United States

Background: Nearly 10% of Medicare beneficiaries aged ≥65 experience food insecurity. Among this demographic, a greater risk of health impacts exist since many have diet-related chronic conditions such as diabetes (affecting 33% of older adults). Food-insecure, diabetic older adults face increased risks of poor diabetes management and diabetes-related complications due to difficulty adhering to a diabetes-appropriate diet. We examined risk factors associated with food insecurity among Medicare beneficiaries with type 2 diabetes (T2D).

Methods: This population-based cross-sectional study analyzed the 2019 Medicare Current Beneficiary Survey Public Use File (MCBS PUF), with a multi-stage cluster sample design and an overall response rate of 65.7%. The study population included community-dwelling, Medicare beneficiaries with T2D aged ≥65 (n=1,343). The MCBS PUF included a 4-item version of the USDA’s food insecurity questionnaire relating to inability to eat balanced meals, skipping meals, eating less, or food running out because of insufficient money. A binary variable was created to represent food insecurity with ≥2 affirmative responses designated as food insecure based on a previously established algorithm. Descriptive statistics and survey-weighted multivariable logistic models were used to examine the risk factors of food insecurity based on socio-demographic information, health conditions, and insurance coverage.

Results: Approximately 11.6% (representing 1.0 million) of study participants with T2D reported food insecurity, with higher proportions for underserved populations such as income &lt;$25,000 (23.9%) and non-Hispanic Black beneficiaries (21.7%). Using multivariable analysis, non-Hispanic Black beneficiaries were more likely to report food insecurity than Non- Hispanic White (odds ratio [OR]=2.44; 95% CI, 1.39-4.29). Beneficiaries with an income &lt;$25,000 were more likely to report food insecurity than for income ≥$25,000 (OR=2.76; 95% CI, 1.34-5.71). Enrollment in Medicare Advantage (vs Traditional Medicare; OR=1.62; 95% CI, 1.07-2.45), having Medicare-Medicaid dual eligibility (vs nondual eligible; OR=2.14; 95% CI, 1.18-3.90), and living with functional limitations (e.g., ADLs ≥1 vs no limitations; OR=2.74; 95% CI, 1.64-4.59) were positively associated with food insecurity.

Conclusion: We found socio-demographic disparities in food insecurity exist among Medicare beneficiaries with T2D. Implementation of screening protocols and interventions related to social determinants of health during Medicare wellness visits may help mitigate food insecurity among this demographic.

AMA Research Challenge 2022

Socio-Demographic Factors Associated with Food Insecurity Among Medicare Beneficiaries with Type 2 Diabetes

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Ricardo Correa, MD, EdD
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Charles Lopresto, DO

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Welcome to the largest national, multi-specialty research event featuring research from 750 medical students, residents and fellows, and international medical graduates.


Background: Nearly 10% of Medicare beneficiaries aged ≥65 experience food insecurity. Among this demographic, a greater risk of health impacts exist since many have diet-related chronic conditions such as diabetes (affecting 33% of older adults). Food-insecure, diabetic older adults face increased risks of poor diabetes management and diabetes-related complications due to difficulty adhering to a diabetes-appropriate diet. We examined risk factors associated with food insecurity among Medicare beneficiaries with type 2 diabetes (T2D).

Methods: This population-based cross-sectional study analyzed the 2019 Medicare Current Beneficiary Survey Public Use File (MCBS PUF), with a multi-stage cluster sample design and an overall response rate of 65.7%. The study population included community-dwelling, Medicare beneficiaries with T2D aged ≥65 (n=1,343). The MCBS PUF included a 4-item version of the USDA’s food insecurity questionnaire relating to inability to eat balanced meals, skipping meals, eating less, or food running out because of insufficient money. A binary variable was created to represent food insecurity with ≥2 affirmative responses designated as food insecure based on a previously established algorithm. Descriptive statistics and survey-weighted multivariable logistic models were used to examine the risk factors of food insecurity based on socio-demographic information, health conditions, and insurance coverage.

Results: Approximately 11.6% (representing 1.0 million) of study participants with T2D reported food insecurity, with higher proportions for underserved populations such as income <$25,000 (23.9%) and non-Hispanic Black beneficiaries (21.7%). Using multivariable analysis, non-Hispanic Black beneficiaries were more likely to report food insecurity than Non- Hispanic White (odds ratio [OR]=2.44; 95% CI, 1.39-4.29). Beneficiaries with an income <$25,000 were more likely to report food insecurity than for income ≥$25,000 (OR=2.76; 95% CI, 1.34-5.71). Enrollment in Medicare Advantage (vs Traditional Medicare; OR=1.62; 95% CI, 1.07-2.45), having Medicare-Medicaid dual eligibility (vs nondual eligible; OR=2.14; 95% CI, 1.18-3.90), and living with functional limitations (e.g., ADLs ≥1 vs no limitations; OR=2.74; 95% CI, 1.64-4.59) were positively associated with food insecurity.

Conclusion: We found socio-demographic disparities in food insecurity exist among Medicare beneficiaries with T2D. Implementation of screening protocols and interventions related to social determinants of health during Medicare wellness visits may help mitigate food insecurity among this demographic.

poster

Abstract Title: Impact of the COVID-19 Pandemic on Medical Students in the 2021-2022 NRMP Application Process

Background: The COVID-19 pandemic significantly changed the undergraduate medical education (UME) NRMP application process (NAP). This included virtual interviews, the suspension or elimination of away rotations, elimination of COMLEX 2 PE/USMLE STEP 2 CS licensing exams, and increased online rotations. Previous literature has reported on the impact the pandemic had on the 2020-2021 NAP; however, limited data exists on the impact of the pandemic on this past cycle, from 2021-2022.1 – 4

Objective: To survey medical students from two colleges of osteopathic medicine regarding the impact the pandemic had on their 2021-2022 NAP in order to better understand challenges faced by students.

Methods: An IRB-approved 20 question survey was developed and distributed after the 2022 match via email and social media. 86 students from the Liberty University College of Osteopathic Medicine and the Kansas City University College of Osteopathic Medicine participated in the study. Likert-scale questions with a range of 1-5 and a comment box were used to assess student experiences related to changes the pandemic had on their match process. Several areas were assessed, e.g., away rotations, virtual interviews, board requirement changes including the suspension of COMLEX Level 2 PE, advising, psychological well-being, etc. Statistical analysis was performed using Qualtrics software. 

Results: 97.59% matched in the 2021-2022 NAP. 94.81% matched in their first-choice specialty. The number of away rotations in matched specialties ranged from 1 to 9 (M=3.22, SD=1.82). Only 39.74% matched at an away rotation site. The average amount of money spent on the entire application process was (M=$3070, SD=$2274). On a scale of 1 to 10, overall impact felt by the pandemic on the 2021-2022 NAP was M=4.92, SD=1.92. 54.5% of students reported the suspension of the third board exam to have impacted their application process high to very highly. However, more students felt highly impacted by the availability of away rotations (61.2%) and the virtual interviewing format (71.6%). Approximately 45% of students rated both stress and anxiety as high impacts. 72.06% of participants sought feedback from students from the 2020-2021 NAP and 48.98% of participants found this feedback to be highly helpful. The impact of the availability of away rotations and stress were positively correlated (r=0.266, p<0.005). The suspension of PE/CS and sleep were negatively correlated (r=-0.054, p<0.006). 

Conclusion: Changes in the 2021-2022 NAP due to COVID-19 positively and negatively impacted students. Student comments indicated that virtual interviews opened up more opportunities to interview and save money. Students also commented that due to the strain of the pandemic, they had less time with their attending physicians and that this could have negatively impacted their letters of recommendation. Overall, cancellation of the PE and CS was viewed positively. And many students sought out feedback from applicants of the 2020-2021 NAP to be better prepared to face the challenges of the continued pandemic.

The Impact of the COVID-19 Pandemic on Medical Students in the 2021-2022 NRMP Application Process

The Prevalence and Incidence of Sarcoidosis at the Phoenix VA Health Care System

Background
Sarcoidosis is a multisystem granulomatous disorder with different manifestations. It typically effects adults <50 years of age of African American or Scandinavian decent. In the United States the prevalence per 100,000 population is estimated to be 141.4, 49.8, 21.7, and 18.9 for African American, White, Hispanics, and Asians, respectively. The incidence of sarcoidosis is estimated to be of 2.3-17.8 per 100,000 per year.
The Phoenix VA Health Care System’s (PVAHCS) Pulmonary department has had multiple cases of sarcoidosis, leading to multiple educational conferences. The aim of the study was to assess burden of sarcoidosis within the PVAHCS.
Methods
A retrospective chart review of sarcoidosis cases from 2017 through 2021 were identified using ICD-10 (D86.0, D86.1, D86.2, D86.3, D86.82, D86.89, D86.9) codes. The prevalence and incidence sarcoidosis at the PVAHCS were calculated. Poisson regression was used to compare the prevalence between 2017 and 2021. 
Results
All rates are reported per 100,000 veterans enrolled in PVAHCS. Of the 345 sarcoidosis cases identified, majority were male (85.8%). From 2017 to 2021, the prevalence of sarcoidosis increased by 51% (100.4 vs 148.2 respectively, P=0.003). The incidence varied from 0 to 44.1 per year. On average, females had higher prevalence and incidence compared to men (788.6 and 30.04 vs 643.4 and 17.64, respectively). Group ages 45-54 and 55-65 have the highest prevalence (253 and 262.4, respectively). Patients ages 75-85 have the highest incidence (50.3). The cumulative incidence was significantly higher in African Americans as compared to other races/ethnicities (923.1 vs 178.73 (Hispanic or Latino), 149.6 (Whites), 71.9 (Native Hawaiians or other Pacific Islanders), and 62.6 (Native Americans, P<0.001).

Conclusion
This is the first study to report the incidence and prevalence of sarcoidosis at PVAHCS. The overall incidence and prevalence were similar to what has been reported and is increasing each year. In our review, PVAHSC African Americans have higher incidence and prevalence whereas females only have higher prevalence of sarcoidosis compared to the reported rates. Further studies should be conducted to determine associated risk factors. Additional efforts must be initiated to optimize care for this population.

The Prevalence and Incidence of Sarcoidosis at the Phoenix VA Healthcare System

Preoperative dealys of 90-120 days from tissue diagnosis of breast cancer to surgery can result in 3.1-4.6% absolute decline in overall survival. This has become the standard of care when assessing timeliness of Breast Programs across the United States. At Temple University Hospital in Philadelphia, we have the unique privilege of treating a primarily underserved population that is at risk for various obstacles to timely medical care. When assessing time to surgery in our patient population, we were able to see that delays in care occur at all stages of the evaluation protocol for possible breast cancer. Of importance, is the significant delay we found to be associated with obtaining initial imaging. Therefore, it is important to include time from abnormal imaging to tissue diagnosis in measurements of timeliness as there can be significant delays associated with imaging.

Timeliness of Care in a North Philadelphia Breast Program

Background:
Iron deficiency anemia (IDA) is an important contributor to the systemic disease process in heart failure (HF). Intravenous (IV) Iron repletion has been shown to be superior to oral iron repletion with respect to decreased side effect profile, improved quality of life, reduced mortality and rehospitalization in HF patients. No study has outlined a multidisciplinary hospital-based process in identifying and treating this specific cohort of patients with IV Iron repletion. 

Objectives: 
Our quality improvement (QI) initiative sought to identify patients with IDA and HF in real time and treat them with IV iron repletion instead of oral iron supplementation during their hospitalization using a multidisciplinary approach. 

Methods: 
Between May 2021 and February 2022, using a daily real time electronic medical record patient intake filter, we identified patients admitted for acute decompensated heart failure with a hemoglobin of less than or equal to 12g/dl. Patients were further analyzed for IDA via laboratory iron panel. In accordance with the European Society of Cardiology (ESC) guidelines, anemic patients with a ferritin <100 µg/L or ferritin of 100-299 µg/L with a transferrin saturation <20% qualified for IV Iron repletion. An IDA QI team was created consisting of internal medicine residents, advanced care practitioners, cardiology fellows, and pharmacists to educate providers, identify and treat qualified patients. Patients were treated with IV Iron Sucrose 300mg/day for three consecutive days.

Results:
54 patients were included in the study with three outliers removed, 16 patients were given oral iron sulfate therapy and 36 received IV iron sucrose therapy. Heart failure with reduced ejection fraction was the predominant HF phenotype with 38 patients. The average hemoglobin of our cohort was 8.6 with a mean corpuscular volume of 90.2, ferritin of 98, serum iron of 26, TIBC of 253, and transferrin of 200. A statistically significant decrease in average hospital length of stay was noted in the IV iron repletion arm of 5 days versus 10 days in the oral repletion group (p <0.01). There was no statistically significant difference in length of stay among HF patients with varying levels of ferritin. 

Conclusion: 
Our quality improvement project successfully created a real time multidisciplinary approach to identifying and treating patients with IDA and HF. A statistically significant decrease in length of stay was associated with IV iron repletion. We increased the utilization of IV iron compared to oral repletion by more than 100% during the same time. As a result of this project, IV iron repletion is now a part of our armamentarium in holistically treating heart failure.

Iron Deficiency Anemia and Treatment in ​Heart Failure: A Novel Multidisciplinary Quality Improvement Project

Background: Atopic dermatitis (AD) is a common relapsing inflammatory skin condition associated with a high economic burden due to its chronicity and multitude of direct and indirect treatment costs. AD disproportionately impacts children and minority populations, and treatment choices are cost-prohibitive for many patients.

Objective: To describe the treatment and management of AD from a cost-conscious perspective.

Methods: A review of the literature was conducted with PubMed using the following key words: atopic dermatitis, cost, medications, treatment, management, efficacy, adherence, education, and prophylactic.

Results: The use of moisturizers prophylactically in high-risk infants who have yet to develop AD may reduce incidence of disease and associated costs. Increasing patient medication adherence and moisturizing between flares also reduces costs in AD. The use of corticosteroids as a first-line treatment is efficacious and cost-effective for mild cases of AD, however in severe cases of AD corticosteroids alone are not sufficient. Systemic biologics are necessary in some patients with severe cases of AD; however, they are associated with high costs. Phototherapy, through portable home units, tanning beds, and natural sunlight are cost-effective alternatives. Effective management of AD improves with education programs for both the patient and their family, reducing long-term costs in the management of this disease.

Conclusion: Reducing AD treatment costs requires consideration of prophylactic therapies, patient education, and should differ based on the severity of disease. A multifaceted approach to AD treatment reduces costs and healthcare barriers. This article is protected by copyright. All rights reserved.


Reducing Costs in Atopic Dermatitis

Abstract Title
Factors Associated With Mortality and Prolonged Hospital Stay Among Skull Fracture Patients

Background
Skull fractures pose a high demand on hospital resources. The implication of skull fracture on patient length of hospitalization and mortality has not been elucidated. Identifying predictors of differential mortality risk and prolonged hospital stay in skull fracture patients present opportunities to improve patient outcomes and management of hospital resources. 

Methods
The 2019 National Emergency Department Sample database was used to outline the demographics of patients with a primary skull fracture. Multivariate logistic regression was used to determine factors that contributed to a long inpatient stay and death. Charlson Comorbidity Index (CCI) was calculated to correct for comorbidities relevant to mortality and hospital stay.

Results
In 2019, 1,769,709 patients presented to the emergency department with primary skull fractures.
Level I trauma center inpatients were at greater odds of long hospital stay (OR:2.40; 95% CI [1.72-3.35], p<0.001). Relative to other income groups, the highest income quartile had the lowest likelihood of a prolonged stay (OR:2.40; 95% CI [1.72-3.35], p<0.001). Inpatients presenting with multiple comorbid conditions (CCI: 3+) reported distinctly high likelihood of long hospital stay (OR:3.20; 95% CI [2.45-4.18], p<0.001) and death (OR: 2.18, CI [1.24-3.83], p=0.007). Medicaid beneficiaries reported lower odds of death due to skull fracture than Medicare inpatients (OR:0.63; 95% CI [0.40-0.98], p=0.04). Skull fractures sustained by fall (OR: 0.37 95% CI [0.23-0.58], p<0.001) or physical assault (OR: 0.34 95% CI [0.18-0.63], p<0.001) observed significantly lower odds of death than other-cause fractures. Vault fracture type was associated with both longest hospital stay (OR:3.49; 95% CI [2.54-4.80], p<0.001) and highest mortality rate (OR: 4357; 95% CI [589-32172], p<0.001). 

Conclusion
Distinct odds of prolonged hospitalization and mortality were realized across a motley of covariate-adjusted inpatient and hospital factors. Mindfulness of the associations reported here may serve well to mitigate bed management inefficiencies and improve skull fracture outcomes.

Factors Associated With Mortality and Prolonged Hospital Stay Among Skull Fracture Patients

Introduction: Availability of inpatient pediatric services has declined across the United States between 2008-2018, with rural areas experiencing steepest declines. Despite the movement of pediatric care to children’s centers, most children are still cared for in community hospitals nationally. Assessing the availability and providers of inpatient pediatric care in Wisconsin is an important step in ensuring the health care needs of children in the state continue to be met. 
Methods: A cross-sectional survey was distributed to Wisconsin hospitals to determine pediatric services and physician workforce. Response rate was 130/138 (94%), including 56/58 (97%) of Critical Access Hospitals (CAHs). Results of specific inpatient pediatric subdivisions were analyzed by descriptive statistics. 
Results: Hospitals that provide inpatient newborn care are mostly staffed by pediatricians (P) and family physicians (FP), while CAHs are staffed by FP. Hospitals with neonatal intensive care units are staffed by neonatologists, with telemedicine utilized in CAHs. Hospitals with general pediatric admissions are staffed by P or FP, while CAHs are staffed by FP. Hospitals with pediatric intensive care units are staffed by pediatric intensivists. 
Conclusions: Despite workforce disparities and shortages, hospitals across Wisconsin, including many CAHs, continue to provide inpatient pediatric services. Family physicians play a major role in the pediatric healthcare delivery in Wisconsin hospitals. Robust inpatient pediatric training of family physicians may enable rural health authorities to continue addressing the gaps that persist in inpatient pediatric care accessibility.

Inpatient Pediatrics and Clinician Workforce in Wisconsin: The State of the State

Advanced liver diseases (ALDs) present with a gross burden to one’s health and quality of life – cirrhosis and liver cancer, for instance, account for approximately 3.5% of deaths across the world. By investigating the preponderance of research grants focused on ALDs within key patient-centered domains such as palliative care, geriatrics, and supportive care, we seek to identify future directions for funding areas of research that greatly benefit patients in critically ill condition. The primary aim of this study was to describe the number and total funding of research grants awarded on palliative care, geriatrics, and supportive care research focused on advanced liver disease. We referred to previous literature on these domains of research to develop and identify search terms to be used in NIH Reporter, a search tool that provides publicly available information on NIH-funded research grants. An abstract and title review of the studies was completed to determine which grants are relevant to the domains in question. After a title and abstract review showed 345 relevant studies on ALD, only 12 (3.5%) were in the domains of PC, geriatrics, and/or supportive care. Likewise, of approximately 146 billion dollars devoted to funding towards ALD research, around 6.6 million dollars (4.5%) were focused towards any of these domains. Our research indicates that there is a greater need for funding in the domains of palliative care, geriatrics, or supportive care research within advanced liver disease. Patient-centered research is important for ensuring improved clinical outcomes and patient quality of life. With the expected increase in our geriatric population over the next several decades, there will need to be greater emphasis on such research domains.

The State of Funding for Palliative Care, Supportive Care, and Geriatrics Research in Advanced Liver Disease

Background:
Survey of procedures performed across all surgical subspecialties at the Iowa City VAMC in FY2018 showed that the rate of 30-day period surgical site infections (SSI) was significantly higher than that of national average. Average cost saving from single deep or organ space SSI and single superficial SSI are approximately $34,407 and $1,000, respectively. SSI places significant financial burden to the healthcare systems and complicates the course of postoperative recovery. 

Methods:
Previously, all patients undergoing surgery at the Iowa City VAMC underwent Chlorohexidine Gluconate (CHG) bath prior to surgery. A new surgical site infection prevention protocol (SSIPP) involving 2% CHG cloths for skin, Povidone Iodine nasal swab, and 0.12% CHG mouth rinse was implemented in October of 2019 (Figure 1,2)). All eligible cases were reviewed since the implementation of the SSIPP. All recorded SSI were categorized into deep/organ space SSI or superficial SSI. This was compared with the rate of SSI recorded before the SSIPP implementation and cost savings were estimated accordingly.

Results:
From 10/01/2019 to 09/30/2020 a total of 885 eligible cases were reviewed, revealing a total of 3 deep/organ space SSI. This is significantly lower than 15 deep/organ space SSI recorded from 01/01/2018 to 12/31/2018 out of 1042 cases (p=0.016). However, rate of superficial SSI from 10/01/2019 to 03/30/2020 was significantly different from that of 2018 (p=0.80).

Compared to 2018, estimated total cost savings from reductions in deep/organ space SSI ($516,105 vs $258,052) and superficial SSI ($9,000 vs $6,000) approximates to $415,884.

Conclusion
SSI is a known surgical complication that places significant financial burden on healthcare systems and puts patients at greater risk of postoperative mortality and morbidity. Preoperative infection prevention protocol involving CHG cloths, Povidone Iodine swab, and CHG mouth rinse has significantly decreased the overall rate of SSI and those that involve deep/organ space SSI. This approximates to total cost savings of $415,884 at no cost to the patient.


Preoperative Infection Prevention Protocol to Reduce Rate of Surgical Site Infections

Introduction: Multimorbidity in surgery is common and associated with worse postoperative outcomes. However, the conventional multimorbidity definition (≥2 comorbidities) labels the vast majority of elderly patients as multimorbid, limiting its clinical benefit. We developed and validated a better surgical specialty-specific multimorbidity definition based on distinct comorbidity combinations called Qualifying Comorbidity Sets (QCSs).

Methods: We used Medicare claims data for patients aged 66-90 years hospitalized for general (GS), orthopedic (OS), or vascular surgery (VS). Using 2016-2017 data, we identified all comorbidity combinations associated with a double-or-greater risk of 30-day mortality compared to the overall population undergoing the same procedure; these were defined as QCSs. We applied these QCSs to 2018-2019 data (GS=462,904 patients, OS=1,493,999, VS=301,336) to obtain 30-day mortality estimates. For further validation, we tested whether multimorbid patients treated at better-resourced (based on nursing resources, surgical volume, teaching status) vs. other hospitals had differential outcomes using multivariate matching.

Results: Compared to the conventional multimorbidity definition, the QCS-based definition labeled fewer patients as multimorbid: GS=85.0% vs. 55.9% (p<0.0001); OS=66.6% vs. 40.2% (p<0.0001); VS=96.2% vs. 52.7% (p<0.0001) (Table 1). Thirty-day mortality was higher by the QCS-based definition: GS=3.96% [conventional] vs. 5.64% [QCS-based] (p<0.0001); OS=1.13% vs. 1.68% (p<0.0001); VS=4.43% vs. 7.00% (p<0.0001). Better-resourced hospitals offered larger mortality benefits for multimorbid vs. non-multimorbid GS and OS patients (GS absolute risk reduction difference-in-difference=-0.94% [95% CI -1.24%,-0.63%], p<0.0001; OS difference-in-difference=-0.20% [95% CI -0.29%,-0.10%], p<0.0001).

Conclusion: Our QCS-based multimorbidity definition identifies a more specific, higher risk pool of patients compared to the conventional definition, allowing for better clinical decision-making.

Next from AMA Research Challenge 2022

The Impact of the COVID-19 Pandemic on Medical Students in the 2021-2022 NRMP Application Process

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