Trends of Academic Faculty Identifying as Hispanic at US Medical Schools, 1990-2021.

Background: According to recent census data, Hispanic and Latino populations comprise the largest minority group in the United States. Despite ongoing efforts for improved diversity, equity, and inclusion, Hispanics remain underrepresented in medicine (UIM). In addition to well-established benefits to patient care and health systems, physician diversity and increased representation in academic faculty positively impact the recruitment of trainees from UIM backgrounds. Disproportionate representation (as compared to increases of certain underrepresented groups in the US population) has direct implications for recruitment of UIM trainees to residency programs. Objective: To examine the number of full-time US medical school faculty physicians who self-identify as Hispanic in light of the increasing Hispanic population in the United States. Methods: We analyzed data from the Association of American Medical Colleges from 1990 to 2021, looking at those academic faculty who were classified as Hispanic, Latino, of Spanish Origin, or of Multiple Race-Hispanic. We used descriptive statistics and visualizations to illustrate the level of representation of Hispanic faculty by sex, rank, and clinical specialty over time. Results: Overall, the proportion of faculty studied who identified as Hispanic increased from 3.1% (1990) to 6.01% (2021). Moreover, while the proportion of female Hispanic academic faculty increased, there remains a lag between females versus males. Conclusions: Our analysis shows that the number of full-time US medical school faculty who self-identify as Hispanic has not increased, though the population of Hispanics in the United States has increased.

Into the Unknown: Characterizing Fellow Uncertainty During the Transition to Unsupervised Practice.

Background: Helping fellows confront and manage uncertainty in the course of diagnosis and treatment of patients has been a growing focus of medical education. How these same fellows confront uncertainty as they make a transition in their professional development is less commonly a focus of training programs. Better understanding of how fellows experience these transitions will allow fellows, training programs, and hiring institutions to navigate transitions more easily. Objective: This study aimed to explore how fellows in the United States experience uncertainty during the transition to unsupervised practice. Methods: Using constructivist grounded theory, we invited participants to engage in semi-structured interviews exploring experiences with uncertainty as they navigate the transition to unsupervised practice. Between September 2020 and March 2021, we interviewed 18 physicians in their final year of fellowship training from 2 large academic institutions. Participants were recruited from adult and pediatric subspecialties. Data analysis was conducted using an inductive coding approach. Results: Experiences with uncertainty during the transition process were individualized and dynamic. Primary sources of uncertainty identified included clinical competence, employment prospects, and career vision. Participants discussed multiple strategies for mitigating uncertainty, including structured graduated autonomy, leveraging professional networks locally and non-locally, and utilizing established program and institutional supports. Conclusions: Fellows' experiences with uncertainty during their transitions to unsupervised practice are individualized, contextual, and dynamic with several shared overarching themes.

Mentorship Programs in Residency: A Scoping Review.

Background: Mentorship during residency training is correlated with improved outcomes. Many residency programs have implemented formal mentorship programs; however, reported data for these programs have not been previously synthesized. Thus, existing programs may fall short on delivering effective mentorship. Objective: To synthesize current literature on formal mentorship programs in residency training in Canada and the United States, including program structure, outcomes, and evaluation. Methods: In December 2019, the authors performed a scoping review of the literature in Ovid MEDLINE and Embase. The search strategy included keywords relevant to mentorship and residency training. Eligibility criteria included any study describing a formal mentorship program for resident physicians within Canada or the United States. Data from each study were extracted in parallel by 2 team members and reconciled. Results: A total of 6567 articles were identified through the database search, and 55 studies met inclusion criteria and underwent data extraction and analysis. Though reported program characteristics were heterogenous, programs most commonly assigned a staff physician mentor to a resident mentee with meetings occurring every 3 to 6 months. The most common evaluation strategy was a satisfaction survey at a single time point. Few studies performed qualitative evaluations or used evaluation tools appropriate to the stated objectives. Analysis of data from qualitative studies allowed us to identify key barriers and facilitators for successful mentorship programs. Conclusions: While most programs did not utilize rigorous evaluation strategies, data from qualitative studies provided insights into barriers and facilitators of successful mentorship programs, which can inform program design and improvement.

Early vs Single Match in the Transition to Residency: Analysis Using NRMP Data From 2014 to 2021.

Background: An Early Result Acceptance Program (ERAP) has been proposed for obstetrics and gynecology (OB/GYN) to address challenges in the transition to residency. However, there are no available data-driven analyses on the effects of ERAP on the residency transition. Objective: We used National Resident Matching Program (NRMP) data to simulate the outcomes of ERAP and compare those to what occurred in the Match historically. Methods: We simulated ERAP outcomes in OB/GYN, using the de-identified applicant and program rank order lists from 2014 to 2021, and compared them to the actual NRMP Match outcomes. We report outcomes and sensitivity analyses and consider likely behavioral adaptations. Results: Fourteen percent of applicants receive a less preferred match under ERAP, while only 8% of applicants receive a more preferred match. Less preferred matches disproportionately affect DOs and international medical graduates (IMGs) compared to US MD seniors. Forty-one percent of programs fill with more preferred sets of applicants, while 24% fill with less preferred sets of applicants. Twelve percent of applicants and 52% of programs are in mutually dissatisfied applicant-program pairs (a pair in which both prefer each other to the match each received). Seventy percent of applicants who receive less preferred matches are part of a mutually dissatisfied pair. In 75% of programs with more preferred outcomes, at least one assigned applicant is part of a mutually dissatisfied pair. Conclusions: In this simulation, ERAP fills most OB/GYN positions, but many applicants and programs receive less preferred matches, and disparities increase for DOs and IMGs. ERAP creates mutually dissatisfied applicant-program pairs and problems for mixed-specialty couples, which provides incentives for gamesmanship.

Campylobacter hepaticus in the Production Environment and Stagnant Water as a Potential Source of C. hepaticus Causing Spotty Liver Disease in Free-Range Laying Hens in Georgia, United States.

Spotty liver disease (SLD) has emerged as an important cause of disease in egg-producing flocks in countries such as the United Kingdom and Australia and has emerged in the United States. The organisms implicated in SLD include Campylobacter hepaticus and, more recently, Campylobacter bilis. These organisms have been found to cause focal lesions on the livers of infected birds. Campylobacter hepaticus infection results in reduced egg production, decreased feed consumption resulting in reduced egg size, and increased mortality of highly valuable hens. In the fall of 2021, birds from two flocks (A and B) of organic pasture-raised laying hens were submitted to the Poultry Diagnostic Research Center at the University of Georgia with a history suspicious of SLD. Postmortem examination of Flock A found 5/6 hens had small multifocal lesions on the liver and were PCR positive for C. hepaticus from pooled swab analysis of samples of the liver and gall bladder. Necropsy of Flock B found 6/7 submitted birds had spotty liver lesions. In pooled bile swabs, 2/7 hens from Flock B were also PCR positive for C. hepaticus. A follow-up visit to Flock A was scheduled 5 days later, as well as a visit to a flock where SLD has not been reported (Flock C), which was used as a comparative control. Samples of the liver, spleen, cecal tonsil, ceca, blood, and gall bladder were collected from six hens per house. Additionally, feed, water nipples, and environmental water (stagnant water outside the house) were collected from the affected farm and the control farm. To detect the organism, all samples collected were subjected to direct plating on blood agar and enrichment in Preston broth with incubation under microaerophilic conditions. After multiple phases of bacterial culture purification from all samples, single bacterial cultures displaying characteristics of C. hepaticus were tested by PCR to confirm identity. From Flock A, liver, ceca, cecal tonsils, gall bladder, and environmental water were PCR positive for C. hepaticus. No positive samples were detected in Flock C. After another follow-up visit, 10 wk later, Flock A was PCR positive for C. hepaticus from gall bladder bile and feces and one environmental water sample displayed a weak positive reaction for C. hepaticus. Flock C was PCR negative for C. hepaticus. To gain more knowledge about C. hepaticus prevalence, a survey of 6 layer hens from 12 different layer hen flocks between the ages of 7 to 80 wk, raised in different housing systems, were tested for C. hepaticus. The 12 layer hen flocks were culture and PCR negative for C. hepaticus. Currently, there are no approved treatments for C. hepaticus and no vaccine is available. The results of this study suggest that C. hepaticus may be endemic in some areas of the United States, and free-range laying hens may be exposed from the environment/stagnant water in areas where they range.

Campylobacter hepaticus en el ambiente de producción avícola y en el agua estancada como fuente potencial de C. hepaticus que causante de la necrosis hepática focal en gallinas ponedoras de corral en Georgia, Estados Unidos. La necrosis hepática focal (SLD, por sus siglas en inglés) se ha convertido en una causa importante de enfermedad en las parvadas productoras de huevo en países como el Reino Unido y Australia y también ha surgido en los Estados Unidos. Los organismos implicados en necrosis hepática focal incluyen Campylobacter hepaticus y, más recientemente, Campylobacter bilis. Se ha encontrado que estos organismos causan lesiones focales en el hígado de las aves infectadas. La infección por C. hepaticus da como resultado una reducción en la producción de huevos, una disminución en el consumo de alimento, lo que resulta en una reducción del tamaño de los huevos y una mayor mortalidad de gallinas de alto valor económico. En el otoño del 2021, aves de dos lotes (A y B) de gallinas de postura criadas en pastos orgánicos se enviaron al Centro de Diagnóstico e Investigación Avícolas de la Universidad de Georgia con antecedentes sospechosos de necrosis hepática focal. En el examen post mortem de la parvada A se encontró que cinco de un total de seis gallinas tenían pequeñas lesiones multifocales en el hígado y fueron positivas mediante PCR para C. hepaticus a partir de un análisis de hisopos combinados de muestras del hígado y de la vesícula biliar. La necropsia de la parvada B encontró que seis de un total de siete aves enviadas tenían lesiones hepáticas irregulares. En muestras agrupadas de bilis, dos de un total de siete gallinas de la parvada B también fueron positivas a C. hepaticus por PCR. Se programó una visita de seguimiento a la Parvada A cinco días después, así como una visita a una parvada en la que no se había reportado la presencia de necrosis hepática focal (Parvada C), que se utilizó como control para propósitos de comparación. Se recolectaron muestras de hígado, bazo, tonsilas cecales, sacos ciegos, sangre y vesícula biliar de seis gallinas por gallinero. Además, se recolectó alimento, muestras de agua de bebederos de niple y agua ambiental (agua estancada fuera de la casa) de la granja afectada y la granja de control. Para detectar el organismo, todas las muestras recolectadas se sometieron a siembra directa en agar sangre y enriquecimiento en caldo Preston con incubación en condiciones microaerófilas. Después de varias fases de purificación del cultivo bacteriano de todas las muestras, se analizaron mediante PCR los cultivos bacterianos individuales que mostraban características de C. hepaticus para confirmar la identidad. De la parvada A, el hígado, el ciego, las tonsilas cecales, la vesícula biliar y el agua ambiental dieron positivo por PCR para C. hepaticus. No se detectaron muestras positivas en la parvada C. Después una segunda visita de seguimiento, 10 semanas después, la parvada A mostró resultado positivo por PCR para C. hepaticus en la bilis de la vesícula biliar y en las heces, y una muestra de agua ambiental mostró una reacción positiva débil para C. hepaticus . La parvada C resultó negativa mediante PCR para C. hepaticus. Para obtener más conocimiento sobre la prevalencia de C. hepaticus, se realizó un muestreo incluyendo seis gallinas de postura de 12 lotes diferentes de gallinas ponedoras entre las edades de 7 a 80 semanas, criadas en diferentes sistemas de alojamiento, para detectar C. hepaticus. Las doce parvadas de gallinas de postura fueron negativas por cultivo y mediante PCR para C. hepaticus. Actualmente, no hay tratamientos aprobados para C. hepaticus y no hay vacuna disponible. Los resultados de este estudio sugieren que C. hepaticus puede ser endémico en algunas áreas de los Estados Unidos, y las gallinas de postura bajo pastoreo pueden estar expuestas al medio ambiente o al agua estancada en las áreas donde están alojadas.

Unmet needs in uncomplicated urinary tract infection in the United States and Germany: a physician survey.

BACKGROUND: Uncomplicated urinary tract infections (uUTIs/acute cystitis) are among the most common infections in women worldwide. There are differences in uUTI treatment guidelines between countries and understanding the needs of physicians in diverse healthcare systems is important for developing new treatments. We performed a survey of physicians in the United States (US) and Germany to understand their perceptions of, and management approaches to uUTI. METHODS: This was a cross-sectional online survey of physicians in the US and Germany who were actively treating patients with uUTI (≥ 10 patients/month). Physicians were recruited via a specialist panel and the survey was piloted with 2 physicians (1 US, 1 Germany) prior to study commencement. Data were analyzed with descriptive statistics. RESULTS: A total of 300 physicians were surveyed (n = 200 US, n = 100 Germany). Across countries and specialties, physicians estimated 16-43% of patients did not receive complete relief from initial therapy and 33-37% had recurrent infections. Urine culture and susceptibility testing was more common in the US and among urologists. The most commonly selected first-line therapy was trimethoprim-sulfamethoxazole in the US (76%) and fosfomycin in Germany (61%). Ciprofloxacin was the most selected following multiple treatment failures (51% US, 45% Germany). Overall, 35% of US and 45% of German physicians agreed with the statement "I feel there is a good selection of treatment options" and ≥ 50% felt that current treatments provided good symptom relief. More than 90% of physicians included symptom relief amongst their top 3 treatment goals. The overall impact of symptoms on patients' lives was rated "a great deal" by 51% of US and 38% of German physicians, increasing with each treatment failure. Most physicians (> 80%) agreed that antimicrobial resistance (AMR) is serious, but fewer (56% US, 46% Germany) had a high level of confidence in their knowledge of AMR. CONCLUSIONS: Treatment goals for uUTI were similar in the US and Germany, although with nuances to disease management approaches. Physicians recognized that treatment failures have a significant impact on patients' lives and that AMR is a serious problem, though many did not have confidence in their own knowledge of AMR.

Use telehealth as needed: telehealth substitutes in-person primary care and associates with the changes in unplanned events and follow-up visits.

BACKGROUND: Telehealth rapidly expanded since the outbreak of the COVID-19 pandemic. This study aims to understand how telehealth can substitute in-person services by 1) estimating the changes in non-COVID emergency department (ED) visits, hospitalizations, and care costs among US Medicare beneficiaries by visit modality (telehealth vs. in-person) during the COVID-19 pandemic relative to the previous year; 2) comparing the follow-up time and patterns between telehealth and in-person care. METHODS: A retrospective and longitudinal study design using US Medicare patients 65 years or older from an Accountable Care Organization (ACO). The study period was April-December 2020, and the baseline period was March 2019 - February 2020. The sample included 16,222 patients, 338,872 patient-month records and 134,375 outpatient encounters. Patients were categorized as non-users, telehealth only, in-person care only and users of both types. Outcomes included the number of unplanned events and costs per month at the patient level; number of days until the next visit and whether the next visit happened within 3-, 7-, 14- and 30-days at the encounter level. All analyses were adjusted for patient characteristics and seasonal trends. RESULTS: Beneficiaries who used only telehealth or in-person care had comparable baseline health conditions but were healthier than those who used both types of services. During the study period, the telehealth only group had significantly fewer ED visits/hospitalizations and lower Medicare payments than the baseline (ED 13.2, 95% CI [11.6, 14.7] vs. 24.6 per 1,000 patients per month and hospitalization 8.1 [6.7, 9.4] vs. 12.7); the in-person only group had significantly fewer ED visits (21.9 [20.3, 23.5] vs. 26.1) and lower Medicare payments, but not hospitalizations; the both-types group had significantly more hospitalizations (23.0 [21.4, 24.6] vs. 17.8). Telehealth was not significantly different from in-person encounters in number of days until the next visit (33.4 vs. 31.2 days) or the probabilities of 3- and 7-day follow-up visits (9.2 vs. 9.3% and 21.8 vs.23.5%). CONCLUSIONS: Patients and providers treated telehealth and in-person visits as substitutes and used either depending on medical needs and availability. Telehealth did not lead to sooner or more follow-up visits than in-person services.

AIDS Drug Assistance Program disenrollment is associated with loss of viral suppression beyond differences in homelessness, mental health, and substance use disorders: An evaluation in Washington state 2017-2019.

AIDS Drug Assistance Programs (ADAPs) are state-administered programs that pay for medical care for people living with HIV in the US. Maintaining enrollment in the programs is challenging, and a large proportion of clients in Washington state (WA) fail to recertify and are disenrolled. In this study we sought to quantify the impact of disenrollment from ADAPs on viral suppression. We conducted a retrospective cohort study of the 5238 clients in WA ADAP from 2017 to 2019 and estimated the risk difference (RD) of viral suppression before and after disenrollment. We performed a quantitative bias analysis (QBA) to assess the effect of unmeasured confounders, as the factors that contribute to disenrollment and medication discontinuation may overlap. Of the 1336 ADAP clients who disenrolled ≥1 time, 83% were virally suppressed before disenrollment versus 69% after (RD 12%, 95%CI 9-15%). The RD was highest among clients with dual Medicaid-Medicare insurance (RD 22%, 95%CI 9-35%) and lowest among privately insured individuals (RD 8%, 95%CI 5-12%). The results of the QBA suggest that unmeasured confounders do not negate the overall RD. The ADAP recertification procedures negatively impact the care of clients who struggle to stay in the program; alternative procedures may reduce this impact.

Safety guidelines for youth agricultural work in the United States: A description of the development and updating process.

To reduce the prevalence of youth injuries and fatalities in agricultural settings, safety professionals considered developing a guideline-focused intervention for how and when youth should conduct farm chores. In 1996, the process to create guidelines started, which then expanded to include professionals from the United States, Canada, and Mexico. This team used a consensus driven approach to develop the guidelines and launch the North American Guidelines for Children's Agricultural Tasks. By 2015, research related to the published guidelines indicated a need to incorporate new empirical evidence and develop dissemination plans based on new technologies. The process for updating the guidelines was supported by a 16-person steering committee and used content experts and technical advisors. The process yielded updated and new guidelines, now called Agricultural Youth Work Guidelines. This report responds to request for further details on the development and update of the guidelines and describes the genesis of the guidelines as an intervention, the process for creating guidelines, recognition of the need to update guidelines based on research, and the process for updating guidelines to assist in others engaged in similar types of interventions.

Disparities in spatial accessibility of primary care in Louisiana: From physical to virtual accessibility.

Telehealth has been widely employed and has transformed how healthcare is delivered in the United States as a result of COVID-19 pandemic. While telehealth is utilized and encouraged to reduce the cost and travel burden for access to healthcare, there are debates on whether telehealth can promote equity in healthcare services by narrowing the gap among diverse groups. Using the Two-Step Floating Catchment Area (2SFCA) and Two-Step Virtual Catchment Area (2SVCA) methods, this study compares the disparities of physical and virtual access to primary care physicians (PCPs) in Louisiana. Both physical and virtual access to PCPs exhibit similar spatial patterns with higher scores concentrated in urban areas, followed by low-density and rural areas. However, the two accessibility measures diverge where broadband availability and affordability come to play an important role. Residents in rural areas experience additive disadvantage of even more limited telehealth accessibility than physical accessibility due to lack of broadband service provision. Areas with greater Black population proportions tend to have better physical accessibility, but such an advantage is eradicated for telehealth accessibility because of lower broadband subscription rates in these neighborhoods. Both physical and virtual accessibility scores decline in neighborhoods with higher Area Deprivation Index (ADI) values, and the disparity is further widened for in virtual accessibility compared to than physical accessibility. The study also examines how factors such as urbanicity, Black population proportion, and ADI interact in their effects on disparities of the two accessibility measures.

Standardizing Child Passenger Safety Screening in the Emergency Department: A Quality Improvement Study.

BACKGROUND: Motor vehicle collisions remain a leading cause of death and injury in children in the United States. Our Level I trauma center found that 53% of children ages 1-19 years are improperly restrained or unrestrained. Our center employs a Pediatric Injury Prevention Coalition with nationally certified child passenger safety technicians who are active in the community yet remain underutilized in the clinical setting. OBJECTIVE: The purpose of the quality improvement project was to standardize child passenger safety screening in the emergency department to increase referrals to a Pediatric Injury Prevention Coalition. METHODS: This quality improvement project utilized a pre-/postdesign of data collected before and after implementing the child passenger safety bundle. Using the Plan-Do-Study-Act model, organizational change processes were identified, and quality improvement interventions implemented from March to May 2022. RESULTS: The total number of families referred was 199, representing 230 children, which was 3.8% of the eligible population. A significant relationship was found between child passenger safety screening and referral to the Pediatric Injury Prevention Coalition in 2019 and 2021, χ2 (1, n = 230) = 239.98, p < .001, and χ2 (1, n = 230) = 240.78, p < .001, respectively. Forty-one percent of the referred families established contact with the Pediatric Injury Prevention Coalition. CONCLUSION: Standardizing child passenger safety screening in the emergency department increased referrals to a Pediatric Injury Prevention Coalition and resulted in improved child safety seat distribution and child passenger safety education.

Disparities associated with Medicare Part D Star Ratings measures among patients with Alzheimer's disease and related dementias.

The Medicare Parts C and D Star Ratings system was established to improve care quality in Medicare. Previous studies reported racial/ethnic disparities in the calculation of medication adherence measures of Star Ratings in patients with diabetes, hypertension, and hyperlipidemia. This study aimed to identify possible racial/ethnic disparities in the calculation of adherence measures of Medicare Part D Star Ratings among patients with Alzheimer's disease and related dementias (ADRD) and diabetes, hypertension, or hyperlipidemia. This retrospective study analyzed the 2017 Medicare data and Area Health Resources Files. Non-Hispanic White (White) patients were compared to Black, Hispanic, Asian/Pacific Islander (Asian), and other patients on their likelihood of being included in the calculation of adherence measures for diabetes, hypertension, and/or hyperlipidemia. To adjust for the individual/community characteristics, logistic regression was used when the outcome is the inclusion in the calculation of one adherence measure; multinomial regression was used when examining the inclusion in the calculation of multiple adherence measures. Analyzing the data of 1438,076 Medicare beneficiaries with ADRD, this study found that Black (adjusted odds ratio, or OR = 0.79, 95% confidence interval, or 95% CI = 0.73-0.84) and Hispanic (OR = 0.82, 95% CI = 0.75-0.89) patients were less likely than White patients to be included in the calculation of adherence measure for diabetes medications. Further, Black patients were less likely to be included in the calculation of the adherence measure for hypertension medications than White patients (OR = 0.81, 95% CI = 0.78-0.84). All minorities were less likely to be included in calculating the adherence measure for hyperlipidemia medications than Whites. The ORs for Black, Hispanic, and Asian patients were 0.57 (95% CI = 0.55-0.58), 0.69 (95% CI = 0.64-0.74), and 0.83 (95% CI = 0.76-0.91), respectively. Minority patients were generally likely to be included in the measure calculation of fewer measures than White patients. Racial/ethnic disparities were observed in the calculation of Star Ratings measures among patients with ADRD and diabetes, hypertension, and/or hyperlipidemia. Future studies should explore possible causes of and solutions to these disparities.

Predictors of opioid prescription among outpatients with osteoarthritis in the United States.

BACKGROUND: Osteoarthritis (OA) management targets pain reduction through multimodal strategies to improve functional status. Among pharmaceutical options, opioids have been selected as a treatment option for pain management, without endorsement by evidence-based guidelines. OBJECTIVE: To examine the predictors of opioid prescriptions for OA during outpatient visits in the United States (US). DESIGN: This study was based on the National Ambulatory Medical Care Survey (NAMCS) database (2012-2016), with a retrospective, cross-sectional study design of US adult outpatient visits with OA. The primary outcome was opioid prescription, and socio-demographic and clinical characteristics were independent variables. Weighted descriptive, bivariate, and multivariable logistic regression analyses were utilized to study patient characteristics and to assess the predictors of opioid prescription. RESULTS: Approximately, 51.68 million (95 percent CI = 44.41-58.95 million) OA-related outpatient visits were made between 2012 and 2016. Most patients were established patients (82.32 percent), and 20.58 percent of the visits resulted in opioid prescriptions. Key prescriptions within the opioid analgesic and combination categories were tramadol-based (5.16 percent) and hydrocodone-based (9.10 percent). Patients who paid through Medicaid were three times more likely (aOR = 3.25, 95 percent CI = 1.60-6.61, p = 0.0012) than those who paid through private insurance to receive an opioid prescrip-tion, new patients were 59 percent less likely (aOR = 0.41, 95 percent CI = 0.24-0.68, p = 0.0007) to receive an opioid prescription as compared to established patients, and obese patients were twice as likely (aOR = 1.88, 95 percent CI = 1.11-3.20, p = 0.0199) than nonobese patients to receive an opioid prescription. CONCLUSIONS: Payment source, obesity, and patient visit status were associated with the receipt of an opioid prescription among OA outpatients. Further research is needed to establish intrinsic factors that drive opioid prescription in this population.

Pharmacists' perspectives on opioid stewardship challenges.

OBJECTIVE: Pharmacists are in a distinctive position to champion opioid stewardship principles in communications with prescribers and patients. This effort is focused on elucidating perceived barriers to uphold these principles observed in pharmacy practice. DESIGN: Qualitative research study. SETTING: A healthcare system, consisting of inpatient and outpatient settings across several United States (US) states in both rural and academic settings. PARTICIPANTS: Twenty-six pharmacists who represented the study setting in the sole healthcare system. INTERVENTIONS: Five virtual focus groups were conducted with the 26 pharmacists from inpatient and outpatient settings across four states in both rural and academic settings. Trained moderators conducted 1-hour focus group meetings that consisted of a mix of poll and discussion questions. MAIN OUTCOME MEASURE: Participant questions were related to awareness, knowledge, and system issues affecting opioid stewardship. RESULTS: All pharmacists reported their routine follow-up with prescribers when questions or concerns arise but noted workload as a barrier to meticulous review of opioid prescriptions. Participants highlighted best practices, including transparency on the rationale for guideline exceptions to improve the management of after-hours concerns. Suggestions were integration of guidelines into prescriber and pharmacist order review workflows and a more visible prescriber review of prescription drug monitoring programs. CONCLUSIONS: Improvements in communication and transparency of information related to opioid prescribing between pharmacists and prescribers would enhance opioid stewardship. Integration of opioid guidelines into opioid ordering and review would improve efficiency, guideline adherence, and, most importantly, patient care.

Tramadol utilization among patients with higher risk of adverse drug events: A claims analysis of commercially insured and Medicare Advantage members.

OBJECTIVE: To assess prescribing of tramadol among patients with contraindications and higher risks of adverse events in a large population of commercially insured and Medicare Advantage members. DESIGN: We performed a cross-sectional analysis evaluating tramadol utilization in patients with higher risk of adverse outcomes. SETTING: This study utilized 2016-2017 data from the Optum Clinformatics Data Mart. PATIENTS AND PARTICIPANTS: Patients with at least one tramadol prescription without a cancer or sickle cell diagnosis during the study period. MAIN OUTCOME MEASURES: We first determined if tramadol was prescribed among patients with contraindications or risk factors for adverse outcomes. We then determined if patient demographic or clinical factors were associated with the use of tramadol in these higher-risk scenarios using multivariable logistic regression models. RESULTS: Among patients with at least one prescription for tramadol, 19.66 percent (99 percent CI: 19.57-19.75) concurrently received an interacting cytochrome P450 isoenzyme medication, 19.24 percent (99 percent CI: 19.15-19.33) concurrently received a serotonergic medication, and 7.93 percent (99 percent CI: 7.88-8.00) concurrently received a benzodiazepine. Additionally, 1.59 percent (99 percent CI: 1.56-1.61) of patients who received tramadol also had a seizure disorder, while 0.55 percent (99 percent CI: 0.53-0.56) of patients were under the age of 18. Overall, nearly one in three patients (31.17 percent) received tramadol in the presence of at least one of these risks (99 percent CI: 31.06-31.27). CONCLUSION: Almost one in three patients prescribed tramadol had a clinically significant drug interaction or contraindication for use, suggesting that prescribers often disregard these concerns. Real-world studies are needed to better understand the likelihood of harms associated with the use of tramadol in these contexts.

Association between age at menarche and risk of myopia in the United States: NHANES 1999-2008.

We evaluate the effect of menarche on myopia in women in the United States (US). A cross-sectional survey and examination were conducted using data from the 1999-2008 US National Health and Nutrition Examination Survey (NHANES), and 8,706 women aged ≥20 years (95% confidence interval [CI], 44.23 to 45.37) were enrolled. Characteristics were compared between nonmyopic and myopic participants. Univariable and multivariable logistic regression analysis was performed to evaluate the risk factors for myopia. A minimum p-value approach was used to estimate the cut-off point for age at menarche. The prevalence of myopia was 32.96%. Mean spherical equivalent (SE) were -0.81 diopters (95% CI, -0.89 to -0.73) and the mean age of menarche was 12.67 years (95% CI, 12.62 to 12.72). In the crude logistic regression model, age (odd ratio [OR] 0.98), height (OR, 1.02), astigmatism (OR, 1.57) (all p < 0.0001), age at menarche (OR, 0.95; p = 0.0005), white ethnicity, being born in the US, higher level of education, and higher annual household income (all p trend <0.0001) were significantly associated with myopia. 1-year increments in age at menarche was associated with a 4% decrease in the risk of myopia after adjusting for age, height, body mass index (BMI), ethnicity, and astigmatism (OR, 0.96; 95% CI, 0.93 to 0.99, p = 0.0288). The cut-off value for age at menarche was 15 years by the maximum chi-square test (p < 0.0001). Age at menarche may attribute to myopia progression, along with other environmental and individual risk factors.