The influence of social determinants of health on epilepsy treatment delays in an Arizona Medicaid population.

OBJECTIVE: The purpose of this study was to better understand the role of social determinants of health (SDoH) in both treatment delays and treatment gaps for individuals with epilepsy (IWE) enrolled in Arizona's Medicaid program using predictive models at the population and individual levels. METHODS: In this retrospective cohort study, two statistical regression models were developed using Arizona Medicaid medical and pharmacy claims records from 2015-2019 and selected census tract-level SDoH data. Three treatment outcomes were defined: timely treatment (treated within thirty days); delayed treatment (treated after thirty days); and untreated. For the first model, least squares regression was used to regress the epilepsy treatment delays on selected SDoH factors at the population-level. For the second model, multinomial logistic regression was used to estimate associations between epilepsy treatment delays and individual-level sociodemographic factors. RESULTS: Of the 5965 IWE identified with a new epilepsy diagnosis during the study period, 43.1% were treated with a mean delay of 180 days. Among the treated population, 42% received timely treatment. A treatment gap of at least 40.6% and potentially up to 56.9% was calculated. Individuals with epilepsy diagnosed in an inpatient setting or in emergency departments were more likely to be treated and receive timely treatment than those diagnosed in an office or clinic setting. Individuals with epilepsy diagnosed in "other" settings were more likely to go untreated or receive delayed treatment than a patient diagnosed in an office or clinic. Compared to IWE aged 31-50 years, IWE aged 0-30 years were more likely to receive timely treatment, IWE aged 51-64 years were more likely to receive delayed treatment, and IWE aged 65 years or older were more likely to go untreated. Widowed IWE were more likely to go untreated relative to single patients. Individuals with epilepsy experiencing homelessness were also more likely to go untreated. Unemployed IWE were more likely to go untreated or receive delayed treatment. Native American IWE were more likely to go untreated compared to White patients. CONCLUSIONS: Treatment gaps and treatment delays are experienced by IWE in the Arizona Medicaid population. The SDoH factors predicted to impact treatment delays include care setting, age, race, marital status, homelessness, and employment.

Necrotizing Sweet Syndrome of the Upper Extremity After Elective Hand Surgery.

Sweet syndrome, or acute febrile neutrophilic dermatosis, is a systemic disease process mainly characterized by hyperpyrexia and skin lesions. A newly described entity, necrotizing Sweet syndrome, is a severe and locally aggressive dermatological condition that clinically and histopathologically resembles a necrotizing soft tissue infection. It is characterized by pathergy, a nonspecific inflammatory response to cutaneous trauma resulting in a propagation of the disease. In contrast to a necrotizing infection, this condition responds to systemic steroids. A high clinical suspicion is required in order to distinguish a necrotizing polymicrobial infection from noninfectious necrotizing Sweet syndrome. We present a case following elective hand surgery.

Subcutaneous histiocytoid Sweet's syndrome in a patient with myelodysplastic syndrome and acute myeloblastic leukemia.

Subcutaneous histiocytoid Sweet's syndrome is a rare variant of histiocytoid Sweet's syndrome (SS). We present a 68-year-old woman with subcutaneous histiocytoid SS in association with refractory myelodysplastic syndrome transformed to acute myeloblastic leukemia (AML), status post induction chemotherapy and with persistent blasts (50%) in the bone marrow and blood, accompanied with neutropenia. The patient presented to the emergency room with fever and altered mental status. Clinical examination revealed approximately 20 scattered 0.5-2 cm, pink to pink-purple non-tender firm nodules on the legs and left arm. The differential diagnosis included Sweet's syndrome (deep), leukemia cutis, infection, polyarteritis nodosa and erythema nodosum. Histopathologic examination of a biopsy from the left arm revealed a nodular infiltrate of neutrophils and histiocytoid mononuclear cells solely in the lobular compartment of the subcutaneous fat with focal areas of necrosis. Most cells in the infiltrate labeled with myeloperoxidase (MPO) including the histiocytoid cells. The cells were negative for CD34 and CD117. All special stains for microorganisms were negative. A diagnosis of subcutaneous histiocytoid SS was made. A subcutaneous histiocytoid SS should be suspected when a neutrophilic/histiocytoid panniculitis, occurring in the setting of myeloid disorders, is encountered and after exclusion of an infectious process and leukemia cutis.

Using focus groups to understand causes for morale decline after introducing change in an IM residency program.

BACKGROUND: Although program evaluation is a core requirement of Internal Medicine residencies, little is reported in the literature regarding resident satisfaction with training. Most program evaluation consists of numerical rating scales from which it is often difficult to pinpoint exact sources of dissatisfaction. METHODS: Our goal in this work is to evaluate the utility of focus group methodology to uncover in detail the reasons for residents' deteriorating morale in an IM residency program, as well as to solicit suggestions for correction. This study employed focus groups (FG) in a qualitative research design, in which descriptive statistics from a resident program evaluation survey served to guide an intensive focus group process. Participants were 40 of 45 2nd and 3rd year internal medicine residents enrolled in the IM residency training program. Five chief residents were trained to conduct 5 focus groups with 8 residents in each group. The focus groups examined possible issues contributing to the deterioration of morale noted in the quantitative survey. RESULTS: Many unexpected themes were uncovered by the FGs. Residents identified the following factors as the major contributors to deteriorating morale: 1) Pace of change 2) Process of change 3) The role of chief residents in change 4) Fear of intimidation and retaliation. Groups also suggested practical recommendations for improving the culture of the residency. CONCLUSION: Introducing change in residency training is a challenging process. Respectful attention to resident frustrations and solution-focused discussions are necessary to understand and improve morale. Focus groups proved to be a useful tool in revealing the precise source of pervasive resident concerns as well as providing potential solutions. In addition, FGs methodology can be adapted in a practical manner to residency evaluation.

Apophysomyces elegans: a novel cause of endogenous endophthalmitis in an immunocompetent individual.

A 20-year-old male presented with sudden onset redness, pain, and decreased vision in his left eye. Best-corrected visual acuity in the left eye was noted to be perception of light positive with inaccurate projection. On clinical examination, he was diagnosed to have left eye endogenous endophthalmitis. Smear and culture of vitreous biopsy were positive for Apophysomyces elegans, a fungus known to cause extensive soft tissue infections systemically characteristically in immunocompetent individual. The patient was treated aggressively with topical, systemic, and intravitreal antifungals but had a poor visual and anatomical outcome. This is a first known report of endogenous endophthalmitis due to Apophysomyces elegans.

Evaluating the network adequacy of vision care services for children in Arizona: A cross sectional study.

Background: Vision challenges are among the most prevalent disabling conditions in childhood, affecting up to 28% of school-age children. These issues can impact the development, learning, and literacy skills of affected children. While vision problems are correctable with timely diagnosis and treatment, insufficient networks can impede children's access to comprehensive, and high-quality care. Objective: The study aims to determine where pediatric vision care network adequacy exists in the state of Arizona and where there are gaps in receiving vision care for children. Methods: This cross-sectional study assessed the adequacy of pediatric vision care networks in Arizona through a "secret shopper" phone survey. Calls were made to practices that accept Arizona's Medicaid program, Arizona Health Care Cost Containment System (AHCCCS) and/or commercial insurance. Providers were contacted following a standardized script to schedule routine appointments on behalf of 10 and 3-year-old patients enrolled in either Medicaid or commercial health insurance plans. The study examined various components of children's access to vision care services, including the reliability of provider directory information, time until the next available appointment, bilingual service offerings, ages served, region of practice and types of care available. Results: A total of 556 practices in Arizona were evaluated through simulations as patients on AHCCCS, and 510 practices were assessed through simulations as patients with commercial health insurance plans. The average wait time for the next available appointment was 13 days for both insurance types. Alarmingly, up to 74% of vision care practices in Arizona do not serve children covered by AHCCCS. Furthermore, only 41% provide services to children 5 years and younger. Conclusions: Our findings underscore the need to improve access to vision care services for children in Arizona, especially racial/ethnic minorities, low-income groups, and rural residents.

Expanding Medicaid managed care: the right choice for Texas?

We set out to determine whether expanding Medicaid managed care in Texas is the solution to the challenges faced by the state of meeting the healthcare needs of a rapidly growing Medicaid population while addressing its own fiscal limitations. We reviewed the Texas Medicaid program, the potential effects of federal healthcare reform, and the state political climate through the perspectives (advantages and disadvantages) of the primary stakeholders: patients, practitioners, hospitals, and insurers. Research was performed through online, federal and state regulatory, and legislative review. In addition, we reviewed government and peer-reviewed reports and articles pertaining to issues related to Medicaid populations, healthcare practitioners, and hospitals that serve them. Each primary stakeholder had potential advantages and disadvantages associated with the expansion of Medicaid managed care. We conclude that expanding Medicaid managed care, if done in a manner responsive to the needs of recipients, can meet enrollees' healthcare needs while controlling the state's costs.

Physician Leadership and Advocacy for Team-Based Care.

Team-based care is a strong focus and narrative in medical and health education and within health care systems. Yet it is essential to consider that there are vast differences in power, education, compensation, and job security among team members in most health professional teams. How should clinicians of status play a role in advocating for lower status members of their health care teams, and why is that role important in improving equity within clinic walls and equity and better patient care for the communities they serve?

Evaluating network adequacy of oral health services for children on Medicaid in Arizona.

PURPOSE: Inadequate networks can prevent patients from being able to see the providers that they trust and depend upon, especially for children insured through Medicaid. To improve our understanding of poor oral health care outcomes, we conducted a test of network adequacy among Medicaid pediatric dental providers in Arizona through a "secret shopper" phone survey. METHODS: This study tested multiple components of children's access to oral health care, including reliability of provider directory information, appointment availability at the practice level for children covered under Medicaid versus commercial insurance, and compliance with regulatory standards. We contacted individual providers, following a standardized script to schedule a routine appointment on behalf of a 5-year-old patient enrolled in either a Medicaid or commercial plan. We documented the time until the next available appointment, if the practice was reached, and if the practice accepted the specified insurance plan. RESULTS: We identified, catalogued, and attempted to call a total of 185 unique practices across Arizona. In four counties, we were unable to identify a single pediatric oral health provider through health plan directories. We observed minimal differences in appointment wait times between callers with commercial insurance and those insured through Medicaid. CONCLUSIONS: Our findings underscore the need to improve the accessibility of pediatric health services, especially in rural regions. Facilitating access to routine and recommended oral health screenings for children enrolled in Medicaid is imperative to appropriate stewardship and fulfilling our commitment to provide this vital public health resource.

Innovations in U.S. Health Care Delivery to Reduce Disparities in Maternal Mortality Among African American and American Indian/Alaskan Native Women.

Despite spending more on health care than any other country, the United States has the worst maternal mortality rate among all developed nations. African American and American Indian/Alaskan Native women have the worst outcomes by race, representing a stark health disparity within the country. Contributing factors disproportionately experienced by these minority populations include challenges of access to consistent and high-quality prenatal care, prevalence of underlying conditions, toxic stress due to systemic racism, and unconscious bias in health care. While many of these factors lie upstream in the lives of women, and seemingly beyond the scope of the clinical walls, the downstream health care delivery system can serve as a vital part of the solution via innovative practices, community-based collaborations, and by serving as advocates for the communities served. Such alignments between clinicians, community leaders, policymakers, and patients that extend beyond the health system can serve as the missing piece needed within the clinic to reverse the trajectory of maternal mortality for American women, especially those from traditionally underserved populations.

State Variability in Peer Review Protections Heightens Liability Risks.

OBJECTIVE: To highlight various state-specific gaps in legal protections involving the peer review process with the goal of helping participants better identify and address potential hazards so they may continue to confidently engage in peer review activities. METHODS: State laws regarding peer review protections involving privilege and confidentiality were searched through Westlaw (a legal research database) and state government websites and categorized. RESULTS: Gaps in protection were identified in 17 states and the District of Columbia. In the 18 jurisdictions in which potential legal gaps were identified, the most common exceptions involved peer review activities that were initiated without a legally required number of participants, were not formally mandated by the institution or other external body, or that were voluntarily discussed outside of the peer review context by participants in the process. CONCLUSION: The widespread variability in state-based peer review protections showcases the complexity of deciphering peer review law and emphasizes the need to not just read the relevant state and federal laws but to obtain the professional guidance of a lawyer experienced in peer review law before engaging in peer review activities. These measures will improve providers' engagement in peer review and strengthen an important tool for quality improvement.

Systems engineering analysis of diagnostic referral closed-loop processes.

BACKGROUND: Closing loops to complete diagnostic referrals remains a significant patient safety problem in most health systems, with 65%-73% failure rates and significant delays common despite years of improvement efforts, suggesting new approaches may be useful. Systems engineering (SE) methods increasingly are advocated in healthcare for their value in studying and redesigning complex processes. OBJECTIVE: Conduct a formative SE analysis of process logic, variation, reliability and failures for completing diagnostic referrals originating in two primary care practices serving different demographics, using dermatology as an illustrating use case. METHODS: An interdisciplinary team of clinicians, systems engineers, quality improvement specialists, and patient representatives collaborated to understand processes of initiating and completing diagnostic referrals. Cross-functional process maps were developed through iterative group interviews with an urban community-based health centre and a teaching practice within a large academic medical centre. Results were used to conduct an engineering process analysis, assess variation within and between practices, and identify common failure modes and potential solutions. RESULTS: Processes to complete diagnostic referrals involve many sub-standard design constructs, with significant workflow variation between and within practices, statistical instability and special cause variation in completion rates and timeliness, and only 21% of all process activities estimated as value-add. Failure modes were similar between the two practices, with most process activities relying on low-reliability concepts (eg, reminders, workarounds, education and verification/inspection). Several opportunities were identified to incorporate higher reliability process constructs (eg, simplification, consolidation, standardisation, forcing functions, automation and opt-outs). CONCLUSION: From a systems science perspective, diagnostic referral processes perform poorly in part because their fundamental designs are fraught with low-reliability characteristics and mental models, including formalised workaround and rework activities, suggesting a need for different approaches versus incremental improvement of existing processes. SE perspectives and methods offer new ways of thinking about patient safety problems, failures and potential solutions.

Two cases of isolated anterior cervical hypertrichosis.

Two unrelated Hispanic females, ages 4 and 3 years, respectively, each presented with a solitary patch of excessive terminal hair growth in the midline of the neck. This rare form of congenital localized hypertrichosis, known as anterior cervical hypertrichosis, is reported here as an isolated defect with no other underlying abnormalities.

Discordance in Perceptions of Barriers to Breast Cancer Treatment Between Hispanic Women and Their Providers.

Despite comparable screening and incidence rates that are 26% below that of non-Hispanic Whites, Hispanic women present with breast cancer at more advanced stages of disease, representing a continuing and troubling health disparity for this population. Reducing these disparities warrant more innovative research approaches to better understand perspectives of Hispanic patients regarding barriers to treatment and how these perspectives compare to those of their providers. A pilot qualitative study was conducted at a major urban cancer center in Arizona that measured both patient and provider perspectives regarding barriers to treatment. Through a multimethod qualitative analysis, researchers surveyed patients and providers to identify perceived barriers and discordance in shared understanding. Data collection and analysis consisted of surveying patients and providers, then performing inductive qualitative analysis. Results indicated the highest concordance, or shared understanding, between patients and providers was in recognizing barriers within delivery of care, such as cost of care and insurance coverage. The greatest discordance, or gaps in shared understanding, existed in upstream barriers of the health care system, such as emotional support and trust in systems. These results underscore the gap in shared understanding between patients and providers regarding upstream barriers to care as well as the nonclinical social determinants of health Hispanic patients face in accessing breast cancer treatment. More research is warranted using this approach as a tool to reduce health disparities.

Dual-time point FDG PET imaging in the evaluation of pulmonary nodules with minimally increased metabolic activity.

PURPOSE: FDG PET has high accuracy in the evaluation of lung nodules. A standardized uptake value (SUV) > or =2.5 is frequently used as a criterion for malignancy in this setting. However, some malignant nodules have only mild FDG activity with a SUV less than 2.5. Assessment of the etiology of lung nodules with only mild metabolic activity remains difficult. This study was undertaken to compare the accuracy of dual-time point and standard single-time FDG PET imaging in the evaluation of such lung nodules. METHODS: Four hundred fifty-seven dual-time FDG PET scans for lung nodules were retrospectively analyzed. Among them, 46 met the selection criteria and were included for the final analysis. Five methods of interpreting FDG PET results were compared. These methods included visual analysis for both initial and delayed images; SUV analysis for both initial and delayed images in which a SUV of 2.5 is regarded as criteria for malignancy; and finally, the retention index analysis in which a 10% increase in SUV on the delayed images was regarded as an indication of malignancy. RESULTS: The lowest accuracies came from the visual and single SUV analysis on the initial images. The visual and single SUV analyses on the delayed images produced increased accuracy. The highest accuracy (84.8%) was obtained when a retention index of more than 10% was used as criteria for malignancy. CONCLUSION: Dual-time FDG PET imaging has the potential for improving accuracy of a test in the evaluation of lung nodules with only borderline levels of increased metabolic activity.