United States

Disparities in Adult Asthma Outcomes Among Disaggregated Asian Americans in the National Health Interview Survey


Rationale
Asthma is a chronic inflammatory lung disease disproportionately affecting racially diverse vulnerable populations. Asthma prevalence and control are not well described amongst Asian American (AA) populations.

Methods
We examined asthma outcomes from the National Health Interview Survey from 2006-2018 for non-Hispanic white adults (NHW) and AA adults (Chinese, Filipino, Asian Indian [AI], and Other Asians [OA]), including asthma prevalence and control (current asthma symptoms, ≥1 asthma attack or ED asthma visits within a year). Using logistic regression, we calculated odds ratios (OR) for AA asthma prevalence/outcomes compared to NHW adults, adjusting for demographic, health, and socioeconomic factors.

Results
Asthma prevalence varied for adults identifying as NHW (n=33764), Chinese (310, OR:0.54), Filipino (603, OR:1.03), AI (236, OR:0.43), and OA (601, OR:0.61).
Over half of the adults had poor control with ongoing asthma symptoms: 62% NHW, 53.5% Chinese (OR:0.72), 50.2% Filipino (OR:0.64), 54.8% AI (OR:0.75), and 59.2% OA (OR:0.82). Filipino adults reported more asthma (OR:1.37) but better control (symptoms [OR:0.74]), while Chinese (OR:0.39) and AI (OR:0.48) adults had fewer ED visits. Sociodemographic and health factors influenced asthma symptoms (OR:1.04-1.77), attacks (OR:1.26-2.04), and ED visits (OR:1.43-3.12).

Conclusion
Asthma prevalence and control varied widely amongst disaggregated AA populations. Sociodemographic and health factors influenced poor asthma control more than racial groups.

Clinical Implications
Our research reveals unique challenges faced by specific Asian subgroups, warranting interventions to reduce asthma-related disparities. Tailored strategies can improve asthma management, access to care, and health outcomes, advancing health equity for Asian Americans.


AMA Research Challenge 2024 

Disparities in Adult Asthma Outcomes Among Disaggregated Asian Americans

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Background
Proton therapy is an advanced radiation treatment that uses a beam of protons to destroy cancer cells while better sparing adjacent tissue compared to conventional X-ray treatments. As of July 2024, there are only 45 operating proton therapy centers in the United States, with an additional 6 member centers in development. 25 states and the District of Columbia have at least 1 proton therapy center, while 25 states do not have a proton therapy center. With patients using Google to learn more about their medical conditions and available treatments, the purpose of this study is to determine the relationship between access to a proton therapy center
and search interest for proton therapy.

Methods
2004-2023 Google trends data for the search term “proton therapy” was analyzed by state using the Health filter. Google Trends used a scale of 0-100 to analyze search interest, with 0 representing the lowest search interest and 100 representing the highest search interest. A two tailed unpaired t-test was utilized to assess differences in search interest between states with a proton therapy center in comparison to states without a proton therapy center.

Results
There is a statistically significant difference in search interest for proton therapy between states with a proton therapy center versus states without a proton therapy center (p<0.0001). On a scale of 0-100, states with a proton therapy center had a mean search interest of 48.46 with a standard deviation of 18.37, while states without a proton therapy center had a mean search interest of 30.44 with a standard deviation of 11.80. Four states had a statistically significant higher search interest in proton therapy compared to other states (p<0.05): Tennessee, Oklahoma, Kansas, and Delaware. Of these four, only Delaware does not have a proton therapy center. Among the 16 states and District of Columbia with the highest search interest in proton therapy, only Delaware did not have a proton therapy center. Among the 15 states with the lowest search interest in proton therapy, only Utah had a proton therapy center.

Conclusion
This study highlights the association between proton therapy search interest and availability. The expansion of this novel treatment will likely impact distribution of patient resources for proton therapy.

Proton Therapy: Probing the Relationship Between Interest and Availability of Proton Therapy Centers

Background
Underserved communities in the USA face significant healthcare disparities, leading to poorer clinical outcomes and higher rates of chronic diseases. Socioeconomic barriers such as inadequate insurance coverage, poor health literacy, poverty, and cultural or linguistic differences impede patients' access to care and exacerbate these health inequities. Patient navigator programs, like the Pharmaceuticals-sponsored initiative at SUNY Downstate Health Sciences University and Kings County Hospital (KCH), help bridge gaps in healthcare and provide continuity and essential support for high-risk patients in underserved communities.

Methods
A novel multi-lingual medical student-staffed two-site, dual-departmental patient navigator program was established by the rheumatology and dermatology specialties at SUNY Downstate Health Sciences University and KCH in June 2021 and August 2022, respectively. 153 patients were recruited from the UHB Arthritis clinic and 26 patients from dermatology clinics, with identified needs such as severe disease manifestations, poor adherence to appointments or medications, and/or language difficulties. Patients were randomly assigned to patient navigators unless they had a specific language need. Patient navigators were recruited from second-year medical students at SUNY Downstate Medical School. Students underwent standardized training, shadowed in the rheumatology and/or dermatology clinics, and received structured didactics. Data was collected on patient demographics, their use of the patient navigator program, and their method of communication, and stored on a HIPAA-compliant secure REDCap database. 

Results
179 patients were enrolled in rheumatology and dermatology programs, paired with 30 active patient navigators, resulting in a PN-to-patient ratio of 1:5.97. The mean age of the patients was 48.5 years (SD 18.8). The male-to-female patient ratio was 1:5.13. Enrolled patients' most common rheumatological and dermatological conditions were lupus (53.6%) and hidradenitis suppurativa (46.2%), respectively. Since the program's initiation, 715 encounters occurred between patients and their navigators. The median number of encounters per patient was 4.00, with a mean of 5.439 (SD 4.98). The primary method of communication between PNs and patients was by telephone (50.4%), or text (30.1%). Navigators attended 91 clinic visits in person with their patients. Most encounters focused on appointment scheduling or reminders (40.3%), wellness checks (19.6%), and addressing patients' active medical issues unrelated to either specialty (14.9%). The mean number of issues addressed by the navigator per encounter was 1.45 (SD 0.849).

Conclusion
The multispecialty Patient Navigator Program demonstrated significant engagement and support for patients with rheumatological and dermatological conditions. Further research will compare patients’ clinic attendance rates before and after patient navigator assignment.




A Novel Multispecialty Patient Navigator Program for Underserved Brooklyn Communities

Background
Clustering is a machine learning technique that identifies distinct groups based on similarities in a given set of variables. This project leverages binary comorbidity, complication, or confounding data to identify distinct patient groups with varying risk profiles. Patients are grouped by similar combinations in a set of variables, this aims to identify key factors associated with an outcome as well as unique, nuanced interactions that are not apparent we term the process of clustering based on comorbidities, complications, or covariates, “CoClustering”. This study aims to guide researchers in applying CoClustering, including selecting appropriate clustering algorithms and understanding their statistical foundations.

Methods
For the illustrative example provided in this framework, the 2015-2019 National Inpatient Sample (NIS) was queried for patients diagnosed with Cerebral Infarction. Using the K-Modes algorithm, patients were clustered based on 18 clinically relevant comorbidities and age groups <65, 65-79, 80+). Cluster quality was assessed using the Davies-Bouldin Index (DBI) and Calinski-Harabasz Index (CHI) to determine the optimal number of clusters. Post-clustering analysis included Odds Ratio analysis of mortality amongst clusters, multivariate logistic regression adjusting for sex, race, income quartile and primary payer.

Results
In the illustrative example, nine unique clusters were formed. Post-clustering analysis showed statistically significant differences in mortality, the highest mortality group (Group 9) had an OR of 6.05 (95% CI: 4.99-7.33) and an AOR of 6.27 (95% CI: 5.11-7.69) when compared to Group 1.

Conclusion
This framework provides clinical researchers with a practical approach to apply clustering for the identification of subgroups in diverse clinical datasets, and a demonstration of the utility of clustering in analyzing highly dimensional comorbidity data. By effectively managing high dimensionality and sparsity in large datasets, machine learning clustering algorithms like K-Modes can reveal clinically relevant patterns and key variables associated with an outcome. The CoClustering technique can be applied broadly, ranging from offering a preliminary analysis of a clinical dataset to identify salient variables to further investigate, to grouping patients with a common diagnosis to better understand individual prognosis, further enabling highly personalized care.

CoCluster: A Framework for Comorbidity, Complication, and Covariate Clustering via Machine Learning

The patient-physician relationship begins when a doctor provides care for their patient. Trust is a fundamental component of the patient-physician relationship for achieving compliance and higher satisfaction rates with medical care. Previous studies have investigated the physician's emotional intelligence as a factor in patient-physician trust. However, this study examined the role of emotional intelligence from the patient’s perspective in the medical student population, compared to existing findings in college students. The study hypotheses stated that emotional intelligence will positively correlate with the trust in physicians in medical students and that the level of emotional intelligence from medical students will be higher, given their evolving level of education.

This IRB-approved study recruited 100 medical students who completed a survey through the online survey platform, Qualtrics. Survey questions included the 11-item Trust in Physician (TPS) Likert scale, a universal scale used to assess patients' views of their physician. Additionally, the survey included the Wong and Law Scale of Emotional Intelligence (WLEIS), which is a self-report Likert measure.

The emotional intelligence of the medical student was positively associated with trust in physician (r = 0.263, n =100, p < .001). In comparison to the study where emotional intelligence of the college student was positively associated with trust in physicians (r = 0.340, n = 202, p < .001). Additionally, on a scale of 1-7, the mean Emotional Intelligence score for medical students was 5.63 (SD = 0.578) and for college students was 5.72 (SD = 0.856), which were not significantly different (t = 0.958, p = 0.339).

This study found that as emotional intelligence of the patients increased, their trust in their physician also increased, in both college and medical student populations. These data indicate a robust generalizable relationship between emotional intelligence of patients and trust in physicians. Further study is needed to unpack the subcomponents and potential causation mechanisms underlying the relationship. We hypothesized that medical students who are exposed to healthcare systems as a patient and in the future as a physician, may self-report a higher level of emotional intelligence which could impact their patient-physician relationship. However, the level of emotional intelligence in the two samples was not significantly different. The findings of this study add to the existing knowledge on the patient-physician relationship and further study is warranted to assess the extent of the impact it has on patient outcome, compliance, and satisfaction with care.

Comparison of Patient-Physician Trust Among Medical Students and College Students

Patients’ Contact Preference for Clinical Care: A Systematic Review of Non-EMR
Contact Modalities

Audrey Amarachi Ojinnaka, MS31; Florence Odaka, MS42; Aman Sandhu MS33
Rahul Kashyap MBBS, MBA, FCCM 3,4

1. Touro College of Osteopathic Medicine, New York, NY
2. Trinity School of Medicine, Warner Robbins, GA
3. Drexel University College of Medicine, Philadelphia, PA
4. Department of Research, WellSpan Health, York, PA

Background: Although Electronic Medical Record (EMR) based contact is a primary means of connection between providers and patients, current literature lacks data on patient preferences for alternative methods. This systematic review aimed to analyze various non-EMR contact modality patient preferences for patients’ clinical care activities.

Methods: PubMed and the Cochrane Library were searched for articles that addressed non-EMR contact modalities (text messages, surveys, leaflets, pamphlets, email, videos, phone calls, in-person contact, electronic contact, email, and/or mail) that compared patients’ expressed preferences for clinical care. Articles were assessed independently by at least two investigators using Rayyan software to determine their final inclusion. A systematic review was conducted using data from original studies to gather patient preferences for each non-EMR contact modality.

Results: The searches retrieved a total of 846 articles, of which 98 met the criteria for full-text screening. Sixty-six of these had two or more contact modalities addressed and were selected for further review. Of these 66 articles, 48 of them addressed clinical care contact. 

When assessing overall patient preference of contact modality for clinical care recruitment, 75.78% preferred video-based [n=9 articles], 60.66% preferred pamphlets [n=8], and 55.94% preferred in-person contact [n=16]. 

When examining emails as a contact method, an average of 46.9% preferred its use for initial contact method [n=26], while for text messaging, 42% preferred its use for initial contact method [n=23], while for phone calls, 41.6% preferred its use for the initial contact method [n=34].

Conclusion: Overall, the top three contact modalities for patients regarding their clinical care were video, pamphlets, and in-person contact. By taking these preferences into account, one can create a communication strategy that respects patients’ autonomy, minimizes intrusion, and fosters a positive experience for their clinical care.


Exploring Patient Preferences: Clinical Studies Contact Through Non-Electronic Medical Records (EMR)/Other Contact Modalities

VARIABLES AFFECTING DURATION OF ONE-LEG STANDING

Authors: 
Samantha J. Eng   
Rutgers Robert Wood Johnson Medical School   
Phone number: 732-500-5192   
Email: sje67@rwjms.rutgers.edu   
  
Martin J. Blaser, M.D. 
Rutgers Robert Wood Johnson Medical School   
Phone number: 848-445-9834 
Email: blaser@cabm.rutgers.edu 

Maria Gloria Dominguez-Bello, Ph.D. 
Rutgers School of Environmental & Biological Sciences 
Phone number: 848-932-5648 
Email: mg.dominguez-bello@rutgers.edu 

Gloria A. Bachmann, M.D., M.M.S.   
Rutgers Robert Wood Johnson Medical School   
Phone number: 732-235-7628   
Email: bachmaga@rutgers.edu  

Background: 
The length of time that a person can stand on one leg, which assesses both balance and strength, has emerged as a potential indicator of longevity, with shorter times linked to increased mortality risk. The goal of this study was to investigate factors that influence one-leg standing times and assess additional data that bear on the use of this test at annual health evaluations as an additional vital sign. 

Methods: 
After IRB approval, the relationship between single leg standing time and body mass index (BMI), age, and exercise habits was assessed in 77 volunteers attending an educational fair at Rutgers University. Participants were categorized by BMI according to CDC guidelines and age group (<13, 13 to 19, the decades between 20 and 70, and >70). Also queried were time of last physical exam, time of last emergency room or urgent care visit, regular exercise type (i.e., walk/run or balance) and frequency, and sports participation. 

Results: 
For the 77 participants, the median (+/-IQR) age was 23 (2.5) years (range 4 to 76 years). The median (+/- IQR) standing time was 64 (5) seconds, ranging from 5 to 423 seconds. Multivariant analysis was conducted to investigate whether standing time differed based on responses to the queried survey topics. A one-way ANOVA revealed statistically significant differences in standing time between participants categorized by their age group (p = 0.040) and BMI range (p = 0.033). A statistically significant difference in standing time between participants who did or did not regularly engage in balance exercises was found using a two-sample t-test assuming unequal variances (p(T<=t) two-tail = 0.007). 

Conclusion: 
These preliminary findings suggest the possibility of using the one-leg standing test as an indicator of fitness age; that is, a patient’s standing time could be an indicator of physical age rather than calendar age. The findings also suggest that BMI and balance exercise participation are possible contributing factors. However, limitations including sample size necessitates further investigation to pinpoint specific group differences and underlying mechanisms. Future research could explore these connections through in-depth qualitative studies performed with more participants.

Variables Affecting Duration of One-Leg Standing

Background
Diversity is a complicated web of constructs that include but are not limited to, a person’s sex, ethnicity, race, heritage, sexual orientation and identity, education, and life experiences. As the world around us gets more intricate, our understanding of all these different factors also becomes more complex. We realized that cultural humility is not something that can be taught through a single informational session; therefore, we wanted to promote real growth and cultural awareness within our Radiology Department by developing an Inclusive Excellence curriculum with a special focus on incorporating aspects into our residency program.
Methods
To promote real growth and cultural awareness within the department and our residency program, we have worked within our university system to develop a curriculum that includes general topics of importance as well as those that are tailored to the radiology department. There are three certification stages (partner, champion, and ambassador) which require a range of total experiences revolving around anti-racism, diversity, equity and inclusion, and health equity. Additionally, the Ambassador level requires a capstone project as this level of certification is geared towards those who are pursuing future leadership roles. We have incorporated several experiences into our resident didactic schedule so that at the conclusion of the four years of residency every graduating resident will have earned the partner level certification. Residents are given ample opportunity and are encouraged to attend additional experiences to reach the other levels of certification during training if so desired.
Results
We have successfully implemented this program for two years, with two residents and seven faculty members obtaining the partner level certification at the conclusion of the 2023-2024 academic year. Additionally, many residents have shown interest in and are slated to complete the champion and ambassador level certification prior to graduation. Furthermore, all residents in the class of 2026 and beyond will graduate with at least a partner level certification. With the many faculty/staff members also completing this training, our department is leading by example and encouraging a more well-rounded and culturally safe work and training environment. 
Conclusion
We understand that true training for inclusive excellence is an ever-evolving continuous process. We hope that by cultivating these opportunities, we can graduate residents that will lead these efforts in their future careers and institutions.


A colorful curriculum to explore the worlds many shades of gray: Implementing an inclusive excellence curriculum in our Radiology Residency Program and Department.

Introduction: 
Medical education utilizes standard clinical practice and recommends clinical
algorithms to inform trainee curricula. The use of race and ethnicity as a medical screening tool impacts medical outcomes by associating race with genetics without considering that race incorporates social, economic, and cultural variables that influence outcomes.
Methods: 
To evaluate underlying factors contributing to differences in hypertension prevalence, control, and treatment recommendations across race/ethnicities, a two-week elective course was developed for third- and fourth-year medical students. In this elective course, students performed self-directed literature-based research on hypertension health disparities. We then developed three videos that addressed the racial/ethnic impact on hypertension prevalence and control and incorporated the students’ research findings. The videos were presented at a lunch-and-learn
session open to the medical students and health professionals that was focused on health care inequities in hypertension. Pre- and post-survey data was collected to assess how the discussion changed participant knowledge and impressions of the role race plays in hypertension prevalence, control, and treatment.
Results: 
Survey results denoted that 100% of lunch-and-learn participants increased their
understanding of the impact of health inequities on hypertension. Overall, there were significant differences in knowledge gained and understanding of health disparities that influence hypertension treatment across participants from all genders and racial or ethnic groups. Notably, pre-survey results indicated that participants tended to agree that treatment guidelines incorporating race improve equity in the treatment of hypertension whereas post-session results
showed that participants were less likely to agree with this assertion.
Conclusions: 
Developing educational opportunities to discuss health inequities can influence
perceptions of patient care.


Addressing Health Disparities in Hypertension: A comprehensive medical elective and survey study among medical students and professionals.


Transgender, nonbinary, and gender nonconforming [TNGNC] patients experience high rates of healthcare discrimination. Fear of discrimination may lead to delays in seeking healthcare and thus poorer health outcomes. Asking for a patient’s pronouns contributes to an inclusive environment, yet little is known about teaching and encouraging this practice among medical students. This study aims to characterize the attitudes and practices of pronoun use of students after implementing a standard pronoun curriculum.

We distributed a survey assessing attitudes toward and frequency of pronoun use to 310 students who completed a standardized pronoun curriculum and trained at continuity clinics. Attitudes (strongly disagree, disagree, agree, strongly agree) and frequencies (never, sometimes, often, always) were scored one to four respectively. T-tests determined factors’ associations with support of including pronoun training in the clinical curriculum [pronoun curriculum], support of asking pronouns in new patients encounters [standard pronoun use], and the frequency students asked patients’ pronouns [student pronoun use]. Factors included student age, gender, and whether the student had ever experienced pronoun use creating a better patient experience [positive patient encounter]. 

The response rate was 32.1%. 54.5% of students reported never asking for pronouns. Common limiting factors were identified as: patient perceived as unreceptive (33.9%) and forgetting (18.4%). Cisgender women compared to cisgender men showed more support for the pronoun curriculum (3.42 vs 2.95, p=0.0062) and standard pronoun use (3.20 vs 2.83, p=0.0398) but no increased frequency of student pronoun use. No respondents self-identified as TNGNC. A positive patient encounter was associated with greater support of the pronoun curriculum (3.57 vs 2.82, p=0.0001) and standard pronoun use (3.43 vs 2.61, p=0.0001) as well as higher student pronoun use (1.90 vs 1.34, p=0.0005). Age showed no significant associations. 

Despite being educated on pronoun use’s importance in gender-affirming care, the majority of medical students in this study reported never asking pronouns, largely limited by perceptions that a patient would be unreceptive. The only factor associated with both favorable attitude and increased student pronoun use was a positive encounter. This likely represents bidirectional causality as asking pronouns is permissive to positive encounters, and these positive experiences further encourage asking. To apply this, educating standardized patients to communicate positive experiences may encourage future pronoun use. Future directions may include implementing and assessing this curriculum change.

Assessing attitudes and practices of second-year medical students asking for patients’ pronouns in clinical encounters

Abstract Title: Assessing the Effectiveness of the Larner College of Medicine's SNAP Challenge

Background: Food insecurity is a critical public health issue in the United States. Despite the essential role of the Supplemental Nutrition Assistance Program (SNAP) in mitigating food insecurity, many medical professionals lack a deep understanding of its challenges and benefits. The Larner College of Medicine's SNAP Challenge aimed to bridge this gap by having participants live on the average SNAP benefit for Vermont for one day and participate in a week-long series of events addressing food insecurity. This study evaluates the effectiveness of the SNAP Challenge in enhancing Medical Students' and Staff's knowledge and attitudes towards food insecurity.

Methods: Data were collected before and after the challenge and associated events from 36 medical students and one staff member. Surveys assessed five areas on a Likert-scale: understanding of food insecurity, awareness of available resources, empathy towards individuals facing food insecurity, confidence in navigating food insecurity resources, and agreement with the adequacy of SNAP benefits. Descriptive statistics, Welch's t-tests, linear regression, and visualizations were completed using R (version 4.0.5). Participants also provided qualitative feedback on the SNAP Challenge through open-ended survey questions addressing their experiences, learning outcomes, and suggestions for improvement.

Results: The SNAP Challenge significantly improved participants' understanding (mean increase from 2.70 to 3.41, p = 0.0095), awareness (mean increase from 2.50 to 3.53, p = 0.0078), and confidence (mean increase from 2.70 to 3.59, p = 0.0151). Linear regression analysis showed that post-intervention survey time was a significant predictor of higher scores in understanding (β = 0.71, p = 0.012), awareness (β = 1.01, p = 0.008), and confidence (β = 0.85, p = 0.010). Qualitative analysis revealed that participants found planning meals and avoiding hunger to be the most challenging aspects of the SNAP Challenge, and they highlighted the extensive planning required to eat nutritiously on a limited budget.

Conclusion: The SNAP Challenge, coupled with a week of educational events, effectively enhanced participants' understanding, awareness, and confidence in addressing food insecurity. This demonstrates the value of experiential learning as an educational tool in medical training. While empathy and perceptions of SNAP adequacy did not significantly change, the challenge highlighted the importance of sustained interventions to influence deeper empathetic responses and perceptions of food assistance programs. These findings support the integration of experiential learning in medical education to better prepare future healthcare professionals to advocate for and support patients experiencing food insecurity.


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Disparities in Adult Asthma Outcomes Among Disaggregated Asian Americans

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Proton Therapy: Probing the Relationship Between Interest and Availability of Proton Therapy Centers

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