Evaluating the network adequacy of vision care services for children in Arizona: A cross sectional study

Background

Vision challenges are among the most prevalent disabling conditions in childhood, affecting up to 28% of school-age children. These issues can impact the development, learning, and literacy skills of affected children. While vision problems are correctable with timely diagnosis and treatment, insufficient networks can impede children's access to comprehensive, and high-quality care.

Objective

The study aims to determine where pediatric vision care network adequacy exists in the state of Arizona and where there are gaps in receiving vision care for children.

Methods

This cross-sectional study assessed the adequacy of pediatric vision care networks in Arizona through a "secret shopper" phone survey. Calls were made to practices that accept Arizona's Medicaid program, Arizona Health Care Cost Containment System (AHCCCS) and/or commercial insurance. Providers were contacted following a standardized script to schedule routine appointments on behalf of 10 and 3-year-old patients enrolled in either Medicaid or commercial health insurance plans. The study examined various components of children's access to vision care services, including the reliability of provider directory information, time until the next available appointment, bilingual service offerings, ages served, region of practice and types of care available.

Results

A total of 556 practices in Arizona were evaluated through simulations as patients on AHCCCS, and 510 practices were assessed through simulations as patients with commercial health insurance plans. The average wait time for the next available appointment was 13 days for both insurance types. Alarmingly, up to 74% of vision care practices in Arizona do not serve children covered by AHCCCS. Furthermore, only 41% provide services to children 5 years and younger.

Conclusions

Our findings underscore the need to improve access to vision care services for children in Arizona, especially racial/ethnic minorities, low-income groups, and rural residents.

Differences in Radiotherapy-Treated Members with Cancer during COVID-19 Pandemic Using Nationwide Claim Data

PURPOSE/OBJECTIVE(S)

This study aimed to identify the impact of the pandemic on radiotherapy activity among members with cancer.

MATERIALS/METHODS

This retrospective study included fully-insured commercial members of a large national payor with cancer aged ≥18 years undergoing radiotherapy from March 1, 2018 to February 28, 2022. Radiotherapy activity was defined as the mean weekly number of treatment courses and attendances (fractions) per month pre-COVID (March 2018 to February 2020); during COVID (March 2020 to February 2021); and post-COVID (March 2021 to February 2022). T-tests assessed differences between pre-COVID and post-COVID on radiotherapy activity by age, gender, and cancer type. Interrupted time series analysis (ITS) assessed change in activity overtime, controlling for pre-COVID trends and other potential confounders. A p-value of <0.05 was considered significant.

RESULTS

The study included 9,275 members, 10,121 courses, and 169,257 fractions; most members were female (57%), the mean age was 57 years (SD = 12). Overall, there was a decline in mean weekly number of courses from the pre-COVID to post-COVID (-18%, p<0.05) timeframe. Females < 70 years experienced the largest decline in mean weekly number of courses (-23%, p<0.05) followed by males aged 70+ (-16%, p<0.05) and males < 70 years (-16%, p<0.05). All cancer types saw a significant decline (p<0.05); breast cancer reported the largest decline (-21%, p<0.05). Fraction numbers significantly declined overall by 27% (p<0.05) from the pre-COVID to post-COVID timeframe. The largest decline in fraction numbers was observed in females < 70 (-28%, p<0.05) followed by males < 70 years (-24%, p<0.05) and males aged 70+ (-22%, p<0.05). No difference between COVID and pre-COVID weeks for courses was observed once pre-COVID trends were accounted for using ITS. Females aged 70+ received 25% (p<0.05) fewer fractions during COVID compared to pre-COVID; a decline which continued to grow even as the pandemic eased (March 2021 to February 2022). Males aged 70+ also experienced a decreased level of fractions during the pandemic (-30%, p<0.05), but increased in the recovery period (+24%, p<0.05). Males < 70 years had an increased level of fractions during the pandemic (+14%, p<0.05).

CONCLUSION

Radiation mean weekly number of courses and fractions between pre-COVID and post-COVID declined with the effect more pronounced in females < 70 years. A decrease in fraction number was observed in all cancer types; specifically, breast cancer had the largest decline. ITS analysis revealed no difference between COVID and pre-COVID weeks for courses as the downward trend was already present prior to the pandemic. These findings suggest while radiotherapy courses and fractions were significantly impacted, fractionation was decreased to a greater extent, indicating an increased adoption of hypofractionation during the pandemic.

Embryo selection through artificial intelligence versus embryologists: a systematic review

STUDY QUESTION

What is the present performance of artificial intelligence (AI) decision support during embryo selection compared to the standard embryo selection by embryologists?

SUMMARY ANSWER

AI consistently outperformed the clinical teams in all the studies focused on embryo morphology and clinical outcome prediction during embryo selection assessment.

WHAT IS KNOWN ALREADY

The ART success rate is ∼30%, with a worrying trend of increasing female age correlating with considerably worse results. As such, there have been ongoing efforts to address this low success rate through the development of new technologies. With the advent of AI, there is potential for machine learning to be applied in such a manner that areas limited by human subjectivity, such as embryo selection, can be enhanced through increased objectivity. Given the potential of AI to improve IVF success rates, it remains crucial to review the performance between AI and embryologists during embryo selection.

STUDY DESIGN SIZE DURATION

The search was done across PubMed, EMBASE, Ovid Medline, and IEEE Xplore from 1 June 2005 up to and including 7 January 2022. Included articles were also restricted to those written in English. Search terms utilized across all databases for the study were: ('Artificial intelligence' OR 'Machine Learning' OR 'Deep learning' OR 'Neural network') AND ('IVF' OR 'in vitro fertili*' OR 'assisted reproductive techn*' OR 'embryo'), where the character '*' refers the search engine to include any auto completion of the search term.

PARTICIPANTS/MATERIALS SETTING METHODS

A literature search was conducted for literature relating to AI applications to IVF. Primary outcomes of interest were accuracy, sensitivity, and specificity of the embryo morphology grade assessments and the likelihood of clinical outcomes, such as clinical pregnancy after IVF treatments. Risk of bias was assessed using the Modified Down and Black Checklist.

MAIN RESULTS AND THE ROLE OF CHANCE

Twenty articles were included in this review. There was no specific embryo assessment day across the studies-Day 1 until Day 5/6 of embryo development was investigated. The types of input for training AI algorithms were images and time-lapse (10/20), clinical information (6/20), and both images and clinical information (4/20). Each AI model demonstrated promise when compared to an embryologist's visual assessment. On average, the models predicted the likelihood of successful clinical pregnancy with greater accuracy than clinical embryologists, signifying greater reliability when compared to human prediction. The AI models performed at a median accuracy of 75.5% (range 59-94%) on predicting embryo morphology grade. The correct prediction (Ground Truth) was defined through the use of embryo images according to post embryologists' assessment following local respective guidelines. Using blind test datasets, the embryologists' accuracy prediction was 65.4% (range 47-75%) with the same ground truth provided by the original local respective assessment. Similarly, AI models had a median accuracy of 77.8% (range 68-90%) in predicting clinical pregnancy through the use of patient clinical treatment information compared to 64% (range 58-76%) when performed by embryologists. When both images/time-lapse and clinical information inputs were combined, the median accuracy by the AI models was higher at 81.5% (range 67-98%), while clinical embryologists had a median accuracy of 51% (range 43-59%).

LIMITATIONS REASONS FOR CAUTION

The findings of this review are based on studies that have not been prospectively evaluated in a clinical setting. Additionally, a fair comparison of all the studies were deemed unfeasible owing to the heterogeneity of the studies, development of the AI models, database employed and the study design and quality.

WIDER IMPLICATIONS OF THE FINDINGS

AI provides considerable promise to the IVF field and embryo selection. However, there needs to be a shift in developers' perception of the clinical outcome from successful implantation towards ongoing pregnancy or live birth. Additionally, existing models focus on locally generated databases and many lack external validation.

STUDY FUNDING/COMPETING INTERESTS

This study was funded by Monash Data Future Institute. All authors have no conflicts of interest to declare.

REGISTRATION NUMBER

CRD42021256333.

Physician Leadership and Advocacy for Team-Based Care

Team-based care is a strong focus and narrative in medical and health education and within health care systems. Yet it is essential to consider that there are vast differences in power, education, compensation, and job security among team members in most health professional teams. How should clinicians of status play a role in advocating for lower status members of their health care teams, and why is that role important in improving equity within clinic walls and equity and better patient care for the communities they serve?

To Assess the Factors Affecting Employee Engagement in Organizations during a COVID-19 Crisis

Purpose: To identify the steps taken by organizations during the time of crisis concerning Human Capital and understand the impact each of these steps has on the employee engagement for the employees within the organization. Proposed Design/Methodology/Approach: Post the literature review, qualitative research is conducted through indepth interviews with the Managers, who were part of the decision-making, in the organizations that went through crisis period (Sample size: 20-30) and a quantitative study is conducted to capture the perspectives of the employees from those organizations (Sample size: 70-100). Practical/Theoretical Implication: The study results enable organizations to stay cognizant of the pros and cons of the decisions they make in terms of employee engagement, which helps in successfully overcoming the crisis with minimal traction. Originality/Value: While there are standalone papers on each topic, this paper converges them coherently to study the overall effect from both employee’s and the organization’s perspectives.

O-261 In-vitro supplementation of vitamin B12 to improve post-thaw viability and DNA integrity

Study question

Does the supplementation of vitamin B12 protect the spermatozoa against damage caused by the freeze-thaw process further improving the overall post-thaw survival and DNA integrity?

Summary answer

The antioxidant property of vitamin B12 protects the spermatozoa and improves the post thaw motility, vitality, and reduces DNA damage caused by freeze-thaw process.

What is known already

Cryopreservation of spermatozoa is an effective way of fertility preservation in humans, often used in Assisted Reproductive Technology(ART). Despite the refinement in cryopreservation, the salvage of post-thaw sperms remains poor. The reactive oxygen species(ROS), that is formed as a result of freeze-thaw process is known to decrease the motility, plasma membrane integrity and increase the DNA fragmentation. Most vitamins have antioxidant properties, that protect the mammalian cells from oxidative stress one such vitamin is cyanocobalamin(vitamin B12). Vitamin B12 modulates oxidative stress through methionine synthase activity and also acts as a scavenger of ROS. Thus protecting the DNA against free radicals.

Study design, size, duration

This prospective observational study was performed for a period of 6 months in 111 men, who attended the fertility clinic. The study population included all semen samples except men with azoospermia, surgically retrieved samples and men on vitamin supplements. The study population contained men ageing between 21-40 years.

Participants/materials, setting, methods

Semen samples were analysed according to WHO 5th edition and were assessed for DNA fragmentation index (DFI) using sperm chromatin dispersion assay (SCD). The ejaculates were split into two as group A: semen samples with equal amount of cryoprotectant and group B: semen samples with equal amount of cryoprotectant supplemented with Vitamin B12 (2mg/ml). They were frozen for a minimum of 24 hrs. Post-thaw motility, vitality and DFI were assessed and compared.

Main results and the role of chance

The mean age of patients in our study was 34.26±4.7yrs. 58.5% of the study population had primary infertility. 37.8% of the study population had male factor infertility, 32.4% had oligoasthenoteratozoospermia(OAT), 31.1% had normozoospermia 16.2% had asthenoteratozoospermia, 13.5% had teratozoospermia, 3.6% had oligozoospermia and rest 2.7% had asthenozoospermia.

There was an overall increase in post thaw motility (41.59±18.09 vs 32.3±18.8,p=0.0005), progressive motility (21.54±13.02 vs 15.91±11.80,p=0.0005), vitality (57.14±15.09 vs 46.76±16.45,p=0.0005) and a significant decrease in DFI (26.69±10.03 vs 32.09±10.00,p=0.0005) in group B compared to group A.

Our study also demonstrated that, Normozoospermia patients had a significant increase in vitality (67.17±13.8 vs 58.51±12.0, p = 0.007) and lower DFI (22.68±9.3 vs 27.6±8.9, p = 0.02) in group B than in group A.

OAT patients had a significant increase in total motility (26.25±12.15 vs 15.7±11.4,p=0.0003), progressive motility (11.69±8.8 vs 6.14±5.8,p=0.0028), vitality (46.06±11.34 vs 34.31±12.99,p=0.0001) and significantly lower DFI (30.22±9.87 vs 36.08±9.7,p=0.012) in group B.

Teratozoospermia patients showed significant increase in progressive motility in group B (27.87±8.81 vs 19.33±10.69,p=0.02) and

Asthenoteratozoospermia patients showed significant increase in total motility (40.72± 13.14 vs 30.89±13.06,p=0.02) and vitality (54.39±12.28 vs 43.78±14.14,p=0.02) in group B.

However, in asthenozoospermic patients the parameters were comparable in both the groups.

Limitations, reasons for caution

Due to ethical reasons the samples were not used for in vitro procedures such as intrauterine insemination(IUI), in vitro fertilization (IVF) and intracytoplasmic sperm injection(ICSI). Hence, no inference was obtained regarding the fertilization rates/ pregnancy rates.

Wider implications of the findings

Our study demonstrated that with supplementation of vitamin B12 the recovery rate significantly increased and also preserved the DNA content. Among the various categories, supplementation of vitamin B12 to OAT samples was more beneficial as it improved the overall viability of the sperms.

Trial registration number

CSP/21/JUL/96/389

TB testing in HIV-positive patients prior to antiretroviral treatment

BACKGROUND: TB diagnosis in patients with HIV is challenging due to the lower sensitivities across tests. Molecular tests are preferred and the Xpert^® MTB/RIF assay has limitations in lower-income settings. We evaluated the performance of loop-mediated isothermal amplification (LAMP) and the lipoarabinomannan (LAM) test in HIV-positive, ART-naïve clinic patients.METHODS: A total of 783 eligible patients were enrolled; three spot sputum samples of 646 patients were tested using TB-LAMP, Xpert, smear microscopy and culture, while 649 patients had TB-LAM testing. Sensitivity, specificity, and negative and positive predictive values were estimated with 95% confidence intervals.RESULTS: Sensitivities for smear microscopy, TB-LAMP and Xpert were respectively 50%, 63% and 74% compared to culture, with specificities of respectively 99.2%, 98.5% and 97.5%. An additional eight were positive on TB-LAM alone. Seventy TB patients (9%) were detected using standard-of-care testing, an additional 27 (3%) were detected using study testing. Treatment was initiated in 57/70 (81%) clinic patients, but only in 56% (57/97) of all those with positive TB tests; 4/8 multidrug-resistant samples were detected using Xpert.CONCLUSION: TB diagnostics continue to miss cases in this high-burden setting. TB-LAMP was more sensitive than smear microscopy, and if followed by culture and drug susceptibility testing as required, can diagnose TB in HIV-positive patients. TB-LAM is a useful add-in test and both tests at the point-of-care would maximise yield.

Evaluating network adequacy of oral health services for children on Medicaid in Arizona

Purpose

Inadequate networks can prevent patients from being able to see the providers that they trust and depend upon, especially for children insured through Medicaid. To improve our understanding of poor oral health care outcomes, we conducted a test of network adequacy among Medicaid pediatric dental providers in Arizona through a “secret shopper” phone survey.

Methods

This study tested multiple components of children's access to oral health care, including reliability of provider directory information, appointment availability at the practice level for children covered under Medicaid versus commercial insurance, and compliance with regulatory standards. We contacted individual providers, following a standardized script to schedule a routine appointment on behalf of a 5-year-old patient enrolled in either a Medicaid or commercial plan. We documented the time until the next available appointment, if the practice was reached, and if the practice accepted the specified insurance plan.

Results

We identified, catalogued, and attempted to call a total of 185 unique practices across Arizona. In four counties, we were unable to identify a single pediatric oral health provider through health plan directories. We observed minimal differences in appointment wait times between callers with commercial insurance and those insured through Medicaid.

Conclusions

Our findings underscore the need to improve the accessibility of pediatric health services, especially in rural regions. Facilitating access to routine and recommended oral health screenings for children enrolled in Medicaid is imperative to appropriate stewardship and fulfilling our commitment to provide this vital public health resource.

The influence of social determinants of health on epilepsy treatment delays in an Arizona Medicaid population

OBJECTIVE

The purpose of this study was to better understand the role of social determinants of health (SDoH) in both treatment delays and treatment gaps for individuals with epilepsy (IWE) enrolled in Arizona's Medicaid program using predictive models at the population and individual levels.

METHODS

In this retrospective cohort study, two statistical regression models were developed using Arizona Medicaid medical and pharmacy claims records from 2015-2019 and selected census tract-level SDoH data. Three treatment outcomes were defined: timely treatment (treated within thirty days); delayed treatment (treated after thirty days); and untreated. For the first model, least squares regression was used to regress the epilepsy treatment delays on selected SDoH factors at the population-level. For the second model, multinomial logistic regression was used to estimate associations between epilepsy treatment delays and individual-level sociodemographic factors.

RESULTS

Of the 5965 IWE identified with a new epilepsy diagnosis during the study period, 43.1% were treated with a mean delay of 180 days. Among the treated population, 42% received timely treatment. A treatment gap of at least 40.6% and potentially up to 56.9% was calculated. Individuals with epilepsy diagnosed in an inpatient setting or in emergency departments were more likely to be treated and receive timely treatment than those diagnosed in an office or clinic setting. Individuals with epilepsy diagnosed in "other" settings were more likely to go untreated or receive delayed treatment than a patient diagnosed in an office or clinic. Compared to IWE aged 31-50 years, IWE aged 0-30 years were more likely to receive timely treatment, IWE aged 51-64 years were more likely to receive delayed treatment, and IWE aged 65 years or older were more likely to go untreated. Widowed IWE were more likely to go untreated relative to single patients. Individuals with epilepsy experiencing homelessness were also more likely to go untreated. Unemployed IWE were more likely to go untreated or receive delayed treatment. Native American IWE were more likely to go untreated compared to White patients.

CONCLUSIONS

Treatment gaps and treatment delays are experienced by IWE in the Arizona Medicaid population. The SDoH factors predicted to impact treatment delays include care setting, age, race, marital status, homelessness, and employment.

Systems engineering analysis of diagnostic referral closed-loop processes

BACKGROUND

Closing loops to complete diagnostic referrals remains a significant patient safety problem in most health systems, with 65%-73% failure rates and significant delays common despite years of improvement efforts, suggesting new approaches may be useful. Systems engineering (SE) methods increasingly are advocated in healthcare for their value in studying and redesigning complex processes.

OBJECTIVE

Conduct a formative SE analysis of process logic, variation, reliability and failures for completing diagnostic referrals originating in two primary care practices serving different demographics, using dermatology as an illustrating use case.

METHODS

An interdisciplinary team of clinicians, systems engineers, quality improvement specialists, and patient representatives collaborated to understand processes of initiating and completing diagnostic referrals. Cross-functional process maps were developed through iterative group interviews with an urban community-based health centre and a teaching practice within a large academic medical centre. Results were used to conduct an engineering process analysis, assess variation within and between practices, and identify common failure modes and potential solutions.

RESULTS

Processes to complete diagnostic referrals involve many sub-standard design constructs, with significant workflow variation between and within practices, statistical instability and special cause variation in completion rates and timeliness, and only 21% of all process activities estimated as value-add. Failure modes were similar between the two practices, with most process activities relying on low-reliability concepts (eg, reminders, workarounds, education and verification/inspection). Several opportunities were identified to incorporate higher reliability process constructs (eg, simplification, consolidation, standardisation, forcing functions, automation and opt-outs).

CONCLUSION

From a systems science perspective, diagnostic referral processes perform poorly in part because their fundamental designs are fraught with low-reliability characteristics and mental models, including formalised workaround and rework activities, suggesting a need for different approaches versus incremental improvement of existing processes. SE perspectives and methods offer new ways of thinking about patient safety problems, failures and potential solutions.

Burden of arrhythmias in patients with obstructive sleep apnea and its impact on mortality: a descriptive study from the National Inpatient Sample

Background

Obstructive sleep apnea (OSA) accounts for significant mortality and morbidity worldwide. A limited but emerging literature has revealed increased risk of sudden cardiac death in patients with OSA. There is paucity of data on arrhythmia burden in patients with OSA, particularly in hospitalized patients.

Purpose

Therefore, we sought to study the prevalence of atrial and ventricular arrhythmias among hospitalized patients with OSA and examine its impact on sudden cardiac death and in-hospital mortality.

Methods

All patients over 18 years of age with OSA were extracted from the National Inpatient Sample (NIS) from 2009–10 using 9th revision of International Classification of Diseases (ICD-9) code 327.23. Demographic data, hospital characteristics, comorbid conditions, and arrhythmia burden including different types of arrhythmia were identified. Clinical outcomes were in-hospital mortality, length of stay and sudden cardiac death. Logistic regression analysis was performed to determine the impact of arrhythmia on in-hospital mortality in patients with OSA. Hospital level discharge weights provided by NIS were used to obtain national estimates of OSA hospitalizations.

Results

OSA was prevalent in 2.8% (n=1,114,297) of all hospitalizations among which 20.1% had any arrhythmia (n=223,974). Patients with arrhythmia were older, more likely to be males, and had higher prevalence of risk factors and comorbid conditions except for chronic liver disease, and smoking (p&lt;0.0001 for all). Arrhythmia burden analysis revealed increase prevalence of both atrial and ventricular arrhythmia in patients with OSA compared to general population. In-hospital mortality (3.48% vs 1.27%; p&lt;0.0001), length of hospital stay (6.4±0.1 vs 5±0.1; p&lt;0.001) and sudden cardiac death (1.34% vs 0.4%; p&lt;0.0001) were higher in OSA patients with arrhythmia compared to OSA patients without arrhythmia. Presence of arrhythmia in OSA patients was associated with increased in-hospital mortality in both unadjusted [OR 2.79 (2.62–2.98); p&lt;0.001] and multivariable model adjusted for all risk factors and comorbid conditions [OR 1.83 (1.69–1.98); p&lt;0.001].

Conclusion

Arrhythmia burden was higher in patients with OSA compared to the general population. Presence of arrhythmia among OSA patients was independently associated with increased in-hospital mortality and longer hospital stays. Routine evaluation to assess arrhythmia burden in patients in OSA could be a potential target to decrease sudden cardiac death in this high risk population.

Funding Acknowledgement

Type of funding sources: None.

P–077 Performance of the postwash total motile sperm count as a predictor of pregnancy at the time of intrauterine insemination

Study question

Is the performance of the postwash total motile sperm count a predictor of pregnancy at the time of intrauterine insemination?

Summary answer

The number of motile spermatozoa inseminated (NMSI) in IUI can be used to define clear range of pre /postwash sperm parameters.

What is known already

There is no consensus about the optimal number of motile spermatozoa inseminated (NMSI) required for a reasonable chance of pregnancy after IUI. A meta-analysis of 16 studies assessing NMSI and IUI outcomes, concluded that at cut-off levels between 0.8 and 5 million, defined as the ability to predict failure to become pregnant. The purpose of this study is to determine the range of NMSI as a predictor of success in IUI.

Study design, size, duration

This prospective study includes 60 patients who underwent semen analysis at an academic infertility centre (SRIHER) during the month of December 2020 and January 2021.

Participants/materials, setting, methods

A total of 60 infertile couples who underwent IUI at our academic centre were enrolled in our study. A detailed history and infertility work up was done before proceeding for IUI, as per the department protocol. The semen was prepared by discontinuous 2 layered density gradient method. The results were analyzed by patient factors including age, BMI, semen parameters, NMSI. The NMSI were divided into 4 groups: A (&lt;1), B (1–4), C (5–9), D (&gt;10).

Main results and the role of chance

The mean age of the infertile couples who underwent IUI was (28.2 ± 3.8) in females and (31.8 ± 3.8) in males respectively. The sperm parameters such as concentration (21.8 ± 14.8), motility (53.15 ± 13.22), morphology (2.43 ± 1.33) respectively. When the NMSI was group C (5–9 x 10 6) the pregnancy rate was 38.5% whereas the pregnancy rate was 37.5% in group D ( &gt;10 x 10 6). In the other sub groups such as group A(&lt;1 x 10 6) and group C (1–4 x 10 6) the pregnancy rate was 14.2% and 12.5% respectively.

Limitations, reasons for caution

Infertile men with Azoospermia, Men with Retrograde ejaculation, Testicular samples, Epididymal samples, Infected samples. All of the above samples were avoided. It cannot be used for counselling during the initial infertility workup, but only during/after the IUI procedure.

Wider implications of the findings: The results suggest that NMSI can be a predictor of success in IUI in patients who are &lt; 30 years of age & ≥35 years, NMSI does not appear to be a useful. The effect of NMSI on pregnancy rate needs to evaluated on a larger scale .

Trial registration number

Not applicable

Innovations in U.S. Health Care Delivery to Reduce Disparities in Maternal Mortality Among African American and American Indian/Alaskan Native Women

Despite spending more on health care than any other country, the United States has the worst maternal mortality rate among all developed nations. African American and American Indian/Alaskan Native women have the worst outcomes by race, representing a stark health disparity within the country. Contributing factors disproportionately experienced by these minority populations include challenges of access to consistent and high-quality prenatal care, prevalence of underlying conditions, toxic stress due to systemic racism, and unconscious bias in health care. While many of these factors lie upstream in the lives of women, and seemingly beyond the scope of the clinical walls, the downstream health care delivery system can serve as a vital part of the solution via innovative practices, community-based collaborations, and by serving as advocates for the communities served. Such alignments between clinicians, community leaders, policymakers, and patients that extend beyond the health system can serve as the missing piece needed within the clinic to reverse the trajectory of maternal mortality for American women, especially those from traditionally underserved populations.

Relationship between online cognition and personality traits: A questionnaire based study of medical college students

Introduction

Current classification systems are not sure where to place the internet use disorder. Is it an addiction, an impulse control disorder, a consequence of another psychiatric morbidity or a consequence of personality trait/personality disorder?

Objectives

We intended to study which personality traits associated with online cognition may contribute towards Problematic internet use(PIU). We also analysed the relationship between number of hours of use/week of internet and PIU along with its relation with two ‘screening’ questions.

Methods

Online cognition scale and Abbreviated Eysenck Personality questionnaires were our measurements of choice in addition to demographic measures and some questions pertaining to online behaviour patterns.

Results

Total 163 responses were analysed. The demographic pools consisted mostly of young adults who had, on average, used the internet for 5.2 years at present rate of 21.81hours/week. We observed significantly higher mean OCS scores in men, in people who thought that the internet interfered with their lives and in those who felt the need to ‘cut-down’. A moderate positive and significant correlation was observed between hpurs/week of internet use and OCS scores. Also, significant positive correlation was observed between Neuroticism and OCS, impulsivity, and loneliness/depression scores. Significant negative correlations were observed between the Lie trait and impulse control. Neuroticism and Lie together contributed to 21.8% of variance in OCS scores.

Conclusions

Neuroticism and Lie traits (representing need for social acceptance) were found to the causing significamn varience in the OCS scores of the subjects. High number of hours/week use of internet was related to the feeling of ‘need to cut down use’.

State Variability in Peer Review Protections Heightens Liability Risks

Objective

To highlight various state-specific gaps in legal protections involving the peer review process with the goal of helping participants better identify and address potential hazards so they may continue to confidently engage in peer review activities.

Methods

State laws regarding peer review protections involving privilege and confidentiality were searched through Westlaw (a legal research database) and state government websites and categorized.

Results

Gaps in protection were identified in 17 states and the District of Columbia. In the 18 jurisdictions in which potential legal gaps were identified, the most common exceptions involved peer review activities that were initiated without a legally required number of participants, were not formally mandated by the institution or other external body, or that were voluntarily discussed outside of the peer review context by participants in the process.

Conclusion

The widespread variability in state-based peer review protections showcases the complexity of deciphering peer review law and emphasizes the need to not just read the relevant state and federal laws but to obtain the professional guidance of a lawyer experienced in peer review law before engaging in peer review activities. These measures will improve providers’ engagement in peer review and strengthen an important tool for quality improvement.

•

Clinical peer review is an important initiative to ensure quality and safety of patient care.

•

There is widespread variability in state-based peer review protections for those conducting quality reviews.

•

Knowledge of state-specific gaps in legal protections involving the peer review process helps providers mitigate risk while conducting this essential practice.

Gastrointestinal side effects of upper gastrointestinal cancer surgery

In this chapter, we describe the gastrointestinal side effects of oesophagectomy, gastrectomy and pancreaticoduodenectomy for cancer, with a focus on long-term functional impairments and their management. Improvements in upper gastrointestinal cancer surgery have led to a growing group of long-term survivors. The invasive nature of these surgeries profoundly alters the upper gastrointestinal anatomy, with lasting implications for long-term function, and how these impairments may be treated. Successfully maintaining a high quality of survivorship requires multidisciplinary approach, with survivorship care plans focused on function as much as the detection of recurrence.

Discordance in Perceptions of Barriers to Breast Cancer Treatment Between Hispanic Women and Their Providers

Despite comparable screening and incidence rates that are 26% below that of non-Hispanic Whites, Hispanic women present with breast cancer at more advanced stages of disease, representing a continuing and troubling health disparity for this population. Reducing these disparities warrant more innovative research approaches to better understand perspectives of Hispanic patients regarding barriers to treatment and how these perspectives compare to those of their providers. A pilot qualitative study was conducted at a major urban cancer center in Arizona that measured both patient and provider perspectives regarding barriers to treatment. Through a multimethod qualitative analysis, researchers surveyed patients and providers to identify perceived barriers and discordance in shared understanding. Data collection and analysis consisted of surveying patients and providers, then performing inductive qualitative analysis. Results indicated the highest concordance, or shared understanding, between patients and providers was in recognizing barriers within delivery of care, such as cost of care and insurance coverage. The greatest discordance, or gaps in shared understanding, existed in upstream barriers of the health care system, such as emotional support and trust in systems. These results underscore the gap in shared understanding between patients and providers regarding upstream barriers to care as well as the nonclinical social determinants of health Hispanic patients face in accessing breast cancer treatment. More research is warranted using this approach as a tool to reduce health disparities.