Emergency medicine physician workforce attrition differences by age and gender.

BACKGROUND: Emergency care workforce concerns have gained national prominence given recent data suggesting higher than previously estimated attrition. With little known regarding characteristics of physicians leaving the workforce, we sought to investigate the age and number of years since residency graduation at which male and female emergency physicians (EPs) exhibited workforce attrition. METHODS: We performed a repeated cross-sectional analysis of EPs reimbursed by Medicare linked to date of birth and residency graduation date data from the American Board of Emergency Medicine for the years 2013-2020. Stratified by gender, our primary outcomes were the median age and number of years since residency graduation at the time of attrition, defined as the last year during the study time frame that an EP provided clinical services. We constructed a multivariate logistic regression model to examine the association between gender and EP workforce attrition. RESULTS: A total of 25,839 (70.2%) male and 10,954 (29.8%) female EPs were included. During the study years, 5905 male EPs exhibited attrition at a median (interquartile range [IQR]) age of 56.4 (44.5-65.4) years, and 2463 female EPs exhibited attrition at a median (IQR) age of 44.0 (38.0-53.9) years. Female gender (adjusted odds ratio 2.30, 95% confidence interval 1.82-2.91) was significantly associated with attrition from the workforce. Male and female EPs had respective median (IQR) post-residency graduation times in the workforce of 17.5 (9.5-25.5) years and 10.5 (5.5-18.5) years among those who exhibited attrition and one in 13 males and one in 10 females exited clinical practice within 5 years of residency graduation. CONCLUSIONS: Female physicians exhibited attrition from the EM workforce at an age approximately 12 years younger than male physicians. These data identify widespread disparities regarding EM workforce attrition that are critical to address to ensure stability, longevity, and diversity in the EP workforce.

Black Women's Perspectives on Breast Cancer Risk Assessment.

PURPOSE: The aim of this study was to gather the perspectives of Black women on breast cancer risk assessment through a series of one-on-one interviews. METHODS: The authors conducted a cross-sectional qualitative study consisting of one-on-one semistructured telephone interviews with Black women in Tennessee between September 2020 and November 2020. Guided by the Health Belief Model, qualitative analysis of interview data was performed in an iterative inductive and deductive approach and resulted in the development of a conceptual framework to depict influences on a woman's decision to engage with breast cancer risk assessment. RESULTS: A total of 37 interviews were completed, and a framework of influences on a woman's decision to engage in breast cancer risk assessment was developed. Study participants identified several emerging themes regarding women's perspectives on breast cancer risk assessment and potential influences on women's decisions to engage with risk assessment. Much of women's decision context was based on risk appraisal (perceived severity of cancer and susceptibility of cancer), emotions (fear and trust), and perceived risks and benefits of having risk assessment. The decision was further influenced by modifiers such as communication, the risk assessment protocol, access to health care, knowledge, and health status. Perceived challenges to follow-up if identified as high risk also influenced women's decisions to pursue risk assessment. CONCLUSIONS: Black women in this study identified several barriers to engagement with breast cancer risk assessment. Efforts to overcome these barriers and increase the use of breast cancer risk assessment can potentially serve as a catalyst to address existing breast cancer disparities. Continued work is needed to develop patient-centric strategies to overcome identified barriers.

Barriers to Implementation of Breast Cancer Risk Assessment: The Health Care Team Perspective.

PURPOSE: To assess health care professionals' perceptions of barriers to the utilization of breast cancer risk assessment tools in the public health setting through a series of one-on-one interviews with health care team members. METHODS: We conducted a cross-sectional qualitative study consisting of one-on-one semistructured telephone interviews with health care team members in the public health setting in the state of Tennessee between May 2020 and October 2020. An iterative inductive-deductive approach was used for qualitative analysis of interview data, resulting in the development of a conceptual framework to depict influences of provider behavior in the utilization of breast cancer risk assessment. RESULTS: A total of 24 interviews were completed, and a framework of influences of provider behavior in the utilization of breast cancer risk assessment was developed. Participants identified barriers to the utilization of breast cancer risk assessment (knowledge and understanding of risk assessment tools, workflow challenges, and availability of personnel); patient-level barriers as perceived by health care team members (psychological, economic, educational, and environmental); and strategies to increase the utilization of breast cancer risk assessment at the provider level (leadership buy-in, training, supportive policies, and incentives) and patient level (improved communication and better understanding of patients' perceived cancer risk and severity of cancer). CONCLUSIONS: Understanding barriers to implementation of breast cancer risk assessment and strategies to overcome these barriers as perceived by health care team members offers an opportunity to improve implementation of risk assessment and to identify a racially, geographically, and socioeconomically diverse population of young women at high risk for breast cancer.

Limited English Proficiency as a Barrier to Inclusion in Emergency Medicine-Based Clinical Stroke Research.

AIMS: Individuals with Limited English Proficiency (LEP) represent a growing percentage of the U.S. population yet face inequities in health outcomes and barriers to routine care. Despite these disparities, LEP populations are often excluded from clinical research studies. The aim of this study was to assess for the inclusion of LEP populations in published acute care stroke research in the U.S. METHODS: A systematic review was conducted of publications from three databases using acute care and stroke specific Medical Subject Heading key terms. The primary outcome was whether language was used as inclusion or exclusion criteria for study participation and the secondary outcome was whether the study explored outcomes by language. RESULTS: A total of 167 studies were included. Twenty-two studies (13.2%) indicated the use of language as inclusion/exclusion criteria within the manuscript or dataset/registry and only 17 studies (10.2%) explicitly included LEP patients either in the study or dataset/registry. Only four papers (2%) include language as a primary variable. CONCLUSIONS: As LEP populations are not routinely incorporated in acute care stroke research, it is critical that researchers engage in language-inclusive research practices to ensure all patients are equitably represented in research studies and ultimately evidence-based practices.

Post-Roe emergency medicine: Policy, clinical, training, and individual implications for emergency clinicians.

In June 2022, the United States Supreme Court decision Dobbs v. Jackson Women's Health Organization overturned Roe v. Wade, removing almost 50 years of precedent and enabling the imposition of a wide range of state-level restrictions on abortion access. Historical data from the United States and internationally demonstrate that the removal of safe abortion options will increase complications and the health risks to pregnant patients. Because the emergency department is a critical access point for reproductive health care, emergency clinicians must be prepared for the policy, clinical, educational, and legal implications of this change. The goal of this paper, therefore, is to describe the impact of the reversal of Roe v. Wade on health equity and reproductive justice, the provision of emergency care education and training, and the specific legal and reproductive consequences for emergency clinicians. Finally, we conclude with specific recommended policy and advocacy responses for emergency medicine clinicians.

Growth of Physicians and Nurse Practitioners Practicing Full Time in Nursing Homes.

OBJECTIVES: The objective was to describe the growth of physicians, nurse practitioners (NPs), and physician assistants (PAs) who practice full time in nursing homes, to assess resident and nursing home characteristics associated with receiving care from full-time providers, and describe variation among nursing homes in use of full-time providers. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: A 20% national sample Medicare data on long-term care residents in 2008 to 2018 and the physicians, NPs, and PAs who submitted charges to Medicare for their care. METHODS: We measured the percentage of provider charges for services rendered in nursing homes, in addition to resident and facility characteristics. RESULTS: Full-time nursing home providers increased from 26.0% of all nursing home providers in 2008 to 44.6% in 2017. The largest increase was in NPs: from 1986 in 2008 to 4479 in 2017. Resident age, sex, Medicaid eligibility, and race/ethnicity had minimal association with the odds of having a full-time provider, whereas residents with an NP primary care provider were 23.0 times more likely (95% confidence interval = 21.6, 24.6) to have a full-time provider. Residents who received care from both a physician and an NP or PA increased from 33.6% in 2008 to 62.5% in 2018. There was large variation among facilities in the percentage of residents with full-time providers, from 5.72% of residents with full-time providers in the bottom quintile of facilities to 91.44% in the top quintile. Individual nursing homes accounted for 59% of the variation in whether a resident had a full-time provider. CONCLUSIONS AND IMPLICATIONS: The percentage of nursing home residents with full-time providers continues to grow, with very large variation among nursing homes.

Assessing Association Between Team Structure and Health Outcome and Cost by Social Network Analysis.

BACKGROUND/OBJECTIVE: To assess the impact of team structure composition and degree of collaboration among various providers on process and outcomes of primary care. DESIGN: Cross-sectional study. SETTING: Data from 20% randomly selected primary care service areas in the 2015 Medicare claims were used to identify primary care practices. PARTICIPANTS: 449,460 patients with diabetes, heart failure, or chronic obstructive pulmonary disease cared for by the identified primary care practices. MEASUREMENTS: Social network analysis measures, including edge density, degree centralization, and betweenness centralization for each practice. RESULTS: When compared with practices with MDs and nurse practitioners (NPs) or/and physicians assistants (PAs), the practices with MDs had only lower degree of centralization and higher MD-to-MD connectedness. Within the primary care practices comprising MDs, NPs, or/and PAs, the nonphysician providers were more connected (measured as edge density) to all providers in the practice but with higher degree of centralization compared with the MDs in the practice. After adjusting for patient characteristics and type of practice, higher edge density was associated with lower odds of hospitalization (odds ratio (OR) = 0.89, 95% confidence interval (CI) = 0.79-0.99), emergency department (ER) admission (OR = 0.80, 95% CI = 0.70-0.92), and total spending (cost ratio (CR) = 0.86, standard error of the mean (SE) = 0.038). Conversely, higher degree centralization was associated with higher rates of hospitalization (OR = 1.15, 95% CI = 1.03-1.28), ER admission (OR = 1.23, 95% CI = 1.08-1.40), and total spending (CR = 1.14, SE = 0.037). However, higher degree centralization was associated with lower rates of potentially inappropriate medications (OR = 0.90, 95% CI = 0.81-0.99). Team leadership by an NP versus an MD was similar in the rate of ER admissions, hospitalizations, or total spending. CONCLUSION: Our findings showed that highly connected primary care practices with high collaborative care and less top-down MD-centered authority have lower odds of hospitalization, fewer ER admissions, and less total spending; findings likely reflecting better communication and more coordinated care of older patients.

Gender Disparities in Academic Emergency Medicine: Strategies for the Recruitment, Retention, and Promotion of Women.

Although women comprise half of all medical students, the number of female academic emergency medicine (EM) physicians remains at approximately 27%. In addition, despite having equivalent credentials, female EM faculty remain underrecognized and undercompensated when compared to their male counterparts. Recent studies have shown superior outcomes among patients treated by EM physicians who are women; however, disparities in advancement persist. This white paper, prepared on behalf of the Academy for Women in Academic Emergency Medicine, describes recent evidence demonstrating gender disparities in the EM workforce including content presented at the 2019 Society for Academic Emergency Medicine Annual Scientific Meeting. The authors describe strategies to address the identified problems. Specific recommendations include individual as well as institutional/systems-level approaches to creating directed programming and initiatives to recruit, support, and promote women at all aspects of the career continuum.

Frequency of Seeing People Walk and Aerobic Physical Activity Among Latino Adults.

BACKGROUND: Little research has examined gender differences in the association of seeing others exercise, in the neighborhood context, with physical activity, particularly for diverse racial/ethnic groups. The authors examined the association between frequency of seeing people walk and aerobic activity by gender among Latinos. METHODS: The authors used cross-sectional 2015 National Health Interview Survey data on Latino participants ≥18 years (n = 5147). Multinomial logistic regression models estimated the association between seeing people walk and level of aerobic physical activity. RESULTS: Men reporting seeing people walk every 2 to 3 days and every day were more likely to meet the aerobic activity recommendation (odds ratio [OR] 2.02; 95% confidence interval [CI], 1.05-3.89 and OR 1.96; 95% CI, 1.23-3.14, respectively). Among women, those seeing people walk every day and every 2 to 3 days were likely to engage in some aerobic activity (OR 1.88; 95% CI, 1.26-2.80 and OR 2.16; 95% CI, 1.23-3.18, respectively) and meet the recommendation (OR 1.73; 95% CI, 1.24-2.42 and OR 1.66; 95% CI, 1.03-2.67, respectively). Women seeing people walk about once a week were also likely to engage in some activity (OR 3.06; 95% CI, 1.59-5.89). CONCLUSIONS: Among Latino men and women, seeing people walk is associated with meeting the aerobic activity guideline. Results suggest that adoption of physical activity may in part be driven by neighborhood-level behavioral norms and by inference characteristics of the neighborhood that support walking.

Development of Autonomous Advanced Disinfection Tunnel to Tackle External Surface Disinfection of COVID-19 Virus in Public Places.

This paper describes a robust autonomous disinfection tunnel to disinfect external surfaces of COVID-19 virus such as clothes and open body sections in public places such as airports, office complexes, schools, and malls. To make the tunnel effective and highly efficient, it has been provided with two chambers with three disinfection processes. Due to the multiple processes, the possibility of neutralizing the virus is quite high and higher than other solutions available at this point for this purpose. Chamber 1 sprays the solution of a disinfectant on the person. This solution can be either a dilute solution of approved chemical or any Ayurvedic/herbal disinfectant. Once the person enters chamber 2, he/she is exposed to hot air at 70 °C along with far-ultraviolet C rays (207-222 nm). Both chambers function autonomously by detecting a person in a chamber using ultrasonic sensors. The proposed tunnel is developed under industry-academia collaboration jointly by Technopark@iitk and ALIMCO under the ambit of the Ministry of Human Resources Development and the Ministry of Social Justice and Empowerment, respectively. The tunnel is referred to as the 'Techno Advanced Disinfection Tunnel' (TADT).

Health Literacy and Self-Rated Health among Homeless Adults.

Poor health literacy reduces the efficacy of behavior change interventions, hampers management of health conditions, and attenuates understanding of the prevention and treatment of diseases. Poor health literacy has also been linked to fair/poor self-rated health in domiciled samples; however, there is a paucity of studies on the relation amongst homeless adults, who bear a disproportionate burden of disease and disability and require high level of care and access to health services. Here, we examined the association between health literacy and self-rated health among a convenience sample of homeless adults. Participants were recruited from six homeless-serving agencies in Oklahoma City (N = 575; 63% men, Mage = 43.6±12.3). Logistic regression was used to assess the association between health literacy (confidence completing medical forms: extremely/quite a bit vs somewhat/little bit/not at all) and self-rated health (poor/fair vs good/very good/excellent) controlling for age, subjective social status, education, race, sex, income, health insurance, employment, social security recipient status, diabetes diagnosis, high blood pressure diagnosis, and high cholesterol diagnosis. In the adjusted model, health literate homeless individuals had greater odds of endorsing good/very good/excellent self-rated health compared to those somewhat/a little bit/not at all confident completing medical forms (AOR = 2.02, [CI95% = 1.35-3.02]). Interventions targeted at adjusting reading level and comprehensibility of health information are needed for homeless individuals with poor/limited health literacy, which may ultimately impact their self-rated health. Shelters and homeless-serving agencies could host classes focused on practical skills for enhancing health literacy and/or provide navigation services.

Exposure to Violence and Sleep Inadequacies among Men and Women Living in a Shelter Setting.

BACKGROUND: Exposure to violence may explain sleep inadequacies reported by homeless adults, with women being potentially more susceptible to violence and sleep disturbances than men. This study examined the association between violence and sleep inadequacies among homeless adults and explored differences by sex. METHODS: Adult participants were recruited from a shelter (N=194; 71.1% men, Mage = 43.8±12.2). Participants self-reported victimization and/or witnessing violence (mugging, fight, and/or sexual assault) at the shelter, sleep duration (over an average 24 hours), insufficient sleep (days without sufficient rest/sleep), and unintentional daytime sleep (days with unintentional sleep) in the past month. Linear regressions were used to estimate associations between violence and sleep inadequacies, controlling for sex, age, race, months homeless, and depression. Moderation by sex was examined via an interaction term following mean-centering of variables. RESULTS: Overall, 20.6% of participants (n=40) reported victimization since moving to the shelter. In the last month, participants reported witnessing an average of 2.9±5.1 acts of violence. Over the same timeframe, participants reported 6.9±2.0 hours of sleep nightly, 11.2±10.7 days of insufficient sleep, and 6.2±8.8 days with unintentional daytime sleep. In adjusted analyses, witnessing violence was associated with insufficient sleep (p=.001). Men and women differed only in age and race in unadjusted analyses; sex was not a significant moderator of any association between violence and sleep in adjusted analyses. CONCLUSIONS: Links between witnessing violence and sleep inadequacies should be considered in shelter health promotion efforts. Successful efforts to minimize violence may reduce insufficient sleep amongst both sexes.

Factors Associated with Refugee Acute Healthcare Utilization in Southern Connecticut.

Our objective was to examine refugees' acute care use early in resettlement. We conducted a retrospective cohort study of acute care use, emergency room and hospital visits, by adult refugees arriving in Southern Connecticut between 2/1/2013 and 2/1/2015. We examined associations between any acute care use and collected demographic as well as health characteristics. Of the 248 refugees in our sample, 57% had a medical evaluation within 30 days of arrival. 102 (41%) had at least one acute care visit within 8 months of arrival. Male sex (OR 1.90, 95% CI 1.09-3.30) and prior history of hypertension (OR 2.87, 95% CI 1.06-7.33) were associated with greater likelihood of an acute care visit within 8 months of arrival, while having a medical evaluation within 30 days of arrival was associated with lower likelihood (OR 0.56, 95% CI 0.32-0.98). Designing systems to ensure timely evaluations of newly arrived refugees may reduce frequent acute care utilization.

Global Health and Emergency Care: Overcoming Clinical Research Barriers.

OBJECTIVES: There are many barriers impeding the conduct of high-quality emergency care research, particularly in low- and middle-income countries. Several of these barriers were originally outlined in 2013 as part of the Academic Emergency Medicine Global Health and Emergency Care Consensus Conference. This paper seeks to establish a broader consensus on the barriers to emergency care research globally and proposes a comprehensive array of new recommendations to overcome these barriers. METHODS: An electronic survey was conducted of a purposive sample of global emergency medicine research experts from around the world to describe the major challenges and solutions to conducting emergency care research in low-resource settings and rank them by importance. The Global Emergency Medicine Think Tank Clinical Research Working Group at the Society for Academic Emergency Medicine 2016 Annual Meeting utilized a modified Delphi technique for consensus-based decision making to categorize and expand upon these barriers and develop a comprehensive array of proposed solutions. RESULTS: The working group identified four broad categories of barriers to conducting emergency care research globally, including 1) the limited availability of research personnel, particularly those with prior research training; 2) logistic barriers and lack of standardization of data collection; 3) ethical barriers to conducting research in resource-limited settings, particularly when no local institutional review board is available; and 4) the relative dearth of funding for global emergency care research. Proposed solutions included building a diverse and interdisciplinary research team structured to promote mentorship of junior researchers, utilizing local research assistants or technologic tools such as telemedicine for language translation, making use of new tools such as mobile health (mHealth) to standardize and streamline data collection, identifying alternatives to local institutional review board approval and the use of community consent when appropriate, and increased advocacy for global emergency care research funding. CONCLUSIONS: Significant barriers to the conduct of high-quality global emergency care research persist, and innovative strategies need to be adopted to promote and grow the field of global emergency care research. This paper provides a global consensus on the most important barriers identified, as well as recommendations for cost-effective strategies for overcoming these barriers with the overall goal of promoting high-quality research and improving emergency care worldwide.

Refugee Resettlement Patterns and State-Level Health Care Insurance Access in the United States.

We sought to evaluate the relationship between state-level implementation of the Patient Protection and Affordable Care Act (ACA) and resettlement patterns among refugees. We linked federal refugee resettlement data to ACA expansion data and found that refugee resettlement rates are not significantly different according to state-level insurance expansion or cost. Forty percent of refugees have resettled to states without Medicaid expansion. The wide state-level variability in implementation of the ACA should be considered by federal agencies seeking to optimize access to health insurance coverage among refugees who have resettled to the United States.