Gender Differences in the Path to Medical School Deanship.

Importance: Women account for only 28% of current US medical school deans. Studying the differences between women and men in their preparation to becoming deans might help to explain this discrepancy. Objective: To identify differences in the leadership development experiences between women and men in their ascent to the medical school deanship. Design, Setting, and Participants: In this qualitative study, volunteers from the roster of the Association of American Medical Colleges Council of Deans were solicited and interviewed from June 15 to November 9, 2023. Women deans were recruited first, then men who had been appointed to their deanships at a similar time to their women counterparts were recruited. Deans were interviewed on topics related to number of applications for deanships, prior leadership roles, leadership development, personal factors, and career trajectories. Interviews were coded, and themes were extracted through conventional content analysis. Main Outcome and Measures: Career and leadership development experiences were elicited using a semistructured interview guide. Results: We interviewed 17 women and 17 men deans, representing 25.8% (34 of 132) of the total population of US medical school deans. Most deans (23 [67.6%]) practiced a medicine-based specialty or subspecialty. No statistically significant differences were found between women and men with regard to years to attain deanship (mean [SD], 2.7 [3.4] vs 3.7 [3.7] years), years as a dean (mean [SD], 5.7 [5.2] vs 6.0 [5.0] years), highest salary during career (mean [SD], $525 769 [$199 936] vs $416 923 [$195 848]), or medical school rankings (mean [SD], 315.5 [394.5] vs 480.5 [448.9]). Their reports indicated substantive gender differences in their paths to becoming a dean. Compared with men, women deans reported having to work harder to advance, while receiving less support and opportunities for leadership positions by their own institutions. Subsequently, women sought leadership development from external programs. Women deans also experienced gender bias when working with search firms. Conclusions and Relevance: This qualitative study of US medical school deans found that compared with men, women needed to be more proactive, had to participate in external leadership development programs, and had to confront biases during the search process. For rising women leaders, this lack of support had consequences, such as burnout and attrition, potentially affecting the makeup of future generations of medical school deans. Institutional initiatives centering on leadership development of women is needed to mitigate the gender biases and barriers faced by aspiring women leaders.

Leadership Experiences and Perceptions of Mid-Career to Senior Clinician-Scientists: A Qualitative Exploration.

PURPOSE: This study aimed to elucidate the experiences and perceptions of mid-career to senior clinician-scientists in academic medicine regarding pursuing, attaining, or rejecting leadership roles as well as their conceptualization of the influence of leadership in their broader career trajectories. METHOD: The authors conducted a qualitative analysis of in-depth, semistructured interviews conducted in 2022 with a diverse sample of clinician-scientists who received new National Institutes of Health K08 or K23 Career Development Awards between 2006 and 2009. A total of 859 of the 915 survey respondents (94%) were eligible to be recruited for the qualitative study. Qualitative analysis was informed by thematic analysis and used a social constructionist approach to understanding participants' conceptualizations of their experiences. Interview transcripts were coded using an iterative, inductive coding process. Themes were generated by reviewing coded data and identifying common patterns in participant narratives, affording particular attention to participants' discussion of the effect of race and/or gender on their leadership experiences. RESULTS: Sixty clinician-scientists participated in individual interviews. Five themes were generated surrounding participants' conceptualizations of their leadership experiences. Themes were (1) feeling unprepared for leadership roles, (2) reluctance and lack of intention in attaining leadership positions, (3) influence of networks on leadership access and decision-making, (4) impact-related benefits and downsides of leadership, and (5) confining ideas of who leaders are. CONCLUSIONS: The study highlighted the need for formal leadership training in academic medicine and the importance of mentorship and sponsorship in attaining and succeeding in leadership positions. Individuals from communities underrepresented in leadership positions faced additional challenges internalizing a leadership identity. Efforts to encourage current leaders to engage in intentional succession planning and development of faculty towards leadership roles, including expansion of institutional leadership development programs, are needed to promote equitable distribution of leadership opportunities.

Burnout Among Mid-Career Academic Medical Faculty.

Importance: Studies reveal that most physicians report symptoms of burnout. Less is known about burnout in mid-career medical faculty specifically. Objective: To characterize burnout and its risk factors, particularly differences by gender, among mid-career medical faculty. Design, Setting, and Participants: Between August 2021 and August 2022, a survey was sent to 1430 individuals who received new National Institutes of Health K08 and K23 career development awards from 2006 to 2009. Data were analyzed between June and October 2023. Main Outcomes and Measures: Personal and work-related burnout as evaluated using the Copenhagen Burnout Inventory (CBI). The CBI score ranges from 0 to 100, with a score of 50 or higher indicating a high degree of burnout. Multivariable models were used to investigate associations between burnout and participant characteristics, including race and ethnicity, sexual orientation and gender identity, academic rank, work climate, experiences of workplace sexual harassment, sleep hours, work and domestic caregiving time, and time allocation changes in work and domestic work hours compared with before the COVID-19 pandemic. Work climate was evaluated by a general climate elements scale assessing elements such as friendliness, respect, and collegiality, and a diversity, equity, and inclusion climate elements scale assessing elements such as homogeneity, sexism, and homophobia; higher scores indicated a more favorable view of the climate. Results: In all, 1430 surveys were sent, 926 candidates responded (65% response rate), and the analytic cohort was limited to the 841 respondents who were still in academic medicine (50.7% men). Burnout was significantly more common for women than men (mean [SD] CBI personal scores, 46.6 [19.4] vs 37.5 [17.2]; P < .001; mean [SD] CBI work-related scores, 43.7 [20.4] vs 34.6 [19.7]; P < .001). In multivariable models, personal burnout was significantly more likely for women (adjusted odds ratio [AOR], 2.29 [95% CI, 1.54-3.41]; P < .001) and with more weekly hours of patient care (AOR, 1.07 [95% CI, 1.00-1.15] for each 5-hour increase; P = .04). Personal burnout was less likely with more nightly sleep hours (AOR, 0.68 [95% CI, 0.56-0.81] for each 1-hour increase; P < .001) and with an improved general work climate rating (AOR, 0.64 [95% CI, 0.48-0.85] for each 1-point increase in general work climate scale score; P = .002). Work-related burnout was also significantly more likely for women than men (AOR, 1.77 [95% CI, 1.17-2.69]; P = .007). Greater work-related burnout was associated with an increase of 8 or more work hours per week compared with before the COVID-19 pandemic (AOR, 1.87 [95% CI, 1.13-3.08]; P = .01), more weekly hours of patient care (AOR, 1.11 [95% CI, 1.03-1.19] for each 5-hour increase; P = .007), and a workplace sexual harassment experience in the past 2 years (AOR, 1.71 [95% CI, 1.11-2.62]; P = .01). Work-related burnout was significantly less likely with more nightly sleep hours (AOR, 0.80 [95% CI, 0.66-0.96] for each 1-hour increase; P = .02) and with an improved general work climate rating (AOR, 0.49; [95% CI, 0.36-0.65] for each 1-point increase in general work climate scale score; P < .001). Conclusions and Relevance: This survey study of K grant awardees revealed substantial rates of burnout among mid-career medical faculty, and burnout rates differed by gender. Evidence-based interventions are needed to realize the benefits of workforce diversity and vitality.

Analysis of Pediatric Clinical Practice Guideline Authors by Gender, Race, and Ethnicity.

Background and Objectives: Clinical practice guidelines (CPGs) have significantly influenced medical practice worldwide. Nevertheless, the authorship of CPGs produced by several medical societies has not been representative of the field and population they address, as women and individuals from racial and ethnic minority groups have been underrepresented as authors. We hypothesized that women and individuals from minoritized racial and ethnic groups would also be underrepresented as authors of CPGs produced by the American Academy of Pediatrics (AAP). Methods: In this cross-sectional study, the gender, race, and ethnic composition of authors and subcommittee participants of AAP-produced CPGs published from January 2010 through May 2023 were analyzed and compared to the 2010 and 2021 U.S. population and 2010 and 2022 U.S. medical school pediatric faculty. Results: Women (39.7%, 127/320 of all positions, and 42.5%, 85/200 of named author positions) and women physicians (35.2%, 101/287 of all positions, and 36.4%, 64/176 of named author positions) were significantly underrepresented-while men and men physicians were significantly overrepresented-from their respective composition in the U.S. Census and pediatric faculty. Women and women physicians from all racial and ethnic groups and men and men physicians from minority racial and ethnic groups were significantly underrepresented-from their respective composition in the U.S. Census and pediatric faculty. No Black man was identified as an author. Conclusions: Medical societies that produce CPGs should be cognizant of these inequities and ensure appropriate authorship diversity.

Professional Experiences and Career Trajectories of Mid- to Senior-Career Women Clinician-Scientists: A Qualitative Study.

Importance: Despite increasing evidence and recognition of persistent gender disparities in academic medicine, qualitative data detailing the association of gender-based experiences with career progression remain sparse, particularly at the mid- to senior-career stage. Objective: To investigate the role gender has played in everyday professional experiences of mid- to senior-career women clinician-scientists and their perceptions of gender-related barriers experienced across their careers. Design, Setting, and Participants: In this qualitative study, a total of 60 of 159 invited clinician-scientists who received National Institutes of Health K08 or K23 awards between 2006 and 2009 and responded to a survey in 2021 agreed to participate. Invitees were selected using random, purposive sampling to support sample heterogeneity. Semistructured in-depth interviews were conducted January to May 2022. For this study, interviews from 31 women were analyzed using the framework approach to thematic analysis. Data analyses were performed between August and October 2023. Main Outcomes and Measures: Descriptive themes of participant experiences of gender and gender-based barriers in academic medicine. Results: A total of 31 women clinician-scientists (8 identifying as Asian [25.8%], 14 identifying as White [45.2%], and 9 identifying as members of a minority group underrepresented in medicine [29.0%]; 14 aged 40-49 years [45.2%] and 14 aged 50-59 years [45.2%]) were included. Among them, 17 participants (54.8%) had children who required adult supervision or care, 7 participants (22.6%) had children who did not require supervision or care, and 6 participants (19.4%) did not have children. There were 4 dominant themes identified within participant experiences in academic medicine: the mental burden of gendered expectations at work and home, inequitable treatment of women in bureaucratic processes, subtle and less subtle professional exclusion of women, and value of communities built on shared identities, experiences, and solidarity. Conclusions and Relevance: This study found that women perceived the institution of academic medicine as a male-centric system misaligned with the needs of women, with associated feelings of exclusion, disillusionment, and loss of trust in their institutions. Findings suggest that the confluence of domestic obligations and unaccommodating institutional environments may make it difficult for women clinician-scientists to achieve established timelines of career progression and productivity; these findings may have long-term implications for the well-being and retention of women in academic medicine.

The Disproportionate Effects of the COVID-19 Pandemic on the Time Allocation of Recipients of NIH Career Development Awards Who Are Women or Caregivers of Dependents.

PURPOSE: To understand time allocation of a national medical faculty cohort 1.5-2 years after the COVID-19 pandemic began, compared to before. METHOD: From August 2021-April 2022, the authors conducted a retrospective survey of 1,430 clinician-researchers who received National Institutes of Health career-development awards between 2006-2009 asking about domestic and professional time allocation pre-pandemic and at the time of surveys (TOS). Of 915 respondents (64%), the 830 who remained in academic positions constituted the analytic sample. Multivariable regression models identified demographic factors associated with each time outcome and change in time between pre-pandemic and TOS, and having experienced ≥8-hour increase of total self-reported weekly professional work hours and domestic labor hours. RESULTS: Median self-reported weekly professional work hours were 55 hours/week pre- pandemic and 60 at TOS. On multivariable analysis, significant predictors of self-reported weekly professional work hours at TOS were having a non-child other dependent (+2.6 hours, P = .03), academic rank (associate -3.1 hours, assistant -9.0 hours; P < .001), and specialty (P < .001). Average self-reported TOS weekly domestic-labor hours were 23.1 among men and 30.2 among women (P < .001). Predictors of total self-reported TOS weekly domestic hours were being a woman (+5.6 hours; P < .001) and having children requiring supervision (+10.2 hours; P < .001). Overall, 9.3% of men (42/450) and 21.6% of women (88/407) experienced a ≥ 8 hour increase in domestic labor (P < .001). On multivariable analysis, women had higher odds of substantial domestic-labor increase (OR = 2.33, 95% CI: 1.47, 3.68), as did those with children requiring supervision (OR = 1.93, 95% CI: 1.25, 2.98) or other dependents (OR = 1.83, 95% CI: 1.13, 2.98). CONCLUSIONS: This study illuminates demands on women and faculty with dependents during the COVID-19 pandemic and suggests increased flexibility and resources are of heightened importance.

Implementing a Family-Centered Rounds Intervention Using Novel Mentor-Trios.

BACKGROUND AND OBJECTIVES: Patient and Family Centered I-PASS (PFC I-PASS) emphasizes family and nurse engagement, health literacy, and structured communication on family-centered rounds organized around the I-PASS framework (Illness severity-Patient summary-Action items-Situational awareness-Synthesis by receiver). We assessed adherence, safety, and experience after implementing PFC I-PASS using a novel "Mentor-Trio" implementation approach with multidisciplinary parent-nurse-physician teams coaching sites. METHODS: Hybrid Type II effectiveness-implementation study from 2/29/19-3/13/22 with ≥3 months of baseline and 12 months of postimplementation data collection/site across 21 US community and tertiary pediatric teaching hospitals. We conducted rounds observations and surveyed nurses, physicians, and Arabic/Chinese/English/Spanish-speaking patients/parents. RESULTS: We conducted 4557 rounds observations and received 2285 patient/family, 1240 resident, 819 nurse, and 378 attending surveys. Adherence to all I-PASS components, bedside rounding, written rounds summaries, family and nurse engagement, and plain language improved post-implementation (13.0%-60.8% absolute increase by item), all P < .05. Except for written summary, improvements sustained 12 months post-implementation. Resident-reported harms/1000-resident-days were unchanged overall but decreased in larger hospitals (116.9 to 86.3 to 72.3 pre versus early- versus late-implementation, P = .006), hospitals with greater nurse engagement on rounds (110.6 to 73.3 to 65.3, P < .001), and greater adherence to I-PASS structure (95.3 to 73.6 to 72.3, P < .05). Twelve of 12 measures of staff safety climate improved (eg, "excellent"/"very good" safety grade improved from 80.4% to 86.3% to 88.0%), all P < .05. Patient/family experience and teaching were unchanged. CONCLUSIONS: Hospitals successfully used Mentor-Trios to implement PFC I-PASS. Family/nurse engagement, safety climate, and harms improved in larger hospitals and hospitals with better nurse engagement and intervention adherence. Patient/family experience and teaching were not affected.

Gender Representation of Editors at Journals Affiliated with Major U.S. Medical Societies.

Objectives: To assess the gender composition of upper-level specialty-specific editor positions among United States (U.S.) medical society-affiliated journals and to evaluate the equitable inclusion of women and women physicians. Materials and Methods: The gender composition of upper-level (e.g., editor-in-chief, deputy) specialty-specific editor positions among 39 U.S. medical society-affiliated journals as of January 5, 2023, was analyzed. Editor positions below the level of associate editor were excluded. Parity (50:50 representation) and equity (compared with the proportion of practicing physicians in each medical specialty) benchmarks were utilized to determine if women are underrepresented in editor positions. Results: A total of 862 editor positions among 39 journals were assessed. Women held 32.9% (284/862) of positions (95% confidence interval [CI]: 29.9%-36.2%), significantly less than expected based on the U.S. population (p < 0.001). Physicians comprised 90.8% (783/862) of positions, of whom 30.4% (238/783) were women physicians (95% CI: 27.3%-33.7%), significantly less than expected (p < 0.001). Thirty-three (84.6%, 95% CI: 70.3%-92.8%) journals were below parity for women overall, whereas 34 (87.2%, 95% CI: 73.3%-94.4%) were below parity for women physicians. Fourteen (35.9%, 95% CI: 22.7%-51.6%) journals were below equity for women physicians. Notably, 13 (33.3%, 95% CI: 20.6%-49.0%) journals were below both parity and equity for women overall and women physicians. Conclusions: This study reveals mixed results in the equitable inclusion of women in editor positions of journals affiliated with U.S. medical societies. Despite the equitable inclusion of women in editorial roles being a remediable issue, approximately one third of journals affiliated with major U.S. medical societies remain inequitable.

Disrupting Faculty-on-Faculty Bullying in Academic Medicine: An Innovative Workshop.

Introduction: Bullying, a severe form of mistreatment, occurs when an individual in an authority position intentionally imposes negative persistent behaviors on a target. In academic medicine, bullying is used to impede the target's professional growth. While there is abundant literature on how to disrupt other forms of mistreatment, the literature related to bullying among academic medical faculty members is scarce. Methods: We developed an interactive workshop on disrupting faculty-on-faculty bullying in academic medicine, with a focus on gender-based bullying, following Kern's model of curriculum development. The workshop consisted of three didactics on the scope of bullying in academic medicine: identifying bullying behaviors, learning strategies to mitigate bullying, and understanding what constitutes comprehensive antibullying policies. The workshop also included three small-group activities to reinforce learned concepts. Results: Eighty-seven faculty attended one of three workshops held over a 6-month period. We received 24 completed evaluations for a 28% rate of return. Most participants rated workshop activities as being well taught and of great value. Many respondents commented that after participating in the workshop, they realized they had likely experienced or witnessed bullying in their careers and that mitigating bullying required effort at multiple levels (individual, institutional, national). Discussion: This workshop fills a need in academic medicine through addressing how faculty members and institutions can help themselves and others to disrupt bullying. We will continue to disseminate this workshop at national conferences and at individual institutions. This resource will allow other educators to offer the workshop at their home institutions.

Gender Representation Among Editors of Major Pediatric Journals.

This cross-sectional study analyzes inequities in the gender of editors for 3 major pediatric journals.

Analysis of Race and Ethnicity Among United States Medical Board Leadership.

Background: The inequitable representation of women and members of racial and ethnic minority groups in leadership positions within academic medicine is an ongoing challenge with practical and realistic solutions. The purpose of this study was to assess the race and ethnicity of individuals in leadership positions among the 24 Member Boards of Directors (Boards) of the American Board of Medical Specialties (ABMS). Methods: We performed a cross-sectional analysis of the race and ethnicity patterns for individuals holding leadership positions among the 24 Boards of the ABMS as of March 1, 2022. Two independent coders with 100% concordance recorded race and ethnicity using online biographies and photographs. Percentages were compared to the Association of American Medical Colleges (AAMC) 2018 data reports. Results: Among 449 director positions, 415 (92.4%) were physicians. Within the physician subset, 12.3% (51/415) Asian, 8.2% (34/415) Black, and 3.4% (14/415) Hispanic individuals were identified. Women who are members of racial and ethnic minority groups have less representation than men of the same race. Of 24 Boards, 37.5% (9/24) had no Asian women, 50.0% (12/24) had no Black women, and 75.0% (18/24) had no Hispanic women. White physicians were overrepresented on 14 of 21 (66.7%) Boards compared to the proportion of active White physicians or White individuals in the United States general population. Conclusion: Disparities exist for members of racial and ethnic minority groups, particularly women from these groups. As a leader in academic medicine, the ABMS should ensure its Boards are diverse with respect to gender, race, and ethnicity. Diverse groups often contribute unique insights that support medical education, advance science, and improve clinical care.

Improving Handoffs in the Perioperative Environment: A Conceptual Framework of Key Theories, System Factors, Methods, and Core Interventions to Ensure Success.

BACKGROUND: Patient handoffs involve the transition of information and responsibility for care from one health care provider to another. They occur frequently during a patient's perioperative care continuum, potentially introducing communication errors that could result in harmful, even fatal consequences. The perioperative environment poses distinct challenges to team communication and patient safety, which in turn leaves the surgical patient uniquely vulnerable to adverse events. CONCEPTUAL FRAMEWORK: The best way to achieve safe, coordinated handoffs throughout the perioperative continuum has yet to be established. However, a variety of theoretical principles, methods, and interventions have been used successfully in operative and nonoperative contexts among multiple disciplines. Informed by a literature review, the authors describe a conceptual framework for the development, implementation, and sustainment of a multimodal perioperative handoff improvement bundle. The conceptual framework presented here begins with overarching objectives for patient-centered handoff improvement efforts. The article outlines theoretical principles that could be used to guide and inform future multimodal interventions, as well as health care system factors to consider. Further, the authors propose employing data-driven quality improvement and research methodologies to conduct, measure, achieve, and sustain long-term success. Finally, this report describes essential evidence-based interventional components to employ. IMPLICATIONS: Future efforts to improve handoff safety in the perioperative environment will require a comprehensive evidence-based approach. The authors believe the conceptual framework presented here outlines essential components for success. It integrates proven theoretical frameworks, consideration of system factors, data-driven iterative methods, and synergistic patient-centered interventions.

Workplace Harassment, Cyber Incivility, and Climate in Academic Medicine.

Importance: The culture of academic medicine may foster mistreatment that disproportionately affects individuals who have been marginalized within a given society (minoritized groups) and compromises workforce vitality. Existing research has been limited by a lack of comprehensive, validated measures, low response rates, and narrow samples as well as comparisons limited to the binary gender categories of male or female assigned at birth (cisgender). Objective: To evaluate academic medical culture, faculty mental health, and their relationship. Design, Setting, and Participants: A total of 830 faculty members in the US received National Institutes of Health career development awards from 2006-2009, remained in academia, and responded to a 2021 survey that had a response rate of 64%. Experiences were compared by gender, race and ethnicity (using the categories of Asian, underrepresented in medicine [defined as race and ethnicity other than Asian or non-Hispanic White], and White), and lesbian, gay, bisexual, transgender, queer (LGBTQ+) status. Multivariable models were used to explore associations between experiences of culture (climate, sexual harassment, and cyber incivility) with mental health. Exposures: Minoritized identity based on gender, race and ethnicity, and LGBTQ+ status. Main Outcomes and Measures: Three aspects of culture were measured as the primary outcomes: organizational climate, sexual harassment, and cyber incivility using previously developed instruments. The 5-item Mental Health Inventory (scored from 0 to 100 points with higher values indicating better mental health) was used to evaluate the secondary outcome of mental health. Results: Of the 830 faculty members, there were 422 men, 385 women, 2 in nonbinary gender category, and 21 who did not identify gender; there were 169 Asian respondents, 66 respondents underrepresented in medicine, 572 White respondents, and 23 respondents who did not report their race and ethnicity; and there were 774 respondents who identified as cisgender and heterosexual, 31 as having LGBTQ+ status, and 25 who did not identify status. Women rated general climate (5-point scale) more negatively than men (mean, 3.68 [95% CI, 3.59-3.77] vs 3.96 [95% CI, 3.88-4.04], respectively, P < .001). Diversity climate ratings differed significantly by gender (mean, 3.72 [95% CI, 3.64-3.80] for women vs 4.16 [95% CI, 4.09-4.23] for men, P < .001) and by race and ethnicity (mean, 4.0 [95% CI, 3.88-4.12] for Asian respondents, 3.71 [95% CI, 3.50-3.92] for respondents underrepresented in medicine, and 3.96 [95% CI, 3.90-4.02] for White respondents, P = .04). Women were more likely than men to report experiencing gender harassment (sexist remarks and crude behaviors) (71.9% [95% CI, 67.1%-76.4%] vs 44.9% [95% CI, 40.1%-49.8%], respectively, P < .001). Respondents with LGBTQ+ status were more likely to report experiencing sexual harassment than cisgender and heterosexual respondents when using social media professionally (13.3% [95% CI, 1.7%-40.5%] vs 2.5% [95% CI, 1.2%-4.6%], respectively, P = .01). Each of the 3 aspects of culture and gender were significantly associated with the secondary outcome of mental health in the multivariable analysis. Conclusions and Relevance: High rates of sexual harassment, cyber incivility, and negative organizational climate exist in academic medicine, disproportionately affecting minoritized groups and affecting mental health. Ongoing efforts to transform culture are necessary.

Five Strategies Leaders in Academic Medicine Can Implement Now to Enhance Gender Equity.

Abundant disparities for women in medicine contribute to many women physicians considering leaving medicine. There is a strong financial and ethical case for leaders in academic medicine to focus on strategies to improve retention. This article focuses on five immediate actions that leaders can take to enhance gender equity and improve career satisfaction for all members of the workplace.

Effect of Patient and Family Centered I-PASS on adverse event rates in hospitalized children with complex chronic conditions.

BACKGROUND: Children with complex chronic conditions (CCCs) are at risk for adverse events (AEs) during hospitalizations. OBJECTIVE: We compared the effect of Patient and Family Centered (PFC)I-PASS on AE rates in children with and without CCCs. DESIGNS, SETTINGS, AND PARTICIPANTS: Patients were drawn from the PFCI-PASS study, which included 3106 hospitalized children from seven North American pediatric hospitals between December 2014 and January 2017. MAIN OUTCOME AND MEASURES: An effect modification analysis did not show difference in the intervention on children with and without CCCs (RRR 0.81, 95% CI [0.59-1.10]; p = .2). RESULTS: In multivariable analysis, the adjusted incidence rate ratiofor AEs in children with CCCs was 0.5 (95% CI = 0.3-0.9, p = .01) with PFC I-PASS exposure; there was no statistically significant change in AEs for children without CCCs [IRR 0.6 (95% CI = 0.3-1.2; p = .1)].