Comorbid Patterns in the Homeless Population: A Theoretical Model to Enhance Patient Care.

INTRODUCTION: From the perspective of social determinants, homelessness perpetuates poor health and creates barriers to effective chronic disease management, necessitating frequent use of emergency department (ED) services. In this study we developed a screening algorithm (checklist) from common comorbidities observed in the homeless population in the United States. The result was a theoretical screening tool (checklist) to aid healthcare workers in the ED, including residents, medical students, and other trainees, to provide more efficacious treatment and referrals for discharge. METHODS: In this retrospective cohort study we used the Nationwide Emergency Department Sample (NEDS) to investigate comorbidities and ED utilization patterns relating to 23 injury-related, psychiatric, and frequent chronic medical conditions in the US adult (≥18 years of age) homeless population. Cases were identified from the NEDS database for 2014-2017 using International Classification of Diseases, 9th and 10 revisions, and Clinical Classification Software diagnosis codes. We performed a two-step cluster analysis including pathologies with ≥10% prevalence in the sample to identify shared comorbidities. We then compared the clusters by sociodemographic and ED-related characteristics, including age, gender, primary payer, and patient disposition from the ED. Chi-square analysis was used to evaluate categorical variables (ie, gender, primary payer, patient disposition from the ED), and analysis of variance for continuous variables (age). RESULTS: The study included 1,715,777 weighted cases. The two-step cluster analysis identified nine groups denominated by most prevalent disease: 1) healthy; 2) mixed psychiatric; 3) major depressive disorder (MDD); 4) psychosis; 5) addiction; 6) essential hypertension; 7) chronic obstructive pulmonary disease (COPD); 8) infectious disease; and (9) injury. The MDD, COPD, infectious disease, and Injury clusters demonstrated the highest prevalence of co-occurring disease, with the MDD cluster displaying the highest proportion of comorbidities. Although the addiction cluster existed independently, substance use was pervasive in all except the healthy cluster (prevalence 36-100%). We used the extracted screening algorithm to establish a screening tool (checklist) for ED healthcare workers, with physicians as the first point of contact for the initial use of the screening tool. CONCLUSION: Healthcare workers in the ED, including residents, medical students, and other trainees, provide services for homeless ED users. Screening tools (checklists) can help coordinate care to improve treatment, referrals, and follow-up care to reduce hospital readmissions. The screening tool may expedite targeted interventions for homeless patients with commonly occurring patterns of disease.

U.S. medical school admissions and enrollment practices: status of LGBTQ inclusivity.

CONTEXT: The failure to collect information on lesbian, gay, bisexual, transgender, and queer (LGBTQ) identity in healthcare and medical education is a part of a systemic problem that limits academic medical institutions' ability to address LGBTQ health disparities. OBJECTIVES: To determine whether accurate sexual and gender minority (SGM) demographic data is being consistently collected for all US medical schools during admissions and enrollment, and whether differences exist between collection practices at osteopathic and allopathic schools. METHODS: Secure, confidential electronic were sent via email in July 2019 to 180 osteopathic (n=42) and allopathic (n=138) medical schools identified through the American Association of Colleges of Osteopathic Medicine Student Guide to Osteopathic Medical Colleges database and the American Association of Medical Colleges Medical School Admissions Requirements database. The nine question survey remained open through October 2019 and queried for; (1) the ability of students to self report SGM status during admissions and enrollment; and (2) availability of SGM specific resources and support services for students. Chi square analysis and the test for equality of proportions were performed. RESULTS: Seventy five of 180 (41.7%) programs responded to the survey; 74 provided at least partial data. Of the 75 respondent schools, 55 (73.3%) allowed applicants to self report a gender identity other than male or female, with 49 (87.5%) of those being allopathic schools compared with 6 (31.6%) osteopathic schools. Similarly, 15 (20.0%) allowed applicants to report sexual orientation, with 14 (25.5%) of those being allopathic schools compared with one (5.3%) osteopathic school. Fifty four of 74 (73.0%) programs allowed matriculants to self report a gender identity other than male or female; 11 of 74 (14.7%) allowed matriculants to report sexual orientation. CONCLUSIONS: Demographics collection practices among American medical education programs that responded to our survey indicated that they undervalued sexual orientation and gender identity, with osteopathic programs being less likely than allopathic programs to report inclusive best practices in several areas. American medical education programs, and their supervising bodies, must update their practices with respect to the collection of sexual orientation and gender identity demographics as part of a holistic effort to address SGM health disparities.

The integration of the "spirituality in medicine" curriculum into the osteopathic communication curriculum at Kansas City University of Medicine and Biosciences.

With grant funding from the John Templeton Spirituality and Medicine Curricular Award to the George Washington Institute for Spirituality and Health, faculty at Kansas City University of Medicine and Biosciences (KCUMB) developed the "Spirituality in Medicine" curriculum. In developing the curriculum, faculty took into consideration competencies required by the Association of American Medical Colleges and qualitative results from surveys of medical school applicants and enrolled students. Strategies for curriculum delivery included lectures, panel discussions, role-playing, and training in the use of a spirituality assessment tool. A majority of the 250 students who received the training in 2010-2011 were able to demonstrate the following competencies: (1) being sensitive to patients' spiritual and cultural needs, (2) assessing patients' and their own spiritual needs, (3) appropriately using chaplain services for patient care, and (4) understanding the effects of health disparities and ethical issues on patient care. Challenges to implementation included a reduction in chaplain availability due to the economic downturn, a lack of student exposure to direct patient care during shadowing, too little religious diversity among chaplains, and changes in assignment schedules. New competencies required by the National Board of Osteopathic Medical Examiners overlap with and help ensure sustainability of the Spirituality in Medicine curriculum. KCUMB leaders have incorporated the use of the spirituality assessment tool into other parts of the curriculum and into service experiences, and they have introduced a new elective in palliative care. Synergistic efforts by faculty leaders for this initiative were critical to the implementation of this curriculum.

Treatment outcomes and medication compliance for children and adolescents, 30 days post-discharge from an in-patient psychiatric hospital.

A variety of authors have suggested that children and adolescents are at risk for serious adverse health outcomes because of a lack of compliance with medication regimens. A lack of compliance includes taking less or more medication than prescribed, and taking medication at the wrong times. One study that examined the medication compliance of 81 students who were 10 years of age or older, and were enrolled in a school-based health center, determined that only 45 students (56%) filled the prescription given to them by the doctor. Of those students who filled the prescription, 76% reported that they always took the medication on time, 22% reported forgetting to take the medication some of the time and 2% reported never taking the medication.