Faculty Bibliography

BACKGROUND:Emergency Medical Services (EMS) is an important resource that interacts with our most vulnerable patients during transport home after hospital discharge. EMS providers may be appropriately situated to support the transition of care to the home environment. OBJECTIVES/OBJECTIVE:This study aimed to determine whether patients transported home by ambulance experience higher rates of return emergency department (ED) visits and readmission compared with similar patients transported home by other means. METHODS:This was a retrospective cohort study conducted at a U.S. tertiary care academic hospital. Patients aged 65 years and over transported home via ambulance after hospital discharge between January and March 2012 were included. Rates of 72-h and 30-day ED revisits and 30-day hospital readmissions were calculated. Odds ratios were calculated and revisit rates between groups were compared. RESULTS:There were 207 patients aged 65 and over transported home by ambulance. Matched controls were found for 162 patients. Compared with the matched controls, the exposed group experienced a statistically significant higher rate of 30-day ED returns (18.519% vs. 10.494%; odds ratio [OR] 1.939; p = 0.043). The exposed group also experienced a higher rate of 72-h ED returns (2.469% vs. 0.617%; OR 4.076) and 30-day readmissions (12.346% vs. 6.173%; OR 2.141), though results did not reach statistical significance. CONCLUSION/CONCLUSIONS:The study findings suggest that transport home via ambulance after hospital discharge could be predictive of a high risk of recidivism independent of established readmission risk factors. Programs that expand the role of EMS to include post-transport interventions may warrant further exploration.

OBJECTIVE:To determine the representation of Black/AA women surgeons in academic medicine among U.S. medical school faculty and to assess the number of NIH grants awarded to Black/AA women surgeon-scientists over the past 2 decades. SUMMARY OF BACKGROUND DATA/BACKGROUND:Despite increasing ethnic/racial and sex diversity in U.S. medical schools and residencies, Black/AA women have historically been underrepresented in academic surgery. METHODS:A retrospective review of the Association of American Medical Colleges 2017 Faculty Roster was performed and the number of grants awarded to surgeons from the NIH (1998-2017) was obtained. Data from the Association of American Medical Colleges included the total number of medical school surgery faculty, academic rank, tenure status, and department Chair roles. Descriptive statistics were performed. RESULTS:Of the 15,671 U.S. medical school surgical faculty, 123 (0.79%) were Black/AA women surgeons with only 11 (0.54%) being tenured faculty. When stratified by academic rank, 15 (12%) Black/AA women surgeons were instructors, 73 (59%) were assistant professors, 19 (15%) were associate professors, and 10 (8%) were full professors of surgery. Of the 372 U.S. department Chairs of surgery, none were Black/AA women. Of the 9139 NIH grants awarded to academic surgeons from 1998 and 2017, 31 (0.34%) grants were awarded to fewer than 12 Black/AA women surgeons. CONCLUSION/CONCLUSIONS:A significant disparity in the number of Black/AA women in academic surgery exists with few attaining promotion to the rank of professor with tenure and none ascending to the role of department Chair of surgery. Identifying and removing structural barriers to promotion, NIH grant funding, and academic advancement of Black/AA women as leaders and surgeon-scientists is needed.

BACKGROUND: Race, ethnicity, and language have been identified as factors impacting uptake of HIV testing. This project sought to compare testing rates between predominant and non-predominant ethnic, racial, or language populations within neighborhood FQHCs.
METHOD(S): We identified Family Health Center network locations at which more than 50% of patients served identified as the same race, and/ or had the same preferred language, and focused our analysis on these sites. We used Excel and SPSS to compare HIV testing rates between predominant and non-predominant population groups at each clinic.
RESULT(S): At 2 of 5 sites with a predominant non-English preferred language, speakers of the predominant language were more likely to receive an HIV test than speakers of other languages (p<0.001 for both sites). The other sites showed no difference by language. Of 2 clinics with a predominant racial population, there was no difference between predominant and non-predominant populations in terms of HIV testing. At all included sites, with one exception, Hispanic ethnicity was associated with a significantly higher rate of HIV testing.
CONCLUSION(S): Predominant/non-predominant race did not affect HIV testing rates, but language and ethnicity did. One mechanism for this may be increased trust associated with patient-provider language concordance, resulting in greater uptake of tests. There is a need for future research to further explore the factors associated with these findings

Annually, approximately 30 million patients are discharged from the emergency department (ED) after a traumatic event¹. These patients are at substantial psychiatric risk, with approximately 10-20% developing one or more disorders, including anxiety, depression or post-traumatic stress disorder (PTSD)^2-4. At present, no accurate method exists to predict the development of PTSD symptoms upon ED admission after trauma⁵. Accurate risk identification at the point of treatment by ED services is necessary to inform the targeted deployment of existing treatment^6-9 to mitigate subsequent psychopathology in high-risk populations^10,11. This work reports the development and validation of an algorithm for prediction of post-traumatic stress course over 12 months using two independently collected prospective cohorts of trauma survivors from two level 1 emergency trauma centers, which uses routinely collectible data from electronic medical records, along with brief clinical assessments of the patient's immediate stress reaction. Results demonstrate externally validated accuracy to discriminate PTSD risk with high precision. While the predictive algorithm yields useful reproducible results on two independent prospective cohorts of ED patients, future research should extend the generalizability to the broad, clinically heterogeneous ED population under conditions of routine medical care.

BACKGROUND: Patient Portals(PP) allow access to medical records and interaction with providers; however activation(PPA) and use (PPU) are limited by language barriers, low health/computer literacy, and poor internet access which are prevalent issues in Federally Qualified Health Centers(FQHC). Little is known of the drivers and patterns of PPA in such settings. We aimed to describe the prevalence of PPA and PPU in adult patients of an FQHC; describe PPU activity, and test demographic, condition, and utilization-related correlates of PPA and PPU.
METHOD(S):We conducted a retrospective chart review in an FQHC that launched a PP in September 2016. We extracted demographics, PPA status(active/not) at data pull, PPU activities, presence of a chronic condition on the problem list, # emergency department, inpatient, subspecialty visits over past year (utilization summed, dichotomized >1 vs. 0-1 visit). Missing values for homelessness were coded to majority category( 0). Analyses included descriptive statistics, bivariate analyses, then logistic regression to test odds of PPA and PPU by. demographics, chronic conditions, and utilization. We report [adjusted odds ratios(confidence interval)].
RESULT(S): Data were analyzed for 62,610 adults [mean age 45(SD 17), 21% Black, 47% Hispanic, 46% Medicaid, 25% Selfpay, speaking English( 60%), Spanish (31%), Chinese(6%), Other(3%), with: hypertension( 19%), diabetes(11%), depression(8%), asthma(6%), CVD(5%); 21% had utilization>1. Overall 23,104(37%) activated the PP. PPU included viewing test results(69%), medications(62% ), immunizations( 51%), billing (38%), asking advice (29%), and scheduling appointments( 16%). PPA and PPU varied by demographics, chronic condition, and utilization, but were consistently higher for females, those who were not Medicaid recipients or Self-pay, English speakers and those with asthma, hypertension, and depression.
CONCLUSION(S): PPA was lower for non-whites and poorer patients, but higher for patients speaking the predominant languages of this FQHC, suggesting that language concordance helps engage patients. Patients with chronic conditions and more healthcare utilization had greater odds of PPA and PPU. On the other hand, Spanish-speakers were less likely to actively use the portal for functions such as scheduling appointments, suggesting that improvements in language capabilities of the platform are needed

BACKGROUND: Moral distress is defined as a situation in which an individual believes they know the ethically appropriate action to take but are unable to take that action. The concept of moral distress is increasingly recognized as an important mediator of occupational stress and burnout in medicine, particularly in the nursing profession. However, there is a dearth of literature on moral distress among physician trainees, with the majority focused on dilemmas in end-of-life care. This study explores the phenomenon of moral distress among internal medicine trainees, with particular focus on drivers, situational contexts, and adaptive strategies such as coping mechanisms.
METHOD(S): We report qualitative data from a mixed methods prospective observational cohort study of internal medicine (IM) residents and associated faculty at a large, urban, academic medical institution. Five focus groups were conducted with 15 internal medicine residents (PGY1- 3), between January and October 2019. In each focus group trained facilitators conducted semi-structured interviews using prompts which focused on definitions of, experiences with, and consequences of moral distress. Transcripts were independently coded by investigators, and analyzed by major themes and sub-themes. Discrepant themes and codes were reviewed by the full research team to establish clarity and consensus. Data were analyzed using Dedoose software.
RESULT(S): Focus group participants were equally distributed by gender (7 women, 8 men) and across training year (30% PGY1, 20% PGY2 40% PGY3). Experience with moral distress was universal among participants, and was identified across four major domains: personal values and morals, professional competency and training challenges, interpersonal relationships and conflicts, and systems/structural issues. Participants identified unique, place-based moral distress across different clinical environments, including intensive care units, wards, and outpatient environments, as well as between private, public, and government- run hospital facilities. Participants described a number of adaptive mechanisms for managing moral distress, including social support and connectivity, humor, and disassociation.
CONCLUSION(S): Physician trainees experience considerable moral distress across multiple domains during the course of their training. They also develop unique adaptive strategies and copingmechanisms tomanage and learn from distressing experiences. This improved understanding ofmoral distress among physician trainees, particularly drivers and protective factors, has important implications for the training of physicians, and may have a role in promoting wellness and resilience among physicians across the training and professional pipeline

BACKGROUND: Payors are increasingly recognizing that social determinants of health(SDH) impact on health outcomes and healthcare costs. Z codes can be used to document and stratify patients into risk pools according to SDH. We report on the impact of SDH screening implementation in a federally qualified health center network on the use of Z codes to document SDH. In this study, we describe the prevalence of SDH screening by department, the prevalence of documented SDH, and the prevalence of documented Z codes for each SDH.
METHOD(S): In October 2017, we initiated SDH screening throughout, but focusing on the internal medicine and women's health departments of a large FQHC network (12 service delivery sites) using the OCHIN tool embedded in the elecrtonic health record. In November 2019, we retrieved the following variables from record: % of all patients who were screened, number of patients screened annually by department, % of positive screens (+ response to any question), % abnormal screens(response that triggers a best practice alert to the treating provider), and documentation of a Z code for positive or abnormal screens.
RESULT(S): There were 624,007 encounters over a 2 year study period; 2,844 patients were screened: 194 in 2017, 1068 in 2018;1644 in 2019. Overall, there were 3052 screening events (some patients received multiple screens). The majority of screening events occurred in women's health [1961(64%)], followed by adult medicine[874(29%)]. Overall, 2350(77%) of screens were "positive", of which 433 had no "abnormal" results and hence did not trigger a best practice alert. Of these 433, the most common positive items were: social isolation(63%), stress(44%), financial resource strain(8%), moved 2+ times(7%). There were 1923(63%) abnormal screens. The top 10 abnormal items in Women's Health and Adult Medicine were: Education less than high school(36% and 37%), physical activity <140 minutes(23% and 25%), hard to pay for medicine/medical care(13% and 26%), hard to pay for utilities(14% and 23%), hard to pay for food(13% and 21%), hard to pay for health insurance(11% and 22%), concerns about housing quality(3% and 9%), hard to pay child care(5% and 5%), exposure to violence(4% and 3%), never get together with family/friends(3% and 3%). Overall, encounters with an SDH screen were more likely to have a documented Z code:26% vs. 1%. Z codes were documented for the following documented needs: insufficient social insurance(53%); lack of access to health care(51%), homelessness(49%), inadequate family support(40%), lack of physical exercise(37%), underachievement in school(34%), personal history of abuse(31%), lack of assistance for care at home(29%), inadequate food supply(1%).
CONCLUSION(S): Presence of a documented SDH screen was associated with documentation of Z codes, however documentation was missing more than half the time for most documented needs. The drivers of Z code documentation deserve further exploration. Qualitative interviews and focus groups with providers may be useful