It has been almost 3 years since the opioid epidemic was declared a national public health emergency under federal law. Solutions have focused on supply-reduction strategies. These approaches, ...however, have failed to significantly curtail opioid overdose and related death. Demand for opioid use arising from social networks and environment is an important contributing factor to the current opioid epidemic. Adoption of existing underused methods is needed to drive further progress. This Perspective proposes the social contagion model as a promising framework through which to operationalize evaluation of the influence of social networks and environment in the opioid epidemic and argues for its greater application. Comparing the current epidemic with previous opioid epidemics reiterates the utility of the social contagion model. This model acknowledges social network influence on individual behavior. It leverages tools from epidemiology, permits evaluation of interpersonal influence, facilitates consideration of disproportionate and collateral effects, and overcomes limitations of traditional models and geographic assumptions inherent to many approaches surrounding the current opioid epidemic. Analyzing the opioid epidemic within a social contagion framework will enhance evaluation methods and enable the design of interventions to reflect the actual demands of the current crisis. If the influence of social networks and environment is not considered, the devastating toll of the opioid epidemic could grow.
Objectives
Research examining emergency department (ED) admission practices within the Department of Veterans Affairs (VA) is limited. This study investigates facility‐level variation in ...risk‐standardized admission rates (RSARs) for emergency care–sensitive conditions (ECSCs) among older (≥65 years) and younger (<65 years) Veterans across VA EDs.
Methods
Veterans presenting to a VA ED for an ECSC between October 1, 2016 and September 30, 2019 were identified and the 10 most common ECSCs established. ECSC‐specific RSARs were calculated using hierarchical generalized linear models, adjusting for Veteran and encounter characteristics. The interquartile range ratio (IQR ratio) and coefficient of variation were measures of dispersion for each condition and were stratified by age group. Associations with facility characteristics were also examined in condition‐specific multivariable models.
Results
The overall cohort included 651,336 ED visits across 110 VA facilities for the 10 most common ECSCs—chronic obstructive pulmonary disease (COPD), heart failure, pneumonia, volume depletion, tachyarrhythmias, acute diabetes mellitus, gastrointestinal (GI) bleeding, asthma, sepsis, and myocardial infarction (MI). After adjusting for case mix, the ECSCs with the greatest variation (IQR ratio, coefficient of variation) in RSARs were asthma (1.43, 32.12), COPD (1.39, 24.64), volume depletion (1.38, 23.67), and acute diabetes mellitus (1.28, 17.52), whereas those with the least variation were MI (1.01, 0.87) and sepsis (1.02, 2.41). Condition‐specific RSARs were not qualitatively different between age subgroups. Association with facility characteristics varied across ECSCs and within condition‐specific age subgroups.
Conclusions
We identified unexplained facility‐level variation in RSARs for Veterans presenting with the 10 most common ECSCs to VA EDs. The magnitude of variation did not appear to be qualitatively different between older and younger Veteran subgroups. Variation in RSARs for ECSCs may be an important target for systems‐based levers to improve value in VA emergency care.
Objectives: COVID-19 has strained the household finances of many Americans who are already experiencing increasing health care expenses. Concerns about the cost of care may deter patients from ...seeking even urgent care from the emergency department (ED). This study examines predictors of older Americans’ concerns about ED visit costs and how cost concerns may have influenced their ED use in the early stages of the pandemic.
Study Design: This was a cross-sectional survey study using a nationally representative sample of US adults aged 50 to 80 years (N = 2074) in June 2020.
Methods: Multivariate logistic regressions assessed the relationships of sociodemographic, insurance, and health factors with cost concerns for ED care.
Results: Of the respondents, 80% were concerned (45% very, 35% somewhat) about costs of an ED visit and 18% were not confident in their ability to afford an ED visit. Of the entire sample, 7% had avoided ED care because of cost concerns in the past 2 years. Of those who may have needed ED care, 22% had avoided care. Predictors of cost-related ED avoidance included being aged 50 to 54 years (adjusted odds ratio AOR, 4.57; 95% CI, 1.44-14.54), being uninsured (AOR, 2.93; 95% CI, 1.35-6.52), having poor or fair mental health (AOR, 2.82; 95% CI, 1.62-4.89), and having an annual household income of less than $30,000 (AOR, 2.30; 95% CI, 1.19-4.46).
Conclusions: During the early COVID-19 pandemic, most older US adults expressed concerns about the financial impact of ED use. Further research should examine how insurance design could alleviate the perceived financial burden of ED use and prevent cost-related care avoidance, especially for those at higher risk in future pandemic surges.
This survey study examines gender differences in mid- to senior-career faculty experiences of receiving and providing mentorship and sponsorship during early career development.
Importance Studies reveal that most physicians report symptoms of burnout. Less is known about burnout in mid-career medical faculty specifically. Objective To characterize burnout and its risk ...factors, particularly differences by gender, among mid-career medical faculty. Design, Setting, and Participants Between August 2021 and August 2022, a survey was sent to 1430 individuals who received new National Institutes of Health K08 and K23 career development awards from 2006 to 2009. Data were analyzed between June and October 2023. Main Outcomes and Measures Personal and work-related burnout as evaluated using the Copenhagen Burnout Inventory (CBI). The CBI score ranges from 0 to 100, with a score of 50 or higher indicating a high degree of burnout. Multivariable models were used to investigate associations between burnout and participant characteristics, including race and ethnicity, sexual orientation and gender identity, academic rank, work climate, experiences of workplace sexual harassment, sleep hours, work and domestic caregiving time, and time allocation changes in work and domestic work hours compared with before the COVID-19 pandemic. Work climate was evaluated by a general climate elements scale assessing elements such as friendliness, respect, and collegiality, and a diversity, equity, and inclusion climate elements scale assessing elements such as homogeneity, sexism, and homophobia; higher scores indicated a more favorable view of the climate. Results In all, 1430 surveys were sent, 926 candidates responded (65% response rate), and the analytic cohort was limited to the 841 respondents who were still in academic medicine (50.7% men). Burnout was significantly more common for women than men (mean SD CBI personal scores, 46.6 19.4 vs 37.5 17.2; P < .001; mean SD CBI work-related scores, 43.7 20.4 vs 34.6 19.7; P < .001). In multivariable models, personal burnout was significantly more likely for women (adjusted odds ratio AOR, 2.29 95% CI, 1.54-3.41; P < .001) and with more weekly hours of patient care (AOR, 1.07 95% CI, 1.00-1.15 for each 5-hour increase; P = .04). Personal burnout was less likely with more nightly sleep hours (AOR, 0.68 95% CI, 0.56-0.81 for each 1-hour increase; P < .001) and with an improved general work climate rating (AOR, 0.64 95% CI, 0.48-0.85 for each 1-point increase in general work climate scale score; P = .002). Work-related burnout was also significantly more likely for women than men (AOR, 1.77 95% CI, 1.17-2.69; P = .007). Greater work-related burnout was associated with an increase of 8 or more work hours per week compared with before the COVID-19 pandemic (AOR, 1.87 95% CI, 1.13-3.08; P = .01), more weekly hours of patient care (AOR, 1.11 95% CI, 1.03-1.19 for each 5-hour increase; P = .007), and a workplace sexual harassment experience in the past 2 years (AOR, 1.71 95% CI, 1.11-2.62; P = .01). Work-related burnout was significantly less likely with more nightly sleep hours (AOR, 0.80 95% CI, 0.66-0.96 for each 1-hour increase; P = .02) and with an improved general work climate rating (AOR, 0.49; 95% CI, 0.36-0.65 for each 1-point increase in general work climate scale score; P < .001). Conclusions and Relevance This survey study of K grant awardees revealed substantial rates of burnout among mid-career medical faculty, and burnout rates differed by gender. Evidence-based interventions are needed to realize the benefits of workforce diversity and vitality.
Despite increasing evidence and recognition of persistent gender disparities in academic medicine, qualitative data detailing the association of gender-based experiences with career progression ...remain sparse, particularly at the mid- to senior-career stage.
To investigate the role gender has played in everyday professional experiences of mid- to senior-career women clinician-scientists and their perceptions of gender-related barriers experienced across their careers.
In this qualitative study, a total of 60 of 159 invited clinician-scientists who received National Institutes of Health K08 or K23 awards between 2006 and 2009 and responded to a survey in 2021 agreed to participate. Invitees were selected using random, purposive sampling to support sample heterogeneity. Semistructured in-depth interviews were conducted January to May 2022. For this study, interviews from 31 women were analyzed using the framework approach to thematic analysis. Data analyses were performed between August and October 2023.
Descriptive themes of participant experiences of gender and gender-based barriers in academic medicine.
A total of 31 women clinician-scientists (8 identifying as Asian 25.8%, 14 identifying as White 45.2%, and 9 identifying as members of a minority group underrepresented in medicine 29.0%; 14 aged 40-49 years 45.2% and 14 aged 50-59 years 45.2%) were included. Among them, 17 participants (54.8%) had children who required adult supervision or care, 7 participants (22.6%) had children who did not require supervision or care, and 6 participants (19.4%) did not have children. There were 4 dominant themes identified within participant experiences in academic medicine: the mental burden of gendered expectations at work and home, inequitable treatment of women in bureaucratic processes, subtle and less subtle professional exclusion of women, and value of communities built on shared identities, experiences, and solidarity.
This study found that women perceived the institution of academic medicine as a male-centric system misaligned with the needs of women, with associated feelings of exclusion, disillusionment, and loss of trust in their institutions. Findings suggest that the confluence of domestic obligations and unaccommodating institutional environments may make it difficult for women clinician-scientists to achieve established timelines of career progression and productivity; these findings may have long-term implications for the well-being and retention of women in academic medicine.
The aim of this review was to examine published randomized controlled trials (RCTs) and quasi-experimental studies that evaluate the association between preoperative smoking cessation programs and ...long-term smoking cessation at a minimum of 6 months, postoperatively.
Systematic review and meta-analysis.
A systematic review was performed utilizing MEDLINE, EMBASE, CINAHL, PSYCHinfo, and COCHRANE databases. All eligible studies of smoking-cessation interventions initiated preoperatively, with cessation measured at a minimum of 6 months postoperatively, were identified. The effect of cessation interventions at 12 months postoperatively in RCTs was evaluated through meta-analyses using Mantel-Haenszel risk ratios (RRs) and 95% CIs. A fixed effects model was conducted initially; however, due to heterogeneity in study characteristics and patient cohorts, a more conservative random effects model was also performed.
Four RCTs and 4 quasi-experimental studies were included. Two RCTs demonstrated an association between interventions and cessation at 12 months, and the quasi-experimental studies showed cessation rates of 48% to 56% at 12 months, postoperatively. In a fixed effects model, interventions were associated with a greater likelihood of cessation at 12 months (RR, 1.50; 95% CI, 1.05-2.15; P = .02), although this effect was not statistically significant after applying a random effects model (RR, 1.61; 95% CI, 0.88-2.96; P = .12).
The literature suggests that preoperative smoking cessation programs will likely precipitate long-term (≥12 months) cessation. Additional studies should identify approaches that optimize preoperative cessation programs in the promotion of short-term, and long-term cessation.
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