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Treating Hepatitis C Virus Infection in Jails as an Offset to Declines in Treatment Activity in the Community, New York City, NY, 2014-2020

Chan, Justin; Akiyama, Matthew J; Julian, Emily; Joseph, Rodrigue; McGahee, Wendy; Rosner, Zachary; Yang, Patricia; MacDonald, Ross
INTRODUCTION/UNASSIGNED:There are scant data on implementation of large-scale direct-acting antiviral treatment for hepatitis C virus in jails in the U.S. New York City Health + Hospitals/Correctional Health Services aimed to scale up hepatitis C virus treatment in the New York City jail system. This study describes the trends in annual hepatitis C virus treatment in New York City jails compared with those in Medicaid-funded treatment in the New York City community from 2014 to 2020. METHODS/UNASSIGNED:In this observational study, we extracted annual counts of direct-acting antiviral prescriptions for hepatitis C virus for those (1) in the New York City community who were covered by Medicaid and (2) those detained in New York City jails for 2014-2020. Data sources were New York City Department of Health and Mental Hygiene annual reports and Correctional Health Services treatment records, respectively. We used linear regression analysis to test for significant trends in annual treatment in these 2 cohorts during 2015-2019. RESULTS/UNASSIGNED:<0.001). In 2019, New York City jail-based treatment initiations totaled the equivalent of 10% of treatment covered by Medicaid in New York City, up from 0.3% in 2015. CONCLUSIONS/UNASSIGNED:Scale up of jail-based hepatitis C virus treatment is an important strategy to offset declines observed in the community. Addressing barriers to care in jail, such as improving testing, linkage to care, and affordability of direct-acting antivirals for jail-based health services, can help sustain high levels of treatment in U.S. jails and other carceral facilities.
PMCID:10844960
PMID: 38322001
ISSN: 2773-0654
CID: 5632612

Bridging the gap: a resident-led transitional care clinic to improve post hospital care in a safety-net academic community hospital

Li, Patrick; Kang, Tiffany; Carrillo-Argueta, Sandy; Kassapidis, Vickie; Grohman, Rebecca; Martinez, Michael J; Sartori, Daniel J; Hayes, Rachael; Jervis, Ramiro; Moussa, Marwa
The transitional period between hospital discharge and primary care follow-up is a vulnerable time for patients that can result in adverse health outcomes and preventable hospital readmissions. This is especially true for patients of safety-net hospitals (SNHs) who often struggle to secure primary care access when leaving the hospital due to social, economic and cultural barriers. In this study, we describe a resident-led postdischarge clinic that serves patients discharged from NYU Langone Hospital-Brooklyn, an urban safety-net academic hospital. In our multivariable analysis, there was no statistical difference in the readmission rate between those who completed the transitional care management and those who did not (OR 1.32 (0.75-2.36), p=0.336), but there was a statistically significant increase in primary care provider (PCP) engagement (OR 0.53 (0.45-0.62), p<0.001). Overall, this study describes a postdischarge clinic model embedded in a resident clinic in an urban SNH that is associated with increased PCP engagement, but no reduction in 30-day hospital readmissions.
PMCID:10953301
PMID: 38508663
ISSN: 2399-6641
CID: 5640602

Plant-based diets and postprandial hyperkalemia

Varshney, Aarushi; Dupuis, Leonie; Aggarwal, Monika; Joshi, Shivam
This Letter to the Editor is a response to St-Jules and Fouque and their interpretation of postprandial hyperkalemia, especially regarding plant-based diets. Based on the reviewed literature review, potassium kinetic studies cited by the authors include only 1 study with a food-based intervention that actually showed reduced postprandial hyperkalemia with plant-based diets. The remainder of the studies used potassium salts or supplements that behave differently compared with whole plant foods. As such, we recommend avoiding restriction of whole plant foods in patients with chronic kidney disease when solely based on the theoretical risk of postprandial hyperkalemia.
PMID: 37354556
ISSN: 1753-4887
CID: 5543052

Racial Implicit Bias and Communication Among Physicians in a Simulated Environment

Gonzalez, Cristina M; Ark, Tavinder K; Fisher, Marla R; Marantz, Paul R; Burgess, Diana J; Milan, Felise; Samuel, Malika T; Lypson, Monica L; Rodriguez, Carlos J; Kalet, Adina L
IMPORTANCE/UNASSIGNED:Racial implicit bias can contribute to health disparities through its negative influence on physician communication with Black patients. Interventions for physicians to address racial implicit bias in their clinical encounters are limited by a lack of high-fidelity (realistic) simulations to provide opportunities for skill development and practice. OBJECTIVE/UNASSIGNED:To describe the development and initial evaluation of a high-fidelity simulation of conditions under which physicians might be influenced by implicit racial bias. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This cross-sectional study, performed on an online platform from March 1 to September 30, 2022, recruited a convenience sample of physician volunteers to pilot an educational simulation. EXPOSURES/UNASSIGNED:In the simulation exercise, physicians saw a 52-year-old male standardized patient (SP) (presenting as Black or White) seeking urgent care for epigastric pain, nausea, and vomiting. The case included cognitive stressors common to clinical environments, including clinical ambiguity, stress, time constraints, and interruptions. Physicians explained their diagnosis and treatment plan to the SP, wrote an assessment and management plan, completed surveys, and took the Race Implicit Association Test (IAT) and Race Medical Cooperativeness IAT. The SPs, blinded to the purpose of the study, assessed each physician's communication using skills checklists and global rating scales. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Association between physicians' IAT scores and SP race with SP ratings of communication skills. RESULTS/UNASSIGNED:In 60 physicians (23 [38.3%] Asian, 4 [6.7%] Black, 23 [38.3%] White, and 10 [16.7%] other, including Latina/o/x, Middle Eastern, and multiracial; 31 [51.7%] female, 27 [45.0%] male, and 2 [3.3%] other), the interaction of physicians' Race IAT score and SP race was significant for overall communication (mean [SD] β = -1.29 [0.41]), all subdomains of communication (mean [SD] β = -1.17 [0.52] to -1.43 [0.59]), and overall global ratings (mean [SD] β = -1.09 [0.39]). Black SPs rated physicians lower on communication skills for a given pro-White Race IAT score than White SPs; White SP ratings increased as physicians' pro-White bias increased. CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this cross-sectional study, a high-fidelity simulation calibrated with cognitive stressors common to clinical environments elicited the expected influence of racial implicit bias on physicians' communication skills. The outlined process and preliminary results can inform the development and evaluation of interventions that seek to address racial implicit bias in clinical encounters and improve physician communication with Black patients.
PMID: 38506811
ISSN: 2574-3805
CID: 5640562

Voice, silence, perceived impact, psychological safety, and burnout among nurses: A structural equation modeling analysis

Lee, Seung Eun; Seo, Ja kyung; Squires, Allison
Background: The organizational studies' literature suggests that employees' expressions of voice and silence may be distinct concepts with different predictors. Organizational researchers also argue that both employees' voice and silence are related to burnout; however, these relationships have not been adequately examined in the healthcare context. Objective: This study aimed to investigate the relationships among nurses' perceived impact, psychological safety, voice behaviors, and burnout using a theoretical model. Voice behaviors were conceptualized as voice and silence. Design: A cross-sectional, correlational study design was employed. Settings: Study data were collected in 34 general hospitals in South Korea. Participants: A total of 1255 registered nurses providing direct care to patients were included in this study. Methods: Using a convenience sampling method, a web-based survey was conducted to obtain data. All variables were measured using standardized instruments. A structural equation modeling analysis was employed to test a hypothesized model positing that perceived impact and psychological safety have both direct and indirect effects on nurse burnout through voice and silence. The response rate was 72.8 %. Results: The findings supported the hypothesized model. Both perceived impact and psychological safety were positively related to expressions of voice, but both were negatively associated with silence. We also found that perceived impact was more strongly associated with voice than with silence, while psychological safety had a stronger impact on silence than on voice. Furthermore, voice reduced burnout, while silence increased it. Finally, perceived impact reduced burnout through voice (β = − 0.10, 95 % confidence interval [− 0.143, − 0.059]) and silence (β = − 0.04, 95 % confidence interval [− 0.058, − 0.014]), and psychological safety also decreased burnout through voice (β = − 0.04, 95 % confidence interval [− 0.057, − 0.016]) and silence (β = − 0.07, 95 % confidence interval [− 0.101, − 0.033]). Additional analyses revealed that prohibitive voice and silence significantly mediated the associations between psychological safety and burnout and perceived impact and burnout, but the mediating role of promotive voice was not statistically significant. Conclusions: It is important to recognize that voice and silence are distinct concepts. Moreover, to reduce nurse burnout, nurse managers and hospital administrators should develop separate strategies for promoting nurses' perceived impact and psychological safety, as their influences on voice and silence differ. Registration: Not applicable. Tweetable abstract: Voice and silence both influence nurse burnout. Separate strategies should be applied to voice and silence, as they are different concepts.
SCOPUS:85181116805
ISSN: 0020-7489
CID: 5629052

Voice, silence, perceived impact, psychological safety, and burnout among nurses: A structural equation modeling analysis

Lee, Seung Eun; Seo, Ja-Kyung; Squires, Allison
BACKGROUND:The organizational studies' literature suggests that employees' expressions of voice and silence may be distinct concepts with different predictors. Organizational researchers also argue that both employees' voice and silence are related to burnout; however, these relationships have not been adequately examined in the healthcare context. OBJECTIVE:This study aimed to investigate the relationships among nurses' perceived impact, psychological safety, voice behaviors, and burnout using a theoretical model. Voice behaviors were conceptualized as voice and silence. DESIGN/METHODS:A cross-sectional, correlational study design was employed. SETTINGS/METHODS:Study data were collected in 34 general hospitals in South Korea. PARTICIPANTS/METHODS:A total of 1255 registered nurses providing direct care to patients were included in this study. METHODS:Using a convenience sampling method, a web-based survey was conducted to obtain data. All variables were measured using standardized instruments. A structural equation modeling analysis was employed to test a hypothesized model positing that perceived impact and psychological safety have both direct and indirect effects on nurse burnout through voice and silence. The response rate was 72.8 %. RESULTS:The findings supported the hypothesized model. Both perceived impact and psychological safety were positively related to expressions of voice, but both were negatively associated with silence. We also found that perceived impact was more strongly associated with voice than with silence, while psychological safety had a stronger impact on silence than on voice. Furthermore, voice reduced burnout, while silence increased it. Finally, perceived impact reduced burnout through voice (β = -0.10, 95 % confidence interval [-0.143, -0.059]) and silence (β = -0.04, 95 % confidence interval [-0.058, -0.014]), and psychological safety also decreased burnout through voice (β = -0.04, 95 % confidence interval [-0.057, -0.016]) and silence (β = -0.07, 95 % confidence interval [-0.101, -0.033]). Additional analyses revealed that prohibitive voice and silence significantly mediated the associations between psychological safety and burnout and perceived impact and burnout, but the mediating role of promotive voice was not statistically significant. CONCLUSIONS:It is important to recognize that voice and silence are distinct concepts. Moreover, to reduce nurse burnout, nurse managers and hospital administrators should develop separate strategies for promoting nurses' perceived impact and psychological safety, as their influences on voice and silence differ. REGISTRATION/BACKGROUND:Not applicable. TWEETABLE ABSTRACT/CONCLUSIONS:Voice and silence both influence nurse burnout. Separate strategies should be applied to voice and silence, as they are different concepts.
PMID: 38160639
ISSN: 1873-491x
CID: 5635082

Building Climate Change into Medical Education: A Society of General Internal Medicine Position Statement

Ghosh, Arnab K; Azan, Alexander; Basu, Gaurab; Bernstein, Joanna; Gillespie, Elizabeth; Gordon, Lesley B; Krishnamurthy, Sudarshan; LeFrancois, Darlene; Marcus, Erin N; Tejani, Mehul; Townley, Theresa; Rimler, Eva; Whelan, Heather; ,
Building expertise in climate and planetary health among healthcare professionals cannot come with greater urgency as the threats from climate change become increasingly apparent. Current and future healthcare professionals-particularly internists-will increasingly need to understand the interconnectedness of natural systems and human health to better serve their patients longitudinally. Despite this, few national medical societies and accreditation bodies espouse frameworks for climate change and planetary health-related education at the undergraduate (UME), graduate (GME), and continuing (CME) medical education level. As a community of medical educators with an enduring interest in climate change and planetary health, the Society of General Internal Medicine (SGIM) recognizes the need to explicitly define structured educational opportunities and core competencies in both UME and GME as well as pathways for faculty development. In this position statement, we build from the related SGIM Climate and Health position statement, and review and synthesize existing position statements made by US-based medical societies and accreditation bodies that focus on climate change and planetary health-related medical education, identify gaps using Bloom's Hierarchy, and provide recommendations on behalf of SGIM regarding the development of climate and planetary health curricula development. Identified gaps include (1) limited systematic approach to climate and planetary health medical education at all levels; (2) minimal emphasis on learner-driven approaches; (3) limited focus on physician and learner well-being; and (4) limited role for health equity and climate justice. Recommendations include a call to relevant accreditation bodies to explicitly include climate change and planetary health as a competency, extend the structural competency framework to climate change and planetary health to build climate justice, proactively include learners in curricular development and teaching, and ensure resources and support to design and implement climate and planetary health-focused education that includes well-being and resiliency.
PMID: 38424345
ISSN: 1525-1497
CID: 5637492

Evaluation of a virtual interprofessional oral-systemic health simulation experience in nursing, dentistry, medicine, and pharmacy education

Roitman, J; Haber, J; Cipollina, J; Feldman, L; Fletcher, J; Allen, K; Crotty, K; Kudlowitz, D; Anderson, M
PURPOSE/OBJECTIVE:The annual teaching oral-systemic health (TOSH) virtual clinical simulation and case study activity exposes interprofessional teams of nurse practitioner, nurse midwifery, dental, medical, and pharmacy students to a virtual clinical simulation experience that uses oral-systemic health as a clinical exemplar for promoting interprofessional core competencies. The present study examines changes in participating students' self-reported interprofessional competencies following participation in virtual TOSH from 2020 to 2022. These findings are also compared to those from in-person TOSH (2019) to examine the equivalence of student outcomes of both the in-person and virtual programs. METHODS:A pre- and post-test evaluation design was used to examine the effectiveness of exposure to the TOSH program on self-reported attainment of interprofessional competencies for participating students using the interprofessional collaborative competency attainment scale. RESULTS:Analysis of pre- and post-surveys demonstrated statistically significant improvement in students' self-rated interprofessional experience competencies following the virtual TOSH program, which aligns with results from the in-person cohorts. Similar findings between the in-person and virtual cohorts indicated no statistically significant difference between the two formats. CONCLUSION/CONCLUSIONS:These findings demonstrate the success of TOSH in promoting attainment of interprofessional competencies among future health professionals. We encourage administrators and faculty who lead health professional programs to take advantage of using virtual simulations as an integral component of interprofessional oral health clinical experiences where students from different health professions learn from and about each other in assessing and treating patients across the lifespan.
PMID: 38400648
ISSN: 1930-7837
CID: 5634632

Lessons in clinical reasoning - pitfalls, myths, and pearls: shoulder pain as the first and only manifestation of lung cancer

Díaz-Abad, Julia; Aranaz-Murillo, Amalia; Mayayo-Sinues, Esteban; Canchumanya-Huatuco, Nila; Schaye, Verity
OBJECTIVES/OBJECTIVE:Lung cancer is the leading cause of cancer-related death and poses significant challenges in diagnosis and management. Although muscle metastases are exceedingly rare and typically not the initial clinical manifestation of neoplastic processes, their recognition is crucial for optimal patient care. METHODS:We present a case report in which we identify the unique scenario of a 60-year-old man with shoulder pain and a deltoid muscle mass, initially suggestive of an undifferentiated pleomorphic sarcoma. However, further investigations, including radiological findings and muscle biopsy, revealed an unexpected primary lung adenocarcinoma. We performed a systematic literature search to identify the incidence of SMM and reflect on how to improve and build on better diagnosis for entities as atypical as this. RESULTS:This atypical presentation highlights the importance of recognizing and addressing cognitive biases in clinical decision-making, as acknowledging the possibility of uncommon presentations is vital. By embracing a comprehensive approach that combines imaging studies with histopathological confirmation, healthcare providers can ensure accurate prognoses and appropriate management strategies, ultimately improving patient outcomes. CONCLUSIONS:This case serves as a reminder of the need to remain vigilant, open-minded, and aware of cognitive biases when confronted with uncommon clinical presentations, emphasizing the significance of early recognition and prompt evaluation in achieving optimal patient care.
PMID: 38387019
ISSN: 2194-802x
CID: 5634472

Neighborhood Segregation and Access to Live Donor Kidney Transplantation

Li, Yiting; Menon, Gayathri; Kim, Byoungjun; Bae, Sunjae; Quint, Evelien E; Clark-Cutaia, Maya N; Wu, Wenbo; Thompson, Valerie L; Crews, Deidra C; Purnell, Tanjala S; Thorpe, Roland J; Szanton, Sarah L; Segev, Dorry L; McAdams DeMarco, Mara A
IMPORTANCE/UNASSIGNED:Identifying the mechanisms of structural racism, such as racial and ethnic segregation, is a crucial first step in addressing the persistent disparities in access to live donor kidney transplantation (LDKT). OBJECTIVE/UNASSIGNED:To assess whether segregation at the candidate's residential neighborhood and transplant center neighborhood is associated with access to LDKT. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:In this cohort study spanning January 1995 to December 2021, participants included non-Hispanic Black or White adult candidates for first-time LDKT reported in the US national transplant registry. The median (IQR) follow-up time for each participant was 1.9 (0.6-3.0) years. MAIN OUTCOME AND MEASURES/UNASSIGNED:Segregation, measured using the Theil H method to calculate segregation tertiles in zip code tabulation areas based on the American Community Survey 5-year estimates, reflects the heterogeneity in neighborhood racial and ethnic composition. To quantify the likelihood of LDKT by neighborhood segregation, cause-specific hazard models were adjusted for individual-level and neighborhood-level factors and included an interaction between segregation tertiles and race. RESULTS/UNASSIGNED:Among 162 587 candidates for kidney transplant, the mean (SD) age was 51.6 (13.2) years, 65 141 (40.1%) were female, 80 023 (49.2%) were Black, and 82 564 (50.8%) were White. Among Black candidates, living in a high-segregation neighborhood was associated with 10% (adjusted hazard ratio [AHR], 0.90 [95% CI, 0.84-0.97]) lower access to LDKT relative to residence in low-segregation neighborhoods; no such association was observed among White candidates (P for interaction = .01). Both Black candidates (AHR, 0.94 [95% CI, 0.89-1.00]) and White candidates (AHR, 0.92 [95% CI, 0.88-0.97]) listed at transplant centers in high-segregation neighborhoods had lower access to LDKT relative to their counterparts listed at centers in low-segregation neighborhoods (P for interaction = .64). Within high-segregation transplant center neighborhoods, candidates listed at predominantly minority neighborhoods had 17% lower access to LDKT relative to candidates listed at predominantly White neighborhoods (AHR, 0.83 [95% CI, 0.75-0.92]). Black candidates residing in or listed at transplant centers in predominantly minority neighborhoods had significantly lower likelihood of LDKT relative to White candidates residing in or listed at transplant centers located in predominantly White neighborhoods (65% and 64%, respectively). CONCLUSIONS/UNASSIGNED:Segregated residential and transplant center neighborhoods likely serve as a mechanism of structural racism, contributing to persistent racial disparities in access to LDKT. To promote equitable access, studies should assess targeted interventions (eg, community outreach clinics) to improve support for potential candidates and donors and ultimately mitigate the effects of segregation.
PMCID:10877505
PMID: 38372985
ISSN: 2168-6114
CID: 5634032