Patients With ST-Segment Elevation Myocardial Infarction and Cerebrovascular Accidents: Impact of COVID-19 Vaccination on Mortality.

Background: Coronavirus disease 2019 (COVID-19) infection is associated with proinflammatory states and adverse health outcomes such as ST-segment elevation myocardial infarction (STEMI) and cerebrovascular accidents (CVA). Limited evidence suggests that COVID-19 vaccination may decrease the adverse impact of COVID-19 infections. This study was designed to determine if patients who received COVID-19 vaccination had lower mortality from STEMI and CVA. Methods: This is a retrospective comparative analysis of 3,050 patients, who were admitted to the hospital and diagnosed with STEMI or CVA between April 1, 2019, and April 1, 2022. Patients were divided into three different timeframes: pre-COVID (April 1, 2019, to March 31, 2020), COVID (April 1, 2020 to March 31, 2021), and post-COVID (April 1, 2021 to March 31, 2022). Chi-square analysis was completed to analyze associations between STEMI, CVA, and vaccination status. A multinominal logistic regression was used to determine significant predictors for in-hospital mortality. Results: A total of 3,050 patients were admitted (1,873 STEMI and 1,177 CVA). STEMI accounted for about 60% of cases in each of the three time periods. There was no statistical difference in STEMI or CVA percentages in the three time periods. There was increased mortality in STEMI and CVA patients (odds ratio (OR) = 11.4; P < 0.001), but patients who received the COVID-19 vaccine were less likely to die (OR = 0.51, 95% confidence interval (CI): 0.28 - 0.93; P < 0.027) when compared to those who were unvaccinated. There was increased risk of death in patients with atrial fibrillation (AFIB) (OR = 2.43; P < 0.001) and chronic heart failure (CHF) (OR = 1.76; P = 0.004). There was increased mortality risk associated with age (OR =1.03; P = 0.001). Patients with coronary artery disease (CAD) (OR = 0.45; P = 0.014) and hyperlipidemia (OR = 0.29; P < 0.001) were less likely to die. Conclusions: Vaccination against COVID-19 was associated with reduced mortality rates in patients hospitalized with STEMI and CVA. Patients with pre-existing cardiovascular comorbidities such as CAD and hyperlipidemia also had lower mortality.

The Impact of a New Internal Medicine Residency Program on Patient Satisfaction Scores for Teaching Hospitalist Faculty Compared to Non-teaching Hospitalist.

INTRODUCTION: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a national survey sent to patients to measure their inpatient experience. Graduate medical education programs may affect a sponsoring institution in various ways, but there has been little research into the effect of teaching hospitalist faculty on HCAHPS scores in a community-based hospital. The aim of the current study is to evaluate if the introduction of internal medicine resident physicians would affect the HCAHPS scores of patients admitted by hospitalist faculty physicians. METHODS: This was a retrospective analysis of anonymous patient satisfaction survey data for internal medicine hospitalist teams from January 2019 to December 2019. Data were retrieved from the Press Ganey database. We compared two groups: teaching hospitalists (N = 12) and non-teaching hospitalists (N = 34). Data were divided into two time periods: January to June (pre-residents) and July to December (post-residents). RESULTS:  From January to June (pre-residents), 646 HCAHPS surveys were returned. For the post-resident cohort (July to December), a total of 487 surveys were returned. The "Recommend" domain, showed a significant improvement in the mean pre-resident to post-resident (57% to 69%; p = 0.0351). CONCLUSION: There was a significant increase in the mean rating of the "Recommend" hospital domain for the teaching hospitalists when compared to the non-teaching after the addition of a new internal medicine residency program.

Performance of third-year medical students on a rural family medicine clerkship.

BACKGROUND AND OBJECTIVES: In 1999 the University of Kansas School of Medicine established a rural option for the required family medicine clerkship to increase student exposure to rural locations. The emphasis at these sites was in experiential learning, and students did not attend lectures. To assure that students who chose the rural option were receiving an equivalent educational experience, we compared the performance of rural students to their peers that received the standard clerkship experience. METHODS: We used data from family medicine clerkship students during 1999--2011 to compare rural students with those that remained on the main campus. Comparison of the groups was made with regard to previous academic performance and demographic data to assess for initial differences. While the rural students were more likely to be Caucasian, there was otherwise no statistical significance between the groups. We then compared their National Board of Medical Examiners (NBME) exam performance and their overall grade. RESULTS: Students who chose a rural location had a significantly higher clerkship grade. This was due to higher clinical evaluations. CONCLUSIONS: Students who completed a rural family medicine clerkship are not at an academic disadvantage. There are many possible explanations for better clinical evaluations, and a comparison of performance on the clinical skills assessment would be useful to determine whether the increased clinical experience during the rural option created a difference in clinical skills.

Common lung conditions: asthma.

Asthma is a common respiratory disease that leads to school and work absenteeism, office and emergency department visits, hospitalization, and mortality. Dyspnea and wheezing are caused by airway inflammation. Asthma severity scores are used to predict the risk of exacerbations. Severity assessment instruments include questions about daytime and nighttime symptoms, use of short-acting beta2-agonists, and the effect of symptoms on daily activities. The 4 components of effective asthma management are monitoring, education, control of environmental factors, and pharmacotherapy. Several national quality measures are used to measure asthma care. The National Healthcare Quality & Disparities reports measure use of drugs, routine examinations, smoking cessation, influenza vaccination, emergency department visits, and urgent ambulatory visits. Electronic health records can be used to create asthma registries to identify patients who are at higher risk of exacerbations. Interventions that have been shown to improve asthma outcomes include asthma self-management and education, risk stratification of asthma patients, and improvement of drug adherence. Providing asthma education for patients and family members has been shown to decrease hospitalizations and emergency department visits.

Common lung conditions: acute dyspnea.

Dyspnea is a subjective experience of breathing discomfort; patients experience qualitatively distinct sensations that vary in intensity. Acute dyspnea might be secondary to an acute problem, or it might be an exacerbation of an existing disease (eg, asthma, chronic obstructive pulmonary disease, heart failure). It also accompanies a variety of illnesses at the end of life. New information has changed differentiation between respiratory and cardiovascular etiologies of acute dyspnea, as well as rapid diagnosis of pulmonary embolism. Management of acute dyspnea from hypercapnic failure also has changed. Patients presenting with dyspnea most commonly have underlying cardiovascular and/or respiratory etiologies, and differentiating between the two can be challenging. B-type natriuretic peptide (BNP) and N-terminal proB-type natriuretic peptide (NT-proBNP) are elevated when ventricular wall tension increases (eg, during a heart failure exacerbation). BNP and NT-proBNP are most useful for identifying patients with dyspnea who do not have heart failure. A BNP level less than 50 pg/mL has a negative predictive value of 96%, effectively ruling out heart failure; a serum BNP level less than 100 pg/mL has a negative likelihood ratio of 0.11. Patients with pulmonary embolism often present with dyspnea, and this condition needs to be diagnosed and managed expeditiously. When pulmonary embolism is suspected, use a clinical decision rule (eg, the Wells rule, the Geneva rule) to establish the probability of this condition. For patients with a low probability, obtain a D-dimer test; if the D-dimer result is negative, monitor the patient. A positive D-dimer result requires further investigation. For patients with intermediate or high probability, obtain computed tomography pulmonary angiography for a definitive diagnosis. Patients who have dyspnea from a chronic obstructive pulmonary disease exacerbation can experience hypercapnic failure. As an adjunct to usual medical treatment, noninvasive positive pressure ventilation decreases the need for mechanical ventilation and is particularly useful in patients who have chosen not to be resuscitated with intubation.

Common lung conditions: chronic obstructive pulmonary disease.

The etiology of chronic obstructive pulmonary disease (COPD) is chronic lung inflammation. In the United States, this inflammation most commonly is caused by smoking. COPD is diagnosed when an at-risk patient presents with respiratory symptoms and has irreversible airway obstruction indicated by a forced expiratory volume in 1 second/forced vital capacity ratio of less than 0.7. Management goals for COPD include smoking cessation, symptom reduction, exacerbation reduction, hospitalization avoidance, and improvement of quality of life. Stable patients with COPD who remain symptomatic despite using short-acting bronchodilators should start inhaled maintenance drugs to reduce symptoms and exacerbations, avoid hospitalizations, and improve quality of life. A long-acting anticholinergic or a long-acting beta2-agonist (LABA) can be used for initial therapy; these drugs have fewer adverse effects than inhaled corticosteroids (ICS). If patients remain symptomatic despite monotherapy, dual therapy with a long-acting anticholinergic and a LABA, or a LABA and an ICS, may be beneficial. Triple therapy (ie, a long-acting anticholinergic, a LABA, and an ICS) also is used, but it is unclear if triple therapy is superior to dual therapy. Roflumilast, an oral selective inhibitor of phosphodiesterase 4, is used to manage moderate to severe COPD. Continuous oxygen therapy is indicated for patients with COPD who have severe hypoxemia (ie, PaO2 less than 55 mm Hg or an oxygen saturation less than 88% on room air). Nonpharmacologic strategies also are useful to improve patient outcomes. Pulmonary rehabilitation improves dyspnea and quality of life. Pulmonary rehabilitation after an acute exacerbation reduces hospitalizations and mortality, and improves quality of life and exercise capacity. Smoking cessation is the most effective management strategy for reducing morbidity and mortality in patients with COPD. Lung volume reduction surgery, bullectomy, and lung transplantation are surgical interventions that are appropriate for some patients with COPD.

Common lung conditions: environmental pollutants and lung disease.

Exposure to environmental pollutants can have short- and long-term effects on lung health. Sources of air pollution include gases (eg, carbon monoxide, ozone) and particulate matter (eg, soot, dust). In the United States, the Environmental Protection Agency regulates air pollution. Elevated ozone concentrations are associated with increases in lung-related hospitalizations and mortality. Elevated particulate matter pollution increases the risk of cardiopulmonary and lung cancer mortality. Occupations with high exposures to pollutants (eg, heavy construction work, truck driving, auto mechanics) pose higher risk of chronic obstructive lung disease. Some industrial settings (eg, agriculture, sawmills, meat packing plants) also are associated with higher risks from pollutants. The Environmental Protection Agency issues an air quality index for cities and regions in the United States. The upper levels on the index are associated with increases in asthma-related emergency department visits and hospitalizations. Damp and moldy housing might make asthma symptoms worse; individuals from lower socioeconomic groups who live in lower quality housing are particularly at risk. Other household exposures that can have negative effects on lung health include radon, nanoparticles, and biomass fuels.

Mid-clerkship feedback is effective in changing students' recorded patient encounters.

BACKGROUND AND OBJECTIVES: Family medicine clerkship directors review students' patient encounter logs. Encounter data can be used to alter students' learning experiences. Our purpose was to determine if students record different types of patient encounters before and after reviewing log data with clerkship directors. METHODS: Clerkship directors met with each student at clerkship midpoint, reviewed encounter data, and encouraged the student to seek out less frequently seen diseases. RESULTS: A total of 56/105 students (53%) saw different types of patients after the review. CONCLUSIONS: More than half of the students recorded different types of patient encounters after an intervention encouraging them to do so.

Eliciting the patient's perspective: does experience or type of case make a difference?

OBJECTIVE: Patient-centered interviewing is an increasingly important aspect of medical education. One way to quantify this skill is the Four Habits Model, which helps to organize medical interviewing. The Four Habits are: invest in the beginning, elicit the patient's perspective, demonstrate empathy and invest in the end. In a previous study at our institution, students were competent in all of the habits but "eliciting the patient's perspective" during a standardized patient case. Based on this study, we hypothesized that the students' poor performance could be related to the type of case or to clinical experience. METHODS: We placed three "eliciting the patient's perspective" items on the checklist for two standardized patients, one with and one without a clear diagnosis. We planned to compare group performance between cases and semesters of the third year. We hypothesized that students would be more patient-centered earlier in the year and with an ambiguous diagnosis. RESULTS: Students were more patient-centered with the ambiguous diagnosis and later in their third year. Patient-centeredness was measured by an eliciting the patient's perspective (EPP) score based on the checklist items. CONCLUSION: Our results provide information that may help guide curriculum development and future study to advance patient-centered interviewing skills.

Information-gathering patterns associated with higher rates of diagnostic error.

Diagnostic errors are an important source of medical errors. Problematic information-gathering is a common cause of diagnostic errors among physicians and medical students. The objectives of this study were to (1) determine if medical students' information-gathering patterns formed clusters of similar strategies, and if so (2) to calculate the percentage of incorrect diagnoses in each cluster. A total of 141 2nd year medical students completed a computer case simulation. Each student's information-gathering pattern included the sequence of history, physical examination, and ancillary testing items chosen from a predefined list. We analyzed the patterns using an artificial neural network and compared percentages of incorrect diagnoses among clusters of information-gathering patterns. We input patterns into a 35 x 35 self organizing map. The network trained for 10,000 epochs. The number of students at each neuron formed a surface that was statistically smoothed into clusters. Each student was assigned to one cluster, the cluster that contributed the largest value to the smoothed function at the student's location in the grid. Seven clusters were identified. Percentage of incorrect diagnoses differed significantly among clusters (Range 0-42%, Chi (2) = 13.62, P = .034). Distance of each cluster from the worst performing cluster was used to rank clusters. This rank was compared to rank determined by percentage incorrect. We found a high positive correlation (Spearman Correlation = .893, P = .007). Clusters closest to the worst performing cluster had the highest percentages of incorrect diagnoses. Patterns of information-gathering were distinct and had different rates of diagnostic error.

Teaching medical students to prioritize preventive services.

BACKGROUND: Clinicians cannot provide all recommended preventive services in a single office visit and must learn to prioritize. This skill is not overtly addressed in medical school. METHODS: We designed a workshop to teach third-year medical students to prioritize preventive services during an office visit. In a prospective controlled trial, we compared performance on a standardized patient case. RESULTS: Students performed well, but there was no significant difference between intervention and control groups' mean scores on the standardized patient encounter. CONCLUSIONS: Our brief intervention failed to increase students' scores on a standardized patient case requiring preventive services prioritization.

Changing practice patterns of family medicine graduates: a comparison of alumni surveys from 1998 to 2004.

BACKGROUND AND OBJECTIVE: The University of Missouri family medicine residency has 297 family physician graduates. We suspected that the practice patterns of graduates were changing. METHODS: All graduates of the residency were surveyed in 1998, 2001, and 2004, asking about practice patterns. To characterize current practice characteristics and scope, we used the latest survey returned by each respondent. We analyzed data for persons who returned all 3 surveys to examine trends across surveys. RESULTS: Annual response rates ranged from 58% to 78%. Of graduates who responded to all 3 surveys, fewer graduates care for patients in the hospital (71.3%, 1998; 56.5%, 2004), practice obstetrics (40.7%, 1998; 23.2%, 2004), or provide primary care for their patients in the emergency department (25.9%, 1998; 13.0%, 2004). Fewer recent graduates perform flexible sigmoidoscopy or exercise electrocardiograms. Graduates who are practicing obstetrics are more likely to be rural or to have graduated since 1994. Those performing flexible sigmoidoscopy are more likely to be male or to have graduated before 1994. The perceived need for more training in practice management is higher for more recent graduates (14.9% for 1975 to 1983 graduates; 31.9% for 1994 to 2003 graduates). CONCLUSIONS: Across the 3 surveys, there was a decline in the proportion of graduates of this family medicine residency program performing procedures, obstetrics, intensive care unit care, or hospital medicine. This study highlights how the practices of family medicine residency graduates may change over time. Data regarding residency graduate practice profiles may help predict the knowledge and skills residency graduates will need in their future practices and evaluate the impact of the Future of Family Medicine recommendations.

Case-based exercises fail to improve medical students' information management skills: a controlled trial.

BACKGROUND: Tomorrow's physicians must learn to access, retrieve, integrate and apply current information into ambulatory patient encounters, yet few medical schools teach 'real time' information management. METHODS: We compared two groups of clerkship students' information management skills using a standardized patient case. The intervention group participated in case-based discussions including exercises that required them to manage new information. The control group completed the same case discussions without information management exercises. RESULTS: After five weeks, there was no significant difference between the control and intervention groups' scores on the standardized patient case. However, third rotation students significantly outperformed first rotation students. CONCLUSION: Case-based exercises to teach information management failed to improve students' performance on a standardized patient case. Increased number of clinical rotations was associated with improved performance.

The ACGME core competencies: a national survey of family medicine program directors.

BACKGROUND AND OBJECTIVES: Beginning in July 2002, all residencies were required to show that their residents were obtaining competency in six core areas defined by the Accreditation Council for Graduate Medical Education (ACGME). METHODS: In 2003, we surveyed all 444 family medicine program directors regarding the ACGME Core Competencies and how programs evaluated them. RESULTS: A total of 287/444 (64.6%) responded. Almost all (279/287) had heard of the ACGME Core Competencies, and most (257/287) had begun to implement evaluation programs. Of program directors responding, 67.6% identified patient care as the most important competency. Evaluation methods most frequently used were active precepting (76.0%), record review (72.8%), and procedure logs (63.8%). The least commonly used tools were OSCE (9.1%), audit of computer utilization and knowledge (10.5%), and simulations (11.1%). Respondents identified time (74.3 %) and faculty development (13.0%) as primary implementation barriers. CONCLUSIONS: Program directors believe that patient care is the most important competency. Some programs are not yet attempting to address the competencies, and some were unaware of the accreditation implications of noncompliance with the Outcome Project. Time was identified as the major barrier to implementing core competency evaluation methods.