Trends and racial disparity in primary pressure ulcer hospitalizations outcomes in the US from 2005 to 2014.

In the United States (US), pressure ulcers affect ≤3 million people and costs exceed 26.8 billion US dollars in spending. To examine trends in primary pressure ulcer (PPU) hospitalization mortality, length of hospital stay (LOS), and inflation-adjusted charges (IAC) in the US from 2005 to 2014 by race/ethnicity. We secondarily examined the relationship between race/ethnicity with PPU mortality, LOS, and IAC with race/ethnicity. This cross-sectional study used Nationwide Inpatient Sample (NIS) data from 2005 to 2014. The study sample included all hospitalizations with the designated ICD-9-CM code of 707.20-25 (pressure ulcer). There was a notable decline in PPU hospitalization from 11.5% to 7.77 % between 2005 and 2014. The mean mortality decreased from 2.32% to 1.12% (P < .001), the mean LOS declined from 9.39 days (P < .001), and the mean IAC per hospitalization decreased from $30,935 to $29,432 (P < .001). Positive changes observed in mortality, LOS, and IAC trends were consistent across different racial and ethnic groups. The results of multivariable logistic and linear regression analyses revealed that Black patients (ß = 0.68, 95% CI 0.36-1.01, P < .001) and patients belonging to the Other race/ethnic category (ß = 0.93, 95% CI 0.18-1.69) had longer hospital stays compared to their White counterparts. Regarding IAC, Black patients (ß = 2846, 95% CI 1254-4439, P < .005), Hispanic patients (ß = 6527, 95% CI 4925-8130), and patients from the Other race/ethnic category (ß = 3473, 95% CI 1771-5174) had higher IAC for PPU treatment compared to their White counterparts. PPU hospitalization discharges, as well as hospitalization mortality, LOS, and IAC, decreased during the study period, however, our findings revealed disparities in PPU outcomes among different racial/ethnic groups. Implications of the findings are discussed.

The effect of educational intervention based on the Progressively Lowered Stress Threshold extended model on the process of caregiving for people with dementia.

BACKGROUND: This study examined the impacts of an educational intervention based on the Progressively Lowered Stress Threshold (PLST) extended model on caregiving for people with dementia (PWD). METHOD: This study was conducted in Isfahan, Iran, from May 2016 to June 2018, with 38 caregivers of PWD as participants assigned to an intervention group. Data were collected using a multi-sectional, researcher-developed questionnaire that recorded the demographic characteristics, and measured the dementia-related knowledge and caregiving practices of the participants. The questionnaire and an educational program were designed in three parts according to the educational needs of caregivers to enhance their practice, skills, and ability to handle challenging behaviours in PWD. The questionnaire's face validity was confirmed by expert review, and its reliability was assessed with Cronbach's alpha coefficient (knowledge section, 0.838; practice section, 0.802). The sampling method used was convenience sampling, and none of the caregivers refused to receive the educational content. Therefore, the evaluation of the program lacks a randomized controlled group. To tailor the intervention program to the participants' needs, the educational content was based on the PLST extended model. RESULTS: The mean scores for knowledge and practice increased following the intervention (P < 0.05). An educational intervention, using the PLST extended care model, thus produced positive impacts in improving the knowledge and practice of caregivers of PWD. CONCLUSION: Educating caregivers with the PLST extended model, with a specific focus on the cultural and religious backgrounds of societies, is recommended.

Use and outcomes of antihypertensive medication treatment in the US hypertensive population: A gender comparison.

Background: Although effective antihypertensive medications have existed for decades, only about half of the hypertensive individuals are considered to have controlled blood pressure. Limited research studies have investigated gender disparity in the utilization and effectiveness of antihypertensive medications treatment. To examine the gender difference in antihypertensive medications' use and the effect of using antihypertensive medication treatment on blood pressure control among the U.S. adult with hypertension. Methods: Analysis of National Health and Nutrition Examination Survey (NHANES) data from (1999-2012) including individuals≥18 years old with hypertension. Study variables included gender, age, race/ethnicity, obesity, smoking, comorbidities, treatment medication type, and continuity of care. We used multivariate logistic regression in STATA V14. The data is presented as adjusted odds ratios (ORs) and 95% confidence interval (CI). Results: Of the 15719 participants, 52% were female. 49% of the antihypertensive medication users had their blood pressure under control (95% CI). In the adjusted logistic regression analysis, use of antihypertensive medications was found to be 12% greater in females as compared to males (OR=1.12; CI=1.02-1.22; P<0.05). No association between gender and blood pressure control was found. Blood pressure control was less likely achieved among 50 years or younger individuals, Blacks and Hispanics, obese, and those taking calcium channel blocker (CCB). Conclusion: Hypertensive females are more likely than males to use antihypertensive medications. The effectiveness of treatment to control blood pressure is equal across males and females. Our findings have implications for practitioners to account gender-specific approaches when discussing adherence to hypertension medication treatment with their patients.

Examining racial disparity in psychotic disorders related ambulatory care visits: an observational study using national ambulatory medical care survey 2010-2015.

BACKGROUND: One of the most consistent research findings related to race and mental health diseases is the disproportionately high rate of psychotic disorder diagnoses among people of color, specifically people of African descent. It is important to examine if a similar pattern exists among specific psychotic disorders. We aimed to examine the racial/ethnic differences in ambulatory care visits diagnosed with schizophrenia-spectrum disorders (SSDs). METHODS: We analyzed data from the National Ambulatory Medical Care Survey (NAMCS) 2010-2015. The study sample included physician office-based visits by individuals diagnosed with SSDs, including schizophrenia, schizoaffective, and unspecified psychotic disorder (n = 1155). We used descriptive and bivariate analysis by race/ethnicity and three multinomial logistic regression models to test the association between the SSDs and race/ethnicity, adjusting for age, gender, insurance, disposition, medication Rx, and co-morbidity, considering the design and weight. RESULT: Of the 1155 visits for SSDs, 44.8% had schizophrenia, 37.4% had schizoaffective disorder diagnosis, and 19.0% had unspecified psychosis disorder. We found significant racial disparities in the diagnosis of SSDs. Black patients were overrepresented in all three categories: schizophrenia (24%), schizoaffective disorder (17%), and unspecified psychosis disorder (26%). Also, a notable percentage of Black patients (20%) were referred to another physician in cases of schizophrenia compared to other ethnoracial groups (p < 0.0001). Moreover, we found a significant disparity in insurance coverage for schizoaffective disorder, with a higher percentage of Black patients (48%) having Medicaid insurance compared to patients from other ethnoracial groups (p < 0.0001). Black patients had nearly twice the odds of receiving a diagnosis of schizophrenia compared to White patients [AOR = 1.94; 95% CI: 1.28-2.95; P = 0.001]. However, they had significantly lower odds of being diagnosed with schizoaffective disorder [AOR = 0.42, 95% CI: 0.26-0.68; P = 0.003]. Race/ethnicity was not associated with receiving an unspecified psychosis disorder. CONCLUSIONS: Our results show that SSDs, more specifically schizophrenia, continue to burden the mental health of Black individuals. Validation of our findings requires rigorous research at the population level that reveals the epidemiological difference of SSDs diagnoses in different race/ethnicity groups. Also, advancing our understanding of the nature of disparity in SSDs diagnoses among the Black population requires disentangling etiologic and systemic factors in play. This could include psychological stress, the pathway to care, services use, provider diagnostic practice, and experiencing discrimination and institutional and structural racism.

Impact of COVID-19 pandemic on relapse of individuals with severe mental illness and their caregiver's burden.

Background: The implementation of quarantine and social distancing measures to control the COVID-19 pandemic led to restrictions at the community level and most of in-person psychiatric services were discontinued. This situation could affect the psychopathology of the patients and the burden of their caregivers. The aim of this study was to investigate the effects of COVID-19 pandemic on people with severe mental illnesses (SMIs) and their caregivers' burden. Method: The study sample consisted of 86 patients with severe mental illness and 86 caregivers. The mental status, relapse rate, and rehospitalization rate of the patients and the general health status and burden of caregivers were investigated in three waves, including before and 3 and 6 months after the COVID-19 pandemic. Results: The relapse rate of the patients was 14%, 33.7%, and 43% (p = 0.000) and the rehospitalization rate was 4.7%, 7%, and 10.5% in waves 0, 1, and 2, respectively (p = 0.000). Most of the psychopathological scales increased in three waves (p = 0.000). The caregivers' burden and health condition worsened during the nine months of the study as well (p = 0.000). Conclusion: The COVID-19 pandemic led to the exacerbation of symptoms and increased the relapse rate in people with SMIs. It also worsened the caregivers' condition. People with severe mental illnesses (SMIs) and their caregivers are one of the most vulnerable groups on which the COVID-19 pandemic had a marked negative effect.

Emergency Department Utilization, Hospital Admissions, and Office-Based Physician Visits Among Under-Resourced African American and Latino Older Adults.

OBJECTIVES: This study uses a theoretical model to explore (a) emergency department (ED) utilization, (b) hospital admissions, and (c) office-based physician visits among sample of under-resourced African American and Latino older adults. METHODS: Nine hundred five African American and Latino older adults from an under-resourced urban community of South Los Angeles participated in this study. Data was collected using face-to-face interviews. Poisson and logistic regression analysis were used to estimate the parameters specified in the Andersen behavioral model. Predictors included predisposing factors, defined as demographic and other personal characteristics that influence the likelihood of obtaining care, and enabling factors defined as personal, family, and community resources that support or encourage efforts to access health services. RESULTS: African American older adults have a greater frequency of hospital admissions, ED, and physician visits than their Latino counterparts. About 25%, 45%, and 59% of the variance of the hospital admissions, ED utilization, and physician visits could be explained by predisposing and enabling characteristics. Lower health-related quality of life was associated with a higher number of hospital admissions, ED, and physician visits. Financial strain and difficulty accessing medical care were associated with a higher number of hospital admissions. Being covered by Medicare and particularly Medi-Cal were positively associated with higher hospital admissions, ED, and physician visits. DISCUSSION: Compared to African American older adults, Latino older adults show higher utilization of (a) emergency department (ED) utilization, (b) hospital admissions, and (c) office-based physician visits. A wide range of predisposing and enabling factors such as insurance and financial difficulties correlate with some but not other types of health care use. Multi-disciplinary, culturally sensitive, clinic- and community-based interventions are needed to address enabling and predisposing factors that influence ED utilization and hospital admission among African American and Latino older adults in under-resourced communities.

Physical and mental health quality of life among underserved African American and Latino older adults.

OBJECTIVES: There is an increasing amount of research on Health-Related Quality of Life (HRQoL) among older adults in the U.S. However, under-resourced and underserved African American and Latino older adults remain underrepresented in research and interventional studies, resulting in limited data on their quality of life and health promotion practices. This study examined the association between HRQoL and several layers of independent variables, including health conditions, level of pain, sleep disorders, and lifestyle factors, among African American and Latino older adults. DESIGN: Nine hundred and five African Americans and Latinos aged 55 years and older from an underserved urban community participated in this face-to-face structured study. Multiple linear regression was performed. RESULTS: This study documented that HRQoL among African American and Latino participants was substantially lower compared with their White counterparts reported by other studies. Adjusting for other relevant variables, this study documented an association between: (1) physical HRQoL and financial strain, perceived health, the severity of pain, number of major chronic conditions, smoking, and binge drinking; and (2) mental HRQoL and financial strain, perceived health status, the severity of pain, and sleep disorders. CONCLUSION: Significantly lower levels of HRQoL among underserved African American and Latino older adults, compared with their White counterparts, point to another important racial/ethnic disparity in the U.S. geriatric population. The devastating consequences of financial strain, excessive chronic conditions, undiagnosed and untreated pain, and sleep disorders are all experienced by underserved African American and Latino older adults, and these factors directly contribute to a lower quality of life among this segment of our population. Longitudinal multi-faceted, multi-disciplinary, culturally sensitive, both clinic- and community-based participatory interventions are needed to address these factors, particularly pain and sleep disorders, in order to enhance the quality of life among these underserved communities.

Predictors of hospital readmissions in adult patients with sickle cell disease.

BACKGROUND: Sickle cell disease (SCD) is the most common inherited blood disorder, affecting primarily Black and Hispanic individuals. In 2016, 30-day readmissions incurred 95,445 extra days of hospitalization, $152 million in total hospitalization costs, and $609 million in total hospitalization charges. OBJECTIVES: 1) To estimate hospital readmissions within 30 days among patients with SCD in the State of California. 2) Identify the factors associated with readmission within 30 days for SCD patients in California. METHODS: We conducted a retrospective observational study of adult SCD patients hospitalized in California between 2005 and 2014. Descriptive statistics and logistic regression models were used to examine significant differences in patient characteristics and their association with hospital readmissions. RESULTS: From 2,728 individual index admissions, 70% presented with single admission, 10% experienced one readmission, and 20% experienced ≥ two readmissions within 30 days. Significant predictors associated with zero vs. one readmission were male gender (OR=1.37, CI: 1.06-1.77), Black ethnicity (OR=3.27, CI: 1.71-6.27) and having Medicare coverage (OR=1.89, CI: 1.30-2.75). Lower likelihood of readmission was found in those with a Charlson Comorbidity index of three or more (OR=0.53, CI: 0.29-0.97). For zero vs. ≥ two readmissions, significant predictors were male gender (OR=1.43, CI: 1.17-1.74), Black ethnicity (OR=6.90, CI: 3.41-13.97), Hispanic ethnicity (OR=2.33, CI: 1.05-5.17), Medicare coverage (OR=3.58, CI: 2.68-4.81) and Medi-Cal coverage (OR=1.70, CI: 1.31-2.20). Lower likelihood for having two or more readmissions were associated with individuals aged 65+ (OR=0.97, CI: 0.96-0.98) and those with self-payment status (OR=0.32, CI: 0.12-0.54). CONCLUSIONS: In California, male, Black, and Hispanic patients, as well as those covered by Medicare or Medi-Cal, were found to have an increased risk of hospital readmissions. Redirecting outpatient goals to address these patient populations and risk factors is crucial for reducing readmission rates.

Psychometric Properties of EQ-5D-3L Applied through Phone Follow-Ups: An Experience in PERSIAN Traffic Cohort.

Objective: To assess psychometric properties of the European Quality of Life 5-Dimension 3-Level Version (EQ-5D-3L) commonly used tool for measuring road traffic injury (RTI) patients' quality of life. Methods: The psychometric study assessed the reliability and applicability of EQ-5D-3L through phone surveys, based on a national cohort platform. Data of 150 RTI patients recruited from the cohort study were included as 50 patients per each follow-up phase (one, six, and twelve months after discharge). A 12- day-time span was between test and retest. We measured psychometric properties (internal consistency reliability and stability reliability) and agreement using Kappa coefficients and percentages of agreement and Bland-Altman method. Data were analysed using software STATA statistical package. Results: The majority of patients were men (80%) with mean age (SD) of 41(14.7%), employed (78%) and educated (86%). The Persian version represented high internal consistency reliability at total level (Cronbach's α=0.81) and moderate to good reliability at phase levels (0.62-0.87). The stability reliability was excellent at total (ICC=0.98, 95% CI: 0.97, 0.98) and phase levels (0.97-0.98. The kappa agreement coefficients were valued moderate to perfect (0.6-0.8, p>0.0001). The Bland-altman plot illustrated high agreement between test and retest scores. No floor and ceiling effects were found. Conclusion: The study revealed that EQ-5D-3L was highly reliable and responsive to be applied through phone interviews at three different times post injury and discharge, as no previous study considered its psychometric properties at various phone follow-ups after RTIs.

Underrepresented in medicine students' perspectives on impactful medical education.

BACKGROUND: Exploring the perceptions of underrepresented in medicine (URiM) students about the medical education curriculum and learning environment could optimize their education outcomes. The current study delineated perceptions of URiM medical students about the unique elements and characteristics of an impactful medical education program that create a positive, supportive learning environment culture. METHODS: We conducted in-depth interviews with 15 URiM students between January 2018 and April 2018. Interviewees were recruited from an accredited medical education program in Historically Black Colleges and Universities (HBCUs). The University is also a member of the Hispanic Association of Colleges and Universities in the U.S. The main question that guided the study was, "What do URiM students at a Historically Black Colleges and Universities (HBCU) medical school believe would make a medical education program (MEP) impactful?" We used the grounded theory analytical approach and performed content analysis via qualitative thematic evaluation. RESULTS: Of 112 enrolled medical students (MS), 15 verbally consented to participation. We identified four general themes and several subthemes. The themes include 1) Grounding learning in the community; 2) Progressive system-based practice competency; 3) Social justice competency and 4) Trauma-informed medical education delivery. Theme 1 included the following subthemes (a) community engagement, and (b) student-run clinic, mobile clinic, and homeless clinic rotations. Theme 2 includes (a) interprofessional learning and (b) multidisciplinary medicine for cultivating a 'just' healthcare system. Theme 3 includes (a) longitudinal social justice curriculum, (b) advocacy, and (c) health disparity research. Theme 4 had the following subdomains (a) early and ongoing mentoring and (b) provision of supportive policies, services and practices to maximize learning and mental health. CONCLUSION: Our learners found that social justice, trauma-informed, community-based curricula are impactful for URiM learners. These findings highlight the need for further research to assess the impact of permeating the championship culture, community cultural wealth, and transformational education in all aspects of the MEP in providing a supporting and positive learning environment for URiM students.

Validity and reliability of the Farsi version of the ascertain dementia 8-item (AD8-F) informant interview in Iranian patients with mild neurocognitive disorder.

BACKGROUND: For screening and distinguishing between mild neurocognitive disorder (mNCD) and normal cognitive age-related changes in primary care centers, a simple and practical tool is necessary. Therefore, this study aims to determine the validity and reliability of the Farsi version of the Ascertain Dementia 8-item (AD8-F) informant interview in patients with mNCD. METHODS: This is a study of the psychometric properties of the Farsi AD8. The participants include sixty informant-patient dyads with mNCD and sixty controls with normal cognition. The AD8 was compared to the mini-mental state examination (MMSE) and the Mini-Cog. As a gold standard, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for mNCD was used. The reliability was measured using internal consistency and test-retest. Validity was assessed by evaluating the content, concurrent, and construct validity. Data were analyzed via Cronbach's α, Pearson correlation, independent t-test, and analysis of variance (ANOVA) and area under the curve (AUC) by statistical package for the social sciences (SPSS) v.23. RESULTS: Cronbach's α was 0.71. Test-retest reproducibility was 0.8. The AD8 had inverse correlations with the Mini-Cog (r = - 0.70, P < 0.01) and MMSE (r = - 0.56, P < 0.01). The area under the curve was 0.88. The optimal cutoff score was > 2. Sensitivity and specificity were 80 and 83%, respectively. The positive predictive value was 83%. The negative predictive value was 81%. CONCLUSION: Our results suggest that this tool can be used as a screening tool to detect a mild neurocognitive disorder in primary care centers.

Psychometric properties of the 12-item WHODAS applied through phone survey: an experience in PERSIAN Traffic Cohort.

BACKGROUND: Due to limited capability to function in post-injury daily life injury, survivors need to be reliably assessed without need to commute more than necessary. The key action is to determine the level of functioning difficulties. Having the opportunity of conducting a national post-crash traffic safety and health cohort study, we aimed to translate into Persian and assess the psychometric properties of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) through phone surveys six month post injury. METHODS: First, having World Health Organization permission, we tested the translation validity by forward translation, expert panel evaluation, back-translation, pre-testing and cognitive interviewing, and finalizing the Persian WHODAS. Then, through a psychometric study within a national cohort platform, the validity, reliability and applicability of the 12-item WHODAS was assessed through phone surveys. We included data of 255 road traffic injury patients enrolled from the cohort at six-month follow-up. The psychometric assessment (internal consistency reliability and stability reliability) was conducted on test-retest data of 50 patients with an average 7-day time span. An exploratory factor analysis tested the construct validity using extraction method of principal component factor and oblique rotation on data from 255 patients. Regarding the multiple criteria including an eigenvalue > 0.9, Cattell's scree test, cumulative variance, and the theoretical basis, the minimum number of factors were retained. Data were analyzed using STATA statistical software package. RESULTS: The respondents were mostly male (81%), employed (71%), educated (87%), and with a mean age of 37.7(14.9). The Persian version had high internal consistency reliability (Cronbach's α = 0.93) and excellent stability reliability (ICC = 0.97, 95% CI: 0.92-0.98). An exploratory factor analysis retained four factors defining 86% of all the variance. Factors of Self-care, Mobility, and Cognition were completely retained. CONCLUSIONS: The brief Pesrian WHODAS 2.0 was highly reliable and valid to be applied through phone interviews post injury.

PERSIAN Traffic Safety and Health Cohort: a study protocol on postcrash mental and physical health consequences.

BACKGROUND: Cohort studies play essential roles in assessing causality, appropriate interventions. The study, Post-crash Prospective Epidemiological Research Studies in IrAN Traffic Safety and Health Cohort, aims to investigate the common health consequences of road traffic injuries (RTIs) postcrash through multiple follow-ups. METHODS: This protocol study was designed to analyse human, vehicle and environmental factors as exposures relating to postcrash outcomes (injury, disability, death, property damage, quality of life, etc). Population sources include registered injured people and followed up healthy people in precrash cohort experienced RTIs. It includes four first-year follow-ups, 1 month (phone-based), 3 months (in-person, video/phone call), 6 and 12 months (phone-based) after crash. Then, 24-month and 36-month follow-ups will be conducted triennially. Various questionnaires such as Post-traumatic Stress Disorder Questionnaire, Patient Health Questionnaire, WHO Disability Assessment Schedules, Cost-related Information, etc are completed. Counselling with a psychiatrist and a medical visit by a practitioner are provided accompanied by extra tools (simulator-based driving assessment, and psychophysiological tests). Through preliminary recruitment plan, 5807, 2905, 2247 and 1051 subjects have been enrolled, respectively at the baseline, first, second and third follow-ups by now. At baseline, cars and motorcycles accounted for over 30% and 25% of RTIs. At first follow-up, 27% of participants were pedestrians engaged mostly in car crashes. Around a fourth of injuries were single injuries. Car occupants were injured in 40% of collisions. DISCUSSION: The study provides an opportunity to investigate physical-psychosocial outcomes of RTIs, predictors and patterns at follow-up phases postinjury through longitudinal assessments, to provide advocates for evidence-based safety national policy-making.

Correlates of Older Adults' E-Health Information-Seeking Behaviors.

INTRODUCTION: The Internet is an important source for health information and a medium for older adults' empowerment in health decision-making and self-caring. Therefore, we aimed to identify the potential motivators and probable barriers of e-health information-seeking behaviors (e-HISB) among older Iranian adults. METHODS: A cross-sectional study assessed the usefulness of self-efficacy, perceived encouragement, positive attitude toward e-HISB, perceived usefulness, challenges of being visited by physicians, and perceived barriers in predicting e-HISB in a sample of 320 older adults in Tabriz, Iran. RESULTS: The self-efficacy for online information seeking, positive attitude toward e-HISB, and perceived usefulness increased the odds of e-HISB by 12.00%, 24.00%, and 15.00%, respectively. In addition, e-health literacy, conflicting information, distrust of online information, and web designs that were not senior-friendly were the major barriers to e-HISB. DISCUSSION/CONCLUSION: The theoretical and practical implications of the motivators and barriers of e-HISB can be instrumental in designing and executing programs aimed at improving e-health literacy among older adults especially during the COVID-19 pandemic.

Distance Learning During COVID-19 Mitigates Learning Loss for Interprofessional Education.

SUMMARY STATEMENT: On-site interprofessional education (IPE) simulation is primarily used to teach students teamwork, communication, and crisis resource management. Participants view it as an educational environment in which to acquire and consolidate skills. Virtual IPE simulation is traditionally seen as an opportunity to supplement, complement, and reinforce on-site IPE (OI). We used VI as the sole simulation method during the COVID-19 pandemic to provide IPE because of constraints of social distancing. The VI resulted in substantially achieving similar learning outcomes to OI. This suggests that VI, which has the advantage of being cheaper and more easily scalable than OI, may be an effective remote learning modality for IPE.

Preparedness for Serious Illnesses: Impact of Ethnicity, Mistrust, Perceived Discrimination, and Health Communication.

BACKGROUND: Increasing severity of serious illness requires individuals to prepare and make decisions to mitigate adverse consequences of their illness. In a racial and ethnically diverse sample, the current study examined preparedness for serious illness among adults in California. METHODS: This cross-sectional study used data from the Survey of California Adults on Serious Illness and End-of-Life 2019. Participants included 542 non-Hispanic White (52%), non-Hispanic Black (28%), and Hispanic (20%) adults who reported at least one chronic medical condition that they perceived to be a serious illness. Race/ethnicity, socio-demographic factors, health status, discrimination, mistrust, and communication with provider were measured. To perform data analysis, we used logistic regression models. RESULTS: Our findings revealed that 19%, 24%, and 34% of non-Hispanic White, non-Hispanic Blacks, and Hispanic believed they were not prepared if their medical condition gets worse, respectively. Over 60% indicated that their healthcare providers never engaged them in discussions of their feelings of fear, stress, or sadness related to their illnesses. Results of bivariate analyses showed that race/ethnicity was associated with serious illness preparedness. However, multivariate analysis uncovered that serious illness preparedness was only lower in the presence of medical mistrust in healthcare providers, perceived discrimination, less communication with providers, and poorer quality of self-rated health. CONCLUSION: This study draws attention to the need for healthcare systems and primary care providers to engage in effective discussions and education regarding serious illness preparedness with their patients, which can be beneficial for both individuals and family members and increase quality of care.

Exploring a novel approach to surgery clerkship didactics during the COVID-19 pandemic: A qualitative study.

BACKGROUND: The COVID-19 pandemic brings unforeseen challenges in medical education. The current study aims to: 1) describe third-year medical students' experiences with the novel Shelf-Exam-Type Question Didactics (SET QD) before (in-person) and during (virtual) COVID-19. METHODS: In this qualitative study using grounded theory, we conducted purposive sampling and used 23 in-depth semi-structured interviews. Audio recordings were transcribed verbatim and the Atlas.Ti software was used to manage the thematic analysis. RESULTS: There are three themes and eight subthemes that emerged: 1) The SET QD Framework (sub-themes: questions as learning opportunities; interleaving; notable clinical scenarios; team learning; accountability). 2) Experienced Educator (subtheme: transformational teaching). 3) Virtual Accessibility (sub-themes: alleviating time constraints, and mitigating life-stressors). CONCLUSIONS: Medical students regarded SET QD as impactful for shelf exam preparation, clinical preparation, and long-term retention of the material. This novel virtual didactic method may be used in non-surgical clerkships as well.

Addressing Patient-Centered Care Through Mindful Listening and Mentalizing in Psychiatry.

This 21st-Century Psychiatrist column reflects the authors' perceptions of the importance of addressing patient-centered care through mindful listening and mentalizing in psychiatry. The authors maintain that adopting a mentalizing stance is a promising approach for clinicians with diverse backgrounds to humanize clinical practice, especially in today's dynamic high-speed, high-paced, and high-technology environment. Mindful listening and mentalizing are particularly consequential for the field of psychiatry since the COVID-19 pandemic prompted an abrupt transition from in-person to virtual platforms for education and clinical care.

Contribution of a positive psychology-based conceptual framework in reducing physician burnout and improving well-being: a systematic review.

BACKGROUND: The PERMA Model, as a positive psychology conceptual framework, has increased our understanding of the role of Positive emotion, Engagement, Relationships, Meaning, and Achievements in enhancing human potentials, performance and wellbeing. We aimed to assess the utility of PERMA as a multidimensional model of positive psychology in reducing physician burnout and improving their well-being. METHODS: Eligible studies include peer-reviewed English language studies of randomized control trials and non-randomized design. Attending physicians, residents, and fellows of any specialty in the primary, secondary, or intensive care setting comprised the study population. Eligible studies also involved positive psychology interventions designed to enhance physician well-being or reduce physician burnout. Using free text and the medical subject headings we searched CINAHL, Ovid PsychINFO, MEDLINE, and Google Scholar (GS) electronic bibliographic databases from 2000 until March 2020. We use keywords for a combination of three general or block of terms (Health Personnel OR Health Professionals OR Physician OR Internship and Residency OR Medical Staff Or Fellow) AND (Burnout) AND (Positive Psychology OR PERMA OR Wellbeing Intervention OR Well-being Model OR Wellbeing Theory). RESULTS: Our search retrieved 1886 results (1804 through CINAHL, Ovid PsychINFO, MEDLINE, and 82 through GS) before duplicates were removed and 1723 after duplicates were removed. The final review included 21 studies. Studies represented eight countries, with the majority conducted in Spain (n = 3), followed by the US (n = 8), and Australia (n = 3). Except for one study that used a bio-psychosocial approach to guide the intervention, none of the other interventions in this review were based on a conceptual model, including PERMA. However, retrospectively, ten studies used strategies that resonate with the PERMA components. CONCLUSION: Consideration of the utility of PERMA as a multidimensional model of positive psychology to guide interventions to reduce burnout and enhance well-being among physicians is missing in the literature. Nevertheless, the majority of the studies reported some level of positive outcome regarding reducing burnout or improving well-being by using a physician or a system-directed intervention. Albeit, we found more favorable outcomes in the system-directed intervention. Future studies are needed to evaluate if PERMA as a framework can be used to guide system-directed interventions in reducing physician burnout and improving their well-being.

Clozapine prescribing barriers in the management of treatment-resistant schizophrenia: A systematic review.

BACKGROUND: Treatment-resistant schizophrenia is prevalent and difficult to manage, as patients fail multiple antipsychotic trials before being considered as treatment-resistant. Currently clozapine is the only Food and Drug Administration-approved pharmacotherapy for treatment-resistant schizophrenia but remains under-prescribed. The purpose of this study is to investigate recent literature on clozapine in order to identify barriers to prescribing clozapine and categorize the recommended solutions. METHODS: We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Using free text and the medical subject headings, we searched MEDLINE/PubMed electronic bibliographic database from 2017 until 2020. Eligible studies included peer-reviewed English language articles with multiple methodologies aiming to identify clozapine barriers in treatment-resistant schizophrenia. We used search terms combining clozapine AND treatment OR treatment-resistant schizophrenia AND barriers AND prescribing OR prescription OR prescriber. We merged search results in a citation manager software, removed duplicates, and screened the remaining articles based on the study eligibility criteria. RESULTS: We retrieved 123 studies, however, only 10 articles exclusively met the study inclusion criteria for full text review. These studies represented 20 countries; 6 were exclusively conducted in the US. The top barriers delineated by the studies include: providers' lack of knowledge and training (n = 7), concern about side effects (n = 8), and poor adherence (n = 7). All studies described more than 1 barrier. Other barriers included prescriber-perceived barriers (n = 4), administrative barriers (n = 5), and other healthcare systems-related barriers (n = 3). Top recommendations to overcome clozapine prescription barriers included improving prescriber clozapine education/training, utilizing interdisciplinary teams and providing integrated care via clozapine clinics, and simplifying blood test monitoring. CONCLUSION: Clozapine remains under-prescribed for patients with treatment-resistant schizophrenia due to multiple barriers related to the individual prescriber, system of care, and technology. It is recommended that by improving prescriber knowledge and training, use of integrated care, and use of technology that can enable continuous, real-time blood test monitoring, these barriers may be overcome.