Development of a Scoring Rubric Assessing Medical Students' Explanations of Pathology Reports.

CONTEXT.­: With increasing availability of immediate patient access to pathology reports, it is imperative that all physicians be equipped to discuss pathology reports with their patients. No validated measures exist to assess how pathology report findings are communicated during patient encounters. OBJECTIVE.­: To pilot a scoring rubric evaluating medical students' communication of pathology reports to standardized patients. DESIGN.­: The rubric was iteratively developed using the Pathology Competencies for Medical Education and Accreditation Council for Graduate Medical Education pathology residency milestones. After a brief training, third- and fourth-year medical students completed 2 standardized patient encounters, presenting simulated benign and malignant pathology reports. Encounters were video recorded and scored by 2 pathologists to calculate overall and item-specific interrater reliability. RESULTS.­: All students recognized the need for pathology report teaching, which was lacking in their medical curriculum. Interrater agreement was high for malignant report scores (intraclass correlation coefficient, 0.65) but negligible for benign reports (intraclass correlation coefficient, 0). On malignant reports, most items demonstrated good interrater agreement, except for discussing the block (cassette) summary, explaining the purpose of the pathology report, and acknowledging uncertainty. Participating students (N = 9) felt the training was valuable given their limited prior exposure to pathology reports. CONCLUSIONS.­: This pilot study demonstrates the feasibility of using a structured rubric to assess the communication of pathology reports to patients. Our findings also provide a scalable example of training on pathology report communication, which can be incorporated in the undergraduate medical curriculum to equip more physicians to facilitate patients' understanding of their pathology reports.

Association Between Congenital Heart Disease-Related Diagnosis Codes and Trauma Surgery Outcomes.

BACKGROUND: Congenital heart disease (CHD) is one the most common congenital anomalies, with a prevalence of 8-10 cases per 1000 live births in the United States. Congenital heart disease has been recognized as a risk factor for poor perioperative and postoperative outcomes in non-cardiac surgery. We aimed to determine if documentation of CHD-related diagnosis codes was associated with similar risks for trauma surgery. METHODS: Data were acquired from the 2010-2019 American College of Surgeons' Trauma Quality Programs Participant Use Files. This study included trauma patients of all ages with one or more surgical procedures and at least one documented non-trauma (comorbidity) International Classification of Diseases code. Patients were stratified based on presence of CHD-related comorbidity codes vs any other comorbidity. Outcomes included mortality, hospital length of stay (LOS), discharge disposition, and in-hospital complications. RESULTS: Using 1:1 propensity score matching, we matched 215 cases with CHD-related comorbid diagnoses to non-CHD controls. Compared to patients with other comorbidities, patients with CHD-related comorbidites were less likely to be discharged home to self-care (odds ratio: 0.44, 95% confidence interval [CI]: 0.25, 078 P = .005) and tended to have prolonged hospital LOS (incidence rate ratio [IRR]: 1.06, 95% CI: 1.001, 1.13, P = .046). CONCLUSIONS: We present the first quantitative multicenter analysis correlating documentation of comorbid CHD-related diagnoses with higher risk of adverse outcomes after trauma surgery. These results support the need to routinely acknowledge and document CHD as comorbidity in trauma admissions that could lead to surgical intervention and for trauma centers to prepare for patients with a possible CHD comorbidity.

Musculoskeletal Knowledge on the in-Training Examination Improves in Family Medicine Residents Participating in a Longitudinal Sports Medicine Clinical Track.

Objectives: The study aims to assess the impacts of a sports medicine (SM) track on musculoskeletal (MSK) knowledge of family medicine (FM) residents. In-training examination (ITE) results were used to compare the MSK knowledge of FM residents with and without SM track participation. Methods: A single-center, retrospective study was completed on 85 FM residents from the 2018 to 2024 graduating classes who completed the ITE from 2017 to 2021. Residents were categorized by participation in the SM track, where half a day of FM continuity clinic per week is replaced with an SM clinic, supervised by a fellowship-trained SM physician. ITE scores throughout training were compared between the 2 groups using mixed-effects regression. Results: The ITE MSK scores increased among both SM track participants (+77 points/year, p = .001) and nonparticipants (+39 points/year, p = .001) throughout their training. By postgraduate year 3, SM track participants performed significantly better on the MSK portion of the ITE (+87 points compared to non-participants, p = .045). No significant difference in total ITE scores was seen between groups. Conclusions: Our data demonstrates that participation in an SM track is associated with an increase in MSK knowledge of ITE, suggesting that an SM track may provide FM residents with a better understanding of MSK conditions.

Continuity of Health Insurance Coverage and Choice of Contraception Method.

Objective: To evaluate whether part-year or year-round uninsurance is associated with reduced likelihood of using prescription contraception methods rather than using nonprescription methods or using no contraceptive methods. Methods: We identified nonpregnant and sexually active female respondents participating in the National Longitudinal Survey of Youth, 1997 cohort between 2007 and 2019. At each interview, we classified the contraceptive method used most frequently as prescription, nonprescription, or none, and used mixed-effects multinomial logistic regression to predict contraceptive method based on health insurance coverage over the past year (classified as continuous private, continuous public, part-year uninsured, or year-round uninsured). Results: Our sample included 3,738 respondents and 18,678 observations (person-years). In the most recent interview, 35% of respondents used prescription contraception, 16% used nonprescription methods only, and 49% used no method. On multivariable analysis using all available years of data, respondents with part-year uninsurance were 20% less likely to use prescription rather than nonprescription methods, as compared to respondents with continuous private insurance (95% confidence interval: -31%, -6%; p = 0.007), but did not differ on the likelihood of using prescription methods rather than no method. Conclusions: Part-year uninsurance was associated with lower use of prescription contraceptive methods rather than nonprescription methods when compared with continuous private insurance coverage. Use of prescription contraceptives was lowest among people with year-round uninsurance. Policy efforts ensuring continuous insurance coverage with greater flexibility of eligibility and enrollment periods may promote greater access to prescription contraceptives.

Reciprocal Association Between Chronic Pain and Health Insurance Type in a Population-based Longitudinal Cohort Study.

Chronic pain is a widespread condition limiting adults' daily activities and labor force participation. In the United States, withdrawal from the workforce could be associated with loss of health insurance coverage, while lack of health insurance coverage can limit access to diagnosis and management of chronic health conditions. We used a longitudinal cohort study of middle-aged adults to investigate whether chronic pain is reciprocally associated with coverage by any insurance and type of insurance coverage over a 2-year period (2018 and 2020). Among 5,137 participants (median age of 57 years in 2018), 29% reported chronic pain in either year, while 9 to 10% were uninsured each year. Using multivariable cross-lagged logistic regression analysis, chronic pain in 2018 was not associated with having any insurance coverage in 2020, and lack of coverage in 2018 was not associated with chronic pain in 2020. In further analysis, we determined that public coverage, other (non-private) coverage, or no coverage in 2018 were associated with an increased risk of chronic pain in 2020; while chronic pain in 2018 increased the risk of coverage by public rather than private insurance 2 years later, as well as the risk of coverage by other (non-private) payors. The reciprocal association of non-private insurance coverage and chronic pain may be related to insufficient access to chronic pain treatment among publicly insured adults, or qualification for public insurance based on disability among adults with chronic pain. These results demonstrate that accounting for the type of health insurance coverage is critical when predicting chronic pain in US populations. PERSPECTIVE: In a longitudinal cohort study of middle-aged US adults, the use of public and other non-private insurance predicts future experience of chronic pain, while past experience of chronic pain predicts future use of public and other non-private insurance.

Nationwide Analysis of Medical Student Publications upon Entry into Residency.

Research participation has been increasingly emphasized in undergraduate medical education, but limited data are available to help students formulate realistic and attainable goals for scholarly productivity. This study provides an objective, all-specialty, nationally representative estimate of PubMed-indexed publications among the 2022 cohort of new interns in the USA, representing their scholarly productivity during medical school. Only 39% of interns included in the analysis had any publications during medical school, and mean number of publications (1.4 ± 3.9) was well below the mean self-reported total of abstracts, presentations, and publications attributed to the same cohort based on residency application data (7.9).

Simulation-Based Analysis of Trial Design in Regional Anesthesia.

Background: In regional anesthesia, the efficacy of novel blocks is typically evaluated using randomized controlled trials (RCTs), the findings of which are aggregated in systematic reviews and meta-analyses. Systematic review authors frequently point out the small sample size of RCTs as limiting conclusions from this literature. We sought to determine via statistical simulation if small sample size could be an expected property of RCTs focusing on novel blocks with typical effect sizes. Methods: We simulated the conduct of a series of RCTs comparing a novel block versus placebo on a single continuous outcome measure. Simulation analysis inputs were obtained from a systematic bibliographic search of meta-analyses. Primary outcomes were the predicted number of large trials (empirically defined as N ≥ 256) and total patient enrollment. Results: Simulation analysis predicted that a novel block would be tested in 16 RCTs enrolling a median of 970 patients (interquartile range (IQR) across 1000 simulations: 806, 1269), with no large trials. Among possible modifications to trial design, decreasing the statistical significance threshold from p < 0.05 to p < 0.005 was most effective at increasing the total number of patients represented in the final meta-analysis, but was associated with early termination of the trial sequence due to futility in block vs. block comparisons. Conclusion: Small sample size of regional anesthesia RCTs comparing novel block to placebo is a rational outcome of trial design. Feasibly large trials are unlikely to change conclusions regarding block vs. placebo comparisons.

Survival and neurobehavioral outcomes following out-of-hospital cardiac arrest in pediatric patients with pre-existing morbidity: An analysis of the THAPCA out-of-hospital arrest data.

AIM: Pre-arrest morbidity in adults who suffer out-of-hospital cardiac arrest (OHCA) is associated with increased mortality and poorer neurologic outcomes. The objective of this study was to determine if a similar association is seen in pediatric patients. METHODS: We performed a secondary analysis of data from the Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital trial. Study sites included 36 pediatric intensive care units across the United States and Canada. The study enrolled children between the ages of 48 hours and 18 years following an OHCA between September 1, 2009 and December 31, 2012. For our analysis, patients with (N = 151) and without (N = 142) pre-arrest comorbidities were evaluated to assess morbidity, survival, and neurologic function following OHCA. RESULTS: No significant difference in 28-day survival was seen between groups. Dependence on technology and neurobehavioral outcomes were assessed among survivors using the Vineland Adaptive Behavior Scales-Second Edition (VABS-II), Pediatric Cerebral Performance Category (PCPC) and Pediatric Overall Performance Category (POPC). Children with pre-existing comorbidities maintained worse neurobehavioral function at twelve months, evidenced by poorer scores on POPC (p = 0.016), PCPC (p = 0.044), and VABS-II (p = 0.020). They were more likely to have a tracheostomy at hospital discharge (p = 0.034), require supplemental oxygen at three months (p = 0.039) and twelve months (p = 0.034), and be mechanically ventilated at twelve months (p = 0.041). CONCLUSIONS: There was no difference in survival to 28 days following OHCA in children with pre-existing comorbidity compared to previously healthy children. The group with pre-existing comorbidity was more reliant on technology following arrest and exhibited worse neurobehavioral outcomes.

Health System Encounters after Loss to Cardiology Follow-Up Among Patients with Congenital Heart Disease.

OBJECTIVE: To analyze receipt of care at other locations within a single rural academic health system after loss to follow-up in a cardiology clinic. STUDY DESIGN: Patients with congenital heart defects seen in the clinic during 2018 and subsequently lost to cardiology follow-up were included in the study. We defined loss to follow-up as not being seen in the clinic for at least 6 months past the most recently recommended follow-up visit. Subsequent visits to other locations, including other subspecialty clinics, primary care clinics, the emergency department, and the hospital, were tracked through 2020. RESULTS: Of 235 patients (median age 7 years, 136/99 female/male), 96 (41%) were seen elsewhere in the health system. Of 96 patients with any follow-up, 40 were seen by a primary care provider and 46 by another specialist; 44 were seen in the emergency department and 12 more were hospitalized. Patients with medical comorbidities or Medicaid insurance and those living closer to the clinic were more likely to continue receiving care within the same health system. CONCLUSIONS: Patients with congenital heart defect are frequently lost to cardiology follow-up. Our study supports collaboration across specialties and between cardiology clinics and affiliated emergency departments to identify patients with congenital heart defect who have been lost to cardiology follow-up but remain within the health system. A combination of in-person and remote outreach to these patients may help them continue cardiology care.

Preventive service utilization among adults with cystic fibrosis covered by private insurance is comparable to the general population.

BACKGROUND: As the life expectancy of the cystic fibrosis (CF) population is lengthening with modulator therapies, diligent age-appropriate screening and preventive care are increasingly vital for long-term health and wellbeing. METHODS: We performed a retrospective analysis comparing rates of receiving age- and sex-appropriate preventive services by commercially insured adult people with CF (PwCF) and adults without CF from the general population (GP) via the Truven Health MarketScan database (2012-2018). RESULTS: We captured 25,369 adults with CF and 488,534 adults from the GP in the United States. Comparing these groups, we found that 43% versus 39% received an annual preventive visit, 28% versus 28% were screened for chlamydia, 38% versus 37% received pap smears every 3 years (21-29-year-old females), 33% versus 31% received pap smears every 5 years (30-64-year-old females), 55% versus 44% received mammograms, 23% versus 21% received colonoscopies, and 21% versus 20% received dyslipidemia screening (all screening rates expressed per 100 person-years). In age-stratified analysis, 18-27-year-old PwCF had a lower rate of annual preventive visits compared to adults in the same age group of the GP (27% versus 42%). CONCLUSIONS: We discovered a comparable-to-superior rate of preventive service utilization in adults with CF relative to the GP, except in young adulthood from 18-27 years. Our findings establish the importance of meeting the primary care needs of adults with CF and call for development of strategies to improve preventive service delivery to young adults.

Predictors of planned home birth before and during the COVID-19 pandemic.

OBJECTIVES: To determine how demographic and clinical predictors of home birth have changed since the onset of the COVID-19 pandemic in the US. METHODS: Using National Vital Statistics birth certificate data, a retrospective population-based cohort study was performed with planned home births and hospital births among women age ≥18 years during calendar years 2019 (pre-pandemic) and 2021 (pandemic-era). Birth location (planned home birth vs. hospital birth) was analyzed using univariate and multivariable logistic regression, systematically examining the interaction of each demographic and clinical covariate with study year. RESULTS: After exclusions, a total of 6,087,768 birth records were retained for analysis, with the proportion of home births increasing from 0.82 % in 2019 to 1.24 % in 2021 (p<0.001). In the final multivariable logistic regression model of planned home birth, five demographic variables retained a statistically significant interaction with year: race and ethnicity, age, educational attainment, parity, and WIC participation. In each case, demographic differences between those having planned home births and hospital births became smaller (odds ratios closer to 1) in 2021 compared to 2019. CONCLUSIONS: Planned home births increased by more than 50 % during the pandemic, with greater socioeconomic diversity in the pandemic-era home birth cohort. The presence of clinical risk factors remained a strong predictor of hospital birth, with no evidence that pandemic-era home births had a higher clinical risk profile as compared to the pre-pandemic period.

Early Literacy Developmental Activities and Pre-Kindergarten Learning Skills in the Context of Childhood Adversity.

OBJECTIVE: School readiness (SR) encompasses a wide range of skills that affect children's ability to succeed in school and later in life. Shared reading is an important strategy that assists children in gaining SR skills, whereas adverse childhood experiences (ACEs) negatively affect a child's SR. This study assessed if early literacy developmental activities (shared reading, singing, or storytelling) were associated with improved SR among children with and without ACEs. METHODS: 2020-2021 National Survey of Children's Health data were used for analysis. We identified children aged 3-5 years to assess their exposure to ACEs, participation in reading/storytelling/singing, and overall SR. RESULTS: In a sample of 17,545 children, 29% of children were exposed to one or more ACEs. Seventy-seven percent of children with no ACEs received daily early literacy developmental activities compared to 23% of children who experienced any ACE. On ordinal logistic regression, daily early literacy developmental activities were associated with 56% greater odds of higher SR among children not exposed to ACEs (OR: 1.56; 95% CI: 1.29, 1.88; P < .01). Among children exposed to ACEs, daily early literacy developmental activities were also associated with higher SR (OR: 1.50; 95% CI: 1.06, 2.13; P = .02). CONCLUSIONS: Shared reading, storytelling, and singing are associated with improved SR in both children who have and have not been exposed to ACEs. However, children exposed to ACEs had fewer experiences with early literacy developmental activities. Future efforts should address the barriers that limit shared reading, singing, or storytelling for children exposed to ACEs.

Parent Gender and Assessment of Children's Health.

Caregiver-reported data on children's health are typically provided by mothers. We investigated whether measures of children's health would significantly differ between mother and father respondents to a nationally representative survey. This study used de-identified data on children age 0 to 17 years from the 2016-2019 National Survey of Children's Health (NSCH). The primary exposure was whether the survey was completed by the child's father (cases) or mother (controls). Outcome variables included general health, special health care needs (SHCN), and unmet health care needs. We identified 85 191 children meeting inclusion criteria, of whom 35.1% had a father respondent. After propensity score matching, 27 738 children with a father respondent were matched to an equal size group of children with a mother respondent. On conditional logistic regression analysis of the matched sample, we found that poor health, SHCN, and unmet health care needs were less likely to be reported for children in the sample by father respondents.

Overlap of pain-related and general measures of disability among adults with chronic pain.

PURPOSE: Chronic pain is known to be correlated with disability. We aimed to determine the overlap between a general self-reported measure of disability and a measure of disability due to pain problems among adults with chronic pain. MATERIALS AND METHODS: We used data from the National Health Interview Survey (NHIS) and analyzed respondents with chronic pain in the past 3 months. General disability was defined as being limited in the kind or amount of work one can do due to any physical, mental, or emotional problem. Pain-related disability was defined as pain limiting one's activity on "most days" or "every day." RESULTS: Based on a sample of 6874 respondents with chronic pain, 58% had either kind of disability, including 9% who reported only pain-related, but not general disability; and 27% who reported both types of disability. Respondents reporting only pain-related, but not general disability tended to be younger and had lower rates of obesity, smoking, diabetes, and hypertension than respondents reporting both pain-related and general disability. DISCUSSION: Among people with chronic pain, most people with disability are experiencing limitations related to pain problems. Assessment of disability without addressing pain interference has likely underestimated the disability burden in this population.