Estimates of HIV testing at visits to United States emergency departments.

OBJECTIVES: Emergency department-based HIV testing rates are historically low, but recent testing trends surrounding the COVID-19 pandemic and launch of the Ending the HIV Epidemic (EHE) initiative are unknown. The objective of the study is to estimate recent trends in the proportion of emergency department visits that included HIV testing. METHODS: We performed a cross-sectional analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS), a weighted nationally representative survey of US emergency departments, from 2014 to 2020. Given EHE's focus on several rural Southern jurisdictions as well as populations disproportionately affected by HIV, we stratified by characteristics including US region and visit-listed race and ethnicity. RESULTS: The proportion of emergency department visits that included HIV testing increased from 2014 (0.6%) to 2018 (1.1%) but was lower in 2019 and 2020 (0.8%). Compared with other regions, the South had the lowest rates of testing in both 2019 (0.6%) and 2020 (0.5%); testing rates in the nonmetropolitan South remained 0.1% or less across all years. Testing rates for emergency department visits by persons who identified as Hispanic/Latino were highest in 2018 (2.2%) but were sharply lower in 2019 and 2020 (0.8%). CONCLUSION: After a small but insufficient increase in emergency department-based HIV testing since 2014, rates decreased between 2018 and 2019 and were stable between 2019 and 2020. Overall, very few emergency department visits during our entire study period included an HIV test, and there were persistently low rates of HIV testing for populations prioritized in national efforts and during visits in rural jurisdictions in the South.

Comparison of US emergency departments by HIV priority jurisdiction designation: A case for geographically targeted screening in teaching hospitals.

The Ending the HIV Epidemic (EHE) Initiative targets a subset of United States (US) priority jurisdictions hardest hit by HIV. It remains unclear which emergency departments (EDs) are the most appropriate targets for EHE-related efforts. To explore this, we used the 2001-2019 National Emergency Department Inventories (NEDI)-USA as a framework to characterize all US EDs, focusing on those in priority jurisdictions and those affiliated with a teaching hospital. We then incorporate multivariable regression to explore the association between ED characteristics and location in an HIV priority jurisdiction. Further, to provide context on the communities these EDs serve, demographic and socioeconomic information and sexually transmitted infection case rate data were included. This reflected 2019 US Census Bureau data on age, race, ethnicity, and proportion uninsured and living in poverty along with 2001-2019 Centers for Disease Control and Prevention case rate data on chlamydia, gonorrhea, and syphilis. We found that EDs in priority jurisdictions (compared to EDs not in priority jurisdictions) more often served populations emphasized in HIV-related efforts (i.e., Black or African American or Hispanic or Latino populations), communities with higher proportions uninsured and living in poverty, and counties with higher rates of chlamydia, gonorrhea, and syphilis. Further, of the groups studied, EDs with teaching hospital affiliations had the highest visit volumes and had steady visit volume growth. In regression, ED annual visit volume was associated with an increased odds of an ED being located in a priority jurisdiction. Our results suggest that geographically targeted screening for HIV in a subset of US priority jurisdiction EDs with a teaching hospital affiliation could be an efficient means to reach vulnerable populations and reduce the burden of undiagnosed HIV in the US.

Unfilled in emergency medicine: An analysis of the 2022 and 2023 Match by program accreditation, ownership, and geography.

Background: The two most recent National Resident Matching Program (NRMP) Match cycles saw a high number of initially unfilled emergency medicine (EM) residency positions. We sought to identify the risk of EM residency program characteristics including accreditation duration, primary clinical site ownership status, and geography pertaining to not initially filling all positions. Methods: We performed a repeated cross-sectional observational study of EM residency programs participating in the 2022 and 2023 NRMP Match cycles and used publicly available data from the NRMP, the Accreditation Council for Graduate Medical Education, the Centers for Medicare & Medicaid Services, and the U.S. Department of Housing and Urban Development. Our primary outcome was the proportion of EM residency programs that did not initially fill positions, with analyses stratified by accreditation duration (>5 or ≤5 years), primary clinical site ownership status, and geographic core-based statistical areas (CBSAs). Results: A total of 219 of 2921 (7.5%) positions in the 2022 Match and 554 of 3010 (18.4%) positions in the 2023 Match were initially unfilled. Over the 2-year period, EM residency programs accredited within the past 5 years had more than double the risk (relative risk [RR] 2.08, 95% confidence interval [CI] 1.69-2.57, chi-square p < 0.001) of not filling all positions compared to those accredited more than 5 years previously. EM residency programs with a primary clinical site under for-profit ownership had a 50% greater risk of not filling all positions when compared to those under nonprofit or governmental ownership (RR 1.50, 95% CI 1.14-1.98, chi-square p = 0.009). In 2023, several CBSAs had a high number of both offered and unfilled positions. Conclusions: EM residency programs accredited within the past 5 years or those with a primary clinical site under for-profit ownership had a greater risk of not filling all positions within the past two Match cycles.

Membership in the Council of Teaching Hospitals and Health Systems Among Emergency Medicine Residency Program-Sponsoring Institutions, 2001-2020.

This cross-sectional study identifies US institutions sponsoring residency programs and examines whether Council of Teaching Hospitals and Health Systems membership is associated with institution characteristics.

Trends of Academic Faculty Identifying as Hispanic at US Medical Schools, 1990-2021.

Background: According to recent census data, Hispanic and Latino populations comprise the largest minority group in the United States. Despite ongoing efforts for improved diversity, equity, and inclusion, Hispanics remain underrepresented in medicine (UIM). In addition to well-established benefits to patient care and health systems, physician diversity and increased representation in academic faculty positively impact the recruitment of trainees from UIM backgrounds. Disproportionate representation (as compared to increases of certain underrepresented groups in the US population) has direct implications for recruitment of UIM trainees to residency programs. Objective: To examine the number of full-time US medical school faculty physicians who self-identify as Hispanic in light of the increasing Hispanic population in the United States. Methods: We analyzed data from the Association of American Medical Colleges from 1990 to 2021, looking at those academic faculty who were classified as Hispanic, Latino, of Spanish Origin, or of Multiple Race-Hispanic. We used descriptive statistics and visualizations to illustrate the level of representation of Hispanic faculty by sex, rank, and clinical specialty over time. Results: Overall, the proportion of faculty studied who identified as Hispanic increased from 3.1% (1990) to 6.01% (2021). Moreover, while the proportion of female Hispanic academic faculty increased, there remains a lag between females versus males. Conclusions: Our analysis shows that the number of full-time US medical school faculty who self-identify as Hispanic has not increased, though the population of Hispanics in the United States has increased.

Characteristics of California Emergency Departments in Centers for Disease Control and Prevention-Designated HIV Priority Counties.

BACKGROUND: Refocused national HIV testing initiatives include a geographic focus. OBJECTIVE: Using a geographic focus, we sought to identify which emergency departments (EDs) might be the most efficient targets for future HIV testing efforts, using California as an example. METHODS: Retrospective analysis of California EDs, emergency physicians, and patients served, along with county-level estimates of HIV prevalence and proportion of the population living in poverty. Emphasis was placed on characterizing EDs affiliated with teaching hospitals and those located in Centers for Disease Control (CDC) and Prevention HIV priority counties. RESULTS: Of the 320 EDs studied, 178 were in priority counties, 29 were affiliated with teaching hospitals, and 24 had both characteristics. Of the 12,869,889 ED visits included, 61.8% occurred in priority counties, 14.7% in EDs affiliated with teaching hospitals, and 12.0% in EDs with both characteristics. The subset of EDs in priority counties with teaching hospital affiliations (compared with priority and nonpriority county ED groups without a teaching hospital affiliation) had higher overall median visit volumes and higher proportions of visits by at-risk and CDC-targeted populations (e.g., individuals who were homeless, those who identified as Black or African American race, and those who identified as Hispanic or Latino ethnicity, all p < 0.01). CONCLUSIONS: EDs in priority counties affiliated with teaching hospitals are major sources of health care in California. These EDs more often serve populations disproportionately impacted by HIV. These departments are efficient targets to direct testing efforts. Increasing testing in these EDs could reduce the burden of undiagnosed HIV in California.

Trends in female first-author abstracts at the Society for Academic Emergency Medicine Annual Meeting, 1990-2020.

OBJECTIVES: To describe first author gender differences and characteristics in 1) Society for Academic Emergency Medicine (SAEM) Annual Meeting abstracts and 2) resulting manuscript publications. METHODS: We performed cross-sectional evaluation of SAEM abstracts from 1990, 1995, 2000, 2005, 2010, 2015, and 2020, compiling and reviewing a random sample of 100 abstracts for each year (total n = 700 abstracts). We documented abstract characteristics, including first author gender, and used the 2020 SAEM scoring rubric. We then searched PubMed to identify manuscript publications resulting from abstracts from 1990 to 2015 (n = 600). Finally, among abstracts that resulted in manuscript publication, we identified first and last author gender on both the abstracts and the resulting publication. RESULTS: Overall, 29% (202/695; n = 5 missing gender) of abstracts had female first authors. Female first authors increased over time (e.g., 17% in 1990 to 35% in 2020). Abstract quality scores were similar (both median [interquartile range] of 11 ([9-12]). Overall, 42% (n = 254/600) of abstracts resulted in a manuscript publication, 39% (n = 65/202) with female and 44% (n = 189/493) with male first authors (p = 0.26). The median time (IQR) from abstract to manuscript publication was longer for abstracts with female first authors vs. those with male first authors (2 [1-3] years and 1 [1, 2] years, p < 0.02); 77% and 78% of publications resulting from abstracts with female and male first authors, respectively, had the same first author. Female first author abstracts more often converted to a male first author manuscript publication (18%, n = 12/65) compared to male first author abstracts converting to female first author publications (7%, n = 14/189). CONCLUSIONS: A minority of SAEM abstracts, and manuscript publications resulting from them, had female first authors. Abstracts with female first authors took longer to achieve manuscript publication, and almost a fifth of female first author abstracts resulted in male first author manuscript publication.

Three decades of demographic trends among academic emergency physicians.

Purpose: To describe trends in emergency medicine faculty demographics, examining changes in the proportion of historically underrepresented groups including female, Black, and Latinx faculty over time. Methods: Data from the Association of American Medical Colleges faculty roster (1990-2020) were used to assess the changing demographics of full-time emergency medicine faculty. Descriptive statistics, graphic visualizations, and logistic regression modeling were used to illustrate trends in the proportion of female, Black, and Latinx faculty. Odds ratios (OR) were used to describe the estimated annual rate of change of underrepresented demographic groups. Results: The number of full-time emergency medicine faculty increased from 214 in 1990 to 5874 in 2020. Female emergency medicine faculty demonstrated increases in representation overall, from 35 (16.36%) in 1990 to 2247 (38.25%) in 2020, suggesting a 3% estimated annual rate of increase (OR 1.03, 95% CI 1.03-1.04) and within each academic rank. A very small positive trend was noted among Latinx faculty (n = 3, 1.40% in 1990 to n = 326, 5.55% in 2020; OR 1.01, 95% CI 1.01-1.02), whereas an even smaller, statistically insignificant increase was observed among Black emergency medicine faculty during the 31-year study period (N = 9, 4.21% in 1990 and N = 266, 4.53% in 2020; OR 1.00, 95% CI 0.99-1.00). Conclusions: Although female physicians have progressed toward equitable representation among academic emergency medicine faculty, no meaningful progress has been made toward racial parity. The persistent underrepresentation of Black and Latinx physicians in the academic emergency medicine workforce underscores the need for urgent structural changes to address contemporary manifestations of racism in academic medicine and beyond.

How we compare: Society for Academic Emergency Medicine faculty membership demographics.

Background: The Society for Academic Emergency Medicine (SAEM) has a core value to promote a diverse workforce for patients, providers, and learners. Understanding the organization's membership demographics and how that compares to the academic emergency medicine (EM) workforce is prerequisite to the success of this core value. Methods: We obtained 2020 faculty membership data sets from the Association of American Medical Colleges (AAMC) and SAEM; data included self-reported sex, race and ethnicity, and academic rank (professor, associate professor, assistant professor, and instructor). We employed standardized mean difference (SMD) to quantify difference in proportions between data sets. Results: We identified 5874 (AAMC) and 2785 (SAEM) faculty. The AAMC (38.3%) and the SAEM (41.3%) had similar proportions of overall female faculty (SMD 0.063) although SAEM (compared to AAMC) had a higher proportion of female full (25.5% vs. 20.5%, SMD 0.121) and assistant (46.5% vs. 41.2%, SMD 0.106) professors. With the exception of Hispanic instructors, SAEM (compared to AAMC) also had higher proportions of Black and Hispanic female faculty at all ranks (SMD ranging from 0.109 to 0.777). Conclusion: SAEM faculty demographics generally reflect that of the academic EM workforce demographics reported in the AAMC database and that overall, the proportions of female, Black, and Hispanic faculty in SAEM are slightly larger than those in the AAMC database. However, faculty who identify as Black or Hispanic in both the AAMC and the SAEM databases (compared to the overall U.S. population) are dramatically underrepresented.

United States 2020 Emergency Medicine Resident Workforce Analysis.

STUDY OBJECTIVE: To characterize the emergency medicine resident physician workforce and the residency programs training them. METHODS: We identified emergency medicine residents in the 2020 American Medical Association (AMA) Physician Masterfile, analyzed demographic information, mapped both county-level population-adjusted and hospital referral region densities, and compared 2020 versus 2008 resident physician densities. We also analyzed all Accreditation Council for Graduate Medical Education (ACGME)-accredited emergency medicine residency programs from 2013 to 2020, mapped state-level population-adjusted densities, and identified temporal trends in program location and state-level program densities. All population-adjusted densities were calculated using the US Census Bureau resident population estimates. RESULTS: There were 6,993 emergency medicine residents in the 2020 AMA dataset with complete information. Most of them (98%) were in urban areas. Compared with 2008, per 100,000 US population, this represents disproportionate increases in urban areas (total [0.5], urban [0.5], large rural [0.2] and small rural [0.05]). We further identified 160 (2013) to 265 (2020) residency programs using the ACGME data. The new programs were 3-year training programs that were disproportionately added to states with an already higher number of programs (Florida [5 to 19], Michigan [11 to 25], New York [21 to 31], Ohio [9 to 18], Pennsylvania [12 to 21], California [14 to 22]). CONCLUSION: The number of emergency medicine residency programs has increased; most new programs were added to the states that already had emergency medicine residency programs. There is an emergency physician "desert" in the rural United States, lacking both residents and residency training programs. This analysis provides essential context to the ongoing conversation about the future of the emergency physician workforce.

External validation of the 4C Mortality Score for hospitalised patients with COVID-19 in the RECOVER network.

OBJECTIVES: Estimating mortality risk in hospitalised SARS-CoV-2+ patients may help with choosing level of care and discussions with patients. The Coronavirus Clinical Characterisation Consortium Mortality Score (4C Score) is a promising COVID-19 mortality risk model. We examined the association of risk factors with 30-day mortality in hospitalised, full-code SARS-CoV-2+ patients and investigated the discrimination and calibration of the 4C Score. This was a retrospective cohort study of SARS-CoV-2+ hospitalised patients within the RECOVER (REgistry of suspected COVID-19 in EmeRgency care) network. SETTING: 99 emergency departments (EDs) across the USA. PARTICIPANTS: Patients ≥18 years old, positive for SARS-CoV-2 in the ED, and hospitalised. PRIMARY OUTCOME: Death within 30 days of the index visit. We performed logistic regression analysis, reporting multivariable risk ratios (MVRRs) and calculated the area under the ROC curve (AUROC) and mean prediction error for the original 4C Score and after dropping the C reactive protein (CRP) component. RESULTS: Of 6802 hospitalised patients with COVID-19, 1149 (16.9%) died within 30 days. The 30-day mortality was increased with age 80+ years (MVRR=5.79, 95% CI 4.23 to 7.34); male sex (MVRR=1.17, 1.05 to 1.28); and nursing home/assisted living facility residence (MVRR=1.29, 1.1 to 1.48). The 4C Score had comparable discrimination in the RECOVER dataset compared with the original 4C validation dataset (AUROC: RECOVER 0.786 (95% CI 0.773 to 0.799), 4C validation 0.763 (95% CI 0.757 to 0.769). Score-specific mortalities in our sample were lower than in the 4C validation sample (mean prediction error 6.0%). Dropping the CRP component from the 4C Score did not substantially affect discrimination and 4C risk estimates were now close (mean prediction error 0.7%). CONCLUSIONS: We independently validated 4C Score as predicting risk of 30-day mortality in hospitalised SARS-CoV-2+ patients. We recommend dropping the CRP component of the score and using our recalibrated mortality risk estimates.

HIV Testing at Visits to US Emergency Departments, 2018.

BACKGROUND: An early HIV diagnosis improves patient outcomes, reduces the burden of undiagnosed HIV, and limits transmission. There is a need for an updated assessment of HIV testing rates in the emergency department (ED). SETTING: The National Hospital Ambulatory Medical Care Survey sampling ED visits were weighted to give an estimate of ED visits across all US states in 2018. METHODS: We analyzed patients aged 13-64 years without known HIV and estimated ED visits with HIV testing and then stratified by race, ethnicity, and region. Descriptive statistics and mapping were used to illustrate and compare patient, visit, and hospital characteristics for visits with HIV testing. RESULTS: Of 83.0 million weighted visits to EDs in 2018 by patients aged 13-64 years without a known HIV infection (based on 13,237 National Hospital Ambulatory Medical Care Survey sample visits), HIV testing was performed in 1.05% of visits. HIV testing was more frequent for patients aged 13-34 years compared with that for patients aged 35-64 years (1.32% vs. 0.82%, P = 0.056), Black patients compared with that for White and other patients (1.73% vs. 0.79% and 0.41%, P = 0.002), Hispanic or Latino patients compared with that for non-Hispanic or Latino patients (2.18% vs. 0.84%, P = 0.001), and patients insured by Medicaid compared with that for patients insured by private or other insurance (1.71% vs. 0.64% and 0.96%, P = 0.003). HIV testing rates were the highest in the Northeast (1.72%), followed by the South (1.05%). CONCLUSIONS: HIV testing occurred in a minority of ED visits. There are differences in rates of HIV testing by race, ethnicity, and location. Although rates of testing have increased, rates of ED-based HIV testing remain low.

National Study on the Contribution of Family Physicians to the US Emergency Physician Workforce in 2020.

BACKGROUND: Family physicians provide a sizable portion of emergency care in the United States. However, there is limited work characterizing this population. METHODS: We completed a cross-sectional analysis of the 2020 American Medical Association Physician Masterfile that was inclusive of all clinically active physicians who designated emergency medicine as their primary or secondary specialty and had family medicine residency training and/or family medicine board certification. We used Accreditation Council for Graduate Medical Education information to determine family medicine residency training and data from the American Board of Medical Specialties to determine family medicine board certification status. We calculated physician density using US Census Bureau estimates; urban-rural assignments were based on Urban Influence Codes. RESULTS: We identified 4354 clinically active emergency physicians (9% of the overall emergency physician workforce). Of these, a majority were male (88%) and completed their training at least 20 years ago (84%), and a majority (59%) reported emergency medicine as their primary specialty. There is notable variation in physician density per 100,000 US population, and these densities declined compared with prior estimates from 2008. CONCLUSIONS: We find that family physicians represent a sizable portion of the overall emergency physician workforce despite decreases in physician densities across the United States.

Multicenter Study of Outcomes Among Persons With HIV Who Presented to US Emergency Departments With Suspected SARS-CoV-2.

BACKGROUND: There is a need to characterize patients with HIV with suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). SETTING: Multicenter registry of patients from 116 emergency departments in 27 US states. METHODS: Planned secondary analysis of patients with suspected SARS-CoV-2, with (n = 415) and without (n = 25,306) HIV. Descriptive statistics were used to compare patient information and clinical characteristics by SARS-CoV-2 and HIV status. Unadjusted and multivariable models were used to explore factors associated with death, intubation, and hospital length of stay. Kaplan-Meier curves were used to estimate survival by SARS-CoV-2 and HIV infection status. RESULTS: Patients with both SARS-CoV-2 and HIV and patients with SARS-CoV-2 but without HIV had similar admission rates (62.7% versus 58.6%, P = 0.24), hospitalization characteristics [eg, rates of admission to the intensive care unit from the emergency department (5.0% versus 6.3%, P = 0.45) and intubation (10% versus 13.3%, P = 0.17)], and rates of death (13.9% versus 15.1%, P = 0.65). They also had a similar cumulative risk of death (log-rank P = 0.72). However, patients with both HIV and SARS-CoV-2 infections compared with patients with HIV but without SAR-CoV-2 had worsened outcomes, including increased mortality (13.9% versus 5.1%, P < 0.01, log-rank P < 0.0001) and their deaths occurred sooner (median 11.5 versus 34 days, P < 0.01). CONCLUSIONS: Among emergency department patients with HIV, clinical outcomes associated with SARS-CoV-2 infection are not worse when compared with patients without HIV, but SARS-CoV-2 infection increased the risk of death in patients with HIV.

Evaluation of Three Commercial and Two Non-Commercial Immunoassays for the Detection of Prior Infection to SARS-CoV-2.

BACKGROUND: Serological testing provides a record of prior infection with SARS-CoV-2, but assay performance requires independent assessment. METHODS: We evaluated 3 commercial (Roche Diagnostics pan-IG, and Epitope Diagnostics IgM and IgG) and 2 non-commercial (Simoa and Ragon/MGH IgG) immunoassays against 1083 unique samples that included 251 PCR-positive and 832 prepandemic samples. RESULTS: The Roche assay registered the highest specificity 99.6% (3/832 false positives), the Ragon/MGH assay 99.5% (4/832), the primary Simoa assay model 99.0% (8/832), and the Epitope IgG and IgM 99.0% (8/830) and 99.5% (4/830), respectively. Overall sensitivities for the Simoa, Roche pan-IG, Epitope IgG, Ragon/MGH IgG, and Epitope IgM were 92.0%, 82.9%, 82.5%, 64.5% and 47.0%, respectively. The Simoa immunoassay demonstrated the highest sensitivity among samples stratified by days postsymptom onset (PSO), <8 days PSO (57.69%) 8-14 days PSO (93.51%), 15-21 days PSO (100%), and > 21 days PSO (95.18%). CONCLUSIONS: All assays demonstrated high to very high specificities while sensitivities were variable across assays.