Objective To assess the relationship between a composite measure of neighborhood disadvantage, the Area Deprivation Index (ADI), and control of blood pressure, diabetes, and cholesterol in the Medicare Advantage (MA) population. Data Sources Secondary analysis of 2013 Medicare Healthcare Effectiveness Data and Information Set, Medicare enrollment data, and a neighborhood disadvantage indicator. Study Design We tested the association of neighborhood disadvantage with intermediate health outcomes. Generalized estimating equations were used to adjust for geographic and individual factors including region, sex, race/ethnicity, dual eligibility, disability, and rurality. Data Collection Data were linked by ZIP+4, representing compact geographic areas that can be linked to Census block groups. Principal Findings Compared with enrollees residing in the least disadvantaged neighborhoods, enrollees in the most disadvantaged neighborhoods were 5 percentage points (P < 0.05) less likely to have controlled blood pressure, 6.9 percentage points (P < 0.05) less likely to have controlled diabetes, and 9.9 percentage points (P < 0.05) less likely to have controlled cholesterol. Adjustment attenuated this relationship, but the association remained. Conclusions The ADI is a strong, independent predictor of diabetes and cholesterol control, a moderate predictor of blood pressure control, and could be used to track neighborhood‐level disparities and to target disparities‐focused interventions in the MA population.

This qualitative study examines the perspectives of representatives of US Medicare Advantage plans on how their organizations can enact programs to promote social determinants of health in light of expansions offered under the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act.

Author Contributions: Mr Meyers had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Sociodemographically disadvantaged patients have worse outcomes on some quality measures that inform Medicare Advantage plan ratings. Performance measurement that does not adjust for sociodemographic factors may penalize plans that disproportionately serve disadvantaged populations. We assessed the impact of adjusting for socioeconomic and demographic factors (sex, race/ethnicity, dual eligibility, disability, rurality, and neighborhood disadvantage) on Medicare Advantage plan rankings for blood pressure, diabetes, and cholesterol control. After adjustment, 20.3 percent, 19.5 percent, and 11.4 percent of Medicare Advantage plans improved by one or more quintiles in rank on the diabetes, cholesterol, and blood pressure measures, respectively. Plans that improved in ranking after adjustment enrolled higher proportions of disadvantaged enrollees. Adjusting quality measures for socioeconomic factors is important for equitable payment and quality reporting. Our study suggests that plans serving disadvantaged populations would have improved relative rankings for three important outcome measures if socioeconomic factors were included in risk-adjustment models.

IntroductionThe electrocardiogram (ECG) is often used to identify which hyperkalemic patients are at risk for adverse events. However, there is a paucity of evidence to support this practice. This study analyzes the association between specific hyperkalemic ECG abnormalities and the development of short-term adverse events in patients with severe hyperkalemia.MethodsWe collected records of all adult patients with potassium (K+) ≥6.5 mEq/L in the hospital laboratory database from August 15, 2010, through January 30, 2015. A chart review identified patient demographics, concurrent laboratory values, ECG within one hour of K+ measurement, treatments and occurrence of adverse events within six hours of ECG. We defined adverse events as symptomatic bradycardia, ventricular tachycardia, ventricular fibrillation, cardiopulmonary resuscitation (CPR) and/or death. Two emergency physicians blinded to study objective independently examined each ECG for rate, rhythm, peaked T wave, PR interval duration and QRS complex duration. Relative risk was calculated to determine the association between specific hyperkalemic ECG abnormalities and short-term adverse events.ResultsWe included a total of 188 patients with severe hyperkalemia in the final study group. Adverse events occurred within six hours in 28 patients (15%): symptomatic bradycardia (n=22), death (n=4), ventricular tachycardia (n=2) and CPR (n=2). All adverse events occurred prior to treatment with calcium and all but one occurred prior to K+-lowering intervention. All patients who had a short-term adverse event had a preceding ECG that demonstrated at least one hyperkalemic abnormality (100%, 95% confidence interval [CI] [85.7–100%]). An increased likelihood of short-term adverse event was found for hyperkalemic patients whose ECG demonstrated QRS prolongation (relative risk [RR] 4.74, 95% CI [2.01–11.15]), bradycardia (HR<50) (RR 12.29, 95%CI [6.69–22.57]), and/or junctional rhythm (RR 7.46, 95%CI 5.28–11.13). There was no statistically significant correlation between peaked T waves and short-term adverse events (RR 0.77, 95% CI [0.35–1.70]).ConclusionOur findings support the use of the ECG to risk stratify patients with severe hyperkalemia for short-term adverse events.

More than 7% of medical students graduate from medical school with at least 1 nonspouse dependent, the majority of whom are likely children. However, there are no national studies on medical students who are parents, and very little is known about what medical schools are doing to support them. A growing literature on the experiences of residents and attending physicians who are parents has neglected to include those of medical students who are parents. It is possible that focusing on research and policy change for residents and attending physicians who are parents without considering medical students may bring about improvements that come too late for many. Further data are needed both on the available policies for students who are parents and on the experiences and needs of these students. Leading national organizations in medical education can help guide medical schools by leveraging their national networks to highlight existing best practices and to foster discussions about how best to support medical students who are parents.According to the 2020 Medical School Graduation Questionnaire (GQ) of the Association of American Medical Colleges (AAMC), 7.3% of graduating medical students reported having at least 1 nonspouse dependent, the majority of whom were likely children. 1 The 2016 AAMC Matriculating Student Questionnaire reported that 3.1% of students entering medical school reported having at least 1 nonspouse dependent. 2 These data indicate that some entering medical students are already parents, and others are becoming first-time parents during medical school. Yet, little is known about this unique student group or what efforts medical schools are making to support them.With 4 years of undergraduate and 3 or more years of graduate medical education, medical students, especially women, spend a substantial portion of their childbearing years in training. With women accounting for over half of medical school classes and the age of entering medical students rising, 3 it is increasingly important to consider the complex intersection between starting a family and becoming a physician.

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temporary federal funding for teaching health centers (THCs) will end unless Congress includes extended fiscal support for the program in the April 2017 budget resolution. Within this context, a review of the state of the THC program is important. The THC graduate medical education (GME) program was established in 2011 by the Affordable Care Act (ACA) to fund community-based, ambulatory primary care residency programs in an effort to address an increasing shortage of clinicians and systemic barriers to primary care residency improvement. 1,2 In 2015, the THC program was renewed as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This Viewpoint discusses the history of the THC GME program, its performance, and recommendations for its sustainability.The ACA substantially expanded the demand for community primary care services by increasing the number of insured patients and community health centers. [3][4][5] However, long-standing concern over the projected shortage of primary care clinicians, especially in underserved and rural communities, undermined the effects VIEWPOINT