The Rapid Evaluation of COVID-19 Vaccination in Emergency Departments for Underserved Patients Study.

STUDY OBJECTIVE: Emergency departments (EDs) often serve vulnerable populations who may lack primary care and have suffered disproportionate COVID-19 pandemic effects. Comparing patients having and lacking a regular source of medical care and other ED patient characteristics, we assessed COVID-19 vaccine hesitancy, reasons for not wanting the vaccine, perceived access to vaccine sites, and willingness to get the vaccine as part of ED care. METHODS: This was a cross-sectional survey conducted from December 10, 2020, to March 7, 2021, at 15 safety net US EDs. Primary outcomes were COVID-19 vaccine hesitancy, reasons for vaccine hesitancy, and sites (including EDs) for potential COVID-19 vaccine receipt. RESULTS: Of 2,575 patients approached, 2,301 (89.4%) participated. Of the 18.4% of respondents who lacked a regular source of medical care, 65% used the ED as their usual source of health care. The overall rate of vaccine hesitancy was 39%; the range among the 15 sites was 28% to 58%. Respondents who lacked a regular source of medical care were more commonly vaccine hesitant than those who had a regular source of medical care (47% versus 38%, 9% difference, 95% confidence interval 4% to 14%). Other characteristics associated with greater vaccine hesitancy were younger age, female sex, Black race, Latinx ethnicity, and not having received an influenza vaccine in the past 5 years. Of the 61% who would accept a COVID-19 vaccine, 21% stated that they lacked a primary physician or clinic at which to receive it; the vast majority (95%) of these respondents would accept the COVID-19 vaccine as part of their care in the ED. CONCLUSION: ED patients who lack a regular source of medical care are particularly hesitant regarding COVID-19 vaccination. Most COVID-19 vaccine acceptors would accept it as part of their care in the ED. EDs may play pivotal roles in COVID-19 vaccine messaging and delivery to highly vulnerable populations.

Changes in Health and Ability to Work Among Medicaid Expansion Enrollees: a Mixed Methods Study.

BACKGROUND: Michigan expanded Medicaid under the Affordable Care Act (Healthy Michigan Plan [HMP]) to improve the health of low-income residents and the state's economy. OBJECTIVE: To understand HMP's impact on enrollees' health, ability to work, and ability to seek employment DESIGN: Mixed methods study, including 67 qualitative interviews and 4090 computer-assisted telephone surveys (response rate 53.7%) PARTICIPANTS: Non-elderly adult HMP enrollees MAIN MEASURES: Changes in health status, ability to work, and ability to seek employment KEY RESULTS: Half (47.8%) of respondents reported better physical health, 38.2% better mental health, and 39.5% better dental health since HMP enrollment. Among employed respondents, 69.4% reported HMP helped them do a better job at work. Among out-of-work respondents, 54.5% agreed HMP made them better able to look for a job. Among respondents who changed jobs, 36.9% agreed HMP helped them get a better job. In adjusted analyses, improved health was associated with the ability to do a better job at work (aOR 4.08, 95% CI 3.11-5.35, p < 0.001), seek a job (aOR 2.82, 95% CI 1.93-4.10, p < 0.001), and get a better job (aOR 3.20, 95% CI 1.69-6.09, p < 0.001), but not with employment status (aOR 1.08, 95% CI 0.89-1.30, p = 0.44). In interviews, several HMP enrollees attributed their ability to get or maintain employment to improved physical, mental, and dental health because of services covered by HMP. Remaining barriers to work cited by enrollees included older age, disability, illness, and caregiving responsibilities. CONCLUSIONS: Many low-income HMP enrollees reported improved health, ability to work, and job seeking after obtaining health insurance through Medicaid expansion.

Primary Care Clinicians' Views About the Impact of Medicaid Expansion in Michigan: A Mixed Methods Study.

BACKGROUND: Michigan's approach to Medicaid expansion, the Healthy Michigan Plan (HMP), emphasizes primary care, prevention, and incentives for patients and primary care practitioners (PCPs). OBJECTIVE: Assess PCPs' perspectives about the impact of HMP on their patients and practices. DESIGN: In 2014-2015, we conducted semi-structured interviews then a statewide survey of PCPs. SETTING: Interviewees came from varied types of practices in five Michigan regions selected for racial/ethnic diversity and a mix of rural and urban settings. Surveys were sent via mail. PARTICIPANTS: Interviewees were physician (n = 16) and non-physician practitioners (n = 3). All Michigan PCPs caring for ≥ 12 HMP enrollees were surveyed (response rate 55.5%, N = 2104). MEASUREMENTS: PCPs' experiences with HMP patients and recent changes in their practices. RESULTS: Interviews include examples of the impact of Medicaid expansion on patients and practices. A majority of surveyed PCPs reported recent increases in new patients (52.3%) and patients who had not seen a PCP in many years (56.2%). For previously uninsured patients, PCPs reported positive impact on control of chronic conditions (74.4%), early detection of serious illness (71.1%), medication adherence (69.1%), health behaviors (56.5%), emotional well-being (57.0%), and the ability to work, attend school, or live independently (41.5%). HMP patients reportedly still had more difficulty than privately insured patients accessing some services. Most PCPs reported that their practices had, in the past year, hired clinicians (53.2%) and/or staff (57.5%); 15.4% had colocated mental health care. Few (15.8%) reported established patients' access to urgent appointments worsened. LIMITATIONS: PCP reports of patient experiences may not be accurate. Results reflect the experiences of PCPs with ≥ 12 Medicaid patients. Differences between respondents and non-respondents present the possibility for response bias. CONCLUSIONS: PCPs reported improved patient access to care, medication adherence, chronic condition management, and detection of serious illness. Established patients' access did not diminish, perhaps due to reported practice changes.

A systematic review of Federal Drug Administration Docket for community consultation and public disclosure in exception from informed consent trials.

BACKGROUND: Exception from informed consent imposes community consultation and public disclosure requirements on clinical investigation in critically ill and injured patients. In 2011, the Food and Drug Administration instructed sponsors to submit publically disclosed information to the Food and Drug Administration Docket, but to date there has been no comprehensive analysis of available data. We summarized the community consultation and public disclosure practices of exception from informed consent trials published on the Food and Drug Administration Docket in order to better understand the breadth of common practices that exists among acute care clinical research. METHODS: We performed quantitative and qualitative analysis of Docket FDA-1995-S-0036 from its initiation until June 2017 in order to summarize existing practices. We developed a 4-point scoring system to categorize public disclosure and community consultation based on inclusion of key components such as a detailed plan, schedule of events conducted, results, and materials uploaded. RESULTS: The 177 docket submissions represented 34 trials. Material related to public disclosure accounted for 49% of pages, community consultation 45%, and 6% other. The median Docket Review Content Score for public disclosure was 3 (mean: 2.5, range: 0-4) and 2 (mean: 2.1, range: 0-4) for community consultation materials. CONCLUSION: The public information contained in the Docket varies broadly by trial and content. Additionally, as evidenced by the wide range of the Docket Review Content Score, submission guidelines are not followed uniformly. Given the apparent uncertainty about what should be submitted, and the need for best practice recommendations, it is valuable to categorize and summarize existing community consultation and public disclosure content.

Value of Near-Peer Mentorship from Protégé and Mentor Perspectives: A Strategy to Increase Physician Workforce Diversity.

PURPOSE: Mentorship is a critical aspect of personal and professional development in academic medicine and helps to improve career satisfaction, productivity, and social networking. However, individuals from communities underrepresented in medicine (URiM) across the training continuum experience difficulty obtaining mentors, even prior to college. The value of near-peer mentorship is less well studied in medicine relative to other fields. The purpose of this mixed methods study is to explore the mentorship experiences of high school student protégés and their medical student mentors, as well as provide a description of the key features of the Doctors of Tomorrow (DOT) program. METHODS: From November 2014 to September 2015, the authors used focus groups and critical incident narratives with 9th grade high school students as well as focus groups and semi-structured interviews with medical students to examine mentor-protégé experiences in the Doctors of Tomorrow (DOT) program. In 2016, thirty-one medical student mentors were asked to complete an online survey about their mentor experiences. Focus group and interview data were audio-recorded and transcribed verbatim. All data were coded using thematic analysis and recurring codes were organized into categories, then compared, scrutinized and arranged into broader themes by all authors. RESULTS: The analysis of data from 70 medical students and 52 high school students revealed that mentors and protégés valued their mentor relationships based on regular in-person and electronic contact, shared common non-academic interests, and the anticipated prolonged nature of the relationship. Mentors also reported they initiated contact with their protégés every 2-3 weeks and monthly outside of program events, with email communication as the most common modality. CONCLUSIONS: Near-peer relationships between high school and medical students may be an innovative strategy to promote health care careers, increase access to mentorship and develop meaningful mentorship relationships for URiM high school students.

Emergency department hospitalization volume and mortality in the United States.

STUDY OBJECTIVE: Although numerous studies have demonstrated a relationship between higher volume and improved outcomes in the delivery of health services, it has not been extensively explored in the emergency department (ED) setting. Therefore, we seek to examine the association between ED hospitalization volume and mortality for common high-risk conditions. METHODS: Using data from the Nationwide Inpatient Sample, a national sample of hospital discharges, we evaluated mortality overall and for 8 different diagnoses between 2005 and 2009 (total admissions 17.55 million). These conditions were chosen because they are frequent (in the top 25 of all ED hospitalizations) and high risk (> 3% observed mortality). EDs were excluded from analysis if they did not have at least 1,000 total annual admissions and 30 disease-specific cases. EDs were then placed into quintiles based on hospitalized volume. Regression techniques were used to describe the relationship between volume (number of hospitalized ED patients per year) and both subsequent early inpatient mortality (within 2 days of admission) and overall mortality, adjusted for patient and hospital characteristics. RESULTS: Mortality decreased as volume increased overall and for all diagnoses, but the relative importance of volume varied, depending on the condition. Absolute differences in adjusted mortality rates between very high-volume EDs and very low-volume EDs ranged from -5.6% for sepsis (95% confidence interval [CI] -6.5% to -4.7%) to -0.2% for pneumonia (95% CI -0.6% to 0.1%). Overall, this difference was -0.4% (95% CI -0.6% to -0.3%). A similar pattern was observed when early hospital deaths were evaluated. CONCLUSION: Patients have a lower likelihood of inhospital death if admitted through high-volume EDs.

Institutional Review Boards' Assessment of Local Context: A Mixed Methods Study.

The nature of the review of local context by institutional review boards (IRBs) is vague. Requirements for single IRB review of multicenter trials create a need to better understand interpretation and implementation of local-context review and how to best implement such reviews centrally. We sought a pragmatic understanding of IRB local-context review by exploring stakeholders' attitudes and perceptions. Semistructured interviews with 26 IRB members and staff members, institutional officials, and investigators were integrated with 80 surveys of similar stakeholders and analyzed with qualitative theme-based text analysis and descriptive statistical analysis. Stakeholders described what they considered to be local context, the value of local-context review, and key processes used to implement review of local context in general and for emergency research conducted with an exception from informed consent. Concerns and potential advantages of centralized review of local context were expressed. Variability in perspectives suggests that local-context review is not a discrete process, which presents opportunities for defining pathways for single IRB review.

Understanding clerkship experiences in emergency medicine and their potential influence on specialty selection: A qualitative study.

Objectives: The specialty of emergency medicine (EM) is experiencing a significant decrease in student interest. In addition, women are historically underrepresented within the specialty at all levels of training and practice. We sought to understand how clinical experiences and perceptions of EM influence specialty selection by medical students, particularly women. Methods: Using a constructivist grounded theory approach, we analyzed semistructured interviews with senior medical students who considered EM as a specialty. We used purposive sampling to recruit from diverse learning environments and represent a variety of experiences. Participants reflected on their specialty selection process and experiences in EM including their perceived acceptance in the work environment. Results: Twenty-five medical students from 11 geographically diverse schools participated. A total of 68% (17/25) identified as women. The majority (21/25, 84%) planned on applying to EM residency. We identified four major themes: (1) distressing interpersonal interactions with patients and the ED care team negatively affect students; (2) EM culture includes behaviors that are perceived as exclusionary; (3) beliefs about the attributes of an ideal EM physician and the specialty itself have a gendered nature; and (4) ease of access to mentors, representation, and early exposure to EM environment increased interest in specialty. Conclusions: Our participants express that EM causes challenges for students to accept the norms of behavior in the field, which is an essential element in joining a group and professional identity formation. In addition, we raise concern that gendered perceptions and language may send exclusionary environmental cues that may negatively impact recruitment of a diverse physician workforce.

Creating opportunities to engage with prospective historically marginalized trainees with clinical simulation.

BACKGROUND: Recruiting a diverse group of medical students, house officers, and faculty in medicine is challenging-particularly for predominantly white, midwest institutions that may not be racially or ethnically diverse. PURPOSE: To evaluate a novel clinical simulation program, SiMfest, for recruiting house officers from historically marginalized populations to our institution to demonstrate our leadership's commitment to high-quality education and recruitment of these students to enhance diversity in academic medicine. METHODS: The Office for Health Equity and Inclusion, institutional leadership, and clinical department chairs developed a novel and engaging series of clinical simulations, SiMfest, to engage the pipeline of historically marginalized trainees and demonstrate our leadership's commitment to high-quality education. SiMfest is a two-hour simulation session presented annually (2017-2019) by our institution at the Student National Medical Association Annual Medical Education Conference. RESULTS: Over 800 students participated in SiMfest sessions over three years. Of the 461 participants who completed a survey after participation, 301 identified as female, and 382 indicated a racial category considered as historically marginalized in medicine-91% of whom identified as African American or Black. Thirty percent (n = 125) of respondents identified as pre-medical (e.g., undergraduate, post-baccalaureate) students and 69% (n = 289) identified as current medical students. Over 80% of students would recommend SiMfest to others. Additionally, 73% (n = 87) of pre-medical and 54% (n = 143) of medical students reported exposure to a previously unknown specialty. Thirty-three department representatives reported their SiMfest experience revealed new information about historically marginalized applicants that they may not have engaged with through the traditional application process but would be more likely to engage with in future diversity, equity, and inclusion initiatives. CONCLUSION: SiMfest harnessed our institution's high-quality training, personnel resources, and diversity, equity, and inclusion values to bring historically marginalized students in medicine and department leadership together to learn about one another and offer experiential learning. SiMfest may serve as a model for other institutions to draw on their strengths to develop innovative recruitment programs that promote the education and engagement of undergraduate and medical students from historically marginalized populations while simultaneously promoting diversity, equity, and inclusion culture change.

Cultural Humility Curriculum to Address Healthcare Disparities for Emergency Medicine Residents.

INTRODUCTION: Emergency medicine (EM) residency programs have variable approaches to educating residents on recognizing and managing healthcare disparities. We hypothesized that our curriculum with resident-presented lectures would increase residents' sense of cultural humility and ability to identify vulnerable populations. METHODS: At a single-site, four-year EM residency program with 16 residents per year, we designed a curriculum intervention from 2019-2021 where all second-year residents selected one healthcare disparity topic and gave a 15-minute presentation overviewing the disparity, describing local resources, and facilitating a group discussion. We conducted a prospective observational study to assess the impact of the curriculum by electronically surveying all current residents before and after the curriculum intervention. We measured attitudes on cultural humility and ability to identify healthcare disparities among a variety of patient characteristics (race, gender, weight, insurance, sexual orientation, language, ability, etc). Statistical comparisons of mean responses were calculated using the Mann-Whitney U test for ordinal data. RESULTS: A total of 32 residents gave presentations that covered a broad range of vulnerable patient populations including those that identify as Black, migrant farm workers, transgender, and deaf. The overall survey response was 38/64 (59.4%) pre-intervention and 43/64 (67.2%) post-intervention. Improvements were seen in resident self-reported cultural humility as measured by their responsibility to learn (mean responses of 4.73 vs 4.17; P < 0.001) and responsibility to be aware of different cultures (mean responses of 4.89 vs 4.42; P < 0.001). Residents reported an increased awareness that patients are treated differently in the healthcare system based on their race (P < 0.001) and gender (P < 0.001). All other domains queried, although not statistically significant, demonstrated a similar trend. CONCLUSION: This study demonstrates increased resident willingness to engage in cultural humility and the feasibility of resident near-peer teaching on a breadth of vulnerable patient populations seen in their clinical environment. Future studies may query the impact this curriculum has on resident clinical decision-making.

The Experiences and Needs of Families of Comatose Patients After Cardiac Arrest and Severe Neurotrauma: The Perspectives of National Key Stakeholders During a National Institutes of Health-Funded Workshop.

OBJECTIVES: Severe acute brain injury (SABI) from cardiac arrest and traumatic brain injury happens suddenly and unexpectedly, carrying high potential for lifelong disability with substantial prognostic uncertainty. Comprehensive assessments of family experiences and support needs after SABI are lacking. Our objective is to elicit "on-the-ground" perspectives about the experiences and needs of families of patients with SABI. DESIGN: Two-phase qualitative study of families and multidisciplinary U.S. healthcare professionals (mHCPs) with expertise in SABI: Phase 1 included semistructured interviews to generate formative findings; phase 2 entailed facilitated discussions to confirm and expand initial findings. SETTING: Phase 1: academic medical center; phase 2: virtual workshop. SUBJECTS: Phase 1 included seven family members and 12 mHCPs. Phase 2 included nationally recruited stakeholders (17 family members and 12 mHCPs). INTERVENTION: None. MEASUREMENTS AND RESULTS: We explored: 1) what are families' needs in the first 48 hours? 2) How are these needs addressed? and 3) How can hospitals better meet these needs? Qualitative analysis included inductive and deductive approaches guided by a conceptual ecological model. Four major needs were identified: 1) challenges in coping with uncertainty in early prognostication, 2) inattention to physical needs of family, 3) deficits in compassionate and consistent communication, and 4) need for engagement with families as stakeholders in improving future practices. Participants' recommendations included: 1) ways to communicate more clearly and consistently, 2) better assistance with navigating resources and access to places for families to care for themselves, and 3) opportunities for families to remain connected with their loved ones, social support networks, and the clinical team. CONCLUSIONS: Stakeholders identified novel insights regarding families' experiences during the hospitalization of comatose SABI patients and factors that can contribute to improved decision-making and physical/emotional outcomes. Interventions to address these unmet needs are promising targets to improve outcomes.

Beneficiaries' perspectives on improved oral health and its mediators after Medicaid expansion in Michigan: a mixed methods study.

OBJECTIVE: To investigate self-reported improved oral health and its mediators, and job-related outcomes, of Medicaid expansion beneficiaries in Michigan. METHODS: This cross-sectional mixed-methods study of adult "Healthy Michigan Plan" (HMP) Medicaid expansion beneficiaries included qualitative interviews with a convenience sample of 67 beneficiaries enrolled for ≥6 months, a stratified random sample survey of 4,090 beneficiaries enrolled for ≥12 months; and Medicaid claims data. We examined unadjusted associations between demographic variables and awareness of dental coverage, self-reported dental care access, dental visits, and self-reported oral health; and between improved oral health and job seeking and job performance. Multivariate analysis examined factors associated with self-reported oral health improvement, adjusting for sociodemographic characteristics, prior health insurance, and having at least one dental visit claim. RESULTS: Among surveyed beneficiaries, 60 percent received ≥1 dental visit and 40 percent reported improved oral health. Adjusted odds ratios (aOR) for improved oral health were higher for African-American beneficiaries [aOR = 1.61; confidence interval (CI) = 1.28-2.03] and those previously uninsured for ≥12 months (aOR = 1.96; CI = 1.58-2.43). Beneficiaries reporting improved oral health were more likely to report improved job seeking (59.9 percent vs 51 percent; P = 0.04) and job performance (76.1 percent vs 65.0 percent; P < 0.001) due to HMP. Interviewees described previously unmet oral health needs, and treatments that improved oral health, functioning, appearance, confidence, and employability. CONCLUSION: Michigan's Medicaid expansion contributed to self-reported improved oral health, which was associated with improved job outcomes. Policymakers should consider the importance of Medicaid dental coverage in reducing oral health disparities and improving the health and socioeconomic well-being of low-income adults and communities when considering this optional benefit.

Facemasks: Perceptions and use in an ED population during COVID-19.

STUDY OBJECTIVE: Facemask use is associated with reduced transmission of SARS-CoV-2. Most surveys assessing perceptions and practices of mask use miss the most vulnerable racial, ethnic, and socio-economic populations. These same populations have suffered disproportionate impacts from the pandemic. The purpose of this study was to assess beliefs, access, and practices of mask wearing across 15 urban emergency department (ED) populations. METHODS: This was a secondary analysis of a cross-sectional study of ED patients from December 2020 to March 2021 at 15 geographically diverse, safety net EDs across the US. The primary outcome was frequency of mask use outside the home and around others. Other outcome measures included having enough masks and difficulty obtaining them. RESULTS: Of 2,575 patients approached, 2,301 (89%) agreed to participate; nine had missing data pertaining to the primary outcome, leaving 2,292 included in the final analysis. A total of 79% of respondents reported wearing masks "all of the time" and 96% reported wearing masks over half the time. Subjects with PCPs were more likely to report wearing masks over half the time compared to those without PCPs (97% vs 92%). Individuals experiencing homelessness were less likely to wear a mask over half the time compared to those who were housed (81% vs 96%). CONCLUSIONS: Study participants reported high rates of facemask use. Respondents who did not have PCPs and those who were homeless were less likely to report wearing a mask over half the time and more likely to report barriers in obtaining masks. The ED may serve a critical role in education regarding, and provision of, masks for vulnerable populations.

Untold stories: Emergency medicine residents' experiences caring for diverse patient populations.

OBJECTIVES: The Accreditation Council for Graduate Medical Education expects specialties to teach and assess proficiency in culturally competent care. However, little guidance has emerged to achieve these goals. Clinical training within socioeconomically disparate settings may provide an experiential learning opportunity. We sought to qualitatively explore resident experiences working in the generic clinical learning environments (i.e., exposure to socioeconomically diverse patients across different training sites) and how it shapes cultural competency-related skill development. METHODS: Residents were recruited from emergency medicine (EM) programs. We used purposeful sampling across all postgraduate years and elicited experiences related to working at the different sites related to cultural identity, frustrating patient encounters, vulnerable populations, and development of health disparities/social determinants of health knowledge. Individual structured interviews were conducted via phone between May and December 2016. Interviews were audiotaped, transcribed, anonymized, and analyzed using systematic and iterative coding methods. RESULTS: Twenty-four interviews revealed three main themes. EM residents' experiences caring for patients across sites shaped their understanding of: (1) potential patient attributes that affected the clinical encounter, (2) difficulties in building rapport had adverse effect on the clinical evaluation, and (3) residency program and training experiences shaped their clinical preparedness and willingness to work in underserved areas. CONCLUSION: Assessing the impact disparate clinical setting exposures have on trainees' preparedness to care for socioeconomically diverse patients can provide valuable insight for medical educators into barriers and facilitators to delivering optimal learning and patient care. Participants provided a breadth of stories illuminating their real-world consciousness and competency with meeting the needs of diverse populations and their access to varied educational outlets to grapple with the disparities they observed. More research is needed to uncover effective strategies to help residents thrive and feel more prepared to care for diverse populations.

Meeting unique requirements: Community consultation and public disclosure for research in emergency setting using exception from informed consent.

BACKGROUND: Exception from informed consent (EFIC) regulations for research in emergency settings contain unique requirements for community consultation and public disclosure. These requirements address ethical challenges intrinsic to this research context. Multiple approaches have evolved to accomplish these activities that may reflect and advance different aims. This scoping review was designed to identify areas of consensus and lingering uncertainty in the literature. METHODS: Scoping review methodology was used. Conceptual and empirical literature related to community consultation and public disclosure for EFIC research was included and identified through a structured search using Embase, HEIN Online, PubMed, and Web of Science. Data were extracted using a standardized tool with domains for major literature categories. RESULTS: Among 84 manuscripts, major domains included conceptual or policy issues, reports of community consultation processes and results, and reports of public disclosure processes and results. Areas of consensus related to community consultation included the need for a two-way exchange of information and use of multiple methods. Public acceptance of personal EFIC enrollment is commonly 64% to 85%. There is less consensus regarding how to assess attitudes, what "communities" to prioritize, and how to determine adequacy for individual projects. Core goals of public disclosure are less well developed; no metrics exist for assessing adequacy. CONCLUSIONS: Multiple methods are used to meet community consultation and public disclosure requirements. There remain no settled norms for assessing adequacy of public disclosure, and there is lingering debate about needed breadth and depth of community consultation.

Developing an electronic health record-derived health equity dashboard to improve learner access to data and metrics.

OBJECTIVES: It is essential to engage learners in efforts aimed at dismantling racism and other contributors to health care disparities. Barriers to their involvement include limited access to data. The objective of our study was to create a data dashboard using an existing quality improvement (QI) infrastructure and provide resident access to data to facilitate exploratory analysis on disparities in emergency department (ED) patient care. METHODS: Focusing on patient populations that have previously been shown in the literature to suffer significant disparities in the ED, we extracted outcomes across a variety of metrics already collected as part of routine ED operations. Using data visualization software, we developed an interactive dashboard for visual exploratory analyses. RESULTS: We designed a dashboard for our resident learners with views that are flexible and allow user selected filters to view clinical outcomes by patient age, treatment area, and chief complaint. Learners were also allowed to select grouping and outcomes of interest to investigate questions and form new hypotheses of their choosing. Available dashboard views included summary counts view to assess ED visits over time by selectable group, a rooming and triage acuity view, time-to-event survival curve view, histogram and box plot views for continuous variables, a view to assess outcome variables by time of day of ED arrival, customizable contingency table views, and correspondence analysis. CONCLUSIONS: Utilizing an existing QI infrastructure, we developed a dashboard that provides a new perspective into commonly collected ED operations data to allow for the exploration of disparities in ED care that is accessible to learners. Future directions include using these data to refine hypotheses on ED disparities, understand root causes, develop interventions, and measure their impact.

To Be Seen, Heard, and Valued: Strategies to Promote a Sense of Belonging for Women and Underrepresented in Medicine Physicians.

Lingering unconscious biases and daily cues continue to permeate and persist in academic medicine environments in the form of the exclusion of physicians who are women or racially/ethnically underrepresented in medicine. Academic medicine environments must change so that women and underrepresented in medicine racial/ethnic groups are seen, heard, and valued. A shared awareness among faculty, administrators, and trainees can inform the development of intentional strategies to alter individual behaviors, academic spaces, and institutional processes to cultivate a sense of belonging. Shifting the norms in medicine and the course of historical exclusion will require professional development in areas of inclusive teaching practices, skills to cultivate mentoring relationships with diverse trainees, and fostering discussions about the relevance of personal identity, as well as attention to the symbolism and imagery in institutional messages (e.g., portraits on the walls, website, marketing campaigns) and to the value of including community involvement in productivity metrics.

Health Risk Assessments in Michigan's Medicaid Expansion: Early Experiences in Primary Care.

INTRODUCTION: Michigan is one of 3 states that have implemented health risk assessments for enrollees as a feature of its Medicaid expansion, the Healthy Michigan Plan. This study describes primary care providers' early experiences with completing health risk assessments with enrollees and examines provider- and practice-level factors that affect health risk assessment completion. METHODS: All primary care providers caring for ≥12 Healthy Michigan Plan enrollees (n=4,322) were surveyed from June to November 2015, with 2,104 respondents (55.5%). Analyses in 2016-2017 described provider knowledge, attitudes, and experiences with the health risk assessment early in Healthy Michigan Plan implementation; multivariable analyses examined relationships of provider- and practice-level characteristics with health risk assessment completion, as recorded in state data. RESULTS: Of the primary care provider respondents, 73% found health risk assessments very or somewhat useful for identifying and discussing health risks, although less than half (47.2%) found them very or somewhat useful for getting patients to change health behaviors. Most primary care provider respondents (65.3%) were unaware of financial incentives for their practices to complete health risk assessments. Nearly all primary care providers had completed at least 1 health risk assessment. The mean health risk assessment completion rate (completed health risk assessments/number of Healthy Michigan Plan enrollees assigned to that primary care provider) was 19.6%; those who lacked familiarity with the health risk assessment had lower completion rates. CONCLUSIONS: Early in program implementation, health risk assessment completion rates by primary care providers were low and awareness of financial incentives limited. Most primary care provider respondents perceived health risk assessments to be very or somewhat useful in identifying health risks, and about half of primary care providers viewed health risk assessments as very or somewhat useful in helping patients to change health behaviors.

Association of Medicaid Expansion With Enrollee Employment and Student Status in Michigan.

Importance: Medicaid community engagement requirements (work, school, job searching, or community service) are being implemented by several states for the first time, but the association of Medicaid coverage with enrollees' employment and school attendance is unclear. Objective: To assess longitudinal changes in enrollees' employment or student status after Michigan's Medicaid expansion. Design, Setting, and Participants: This survey study included 4090 nonelderly, adult Healthy Michigan Plan enrollees from March 1, 2017, to January 31, 2018. Main Outcomes and Measures: Self-reported employment or student status. Proportionate sampling was stratified by income and geographic region. Mixed-effects regression models with time indicators were used to assess longitudinal changes in the proportion of enrollees who were employed or students. Results: The response rate for the initial survey was 53.7% and for the follow-up survey was 83.4%. Of the 3104 respondents to the 2017 follow-up survey (mean [SD] age in 2017, 42.2 [13.0] years; 1867 [53.0%] female), 54.3% were employed or students in 2016, and this number increased to 60.0% in 2017 (percentage point change, 5.7; P < .001). Non-Hispanic black enrollees had significantly larger gains in employment or student status compared with non-Hispanic white enrollees (percentage point change, 10.7 vs 3.5; P = .02). Changes in employment or student status were not associated with improved health status. Conclusions and Relevance: Employment or student status increased from 2016 to 2017 among Michigan Medicaid expansion enrollees. These findings provide information about whether Medicaid coverage or community engagement requirements are best to promote the desired outcomes of employment and student status.

Factors influencing primary care providers' decisions to accept new Medicaid patients under Michigan's Medicaid expansion.

OBJECTIVES: Michigan expanded Medicaid under the Affordable Care Act (ACA) through a federal waiver that permitted state-mandated features, including an emphasis on primary care. We investigated the factors associated with Michigan primary care providers (PCPs)' decision to accept new Medicaid patients under Medicaid expansion. STUDY DESIGN: Statewide survey of PCPs informed by semistructured interviews. METHODS: After Michigan expanded Medicaid on April 1, 2014, we surveyed 2104 PCPs (including physician and nonphysician providers, such as nurse practitioners and physician assistants) with 12 or more assigned Medicaid expansion enrollees (response rate, 56%). To guide survey development and interpretation, we interviewed a separate group of 19 PCPs with Medicaid expansion enrollees from diverse urban and rural regions. Survey questions assessed PCPs' current acceptance of new Medicaid patients. RESULTS: Of the 2104 surveyed PCPs, 78% reported that they were currently accepting additional Medicaid patients; 58% reported having at least some influence on the decision. Factors considered very/moderately important to the Medicaid acceptance decision included practice capacity to accept any new patients (69%), availability of specialists for Medicaid patients (56%), reimbursement amount (56%), psychosocial needs of Medicaid patients (50%), and illness burden of Medicaid patients (46%). PCPs accepting new Medicaid patients tended to be female, minorities, nonphysician providers, specialized in internal medicine, paid by salary, or working in practices with Medicaid-predominant payer mixes. CONCLUSIONS: In the era after Medicaid expansion, PCPs placed importance on practice capacity, specialist availability, and patients' medical and psychosocial needs when deciding whether to accept new Medicaid patients. To maintain primary care access for low-income patients with Medicaid, future efforts should focus on enhancing the diversity of the PCP workforce, encouraging healthcare professional training in underserved settings, and promoting practice-level innovations in scheduling and integration of specialist care.