Post hoc depression analysis from a pharmacist-led diabetes trial.

Introduction: Diabetes and depression may present concurrently, and clinical pharmacists are well equipped to manage these conditions. Clinical pharmacists were grant funded to implement a diabetes-focused randomized controlled trial in a Federally Qualified Health Center. The objective of this analysis is to evaluate if glycemic control and depressive symptoms improve for patients with diabetes and depression with additional management from clinical pharmacists compared with those receiving the standard of care. Methods: This is a post hoc subgroup analysis of a diabetes-focused randomized controlled trial. Pharmacists enrolled patients with type 2 diabetes mellitus (T2DM) and a glycated hemoglobin (A1C) greater than 8% and randomly assigned them to 1 of 2 cohorts, one managed by the primary care provider alone and one with additional care from the pharmacist. Pharmacists completed encounters with patients who have T2DM with or without depression to comprehensively optimize pharmacotherapy while tracking glycemic and depressive outcomes throughout the study. Results: A1C improved from baseline to 6 months in patients with depressive symptoms who received additional care from pharmacists by -2.4 percentage points (SD, 2.41) compared with a -0.1 percentage point (SD, 1.78) reduction in the control arm (P .0081), and there was no change in depressive symptoms. Discussion: Patients with T2DM and depressive symptoms experienced better diabetes outcomes with additional pharmacist management compared with a similar cohort of patients with depressive symptoms, managed independently by primary care providers. These patients with diabetes and comorbid depression received a higher level of engagement and care from the pharmacists, which led to more therapeutic interventions.

Educator's blueprint: A how-to guide for developing high-quality multiple-choice questions.

Multiple-choice questions are commonly used for assessing learners' knowledge, as part of educational programs and scholarly endeavors. To ensure that questions accurately assess the learners and provide meaningful data, it is important to understand best practices in multiple-choice question design. This Educator's Blueprint paper provides 10 strategies for developing high-quality multiple-choice questions. These strategies include determining the purpose, objectives, and scope of the question; assembling a writing team; writing succinctly; asking questions that assess knowledge and comprehension rather than test-taking ability; ensuring consistent and independent answer choices; using plausible foils; avoiding grouped options; selecting the ideal response number and order; writing high-quality explanations; and gathering validity evidence before and evaluating the questions after use.

Resident Physician Interactions and Engagement With Written Assessments of Performance.

BACKGROUND AND OBJECTIVES: Despite the requirements of the Accreditation Council for Graduate Medical Education (ACGME) to provide feedback, assessments are often not meeting the needs of resident learners. The objective of this study was to explore residents' approach to reviewing, interpreting, and incorporating the feedback provided in written faculty assessments. METHODS: We conducted semistructured interviews with 14 family medicine residents. We used line-by-line iterative coding of the transcripts through the constant comparative method to identify themes and reach a consensus. RESULTS: The study revealed the following themes: (1) residents value the narrative portion of assessments over numerical ratings, (2) performance reflection and reaction are part of the feedback process, (3) residents had difficulty incorporating formal assessments as many did not provide actionable feedback. CONCLUSIONS: Residents reported that narrative feedback gives more insight to performance and leads to actionable changes in behaviors. Programs should consider education for both faculty and residents on the usefulness, importance, and purpose of the ACGME Milestones in order to accurately determine resident competency and provide a summative assessment. Until the purpose of the ACGME Milestones is realized and utilized, it should be noted that the comment portion of evaluations will likely be the focus of the resident's interaction with their assessments.

Polysomnography findings in children with spinal muscular atrophy after onasemnogene-abeparvovec.

BACKGROUND: Sleep disordered breathing (SDB) is common in patients with neuromuscular diseases, including spinal muscular atrophy (SMA). While polysomnography (PSG) findings have been described in natural history studies of patients with SMA, reports regarding PSG in treated children are limited to nusinersen. We aim to describe the sleep characteristics in a cohort of children treated with Onasemnogene-abeparvovec. METHODS: We conducted a cross-sectional cohort study of children with SMA followed at the University of Florida Center for neuromuscular and rare diseases and had a diagnostic or split night PSG after SMA treatment. RESULTS: Eight children were included in the cohort (four female), aged 5-250 days at diagnosis. Five children had two survival motor neuron 2 (SMN2) copies, two had three SMN2 copies and one subject had four SMN2 copies. Median age at the time of treatment was 46.5 days (range 20-257). All children received onasemnogene-abeparvovec (OA) before their PSG; in addition to OA, one received nusinersen and one received risdiplam. Apnea hypopnea index (AHI) ranged from 3.6 to 24.1/h. REM AHI was higher than NREM AHI. Median Children's Hospital of Philadelphia Infant test of neuromuscular disorders (CHOP-Intend) score at the time of PSG was 55 (range 33-64). There was no correlation between age at treatment, CHOP-Intend score and AHI. CONCLUSION: SDB is common in treated children with SMA, regardless of age at diagnosis, treatment and neuromotor scores. While AHI may not be the only indicator of SDB in this population, indications, timing of PSG in this cohort remain unknown.

The test developer's dilemma: Evaluating the balance of feasibility and empiric performance of test development techniques for repeated written assessments.

PURPOSE: Written assessments face challenges when administered repeatedly, including resource-intensive item development and the potential for performance improvement secondary to item recall as opposed to understanding. This study examines the efficacy of three-item development techniques in addressing these challenges. METHODS: Learners at five training programs completed two 60-item repeated assessments. Items from the first test were randomized to one of three treatments for the second assessment: (1) Verbatim repetition, (2) Isomorphic changes, or (3) Total revisions. Primary outcomes were the stability of item psychometrics across test versions and evidence of item recall influencing performance as measured by the rate of items answered correctly and then incorrectly (correct-to-incorrect rate), which suggests guessing. RESULTS: Forty-six learners completed both tests. Item psychometrics were comparable across test versions. Correct-to-incorrect rates differed significantly between groups with the highest guessing rate (lowest recall effect) in the Total Revision group (0.15) and the lowest guessing rate (highest recall effect) in the Verbatim group (0.05), p = 0.01. CONCLUSIONS: Isomorphic and total revisions demonstrated superior performance in mitigating the effect of recall on repeated assessments. Given the high costs of total item revisions, there is promise in exploring isomorphic items as an efficient and effective approach to repeated written assessments.[Box: see text].

Preparing Effective Narrative Evaluations for the Medical School Performance Evaluation (MSPE).

Introduction: In 2016, the AAMC Medical School Performance Evaluation (MSPE) Task Force issued recommendations to standardize the MSPE but did not address the quality of the written narratives in that document. Narrative evaluations are hampered by code words, polite rhetoric, and bias to the detriment of students. To address this, the AAMC's Group on Student Affairs and Group on Educational Affairs convened an expert group to consider the state of narratives in the MSPE and develop resources to improve their quality. Methods: A series of interactive workshops was developed and presented at an AAMC webinar and national meetings. A presentation outlining challenges and possible approaches to improvement was followed with large-group discussion and/or small-group breakout activity to analyze and improve upon sample clinical comments and create summary clerkship paragraphs. The initial webinar used polling questions and free-text prompts to gather feedback for future workshops. Anonymous survey responses were collected at the end of each subsequent workshop to determine perceived effectiveness and potential utility at participants' institutions. Results: Over 680 administrators, faculty, and staff participated in the webinar or in one of four national-level workshops. Respondents agreed that the modules would be useful in faculty development and wanted to replicate their learning at their own institutions for overall better impact on the quality of MSPE narratives. Discussion: This resource addresses an important gap in the medical education literature. A variety of stakeholders affirmed that these workshops have value in training writers to improve their narrative comments for the MSPE.

Pharmacists improve diabetes outcomes: a randomized controlled trial.

BACKGROUND: There is a growing shortage of primary care physicians. Pharmacists can fill the gap, and interdisciplinary teams are being evaluated as part of health care reform. OBJECTIVE: This study aimed to determine whether adding a pharmacist to an interprofessional health team will improve diabetes outcomes. METHODS: In this 2-phase pilot study, Medicaid-eligible patients with diabetes were randomized to receive standard of care (control arm) or standard of care plus the care of a pharmacist (intervention arm) for 12 months (phase 1). The primary outcome was change in glycated hemoglobin (A1C) from baseline. Secondary outcomes included identifying and correcting medication therapy problems (MTPs) for comorbid conditions, adherence to preventive care visits, health care utilization, self-rated health, and satisfaction surveys. After phase 1, patients in the control arm who did not achieve an A1C of < 8% were eligible to enroll into phase 2 where they received treatment with a pharmacist for 6 months. RESULTS: Of the 239 patients enrolled, 122 completed phase 1. At 12 months, intervention patients' mean A1C was 1.85 percentage point (pp) below baseline versus 0.94 pp for control (between-group difference 0.91 pp; P = 0.0218). Most control patients (79%) who completed phase 1 and enrolled into phase 2 improved their A1C by more than 1 pp (P < 0.01). The pharmacists completed 806 patient visits and identified 2638 MTPs. Intervention patients were more adherent to preventive care visits with nutrition (P = 0.043), ophthalmology (P = 0.002), and dentistry (P = 0.007). For intervention patients, 78% rated their experience with the pharmacist as excellent whereas, for control patients, 37% rated their experience with their provider as excellent. CONCLUSION: Pharmacist comanagement of patients with diabetes can significantly improve glucose control and patient satisfaction. Creative payment models were used to include pharmacists in the interprofessional patient care team.

Sleep and asthma management in youth with poorly-controlled asthma and their caregivers: a qualitative approach.

OBJECTIVE: Youth with poorly-controlled asthma are at increased risk for sleep disturbances caused by nocturnal symptoms like coughing. Asthma-related sleep disturbances can have downstream consequences for youth with asthma and their families. This study aims to describe (1) sleep disturbances in adolescents with poorly-controlled asthma and their caregivers and (2) the relationship between sleep and asthma management. METHODS: Adolescents with poorly-controlled asthma and their caregivers completed the Family Asthma Management System Scale (FAMSS), a semi-structured interview that assesses youth asthma management within the family context. Interviews were audio-recorded and transcribed. Two authors coded each transcript for sleep-related data in NVivo using descriptive content analysis. RESULTS: Thirty-three adolescents ages 12-15 years old (M = 13.2, SD = 1.2) with poorly-controlled asthma and their caregivers participated in this study. Four main themes emerged: sleep difficulties, sleep environment, sleep and self-management, and fatigue and self-management. 42% of youth and caregivers reported worse nocturnal asthma symptoms (e.g. coughing) that caused frequent nighttime awakening. Approximately 27% of caregivers expressed distress over their child's nocturnal asthma and described their management strategies (e.g. co-sleeping, nighttime symptom monitoring). Adolescents described sleepiness as a barrier to asthma self-management tasks (e.g. medication adherence, response to exacerbation). CONCLUSION: Interview responses demonstrated the considerable interrelationship of sleep and asthma management in adolescents with poorly-controlled asthma. Asthma providers should consider discussing sleep difficulties with their adolescent patients and their families. Addressing these difficulties may help adolescents improve their asthma self-management and help caregivers better cope with their child's disease.

Coaching educators: Impact of a novel national faculty development program for didactic presentation skills.

BACKGROUND: Didactic lectures remain common in medical education. Many faculty physicians do not receive formal training on public presentations or leading instructional sessions. Coaching has emerged in medical education with the potential to positively impact skills. We sought to evaluate a novel, national faculty peer-coaching program created to improve lecture presentation skills and foster career development. METHODS: This was a mixed-methods study of participant and faculty perceptions after completing the Council of Residency Directors in Emergency Medicine Academy Coaching Program. Participants completed an online evaluative survey consisting of multiple choice and Likert-type items. Program coaches participated in semistructured interviews. Descriptive statistics were reported for survey data. Thematic qualitative analysis by two independent reviewers was performed on interview data. RESULTS: During 2012 to 2017, a total of 30 participants and 11 coaches from 37 residency programs across the United States engaged in the program. Twenty-four (80%) participants completed the survey. Eight (73%) coaches participated in semistructured interviews. Data were collected between October and December 2018. The mean ± SD numbers of national presentations participants had given before and after the coaching program were 6.92 ± 7.68 and 16.42 ± 15.43, respectively. Since their coaching, most participants (87.5%) have been invited to give a lecture at another institution. Many participants felt that the program improved their lecture evaluations, public speaking, ability to engage an audience, and professional development. Almost all (92%) would recommend the program to a colleague. The coaches perceived multiple benefits including improved skills, self-reflection, networking, career advancement, and personal fulfillment. Suggestions for improvement included improved administrative processes, more clear expectations, increased marketing, and increased participant and coach engagement. CONCLUSION: Participants and coaches perceived multiple benefits from this novel, national faculty coaching program. With identification of the success, challenges, and suggestions for improvement, others may benefit as they develop coaching programs in medical education.

Graduate medical education tool kit for the Supplemental Offer and Acceptance Program: Navigating the National Resident Matching Program supplemental offer assistance program.

More residency training programs are involved in the National Resident Matching Program (NRMP) Supplemental Offer and Acceptance Program (SOAP) than in the past, which is unanticipated by many. Without an action plan in place, the SOAP process can be chaotic and could result in offers to incompletely vetted residency applicants and unfilled residency slots. Faced with this challenge, it is important that programs have a unified, clear process and action plan for the SOAP. Our instution has created a SOAP tool kit that documents our strategies, scripts, and timelines in preparation of SOAP. The success of our approach has been gauged by the positive response from the key stakeholders who found this easy to use without significant advanced training. Faculty and staff noted significant efficiencies and improvements in the process when using the SOAP tool kit. Applicants indicated that the process was more organized than other residency programs they interacted with during the SOAP week. We anticipate that the use of the documents in the SOAP tool kit will help other training programs improve their performance during the SOAP process.

Knuckle cracking at night associated with sodium oxybate treatment.

NONE: During upward titration of a dose of sodium oxybate therapy for narcolepsy with cataplexy, a 25-year-old woman was observed by her husband to have new onset of knuckle-cracking and moaning behaviors during sleep ≥1 nights each week. The patient did previously occasionally crack her knuckles during the day (but never at night). These behaviors had not been evaluated by polysomnography. After transition of care, polysomnography with video monitoring was ordered and revealed 2 knuckle-cracking episodes that developed out of stage N2 sleep and were likely a non-rapid eye movement sleep parasomnia associated with sodium oxybate treatment.

Integrating Behavioral Health into Primary Care: The Role of Psychiatric Nursing in the Development of the Interprofessional Team.

BACKGROUND: Integrated behavioral health in a primary care setting is a paradigm shift that requires academic reconfiguration on how health care professionals are educated and trained in the clinical arena. METHOD: An academic university was able to create interprofessional didactic and clinical learning experiences for students within the Schools of Nursing, Social Work, Health Professions-Rehabilitation Counseling Department and Pharmacy resulting in improved models for patient care delivery. RESULTS: Interdisciplinary faculty developed the didactic, clinical and evaluative areas based on the HRSA grant work plan. Deliverables included 18 modules, case studies focused on population health, and team-focused standardized patient experiences to test their behavioral health and psychiatric skills in a primary care setting. CONCLUSIONS: Faculty from the different disciplines were able to collaborate on the deliverables, take the opportunities to engage students and collaborate on scholarly presentations at a national, state and local professional organizations. Academic course for interprofessional practice has been developed and implemented as an outcome of this grant.