Does clinical research account for diversity in deploying digital health technologies?

Digital health technologies (DHTs) should expand access to clinical research to represent the social determinants of health (SDoH) across the population. The frequency of reporting participant SDoH data in clinical publications is low and is not known for studies that utilize DHTs. We evaluated representation of 11 SDoH domains in 126 DHT-enabled clinical research publications and proposed a framework under which these domains could be captured and subsequently reported in future studies. Sex, Race, and Education were most frequently reported (in 94.4%, 27.8%, and 20.6% of publications, respectively). The remaining 8 domains were reported in fewer than 10% of publications. Medical codes were identified that map to each of the proposed SDoH domains and the resulting resource is suggested to highlight that existing infrastructure could be used to capture SDoH data. An opportunity exists to increase reporting on the representation of SDoH among participants to encourage equitable and inclusive research progress through DHT-enabled clinical studies.

Racial, Ethnic, and Language-Based Inequities in Inpatient Opioid Prescribing by Diagnosis from Internal Medicine Services, a Retrospective Cohort Study

Introduction

Opioid administration is extremely common in the inpatient setting, yet we do not know how the administration of opioids varies across different medical conditions and patient characteristics on internal medicine services. Our goal was to assess racial, ethnic, and language-based inequities in opioid prescribing practices for patients admitted to internal medicine services.

Methods

We conducted a retrospective cohort study of all adult patients admitted to internal medicine services from 2013 to 2021 and identified subcohorts of patients treated for the six most frequent primary hospital conditions (pneumonia, sepsis, cellulitis, gastrointestinal bleed, pyelonephritis/urinary tract infection, and respiratory disease) and three select conditions typically associated with pain (abdominal pain, acute back pain, and pancreatitis). We conducted a negative binomial regression analysis to determine how average administered daily opioids, measured as morphine milligram equivalents (MMEs), were associated with race, ethnicity, and language, while adjusting for additional patient demographics, hospitalization characteristics, medical comorbidities, prior opioid therapy, and substance use disorders.

Results

The study cohort included 61,831 patient hospitalizations. In adjusted models, we found that patients with limited English proficiency received significantly fewer opioids (66 MMEs, 95% CI: 52, 80) compared to English-speaking patients (101 MMEs, 95% CI: 91, 111). Asian (59 MMEs, 95% CI: 51, 66), Latinx (89 MMEs, 95% CI: 79, 100), and multi-race/ethnicity patients (81 MMEs, 95% CI: 65, 97) received significantly fewer opioids compared to white patients (103 MMEs, 95% CI: 94, 112). American Indian/Alaska Native (227 MMEs, 95% CI: 110, 344) patients received significantly more opioids. Significant inequities were also identified across race, ethnicity, and language groups when analyses were conducted within the subcohorts. Most notably, Asian and Latinx patients received significantly fewer MMEs and American Indian/Alaska Native patients received significantly more MMEs compared to white patients for the top six most frequent conditions. Most patients from minority groups also received fewer MMEs compared to white patients for three select pain conditions. Discussion. There are notable inequities in opioid prescribing based on patient race, ethnicity, and language status for those admitted to inpatient internal medicine services across all conditions and in the subcohorts of the six most frequent hospital conditions and three pain-associated conditions. This represents an institutional and societal opportunity for quality improvement initiatives to promote equitable pain management.

Association of Language Barriers With Perioperative and Surgical Outcomes: A Systematic Review

Importance

English language proficiency has been reported to correlate with disparities in health outcomes. Therefore, it is important to identify and describe the association of language barriers with perioperative care and surgical outcomes to inform efforts aimed at reducing health care disparities.

Objective

To examine whether limited English proficiency compared with English proficiency in adult patients is associated with differences in perioperative care and surgical outcomes.

Evidence Review

A systematic review was conducted in MEDLINE, Embase, Web of Science, Sociological Abstracts, and CINAHL of all English-language publications from database inception to December 7, 2022. Searches included Medical Subject Headings terms related to language barriers, perioperative or surgical care, and perioperative outcomes. Studies that investigated adults in perioperative settings and involved quantitative data comparing cohorts with limited English proficiency and English proficiency were included. The quality of studies was evaluated using the Newcastle-Ottawa Scale. Because of heterogeneity in analysis and reported outcomes, data were not pooled for quantitative analysis. Results are reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guideline.

Findings

Of 2230 unique records identified, 29 were eligible for inclusion (281 266 total patients; mean [SD] age, 57.2 [10.0] years; 121 772 [43.3%] male and 159 240 [56.6%] female). Included studies were observational cohort studies, except for a single cross-sectional study. Median cohort size was 1763 (IQR, 266-7402), with a median limited English proficiency cohort size of 179 (IQR, 51-671). Six studies explored access to surgery, 4 assessed delays in surgical care, 14 assessed surgical admission length of stay, 4 assessed discharge disposition, 10 assessed mortality, 5 assessed postoperative complications, 9 assessed unplanned readmissions, 2 assessed pain management, and 3 assessed functional outcomes. Surgical patients with limited English proficiency were more likely to experience reduced access in 4 of 6 studies, delays in obtaining care in 3 of 4 studies, longer surgical admission length of stay in 6 of 14 studies, and more likely discharge to a skilled facility than patients with English proficiency in 3 of 4 studies. Some additional differences in associations were found between patients with limited English proficiency who spoke Spanish vs other languages. Mortality, postoperative complications, and unplanned readmissions had fewer significant associations with English proficiency status.

Conclusions and Relevance

In this systematic review, most of the included studies found associations between English proficiency and multiple perioperative process-of-care outcomes, but fewer associations were seen between English proficiency and clinical outcomes. Because of limitations of the existing research, including study heterogeneity and residual confounding, mediators of the observed associations remain unclear. Standardized reporting and higher-quality studies are needed to understand the impact of language barriers on perioperative health disparities and identify opportunities to reduce related perioperative health care disparities.

Knowledge Gaps in Anesthetic Gas Utilization in a Large Academic Hospital System: A Multicenter Survey

Inhaled anesthetics account for a significant portion of the greenhouse gases generated by perioperative services within the healthcare systems. This cross-sectional study aimed to identify knowledge gaps and practice patterns related to carbon dioxide (CO₂) absorbents and intraoperative delivery of fresh gas flows (FGF) for future sustainability endeavors. Secondary aims focused on differences in these knowledge gaps based on the level of training. Surveys were distributed at five large academic medical centers. In addition to site-specific CO₂ absorbent use and practice volume and experience, respondents at each institution were queried about individual practice with FGF rates during anesthetic maintenance as well as the cost-effectiveness and environmental impact of different volatile anesthetics. Results were stratified and analyzed by the level of training. In total, 368 (44% physicians, 30% residents, and 26% nurse anesthetists) respondents completed surveys. Seventy-six percent of respondents were unaware or unsure about which type of CO₂ absorbent was in use at their hospital. Fifty-nine percent and 48% of respondents used sevoflurane and desflurane with FGF ≥1 L/min, respectively. Most participants identified desflurane as the agent with the greatest environmental impact (89.9%) and a greater proportion of anesthesiologists correctly identified isoflurane as a cost-effective anesthetic (78.3%, p=0.02). Knowledge gaps about in-use CO₂ absorbent and optimal FGF usage were identified within the anesthesia care team. Educational initiatives to increase awareness about the carbon emissions from anesthesia and newer CO₂ absorbents will impact the environmental and economic cost per case and align anesthesia providers toward healthcare decarbonization.

Unused opioid prescription prevalence after pediatric ambulatory surgery: a survey study

Background

Surgery is a risk factor for opioid initiation, persistent use, and subsequent misuse in pediatric patients. The objective of this study was to assess the rate of postoperative opioid prescribing and extent of unused opioid prescriptions on the first postoperative day after pediatric ambulatory surgery.

Methods

A telephone survey was administered on postoperative day 1 (POD1) to guardians of all pediatric patients who underwent ambulatory surgery at a single medical center. Participants were asked whether postoperative opioids were prescribed, and, if yes, whether they were currently taking them. Multivariable logistic regression was used to assess factors associated with postoperative opioid prescribing and unused opioids on POD1.

Results

Of 1344 pediatric patients who underwent ambulatory surgical procedures, 849 (63.1%) guardians responded to the survey. 275 (32.4%) were prescribed postoperative opioids, and 164 (59.6%) reported not taking opioids on POD1. The highest rates of unused opioid prescriptions were from orthopedic and plastic surgery services (28% and 29%, respectively). Governmental insurance status predicted having unused opioids (OR 0.59, CI 0.35–0.97).

Conclusions

Unused opioid prescriptions were prevalent in this pediatric ambulatory surgical population. Opportunities remain to streamline opioid prescribing in pediatric patients undergoing ambulatory surgical procedures.

Association of Language Barriers With Process Outcomes After Craniotomy for Brain Tumor

BACKGROUND

Little is known about the independent association of language barriers on postoperative process outcomes after craniotomies.

OBJECTIVE

To evaluate the association of limited English proficiency (LEP) with length of stay (LOS), discharge disposition, hospitalization costs, and rate of 30-day readmission after craniotomy for brain tumor.

METHODS

This is a retrospective cohort study of adult patients who underwent craniotomies for brain tumor from 2015 to 2019 at a high-volume neurosurgical center. Multivariable logistic regression was used to evaluate the association of LEP with discharge disposition and 30-day readmission. Negative binomial regression was used to evaluate the association of LEP with LOS and hospitalization cost.

RESULTS

Of the 2232 patients included, 7% had LEP. LEP patients had longer LOS (median [IQR] 5 [3-8] days vs 3 [2-5] days, P < .001), higher costs of hospitalization (median [IQR] $27 000 [$21 000-$36 000] vs $23 000 [$19 000-$30 000], P < .001), and were more likely to be discharged to skilled care facilities (37% vs 21%, P < .001) compared with English proficient patients. In multivariable models, the association between LEP and longer LOS (incidence rate ratio 1.11, 95% CI 1.00-1.24), higher hospitalization costs (incidence rate ratio 1.13, 95% CI 1.05-1.20), and discharge to skilled care (OR 1.76, 95% CI 1.13-2.72) remained after adjusting for confounders. There was no difference in 30-day readmission rates by language status.

CONCLUSION

LEP is an independent risk factor for extended LOS, higher hospitalization cost, and discharge to skilled care in neurosurgical patients who undergo craniotomy for brain tumor. Future research should seek to understand mediators of these observed disparities.

Language barriers and postoperative opioid prescription use after total knee arthroplasty

Background

Patients with limited English proficiency (LEP) face difficulties in access to postoperative follow-up care, including post-discharge medication refills. However, prior studies have not examined how utilization of prescription pain medications after discharge from joint replacement surgeries differs between English proficient (EP) and LEP patients.

Objective

This study explored the relationship between English language proficiency and opioid prescription refill requests after hospital discharge for total knee arthroplasty (TKA).

Methods

This was an observational cohort study of patients ≥18 years of age who underwent TKA between January 2015 and December 2019 at a single academic center. LEP status was defined as not having English as the primary language and requesting an interpreter. Primary outcome variables included opioid pain medication refill requests between 0 and 90 days from discharge. Multivariable logistic regression modeling calculated the odds ratios of requesting an opioid refill.

Results

A total of 2148 patients underwent TKA, and 9.8% had LEP. Postoperative pain levels and rates of prior opioid use did not differ between LEP and EP patients. LEP patients were less likely to request an opioid prescription refill within 30 days (35.3% vs 52.4%, p < 0.001), 60 days (48.7% vs 61.0%, p = 0.004), and 90 days (54.0% vs 62.9%, p = 0.041) after discharge. In multivariable analysis, LEP patients had an odds ratio of 0.61 of requesting an opioid refill (95% CI, 0.41–0.92, p = 0.019) within 30 days of discharge. Having Medicare insurance and longer lengths of hospitalization were correlated with lower odds of 0–30 days opioid refills, while prior opioid use and being discharged home were associated with higher odds of opioid refill requests 0–30 days after discharge for TKA.

Conclusions

Language barriers may contribute to poorer access to postoperative care, including prescription medication refills. Barriers to postoperative care may exist at multiple levels for LEP patients undergoing surgical procedures.

Association of English Language Proficiency With Hospitalization Cost, Length of Stay, Disposition Location, and Readmission Following Total Joint Arthroplasty

This cohort study examines patient outcomes following total joint arthroplasty to evaluate their association with limited English proficiency.

Development and validation of the safe transfusion assessment tool

BACKGROUND

Given the prevalence and risks of blood transfusion, it is essential that trainees and practicing clinicians have a thorough understanding of relevant transfusion medicine competencies. The aim of this research was to develop and gather validity evidence for an instrument to assess knowledge of core transfusion-related competencies.

METHODS

We developed the safe transfusion assessment tool (STAT) using a multistep process. Initially, 20 core competencies in transfusion medicine were identified through a consensus-driven Delphi process. Learning objectives and assessment items pertinent to each competency were created. Next, a 13-item assessment tool was piloted with multidisciplinary experts and trainees. Multiple iterative revisions were made based on feedback. Finally, the 12-item STAT was administered to 100 participants of varying training level and specialty to establish validity, difficulty and item discrimination indices, and perceived utility.

RESULTS

Analysis of instrument item difficulty and item discrimination indices demonstrated the ability of the STAT to assess essential knowledge in transfusion medicine relevant to trainees and clinicians in multiple programs and practice settings. Eight of twelve items discriminated between learners with varying degrees of expertise. Hundred percent of students and trainees rated the STAT as Extremely Helpful or Somewhat Helpful and the majority planned to utilize the answer guide as a study aid.

CONCLUSION

The STAT is a concise, valid, and reliable knowledge assessment tool that may be used by researchers and educators to augment transfusion medicine curricula (www.safetransfusion.ucsf.edu). Scores can help inform departments on areas in which trainees require additional support and areas of potential educational interventions.

Limited use of nonopioid analgesics after pediatric ambulatory surgery

OBJECTIVE

This study sought to determine the rate at which nonopioid analgesics were utilized in postoperative pain management plans after pediatric ambulatory surgery in patients who were also prescribed postoperative opioids.

DESIGN

Retrospective cohort analysis.

PARTICIPANTS

Patients ≤ 21 years old who were prescribed opioid medications after undergoing ambulatory surgery at a tertiary-care medical center.

METHODS

Postoperative day 1 (POD1) opioid prescription and use survey data along with electronic medical record data were extracted and analyzed for patients meeting inclusion criteria between April 2017 and December 2017.

MAIN OUTCOME MEASURE

Recommendation to take nonopioid analgesics after discharge.

RESULTS

A total of 849 (63.2 percent) patients responded to the survey and 275 (32.4 percent) of these cases were prescribed postoperative opioids. Of the 273 cases included in this study, 137 (50.2 percent) received recommendations to take at least one nonopioid analgesic as well, and 164 (60.1 percent) reported using their prescribed opioids on POD1. Opioid use did not vary significantly with nonopioid analgesic recommendations. There was significant variability in opioid and nonopioid analgesic prescribing and recommendation patterns across surgical subspecialties.

CONCLUSIONS

There was limited use of nonopioid analgesics in postoperative pain management plans after pediatric ambulatory surgery. This leaves many patients with only opioid-based agents as the first-line medication for postoperative pain management. These findings highlight an opportunity to educate prescribers and patients on the importance of step-wise multimodal analgesic plans.

Mentoring up: Twelve tips for successfully employing a mentee-driven approach to mentoring relationships

Effective mentorship is critical for achieving professional success, influencing outcomes such as career selection and advancement, self-confidence and performance, and sense of community and fulfillment. Despite the established importance of mentorship, however, mentoring relationships can be challenging to develop and sustain. 'Mentoring up' is a concept adapted from the business concept of 'managing up' that encourages mentees to actively drive their mentoring relationships to ensure desired results. In this article, we hope to empower mentees with twelve strategies and practical steps to cultivate and maintain quality mentoring relationships, and successfully drive their mentoring relationships in a direction that serves their needs and achieves desired outcomes.

Defining core competencies in transfusion medicine for resident physicians: A multi-specialty Delphi consensus study

BACKGROUND

Although resident physicians across disciplines are responsible for ordering blood products and managing sequelae of blood product transfusion, no designated set of competencies in transfusion medicine has been established for postgraduate trainees. The primary goal of this study was to determine core transfusion-related competencies that such residents should possess.

STUDY DESIGN AND METHODS

A modified Delphi method was used to achieve consensus among a panel of clinical faculty and program leadership in six medical specialties to establish core transfusion-related competencies for resident physicians. Review of transfusion education literature, relevant clinical responsibilities, and specialty licensing requirements facilitated generation of an initial transfusion medicine topic list and additional topics were considered if suggested by experts. In two Delphi rounds, experts rated the clinical significance of initial topics on a 5-point Likert scale. Select topics were deemed core competencies if identified as Extremely Important or Moderately Important by at least 75% of panelists to meet a minimum content validity index (CVI) of 0.75 and if topics achieved a minimum content validity ratio (CVR) of 0.5.

RESULTS

Nineteen invited clinical experts completed both Delphi rounds with 100% completion across the two rounds. Twenty transfusion medicine topics achieved minimum CVI 0.75 and minimum CVR 0.5. Highest-ranked topics by level of importance include Red Blood Cell (RBC) Transfusion Indications, Platelet Transfusion Indications, and Pulmonary Reactions.

CONCLUSIONS

Multispecialty panelists across six medical specialties reached consensus in identification of core transfusion-related competencies for resident physicians. Such consensus-driven core competencies may inform the development of transfusion medicine curricula and assessments to improve transfusion safety.

Language-Related Disparities in Pain Management in the Post-Anesthesia Care Unit for Children Undergoing Laparoscopic Appendectomy

Race and ethnicity are associated with disparities in pain management in children. While low English language proficiency is correlated with minority race/ethnicity in the United States, it is less frequently explored in the study of health disparities. We therefore investigated whether English language proficiency influenced pain management in the post-anesthesia care unit (PACU) in a cohort of children who underwent laparoscopic appendectomy at our pediatric hospital in San Francisco. Our primary exposure was English language proficiency, and our primary outcome was administration of any opioid medication in the PACU. Secondary outcomes included the amount of opioid administered in the PACU and whether any pain score was recorded during the patient's recovery period. Statistical analysis included adjusting for demographic covariates including race in estimating the effect of language proficiency on these outcomes. In our cohort of 257 pediatric patients, 57 (22.2%) had low English proficiency (LEP). While LEP and English proficient (EP) patients received the same amount of opioid medication intraoperatively, in multivariable analysis, LEP patients had more than double the odds of receiving any opioid in the PACU (OR 2.45, 95% CI 1.22-4.92). LEP patients received more oral morphine equivalents (OME) than EP patients (1.64 OME/kg, CI 0.67-3.84), and they also had almost double the odds of having no pain score recorded during their PACU recovery period (OR 1.93, CI 0.79-4.73), although the precision of these estimates was limited by small sample size. Subgroup analysis showed that children over the age of 5 years, who were presumably more verbal and would therefore undergo verbal pain assessments, had over triple the odds of having no recorded pain score (OR 3.23, CI 1.48-7.06). In summary, English language proficiency may affect the management of children's pain in the perioperative setting. The etiology of this language-related disparity is likely multifactorial and should be investigated further.

Assessment of Unused Opioids Following Ambulatory Surgery

Background

Surgery is a risk factor for opioid initiation and subsequent abuse. Discharge opioid prescription patterns after surgery are often varied and not evidence based, which may lead to unnecessary prescription of opioids. We aimed to assess opioid prescribing and unused opioid prescriptions in ambulatory surgery patients at our academic hospital.

Methods

We conducted a retrospective observational study based on phone survey and electronic medical records. Adult patients who underwent ambulatory surgery at our large, multisite, tertiary-care hospital system were asked whether they were using the opioids that were prescribed at discharge. Our main outcomes were opioid prescription (defined as being prescribed an opioid on discharge) and unused opioid prescription (defined as being prescribed an opioid but not taking any opioids on postoperative day 1). We evaluated predictors of opioid prescription and unused opioid prescription through univariable and multivariable analyses. We also stratified outcomes by surgical service.

Results

Of 4248 adult patients who underwent ambulatory surgical procedures, 3279 (77.2%) responded to the survey. Of all responders, 2146 (65.4%) were prescribed postoperative opioids, and 1240 (57.8%) reported not taking them on postoperative day 1. The highest rates of unused opioid prescriptions were for patients whose primary service were orthopedic surgery (65%) and plastic surgery (62%).

Discussion

Opioid prescribing and unused opioid prescriptions are prevalent in our hospital’s ambulatory surgical population. Patients undergoing selected ambulatory surgical procedures may not require as much opioid as is currently being prescribed.

Millennial Resident Study Habits and Factors that Influence American Board of Anesthesiology In-Training Examination Performance: A Multi-Institutional Study

BACKGROUND

In this study, we described Millennial anesthesiology residents' learning preferences and study habits and how they correlate with performance on the In-Training Exam (ITE).

METHODS

A confidential questionnaire including personal characteristics, previous examination performance, study habits, study material preferences, and perceived residency program support was emailed to 1047 anesthesiology residents from 30 ACGME-accredited residency programs across the United States.

RESULTS

Four hundred and twelve residents (39.4%) responded to the survey, and 240 of those respondents (58.3%) self-reported their 2017 ITE scores. The majority (95.9%) were Millennials. Respondents preferentially used online multiple-choice questions (92.3%) to prepare for the ITE, but many also used traditional anesthesiology textbooks (35.5%) and review books (46.7%). Respondents preferred independent study (94.6%) to group study (5.4%), and handwritten notes (69.4%) to taking notes on a laptop (26.8%) or tablet (3.8%). Less than half (47.5%) of respondents felt supported by their residency program in exam preparation, and 30.7% felt lack of support. Factors correlated with ITE scores on univariate analysis included prior USMLE 1 scores (p < .0000) and USMLE 2 scores (p < .0000), clinical anesthesia year (p < .0000), test anxiety score (p = .0004), prior failure of the basic exam (p = .0026), and prior failure of any board exam (p = .0124).

CONCLUSIONS

Millennial learners have consistent performance on ITE exams regardless of personal characteristics, preferred study methods, or materials used. Prior exam performance is the most important predictor of future performance. Currently available study materials are meeting residents' needs and preferences, and while residency program offerings do not affect ITE performance, residents would like to feel more supported.