44 articles found

Application of the ARIMA Model to Forecast Future Overdose Deaths

Original Research

Application of the ARIMA Model to Forecast Future Overdose Deaths

12 February 2026

Current data for opioid policy in affected states is outdated by 1-2 years, highlighting the necessity for a predictive model to forecast fatal drug overdoses and aid in the implementation of evidence-based preventative policies. We utilized Auto-ARIMA, an automated version of the ARIMA linear regression model, to forecast overdose deaths in the U.S., each state, and Washington D.C. Our forecasts for 2021 and 2022 were based on data from 2015 to 2021, sourced from the CDC's Vital Statistics Rapid Release program. Our ARIMA model forecasts an increase in overdose deaths across the U.S. and in many states, with some states potentially seeing a doubling of deaths from 2020 to 2022. This research represents an initial step in using real-time forecasts to evaluate the effectiveness of state-level public health policies in combating the opioid crisis.

Parash Bhakta

Neha Balapal

Saadh Ahmed

+7

Abstract

Understanding PrEP: Perceptions and Misconceptions Amongst Men Who Have Sex With Men in Upstate South Carolina

12 February 2026

Despite the effectiveness of pre-exposure prophylaxis (PrEP) in preventing HIV, uptake among men who have sex with men (MSM) in Upstate South Carolina remains limited. This study investigates barriers to PrEP access and utilization in this population to guide targeted public health strategies. A cross-sectional survey of MSM aged 18 and older was conducted to collect demographic information, perceptions and misconceptions about PrEP, and reported obstacles to accessing it. Pearson correlation tests were used to examine associations between participant characteristics and identified barriers. Social stigma, financial constraints, and limited provider engagement emerged as the most frequently reported barriers. Notably, lower socioeconomic status was significantly associated with perceptions of discrimination in healthcare settings, while racial and ethnic minority participants were more likely to express a desire for proactive discussions about PrEP with their providers. Participants also emphasized the need for clearer pathways to locate PrEP access programs and indicated that reducing wait times for initiation would improve their likelihood of starting PrEP. These results highlight the need for interventions that address both social and structural barriers to PrEP uptake. Expanding financial support, increasing provider involvement, and implementing statewide public awareness efforts are critical to improving access and reducing disparities among MSM in this region.

Jack Golder

Christian Zanetti-Weeks

Evan Lagerberg

+1

Abstract

Eating Disorders & Sports Participation

12 February 2026

Eating disorder research is scarce due to the stigma surrounding the condition. Much of the research has focused on the influence of societal norms and social media, while many patients attribute their relationship with physical activity as problematic. This study focused on self-reported symptoms potentially indicative of an eating or body image disorder, even if a diagnosis is not present, and how those symptoms differed across athletes and non-athletes. The 11 eating disorder questions, which were coded on a scale from 1 to 5, included how much people are worried about their physical appearance and how much exercise is perceived to be a tool for controlling and altering one’s physique. Differences in self-reported symptoms were also considered between genders. Predicting the severity of eating and body image issues from sports participation alone proved to be inconclusive, but a strong association between gender and eating disorders existed. Additionally, predicting eating disorders from sports participation when accounting for gender was more statistically-significant, demonstrating unique psychological pressures on women, whether involved in athletics or not, that predispose them to an eating or body image disorder that are not as apparent in men.

Ajay Krishnan

An Entropy-Based Approach to Decision Tree Analysis in Emergency Medicine: Optimization of Diagnostic Tool Selection to Thoracic Aortic Dissection

Original Research

An Entropy-Based Approach to Decision Tree Analysis in Emergency Medicine: Optimization of Diagnostic Tool Selection to Thoracic Aortic Dissection

22 January 2026

Title An Entropy-Based Approach to Decision Tree Analysis in Emergency Medicine: Optimization of Diagnostic Tool Selection to Thoracic Aortic Dissection Authors & Affiliations Daerin Hwang, Abdel Badih el Ariss1, Norawit Kijpaisalratana1, Paul Chong2, Pedram Safari4, David Chen3, Ahmad Hassan1 1 Massachusetts General Hospital, Harvard Medical School 2 Campbell university 3 Temerty Faculty of Medicine, University of Toronto 4 MGH Institute of Health Professions CHARACTER COUNT: 2050 / 2050 Introduction Shannon entropy is a key concept in both machine learning and information theory, significantly influencing decision tree modeling. In emergency medicine, the utilization of testing and imaging tools to reduce uncertainty is vital for enhancing medical decision-making, especially in time-sensitive scenarios. While sensitivity and specificity assess test accuracy, entropy provides insight into how much a test clarifies the overall clinical picture, which is crucial in time-sensitive situations like thoracic aortic dissection. The aim of this study is to evaluate and compare the effectiveness of entropy and entropy reduction against conventional metrics of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), in the diagnostic evaluation of thoracic aortic dissection. Methodology We gathered diagnostic metrics, including true positives and negatives, as well as false positives and negatives, from a well-established online diagnostic accuracy database known as "Get the Diagnosis" for thoracic aortic dissection. Data collection took place from November 17, 2022, to January 22, 2023. This dataset allowed us to compute sensitivities, specificities, negative predictive values (NPVs), and positive predictive values (PPVs). A decision tree representing the diagnostic tool was created and examined for Shannon entropy and entropy reduction across the various child nodes. The decision tree was based on 2x2 diagnostic tables, covering total cases (N), true positives (TP), false positives (FP), false negatives (FN), and true negatives (TN). Results Using a helical CT scan for thoracic aortic dissection, we observed a sensitivity of 97.64% and a specificity of 98.90%, whereas MRI exhibited a lower sensitivity (93.33%) but a higher specificity (99.30%). However, entropy removal calculations revealed that the helical CT scan removed 87.23% of entropy associated with thoracic aortic dissection, while MRI removed 81.36%. Within these populations studied, this suggests helical CT scan may provide greater reduction in diagnostic uncertainty than MRI in thoracic aortic dissection assessment and underscores the unique insights offered by entropy removal, which sensitivity and specificity fail to provide. Conclusion Unlike sensitivity and specificity, entropy captures the inherent variability and uncertainty in diagnostic data, especially in complex medical scenarios where it accommodates individual variability in patient responses and disease manifestations.

Daerin Hwang

Abdel Badih El Ariss

Norawit Kijpaisalratana

+4

A Qualitative Assessment of the Feasibility, Usability, and Clinical Impact of the Keva365 Remote Patient Monitoring Platform for Asthma Management

Original Research

A Qualitative Assessment of the Feasibility, Usability, and Clinical Impact of the Keva365 Remote Patient Monitoring Platform for Asthma Management

30 October 2025

Background Remote Patient Monitoring (RPM) has emerged as a promising approach to managing chronic conditions like asthma, particularly during the COVID-19 pandemic. However, limited research exists on the use of qualitative analysis to capture patient feedback and experiences in RPM programs. This study extends a quantitative observational study that explored the impact of RPM on patients with moderate-to-severe asthma. Objective The aim of this study was to evaluate the feasibility and usability of Keva365, a digital therapeutic platform designed for remote asthma management, and to explore its impact on patient-provider relationships, asthma management, patient compliance, and engagement. Methods A purposeful sample of six patients with moderate-to-severe persistent asthma participated in the study. Over a nine-month period, participants were interviewed once using an open-ended question guide to collect qualitative data. The interviews were recorded, transcribed, and analyzed thematically using NVivo software. Data were used to assess the feasibility of the RPM intervention, its usability, and its impact on patient experiences. Written consent to publish these details has been obtained from all participants that were included in this research. Results Thematic analysis identified key themes related to patients' experiences with the app, their compliance and engagement with the program, their relationships with providers, and asthma management. All participants reported positive experiences with the program, noting the app’s usability, efficiency, and impact on their relationships with healthcare providers. Participants expressed high levels of satisfaction and a willingness to recommend the program to others. Feedback from the interviews contributed to near real-time modifications of the RPM application, enhancing its usability and navigation. Conclusions The study found that integrating patient feedback is essential for improving the usability of RPM platforms. Continuous iterative refinement based on patient experiences can lead to more patient-centered digital health solutions, enhancing both patient compliance and the overall care experience. The findings suggest that RPM programs can effectively support asthma management while fostering positive patient-provider relationships. make a scope statement for Conduct Science journal that focuses on current and latest research that focuses on shaping the future of medicine.

Naomi Rajput

Jyotsna Mehta

Denzil Reid

+1

A Message from the Editor-in-Chief

Letter from the Editorial team

A Message from the Editor-in-Chief

27 September 2025

This is the official Letter from the Editor for Volume 1, Issue 1 of The Journal of the American Medical Student Association. In this inaugural note, the Editor-in-Chief introduces the journal’s mission.

Andres Felipe Diaz

Humanizing Critical Care: Transforming ICUs Through Empathy and Innovation

Original Research

Humanizing Critical Care: Transforming ICUs Through Empathy and Innovation

2 September 2025

Background: Intensive Care Units (ICUs) in resource-limited settings face persistent challenges, including high infection rates, staffing shortages, and inconsistent patient-family engagement. Standardized ICU audits provide a structured approach to assessing and improving infection control, staff preparedness, and patient-centered care. This study evaluates CritiCore, a structured ICU audit framework innovation piloted and applied longitudinally over three sequential cycles at a single center, designed to drive iterative, evidence-based quality improvements through targeted intervention cycles. Methods: CritiCore was implemented at Evercare Hospital Lahore, Pakistan, across three cycles: baseline audit (November 2024), first re-audit (January 2025), and second re-audit (April 2025). Each cycle included structured observational assessments, infection-surveillance review, and multidisciplinary stakeholder interviews with ~20 ICU professionals (physicians, nurses, infection control specialists, and administrative staff). Findings from each audit informed targeted interventions focusing on real-time infection surveillance, simulation-based staff training, and standardized patient-family engagement strategies (Empatheon). Results: The initial audit revealed elevated hospital-acquired infection rates (≈40–50%), linked to inconsistent hand hygiene and ventilation gaps. Staffing continuity was affected by reliance on locum personnel and limited simulation-based training. Patient-family engagement was inconsistent, with unclear visitation policies and fragmented communication. By the first re-audit, adherence to infection-control protocols improved, simulation training participation increased, and structured family communication and visitation protocols were adopted. By the second re-audit, most improvements were sustained, with additional gains in simulation training coverage, consistency of family engagement, and environmental control measures. Infection control adherence remained markedly higher than baseline, and staffing continuity improvements were maintained. Conclusion: This three-cycle ICU audit from Lahore demonstrates the feasibility and sustained impact of a structured, iterative quality-improvement framework in an LMIC private hospital. The same CritiCore approach was subsequently rolled out at Evercare hospitals in Nigeria (twice) and Kenya (once), supporting adaptability across diverse settings; a formal multi-site analysis is planned. Keywords: critical care transformation; Evercare hospitals; ICU audit; infection surveillance; LMICs; patient-family engagement; quality improvement; staff training; Empatheon.

Asad I Mian

Muhammad Taha Anver

Mahreen Sulaiman

+4

Money as Medicine: Beyond the Monetary Value of Cash Assistance Programs

Discussion

Money as Medicine: Beyond the Monetary Value of Cash Assistance Programs

29 August 2025

Social determinants of health (SDOH)—the root causes of health disparities—often fall outside the scope of traditional clinical care. In this discussion, we argue that financial interventions, particularly cash assistance programs, play a transformative role in improving health outcomes by addressing SDOH. Drawing on lessons from established public health approaches, we explore the concept of "Money as Medicine," which reframes cash assistance not just as economic relief but as a vital component of healthcare, directly impacting physical and mental well-being.1 To build healthier communities, we recommend integrating cash assistance programs into the healthcare system to reduce emergency department (ED) utilization, enhance mental health, and promote overall health stability. We explore key evidence, highlight successful models, such as the nonprofit Link Health, and propose pathways for integration.

Julissa Barrios

Timothy Scheinert

Jessica Johnson

+3

Empathy-Driven Innovation: Human-Centered Design Thinking for Transforming Healthcare Delivery

Original Research

Empathy-Driven Innovation: Human-Centered Design Thinking for Transforming Healthcare Delivery

23 August 2025

Empathy-Driven Innovation: Human-Centered Design Thinking for Transforming Healthcare Delivery Sulaiman M¹, Amran H², Tarar K3, Pervaiz S³, Lalani D³, Shonibare A⁴, Khan I⁵, Mian A 1,5 ¹Innovly, ²Rashid Latif Medical College, ³Evercare Hospital Lahore, ⁴Evercare Hospital Lekki, ⁵Evercare Group, Background/Rationale/Purpose Healthcare systems in LMICs face unique systemic challenges, particularly in high-stakes areas like Emergency Medicine (EM) and Intensive Care Units (ICUs). Resource limitations, fragmented workflows, and communication gaps exacerbate inefficiencies, compromising patient care and operational outcomes. These challenges necessitate innovative approaches tailored to address the specific needs of critical care environments. Human-Centered Design Thinking (HCDT) offers a transformative methodology to tackle such issues by prioritizing empathy, collaboration, and iterative problem-solving. By aligning systemic improvements with the needs of patients, families, and care teams, HCDT can enhance both clinical outcomes and operational efficiency. In this context, HCDT workshops were conducted in 2024 at Evercare hospitals in Lekki, Lagos, Nigeria, and Lahore, Pakistan, focusing on identifying and resolving critical issues in emergency and intensive care management. Objectives The workshops aimed to: 1. Identify critical pain points within emergency and intensive care operations, including specific units such as the Emergency Department, PICU, NICU, MICU, SICU, CCU, and Special Care Units. 2. Co-create actionable solutions through multidisciplinary collaboration among participants from diverse professional backgrounds. 3. Foster a culture of empathy-driven innovation to enhance patient care, team dynamics, and operational efficiency. 4. Empower participants to integrate design thinking principles into their daily workflows, encouraging sustainable and innovative practices. Methodology The workshops employed Stanford d.school’s five-step HCDT framework: Empathy, Problem Definition, Ideation, Prototyping, and Testing (see Fig. 1). Each step was implemented in a structured manner, as listed below briefly. • During the Empathy phase, participants reflected on patient and staff interactions to create detailed empathy maps. • Problem Definition sessions used the PICO framework to dissect identified challenges, encouraging participants to craft "how might we" questions. PICO is a structured problem-dissection tool designed to guide teams in identifying and analyzing challenges by breaking them into four key components: Problem/Population (P) to define the issue and those affected, Ideation (I) to explore why the problem exists and its underlying causes, Context (C) to understand its relevance to local or global settings, and Outcome (O) to define the desired impact, feasibility, and sustainability of potential solutions. • The Ideation phase involved brainstorming sessions using divergent and convergent thinking techniques to generate and refine solutions. • Prototyping activities encouraged participants to create tangible models, such as digital tools or workflow processes. • The Testing phase involved conceptualizing success metrics and feedback loops for real-world application. Figure 1. Evercare Group 2.0 workshops on HCDT as a 5-step process (see text for details). Workshop Structure (Operations and format shown in Table 1 below as an example) • The workshops, conducted at Lekki and Lahore in January and April of 2024, respectively, were between two to two and a half days long. • They were designed to be contextually relevant for LMIC settings, emphasizing low-cost, scalable, and inclusive approaches to foster innovative problem-solving. • Activities included empathy mapping, assumption-storming, PICO-guided problem dissection, and collaborative brainstorming. • Facilitators used a mix of lectures, role-playing, and hands-on problem-solving exercises. • All sessions were led by Evercare-based co-facilitators under the supervision and support of Prof. Dr. Asad Mian (senior author) as team lead. Date Module Details/Activities Facilitator(s) 01/25/24 Introduction Introduction to HCDT: discuss need for complex problem solving; hack process AM 01/25/24 Five steps of design thinking Pre-thinking exercise: Break the ice; Recap HCDT in small groups; choose a specific topic within the theme to be hacked; E.g.: I would like to work on XYZ Assumption-storm: Pen down assumptions on a paper regarding the selected topic AM/team Step I: Empathy Looking through the lens of empathy: Participants will: • Observe: what the learner is doing • Engage: talk to them • Watch: look at them, observe the pattern • Listen: what are they saying • Unpack: Create an empathy map at the end AM/team Step II: Problem Identification and Dissection State the problem: Ask participants to write a problem statement, followed by a brief intro to PICO guidelines for problem dissection. • Create multiple “how might we” questions • Choose one problem and dissect it using the PICO guidelines AM/team 01/26/24 Step III: Ideation Low hanging fruit ideas to moonshots: Process of divergent and convergent thinking; ask participants to: • Through divergent thinking, pen down 15-20 ideas, using “anything goes” approach • through convergent thinking, shortlist the three innovative, yet doable ideas AM/team time permitting Step IV: Prototyping Embrace experimentation Ask participants to: • Think of a prototype and create something too (for their identified solution) • Common examples: Sketch, meeting, tool, activity, google form, plan • Doodle it • Have a hypothesis, the questions they’re trying to answer, pass/fail conditions AM/team time permitting Step V: Testing Testing: Reflect on testing ; think of a testing paradigm for their favorite solution identified AM/team Table 1. Schedule breakdown for the HCDT workshop at Lekki, Lagos, Nigeria. Total time ~ 5 hours over 2 days. • Participants represented diverse professional roles, including clinicians, paramedics, nurses, and administrators, ensuring multidisciplinary collaboration throughout the workshops. • Evaluations were collected from the participants at the end of each workshop. • True to the low-cost and low fidelity nature of HCDT, other than PowerPoint/projection, laptops, Wi-Fi, the requirement was to be non-judgmental and non-hierarchical. • This structured methodology empowered participants to generate actionable, context-specific solutions for critical care challenges. The outcomes of these workshops, including the innovative prototypes and their potential impact, are detailed in the following sections. Results Participant Demographics: A total of 41 participants attended the sessions in Lekki, and 45 in Lahore, with completed evaluations from 23 participants at each site. The majority of respondents were aged 31-40 years (52.2% in Lekki and 56.5% in Lahore), with a slightly higher proportion of males at both locations. Key Findings 1. Lekki (Emergency and Acute Care): o Pain Points: Inefficient referrals, delayed emergency responses, and fragmented communication. o Solutions: Referral coordinators, standardized checklists, and digital tools for communication. o Metrics: Potential to reduce delays and improve patient satisfaction. 2. Lahore (ICU Management): o Pain Points: Delayed triage protocols and lack of empathy in patient care. o Solutions: Empathy training leading to the establishment of Empatheon and revised triage protocols. o Metrics: Improved staff confidence, triage accuracy, and patient satisfaction. Satisfaction Levels Lekki The HCDT workshop in Lekki demonstrated high participant satisfaction, as illustrated in the Educational Value and Logistical Factors graphs in Fig. 2A & B. Most participants rated inspiration (65% giving a score of 5) and knowledge enhancement (57% rating 5) very positively. The practicality of solutions also stood out, with 65% rating it 5. Team diversity and plans for further development were similarly well-rated, with the majority assigning scores of 4 or 5. For logistical factors, the workshop's relaxed and fun atmosphere received overwhelmingly positive ratings (74% scoring 5). However, adequacy of time received slightly more mixed feedback, with 43% rating it 5 and 35% rating it 4. Fig. 2A. Likert score distributions for Education Value for the HCDT workshop at Lekki, Jan 2024. Fig. 2B. Likert score distributions for Logistical Factors for the HCDT workshop at Lekki, Jan 2024. Lahore The HCDT workshop in Lahore also received strong feedback, as seen in the Educational Value and Logistical Factors graphs in Fig. 3A & B. Inspiration and knowledge enhancement were highly rated, with 70% of participants giving a score of 5 for each. Confidence in the practicality of solutions and team diversity were also notable, with the majority assigning ratings of 4 or 5. For logistical factors, while time adequacy received mixed ratings (43% rating 5, 39% rating 4), the relaxed and enjoyable workshop atmosphere was a highlight, with 57% scoring it 5. Fig. 3A. Likert score distributions for Education Value for the HCDT workshop at Lahore, April 2024. Fig. 3B. Likert score distributions for Logistical Factors for the HCDT workshop at Lahore, April 2024. Fig 4. Participant brainstorming sessions, role-playing activities, and empathy-mapping exercises demonstrate the high level of engagement and collaboration throughout the workshops (shown here for Lekki, Nigeria). Post HCDT Incubation: Lekki, Lagos, Nigeria Four teams—DEC-I, ERA, TalkLine, and Communications Hub—developed targeted prototypes addressing key challenges in emergency medicine, including referral inefficiencies, emergency response delays, and communication gaps among interdisciplinary teams (see Table 2). Prototypes ranged from referral pathways and pre-ED care improvements to communication training programs tailored to acute care and paramedic operations. While the teams advanced to the prototyping phase, no real-world testing has been conducted yet. Team/Startup Name Team Composition Empathy/Pain Point/Problem Statement Ideation (Convergent Thinking) Prototyping Stage DEC-I (Referral System Improvement) 11 members (paramedic, nurses, admin, orthopedic technician, etc.) Poor referral system causing delays, miscommunication, staff burnout, and increased morbidity/mortality. Policies/protocols, referral coordinator role, and centralized referral platform. Focus on ED policies; paper-based solutions; metrics like reduced wait times and improved satisfaction. ERA (Emergency Response Enhancement) 9 members (paramedics, intensivist, medical administrator, nurse, etc.) Emergency response delays affecting patients, staff, Evercare reputation, and economic productivity. Training/retraining emergency response team on communication and empathy. Focus on paramedics and pre-ED care; develop training; measure reduced response times and patient feedback. TalkLine (Communication Improvement) 11 members (ED staff, ICU staff, OBGYN, dialysis, business development, etc.) Communication gaps among caregivers and with patients, leading to poor satisfaction and patient experience. Workshops on communication, feedback template use, and conflict resolution. Training on communication practices; conflict resolution; feedback mechanisms integrated into processes. Communications Hub (Communication Improvement) 10 members (physiotherapists, medical officers, admin, interns, radiographers, etc.) Poor interdisciplinary staff communication impacting operations and patient experience. Training on communication ethics, respect, and task documentation. Merge with TalkLine; focus on communication ethics; use feedback mechanisms and reflective practices. Table 2. Lekki, Nigeria: Summary of each team's composition, problem focus, and proposed solutions. Post-HCDT Incubation: Lahore, Pakistan The HCDT workshop in Lahore resulted in the formation of five teams focused on addressing challenges in ICUs and Critical Care Medicine, including staff turnover, communication gaps, and humanizing care. While there were five teams in total, detailed information could only be curated for three teams (see Table 3): Health Heroes, SHAFAA, and Empathy Listeners. These teams developed innovative solutions addressing critical issues such as improving staff well-being, enhancing communication in high-stakes ICU environments, and creating compassionate care models. Their prototypes reflect a commitment to improving outcomes in critical care settings, aligning with Evercare’s mission of patient-centered excellence. Team/Startup Name Team Composition Empathy/Pain Point/Problem Statement Ideation (Convergent Thinking) Prototyping Stage Health Heroes (ICU Staff Turnover Reduction) 5 members (nurses, ICU physicians, admin, patient experience staff) High nurse turnover in a 30-bed ICU, leading to reduced care quality, staff burnout, and recruitment costs. Flexible scheduling, wellness programs, recognition and rewards, and professional development. Tested shift options, wellness events, recognition initiatives, and training programs; feedback loops to refine prototypes. SHAFAA (ICU Communication Improvement) 4 members (ICU nurses, admin, communication specialists) Ineffective communication in ICU impacting treatment timelines, trust, and financial and emotional costs. Setup of counseling rooms, interactive patient education, and communication training for ICU teams. Created counseling rooms, modules for patient/family education, and introduced communication training; focused on measurable patient feedback. Empathy Listeners (Humanization of ICU Care) 6 members (nurses, occupational therapist, ICU admin, patient care team) Dehumanization of ICU environments affecting emotional and psychological well-being of patients, families, and staff. Training on humanization protocols, empowerment of stakeholders, and open communication policies. Implemented competency evaluations, family engagement strategies, and humanization-focused communication; used patient feedback tools to refine. Table 3. Lahore, Pakistan: Summary of three teams’ composition, problem focus, and proposed solutions. Empatheon: Transforming ICU Care A standout result from Lahore was the evolution of the Empathy Listeners initiative into Empatheon, a program dedicated to redefining ICU care through a human-centered and iterative approach (see Table 4). Leveraging PDSA (Plan-Do-Study-Act) cycles, Empatheon systematically tests and refines interventions to address key challenges and ensure sustainable improvements. Area of Focus Key Actions/Initiatives Outcomes/Updates Next Steps Psychological Support -Initiated psychology consults with four sessions conducted. - Addressing burnout and mental health gaps. - Expand access to psychological support services. - Incorporate structured mental health training for staff. Focused Group Sessions - Held three sessions with ICU SMOs, nursing, housekeeping, and pharmacy staff. - Identified issues and co-developed solutions, including: Formalized consultant rounds in HDU; Reinforced security and attendant policies; Enhanced pharmacy-nursing collaboration. - Adjusted timing of educational sessions to better suit nursing staff schedules. - Key systemic issues resolved. - Greater staff engagement and collaboration. - Continue focused group sessions to identify new challenges. - Establish routine follow-ups on implemented solutions. Mid-Intervention Analysis - Assessed communication and employee well-being challenges: - 47% reported handover challenges. - 57% highlighted gaps in burnout support. - 60% indicated a lack of psychological support. - Data-driven insights guiding targeted actions for improvement. - Use insights to prioritize staff training and system-level interventions. - Leverage trends for sustained progress. Communication Training - Introduced training to improve interactions across teams and with patients and families. - Enhanced collaboration and patient-family engagement. - Conduct periodic training refreshers. - Develop scenario-based workshops to strengthen practical skills. Feedback Mechanisms - Established tools to track progress and monitor outcomes. - Focus on reducing complaints and improving satisfaction scores. - Use PDSA cycles to refine feedback tools. - Request a dedicated budget for scaling the initiative. Table 4. Summary of Empatheon’s recent progress and next steps. Empatheon’s impact on the double bottom line Empatheon is redefining ICU care by addressing systemic challenges such as communication gaps, staff well-being, and patient-family dynamics. The program emphasizes the double bottom line, creating both social value through improved care quality, staff morale, and patient-family engagement, and financial impact by reducing inefficiencies, minimizing staff turnover, and fostering operational excellence. Through its iterative approach and focus on continuous improvement, Empatheon serves as a model for human-centered, scalable critical care innovation in resource-constrained environments. Discussion The workshops demonstrated the transformative potential of Human-Centered Design Thinking (HCDT) in addressing systemic challenges in healthcare delivery, particularly in resource-constrained settings. By leveraging empathy-driven insights and practical, low-cost solutions, participants co-created innovative approaches to complex problems in emergency medicine and intensive care. Key Insights 1. Empathy as the Foundation: Empathy mapping uncovered critical systemic challenges, fostering a deeper understanding of the needs of patients, families, and healthcare teams. 2. Collaborative Problem-Solving: The inclusion of diverse, multidisciplinary participants bridged clinical and administrative workflows, enriching the problem-solving process. 3. Scalable Innovation: Solutions such as referral coordinators, communication protocols, and empathy-driven ICU improvements laid the groundwork for broader implementation and system-wide transformation. By emphasizing empathy, collaboration, and resourcefulness, the workshops showcased how practical, adaptive innovation—rooted in Jugaar innovation principles—can be tailored to the unique realities of low- and middle-income countries (LMICs). Conclusion and Next Steps The success of these workshops highlights the potential of HCDT to foster a culture of empathetic and innovative healthcare delivery. By addressing critical pain points with resourceful and scalable solutions, HCDT provides a replicable framework for sustainable transformation in healthcare systems. Strategic Outcomes • Enhanced Quality of Care: Strengthened patient and employee experiences through empathy-driven design. • Innovation and Diversification: Solutions developed during the workshops demonstrate the potential for broader application and adaptation across varying healthcare settings. • Scalability and Adaptability: The methodologies emphasize feasibility in resource-constrained environments while remaining adaptable to diverse healthcare contexts. • Skill Development and Sustainability: Training initiatives and iterative processes create a foundation for continuous improvement and measurable impact. Future Directions 1. Prototype validation: Testing solutions in real-world settings with a focus on measurable outcomes such as patient satisfaction and operational efficiency. 2. Scaling training programs: Expanding HCDT workshops to other regions, tailoring modules to address unique challenges and opportunities. 3. Integrating HCDT into broader frameworks: HCDT’s methodology aligns with broader innovation management frameworks, such as those exemplified by Innovly, which emphasize scalable, context-driven solutions for sustainable transformation in healthcare. HCDT’s structured approach not only fosters empathetic and innovative solutions but also addresses inefficiencies that directly impact hospital operations. By optimizing workflows, reducing communication gaps, and improving staff engagement, HCDT has the potential to enhance operational efficiency, indirectly supporting financial sustainability in healthcare systems. By embedding human-centered design principles into healthcare systems, organizations can create solutions that are empathetic, sustainable, and impactful—setting new benchmarks for innovation and resilience in addressing complex challenges. References 1. Mian, A. I. (2021). #C2i-Create-2-Innovate: Expansion From The Merely Technical To The Metaphorical. In A. I. Mian (Ed.), MEDJACK: The Extraordinary Journey of an Ordinary Hack (Kindle Edition). SEED Pvt Ltd. 2. Dam, R. F. (2023). The 5 Stages in the Design Thinking Process. Interaction Design Foundation. Retrieved from https://www.interaction-design.org 3. Saeed, N., Sulaiman, M., & Mian, A. I. (2023). Human-Centered Design Thinking in the Emergency Department: Channeling the Chaos Together. ACEP Newsroom. 4. Salim, Y. (2024). Healthcare Innovation Powered by AI. The Express Tribune. 5. World Health Organization. (2022). Trauma Care Manual. Geneva: World Health Organization. 6. Kelley, T. (2016). The Art of Innovation: Lessons in Creativity from IDEO. Profile Books. 7. Thiel, P. (2014). From Zero to One: Notes on Startups, or How to Build the Future. Crown Currency.

Mahreen Sulaiman

Hira Amran Chowdhry

Kazim Ali Tarar

+5

From Boarding to Breakthrough: Tailored Interventions for Vulnerable Patients

Original Research

From Boarding to Breakthrough: Tailored Interventions for Vulnerable Patients

22 August 2025

Emergency Department (ED) boarding–prolonged stays in the ED while awaiting inpatient placement–is a crisis exacerbating crowding, increasing costs, and negatively impacting health outcomes. Vulnerable populations, including individuals with low socioeconomic status (SES), medically-complex older adults, and psychiatric patients are disproportionately affected. Yet, solutions tailored to their needs remain underexplored. This discussion examines root causes of boarding and proposes innovative, scalable interventions to mitigate its harms, specifically for marginalized groups. We highlight three strategies: (1) Patient Navigators, who assist low-SES patients navigating healthcare systems, (2) Community Paramedicine, which delivers in-home care to complex patients, and (3) Emergency Psychiatric Assessment, Treatment and Healing (EmPATH) Units, which provide targeted care for psychiatric patients. All three are associated with reduced ED visits. Traditional approaches to boarding have fallen short, particularly for vulnerable populations. Patient navigation, Community Paramedicine, and EmPATH units represent feasible, evidence-based solutions that health systems can implement. Broader adoption of these models can alleviate crowding, enhance care quality, and promote health equity. Future efforts must align these innovations with policy and funding mechanisms to ensure sustainable, system-wide improvements.

Alister Martin

Timothy Scheinert

Amelia Papadimitriou

+1

Innovation Skills Assessment in Healthcare: Benchmarking Capacities in Low-Resource Settings

Original Research

Innovation Skills Assessment in Healthcare: Benchmarking Capacities in Low-Resource Settings

17 August 2025

ABSTRACT Background: Innovation is a key driver of healthcare transformation, particularly in low-resource settings where systemic constraints often hinder service delivery. Assessing innovation capacities among healthcare employees can inform workforce development strategies. This study applies the previously validated Innovation Skills Assessment (ISA) tool to examine workforce innovation potential at a tertiary care hospital in Pakistan, offering insights for targeted capacity-building interventions. Methods: A cross-sectional survey was conducted at Mukhtar A. Sheikh Hospital in Multan, Pakistan, using the ISA tool adapted from the General Innovation Skills Aptitude Test. The survey captured demographic data and assessed innovation skills across four pillars: idea generation, risk-taking, interpersonal relationships, and idea implementation. A total of 250 electronic surveys were distributed via hospital communication channels, with 161 responses (64% response rate). Responses were rated on a 5-point Likert scale, and mean scores with standard deviations were calculated for each pillar. Descriptive statistics were used to explore observable trends across age, gender, education level, and job designation, without formal hypothesis testing. Results: Participants aged 36–45 years had the highest overall mean scores (4.48 ± 0.31), with notable strengths in idea generation (4.48 ± 0.31) and implementation (4.53 ± 0.33). Males showed higher average scores across all pillars, with interpersonal relationships as the strongest domain (4.49 ± 0.42). Participants with intermediate education reported higher mean scores in creativity and risk-taking (4.36 ± 0.45 and 4.20 ± 0.57, respectively). These patterns suggest potential demographic influences on innovation capacities. Conclusion: The ISA tool can be feasibly applied to map innovation skills within healthcare workforces in low-resource contexts. The identified trends may help guide workforce development through tailored training and institutional policies that promote a culture of innovation. Keywords: Innovation Skills Assessment, Healthcare Workforce, Low-Resource Settings, Human-Centered Design, Capacity-Building, Pakistan, Benchmarking, Workforce Innovation

Ahmed Raheem

Hasan N Tahir

Zeeshan Ahsan Allana

+5

Human Drugs & Veterinary Drugs - A Cost Comparison

Original Research

Human Drugs & Veterinary Drugs - A Cost Comparison

16 August 2025

Objective: The aim of this study was to provide an updated comparison of veterinary drug costs with human pharmacy equivalents. Design: A cross-sectional study was conducted by identifying the 50 most common drugs from Medicare Part D spending data, and obtaining the costs of these drugs, in addition to select antidepressants and ophthalmic medications, from human retail (GoodRx, DiRx, and Cost Plus Drugs) and veterinary pharmacy websites (Chewy and Pet Meds). Main outcome measures: Drug costs per tablet were calculated using 30-, 60-, and 90-count quantities. Drug cost data was normalized, and costs were compared via Student’s T-test. Results: 41 drugs were analyzed between human and veterinary pharmacy alternatives. For 90-day supply costs, Cost Plus Drugs provided the cheapest price for 30/41 cases. The lowest normalized drug cost per unit 90-day supply was 0.4406 for Cost Plus Drugs, with DiRx second at 0.5789 (p < .05). For 30-day supply costs, Chewy provided the cheapest price for 30/41 cases. The lowest normalized drug cost per unit for a 30-day supply was 0.4665 for Chewy, with no significant difference to Cost Plus Drugs at 0.5270 (p > .05). Conclusion: These results demonstrate that home-delivery pharmaceutical services offer more affordable options and address the high cost of human medications compared to equivalent veterinary medications. This represents a step forward in identifying solutions to reduce healthcare expenditures and pharmaceutical costs.

Paul Chong

Kevin Shannon

Julian Fine

+2

Leveraging Text-Based Outreach to Improve Enrollment in Federal Benefit Programs and Address Broadband Internet Access

Original Research

Leveraging Text-Based Outreach to Improve Enrollment in Federal Benefit Programs and Address Broadband Internet Access

13 August 2025

Background: Federal benefit programs form the backbone of a social safety-net that provides access to essential services for millions of Americans. However, access to these programs is hampered by complex application processes and administrative barriers. Link Health is a Boston-based nonprofit organization that, through strategic community partnerships, has developed a framework to streamline benefit program enrollment, resulting in the disbursal of over $4 million in benefits. We evaluate the effectiveness of embedding benefits access within existing private messaging frameworks as a strategy for reducing systemic barriers to federal program utilization and improve broadband internet access. Methods: In this prospective observational study of data from June 2024 through December 2024, Link Health conducted a targeted Massachusetts-based text-messaging campaign aimed at enrolling patients from partner community health centers in the Lifeline program, a broadband phone and internet access discount. DaisyChain, a web-based communication platform, enabled Link Health’s multilingual digital navigator team to collect patient responses and conduct follow-ups. Results: The campaign reached 68,529 patients, with 2.15% (n=1,470) engaging with the initial message. Among those who engaged, 41.84% identified as Hispanic, 35.58% as White, 10.61% as Black or African American, and 2.79% as Asian. 62.59% of participants preferred English, 32.31% preferred Spanish, and 5.10% preferred another language. 68.91% of sign-ups were female. Applicants were predominantly working and middle-age adults, with 24.15% of applicants between the ages of 35-44 years and 24.15% between 45-54 years. Patients primarily qualified for Lifeline through SNAP (64.97%), Medicare (37.21%), or Medicaid (41.16%). Conclusion: This study describes the effectiveness and feasibility of text-based initiatives in connecting patients from racially and linguistically diverse communities with the Lifeline benefit program. The campaign successfully and predominantly engaged Hispanic, publicly-insured groups, with an especially high enrollment rate among working and middle-age adults. By integrating digital technology with public health, Link Health’s text-messaging campaign provides a scalable and replicable framework to improve access to federal benefits.

Abhi Jain

Timothy Scheinert

Sammer Marzouk

+3

A Three-Pillar Approach to Benefit Enrollment Reaches Underserved Communities

Original Research

A Three-Pillar Approach to Benefit Enrollment Reaches Underserved Communities

31 July 2025

Background. The Affordable Connectivity Program (ACP), established in 2021, provided eligible low-income households a monthly $30 internet subsidy. Despite its role in reducing digital disparities, only 40% of eligible households enrolled nationally. Link Health (LH), a Boston-based grassroots initiative, implemented a three-pillar (active, passive, and digital) outreach model to increase ACP uptake in Massachusetts and Texas. Methods. From November 2022 to May 2024, LH partnered with community health centers in Boston and Houston to deliver on-site sign-up clinics (active approach), distribute multilingual printed materials (passive approach), and provide personalized text-message support (digital approach). Multilingual volunteers led screening and application filing, with follow-up via a dedicated helpline. Enrollment data were collected across 17 clinics and analyzed descriptively. Results. Of approximately 9,774 individuals screened, 1,086 (11.1%) enrolled in the ACP. Enrollees were predominantly racial/ethnic minorities (78.9%), with 55.4% Hispanic/Latinx and 23.5% Black/African American. 68.4% of enrollees qualified for the ACP through current Medicaid enrollment, and 29.2% qualified through current SNAP enrollment. Digital sign-ups constituted 33.8% of enrollments. LH’s efforts distributed an estimated $390,960 in annual subsidies. Conclusion. LH’s community-driven, three-pillar strategy bridged barriers to ACP enrollment. This model may inform future initiatives aimed at closing the digital divide and advancing health equity through targeted benefit enrollment.

Nicholos P Joseph

Timothy Scheinert

Ashley K Roth

+4

Leveraging Network Analysis for Global Connectivity in Emergency Medicine

Original Research

Leveraging Network Analysis for Global Connectivity in Emergency Medicine

29 July 2025

Introduction: In the field of international emergency medicine (IEM), navigating the vast and often fragmented online resources can be a challenge. This abstract explores how network analysis, a method examining connections within a system, can be applied to improve online accessibility and navigability of these resources. By focusing on the International Federation for Emergency Medicine (IFEM), the study aims to utilize network analysis to understand the current digital landscape of IEM stakeholders and their connections. This will ultimately lead to recommendations for improved information sharing within the IEM community. Methods: We focused our data collection on the IFEM website (www.ifem.cc), a central node connected to global emergency medicine organizations. Using an automated network analysis pipeline, we crawled the IFEM website to three levels deep with the Screaming Frog SEO Spider tool, mapping its structure and extracting pertinent data. The BeautifulSoup library was then used to parse the HTML content, while the Gemini 1.0 Pro language model helped filter and identify relevant information about global emergency medicine organizations. This results were then compared with the official IFEM member list for validation. Finally, Geographical details were pinpointed using the Geopy library and Nominatim tool to convert names and countries into exact coordinates. An interactive global map of these organizations was created with the Folium library, enhancing our understanding of the global emergency medicine network and its interconnections. Results: We identified 4,775 external links, narrowing down to 156 unique base URLs for further content analysis. On the IFEM website, of 55 countries listed, only 41 had accessible links; 10 were non-functional, and 3 were missing. Our automated pipeline pinpointed 41 pertinent multilingual URLs from the available ones, achieving 100% accuracy rate. Our analysis also revealed 28 additional URLs, potentially linked to EM organizations not listed on their member page. Conclusion: By leveraging an automated network analysis pipeline, we gained valuable insights into the digital connections between emergency medicine organizations. This approach not only identified key organizations and their connections but also potentially improved the accessibility and navigation of online information in emergency medicine

Norawit Kijpaisalratana

Abdel badih El Ariss

Jeffrey Yuan

+6

LipidLlama: A Multilingual AI Chatbot for Personalized Cardiovascular Risk Assessment

Original Research

LipidLlama: A Multilingual AI Chatbot for Personalized Cardiovascular Risk Assessment

23 July 2025

Background Cardiovascular disease is the leading cause of death worldwide. Many patients with cardiovascular disease struggle to understand their risk factors and medical test results due to health literacy limitations and/or inadequate resources for personalized education. Existing digital solutions often provide generic, one-size-fits-all information with varying degrees of medical accuracy. Methods LipidLlama addresses this gap by integrating a rule-based AI system—adapted from a validated cardiovascular risk assessment tool—and a chatbot powered by a Large Language Model (LLM) enhanced with retrieval augmented generation (RAG). To improve document retrieval, a custom query-only adapter was trained on synthetic query corpus document pairs. Response quality was independently evaluated by three board-certified physicians (two cardiologists and one internist) who rated 30 responses to synthetically generated, realistic patient queries using a 5-point Likert scale across four dimensions: correctness, conciseness, comprehensiveness, and comprehensibility. Rater reliability was assessed using generalizability theory. Results The trained adapter improved top-k document retrieval accuracy from 67% to 80%. Responses received consistently high clinical ratings across all dimensions (mean composite score = 18.21, 95% CI: 17.80-18.62) and demonstrated strong reliability metrics across raters (generalizability coefficient E⍴² = 0.88; dependability coefficient Φ = 0.84). Conclusion LipidLlama provides clinically grounded, personalized explanations in response to cardiovascular health questions. With further clinical validation, this mobile health application has the potential to enhance health literacy and minimize provider burden, significantly improving access to preventive cardiovascular care, particularly in underserved communities.

Tyler J Smith

Amogh Karnik

Jonathan Hourmozdi

+2

Transforming Emergency Care: Scalable Clinical Audit Innovations for Emerging Markets

Original Research

Transforming Emergency Care: Scalable Clinical Audit Innovations for Emerging Markets

22 July 2025

Resource constraints, staff brain drain, operational inefficiencies, and incidents of workplace violence undermine emergency care outcomes in emerging markets. The Emergency and Trauma Excellence (EmTEx) framework, a structured and human-centered approach, was implemented at Evercare Hospital Lahore to address these systemic challenges. A two-day clinical audit, led by a senior emergency physician, pediatrician, and innovation consultant, evaluated resuscitation readiness, triage efficiency, infection control, staffing adequacy, and staff safety using JCIA-inspired checklists, staff interviews, and facility walkthroughs. Findings revealed insufficient resuscitation spaces, poor separation of pediatric and adult patients, inconsistent triage protocols during peak hours, staffing shortages, and reports of aggression toward healthcare staff during high patient volumes of up to 190 daily. Additional gaps in infection control practices and variability in triage accuracy highlighted operational inefficiencies. Recommendations included tablet-based triage systems for real-time data capture, enhanced isolation zones for infection control, structured staff training programs, and robust safety measures such as de-escalation training and security protocols. Projected outcomes include a 20–30% reduction in patient wait times, improved workflows, and enhanced staff safety and engagement. These findings underscore the scalability of the EmTEx framework, demonstrating its ability to deliver empathy-driven solutions for transforming emergency care in resource-limited settings.

Asad I Mian

Muhammad Taha Anver

Mahreen Sulaiman

+5

Evaluating Pediatric Healthcare Spaces: Evidence-Based Recommendations for Design and Engagement

Original Research

Evaluating Pediatric Healthcare Spaces: Evidence-Based Recommendations for Design and Engagement

22 July 2025

Background Hospital environments significantly impact pediatric patients’ physical and emotional well-being. However, conventional hospital designs often fail to integrate child-friendly engagement strategies, leading to increased anxiety, reduced caregiver satisfaction, and operational inefficiencies. The HackPeds clinical audit, grounded in a continuous quality improvement framework, evaluated pediatric healthcare spaces at Evercare Hospital Lahore to identify systemic gaps and implement targeted interventions over a structured audit cycle. Methods A two-phase clinical audit was conducted at Evercare Hospital Lahore, with an initial assessment in November 2024, followed by a structured re-audit in January 2025, allowing for approximately three months of intervention implementation. The assessment was inspired by Joint Commission International and similar global pediatric care standards while also incorporating human-centered design principles. A checklist-based facility evaluation, structured staff interviews, and real-time benchmarking against best practices were used. The auditor, a pediatrician, emergency medicine consultant, and health innovation expert, assessed spatial utilization, caregiver engagement, and pediatric emergency preparedness, among other factors. Results The initial audit identified underutilized pediatric spaces, lack of interactive play zones, inconsistent emergency preparedness, and inadequate staff training in play therapy. Over the three-month intervention period, structured play areas were introduced, pediatric emergency response protocols were strengthened, and caregiver education initiatives were expanded. The January 2025 re-audit showed improvements in the use of engagement spaces, staff preparedness, and caregiver participation in pediatric care activities, although gaps remained in optimizing space utilization and embedding structured storytelling interventions. Conclusion By embedding continuous quality improvement strategies and structured re-audit cycles, HackPeds provides a scalable framework for pediatric healthcare transformation. The model is positioned for multi-site validation across Evercare Group hospitals in Nigeria and Kenya, with potential for broader adaptation in global pediatric healthcare settings. Future audits will assess longitudinal impact and sustainability to optimize pediatric patient experience, caregiver engagement, and emergency preparedness. Keywords: Pediatric hospital design, clinical audit, quality improvement, human-centered design, play therapy, storytelling in healthcare, pediatric emergency care, caregiver engagement, healthcare innovation, global health scalability.

Asad I Mian

Muhammad Taha Anver

Mahreen Sulaiman

+4

Building the TacMed Chatbot to Support Medical Education in Low-Resource Settings: A Low-Code Platform Approach

Abstract

Building the TacMed Chatbot to Support Medical Education in Low-Resource Settings: A Low-Code Platform Approach

16 June 2025

Introduction As technology continues to advance, humans and technology have developed together to meet our needs, changing the way we live. This evolution forms the foundation of cyberpsychology [1]. Chatbots, which are virtual agents that communicate with users, play an important role in fields like customer service, healthcare, and e-commerce [2,3]. Chatbots can either follow simple rules (rule-based) or use AI technologies like Natural Language Processing (NLP) and Machine Learning to interact more intelligently. However, AI chatbots may present challenges, including the risk of delivering incorrect information, especially in high-stakes domains like healthcare. Health Tech Without Borders (HTWB) developed a TacMed Chatbot for frontline responders in Ukraine. The chatbot provides lifesaving medical information in critical situations. This study describes the steps taken to build this chatbot using a low-code platform, addressing the rationale behind the design choices and the process of deployment. Methods Pre-planning and Research The TacMed Chatbot project began by assessing the needs of Ukrainian frontline responders. The results highlighted the need for a simple, protocol-based tool, as many first responders in conflict zones had limited medical education and worked in high-stress conditions. A decision was made to use a low-code platform to develop the chatbot, focusing on decision tree logic. A low-code platform is a software development approach that requires minimal coding, enabling rapid application development using visual interfaces. This makes it accessible and allows for faster deployment of applications. The TacMed Chatbot was built using a low-code platform to streamline development and localization. Decision tree logic is a structured rule-based model that guides users through predefined steps based on their inputs, ensuring consistency and reliability Chatbot Design The chatbot used vetted information from sources such as Stop the Bleed and Tactical Combat Casualty Care (TCCC) protocols. A low-code platform was selected to facilitate decision tree logic and ensure seamless localization into multiple languages. Key design considerations included adapting the chatbot for Ukrainian medical terminology and integrating visual aids to support understanding. Testing Phase The testing phase involved diverse user groups, including medical professionals and civilians, across the US, EU, Ukraine, and Middle East. The team ran feedback sessions and tested the chatbot’s clarity and usability during a conference in Lutsk, Ukraine and virtually to medical professionals in Sudan. The goal was to ensure the chatbot was simple, effective, and appropriate for both healthcare professionals and non-medical users. Results By the end of July 2023, the TacMed Chatbot had delivered over 32,000 messages to more than 500 users. Its primary use cases involved providing emergency medical protocols for treating war casualties. Feedback from users indicated the chatbot's ease of use and its potential to be a valuable educational tool for frontline workers. Discussion The medical field continues to embrace chatbots, leveraging digital technologies to drive economic growth and improve public services. The TacMed Chatbot is an example of how technology can be harnessed to support healthcare delivery in conflict zones. The development process highlighted the benefits of using a low-code platform [4], which allowed for efficient creation, localization, and easy adjustments. Despite not utilizing AI, the TacMed Chatbot proved effective in delivering critical medical information. It complemented other educational tools and demonstrated the potential for chatbots to enhance long-term memory retention for medical protocols. However, further developments could integrate AI to handle unrecognized queries, enhancing the chatbot's ability to provide broader support. Limitations The TacMed Chatbot, while effective, does not incorporate advanced AI, limiting its ability to handle complex or out-of-scope queries. Moreover, it was designed primarily for frontline workers in Ukraine and Sudan, and its adoption may face challenges in other regions due to language and cultural differences. Additionally, its reliance on decision tree logic may restrict flexibility in responding to unique situations outside the predefined protocols. Conclusion and Future Directions The TacMed Chatbot has demonstrated the potential of simple chatbot technology to support emergency medical care, especially in high-pressure environments like warzones. The success of this tool highlights the need for continued collaboration between medical professionals, NGOs, and technologists to improve healthcare delivery in disaster and conflict settings. In the future, we aim to update the chatbot to incorporate AI to understand questions it doesn't recognize and provide more personalized answers. Future studies can focus on creating chatbots that are adaptable for global use, aiming to build systems that can improve medical education and response during crises around the world. Acknowledgements XR at Yale, Randall Rode, HTWB team

Ahmad Hassan

Marianna Petrea-Imenokhoeva

Stella Nam

+7

Trends in Chronic Kidney Disease–Related Mortality Among Type 2 Diabetes Mellitus Patients in the United States from 1999-2020.

Abstract

Trends in Chronic Kidney Disease–Related Mortality Among Type 2 Diabetes Mellitus Patients in the United States from 1999-2020.

15 June 2025

Background Type 2 Diabetes Mellitus (T2DM) affects around 34.2 million people in the U.S., or 10.5% of the population [1], and is the leading cause of chronic kidney disease (CKD) [2,3]. About 40% of adults with T2DM have some degree of CKD [4]. T2DM has unique mechanisms like insulin resistance and metabolic syndrome that speed up CKD progression. Research [5] has shown that diabetic kidney disease (DKD) in T2DM patients causes albuminuria, declining kidney function, and increased cardiovascular risks. CKD in T2DM patients also raises the risk of heart problems and death. Socio-demographic factors, especially in minority populations, affect outcomes, with non-Hispanic Black and Native American groups facing worse results due to healthcare inequities [6]. Most studies focus on advanced CKD or end-stage renal disease (ESRD), but early-to-moderate stages, where intervention can help, are often overlooked. Objective To determine mortality trends for T2DM-associated CKD from 1999 to 2020 among adults in the United States, emphasizing early-to-moderate CKD stages to highlight opportunities for early intervention. Methods In December 2024, data on CKD-related deaths among patients with T2DM in the United States was collected from the Centers for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research database (CDC WONDER) [7]. Death certificates were used to identify CKD and T2DM with ICD-10-CM codes (E11 for T2DM, N18 for CKD). The data was categorized into two age groups: young (25–64 years) and older (>64 years). Institutional review board approval was not needed as the data was de-identified. Data collected included year, population size, demographics, CKD stage, geographic regions, and urban-rural classification. CKD severity was divided into early (stages 1-2), moderate (stages 3-4), and advanced (stage 5 or ESRD). Demographics included age, race/ethnicity, and gender. Urban and rural areas were classified by the National Center for Health Statistics. Crude and age-adjusted mortality rates (AAMRs) per 1,000,000 individuals were calculated. Trends in AAMRs were assessed using Joinpoint regression, and annual percent changes (APCs) were determined with 95% confidence intervals (CIs). Statistical significance was set at p< 0.05. The inclusion criteria included adults aged 25 years and older with CKD listed as a cause of death and T2DM as an underlying or contributing cause. Only deaths occurring in the United States between 1999 and 2020 were included. Additionally, individuals with complete demographic and geographic information in the dataset were considered. The exclusion criteria comprised patients without documented CKD or T2DM on the death certificate, pediatric populations under 25 years, and cases with missing or incomplete data regarding key variables such as age, sex, or geographic classification. Results There were a total of 90,615 CKD-related deaths among adults with T2DM between 1999 and 2020. The AAMR was 15.0 in 1999, which increased to 26.0 by 2009 (APC: 4.20; 95% CI: 1.98-6.48), after which there was a sharp rise to 56.0 by 2012 (APC: 20.5; 95% CI: -0.03-45.28). It then gradually declined to 3.6 (95% CI: 2.8–4.5) in 2015. By 2020, the AAMR steadily rose to 7.5 (APC: 30.5, 95% CI: 18.91-43.2). The AAMRs for men were higher than those for women throughout the years (23.2 with 95% CI of 22.96–23.39 vs.16.1 with 95% CI of 15.97–16.28). NH American Indian or Alaska Native patients had the highest AAMR (56.2, 95% CI: 53.2–59.2]), followed by NH Black or African American (32.0, 95% CI: 31.5–32.6), Hispanic or Latino (28.7, 95% CI: 28.1–29.3), NH Asian or Pacific Islander (16.6, 95% CI: 16.0–17.2), and NH White populations (16.2, 95% CI: 16.1–16.4). Nonmetropolitan areas experienced a relatively greater mortality burden with higher AAMR (23.3, 95% CI: 23.5–24.2) compared to metropolitan areas (16.9, 95% CI: 17.8–18.1), while the Western region had the highest overall AAMR (22.8, 95% CI: 22.5–23.1), followed by the Midwestern (22.1, 95% CI: 21.8–22.4), Southern (18.0, 95% CI: 17.8–18.2), and Northeastern (12.9, 95% CI: 12.7–13.1) regions. Early CKD stages (Stages 1 and 2) showed lower mortality rates, with age-adjusted mortality rates (AAMR) significantly lower than those for later stages. For example, in 2015, the AAMR for individuals in Stage 1 was 3.6 (95% CI: 2.8-4.4), compared to 56.0 (95% CI: 54.2-57.8) for individuals in later stages (Stages 3-5). CKD stages contributed significantly to overall mortality, particularly among minority populations and non-metropolitan areas, underscoring the importance of early detection and management strategies. Discussion Our study found several key trends in CKD and T2DM mortality: First, advanced CKD stages had the highest mortality rates. Mortality increased from 1999 to 2012, declined until 2015, and then rose again from 2015 to 2020. Although the increase in AAMR from 2009 to 2012 was not statistically significant, it may still have practical relevance, as it aligns with broader public health concerns such as rising comorbidities, healthcare disparities, and changes in diagnostic practices. Future research with larger datasets or alternative analytical approaches could further clarify whether this trend represents a true shift in CKD-related mortality among T2DM patients. Men had higher mortality rates than women. Native American and Alaska Native populations had the highest mortality, and non-metropolitan areas had more deaths than metropolitan ones. Mortality rates varied by state, with the Western U.S. showing the highest and the Northeast the lowest. Mortality trends suggest improvements from 2012 to 2015, possibly due to better management of risk factors like hypertension, particularly with the use of SGLT2 inhibitors, which have been shown to improve kidney outcomes in Type 2 diabetes patients [8]. However, mortality increased after 2015, which may be attributed to factors such as changes in healthcare access, socioeconomic disparities, or a deterioration in the management of risk factors and dietary habits. Early CKD stages showed lower mortality, emphasizing the importance of early intervention. Medications like SGLT2 inhibitors, which help slow CKD progression, are key in these stages [8]. We also found racial disparities, with Native Americans and African Americans facing higher mortality rates, consistent with previous studies [9,10]. This is influenced by increased burden of comorbidities like diabetes mellitus, poorly controlled blood pressure, obesity, and liver diseases [9,11,12], social determinants of health, healthcare access, and genetic predispositions as contributors to these disparities. Early CKD stages offer opportunities for intervention to prevent further progression, highlighting the importance of screening, lifestyle changes, and medication. Limitations include reliance on death certificate data and lack of detailed clinical information. Additionally, unmeasured confounders such as socioeconomic status and healthcare access may impact outcomes. Missing data on key variables like medication use may limit the completeness of the analysis. Lastly, findings may not be generalizable to non-U.S. populations with different healthcare practices. Future research should incorporate cohort-based analyses and explore the impact of emerging therapies, such as finerenone and dual GLP-1 receptor agonists, on CKD outcomes in T2DM. Conclusions The highest mortality was seen in men, American Indians, or Alaska Natives, as well as those living in the Western region and non-metropolitan areas. This study highlights the entire spectrum of CKD in T2DM patients, with disparities in mortality burden based on gender, race, and geographic region. Emphasizing early detection and targeted interventions is critical to improving outcomes in this vulnerable population.

Ahmad Hassan

Sana Yameen

Rabia Imtiaz

+3

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