United States

Background: With 8.4% of Americans uninsured, free clinics act as safety nets for those without healthcare access. The CommunityCare Clinics (CCC) operate student-run free clinics in Toledo, Ohio. This study compared the demographics of patients served within these clinics to the city’s census data to analyze health needs, barriers to care, and characteristics of the underserved population.

Methods: This retrospective survey reviewed 1,338 visits at five clinic sites from February 2023- February 2024. Parameters included race, insurance, education, sex, health insurance status, and primary language. Comparative analysis was completed using 2020 Census data for Toledo, OH.

Results: Significant differences were found between the demographic characteristics of those served in the clinic population and the population of Toledo. The clinic served 22.63% fewer White patients, 17.27% more Hispanic/Latino patients, and 5.62% fewer African American patients than the city population. Among patients under 65 years, 61.91% were uninsured compared to 8.3% in Toledo. Fewer English speakers (66.60% vs. 93.2%) and more Spanish speakers (21.72% vs. 3.2%) were treated. The clinic had slightly fewer high school graduates (82.97% vs. 87.10%) but more higher education recipients (27.10% vs. 19.6%). 

Conclusions: This study highlights the demographic differences between the clinic and the city, helping identify those benefiting from these services. The inconsistency in patient demographics across free clinics in the United States should be considered by policymakers and public health agencies.


AMA Research Challenge 2024 

The Demographic Gap: A Comparative Analysis of the Demographics of Free Clinic Patients With the City Served

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COVID-19 disproportionately affected under-resourced communities. In response, the Unified Government Public Health Department (UGPHD) integrated a social needs screening into its Contact Tracing Investigation (CTI) program. This study aims to describe this approach, identify community needs, and analyze factors associated with specific social needs. Volunteers from the CTI program contacted Wyandotte County, Kansas residents who tested positive for COVID-19 to conduct both contact tracing and assess social needs. Key areas of need included food, workplace documentation, behavioral health support, federal assistance eligibility, and community health worker (CHWs) referral. The CTI program connected community members to 4,400+ resources. Non-English speakers and residents in high-deprivation areas requested food, work release letters, and federal aid more frequently. Requests for CHWs were common among those identifying as non-White, requiring interpreters, or unemployed. The UGPHD's CTI program successfully linked residents to essential social services, highlighting the value of public health departments in supporting underserved communities.

The Disease Investigation Process: A Vehicle for Social Services

Background
Fostering cultural competence in medical education and healthcare settings is crucial for treating diverse patient populations. Middle Eastern North African (MENA)-Americans are categorized as White in the U.S. racial categorization, however, their health needs and experiences drastically. To provide culturally appropriate care, there is a need for disaggregated data on the 3.5 million MENA-Americans from White individuals. This literature view aims to highlight the techniques and strategies to advance MENA health, patient education, and cultural competence among healthcare.
Methods
A comprehensive search using keywords like “MENA,” “Middle Eastern,” “North African,” “health outcomes,” “patient outcomes,” “minority health,” and “medical education” was conducted in PubMed, This yielded 216 papers for consideration. Inclusion criteria focused on studies related to MENA-American health, medical education on MENA health, and culturally competent care for MENA-American individuals. After abstract screening, 90 papers were selected for full-text review, with 22 meeting the inclusion criteria. 
Results
All 22 articles highlight the need for increased cultural education of this minority group, with key cultural factors identified include language and communication (n=9), family and community involvement (n=12), religious practices and dietary needs (n=9), cultural education (n=8), and stigma (n=5). 10 studies highlight the need for integration of traditional cultural practices into healthcare interventions. Only three intervention studies were identified, which included health education classes (n=2) and online interactive patient simulations (n=1). Eighteen studies offered recommendations for potential future health interventions, including culturally tailored prevention programs, recruitment of Arabic-speaking providers, and implementation of cultural training modules.
Conclusion
This literature review highlights the importance of tailored efforts to improve MENA health, patient and medical education, and cultural competence in healthcare settings. Although research on MENA-American health is limited, there is a growing understanding of the cultural considerations necessary for caring for this community. It is vital to move towards implementing interventions to fill in the gaps that have been highlighted in the literature. Doing so will enhance cultural competence and ultimately improve the care that MENA-Americans receive.


The Need for Cultural Competence in Serving the MENA-American Community​

Introduction: 

Most Americans now live in states that have a medical marijuana dispensary. Increases in the number of patients enrolled in medical marijuana programs nationally between 2016 and 2020 parallel a steady increase in the number of qualifying conditions (QC) with limited to no evidence. Like other states, Pennsylvania’s medical marijuana program has experienced rapid expansion since its inception in 2017, with the number of enrolled patients surging from 1,230 in 2017 to 432,717 in 2023. 

Research Question: 

To what extent were certifications in the Pennsylvania medical marijuana (MMJ) program evidence-based? 

Methods: 

QCs, zip-codes, and certification dates for each MMJ patient from 2017-2023 were obtained from the Pennsylvania Department of Health and the US Census Bureau's Population Estimates Program (PEP) datasets. Using the NAS 2017 report, Pennsylvania’s 21 QCs were categorized as either evidence-based (substantial to conclusive evidence) or not evidence-based (limited to no evidence). 

Results: 

In 2017, 67.6% of enrolled MMJ patients had at least one evidence-based condition. Following the addition of anxiety disorders as a QC in 2019, we observed a continuous decline in the share of evidence-based certifications. In 2023, 41.1% of patients had at least one evidence-based QC. From 2017-2019, the most common patient was certified for only chronic pain (37.3%-46.5%). From 2020-2023, patients having only anxiety disorders were the most common MMJ patient (31.7%-43.5%). 

Conclusion: 

The decrease in the proportion of evidence-based MMJ certifications from 2019-2023 indicates that national patterns between 2016-2020 extend into 2023 for the Pennsylvania MMJ program. Given that evidence-based medicine is the gold standard, there is a need for further research into the impacts of marijuana on anxiety disorders, for lawmakers to re-evaluate QCs, and for providers to more rigorously make MMJ certifications. 



The Pennsylvania Paradox: Medical Marijuana’s Rapid Growth Amidst Evidence-Based Uncertainty from 2017- 2023 ​​

Trends in Cannabis Use and Associated Volatile Organic Compounds: Implications for Public Health Policy
Andrew Goulian MPH, Brielle Goldstein, David Bell MD, MPH
California Northstate University College of Medicine, Elk Grove, CA
Mailman School of Public Health Columbia University, New York, NY

Background
The legalization of cannabis has increased its accessibility and use across the United States, raising concerns about public health. This study investigates the trends in cannabis use from 2009 to 2018 and examines the association with volatile organic compounds (VOCs) such as benzene and ethylbenzene, which are found in cannabis smoke. The objective is to understand the impact of these trends on public health and policy.

Methods
Data on cannabis use were obtained from the National Health and Nutrition Examination Survey (NHANES) from 2009 to 2018, including a total of 8,912 participants. These data were merged with demographic variables (gender, age, race/ethnicity, education level, household income) and blood levels of VOCs (benzene and ethylbenzene). A survey-weighted logistic regression model was used to examine the associations between cannabis use and these variables. Time-series analysis was conducted to observe trends over the decade.

Results
The logistic regression model showed significant associations between cannabis use and several variables. Males had lower odds of cannabis use compared to females (p<0.001). Higher education levels were associated with higher odds of cannabis use (p<0.001), and higher household income was associated with lower odds of cannabis use (p<0.05). Blood levels of benzene were significantly associated with higher odds of cannabis use (p<0.001), while blood levels of ethylbenzene were associated with lower odds of cannabis use (p<0.001). Over the decade of analysis, the number of states that legalized recreational cannabis increased from 0 to 10, reflecting a broader trend of increased cannabis accessibility.

Conclusion and Impact
The findings highlight significant demographic and chemical exposure factors associated with cannabis use. The increase in cannabis legalization and its associated VOC exposure pose potential public health risks. Public health policies should address the implications of increased cannabis use and associated VOC exposure, particularly focusing on preventive measures and education to mitigate these risks. The study underscores the need for ongoing surveillance and research to inform evidence-based public health strategies in the context of evolving cannabis legislation. This research is critical for informing policymakers on the health risks of cannabis-related VOC exposure and could shape future regulations to promote health equity and safer cannabis consumption.

Trends in Cannabis Use and Associated Volatile Organic Compounds: Implications for Public Health Policy

Nearly 30% of the population of Guam relies on the local Medicaid program for healthcare coverage. Due to a high prevalence of non-communicable disease, access to affordable chronic care management is crucial to sustaining the island territory’s healthcare system. With nearly $130 million in federal match funding, understanding the spending trends of Guam’s Medicaid program may yield insight to how these funds are being accessed by the patient population. Data was obtained from the Medicaid section of the Medicaid and MIP Expenditure and Demographic End of 4th Quarter Report available on the Guam Department of Health and Human Services Bureau of Health Care Financing Administration web page. A data set was constructed from reports published for fiscal years 2014-2023. Categories for expenditure were titled “Type of Service” on the report and all services provided in the report were included in the data set. Regression analysis was performed to determine average change in expenses over time. Between 2014 and 2023, total expenses increased from $57.9 million to $115.3 million (R2=0.84). 16 out of 24 services had an average increase in expenses. Amongst services, the greatest average increase was observed in Inpatient Hospital services with $6,601,156 (p=0.00005; R2=0.8). The greatest average annual decrease was observed in Dental services with -$897,347 (p=0.003; R2=0.6) Increases in Emergency Room services (p=0.004; R2=0.6), Outpatient Hospital services (p=0.001; R2=0.8), and Home Health services (p=0.02; R2=0.7) were also observed. No statistically significant increase was seen in FQHC with an annual average decrease of -$75,170 (p=0.2; R2=0.1) Although there has been a dramatic increase in total spending by the Guam Medicaid program, there is disparity in how this increase has been distributed across available services. Between 2014 and 2023, there have been increases in spending observed in Hospital services (Inpatient, Outpatient, and Emergency Room) with no increase in spending for primary care services (FQHC) during this time of overall spending growth. Publicly funded Dental services have observed dramatically decreased reimbursement. Information regarding disease prevalence and healthcare infrastructure must be considered to fully contextualize these findings. Local and federal policy makers should acknowledge these trends and ensure that distribution of the territorial Medicaid resources aligns with the needs of the island community.

Trends in Local Medicaid Spending in a U.S. Pacific Island Territory

Abstract

Introduction. Vaccine hesitancy is a significant threat to public health, and its contributing factors remain understudied. This study sought to better understand COVID-19 vaccination rates in Kansas and to compare vaccine perception between rural and urban communities.

Methods. Cross-sectional survey data of 2,196 Kansas residents were obtained through the Rapid Acceleration of Diagnostics Underserved Populations (RADx-UP) grant project at the University of Kansas Medical Center, which utilized convenience sampling to survey individuals residing in 10 Kansas counties. Demographic profiles, vaccination status, and vaccine perceptions were analyzed.

Results. RADx-UP survey data indicated a significant relationship between rurality and vaccine acceptance, with rural participants reporting lower vaccination rates compared to urban counterparts (70.1% vs 79.9%; X2 [1, n = 1995] = 24.2; P < .001). Family safety emerged as a

primary motivator for vaccination across all respondents. Concerns about vaccine side effects were the dominant reason cited for vaccine hesitancy, most prominently in rural areas.

Conclusions. Our findings suggest significant differences between rural and urban populations regarding vaccination uptake and hesitancy. Nuanced understanding of target populations and vaccine hesitancy will facilitate more effective vaccination efforts. Future research would benefit from investigation of optimizing delivery of trustworthy and accessible information to the public regarding vaccinations.

Understanding COVID-19 Vaccine Hesitancy in Rural and Urban Kansas: A Cross-Sectional Survey Analysis

Background
Clinical trials are the gold standard for generating evidence on the safety and efficacy of potential new treatments. Yet, Black patients are historically underrepresented in clinical trials for the diseases that disproportionately affect this group. The lack of inclusivity in clinical trials impacts the generalizability of findings and contributes to disparities in health outcomes. To better understand the factors contributing to African American enrollment in trials, we conducted a survey to evaluate the factors contributing to African American’s willingness to participate in clinical trials. The purpose of the study was to identify barriers and facilitators to African Americans' willingness to participate in clinical trials and develop culturally sensitive strategies to enhance the enrollment of diverse patient populations in clinical trials. 
Methods
We created a web-based survey consisting of 38 questions subdivided into three sections: (1) cultural affinity, (2) trust, and (3) background information. The survey was administered via Jotform, a HIPAA-compliant web application. Our target population was Black Americans in the Southern U.S. Participants were recruited using a combination of community-based recruitment and traditional recruitment methods, such as social media and radio advertisements.
Results
260 Black adults completed the survey. The most commonly reported barriers to participation included the history of medical research on African Americans, concerns about potential side effects of an experimental treatment, and the absence of Black clinicians involved in research. Facilitators to research participation included greater representation of African Americans in medical research, physician recommendation, IRBs with African American members, thorough explanations about the study, and relevance of the study to the black community. Other notable findings include that only 27.6% and 37.5% of respondents indicated that free transportation to and from the research sites and being paid for participation would make them more willing to participate in clinical research.
Conclusion
Our findings indicate that Black Americans are open to participating in clinical research. However, culturally sensitive trust and safety measures should be implemented to address the negative effects of a history of abuse, dishonesty, and lack of Black leadership in medicine on people of color’s ability to trust medical research. Plain language study material and explanations, diverse representation in leadership, and active community engagement in the study process are vital steps toward increasing African American research participation.


Understanding factors inﬂuencing African Americans' participation in clinical trials

Background
First-generation low-income (FGLI) medical students face unique challenges that influence their career paths. These students often encounter significant socioeconomic barriers, including financial burdens, lack of mentorship, and limited diversity within medical fields. The journey through medical school is particularly arduous for FGLI students who often lack the financial resources and professional networks available to their peers from more affluent backgrounds. Additionally, the high cost of medical education and the substantial debt burden can discourage these students from pursuing lower-paying specialties, further limiting their career choices. Understanding these factors is crucial for developing strategies to support FGLI students and enhance diversity within the medical profession.

Methods
A comprehensive literature search was conducted across PubMed, CINAHL via Ebsco, and Embase via Elsevier databases from January 1, 2018, to June 27, 2024. Included studies were randomized controlled trials, cohort studies, case-control studies, cross-sectional studies, surveys, or systematic reviews focusing on FGLI medical students in the United States. Interventions involving support from medical schools, such as financial aid, mentorship programs, and early exposure to various specialties, were also considered.

Results
The review identified that financial burdens, particularly student debt, are significant barriers that often deter FGLI students from pursuing lower-paying specialties such as primary care. The lack of diversity and mentorship within certain medical fields further exacerbates these challenges, making it difficult for minority and low-income students to find role models and supportive networks. Studies highlighted the effectiveness of interventions such as pipeline programs, which provide early exposure to various specialties and financial support mechanisms, in addressing these barriers. These interventions provide FGLI students with the tools and confidence needed to pursue a broader range of specialties, including those traditionally less accessible to them.

Conclusion
Addressing the financial, social, and educational barriers faced by FGLI medical students through comprehensive and targeted interventions is essential. By implementing strategies that include financial support, enhanced mentorship, and early exposure to various specialties, medical schools can foster a more inclusive and diverse medical workforce. This approach will not only improve the recruitment and retention of FGLI students in a broader range of specialties but also enhance patient care and health outcomes across communities. Future research should focus on examining the long-term effects of these interventions and uncovering additional barriers and solutions to support the career development of FGLI medical students.

What are the primary factors influencing specialty choice among FGLI medical students?

Title: Missed Opportunities in HIV Screening and Transmission Prevention in Southeastern United States: A Retrospective Cohort Study 

Authors: Cecily Kaufmann, BSN, RN, David Hudon, MPH, Phillip Moschella, MD, Heather Brown, MD, Caroline Derrick, PharmD, Sharon Weissman, MD, Divya Ahuja, MD, Sarah Battle, MD 

Background: Despite extensive HIV prevention efforts, the high incidence of HIV in the Southeastern United States underscores the urgent need for enhanced public health initiatives. This study examined new HIV diagnoses in the Midlands of South Carolina and identified missed opportunities (MOs) for early detection in the 365 days prior to new HIV diagnosis. In addition, MOs for pre-exposure prophylaxis (PrEP) discussion for HIV transmission prevention were evaluated. 

Methods: This retrospective cohort study analyzed 127 new HIV diagnoses in adults ≥ 18 years of age in the Midlands area of South Carolina between January 1, 2022 and December 31, 2023. Patient demographics, risk factors, and clinical characteristics of all healthcare visits from the 365 days prior to HIV diagnosis were evaluated. Descriptive statistical analysis focused on characterizing HIV screening MOs and PrEP discussion MOs. 

Results: The cohort predominantly consisted of Black or African American males, but included 18.8% females and 12.5% Caucasians. While men who only have sex with men (MSM) was common (28.3%), exclusive heterosexual activity (43.3%) was surprisingly more prevalent. Of the 117 patients without a diagnosis of acute retroviral syndrome (ARS), 40.1% had severe immunosuppression (CD4 <200 cells/mm³). In the year prior to non-ARS HIV diagnosis, there were a total of 414 MOs for HIV screening (mean of 3.5 per patient), with 45.7% in the Emergency department visits and 12.1% in urgent care, and 42.3% in outpatient clinics. The most common clinics for screening MOs were Family Medicine, Internal Medicine, Cardiology, and Orthopedic Surgery. In the year prior to ARS diagnosis, there were 34 MOs for PrEP discussions (mean of 3.4 per patient). The most common clinics for PrEP MOs were Family Medicine and Orthopedic Surgery. For both types of MOs, patients were most frequently seen for chronic health conditions (10.5% of the MOs for screening and 14.1% of the MOs for HIV PrEP). Only ten patients (7.8%) had ever had a previous negative HIV screen, and only one (0.8%) had a screen done in the year prior to HIV diagnosis. Only seven patients had previously been offered PrEP. 

Conclusions: This study highlights the substantial number of missed opportunities for HIV screening and PrEP discussions in all locations of medical care, from the Emergency Department to subspecialty clinics. Given the diverse risk factors seen in this study, not only should universal opt-out HIV screening be implemented in high incidence regions, but consideration should be given to frequent HIV screening and PrEP discussions in all adults irrespective of their sexual orientation.

Missed Opportunities in HIV Screening and Transmission Prevention in Southeastern United States: A Retrospective Cohort Study

Background:
Heart failure (HF) is a complex medical condition associated with high hospital readmission rates, placing a significant burden on hospital resources. Attempts to improve outcomes and quality of life for these patients have led to significant advances in patient care in terms of medical therapies and risk reduction measures. However, the increased complexity of treating HF associated with these advances has also made healthcare navigation and patient compliance more difficult. For patients hospitalized with heart failure, goal-directed medical therapy (GDMT) leads to improved patient outcomes and reduces rehospitalizations, thus reducing the cost of care. Inadequate GDMT translates to a 29% excess mortality risk over just a 2-year period of follow-up. While patient compliance encompasses a large realm of social determinant factors, the consistent prescription of GDMT by physicians is the first step. 

Methods:
We analyzed prescription rates of patients hospitalized between 2/1/2024 – 5/1/2024 with HF with reduced ejection fraction (HFrEF). This included 54 patients who were pre-educational interventions and 80 patients who were post-educational interventions. The Quality Improvement (QI) project intervention included an in-person presentation as well as an email sent to all internal medicine residents with a succinct one-pager and full PowerPoint presentation. It additionally involved the creation of an HF order set hard-coded into the hospital’s electronic medical record. This included but was not limited to a list of GDMT medications (angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARB) or angiotensin receptor/neprilysin inhibitor (ARNI), beta blockers (BB), mineralocorticoid receptor antagonist (MRA)), daily weights, ins and outs, a therapeutic diet, elevation of the bed, cardiac rehabilitation referral, and other useful lab work. Of note, sodium-glucose cotransporter 2 (SGLT-2) inhibitors were excluded as part of GDMT as they are not on the formulary at our institution.

Results: 
After the QI project intervention, beta blocker prescription rates rose from 77.8% to 92.5%. Angiotensin receptor blocker prescription rates changed from 81.5% to 76.3%. Mineralocorticoid receptor antagonist prescription rates rose from 46.3% to 57.5%. 

Conclusion: 
This project demonstrated that educational sessions as well as HF order sets can improve GDMT prescription rates. However, our results also indicate the need for continued improvements. Repeat educational sessions as well as improvement of order sets with the incorporation of heart failure coordinators and care management consults are starting points to continue optimizing GDMT rates.

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