Fostering Psychological Safety and Supporting Mental Health Among Cardiovascular Health Care Workers: A Science Advisory From the American Heart Association.

The psychological safety of health care workers is an important but often overlooked aspect of the rising rates of burnout and workforce shortages. In addition, mental health conditions are prevalent among health care workers, but the associated stigma is a significant barrier to accessing adequate care. More efforts are therefore needed to foster health care work environments that are safe and supportive of self-care. The purpose of this brief document is to promote a culture of psychological safety in health care organizations. We review ways in which organizations can create a psychologically safe workplace, the benefits of a psychologically safe workplace, and strategies to promote mental health and reduce suicide risk.

Assessing Telemental Health Uptake and Associated Health Care Resource Implications among Mississippi Medicaid Enrollees with Major Depression.

Objective: Investigate the association between Telemental Health (TMH) uptake and sociodemographic characteristics, and how TMH uptake relates to health care resource utilization and Medicaid expenditures among Mississippi Medicaid enrollees with major depression. Methods: A retrospective cohort study was conducted (2019-2020), comparing those who utilized TMH and those who did not. Results: Among the 21,239 identified enrollees, 806 (3.79%) utilized TMH. The TMH cohort was more likely to be of older age, non-Hispanic White, comprehensive managed care organization enrollees, rural residents, and from areas with a higher area deprivation index, and have higher Charlson comorbidity index scores. The TMH cohort also exhibited higher mental health-related and all-cause outpatient and emergency department utilization, along with higher Medicaid expenditures. Conclusion: As the first study investigating telehealth utilization among Mississippi Medicaid enrollees, this study highlights sociodemographic disparities in telehealth adoption. Addressing barriers hindering telehealth adoption among vulnerable populations and ensuring the availability of quality data are vital for future research.

Telemental Health Services Usage and Association with Health Care Utilization and Expenditures Among Vulnerable Medicare Beneficiaries in 2019: A Comparative Study Using Propensity Score Matching.

Background: Telemental health (TMH) offers a promising approach to managing major depressive disorder (MDD). The objective of our work was to evaluate TMH usage among a vulnerable population of MDD Medicare beneficiaries and its association with health care utilization and expenditures. Methods: This cohort study analyzed 2019 Mississippi Medicare fee-for-service data for adult beneficiaries with MDD. Subjects were matched by the use of TMH following 1:1 propensity score matching. Comparisons between TMH and non-TMH cohorts were made on health care utilization and expenditure outcomes, adjusting for provider types postmatching. Results: Among 7,673 identified beneficiaries, 551 used TMH and 7,122 did not. Prematching, TMH cohort showed greater proportions of dual beneficiaries, rural residents, subjects with income below $40,000, those with disability entitlement, and higher Charlson comorbidity index scores, compared to the non-TMH cohort (all p < 0.001). Moreover, the TMH cohort had fewer outpatient visits, but more inpatient admissions, emergency department (ED) visits, and higher medical, pharmacy, and total expenditures (all p < 0.001). Postmatching, TMH was associated with a 25% reduction in outpatient visits (p < 0.001) and a 20% reduction in pharmacy expenditures (p = 0.01), with no significant effect on inpatient admissions, ED visits, medical expenditures, or total expenditures. Conclusions: These results underscore the potential of TMH in enhancing accessible health care services for vulnerable populations and affordable services for Medicare. Our results provide a robust baseline for future policy discussions concerning TMH. Future studies should consider identifying barriers to TMH use among vulnerable populations and ensuring equitable and high-quality patient care.

A New Frontier in Telehealth Research: A National Telehealth Data Warehouse.

Importance: Given the rapid increase in telehealth utilization since the onset of the COVID-19 pandemic, it has become essential to examining the vast amount of available data on telehealth encounters to conduct more cogent, robust, and large-scope research studies to examine the utility, cost-impact, and effect on clinical outcomes that telehealth can potentially provide. However, the diversity of data collected by numerous telehealth organizations has made that type of analysis difficult. Objective: The University of Mississippi Medical Center (UMMC), a Telehealth Center of Excellence designated by the Health Resources and Services Administration, is creating a National Telehealth Data Warehouse. Design: UMMC will develop the data warehouse in Microsoft Azure and will use a data dictionary that was created by the Center for Telehealth and eHealth Law (CTeL) to support their national cost-benefit study on the use of telehealth during COVID-19. Impact: The data warehouse will provide unparalleled opportunities to conduct cost-benefit and cost-effectiveness analyses on telehealth, to develop and test quality measures specific to telehealth, and to understand how telehealth and reduce disparities in health care and expand access to care for everyone. The warehouse is expected to go live in the Summer of 2023.

Framework for Evaluating and Developing Sustainable Telehealth Programs.

During the COVID-19 pandemic and public health emergency, telehealth programs vastly expanded with strong support from various federal and state agencies. However, the uncertainty regarding future reimbursement policies for telehealth services has resulted in concerns about long-term sustainability of innovative health service delivery models beyond the financial support. Given the limited literature on creating telehealth programs with long-term sustainability in consideration, we have developed a framework for gathering appropriate data during various stages of program implementation to evaluate clinical effectiveness and economic sustainability that is applicable across various settings, with additional attention to health equity. Recognizing the difficulty of sustaining telehealth programs solely through a fee-for-service payment model, we encourage all telehealth stakeholders, especially payers and policymakers, to consider cost-effectiveness of telehealth programs and support alternate payment models for ensuring long-term sustainability.

Entropic Dynamics in a Theoretical Framework for Biosystems.

Central to an understanding of the physical nature of biosystems is an apprehension of their ability to control entropy dynamics in their environment. To achieve ongoing stability and survival, living systems must adaptively respond to incoming information signals concerning matter and energy perturbations in their biological continuum (biocontinuum). Entropy dynamics for the living system are then determined by the natural drive for reconciliation of these information divergences in the context of the constraints formed by the geometry of the biocontinuum information space. The configuration of this information geometry is determined by the inherent biological structure, processes and adaptive controls that are necessary for the stable functioning of the organism. The trajectory of this adaptive reconciliation process can be described by an information-theoretic formulation of the living system's procedure for actionable knowledge acquisition that incorporates the axiomatic inference of the Kullback principle of minimum information discrimination (a derivative of Jaynes' principle of maximal entropy). Utilizing relative information for entropic inference provides for the incorporation of a background of the adaptive constraints in biosystems within the operations of Fisher biologic replicator dynamics. This mathematical expression for entropic dynamics within the biocontinuum may then serve as a theoretical framework for the general analysis of biological phenomena.

Do Hospitals Providing Telehealth in Emergency Departments Have Lower Emergency Department Costs?

Background: Since 2003, the University of Mississippi Medical Center has operated a robust telehealth emergency department (ED) network, TelEmergency, which enhances access to emergency medicine-trained physicians at participating rural hospitals. TelEmergency was developed as a cost-control measure for financially constrained rural hospitals to improve access to quality, emergency care. However, the literature remains unclear as to whether ED telehealth services can be provided at lower costs compared with traditional in-person ED services. Introduction: Our objective was to empirically determine whether TelEmergency was associated with lower ED costs at rural hospitals when compared with similar hospitals without TelEmergency between 2010 and 2017. Materials and Methods: A panel of data for 2010-2017 was constructed at the hospital level. Hospitals with TelEmergency (n = 14 hospitals; 112 hospital-years) were compared with similar hospitals that did not use TelEmergency from Arkansas, Georgia, Mississippi, and South Carolina (n = 102; 766 hospital-years), matched using Coarsened Exact Matching. The relationship between total ED costs and treatment (e.g., participation in TelEmergency) was predicted using generalized estimating equations with a Poisson distribution, a log link, an exchangeable error term, and robust standard errors. Results: After controlling for ownership type, critical access hospital status, year, and size, TelEmergency was associated with an estimated 31.4% lower total annual ED costs compared with similar matched hospitals that did not provide TelEmergency. Conclusions: TelEmergency utilization was associated with significantly lower total annual ED costs compared with similarly matched hospitals that did not utilize TelEmergency. These findings suggest that access to quality ED care in rural communities can occur at lower costs.

Psychiatry Clinical Skills Evaluation: a Multisite Study of Validity.

OBJECTIVE: Since 2007, the American Board of Psychiatry and Neurology (ABPN) has required that residency programs conduct a specific clinical skills evaluation (CSE) of physician-patient interaction, psychiatric interview and mental status examination, and case presentation on a directly observed patient interview as a prerequisite for certification. The authors examined a multisite database of CSE assessments to investigate the validity of the evaluation. METHODS: The authors collected 1156 CSE assessments from 4 residency programs conducted over a 6-year period, compared scoring patterns among the programs, score improvement over 4 years of residency, time and number of CSEs required to meet ABPN requirements, and patterns of scoring for individual faculty evaluators. RESULTS: The distribution of scores within each of the 4 programs showed similar, but nonidentical patterns. The number of CSEs required to meet the ABPN standards (3.5) and the point in training at which this was completed (late PGY-2) were the same in all programs. CSE scores were highly correlated with year of training but were not correlated with performance on an unrelated cognitive examination. Individual faculty members tended to stay within a moderate range of scores over multiple residents, partially attributable to year of training. CONCLUSIONS: Taken together, these findings support the validity of the CSE as a measure of residents' clinical skills in the specified areas and demonstrate a moderate-high degree of consistency in the scoring of the CSE across these 4 programs.

Emergent Bleeding in Patients Receiving Direct Oral Anticoagulants.

Direct oral anticoagulants (DOACs) offer clinical advantages over warfarin, such as minimal medication and food interactions and fixed dosing without the need for routine monitoring of coagulation status. As with all anticoagulants, bleeding, either spontaneous or provoked, is the most common complication. The long-term use of these drugs is increasing, and there is a crucial need for emergency medicine service professionals to understand the optimal management of associated bleeding. This review aims to describe the indications and pharmacokinetics of available DOACs; to discuss the risk of bleeding; to provide a treatment algorithm to manage DOAC-associated emergency bleeding; and to discuss future directions in bleeding management, including the role of specific reversal agents, such as the recently approved idarucizumab for reversal of the direct thrombin inhibitor dabigatran. Because air medical personnel are increasingly likely to encounter patients receiving DOACs, it is important that they have an understanding of how to manage patients with emergent bleeding.

Validation of the Sonographic Ottawa Foot and Ankle Rules (SOFAR) Study in a Large Urban Trauma Center.

INTRODUCTION: Differentiating the severity of acute ankle injuries is a common problem in the emergency department (ED). The Ottawa Foot and Ankle Rules (OFAR) were designed to obviate the need for unnecessary x-rays. Although these rules have been determined to be very sensitive, they lack the specificity necessary to make them practically useful for a condition in which a misdiagnosis could result in a significant disability. Our study objective was to determine if the addition of a bedside ultrasound (US) to the evaluation process could be used to significantly reduce the number of negative x-rays in OFAR positive patients. METHODS: A prospective observational studywas conducted in a Level I urban trauma center over a 12 month period in which bedside US was utilized to detect foot and/or ankle fractures in OFAR positive patients of age 18 years and older. All patients in the study received foot and/or ankle x-rays based on OFAR exam. Prior to viewing the x-rays, trained clinicians performed bedside US targeting the medial and lateral malleoli, navicular, and base of the 5th metatarsal and provided a diagnostic impression based on their US findings. The US findings were then compared to the formal x-ray interpretation. RESULTS: A total of fifty patients was enrolled into the study of which twenty-one patients were discovered to have a fracture by US. The sensitivity ofUS in detecting foot and/or ankle fractures was 100% (95% Confidence Interval [CI] 78%-100%) and the specificity of OFAR increased from 50% (95% CI 37%-63%) to 100% (95% CI 87%-100%) with the addition of US. The negative predictive value was 100% (95% CI 89%-100%), and the positive predictive value was 100% (95% CI 81%-100%). CONCLUSIONS: Among OFAR positive patients, bedside US has high sensitivity and specificity for detecting foot and/or ankle fractures. Further studies should be conducted to determine if utilizing bedside US in addition to OFAR could significantly reduce the number of x-rays and improve the efficiency and costs associated with evaluating these injuries in the ED. Implication for health policy/medical education/research/ practice. Utilizing bedside ultrasonography in addition to Ottawa Foot and Ankle Rules in acutely injured patients could significantly reduce the number of ordered x-rays and length of stay in the emergency department.

Prevalence of intubation rescue by air medical personnel during transfers from rural emergency departments.

OBJECTIVE: Non-emergency-trained providers in rural emergency departments (ED) often lack the skills required for emergency resuscitations and rely on air medical transport teams to provide the initial airway stabilization of these patients. In this study, we determined the prevalence with which endotracheal intubations are required of air medical personnel upon arrival to rural EDs including intubations that were first attempted by the local provider. METHODS: A retrospective database review was conducted of all air medical transfers from rural hospitals for a 28-month period. Those patients requiring an airway were categorized according to which provider initiated the intubation procedure. The prevalence of intubations performed by air medical and local providers was recorded as the percent of the total number of intubations. RESULTS: There were a total of 217 patients from 11 rural EDs requiring airway support. Air medical personnel were responsible for 85% of the intubations. Alternative airway support was necessary in 5% of the patients after unsuccessful intubation attempts. The failed intubations tended to be slightly older and female. CONCLUSION: Our study suggests that the vast majority of the intubations for patients requiring a helicopter evacuation from these rural settings are performed by the air medical personnel.

DSM-5: a teachable moment.

The rollout of DSM-5 is both a challenge and an opportunity for psychiatrists and particularly for trainees. Psychiatric education in the wake of DSM-5 will go beyond memorizing lists of new criteria. Teachers and learners alike will seize the "teachable moment" to learn new content, model how to approach and apply new understanding, think about how new knowledge is developed, and appreciate the importance of public dialogue.We can capitalize on this moment to improve the teaching of assessment skills as a central focus of residency training.

Emergency department triage of low acuity patients to a Federally Qualified Health Center.

Many emergency departments (ED) are experiencing ever increasing volumes as they serve as a safety net for patients without established access to primary care. Impending physician shortages, our aging population, and recent changes in national healthcare policy are expected to further exacerbate this situation and worsen ED overcrowding. These conditions could result in a dilution of ED resources and significantly impact the ability of emergency personnel to provide quality care for patients with serious illnesses. Previous studies have demonstrated that low acuity patients without emergencies can be safely and legally identified in triage and can be sent away from the ED for further outpatient treatment and evaluation. However, without a specific designated clinic follow up, these patients often fail to get the appropriate care required. In this study, we couple the ED medical screening exam process with a timely medical referral system to a local Federally Qualified Healthcare Clinic (FQHC). These referred patients were monitored for subsequent success in satisfaction with their primary care needs and their rate of recidivism to the ED. Most of the non-emergent patients who were judged to be appropriate to refer to the FQHC were satisfied with their medical screening process (89%) and most elected to attend the same day clinic appointment at the FQHC (85%). Only 17% of these patients who were referred out of our ED returned to be seen in our ED within the three-month interval. We concluded that referring low acuity patients out of the emergency department to a primary care clinic setting provided an opportunity for these patients to establish a medical home for future access to non-emergent health care.

Prevalence and Professional Impact of Mental Health Conditions Among Cardiologists.

BACKGROUND: Mental illness among physicians is an increasingly recognized concern. Global data on mental health conditions (MHCs) among cardiologists are limited. OBJECTIVES: The purpose of this study was to investigate the global prevalence of MHCs among cardiologists and its relationships to professional life. METHODS: The American College of Cardiology conducted an online survey with 5,931 cardiologists globally in 2019. Data on demographics, practice, MHC, and association with professional activities were analyzed. The P values were calculated using the chi-square, Fischer exact, and Mann-Whitney U tests. Univariate and multivariate logistic regression analysis determined the association of characteristics with MHC. RESULTS: Globally, 1 in 4 cardiologists experience any self-reported MHC, including psychological distress, or major or other psychiatric disorder. There is significant geographic variation in MHCs, with highest and lowest prevalences in South America (39.3%) and Asia (20.1%) (P < 0.001). Predictors of MHCs included experiencing emotional harassment (OR: 2.81; 95% CI: 2.46-3.20), discrimination (OR: 1.85; 95% CI: 1.61-2.12), being divorced (OR: 1.85; 95% CI: 1.27-2.36), and age <55 years (OR: 1.43; 95% CI: 1.24-1.66). Women were more likely to consider suicide within the past 12 months (3.8% vs 2.3%), but were also more likely to seek help (42.3% vs 31.1%) as compared with men (all P < 0.001). Nearly one-half of cardiologists reporting MHCs (44%) felt dissatisfied on at least one professional metric including feeling valued, treated fairly, and adequate compensation. CONCLUSIONS: More than 1 in 4 cardiologists experience self-reported MHCs globally, and the association with adverse experiences in professional life is substantial. Dedicated efforts toward prevention and treatment are needed to maximize the contributions of affected cardiologists.

Development and validation of a new measurement instrument to assess internship experience of medical doctors in low-income and middle-income countries.

Routine surveys are used to understand the training quality and experiences of junior doctors but there are lack of tools designed to evaluate the training experiences of interns in low-income and middle-income countries (LMICs) where working conditions and resource constraints are challenging. We describe our process developing and validating a 'medical internship experience scale' to address this gap, work involving nine LMICs that varied in geographical locations, income-level and internship training models. We used a scoping review of existing tools, content validity discussions with target populations and an expert panel, back-and-forth translations into four language versions and cognitive interviews to develop and test the tool. Using data collected from 1646 interns and junior medical doctors, we assessed factor structure and assessed its reliability and validity. Fifty items about experiences of medical internship were retained from an initial pool of 102 items. These 50 items represent 6 major factors (constructs): (1) clinical learning and supervision, (2) patient safety, (3) job satisfaction, (4) stress and burnout, (5) mental well-being, and (6) fairness and discrimination. We reflect on the process of multicountry scale development and highlight some considerations for others who may use our scale, using preliminary analyses of the 1646 responses to illustrate that the tool may produce useful data to identify priorities for action. We suggest this tool could enable LMICs to assess key metrics regarding intern straining and initial work experiences and possibly allow comparison across countries and over time, to inform better internship planning and management.

Predictors of Metformin Failure: Repurposing Electronic Health Record Data to Identify High-Risk Patients.

CONTEXT: Metformin is the first-line drug for treating diabetes but has a high failure rate. OBJECTIVE: To identify demographic and clinical factors available in the electronic health record (EHR) that predict metformin failure. METHODS: A cohort of patients with at least 1 abnormal diabetes screening test that initiated metformin was identified at 3 sites (Arizona, Mississippi, and Minnesota). We identified 22 047 metformin initiators (48% female, mean age of 57 ± 14 years) including 2141 African Americans, 440 Asians, 962 Other/Multiracial, 1539 Hispanics, and 16 764 non-Hispanic White people. We defined metformin failure as either the lack of a target glycated hemoglobin (HbA1c) (<7%) within 18 months of index or the start of dual therapy. We used tree-based extreme gradient boosting (XGBoost) models to assess overall risk prediction performance and relative contribution of individual factors when using EHR data for risk of metformin failure. RESULTS: In this large diverse population, we observed a high rate of metformin failure (43%). The XGBoost model that included baseline HbA1c, age, sex, and race/ethnicity corresponded to high discrimination performance (C-index of 0.731; 95% CI 0.722, 0.740) for risk of metformin failure. Baseline HbA1c corresponded to the largest feature performance with higher levels associated with metformin failure. The addition of other clinical factors improved model performance (0.745; 95% CI 0.737, 0.754, P < .0001). CONCLUSION: Baseline HbA1c was the strongest predictor of metformin failure and additional factors substantially improved performance suggesting that routinely available clinical data could be used to identify patients at high risk of metformin failure who might benefit from closer monitoring and earlier treatment intensification.

Early emergency management of acute decompensated heart failure.

PURPOSE OF REVIEW: Acute decompensated heart failure (ADHF) is characterized by a complex spectrum of pathophysiology that emerges as a common clinical disease state, which manifests as a failure of the circulation to provide for the needs of the body systems. Whereas ADHF is often characterized by the findings of pulmonary congestion and dyspnea, a variety of clinical presentations are possible, with each requiring differing management strategies. This review examines the approach of the four-quadrant clinical profile for differentiation of the ADHF patient during the emergent resuscitative phase of the decompensation. RECENT FINDINGS: Clinical and diagnostic information can be used to determine the relative degree of pulmonary congestion and peripheral tissue perfusion in patients suspected of ADHF. This information can be used in a four-quadrant approach to differentiate patients into pathophysiologic categories. These profiles can then be translated into management strategies from a physiology based perspective in which the specific mechanisms of the failure are targeted. SUMMARY: ADHF can present in a variety of clinical forms in the emergent setting. Categorization of the ADHF patient according to their individual hemodynamic profile can assist in management decisions during the emergent resuscitative phase of the decompensation based upon an approach that targets causative pathophysiologic mechanisms.

Clinical skills verification in general psychiatry: recommendations of the ABPN Task Force on Rater Training.

OBJECTIVE: The American Board of Psychiatry and Neurology (ABPN) announced in 2007 that general psychiatry training programs must conduct clinical skills verification (CSV), consisting of observed clinical interviews and case presentations during residency, as one requirement to establish graduates' eligibility to sit for the written certification examination. To facilitate implementation of these requirements, the ABPN convened a task force to prepare training materials for faculty and programs to guide them in the CSV process. This article reviews the specific requirements for the CSV experience within general residency programs, and briefly describes the recommendations of the task force for faculty training and program implementation. METHODS: Materials prepared by the ABPN Task Force include background information on the intent of the observed interview, a literature review on assessment methods, aids to train faculty in direct observation of clinical work, directions for effective feedback, notes regarding special issues for cross-cultural trainees, clarification of performance standards, and recommendations for structuring and conducting the assessments. RESULTS: Recommendations of the task force include the use of a variety of clinical settings for CSV assessments, flexibility in the duration of CSV interviews, use of formative and summative feedback after each CSV assessment, and frequent use of the CSV across all years of training. Formal faculty training is recommended to help establish performance parameters, increase interrater reliability, and improve the quality of feedback. CONCLUSIONS: The implementation of the CSV process provides psychiatry training programs with an excellent opportunity to assess how interviewing skills are taught and evaluated. In the process, psychiatry educators have an opportunity to establish performance parameters that will guide the training of residents in patient interaction and evaluation.

COVID-19 Inpatient Mortality Disparities Among American Indian Adults in Mississippi's Safety Net Hospital.

BACKGROUND: Long-standing health disparities experienced by American Indians (AIs) are associated with increased all-cause mortality rates and shortened life expectancies when compared to other races and ethnicities. Nationally, these disparities have persisted with the COVID-19 pandemic as AIs are more likely than all other races to be infected, hospitalized, or die from SARS-CoV-2. The Mississippi Band of Choctaw Indians, the only federally recognized American Indian tribe in the state, has been one of the hardest hit in the nation. METHODS: Using de-identified data from the University of Mississippi Medical Center's COVID-19 Research Registry, a retrospective cohort study was conducted to assess COVID-19 inpatient mortality outcomes among adults (≥ age 18) admitted at the state's safety net hospital in 2020. RESULTS: Exactly 41% (n = 25) of American Indian adults admitted with a deemed diagnosis of COVID-19 died while in hospital, in comparison to 19% (n = 153) of blacks and 23% (n = 65) of whites. Racial disparities persisted even when controlling for those risk factors the CDC reported put adults at greatest risk of severe outcomes from the disease. The adjusted probability of inpatient mortality among American Indians was 46% (p < 0.00) in comparison to 19% among blacks and 20% among whites. CONCLUSION: Although comorbidities were commonly observed among COVID-19 + American Indian inpatients, only one was associated with inpatient mortality. This challenges commonly cited theories attributing disparate COVID-19 mortality experiences among indigenous populations to disparate comorbidity experiences. Expanded studies are needed to further investigate these associations.