Opioid-Related Emergency Department Visits Before and During COVID-19: Association with Community-Level Factors.

Background: The purpose of the study was to investigate the relationship between community-level variables and emergency department (ED) visit rates before and during COVID-19. The focus was on opioid-related ED visits. Despite large declines in overall ED visits during COVID-19, opioid-related visits increased. While visits for avoidable conditions decreased, the opposite was true for opioid-related visits. Methods: We combined data from Florida EDs with community-level variables from the 2020 American Community Survey. The outcome measures of the study were quarterly ZIP code tabulation-area-level ED visit rates for opioid-related ED visits as well as visit rates for all other causes. Associations with opioid-related visit rates were estimated before and during COVID-19. Results: The associations between community-level variables and opioid-related visit rates did not match those found when analyzing overall ED visit rates. The increase in opioid-related visits during COVID-19 was not unique to or more prevalent in areas with a larger percentage of racial/ethnic minority populations. However, socioeconomic status was important, as areas with higher unemployment, lower income, lower home ownership, and higher uninsured had higher overall ED visit rates and opioid visit rates during the pandemic. In addition, the negative association with income increased during the pandemic. Conclusion: These results suggest socioeconomic status should be the focus of prevention and treatment efforts to reduce opioid-related visits in future pandemics. Healthcare organizations can use these results to target their prevention and treatment efforts during future pandemics.

Disciplinary Intersection of Medicine and Business: A Novel Population Health Management Premedical Pathway for Medicine and Other Health Care Professions.

Premedical students typically pursue undergraduate specialization in basic biological and other sciences, learning to understand living systems at a microscopic, genetic, or molecular level. However, curricula in the basic sciences do not traditionally include courses that enable students to learn about living systems at the macro level-understanding individuals within their environment, as well as understanding and managing the health of populations, especially those with underlying conditions or the underserved. This disconnect can be bridged by creating novel curricular programs intersecting medicine and business. Population health management is a multidisciplinary field that aims to improve the patient experience, reduce health care costs, and improve treatment outcomes. Though related to public health, the 2 fields differ in significant ways. Population health management emphasizes health outcomes and their measurements and seeks to improve health outcomes based on a full understanding of risk, behaviors, lifestyle, environment, and all social determinants of health. A shift in premedical education that connects the medical sciences with business requires curricular reform with the emerging field of population health management at their intersection, allowing students to be better prepared for future medical practices and to understand expectations, benchmarks, business, and economics in a new value-based health care system.

Disparities in Emergency Department Visits for Opioid and Stimulant Overdoses in Florida During COVID-19.

Emergency department (ED) visits for drug overdoses increased nationally during COVID-19 despite declines in all-cause ED visits. The study purpose was to compare characteristics of ED visits for opioid and stimulant overdoses before and during COVID-19 in Florida. This study tested for disparities in ED visits for opioid and stimulant overdoses by race/ethnicity, age, and insurance status. The study identified ED visits for opioid and stimulant overdose in Florida during quarters two and three of 2019 and compared them with quarters two and three of 2020. Overall, there was an increase in the number of opioid and stimulant overdoses during COVID-19. Combined with the decline in the number of all-cause ED visits, drug overdoses represented a larger share of ED visits during COVID-19 compared with before COVID-19. The study did not find evidence of disparities by race/ethnicity, as each group experienced similar increases in the likelihood of ED visits involving drug overdoses during COVID-19. Differences emerged according to age and insurance status. ED visits involving those under age 18 were more likely to involve opioid or stimulant overdose, and ED visits among those over age 65 were less likely to involve opioid overdose during COVID-19. ED visits among those with vulnerable insurance status were more likely to involve opioid overdose during COVID-19. Patterns of behavior change during periods of restricted activity due to a pandemic. These changes in behavior change the mix of risks that people face, suggesting the need for a reallocation of population health management resources during pandemics.

Redesign of US Medical Schools: A Shift from Health Service to Population Health Management.

The integration of medical schools and clinical partners is effectively established through the formation of academic medical centers (AMCs). The tripartite mission of AMCs emphasizes the importance of providing critical clinical services, medical innovation through research, and the education of future health care leaders. Although AMCs represent only 5% of all hospitals, they contribute substantially to serving disadvantaged populations of patients, including an estimated 37% of all charity care and 26% of all Medicaid hospitalizations. Currently, most AMCs use a business model centered upon revenue generated from hospital services and/or practice plans. In the last decade, mounting financial demands have placed significant pressure on AMC finances because of the rising costs associated with complex clinical care and operating diverse graduate medical education programs. A shift toward population health-centric health care management strategies will profoundly influence the predominant forms of health care delivery in the United States in the foreseeable future. Health systems are increasingly pursuing new strategies to manage financial risk, such as forming Accountable Care Organizations and provider-sponsored plans to provide value-based care. Refocusing research and operational capacity toward population health management fosters collaboration and enables reintegration with hospital and clinical partners across care networks, and can potentially create new revenue streams for AMCs. Despite the benefits of population health integration, current literature lacks a blueprint to guide AMCs in the transformation toward sustainable population health management models. The purpose of this paper is to propose a modern conceptual framework that can be operationalized by AMCs in order to achieve a sustainable future.

A Call to Action: Preventing Opioid and Substance Abuse in South Florida Youth.

Description The opioid crisis poses a substantial threat to youth throughout the nation. This crisis has been exacerbated by the COVID-19 pandemic, reversing some of the positive national trends in the fight against the opioid epidemic. Some risk factors for youth opioid use have been identified nationally. The South Florida tri-county region of Miami-Dade, Broward and Palm Beach is a culturally distinct region which may not follow national trends and likely has unique risk and protective factors. To address the concerning spike in youth opioid use in South Florida, a community coalition was formed to identify factors unique to South Florida and create a plan for early awareness and prevention.

Transitioning to Value-Based Diabetes Care: A Call for Action Derived from Primary Care Providers in South Florida.

Background: In Florida, 2.4 million people have diabetes and 5.8 million are pre-diabetic. Not only has the prevalence of diabetes doubled over the past 20 years from 5.2 in 1992 to 11.2 in 2014, but the Centers for Disease Control and Prevention expects 1 out of every 3 adults will have diabetes by the year 2050. In addition, in every year since 1996, Florida well exceeds the national levels in terms of prevalence of diabetes, and the gap is getting wider. A study was conducted to gather information from key physician stakeholders as to how to address unmet needs of patients at risk for, or whom already have, diabetes in a tri-county region of South Florida where the prevalence of diabetes is very high. Objective: The goal was to catalyze innovation and generate solutions for high quality and affordable diabetes care by convening community physicians in South Florida and querying them about solutions for delivering value-based care. Methods: A physician-led task force of community physicians was convened to uncover unmet needs in the diabetes care continuum, identify areas of improvement for coordinating care across the continuum and effectively accessing specialty care. Focus groups were convened with 30 participants to capture qualitative data relative to unmet needs, utilizing the Rapid Ideation Technique. A survey instrument was designed and administered to the twenty-one community clinicians on the task force to augment the qualitative data with quantitative data. The first part of the survey captured characteristics of the participating clinicians, their practices, their diabetes services and management approaches. The second part of the survey captured individual ratings of the importance and merit of needs and/or potential solutions generated. Results: The focus groups generated a wealth of information regarding challenges, issues, areas of opportunities, and potential solutions that could be organized within eight main themes: care coordination and integration; patient engagement, education and behavioral change; physician and practice support; EMR and data issues; telehealth solutions; health informatics and data analytics; and access to care. The surveys culminated in the formation of a Call-For-Action Agenda for immediate work. Conclusions: The ultimate goal of the taskforce was to catalyze innovation and generate solutions for high quality and affordable care. This article reports the findings and provides a roadmap for the future.

Management Principles to Drive the Creation of a 21st Century Medical School.

Introduction: There are currently no data, blueprints, best practices, or financial models available to guide the creation of a new medical school. Yet, the United States is experiencing unprecedented growth of new allopathic medical schools. Findings: This article brings logic to the process. It converts the complexity of what is often regarded as an administrative exercise into the first published framework of management principles. Those principles were then translated into a process map and a financial optimization model. All three elements can be successfully implemented for establishing an accredited, value-driven medical education program that minimizes time from inception to implementation, and ensures sustainability over time. Outcomes: This case report provides a blueprint for planning and implementation of a new medical school. Outcomes include both process and optimization models, as well as valuable insights that have utility when considering a new medical school to mitigate the projected nationwide shortage of physicians.

A Perspective on Research, Education, Practice and Policy in the COVID-19 Era.

Description The coronavirus disease 2019 (COVID-19) pandemic has unleashed a global health crisis, precipitating massive efforts aimed at understanding, preventing, preparing for, treating and responding to the novel coronavirus domestically and internationally. Given the profound and ongoing impact of COVID-19, the HCA Healthcare Journal of Medicine organized this special issue of the journal as a mechanism for capturing groundbreaking studies, advances and perspectives that have the potential to shape health and health care for decades to come.

Effects of web-based instruction and patient preferences on patient-reported outcomes and learning for women with advanced ovarian cancer: A randomized controlled trial.

A randomized controlled trial was conducted of a web-based intervention to improve advanced care planning in women with ovarian cancer. A secondary analysis of 35 randomized women focused on changes in distress and knowledge about ovarian cancer through distress monitoring and information tailored to patients' cognitive coping style (monitoring, blunting). Pre-/postresults indicated the Intervention group demonstrated lower distress (p = 0.06); blunting was associated with lower depression (p = 0.04); knowledge in both groups was unchanged. Women in the Intervention vs. Control group reported their family was less likely to be upset by cancer information (p = 0.0004). This intervention reduced distress while incorporating patient preferences.

Designing an Educational Website to Improve Quality of Supportive Oncology Care for Women with Ovarian Cancer: An Expert Usability Review and Analysis.

A broad-based research team developed a Health Insurance Portability and Accountability Act (HIPAA)-compliant educational website for women with ovarian cancer to improve the quality of supportive oncology care. Prior to a randomized clinical trial of the website, initial usability testing was implemented to evaluate the website. The initial review found that 165/247 checklist items had sufficient information to allow for evaluation with the website achieving an overall score of 63%. By category, lowest scores were for the Home Page, Task Orientation, Page Layout & Visual Design, and Help, Feedback & Error Tolerance. Major issues thought to potentially impede actual usage were prioritized in redevelopment and the second usability review, conducted by the same expert, saw an improvement in scores. Incorporating usability concepts from the start of development, fulfilling the positive expectations of end-users and identifying technical and personal factors that optimize use may greatly enhance usage of health websites.

Development and pilot of an advance care planning website for women with ovarian cancer: a randomized controlled trial.

OBJECTIVE: Few available tools facilitate cancer patients and physicians' discussions of quality of life and end-of-life. Our objective was to develop a web-based tool to promote advance care planning for women with ovarian cancer. METHODS: Women with ovarian cancer, their families, clinicians and researchers met to identify ways to improve cancer care. A prototype website was created to address advance care planning, focusing on advance healthcare directives (AHD) and palliative care consultation. Patients were recruited from a gynecologic oncology clinic for a pilot randomized controlled trial. Primary outcomes included completion of an AHD and palliative care consultation. RESULTS: At study completion, 53 women with ovarian cancer were enrolled and 35 completed the study. The mean age at enrollment was 57.9 ± 9.5 years; most were newly diagnosed or at first recurrence. There were no statistical differences in completion of AHD (p=0.220) or palliative care consultation (p=0.440) between intervention and control groups. However, women in the intervention group showed evidence of moving toward decision making regarding AHD and palliative care and lower decisional conflict. Women assigned to the intervention, compared to control website, were highly satisfied with the amount (p=0.054) and quality (p=0.119) of information and when they accessed the website, used it longer (p=0.049). Overall website use was lower than expected, resulting from several patient-related and design barriers. CONCLUSIONS: A website providing information and decisional support for women with ovarian cancer is feasible. Increasing frequency of website use requires future research.

The informatics imperative in veterinary medicine: collaboration across disciplines.

Information and data management are essential to support the collaborative and interdisciplinary pursuits of an academic veterinary medicine enterprise, ranging from research conducted by individual investigators, education processes, clinical care, and outreach to administration and management. Informatics is an academic discipline that focuses on the creation, management, storage, retrieval, and use of information and data and how technology can be applied to improve access to and use of these resources. In this article, we discuss the challenges in integrating informatics across a large academic enterprise from a veterinary medicine point of view. As a case study, we describe an example program of informatics at the University of Minnesota designed to support interdisciplinary collaboration.

Deidentification of facial images using composites.

PURPOSE: Maxillofacial surgeons rely on photography for education and documentation. Photographs of the face, unlike those of other body regions, are readily identifiable. Traditional methods of facial image deidentification decrease educational quality or fail to adequately conceal identity. In the present study, a method that uses blended facial composites to deidentify original facial images was developed. This method allows significant components of the original face to be visualized while concealing its identity. MATERIALS AND METHODS: The method was used to develop 20 different composite facial images that were viewed by student subjects. Ten of these images contained at least one third of a face that was familiar to the subjects. Subjects viewed the composite faces twice--first unaware that the faces were composites, and then primed to the presence of composites. Subjects later rated the efficacy of this method for image deidentification. RESULTS: When unaware that they were viewing composite images, no subjects recognized the familiar faces within the composites or rated them as familiar (0/120 total views, 0%). When later primed to the potential presence of familiar faces within composites, the identification rate increased significantly (74/120, 62%; P < .001). Results were similar no matter which portion of the familiar face (upper, 67%; mid, 54%; lower, 67%) was present. Subjects rated all composites as clinically realistic patient images. They also rated composites as more effective at deidentification than traditional methods. CONCLUSION: The use of composites appears to be a promising concept for facial image deidentification. Further larger-scale studies are needed to validate these findings.

Reorganization of visual processing is related to eccentric viewing in patients with macular degeneration.

PURPOSE: Neural evidence exists for cortical reorganization in human visual cortex in response to retinal disease. Macular degeneration (MD) causes the progressive loss of central visual acuity. To cope with this, MD patients often adopt a preferred retinal location (PRL, i.e., a functional retinal area in their periphery used to fixate instead of the damaged fovea). The use of a PRL may foster cortical reorganization. METHODS: We used fMRI to measure brain activity in calcarine sulcus while visually stimulating peripheral visual regions in MD patients and age-matched control participants. RESULTS: We found that visual stimulation of the PRL in MD patients increased brain activity in cortex normally representing central vision relative to visual stimulation of a peripheral region outside the patients' PRL and relative to stimulation in the periphery of age-matched control participants. CONCLUSIONS: These data directly link cortical reorganization in MD to behavioral adaptations adopted by MD patients. These results not only confirm that large-scale cortical reorganization of visual processing occurs in humans in response to retinal disease, but also relate this reorganization to functional changes in patient behavior.

Toward a deeper understanding of the role of interaction in information visualization.

Even though interaction is an important part of information visualization (Infovis), it has garnered a relatively low level of attention from the Infovis community. A few frameworks and taxonomies of Infovis interaction techniques exist, but they typically focus on low-level operations and do not address the variety of benefits interaction provides. After conducting an extensive review of Infovis systems and their interactive capabilities, we propose seven general categories of interaction techniques widely used in Infovis: 1) Select, 2) Explore, 3) Reconfigure, 4) Encode, 5) Abstract/Elaborate, 6) Filter, and 7) Connect. These categories are organized around a user's intent while interacting with a system rather than the low-level interaction techniques provided by a system. The categories can act as a framework to help discuss and evaluate interaction techniques and hopefully lay an initial foundation toward a deeper understanding and a science of interaction.

The impact of auditory and haptic feedback on computer task performance in patients with age-related macular degeneration and control subjects with no known ocular disease.

PURPOSE: To determine the impact of auditory and haptic (tactile) feedback on computer task performance of patients with age-related macular degeneration (AMD) compared to controls. METHODS: Thirty patients with AMD and 29 similarly aged controls with no known ocular disease completed timed computer icon "drag and drop" tasks under all four possible conditions of presence or absence of auditory and haptic feedback in a two-factor repeated measures design. Patient recruitment was stratified by best eye acuity: 20/20-20/50; 20/60-20/100; <20/100. Controls had best eye acuity>or=20/30. Task completion time was quantified using final target highlight time (FTHT) and total trial time, measured in milliseconds. RESULTS: Mean+/-standard deviation (SD) FTHT with neither feedback type in the three patient and control groups was, respectively: 1,110+/-356, 1,682+/-1,069, 1,763+/-831, 924+/-533. Auditory feedback improved performance [%FTHT decrease, p-value] in all groups, respectively: 18%, P=0.018; 38%, P=0.054; 57%, P=0.001; 19%, P=0.001. Haptic feedback improved performance in the worst acuity AMD group and controls: 46%, P=0.009; 17%, P=0.038. In the worst acuity AMD group, auditory and/or haptic feedback was associated with a 4-6 second mean (for each task) reduction in total trial time. CONCLUSION: Auditory and haptic feedback can substantially increase performance speed of computer "drag and drop" tasks for patients with AMD, particularly in those patients with the most compromised vision.

A review and a framework of handheld computer adoption in healthcare.

Wide adoption of mobile computing technology can potentially improve information access, enhance workflow, and promote evidence-based practice to make informed and effective decisions at the point of care. Handheld computers or personal digital assistants (PDAs) offer portable and unobtrusive access to clinical data and relevant information at the point of care. This article reviews the literature on issues related to adoption of PDAs in health care and barriers to PDA adoption. Studies showed that PDAs were used widely in health care providers' practice, and the level of use is expected to rise rapidly. Most care providers found PDAs to be functional and useful in areas of documentation, medical reference, and access to patient data. Major barriers to adoption were identified as usability, security concerns, and lack of technical and organizational support. PDAs offer health care practitioners advantages to enhance their clinical practice. However, better designed PDA hardware and software applications, more institutional support, seamless integration of PDA technology with hospital information systems, and satisfactory security measures are necessary to increase acceptance and wide use of PDAs in healthcare.

Software-based compensation of visual refractive errors of computer users.

For human beings, vision is one of the most important senses in interacting with the surrounding environment, as well as with any tools that require visual communication. As such, the ability to interact effectively with computers through typical graphic user interfaces (GUIs) is greatly affected by any refractive errors present in an individual's visual system. If the refractive errors can be mathematically modeled, a system for overcoming these aberrations can be devised which can increase the effective human-computer interaction for these individuals. Several methods, such as Adaptive Optics, have been proposed that attempt to solve this problem using electro-mechanical devices. These methods are costly and impractical, preventing most visually impaired individuals from benefiting from their use. In contrast, an image-processing method, based on deconvolution techniques, has recently been proposed for the pre-compensation of images to be displayed in a computer. This method is much more practical, being completely implemented in software, and has achieved encouraging results. Previous results have yielded an average 50% increase in visual efficiency in the compensation of a known artificial aberration introduced into the field of vision of experimental subjects. This paper describes the difficulties encountered with the present software-only compensation and proposes several methods for overcoming these obstacles. The difficulties, as well as the proposed solutions, are described theoretically and followed by examples using a lens system showing the improvement over previous methods.