Understanding clerkship experiences in emergency medicine and their potential influence on specialty selection: A qualitative study.

Objectives: The specialty of emergency medicine (EM) is experiencing a significant decrease in student interest. In addition, women are historically underrepresented within the specialty at all levels of training and practice. We sought to understand how clinical experiences and perceptions of EM influence specialty selection by medical students, particularly women. Methods: Using a constructivist grounded theory approach, we analyzed semistructured interviews with senior medical students who considered EM as a specialty. We used purposive sampling to recruit from diverse learning environments and represent a variety of experiences. Participants reflected on their specialty selection process and experiences in EM including their perceived acceptance in the work environment. Results: Twenty-five medical students from 11 geographically diverse schools participated. A total of 68% (17/25) identified as women. The majority (21/25, 84%) planned on applying to EM residency. We identified four major themes: (1) distressing interpersonal interactions with patients and the ED care team negatively affect students; (2) EM culture includes behaviors that are perceived as exclusionary; (3) beliefs about the attributes of an ideal EM physician and the specialty itself have a gendered nature; and (4) ease of access to mentors, representation, and early exposure to EM environment increased interest in specialty. Conclusions: Our participants express that EM causes challenges for students to accept the norms of behavior in the field, which is an essential element in joining a group and professional identity formation. In addition, we raise concern that gendered perceptions and language may send exclusionary environmental cues that may negatively impact recruitment of a diverse physician workforce.

Cultural Humility Curriculum to Address Healthcare Disparities for Emergency Medicine Residents.

INTRODUCTION: Emergency medicine (EM) residency programs have variable approaches to educating residents on recognizing and managing healthcare disparities. We hypothesized that our curriculum with resident-presented lectures would increase residents' sense of cultural humility and ability to identify vulnerable populations. METHODS: At a single-site, four-year EM residency program with 16 residents per year, we designed a curriculum intervention from 2019-2021 where all second-year residents selected one healthcare disparity topic and gave a 15-minute presentation overviewing the disparity, describing local resources, and facilitating a group discussion. We conducted a prospective observational study to assess the impact of the curriculum by electronically surveying all current residents before and after the curriculum intervention. We measured attitudes on cultural humility and ability to identify healthcare disparities among a variety of patient characteristics (race, gender, weight, insurance, sexual orientation, language, ability, etc). Statistical comparisons of mean responses were calculated using the Mann-Whitney U test for ordinal data. RESULTS: A total of 32 residents gave presentations that covered a broad range of vulnerable patient populations including those that identify as Black, migrant farm workers, transgender, and deaf. The overall survey response was 38/64 (59.4%) pre-intervention and 43/64 (67.2%) post-intervention. Improvements were seen in resident self-reported cultural humility as measured by their responsibility to learn (mean responses of 4.73 vs 4.17; P < 0.001) and responsibility to be aware of different cultures (mean responses of 4.89 vs 4.42; P < 0.001). Residents reported an increased awareness that patients are treated differently in the healthcare system based on their race (P < 0.001) and gender (P < 0.001). All other domains queried, although not statistically significant, demonstrated a similar trend. CONCLUSION: This study demonstrates increased resident willingness to engage in cultural humility and the feasibility of resident near-peer teaching on a breadth of vulnerable patient populations seen in their clinical environment. Future studies may query the impact this curriculum has on resident clinical decision-making.

Facemasks: Perceptions and use in an ED population during COVID-19.

STUDY OBJECTIVE: Facemask use is associated with reduced transmission of SARS-CoV-2. Most surveys assessing perceptions and practices of mask use miss the most vulnerable racial, ethnic, and socio-economic populations. These same populations have suffered disproportionate impacts from the pandemic. The purpose of this study was to assess beliefs, access, and practices of mask wearing across 15 urban emergency department (ED) populations. METHODS: This was a secondary analysis of a cross-sectional study of ED patients from December 2020 to March 2021 at 15 geographically diverse, safety net EDs across the US. The primary outcome was frequency of mask use outside the home and around others. Other outcome measures included having enough masks and difficulty obtaining them. RESULTS: Of 2,575 patients approached, 2,301 (89%) agreed to participate; nine had missing data pertaining to the primary outcome, leaving 2,292 included in the final analysis. A total of 79% of respondents reported wearing masks "all of the time" and 96% reported wearing masks over half the time. Subjects with PCPs were more likely to report wearing masks over half the time compared to those without PCPs (97% vs 92%). Individuals experiencing homelessness were less likely to wear a mask over half the time compared to those who were housed (81% vs 96%). CONCLUSIONS: Study participants reported high rates of facemask use. Respondents who did not have PCPs and those who were homeless were less likely to report wearing a mask over half the time and more likely to report barriers in obtaining masks. The ED may serve a critical role in education regarding, and provision of, masks for vulnerable populations.

Beneficiaries' perspectives on improved oral health and its mediators after Medicaid expansion in Michigan: a mixed methods study.

OBJECTIVE: To investigate self-reported improved oral health and its mediators, and job-related outcomes, of Medicaid expansion beneficiaries in Michigan. METHODS: This cross-sectional mixed-methods study of adult "Healthy Michigan Plan" (HMP) Medicaid expansion beneficiaries included qualitative interviews with a convenience sample of 67 beneficiaries enrolled for ≥6 months, a stratified random sample survey of 4,090 beneficiaries enrolled for ≥12 months; and Medicaid claims data. We examined unadjusted associations between demographic variables and awareness of dental coverage, self-reported dental care access, dental visits, and self-reported oral health; and between improved oral health and job seeking and job performance. Multivariate analysis examined factors associated with self-reported oral health improvement, adjusting for sociodemographic characteristics, prior health insurance, and having at least one dental visit claim. RESULTS: Among surveyed beneficiaries, 60 percent received ≥1 dental visit and 40 percent reported improved oral health. Adjusted odds ratios (aOR) for improved oral health were higher for African-American beneficiaries [aOR = 1.61; confidence interval (CI) = 1.28-2.03] and those previously uninsured for ≥12 months (aOR = 1.96; CI = 1.58-2.43). Beneficiaries reporting improved oral health were more likely to report improved job seeking (59.9 percent vs 51 percent; P = 0.04) and job performance (76.1 percent vs 65.0 percent; P < 0.001) due to HMP. Interviewees described previously unmet oral health needs, and treatments that improved oral health, functioning, appearance, confidence, and employability. CONCLUSION: Michigan's Medicaid expansion contributed to self-reported improved oral health, which was associated with improved job outcomes. Policymakers should consider the importance of Medicaid dental coverage in reducing oral health disparities and improving the health and socioeconomic well-being of low-income adults and communities when considering this optional benefit.

Developing an electronic health record-derived health equity dashboard to improve learner access to data and metrics.

OBJECTIVES: It is essential to engage learners in efforts aimed at dismantling racism and other contributors to health care disparities. Barriers to their involvement include limited access to data. The objective of our study was to create a data dashboard using an existing quality improvement (QI) infrastructure and provide resident access to data to facilitate exploratory analysis on disparities in emergency department (ED) patient care. METHODS: Focusing on patient populations that have previously been shown in the literature to suffer significant disparities in the ED, we extracted outcomes across a variety of metrics already collected as part of routine ED operations. Using data visualization software, we developed an interactive dashboard for visual exploratory analyses. RESULTS: We designed a dashboard for our resident learners with views that are flexible and allow user selected filters to view clinical outcomes by patient age, treatment area, and chief complaint. Learners were also allowed to select grouping and outcomes of interest to investigate questions and form new hypotheses of their choosing. Available dashboard views included summary counts view to assess ED visits over time by selectable group, a rooming and triage acuity view, time-to-event survival curve view, histogram and box plot views for continuous variables, a view to assess outcome variables by time of day of ED arrival, customizable contingency table views, and correspondence analysis. CONCLUSIONS: Utilizing an existing QI infrastructure, we developed a dashboard that provides a new perspective into commonly collected ED operations data to allow for the exploration of disparities in ED care that is accessible to learners. Future directions include using these data to refine hypotheses on ED disparities, understand root causes, develop interventions, and measure their impact.

The Rapid Evaluation of COVID-19 Vaccination in Emergency Departments for Underserved Patients Study.

STUDY OBJECTIVE: Emergency departments (EDs) often serve vulnerable populations who may lack primary care and have suffered disproportionate COVID-19 pandemic effects. Comparing patients having and lacking a regular source of medical care and other ED patient characteristics, we assessed COVID-19 vaccine hesitancy, reasons for not wanting the vaccine, perceived access to vaccine sites, and willingness to get the vaccine as part of ED care. METHODS: This was a cross-sectional survey conducted from December 10, 2020, to March 7, 2021, at 15 safety net US EDs. Primary outcomes were COVID-19 vaccine hesitancy, reasons for vaccine hesitancy, and sites (including EDs) for potential COVID-19 vaccine receipt. RESULTS: Of 2,575 patients approached, 2,301 (89.4%) participated. Of the 18.4% of respondents who lacked a regular source of medical care, 65% used the ED as their usual source of health care. The overall rate of vaccine hesitancy was 39%; the range among the 15 sites was 28% to 58%. Respondents who lacked a regular source of medical care were more commonly vaccine hesitant than those who had a regular source of medical care (47% versus 38%, 9% difference, 95% confidence interval 4% to 14%). Other characteristics associated with greater vaccine hesitancy were younger age, female sex, Black race, Latinx ethnicity, and not having received an influenza vaccine in the past 5 years. Of the 61% who would accept a COVID-19 vaccine, 21% stated that they lacked a primary physician or clinic at which to receive it; the vast majority (95%) of these respondents would accept the COVID-19 vaccine as part of their care in the ED. CONCLUSION: ED patients who lack a regular source of medical care are particularly hesitant regarding COVID-19 vaccination. Most COVID-19 vaccine acceptors would accept it as part of their care in the ED. EDs may play pivotal roles in COVID-19 vaccine messaging and delivery to highly vulnerable populations.

Meeting unique requirements: Community consultation and public disclosure for research in emergency setting using exception from informed consent.

BACKGROUND: Exception from informed consent (EFIC) regulations for research in emergency settings contain unique requirements for community consultation and public disclosure. These requirements address ethical challenges intrinsic to this research context. Multiple approaches have evolved to accomplish these activities that may reflect and advance different aims. This scoping review was designed to identify areas of consensus and lingering uncertainty in the literature. METHODS: Scoping review methodology was used. Conceptual and empirical literature related to community consultation and public disclosure for EFIC research was included and identified through a structured search using Embase, HEIN Online, PubMed, and Web of Science. Data were extracted using a standardized tool with domains for major literature categories. RESULTS: Among 84 manuscripts, major domains included conceptual or policy issues, reports of community consultation processes and results, and reports of public disclosure processes and results. Areas of consensus related to community consultation included the need for a two-way exchange of information and use of multiple methods. Public acceptance of personal EFIC enrollment is commonly 64% to 85%. There is less consensus regarding how to assess attitudes, what "communities" to prioritize, and how to determine adequacy for individual projects. Core goals of public disclosure are less well developed; no metrics exist for assessing adequacy. CONCLUSIONS: Multiple methods are used to meet community consultation and public disclosure requirements. There remain no settled norms for assessing adequacy of public disclosure, and there is lingering debate about needed breadth and depth of community consultation.

To Be Seen, Heard, and Valued: Strategies to Promote a Sense of Belonging for Women and Underrepresented in Medicine Physicians.

Lingering unconscious biases and daily cues continue to permeate and persist in academic medicine environments in the form of the exclusion of physicians who are women or racially/ethnically underrepresented in medicine. Academic medicine environments must change so that women and underrepresented in medicine racial/ethnic groups are seen, heard, and valued. A shared awareness among faculty, administrators, and trainees can inform the development of intentional strategies to alter individual behaviors, academic spaces, and institutional processes to cultivate a sense of belonging. Shifting the norms in medicine and the course of historical exclusion will require professional development in areas of inclusive teaching practices, skills to cultivate mentoring relationships with diverse trainees, and fostering discussions about the relevance of personal identity, as well as attention to the symbolism and imagery in institutional messages (e.g., portraits on the walls, website, marketing campaigns) and to the value of including community involvement in productivity metrics.

Association of Medicaid Expansion With Enrollee Employment and Student Status in Michigan.

Importance: Medicaid community engagement requirements (work, school, job searching, or community service) are being implemented by several states for the first time, but the association of Medicaid coverage with enrollees' employment and school attendance is unclear. Objective: To assess longitudinal changes in enrollees' employment or student status after Michigan's Medicaid expansion. Design, Setting, and Participants: This survey study included 4090 nonelderly, adult Healthy Michigan Plan enrollees from March 1, 2017, to January 31, 2018. Main Outcomes and Measures: Self-reported employment or student status. Proportionate sampling was stratified by income and geographic region. Mixed-effects regression models with time indicators were used to assess longitudinal changes in the proportion of enrollees who were employed or students. Results: The response rate for the initial survey was 53.7% and for the follow-up survey was 83.4%. Of the 3104 respondents to the 2017 follow-up survey (mean [SD] age in 2017, 42.2 [13.0] years; 1867 [53.0%] female), 54.3% were employed or students in 2016, and this number increased to 60.0% in 2017 (percentage point change, 5.7; P < .001). Non-Hispanic black enrollees had significantly larger gains in employment or student status compared with non-Hispanic white enrollees (percentage point change, 10.7 vs 3.5; P = .02). Changes in employment or student status were not associated with improved health status. Conclusions and Relevance: Employment or student status increased from 2016 to 2017 among Michigan Medicaid expansion enrollees. These findings provide information about whether Medicaid coverage or community engagement requirements are best to promote the desired outcomes of employment and student status.

Health Risk Assessments in Michigan's Medicaid Expansion: Early Experiences in Primary Care.

INTRODUCTION: Michigan is one of 3 states that have implemented health risk assessments for enrollees as a feature of its Medicaid expansion, the Healthy Michigan Plan. This study describes primary care providers' early experiences with completing health risk assessments with enrollees and examines provider- and practice-level factors that affect health risk assessment completion. METHODS: All primary care providers caring for ≥12 Healthy Michigan Plan enrollees (n=4,322) were surveyed from June to November 2015, with 2,104 respondents (55.5%). Analyses in 2016-2017 described provider knowledge, attitudes, and experiences with the health risk assessment early in Healthy Michigan Plan implementation; multivariable analyses examined relationships of provider- and practice-level characteristics with health risk assessment completion, as recorded in state data. RESULTS: Of the primary care provider respondents, 73% found health risk assessments very or somewhat useful for identifying and discussing health risks, although less than half (47.2%) found them very or somewhat useful for getting patients to change health behaviors. Most primary care provider respondents (65.3%) were unaware of financial incentives for their practices to complete health risk assessments. Nearly all primary care providers had completed at least 1 health risk assessment. The mean health risk assessment completion rate (completed health risk assessments/number of Healthy Michigan Plan enrollees assigned to that primary care provider) was 19.6%; those who lacked familiarity with the health risk assessment had lower completion rates. CONCLUSIONS: Early in program implementation, health risk assessment completion rates by primary care providers were low and awareness of financial incentives limited. Most primary care provider respondents perceived health risk assessments to be very or somewhat useful in identifying health risks, and about half of primary care providers viewed health risk assessments as very or somewhat useful in helping patients to change health behaviors.

Factors influencing primary care providers' decisions to accept new Medicaid patients under Michigan's Medicaid expansion.

OBJECTIVES: Michigan expanded Medicaid under the Affordable Care Act (ACA) through a federal waiver that permitted state-mandated features, including an emphasis on primary care. We investigated the factors associated with Michigan primary care providers (PCPs)' decision to accept new Medicaid patients under Medicaid expansion. STUDY DESIGN: Statewide survey of PCPs informed by semistructured interviews. METHODS: After Michigan expanded Medicaid on April 1, 2014, we surveyed 2104 PCPs (including physician and nonphysician providers, such as nurse practitioners and physician assistants) with 12 or more assigned Medicaid expansion enrollees (response rate, 56%). To guide survey development and interpretation, we interviewed a separate group of 19 PCPs with Medicaid expansion enrollees from diverse urban and rural regions. Survey questions assessed PCPs' current acceptance of new Medicaid patients. RESULTS: Of the 2104 surveyed PCPs, 78% reported that they were currently accepting additional Medicaid patients; 58% reported having at least some influence on the decision. Factors considered very/moderately important to the Medicaid acceptance decision included practice capacity to accept any new patients (69%), availability of specialists for Medicaid patients (56%), reimbursement amount (56%), psychosocial needs of Medicaid patients (50%), and illness burden of Medicaid patients (46%). PCPs accepting new Medicaid patients tended to be female, minorities, nonphysician providers, specialized in internal medicine, paid by salary, or working in practices with Medicaid-predominant payer mixes. CONCLUSIONS: In the era after Medicaid expansion, PCPs placed importance on practice capacity, specialist availability, and patients' medical and psychosocial needs when deciding whether to accept new Medicaid patients. To maintain primary care access for low-income patients with Medicaid, future efforts should focus on enhancing the diversity of the PCP workforce, encouraging healthcare professional training in underserved settings, and promoting practice-level innovations in scheduling and integration of specialist care.

Changes in Health and Ability to Work Among Medicaid Expansion Enrollees: a Mixed Methods Study.

BACKGROUND: Michigan expanded Medicaid under the Affordable Care Act (Healthy Michigan Plan [HMP]) to improve the health of low-income residents and the state's economy. OBJECTIVE: To understand HMP's impact on enrollees' health, ability to work, and ability to seek employment DESIGN: Mixed methods study, including 67 qualitative interviews and 4090 computer-assisted telephone surveys (response rate 53.7%) PARTICIPANTS: Non-elderly adult HMP enrollees MAIN MEASURES: Changes in health status, ability to work, and ability to seek employment KEY RESULTS: Half (47.8%) of respondents reported better physical health, 38.2% better mental health, and 39.5% better dental health since HMP enrollment. Among employed respondents, 69.4% reported HMP helped them do a better job at work. Among out-of-work respondents, 54.5% agreed HMP made them better able to look for a job. Among respondents who changed jobs, 36.9% agreed HMP helped them get a better job. In adjusted analyses, improved health was associated with the ability to do a better job at work (aOR 4.08, 95% CI 3.11-5.35, p < 0.001), seek a job (aOR 2.82, 95% CI 1.93-4.10, p < 0.001), and get a better job (aOR 3.20, 95% CI 1.69-6.09, p < 0.001), but not with employment status (aOR 1.08, 95% CI 0.89-1.30, p = 0.44). In interviews, several HMP enrollees attributed their ability to get or maintain employment to improved physical, mental, and dental health because of services covered by HMP. Remaining barriers to work cited by enrollees included older age, disability, illness, and caregiving responsibilities. CONCLUSIONS: Many low-income HMP enrollees reported improved health, ability to work, and job seeking after obtaining health insurance through Medicaid expansion.

A systematic review of Federal Drug Administration Docket for community consultation and public disclosure in exception from informed consent trials.

BACKGROUND: Exception from informed consent imposes community consultation and public disclosure requirements on clinical investigation in critically ill and injured patients. In 2011, the Food and Drug Administration instructed sponsors to submit publically disclosed information to the Food and Drug Administration Docket, but to date there has been no comprehensive analysis of available data. We summarized the community consultation and public disclosure practices of exception from informed consent trials published on the Food and Drug Administration Docket in order to better understand the breadth of common practices that exists among acute care clinical research. METHODS: We performed quantitative and qualitative analysis of Docket FDA-1995-S-0036 from its initiation until June 2017 in order to summarize existing practices. We developed a 4-point scoring system to categorize public disclosure and community consultation based on inclusion of key components such as a detailed plan, schedule of events conducted, results, and materials uploaded. RESULTS: The 177 docket submissions represented 34 trials. Material related to public disclosure accounted for 49% of pages, community consultation 45%, and 6% other. The median Docket Review Content Score for public disclosure was 3 (mean: 2.5, range: 0-4) and 2 (mean: 2.1, range: 0-4) for community consultation materials. CONCLUSION: The public information contained in the Docket varies broadly by trial and content. Additionally, as evidenced by the wide range of the Docket Review Content Score, submission guidelines are not followed uniformly. Given the apparent uncertainty about what should be submitted, and the need for best practice recommendations, it is valuable to categorize and summarize existing community consultation and public disclosure content.

Patient and Surrogate Views of Community Consultation for Emergency Research.

OBJECTIVE: Pretrial community consultation (CC) is required for emergency research conducted under an exception from informed consent (EFIC) in the United States. CC remains controversial and challenging, and minimal data exist regarding the views of individuals enrolled in EFIC trials on this process. It is important to know whether participants perceive CC to be meaningful and, if so, whom they believe should be consulted. METHODS: We conducted a secondary analysis of data from two studies interviewing patients and surrogates of two recent EFIC trials (PEER-RAMPART and PEER-ProTECT). These interviews included similar open- and closed-ended questions regarding participants' views of the importance of CC, the rationale for their responses, and their views regarding which populations should be included in consultation efforts. A template analytic strategy was used for qualitative analysis of textual data, and descriptive statistics were tabulated to characterize demographic data and instances of major themes. RESULTS: Ninety percent of participants perceived CC to be valuable. Participants' reasons for finding CC valuable clustered in two categories: 1) as a method of informing the public about the trial to be conducted and 2) as a way of obtaining input and feedback from the community. Participants cited the medical community (43%) and individuals with a connection to the study condition (41%) as the most important groups to involve in consultation efforts; only 5% suggested consulting the general public in the area where the research will be conducted. CONCLUSION: Participants in EFIC trials and their decision makers generally valued CC as a method of informing and seeking input from the community. Participants felt that the most appropriate groups to consult were the medical community and individuals with connections to the condition under study. Consultation efforts focused on these two groups, rather than the general public, may be more efficient and more meaningful to individuals involved in EFIC trials. These findings also reinforce the importance of the distinction between public disclosure and CC.

Emergency department hospitalization volume and mortality in the United States.

STUDY OBJECTIVE: Although numerous studies have demonstrated a relationship between higher volume and improved outcomes in the delivery of health services, it has not been extensively explored in the emergency department (ED) setting. Therefore, we seek to examine the association between ED hospitalization volume and mortality for common high-risk conditions. METHODS: Using data from the Nationwide Inpatient Sample, a national sample of hospital discharges, we evaluated mortality overall and for 8 different diagnoses between 2005 and 2009 (total admissions 17.55 million). These conditions were chosen because they are frequent (in the top 25 of all ED hospitalizations) and high risk (> 3% observed mortality). EDs were excluded from analysis if they did not have at least 1,000 total annual admissions and 30 disease-specific cases. EDs were then placed into quintiles based on hospitalized volume. Regression techniques were used to describe the relationship between volume (number of hospitalized ED patients per year) and both subsequent early inpatient mortality (within 2 days of admission) and overall mortality, adjusted for patient and hospital characteristics. RESULTS: Mortality decreased as volume increased overall and for all diagnoses, but the relative importance of volume varied, depending on the condition. Absolute differences in adjusted mortality rates between very high-volume EDs and very low-volume EDs ranged from -5.6% for sepsis (95% confidence interval [CI] -6.5% to -4.7%) to -0.2% for pneumonia (95% CI -0.6% to 0.1%). Overall, this difference was -0.4% (95% CI -0.6% to -0.3%). A similar pattern was observed when early hospital deaths were evaluated. CONCLUSION: Patients have a lower likelihood of inhospital death if admitted through high-volume EDs.