Disciplinary Intersection of Medicine and Business: A Novel Population Health Management Premedical Pathway for Medicine and Other Health Care Professions.

Premedical students typically pursue undergraduate specialization in basic biological and other sciences, learning to understand living systems at a microscopic, genetic, or molecular level. However, curricula in the basic sciences do not traditionally include courses that enable students to learn about living systems at the macro level-understanding individuals within their environment, as well as understanding and managing the health of populations, especially those with underlying conditions or the underserved. This disconnect can be bridged by creating novel curricular programs intersecting medicine and business. Population health management is a multidisciplinary field that aims to improve the patient experience, reduce health care costs, and improve treatment outcomes. Though related to public health, the 2 fields differ in significant ways. Population health management emphasizes health outcomes and their measurements and seeks to improve health outcomes based on a full understanding of risk, behaviors, lifestyle, environment, and all social determinants of health. A shift in premedical education that connects the medical sciences with business requires curricular reform with the emerging field of population health management at their intersection, allowing students to be better prepared for future medical practices and to understand expectations, benchmarks, business, and economics in a new value-based health care system.

Disparities in Emergency Department Visits for Opioid and Stimulant Overdoses in Florida During COVID-19.

Emergency department (ED) visits for drug overdoses increased nationally during COVID-19 despite declines in all-cause ED visits. The study purpose was to compare characteristics of ED visits for opioid and stimulant overdoses before and during COVID-19 in Florida. This study tested for disparities in ED visits for opioid and stimulant overdoses by race/ethnicity, age, and insurance status. The study identified ED visits for opioid and stimulant overdose in Florida during quarters two and three of 2019 and compared them with quarters two and three of 2020. Overall, there was an increase in the number of opioid and stimulant overdoses during COVID-19. Combined with the decline in the number of all-cause ED visits, drug overdoses represented a larger share of ED visits during COVID-19 compared with before COVID-19. The study did not find evidence of disparities by race/ethnicity, as each group experienced similar increases in the likelihood of ED visits involving drug overdoses during COVID-19. Differences emerged according to age and insurance status. ED visits involving those under age 18 were more likely to involve opioid or stimulant overdose, and ED visits among those over age 65 were less likely to involve opioid overdose during COVID-19. ED visits among those with vulnerable insurance status were more likely to involve opioid overdose during COVID-19. Patterns of behavior change during periods of restricted activity due to a pandemic. These changes in behavior change the mix of risks that people face, suggesting the need for a reallocation of population health management resources during pandemics.

Redesign of US Medical Schools: A Shift from Health Service to Population Health Management.

The integration of medical schools and clinical partners is effectively established through the formation of academic medical centers (AMCs). The tripartite mission of AMCs emphasizes the importance of providing critical clinical services, medical innovation through research, and the education of future health care leaders. Although AMCs represent only 5% of all hospitals, they contribute substantially to serving disadvantaged populations of patients, including an estimated 37% of all charity care and 26% of all Medicaid hospitalizations. Currently, most AMCs use a business model centered upon revenue generated from hospital services and/or practice plans. In the last decade, mounting financial demands have placed significant pressure on AMC finances because of the rising costs associated with complex clinical care and operating diverse graduate medical education programs. A shift toward population health-centric health care management strategies will profoundly influence the predominant forms of health care delivery in the United States in the foreseeable future. Health systems are increasingly pursuing new strategies to manage financial risk, such as forming Accountable Care Organizations and provider-sponsored plans to provide value-based care. Refocusing research and operational capacity toward population health management fosters collaboration and enables reintegration with hospital and clinical partners across care networks, and can potentially create new revenue streams for AMCs. Despite the benefits of population health integration, current literature lacks a blueprint to guide AMCs in the transformation toward sustainable population health management models. The purpose of this paper is to propose a modern conceptual framework that can be operationalized by AMCs in order to achieve a sustainable future.

A Call to Action: Preventing Opioid and Substance Abuse in South Florida Youth.

Description The opioid crisis poses a substantial threat to youth throughout the nation. This crisis has been exacerbated by the COVID-19 pandemic, reversing some of the positive national trends in the fight against the opioid epidemic. Some risk factors for youth opioid use have been identified nationally. The South Florida tri-county region of Miami-Dade, Broward and Palm Beach is a culturally distinct region which may not follow national trends and likely has unique risk and protective factors. To address the concerning spike in youth opioid use in South Florida, a community coalition was formed to identify factors unique to South Florida and create a plan for early awareness and prevention.

Transitioning to Value-Based Diabetes Care: A Call for Action Derived from Primary Care Providers in South Florida.

Background: In Florida, 2.4 million people have diabetes and 5.8 million are pre-diabetic. Not only has the prevalence of diabetes doubled over the past 20 years from 5.2 in 1992 to 11.2 in 2014, but the Centers for Disease Control and Prevention expects 1 out of every 3 adults will have diabetes by the year 2050. In addition, in every year since 1996, Florida well exceeds the national levels in terms of prevalence of diabetes, and the gap is getting wider. A study was conducted to gather information from key physician stakeholders as to how to address unmet needs of patients at risk for, or whom already have, diabetes in a tri-county region of South Florida where the prevalence of diabetes is very high. Objective: The goal was to catalyze innovation and generate solutions for high quality and affordable diabetes care by convening community physicians in South Florida and querying them about solutions for delivering value-based care. Methods: A physician-led task force of community physicians was convened to uncover unmet needs in the diabetes care continuum, identify areas of improvement for coordinating care across the continuum and effectively accessing specialty care. Focus groups were convened with 30 participants to capture qualitative data relative to unmet needs, utilizing the Rapid Ideation Technique. A survey instrument was designed and administered to the twenty-one community clinicians on the task force to augment the qualitative data with quantitative data. The first part of the survey captured characteristics of the participating clinicians, their practices, their diabetes services and management approaches. The second part of the survey captured individual ratings of the importance and merit of needs and/or potential solutions generated. Results: The focus groups generated a wealth of information regarding challenges, issues, areas of opportunities, and potential solutions that could be organized within eight main themes: care coordination and integration; patient engagement, education and behavioral change; physician and practice support; EMR and data issues; telehealth solutions; health informatics and data analytics; and access to care. The surveys culminated in the formation of a Call-For-Action Agenda for immediate work. Conclusions: The ultimate goal of the taskforce was to catalyze innovation and generate solutions for high quality and affordable care. This article reports the findings and provides a roadmap for the future.

Management Principles to Drive the Creation of a 21st Century Medical School.

Introduction: There are currently no data, blueprints, best practices, or financial models available to guide the creation of a new medical school. Yet, the United States is experiencing unprecedented growth of new allopathic medical schools. Findings: This article brings logic to the process. It converts the complexity of what is often regarded as an administrative exercise into the first published framework of management principles. Those principles were then translated into a process map and a financial optimization model. All three elements can be successfully implemented for establishing an accredited, value-driven medical education program that minimizes time from inception to implementation, and ensures sustainability over time. Outcomes: This case report provides a blueprint for planning and implementation of a new medical school. Outcomes include both process and optimization models, as well as valuable insights that have utility when considering a new medical school to mitigate the projected nationwide shortage of physicians.

Effects of web-based instruction and patient preferences on patient-reported outcomes and learning for women with advanced ovarian cancer: A randomized controlled trial.

A randomized controlled trial was conducted of a web-based intervention to improve advanced care planning in women with ovarian cancer. A secondary analysis of 35 randomized women focused on changes in distress and knowledge about ovarian cancer through distress monitoring and information tailored to patients' cognitive coping style (monitoring, blunting). Pre-/postresults indicated the Intervention group demonstrated lower distress (p = 0.06); blunting was associated with lower depression (p = 0.04); knowledge in both groups was unchanged. Women in the Intervention vs. Control group reported their family was less likely to be upset by cancer information (p = 0.0004). This intervention reduced distress while incorporating patient preferences.

Designing an Educational Website to Improve Quality of Supportive Oncology Care for Women with Ovarian Cancer: An Expert Usability Review and Analysis.

A broad-based research team developed a Health Insurance Portability and Accountability Act (HIPAA)-compliant educational website for women with ovarian cancer to improve the quality of supportive oncology care. Prior to a randomized clinical trial of the website, initial usability testing was implemented to evaluate the website. The initial review found that 165/247 checklist items had sufficient information to allow for evaluation with the website achieving an overall score of 63%. By category, lowest scores were for the Home Page, Task Orientation, Page Layout & Visual Design, and Help, Feedback & Error Tolerance. Major issues thought to potentially impede actual usage were prioritized in redevelopment and the second usability review, conducted by the same expert, saw an improvement in scores. Incorporating usability concepts from the start of development, fulfilling the positive expectations of end-users and identifying technical and personal factors that optimize use may greatly enhance usage of health websites.

Cost-Effectiveness of Integrating a Clinical Decision Rule and Staged Imaging Protocol for Diagnosis of Appendicitis.

OBJECTIVE: To evaluate the cost-effectiveness of a diagnostic protocol for appendicitis in children, the use of a validated clinical decision rule (CDR) and a staged imaging protocol, compared with usual care. METHODS: We estimated the cost-effectiveness of the three competing strategies using parameters from existing literature as well as a Markov model developed to simulate the effects of exposure to ionizing radiation from a single computed tomography (CT) study in the course of diagnosis. The simulation model was applied to a hypothetical cohort of 100,000 boys and girls, age 10 years, presenting with acute abdominal pain to emergency departments in the United States. RESULTS: The integrated strategy, the CDR followed by staged imaging, was found to be the most cost-effective approach. Cost savings accrued from the reduction in CT utilization for low-risk patients compared with the other two strategies. The addition of ultrasound (US) to the CDR strategy reduced CT utilization by an additional 10.9%, its main cost advantage, with negligible change in net health benefits from false-negative US results, and associated morbidity or mortality. CONCLUSIONS: Results suggest that the integration of staged imaging with the CDR for the diagnosis of appendicitis in children is a cost-effective and cost-saving approach. The model estimates a further 10.9% reduction in the number of CTs from the incorporation of US for patients scoring high or medium risk, in excess of the 19.5% reduction estimated in the CDR validation study.

Long-Term Services and Supports for Older Adults: A Review of Home and Community-Based Services Versus Institutional Care.

Despite a shift from institutional services toward more home and community-based services (HCBS) for older adults who need long-term services and supports (LTSS), the effects of HCBS have yet to be adequately synthesized in the literature. This review of literature from 1995 to 2012 compares the outcome trajectories of older adults served through HCBS (including assisted living [AL]) and in nursing homes (NHs) for physical function, cognition, mental health, mortality, use of acute care, and associated harms (e.g., accidents, abuse, and neglect) and costs. NH and AL residents did not differ in physical function, cognition, mental health, and mortality outcomes. The differences in harms between HCBS recipients and NH residents were mixed. Evidence was insufficient for cost comparisons. More and better research is needed to draw robust conclusions about how the service setting influences the outcomes and costs of LTSS for older adults. Future research should address the numerous methodological challenges present in this field of research and should emphasize studies evaluating the effectiveness of HCBS.

Reliability and validity of a test designed to assess combat medics' readiness to perform life-saving procedures.

OBJECTIVES: Reducing preventable deaths because of uncontrolled hemorrhage, tension pneumothorax, and airway loss is a priority. As part of a research initiative comparing different training models, this study evaluated the reliability and validity of a test that assesses combat medic performance during a polytrauma scenario using live animal models. METHODS: Nine procedural checklists and seven global rating scales were piloted with four cohorts of soldiers (n = 94) at two U.S. training sites. Cohorts represented "novice" to "proficient" trainees. Procedure scores and a mean global score were calculated per subject. The intraclass correlation was calculated per procedure, with 0.70 as the threshold for acceptability. An overall difference among cohorts was hypothesized: Cohort 4 (proficient) > Cohort 3 (competent) > Cohort 2 (beginners) > Cohort 1 (novice) trainees. Data were analyzed using Kruskal-Wallis and analysis of variance. RESULTS: At Site A, intraclass correlation coefficients ranged from 74% to 93% for 6 of 9 procedures. Cohorts differed significantly on hemorrhage control, needle decompression, cricothyrotomy, amputation management, chest tube insertion, and mean global scores. Cohort 4 outperformed the others, and Cohorts 2 and 3 outperformed Cohort 1. CONCLUSION: The test differentiates novices from beginners, competent, and proficient trainees on difficult procedures and overall performance.

Validity and acceptability of a high-fidelity physical simulation model for training of laparoscopic pyeloplasty.

PURPOSE: The objective was to determine the acceptability and preliminary construct validity for a high-fidelity synthetic renal pelvis/ureter tissue analogue model for use as a simulation model for training of laparoscopic pyeloplasty. MATERIALS AND METHODS: The pyeloplasty model was designed with incorporated assessment lines for use in post-task Black Light Assessment of Surgical Technique (BLAST)™. Practicing urologists participating in the 2011 and 2012 American Urological Association Mentored Renal Laparoscopy courses performed a simulated laparoscopic pyeloplasty procedure and completed a post-task evaluation of the model. RESULTS: Practicing urologists found the model acceptable and rated the model favorably in terms of content and face validity. Urologists who had performed a laparoscopic pyeloplasty procedure in the last 5 years outperformed those who had not by demonstrating increased patency (P<0.05), decreased twisting (P<0.05), and decreased leakage (P<0.10) at the anastomosis. CONCLUSIONS: The BLAST™ pyeloplasty model demonstrated evidence of acceptability and content, face, and construct validity for training practicing urologists to perform laparoscopic pyeloplasty.

Development and pilot of an advance care planning website for women with ovarian cancer: a randomized controlled trial.

OBJECTIVE: Few available tools facilitate cancer patients and physicians' discussions of quality of life and end-of-life. Our objective was to develop a web-based tool to promote advance care planning for women with ovarian cancer. METHODS: Women with ovarian cancer, their families, clinicians and researchers met to identify ways to improve cancer care. A prototype website was created to address advance care planning, focusing on advance healthcare directives (AHD) and palliative care consultation. Patients were recruited from a gynecologic oncology clinic for a pilot randomized controlled trial. Primary outcomes included completion of an AHD and palliative care consultation. RESULTS: At study completion, 53 women with ovarian cancer were enrolled and 35 completed the study. The mean age at enrollment was 57.9 ± 9.5 years; most were newly diagnosed or at first recurrence. There were no statistical differences in completion of AHD (p=0.220) or palliative care consultation (p=0.440) between intervention and control groups. However, women in the intervention group showed evidence of moving toward decision making regarding AHD and palliative care and lower decisional conflict. Women assigned to the intervention, compared to control website, were highly satisfied with the amount (p=0.054) and quality (p=0.119) of information and when they accessed the website, used it longer (p=0.049). Overall website use was lower than expected, resulting from several patient-related and design barriers. CONCLUSIONS: A website providing information and decisional support for women with ovarian cancer is feasible. Increasing frequency of website use requires future research.

Linear regression metamodeling as a tool to summarize and present simulation model results.

BACKGROUND / OBJECTIVE: Modelers lack a tool to systematically and clearly present complex model results, including those from sensitivity analyses. The objective was to propose linear regression metamodeling as a tool to increase transparency of decision analytic models and better communicate their results. METHODS: We used a simplified cancer cure model to demonstrate our approach. The model computed the lifetime cost and benefit of 3 treatment options for cancer patients. We simulated 10,000 cohorts in a probabilistic sensitivity analysis (PSA) and regressed the model outcomes on the standardized input parameter values in a set of regression analyses. We used the regression coefficients to describe measures of sensitivity analyses, including threshold and parameter sensitivity analyses. We also compared the results of the PSA to deterministic full-factorial and one-factor-at-a-time designs. RESULTS: The regression intercept represented the estimated base-case outcome, and the other coefficients described the relative parameter uncertainty in the model. We defined simple relationships that compute the average and incremental net benefit of each intervention. Metamodeling produced outputs similar to traditional deterministic 1-way or 2-way sensitivity analyses but was more reliable since it used all parameter values. CONCLUSIONS: Linear regression metamodeling is a simple, yet powerful, tool that can assist modelers in communicating model characteristics and sensitivity analyses.

Comparing Bayesian and frequentist approaches for multiple outcome mixed treatment comparisons.

OBJECTIVES: Bayesian statistical methods are increasingly popular as a tool for meta-analysis of clinical trial data involving both direct and indirect treatment comparisons. However, appropriate selection of prior distributions for unknown model parameters and checking of consistency assumptions required for modeling remain particularly challenging. We compared Bayesian and traditional frequentist statistical methods for mixed treatment comparisons with multiple binary outcomes. DATA: We searched major electronic bibliographic databases, Food and Drug Administration reviews, trial registries, and research grant databases up to December 2011 to find randomized studies published in English that examined drugs for female urgency urinary incontinence (UI) on continence, improvement in UI, and treatment discontinuation due to harm. METHODS: We describe and fit fixed and random effects models in both Bayesian and frequentist statistical frameworks. In a hierarchical model of 8 treatments, we separately analyze 1 safety and 2 efficacy outcomes. We produce Bayesian and frequentist treatment ranks and odds ratios across all drug v placebo comparisons, as well as Bayesian probabilities that each drug is best overall through a weighted scoring rule that trades off efficacy and safety. RESULTS: In our study, Bayesian and frequentist random effects models generally suggest the same drugs as most attractive, although neither suggests any significant differences between drugs. However, the Bayesian methods more consistently identify one drug (propiverine) as best overall, produce interval estimates that are generally better at capturing all sources of uncertainty in the data, and also permit attractive "rankograms" that visually capture the probability that each drug assumes each possible rank. CONCLUSIONS: Bayesian methods are more flexible and their results more clinically interpretable, but they require more careful development and specialized software.

Adding decision models to systematic reviews: informing a framework for deciding when and how to do so.

OBJECTIVE: Decision models are sometimes used alongside systematic reviews to synthesize evidence. Clarity, however, is lacking about when and how to conduct modeling studies in tandem with systematic reviews, as well as about how to evaluate and present model results. The objective of this study was to collect and analyze information from various sources to inform the development of a framework for deciding when and how a decision model should be added to a systematic review. METHODS: We collected data through 1) review and analysis of evidence reports that used decision models; 2) review and synthesis of current best practices for the development of decision models; 3) interviews of Evidence-Based Practice Center directors and selected staff, United States Preventive Services Task Force members, and decision modelers who developed models used by the United States Preventive Services Task Force; and 4) a focus group of expert modelers. RESULTS: Models are well suited to address gaps in the literature, better suited for certain types of research questions, and essential for determining the value of information relating to future research. Opinions differ regarding whether model outputs constitute evidence, but interviewees expressed concern over the lack of standards and directions in grading and reporting such "evidence." Interviews of stakeholders and modelers revealed the importance of communication and presentation of model results as well as the importance of model literacy and involvement of stakeholders. CONCLUSIONS: The study demonstrates the need for a framework for deciding when and how to use models alongside systematic reviews and provides information to develop such a framework.

Benefits and harms of pharmacologic treatment for urinary incontinence in women: a systematic review.

BACKGROUND: Urinary incontinence (UI) in women adversely affects quality of life. PURPOSE: To conduct a systematic literature review of drugs for urgency UI in women. DATA SOURCES: MEDLINE, the Cochrane Central Register of Controlled Trials, SCIRUS, and Google Scholar were searched for articles published from 1966 to November 2011. STUDY SELECTION: Randomized, controlled trials (RCTs) reported in English. DATA EXTRACTION: Rates of outcomes and risk of bias were extracted by using a standardized form to pool absolute risk differences and calculate the number of attributable events per 1000 patients treated, with 95% CIs. DATA SYNTHESIS: 94 RCTs were eligible. Pooled analyses showed that among drugs for urgency UI, per 1000 treated women, continence was restored in 130 with fesoterodine (CI, 58 to 202), 85 with tolterodine (CI, 40 to 129), 114 with oxybutynin (CI, 64 to 163), 107 with solifenacin (CI, 58 to 156), and 114 with trospium (CI, 83 to 144). Rates of treatment discontinuation due to adverse effects were 31 per 1000 treated with fesoterodine (CI, 10 to 56), 63 with oxybutynin (CI, 12 to 127), 18 with trospium (CI, 4 to 33), and 13 with solifenacin (CI, 1 to 26). The studies' inconsistent definitions of reduction in UI and quality of life hampered synthesis of evidence. LIMITATION: Evidence for quality-of-life improvements and comparative effectiveness with drugs was limited, and evidence for the effects of race, baseline severity of UI, and comorbid conditions on treatment success was insufficient. CONCLUSION: Overall, drugs for urgency UI showed similar small benefit. Therapeutic choices should consider the harms profile. Evidence for long-term adherence and safety of treatments is lacking.

Results availability from clinical research of female urinary incontinence.

AIMS: To ascertain possible publication bias by examining the completeness and publication of studies on nonsurgical treatments for female urinary incontinence (UI). METHODS: We analyzed information about studies from several trial registries through May 2010. We searched Medline using study registration identifiers to determine publication status, and compared percentages of completed and published studies by study and subject characteristics. RESULTS: Among the 166 closed studies, we found 120 completed (73%), 12 terminated (7%), 3 withdrawn (2%), and 4 (2%) that provided no reasons for noncompletion. Only 17% of closed registered studies (28/166 studies) were published in peer-reviewed journals; publication that did occur was an average of 2.2 years after study completion. The proportion of studies published did not increase over time. Studies sponsored by industry were published less often than those funded by NIH (OR = 0.04; 95%CI: 0.004-0.38). Drug studies were published less often than studies of other interventions (OR = 0.22; 95%CI: 0.05-0.96). Of the 166 closed studies, 7 (4%) posted results on the ClinicalTrials.gov website. Of Phases III and IV trials, 7% and 3% posted results, respectively. CONCLUSIONS: The absence of results from a substantial proportion of conducted studies suggests that treatment decisions for women with UI are based on selected rather than comprehensive evidence of benefits and harms. Regulatory policy for clinical research should guarantee availability of the outcomes for the public, clinicians, and policymakers.

Introduction and validation of the American Urological Association Basic Laparoscopic Urologic Surgery skills curriculum.

BACKGROUND AND PURPOSE: The Fundamentals of Laparoscopic Surgery (FLS(™)) skills curriculum has validity evidence supporting use for assessing laparoscopic skills for general surgeons. As charged by the American Urological Association (AUA) Laparoscopy, Robotic, and New Surgical Technology Committee, we sought to develop and validate a urology-specific FLS, referred to as the Basic Laparoscopic Urologic Surgery (BLUS(©)) skills curriculum. The psychomotor component consists of three existing FLS tasks and one new clip-applying task. MATERIALS AND METHODS: An animate renal artery model was designed for a clip-applying skills task. We assessed the acceptability and construct validity of using BLUS for basic laparoscopic skills assessment for urologists. A cohort of practicing urologists, fellows, residents, and medical students completed the tasks at the AUA Annual Meetings in 2010 and 2011. RESULTS: All exercises were acceptable and demonstrated excellent face and content validity (>4.5/5 on a five-point Likert scale). Practicing clinical urologists (N=81) outperformed residents and medical students (N=35) in time to completion of circle cut (P<0.01) and in keeping scissor tips toward the center of the circle (P<0.01). Practicing urologists who reported >3 laparoscopic procedures per week were faster at the peg-transfer exercise (P<0.05) and the cutting exercise (P<0.01) than those reporting one to two procedures. More errors were committed for clip-applying among practicing urologists who perform one to two laparoscopic procedures (1.24) vs. those who perform >3 procedures (0.57) per week (P<0.01). CONCLUSIONS: All exercises including the novel clip-applying model demonstrated good acceptability and evidence of construct validity (face, content, concurrent and convergent validity) for assessment of basic laparoscopic skill for urologic surgeons.