Bridging Anatomy, Histology, and Pathology: A Novel Curriculum Component Incorporating Self-directed Learning for First-Year Medical Students.

During cadaveric dissection or prosection, medical students frequently encounter pathology that can be a springboard to further learning. We designed a novel educational activity linking anatomy, histology, and pathology that incorporated self-directed learning and teamwork, followed by feedback and instruction from pathologists. Post-activity, more than 97% of students rated the activity as useful (Likert scale of 1 to 5), indicating this activity should be continued in the future. Strengths included self-directed learning, content and design, and teamwork, peer, and faculty interactions. Clarity of assignment expectations, range of pathologies, and virtual presentation format remained areas for improvement.

Social determinants of health: are colonoscopies always fit for duty?

OBJECTIVES: Colorectal cancer (CRC) screening rates continue to be low among safety-net populations. We sought to elucidate the impact of social determinants of health (SDOH) on the noncompletion of fecal immunochemical tests (FITs) and colonoscopies at the Providence Community Health Centers (PCHC). STUDY DESIGN: This was a retrospective cohort review of PCHC patients with associated SDOH profiles between December 1, 2018, and December 1, 2019. METHODS: We analyzed fulfilled and unfulfilled CRC screening orders (FITs and colonoscopies) and examined associations and odds ratios between order noncompletion and the presence of SDOH variables. The study sample consisted of a total of 517 orders (fulfilled and unfulfilled; FIT, n = 348; colonoscopy, n = 169). RESULTS: FITs were completed more often than colonoscopies (81.3% vs 65.7%, respectively; P < .001). Colonoscopy noncompletion was associated with patient-reported social determinants of "housing insecurity/homelessness" (P = .0083) and "living conditions" (P = .048) and staff-reported "behavioral health problem" (P = .048). The presence of housing insecurity/homelessness increased the likelihood of an unfulfilled colonoscopy order (odds ratio, 7.5; 95% CI, 1.3-75.0). Patients who reported any SDOH need had a statistically significant increase in colonoscopy noncompletion (P = .0022), whereas FIT noncompletion was not associated with the presence of SDOH needs (P = .81). CONCLUSIONS: Providers should consider FITs as a strategic real-world modality for patients with SDOH needs.

Impact of medical school responses during the COVID-19 pandemic on student satisfaction: a nationwide survey of US medical students.

PURPOSE: Medical schools have faced various challenges in preparing their clinical students for the frontlines of a pandemic. This study investigated medical students' satisfaction with their institutions during the coronavirus disease 2019 (COVID-19) pandemic with the intention of guiding educators in future public health crises. METHODS: In this cross-sectional study surveying students in clinical rotations, the primary outcome was overall satisfaction regarding medical schools' responses to the pandemic, and the four secondary outcomes were school communication, exposure to COVID-19, availability of personal protective equipment, and access to COVID-19 testing. RESULTS: The survey was distributed to ten medical schools, of which 430 students responded for a response rate of 13.0%. While most students were satisfied (61.9%, n=266) with their schools' response, more than one in five (21.9%, n=94) were dissatisfied. Among the four secondary outcomes, communication with students was most predictive of overall satisfaction. CONCLUSION: In future crises, schools can best improve student satisfaction by prioritizing timely communication.

Disparities in Pediatric Emergency Department Length of Stay and Utilization Associated With Primary Language.

OBJECTIVE: The aim of the study was to investigate the association between primary language and length of stay (LOS) in the pediatric emergency department (ED) within the context of known disparities impacting healthcare experiences and outcomes for patients with language barriers. METHODS: We conducted a retrospective cohort study of consecutive encounters of patients presenting to, and discharged from, an urban pediatric ED from May 2015 through April 2018. Encounters were grouped into English primary language (EPL), Spanish (SPL), and other (OPL). Mean LOS comparisons were stratified by Emergency Severity Index (ESI). Bivariate and multivariate analyses were used to examine the relationship between LOS and variables, including age, sex, race/ethnicity, insurance, and time of presentation. RESULTS: A total of 139,163 encounters were included. A higher proportion of SPL and OPL encounters were characterized as lower ESI acuity compared with EPL. Significantly longer LOS for SPL and OPL encounters was observed in the 2 lower acuity strata. The ESI 4-5 stratum demonstrated the greatest LOS disparity between EPL, SPL, and OPL (94 vs 103 vs 103 minutes, respectively, P < 0.001). In the highest acuity stratum, ESI 1-2, there was a nonsignificant trend toward longer LOS among EPL encounters (P = 0.08). The multivariate model accounted for 24% of LOS variance, but effect sizes were small for all variables except for ESI and age. CONCLUSIONS: Patients with Spanish or other non-EPL who were triaged to lower acuity ESI levels experienced longer LOS in the pediatric ED than English-speaking counterparts. They also used the ED more frequently for low acuity issues, possibly reflecting disparities in access to primary care.

Impact of nasal dilator strips on measures of sleep-disordered breathing in pregnancy.

STUDY OBJECTIVES: Women with sleep-disordered breathing (SDB) in pregnancy are at a greater risk of developing serious adverse perinatal outcomes. However, the pathogenesis of SDB in pregnancy is poorly understood. As nasal congestion is common in pregnancy, nasal obstruction may contribute to SDB in this population. This study aims to assess the impact of nasal dilator strips (NDS) on measures of SDB and their potential for use as a placebo condition. METHODS: Pregnant women ≥ 18 years old, body mass index ≥ 27 kg/m2, and habitual snoring were enrolled. Participants completed 2 consecutive level III home sleep apnea tests and used NDS during the second test. Objective measures including respiratory event index and pulse transit time drop index, a measure of increased arterial stiffness, were compared across tests. Subjective assessments of participants' perceived impact of NDS use was also obtained. RESULTS: 54 women, 59% White, 60% in the third trimester were enrolled. Median time between the 2 studies was 1 day (interquartile range [IQR] 4). There was no significant change between the night without NDS use and the night with NDS use in respiratory event index (5.30 [IQR 6.20] vs 4.80 [IQR 6.78], P = .8) or pulse transit time drop index (6.8 [IQR 13.3] vs 6.6 [IQR 15.8], P = .360). Subjective measures of sleep did not differ between the 2 nights. CONCLUSIONS: Despite the high prevalence of pregnancy-associated rhinitis, NDS do not have a significant impact on measures of SDB. Results from this study support the use of NDS as an appropriate placebo in prenatal clinical trials. CITATION: Maxwell M, Sanapo L, Monteiro K, et al. Impact of nasal dilator strips on measures of sleep-disordered breathing in pregnancy. J Clin Sleep Med. 2022;18(2):477-483.

Medical Advisability of Youth Pitching Recommendations on the Internet.

BACKGROUND: As the incidence of youth pitching injuries and surgical procedures attributed to overuse has drastically increased, there are quality concerns about popular internet resources regarding arm care for youth pitchers. PURPOSE/HYPOTHESIS: To assess the medical advisability of online arm care recommendations for youth pitchers. It was hypothesized that websites contain misleading arm-care information that is discordant with medical advice. STUDY DESIGN: Cross-sectional study. METHODS: We reviewed the first 100 websites populated after a Google search for youth pitching recommendations. Websites were categorized by type (athletic organization, commercial, or educational) and content quality (medically advisable, discordant, or neutral), the latter with respect to the Pitch Smart guidelines used by Major League Baseball. Chi-square tests of independence and z tests of independent proportions were used to compare column proportions among categories of website content quality for each type of website source. Given the small sample sizes in some instances, the Fisher-Freeman-Halton exact test was performed to assess the relationship between website source type and quality of information. RESULTS: Of the 99 qualifying websites, 76 were categorized as medically advisable, 16 as discordant, and 7 as neutral. In addition, 92% of educational websites and 94.7% of athletic organization websites featured exclusively advisable content, whereas only 54.8% of commercial websites were advisable. Of the 16 discordant websites, 15 were commercial sites. Educational websites were significantly more advisable and neutral in content when compared with discordant information, while commercial websites were significantly predictive of discordant content. Among the first 50 websites populated according to Google, 42 (84%) were advisable, 6 (12%) discordant, and 2 (4%) neutral. The remaining websites (n = 49) featured 34 (69.4%) that were advisable, 10 (20.4%) discordant, and 5 (10.2%) neutral. CONCLUSION: Study findings indicated that websites of an educational nature are predictive of medically advisable content, while commercial websites (eg, blogs) are associated with discordant information. The abundance and availability of inaccurate internet information should be appreciated by medical professionals and parents/coaches of youth baseball players.

Birth Stories, Support, and Perinatal Emotional Health among Minority Adolescent Mothers: A Mixed Methods Study.

STUDY OBJECTIVE: To explore minority, adolescent birth and perinatal experiences to inform and improve quality of care for this unique group. DESIGN: Mixed quantitative and qualitative study guided by Bourdieu's Social Fields framework. SETTING: Clinic dedicated to parenting adolescents, and a local charter school founded to serve pregnant and parenting young adults. PARTICIPANTS: Sample size for quantitative data: n = 27; qualitative data: n = 14. Average age was 16.39 years (SD = 1.29); most self-identified as Latina/Hispanic or African American/Black/Afro-Caribbean/African. INTERVENTIONS AND MAIN OUTCOME MEASURES: We used 2 validated surveys: Birth Satisfaction Scale-Revised (BSS-R), and the Postpartum Worry Scale-Revised (PWS-R). The BSS-R has 10 items, and quantifies labor and delivery experiences. The PWS-R has 20 items, and quantifies maternal, infant, and social-emotional worries. The qualitative, semistructured 30-minute interviews with a subset of survey respondents further explored perinatal mental health, labor experiences, and support networks. RESULTS: BSS-R data resulted in an average score of 25.14 (SD = 5.35), which correlated to moderate satisfaction with birth experience (range, 0-40 with 0 = most negative). The PWS-R average score of 55.79 (SD = 21.06) indicated elevated postpartum worry (range, 20-100 with 20 = most worry). Qualitative interviewees worried about relationships and newborn well-being; support networks fluctuated; distinct events, pain, and fear during labor dominated birth stories. Advice for peers included: tending to social support, stress, and self-care. Nonjudgmental communication, empathy, and emotional connection were desired attributes of their health care team. Participants had anxiety related to social networks and newborn care. Although birth experiences were moderately positive, they were also described as stressful. However, participants were resourceful, insightful, and took advantage of social supports. CONCLUSION: Birth experiences, patterns of stress, and support networks are uniquely identified and utilized by adolescent mothers. Being heard and feeling connected to providers empowered this group of young, minority adolescents. Participant advice could inform future educational courses, programs, and hospital innovations for perinatal adolescents.

Effects of a Poetry Intervention on Emotional Wellbeing in Hospitalized Pediatric Patients.

BACKGROUND AND OBJECTIVES: The hospital is often a challenging and unfamiliar environment for families. Hospitalization can increase stress and anxiety among children and caregivers. In this study, we are the first to explore the possible therapeutic effects of poetry on hospitalized pediatric patients' emotional wellbeing. PATIENTS AND METHODS: Patients aged 8 to 17 years old admitted to the inpatient pediatric ward and their parents or guardians were eligible for inclusion. With the validated Pediatric Quality of Life Present Functioning Visual Analogue Scales, 6 items were measured before and after the poetry intervention for each participant: fear, sadness, anger, worry, fatigue, and pain in the present moment. The intervention itself consisted of poetry-based reading and writing exercises. Participants and parents also completed an open-ended qualitative survey on their experience. RESULTS: Data from 44 participants were analyzed. Using the Wilcoxon signed rank test, we showed that the poetry intervention had a statistically significant reduction in 5 of the 6 Pediatric Quality of Life Present Functioning Visual Analogue Scales symptom measures: fear (P = .021), sadness (P = .004), anger (P = .039), worry (P = .041), and fatigue (P < .001). Reduction in pain was not statistically significant (P = .092). Six coded themes emerged from qualitative analysis: the poetry intervention facilitated (1) happiness and (2) family involvement, was viewed as a (3) good distraction and (4) screenless activity, and cultivated (5) creativity and (6) self-reflection. CONCLUSIONS: The poetry intervention led to statistically significant reductions in fear, sadness, anger, worry, and fatigue but not in pain. The study reveals promising results and serves as a starting point for future investigations on the therapeutic impact of poetry on hospitalized pediatric patients.

Factors affecting opioid management for injured children after hospital discharge.

INTRODUCTION: Prescription opioid misuse is a national crisis. Injured children often receive opioid medication at hospital discharge, but the role these prescriptions play in the opioid crisis has not been fully elucidated. Whether these opioids are administered, the duration of severe pain requiring opioids, and what the final disposition of unused opioids is in this population remain unknown. METHODS: A survey of parent/guardian perceptions of their child's pain after injury, duration of opioid administration, opioid storage and disposal, and perceptions of opioid education was designed. During a 12-month period, parents of injured children admitted to an ACS Level 1 Pediatric Trauma Center were prospectively enrolled by convenience sample. Surveys were in two steps with an enrollment survey prior to discharge and a follow-up survey 7-10 days after discharge. RESULTS: Seventy of 114 (61.4%) enrolled parents/guardians completed follow-up survey. Of the 79.1% that reported an opioid prescription for their child, 92.5% filled it. Of those reporting on opioid usage, 10.4% never used the opioid, 75% used opioids <3 days, 12.5% 4-7 days, 2% >7 days. Of those who filled the opioid prescription, 83.7% reported having leftover doses. Reasons for discontinuing opioids included the child no longer had pain (87.2%), the child ran out of medication (5.1%), other (7.7%). Regarding storage, 53.3% reported utilizing an unlocked bathroom cabinet, and 81.3% unlocked kitchen space. Of those reporting unused opioids, 83.3% reported not disposing them, and 38.2% reported no plan for disposal. CONCLUSION: The majority of parents/guardians of injured children report resolution of severe pain requiring opioids within 72 h of hospital discharge, and virtually all by 7 days. The majority of injured children were prescribed a greater number of doses than they needed to treat their pain. Many parents/guardians store opioids in unsecure locations and a significant proportion report no plan to dispose of unused opioid doses. Further investigation is warranted to quantify and address the gap between pain control needs and opioid prescribing practices. The rate of unsecure storage and plan to retain unused opioids are potential targets for discharge opioid education. TYPE OF STUDY: Cross-sectional survey. LEVEL OF EVIDENCE: Level IV.

Assessing Food Insecurity in Medical Students.

BACKGROUND AND OBJECTIVES: Food insecurity, defined as the lack of reliable access to sufficient quantities of affordable, nutritious food and present in 11.1% of the general population, has not been assessed in medical students. Food insecurity is related to adverse outcomes for both health and academics in undergraduate students. Assessing the presence of food insecurity in medical students, a population at high risk for burnout and depression, may allow for intervention in order to improve overall wellness in this population. The objectives of this study were to assess the prevalence of food insecurity in a medical student population and identify potential reasons for any measured food insecurity. METHODS: We used a questionnaire that included the US Household Food Security Survey Module: Six-Item Short Form. The survey was emailed to all students enrolled at a Northeastern medical school (N=588) to assess food insecurity in the previous 3 months. The questionnaire included potential reasons for food insecurity. RESULTS: The survey response rate was 22.4%. Food insecurity was present in 11.8% of these respondents. The main reasons selected for food insecurity were not being able to get to the store (33.9%), followed by insufficient funds (30.4%). CONCLUSIONS: Prevalence of food insecurity in medical students may be similar to the general population. While the results of this study represent only one medical school, we believe these results are similar at other medical schools. Interventions to reduce food insecurity in this population are necessary to improve overall student wellness.

Thinning or dehiscence of bone in structures of the middle cranial fossa floor in superior semicircular canal dehiscence.

BACKGROUND: Superior semicircular canal dehiscence (SSCD) is a rare inner ear disorder; currently, it is unknown whether the etiopathology underlying this structural irregularity affects neighboring structures. The goal is to investigate the prevalence of bone thinning in areas of the middle cranial fossa (MCF) floor in SSCD and non-SSCD patients. METHODS: This retrospective study analyzed 100 patients from March 2011 to June 2017 at a tertiary referral center. 100 patients undergoing 118 SSCD repair surgeries (18 bilateral) were identified. 12 SSCD ears were excluded due to lack of pre-operative computed tomography (CT) scans or history of prior SSCD repair at an outside facility. Non-SSCD ears were identified from routinely-obtained CT scans for temporal bone fracture (fractured sides excluded) for a total of 101 ears; 26 non-SSCD ears were excluded due to lack of high-resolution imaging. RESULTS: Univariate analyses reveal that SSCD diagnosis is associated with higher rates of geniculate ganglion (GG) dehiscence compared with non-SSCD controls (42.7 vs. 24%; χ2(1) = 9.69,P = 0.008). Individuals with SSCD depicted significantly thinner bone overlying the geniculate ganglion (GG) (0.23 ± 1.2 mm) compared to controls (0.28 ± 1.8 mm, (t(1 6 4)) = 2.1, P = 0.04). SSCD patients presented thinner bone overlying the internal auditory canal (IAC) (0.33 ± 1.3 mm) compared to patients without SSCD (0.46 ± 1.6 mm, (t(2 5 7) = 6.4, P < 0.001). CONCLUSIONS: The increased prevalence of dehiscence of the MCF in this cohort of SSCD patients compared to non-SSCD patients suggests that the etiology underlying SSCD affects surrounding structures.

Discharge narcotic prescribing and management practices at pediatric trauma centers in the United States.

INTRODUCTION: Trauma is the leading cause of mortality among children in the US. Injured children often receive narcotic pain medication throughout their hospital stays and upon discharge from pediatric trauma centers. While effective, narcotics carry significant risks. There is a dearth of knowledge regarding narcotic education, prescribing practices, and pain management training at pediatric trauma centers. We hypothesize that there is a lack of standardization in these practices among pediatric trauma centers nationally. METHODS: A national survey was sent to medical directors at ACS-verified and state designated level 1 and 2 pediatric trauma centers. Data were collected over 6 months on discharge narcotic education and prescribing practices. RESULTS: Of 97 surveys sent, 92 were returned (94.8% response). Responses show that narcotics are most commonly prescribed by residents (79.1%). Electronic Medical Record (EMR) prescribing is common (89.2%); however, only 1.75% of EMRs give recommendation to prescribe naloxone. Only 9.7% report a standardized format of narcotic education. Most healthcare staff providing narcotic education receive no training in nonpharmacological pain management (68.8%). Most centers report no formal process to reduce the quantity of discharge narcotics prescribed (71.0%). Respondents report many barriers to providing discharge narcotic education to patients and families, including staff training on how to provide discharge narcotic education, staff availability, patient/ parent literacy, and format of available educational resources. CONCLUSION: The study results show that there is lack of standardization in discharge narcotic education and prescription practices among pediatric trauma facilities nationally and highlight the need for a standardized narcotic prescribing and management protocol. Despite the growing national concern of opiate misuse, particularly among children, respondents report inability to deliver adequate narcotic education owing to various communication and systems barriers. TYPE OF STUDY: Cross-sectional survey. LEVEL OF EVIDENCE: Level IV.

Outcomes of a Longitudinal Quality Improvement and Patient Safety Preclerkship Curriculum.

PURPOSE: To evaluate whether quality improvement (QI) and patient safety (PS) training in preclerkship medical education resulted in students' development and retention of knowledge, application-based and perceived skills, and attitudes throughout clerkships. METHOD: A longitudinal QI/PS curriculum with multimodal curricular components was implemented in the preclerkship curriculum between 2015 and 2017 at the Warren Alpert Medical School of Brown University, Rhode Island. Assessments were administered at baseline (T1), end of year 1 (T2), Clinical Skills Clerkship (T3), and end of clerkships (T4) in the intervention cohort (n = 97). In 2018, T4 data for this cohort were compared with a prior control cohort (n = 97) at T4. RESULTS: Results of knowledge-based multiple-choice questions (MCQs) (t[134] = -1.57, P < .001) and application-based skills (t[132] = -8.91, P < .001) demonstrated significant improvement from T1 to T2 (intervention cohort). Assessments of perceived skills showed significant growth from T1 to T2 (t[137] = -23.38, P < .001). Performance on application-based skills significantly improved from T2 to T3 (t[123] = -4.11, P < .001). Compared with the control cohort, the intervention cohort had significantly higher scores on MCQs (t[187.88] = 3.98, P < .001), application-based skills (t[72.69] = 6.40, P < .001), perceived skills (t[106.99] = 5.24, P < .001), and attitudes (t[152] = 5.86, P < .001). CONCLUSIONS: Incorporation of preclerkship QI/PS training resulted in improvements in knowledge, application-based and perceived skills, and attitudes that were retained throughout clerkships.

Knowledge, Attitudes, and Confidence in Accountable Care Organization-Based Payment Models Among RI Physicians.

Study Objective or Background: To assess Rhode Island (RI) physician knowledge, attitudes, and confidence to succeed in Accountable Care Organizations (ACOs). Study Design and Methods: We surveyed RI physicians' attitudes and beliefs about ACOs, including scales measuring Physician Knowledge (7 Multiple Choice and True/False items), Attitudes (8 Likert scale items), and Confidence (7 Likert Scale Items), and examined how physician characteristics related to these measures. Primary Results: The response rate was 6 percent (72/1183). Means (100-point scale) and standard deviations were calculated for Knowledge 65.3 (22), Attitudes for ACO participants 56.3 (13.2) and ACO non-participants 42.7 (14.3), and Confidence 32.4 (25.9). Primary care physicians had higher Attitudes compared with specialists among ACO participants (60.2 vs. 51.8, p=.047) and ACO non-participants (48.2 vs. 34.4, p=.030). Principal Conclusions: RI Physicians have low scores in Knowledge, Attitudes, and Confidence scales in ACOs. Primary care physicians have more positive Attitudes about ACOs than specialists. This study is limited by its low response rate. [Full article available at http://rimed.org/rimedicaljournal-2019-03.asp].

Prevalence of Tobacco Use and Overweight/Obesity in Rhode Island: Comparisons of Survey and Claims Data.

Many states, including Rhode Island, have begun to collect insurance claims data to better understand healthcare spending and local health outcomes. In this study, we sought to determine whether or not the prevalence of tobacco use and overweight/obesity in the Rhode Island All-Payer Claims Database (APCD) was comparable to that predicted by national behavioral survey data. We found that the prevalence of these lifestyle-related health problems was lower in local claims data than in survey data, suggesting that this database should be used with caution when exploring issues related to the prevalence of tobacco use and overweight/ obesity in Rhode Island. [Full article available at http://rimed.org/rimedicaljournal-2019-03.asp].

A qualitative analysis of interprofessional students' perceptions toward patients with opioid use disorder after a patient panel experience.

Background: Students from health professional schools participated in a half-day interprofessional education workshop centered on substance use disorder training. One component was a patient panel featuring individuals with a history of opioid use disorder who described the impact of addiction on their lives and their road to recovery using varied treatment options. We hypothesized that interacting with individuals with opioid use disorder early in training would elicit more humanistic perspectives and decrease bias and stigma in future health care professionals. Methods: After participating in the panel experience, health professional students (N = 580) from medicine, nursing, pharmacy, physical therapy, and social work were asked to complete short, 5-minute, rapid reflections. Prompts asked students whether the panel changed their perception of individuals with substance use disorder, to reflect on their attitudinal changes or lack thereof, and how working in interprofessional teams could impact the management and treatment of these patients. Conventional content analysis was performed. Results: Eighty-nine percent of students who attended the session completed the rapid reflections (n = 514). Overall, approximately 70% (n = 369) of students indicated that their perceptions of individuals with substance use disorder had changed as a result of the patient panel, with students from pharmacy more likely to indicate a change in attitudes. Themes across all professions included a change toward a more humanistic perspective, value of hearing real patient stories, and learning about treatment and recovery options. Student responses described how interprofessional health care teams can provide more holistic care with a broader range of therapeutic options that may improve long-term outcomes. Conclusions: A patient panel experience is influential on interprofessional students' attitudes toward patients who suffer from opioid use disorder. Students identified an interprofessional approach as being a valuable component of management and treatment of these patients.

"Tweet"-format reflective writing: A hidden needs assessment?

BACKGROUND: Medical student reflection is integral for professional development. Preliminary findings suggest that short-format writing promotes reflection and identifies impactful experiences. We sought to determine whether reflective writing could be used as a clerkship needs assessment. METHODS: During their surgical clerkship, medical students submitted "tweet"-format reflections and completed a standardized evaluation. "Tweet" content was analyzed using modified grounded theory methods and coded by valence, content, and reflection. Sub-coding was conducted to compare feedback between "tweets" and evaluations. RESULTS: We analyzed 286 reflections and 214 evaluation comments; 176 "tweets" were reflective (62%). "Tweets" commented on "patient interaction" (53%), "educational experience" (38%), "physician interaction" (26%), and "career decisions" (10%). A significant difference was observed between "tweets" and evaluations with regard to the number that provided feedback on experiences with "critically ill or dying patients." CONCLUSIONS: Reflections provided real-time reactions to impactful clerkship events, notably those involving critically ill or dying patients. This focus on illness may represent an unmet need for discussions related to end of life care. Overall, reflections provided more actionable feedback compared to evaluations.

Opioid Overdose Hospitalizations among Medicare-Disability Beneficiaries.

INTRODUCTION: As the opioid epidemic progresses, a better understanding of those at elevated risk of opioid overdose is needed, particularly for populations whose growing risk may be overlooked. Medicare recipients under age 65 (Medicare-disability beneficiaries [MDBs]) are one such population. We sought to analyze characteristics of opioid-overdose hospitalizations among MDBs and quantify the contribution of this population to opioid-overdose hospitalizations overall. METHODS: This retrospective cohort study included patients hospitalized for opioid overdose in the National/Nationwide Inpatient Sample from 1998 to 2013. The primary outcome measurements were number and characteristics of discharges, including patient sex, age, race, prescription opioid versus heroin overdose, and comorbidities. RESULTS: MDBs constituted 11.7% of US opioid overdose hospitalizations among those under 65 years of age in 1998; this proportion grew to 24.5% by 2013 (P < .0001). The proportion of female patients grew markedly among this cohort (P < .0001) and were disproportionately represented among MDBs (P < .0001). Prescription opioid overdose accounted for a larger proportion of opioid overdose hospitalizations among MDBs than among non-Medicare-insured patients under 65 years old (P < .0001). MDBs generally exhibited greater comorbidity burden versus non-Medicare-insured patients under age 65; however, chronic drug and alcohol abuse were less commonly documented among the Medicare cohort (P < .0001). CONCLUSIONS: MDBs constitute a substantial and growing proportion of opioid overdose hospitalizations in the United. To prevent opioid overdoses among MDBs, care must be taken to address the unique needs of this population.

Impact Of Risk Adjustment For Socioeconomic Status On Medicare Advantage Plan Quality Rankings.

Sociodemographically disadvantaged patients have worse outcomes on some quality measures that inform Medicare Advantage plan ratings. Performance measurement that does not adjust for sociodemographic factors may penalize plans that disproportionately serve disadvantaged populations. We assessed the impact of adjusting for socioeconomic and demographic factors (sex, race/ethnicity, dual eligibility, disability, rurality, and neighborhood disadvantage) on Medicare Advantage plan rankings for blood pressure, diabetes, and cholesterol control. After adjustment, 20.3 percent, 19.5 percent, and 11.4 percent of Medicare Advantage plans improved by one or more quintiles in rank on the diabetes, cholesterol, and blood pressure measures, respectively. Plans that improved in ranking after adjustment enrolled higher proportions of disadvantaged enrollees. Adjusting quality measures for socioeconomic factors is important for equitable payment and quality reporting. Our study suggests that plans serving disadvantaged populations would have improved relative rankings for three important outcome measures if socioeconomic factors were included in risk-adjustment models.