Understanding barriers to well-child visit attendance among racial and ethnic minority parents.

OBJECTIVES: To assess racial and ethnic minority parents' perceptions about barriers to well-child visit attendance. METHODS: For this cross-sectional qualitative study, we recruited parents of pediatric primary care patients who were overdue for a well-child visit from the largest safety net healthcare organization in central Massachusetts to participate in semi-structured interviews. The interviews focused on understanding potential knowledge, structural, and experiential barriers for well-child visit attendance. Interview content was inductively coded and directed content analysis was performed to identify themes. RESULTS: Twenty-five racial and ethnic minority parents participated; 17 (68%) of whom identified Spanish as a primary language spoken at home. Nearly all participants identified the purpose, significance, and value of well-child visits. Structural barriers were most cited as challenges to attending well-child visits, including parking, transportation, language, appointment availability, and work/other competing priorities. While language emerged as a distinct barrier, it also exacerbated some of the structural barriers identified. Experiential barriers were cited less commonly than structural barriers and included interactions with office staff, racial/ethnic discrimination, appointment reminders, methods of communication, wait time, and interactions with providers. CONCLUSIONS: Racial and ethnic minority parents recognize the value of well-child visits; however, they commonly encounter structural barriers that limit access to care. Furthermore, a non-English primary language compounds the impact of these structural barriers. Understanding these barriers is important to inform health system policies to enhance access and delivery of pediatric care with a lens toward reducing racial and ethnic-based inequities.

Rationale and Design of Healthy at Home for COPD: an Integrated Remote Patient Monitoring and Virtual Pulmonary Rehabilitation Pilot Study.

Chronic Obstructive Pulmonary Disease (COPD) is a common, costly, and morbid condition. Pulmonary rehabilitation, close monitoring, and early intervention during acute exacerbations of symptoms represent a comprehensive approach to improve outcomes, but the optimal means of delivering these services is uncertain. Logistical, financial, and social barriers to providing healthcare through face-to-face encounters, paired with recent developments in technology, have stimulated interest in exploring alternative models of care. The Healthy at Home study seeks to determine the feasibility of a multimodal, digitally enhanced intervention provided to participants with COPD longitudinally over six months. This paper details the recruitment, methods, and analysis plan for the study, which is recruiting 100 participants in its pilot phase. Participants were provided with several integrated services including a smartwatch to track physiological data, a study app to track symptoms and study instruments, access to a mobile integrated health program for acute clinical needs, and a virtual comprehensive pulmonary support service. Participants shared physiologic, demographic, and symptom reports, electronic health records, and claims data with the study team, facilitating a better understanding of their symptoms and potential care needs longitudinally. The Healthy at Home study seeks to develop a comprehensive digital phenotype of COPD by tracking and responding to multiple indices of disease behavior and facilitating early and nuanced responses to changes in participants' health status. This study is registered at Clinicaltrials.gov (NCT06000696).

Resuscitation Quality Improvement® (RQI®) HeartCode Complete® program improves chest compression rate in real world out-of hospital cardiac arrest patients.

BACKGROUND: The Resuscitation Quality Improvement® (RQI®) HeartCode Complete® program is designed to enhance cardiopulmonary resuscitation (CPR) training by using real-time feedback manikins. Our objective was to assess the quality of CPR, such as chest compression rate, depth, and fraction, performed on out-of-hospital cardiac arrest (OHCA) patients among paramedics trained with the RQI® program vs. paramedics who were not. METHODS AND RESULTS: Adult OHCA cases from 2021 were analyzed; 353 OHCA cases were classified into one of three groups: 1) 0 RQI®-trained paramedics, 2) 1 RQI®-trained paramedic, and 3) 2-3 RQI®-trained paramedics. We reported the median of the average compression rate, depth, and fraction, as well as percent of compressions that were between 100 to 120/minute and percent of compressions that were 2.0 to 2.4 inches deep. Kruskal-Wallis Tests were used to assess differences in these metrics across the three groups of paramedics. Of 353 cases, the median of the average compression rate/minute among crews with 0, 1, and 2-3 RQI®-trained paramedics was 130, 125, and 125, respectively (p = 0.0032). Median percent of compressions between 100 to 120 compressions/minute was 10.3%, 19.7%, and 20.1% among crews with 0, 1, and 2-3 RQI®-trained paramedics, respectively (p = 0.0010). Median of the average compression depth was 1.7 inches across all three groups (p = 0.4881). Median compression fraction was 86.4%, 84.6%, and 85.5% among crews with 0, 1, and 2-3 RQI®-trained paramedics, respectively (p = 0.6371). CONCLUSIONS: RQI® training was associated with statistically significant improvement in chest compression rate, but not improved chest compression depth or fraction in OHCA.

Threshold adjusted vagus nerve stimulation after asphyxial cardiac arrest results in neuroprotection and improved survival.

BACKGROUND: Vagus nerve stimulation (VNS) has shown therapeutic potential in a variety of different diseases with many ongoing clinical trials. The role of VNS in reducing ischemic injury in the brain requires further evaluation. Cardiac arrest (CA) causes global ischemia and leads to the injury of vital organs, especially the brain. In this study, we investigated the protective effects of customized threshold-adjusted VNS (tVNS) in a rat model of CA and resuscitation. METHODS: Sprague-Dawley rats underwent 12 min asphyxia-CA followed by resuscitation. Rats were assigned to either post-resuscitation tVNS for 2 h or no-tVNS (control). tVNS was applied by electrode placement in the left cervical vagus nerve. To optimize a threshold, we used animal's heart rate and determined a 15-20% drop from baseline levels as the effective and physiological threshold for each animal. The primary endpoint was 72 h survival; secondary endpoints included neurological functional recovery, reduction in brain cellular injury (histopathology), cardiac and renal injury parameters (troponin I and creatinine levels, respectively). RESULTS: In comparison to the control group, tVNS significantly improved 72 h survival and brain functional recovery after 12 minutes of CA. The tVNS group demonstrated significantly reduced numbers of damaged neurons in the CA1 hippocampal region of the brain as compared to the control group. Similarly, the tVNS group showed decreased trend in plasma troponin I and creatinine levels as compared to the control group. CONCLUSIONS: Our findings suggest that using tVNS for 2 h after 12 minutes of CA attenuates ischemia neuronal cell death, heart and kidney damage, and improves 72 h survival with improved neurological recovery.

Prioritizing Child Health: Promoting Adherence to Well-Child Visits in an Urban, Safety-Net Health System During the COVID-19 Pandemic.

BACKGROUND: After discovering racial/ethnic disparities in adherence to well-child visits, UMass Memorial Health worked to identify and mitigate barriers to adherence for patients and families across 53 primary care practices in central Massachusetts. METHODS: When the systemwide goal to reduce racial/ethnic disparities in well-child visit adherence was established, a multidisciplinary team of leaders from UMass Memorial Health worked together to engage patients and stakeholders to identify obstacles to adherence. Transportation, language, and scheduling were identified as barriers. The team employed a number of countermeasures to address these barriers: A new workflow was created for requesting free curb-to-curb transportation for Medicaid patients, practices were provided with tip sheets for accessing interpreter services, and a protocol for scheduling appointment reminders was developed. In addition, the team leveraged robust data analytics to communicate real-time data to practices to keep them informed of their progress toward the system's health equity goal. Primary data results are reported from October 1, 2020, to September 30, 2021. RESULTS: For patients who identified as Hispanic/Latinx, adherence rose from 64.3% at baseline to 74.1% (p < 0.001); and for patients who identified as Black/African American, adherence rose from 58.7% at baseline to 71.9% (p < 0.001). The gap in adherence to well-child visits for Black/African American and Hispanic/Latinx children compared to White children narrowed (12.4 percentage points to 5.1; p < 0.001; 6.8 percentage points to 2.9; p < 0.001). CONCLUSION: Through a unique partnership between health system leaders, frontline staff, and the system's informatics team and by engaging caregivers to identify and address barriers to well-child visits, UMass Memorial Health was able to improve adherence to well-child visits among patients who identify as Black/African American or Hispanic/Latinx.

SUPPORT-AF II: Supporting Use of Anticoagulants Through Provider Profiling of Oral Anticoagulant Therapy for Atrial Fibrillation: A Cluster-Randomized Study of Electronic Profiling and Messaging Combined With Academic Detailing for Providers Making Decisions About Anticoagulation in Patients With Atrial Fibrillation.

BACKGROUND: Previous provider-directed electronic messaging interventions have not by themselves improved anticoagulation use in patients with atrial fibrillation. Direct engagement with providers using academic detailing coupled with electronic messaging may overcome the limitations of the prior interventions. METHODS AND RESULTS: We randomized outpatient providers affiliated with our health system in a 2.5:1 ratio to our electronic profiling/messaging combined with academic detailing intervention. In the intervention, we emailed providers monthly reports of their anticoagulation percentage relative to peers for atrial fibrillation patients with elevated stroke risk (CHA2DS2-VASc ≥2). We also sent electronic medical record-based messages shortly before an appointment with an anticoagulation-eligible but untreated atrial fibrillation patient. Providers had the option to send responses with explanations for prescribing decisions. We also offered to meet with intervention providers using an academic detailing approach developed based on knowledge gaps discussed in provider focus groups. To assess feasibility, we tracked provider review of our messages. To assess effectiveness, we measured the change in anticoagulation for patients of intervention providers relative to controls. We identified 85 intervention and 34 control providers taking care of 3591 and 1908 patients, respectively; 33 intervention providers participated in academic detailing. More than 80% of intervention providers read our emails, and 98% of the time a provider reviewed our in-basket messages. Replies to messages identified patient refusal as the most common reason for patients not being on anticoagulation (11.2%). For the group of patients not on anticoagulation at baseline assigned to an intervention versus control provider, the adjusted percent increase in the use of anticoagulation over 6 months was 5.2% versus 7.4%, respectively (P=0.21). CONCLUSIONS: Our electronic messaging and academic detailing intervention was feasible but did not increase anticoagulation use. Patient-directed interventions or provider interventions targeting patients declining anticoagulation may be necessary to raise the rate of anticoagulation. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT03583008.

A National Assessment on Patient Safety Curricula in Undergraduate Medical Education: Results From the 2012 Clerkship Directors in Internal Medicine Survey.

OBJECTIVES: Patient safety is a cornerstone of quality patient care, and educating medical students about patient safety is of growing importance. This investigation was a follow-up to a 2006 study to assess the current status of patient safety curricula within undergraduate medical education in North America with the additional goals of identifying areas for improvement and barriers to implementation. METHODS: Thirteen items regarding patient safety were part of the 2012 Clerkship Directors in Internal Medicine annual survey. Questions addressed curriculum content, delivery, and barriers to implementation. RESULTS: Ninety-nine clerkship directors (82%) responded. Forty-one (45.6%) reported that their medical school had a patient safety curriculum taught during medical school as compared with 25% in a 2006 survey. Fifteen (20%) reported satisfaction with students' level of safety competency at the end of the clerkship. Barriers to implementation included lack of faculty time (n = 57, 78.1%), lack of trained faculty (n = 47, 65.3%), and lack of a mandate from school's dean's office (n = 27, 38.0%). CONCLUSIONS: Our study found that less than half of North American medical schools have a formal patient safety curriculum; although this is higher than in 2006, it still exemplifies a major gap in undergraduate medical education.

Medical student awareness of and interest in clinical informatics.

OBJECTIVE: We aimed to investigate medical students' attitudes about Clinical Informatics (CI) training and careers. MATERIALS AND METHODS: We distributed a web-based survey to students at four US allopathic medical schools. RESULTS: Five hundred and fifty-seven medical students responded. Interest in CI training opportunities (medical school electives, residency electives, or academic fellowships) surpassed respondents' prior awareness of these opportunities. Thirty percent of student respondents expressed at least some interest in a CI-related career, but they were no more aware of training opportunities than their peers who did not express such an interest. DISCUSSION: Almost one third of medical students who responded to our survey expressed an interest in a CI-related career, but they were generally unaware of CI training and mentoring opportunities available to them. Early outreach to such medical students, through elective classes, professional society incentives, or expert partnerships, may positively influence the size and skill set of the future CI workforce. CONCLUSION: We should work as a field to increase the quantity, quality, and publicity of CI learning opportunities for interested medical students.

Quality improvement "201": context-relevant quality improvement leadership training for the busy clinician-educator.

Development of quality improvement (QI) skills and leadership for busy clinician-educators in academic medical centers is increasingly necessary, although it is challenging given limited resources. In response, the authors developed the Quality Scholars program for primary care teaching faculty. They conducted a needs assessment, evaluated existing internal and national resources, and developed a 9-month, 20-session project-based curriculum that combines didactic and hands-on techniques with facilitated project discussion. They also conducted pre-post tests of knowledge and attitudes, and evaluations of each session, scholars' projects, and program sustainability and costs. In all, 10 scholars from all 3 generalist disciplines comprised the first class. A wide spectrum of previous experiences enhanced collaboration. QI knowledge increased slightly, and reported self-readiness to lead QI projects increased markedly. Protected time for project work and group discussion of QI topics was seen as essential. All 10 scholars completed projects and presented results. Institutional leadership agreed to sustain the program using institutional funds.

Commentary: Medical malpractice and patient safety: tear down that wall!

Although medical malpractice influences the way that physicians learn to practice medicine, information related to malpractice cases is among the most closely guarded data in the hospital and is rarely available to training programs. In this issue, Hochberg and colleagues describe an intervention in which they used data from their hospital's closed malpractice cases as part of a training seminar for surgical residents on malpractice. The authors of this commentary believe that there is very low risk and great potential value to more openly sharing this type of information. They point to potential conflicts between the goals of the risk management discipline (as it has been practiced in some settings in the past) and those of the patient safety discipline as one reason such data are not disseminated widely, and they highlight what they believe to be hopeful trends toward greater transparency. They call on patient safety professionals and educators to use their hospitals' malpractice data to better prepare learners and improve patient care.

Using standardized patients to assess professionalism: a generalizability study.

BACKGROUND: Assessment of professionalism in undergraduate medical education is challenging. One approach that has not been well studied in this context is performance-based examinations. PURPOSE: This study sought to investigate the reliability of standardized patients' scores of students' professionalism in performance-based examinations. METHODS: Twenty students were observed on 4 simulated cases involving professional challenges; 9 raters evaluated each encounter on 21 professionalism items. Correlational and multivariate generalizability (G) analyses were conducted. RESULTS: G coefficients were .75, .53, and .68 for physicians, standardized patients (SPs), and lay raters, respectively. Composite G coefficient for all raters reached acceptable level of .86. Results indicated SP raters were more variable than other rater types in severity with which they rated students, although rank ordering of students was consistent among SPs. CONCLUSIONS: SPs' ratings were less reliable and consistent than physician or lay ratings, although the SPs rank ordered students more consistently than the other rater types.

Patient safety education at U.S. and Canadian medical schools: results from the 2006 Clerkship Directors in Internal Medicine survey.

PURPOSE: To describe current patient safety curricula at U.S. and Canadian medical schools and identify factors associated with adoption of these programs. METHOD: A survey was mailed to institutional members of the Clerkship Directors in Internal Medicine at U.S. and Canadian academic medical schools in 2006. Respondents self-reported implementation of patient safety curricula and associated methods of instruction at the institution level. RESULTS: The survey had a 76% response rate (83/110). Only 25% of institutional members reported that their schools had explicit patient safety curricula. All respondents that reported having curricula use lectures and small-group instruction, and these were more likely to occur in preclinical settings. Topics and methods of instruction included reporting adverse incidents and analysis of medical errors; improvement of physician order writing to prevent medication errors; core measures; national patient safety goals; and standardization of medical care through the use of clinical guidelines and order set templates. Although only 25% of respondents reported having explicit curricula, 72% agreed that patient safety instruction should occur during medical school. CONCLUSIONS: Despite calls from regulatory, medical, and educational organizations to increase patient safety training of medical students, internal medicine clerkship directors report that few schools in the United States and Canada have implemented specific patient safety curricula. Most existing patient safety curricula use lecture and small-group discussion as preferred methods of instruction.

Procedural and interpretive skills of medical students: experiences and attitudes of fourth-year students.

BACKGROUND: Recent data do not exist regarding fourth-year medical students' performance of and attitudes toward procedural and interpretive skills, and how these differ from third-year students'. METHOD: Cross-sectional survey conducted in February 2006 of 122 fourth-year students from seven U.S. medical schools, compared with their responses in summer 2005. Students estimated their cumulative performance of 22 skills and reported self-confidence and perceived importance using a five-point Likert-type scale. RESULTS: The response rate was 79% (96/122). A majority reported never having performed cardioversion, thoracentesis, cardiopulmonary resuscitation, blood culture, purified protein derivative placement, or paracentesis. One fifth of students had never performed peripheral intravenous catheter insertion, phlebotomy, or arterial blood sampling. Students reported increased cumulative performance of 17 skills, increased self-confidence in five skills, and decreased perceived importance in three skills (two-sided P < .05). CONCLUSIONS: A majority of fourth-year medical students still have never performed important procedures, and a substantial minority have not performed basic procedures.

Between two worlds: a multi-institutional qualitative analysis of students' reflections on joining the medical profession.

BACKGROUND: Recent changes in healthcare system and training mandates have altered the clinical learning environment. We incorporated reflective writing into Internal Medicine clerkships (IMcs) in multiple institutions so students could consider the impact of clerkship experiences on their personal and professional development. We analyzed student reflections to inform curricula and support learning. METHODS: We qualitatively analyzed the reflections of students at 3 US medical schools during IMcs (N = 292) to identify themes, tone, and reflective quality using an iterative approach. Chi-square tests assessed differences between these factors and across institutions. FINDINGS: Students openly described powerful experiences. Major themes focused on 4 categories: personal issues (PI), professional development (PD), relational issues (RI), and medical care (MC). Each major theme was represented at each institution, although with significant variability between institutions in many of the subcategories including student role (PI), development-as-a-physician (PD), professionalism (PD) (p < 0.001). Students used positive tones to describe student role, development-as-a-physician and physician-patient relationship (PD) (p < 0.01-0.001), and negative tones for quality and safety (MC) (p < 0.05). Only 4% of writings coded as professionalism had a positive tone. Students employed a "reporting" voice in writing about clinical problem-solving, healthcare systems, and quality/safety (MC). DISCUSSION: Reflection is considered important to professional development. Our analysis suggests that students at 3 institutions reflect on similar experiences. Theme variability across institutions implies curricula should be tailored to local culture. Reflective quality analysis suggests students are better equipped to reflect on certain experiences over others, which may impact learning. Student reflections can function as a mirror for our organizations, offer institutional feedback for support and improvement, and inform curricula for learners and faculty.

Disagreement between students and preceptors regarding the value of teaching behaviors for ambulatory care settings.

BACKGROUND: Medical students and preceptors commonly disagree on methods of clinical instruction in ambulatory care, although the extent of the problem is not documented. PURPOSE: The purpose is to identify disagreement and concordance between students and preceptors for teaching behaviors in ambulatory care. METHODS: We surveyed students and preceptors at 4 U.S. schools. Respondents rated 58 behaviors on two scales. Disagreement was recognized when the percentage of students and preceptors who recommended a behavior and rated it important differed by over 15% (p < .01). RESULTS: Disagreement was identified for 8 behaviors (14%). Six were valued less by students, including "watch the student perform critical tasks in history taking and other communication" (59% compared with 82%). Two behaviors were valued more by students, including "delegate responsibility to the student for the wrap up discussion with the patient" (82% compared with 61%). CONCLUSIONS: Students and preceptors disagree regarding the value of a minority of teaching behaviors. Because some are potentially important, however, early negotiation regarding their use may enhance teaching effectiveness and mutual satisfaction with learning.

Assessing professionalism in the context of an objective structured clinical examination: an in-depth study of the rating process.

INTRODUCTION: Professionalism is fundamental to the practice of medicine. Objective structured clinical examinations (OSCEs) have been proposed as appropriate for assessing some aspects of professionalism. This study investigated how raters assign professionalism ratings to medical students' performances in OSCE encounters. METHODS: Three standardised patients, 3 doctor preceptors, and 3 lay people viewed and rated 20 videotaped encounters between 3rd-year medical students and standardised patients. Raters recorded their thoughts while rating. Qualitative and quantitative analyses were conducted. Comments about observable behaviours were coded, and relative frequencies were computed. Correlations between counts of categorised comments and overall professionalism ratings were also computed. RESULTS: Raters varied in which behaviours they attended to, and how behaviours were evaluated. This was true within and between rater type. Raters also differed in the behaviours they consider when providing global evaluations of professionalism. CONCLUSIONS: This study highlights the complexity of the processes involved in assigning ratings to doctor-patient encounters. Greater emphasis on behavioural definitions of specific behaviours may not be a sufficient solution, as raters appear to vary in both attention to and evaluation of behaviours. Reliance on global ratings is also problematic, especially if relatively few raters are used, for similar reasons. We propose a model highlighting the multiple points where raters viewing the same encounter may diverge, resulting in different ratings of the same performance. Progress in assessment of professionalism will require further dialogue about what constitutes professional behaviour in the medical encounter, with input from multiple constituencies and multiple representatives within each constituency.

Procedural and interpretive skills of medical students: experiences and attitudes of third-year students.

BACKGROUND: Recent data do not exist on medical students' performance of and attitudes toward procedural and interpretive skills deemed important by medical educators. METHOD: A total of 171 medical students at seven medical schools were surveyed regarding frequency of performance, self-confidence, and perceived importance of 21 procedural and interpretive skills. RESULTS: Of the 122 responding students (71% response rate), a majority had never performed lumbar puncture, thoracentesis, paracentesis, or blood culture, and students reported lowest self-confidence in these skills. At least one-quarter of students had never performed phlebotomy, peripheral intravenous catheter insertion, or arterial blood sampling. Students perceived all 21 skills as important to learn and perform during medical school. CONCLUSION: Through the third year of medical school, a majority of students had never performed important procedures, and a substantial minority had not performed basic procedures. Students had low self-confidence in skills they rarely performed, but perceived all skills surveyed as important.

Learning from mistakes. Factors that influence how students and residents learn from medical errors.

CONTEXT: Trainees are exposed to medical errors throughout medical school and residency. Little is known about what facilitates and limits learning from these experiences. OBJECTIVE: To identify major factors and areas of tension in trainees' learning from medical errors. DESIGN, SETTING, AND PARTICIPANTS: Structured telephone interviews with 59 trainees (medical students and residents) from 1 academic medical center. Five authors reviewed transcripts of audiotaped interviews using content analysis. RESULTS: Trainees were aware that medical errors occur from early in medical school. Many had an intense emotional response to the idea of committing errors in patient care. Students and residents noted variation and conflict in institutional recommendations and individual actions. Many expressed role confusion regarding whether and how to initiate discussion after errors occurred. Some noted the conflict between reporting errors to seniors who were responsible for their evaluation. Learners requested more open discussion of actual errors and faculty disclosure. No students or residents felt that they learned better from near misses than from actual errors, and many believed that they learned the most when harm was caused. CONCLUSIONS: Trainees are aware of medical errors, but remaining tensions may limit learning. Institutions can immediately address variability in faculty response and local culture by disseminating clear, accessible algorithms to guide behavior when errors occur. Educators should develop longitudinal curricula that integrate actual cases and faculty disclosure. Future multi-institutional work should focus on identified themes such as teaching and learning in emotionally charged situations, learning from errors and near misses and balance between individual and systems responsibility.

Reconciling medications at admission: safe practice recommendations and implementation strategies.

BACKGROUND: Fifty hospitals collaborated in a patient safety initiative developed and implemented by the Massachusetts Coalition for the Prevention of Medical Errors and the Massachusetts Hospital Association. METHODS: A consensus group identified safe practices and suggested implementation strategies. Four collaborative learning sessions were offered, and teams monitored their progress and shared successful strategies and lessons learned. Reports from participating teams and an evaluation survey were then used to identify successful techniques for reconciling medications. RESULTS: For the 50 participating hospitals, implementation strategies most strongly correlated with success included active physician and nursing engagement, having an effective improvement team, using small tests of change, having an actively engaged senior administrator, and sending a team to multiple collaborative sessions. DISCUSSION: Adoption of the reconciling safe practices proved challenging. The process of writing medication orders at patient transfer points is complex. The hospitals' experiences demonstrated that implementing the proposed safe practices requires a team effort with leadership support and vigilant measurement.