Objectives: Pregnant women living in rural areas of the United States are not equitably served by healthcare systems and may be disproportionately affected by sexually transmitted infections (STIs). We examined the impact of location of pregnancy care on STI screening and positivity in a statewide health system.
Methods: Pregnant women seeking care within a statewide health system during 2021-2022 were categorized by location of care at either the main university hospital (urban) or regional (rural) hospitals. We assessed STI screening and positivity for chlamydia, gonorrhea, and trichomoniasis within each setting and by the Social Vulnerability Index (SVI) assigned to the person's census tract (high ≥0.75 vs low <0.75). We identified 12,921 unique pregnancy episodes: 9051 (70%) within the university hospital and 3870 (30%) in regional hospitals.
Results: The mean census tract SVI among all women was 0.54 (standard deviation 0.29), and 29% of pregnant women resided in areas with a high SVI. Women in care at a regional hospital were more likely to reside in areas with a high SVI compared with the university hospital (41% v. 23%). In total, 75% of pregnant women were screened for any STI (9727/12,921). Compared with university hospitals, STI screening rates during pregnancy were lower (77% vs 70%) and STI positivity during pregnancy was higher in regional hospitals (chlamydia [3.9% vs 6.4%], gonorrhea [0.6% vs 1.3%], and trichomoniasis [4.6% vs 8%]).
Conclusions: In a statewide health system, pregnancy care provided in rural regional hospitals was associated with lower STI screening rates and higher STI positivity.
Objective: Severe alcohol withdrawal (SAW) is a common cause of hospital admission in the United States. There has been increased interest in phenobarbital use for SAW treatment. We aimed to investigate variability in alcohol withdrawal management protocols at different hospitals within a geographic region, with a focus on phenobarbital use.
Methods: We e-mailed a survey to intensive care unit physician leadership to all New York City acute care hospitals as well as large acute care hospitals in Massachusetts regarding their protocols for SAW.
Results: Of 13 respondents, eight have SAW protocols, six of whom have a distinct phenobarbital protocol. Phenobarbital load locations were in the emergency department or intensive care unit. Loading doses ranged from 8 to 15 mg/kg. Three protocols recommended an oral/intramuscular phenobarbital taper, and two protocols specified as needed phenobarbital rescue doses on hospital wards. There was some overlap in other rescue medications, but frequency and dose were not specified. Only two respondents of the survey included benzodiazepines as a rescue medication option.
Conclusions: There is some evidence that phenobarbital use for SAW has comparable to improved efficacy in certain patient outcomes. It appears that current evidence may have led to the adoption of phenobarbital use in SAW protocols in several urban university hospitals. Our results demonstrate, however, that there is significant irregularity in dosing, tapers, and concomitant benzodiazepine use. Phenobarbital protocols for SAW are common among large urban hospitals, but protocols are not standardized. More research and interhospital collaboration should be undertaken to reduce variability and optimize treatment protocols.
Objectives: Although healthcare disparities between rural and urban populations are documented, access to pulmonary subspecialty care in rural regions is not well characterized. This study aimed to quantify rural-urban disparities in access to pulmonology, pulmonary critical care medicine (PCCM), and sleep medicine physicians in Georgia.
Methods: The Georgia Composite Medical Board's 2024 Physician Workforce Database was used to identify pulmonologists, PCCM, and sleep medicine physicians and their primary office location. County-level data were obtained using the US Census. The 2023 Rural-Urban Continuum Codes were used to classify counties as metropolitan (codes 1-3) or nonmetropolitan (codes 4-9). Physician density was calculated per 100,000 residents and per 100 mi2. Travel burden was calculated as the linear distance from each county centroid to the nearest physician practice.
Results: A total of 122 pulmonologists, 204 PCCM physicians, and 49 sleep medicine physicians were identified across Georgia's 159 counties (74 metropolitan and 85 nonmetropolitan). Nonmetropolitan counties contained only seven pulmonologists, 16 PCCM physicians, and two sleep medicine physicians. Most physicians practiced in counties classified as code 1 (most urbanized), which also had the lowest travel burden. Metropolitan counties had an average of 0.67 pulmonologists, 1.06 PCCM physicians, and 0.20 sleep medicine physicians per 100,000 residents, compared with 0.20, 0.41, and 0.07/100,000 residents in nonmetropolitan counties (P < 0.001). In addition, travel burden to the nearest physician was significantly greater in nonmetropolitan counties across all three subspecialties (P < 0.001).
Conclusions: There are significant rural-urban disparities in access to pulmonary subspecialty care in Georgia, with severe shortages in rural counties.
Objective: Trainee autonomy is a value emphasized by formal governing bodies within graduate medical education, yet prior data demonstrate that pediatric residents perceive less autonomy than attendings report providing. Independent rounding (IR) is one practice that has been demonstrated in qualitative studies to promote autonomy. The objective of our study was to promote graduated trainee autonomy and to understand the interprofessional perspectives on the implementation of IR across various domains.
Methods: A single-center mixed-methods study was conducted between July 2021 and June 2022 at a quaternary children's hospital. IR was introduced on one inpatient team 1 day/week for the academic year. Postsurveys were sent to participants that included resident trainees, medical students, attendings, and nurses comparing IR with traditional rounding.
Results: Attendings and trainees who rotated on one of the inpatient pediatrics teams were automatically enrolled in this study, which included 26 medical students, 41 interns, 22 senior residents, and 15 attending physicians. IR was well received among all participants. All senior residents reported improved perceptions of autonomy. There was overall improved or lack of change in perceptions of patient safety, teaching and feedback, and clinical workflow. All attendings and trainees endorsed that residents should have the opportunity to round independently, with trainees feeling that the opportunity should be more frequent than once per week.
Conclusions: IR is a feasible and well-received method of promoting graduated trainee autonomy.
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.
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