Factors Associated with Medical Students' Attitudes About Cost-Conscious Care: A Mixed-Methods Multi-school Study.

BACKGROUND: Because physician practices contribute to national healthcare expenditures, initiatives aimed at educating physicians about high-value cost-conscious care (HVCCC) are important. Prior studies suggest that the training environment influences physician attitudes and behaviors towards HVCCC. OBJECTIVE: To explore the relationship between medical student experiences and HVCCC attitudes. DESIGN: Quantitative and qualitative analysis of a multi-institutional survey. PARTICIPANTS: Medical students from nine US medical schools. APPROACH: A 44-item survey that included the Maastricht HVCCC Attitudes Questionnaire, a validated tool for assessing HVCCC attitudes, was administered electronically. Attitudinal domains of high-value care (HVC), cost incorporation (CI), and perceived drawbacks (PD) were compared using one-way ANOVA among students with a range of exposures. Open text responses inviting participants to reflect on their attitudes were analyzed using classical content analysis. KEY RESULTS: A total of 740 students completed the survey (response rate 15%). Students pursuing a "continuity-oriented" specialty held more favorable attitudes towards HVCCC than those pursuing "technique-oriented" specialties (HVC sub-score = 3.20 vs. 3.06; p = 0.005, CI sub-score = 2.83 vs. 2.74; p < 0.001). Qualitative analyses revealed personal, educational, and professional experiences shape students' HVCCC attitudes, with similar experiences interpreted differently leading to both more and less favorable attitudes. CONCLUSION: Students pursuing specialties with longitudinal patient contact may be more enthusiastic about practicing high-value care. Life experiences before and during medical school shape these attitudes, and complex interactions between these forces drive student perceptions of HVCCC.

Impact of an opioid use disorder consult service on hospitalized trauma patients with opioid use disorder.

BACKGROUND: Opioid use disorder (OUD) is common in the hospitalized trauma population, being a comorbid diagnosis in approximately 1% of operative trauma cases. The impact of an addiction consult service in this population has been less well studied but may lead to increased provision of evidence-based OUD treatment and improved postdischarge outcomes. METHODS: One hundred thirteen patients with an International Classification of Diseases diagnosis of OUD who were admitted to the trauma service at a single academic hospital between January 2020 to December 2021 were included in a retrospective chart review. Wilcoxon rank-sum tests were used to evaluate differences between patients who received an OUD consult and those who did not. Regression analysis was used to assess differences in postdischarge acute care utilization, attendance of follow-up appointments, initiation of and discharge on medication for opioid use disorder (MOUD), naloxone prescribing at discharge, and length of stay (LOS) between the consult and no-consult groups. RESULTS: Eighty-one patients in the study population received a consult and 32 did not. Patients in the consult group were more likely to have started MOUD during their admission (odds ratio [OR], 2.09; p < 0.001), be discharged with naloxone (OR, 1.89; p < 0.001), have a plan in place for continued OUD treatment at discharge (OR, 1.43; p < 0.001), and attend scheduled follow-up appointments with the trauma team (OR, 1.76; p = 0.02). Differences in acute care utilization and LOS between the two groups were not statistically significant. CONCLUSION: An OUD consult service can provide benefit to hospitalized trauma patients by increasing likelihood of starting MOUD, of discharging with MOUD and naloxone, and of attending trauma follow-up appointments without increasing LOS or acute care utilization. Thus, addiction consult service interventions during hospital admissions for trauma may serve to facilitate both evidence-based OUD care and posthospitalization trauma care. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Colonial Geographies: Indigenous Access to Primary Care in British Columbia.

This article considers the demonstrated lack of access to primary health services in remote Indigenous communities in British Columbia as a form of structural exclusion shaped by the history of settler colonialism. Drawing on collaborative research conducted with an Indigenous nursing organization, I link ethnographic case studies with historical research demonstrating how racially segregated health care developed within an assimilatory political mandate. I argue that access to and quality of care must be understood as two inter-related dimensions of health equity, which must be regarded by decision-makers as a key site for addressing the health disparities faced by Indigenous populations.

Validation of a clinical decision instrument for emergent neuroimaging after a seizure: Let's image malignancy, intracranial hemorrhage, and trauma (LIMIT).

BACKGROUND: Given the many causes of seizures, emergency physicians often utilize brain computed tomography (CT) to evaluate for intracranial pathology. However, a CT exposes patients to 100 times more radiation than a chest radiograph. Previously, we developed a four-item clinical decision instrument (CDI) to determine which patients with status epilepticus (SE) do not require emergent neuroimaging. In this study, we seek to prospectively validate our CDI in patients with a history of seizures with both SE and generalized tonic-clonic seizures. METHODS: This was a prospective observational study of 1,739 consecutive patients who were recruited from two urban hospitals in Philadelphia, Pennsylvania. All patients, 18 years and older, who presented with a chief complaint of seizure and had emergency neuroimaging performed were eligible for inclusion. Patients were excluded from analysis if this was a first-time seizure, had a ventriculoperitoneal shunt, or had focal neurologic deficits. RESULTS: A total of 376 patients were in the final analysis. Of the 376 patients, 10 patients (3%) had positive CTs. Nine of the 10 of the patients were identified by our CDI, resulting in a negative predictive value (NPV) of 99.5%. On secondary analysis, we refined our CDI from four to three criteria: 1) history of intracranial hemorrhage (ICH), 2) active malignancy, and 3) trauma. These criteria also had a NPV of >99% when applied to patients in SE. CONCLUSION: The validation of our CDI showed improved NPV when compared to the derivation set. Use of the criteria of history of ICH, active malignancy, and trauma could have reduced the use of emergent neuroimaging in our cohort by up to 49%. This CDI should be validated in a larger subset of patients and in multiple centers prior to widespread adoption.