Southern Medical Journal最新文献

Objectives: Coverage by private insurance is associated with lower chronic pain prevalence, but the significance of different types of private coverage for the epidemiology of chronic pain is poorly understood. The primary outcome was pain prevalence. Among respondents with chronic pain, secondary outcomes included experiences of severe pain, high-impact pain, and opioid use.

Methods: We compared the prevalence of chronic pain among privately insured adults (aged 18-64 years) based on coverage source, coverage continuity, and relation to the policyholder using the 2019-2021 and 2023 rounds of the National Health Interview Survey.

Results: Based on a sample of 52,852 adults, we estimated that 16% of adults aged 18 to 64 years with private coverage had chronic pain, 10% had privately purchased insurance (as opposed to employer-sponsored), 4% experienced coverage gaps within the past year, and 33% were covered by a relative's policy (vs own policy). On multivariable analysis, compared with adults with employer-sponsored insurance, those with privately purchased insurance had lower odds of reporting chronic pain (odds ratio 0.86, 95% confidence interval 0.78-0.95; P = 0.004). Compared with adults with continuous private insurance coverage, those who experienced coverage gaps in the past year had higher odds of chronic pain (odds ratio 1.28, 95% confidence interval 1.11-1.47; P < 0.001). There was no difference in chronic pain prevalence based on relation to the policyholder and no differences in any secondary outcomes based on the study exposures.

Conclusion: These results suggest that protecting the continuity of private coverage may help improve pain management and control the population prevalence of chronic pain.

Objectives: This study aimed to assess the associations of smoking status and prescription of smoking cessation medication on rehospitalizations. Tobacco use remains a major public health issue in the United States as it is linked to a broad spectrum of serious diseases. Although intensive inpatient tobacco treatment programs have shown success, the impact of prescription of smoking cessation medications alone on hospital readmissions has not been studied thoroughly.

Methods: We conducted a retrospective cohort study of patients from a primary care clinic hospitalized between July 1, 2013 and December 31, 2020. The primary outcomes of interest were rehospitalization rates by smoking status and by smoking cessation medication prescription among current smokers.

Results: Of the 11,164 patients studied, rehospitalization rates at all time points were higher among current and former smokers compared to never smokers. After adjusting for covariates, former and current smokers had higher odds of rehospitalization within 365 days compared with never smokers (odds ratio [OR] 1.14, 95% confidence interval [CI] 1.03-1.25; OR 1.15, 95% CI 1.01-1.31, respectively). Among current smokers, those prescribed tobacco cessation medications had a lower likelihood of rehospitalization within 365 days after adjusting for confounders (OR 0.75, 95% CI 0.56-0.99).

Conclusions: This study confirms that both current and former smokers are at an increased risk for rehospitalization compared with never smokers. Notably, the prescription of tobacco cessation medications is associated with a decreased risk of rehospitalization among current smokers; however, the low prescription rate of these therapies highlights a significant gap in care. Improved treatment of tobacco use during hospitalizations could lower rehospitalization rates.

Objectives: Burnout in the healthcare workforce is a growing concern in the United States, with varying levels reported across different demographic groups. This study aimed to explore burnout and resilience domains among healthcare workers, focusing on gender and race/ethnicity differences within the University of Utah Health System.

Methods: A cross-sectional survey was conducted at the University of Utah Hospitals and Clinics using Press Ganey's validated burnout and resiliency measure. The survey, completed by 9023 participants in October 2019, assessed key outcomes related to workplace well-being, including engagement, resilience, activation, decompression, safety, stress, and burnout. Data were analyzed using χ² and Wilcoxon rank-sum tests and multivariable logistic regression, with further stratification by gender and race/ethnicity.

Results: The study found significant variations in burnout and resilience across gender and race/ethnicity. Women reported higher levels of activation, stress, and burnout, and lower levels of perceived safety compared with men. Racial/ethnic differences were also observed, with non-Hispanic White and Other racial groups reporting higher burnout levels, whereas Hispanic respondents demonstrated higher resilience and decompression. Intersectional analysis revealed lower activation levels among men across most racial/ethnic groups and higher resilience and decompression among non-Hispanic White men compared with women.

Conclusions: This study reveals significant variations in burnout and resilience across gender and race/ethnicity within the healthcare workforce, emphasizing the need for nuanced and tailored approaches to enhance well-being in a diverse healthcare workforce.

Objective: The objective was to investigate whether medical students can learn a pediatric musculoskeletal examination independently by studying the pediatric Gait, Arms, Legs, and Spine (pGALS) assessment.

Methods: Fourth-year medical students were surveyed in 2018 regarding confidence and experience with the pediatric musculoskeletal training. Students performed an initial scored musculoskeletal examination on a standardized pediatric patient reporting chronic joint concerns. The total score had a theoretic range from 0 to 42, and scoring was based on the pGALS examination for children presenting with joint pain. Subsequently, students watched training pGALS videos. After this intervention, students completed follow-up physical examinations and surveys.

Results: Fourteen graduating medical students participated. Of these students, 12 students planned to enter a pediatric residency. On the initial survey, participants were the least confident in their pediatric musculoskeletal examination skills compared with all other pediatric physical examinations. Before the pGALS training, 21.4% of participants reported being confident or very confident in their pediatric musculoskeletal examination skills, compared with 100% of participants after training (P < 0.0001). The pre- and post-musculoskeletal examination scores were also statistically different (P = 0.0001). There were no participants who believed that they received extensive education in the pediatric musculoskeletal examination as part of their medical education. All of the participants desired further musculoskeletal training. All of the participants believed that the pGALS tool was beneficial.

Conclusions: Graduating medical students may not be confident nor proficient at the pediatric musculoskeletal examination. Instruction in the pGALS assessment may be a low-cost and efficient way to improve confidence and proficiency in the pediatric musculoskeletal examination.

Objectives: Certified athletic trainers (ATCs) are increasingly used in sports medicine clinics. Patient comfort for ATCs as clinical coordinators has yet to be determined. This study aims to determine patient comfort with ATCs as clinical coordinators compared with registered nurses (RNs).

Methods: One hundred patients from a sports medicine clinic at a singular academic institution were recruited for a cross-sectional survey study. Patients completed a 10-question survey measuring patient comfort between ATCs and RNs in clinical tasks on a scale of 1 through 10. Demographic data of patients were collected, and Wilcoxon signed rank tests were used to compare medians of survey responses.

Results: The average age of respondents was 45.0 years (standard deviation 17.4), with 53% male patients. Patients were more comfortable with ATCs in performing an initial musculoskeletal (MSK) assessment, answering MSK-related questions, answering questions following orthopedic surgery, and coordinating care for an MSK injury (P < 0.01). RNs were preferred by patients for calling in medications (P < 0.001).

Conclusions: ATCs are preferred as clinical coordinators over nurses in most aspects of MSK care; however, RNs were preferred for calling in medications.

Objectives: States bordering the lower Mississippi River have large Black populations totaling 1,996,897. In 2019, 7506 Blacks there died of heart disease. These four states have high heart disease death rates. This analysis examined geographic variation in heart disease to suggest populations to target for intervention and suggest hypotheses for future study.

Methods: Vital statistics data from the Centers for Disease Control and Prevention were examined for non-Hispanic Blacks aged 35 to 84 years in Arkansas, Tennessee, Louisiana, and Mississippi. "Diseases of Heart" in the Centers for Disease Control and Prevention's 113 cause list was selected. Combined data from 1999-2019 were examined by state and county/parish. Numbers and age-adjusted mortality rates (AAMRs) were shown in the tables, charts, and maps. AAMRs based on fewer than 50 deaths were not reported.

Results: The number of deaths in 2019 follows: Arkansas 871, Louisiana 2762, Mississippi 1940, and Tennessee 1933. AAMR per 100,000 were Arkansas 392, Louisiana 374, Mississippi 357, Tennessee 354. In 1999-2019, AAMR varied threefold among counties. The county with the highest AAMR was Franklin Parish, Louisiana (736). Next were Desha County, Arkansas (672), Webster County, Mississippi (669), Madison Parish, Louisiana (660), and Hardin County, Tennessee (637). The lowest rate was in Lincoln Parish, Louisiana (258), preceded by St. Helena Parish, Louisiana (275), Saline County, Arkansas (277), Conway County, Arkansas (292), and Pontotoc County, Mississippi (303). AAMR were generally high in the Mississippi Delta region of Mississippi, Louisiana, and Arkansas. Racial disparity was greater in women than men and declined during the period in women but not in men.

Conclusions: County AAMR varied threefold in states along the lower Mississippi. These counties should be targeted with culturally appropriate interventions to reduce heart disease deaths. Further research should evaluate the social determinants of health that cause this geographic variation in mortality.

Objectives: Helicobacter pylori is the strongest risk factor for non-cardia gastric adenocarcinoma, the cancer with the greatest racial disparity in US cancer mortality. The 2017 American College of Gastroenterology guidelines recognized that local H pylori antibiotic resistance data are often unavailable in the United States, highlighted increasing clarithromycin resistance, and recommended that providers review previous antibiotic exposures before selection of an H pylori treatment regimen.

Methods: We analyzed a retrospective cohort of 477 patients with H pylori diagnosed on upper endoscopy (or esophagogastroduodenoscopy [EGD]) from 2015 to 2019. Clinical data abstracted included all EGD findings, H pylori diagnoses, treatments, eradication testing, and prior macrolide and metronidazole exposures.

Results: Overall, eradication testing rates were low after index EGD, with 50% of the 477 patients receiving eradication testing after H pylori diagnosis although eradication testing rates increased from 35% in 2015 to 64% in 2019 (P < 0.0001). During this time period, H pylori treatment practice patterns shifted from triple to quadruple therapy without a corresponding increase in successful eradication, and overall, successful eradication was achieved in 72% of patients. After an initial H pylori diagnosis, 202 patients were treated, followed by completion of eradication testing. We found no significant differences in eradication rates based on prior antibiotic exposures; comparing H pylori eradication rates for previous macrolide treated with clarithromycin (85%), previous metronidazole treated with metronidazole (73%) versus no prior antibiotic exposure (86%).

Conclusions: Although guidelines suggest querying prior antibiotic exposures before selecting H pylori therapy, our findings emphasize that alternative methods to improve eradication rates may be important. Although practice patterns shifted to use more metronidazole-based therapy, as currently suggested as first-line H pylori therapy in the United States, this change was not associated with an overall improvement in eradication rates.

Objective: Data are lacking on the effect of pediatric clerkship duration on National Board of Medical Examiners pediatric shelf examination scores. Our school has recently changed its clerkship structure, transitioning from separate ambulatory and inpatient clerkships with examination at the end of each clerkship to a combined 8-week ambulatory and inpatient clerkship with a single examination. We hypothesized that students in the split model would score higher on their second shelf attempt and ambulatory students would score higher than those with inpatient first. We hypothesized that the combined clerkship model would yield higher shelf scores than aggregate scores in the split model.

Methods: Examination scores for the split versus combined clerkship model were analyzed. Students completed surveys assessing their comfort caring for pediatric patients before and after the change in clerkship structure.

Results: Students from the split (n = 361) and combined (n = 250) models were analyzed. For the survey, 110 students (44%) responded from the split model and 193 (77%) from the combined model. Combined model had statistically significant (P < 0.05) higher National Board of Medical Examiners scores than the split model. This was driven by a lower score (P < 0.001) on the second attempt compared with combined or the first time. Students who took inpatient first scored significantly higher than those who took ambulatory first in the split model. Surveys showed significantly higher comfort (P < 0.05) in the combined clerkship.

Conclusions: Understanding how to maximize student comfort caring for pediatric patients and scores on the shelf examination are important for curriculum design and for continuing to attract students to the specialty.