United States

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.

2023 AMA Research Challenge

Rethinking EMS in the Fight for Rural Health Equity

poster

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**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.

Patient Perceptions on Transfers from Planned Community Births to Hospital care in Washington State

Inappropriate Administration of Mitomycin in Cataract Patient

Background
This study describes the unintended intracameral administration of the chemotherapeutic agent mitomycin following a cataract extraction. The operating physician intended to use cefuroxime (antibiotic); however, mitomycin was used instead due to an intraoperative mishap, leading to permanent vision loss.

Case Presentation
An 83-year-old male seen in the clinic for an eye exam was found to have visually significant bilateral cataracts. Vision in the right eye (OD) was 20/80, and vision in the left eye (OS) was 20/70. He subsequently underwent technically uncomplicated cataract surgery in the right eye.

At postoperative visit one, vision was 20/250 OD, less than anticipated for unclear reasons. On subsequent visits, the patient was found to have worsening photophobia, increasing conjunctival inflammation, corneal edema, and an elevated intraocular pressure of 27mmHg. There was also worsening corneal edema and an exacerbation of intraocular inflammation. Given the variety and complexity of symptoms despite an otherwise uncomplicated surgery, an investigation was launched at the surgery center.

Discussion
The investigative report found the cause of the patient's postoperative symptoms to be unintentional intracameral mitomycin administration. In this case of mitomycin-induced ocular insult, the surgery center kept both chemotherapy drugs and antibiotics in refrigerators that were proximate to one another. The wrong medication had circulated through three different hands, eventually being injected into the patient's eye without knowledge. 

Since this event, the surgery center has moved the medication housing the chemotherapeutic agents to a different part of the building and added extensive colored labeling. Implementing a scanning system may have prevented this injury by prohibiting the nurse from withdrawing a particular medication if not ordered by the surgeon. There may also be reasons to evaluate the concurrence of fatigue associated with errors. Enforcing verbal repetition for orders may also help reduce the misadministration of medications.

In this case, a system failure led to the misadministration of the mitomycin. Rather than focusing on the inability to precisely diagnose chemotherapeutic agent toxicity, in a reactive analysis, there should be aims to promote a system where there is no error or the error is overtly obvious. This case serves to illustrate that instead of assigning human blame, system changes are necessary to reduce medical errors in order to give patients the care they deserve while minimizing risk to their health.

The Cataract Conundrum

Background:
Deciding when a patient is a candidate for Total Hip (THA) or Knee (TKA) Arthroplasty to treat arthritis is complex. Accordingly, shared decision-making (SDM) between patient and surgeon regarding candidacy for THA/TKA is considered best practice. However, successful SDM requires clear communication of specific symptoms, their individualized functional impact, and a mutual understanding of expectations. Understanding a patient’s perspective and where communication gaps may occur can improve this conversation. The OPTION (Objective Performance Threshold Indicating Operative Need) Survey was developed to guide SDM regarding readiness for THA/TKA. Survey results provide critical insights into this conversation: specifically, surgeon perception of the patient’s experience, how individual patient priorities differ in arthritis management, and how radiographic data align with patients’ symptoms. 
Methods:
The OPTION survey was created in partnership with a panel of 10 active THA/TKA patients and 10 arthroplasty surgeons using a modified Delphi methodology that employed three sequential meetings with each group. It interrogates patient-reported pain VAS, activity limitation, duration of treatment, prior treatments, quality of life (QOL), treatment priorities, patient readiness for surgery, and xray changes. As an IRB- approved pilot, OPTION criteria surveys were completed during 643 patient-surgeon encounters discussing TKA/THA candidacy at 15 clinical sites in the US. Each OPTION survey was independently and anonymously completed by the patient before the encounter and verified by the surgeon after the encounter. 
Results:
Within each domain, there was disagreement in patient and surgeon response in less than 10% of cases. With questions of pain VAS, activity limitation, and QOL, where surgeon and patient responses differed, the surgeon most often understated the patient’s reported subjective experience. Higher patient prioritization of pain relief, minimizing activity limitation, and avoiding medications directly correlated with readiness for surgery. Avoiding high cost was consistently the lowest patient priority across groups; cost prioritization dropped most substantially once QOL was impacted. Surgeon-graded radiographic joint space narrowing correlated with patient-reported QOL impact and readiness for surgery. While early joint space loss was seen with mild activity limitation and pain, a ceiling effect was evident with respect to joint space narrowing as pain and activity limitation increased. 
Conclusion:
- When patient and surgeon disagree, surgeons tend to underestimate the patient- reported experience of arthritis. 
- Patient priorities in arthritis treatment vary depending upon the individualized functional impact of various factors on their personal experience. 
- Radiographic joint space narrowing does not reflect the full picture of the patient experience with arthritis. 


Incorporating Patient Preferences into the Science of Shared Decision-Making for Discretionary Surgery: Understanding Surgeon and Patient Perspectives Regarding When it is Time for Elective Total Hip or Knee Replacement

Background: The impact of socioeconomic status (SES) on health outcomes is an increasingly important topic. Identifying which patients are more likely to present with advanced musculoskeletal pathology is a top priority. The Area Deprivation Index (ADI) ranks neighborhoods across the United States based on socioeconomic disadvantage. The Childhood Opportunity Index 2.0 (COI 2.0) measures community resources and ranks neighborhoods according to the social determinants of health. Our study aimed to determine the relationship between scoliosis curve magnitude at presentation and SES as measured by the ADI and COI 2.0.

Methods: We retrospectively identified 1,649 patients presenting for adolescent idiopathic scoliosis at a single academic center between June 27, 2018 and June 6, 2023. The patients were divided into a non-surgical and surgical cohort with 1,510 and 139 patients, respectively. Curve magnitude at initial presentation (Cobb angle), BMI, and address were recorded using the electronic health record. Patients’ addresses were used to determine their ADI and COI 2.0 scores. The information was assessed using univariate analysis.

Results: Patients in the surgical cohort were more likely to have a higher ADI National Percentile, higher ADI State Decile, higher BMI, and greater Cobb angle at presentation compared to the non-surgical cohort (p = <0.05). Within the surgical cohort, patients with a higher BMI were more likely to have a greater Cobb angle at initial presentation (p = <0.05). Within the non-surgical cohort, patients with a Cobb angle >45 were more likely to have a higher ADI State Decile and live in neighborhoods with a higher poverty rate compared to patients with a curve <45 (p = <0.05). Within the non-surgical cohort, patients with a Cobb angle >45 were more likely to live near hazardous waste dump sites compared to patients with a curve <45 (p = <0.05).

Conclusion: There are significant associations between SES and scoliosis curve magnitude at presentation. Patients that have undergone surgery are more likely to be socioeconomically disadvantaged at a state and national level, according to the ADI. Non-surgical patients with a greater amount of socioeconomic disadvantage at the state level, those who live in neighborhoods with higher poverty rates, and those with greater environmental pollutant exposure are more likely to present with a Cobb angle that exceeds bracing indications (>45). More work must be done on a state and national level to identify, treat, and educate socioeconomically disadvantaged patients before their curve magnitude exceeds non-operative management.

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Next from 2023 AMA Research Challenge

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