United States

Background: While the impact of social and environmental exposure on cardiovascular risks is often reported individually, the combined effect is poorly understood. 
Objectives: We aim to study the association between a combination of social and environmental determinants of health and the incremental impact of environmental factors on cardiovascular disease (CVD) and risk factors prevalence.
Methods: Utilizing the 2022 Environmental Justice Index (EJI), socio-environmental EJI ranks were divided into quartiles, Q1-Q4 (Q1: the least, Q4: the most vulnerable census tracts). Age-adjusted rate ratios (RR) of health measures reported in the Prevention Population-Level Analysis and Community Estimates (PLACES) data were compared between quartiles using multivariable Poisson regression. A second regression model was used to assess the independent effect of environmental burden and social vulnerability. 
Results: The prevalence of CVD and other adverse health measures increased with EJI and EBM quartiles. Q4-EJI was associated with a higher rate of coronary artery disease (CAD) (RR: 1.684, 95%CI: .660-1.708, p&lt;0.001) and stroke (RR: 2.112, 95%CI:2.078-2.147, p&lt;0.001) compared with Q1-EJI. Similarly, the risk of CAD (RR:1.143, 95% CI:1.127–1.159, p&lt;0.001) and stroke (RR:1.118, 95% CI:1.102-1.135, p&lt;0.001) was significantly higher in Q4 than in Q1-EBM. Similar results were observed for chronic kidney disease, hypertension, diabetes, obesity, high cholesterol, lack of health insurance, sleep &lt; 7 hours, no leisure time physical activity, and impaired mental and physical health &gt; 14 days.
Conclusion: The prevalence of CVD and its risk factors is higher in areas with increased social and environmental adversities, and environmental exposure plays an important role independent of social factors.


AMA Research Challenge 2023

The Impact of Environmental Injustice on Cardiovascular Diseases and Risk Factors in the United States

Background: While the impact of social and environmental exposure on cardiovascular risks is often reported individually, the combined effect is poorly understood. 
Objectives: We aim to study the association between a combination of social and environmental determinants of health and the incremental impact of environmental factors on cardiovascular disease (CVD) and risk factors prevalence.
Methods: Utilizing the 2022 Environmental Justice Index (EJI), socio-environmental EJI ranks were divided into quartiles, Q1-Q4 (Q1: the least, Q4: the most vulnerable census tracts). Age-adjusted rate ratios (RR) of health measures reported in the Prevention Population-Level Analysis and Community Estimates (PLACES) data were compared between quartiles using multivariable Poisson regression. A second regression model was used to assess the independent effect of environmental burden and social vulnerability. 
Results: The prevalence of CVD and other adverse health measures increased with EJI and EBM quartiles. Q4-EJI was associated with a higher rate of coronary artery disease (CAD) (RR: 1.684, 95%CI: .660-1.708, p<0.001) and stroke (RR: 2.112, 95%CI:2.078-2.147, p<0.001) compared with Q1-EJI. Similarly, the risk of CAD (RR:1.143, 95% CI:1.127–1.159, p<0.001) and stroke (RR:1.118, 95% CI:1.102-1.135, p<0.001) was significantly higher in Q4 than in Q1-EBM. Similar results were observed for chronic kidney disease, hypertension, diabetes, obesity, high cholesterol, lack of health insurance, sleep < 7 hours, no leisure time physical activity, and impaired mental and physical health > 14 days.
Conclusion: The prevalence of CVD and its risk factors is higher in areas with increased social and environmental adversities, and environmental exposure plays an important role independent of social factors.

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Background
Socioeconomic status (SES) is an essential predictor for healthcare outcomes, including dermatological health. With marginalized Black and Hispanic communities disproportionately overrepresenting the population in poverty in the 2022 Census, their ability to afford quality care and attain access to dermatologists for routine skin cancer screenings remain unresolved health equity issues. With the lack of research on dermatologic malignancies and contributing disparities affecting minority populations, it is essential to understand the grave impacts of SES on this population. This literature review explores the financial restraints of underserved communities and the effects of not being able to afford skin cancer screening.

Methods
An exhaustive literature review was conducted, utilizing Still OneSearch, DynaMed, Google Scholar, PubMed, MEDLINE, and National Institutes of Health online databases. The search strategy included the keywords “socioeconomic status”, “poverty”, “skin cancer screening”, and “underserved or marginalized” to discover related articles. Filters for peer-reviewed sources with publication dates between 2018 - 2023 were applied, further narrowing the results. Once studies of interest were selected, pertinent components were referenced following AMA format.

Results 
Individuals with low SES are less likely to attain specialized dermatological care due to financial strain, lack of insurance coverage, and decreased accessibility. Other contributing factors include the absence of affordable transportation and job inflexibility to attend appointments. Due to these economic challenges preventing early skin cancer detection, patients are frequently diagnosed with thicker melanoma lesions. Patients with limited income, having Medicaid or Medicare insurance rather than private insurance, are more often diagnosed with advanced malignant lesions with inferior prognoses. In a cross-sectional review of the National Health Interview Survey (NHIS), 20.34% (95% Cl 18.97–21.71%) of skin cancer patients reported worrying about medical costs, and 51.41% of uninsured patients expressed additional concerns regarding housing. In a 2018 study, 42.4% of patients with malignant skin lesions had depleted their life savings within the first two years of their diagnoses. Besides economic burden, patients with financial stress had lower odds of following up with their specialist or participating in clinical trials. Patients making annually less than USD 50,000 were 32% less likely than those with higher incomes to enroll in clinical trials. 

Conclusion
Patients from socioeconomically disadvantaged backgrounds habitually suffer disproportionate dermatological outcomes compared to their affluent counterparts. Recognizing the impacts of socioeconomic status on skin health and screening will have countless effects on healthcare advocacy and potentially influence policy change, making dermatologic care more accessible and equitable.

Beyond the Margins: Examining the Impact of Socioeconomic Status on Skin Cancer Screening in Marginalized Communities

Background
While prehospital drug-assisted airway management utilizing both a sedative agent and neuromuscular blocking agent (NMBA) has been well studied, sedative-assisted intubation (SAI) without concurrent NMBA use has not been studied at the national level. Further, we have been unable to identify any prehospital SAI studies focusing on ketamine. This study’s purpose is to analyze SAI practices by emergency medical services (EMS) across the United States and understand ketamine’s role.

Methods
Using the National Emergency Medical Services Information System (NEMSIS) 2021 dataset, we included adult patients who received either ketamine, a benzodiazepine (midazolam, lorazepam, or diazepam), etomidate, or a benzodiazepine-etomidate combination to facilitate SAI. We excluded patients who experienced cardiac arrest prior to any intubation attempts. Primary outcome measures were first-pass intubation success, overall intubation success, and the incidence of post-intubation complications. Using multivariate logistic regression to account for significant baseline measures, we calculated the adjusted odds ratio (OR) of intubation success for each induction agent. 

Results
Of the 4,128 eligible patients, 1,170 underwent SAI using ketamine. The overall intubation success rate using ketamine was 75.47% (884/1,171) and not significantly different compared to the other three sedative agents, with lower success rates compared to etomidate (1,177/1,517, 77.59%, P=.21) and a benzodiazepine-etomidate combination (361/453, 79.69%, P=.08), and greater success compared to benzodiazepines (709/988, 71.76%, P=.06). Compared to the other sedative agents, ketamine had significantly greater incidences of hypoxemia (oxygen saturation less than 90%) (n=416, P<.001), hypotension (systolic blood pressure less than 90 mmHg) (n=337, P<.001), hypocarbia (n=592, P<.001), and cardiac arrest (n=61, P<.001). In multivariate logistic regression using benzodiazepines as the intercept, ketamine was not associated with greater first-pass success (OR 1.03; 95% confidence interval [CI] 0.85-1.24) or overall intubation success (OR 1.17; 95% CI 0.95-1.43).

Conclusion
Compared to other induction agents, ketamine in SAI was not associated with greater intubation success and was associated with a greater incidence of complications. Further investigation is needed to delineate SAI practices in paramedic systems with and without NMBAs, as well as to examine how EMS choice of induction agent may vary amongst different patient subgroups.

The use of ketamine for prehospital sedative-assisted intubation

Background
Rural EMS agencies have long struggled to financially maintain operations because of low call volumes and higher operating costs, and closures have only increased as higher portions of the rural population are uninsured or covered under Medicare and Medicaid. Similarly, community health workers (CHWs) do not have enough volume in rural areas to be financially sustainable. Community paramedicine (CP) models, which combine elements of EMS and CHWs, have demonstrated remarkable success in improving care and reducing costs. However, these models have had limited uptake in rural areas due to reimbursement and regulatory challenges and the models’ emphasis on paramedics rather than inexpensive emergency medical technicians-basic (EMT-Bs) or advanced emergency medical technicians (AEMTs).

Methods
We conducted a narrative literature review to assess the feasibility of dual-certifying EMT-Bs and AEMTs as CHWs to improve the financial sustainability of rural EMS agencies and improve healthcare access. We used Pubmed to search for both original articles and reviews on rural CP, and Google was used to identify gray literature relating to the regulatory, financial, and governance structures of CP and CHWs. Both scholarly and gray literature were only included if they included studies in the USA and were within the last 10 years. 

Results
The scope of practice and training of CP programs varied widely, but most programs involved care coordination, health assessments, health education and promotion, and prevention of ED visits and rehospitalizations. EMT-Bs and AEMTs are in 29% and 10% of CP programs, respectively, even though the majority of rural EMS personnel are non-paramedics. Five states provide Medicaid reimbursement specifically for CP services, and fourteen states provide EMS reimbursement for treatment without transport, but not specifically CP services. Medicare only pays for some CP services under the experimental ET3 model. Conversely, at least 29 state Medicaid agencies reimburse for CHW services, and 21 states have CHW certification programs with another 14 states currently developing them. Medicare also pays for CHW services as of 2021. 

Conclusion
Training rural EMT-Bs/AEMTs to become certified CHWs may be a viable method of increasing EMS agencies’ income by increasing their reimbursable patient encounters in states that reimburse CHWs. This would enable rural EMS providers to avoid the regulatory and reimbursement challenges of other CP programs while increasing the financial sustainability of their agency. While the CHW and EMT-B scopes of practice will limit the extent of care they can provide more than paramedic-based programs, they could significantly expand rural access to both EMS and CHW services with appropriate physician oversight.

Rethinking EMS in the Fight for Rural Health Equity

**Scoring is only possible in the semifinals hall**

**Abstract:**



Depression and Anxiety - Diagnosis and Management in Primary Care:
Alternate Therapy Modalities: A Review

Background: About half of Minneapolis VA patients reside in rural areas, receiving their primary care at a Community Based Outpatient Clinic (CBOC). Although some CBOC’s are over 200 miles away, patients must travel to the Twin Cities for surgical services. 

Methods: The 167 consecutive patients who opted for telehealth postoperative visits were surveyed. Data collected included travel time and distance to the Minneapolis VA and their local CBOC, need for transportation assistance to the clinic/VA, complications as a result of telehealth and a 1-10 overall satisfaction score. 

Results: Respondents reported a mean + SD satisfaction score of 9.60 ± 1.20, with a mean cost savings of $51.94 ± $40.92, decrease in travel time of 99.4 ± 76.58 minutes and no post-surgical complications missed. 

Conclusions: The telehealth program appears to be safe, saves time and money for veterans and results in extremely high patient satisfaction.


Efficacy of Telehealth for Postoperative Visits at the Minneapolis VA

Robotic assisted surgery (RAS) is a form of minimally invasive surgery. During RAS, surgical instruments are connected to a robotic system that is controlled by a surgeon located at an isolated console. Although RAS has advantages such as faster recovery times and less post-operative pain for patients, there are challenges that the technology brings to the operating room such as changes in workflow and space constraints. Therefore, we sought to understand expert perspectives on current and future challenges of surgical team members during the use of RAS. This study aims to identify expert perceptions of RAS for potential future opportunities and improvements for RAS workflow. In-person observations were conducted to learn more about the overall process and workflow of RAS. Focus groups were conducted with eleven surgical techs, eight circulating nurses, and two medical administrations. The focus group questions were used for insights on staff demographics, RAS experience between different hospitals, built environments, training, and interactions. These results were then used to perform a thematic analysis, and the following themes emerged: training, usability, communication, environment, management, and scheduling. These themes were further broken down into subthemes. Definitions and quotes were used to help define each subtheme. Further thematic analysis needs to be conducted to gain additional perspectives from other RAS operating room team members.

Integrating Expert Perspectives On Current and Future Challenges for Robotic Assisted Surgery (RAS) Workflow

Introduction-
The internet has become a prominent tool for patients, with an estimated 80% of Americans having turned to the internet for health information. The Literacy Project proports that over half of Americans would struggle to read a book written beyond an 8th grade reading level. Studies have found association between poor patient understanding and worse outcomes and decreased patient satisfaction.

To combat these issues related to the readability of patient education materials, The American Medical Association (AMA) recommends patient health information be written at a 6th grade reading level. Previous studies into the readability of online patient information on a wide variety of topics have revealed much online patient education materials surpass this recommendation. With one recent study of the readability of online patient information on the topic of appendectomies was 12th-14th grade, well beyond the abilities of the average American reader and AMA recommendations. 

Because caring for a surgical wound is a prolonged process and often involves at home care, online resources on this topic may particularly useful to patients. Despite this, investigations into the readability of these sources are lacking. This study provides formal assessment of the current state of the readability of online patient education materials on the topic of surgical wound care.

Methods-
A google search for “surgical wound care” was done with a cleared browser. The first 30 results to meet criteria were analyzed. Advertisements, audiovisual resources, and scientific/professional articles were excluded.

The analysis tool readable.com was used to obtain Flesch Kincaid Grade Level Scores and Gunning Fog Index Scores (measures of grade level required to read) as well as Flesch Reading Ease Scores (measure of general ease of read). Average scores with 95% confidence intervals were calculated to compare to recommended reading levels. Associations between readaility and source were also explored.

Results-
Average Flesch Kincaid Grade Level Score was 6.8 95% CI [6.1, 7.5] and average Gunning Fog Index Score was 8.9 95% CI [8.1, 9.7]. The average Flesch Reading Ease Score was 65.3 95% CI [60.9, 69.7], with scores over 60 indicating overall easy readability. Only 10% (3/30) Flesch Reading Ease Score were above 80. (12/30) met AMA recommendations by Flesch Kincaid grade scores, but none met AMA recommendations by Gunning Fog Index Score. 

Information sources could be categorized as; health information websites, government affiliated organizations, hospitals/health systems, private clinics, and others (ie- insurance company). These categorizations aren’t completely mutually exclusive.

There was no statistical difference in scores between organizations with/without government affiliation. 

Conclusions-
Flesch Kincaid Grade Level Scores indicated nearly half (12/30) met AMA criteria, but Flesch Reading Ease Scores and Gunning Fox Grade Level Scores indicated 3/30 and 0/30 met AMA guidelines, respectively. While this is considerable variance, it resulted from a difference of only 2.1 grade levels between average scores of the different grade level calculation methods. Additionally, half of all materials were still within 2.3 grade levels of AMA recommendations based on Gunning Fox Grade Level Scores. Taken together, this likely indicates that there is a proportion of patient information materials that meet AMA guidelines, but the majority still do not meet AMA recommendations and a significant number of people would likely have some trouble with them. 

While there is inherent complexity to medical topics, there are many simple ways to improve the readability of any writing. These include things like removing unnecessary words and breaking up longer sentences. Given the large number of patient education materials within a couple grade levels of the AMA guideline, simple modifications to writing techniques like these may bring a significant proportion into compliance.


Readability Assessment of Online Patient Education Materials on Surgical Wound Care

Background 
Due to the harmful effects of unmet social needs on patient health outcomes, professional societies currently recommend providers in all healthcare settings screen patients for social risk factors. Unfortunately, current literature shows that patients with social risk factors have difficulty accessing primary care and have increased preventable emergency care utilization. Limited research is available to determine if ambulatory clinics adequately capture vulnerable populations. This study compares the prevalence of social risk factors among patients screened in primary care clinics to the prevalence of those factors in Connecticut in general to determine if vulnerable populations are receiving ambulatory care.

Methods 
Researchers reviewed data from screenings performed from 9/13/2021 to 5/6/2022 at 3 primary care clinics in Connecticut. Volunteers screened patients for social risk factors using the Protocol for Responding to and Assessing Patients’ Assets, Risk, and Experiences assessment tool. To determine the screening’s effectiveness; the measured prevalence of unemployment, food insecurity, low educational attainment (no GED equivalent), utilities stress, homelessness, and decreased English fluency was compared to state-wide prevalence of those factors. Investigators determined the state-wide prevalence of utilities stress and homelessness through finding the proportion of the population that received CT Energy Assistance Program benefits or contacted the CT Coordinated Access Network in need of housing assistance. Government data published between 2019 and 2021 provided the prevalence of all other factors. Researchers compared the prevalences using Chi-Square Tests of Independence with a p-values of <0.05.

Results
Volunteers screened 2,150 patients. Analysis found no significant difference between the state-wide prevalence of educational attainment (8.9% vs. 8.7%, p=0.79), utility stress (5.8% vs. 5.7%, p=0.87), food insecurity (4.2% vs. 4.7%, p=0.21), and decreased English fluency (10.0% vs. 10.3%, p=0.61) and the prevalence of those factors among patients screened. Patients screened had a significantly higher prevalence of unemployment (9.2% vs. 6.3%, p<0.05) and homelessness (3.0% vs. 1.3%, p<0.05) compared to the state overall.

Conclusion 
Although current literature shows that vulnerable populations experience barriers to receiving primary care and have increased utilization of emergency care, our study found that the prevalence of social risk factors among patients seen in ambulatory clinics was similar to, if not higher than, the prevalence of those factors in the state overall. This indicates that ambulatory clinics adequately capture vulnerable populations. Results argue that the screening performed was effective in identifying social risk factors and that ambulatory clinics could be an adequate site for targeted interventions. Generalizability of these results to other states, pediatric populations, and specialty clinics may be limited as the screenings reviewed were performed with adults at primary care clinics in Connecticut.

Social Determinants of Health Screening Demonstrates that Vulnerable Populations Do Receive Ambulatory Care

Background: Many medical schools have begun including health systems science (HSS) in their curricula to address emerging healthcare needs. With this principle in mind, a clinical reasoning exercise was developed by the Johns Hopkins neurology clerkship team in 2017. Students are given a standardized case of a patient presenting with falls and asked to develop an assessment & plan. During the COVID-19 pandemic, Johns Hopkins replaced tiered grading (honors/high pass/pass/fail) with pass/fail grading for core clerkships. This study seeks to determine if clerkship grading (tiered versus pass/fail) influences the quality of the differential diagnoses, localization of the disease process, clinical reasoning, and diagnostic/management options.

Methods: Data was extracted from the case reports submitted by students in the Neurology clerkship between 2017 and 2022. Report elements in tiered versus pass/fail curricula were compared using chi-squared tests.

Results: Of the 592 students, 306 (51.7%) were in the tiered curriculum, and 286 (48.3%) were in the pass/fail curriculum. With respect to differential diagnoses, students were more likely to include drug-induced parkinsonism (p<0.05) in the tiered system, and Lewy body dementia (p<0.05) in the pass/fail system. The inclusion of other diagnoses was not significantly different between the two systems. For localization, students were more likely to localize to the substantia nigra specifically (p<0.05) in the pass/fail compared to tiered system. Clinical reasoning elements like dysautonomia and timing (p<0.05) were cited more in the tiered system, while discussion of REM sleep behavior was not significantly different between the two systems. Students were more likely to order labs but less likely to order imaging (p<0.05) in the tiered versus pass/fail system. Lastly, for management, students were more likely to request outside consultations/referrals, initiate physical therapy, stop metoclopramide, and treat urinary symptoms and hypotension (p<0.05) in the tiered versus pass/fail system. Treatment with carbidopa-levodopa did not significantly differ between the two systems.

Conclusion: Although clerkship grading does not appear to influence differential formation or clinical reasoning strongly, it does influence diagnostic testing and management choices. Tiered grading correlates with aspects of HSS, including value-based care (deferring imaging, stopping metoclopramide) and interprofessional collaboration (consults, physical therapy).

Looking Backwards to Look Forward: An Analysis of Clinical Reasoning Reports in the Neurology Core Clerkship before and after the transition to Pass/Fail Grading

Background: While most births in the U.S occur in a hospital, out-of-hospital births have been increasing in popularity with one in every 61 births occuring at home or in a community birthing center. The fear of disrespect and loss of autonomy have been cited as primary drivers for planned home births with data showing higher rates of mistreatment occurring in hospital settings than at home. This was especially apparent for individuals who transferred from a community setting to the hospital after the onset of labor. Approximately 10% of home births will experience transfer to a hospital due to urgent and non-urgent reasons. Despite this, there are still no standardized guidelines for managing home birth transfers to hospital care which can lead to delays in receiving care. Additionally, there have been reports of significant opposition to home births among hospital-based clinicians (HBCs) which negatively impacts the birthing person’s experience with hospital births. 

Washington’s Smooth Transitions™ Quality Improvement Program aims to better understand the perceptions of birthing persons on transfers from planned community births to hospitals in order to identify barriers and areas of improvement. 

Methods: Smooth Transitions distributed an online mixed-methods survey to birthing persons upon discharge to capture lived experiences of home to hospital birth transfers in 17 Washington-based hospitals. Free response questions inquired about quality of care, overall birthing experience, and collaboration between the birthing care team. The data was coded for thematic content to identify best practices and potential areas of improvement.

Results: A total of 190 birthing persons completed the survey. 18% of these respondents felt that their personal preferences were not respected by the HBCs and 21% felt pushed into agreeing with care options. Birthing persons valued the HBCs respecting their autonomy, birth plan, and support team. Areas of improvement included shorter check-in times, allowing the community midwife to be present and more involved in care plans, and better patient education provided by the HBCs.

Conclusion: Birthing persons’ perceptions of transfers help us better understand opportunities for improving their experience with hospital births. Respondents self-reported various levels of disrespect, lack of autonomy, and inadequate informed consent by HBCs which were exacerbated by patient-provider disagreements around care plans. Further efforts need to be made to understand and reconcile the goals of care for HBCs, patients, and their support team. This will help to create a best practices guideline for these transfers and improve maternal and fetal health outcomes.

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Next from AMA Research Challenge 2023

Beyond the Margins: Examining the Impact of Socioeconomic Status on Skin Cancer Screening in Marginalized Communities