Tara Lagu

Disability and social risk factors remain understudied among hospitalized patients, despite known associations with poor outcomes. This research aimed to describe social risks among hospitalized patients with disability (PWD) to better inform patient‐centered care. We screened adult patients admitted to general medicine services at a large, urban academic medical center for social risks and chronic disability. We examined patients with and without self‐reported disability, stratified by demographic characteristics and social risk. Compared with patients who did not report disability, PWD reported more social risks. When examined by disability type, patients with visual, dressing/bathing, and communication‐related disabilities were more likely to report transportation barriers than patients with disabilities unrelated to those domains. More patients who reported a learning disability also reported housing instability, when compared with patients with disabilities unrelated to learning. Co‐occurrence of disability and social risks are significant and warrant further examination as barriers to delivery of high‐quality care.

Background: Improving cardiac rehabilitation (CR) participation is a national priority. This study examines the prevalence and cost of copays and their relationship with CR attendance and dropout. Methods: We analyzed the AACVPR (American Association of Cardiovascular and Pulmonary Rehabilitation) registry using the AACVPR Data Analytic Center, including patients from 2012 to 2021 with recorded copayment (including 0) while excluding those without this data. The primary outcome was the association between total CR sessions attended and both copay presence and amount, assessed using multivariable models, adjusting for key literature‐based adherence predictors and baseline patient characteristics. Results: Among 59 838 patients with copay data, 16 339 (27.3%) had a copay. The median (interquartile range) copay was $24.00 (20, 34). Medicare, Medicaid, private, and Other insurances charged a median (interquartile range) copay of $20.00 (20–25), $3.70 (3, 12), $30.00 (20–40), and $25.00 (20 to 36), respectively. Copays were more common in New York and the Northeast and less common in California and the Midwest. The highest copay amounts were observed in South Dakota, Oklahoma, and Connecticut (>$34.00). In multivariable model, the presence of copay was associated with attendance at 4.9 (95% CI: 4.3 to 5.6, P P <0.001) fewer CR sessions. Copays were cited as the reason for early dropout in 23% of cases. Conclusions: Copays for CR were common, costly, and associated with fewer CR sessions. Policymakers should reconsider these policies to promote CR participation.

New policies require hospitals to identify and address patients' health‐related social needs (HRSN) yet provide minimal guidance on how screening should be conducted. This observational study occurred at a large academic hospital serving a diverse population. Hospital and research staff independently screened newly admitted medical patients for six HRSNs using an instrument designed by a quality improvement team. We calculated κ statistics to assess HRSN agreement between hospital and research staff. Analysis of 413 patients revealed fair to moderate agreement between hospital and research staff screenings ( κ = 0.25–0.54). Hospital staff identified fewer patients with needs related to medication affordability, housing, food, transportation, and mental health, but identified a higher proportion with needs related to the usual source of care. Hospital staff underestimate the proportion of patients with HRSN, potentially excluding patients from referral to social services.

Background: Continuous intravenous inotropic support (CIIS) can improve symptoms and functional status for patients with stage D heart failure (HF), but characteristics and outcomes of large cohorts treated with CIIS as a palliative therapy have not been described. Methods and Results: We identified Medicare fee‐for‐service (FFS) beneficiaries with diagnostic codes for HF in 2016 to 2017. After excluding beneficiaries who received advanced HF surgical therapies 2014 to 2018 and prior CIIS, we included remaining beneficiaries who initiated CIIS from 2016 to 2017. Primary outcomes were rates of admission, death, palliative care, and hospice utilization within 1 year of CIIS initiation. We identified 1 463 942 Medicare beneficiaries with HF in 2016 to 2017, of whom 3706 (0.3%) beneficiaries initiated palliative CIIS (58.9% male, 82.1% White, 67.1% from urban areas, average age 78 [SD=6.8] years). Average Charlson Comorbidity Index Score was 5.8 (SD=3.1). Only 6.5% of CIIS users had a diagnostic code suggesting receipt of palliative care services. Within 1 year of CIIS initiation, 72.2% of beneficiaries had at least 1 all‐cause admission, 55.7% had ≥2 admissions, and 38% had died. Almost 18% of CIIS users had a claim for hospice services; of CIIS users who died, 43.3% had a hospice claim. Conclusions: Among Medicare FFS beneficiaries with HF, palliative CIIS is rare and primarily utilized among older beneficiaries with high global comorbidity. Despite the palliative indication, beneficiaries have high rates of admission and low use of palliative care services. Palliative care and associated services should be better integrated into the care of patients with palliative CIIS.

Purpose: As a requirement for accreditation, medical schools must have technical standards to outline essential abilities for admission, progression, and graduation. In the absence of national guidance, the AMA published recommendations in 2021 for schools to use “functional” technical standards language (focused on achieving outcomes), as opposed to “organic” (focused on body functions). This study benchmarks the extent to which U.S. MD- and DO-granting programs have adopted functional language and assesses public availability of technical standards. Method: In 2023, the authors conducted a national cross-sectional content analysis of technical standards from all fully accredited U.S. MD- and DO-granting medical schools (N = 192) using AMA-endorsed criteria. Three technical standard domains—observation, communication, and motor—were coded as “functional,” “organic,” or “mixed,” generating a composite score for each school. Descriptive analysis was used to identify patterns and associations. Results: Of 192 eligible schools, 99.4% of MD and 100.0% of DO programs provided their technical standards online; one school did not have technical standards. The mean composite score was 1.24 (95% confidence interval, 1.02–1.46; SD = 1.55) out of a possible 6 for fully functional standards. MD programs were more likely to use functional language than DO programs, reflected in the higher overall mean score of 1.43 (SD = 1.59) for MD programs compared to 0.37 (SD = 1.00; P < .001) for DO programs. Schools established in 2010 or after were less likely to have functional technical standards than older schools ( P = .01), and schools reporting updates to their technical standards in 2022 or later had slightly higher functional scores than schools with less recent updates. Conclusions: Adoption of functional technical standards is varied. Most medical schools maintain restrictive organic language despite AMA recommendations. Greater alignment with functional standards could enhance inclusion of people with disabilities in medicine.

Background Accounting for approximately 1 in 4 community-dwelling adults in the United States (US), people with disabilities (PWD) experience significant disparities in health care quality, access, and outcomes. At the same time, US physicians have reported feeling unprepared to care for PWD and have revealed significant negative bias about this population. Objective To understand how physicians are trained to care for PWD in US medical schools. Design Qualitative, critical theory paradigm. Participants US medical school faculty (n = 8) and students (n = 9) were purposively sampled for knowledge of disability-related training based on known engagement in activities to advance disability-related medical education. Inclusion was limited to English language proficiency. Interventions n/a. Approach Data were collected through focus groups, hosted virtually with separate groups for faculty and medical students between September 2021 and February 2022. Each meeting was recorded, transcribed, and de-identified. Deductive and inductive coding schemes were applied by multiple coders until reaching thematic saturation. Key Results Prominent themes revealed critical shortfalls in medical education, including (1) disability being omitted from standard curricula; (2) disability being framed as a problem within individuals; (3) pervasive discrimination against PWD in medicine; and (4) over-reliance on ad hoc faculty and student-led efforts to cultivate curricular change. Data also revealed multifactorial barriers to including disability training as part of US medical education, such as avoidance of personal and institutional responsibility, and permeations of ableism across social and training contexts. Conclusions Medical education may perpetuate negative bias about disability through a hidden curriculum. Insufficient support from institutional and licensing authorities has stymied efforts to expand and improve disability-related training such that disability is not included in existing curricula focused on mitigating health care disparities — despite known vulnerabilities for PWD. Without improvements to disability-related curricular content, physicians will remain ill-equipped to care for the nation’s largest minority group.

Background: Many United States hospitals explicitly pursue “anchor missions” by committing to intentionally apply place-based economic power and human capital in partnership with the community. Little is known about how hospital-community partnerships are implemented or whether they impact social determinants of health (SDOH) and population health. We qualitatively analyzed healthcare institutions from a national network to understand barriers and facilitators while implementing hospital-community partnerships that aim to improve population health. Methods: We used qualitative analysis of responses to open-ended items on a cross-sectional survey to explore how hospitals with anchor missions address SDOH. We administered the survey to healthcare systems participating in the Healthcare Anchor Network (HAN), a national network of hospitals with explicit goals to address SDOH and improve population health. Results: Responses were from 16 organizations. Two themes emerged: 1) healthcare systems faced many demands (i.e., COVID-19, financial stability), which competed with prioritization of the anchor mission, and 2) senior leadership engagement was critical for impact of the anchor mission and efforts to address SDOH and population health. Strategies to engage leadership included peer networking and providing repetitive education on community health inequities to hospital leaders. Conclusions: Although health systems show enthusiasm for population health, competing priorities often constrain anchor mission efforts to improve SDOH and population health outcomes. With external encouragement, such as changes to federal or state quality metrics reporting, payment incentives to address community health, or other policy changes, health systems will engage more with communities and be able to address SDOH.