs in the nation are filling a real need in providing manpower for hospital emergency rooms. With the increasing identification and distribution of emergency physicians, there has been an attempt to develop emergency medicine as a distinct discipline and to establish its legitimacy in the structure of academic medical centers. A variety of problems must be addressed to clarify the role of emergency medicine in the academic setting.

Curriculum↗
PubMed2026

Management of complex lipid disorders in a community lipid clinic setting: Implementing a multidisciplinary model.

BACKGROUND: Large treatment gaps exist in the management of lipid disorders, and many high-risk patients have factors that complicate management efforts. While lipid clinics exist within academic medical centers, most of these patients are cared for in community settings. OBJECTIVE: To report our experience and results managing challenging and complex lipid disorders in a community-based lipid clinic. METHODS: We established a specialized lipid clinic in a community medical setting, with a focus on patients with management challenges and/or suspicion of a genetic lipid disorder, employing a multidisciplinary approach to optimize patient outcomes, emphasizing appropriate medical therapies and lipid genetic testing in selected patients. Retrospective electronic health record data were collected to analyze patient characteristics, treatment patterns, and lipid results. RESULTS: Over the period 2022 through 2024, 183 patients were seen (mean 63 years, 62% female). The challenging nature of the patient population was highlighted by high rates of statin intolerance (50%), no lipid medical therapy at baseline (50%), and comorbidities (atherosclerotic cardiovascular disease [ASCVD], diabetes, and/or hypertension-61%). Despite this, over a mean follow-up of 9.4&#xa0;&#xb1;&#xa0;7.3 months, we observed a mean low-density lipoprotein cholesterol&#xa0;decrease of 49&#xa0;mg/dL (-24.5%, P&#xa0;<&#xa0;.001), along with significant decreases in total cholesterol and triglycerides. Pathogenic dyslipidemia genetic variants were discovered in 21 patients (of 105 tested). Significant lipid improvements in the whole cohort, as well as multiple subgroups, were associated with greater utilization of combination therapies. CONCLUSION: Patients with complex lipid disorders can be successfully managed within a specialized lipid clinic in community medical settings. Applying such a multidisciplinary model outside of traditional academic medical centers offers the potential to raise the level of lipid management and ASCVD prevention more broadly in larger populations.

Combination medical therapy↗
PubMed2026

Patient and hospital factors associated with disparities in acute stroke treatment in community and academic hospitals.

BACKGROUND: Systemic barriers may affect identification, emergency transportation (EMS), and care coordination for people with stroke. We assessed patient- and hospital-level factors for associations with pre-hospital and emergency department care. We compared trends for patients presenting to an academic medical center (AMC) versus community hospitals (CHs). METHODS: We conducted a retrospective cohort study at an AMC (Tufts Medical Center) with 542 patients aged &#x2265;18&#xa0;years hospitalized with acute ischemic stroke or transient ischemic attack between 1/1/2018-12/31/2020 who presented directly to AMC or presented to AMC as a transfer from initial contact CHs. Primary outcomes were EMS use, stroke code activation, door-to-CT time, and door-to-needle time. RESULTS: AMC patients identifying as non-Hispanic Asian (odds ratio (OR)&#xa0;=&#xa0;0.25; 95% confidence interval (CI)&#xa0;=&#xa0;0.13-0.47) and Hispanic (OR&#xa0;=&#xa0;0.19; 95% CI&#xa0;=&#xa0;0.05-0.72) and CH non-Hispanic Black/African-American patients (OR&#xa0;=&#xa0;0.17; 95% CI&#xa0;=&#xa0;0.05-0.62) were less likely to use EMS compared to non-Hispanic white patients. Patients with non-English primary language were less likely to use EMS (OR&#xa0;=&#xa0;0.38; 95% CI&#xa0;=&#xa0;0.23-0.63) compared to English-speaking patients in both hospital settings. CH Hispanic patients were less likely to have stroke code activation (OR&#xa0;=&#xa0;0.24; 95% CI&#xa0;=&#xa0;0.05-0.86) compared to non-Hispanic white patients. CH patients were less likely to have stroke code activation (OR&#xa0;=&#xa0;0.12; 95% CI&#xa0;=&#xa0;0.07-0.19), had 31% shorter door-to-CT time (95% CI&#xa0;=&#xa0;15-43% shorter), and had 29% longer door-to-needle time (95% CI&#xa0;=&#xa0;5-58% longer). CONCLUSION: Patient-level factors and hospital setting were associated with differences in acute care suggesting opportunities for community outreach on EMS use, interventions to alleviate language barriers, and a need to address systemic biases.

Humans↗
PubMed1979

A Marxian interpretation of the growth and development of coronary care technology.

Cost containment efforts will fail if they continue to ignore the structural relationships between health care costs and private profit in capitalist society. The recent history of coronary care shows that apparent irrationalities of health policy make sense from the standpoint of capitalist profit structure. Coronary care units (CCUs) gained wide acceptance, despite high costs. Studies of CCU effectiveness, using random controlled trials and epidemiologic techniques, do not show a consistent advantage of CCUs over non-intensive ward care or simple rest at home. From a Marxian perspective, the proliferation of CCUs and similar innovations is a complex historical process that includes initiatives by industrial corporations, cooperation by clinical investigators at academic medical centers, support by private philanthropies linked to corporate interests, intervention by state agencies, and changes in the health care labor force. Cost-effective methodology obscures the profit motive as a basic source of high costs and ineffective practices. Health-policy alternatives curtailing corporate involvement in medicine would reduce costs by restricting profit.

Academic Medical Centers↗
PubMed2025

Candida auris outbreak in a cardiothoracic transplant intensive care unit: implications for infection prevention practices and keeping pace with an evolving landscape.

OBJECTIVE: To describe the mitigation strategies for a Candida auris outbreak in a cardiothoracic transplant intensive care unit (CTICU) and its implications for infection prevention practices. DESIGN: Retrospective cohort study from July 2023 to February 2024. SETTING: A large academic medical center. METHODS: A multidisciplinary team convened to conduct the outbreak investigation and develop mitigation strategies in the CTICU. RESULTS: From July 2023 to February 2024, 34 possible hospital-onset cases of C. auris were identified in our CTICU. Whole-genome sequencing and phylogenetic analysis based on pairwise single nucleotide polymorphism (WG-SNP) distance revealed two distinct outbreak clusters. Of the 34 patients, 11 (32.3%) were solid organ transplant recipients and 12 (35.3%) had a mechanical circulatory support device. Of the cohort, only 11/34 (32.3%) had prior exposure to high-risk healthcare facilities within six months prior to admission, as follows: acute inpatient rehabilitation facilities (AIRs) (n = 5, 14.7%), skilled nursing facilities (SNFs) (n = 3, 8.8%), and long-term acute care hospitals (LTACHs) (n = 3, 8.8%). The cohort had a median of 22.0 antibiotic-days prior to their positive results. Five (14.7%) patients had C. auris candidemia, three of whom expired likely due to infection. Infection Prevention (IP) interventions addressed several modes of transmission, including healthcare personnel hands, shared patient equipment, and the environment. CONCLUSION: Our experience suggests that the epidemiology of C. auris may be changing, pointing towards a rising prevalence in acute care settings. IP interventions targeting hand hygiene behavior and promoting centralizing cleaning and disinfection of shared patient equipment may have contributed to outbreak resolution.

Humans↗
PubMed2021

Early-Onset Atrial Fibrillation and the Prevalence of Rare Variants in Cardiomyopathy and Arrhythmia Genes.

IMPORTANCE: Early-onset atrial fibrillation (AF) can be the initial manifestation of a more serious underlying inherited cardiomyopathy or arrhythmia syndrome. OBJECTIVE: To examine the results of genetic testing for early-onset AF. DESIGN, SETTING, AND PARTICIPANTS: This prospective, observational cohort study enrolled participants from an academic medical center who had AF diagnosed before 66 years of age and underwent whole genome sequencing through the National Heart, Lung, and Blood Institute's Trans-Omics for Precision Medicine program. Participants were enrolled from November 23, 1999, to June 2, 2015. Data analysis was performed from October 24, 2020, to March 11, 2021. EXPOSURES: Rare variants identified in a panel of 145 genes that are included on cardiomyopathy and arrhythmia panels used by commercial clinical genetic testing laboratories. MAIN OUTCOMES AND MEASURES: Sequencing data were analyzed using an automated process followed by manual review by a panel of independent, blinded reviewers. The primary outcome was classification of rare variants using American College of Medical Genetics and Genomics criteria: benign, likely benign, variant of undetermined significance, likely pathogenic, or pathogenic. Disease-associated variants were defined as pathogenic/likely pathogenic variants in genes associated with autosomal dominant or X-linked dominant disorders. RESULTS: Among 1293 participants (934 [72.2%] male; median [interquartile range] age at enrollment, 56 [48-61] years; median [interquartile range] age at AF diagnosis, 50 [41-56] years), genetic testing identified 131 participants (10.1%) with a disease-associated variant, 812 (62.8%) with a variant of undetermined significance, 92 (7.1%) as heterozygous carriers for an autosomal recessive disorder, and 258 (20.0%) with no suspicious variant. The likelihood of a disease-associated variant was highest in participants with AF diagnosed before the age of 30 years (20 of 119 [16.8%; 95% CI, 10.0%-23.6%]) and lowest after the age of 60 years (8 of 112 [7.1%; 95% CI, 2.4%-11.9%]). Disease-associated variants were more often associated with inherited cardiomyopathy syndromes compared with inherited arrhythmias. The most common genes were TTN (n&#x2009;=&#x2009;38), MYH7 (n&#x2009;=&#x2009;18), MYH6 (n&#x2009;=&#x2009;10), LMNA (n&#x2009;=&#x2009;9), and KCNQ1 (n&#x2009;=&#x2009;8). CONCLUSIONS AND RELEVANCE: In this cohort study, genetic testing identified a disease-associated variant in 10% of patients with early-onset AF (the percentage was higher if diagnosed before the age of 30 years and lower if diagnosed after the age of 60 years). Most pathogenic/likely pathogenic variants are in genes associated with cardiomyopathy. These results support the use of genetic testing in early-onset AF.

Adult↗
PubMed2026

Neighborhood Deprivation and Screening Mammography Utilization: A Retrospective Cross-Sectional Study.

RATIONALE AND OBJECTIVES: Access to screening mammography reduces breast cancer mortality disparities. The Area Deprivation Index (ADI) is a validated measure of neighborhood socioeconomic disadvantage linked to adverse health outcomes. There is limited data evaluating mammography utilization among patients residing in areas of higher deprivation. This study evaluated the association between ADI and screening mammography utilization within an accountable care organization (ACO) affiliated with a multicenter academic medical center in the Upper Midwest. METHODS: This retrospective cross-sectional study included women aged 40-85 years attributed to the ACO in 2022, based on Wisconsin Collaborative for Healthcare Quality criteria. The primary outcome was receipt of screening mammography within two years. The primary exposure was ADI, analyzed by decile (ordinal) and as low (deciles 1-5) versus high (deciles 6-10) deprivation. The logistic regression models evaluated associations between ADI and screening, unadjusted and adjusted for age, race, ethnicity, and preferred language. RESULTS: Among 7463 participants with geographic data, 74.4% completed screening. Screening rates were 75.7% in low-deprivation areas versus 66.2% in high-deprivation areas. Increasing ADI decile was associated with reduced screening in unadjusted (OR 0.891, 95% CI 0.87-0.91, p<0.001) and adjusted analyses (OR 0.897, 95% CI 0.88-0.92, p<0.001). Black participants (OR 0.444, p<0.001) and individuals preferring non-English languages (OR 0.333, p<0.001) had lower screening odds after adjustment. CONCLUSION: Higher neighborhood deprivation is independently associated with lower screening mammography utilization. Targeted, equity-focused interventions addressing neighborhood, racial, and language-related barriers are needed to reduce screening disparities.

Area deprivation Index↗
PubMed2025

Imprecision medicine: Systematic gaps in reporting variants of uncertain significance (VUS) and their reclassifications.

PURPOSE: Variants of uncertain significance (VUS) are frequently encountered during clinical genetic testing. To explore the clinical burden of VUS, we developed the Brotman Baty Institute Clinical Variant Database, which is an electronic health record (EHR)-linked database of clinical germline genetic variant information from patients with rare genetic disorders seen at 2 tertiary academic medical centers. METHODS: We retrospectively reviewed EHRs and genetic testing reports from 5158 patients seen across diverse adult genetics practices at these institutions from 2015 to 2024. We also compared these EHR-based variant classifications with those in ClinVar. RESULTS: The number of reported VUS relative to pathogenic or likely pathogenic variants can vary by over 14-fold depending on the primary indication for genetic testing and 3-fold depending on self-reported race. Furthermore, at least 1.6% of variant classifications used in the EHR for clinical care are outdated based on ClinVar variant classifications, including 26 instances in which the testing lab updated ClinVar, but the reclassification was never communicated to the patient. CONCLUSION: Our findings reveal that the clinical burden of VUS in adult medical genetics is unequally distributed across patients. We also highlight a deficiency in existing systems for communicating variant reclassifications to ClinVar, patients, and providers.

Humans↗