Journal of general internal medicine
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Health-related social needs, such as food insecurity, housing instability, and lack of transportation, are associated with worse health outcomes, and are increasingly the focus of health-related social needs interventions within healthcare. Adoption of health-related social needs interventions is often justified by the potential to reduce healthcare costs. However, this can present a conundrum to clinicians. ⋯ In cases where health-related social needs interventions improve health but are not cost-saving, these two types of justifications can conflict. We provide a framework for considering these issues, and an agenda for scholarly work on this topic. Ultimately, if promoting patient and public health are key values for our profession, then understanding when to emphasize values-based care, rather than simply value-based care, is crucial to fulfilling our professional duty.
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Guidelines recommend most benzodiazepine (BZD) treatment be short-term, though chronic BZD use is increasing. ⋯ A small minority of patients prescribed chronic BZD in a given year are no longer prescribed BZDs 1 year later. There is significant variation in the likelihood of discontinuation accounted for by non-clinical factors such as race, geography, and a patient's provider, which had a stronger association with the odds of discontinuation than almost every other patient-level variable. Provider-facing elements of interventions to reduce BZD prescribing may be critical.
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Nonbacterial thrombotic endocarditis (NBTE) associated with malignancy is rare; its infrequency and similarity to other diagnoses make it a significant diagnostic challenge. A 63-year-old woman on rivaroxaban for prior deep vein thrombosis presented with left upper extremity weakness and left facial droop with imaging demonstrating multiple strokes. Echocardiograms revealed mitral and aortic valve vegetations. ⋯ Workup confirmed non-mucinous metastatic biliary adenocarcinoma. The patient was placed on a heparin drip then switched to low molecular weight heparin without further embolic events and was discharged to a rehabilitation facility in stable condition with plans for chemotherapy as an outpatient. These clinical, imaging, and histologic findings were consistent with a rare case of NBTE associated with primary non-mucinous gallbladder malignancy complicated by recurrent strokes in which direct oral anticoagulants did not provide adequate anticoagulation.