Perioperative pain optimization in the age of the opioid epidemic.

PURPOSE OF REVIEW: The opioid epidemic remains a constant and increasing threat to our society with overdoses and overdose deaths rising significantly during the COVID-19 pandemic. Growing evidence suggests a link between perioperative opioid use, postoperative opioid prescribing, and the development of opioid use disorder (OUD). As a result, strategies to better optimize pain management during the perioperative period are urgently needed. The purpose of this review is to summarize the most recent multimodal analgesia (MMA) recommendations, summarize evidence for efficacy surrounding the increased utilization of Enhanced Recovery After Surgery (ERAS) protocols, and discuss the implications for rising use of buprenorphine for OUD patients who present for surgery. In addition, this review will explore opportunities to expand our treatment of complex patients via transitional pain services. RECENT FINDINGS: There is ample evidence to support the benefits of MMA. However, optimal drug combinations remain understudied, presenting a target area for future research. ERAS protocols provide a more systematic and targeted approach for implementing MMA. ERAS protocols also allow for a more comprehensive approach to perioperative pain management by necessitating the involvement of surgical specialists. Increasingly, OUD patients taking buprenorphine are presenting for surgery. Recent guidance from a multisociety OUD working group recommends that buprenorphine not be routinely discontinued or tapered perioperatively. Lastly, there is emerging evidence to justify the use of transitional pain services for more comprehensive treatment of complex patients, like those with chronic pain, preoperative opioid tolerance, or substance use disorder. SUMMARY: Perioperative physicians must be aware of the impact of the opioid epidemic and explore methods like MMA techniques, ERAS protocols, and transitional pain services to improve the perioperative pain experience and decrease the risks of opioid-related harm.

Five Strategies Leaders in Academic Medicine Can Implement Now to Enhance Gender Equity.

Abundant disparities for women in medicine contribute to many women physicians considering leaving medicine. There is a strong financial and ethical case for leaders in academic medicine to focus on strategies to improve retention. This article focuses on five immediate actions that leaders can take to enhance gender equity and improve career satisfaction for all members of the workplace.

The 2017 North Carolina STOP Act is Associated With an Accelerated Decrease in Opioid Dispensing: A Statewide Analysis, 2013-2019.

Background: This study aimed to: 1) quantify the dispensing and days' supply of opioid prescriptions prior to and after the NC STOP Act went into effect among Medicare Part D beneficiaries; 2) evaluate how the STOP Act impacted physician assistant and nurse practitioner opioid prescribing; and 3) evaluate whether the NC STOP Act is associated with reductions in opioid prescriptions' days' supply among Medicare Part D beneficiaries. Methods: This was a secondary analysis of Medicare Part D Public Use Files for 2013-2019. Only North Carolina providers and select Schedule II (CII) and III (CIII) drugs and tramadol (CV) were included in the analysis. Multivariable Poisson regression models were used to analyze the data. Results: In 2013, there were population-adjusted 180,565.2/100,000 claims for the included CII and CIII opioids, which decreased to 79,329.12/100,000 claims in 2019. Each of the multivariable Poisson regression models indicates a reduction in per-provider populationadjusted claims and days' supply after the NC STOP Act went into effect for both selected CII and CIII medications and for tramadol. The results also indicate that the number of prescriptions for CII, CIII, and tramadol decreased over time. Limitations: Due to the nature of the observational study design, we cannot conclude that the 2017 legislation had an effect on populationadjusted claims for certain CII and CIII opioids. Conclusions: Since 2013 there has been a decreasing trend in certain CII and CIII opioids dispensations in Medicare beneficiaries, and the trend accelerated after the STOP Act went into effect.

Designing Actionable Solutions and Curriculum for Pain Disparities Education.

The Liaison Committee on Medical Education (LCME) require medical schools to teach their students how to recognize and work toward eliminating health disparities. However, time constraints and a dearth of guidance for educators in teaching pain disparities curricula pose significant challenges. Herein we describe successes and lessons learned after designing, implementing, and evaluating an innovative pain disparities curriculum that was embedded in a longitudinal health equity curriculum for third year medical school students at an academic institution. Although the curriculum was developed for medical school students, the concepts may be broadly applicable to other training settings such as residency and fellowship programs.

The experiences of community organizations partnering with a medical school to improve students' understanding of the social determinants of health: A qualitative study.

PURPOSE: There has been increasing interest among national organizations for medical schools to provide students experiential training in the social determinants of health (SDH) through community partnerships. Despite this interest, there is limited data about how these experiential activities can be designed most effectively, and community organizations' views of partnering with medical schools on these curricula is unknown. The authors' objective was to determine community organizations' and clinical clerkship directors' perceptions of the benefits and challenges of utilizing academic-community partnerships to improve medical students' understanding of the SDH. METHODS: The authors conducted a qualitative study consisting of open-ended, semi-structured interviews (between 2018 and 2021). All community organizations and clinical clerkship directors who partnered with a health equity curriculum were eligible to participate. Semi-structured interviews elicited participants' perceptions of the academic-community partnership; experience with the curriculum and the students; and recommendations for improving the curriculum. All interviews were audio recorded and transcribed. The authors used a directed content analysis approach to code the interviews inductively and identified emerging themes through an iterative process. RESULTS: Of the fifteen participants interviewed, ten were from community organizations and five from clinical clerkships. Three primary themes emerged: (1) community organizations felt educating students about the SDH aligned with the organization's mission and they benefited from consistent access to volunteers; (2) students benefited through greater exposure to the SDH; (3) participants suggested standardizing students' experiences, ensuring the students and organizations are clear about the goals and expectations, and working with organizations that have experience with or the capacity for a large volume of volunteers as ways to improve the experiential activity. CONCLUSION: This study found that community organizations were very willing to partner with a medical school to provide students experiential learning about the SDH, and this partnership was beneficial for both the students and the organizations.

Implementation of Individualized Pain Care Plans Decreases Length of Stay and Hospital Admission Rates for High Utilizing Adults with Sickle Cell Disease.

OBJECTIVE: Patients with sickle cell disease (SCD) face inconsistent effective analgesic management, leading to high inpatient healthcare utilization and significant financial burden for healthcare institutions. Current evidence does not provide guidance for inpatient management of acute pain in adults with sickle cell disease. We conducted a retrospective analysis of a longitudinal cohort quality improvement project to characterize the role of individualized care plans on improving patient care and reducing financial burden in high healthcare-utilizing patients with SCD-related pain. METHODS: Individualized care plans were developed for patients with hospital admissions resulting from pain associated with sickle cell disease. A 2-year prospective longitudinal cohort quality improvement project was performed and retrospectively analyzed. Primary outcome measure was duration of hospitalization. Secondary outcome measures included: pain intensity; 7, 30, and 90-day readmission rates; cost per day; total admissions; total cost per year; analgesic regimen at index admission; and discharge disposition. RESULTS: Duration of hospitalization, the primary outcome, significantly decreased by 1.23 days with no worsening of pain intensity scores. Seven-day readmission decreased by 34%. Use of intravenous hydromorphone significantly decreased by 25%. The potential cost saving was $1,398,827 as a result of this quality initiative. CONCLUSIONS: Implementation of individualized care plans reduced both admission rate and financial burden of high utilizing patients. Importantly, pain outcomes were not diminished. Results suggest that individualized care plans are a promising strategy for managing acute pain crisis in adult sickle cell patients from both care-focused and utilization outcomes.

Addressing the mandate for hand-off education: a focused review and recommendations for anesthesia resident curriculum development and evaluation.

The Accreditation Council for Graduate Medical Education requires that residency programs teach residents about handoffs and ensure their competence in this communication skill. Development of hand-off curricula for anesthesia residency programs is hindered by the paucity of evidence regarding how to conduct, teach, and evaluate handoffs in the various settings where anesthesia practitioners work. This narrative review draws from literature in anesthesia and other disciplines to provide recommendations for anesthesia resident hand-off curriculum development and evaluation.

Why do pregnant women die? A review of maternal deaths from 1990 to 2010 at the University of Alabama at Birmingham.

BACKGROUND: The number of reported pregnancy-related deaths in the United States steadily increased from 7.2 deaths per 100,000 live births in 1987 to a high of 17.8 deaths per 100,000 live births in 2009. Compared to Caucasian women, African American women were nearly 4 times as likely to die from childbirth. To better understand the reason for this trend, we conducted a case-control study at University of Alabama at Birmingham (UAB) Hospital. Our primary study hypothesis was that women who died at UAB were more likely to be African American than women in a control group who delivered an infant at UAB and did not die. We expected to find a difference in race proportions and other patient characteristics that would further help to elucidate the cause of a racial disparity in maternal deaths. METHODS: We reviewed all maternal deaths (cases) at UAB Hospital from January 1990 through December 2010 identified based on electronic uniform billing data and ICD-9 codes. Each maternal death was matched 2:1 with women who delivered at a time that most closely coincided with the time of the maternal death in 2-step selection process (electronic identification and manual confirmation). Maternal variables obtained were comorbidities, duration of hospital stay, cause of death, race, distance from home to hospital, income, prenatal care, body mass index, parity, insurance type, mode of delivery, and marital status. The strength of univariate associations of maternal variables and case/control status was calculated. The association of case/control status and race was also examined after controlling for residential distance from the hospital. RESULTS: There was insufficient evidence to suggest racial disparity in maternal death. The proportion of African American women was 57% (42 of 77) in the maternal death group and 61% (94 of 154) in the control group (P = 0.23). The univariate odds ratio for maternal death for African American to Caucasian race was 0.66 (95% confidence interval [CI], 0.37-1.19); the adjusted odds ratio was 1.46 (95% CI, 0.73-3.01). Longer compared with shorter distance of residence to the hospital was a highly significant predictor (P < 0.001) of maternal death. CONCLUSIONS: We did not observe a racial disparity in maternal deaths at UAB Hospital. We suggest that the next step toward understanding racial differences in maternal deaths reported in the United States should be directed at the health care delivery outside the tertiary care hospital setting, particularly at eliminating access barriers to health care for all women.

Associations Between Patterns of Daily Stepping Behavior, Health-Related Quality of Life, and Pain Symptoms Among Older Adults with Chronic Pain: A Secondary Analysis of Two Randomized Controlled Trials.

Purpose: One's amount, intensity, and distribution of physical activity may have implications for whether it has positive or negative effects on pain and quality of life for older adults living with chronic pain. Thus, we investigated baseline patterns of stepping related to pain symptoms and health-related quality of life at baseline and over a 12-week follow-up period. Patients and Methods: Participants were low-active older adults (69.54±6.74 years) with obesity and chronic pain who enrolled in one of two randomized controlled trials. Participants completed measures of pain intensity, interference, and health-related quality of life and wore an accelerometer for 7 days at baseline and week 12. Functional principal components analysis identified patterns of within-day stepping behavior at baseline, and linear regressions were used to investigate how these component scores related to pain and health-related quality of life at baseline and over 12 weeks. Results: Two patterns were extracted; one describing more vs less stepping and the second capturing movement later vs earlier in the day. More baseline stepping was associated with better physical functioning (B=0.148, p<0.001) and energy (B=0.073, p=0.033), while a later start in the day was associated with worse social functioning (B=-0.193, p=0.031). More stepping at baseline predicted positive changes in physical functioning (B=0.094, p=0.019), emotional role limitations (B=0.132, p=0.049), energy (B=0.112, p<0.001), social functioning (B=0.086, p=0.043), pain (B=0.086, p=0.009), general health (B=0.081, p=0.003) and pain intensity (B=-0.039, p=0.003). A later start to the day was associated with worsening physical functioning (B=-0.229, p<0.001), physical (B=-0.282, p=0.047) and emotional role limitations (B=-0.254, p=0.048), general health (B=-0.108, p=0.041), and pain interference (B=0.055, p=0.043). Conclusion: Findings suggest there is value in activity patterns as an indicator for additional behavioral intervention, as those who move little and/or delay daily movement are likely to experience subsequent decrements in quality of life and pain symptoms.

Successes and lessons learned from a mobile health behavior intervention to reduce pain and improve health in older adults with obesity and chronic pain: a qualitative study.

Introduction: Chronic pain is a prevalent issue among older adults in the United States that impairs quality of life. Physical activity has emerged as a cost-effective and non-pharmacological treatment for chronic pain, offering benefits such as improved physical functioning, weight loss, and enhanced mood. However, promoting physical activity in older individuals with chronic pain is challenging, given the cyclical relationship between pain and sedentary behavior. The Mobile Intervention to Reduce Pain and Improve Health (MORPH) trial was designed as an innovative, mobile health (mHealth) supported intervention to address this issue by targeting daylong movement, weight loss, and mindfulness to manage pain in older adults with chronic multisite pain. The objective of this paper is to provide the result of a qualitative analysis conducted on post-intervention interviews with MORPH participants. Methods: At the conclusion of the MORPH study, 14 participants were interviewed regarding their experience with the program. All interviews were conducted by phone before being transcribed and verified. A codebook of significant takeaways was created based on these accounts. Summaries were further synthesized into themes using the principles of thematic analysis. Results: Three key themes of the MORPH intervention emerged from the qualitative interviews: MORPH technology (smart scales, Fitbit, MORPH Companion App) facilitated program adherence and accountability; MORPH intervention components (food tracking and mindfulness activities) facilitated program adherence and awareness, respectively; and, group meetings provided motivational support and accountability. Mobile health technologies, including a dedicated MORPH app, facilitated self-monitoring strategies, helped to break the cycle of old habits, and provided participants with immediate feedback on successes; however, technical issues required timely support to maintain engagement. Food tracking contributed to adherence and accountability for weight loss. Mindfulness activities increased participants' awareness of anxiety provoking thoughts and pain triggers. Finally, social support via group meetings and connection, played a crucial role in behavior change, but participants noted consistency in the delivery medium was essential to fostering genuine connections. Conclusion: Overall, the study results highlight the key considerations related to program technology, intervention components, and the value of social support that can help to guide the development of future interventions similar to MORPH.

Local Culture and Community Through a Digital Lens: Viewpoint on Designing and Implementing a Virtual Second Look Event for Residency Applicants.

BACKGROUND: The COVID-19 pandemic altered how residency interviews occur. Despite 2 years of web-based interviews, these are still perceived as inferior to in-person experiences. Showcasing a program and location is critical for recruitment; however, it is difficult to highlight the program's location and community digitally. This article presents the authors' viewpoints on designing and implementing a virtual second look for residency applicants. OBJECTIVE: Our objective was to host a web-based event to feature the benefits of living in Winston-Salem, North Carolina, for residency applicants, enhance recruitment efforts, and ensure a successful residency match. The goal was to cover topics that interested all applicants, highlight how Winston-Salem is a special place to live, involve current residents, and engage community members. METHODS: Three programs-child neurology, neurology, and family medicine were chosen for a pilot virtual second look. All residency program directors' were asked to recommend community contacts and help identify residents and faculty who may serve as content experts on one of the topics in the panel discussions. A total of 24 community leaders from restaurants, venues, schools, and businesses were contacted, and 18 agreed to participate. The panel discussions included living in and raising a family in Winston-Salem, experiencing Winston-Salem arts and music, where to eat and drink like a local, and enjoying sports and outdoors in the area. The 2-hour event was hosted on Zoom. Postevent feedback assessments were automatically sent to each registrant through Research Electronic Data Capture (REDCap). This study was deemed exempt from Wake Forest University Health Sciences institutional review board review (IRB00088703). RESULTS: There were 51 registrants for the event, and 28 of 48 registrants provided postevent feedback, which was positive. The authors found in the MATCH residency results that 2 of 2 child neurology positions, 4 of 6 adult neurology positions, and 1 of 10 family medicine positions attended our second look event. One adult neurology resident who did not participate was an internal candidate. All respondents agreed or strongly agreed that the session was valuable, well organized, and met their expectations or goals. Furthermore, all respondents gained new information during this web-based event not obtained during their interview day. CONCLUSIONS: The virtual second look event for residency attendees featured the benefits of living in Winston-Salem, and the perspectives of current residents. Feedback from the session was overall positive; however, a top desire would be devoting more time for the applicants to ask questions directly to the community leaders and our resident trainees. This program could be reproducible by other institutions. It could be broadened to a graduate medical education-wide virtual second look event where all medical and surgical programs could opt to participate, facilitating an equitable opportunity for prospective applicants.

Associations between patterns of physical activity, pain intensity, and interference among older adults with chronic pain: a secondary analysis of two randomized controlled trials.

Background: Clinical management of chronic pain often includes recommendations to engage in physical activity (PA), though there are little data on the interplay between pain symptoms and key aspects of PA participation (e.g., intensity and bout duration) among older adults. Herein we investigate the longitudinal relationships between changes in PA behavior and changes in pain intensity and interference among low-active older adults with obesity and chronic pain. Methods: Participants (N = 41) were enrolled in two randomized pilot trials wherein they were assigned to an intervention focused on participation in frequent PA across the day, or to a low-contact control. Participants completed the 3-item PROMIS pain intensity scale and 8-item PROMIS pain interference scale before and after the interventions. Participants also wore an ActivPAL accelerometer for 7 days before and during the final week of the interventions. Results: A series of linear regression analyses demonstrated that increased time spent stepping at a high-light intensity in very short bouts was associated with increased pain intensity scores. By contrast, increased time spent stepping at a high-light intensity in bouts of 5-20 min was associated with reductions in pain intensity and interference scores. Increased time spent stepping at a moderate intensity overall was associated with reduced pain intensity scores, and time spent stepping at a moderate intensity for 10-20 min associated with reduced pain interference. Conclusion: These findings suggest older adults with chronic pain may benefit by moving at high-light or moderate intensities in brief bouts of at least 5 min in duration.

A biopsychosocial approach assessing pain indicators among Black men.

Introduction: The lack of empirical evidence documenting the pain experience of Black men may be the result of social messaging that men are to project strength and avoid any expression of emotion or vulnerability. This avoidant behavior however, often comes too late when illnesses/symptoms are more aggressive and/or diagnosed at a later stage. This highlights two key issues - the willingness to acknowledge pain and wanting to seek medical attention when experiencing pain. Methods: To better understand the pain experience in diverse raced and gendered groups, this secondary data analysis aimed to determine the influence identified physical, psychosocial, and behavioral health indicators have in reporting pain among Black men. Data were taken from a baseline sample of 321 Black men, >40 years old, who participated in the randomized, controlled Active & Healthy Brotherhood (AHB) project. Statistical models were calculated to determine which indicators (somatization, depression, anxiety, demographics, medical illnesses) were associated with pain reports. Results: Results showed that 22% of the men reported pain for more than 30 days, with more than half of the sample being married (54%), employed (53%), and earning an income above the federal poverty level (76%). Multivariate analyses showed that those reporting pain were more likely to be unemployed, earn less income, and reported more medical conditions and somatization tendencies (OR=3.28, 95% CI (1.33, 8.06) compared to those who did not report pain. Discussion: Findings from this study indicate that efforts are needed to identify the unique pain experiences of Black men, while recognizing its impact on their identities as a man, a person of color, and someone living with pain. This allows for more comprehensive assessments, treatment plans, and prevention approaches that may have beneficial impacts throughout the life course.

Racism exposure and trauma accumulation perpetuate pain inequities-advocating for change (RESTORATIVE): A conceptual model.

Experiences of racism occur across a continuum from denial of services to more subtle forms of discrimination and exact a significant toll. These multilevel systems of oppression accumulate as chronic stressors that cause psychological injury conceptualized as racism-based traumatic stress (RBTS). RBTS has overlapping symptoms with posttraumatic stress disorder (PTSD) with the added burden that threats are constantly present. Chronic pain is a public health crisis that is exacerbated by the intersection of racism and health inequities. However, the relationship between RBTS and pain has not yet been explored. To highlight how these phenomena are interlinked, we present Racism ExpoSure and Trauma AccumulatiOn PeRpetuate PAin InequiTIes-AdVocating for ChangE (RESTORATIVE); a novel conceptual model that integrates the models of racism and pain and demonstrates how the shared contribution of trauma symptoms (e.g., RBTS and PTSD) maintains and perpetuates chronic pain for racialized groups in the United States. Visualizing racism and pain as "two halves of the same coin," in which the accumulative effects of numerous events may moderate the severity of RBTS and pain, we emphasize the importance of within-group distinctiveness and intersectionality (overlapping identities). We call on psychologists to lead efforts in applying the RESTORATIVE model, acting as facilitators and advocates for the patient's lived experience with RBTS in clinical pain care teams. To assist with this goal, we offer suggestions for provider and researcher antiracism education, assessment of RBTS in pain populations, and discuss how cultural humility is a central component in implementing the RESTORATIVE model. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A remote group-mediated daylong physical activity intervention for older adults with chronic pain: Results of the MORPH-II randomized pilot trial.

Chronic pain is a debilitating condition that affects many older adults who often have limited access to non-pharmacological pain management strategies. One potentially effective and novel lifestyle medicine for chronic pain involves increasing physical activity through frequent movement across the day, thereby also decreasing the presence of extended sedentary bouts. The MORPH-II pilot randomized controlled refinement trial iterated on the MORPH trial, which was a first-of-its-kind group-mediated daylong physical activity (DPA) intervention for older adults with chronic pain rooted in social cognitive and self-determination theories and supported by an mHealth toolset designed to foster social connection and awareness of physical activity patterns. MORPH-II was delivered fully remotely via videoconference software and supported by a technology kit comprising an iPad, activity monitor, and wireless weight scale. It was also implemented a refined coaching model designed to help participants better understand their own patterns of activity. A total of 44 participants were randomized to receive the 12-week group-mediated DPA intervention or to a low-contact control. Qualitative interviews suggest the program was well-received by participants and that participants developed an understanding of how patterns of physical activity related to their pain symptoms. Participants also highlighted several additional areas for refinement related to the coaching model and feedback provided within the mHealth app. Analyses of covariance, controlling for baseline values, revealed a small effect (η 2 = 0.01) on pain intensity favoring the intervention condition, though both groups improved during the study period. There was a large effect favoring the intervention condition on ActivPAL-assessed average daily steps (η 2 = 0.23) and postural shifts (η 2 = 0.24). Control participants spent less time in short sedentary bouts (η 2 = 0.09), and there was a small effect (η 2 = 0.02) indicating intervention participants spent less time in extended sedentary bouts. Finally, relative to control, intervention participants demonstrated a moderate improvement in autonomy satisfaction (η 2 = 0.05), relatedness frustration (η 2 = 0.05), and competence frustration (η 2 = 0.06), and a large magnitude improvement in competence satisfaction (η 2 = 0.22). These findings indicate that the MORPH-II intervention was feasible and acceptable, and may positively impact steps, postural breaks, and several key domains of basic psychological needs detailed in self-determination theory.

Leadership roles and initiatives for diversity and inclusion in academic anesthesiology departments.

A cultural change in medicine has placed a renewed focus on the importance of a diverse and inclusive healthcare workforce. The methods employed by anesthesiology departments in pursuit of diversity and inclusion needs to be examined. OBJECTIVE: This study's objective was to assess the frequency of established leadership infrastructures and initiatives that promote diversity and inclusion within academic anesthesiology departments. DESIGN: This was a cross-sectional survey study. The authors emailed an electronic survey to 98 academic anesthesiology departments to assess leadership roles, dissemination platforms and initiatives used to support diversity and inclusion. SETTING: Academic anesthesiology department in the United States with at least 60 residents. MAIN OUTCOME AND MEASURES: The measure tested was the existence and quantification of leadership roles and initiatives directed at diversity and inclusion efforts at academic anesthesiology departments. RESULTS: The survey response rate was 49.4% (95% CI 39.3-59.6%). While 62.5% (95% CI 47.0-75.8%) of respondents reported having faculty members with a diversity and inclusion role, only 27.5% (95% CI 16.1-42.8%) reported a clearly defined leadership role such as vice-chair or committee chair. Seventy percent of respondents reported initiatives geared towards diversity using multiple platforms to showcase these initiatives. CONCLUSIONS: Based on these survey results, many anesthesia departments have developed initiatives to promote their departmental diversity. However, only a minority have established clearly defined leadership roles, which may be critical to enhance departmental success in promoting diversity and inclusion.

Building on Lessons Learned in a Mobile Intervention to Reduce Pain and Improve Health (MORPH): Protocol for the MORPH-II Trial.

BACKGROUND: Engaging in sufficient levels of physical activity, guarding against sustained sitting, and maintaining a healthy body weight represent important lifestyle strategies for managing older adults' chronic pain. Our first Mobile Health Intervention to Reduce Pain and Improve Health (MORPH) randomized pilot study demonstrated that a partially remote group-mediated diet and daylong activity intervention (ie, a focus on moving often throughout the day) can lead to improved physical function, weight loss, less pain intensity, and fewer minutes of sedentary time. We also identified unique delivery challenges that limited the program's scalability and potential efficacy. OBJECTIVE: The purpose of the MORPH-II randomized pilot study is to refine the MORPH intervention package based on feedback from MORPH and evaluate the feasibility, acceptability, and preliminary efficacy of this revised package prior to conducting a larger clinical trial. METHODS: The MORPH-II study is an iteration on MORPH designed to pilot a refined framework, enhance scalability through fully remote delivery, and increase uptake of the daylong movement protocol through revised education content and additional personalized remote coaching. Older, obese, and low-active adults with chronic multisite pain (n=30) will be randomly assigned to receive a 12-week remote group-mediated physical activity and dietary weight loss intervention followed by a 12-week maintenance period or a control condition. Those in the intervention condition will partake in weekly social cognitive theory-based group meetings via teleconference software plus one-on-one support calls on a tapered schedule. They will also engage with a tablet application paired with a wearable activity monitor and smart scale designed to provide ongoing social and behavioral support throughout the week. Those in the control group will receive only the self-monitoring tools. RESULTS: Recruitment is ongoing as of January 2021. CONCLUSIONS: Findings from MORPH-II will help guide other researchers working to intervene on sedentary behavior through frequent movement in older adults with chronic pain. TRIAL REGISTRATION: ClinicalTrials.gov NCT04655001; https://clinicaltrials.gov/ct2/show/NCT04655001. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/29013.

Association of a Health Equity Curriculum With Medical Students' Knowledge of Social Determinants of Health and Confidence in Working With Underserved Populations.

Importance: National organizations recommend that medical schools train students in the social determinants of health. Objective: To develop and evaluate a longitudinal health equity curriculum that was integrated into third-year clinical clerkships and provided experiential learning in partnership with community organizations. Design, Setting, and Participants: This longitudinal cohort study was conducted from June 2017 to October 2020 to evaluate the association of the curriculum with medical students' self-reported knowledge of social determinants of health and confidence working with underserved populations. Students from 1 large medical school in the southeastern US were included. Students in the class of 2019 and class of 2020 were surveyed at baseline (before the start of their third year), end of the third year, and graduation. The class of 2018 (No curriculum) was surveyed at graduation to serve as a control. Data analysis was conducted from June to September 2020. Exposures: The curriculum began with a health equity simulation followed by a series of modules. The class of 2019 participated in the simulation and piloted the initial 3 modules (pilot), and the class of 2020 participated in the simulation and the full 9 modules (full). Main Outcomes and Measures: A linear mixed-effects model was used to evaluate the change in the self-reported knowledge and confidence scores over time (potential scores ranged from 0 to 32, with higher scores indicating higher self-reported knowledge and confidence working with underserved populations). In secondary analyses, a Kruskal-Wallis test was conducted to compare graduation scores between the no, pilot, and full curriculum classes. Results: A total of 314 students (160 women [51.0%], 205 [65.3%] non-Hispanic White participants) completed at least 1 survey, including 125 students in the pilot, 121 in the full, and 68 in the no curriculum classes. One hundred forty-one students (44.9%) were interested in primary care. Total self-reported knowledge and confidence scores increased between baseline and end of clerkship (15.4 vs 23.7, P = .001) and baseline and graduation (15.4 vs 23.7, P = .001) for the pilot and full curriculum classes. Total scores at graduation were higher for the pilot curriculum (median, 24.0; interquartile range [IQR], 21.0-27.0; P = .001) and full curriculum classes (median, 23.0; IQR, 20.0-26.0; P = .01) compared with the no curriculum class (median, 20.5; IQR, 16.25-24.0). Conclusions and Relevance: In this cohort study of medical students, a dedicated health equity curriculum was associated with a significant improvement in students' self-reported knowledge of social determinants of health and confidence working with underserved populations.