Between December 2021 and June 2022, researchers conducted a multicenter cross-sectional study and the relationship between IA, emotional intelligence (EI), and sociodemographic traits in Spanish undergraduate nursing students aged 18 to 24 years. The researchers gathered sociodemographic data through participant questionnaires and utilized the Internet Addiction Test (IAT) scale and Trait Meta-Mood (TMMS-24) scale to measure IA and EA, respectively. Students qualified for IA if they scored 40 and greater on the IAT. For EI, students were assessed across three dimensions: attention, emotional repair, and emotional clarity.

A total of 532 nursing students from 2 universities and 3 campuses were included in the final analysis and the majority were women (n=453; 85.2%). Overall, 11.1% (n=59) of participants qualified for internet addiction. This cohort of students with IA displayed significantly higher levels of attention (median=31; P =.010; Cohen d = -0.375) than the other students (median=28). However, internet addiction was also associated with significantly lower levels of emotional clarity (median=22; P =.031; Cohen d =0.307) than controls (median=24).

Noteworthy gender differences were observed across participants, regardless of IA status. Overall, women displayed higher attention scores (median=28; P =.033) than men (median=27), while men exhibited higher emotional repair scores (median=26; P =.048) than women (median=24).

Furthermore, significant age-related differences were detected using the Kruskal-Wallis H test. Age groups significantly differed regarding their IA (P <.001), with younger students aged 18 (median=28) and 19 (median=27) years displaying the highest addiction scores. Age groups also had significantly different scores across emotional clarity (P =.024) and emotional repair (P =.047), with students aged 24 years and older displaying the highest scores (clarity: median=26; repair: median=27), compared to all the younger age groups.

The researchers also assessed the relationship between IA scores and the EI dimensions using Spearman correlations. Emotional clarity (Rho= -0.169; P <.01) and emotional repair (Rho= -0.095; P <.05) were both significantly, but weakly, correlated to IA values.

The authors concluded, “The development of programs which improve emotional intelligence could be essential to facilitate the emotional management of internet addiction.”

This study was limited by the use of a cross-sectional design, as it did not allow for the determination of causal relationships.

The post Lowered Emotional Clarity in Nursing Students With Internet Addiction appeared first on The Cardiology Advisor.

Researchers found that, among cancer patients with private insurance, those living in states that did not provide coverage parity or payment parity were less likely to use telehealth in the first year of the COVID-19 pandemic.

The study included 53,982 patients who were diagnosed with breast cancer (33.3%), prostate cancer (28.9%), lung cancer (16.8%), colorectal cancer (12.3%), or lymphoma (8.7%) between March 2020 and March 2021.

Most of these patients (76.1%) had Medicare Advantage. Among patients who had private insurance, 11.0% lived in a state with telehealth coverage and payment parity, 7.4% lived in a state with coverage parity only, and 5.4% lived in a state with no or unspecified telehealth parity laws.

Most patients (70.6%) lived in states that allowed cross-state telehealth, but 29.4% lived in states with policies limiting cross-state telehealth.

In a multivariable analysis, several factors were associated with lower odds of using telehealth, including:

• Having private insurance and living in a state with coverage parity alone (vs both coverage and payment parity; odds ratio [OR], 0.82; 95% CI, 0.74-0.92; P =.001)
• Having private insurance and living in a state with no or unspecified telehealth parity laws (OR, 0.77; 95% CI, 0.70-0.85; P <.001)
• Having Medicare Advantage (OR, 0.59; 95% CI, 0.54-0.65; P <.001)
• Living in a state with limitations on cross-state telehealth (OR, 0.80; 95% CI, 0.76-0.85; P <.001)
• Having colorectal cancer (vs breast cancer; OR, 0.90; 95% CI, 0.84-0.97; P =.007)
• Being non-Hispanic Black (vs non-Hispanic White; OR, 0.83; 95% CI, 0.76-0.91; P <.001)
• Being 50-64 years of age (OR, 0.70; 95% CI, 0.64-0.77; P <.001), 65-74 years of age (OR, 0.67; 95% CI, 0.60-0.74; P <.001), or 75 years of age or older (OR, 0.61; 95% CI, 0.55-0.69; P <.001).

Patients diagnosed with cancer from May 2020 through March 2021 also had lower odds of using telehealth than patients diagnosed in March 2020 (P =.032 for May 2020; P <.001 for all other months).

The researchers noted that, despite having telehealth coverage, patients with Medicare Advantage were less likely to use telehealth than patients with private insurance. The researchers speculated that this could be related to patient or provider preferences, complexity of care, digital literacy or comfort with technology, access to digital technology, or reliable internet access.

When the researchers looked only at patients who were younger than 65 years of age and had private insurance, the results were similar to those seen in the overall population.

“Telehealth use by patients diagnosed with cancer during the pandemic was higher among those living in states with more generous parity and less restrictive rules for cross-state practice,” the researchers concluded. “Policy makers contemplating whether to permanently relax certain telehealth policies must consider the impact on vulnerable patient populations who can benefit from telehealth.”

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The American Academy of Physician Associates (AAPA) released reports, that explore patient experiences in California, Florida, Massachusetts, North Carolina, Oklahoma, South Dakota, Tennessee, Texas, Virginia, and Washington, in follow-up to a national Harris Poll survey AAPA released in May 2023.

“The robust research conducted by The Harris Poll affirms that across the country, patients are feeling anxious and uncertain about their well-being and the future of healthcare. They see PAs as an essential but underutilized group of medical providers whose experience and expertise position them to expand access to care,” AAPA CEO Lisa M. Gables, CPA, said.

The current survey mirrors the national finding that 91% of US adults support updating PA laws. The research also found that 9 in 10 adults say PAs improve the quality of health care, noted AAPA.

The surveyed states represent a diverse cross-section of the American health care landscape. “The surveys capture a wide range of health care experiences, from urban to rural settings and diverse patient pools, reflecting the challenges and strengths within different regions of the country,” said AAPA. Moreover, the 10 states represent “varied PA regulatory environments, providing a more nuanced understanding of health care dynamics and highlighting the importance of PA practice laws in shaping patient care.”

Key state-level findings include the following:

• Workforce concerns: 68% of adults are concerned that health care workforce shortages will impact them as a patient. Adults in Virginia and Washington were more likely to voice these concerns (77% in both states).

• Delayed or skipped care: 44% of adults have skipped or delayed health care services they needed in the past 2 years. Adults in Oklahoma and South Dakota were more likely to report skipping or delaying care (55% in both states).

• Resource shortages: 42% of adults say that their community does not have the resources needed to keep people healthy. Adults in Tennessee and Oklahoma were more likely to report insufficient resources (47% and 46% respectively).

• Health care coordination challenges: 65% of adults say coordinating and managing health care is overwhelming and time consuming. Adults in Texas and Washington were more likely to report these concerns (71% in both states).

How the Survey Was Conducted

The research was conducted online from February 23 to March 9, 2023, by The Harris Poll on behalf of AAPA and included 2519 adults. In addition to the national sample, oversamples were collected in 6 states including California (n=513), Massachusetts (n=503), Oklahoma (n=507), Tennessee (n=505), Virginia (n=509), and Washington (n=518). Surveys were fielded in Florida (n=510), North Carolina (n=509), South Dakota (n=507), and Texas (n=508), from July 26 to August 13, 2023. Interviews were conducted in English and Spanish.

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In the United States (US), more than 100,000 individuals died of poisoning and drug overdose in the 12 months preceding April 2021. This rate represented a 28.5% increase from the year before.

After poisoning, patients presenting with cardiac arrest may require specialized treatment. For example, following poisoning with β-adrenergic receptor antagonists or calcium channel antagonists, these patients will not respond to atropine, standard vasopressors, or cardiac pacing.

The guideline authors emphasized, “Treatment of cardiac arrest and life-threatening toxicity due to poisoning often requires specialized treatments that most clinicians do not use frequently such as antidotes and venoarterial extracorporeal membrane oxygenation, in addition to effective basic and advanced life support. Timely consultation with a medical toxicologist, clinical toxicologist, or regional poison center facilitates rapid and effective therapy.”

Opioids

Opioids are responsible for most poisoning events. In the US, and other countries, the opioid epidemic continues to worsen. Of the more than 100,000 deaths in the 12 months preceding April 2021, 75,673 involved opioids, a near 35% increase from the year prior.

The mainstay of patient care in the setting of opioid-associated toxicity is early identification and emergency response activation. An opioid overdose deteriorates to cardiopulmonary arrest making ventilation the highest priority. Administration of naloxone can restore respiration and airway reflexes in patients impaired by an opioid overdose. Alternatives to administering naloxone include observation, if the patient is breathing normally, or ventilatory support.

Administration of naloxone in cases with cardiac arrest has not been shown to improve patient outcomes. As such, the guideline authors emphasized that respiratory support should be the primary focus of treatment. Of note, responders to naloxone may develop recurrent central nervous system (CNS) or respiratory depression and need a longer observational period before discharge. In addition, some patients may require repeat doses of naloxone, as its duration of action can be shorter than the respiratory depressive effect of the opioids.

β-blockers

β-blockers are associated with one of the highest poisoning mortalities. Patients with β-blocker poisoning present with bradycardia and reduced cardiac contractility.

Common treatments for β-blocker poisoning include atropine, glucagon, calcium, vasopressors, high-dose insulin, and intravenous lipid emulsion. The guideline authors do not recommend for the use of nonadrenergic vasopressors (vasopressin, angiotensin II, amrinone, milrinone, methylene blue, and hydroxocobalamin).

Calcium channel blockers

Calcium channel blockers are also a leading cause of poisoning mortality, in part because these drugs are often prescribed in sustained-release forms and have long half-lives. Poisoning from both dihydropyridine and nondihydropyridine classes of calcium channel blockers present as severe shock from bradycardia, vasodilation, or loss of inotropy.

Treatment options for poisoning from calcium channel blockers include atropine, calcium, vasopressors, high-dose insulin therapy, nitric oxide inhibitors, and intravenous lipid emulsion therapy. As with β-blockers, the use of nonadrenergic vasopressors is not recommended.

Other poisonings

In addition to the most common (opioids) and most life-threatening (β- and calcium channel blockers) poisoning events, the guideline authors had specific recommendations about 9 additional poisonings.

• Benzodiazepines
  • Poisonings involving benzodiazepines often occur in combination with opioids and/or alcohol. Patients present with CNS depression with loss of protective airway reflexes. Benzodiazepine poisoning can be treated with flumazenil; however, this treatment can cause seizures or benzodiazepine withdrawal.
• Cocaine
  • Cocaine toxicity events are marked by tachycardia, hypertension, hyperthermia, diaphoresis, elevated psychomotor activity, and seizures. Benzodiazepines are recommended for initial management of blood pressure and psychomotor activity. For severe cases, calcium channel blockers, α1-adrenergic receptor antagonists, and nitrates may treat symptoms of hypertension and chest pain.
• Cyanide
  • This toxicity often affects laboratory or industrial workers or individuals exposed to structure fires. After exposure, poisoned individuals can develop rapid cardiovascular collapse, metabolic acidosis, depressed mental status, seizure, and death. These patients should be treated with hydroxocobalamin or alternatively, sodium nitrite plus sodium thiosulfate.
• Digoxin
  • Patients with digoxin and related cardiac glycoside poisoning can present with gastrointestinal symptoms, hyperkalemia, cardiac conduction abnormalities, and confusion. The recommended treatment is digoxin-specific immune antibody fragments (digoxin-Fab).
• Local anesthetics
  • Local anesthetic systemic toxicity (LAST) results in CNS toxicity with symptoms of seizure, agitation, syncope, dysarthria, perioral numbness, confusion, obtundation, and dizziness, and in some cases, with cardiovascular toxicity. The recommended treatment for LAST is intravenous lipid emulsion. If seizures occur, benzodiazepines are recommended.
• Methemoglobinemia
  • Patients with methemoglobinemia poisoning present as catatonic or with shortness of breath and fatigue. In severe cases, methemoglobinemia toxicity can lead to cardiovascular collapse and death. The best treatment for methemoglobinemia poisoning is methylene blue.
• Organophosphates and carbamates
  • These agents cause excess parasympathetic and nicotinic functioning and affect the CNS. Early treatment is important to prevent deterioration to respiratory and cardiac arrest. Treatment includes dermal decontamination, atropine, benzodiazepines, and oximes.
• Sodium channel blockers
  • Toxicity from sodium channel blockers causes QRS prolongation, hypotension, seizure, ventricular dysrhythmia, and cardiovascular collapse. Depending on the specific drug, additional effects on cardiac receptors or ion channels may occur. For the treatment of life-threatening cardiotoxicity, the recommended treatment is sodium bicarbonate.
• Sympathomimetics
  • This type of poisoning results in adrenergic nervous system activation. It is often difficult to determine the culprit substance, and clinicians must often rely on treating presenting symptoms. Some examples of symptom management include sedation for severe agitation, rapid external cooling for hyperthermia, vasodilators for coronary vasospasm, and mechanical circulatory support for cardiogenic shock. The authors noted that prolonged physical restraint without sedation can be potentially harmful.

The post American Heart Association Guideline Update on Poisoning-Related Cardiac Arrest appeared first on The Cardiology Advisor.

Investigators conducted an overview of reviews assessing interventions designed to prevent physician burnout and identified additional strategies that could be implemented within rheumatology practices. The included reviews consisted of studies with a minimum of 10% participation from physicians, with burnout or a similar measure of work-related stress as the primary outcome.

A total of 17 reviews were included in the final analysis, consisting of 15 systematic reviews, 1 realist review, and 1 umbrella review. All reviews were published between 2015 and 2021.

The investigators noted the presence of significant heterogeneity and low-quality evidence, risk for bias, and variability in terms of study designs, interventions, outcome measures, and burnout conceptualizations among the considered reviews. Review findings suggested cautious interpretation due to this variability.

Mindfulness-based interventions demonstrated the strongest evidence, but even within this category, the considerable heterogeneity among intervention protocols was identified as a weakness.

Each review included a varying number of primary studies, ranging from 6 to 81 (median, 19 studies; interquartile range [IQR], 13-36 studies). Additionally, the number of relevant primary studies for each review ranged from 2 to 24 (median, 7 studies; IQR, 5-11 studies).

Meta-analyses were conducted within 6 of the reviews, with results suggesting that the tested interventions resulted in slight to moderate reductions in burnout. In 2 comparative analyses, organization-directed interventions were found to be more effective than physician-directed interventions. The third comparative analysis demonstrated that physician-directed interventions were more effective.

Use of the AMSTAR-2 measurement tool (designed to assess the methodological quality of systematic reviews) led to the exclusion of the realist review and umbrella review. Among the remaining reviews assessed, 1 review received a moderate rating, 6 were rated as low, and 9 were classified as critically low.

This study was limited by inconsistencies among the included reviews. Additionally, while the current study focused on burnout as an outcome, other outcomes such as depression or anxiety may contribute to burnout and should be considered in future reviews.

The study authors concluded, “Future work should focus on interventions that address physician workflow, organizational strategies, peer support, formal communication training, leadership support, and addressing stress, mental health, and mindfulness.”

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A significant amount of follow-up visits in rheumatology clinics are due to IA. In an effort to offset the increasing clinician workload, researchers evaluated the utility of ePROMs as a healthcare resource for monitoring disease activity and treatment decisions.

A systematic literature review was conducted to identify nonrandomized and randomized controlled trials (RCTs) that evaluated the clinical impact of ePROM utilization among patients with IA.

Meta-analyses were conducted to assess outcomes of interest, including rates of remission, treatment intensification, disease flare, face-to-face appointments, and between-group disease activity scores.

Data from 8 studies comprised of 4473 patients were included in the review, of which 6 were RCTs and 2 were pre-post observational cohort studies. Seven of the 8 studies focused on patients with rheumatoid arthritis.

A meta-analysis of studies using ePROM measures revealed that disease activity was lower at follow-up among the ePROM groups compared with control groups (standardized mean difference [SMD], -0.15; 95% CI, -0.27 to -0.03). A sensitivity analysis adjusted for follow-up length revealed similar findings (SMD, -0.21; 95% CI, -0.37 to -0.05). Despite a small effect size, none of the studies utilizing ePROM monitoring demonstrated worsening patient disease activity.

A total of 5 studies evaluated remission and/or low disease activity between ePROM and control groups. Higher rates of remission were found among the ePROM groups at follow-up (odds ratio, 1.65; 95% CI, 1.02-2.68).

When evaluating for resource utilization, fewer face-to-face visits were necessary during follow-up among ePROM vs control groups (SMD, -0.93; 95% CI, -2.14 to 0.28).

This analysis was limited by risk for bias and heterogeneity among the included studies.

The study authors concluded, “The findings are encouraging in the current climate and show promise in the potential of ePROM remote monitoring as an adjunct to care, with potential for reduction in other healthcare resource use. Further robust and focused research in the use of ePROM monitoring as a lone adjunct compared to routine care is needed, with longer follow-up.”

Disclosure: One or more of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.

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Medical training typically coincides with major reproductive years for women physicians, which can cause significant fertility, stress, and professional strain. Researchers surveyed physicians and medical school students to assess the relationship of this profession with family building.

The researchers used social media and email lists as the main methods to recruit participants. The questionnaire was sent to physicians and medical school students from April to May 2021.

The researchers sought to assess the psychologic and social burden of delayed childbearing, which can lead to infertility complications and the need for ART. These factors can impact the physicians’ well-being and also cause strain to relationships.

A total of 3310 people completed the survey, with most participants desiring to have biological children (n=3068 [92.7%]). A majority of participants were women (n=2982 [90.1%]) and completed their medical training (n=1738 [52.5%]).

Over half of the participants reported delaying family building due to their career (n=1985 [60.1%]) and most of these participants regretted that decision (n=1110 [55.8%]). The most reported reason for delaying family building was the time burden of residency.

Most participants who regretted delaying childbearing were aged 32 to 36 (n=325 [64.2%]). There were 457 (57.0%) participants aged 37 and older and 328 (48.4%) participants younger than age 32 who regretted delaying family building.

Out of all the participants, 698 (21.1%) reported infertility and 19.2% used ART, with older participants having a higher proportion of both.

A total of 903 participants documented fertility complications that impacted their well-being. There were 200 (38%) participants who used ART and 187 (9.2%) participants who did not use ART that required family-building stress therapy.

Compared with participants who did not require ART (n=145 [7.2%]), nearly half of all participants (n=229 [43.5%]) who used ART reported stress in their relationships.

“The high rates of regret of delaying family building, subsequent infertility and use of ART, and relationship strain, in therapy needs, make family building arduous for many physicians and medical students, especially ART users,” the researchers wrote. They concluded, “Our data highlight the need to change how we support family building for the entire physician workforce.”

Study limitations are the inability to estimate response rate or bias, which can limit generalizability.

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Researchers used data from comparative surveys between the multidisciplinary healthcare team and patients, revealing critical discordances between the groups, which enabled healthcare teams to identify gaps in care and develop ways to improve treatment, including shared decision making. The study findings were published in Professional Case Management.

Multidisciplinary healthcare teams may inadvertently propagate healthcare disparities due to a lack of experience or awareness of individualized, patient-centered goals of care. Significant healthcare disparities continue particularly in Black patients with MM, who are twice as likely to develop the disease and have an earlier age of onset compared with non-Black patients. Additionally, Black patients with MM are less likely to undergo stem cell transplantation, receive timely access to certain therapies, or be enrolled in clinical trials.

In this study, researchers conducted a large-scale, equity-focused initiative that focused on identifying and addressing racial disparities and health inequities in patients with MM. The study implemented quality improvement goals specific to each of the interprofessional cancer care teams via audit-feedback sessions.

Multidisciplinary cancer care teams in 2 large oncology systems and 4 community clinics in Chicago; Washington, DC; Columbus, Ohio; Charlotte, North Carolina; Indianapolis; and Denver participated. Teams consisted of hematologists/oncologists, nurse practitioners/physician assistants, primary care physicians, and case managers/nurse navigators.

Teams evaluated and compared their own beliefs and perspectives with those of their patients to reveal and address discrepancies. Baseline chart audits indicated inequities of care including disparities in clinical practice metrics, treatment history, patient-centered measures, and patient/disease characteristics.

Survey tools revealed significant differences between patients with MM and their healthcare team members. Healthcare teams reported cost of treatment as the biggest challenge (59% vs 9% of patients), whereas patients reported confidence in their treatment plan as the biggest challenge (32% vs 18% of healthcare team members).

Differences between Black/Hispanic patients and White patients were also noted. For example, 63% of healthcare team members and 47% of patients noted length of survival as an important goal of MM care. But racial differences in the importance of this goal of care were noted between Black/Hispanic patients and White patients — 38% vs 56%, respectively, reported length of survival as an important goal of care.

Subsequently, follow-up chart audits at 6 months showed changes in documented clinical behavior. Multidisciplinary teams developed action plans to address sustainable reductions in health disparities in patients with MM to address health equity and overall care.

“Using patient data as well as team-driven data to identify problems and inform strategies for change can assist clinics and their teams in mitigating health disparities, which can improve patient outcomes at the point of care,” the authors concluded in their report.

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For the 2023–2024 season, all influenza vaccines are expected to be quadrivalent, containing hemagglutinin (HA) derived from one influenza A(H1N1)pdm09 virus, one influenza A(H3N2) virus, one influenza B/Victoria lineage virus, and one influenza B/Yamagata lineage virus.

Egg-based influenza vaccines:

• Will contain HA derived from an influenza A/Victoria/4897/2022 (H1N1)pdm09-like virus, an influenza A/Darwin/9/2021 (H3N2)-like virus, an influenza B/Austria/1359417/2021 (Victoria lineage)-like virus, and an influenza B/Phuket/3073/2013 (Yamagata lineage)-like virus.
• These include Afluria Quadrivalent, Fluarix Quadrivalent, FluLaval Quadrivalent, Fluzone Quadrivalent (all standard dose), Fluzone High-Dose Quadrivalent (high-dose formulation), Fluad Quadrivalent (standard dose with MF59 adjuvant), and FluMist Quadrivalent intranasal spray.

Cell culture-based inactivated or recombinant influenza vaccines:

• Will contain HA derived from an influenza A/Wisconsin/67/2022 (H1N1)pdm09-like virus, an influenza A/Darwin/6/2021 (H3N2)-like virus, an influenza B/Austria/1359417/2021 (Victoria lineage)-like virus, and an influenza B/Phuket/3073/2013 (Yamagata lineage)-like virus.
• These include Flucelvax Quadrivalent (standard dose cell culture-based) and Flublok Quadrivalent (recombinant).

Updates to the guidance for this upcoming influenza season include the following:

• ACIP recommends all persons 6 months of age and older with egg allergy receive influenza vaccine (egg-based or nonegg-based) that is otherwise appropriate for the recipient’s age and health status.
  • It is no longer recommended that individuals who have had an allergic reaction to egg with symptoms other than urticaria should be vaccinated in a medical setting supervised by a health care provider who is able to recognize and manage severe allergic reactions if an egg-based vaccine is used.
  • Egg allergy alone does not require additional safety measures for influenza vaccination beyond those recommended for any recipient of any vaccine, regardless of severity of previous reaction to egg.
  • All vaccines should be administered in settings in which personnel and equipment needed for rapid recognition and treatment of acute hypersensitivity reactions are available.
  • Additional information about this recommendation can be found here.

Regarding simultaneous administration of influenza vaccine with the new respiratory syncytial virus (RSV]) vaccine, data included in the prescribing information for GSK’s Arexvy show no evidence for interference in the immune response to any of the antigens contained in both concomitantly administered vaccines. In this study (ClinicalTrials.gov Identifier: NCT04841577), participants 60 year of age and older received 1 dose of Arexvy and Fluarix Quadrivalent. The criteria for noninferiority of the immune responses in the control vs coadministration group were met, though RSV and influenza antibody titers were somewhat lower with coadministration; the clinical significance of this is unknown.

The full report, which includes guidance for influenza vaccination of specific populations (eg, children, pregnant people, older patients, immunocompromised individuals), and situations (eg, history of Guillain-Barré Syndrome) can be found here.

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Over the years, we have experienced an increase in extreme weather-related events as a result of climate change. This global phenomenon affects health on many levels, making it of critical importance to physicians. Climate change refers to the change in temperature and weather patterns that have been occurring globally.¹ According to the Intergovernmental Panel on Climate Change (IPCC) within the United Nations, the main drivers of climate change have been human activities, including burning fossil fuels such as gas, coal, and oil.² Given the consistent change in global temperatures, extreme weather events will continue to occur until serious action is taken.

Climate Change Is a Public Health Crisis

At the 2022 annual meeting of the American Medical Association (AMA), climate change was declared a public health crisis. AMA Board Member Ilse R. Levin, DO, MPH, stated that “the scientific evidence is clear — our patients are already facing adverse health effects associated with climate change, from heat-related injuries, vector-borne diseases, and air pollution from wildfires to worsening seasonal allergies and storm-related illness and injuries. Taking action now won’t reverse all of the harm done, but it will help prevent further damage to our planet and our patients’ health and well-being.”³

Human health can be both directly and indirectly affected by climate change. The rising global temperatures are directly leading to an increase in severe weather, causing storms, floods, droughts, heat waves, and wildfires. These severe weather events can cause injury, starvation, heat stroke, and burns, for example. However, these weather events can also indirectly affect health by disrupting water quality and food availability, and causing air pollution, among other adverse effects.

Severe Weather Events Affect Patient Health

At present, more than 800 active wildfires are burning throughout Canada and more than 200 wildfires are burning in the United States, causing serious air pollution across both nations.⁴ The smoke from these wildfires is composed of toxic gases and fine particulate matter that can irreparably damage the lungs.⁵

These particulates have also been linked to cardiovascular disease, including stroke, heart attack, heart failure, and atrial fibrillation.⁶ Damage to the lungs and heart can also leave patients susceptible to infectious diseases,⁷ which continues to be a significant concern with the recent COVID-19 pandemic still looming.

In 2016, persistent rainfall from a summer storm resulted in disastrous flooding in the state of Louisiana, having dropped 7.1 trillion gallons of water on the state.⁸ This storm was later attributed to climate change. Authors of a study published in 2016 estimated that the rise in global warming since 1985 has increased rainfall by up to 20%.⁹ In addition to leaving nearly 150,000 homes damaged as a result of flooding,¹⁰ a major result of this and similar floods is the rise in mosquito populations.¹¹

The increase in precipitation and rising temperatures due to climate change encourage mosquito survival and replication. Certain infectious diseases — including those spread by mosquitoes — are increasing as a result of climate change. These diseases — referred to as vector-borne diseases — are caused by living organisms that transmit infections to humans.¹² An example of vectors are blood-sucking insects, including mosquitoes, ticks, and fleas, which transmit such diseases as malaria, Zika, Lyme disease, and plague, among many others. 

Malaria — a blood-borne disease caused by the Plasmodium parasite — can progress to severe illness and death within 24 hours if left untreated.¹³ Malaria outbreaks in the United States are rare, with the last outbreak occurring in 2003. As of July 2023, there have been 8 confirmed, locally acquired cases of malaria, with more likely to occur by the end of the year.¹⁴ The frequency of mosquito-borne diseases like malaria is predicted to increase in the years to come as a direct result of climate change.¹⁵

Mental Health Risks Due to Climate Change

In addition to physical health effects, climate change is also having direct effects on mental health. Changes in mental health as a result of climate change may be difficult to detect; however, addressing them is critical to ensuring overall well-being.

“Climate grief” is the experience many patients feel as a result of the looming effects of climate change. This phenomenon includes anxiety and fear about how the Earth will change over the coming years, as well as depression and stress over how to help reduce global warming, given the scope of the problem.¹⁶ 

Climate change can also affect mental health directly, as in the case of anxiety, depression, or/or post-traumatic stress disorder (PTSD) experienced by in those who experience a natural disaster, including floods¹⁷ and wildfires.¹⁸

Authors of a 2021 study published in Behavioral Sciences reported that patients who lived in communities damaged by wildfires experienced increased rates of PTSD up to 10 years after the fires ceased.¹⁸

Authors of another study published in 2022 in Neurotoxicology found that those who live in communities affected by heavy smoke exposure are at increased risk of developing anxiety and depressive disorders. These diagnoses have been linked to living in areas with drastically elevated air pollution levels.¹⁹

How Can Physicians Be Prepared To Discuss Climate Change With Patients?

Climate change affects human health in widespread and complex ways. Physicians therefore need to be prepared to handle the health-related effects of climate change.

The first step toward helping patients is to become educated on how climate change can affect health. The health effects of climate change are expansive and multifaceted. Numerous online continuing medical education (CME) courses on the health effects of climate change are available for physicians.^20-22 These courses provide background information on the types of events caused by climate change, as well as the health risks to patients and treatment options for physicians.

Additionally, the World Health Organization (WHO) provides information on climate change and how it affects human health, and this information can serve as a useful tool for physicians.²³ The WHO also organizes a Global Conference on Health and Climate Change every 2 years; this symposium supports engagement, education, and policy change.²⁴

It is important for physicians to be aware of the effects of climate change so that they can consider these environmental changes in diagnoses. For example, if a patient presents with unusual symptoms, physicians should consider the potential increase in vector-borne diseases that may otherwise be overlooked. In an episode of “AMA Moving Medicine,” Renee Salas, MD, MPH, MS, a climate and health expert and emergency physician at Massachusetts General Hospital, encourages physicians to approach medicine with a “climate lens.” This approach includes considering all the current and future climate changes and how they can affect health and the provision of health care.²⁵ 

In 2021, a physician treating a woman in the emergency department of a British Columbia hospital cited climate change as the underlying cause for her condition. The patient presented with dehydration and asthma, both of which occurred as a direct result of the heat wave and air pollution from wildfires caused by climate change.²⁶ This unprecedented diagnosis serves as an example of how physicians need to consider the impact of climate change on health when evaluating patients.

By recognizing the effects of extreme weather caused by climate change, physicians can be better prepared to address symptoms and appropriately diagnose patients.

Physicians should also be aware of the mental health changes that can occur due to extreme weather events resulting from climate change, as well as the mental health changes that could be expected within their geographic region. Physicians should be prepared to talk to their patients about mental health and be aware of the resources available to them — including referring patients to mental health providers, when necessary.

Methods for Communicating Health Risks to Patients

The spread of misinformation within the United States has been on the rise in recent years.^27,28 Physicians play an important role in countering misinformation as they have an ethical duty to provide patients with information regarding their health. By accurately educating patients on climate change and the health effects of climate change-related weather events, physicians can help overcome misinformation. However, some physicians may hesitate to discuss the effects of climate change with patients for a  number of reasons, including avoidance of political resentment, lack of time, and a lack of knowledge as to how to appropriately broach the subject.²⁹ The following are several approaches that physicians can use to discuss this topic with patients.

1. Incorporate Brief Educational Messages

Physicians can broach the topic of climate change and health by using brief educational messages with their patients. This could include mentioning that air pollution is currently higher than usual due to wildfires in Canada and the United States, and that difficulty breathing and increased coughing may occur as a result. By simply mentioning the change that is occurring and how it can affect the patient, the physician can avoid controversy while still delivering an educational message.

2. Ask Permission to Discuss Controversial Topics

Physicians can ask permission of their patients prior to discussing controversial topics. By first asking permission, the physician respects the patient’s decisions and feelings. This strategy helps to build trust and mitigate resistance and arguments when discussing difficult or sensitive topics.

3. Emphasize the Consequences to the Patient

An effective method for discussing the effects of climate change is to emphasize the health consequences of the weather event. By starting a discussion about how a particular symptom is caused by climate change, physicians can appeal to the patient’s main interest. For example, if a patient presents with asthma and difficulty breathing, physicians can start the conversation by mentioning that the difficulty breathing is likely a result of high air pollution caused by climate change. By first beginning with the cause of their symptoms, physicians can set the scene and allow the conversation to evolve.

4. Acknowledge the Difficulties Associated With Changes

If air pollution is the current issue a physician is trying to convey, simply stating that a patient should not go outside can be met with resistance and dismissal. Physicians can make sure to include statements of understanding at the arduous task of avoiding pollution when being outside is a part of a patient’s daily lifestyle. Providing simple alternatives (eg, wearing a pollution-filtering mask when outside) and qualifying that they recognize how frustrating it is for the patient can help to convey the importance of the message while building trust through empathy.

5. Be Open to Different Approaches

It is important for physicians to be open to trying different approaches with their patients. Each patient has a unique set of experiences and world views. Strategies that work for one person might not be appropriate for another. While this can make effectively conveying health risks to patients difficult, it is essential that physicians alter their approach to fit each patient’s needs.

Be an Advocate for Change

Physicians should consider the impact they can make on climate change. Providing community assistance can mean volunteering at local shelters and food banks, giving talks on how people can prepare for weather-related health events (eg, air pollution or extreme heat), and advocating for changes to the environmental footprint. Physicians can work to reduce the energy bill at their practice or support programs that work to reduce the environmental footprint in the community. Physicians can also encourage eco-friendly transportation, such as the use of bike paths and public transportation, instead of commuting by car. Small changes can have a huge impact, and encouraging others to make changes is the first step toward a global effect on climate change.

“Climate Change is Widespread, Rapid, and Intensifying”

The IPCC reported that “climate change is widespread, rapid, and intensifying.”² The effects we are seeing so far are only the beginning, and they will continue to worsen in years to come unless significant changes are implemented. The unfortunate reality is that we all need to be prepared to handle these changes, and it is the duty of physicians to be prepared to educate their patients on how to do this. Although this is a difficult task, becoming educated on the events, how they affect human health, how to effectively convey these messages, and how to help combat these changes are necessary for physicians to ensure positive outcomes among their patients.

Originally appeared on Infectious Disease Advisor.

The post Impact of Recent Climate Change Events on Health appeared first on The Cardiology Advisor.

Researchers conducted a study to evaluate the effectiveness of ozone in combination with UV-C air treatment for sanitizing surfaces in hospital settings. Ozone and UV-C air treatment was delivered via the O3zy Light device, a contactless system consisting of a wheel-mounted portable ozone generator plus UV-C sanitizer. The effectiveness of the O3zy device was assessed at 3 hospitals in Italy during a 3-week period. The device was used in settings classified as low- and medium- to high-risk areas for hospital-acquired infection. Samples were collected from each setting once weekly for 3 consecutive weeks following use of the device and tested for Gram-positive (Staphylococcus aureus, non-β–haemolytic staphylococci, Clostridioides) and Gram-negative (Enterobacterales, Escherichia coli, Klebsiella, and Pseudomonas aeruginosa) bacteria, as well as mold and yeasts (Candida and Aspergillus species).

Samples were collected from a total of 240 low-risk and 144 medium- to high-risk areas. Low-risk areas included rehabilitation gyms and changing rooms, and high-risk areas included neurorehabilitation rooms.

In low-risk areas, UV-C irradiation of the air was performed continuously and ozone was used when areas were not occupied by patients. Overall, the combined use of UV-C and ozone treatment reduced the presence of Gram-negative bacteria by more than 99%. However, reductions in C difficile spores and Aspergillus species varied throughout the study. For C difficile, spores were reduced by 41% at week 0 and 79% at week 2; reductions in Aspergillus species during this period ranged between 44% and 97%. Of note, the effectiveness of UV-C plus ozone disinfection was associated with the number of treatments carried out over the 3-week period.

In medium- to high-risk areas, UV-C plus ozone treatment was effective against Gram-positive bacteria (S aureus and non-β-haemolytic staphylococci), Gram-negative bacteria, and Candida species. As with in low-risk areas, reduced susceptibility to the combined use of UV-C and ozone was observed for Clostridioides and Aspergillus species sampled from medium- to high-risk areas.

Limitations of this study include its short duration, potentially resulting in preliminary outcomes that are difficult to generalize to all hospital settings. In addition, further research is needed to compare the cost-effectiveness of no-touch sanitation devices with that of conventional cleaning procedures.

According to the researchers, “[T]he proposed no-touch device may be evaluated in future research to assess the needed requirements for its possible and full implementation in hospitals.”

The post Ozone Plus UV-C Air Disinfection Effective for Hospital Pathogen Control appeared first on The Cardiology Advisor.

As it relates to a person’s occupation, a “niche” is defined as a place, activity, status, or employment for which someone is best suited.¹ Finding one’s niche in medicine can be akin to choosing a specialty or identifying a space within a chosen specialty where a physician finds purpose and pride. 

Given the nature of their work, physicians are more susceptible to high stress levels and burnout compared with workers in other fields.² Because it allows physicians to create meaning in their medical practice, finding one’s niche may protect against burnout and other negative effects of work-related stress.³ This article will provide physicians with a framework for identifying and acting on their niche.

How Do You Identify Your Niche? 

The first step in identifying your niche in medicine is to make an honest assessment of your passions and interests within the field. The American Academy of Family Physicians (AAFP) shares questions to consider when choosing a medical specialty, which is an essential step toward finding your niche.⁴ These and other relevant considerations are reviewed in the Table.

Table. Questions to Answer When Choosing a Medical Specialty 

Answering these questions can help with choosing a specialty that aligns with your goals and values. Identifying physician mentors in your desired specialty is also essential. Mentors have a wealth of experience to share, including strategies for applying to residency programs, managing work-related stress, and setting personal and professional priorities.⁵ 

Because choosing a specialty is only the start of the process to define your niche as a physician, mentors can also support you beyond this decision. Within specialties, there are also subspecialties to consider for people who want to focus their practice on a specific aspect of medical care.⁶ 

After exploring your desired specialty or subspecialty, engagement with your community can help further explore your niche in the medical field. Your patients make up the majority of the community where you train or work. Understanding their priorities and concerns from their perspective can identify meaningful ways to integrate community health promotion into your practice.

Since exposure to new facets of the healthcare system and your community may spark unexpected interests, discovering and refining your niche continues as you complete your training and move into independent practice. Personal priorities may also change as you progress through life. The process of identifying a medical niche is highly individual, but having a framework like the one outlined above can help guide the process.   

How Do You Act On It Once You’ve Identified Your Niche?

Putting your medical niche into practice typically begins with applying for residency. The residency application process can be grueling, but it presents several opportunities to ensure your choice of residency is the best fit for you.

Talking with people you meet while applying for residency — including current residents and program faculty — can offer insight into the environment and culture of an institution and community.⁷ Asking how they chose their current program and how they feel about the program will allow you to determine if their motivations and values align with yours.

When comparing different programs within your chosen specialty, it is important to compare them based on factors that directly affect the daily experience of residency training, as opposed to name recognition or prestige.⁷  These factors include location, curriculum details, interpersonal experiences with current residents and faculty, institutional values, and investment in community health. You should also consider these factors when applying for a fellowship once your residency has been completed. 

Residency, potentially followed by a fellowship, is your first practical opportunity to self-assess the fit between you and your chosen specialty/residency program. Because of the extreme demands of residency and fellowship, physicians may experience burnout and question their career choices during this time.⁸ Signs of burnout include⁹:

• Feeling ineffective or meaningless at work;
• Low motivation;
• Lack of personal accomplishment;
• Self-doubt; 
• Emotional exhaustion; 
• Depersonalization; and 
• Feeling helpless.

If you experience signs of burnout, addressing them should be a top priority. Interventions to prevent and reduce burnout often require institutional action; however, there are a number that are within your control, including⁹: 

• Engaging in effective self-care practices;
• Going to therapy to process trauma and learn effective mindfulness/coping strategies;
• Seeking advice and support from trusted friends, family, or mentors; and 
• Defining and acting on your passions.

During times of stress and burnout, reminding yourself why you chose your particular medical niche can reconnect you to joy and motivation.⁹ However, difficult experiences times may also lead to changed perspectives and goals.

Adapting to Change

During your career, you may discover new passions or technologies that change the way you practice. You may even discover that your clinical focus or clinical work, in general, is no longer fulfilling for personal or professional reasons. Adaptability is key to navigating these changes and fulfilling your niche. 

Although making big career changes in medicine can feel impossible, many physicians have moved through them successfully, and their experiences can provide guidance and inspiration. Bonnie Darves interviewed several physicians who for various reasons decided to pursue nonclinical work, either alone or in combination with clinical work, and published her findings in The New England Journal of Medicine (NEJM) Career Center.¹⁰

Heather Fork practiced dermatology for 10 years before deciding she wanted to help people in a different way through career coaching.¹⁰ She now runs The Doctor’s Crossing, a company dedicated to supporting physicians who are looking for a career change. 

In her interview with Ms Darves, she encourages physicians to explore their interests within and outside of medicine if they are feeling unfulfilled.¹⁰ Taking inventory of your current circumstances and interests can help identify areas for improvement in your current role or illuminate an entirely new career path.

Yasmine Ali, a cardiologist, applied these principles to her career.¹⁰ When she was feeling unfulfilled after 10 years of cardiology practice, she looked to her interests for inspiration and decided to combine writing and preventive medicine in a new, gratifying career path. Now, Dr Ali is the president of LastSky Writing, LLC, a company that provides medical consulting and writing services, and runs a preventive medicine practice. 

Hodon Mohamed, an obstetrician-gynecologist, has also combined clinical and nonclinical work to achieve a career that works for her.¹⁰ Along with working 2 clinical shifts per week, she also works as a medical director, in utilization management, and as a career coach. She finds coaching physicians particularly rewarding, noting that physicians often do not discuss their issues, and she enjoys helping them discover their passions. 

Importantly, career changes such as these can take time to develop. Feliciano Yu is a pediatrician whose career has evolved over the past 2 decades from pediatric clinical practice to a full-time administrative role focused on informatics, care quality, and outcomes research.¹⁰ This evolution began as an interest in computers that led to Dr Yu obtaining degrees in both public health and health informatics. In his current role, Dr Yu feels like he is still caring for patients, just in a new way. 

These are just a few examples of physicians who have successfully changed their careers. Their stories emphasize the importance of frequent and honest self-assessment of your job fulfillment and that the right niche in medicine looks different for every physician. 

Be True To Yourself

Finding a niche in medicine that aligns with your priorities and values is essential to long-term job satisfaction. In a field in which burnout may be becoming more commonplace, pursuing a medical career that feels purposeful and promotes your wellness is a radical and important act. You are not alone in this pursuit; look to friends, family, and mentors for support, while also remaining true to yourself and your goals. 

Originally appeared on Dermatology Advisor.

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The final rule requires that the transfer of a controlled substance prescription in schedule II-V be communicated between 2 licensed pharmacists and that the prescription remains in electronic form with no changes during the transmission. The transfer can only be done once; any refills on the prescription (schedule III, IV, or V drugs) will be transferred to the receiving pharmacy as well. Electronic records of the transfer must be maintained by both pharmacies for 2 years from the date of the transfer.

Prior to the amendment, a pharmacy that could not fill an electronic prescription for a controlled substance could only inform the patient that it could not be filled. Since an electronic prescription cannot be printed and given to the patient by the pharmacist, the patient would need to call their doctor and request another prescription be sent to a different pharmacy. The DEA revised its regulations in an effort to reduce the potential for duplicate controlled substance prescriptions.

The final rule has been published in the Federal Register and provides additional information on the regulations, including procedures for proper documentation of the transfer.

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Changing trastuzumab dosing strategies for breast cancer treatment can reduce greenhouse gas emissions, according to research published in JCO Oncology Practice.

Using a case-control simulation, researchers found that shortening treatment duration and lengthening the time between doses reduced greenhouse gas emissions per person, leading to a reduction in deaths due to these emissions.

For the simulation, the researchers used data from 102 patients with HER2-positive breast cancer, including 63 who received trastuzumab in the neoadjuvant setting, 57 who received it in the adjuvant setting, and 30 who received it in the metastatic setting.

A streamlined life-cycle analysis was performed for 3 different trastuzumab dosing strategies:

• A 6-month adjuvant period with dosing once every 3 weeks
• A 6-month adjuvant period with dosing once every 4 weeks
• A 12-month adjuvant period with dosing once every 4 weeks.

These 3 strategies were compared to the standard dosing strategy — 12 months of adjuvant therapy with a dosing interval of once every 3 weeks.

The 6-month period with dosing every 3 weeks was estimated to reduce greenhouse gas emissions per person by 9.9% in the adjuvant setting, but there were no reductions in the neoadjuvant or metastatic settings.

The 6-month period with dosing every 4 weeks was estimated to reduce greenhouse gas emissions per person by 4.5% in the neoadjuvant setting, 18.7% in the adjuvant setting, and 14.6% in the metastatic setting.

The 12-month period with dosing every 4 weeks was estimated to reduce greenhouse gas emissions per person by 4.5% in the neoadjuvant setting, 10.4% in the adjuvant setting, and 14.6% in the metastatic setting.

The estimated number of excess disability-adjusted life-years lost because of greenhouse gas emissions associated with trastuzumab treatment was:

• 8.1 with the standard dosing strategy 
• 7.5 with the 6-month period and dosing every 3 weeks
• 7.1 with the 12-month period and dosing every 4 weeks
• 6.6 with the 6-month period and dosing every 4 weeks.

The estimated number of excess deaths worldwide due to greenhouse gas emissions associated with trastuzumab treatment was:

• 4.6 with the standard dosing strategy
• 4.3 with the 6-month period and dosing every 3 weeks
• 4.0 with the 12-month period and dosing every 4 weeks
• 3.7 with the 6-month period and dosing every 4 weeks.

The researchers noted that there are limitations to this study, including that 6 months of adjuvant trastuzumab has not been found to be as effective as treatment for 12 months.

“Alternative dosing strategies may materially reduce the population health impacts of cancer care by reducing environmental impact,” the researchers concluded. “Clinical trials of alternative dosing strategies are justified on the basis of environmental and population health impacts.”

Disclosures: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures.

Reference

Jacobson SI, Kacew AJ, Knoebel RW, Hsieh P-H, Ratain MJ, Strohbehn GW. Alternative trastuzumab dosing schedules are associated with reductions in health care greenhouse gas emissions. JCO Oncol Pract. Published online July 14, 2023. doi:10.1200/OP.23.00227

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“I am deeply concerned about high rates of procedural terminations due to ‘red tape’ and other paperwork issues,” Health and Human Services Secretary Xavier Becerra wrote in a letter sent Friday to all governors, the Associated Press reported.

The changes are happening now because a prohibition on removing Medicaid coverage during the pandemic has now been lifted. States have now begun doing annual eligibility redeterminations. Among 18 states that began this review in April, about 1 million people continued to receive their health coverage, the AP reported. Another 715,000 lost that coverage, but in four of five cases, that was for procedural reasons, according to data from the federal U.S. Centers for Medicare and Medicaid Services.

Becerra encouraged governors to make efforts to keep people on Medicaid, including by using electronic information from federal programs, such as food stamps, to confirm eligibility.

Data suggest that some states did a better job than others of answering questions about Medicaid coverage, the AP reported. The average call center wait time was a minute or less in April in 19 states and Washington, D.C. Conversely, it was 51 minutes in Idaho, 44 minutes in Missouri, and 40 minutes in Florida.

The AP and health care advocacy groups gathered data showing that about 3.7 million people already have lost Medicaid coverage, including about 500,000 in Texas, 400,000 in Florida, and 225,000 in California. In California, 89 percent of those cuts were for procedural reasons. That was true also for 81 percent in Texas and 59 percent in Florida, according to the AP.

Some states are voluntarily slowing cuts while working with CMS. South Carolina extended its eligibility renewal deadline from 60 days to 90 days. Michigan renewed more than 103,000 Medicaid recipients in June, while removing 12,000. Yet, more than 100,000 people have incomplete June eligibility cases.

Meanwhile, the insurance companies that run the Medicaid programs for the states are working to ensure people still have some health coverage. Officials from Molina Healthcare, a multistate insurer, said the company is working to enroll those dropped from Medicaid in individual insurance plans sold through state-based marketplaces, the AP reported.

Associated Press Article

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As health care providers, we want to do everything we can to help our patients achieve wellness. It can be tempting to share all of the information we have learned with them toward that goal of patient education and health literacy. However, all the best information can’t be helpful if our patients can’t act on it because they don’t remember it.

To ensure patients have useful information they can benefit from, it is important to avoid patient education overload. Health care providers should help patients improve their health literacy and use effective 2-way communication to achieve better patient commitment to treatment and satisfaction.

Is More Information Always Better?

Research has consistently found that patients often forget information given to them by their physicians.¹ Patients can immediately forget 40% to 80% of the medical information and recommendations they receive. Of the information they remember, only about one-half of it is typically recalled correctly.² For any recommendation to be effective, patients must be able to remember what it is and how to achieve it.

A lower ability to recall medical information is associated with several factors, including^3,4:

• Older age;
• Low health literacy;
• High and low anxiety; 
• Large amount of information; and 
• Low level of education.

The type, structure, and length of information can influence how much of the information a patient can retain.⁵ The more recommendations a patient is given, the higher the likelihood they will be forgotten. A 2011 study conducted at a family practice in Slovenia found that there is a higher likelihood that recommendations will be forgotten when patients are given 3 or 4 at one time, compared with just 1 or 2 recommendations. The study authors recommend that if more than 1 or 2 recommendations are needed, a follow-up appointment should be scheduled.⁴ 

Effective Communication

Effective communication can improve patient satisfaction and recall, ultimately improving patient outcomes.⁶ 

A component of optimal health care delivery is ensuring that health information as communicated by clinicians is understood by their patients. The most effective type of communication will differ among patients. Health care providers have the responsibility of providing patients the information they need to achieve health and wellness, and patients have the responsibility of acting on the information.⁷ 

Health Literacy

Improving patient care and communication should focus on improving patient health literacy. Health literacy refers to an individual’s ability to find, understand, and use health-related information to make decisions and take action. According to the Agency for Healthcare Research and Quality (AHRQ), health literacy in the United States is low, with only 12% of Americans demonstrating health literacy skills adequate to navigate the complex health care system.⁸

Health literacy is one of the best predictors of a patient’s health. Low health literacy is linked to⁹:

• Poor management of chronic illness;
• Decreased ability to participate in shared decision-making with health care providers; and
• Lower levels of adherence to medical therapies. 

Although health literacy can be an important factor in predicting a patient’s outcomes, clinicians do not necessarily need to evaluate their patient’s level of health literacy. Instead, health care providers should use universal precautions for all patients, regardless of their health literacy level. Universal precautions aim to¹⁰:

• Simplify communication;
• Confirm patient understanding;
• Improve the navigability of health care services; and
• Support patients.  

Barriers to Patient Education

Health care providers should be aware of what potential barriers may exist for patients to understand medical information. 

Recall of medical information is strongly associated with patient education levels. One study found that people with less than a high school diploma recalled approximately 38% of recommendations made during an ambulatory care visit, while people with a college degree were able to recall approximately 65% of recommendations.¹ 

It may not be possible for a clinician to be able to determine patient education levels, but patients with low health literacy often have red flags, such as¹¹:

• Missed appointments;
• Incomplete written forms;
• Lack of adherence to medication;
• Inability to state the name or purpose of a medication;
• Inability to provide a complete or coherent history; and
• Lack of follow-through on testing or laboratory appointments. 

Strategies to Improve Health Literacy & Patient Education

Even if a patient has high health literacy, clinicians should still take precautions to ensure comprehension. AHRQ provides a health literacy universal precautions toolkit to help health care providers promote better understanding for everyone.¹⁰ The toolkit is available here. 

Use Clear Communication

Clear communication can help patients to better understand medical information. Tips for clear communication include¹²:

• Maintaining a friendly attitude;
• Avoiding the use of medical jargon;
• Using the patient’s own words;
• Speaking at a moderate pace; and
• Avoiding interrupting patients when they are speaking.

Focus on What the Patient Needs To Know

Health care providers should prioritize the information that needs to be discussed. Information should be limited to 3 to 5 key points. Repeating these key points can also help with patient recall.¹² 

Key points should be specific and focus on the steps the patient must take when they leave the examination room and when they return home to successfully follow treatment instructions. Patients are more likely to remember specific advice compared with generalized information.³

Key information should be prioritized based on the patient’s goals. For example, the key points for a patient being seen to diagnose a new condition will be different from those provided to a patient following up on an existing condition.¹² 

Use the Teach-back Method

The teach-back method allows health care providers to ensure that medical information is given to patients in a way they can understand and act on. This method has been shown to help²:

• Improve a patient’s understanding and adherence to recommendations;
• Reduce the number of canceled appointments;
• Decrease the number of callbacks; and
• Increase patient satisfaction.

The teach-back method should be framed as a test of how well the health care provider explained knowledge instead of a test of the patient’s knowledge. Instead of asking yes or no questions to confirm knowledge (such as, “Does that make sense?”), use open-ended questions where the patient must summarize recommendations in their own words.²

Examples of starter phrases that can be used in the teach-back method include²:

• “We covered a lot today. To make sure I explained things clearly, can you describe 3 actions you agreed to take today?”
• “This is a new diagnosis for you. To make sure you understand, can you tell me what this condition means?”
• “I’ve noticed lots of people have trouble remembering how to use their medication. Can you show me how you use your medication?”

Health care providers should check for understanding throughout the patient encounter instead of waiting until the end. Incorrect or incomplete understanding should be corrected immediately before moving on.²

Some providers may feel that the teach-back method feels awkward or time-consuming when they first incorporate this method into their practice. However, when used over time, it can improve patient outcomes and satisfaction without increasing the length of a visit.² 

Use Alternative Teaching Styles

The use of different types of patient education materials may encourage effective retention of information among patients with different learning styles. Although oral communication is a faster way to share information, written communication may result in better patient recall. Ideally, information should be provided in more than 1 form.³

Health care providers should consider having patient education materials available in different formats, such as¹³:

• Printed materials;
• Pictographs and infographics;
• Videos;
• Slide presentations;
• Models/props;
• Group classes; and
• 1:1 teaching.

It is important to evaluate a patient’s ability to effectively use the educational materials they are given. Materials should be provided in a language the patient speaks and ideally in their native language.¹⁴ 

Written materials should be easy to understand. The average US adult reads at approximately an 8th-grade level, but up to 20% of adults read at or below a 5th-grade level. Written materials should be written at a 5th- or 6th-grade level to ensure all patients can understand the information.¹⁴ Pictographs or drawings serve as a useful form of communication for all patients, especially when literacy is unknown.³ 

Before using technology, it is important to make sure the patient is able to use it. For example, if a patient is instructed to watch a YouTube video, they should have access to a computer and know how to search for the video.¹⁴ 

It may help to keep a tally of which materials are given to patients most often or how often the office runs out of each printed material. 

Measuring Patient Education Outcomes 

The continuous measuring of outcomes is important to improve the health literacy of patients. One of the fastest and easiest ways to measure outcomes is to ask for patient feedback. Feedback can be obtained verbally during the encounter or by a written survey at the end of a visit. Examples of feedback questions include¹⁵:

• “Which parts of today’s visit did you find clear and easy to understand?”
• “Which parts did you find confusing?”
• “What information has been helpful for you?”
• “Is it clear what you need to do based on the information given to you today?”

Other methods for receiving patient feedback include¹⁵:

• Suggestion boxes;
• Shadowing patients during visits and while using health tools (such as a patient portal); and
• Walkthroughs with a person unfamiliar with the practice. 

The rate of patient adherence to treatment can also indicate the efficacy of communication. Studies show that patients with chronic conditions such as hypertension and type 2 diabetes who are satisfied with their provider’s communication are more adherent to their treatment.^16,17 

Patient Education & Health Literacy is Key

Patients are only able to take action on medical recommendations they understand and remember. Health care providers are responsible for improving health literacy by providing recommendations in a way that patients can understand.

The post Patient Education & Information Overload: How Much Is Too Much? appeared first on The Cardiology Advisor.

Linda H. Aiken, Ph.D., R.N., from University of Pennsylvania in Philadelphia, and colleagues assessed well-being and turnover rates of physicians and nurses in hospital practice. A survey of 21,050 physicians and nurses at 60 nationally distributed U.S. Magnet hospitals sought to identify actionable factors associated with adverse clinician outcomes, patient safety, and clinicians’ preferences for interventions.

The researchers found that high burnout was common among hospital physicians (32 percent) and nurses (47 percent), with nurse burnout associated with higher turnover of both nurses and physicians. Physicians (12 percent) and nurses (26 percent) rated their hospitals unfavorably on patient safety; they reported having too few nurses (28 and 54 percent, respectively), having a poor work environment (20 and 34 percent, respectively), and lacking confidence in management (42 and 46 percent, respectively). Fewer than one in 10 clinicians described their workplace as joyful. Both physicians and nurses reported that management interventions to improve care delivery were more important to their mental health and well-being than interventions specifically directed at improving clinicians’ mental health. The highest-ranking intervention was improving nurse staffing (87 percent of nurses and 45 percent of physicians).

“Enhancing clinician well-being and retention requires deliberate actions by management to improve nurse staffing, work environments, and patient safety culture,” the authors write.

Abstract/Full Text

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Researchers identified 21,281 patients who underwent surgery at the Zhengzhou Central Hospital between 2020 and 2021 for inclusion in the study.

The patients were evaluated for incidence of moderate to severe postoperative pain (MSPP) and adverse events. Outcomes were compared between patients who received standard acute pain service (APS; n=10,494) in 2020 or VPU (n=10,787) in 2021. The MSPP outcome was defined as a numeric rating scale (NRS) score of 5 or higher.

The most common surgical indications were gynecologic, ear nose throat, obstetrics, orthopedic, and urology.

Fewer VPU recipients reported MSPP (9.79% vs 28.03%), postoperative nausea and vomiting (9.38% vs 17.19%), and dizziness (7.12% vs 13.41%) compared with the APS group, respectively.

Overall, VPU reduced MSPP by 65.07%, postoperative nausea and vomiting by 45.43%, and dizziness by 46.91% compared with standard pain management.

No group differences were identified in the average length of stay (mean, 4.7-5.1 days; P >.05) or per-capita hospitalization costs (mean, $2422-$2563; P >.05); however, the APS intervention was associated with fewer per-capita clinician rounds (mean, 2 vs 5; P <.001) and lower per-capita opioid consumption rate (mean morphine equivalents, 116.5 vs 142.6; P <.05) compared with VPU, respectively.

The limitations of this study included its single center, retrospective design.

The study authors concluded, “This study demonstrated the viability and efficacy of VPU model in reducing the incidence of moderate to severe postoperative pain, nausea, vomiting, and dizziness, compared with APS. Therefore, this new model is a promising solution for acute pain management among postoperative patients.”

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Researchers in Southern California conducted a retrospective cohort study between January 2016 and December 2021 to evaluate trends in uropathogenic E coli resistance among adult outpatients with uncomplicated UTIs. The Mantel-Haenszel method was used to assess trends in class-specific resistance and MDR over time.

A total of 174,185 patients were included in the final analysis, of whom the mean age was 52 years, 92% were women, 46% were Hispanic, 18% had diabetes, and 15% had chronic obstructive pulmonary disease. Overall, 75% of uncomplicated UTIs were identified among patients during in-person visits and 25% were identified during telehealth visits.

Among patients who submitted urine samples for culture analysis, uropathogenic E coli isolates were most frequently identified among those aged 60 to 69 years (17%), followed by those aged 50 to 59 (16%), 18 to 29 (15%), and 80 years and older (10%).

Overall, the percentage of patients with MDR uropathogenic E coli isolates decreased from 13% (n=4988) in 2016 to 12% (n=2444) in 2021, with similar findings after adjustment by in-person vs telehealth visits.

Further analysis of MDR uropathogenic E coli isolates showed that 29% were resistant to penicillins and 12% were resistant to both pencillins and TMP-SMX. Resistance to penicillins and TMP-SMX, as well as at least 1 antibiotic drug class, was noted in 7% of MDR uropathogenic E coli isolates. Overall, 19% of MDR uropathogenic E coli isolates were resistant to 1 antibiotic drug class, and 17%, 8%, and 4% were resistant to 2, 3, and 4 antibiotic drug classes, respectively.

The most commonly prescribed antibiotics in the 12 months prior to diagnosis of uncomplicated UTI included first-generation cephalosporins (34%), penicillins (20%), and fluroquinolones (19%). Of note, increases in prescriptions for first-generation cephalosporins (30% to 46%), nitrofurantoin (11% to 27%), and third-generation cephalosporins (5% to 9%) were observed between 2016 and 2021.

The trends in AMR observed in this analysis were consistent over time and by care setting.

Study limitations include the lack of data on dosing and duration of antibiotic therapy, the use of lower than usual laboratory thresholds to indicate culture positivity, and the potential inclusion of some patients with asymptomatic bacteriuria.

“Virtual healthcare may expand access to UTI care, without increased risk of multi-drug resistance,” the researchers noted. “Ongoing surveillance of local microbial prevalence and resistance patterns are needed to further guide appropriate prescribing for UTI empiric therapy,” the researchers concluded.

Disclosures: Multiple authors declared affiliations with pharmaceutical, biotech, and/or device companies. Please see the original reference for a full list of disclosures.

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Investigators conducted a single-blinded, multicenter, randomized controlled trial (ClinicalTrials.gov Identifier: NCT03496896) to assess the effects of a transitional care intervention for higher-risk medical patients using a composite outcome of 30-day unplanned readmission or death.

Patients with an increased risk for unplanned readmissions and discharged from 4 hospitals in Switzerland from April 2018 to January 2020 were randomly assigned in a 1:1 ratio to receive a standardized multimodal care transition from a trained team of discharge nurses or usual care. The data were analyzed from April to September 2022.

Adult patients (aged ≥18 years) were eligible if their hospital stay was 1 day or longer, they had a higher risk of readmission (simplified HOSPITAL score ≥4 points), and they were scheduled to be discharged home or to a nursing home.

The intervention group included a predischarge component that involved identification of medication discrepancies in admission and discharge lists, a 15-minute patient education session about the patient’s main diseases with use of teach-back to confirm their understanding, and planning for the first postdischarge follow-up visit with their primary care physician within 7 days of discharge. The group also received educational materials. The control group received usual care from their managing hospitalist and a 1-page study information sheet.

The primary composite outcome was the number of patients who were discharged alive with an unplanned readmission or died from any cause within 30 days of discharge.

A total of 1386 participants (mean age, 72 [SD, 14] years; 51% men) were included in the primary analysis, 692 in the intervention group and 694 in the control group.

For the intervention group, the primary outcome occurred in 145 patients (21%; 95% CI, 18%-24%) compared with 134 patients (19%; 95% CI, 17%-22%; P =.44) in the control group. A secondary analysis of the per-protocol data confirmed the results. For the intention-to-treat analysis, the risk difference was 1.7% (95% CI, -2.5% to 5.9%; P =.44).

A total of 251 unplanned readmissions were recorded, and diagnoses were the same as for the index admissions in 33% of patients. No difference was observed between treatment groups for risk for unplanned readmissions without death, although strata-specific analyses demonstrated the same heterogeneity that occurred with the primary outcome.

In the intervention group, 32 patients died compared with 18 (P =.04) in the control group. The difference in mortality without unplanned readmission was not statistically significant, and no differences were found regarding health care use, patient satisfaction, or readmission costs in the intervention group.

Among several limitations, outcomes were limited to 30 days, and the participants could not be blinded, which could have resulted in different health behaviors. Also, several intervention components were not fully standardized, and the study may have been underpowered. In addition, the design did not allow assessment of which components worked or did not work.

“Results of this study suggest that the difficulties in preventing hospital readmissions continue, even when using multimodal interventions targeting higher-risk patients,” the researchers wrote.

Disclosure: One of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.

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Specific regulations for artificial intelligence (AI) technologies may be warranted to ensure the confidentiality of patient data. Currently, hospitals may use anonymized patient data or share or sell it to further development of AI, which can pose risks to patient privacy. “AI also makes it easier to re-identify patients from de-identified data that’s been shared by triangulating from different data sources,” according to W. Nicholson Price II, a professor of law at the University of Michigan Law School in Ann Arbor, who specializes in intellectual property, health law, and regulation.

He pointed out that potential risks to patients may not have manifested yet, but could occur as the AI technologies become powerful. Businesses and consumers and others affected by these systems have a right to know if technologies have been adequately vetted and risks have been appropriately mitigated, according to Price.

Health care providers, Price said, need to be careful about how they share and use patient data. “The HIPAA safe harbor [rules] means that sharing de-identified patient data is still probably okay for now from a HIPAA perspective, though that could potentially change,” he said. “We need to have a conversation about how health data are used to develop AI. Right now, it’s too easy to get data for some entities and too hard for others. We’re not getting the balance right, and that needs to change. How we get to a better place, though, is a really tough question.”

Niam Yaraghi, PhD, an assistant professor of business technology at Miami Herbert Business School of the University of Miami in Florida, agrees, saying we are in a new era in terms of policing protected health information (PHI). In principle, AI is a set of statistical methods designed to uncover patterns in data. With recent advances in this area, it is now easier than ever to uncover patterns that we may have not been aware of in the past.

“This could create a major threat to re-identification of anonymized data, especially when such data are merged with other sources of data across multiple platforms,” said Dr Yaraghi, who also is a Senior Fellow at the Brookings Institution’s Center for Technology Innovation in Washington, DC. “Our privacy protection laws, including HIPAA, are outdated and do not have provisions to help protect the privacy of patients in these new situations.”

One of the biggest issues facing physicians is educating their employees and vendors. Many physicians may not realize how their patient data are being used, Dr Yaraghi said. “As AI makes it easier to mine the data, the benefits for the AI users increase, while the privacy risks for the patients also increase. It is a win-lose game between the data miners and the patients,” he said.

Physicians should not underestimate the threat AI technology poses to medicine and the delivery of care, he noted. “They have to be extra vigilant about the possibility of re-identification when it comes to sharing of their data outside their organization,” he said. “They can no longer assume that their older methods of masking the data would still protect the privacy of their patients.”

On April 25, 2023, 4 federal agencies jointly pledged to uphold America’s commitment to the core principles of fairness, equality, and justice as emerging automated systems and AI become increasingly common in peoples’ daily lives. It is impacting not only patient privacy but also civil rights, fair competition, consumer protection, and equal opportunity. The Civil Rights Division of the United States Department of Justice, the Consumer Financial Protection Bureau, the Federal Trade Commission, and the Equal Employment Opportunity Commission released a joint statement outlining a commitment to enforce their respective laws and regulations.

All 4 agencies have previously expressed concerns about potentially harmful uses of AI and resolved to vigorously enforce their collective authorities and to monitor the development and use of automated systems. Now that AI has spread to every corner of the economy, it is paramount that regulators stay ahead of its growth.

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The objective of the program was to promote personalized diet and lifestyle interventions, and it included 3 key components: an adaptive application using patient data to allow tracking their progress, a dashboard that displays data for patients and health coaches, and a remote coaching session in which patients and coaches review data and implement changes.

A retrospective study evaluated the feasibility and effect of the digital care program among patients with autoimmune diseases who participated in the program between 2020 and 2022.

Outcomes were evaluated using the Patient-Reported Outcomes Measurement Information System (PROMIS29) and the PROMIS short form Self-Efficacy for Managing Chronic Conditions-Managing Symptoms (MSx) instrument.

A total of 202 patients were enrolled in the study, with a mean age of 46.2 (SD, 12.2) years; 77.0% were women; 71% were White; and 15% had “long COVID.”

The participants spent an average of 17 weeks in the program and tracked data on 86% of days. The participants logged data 7.6 times per day, for a total of 756 observations per patient. The mean number of completed coaching sessions was 14.

All outcomes changed significantly from baseline. Significant increases to physical function, ability to manage symptoms, cognitive function, and ability to participate in social activities scores (all P <.0001) and decreases to anxiety, depression, fatigue, sleep disturbance, pain interference, and pain intensity scores (all P <.0001) were observed.

Stratified by diagnoses, patients with RA reported significant changes to all outcomes; patients with other autoimmune diseases reported changes to 9 outcomes; patients with psoriatic arthritis and psoriasis reported changes to 8 outcomes; patients with systemic lupus erythematosus reported changes to 7 outcomes; and patients with inflammatory bowel disease, multiple sclerosis, and ankylosing spondylitis reported changes to 4 outcomes. In addition, the subset of patients with “long COVID” reported significant changes to all outcomes, except pain intensity.

Stratified by severity of outcomes at baseline, individuals who started with more severe symptoms reported greater changes in scores during the program.

The most prevalent symptom triggers included excessive or insufficient food intake of specific foods, ingredients, and beverages.

The study authors concluded, “These findings should prompt further investigation into the utility of [personalized] trials to [optimize] the success of non-pharmacological interventions in alleviating symptoms and improving [HRQOL] in patients with [autoimmune diseases].”

Disclosures: This research was supported by Mymee. Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures.

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In a recently released report about the increasing threat of cybercrime, the FBI emphasized that it is crucial for individuals and entities to report cyber incidents to its Internet Crime Complaint Center (IC3), “as that valuable information helps fill in gaps that are crucial to advancing our investigations. Your efforts are critical to our ability to pursue the perpetrators and share intelligence to protect your fellow citizens.”

The IC3 enables the FBI to collect data, identify trends, and pursue threats related to cybercriminal activity.

“Today’s cyber landscape has provided ample opportunities for criminals and adversaries to target U.S. networks, attack our critical infrastructure, hold our money and data for ransom, facilitate large-scale fraud schemes, and threaten our national security,” the 32-page Internet Crime Report 2022 report reads. “At the FBI, we know ‘cyber risk is business risk’ and ‘cyber security is national security.’”

Cybercrime Statistics

As of December 31, 2022, the IC3 had received more than 7 million complaints, according to the report. In 2022 alone, the IC3 received 800,944 complaints. Although this was a 5% decrease from 2021, the potential total dollar loss jumped from $6.9 billion in 2021 to more than $10.2 billion in 2022. California led the nation in the number of cyber victims in 2022 (80,766), followed by Florida (42,792) and Texas (38,661).

“We have seen cyber threats emanate from around the world and witnessed the scope and sophistication of these scams and attacks deepen,” according to the report. “As these threats increase, we continue to encourage victims to report cyber incidents and cyber-enabled frauds to the FBI so that we may impose risks and consequences on malicious cyber actors.”

Freezing of Assets

The FBI’s Recovery Asset Team (RAT), which was established in 2018, streamlines communications with financial institutions and FBI field offices to assist freezing of funds for victims of cybercriminal activity. In 2022, RAT initiated the Financial Fraud Kill Chain (FFKC) on 2,838 Business Email Compromise (BEC) complaints involving domestic-to-domestic transactions with potential losses of over $590 million. A monetary hold was placed on approximately $433 million, which represented a 73% success rate. In 2022, RAT saw a 64% increase in FFKCs initiated compared to 2021.

State Actors Especially Dangerous

Mikhail Gofman, PhD, Director of the Center for Cybersecurity at California State University in Fullerton, said so far this year the number and sophistication of cyber attacks are both on the rise. “Especially dangerous are state actors looking to attack the critical infrastructure, including health care, with ransomware being a popular form of attack against health care organizations,” Dr Gofman said.

He added, “It is critical that all health care organizations implement good security governance where security policies govern all operational aspects of the organization, the policies are enforced, and each employee is trained in their obligations of protecting the organizational security.” 

By quickly reporting cyber attacks, Dr Gofman said, all affected parties can take the proper measures to help limit the negative impacts. Further, he noted that the affected organizations can receive assistance from their vendors, contractors, and federal and state agencies in limiting the impacts of the breach. All these entities can help investigate the cause.

“In addition, reporting one’s incidents will have an overall positive effect on national security by prompting organizations to prepare and take proper measures,” he said. “For example, when a health care organization is a victim of a ransomware attack, reporting the incident can help other health care organizations prepare for and prevent the attack.”

John Pescatore, Director of Emerging Security Trends at SANS Institute, a private US for-profit company specializing in information security and cybersecurity training, said rapidly determining the extent of an attack and notifying impacted customers is critical for businesses and government agencies. “That often results in press coverage, but it is always better to be the one who tells your customer first,” Pescatore said. “Notifying law enforcement or other officials is less important, but often required by regulations.”

Cybercriminals Getting Better

In general, he said, regulatory officials are not going to help health care businesses directly.  However, once regulatory agents have knowledge of the issues they can generate statistics.

“Attackers are continually getting faster in exploiting vulnerabilities and more sophisticated in avoiding detection,” Pescatore said. “In the medical world, it is well known that washing hands and wearing masks is essential hygiene. The same is true in cybersecurity; there are several essential security hygiene practices that make it easier to both evade threats and to quickly detect those attacks that get through.”

He said 90% of successful attacks use phishing emails to steal reusable passwords. “Using multi-factor authentication, as simple as an added text message, thwarts over 90% of those attacks,” Pescatore said.

Noah Jellison, Executive Director for The Risk Institute at Fisher College of Business at The Ohio State University in Columbus, said there are tens of thousands of cyber attacks, if not more, that occur on a daily basis, and the number keeps increasing. “Therefore, it is virtually impossible to report every single cyber attack that occurs,” Jellison said. “In some cases, it could take months or even longer to definitively identify whether a cyber attack had occurred or not.”

Vigilance Is Tough

Cyber attackers can leverage the knowledge of knowing who business partners are, according to Jellison. If an attacker knows that your health organization is doing business with another organization that has potentially less mature cyber security standards and practices than you, then they might directly target and attack that health care organization to get to you. He said it is now much more like a game of chess where you must try and think so many steps ahead of the opponent. “Even staying vigilant becomes an overwhelming endeavor, especially in the health care space and especially with physicians and smaller medical practices, which may not have the resources, funds and/or technical expertise to be vigilant enough,” Jellison said.

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The educational intervention involved videos consisting of 3 modules, which were focused on communication with one’s doctor, understanding clinical trials, and speaking with one’s doctor about clinical trials.

The PACES framework was emphasized in some components of the training videos, which includes the following steps: present information, ask questions, check understanding, express concerns, and state preferences. A link to a reference guide on clinical trial conversations was also provided.

Study participants included patients with a blood cancer, and caregivers, family members, and friends of patients, with recruitment based on The Leukemia and Lymphoma Society constituency database.

Participants completed a pre-survey prior to watching the videos and a post-survey after watching them. Surveys involved a range of topics, such as patient clinical characteristics, perspectives on communication with doctors about CCTs, and others. The Patient Report of Communication Behavior (PRCB) was used for monitoring changes in behavior based on the intervention.

There were 192 participants in the study who completed the intervention and both surveys, including 160 patients and 32 caregivers, family members, or friends. Following the intervention, participants showed an increase in CCT knowledge mean score, compared with pre-survey knowledge (P <.001). On average, 91% knowledge-based questions had correct responses on the post-survey, compared with 81% on the pre-survey.

A metric of readiness to change regarding communication about CCTs involved confidence, perceived importance, and likelihood to communicate; the mean score for this metric was significantly higher on the post-survey than on the pre-survey (P <.0001). Confidence in communicating with doctors also appeared significantly higher on the post-survey than on the pre-survey (P <.0001).

The post-survey mean score on the PRCB also was higher than on the pre-survey (P <.001). The increase in the mean PRCB score was greater among participants who had never had a conversation with a doctor about CCTs before, particularly among those who were at least 65 years of age. Participants identifying as female also showed higher mean scores than those identifying as other genders did in some analyses.

The researchers considered the intervention to be efficacious across multiple evaluated metrics. “This type of training can further equip patients and caregivers with the skills to advocate for themselves effectively, to increase the chance of discussion of clinical trials among all eligible and interested patients,” the researchers wrote in their report.

Disclosures: This research was supported by Gilead and Kite Oncology.

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While there are other important financial and nonfinancial goals, the greatest financial task of your life is to build a nest egg that will allow you to live a comfortable retirement over multiple decades after you no longer can or wish to work. For most physicians, this will require an accumulation period of 10 to 30 years of hard work, methodical saving, and disciplined investing.

The greatest wealth building tool for most physicians is their income. While the average household income in America is around $70,000 per year, according to the 2022 Medscape Physician Compensation Report, the average cardiologist is earning $490,000.¹ While that sort of an income is accompanied by a large tax bill, there is still plenty of money left after taxes to support a robust investing plan. However, the first challenge for any physician interested in a dignified retirement is to carve out a large chunk of that income and designate it for retirement.

Financial independence or retirement is best thought of as a sum of money, rather than an age. The length of your career from the time you leave training until you are financially independent is most dependent on your savings rate. The bad news about retirement is that it requires a large sum of money, approximately 25 times your annual spending.² The good news is that over a traditional full career, a reasonable investing plan will ensure your money (and compound interest) do a lot of the heavy lifting of accumulating that large sum. You only need to save about 20% of your gross income, assuming reasonable investment returns. However, if you wish to retire early, a savings rate of more than 20% of your gross income, perhaps as high as 50% of your gross income, is required. The higher the rate, the earlier the retirement.

It would not be unusual for a cardiologist with a mid to high 6 figure income to have an effective tax rate of 25 to 30% of gross. Add a 20% savings rate to that and it quickly becomes clear that spending more than half of your gross income is a bad idea. Thus, the first challenge for graduating cardiology fellows is to avoid ever growing into their full income. In fact, a short period of time (2-5 years) of “living like a resident” after completing training can really jumpstart the process (as well as pay off student loans).

The government and your employer want to encourage you to save more for retirement. They both provide important benefits to you that can boost your after-tax returns and protect your assets from lawsuits, speeding up the process of accumulating a large nest egg. While anyone can save and invest an unlimited amount in a nonqualified, fully taxable brokerage account, retirement accounts are a better way to save for retirement whenever possible. Accounts such as Roth IRAs, 401(k)s, 403(b)s, 457(b)s, cash balance plans, and solo 401(k)s are commonly used by physicians. Each of these accounts allows for tax-protected growth as well as either an upfront tax deduction (traditional, tax-deferred accounts) or tax-free withdrawals (Roth accounts). These accounts also receive substantial asset protection benefits. That means that if you are in the rare position of facing a malpractice judgment above policy limits that is not reduced on appeal and you are forced to declare bankruptcy, you get to keep your retirement account money.

Employers may also offer matching or profit-sharing contributions. Not contributing enough to obtain the full match is the equivalent of leaving part of your salary on the table. It is critical to understand how each of the accounts available to you works in order to maximize your benefits. For instance, many doctors don’t realize they can still contribute to a Roth IRA each year despite their high income; they just have to do it indirectly via a process known as “The Backdoor Roth IRA.” Physicians are also often surprised to learn that they may be able to use more than 1 401(k) if they have 2 unrelated employers or have some self-employment income.³ Most of the investments in these types of accounts are mutual funds, and the data is clear that it is generally best to use low-cost, broadly-diversified index mutual funds when available.

Some physicians have the time, interest, and funds to seek out nontraditional investments. Real estate is a common choice, whether done actively by directly owning rental properties, or passively through private investments such as funds, Real Estate Investment Trusts (REITs), and syndications. Others find an entrepreneurial itch to scratch and open their own small businesses, which may or may not be related to their practice. These sorts of investments not only help to build a nest egg, but can also provide substantial passive income that can be spent along the way instead.

While it is entirely possible (and recommended) for a physician to become financially knowledgeable and disciplined enough to do this themselves, most physicians will benefit from obtaining professional financial planning advice and investment management services. The key is to obtain good advice at a fair price. While good advice can be difficult to recognize without actually being financially knowledgeable enough to do it yourself, a fair price ranges from $5,000 to $15,000 per year for a “full-service” advisor. It is also possible to pay a flat hourly rate to get occasional advice and do a periodic check-in to ensure you’re on track, essentially blending the do-it-yourself and the professional methods. Naturally, there is no price low enough for bad advice, which is unfortunately the vast majority. Most financial professionals calling themselves financial advisors are actually commissioned salespeople masquerading as advisors. Make sure your advisor is an experienced, fee-only fiduciary with a meaningful designation and commitment to the profession such as a Certified Financial Planner (CFP).

Your hospital or group may also offer resources including education or even formal advice. While you should take advantage of these resources, don’t assume they are competent just because they are associated with the employer or your retirement plan. The same conflicts of interest still exist. Take advantage of free resources. There has never been as much high-quality, free educational financial material on the internet as there is today. Physician financial blogs, email newsletters, podcasts, videos, online courses, books, forums, and conferences are now widely available and can be used to supplement or even replace a traditional financial advisor.

Unfortunately, the date of your retirement may not be entirely in your control. Death, disability, illness, burnout, and family factors can shorten a career or otherwise dramatically impact the ability of a physician to earn. Becoming financially independent provides a doctor the option to retire early, but many financially independent doctors continue to practice on their own terms well beyond that point. Financial freedom has many benefits besides the ability to leave paid work at a time of your choosing.

Was this article relevant to you or your practice? We, at Cardiology Advisor, would like to cover topics that cater to the needs of health care providers in the cardiology field. If you have a moment, please feel free to click the following link to fill out our survey regarding potential future feature topics. Thank you for your time and we look forward to hearing from you!

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The largest clinical workforce in the United States are primary care practitioners (PCPs). As such, integration of addiction services into primary care would be a practical way to increase access to addiction services.

This decision analytical model study was designed to estimate the long-term clinical outcomes and costs of integrating addiction services into primary care. Investigators used a Reducing Infections Related to Drug Use Cost-Effectiveness (REDUCE) microsimulation model to evaluate 3 scenarios: PCPs referring patients who inject opioids to external addiction care (standard care control), PCP services with buprenorphine prescribing and referral to offsite harm reduction kits (BUP), or PCP services with onsite buprenorphine prescribing and harm reduction kits (BUP plus HR). The primary outcomes were mortality from overdose, severe skin and soft tissue infections (SSTIs), and infective endocarditis (IE); costs; and incremental cost-effectiveness ratios (ICERs) of the 3 scenarios.

A total of 2,250,000 (mean age 44 years, 70% men) people in the US who inject opioids were simulated.

The control condition associated with a total of 772,722 deaths of which 11.17% were due to overdose, 5.76% to SSTI, and 38.94% to IE. The BUP scenario associated with 254,927 averted deaths, 517,795 deaths due to overdose (11.18%), SSTI (2.10%), and IE (36.34%). The BUP plus HR scenario associated with 260,822 averted deaths and 511,900 deaths. The proportion of deaths due to overdose (11.18%), SSTI (2.11%), and IE (36.46%) were similar to the BUP scenario.

The overall life expectancies were 70.72, 73.37, and 73.43 years for the control, BUP, and BUP plus HR scenarios, respectively.

The total costs of care per person were $67,192 for hospitalizations and $43,372 for outpatient care in the control condition compared with $65,440 and $104,649 in the BUP scenario and $63,860 and $111,373 in the BUP plus HR scenario, respectively. Overall, the total health care costs were $100,564 for standard care, $170,089 for BUP, and $175,233 for BUP plus HR.

Although more costly than the control condition, the BUP and BUP plus HR scenarios averted 159.8-160.9 overdose deaths per 10,000 people, 395.5-399.4 SSTI deaths per 10,000 people, and 576.5-599.4 IE deaths per 10,000 people.

Overall, considering costs and benefits, the BUP plus HR scenario was most cost-effective, with an ICER of $34,000.

The estimated budgetary impact of the BUP plus HR scenario was $149.00 for attending a 1-time 8-hour buprenorphine waiver training session, $707.20 in opportunity costs for attending the training session, a $5000.00 reduction in revenue from patient visits for a 1-month period to account for the PCP becoming familiar with buprenorphine prescribing, and $7092.00 for purchasing harm reduction and naloxone supplies for 30 patients.

Study authors concluded, “The findings of this decision analytical model suggest that integrating buprenorphine and harm reduction kits in primary care will improve clinical outcomes and modestly increase costs. There is a clinical and cost benefit of adding harm reduction services onsite along with buprenorphine.”

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The COVID-19 pandemic is ushering in a new wave of telemedicine enabling physicians to maintain quality of care without an office visit. Moreover, the widespread use of telemedicine has helped small independent primary care practices (SIPs), which are defined as those with 5 or fewer clinicians. SIPs provide primary care for a substantial proportion of the US population, and SIPs who were early adopters of telemedicine are benefiting significantly.

Up to 42% of smaller clinics switched to telehealth during the height of the pandemic, said Sristi Sharma, MD, a preventive medicine physician at UC Davis in California, who has been tracking telemedicine trends.

“Telehealth practice helped providers in small independent solo practices continue to manage their patients during the pandemic,” Dr Sharma said. Smaller practices were able to adapt quickly to telehealth during this period despite uncertainties about reimbursement and policies during the pandemic.

Solo practitioners are expected to build on their investment in telehealth through improved infrastructure, tools, and training, she said. Telehealth waivers granted by the state and federal agencies have been extended and are being reevaluated for the long-term, Dr Sharma said. In addition, there are significant federal investments being made to improve the broadband capacity in the country via the 2022 Infrastructure Investment and Jobs Act. “All of these are synergistically going to assist the solo practitioners to maintain and expand telehealth services to provide care for their patients,” Dr Sharma said.

The rapid transition from in-person care to telemedicine visits at the start of the COVID‑19 pandemic did not adversely affect the quality of care and even improved some aspects of it. Further, telemedicine may help reverse trends over the past 30 years showing a decline in the number of SIPs. Government mandates and advanced alternative payment models have been difficult for SIPS, who have limited resources for implementing the systems changes necessary to meet current quality standards.

Telemedicine Evolving, Improving

During the COVID-19 pandemic, routine blood pressure assessments decreased because of global disruptions to medical care delivery. Telemedicine successfully filled that gap. “I anticipate that the practice of medicine will continue to include widespread use of telehealth in the future, especially for ambulatory care,” Dr Sharma said. “Apart from patient and provider preference, there are other factors. They include supportive state and federal requirements, focus on improving telehealth infrastructure, and continuous innovation in the field that will ensure that telehealth is the future of medicine.”

A new study has found that a remote hypertension program successfully supported patients through the pandemic in achieving their blood pressure goals. The study, published in the Journal of the American Heart Association, demonstrated the potential for remote programs to provide more effective and equitable care for hypertension, as well as other chronic conditions. The program provided care when patients needed it most, and the program demonstrated the efficacy of a team-based approach through an entirely remote management system, according to the researchers.

The study included 1,256 participants with 605 enrolled in the program during the 6 months before the March 2020 pandemic shutdown and another 651 were enrolled during the 6 months after March 2020. Patients received a digitally connected home blood pressure monitor, which enabled them to collect a more complete and accurate set of measurements than those obtained in an office visit.

An evidence-based clinical algorithm analyzed home blood pressure recordings and guided pharmacological decision-making. It included a team approach with trained patient navigators, pharmacists, and supervising physicians working together to implement a therapeutic strategy with each patient. The rates of achieving goal blood pressure improved to 94.6% during the pandemic compared with 75.8% pre-pandemic. “Telehealth has the potential to make health care equitable and accessible to almost 90% of US adults, including those in the medically underserved communities, owing to their use of smartphones,” Dr Sharma said.

The pandemic has offered all practices, large and small, an enormous opportunity in the form of telehealth. Both patients and physicians like the format, said John Machata, MD, a board-certified family physician in Wickford, Rhode Island, who has been in practice for 39 years (12 years as an SIP) and is retiring as of April 1, 2023. He said independent solo practices continue to be gobbled up by large groups, which are usually operated by hospital networks. While telemedicine may help SIPs, even greater efforts are needed to protect solo practitioners.

“Patients deserve choices,” Dr Machata said. “Do we want patients’ only choice to be cared for by overworked doctors seeing as many patients per hour as possible because bean-counter bosses treat medical care like an assembly line? Small practices offer patients the ability to receive personal care at a relaxed pace.”

Both business skills and telemedicine have not been high priorities for medical school training programs. Unless this changes, overall care could be negatively impact, Dr Machata said. “Given that two-thirds of graduates are employed after their education, the incentive to teach business skills continues to fade,” he said. “Medical schools seem content to permit insurance companies and bean counters to control the business side of medicine.”

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This long-term follow-up study was conducted between July 18 and June 2022 among HCWs employed at a nephrology department in Europe. Researchers assessed the effects of 2 feedback interventions for hand hygiene adherence on preventing hospital-acquired bloodstream infections (HABSIs) and hospital-acquired urinary tract infections (HAUTIs). Data on HAI incidence were collected 2 years before (control period) and 2 years after implementation of an electronic hand hygiene monitoring system. Differences in infection incidence between the 2 periods were evaluated via log-rank testing. Data compiled from the monitoring system were provided to HCWs in both individual and group sessions.

There were 181 HCWs included in the analysis, of whom 142 were caregivers and 39 were physicians. Baseline hand hygiene adherence rates were higher among caregivers vs physicians (40% vs 22%; P <.001), though increased rates were observed among both groups when feedback on hand hygiene was provided in group sessions.

The researchers found that feedback received in group sessions resulted in the highest increase in hand hygiene adherence rates among HCWs with low to moderately-low baseline adherence rates. However, feedback provided in individual sessions among the same group of HCWs was associated with lowest improvement in hand hygiene rates.

In regard to incident HABSI diagnoses, rates were significantly reduced in the intervention period (4 per 10,000 patient-days; 95% CI, 2-11) compared with the control period (14 per 10,000 patient days; 95% CI, 9-21). However, the rate of HAUTI diagnoses did not significantly differ between the intervention (35 per 10,000 patient days; 95% CI, 22-42) and control (36 per 10,000 patient-days; 95% CI, 28-47) periods.

“[W]e found that the overall HHC [hand hygiene compliance] improvements on ward level were driven by a collective effort and not by a few high performers,” the researchers noted.

Limitations of this study include the small sample size, the observational design, and potentially insufficient data. In addition, hand hygiene was not monitored outside designated zones within the hospital.

According to the researchers “This study is important because it helps us understand the patterns of individual HHC in response to interventions.”

Disclosure: Some authors declared affiliations with industry. Please see the reference for a full list of disclosures.

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Historically, greater calorie and protein deficits among patients in the ICU have been associated with higher risks of prolonged mechanical ventilation, long ICU stays, and mortality. Recently, however, standard targets for ICU calorie and protein intake have been challenged. Researchers therefore sought to compare the effects of low-calorie, low-protein feeding with standard-calorie, standard-protein feeding during the acute phase of critical illness in the NUTRIREA-3 trial (ClinicalTrials.gov Identifier: NCT03573739)

Primary outcomes were time to ICU discharge and 90-day all-cause mortality. Secondary outcomes included secondary infections, liver dysfunction, and gastrointestinal events.

The parallel-group, open-label, controlled, randomized study was conducted in 61 ICUs in France from July 2018 through early December 2020. The trial involved 3036 adults receiving invasive mechanical ventilation and vasopressor support for shock (adrenaline, dobutamine, or noradrenaline) who were randomly assigned to receive early nutrition (within 24 hours of intubation) during their first 7 days in ICU with either low or standard calorie and protein targets (low group: 6 kcal/kg per day and 0.2-0.4 g/kg per day protein; standard group: 25 kcal/kg per day and 1.0-1.3 g/kg per day protein).

The low calorie/protein group included 1521 patients (33.6% women; mean age, 66 years); the standard calorie/protein group included 1515 patients (32.3% women; mean age, 66 years). Almost 70% of patients in each group had no fatal underlying disease and more than 25% were expected to die within 5 years, with the balance expected to survive less than 1 year according to patients’ McCabe scores. More than 70% had a pre-existing illness at ICU admission including more than 9% with malnutrition. Other baseline characteristics were similar between groups.

Protocol adherence was high, with daily calorie and protein intakes near target levels in both groups, and nearly 60% of patients in each group receiving enteral feeding only. There was no between-group difference in cumulative incidence of hypoglycemia, blood concentrations of potassium and magnesium, or in serum C-reactive protein.

The researchers found no statistically significant between-group difference in mortality. Notably, 41.3% of patients in the low group and 42.8% of patients in the standard group died by day 90 (absolute difference, -1.5%; 95% CI, -5.0 to 2.0; P =.41).

There was a significant between-group difference in time to discharge. Median time to readiness for ICU discharge in the low group was 8.0 days (interquartile range [IQR], 5.0-14.0) and 9.0 days in the standard group (IQR, 5.0-17.0) (hazard ratio [HR], 1.12; 95% CI, 1.02-1.22; P =.015).

No statistically significant between-group difference was found in the proportions of patients with secondary infections (HR, 0.85; 95% CI, 0.71-1.01; P =.06). The low group had statistically significant lower proportions of patients with liver dysfunction (HR, 0.92; 95% CI, 0.86-0.99; P =.032), bowel ischemia (HR, 0.50; 95% CI, 0.26-0.95; P =.030), diarrhea (HR, 0.83; 95% CI, 0.73-0.94; P =.004), and vomiting (HR, 0.77; 95% CI, 0.67-0.89; P <.001).

Study limitations include the lack of accounting for variation in the duration of the acute phase of critical illness and the lack of adjustment for multiple outcomes in final analysis.

“Day 90 all-cause mortality did not differ between low versus standard calorie and protein intakes during the acute phase of critical illness requiring invasive mechanical ventilation and vasoactive support,” researchers concluded. “Compared with patients receiving standard calorie and protein intakes, those receiving low intakes had a shorter time to readiness for ICU discharge analyzed with death as a competing event.”

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This retrospective analysis was conducted at a tertiary hospital in South Korea between January 2012 and December 2021. The primary objective was to monitor the incidence of occupational blood exposures and post-exposure prophylaxis and follow-up care completion rates among HCWs. All exposure related to needlestick injuries, percutaneous injuries from sharps, and mucosal exposures to blood were included in the analysis. Descriptive statistics and chi-square testing were used to analyze the data.

A total of 1086 occupational blood exposures were analyzed among HCWs (mean age, 32 years), with more exposures reported by women (71.8%) than men (28.2%). Further analysis of exposures showed most were caused by needlestick injury (88.5%). Exposure rates were highest among nurses (44.6%), followed by interns (14.4%), custodial staff (12.2%), and residents (11.7%).

For the 1086 exposed HCWs, 633 (58.3%) did and 453 (42.7%) did not require PEP. A total of 444 (70.1%) exposed HCWs completed follow-up care, none of whom seroconverted to hepatitis B virus, hepatitis C virus, HIV, or syphilis. Rates of PEP completion were found to significantly differ by gender (P =.024), occupation (P <.001), and exposure frequency (P <.001).

Among the 189 exposed HCWs who did not complete follow-up care, 99 were exposed to an unknown infection source or Hepatitis C virus. The most commonly reported reasons for follow-up care discontinuation were unknown/unclear (79.9%) and resignation from the health care facility (20.1%).

The mean incidence of occupational blood exposure was 7.82 per 100 beds and 3.0 per 100 HCWs.

Limitations of this study include the possibility that some exposures may not have been reported.

According to the researchers, “[T]here is a need to establish a national surveillance system for collecting information regarding the types, frequency, situational data, and follow-up care pertinent to OBEs among HCWs, which could then inform the development of intervention strategies.”

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Lucy Skinner, from Geisel School of Medicine at Dartmouth in Hanover, New Hampshire, and colleagues investigated differences in earnings and hours worked for male and female physicians at various ages and family status. Analysis included responses from 95,435 physicians aged 25 to 64 years participating in the American Community Survey from 2005 to 2019.

The researchers found that compared to male physicians, female physicians were more likely to be single (18.8 versus 11.2 percent) and less likely to have children (53.3 versus 58.2 percent). With age, male-female earnings gaps grew, and were approximately $1.6 million for single physicians, $2.5 million for married physicians without children, and $3.1 million for physicians with children, when totaled from age 25 to 64 years. However, gaps in earnings per hour did not vary by family structure, with male physicians earning between 21.4 and 23.9 percent more per hour than female physicians. For hours worked, the male-female gap was 0.6 percent for single physicians, 7.0 percent for married physicians without children, and 17.5 percent for physicians with children.

“Addressing the barriers that lead to women working fewer hours could contribute to a reduction in the male-female earnings gap while helping to expand the effective physician workforce,” the authors write.

Abstract/Full Text

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When choosing where to set up a practice, physicians must consider much more than average malpractice insurance rates and Geographic Practice Cost Indices (GPCI). Every year, several lists are published picking the top states in which to practice medicine. Malpractice insurance premiums vary significantly between states. What is best for one clinician might not be quite as important for another, however, especially at different stages of their career.

“When comparing factors like annual physician pay, pay growth potential, cost of living, affordability, and access to recreation and entertainment, some cities score dramatically higher than others,” said Christopher R. Friese, PhD, RN, Health Management & Policy Director at the Center for Improving Patient and Population Health at the University of Michigan in Ann Arbor, Michigan.

Recently, WalletHub compared the 50 states and the District of Columbia across 19 key metrics. The data, which were released in March, included the average annual wage for physicians, hospitals per capita, and the quality of the public hospital system. The top 5 states were South Dakota, Minnesota, Wisconsin, Montana, and Idaho. There may be other factors, however, that are not included in these lists of best cities in which to practice medicine.

Support Staff Considerations

While contentious in some circles, Dr Friese said there are major advantages in the states that allow full scope of practice for advanced practice nurses and physician assistants because clinicians can focus on new and complex patients and allow the team to provide all the services needed. Physicians interviewing for positions should ask about the staffing model in the practice. Dr Friese said it is important to look at how many nurses and how many medical and nursing assistants are part of the practice. Has the level of supportive staffing been the same for a steady period of time?

If not adequately staffed by a supportive team, the workloads will be significantly higher, he said. An important factor is the percentile of nurse staffing levels compared with benchmark facilities. “For physicians exploring new opportunities, consider your surroundings and what kind of team will be available to support you in delivering the best care for your patients and reducing the likelihood of burnout,” Dr Friese said.

Michael French, MA, practitioner in residence at the University of New Haven’s School of Health Sciences in West Haven, Connecticut, applies philosophical methods for understanding the experiential aspects of mental illness, ethical issues in treatment, and uses of technology and data in healthcare. He said the first criteria should be what is best for the clinician’s family and themselves. “Burnout is prevalent among physicians, and keeping yourself and your family in an area where you can thrive will aid you in keeping your health in order,” French said. “The second criteria I would recommend is that you look for states where you align with the state’s medical politics.”

Medical politics have come to forefront in the last 3 years and some fields of medicine are being highly impacted, French said. Medical politics are playing a major role in areas of reproductive health, with scores of new abortion laws and other restrictions. French said some states and cities were much more politically influenced when it came to mask wearing and other actions required during the COVID-19 pandemic.

If a physician is starting their own practice, he recommends carefully considering whether they are ready for the business management and the accounting departments required. Overall, private practices have been decreasing, with 2021 being the first year the American Medical Association (AMA) recording more doctors working outside of private practice than within. The AMA’s most recent survey showed that 70% of doctors under the age of 40 are working for someone else.

Expansion of Hospital Networks

The economic expansion of hospital networks mirrors the process that has occurred in the corporate world, according to French. Large companies are expanding to include private practices in their network as well as buying other hospitals to include in their systems. “To run a practice within the network of a hospital can be a useful addition for some, as doing so can make many processes more convenient, but for those who want to run their own practice without potential interference, it may be unwelcomed,” French said. “I believe that it can be a great time to run a medical practice, but it is a far different time to run one than it was even a decade ago.”  

Provider Shortage

Jonathan Henderson, MD, immediate past president of LUGPA, an organization that represents urologists in large independent practices, said establishing an independent practice today is more difficult than ever before in the modern era. The reasons are many and apply to all settings, including independent practice, hospital employment, and academic settings. “The patient backlog from 2 years of the pandemic is daunting, and the shortage of providers is more critical than ever and heightens daily,” Dr Henderson said. “There is a national labor shortage, and supply chain disruptions continue to be compounded in unexpected ways.” 

Ron Holder, Chief Operating Officer of the Medical Group Management Association, said currently licensed vocational or licensed practical nurses are being recruited away from practices by health care and nonhealth care organizations. That needs to be considered when looking at different cities to establish a medical practice.

“Retail and restaurants alike are offering starting pay in excess of what some practices pay for front desk, back office, or clinical support staff,” Holder said. “Urology practices have an additional competitive hurdle on top of that. Whereas many practices rely on medical assistants and licensed vocational nurses, urology practices tend to have a greater need for registered nurses due to the procedures and other duties that require a higher level of licensure.”

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Researchers sought to evaluate the effectiveness of simulation-based teaching vs traditional teaching of TEE in improving the knowledge and skills of cardiology fellows.

Researchers conducted a multicenter, parallel-group, randomized study (SIMULATOR; ClinicalTrials.gov Identifier: NCT05564507) that enrolled consecutive cardiology fellows (year 1-4) from 42 centers in France between November 2020 and 2021.

The primary study endpoints were the differences in scores in the final practical and theoretical tests 3 months after training.

Self-assessment of proficiency and TEE duration were also evaluated.

Of a total of 375 cardiology fellows, 324 (62.6% women; mean age, 26.4 years) were randomly assigned 1:1 into the simulation group (n=162) or the traditional group (n=162). Researchers noted that 20% of all participants had previously observed more than 20 TEEs.

Researchers found baseline test scores before training were similar between the 2 groups. Higher theoretical and practical test scores were achieved in the simulation vs traditional group after the training (47.2% [SD, 15.6%] vs 38.3% [SD, 19.8%]; P <.001) and (74.5% [SD, 17.7%] vs 59.0% [SD, 25.1%]; P <.001), respectively.

The 2 groups were comparable in TEE duration before training. However, the duration to perform a complete TEE was significantly lower in the simulation vs traditional group after training (8.3 [SD, 1.4] vs 9.4 [SD, 1.2] minutes; P <.001). .

Self-confidence in performing a TEE after training was higher in the simulation vs traditional group (mean score, 3.3; 95% CI, 3.1-3.5 vs 2.4; 95% CI, 2.1-2.6; P <.001).

Effectiveness of the simulation training was greater among fellows with 2 years or less of training vs those with more than 2 years of training (theoretical test: increase of 11.9 points; [95% CI, 7.2-16.7 points] vs increase of 4.25 points; [95% CI, -1.05 to 9.5 points]; P =.03; practical test: increase of 24.9 points; [95% CI, 18.5-31.0 points] vs increase of 10.1 points; [95% CI, 3.9-16.0 points]; P =.001).

Study limitations included that cardiology fellows in the simulation group may have manipulated the TEE probe during training sessions; the traditional group may have received more online training than the simulation group; and the lack of data on the number of TEEs performed by the fellows in both groups during the study period.

Researchers acknowledged the 2-hour training sessions were not sufficient to achieve expert level in TEE and the final results of the simulation group were moderate (47 of 100 points in theoretical and 74 of 100 points in practical).

They added, “These results also highlight the difference between improving TEE skills and becoming autonomous in performing a TEE alone.”

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.

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The federal Office for Civil Rights (OCR) is warning physicians about privacy requirements when using online tracking technologies.

In December 2022, OCR issued a bulletin to highlight obligations related to regulated entities under HIPAA when using online tracking technologies such as Google Analytics or Meta Pixel. This is the first time a specific alert has been issued to physicians over the use of technology platforms.

The bulletin addresses potential impermissible disclosures of ePHI by HIPAA regulated entities to online technology tracking vendors. It suggests steps that regulated entities should take to protect ePHI when using tracking technologies.

“We are in for quite a few changes in the coming months with a number of updates,” said Katina Michael, PhD, the director of the Society Policy Engineering Collective at Arizona State University in Tempe. “We always note that technology moves far ahead of regulation, and this can be said particularly for health-related innovations.”

These technologies collect and analyze information about how to interact with a regulated entity’s website or mobile application. Some regulated entities regularly share electronic protected health information (ePHI) with online tracking technology vendors. Some may be doing so in a way that violates HIPAA rules by causing impermissible disclosures of ePHI to tracking technology vendors.

Text-based medicine is gaining significant momentum, a trend fueled by the ongoing COVID-19 pandemic. “People are more willing to entertain the idea of gaining access to a medical professional ‘on demand’,” Dr Michael said. “One of the major changes being witnessed is how to book a doctor or dentist or optometrist in your medical insurer’s network. On top of scheduling apps, we now have the ability to receive phone consultations, especially if we have COVID-like symptoms and need treatment.”

Text-based medicine allows greater access to care options, Dr Michael said. Patients can consult with clinicians over their smartphones, an attractive feature for individuals who do not want to or cannot travel for an in-person visit.

There is a growing concern about new laws that may hamper this trend in medicine. Physicians can answer general questions, and even a transcript of the conversation can be retained for follow-up. “This might be a great method for chronic sufferers and this kind of patient-physician exchange can provide for transparency and accountability. However, privacy issues are fraught. Increasingly we have seen data breaches of not just medical offices, but also major health insurers,” Dr Michael said.

A data breach can allow a cybercriminal the ability to gain access to transcripts of text-based correspondence between a physician and a patient. The data could become available on the dark web. The breach could involve a patient who is a pilot dealing with anxiety or a female physician experiencing postnatal depression but still wishes to practice. “The range of scenarios is endless,” Dr Michael said. “The question becomes, is one’s right to privacy guaranteed through this kind of medical service offering? The answer is no, it cannot be.”

“HIPAA governs how your data are used by providers and health insurers, but does not govern what individuals do with their data,” said Kevin Schulman, MD, Professor of Medicine at the Clinical Excellence Research Center at Stanford University, Palo Alto, California. “To me, the issue is not laws but consumer awareness that they can now determine whom to share their data with, and should be sure that their apps and services are trusted vendors.” For example, sharing personal medical histories and posting medical charts online is common, but consumers may not fully understand their personal implications of these postings.

That said, HIPAA is intended to protect patients from the misuse of their data by provider organizations. “Providers selling our data for advertising, directly or indirectly through trackers is exactly what HIPAA was intended to prohibit,” Dr Schulman said.

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Marie Loiselle, Ph.D., from Maharishi International University in Fairfield, Iowa, and colleagues studied the effects of the TM technique on academic physician burnout and depression. The analysis included 40 academic physicians (15 specialties) at a medical school and affiliated Veterans Affairs hospital, randomly assigned to TM or a control group. Researchers measured physicians on the Maslach Burnout Inventory, Beck Depression Inventory, Insomnia Severity Index, Perceived Stress Scale, and Brief Resilience Scale at baseline, one month, and four months. Qualitative interviews were also conducted at baseline and four months.

The authors observed significant improvements in the TM group versus controls at four months for total burnout, including the Maslach Burnout Inventory dimensions of emotional exhaustion, personal accomplishment, and depression. Findings from qualitative interviews supported quantitative outcomes, with those physicians regularly practicing the TM technique reporting relief from classic burnout and depression symptoms reported at baseline. The control group did not show similar changes.

“Larger longitudinal studies with a wider range of health care providers are needed to validate these findings for extrapolation to the greater medical community,” the authors write.

Abstract/Full Text (subscription or payment may be required)

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The daily demands of practicing medicine can amount to “’an ongoing assault,’” noted  a 2022 article published by the American Medical Association.¹

Physician burnout and the number of physicians intending to leave their jobs — already at high levels before the COVID-19 pandemic — has increased in the pandemic’s wake. A survey of more than 20,000 US physicians and advanced practice clinicians found that burnout increased from 45% in 2019 to 60% in late 2021, and that intent to leave medicine increased from 24% to more than 40% during the same period.² Forbes has reported that by 2025, 47% of all health care professionals will have left the profession,³ while the Association of American Medical Colleges predicts a potential shortage of up to 48,000 primary care physicians and 77,100 specialists in the US by 2034.⁴

Fueling these projected mass retirements and physician shortages is “a broken health care system” that stresses quantity of patients seen over the quality of care provided, which has created “a lack of self-worth” among many physicians, said Robyn Tiger, MD, DipABLM. Dr Tiger, a radiologist who practiced medicine for 15 years before moving into lifestyle medicine, is the founder of StressFreeMD, which offers the CME-accredited course, Rx Inner Peace: A Physician’s Guide for Self-Care.

“With physician stress, anxiety, depression, and burnout on the rise, and having personally lost 3 medical colleagues to suicide, I am deeply passionate about sharing what I have learned with as many physicians as I can,” said Dr Tiger, who began working with physicians and others on stress relief and self-care after overcoming her own stress-related illnesses. She now serves as a subject matter expert in stress management for the American College of Lifestyle Medicine, in addition to serving on the Wellness and Resilience Committee of the North Carolina Medical Society and with the Healthy Healer Program of the Western Carolina Medical Society.

In the following indepth interview, Dr Tiger discusses the impact of burnout and stress on clinicians and what can be done to address this problem.

What kinds of issues do you see among the physicians you work with?

They are exhausted emotionally and physically, they lack self-worth, and they’re not sure what the meaning of their own life is anymore. They are even concerned that they made a wrong choice in going into medicine. Burnout is described as 3 components: emotional exhaustion, cynicism, and lack of self-worth. Physicians are describing all of that and more. They are anxious, reactive, and saying and doing things they wish they could take back. They feel unfulfilled, many report low libido — I hear that a lot. It’s also affecting their family life — their kids don’t want to be around them, and many are on the brink of or getting divorced. It’s disrupting everything, and it’s extremely hard.

There are those who say that physician burnout is a systemic problem that can’t be addressed simply through self-care.⁵ What are your thoughts about that?

There are 2 important components here: First, the health care system needs to change. I know that some major organizations and even our government is working to do that….[through] a national agenda for physician well-being.⁶ Beyond that, clinicians, as humans, need to be educated on how to be the healthiest version of themselves, so they don’t get sick from chronic stress, and so they can take care of other people and live the life they deserve to live.

I’m not at the level where I can make changes nationally throughout the health care system, I’m coming from the side of how we can educate the human. I created a CME-accredited program called Rx Inner Peace, [which is supported by] 10 pages of referenced literature. The program is not just telling you to “go do yoga”; it’s teaching you what you need to learn to become the healthiest version of yourself, so that you can prevent or reverse disease.

What led you to transition from practicing medicine to working with burned-out physicians?

Dr Tiger: Several years in[to my medical practice], I found myself developing lots of illnesses and symptoms that I couldn’t really put together. They seemed very disconnected, and they didn’t all happen at one time. I had things like really bad vertigo,… tinnitus, difficulty sleeping, and bleeding gums. I also had really bad reflux, horrible chest pain, and migraine headaches with really violent vomiting.

I developed pain in my body — my joints, muscles, you name it. Every day I just felt like I couldn’t move, like I was like trapped in this tense body. No trauma, just pain. I had paresthesia that would develop at the most inopportune times in my hands, feet, and back. I’d be doing a breast biopsy and couldn’t feel the biopsy gun in my hand.

I went to gastroenterologists, and they put me on pills. I went to a neurologist, and they put me on pills. I went to the periodontist, and they were injecting antibiotics into my gums. I took so much medication and had lots of imaging studies. Being a radiologist, I was getting everything imaged and the results were all negative. All of my blood tests were negative too, and nobody could figure out was the matter with me. Every doctor saw me as a symptom that they gave a pill to. I also went to a physical therapist, and I saw a physiatrist for all the pain. Nobody could figure it out.

The suffering was just so intense that I just didn’t want to feel it anymore, and I had lost 3 physician friends to suicide…2 of them overdosed and 1 jumped off a bridge. I didn’t want that to happen to me. My own family and friends didn’t know completely what was going on with me because I kept it all inside. I did see a mental health care professional, and it really didn’t help.

That’s when I decided I could either go down the path I’m on and end up like those colleagues, or I could try and figure out if I could make myself better. I kept hearing more and more about things like yoga and meditation, and I thought they were weird. Even so, I went to a yoga class after working an entire day, totally exhausted and having all kinds of preconceived notions, and at the end of the first session, I felt calm, grounded, and clear, and I was awake — I wasn’t even tired anymore. That was my first “aha” moment.

My left brain wanted to unpack the physiology as to what led to this 180-degree shift so quickly, so I kept going to the classes to learn more. I decided to go into yoga teacher training to learn more. As I continued with classes and teacher training, the symptoms I described started to get better. Then I learned about the field of yoga therapy, [where] I could take the principles I learned in yoga and study them more deeply to help people with many types of symptoms and illnesses and diseases. Through that training and continuing with yoga therapy, all my symptoms went away 100%. I went on to become certified in meditation and life coaching. I’m also certified through iRest, a specific type of meditation that was originally created for Walter Reed Army Hospital to help our military relieve their suffering from post-traumatic stress disorder.

I realized that the diagnosis that nobody made was that I was suffering from chronic stress. When I learned how to relieve that stress and work with my own physiology and mind, I was able to relieve what I was experiencing, which is in the spectrum of what we may call burnout now.

How long have you been working with other physicians on stress and burnout relief, and what kind of results have you seen?

I stopped practicing medicine in 2012 and have been in this space for a decade now. I had been working with several populations — people with cancer, first responders, military veterans, health care professionals, and anyone else who wanted help. Then, in 2020 when the pandemic hit, I decided that I needed to help my colleagues [and] pivoted to focus my attention specifically on physicians. I don’t know exactly how many I’ve worked with, but it’s in the thousands.

The results have been pretty amazing. Physicians say things like, “I’m sleeping well for the first time in decades,” and “My body no longer feels like the tin man.” I’ve had them say to me, “Because of you, my marriage was saved,” and “I found joy in medicine again because of you,” and “My kids want to spend time with me again.”

I basically teach what we were never taught in medical school, which is how to regulate your nervous system and how to work with your thoughts; for me, it’s a 2-part, mind-body approach. My job really is to help [physicians] help themselves. I give them the education and they’re the ones experiencing the transformation.

Is there any evidence to support the efficacy of this approach to dealing with stress and burnout?   

There’s lots of literature out there. That’s actually how I got into yoga therapy to begin with, because when I started to feel better, I dove into the medical literature to find out why. I was surprised to find so many articles published in our own medical literature about the benefits and changes that disciplines such as yoga therapy and meditation can create for many types of symptoms and illnesses and diseases.^7-9

There also have been randomized clinical trials on coaching and lots of literature on the topic. For example, Cleveland Clinic recently reported they saved $133 million dollars in retention [through a peer-based coaching and mentoring program promoting clinician well-being], because with every physician that leaves, it costs the medical system as much as a million dollars.^10,11

Is there anything else physicians should be aware of in dealing with stress and burnout?

I would like physicians to know that they’re not alone if they’re feeling anything or everything that I described. It’s not okay, but it’s normal.

Also, if someone is having any type of suicidal thoughts, please seek help. To reach the 988 Suicide & Crisis Lifeline, they can call or text 988 or chat 988lifeline.org. [This was formerly the National Suicide Prevention Lifeline.] There is also a phone number (1-888-409-0141), a hotline for physician-to-physician mental health help that doctors and medical students can call and speak to another doctor. There are no notes and nothing is kept where they have to be concerned that their mental health issues could be recorded and held against them.

If you or someone you know is struggling or in crisis, help is available. Call or text 988 or chat 988lifeline.org

Resources

• 988 Suicide & Crisis Lifeline | SAMHSA
• Preventing physician suicide | American Medical Association
• Suicide Prevention and Emergency Help | AAFP
• Physician Support Line and their resource list: Physicians Who Need Help
• AMA Steps Forward: Transform your Practice

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Researchers conducted a retrospective study among patients hospitalized at a single center to determine rates of nosocomial COVID-19 transmission following potential exposure events. The risk for nosocomial COVID-19 transmission was evaluated during the periods of Alpha (January-March and April-July 2021), Delta (August-October 2021), and Omicron (November 2021-January 2022) predominance. The researchers calculated the secondary attack rate, defined as the number of patients with confirmed infection divided by the number of patients for whom the outcome of a potential exposure event was known. The risk of 30-day mortality was assessed among all exposed patients who tested positive for infection, and mortality rates for variant-specific period of predominance were compared.

Univariable mixed-effects logistic regression was used to determine associations between COVID-19 transmission and index case transmission attribution, hospital location at time of exposure, and date of exposure. Patients with index infection were inpatients with polymerase chain reaction-confirmed infection who were in close proximity to patients considered to be susceptible to infection.

The analysis included a total of 1378 patients (median age, 70 [IQR, 52-81]; 57% men) who were potentially exposed to a patient (n=346; median age, 68 [IQR, 68-81]; 55.0% men) with index infection. Of patients with potential exposure, the majority (94%) were exposed to 1 index case, and 46% were unvaccinated.

Of 1291 exposed patients who were available for SARS-CoV-2 testing, 87 tested positive for infection. Analysis of these patients indicated a secondary attack rate of 15.5% (95% CI, 13.5%-17.5%), and older patients were more likely to test positive compared with younger patients (median age, 76 vs 68 years, respectively; P <.001).

The researchers found exposure risk was significantly associated with hospital location. Compared with patients exposed in admission wards, the risk for COVID-19 transmission was 3.0- (95% CI, 2.9-20.8), 2.8- (95% CI, 1.3-5.9), and 7.8-times (95% CI, 2.9-20.8) higher for those exposed in medical, surgical, and rehabilitation wards, respectively. Patients who developed COVID-19 infection had a median exposure duration of 3 (IQR, 1-6) days, with most testing positive at days 4 (75%) and 5 (80%).

Compared with patients who tested positive for infection between January and March 2021, the risk of mortality was significantly lower among those who tested positive during the period in which the Omicron variant was predominant (odds ratio, 0.32; 95% CI, 0.10-0.92; P =0.04).

Study limitations include the observational design. Moreover, the rate of nosocomial COVID-19 infection may have been underestimated as some patients were not screened following exposure.

According to the researchers, “Ongoing surveillance in hospitals will greatly help track vaccine effectiveness in reducing transmissibility and mortality of patients with nosocomial SARS-CoV-2 infection…”

The post Nosocomial COVID-19 Transmission Often Detected Within 5 Days of Exposure appeared first on The Cardiology Advisor.

Transgender individuals can have complex medical problems, including dermatologic issues. Therefore, dermatologists should identify the specific dermatologic needs and nuances in treatment in this population of patients, as well as discuss these issues using appropriate terminology that puts the patients at ease, the researchers advised.

Transmasculine patients frequently require isotretinoin for severe acne that results from testosterone therapy. The use of teratogenic medications requires additional consideration when treating patients who identify as transgender, as discussions about reproductive potential can enhance gender dysphoria, such as being asked to do a pregnancy test, noted the authors.

Neutral and inclusive terminology is important for creating an environment that is culturally welcoming for all patients. Making assumptions of gender identity, pronoun choice, or sexual identity can adversely affect the clinician-patient relationship. Providers should use patient-centered language, including the patients’ name and chosen pronouns and their terms for their sexual orientation, gender identity, sexual behavior, and anatomy, the researchers recommended.

Clinicians also are advised to have an open discussion with their patients regarding their anatomy and pregnancy potential and current or future sexual practices that could result in pregnancy. Counseling is recommended for pregnancy prevention, which should focus on the patients’ reproductive potential as opposed to their gender assigned at birth.

An organ inventory also is recommended, as it can help clinicians identify patients with reproductive potential and may lead to discussion of the need for regular pregnancy testing and/or contraception. Clinicians have been advised to avoid words such as “breast,” “vagina,” or “penis” and instead use words such as “chest” and “genital”’ to avoid eliciting gender dysphoria. Transmasculine patients who were assigned female at birth and have a functioning uterus and ovaries should still be considered as having reproductive potential, even if they are currently receiving testosterone therapy and are currently amenorrhoeic.

“In essence, the discussion of reproductive potential in transgender patients is a highly sensitive conversation and we would encourage the use of neutral terminology and the use of an organ inventory when discussing contraception and reproductive potential with this patient group,” stated the researchers. “This helps maintain patient rapport while also ensuring pregnancy potential and contraception requirements are adequately discussed with transgender patients.”

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An estimated 60 million people comprising one-fifth of the United States (US) population, reside in areas defined as rural.¹ These individuals face numerous disparities in both health outcomes and health care access compared to those living in urban areas. The prevalence of cardiovascular disease (CVD) is 40% higher among rural vs urban residents, and mortality rates associated with all types of CVD and stroke are also higher in rural areas.^1-3

The availability of specialists, including cardiologists, is especially sparse in the rural US, and researchers have found significant inequities between patients receiving cardiology treatment in rural vs urban hospitals.^4,5 In a retrospective study published in January 2022 in the Journal of the American College of Cardiology, Loccoh et al examined differences in outcomes between Medicare beneficiaries (n=2,182,903) presenting to rural or urban hospitals with acute cardiovascular conditions.⁵

Patients receiving treatment for acute myocardial infarction (AMI) at rural hospitals showed lower rates of cardiac catheterization (49.7% vs 63.6%; P <.001), percutaneous coronary intervention (42.1% vs 45.7%; P <.001), and coronary artery bypass graft (9.0% vs 10.2%; P <.001) compared with those treated at urban hospitals.⁵

Among patients with ischemic stroke, rates of thrombolysis (3.1% vs 10.1%; P <.001) and endovascular therapy (1.8% vs 3.6%; P <.001) were also lower at rural vs urban hospitals.⁵

In addition, 30-day mortality was higher among rural vs urban patients with AMI (HR, 1.10; 95% CI, 1.08-1.12), heart failure (HR, 1.15; 95% CI, 1.13-1.16), and ischemic stroke (HR, 1.20; 95% CI, 1.18-1.22) after adjustment for demographic factors and comorbidities. The most pronounced differences in mortality were observed among patients receiving treatment at critical access hospitals in remote rural areas.⁵ 

Improving cardiology care and outcomes in the rural US will require a range of efforts from various stakeholders. “Governmental or health care systems that incentivize physician practices in these areas are needed – such as programs that pay down student loans and provide loan forgiveness, for example,” Deirdre Mattina, MD, FACC, general cardiologist in the section of regional cardiovascular medicine at the Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute at Cleveland Clinic in Ohio, told Cardiology Advisor.

Additionally, she noted, “Medicaid services are often reimbursed at lower rates than commercial insurance plans, which creates disparities in health care delivery by disincentivizing physicians to offer care to this vulnerable population.”

Along with better reimbursement models and programs that provide benefits to physicians practicing in underserved locations including the rural US, the further integration of telehealth into cardiology practices is needed to provide a “bridge to infrequent in-person care,” Dr Mattina said.⁶

To learn more about these regional disparities in access to cardiology care, we interviewed Laxmi Mehta, MD, clinical professor of internal medicine and section director of preventative cardiology and women’s cardiovascular health at The Ohio State University Wexner Medical Center in Columbus; Sameed Khatana MD, MPH, senior fellow and assistant professor of cardiovascular medicine in the Perelman School of Medicine at the University of Pennsylvania, and staff cardiologist at the Philadelphia VA Medical Center; and Basera Sabharwal, MD, chief cardiology fellow at Mount Sinai Morningside in New York.

What factors are driving the shortage in access to cardiology care in the rural US? 

Dr Mehta: Transportation issues including lack of vehicle access, long travel distances, high costs of transportation, and inadequate infrastructure in transportation means can contribute to poor access to care. Rural hospitals are often designated as critical access hospitals, which are typically smaller and have less capacity for intensive care or rehabilitation services. As rural hospitals continue to close nationwide, access is even more challenging for rural patients. Furthermore, workforce shortages also impact staffing in rural areas and in turn limit access to adequate care. High rates of uninsurance amongst rural populations also result in financial strain and impact access to care.

Dr Khatana: Access to cardiology care, like other types of health care, is determined by many different factors including the supply of health care providers, availability of emergency departments and hospitals, as well as health insurance coverage. The number of physicians in rural areas has been declining for decades. Rural hospitals have also been closing at a greater rate than urban hospitals due to factors such as low reimbursement, staffing shortages, and low patient volume. Additionally, we know that many states with large rural populations in the South and Midwest have not expanded Medicaid health insurance, therefore depriving many rural low-income individuals of health insurance.

Dr Sabharwal: Battling health care disparities between rural and urban areas has been ongoing for over a decade now. In general, life expectancy in urban populations is about 3 to 4 years higher than in rural areas, with some indigenous populations having a life expectancy that is 5 to 6 years lower than people living in urban areas.¹ Multiple factors are responsible for this, including higher rates of common but treatable risk factors such as high blood pressure, diabetes, smoking, and high cholesterol.

Another primary reason for health care disparities is social determinants of health including income, education, employment, housing, distance from a health care center, transportation, food insecurity, and limited or no health insurance. All of these factors, as well as scarcity of primary care providers for screening and treatment of common conditions like high blood pressure, and less favorable mental and behavioral health care availability, lead to an increase CVD and stroke. 

Regarding acute care, distance to a hospital center is extremely important. On average, rural residents live more than 10 miles from a hospital, which is twice as far than those living in urban locations. Moreover, hospitals in rural areas see a lower volume of complex and critical diseases, leading to lack of experience in these areas and thus differential disease outcomes between urban and rural hospitals. This gap becomes even wider for complex CVDs. Health practitioners in urban areas are super-specialized, and the high volumes they deal with lead to improved health metrics of those diseases. On the other hand, care in rural areas is less specialized and practitioners practice more widely.

Data shows that less than 10% of US physicians practice in rural areas, and even fewer have more specialized training.⁷ Health care centers including both clinics and hospitals are finding it tougher to retain specialized physicians in these communities. There’s even a shortage of nurses and support staff in these regions, which adds tremendously to the problem.

What are some of the measures needed to help reduce these gaps? 

Dr Mehta: New models and site of care delivery are essential, including expanding telehealth services and digital technology, as well as training of the entire care team so that community health care workers and other care team members can provide care and expand access for patients. Flexible payment and funding models are necessary to support rural delivery of care. Expanding affordable health care insurance may also be impactful.

Dr Khatana: Shoring up the financial health of rural hospitals so that they can continue to operate is an important step. In Pennsylvania, the state is testing a model called the Pennsylvania Rural Health Model, which will provide hospitals with a “global budget” in which CMS and other participating health insurance payers will pay certain rural hospitals a fixed amount of money to cover all costs of hospital-based care. The goal of this program is to provide more predictable finances to rural hospitals.⁸ 

Additionally, training programs need to be set up in rural areas with a focus on providing for the needs of rural programs. Expanding the scope of practice of advanced practice providers such as nurse practitioners and physician assistants to provide cardiovascular care may also address the issue of the shortage of providers.

Dr Sabharwal: Access to health care has changed in the last few years with the rise in telehealth since the pandemic began. This is extremely important and useful, especially in rural areas where long distance travel for routine care is a barrier. With telehealth, these patients can get regular screening, monitoring, and treatment of diseases including CVDs, and they must travel to specialized centers only when necessary. If we can improve primary prevention of heart disease by treating the risk factors, there will be less heart disease requiring treatment. This requires routine health checks and follow-ups, which can be easily done via telehealth.

Another helpful measure would be to include mandatory rotations in rural outreach centers during residency and fellowship training. This will increase care at those centers with a probable increase in physicians ultimately staying at those practices.⁹

Other measures would be to make rural practices more attractive to physicians at the end of their training, such as through loan forgiveness programs to those willing to work in rural areas, or by combining practices with urban centers wherein physicians agreeing to practice with the majority of their time in rural centers are still able to rotate monthly or every 3 months, for example, through urban centers with exposure to complex diseases.

Churches and other faith-based organizations are cornerstones of rural communities. Collaboration with these organizations for routine health care workshops with cardiologists and other specialists from urban areas would improve care provided in rural populations. Economic development in rural areas as well as improvement in insurance availability for policies like Medicaid would also decrease the health care disparity gap between rural and urban areas.

What are your recommendations for clinicians interested in providing and advocating for increased access to cardiology care in rural areas? 

Dr Mehta: Clinicians should work on expanding their virtual care of patients and be creative in utilizing technology to address health equity. Development of a diverse workforce that incorporates people with differing training will help expand the reach of care for rural patients. Community education is mandatory regarding cardiovascular risk factors, and healthy lifestyle may be beneficial in improving overall cardiovascular health.

The AHA is committed to bringing equitable care to rural communities through its Rural Health Care Outcomes Accelerator, which includes the Get with the Guidelines Quality Program at no cost for rural hospitals, as well as access to participate in rural learning collaboratives and access to the AHA’s Lifelong Learning Center.¹¹

Dr Khatana: Clinicians interested in providing care in rural areas need to form connections with providers already in these areas. Specialty care, including cardiology, is hard to access, so having formal and informal relationships with rural health care providers can help.

Clinicians can also advocate to health system leaders to partner with rural hospitals to help coordinate necessary cardiovascular care when needed. They should also advocate for the expansion of health insurance coverage for low-income patients in rural areas in states that have not yet expanded Medicaid health insurance.

Dr Sabharwal: Caring for these medically underserved patients can be challenging. For those interested in providing cardiovascular care in this high-risk population, they should begin in their early years of training so they can understand the needs of the community and learn to navigate their practice and the system to provide optimal care in these areas. There are multiple organizations within the health care system that are focusing on such efforts, including the American Heart Association (AHA) as well as community groups. Getting involved with such organizations will help achieve the goal of improving cardiovascular care in these communities.  

What are remaining research needs regarding this topic?

Dr Mehta: Research is necessary to determine optimal delivery of care models, including how best to leverage digital technology. Research on effective rural-based quality measures and how to best support community-centered approaches to care is also needed.

Dr Khatana: Unanswered questions include whether improving the finances of rural hospitals will prevent such hospitals from closing. A study by my colleagues and I, published in JAMA in 2021, showed that cardiovascular health was associated with economic prosperity of an area.¹⁰ Future research needs to study whether improving the economic prospects of an area can lead to improvement in health outcomes, including for CVD.

Dr Sabharwal: Health care centers in rural areas lack patient volume and quality metrics. Some metrics require a large sample size to be reliable. These 2 factors combined make data from rural centers difficult to interpret. Further research in this area is needed to better understand the needs of rural communities. In addition, research to analyze how telemedicine performs in these populations would help to better strategize care in these communities. 

The post Expert Roundtable: Addressing the Rural Cardiology Shortage  appeared first on The Cardiology Advisor.

The guidelines were developed in response to the increased use of cannabis during the past 20 years and concerns that potential interactions between cannabis products and anesthesia. Recreational cannabis use has been legalized in 21 states, Washington DC, and Guam. Marijuana was used by 52.5 million people in the US in 2021, according to the Substance Abuse and Mental Health Services Administration (SAMHSA). The guidelines cover preoperative, intraoperative, and immediate postoperative care considerations.

Clinicians should ask patients if they use cannabis medicinally or recreationally before surgical procedures “and be prepared to possibly change the anesthesia plan or delay the procedure in certain situations,” said Samer Narouze, MD, PhD, senior author and ASRA Pain Medicine president. “They also need to counsel patients about the possible risks and effects of cannabis. For example, even though some people use cannabis therapeutically to help relieve pain, studies have shown regular users may have more pain and nausea after surgery, not less, and may need more medications, including opioids, to manage the discomfort. We hope the guidelines will serve as a roadmap to help better care for patients who use cannabis and need surgery.”

Recommendations with Grade A support include the following:

• Universal screening for cannabinoid use should be performed before surgery and should include the type of cannabis or cannabinoid product, time of last consumption, route of administration, amount, and frequency of use
• Counseling frequent, heavy users on the potentially negative effects of cannabis use on postoperative pain control
• Postponing elective surgery in patients who have altered mental status or impaired decision-making capacity at the time of surgery
• Counseling pregnant patients on the risks of cannabis use to the unborn child

Other recommendations include the following:

• Delay elective surgery for a minimum of 2 hours after smoking cannabis because of increased perioperative risk of acute myocardial infarction (Grade C)
• Consider adjusting anesthesia delivery for surgery based on the patient’s symptoms and timing of the last cannabis consumption (Grade C)
• Do not automatically adjust ventilation settings during surgery in patients taking only oral cannabis since currently available evidence does not indicate adjustments are needed (Grade C)
• Consider adjustment of ventilation settings during surgery in chronic cannabis smokers, particularly in those with other conditions that are associated with an increased risk of lung disease (Grade C)
• Increase vigilance of cardiac and neurologic adverse events, which frequently occur after surgery, but the routine use of additional monitoring after surgery for cardiac or neurologic problems is not recommended (Grade C)
• Use multiple methods of anesthesia and pain control including regional analgesia if appropriate and use opioids as rescue medication (Grade C)
• Prescribe opioids when needed for management of perioperative pain in patients who use cannabis but with increased vigilance (Grade C)
• Counsel patients about the risk of cannabis withdrawal symptoms and monitor after surgery for symptoms (Grade C)
• Use a cannabinoid agonist such as dronabinol at a low dose to treat severe cannabis withdrawal symptoms postoperatively (Grade C)
• Universal toxicology screening for cannabinoids is not currently indicated based on insufficient available evidence (Grade D)

The guidelines are based on an extensive literature review and experiences from the organization’s Perioperative Use of Cannabis and Cannabinoids Guidelines Committee, which included 13 experts including anesthesiologists, chronic pain physicians, and a patient advocate. The committee addressed 9 questions using a modified Delphi consensus method with ≥75% agreement required for recommendations to be approved. All 21 recommendations achieved full consensus.

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Gwyneth A. Sullivan, M.D., from the Northwestern University Feinberg School of Medicine in Chicago, and colleagues conducted a literature search to identify quality improvement initiatives that aimed to decrease the environmental impact of the operating room while reducing costs. To inform data extraction, the triple bottom line framework, which considers the environmental, financial, and social impacts of interventions to guide decision-making, was used.

Data were included from 23 unique quality improvement initiatives that described 28 interventions. Eleven (39.3 percent), eight (28.6 percent), three (10.7 percent), and six (21.4 percent) interventions, respectively, were categorized as refuse, reduce, reuse, and recycle. The researchers found that the potential annual cost savings varied from $2,233 (intervention: transition to a waterless surgical scrub; environmental impact: 2.7 million liters of water saved annually) to $694,141 (intervention: education to reduce regulated medical waste; environmental impact: 30 percent reduction in regulated medical waste), although the methods of measuring environmental impact and cost savings varied considerably among studies.

“The opportunity to reduce our carbon footprint falls squarely on us, and I see surgeons taking a prominent role in leading efforts, not just locally with their green implementation teams, but in setting national standards and policies that will move this effort forward for an overall sustainable way of approaching health care delivery,” a coauthor said in a statement.

Abstract/Full Text

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“That’s unethical!”  So begins many a conversation (or sometimes maybe just an accusation) that prompts the input of an ethics consultant to help manage an ethical conflict in patient care.  This month’s column will review what an ethics consultant does, when an ethics consultation can be of assistance to the health care professional, when consultation from another resource would be more useful, and how to optimize the input of an ethics consultant.

An ethics consultant is an individual trained in resolving conflicts over values in a health care setting, with values being deeply held beliefs, standards, or principles that guide decision-making. These consultants are often trained in varying professional backgrounds of law, social work, philosophy, nursing, chaplaincy, or medicine among others, but they share an expertise in ethics theory and analysis. Consultants are most often called to assist with a conflict in patient care, but people in health care management, research, and administration also can seek their input.

Ethics consultants begin by identifying and clarifying the conflict to ensure it is related to ethics.  It is not uncommon for them to be called on a legal or clinical matter which is outside the scope of their function.¹ Nonetheless, clinicians who are struggling with a challenging case may mistake a legal question for an ethical one. For example, a clinician may ask an ethics consultant about their legal liability if they prescribe a medication that a patient is demanding but that they do not think is medically indicated? Clearly, an ethics consultant cannot provide expert legal advice about risk of liability for patient care questions. In such a case, the consultant will refer the clinician to their counsel for an authoritative legal response. 

Sometimes though, the legal question may lead to a related ethics question. In the example above, if the lawyer indicates that a clinician can provide the requested treatment as the liability for doing so is low, but the clinician is still not sure if they should accede to the patient’s request, the clinician can request further advice from the ethics consultant.  The consultant can then help gather more information from the various stakeholders, in this case, the physician and patient, to resolve the ethics conflict. Speaking with the stakeholders directly, as any medical consultant, helps elucidate and amplify what those specific values are. In this case, the first value could be the clinician’s professional responsibility to provide patient-centered care; that is, providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.² The second value could be that the clinician also has a professional obligation as part of their licensure to only provide treatments that adhere to generally accepted standards of care. 

This example points out an important aspect of ethics consultation: that it does not always represent a conflict over one position that is clearly right and another that is clearly wrong.  Rather, the ethics questions are often between one position that is “right” and another one that is “right” in a different way. Thus, the process is often about managing equally reasonable positions that need to be balanced to resolve the problem.

Returning to the example, it becomes clearer how the ethics consultation process can be uniquely helpful in approaching a resolution. By first explicitly identifying the conflicting values, it helps to create a resolution that is responsive to those values, even when one of those values should be prioritized. In other words, even if there is strong ethical justification for the clinician to deny the patient’s request for the requested treatment because doing so is not consistent with generally accepted standards of treatment, the ethics consultation process helps to promote and honor the other relevant values. This might mean recommending to the clinician that they try to identify the patient’s interests behind their request. Does the patient have mistaken ideas about the utility of the requested medication? Is there a reason behind their request that has not yet been articulated? This approach then creates space for honoring both values: patient-centeredness and professional obligations. 

What should clinicians do when they believe they have an ethical concern and need assistance?  First, clinicians should be aware of how to contact their local ethics resources. The threshold to contact them should be low: It is better to contact them and not need them rather than make an assumption that they may not be helpful. Second, they should expect that the ethics consultant can help with ethical dilemmas in patient care, but that the consultant may first recommend another resource to find the definitive answer to the problem, which might include another clinical service, legal, risk management, or chaplaincy. However, even when that additional service is needed, ethics may be helpful as the issue develops or related ethics questions need to be answered. Finally, as clinicians begin to work more with ethics consultants over time, they will likely develop a heightened sensitivity to when ethics can be helpful in the course of clinical care. As some like to say, be aware when your ethics antennae go up, and when they do, you can get help.

David J. Alfandre, MD, MSPH, is a health care ethicist and an Associate Professor in the Department of Population Health at the NYU School of Medicine in New York. The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the VA National Center for Ethics in Health Care or the US Department of Veterans Affairs.

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The Federal Bureau of Investigation in September warned that it has received multiple reports of cybercriminals increasingly targeting health care payment processors to redirect payments to themselves. Typically, this involves a cybercriminal obtaining employees’ publicly-available personal identifiable information and other data to impersonate victims and gain access to files, health care portals, payment information, and websites to then redirect payments to the cybercriminal’s bank account.

“The FBI issues these warnings regularly, so it is not surprising,” said Paul Hales, a HIPAA compliance attorney based in St. Louis, Missouri. “The payment processor is to blame, but not solely. It is both. Medical practices must follow HIPAA rules for hiring payment processing business associates.”

From June 2018 to January 2019, cybercriminals targeted and accessed at least 65 health care payment processors throughout the United States to replace legitimate customer banking and contact information with accounts controlled by the cybercriminals, according to the FBI. One victim reported a loss of approximately $1.5 million.

In February 2022, a cybercriminal obtained credentials from a major health care company and changed direct deposit banking information from a hospital to a consumer checking account belonging to the cybercriminal, resulting in a $3.1 million loss. In April 2022, a health care company with more than 175 medical providers discovered that a cybercriminal posing as an employee had changed Automated Clearing House instructions of one of their payment processing vendors to direct payments to the cybercriminal rather than the intended providers.

Health care payment processors are HIPAA business associates and must comply with the HIPAA rules governing their interconnected relationship with medical practices and how each uses and discloses protected health information.

The FBI recommends all medical practices ensure antivirus software and anti-malware are enabled and security protocols are updated regularly. It also recommends conducting regular network security assessments to stay up to date on compliance standards and regulations. These types of security checks should include performing penetration tests and vulnerability scans. Practices should create protocols for employees to report suspicious emails, and changes to email exchange server configurations. The FDA also recommended that any direct request for account actions “needs to be verified through the appropriate, previously established channels before a request is sanctioned.”

Medical practices are being told to train all their employees on how to identify and report phishing, social engineering, and spoofing attempts. Some practices may want to consider pursuing options in authentication or barrier layers to decrease or eliminate the viability of phishing.

“Risk analysis is fundamental to HIPAA compliance. Federal auditors found over 80% of business associates failed this Security Rule requirement. Physician due diligence is essential before engaging a business associate,” Hales said. “And they must have an updated business associate agreement in place.”

Physicians may want to work with their legal counsel to protect against business associate negligence. Cyber insurance and risk-shifting contract language are prospective defensive measures, Hales said.

Another approach would be to use hard tokens that permit access to software and verify identity with a physical device instead of authentication codes.

“This kind of token allows software access through verification of a physical device rather than codes or passwords. Although cost can be a concern for using hard tokens compared with other authentication types, such as SMS authentications, hard tokens have an advantage in protecting confidential data,” said cybersecurity specialist Soumitra Bhuyan, PhD, an associate professor at Rutgers University in New Brunswick, New Jersey.

The individual with the hard token needs to be present to access data. Consequently, systems based on hard tokens are difficult to breach remotely. However, hard tokens come with some limitations. They are costly for a large organization to implement and, with any physical devices, they can be lost, Dr Bhuyan said.

Steve Akers, Chief Security Officer for TECH LOCK, a division of Clearwater that provides managed threat detection and response services, said the reason health care payment processors now are under attack is because they are the lowest hanging fruit. “Hitting the supply chain, or in the case of [health care business associates], has proven to be a more lucrative path than targeting the bigger companies, as they typically have fewer resources and less investment in cybersecurity but may have access to many of the same data sets,” Akers said.  

One way to mitigate vulnerabilities related to third-party vendors may be to put special alerts with email banners warning employees of communications originating outside of the organization. It is also suggested that all medical practices require a special verification of any changes to existing invoices, bank deposits, and contact information for interactions with third-party vendors and organizational collaborations.

A hard token could be a special USB stick that must be plugged into the computer or it could be some personal aspect, such as fingerprints or face identification, said Stuart Madnick, PhD, of the Massachusetts Institute of Technology in Boston, where he is the John Norris Maguire Professor of Information Technology in the Sloan School of Management and Professor of Information Technology and Engineering Systems in the School of Engineering. “All of these make it much harder for a hacker to break into your account even if he or she has stolen your ID and password,” Dr Madnick said. “In highly secure situations, such as the CIA, hard tokens are probably widely used. But for the average doctor, it is one additional thing you need to carry around and secure.”

Cybersecurity specialists agree no method is 100% fool-proof. There is always a way that a determined attacker can get through. “We promote the need for resilience,” Dr Madnick said. “If the attacker gets in, how do you minimize the amount of damage that can be done? For example, keep the data encrypted, so even if stolen, it is useless to the hacker.”

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Benjamin Talbot, M.B.B.S., from the University of New South Wales in Sydney, and colleagues conducted an online survey to examine environmental sustainability practices within dialysis facilities between November 2019 and December 2020. Responses were obtained from 132 dialysis facilities.

Most responses were obtained from public satellite facilities, in-center dialysis facilities, and co-located dialysis and home therapy facilities (40, 25, and 21 percent, respectively). The researchers found opportunities for improvement in environmental sustainability practices in three domains: culture; building design, infrastructure, and energy use; and operations. Specifically, a minority of facilities reported having an environmental sustainability strategy in place or undertaking sustainability audits (33 and 20 percent, respectively); only 7 percent reported inclusion of environmental training during staff induction. Few facilities reported renewable energy use, reclaiming reverse osmosis reject water, or using motion-sensor light switches (14, 13, and 44 percent, respectively). A minority of facilities reported waste management education, auditing waste generation, or considering environmental sustainability in procurement decisions (36, 17, and 25 percent, respectively).

“Environmental sustainability practices, education, and improvements are currently not prioritized,” the authors write. “Most facilities reported only informal efforts to raise awareness of environmental sustainability, and strategies or policies to drive this were not often in place.”

Several authors disclosed financial ties to the pharmaceutical industry.

Abstract/Full Text

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Researchers conducted a pilot hybrid type 1 trial at the Veterans Affairs Boston Health Care System between 2017 and 2018. Veterans who were exposed to trauma (N=37) presenting for routine care were randomly assigned in a 1:1:1 ratio to receive UP (n=13), PCT (n=13), or TAU (n=11). The UP and PCT sessions lasted 50 minutes. The UP intervention contained components similar to cognitive behavioral therapy and comprised 8 modules whereas PCT was a manualized supportive therapy focused on current symptoms and functioning. The outcomes of this study were the change in symptom severity at 3 months.

The TAU, PCT, and UP cohorts included patients with mean ages of 51.04, 48.08, and 42.08 years; 100.0%, 84.6%, and 61.5% were men; 54.5%, 76.9%, and 84.6% were White; and the number of traumas was 14.27, 16.77, and 19.54, respectively.

The index trauma events included sexual assault (n=6), sudden violent death (n=5), life-threatening illness or injury (n=4), severe human suffering (n=4), combat or war-zone exposure (n=3), sudden accidental death (n=3), natural disaster (n=3), transportation accident (n=1), assault with a weapon (n=1), or other (n=5). At baseline, the most common diagnoses included major depressive disorder (n=11), posttraumatic stress disorder (n=9), and persistent depressive disorder (n=6).

Among the TAU group, 62.5% attended individual treatments with an average of 8.3 sessions, 27.3% received medication plus attended an average of 4.0 psychiatry sessions, 18.2% received both individual and group treatments, and 12.5% attended only group sessions (mean, 5.7 sessions). More PCT recipients dropped out of the study (38.5%) compared with no UP recipients (χ², 3.96; P =.047).

Overall, effect sizes were largest for UP recipients with regard for the change between baseline and 3 months in Clinical Severity Rating scores (d, -3.23), the number of comorbid diagnoses (d, -0.66; P =.012), impairment in functioning (d, -0.55; P =.002), and 9-item Patient Health Questionnaire scores (d, -1.55; P <.001) compared with those in the PCT and TAU groups. Compared with only PCT, the effect sizes for UP were larger for the change in overall anxiety severity and impairment scale (OASIS) anxiety (d, -0.48; P =.006) and depression (d, -0.60; P ≤.001) scores.

This study was limited by the sample sizes and the group differences at baseline.

Study authors conclude, “This study demonstrates the promise of the UP for trauma-exposed individuals with multiple diagnoses. It also represents the first attempt to systematically examine the UP in a routine care setting. If replicated with a larger sample, the findings may suggest that the UP can serve as a transdiagnostic protocol to train clinicians in one evidence‐based cognitive behavioral therapy that can be applied across diverse patient populations.”

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Clinicians should not allow their own preconceptions about aging to prevent them from providing optimal care to their older patients, according to the lead author of a study linking everyday ageism to a higher prevalence of physical and mental health problems.

“Take the time to get to know older patients as individuals and ask questions about their needs and preferences, rather than make assumptions based on age,” said Julie Ober Allen, PhD, MPH, of the University of Oklahoma in Norman. “Clinicians who are more aware of their assumptions and stereotypes about aging and older adults, which we have all been socialized to have, are better able to monitor their behavior to make sure they don’t act on ageist beliefs.”

Dr Allen recommends that clinicians discuss aging-related cognitive and physical change as a part of human development across the life course rather than inherently representing decline, loss, or something to mourn. While older adults often are resilient, they also may be less likely to adapt successfully or ask for support from others if they believe these efforts will not make a difference. “There’s other research indicating that negative beliefs about aging may serve as a self-fulfilling prophecy,” Dr Allen said.

She and her colleagues surveyed 2035 individuals aged 50 to 80 years from the National Poll on Healthy Aging. The higher a person’s score on a scale of everyday ageism experiences, the more likely they were to be in poor physical or mental health, to have more chronic health conditions, or to show signs of depression. In this cross-sectional study, which was published online in JAMA Network Open, everyday ageism was found to be highly prevalent and associated with multiple indicators of poor physical and mental health.

While the study does not show cause and effect, the investigators noted that the linkages between ageism and health need to be explored further and taken into account when designing programs to encourage good health and well-being among older adults.

The researchers used the Everyday Ageism Scale, which calculates a score based on an individual’s answers to 10 questions about their own experiences and beliefs regarding aging. In the current study, 93.4% of the older adults surveyed said they regularly experienced at least one of the 10 forms of ageism. Approximately 80% agreed with the statement that “having health problems is part of getting older,” even though 83% described their own health as good or very good. This kind of internalized ageism also included agreeing with the statements that feeling lonely, depressed, or sad is part of aging.

In this study, 65% of the older adults said they regularly see, hear, or read jokes about older people, or messages that older adults are unattractive or undesirable. Interpersonal ageism was reported as a regular occurrence by 45% of the respondents. Interpersonal ageism was defined as older persons believing that others assume they have problems using technology, seeing, hearing, understanding, remembering, or acting independently, or they do not contribute anything of value.

“Everyday ageism is often subtle and may or may not be intentionally discriminatory,” the investigators wrote. They added that the “microaggressions” that that define everyday ageism “may communicate that older adults are not fully accepted and respected, appreciated for their individuality, or deserving of the rights and privileges afforded other members of society.”

Geriatrician John Morley, MD, of Saint Louis University School of Medicine in Missouri, said physicians need to treat older persons the same as other adults and avoid ageism in patient care. “Be careful not to use ageist language,” Dr Morley said. “Be respectful. Technology has a great future for geriatric care as the average physician has poor understanding of geriatric syndromes. Health care professionals need to know the computer literacy of their older patients. When it’s poor, they need to work with a family member if the patient agrees.”

While portals can greatly enhance care, physician interaction with patients remains central to ensuring communication barriers are address. Dr Morley said office staff should have protocols to address older patients’ communication capabilities and prevent ageism in patient care. “In persons with poor digital skills, the physician and his staff need to work directly with the patient,” he said. “The digital testing can be done in the office by an office staff. We are in a large digital divide and health care professionals need to assess how the patient wishes to interact.” 

Dr Allen agrees. Having options and asking patients how they prefer to communicate is an important, perhaps under-recognized, aspect of healthcare provision, she said. Addressing the issue of digital skills could also benefit other groups who are affected by the digital divide, such as low-income individuals, rural patients, and those who are simply less tech savvy, she said.

Wanda Jirau-Rosaly, MD, a geriatrician at the Medical College of Georgia at Augusta University, said there is a great deal of societal misinformation and preconceived notions about aging. “Without conscious knowledge, physicians may be the ones giving older adults ageist messages and having ageist assumptions about our patients,” Dr Jirau-Rosaly said. “We must remember, older adults have lived life [and] have lots of living knowledge and experiences that they can even teach us about.”

Although younger individuals have grown up with technology, Dr Jirau-Rosaly said many of her older adults spend hours on the internet browsing instead of watching TV. “To me, more than technology causing a divide due to age is the fact that we do not communicate as well. We write a couple of sentences through a portal,” Dr Jirau-Rosaly said. “Technology feels impersonal and that is what may create the age divide. Some of my patients show me how to use different applications on my phone. Assuming that technology is an aging issue is ageist in itself. Asking the patient how they prefer to communicate is best practice.”

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César Caraballo, M.D., from Yale New Haven Hospital in Connecticut, and colleagues describe trends in racial and ethnic disparities in barriers to timely medical care in a cross-sectional study of 590,603 adults from 1999 to 2018. Temporal trends in disparities relating to five specific barriers to timely medical care were assessed: inability to get through by telephone, no appointment available soon enough, long waiting times, inconvenient office or clinic hours, and lack of transportation.

The researchers found that the proportion reporting any of the five barriers to timely medical care was 7.3, 6.9, 7.9, and 7.0 percent for Asian, Black, Hispanic/Latino, and White individuals, respectively, in 1999. From 1999 to 2018, there was an increase seen in this proportion across all race and ethnicity groups (by 5.7, 8.0, 8.1, and 5.9 percentage points for Asian, Black, Hispanic/Latino, and White individuals, respectively), resulting in a slight increase in the between-group disparities. In 2018, the proportion reporting any barrier was 2.1 and 3.1 percentage points higher among Black and Hispanic/Latino individuals, respectively, versus Whites.

“There is considerable scope for implementing changes to remove the barriers to medical care and to eliminate these racial and ethnic disparities,” the authors write.

Several authors disclosed financial ties to the health care industry.

Abstract/Full Text

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Lisa M. Meeks, from University of Michigan, Ann Arbor, and colleagues used data from a nationally representative sample of 5,851 physicians to examine workplace mistreatment experienced by physicians with disabilities and determine whether physicians with disabilities are more likely to experience mistreatment in their workplace than physicians without disabilities.

The researchers found that the majority of physicians with disabilities reported at least one type of mistreatment (64 percent) and were more likely to experience all types of mistreatment both from coworkers and from patients, compared with nondisabled physicians. Physicians with disabilities were more likely to have been threatened with physical harm by coworkers (odds ratio [OR], 8.03) and patients (OR, 2.6) and were more than 17 times more likely to have been physically harmed by coworkers and 6.5 times more likely to have been physically harmed by patients. Physicians with disabilities were 5.8 times more likely to be subjected to unwanted sexual advances from coworkers and 3.6 times more likely from patients versus their nondisabled peers.

“Our findings suggest the need for disability-focused anti-mistreatment policies and practices,” the authors write.

Abstract/Full Text

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Many patients share personal health data when they sign up for and use medical apps and websites or share details of their health issues with others on social media. Digital medicine companies and social media platforms may be tracking this information and using it to develop targeted ads aimed at individuals with specific medical problems or generate leads for future marketing purposes. The authors of a recent study published in the journal Patterns say most individuals are not fully aware of how they are being followed and manipulated by digital medicine companies and social media platforms.

HIPAA rules bar “covered entities” such as medical practices and hospitals from disclosing protected health information without patients’ consent. But for data generated outside of “the digital walls” of these covered entities, “patients are mostly on their own with respect to understanding how companies utilize their personal and health data, especially when asking questions about their health conditions on social media,” wrote investigators Andrea Downing of The Light Collective, an advocacy group based in Eugene, Oregon, and Eric Perakslis, PhD, Chief Science and Digital Officer at the Duke Clinical Research Institute in Durham, North Carolina.

The team explored this issue in a study of health-advertising tactics of 5 digital medicine companies, with a focus on 5 clinical services. They recruited 10 patient advocates in the hereditary cancer community and asked them to share data on how their online activities were being tracked. The participants downloaded and shared their JavaScript Object Notation (JSON) files, which reveal how data are shared between web servers and web apps. The investigators used these files to determine how information flows from health-related websites and apps to Facebook to target advertising.

Downing and Dr Perakslis reviewed the companies’ websites for third-party ad trackers and looked at whether use of these ad trackers complied with the companies’ own privacy policies. They also looked at Facebook’s ad library for each participant to determine whether health data obtained through these companies influenced the types of ads that the participants were seeing.

“We demonstrated that personal data and personal health data can be easily obtained without the aid of highly sophisticated cyberattack techniques but with rather commonplace third-party advertising tools,” the authors wrote in a paper published in the journal Patterns.

They also observed, “While tools we identified are not inherently good or bad, applying commonplace advertising tolls designed for social media marketing can expose sensitive health information in the form of leads. These marketing tools reveal a dark pattern used to track vulnerable patient journeys across platforms as they browse online, in some ways unclear to the companies and patient populations who are engaging through Facebook.”

The authors say they hope these new data trigger an overdue dialogue about health privacy and how it affects specific patient populations.

In an interview, Dr Perakslis pointed out that physicians’ role regarding protected health information is spelled out under HIPAA, but this is not the case for marketing software designed to spread data as prolifically as possible. “Everyone needs to be really careful about what software they use,” Dr Perakslis said. “Most people don’t know what the apps do, and many people have hundreds [of apps].”

The 5 companies included in the analysis provide information or services (including genetic testing) related to inherited cancer risk. The investigators determined that 2 of the companies’ targeted ads were consistent with their own privacy policies. The other 3 did not comply with their own policies and claims of privacy.  

Angie Raymond, JD, PhD, Director of the Program on Data Management and Information Governance at Indiana University and with the Department of Business Law and Ethics at Kelley School of Business, Bloomington, Indiana, said the privacy community did a great job of moving HIPAA into the common vernacular. However, it did a rather poor job of explaining the limitations of the key terms “health” and “covered-entity.” Dr Raymond said this is where things begin to fall down. “It is really leaving people and their health data very vulnerable. We need to do much better,” Dr Raymond said.

Dr Raymond believes privacy protections need to be designed into the technologies that people use. “We do need to move existing protections into a digital world,” he said. “We may need to consider building protections in some new areas that have emerged because of the ubiquitous nature of the digital world and aggregation of data. But, without design we will likely keep chasing our tails.”

Michael S. Sinha, MD, JD, MPH, Assistant Professor in the Center for Health Law Studies at Saint Louis University School of Law in Missouri, said when HIPAA was established, Congress had not contemplated the issue of “mining” PHI from a patient’s online portal or other PHI platform—often without their knowledge or consent—for advertising purposes. Dr Sinha would like to see new federal legislation passed that specifically addresses patient privacy rights.

“This is an emerging problem in health privacy,” Dr Sinha said. “Technology has advanced, real problems are manifesting, and it is time for policymakers to act. Passing new comprehensive health privacy legislation that addresses these critical issues by closing privacy loopholes is an important next step.”

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During morning clinic, one of your older patients arrives for his appointment with his son.  This particular patient had previously attended his appointments alone, but in the past year he has been arriving with a family member. Today, his son tells you that his dad, who lives alone, has been having more trouble remembering to take his medication and to pay his bills. He and his siblings have been discussing the patient’s willingness to move into a nearby assisted living facility. The patient asks you how his kids can be helpful when he has trouble making health care decisions for himself.

Facilitating deciding for others is a central part of health care for many clinicians. Although pediatricians and geriatricians are more likely to have to engage family members to help make health care decisions for some of their patients, clinicians in all specialties should understand the principles and procedures for deciding on behalf of others in an ethically strong way. 

First and foremost is that adult patients make decisions on their own behalf unless they lack decision-making capacity (DMC) or they voluntarily choose to cede that decision-making authority to another person. DMC is a determination by a health care professional about a patient’s ability to make a specific health care decision at a particular point in time. Patients should be presumed to possess DMC unless there is a compelling reason to conclude otherwise. Moreover, DMC determinations should not be based on the content of the decision, but rather on the patient’s decision-making process. For example, a patient should not be presumed to lack DMC simply because they have chosen to decline a beneficial treatment contrary to the clinician’s recommendation. However, if the patient is significantly impaired by intoxication and chooses to decline a particular intervention, it may not be unreasonable to question their decision-making ability.  

Although critically assessing DMC for the broad range of health care decisions is beyond the scope of this article, clinicians should appreciate some general principles about the process.  Patients with DMC should be able to understand the relevant clinical information of the proposed decision, including its risks, benefits, and alternatives; appreciate the consequences of the decision as it relates to them specifically; be able to rationally manipulate the provided information; and clearly communicate a choice.

It is no small matter to decide that a patient lacks DMC as that can portend significant consequences to the patient’s autonomy. At the same time, allowing patients to make decisions when they lack to capacity can be harmful as well. When patients lack DMC, an authorized individual (often referred to as a surrogate decision maker) must make decisions on their behalf. There is a hierarchy that determines which individual has priority, and this is usually based on state law for clinicians who practice in non-federal health care settings.  Although the hierarchy will undoubtedly vary by state (you should consult your local counsel or ethics consultation resources for specifics), the prioritized list of available surrogate decision-makers usually starts with a durable power of attorney for health care (ie, health care proxy), then legal guardian, spouse, adult child, parent, sibling, or another family member. Some states and jurisdictions allow for someone not on the specific hierarchy of surrogates (eg, an uncle, niece, close friend) to serve as an authorized decision maker if there is no one else available and they can demonstrate that they know the patient and can represent their best interests.  Finally, although a court-appointed guardian could usually be appointed, in practice, this process is often costly and time consuming and impractical for time-sensitive decisions. 

When there is no surrogate available on the hierarchy, most states have a legal process by which the health care team can make timely health care decisions on behalf of the patient with varying levels of oversight. These procedural protections help ensure that these vulnerable “unbefriended” patients are not exploited.  This process often includes identifying legal documents that can represent the patient’s prior known preferences, including relevant health record documentation, advance directives, living wills, and physician orders for life sustaining treatments (POLSTs).

Regardless of who the ultimate surrogate decision makers are, they all have certain ethical responsibilities. These decision makers are not free to make health care decisions however they want or simply to meet their own needs, but rather are obligated to decide based on what the patient would have wanted if it is known. This is referred to as “substituted judgment” and can often be found in the health care documents specified above. When there is insufficient knowledge or documentation of a patient’s preferences for care, surrogates must base their decisions on “best interests” reasoning, which essentially translates to what they believe is best for that patient at that time. Finally, even when a patient lacks DMC, the surrogate and the clinician should seek to involve the patient in as much of the decision-making process as possible. This can assist the surrogate to decide as well as to respect the patient’s ability to participate in health care decisions, even if that ability is diminished.

Strong ethical practices for surrogate decision making help to maximize patients’ bodily autonomy by enhancing their ability to speak for themselves even as illness infringes on their ability to do so. When patients are unable to exercise their rights any longer, they depend on family, friends, and sometimes health care professionals to do the right thing and make those decisions for them based on what the patient would have wanted if known, and if not known, then on their best interest.  

David J. Alfandre, MD, MSPH, is a health care ethicist and an associate professor in the Department of Population Health at the NYU School of Medicine in New York. The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the VA National Center for Ethics in Health Care or the US Department of Veterans Affairs.

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