United States

Background: Chronic disease appointment deferral was a potent problem throughout the pandemic. Additionally, literature shows poorer health for non-English-speaking patients. This study aims to bridge the existing gap in research for this patient population while assessing the state of primary care during the pandemic via chronic disease appointments.
Methods: The Larry A. Green Center launched a series of national surveys (n &gt; 500) with a unique series of questions to obtain temporal, pressing information surrounding primary care’s response to the pandemic. We analyzed changes based on clinic perception of chronic disease appointment incidence using two of these surveys. We further stratified the data by the proportion of non-English speaking patients in each clinic and used Chi-square analysis to analyze significance.
Results: In October 2021, clinics with less English-speaking patients had a greater decrease in stable chronic disease appointments and a larger increase in unstable chronic disease appointments: Among clinics reporting ≥ 90% English speakers (n = 336), 36% (n = 121, p = 0.03) reported less stable chronic disease visits, and 30% (n = 99, p =0.01) reported more visits for unstable chronic disease. In clinics with ≤ 80% English-speaking patients (n = 239), 47% (n = 110, p = 0.03) reported a decrease in stable chronic disease appointments, and 40% (n = 97, p = 0.01) reported an increase in unstable chronic disease appointments. 
In March 2023, the clinics with the least English-speaking patients had a higher incidence of reporting a detrimental change in the stability of their patients’ chronic conditions: 32% (n = 273) of all total clinics, 29% (n = 125) of clinics with ≥ 90% English-speaking patients, 39% (n = 74) of clinics with 81 to 90% English-speaking patients, 42% (n = 48) of clinics with 50-80% English-speaking patients, and 49% (n = 26) of clinics with ≤ 50% English-speaking patients reported a transition from stable to unstable chronic disease due to lack of access to care (p = 0.001). 
Conclusion:
These findings suggest a clinician-reported transition of chronic conditions from stable to unstable, raising concern surrounding deferred care during the pandemic. This emphasizes the need for programs to improve accessibility to clinic visits. Furthermore, additional emphasis should be placed on clinics serving non-English speaking patients, as our study reveals higher rates of care deferral in this population.

AMA Research Challenge 2023

Navigating the Deferral Dilemma: Understanding Access to Chronic Disease Care for Non-English Speakers and Overall

Background: Chronic disease appointment deferral was a potent problem throughout the pandemic. Additionally, literature shows poorer health for non-English-speaking patients. This study aims to bridge the existing gap in research for this patient population while assessing the state of primary care during the pandemic via chronic disease appointments.
Methods: The Larry A. Green Center launched a series of national surveys (n > 500) with a unique series of questions to obtain temporal, pressing information surrounding primary care’s response to the pandemic. We analyzed changes based on clinic perception of chronic disease appointment incidence using two of these surveys. We further stratified the data by the proportion of non-English speaking patients in each clinic and used Chi-square analysis to analyze significance.
Results: In October 2021, clinics with less English-speaking patients had a greater decrease in stable chronic disease appointments and a larger increase in unstable chronic disease appointments: Among clinics reporting ≥ 90% English speakers (n = 336), 36% (n = 121, p = 0.03) reported less stable chronic disease visits, and 30% (n = 99, p =0.01) reported more visits for unstable chronic disease. In clinics with ≤ 80% English-speaking patients (n = 239), 47% (n = 110, p = 0.03) reported a decrease in stable chronic disease appointments, and 40% (n = 97, p = 0.01) reported an increase in unstable chronic disease appointments. 
In March 2023, the clinics with the least English-speaking patients had a higher incidence of reporting a detrimental change in the stability of their patients’ chronic conditions: 32% (n = 273) of all total clinics, 29% (n = 125) of clinics with ≥ 90% English-speaking patients, 39% (n = 74) of clinics with 81 to 90% English-speaking patients, 42% (n = 48) of clinics with 50-80% English-speaking patients, and 49% (n = 26) of clinics with ≤ 50% English-speaking patients reported a transition from stable to unstable chronic disease due to lack of access to care (p = 0.001). 
Conclusion:
These findings suggest a clinician-reported transition of chronic conditions from stable to unstable, raising concern surrounding deferred care during the pandemic. This emphasizes the need for programs to improve accessibility to clinic visits. Furthermore, additional emphasis should be placed on clinics serving non-English speaking patients, as our study reveals higher rates of care deferral in this population.

poster

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Background: Primary care physicians are the principal clinicians treating addiction medicine in the U.S., yet chronically lag behind the demand for substance abuse care. Current literature has detailed worsening substance abuse and addiction with the onset of COVID-19, especially among minority individuals. Our study works to understand low-income individuals from the perspective of primary care, for which current literature is lacking. 
Methods: The Larry Green Center gathered perception data surrounding many pandemic-related impacts on primary care using the weekly "Quick COVID-19 Primary Care" surveys. This study selected six nationwide surveys (n=582-1472) in 2020, 2021, & 2023. Each survey was selected based on their inclusion of addiction medicine questions and was analyzed using descriptive statistics. Surveys were stratified by income with significance testing via Chi-Square analysis (p<0.05). 
Results: Polled primary care clinics revealed an increased perception of addiction during all stages of COVID-19 compared to pre-pandemic levels. Three surveys in 2020 revealed that 31-39% of clinics reported more addiction. A marked increase occurred in December 2021 with 48% of clinics reporting more addiction. No data existed for 2022; however, 41% of clinics reported more addiction in March 2023, demonstrating persistent elevation. After stratification to income, roughly 26% of clinics reporting more addiction served 10-19% of low-income patients. This proportion was consistent for clinics with 20-49% low-income patients, which comprised approximately 25% of all clinics reporting more addiction. Clinics reporting more addiction over the fielded surveys were nearly twice as likely (~48%) to serve the highest proportion of low-income patients (>50% low income). All findings were significant at p<0.05. 
Conclusion: Perception data collected from primary care clinics during COVID-19 suggest a worsening addiction epidemic that disproportionately affected lower-income patients. Chronically underfunded primary care clinics need greater financial resources to tackle systemic stressors beyond COVID-19 that will continue to exacerbate the addiction epidemic in the U.S. Training primary care physicians in addiction medicine, eliminating barriers to addiction care, and targeting low-income patient populations may help to mitigate the current trend of addiction in the U.S.

Primary Care Offices Report More Substance Abuse Amidst COVID-19 - Expanding the Demographic Portrait

Background: The COVID-19 pandemic resulted in a national lockdown in Chile and delays in surgical care. This study aims to assess the effects of COVID-19 and Chile’s counteracting policies on surgical waitlist lengths a public hospital. 

Methods: Data on surgical waitlists at the closing of the year from 2016 to 2022 were obtained from Hospital La Florida. A one-way ANOVA with a Bonferroni correction was used to determine which years had a statistically significant difference in surgical waitlist times. The aggregate data for all surgical specialties was used to analyze which years had a statistically significant difference.

Results: There was a notable decrease in waitlist length each year from 2016 to 2019, with a statistically significant difference in waitlist length in 2016 and 2017 compared to 2019 (p = <0.001 and 0.023, respectively), and a nonsignificant difference in 2018 (p = 1.00). In 2020, there was a significant increase in waitlist length compared to 2019 (p = 0.001). The waitlist lengths returned to pre-pandemic levels after 2020, with no difference in waitlist lengths in 2021 and 2022 when compared to 2019 (p= 0.31 and 1.00, respectively).

Conclusion: The COVID-19 pandemic resulted in significantly increased surgical waitlists, with large improvements in waitlist lengths through Chile’s varied policies in resource management, budgeting, efficiency, and collaboration. Further work should assess which strategies were most successful in shortening surgical waitlists to continue removing the burden of surgical delays for patients.

The Impact and Health System Response of COVID-19 on Surgical Waitlists in Chile

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**Abstract:**



Correlating Sickle Cell Disease Across Seasonality and Geography

Many epidemiological studies have investigated the association between coffee consumption and risks for various types of cancer, yet results are conflicting. To determine the impact of coffee consumption on cancer incidence, we systematically reviewed high-quality prospective cohort studies for 10 major cancer types and performed meta-analyses of 63 studies from different countries. For each cancer type, we calculated summary relative risks using the DerSimonian–Laird random-effects model and assessed dose-response relationships. Our meta-analyses found that caffeinated coffee consumption, but not decaffeinated coffee, prevented liver and skin cancers, highlighting the significant role of caffeine in cancer prevention. Furthermore, both caffeinated and decaffeinated coffee prevented endometrial cancer, indicating the role of other active compounds in coffee. Collectively, our meta-analyses revealed that coffee consumption, particularly caffeinated coffee, prevents the incidence of liver, endometrial, and skin cancers in a dose-dependent manner, suggesting that coffee consumption has a large impact on public health.

Meta-Analyses of Prospective Studies on Cancer Incidence and Caffeinated or Decaffeinated Coffee

Our objectives were to examine whether there are racial differences in diffuse and anaplastic astrocytoma survivorship in children, and if so, to identify which racial groups have poorer survival.
Brain tumors represent the leading cause of cancer deaths in children. Moreover, 60% of these tumors are astrocytomas, neoplasms of the star-shaped glial cells, astrocytes, which provide physical support and aid in neurotransmission. Diffuse astrocytomas are indolent with low metastatic tendency and have survival ranges greater than 5 years. Anaplastic astrocytomas, however, represent a more aggressive neoplasm with greater metastatic potential and carry a survival range of 2-5 years. Both tumors are more common in adulthood, commonly reside in the frontal and temporal lobes, and are associated with few risk factors aside from ionizing radiation or genetic mutations such as p53. Current treatment of these cancers includes surgical resection, external-beam radiotherapy (EBRT), and adjuvant chemotherapy, dependent on location, histology, time since diagnosis, and other factors. Previous research supports an association between race and survival in children for brain malignancies generally; given racial disparities in healthcare delivery exist, we sought to bridge this gap to identify pitfalls in pediatric astrocytoma treatment due to its prevalence.
We analyzed 5-year relative survival rates in children under 15 with localized diffuse or anaplastic astrocytomas from 2000-2018 using the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) Program. The tumor classification used ICD-O-3 codes 9400-9401, 9410-9411, and 9420.
Racial groups included were Hispanic, Non-Hispanic Asian/Pacific Islander (NHAPI), Non-Hispanic Black (NHB), and Non-Hispanic White (NHW). Incidence for Hispanics and Non-Hispanics was based on the North American Association of Central Cancer Registries Hispanic Latino Identification Algorithm. Analysis of variance (ANOVA) and subsequent post- hoc two-sample T-tests were performed to assess associations between race and relative survival.
The ANOVA assuming that mean survival is equal across racial groups was statistically significant (p=3.9552-8) with an alpha level of 0.05. Post-hoc two-sample t-tests assuming unequal variances showed significantly different survival rates of NHAPI when compared to Hispanics, NHB, and NHW (p=0.01925, p=0.01888, p=0.00142, respectively where alpha=0.025).
Non-Hispanic Asians and Pacific Islanders have significantly worse survival compared to any other racial group. This varies from adult and pediatric research which associate lower survival in Black populations compared to White populations with the same brain tumor. These findings identify a unique racial difference not before described in the pediatric population and emphasize the need for closer inspection of neurooncological treatment practices.

Racial Differences in Pediatric Localized Diffuse and Anaplastic Astrocytoma Survival

Background
Racial disparities among cancer patients have become a national concern due to their effects on cancer prognosis. This study aims to address these disparities by examining the racial composition and potential inequalities among cancer patients treated at the Prisma Health Cancer Institute. The findings from this study are compared with national trends to provide insights into the impact of race on patient treatment outcomes. Factors such as cancer staging, histology, molecular characteristics, treatment, demographics, and lifestyle are analyzed to gain a comprehensive understanding of their impact on disease prognosis, treatment, and outcome.

Methods
The study includes 586 cancer patients diagnosed with breast (397) and lung (171) cancer between 2014 and 2022. Patients were categorized by race: Asian, African American, Hawaiian/Pacific Islander, Latino, Multi-Race, White, and patients with missing race information. The JMP software was used for statistical analysis of the racial composition in terms of diagnosis distribution, cancer staging, cancer histology, smoking status, cancer molecular subtypes, and other factors.

Results
In the studied group, African American males had a higher likelihood (3.17%) of breast cancer diagnosis compared to White males (0.84%). Additionally, the African American population showed a greater proportion of stage IV lung cancer (11.11%) compared to the White population (4.63%). Our data for breast cancer in males and stage IV lung cancer were similar to national trends, with African Americans having an increased probability of these characteristics. Notably, the incidence of triple-negative breast cancer was similar between African American (14.63%) and White (13.18%) females in the studied cohort, Our data differed from the national trend for triple-negative breast cancer, where African American females have a higher likelihood of the diagnosis.

Conclusion
This study provides a focused examination of patients treated at the Prisma Health Cancer Institute, shedding light on population differences in two highly lethal cancers. Our study combines multiple factors such as molecular, clinical, and demographic data to identify areas of disparity concerning cancer patients. The research aims to improve treatment and care for minority patients. The findings contribute to a better understanding of racial disparities in cancer outcomes, potentially leading to ethnicity-specific and minority-inclusive interventions. Moreover, this research has the potential to enhance physician-patient interactions and promote more equitable healthcare.

Racial Composition Analysis Using Molecular, Clinical, and Demographic Data of Cancer Patients from the Prisma Health Cancer Institute

Background
The presence of wounds, from either acute or chronic circumstances, places a significant burden on a patient’s quality of life (QoL). In the US, as the number of patients with chronic health conditions such as diabetes mellitus, vascular disease, and obesity continues to rise, so does the risk of complications of wounds. Some of these complications include the increased risk of infection and further issues with tissue revascularization, both of which are associated with worse morbidity. The increasing patient population signifies the necessity for proper community education on wound care in the home and after in-office procedures to reduce the risk of further complications. Our study gathered community knowledge from a student-run free-dermatology clinic, according to AAD guidelines, to better assess community knowledge of wound care.

Methods
Using a 6-question paper survey with five multiple-choice questions and one 5-point Likert scale rating for confidence assessment of wound care knowledge (1 equating not confident and 5 equating very confident) was voluntarily answered by patients aged 18 years and older at a Free Student-Faculty Collaborative Dermatology Clinic. A quantitative analysis was run to interpret the 30 results. A one-tailed T-test was used to evaluate the responses to the multiple-choice questions under the assumption that getting three out of four questions indicated sufficient knowledge. 

Results
Although the average confidence from the responses was 4.33 using a Likert scale rating, further inquiry showed only 7.4% were using a method consistent with current AAD guidelines. Our results showed 51.85% of respondents were able to identify all the characteristics of an infected wound and 66.7% correctly chose the use of mild soap and water for washing. Only 23.1% of responses correctly identified that wounds need to be kept moist. Analyzing the multiple-choice questions, only 37.03% demonstrated sufficient knowledge of wound care (p<0.0005).

Conclusion
Our study demonstrated the importance of providing patients with standardized wound care education. Presently at our clinic, a wound care recommendation sheet in accordance with AAD recommendations is offered to patients who recieve biopsies or in-office procedures. The initiative was implemented to help close the education gap for patients regarding wound care. Clinics and providers can similarly provide materials or have posters in the office to highlight similar wound care recommendations. A limitation of this study was the small sample size and possible misinterpretation of the questions based on individual comprehension.

Wound Care Knowledge in the Community Setting: Closing the Patient Education Gap

Background
Neurological symptoms affect greater than one third of adult COVID-19 patients. As growing literature illustrates COVID-19 as both a pulmonary and a vascular disease, neurological sequelae are frequently noticed but still not fully understood. Elevated intracranial pressure (ICP) findings have been noted increasingly in COVID-19 patients and has been associated with higher mortality amongst COVID-19 ICU patients. Yet, there is a dearth of literature explaining these disease processes and providing providers with standardized clinical recommendations for detection and therapy. Through a standardized case series, our study aims to better characterize COVID-19 and elevated ICP findings in patients, report treatment modalities and their outcomes, and discuss potential therapies and areas for further inquiry.
Methods
In this retrospective case series, adult neurology patients who had both received a diagnosis of idiopathic intracranial hypertension (IIH) and had COVID-19 were interviewed using a standardized questionnaire that surveyed data regarding symptom types and length and treatment modalities. Qualitative analysis and review of patients' clinical and laboratory data were evaluated.
Results
Amongst eight patients interviewed, six successfully completed surveying and met all study criteria. The cohort comprises five females and one male and BMIs ranging from 35 to 51. The most common IIH symptoms included headache, vision changes or loss, tinnitus, dizziness, nausea, and auditory changes. Four had an IIH diagnosis before contracting COVID-19, and two had findings of IIH only after contracting COVID-19. Most patients who had an IIH diagnosis prior to contracting COVID-19 experienced vision changes or loss. No patients who had IIH only after COVID-19 reported symptomatic vision changes or loss. Patients with the preexisting IIH diagnosis also more commonly experienced headaches. All patients with prior IIH used acetazolamide. Three patients who had prior IIH diagnoses reported improvement with therapeutic lumbar puncture. All six patients had improvement of symptoms with treatment and over time.
Conclusion
Patients with IIH may be at increased risk for higher severity of COVID-19 neurological morbidity, specifically visual changes and headaches. Detection of papilledema in patients at risk for elevated ICP who contract COVID-19 may be an important step in detection of new IIH diagnosis and early treatment for worsening neurological and ophthalmic sequelae. Acetazolamide and therapeutic LP may present as useful tools to address ICP exacerbation in IIH and COVID-19 patients. Further study of COVID-19 and IIH therapy strategies is important for preventing vision loss and serious neurological damage.

Neurological Sequelae in Idiopathic Intracranial Hypertension and
COVID-19 Patients: A Novel Case Series

Endometrial cancer is the most common cancer of the female reproductive organs in the United States. Endometrial carcinomas encompass a variety of neoplasms with varying patient outcomes and prognoses. Given the higher incidence of endometrial cancer in the United States, it is important to examine the factors contributing to the worsened prognosis of a late vs. early-stage diagnosis. 


Demographics in Early vs. Late-Stage Endometrial Cancer: A NCBD Review


Background
In 1960, childbearing education classes (CEC) were created to educate women about the labor and delivery process. Women who attended CEC have higher rates of vaginal deliveries versus cesarean delivery. Other benefits of CEC are increased confidence, increased likelihood of breastfeeding, better communication between the patient and their care team, a decrease in analgesic use, and increased labor and delivery satisfaction. Knowledge is powerful in situations of the unknown. Demographics of women who attend CEC are most commonly white, have a college degree, and are considered above the poverty line. One theory behind these findings is the lack of availability of CEC to women of lower education and lower socioeconomic status. 
Methods
We created a list of counties in South Dakota and their respective clinics and hospitals and contacted each location to see if they offer CEC. If they did not, we asked for a referral location. We wanted to create a map showing each CEC offered in South Dakota and map out the distance between each CEC and estimate how big of a radius each CEC covers.
Results
There are only 17 CECs held in the state of South Dakota. 13 CECs are offered full-time and four are offered on a periodic or individual basis. We found the average distance between each CEC to be 50.49 miles. Our results showed a greater disparity than we originally anticipated. 
Conclusion
CEC is lacking in South Dakota, especially in rural areas. South Dakota has the highest birth rate per 1,000 people in the United States, creating a need for CEC and education before delivery. This information shows the disparity in South Dakota and can serve as a reference point for other rural areas to bring attention to the importance of CEC and geographic obstacles.

Next from AMA Research Challenge 2023

Primary Care Offices Report More Substance Abuse Amidst COVID-19 - Expanding the Demographic Portrait

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