An Op-Ed Writing Curriculum for Medical Students to Engage in Advocacy Through Public Writing

BACKGROUND

Op-ed writing can be a powerful and accessible advocacy tool for physicians, but training is lacking in undergraduate medical education.

AIM

To train and engage first-year medical students in op-ed writing.

SETTING

Midwestern research-intensive medical school.

PARTICIPANTS

All students in a required first-year health policy course in 2021 and 2022.

PROGRAM DESCRIPTION

For their health policy course's final assignment, students could opt to write an op-ed on a healthcare issue of their choice. All students received written instruction on op-ed writing. Additionally, they could access a seminar, coaching and editing by peers and faculty, and publication guidance.

PROGRAM EVALUATION

Of 179 students over 2 years, 105 chose to write op-eds. Fifty-one attended the seminar, 35 attended peer coaching sessions, 33 accessed structured peer editing, and 23 received faculty assistance. Thirty-eight students submitted a total of 42 op-eds for publication. Twenty-two pieces were published in major outlets and 17 in the university's health policy review. Of the 22 in major outlets, 21 received editing from either peers or faculty.

DISCUSSION

An op-ed writing curriculum can be integrated into an existing medical school health policy course, resulting in a high level of engagement and in published op-eds by medical students.

US Medical-Legal Partnerships to Address Health-Harming Legal Needs: Closing the Health Injustice Gap

The medical-legal partnership (MLP) model is emerging across the USA as a powerful tool to address the adverse social conditions underlying health injustice. MLPs embed legal experts into healthcare teams to address health-harming legal needs with civil legal remedies. We conducted a narrative review of peer-reviewed articles published between 2007 and 2022 to characterize the structure and impacts of US MLPs on patients, providers, and healthcare systems. We found that MLPs largely serve vulnerable patient populations by integrating legal experts into community-based clinical settings or children's hospitals, although patient populations and settings varied widely. In most models, healthcare providers were trained to screen patients for legal needs and refer them to legal experts. MLPs provided a wide range of services, such as assistance accessing public benefits (e.g., Social Security, Medicaid, cash assistance) and legal representation for immigration and family law matters. Patients and their families also benefited from increased knowledge about legal rights and systems. Though the evidence base remains nascent, available studies show MLPs to be associated with greater access to care, fewer hospitalizations, and improved physical and mental health outcomes. Medical and legal providers who were engaged in MLPs reported interdisciplinary learning, and healthcare systems often experienced high returns on investment through cost savings and increased Medicaid reimbursement. Many MLPs also conducted advocacy and education to effect broader policy changes related to population health and social needs. To optimize the MLP model, more rigorous research, systematic implementation practices, evaluation metrics, and sustainable funding mechanisms are recommended. Broader integration of MLPs into healthcare systems could help address root causes of health inequity among historically marginalized populations in the USA.

Association of high-priority exceptions with waitlist mortality among heart transplant candidates

BACKGROUND

The US heart allocation system ranks candidates using six categorical status levels. Transplant programs can request exceptions to increase a candidate's status level if they believe their candidate has the same medical urgency as candidates who meet the standard criteria for that level. We aimed to determine if exception candidates have the same medical urgency as standard candidates.

METHODS

Using the Scientific Registry of Transplant Recipients, we constructed a longitudinal waitlist history dataset of adult heart-only transplant candidates listed between October 18, 2018 and December 1, 2021. We estimated the association between exceptions and waitlist mortality with a mixed-effects Cox proportional hazards model that treated status and exceptions as time-dependent covariates.

RESULTS

Out of 12,458 candidates listed during the study period, 2273 (18.2%) received an exception at listing and 1957 (15.7%) received an exception after listing. After controlling for status, exception candidates had approximately half the risk of waitlist mortality as standard candidates (hazard ratio [HR] 0.55, 95% confidence interval [CI] [0.41, 0.73], p < .001). Exceptions were associated with a 51% lower risk of waitlist mortality among Status 1 candidates (HR 0.49, 95% CI [0.27, 0.91], p = .023) and a 61% lower risk among Status 2 candidates (HR 0.39, 95% CI [0.24, 0.62], p < .001).

CONCLUSIONS

Under the new heart allocation policy, exception candidates had significantly lower waitlist mortality than standard candidates, including exceptions for the highest priority statuses. These results suggest that candidates with exceptions, on average, have a lower level of medical urgency than candidates who meet standard criteria.

Inequities in Treatments and Outcomes Among Patients Hospitalized With Hypertrophic Cardiomyopathy in the United States

Background Hypertrophic cardiomyopathy (HCM) is the most common heritable cardiac disease. In small studies, sociodemographic factors have been associated with disparities in septal reduction therapy, but little is known about the association of sociodemographic factors with HCM treatments and outcomes more broadly. Methods and Results Using the National Inpatient Survey from 2012 to 2018, HCM diagnoses and procedures were identified by International Classification of Diseases, Ninth/Tenth Revision, Clinical Modification (ICD-9-CM and ICD-10-CM) codes. Logistic regression was used to determine the association of sociodemographic risk factors with HCM procedures and in-hospital death, adjusting for clinical comorbidities and hospital characteristics. Of 53 117 patients hospitalized with HCM, 57.7% were women, 20.5% were Black individuals, 27.7% lived in the lowest zip income quartile, and 14.7% lived in rural areas. Among those with obstruction (45.2%), compared with White patients, Black patients were less likely to undergo septal myectomy (adjusted odds ratio [aOR], 0.52 [95% CI, 0.40-0.68]), or alcohol septal ablation (aOR, 0.60 [95% CI, 0.42-0.86]). Patients with Medicaid were less likely to undergo each procedure (aOR, 0.78 [95% CI, 0.61-0.99] for myectomy; aOR, 0.54 [95% CI, 0.36-0.83] for ablation). Women (aOR, 0.66 [95% CI, 0.58-0.74]), patients with Medicaid (aOR, 0.78 [95% CI, 0.65-0.93]), and patients from low-income areas (aOR, 0.77 [95% CI, 0.65-0.93]) were less likely to receive implantable cardioverter-defibrillators. Women (aOR, 1.23 [95% CI, 1.10-1.37]) and patients from towns (aOR, 1.16 [95% CI, 1.03-1.31]) or rural areas (aOR, 1.57 [95% CI, 1.30-1.89]) had higher odds of in-hospital death. Conclusions Among 53 117 patients hospitalized with HCM, race, sex, social, and geographic risk factors were associated with disparities in HCM outcomes and treatment. Further research is required to identify and address the sources of these inequities.

Racial Inequities Across Rural Strata in Acute Stroke Care and In-Hospital Mortality: National Trends Over 6 Years

BACKGROUND

There are glaring racial and rural-urban inequities in stroke outcomes. The objective of this study was to determine whether there were recent changes to trends in racial inequities in stroke treatment and in-hospital mortality, and whether racial inequities differed across rural strata.

METHODS

Retrospective analysis of Black and White patients >18 years old admitted to US acute care hospitals with a primary discharge diagnosis of stroke (unweighted N=652 836) from the National Inpatient Sample from 2012 to 2017. Rural residence was classified by county as urban, town, or rural. The primary outcomes were intravenous thrombolysis and endovascular therapy use among patients with acute ischemic stroke, and in-hospital mortality for all stroke patients. Logistic regression models were run for each outcome adjusting for age, comorbidities, primary payer, and ZIP code median income.

RESULTS

The sample was 53% female, 81% White, and 19% Black. Black patients from rural areas had the lowest odds of receiving intravenous thrombolysis (adjusted odds ratio [aOR], 0.43 [95% CI, 0.37-0.50]) and endovascular therapy (aOR, 0.60 [0.46-0.78]), compared with White urban patients. Black rural patients were the least likely to be discharged home after a stroke compared with White/urban patients (aOR, 0.79 [0.75-0.83]), this was true for Black patients across the urban-rural spectrum when compared with Whites. Black patients from urban areas had lower mortality than White patients from urban areas (aOR, 0.87 [0.84-0.91]), while White patients from rural areas (aOR, 1.14 [1.10-1.19]) had the highest mortality of all groups.

CONCLUSIONS

Black patients living in rural areas represent a particularly high-risk group for poor access to advanced stroke care and impaired poststroke functional status. Rural White patients have the highest in-hospital mortality. Clinical and policy interventions are needed to improve access and reduce inequities in stroke care and outcomes.

Impact of the COVID-19 Pandemic on Patients Without COVID-19 With Acute Myocardial Infarction and Heart Failure

Background Excess mortality from cardiovascular disease during the COVID-19 pandemic has been reported. The mechanism is unclear but may include delay or deferral of care, or differential treatment during hospitalization because of strains on hospital capacity. Methods and Results We used emergency department and inpatient data from a 12-hospital health system to examine changes in volume, patient age and comorbidities, treatment (right- and left-heart catheterization), and outcomes for patients with acute myocardial infarction (AMI) and heart failure (HF) during the COVID-19 pandemic compared with pre-COVID-19 (2018 and 2019), controlling for seasonal variation. We analyzed 27 427 emergency department visits or hospitalizations. Patient volume decreased during COVID-19 for both HF and AMI, but age, race, sex, and medical comorbidities were similar before and during COVID-19 for both groups. Acuity increased for AMI as measured by the proportion of patients with ST-segment elevation. There were no differences in right-heart catheterization for patients with HF or in left heart catheterization for patients with AMI. In-hospital mortality increased for AMI during COVID-19 (odds ratio [OR], 1.46; 95% CI, 1.21-1.76), particularly among the ST-segment-elevation myocardial infarction subgroup (OR, 2.57; 95% CI, 2.24-2.96), but was unchanged for HF (OR, 1.02; 95% CI, 0.89-1.16). Conclusions Cardiovascular volume decreased during COVID-19. Despite similar patient age and comorbidities and in-hospital treatments during COVID-19, mortality increased for patients with AMI but not patients with HF. Given that AMI is a time-sensitive condition, delay or deferral of care rather than changes in hospital care delivery may have led to worse cardiovascular outcomes during COVID-19.

Aortic Size and Clinical Care Pathways Before Type A Aortic Dissection

Patients with aortic enlargement are recommended to undergo serial imaging and clinical follow-up until they reach surgical thresholds. This study aimed to identify aortic diameter and care of patients with aortic imaging before aortic dissection (AD). In a retrospective cohort of AD patients, we evaluated previous imaging results in addition to ordering providers and indications. Imaging was stratified as >1 or <1 year: 62 patients (53% men) had aortic imaging before AD (most recent test: 82% echo, 11% computed tomography, 6% magnetic resonance imaging). Imaging was ordered most frequently by primary care physicians (35%) and cardiologists (39%). The most frequent imaging indications were arrhythmia (11%), dyspnea (10%), before or after aortic valve surgery (8%), chest pain (6%), and aneurysm surveillance in 13%. Of all patients, 94% had aortic diameters below the surgical threshold before the AD. Imaging was performed <1 year before AD in 47% and aortic size was 4.4 ± 0.8 cm in ascending aorta and 4.0 ± 0.8 cm in sinus. In patients whose most recent imaging was >1 year before AD (1,317 ± 1,017 days), the mean ascending aortic diameter was 4.2 ± 0.4 cm. In conclusion, in a series of patients with aortic imaging before AD, the aortic size was far short of surgical thresholds in 94% of the group. In >50%, imaging was last performed >1 year before dissection.

Reducing Cardiovascular Maternal Mortality by Extending Medicaid for Postpartum Women

Maternal mortality has been increasing in the United States over the past 3 decades, while decreasing in all other high-income countries during the same period. Cardiovascular conditions account for over one fourth of maternal deaths, with two thirds of deaths occurring in the postpartum period. There are also significant healthcare disparities that have been identified in women experiencing maternal morbidity and mortality, with Black women at 3 to 4 times the risk of death as their White counterparts and women in rural areas at heightened risk for cardiovascular morbidity and maternal morbidity. However, many maternal deaths have been shown to be preventable, and improving access to care may be a key solution to addressing maternal cardiovascular mortality. Medicaid currently finances almost half of all births in the United States and is mandated to provide coverage for women with incomes up to 138% of the federal poverty level, for up to 60 days postpartum. In states that have not expanded coverage, new mothers become uninsured after 60 days. Medicaid expansion has been shown to reduce maternal mortality, particularly benefiting racial and ethnic minorities, likely through reduced insurance churn, improved postpartum access to care, and improved interpregnancy care. However, even among states with Medicaid expansion, significant care gaps exist. An additional proposed intervention to improve access to care in these high-risk populations is extension of Medicaid coverage for 1 year after delivery, which would provide the most benefit to women in Medicaid nonexpanded states, but also improve care to women in Medicaid expanded states.

Sociodemographic differences in utilization and outcomes for temporary cardiovascular mechanical support in the setting of cardiogenic shock

BACKGROUND

Temporary mechanical circulatory support (MCS) devices are increasingly used in cardiogenic shock, but whether sociodemographic differences by sex, race and/or ethnicity, insurance status, and neighborhood poverty exist in the utilization of these devices is unknown.

METHODS

Retrospective cross-sectional study using the National Inpatient Sample for 2012-2017. Logistic regression models were used to examine predictors of use of temporary MCS devices and for in-hospital mortality, clustering by hospital-year.

RESULTS

Our study population included 109,327 admissions for cardiogenic shock. Overall, 14.3% of admissions received an intra-aortic balloon pump, 4.2% a percutaneous ventricular assist device, and 1.8% extracorporeal membranous oxygenation (ECMO). After adjusting for age, comorbidities, and hospital characteristics, use of temporary MCS was lower in women compared to men (adjusted odds ratio [aOR] = 0.76, P < .001), Black patients compared to white ones (aOR = 0.73, P < .001), those insured by Medicare (aOR = 0.75, P < .001), Medicaid (aOR = 0.74, P < .001), or uninsured (aOR = 0.90, P = .015) compared to privately insured, and those in the lowest income neighborhoods (aOR = 0.94, P = .003) versus other neighborhoods. Women, admissions covered by Medicare, Medicaid, or uninsured, and those from low-income neighborhoods also had higher mortality rates even after adjustment for MCS implantation.

CONCLUSIONS

There are differences in the use of temporary MCS in the setting of cardiogenic shock among specific populations within the United States. The growing use of MCS for treating cardiogenic shock highlights the need to better understand its impact on outcomes.

A sign on CT that predicts a hazardous ureteral anomaly

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In a prior case series, we noted a sign on CT associated with inguinoscrotal herniation of the ureter.

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In this study, we analyzed all CT urograms performed at our institution over 1 year.

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Deviation of the ureter from the psoas muscle at L4 by >1 cm should raise suspicion for a distal ureteral anomaly.

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Morbid obesity and congenital anomalies may result in a similar imaging appearance.

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Awareness of this anomaly can have significant operative implications.

Introduction

An aberrant course of the distal ureter can pose a risk of ureteral injury during surgery for inguinal hernia repair and other groin operations. In a recent case series of inguinoscrotal hernation of the ureter, we found that each affected ureter was markedly anterior to the psoas muscle at its mid-point on abdominal CT. We hypothesized that this abnormality in the abdominal course of the ureter would predict the potentially hazardous aberrant course of the distal ureter.

Presentation of cases

We reviewed all evaluable CT urograms performed at St. Louis University Hospital from June 2012 to July 2013 and measured the ureteral course at several anatomically fixed points.

Discussion

93% (50/54) of ureters deviated by less than 1 cm from the psoas muscle in their mid-course (at the level of the L4 vertebra). Reasons for anterior deviation of the ureter in this study included morbid obesity with prominent retroperitoneal fat, congenital renal abnormality, and post-traumatic renal/retroperitoneal hematoma. We determined that the optimal level on abdominal CT to detect the displaced ureter was the mid-body of the L4 vertebra.

Conclusion

Anterior deviation of the ureter in its mid-course appears to predict inguinoscrotal herniation of the ureter. This finding is a sensitive predictor and should raise concern for this anomaly in the appropriate clinical setting. It is not entirely specific as morbid obesity and congenital anomalies may result in a similar imaging appearance. We believe that this association has not been reported previously. Awareness of this anomaly can have significant operative implications.

Diffusion-weighted MRI hyperintensity patterns differentiate CJD from other rapid dementias

BACKGROUND

Diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) MRI have high sensitivity and specificity for Creutzfeldt-Jakob disease (CJD). No studies, however, have demonstrated how MRI can distinguish CJD from nonprion causes of rapidly progressive dementia (npRPD). We sought to determine the diagnostic accuracy of MRI for CJD compared to a cohort of npRPD subjects.

METHODS

Two neuroradiologists blinded to diagnosis assessed DWI and FLAIR images in 90 patients with npRPD (n = 29) or prion disease (sporadic CJD [sCJD], n = 48, or genetic prion disease [familial CJD, n = 6, and Gerstmann-Sträussler-Scheinker, n = 7]). Thirty-one gray matter regions per hemisphere were assessed for abnormal hyperintensities. The likelihood of CJD was assessed using our previously published criteria.

RESULTS

Gray matter hyperintensities (DWI > FLAIR) were found in all sCJD cases, with certain regions preferentially involved, but never only in limbic regions, and rarely in the precentral gyrus. In all sCJD cases with basal ganglia or thalamic DWI hyperintensities, there was associated restricted diffusion (apparent diffusion coefficient [ADC] map). This restricted diffusion, however, was not seen in any npRPD cases, in whom isolated limbic hyperintensities (FLAIR > DWI) were common. One reader's sensitivity and specificity for sCJD was 94% and 100%, respectively, the other's was 92% and 72%. After consensus review, the readers' combined MRI sensitivity and specificity for sCJD was 96% and 93%, respectively. Familial CJD had overlapping MRI features with sCJD.

CONCLUSIONS

The pattern of FLAIR/DWI hyperintensity and restricted diffusion can differentiate sCJD from other RPDs with a high sensitivity and specificity. MRI with DWI and ADC should be included in sCJD diagnostic criteria. New sCJD MRI criteria are proposed.

How surgeon age affects post-treatment surveillance strategies for melanoma patients

The intensity of post-treatment melanoma patient follow-up varies widely among physicians. We investigated whether physician age accounts for the observed variation in surveillance intensity among plastic surgeons. A custom-designed questionnaire was mailed to USA and non-USA surgeons, all of whom were members of the American Society of Plastic and Reconstructive Surgeons. Subjects were asked how they use 14 specific follow-up modalities during years 1-5 and 10 following primary treatment for patients with cutaneous melanoma. Repeated-measures analysis of variance was used to compare practice patterns by TNM stage, year post-surgery, and age. Of the 3,032 questionnaires mailed, 1,142 (38%) were returned. Of those returned, 395 (35%) were evaluable. Non-evaluability was usually due to lack of melanoma patient follow-up in surgeons' practices. Follow-up strategies for most of the 14 modalities were highly correlated across TNM stages and years post-surgery, as expected. The pattern of testing varied significantly by surgeon age for 3 modalities (complete blood count, liver function tests, and chest X-ray), but the variation was quite small. We concluded that the post-treatment surveillance practice patterns of ASPRS members caring for patients with cutaneous melanoma vary only marginally with physician age. Continuing medical education could account for this observation.

Effect of initial tumor stage on patient follow-up after potentially curative surgery for cutaneous melanoma

The optimal follow-up strategy after completion of therapy for melanoma is not known. We evaluated the effect of TNM stage on the self-reported surveillance strategies employed by practicing plastic surgeons caring for otherwise healthy patients subjected to potentially curative treatment for cutaneous melanoma. Hypothetical patient profiles and a detailed questionnaire based on these profiles were mailed to a random sample (N=3,032) of the 4,320 members of the American Society of Plastic and Reconstructive Surgeons. The effect of TNM stage on the surveillance strategies chosen was analyzed by repeated-measures ANOVA. There were 1,142 responses to the 3,032 surveys; 395 were evaluable. Plastic surgeons often do not provide postoperative follow-up themselves; this was the most frequent reason for non-evaluability. Surveillance of patients after resection of melanoma relies most heavily on office visits, chest X-ray, CBC, and liver function tests. All other surveillance modalities are used infrequently. Most respondents modify their surveillance practices slightly according to the patient's initial TNM stage. Most commonly used modalities are employed significantly more frequently with increasing TNM stage. This effect persists through ten years of follow-up, but the differences across stages are tiny. We conclude that most plastic surgeons performing surveillance after potentially curative surgery in otherwise healthy patients with melanoma use similar follow-up strategies for patients of all TNM stages. These data permit the rational design of a controlled clinical trial of high-intensity vs. low-intensity follow-up.

Current practice of patient follow-up after potentially curative resection of cutaneous melanoma

Follow-up care for patients who have undergone potentially curative resection of cutaneous melanoma varies widely among physicians, and the underlying rationale has not been assessed. To quantify current practice patterns and to discern motivation, a custom-designed questionnaire was mailed to U.S. and non-U.S. surgeons, all of whom were members of the American Society of Plastic and Reconstructive Surgeons (ASPRS). Surveys were mailed to 3,032 ASPRS members, chosen randomly from a total of 4,320 members. Of the 1,142 questionnaires that were returned, 395 were evaluable. Nonevaluability was usually due to lack of melanoma patients receiving follow-up in the surgeons' practices. Surveillance of patients after resection of melanoma relies most heavily on office visit, chest x-ray, complete blood count, and liver function tests. There was surprisingly little influence of elective node dissection on follow-up practices. Imaging tests such as computed tomography, magnetic resonance imaging, and position emission tomography scan were rarely employed. Surveillance is motivated by many factors, particularly early detection of recurrence of the index melanoma and second primary melanomas. This survey provides information regarding current follow-up strategies recommended by ASPRS surgeons after potentially curative resection of cutaneous melanoma. There is considerable variation in surveillance intensity and in motivation among practitioners, thus representing a lack of consensus.