Asthma policy in Illinois: A survey of school nursing and staff knowledge and implementation patterns

OBJECTIVE

Our goal is to examine gaps in self-carry, asthma emergency protocol, and stock inhaler policy knowledge in Illinois schools.

DESIGN

A 30-item REDCap cross-sectional survey developed by a team of stakeholders was disseminated. Questions assessed policy knowledge, awareness, and practices regarding asthma emergency protocols, self-carry, and stock inhalers.

SAMPLE

Participants were Illinois school nurses belonging to a governmental organization listserv.

MEASUREMENTS

Analysis utilized Chi-square tests, descriptive statistics, and t-tests.

RESULTS

Nurses reported 36% of students on average self-carried asthma medication. Thirty percent of nurses were not aware of their emergency asthma policy and only 60% reported having an emergency asthma protocol in their school(s). Fifty-four percent of nurses were aware of stock inhaler programming. Of the 10.3% who reported a stock inhaler program, a lower frequency reported calling 911 for asthma emergencies. Perceived school asthma prevalence varied from 0%-87%.

CONCLUSIONS

Our survey demonstrates large variation in knowledge and implementation of school-based asthma health policy. This is likely due to variations in health policy education dissemination. Future efforts should focus on the dissemination and implementation of school-based asthma health policies to improve their more universal adoption and better support school-based asthma management.

The ACHIEVE Program: Bringing Chicago Youth and Community Organizations Together to Impact Local Disparities

To evaluate the Advancing Community Health and Individual leadership through a noVel Educational (ACHIEVE) program uniting Chicago high school and undergraduate students (scholars) and community organizations to empower youth to meaningfully impact communities while enhancing organizational capacity. Between 2020 and 2022, the ACHIEVE program engaged cohorts of youth in classroom-based learning and community-based projects targeting health and education disparities. Pre and post-program surveys were administered to scholars to assess knowledge about disparities, skills, and self-efficacy. Semi-structured interviews were conducted with community organization leaders to examine programmatic impact. Descriptive and thematic analyses were performed. Across four cohorts (March 2020; September 2020-May 2021; September-November 2021; March-May 2022), 85 students participated in the ACHIEVE program. Scholars supported 19 community-based projects that increased awareness of local issues and resources and evaluated programs. Scholars reported advancement in their knowledge and skills as well as interest in sustaining their community engagement. Leaders shared several benefits at the organizational and community levels from collaborating with scholars. The ACHIEVE program enabled bidirectional learning between scholars and organizations. It also demonstrated that youth can contribute positively to addressing disparities while supporting local organizations and communities.

Antidepressant Dispensing to US Adolescents and Young Adults: 2016-2022

BACKGROUND

Mental health worsened in adolescents and young adults after the coronavirus disease 2019 (COVID-19) outbreak in March 2020, but whether antidepressant dispensing to this population changed is unknown.

METHODS

We identified antidepressant prescriptions dispensed to US individuals aged 12 to 25 years from 2016 to 2022 using the IQVIA Longitudinal Prescription Database, an all-payer national database. The outcome was the monthly antidepressant dispensing rate, defined as the monthly number of individuals with ≥1 dispensed antidepressant prescription per 100 000 people. We fitted linear segmented regression models assessing for level or slope changes during March 2020 and conducted subgroup analyses by sex and age group.

RESULTS

Between January 2016 and December 2022, the monthly antidepressant dispensing rate increased 66.3%, from 2575.9 to 4284.8. Before March 2020, this rate increased by 17.0 per month (95% confidence interval: 15.2 to 18.8). The COVID-19 outbreak was not associated with a level change but was associated with a slope increase of 10.8 per month (95% confidence interval: 4.9 to 16.7). The monthly antidepressant dispensing rate increased 63.5% faster from March 2020 onwards compared with beforehand. In subgroup analyses, this rate increased 129.6% and 56.5% faster from March 2020 onwards compared with beforehand among females aged 12 to 17 years and 18 to 25 years, respectively. In contrast, the outbreak was associated with a level decrease among males aged 12 to 17 years and was not associated with a level or slope change among males aged 18 to 25 years.

CONCLUSIONS

Antidepressant dispensing to adolescents and young adults was rising before the COVID-19 outbreak and rose 63.5% faster afterward. This change was driven by increased antidepressant dispensing to females and occurred despite decreased dispensing to male adolescents.

Utilization, quality, and spending for pediatric Medicaid enrollees with primary care in health centers vs non-health centers

BACKGROUND

Limited research has explored the performance of health centers (HCs) compared to other primary care settings among children in the United States. We evaluated utilization, quality, and expenditures for pediatric Medicaid enrollees receiving care in HCs versus non-HCs.

METHODS

This national cross-sectional study utilized 2012 Medicaid Analytic eXtract (MAX) claims to examine children 0-17 years with a primary care visit, stratified by whether majority (> 50%) of primary care visits were at HCs or non-HCs. Outcome measures include utilization (primary care visits, non-primary care outpatient visits, prescription claims, Emergency Department (ED) visits, hospitalizations) and quality (well-child visits, avoidable ED visits, avoidable hospitalizations). For children enrolled in fee-for-service Medicaid, we also measured expenditures. Propensity score-based overlap weighting was used to balance covariates.

RESULTS

A total of 2,383,270 Medicaid-enrolled children received the majority of their primary care at HCs, while 18,540,743 did at non-HCs. In adjusted analyses, HC patients had 20% more primary care visits, 15% less non-primary care outpatient visits, and 21% less prescription claims than non-HC patients. ED visits were similar across the two groups, while HC patients had 7% lower chance of hospitalization than non-HC. Quality of care outcomes favored HC patients in main analyses, but results were less robust when excluding managed care beneficiaries. Total expenditures among the fee-for-service subpopulation were lower by $239 (8%) for HC patients.

CONCLUSIONS

In this study of nationwide claims data to evaluate healthcare utilization, quality, and spending among Medicaid-enrolled children who receive primary care at HCs versus non-HCs, findings suggest primary care delivery in HCs may be associated with a more cost-effective model of healthcare for children.

Analysis of narrative assessments of internal medicine resident performance: are there differences associated with gender or race and ethnicity?

BACKGROUND

Equitable assessment is critical in competency-based medical education. This study explores differences in key characteristics of qualitative assessments (i.e., narrative comments or assessment feedback) of internal medicine postgraduate resident performance associated with gender and race and ethnicity.

METHODS

Analysis of narrative comments included in faculty assessments of resident performance from six internal medicine residency programs was conducted. Content analysis was used to assess two key characteristics of comments- valence (overall positive or negative orientation) and specificity (detailed nature and actionability of comment) - via a blinded, multi-analyst approach. Differences in comment valence and specificity with gender and race and ethnicity were assessed using multilevel regression, controlling for multiple covariates including quantitative competency ratings.

RESULTS

Data included 3,383 evaluations with narrative comments by 597 faculty of 698 residents, including 45% of comments about women residents and 13.2% about residents who identified with race and ethnicities underrepresented in medicine. Most comments were moderately specific and positive. Comments about women residents were more positive (estimate 0.06, p 0.045) but less specific (estimate - 0.07, p 0.002) compared to men. Women residents were more likely to receive non-specific, weakly specific or no comments (adjusted OR 1.29, p 0.012) and less likely to receive highly specific comments (adjusted OR 0.71, p 0.003) or comments with specific examples of things done well or areas for growth (adjusted OR 0.74, p 0.003) than men. Gendered differences in comment specificity and valence were most notable early in training. Comment specificity and valence did not differ with resident race and ethnicity (specificity: estimate 0.03, p 0.32; valence: estimate - 0.05, p 0.26) or faculty gender (specificity: estimate 0.06, p 0.15; valence: estimate 0.02 p 0.54).

CONCLUSION

There were significant differences in the specificity and valence of qualitative assessments associated with resident gender with women receiving more praising but less specific and actionable comments. This suggests a lost opportunity for well-rounded assessment feedback to the disadvantage of women.

A Model of Community Health Worker Integration into Schools: Community-based Participatory Research in Action

BACKGROUND

Schools are rich sites for collaborations between health and educational sectors.

OBJECTIVES

To identify lessons learned from formation of a community-academic partnership and application of community-based participatory research (CBPR) to develop a model that integrates community health workers into schools.

METHODS

Individuals from an academic medical center, a large public school district, and a community-based research institute applied CBPR principles to reimagine schools as a place for improving the health of children.

LESSONS LEARNED

Three lessons emerged. Leveraging each team member's expertise centered the partnership on community strengths, co-learning, and stakeholder engagement. Adherence to CBPR's principles of power sharing and equity helped navigate the challenges of collaboration between large institutions. Early focus on sustainability helped address unexpected issues, build capacity, and boost advocacy.

CONCLUSIONS

This partnership demonstrates how CBPR fosters conditions in which equitable partnerships between research institutions and public schools can thrive to promote childhood health.

Exploring gender and thematic differences in qualitative assessments of internal medicine resident performance

INTRODUCTION

Evidence suggests gender disparities in medical education assessment, including differences in ratings of competency and narrative comments provided in resident performance assessments. This study explores how gender manifests within the content of qualitative assessments (i.e., narrative comments or performance feedback) of resident performance.

METHODS

Qualitative content analysis was used to explore gender-based differences in narrative comments included in faculty assessments of resident performance during inpatient medicine rotations at six Internal Medicine residency programs, 2016-2017. A blinded, multi-analyst approach was employed to identify themes across comments. Patterns in themes with resident gender and post-graduate year (PGY) were explored, focusing on PGY2 and PGY3 when residents are serving in the team leader role.

RESULTS

Data included 3,383 evaluations with narrative comments of 385 men (55.2%) and 313 women residents (44.8%). There were thematic differences in narrative comments received by men and women residents and how these themes manifested within comments changed with training time. Compared to men, comments about women had a persistent relationship-orientation and emphasized confidence over training including as interns and in PGY2 and PGY3, when serving as team leader. The relationship-orientation was characterized not only by the residents' communal attributes but also their interpersonal and communication skills, including efforts supporting others and establishing the tone for the team. Comments about women residents often highlighted confidence, including recommendations around behaviors that convey confidence in decision-making and team leadership.

DISCUSSION

There were gender-based thematic differences in qualitative assessments. Comments about women resident team leaders highlight relationship building skills and urge confidence and actions that convey confidence as team leader. Persistent attention to communal skills suggests gendered expectations for women resident team leaders and a lost opportunity for well-rounded feedback to the disadvantage of women residents. These findings may inform interventions to promote equitable assessment, such as providing feedback across the competencies.

Parental leave, childcare policies, and workplace bias for hepatology professionals: A national survey

BACKGROUND

The presence of workplace bias around child-rearing and inadequate parental leave may negatively impact childbearing decisions and sex equity in hepatology. This study aimed to understand the influence of parental leave and child-rearing on career advancement in hepatology.

METHODS

A cross-sectional survey of physician members of the American Association for the Study of Liver Diseases (AASLD) was distributed through email listserv in January 2021. The 33-item survey included demographic questions, questions about bias, altering training, career plans, family planning, parental leave, and work accommodations.

RESULTS

Among 199 US physician respondents, 65.3% were women, and 83.4% (n = 166) were attendings. Sex and racial differences were reported in several domains, including paid leave, perceptions of bias, and child-rearing. Most women (79.3%) took fewer than the recommended 12 paid weeks of parental leave for their first child (average paid leave 7.5 wk for women and 1.7 for men). A majority (75.2%) of women reported workplace discrimination, including 83.3% of Black and 62.5% of Hispanic women. Twenty percent of women were asked about their/their partners' pregnancy intentions or child-rearing plans during interviews for training. Women were more likely to alter career plans due to child-rearing (30.0% vs. 15.9%, p = 0.030). Women were also more likely to delay having children than men (69.5% vs.35.9%).

CONCLUSIONS

Women reported sex and maternity bias in the workplace and during training interviews, which was more frequently experienced by Black and Hispanic women. As two-thirds of women had children during training, it is a particularly influential time to reevaluate programmatic support to address long-term gender disparities in career advancement.

Evaluating inhaler education interventions for hospitalized children with asthma: A randomized controlled trial

BACKGROUND

Most children with asthma have poor inhaler technique, with detrimental morbidity effects. Guidelines recommend clinicians provide inhaler education at every opportunity, yet resources are limited. A low-cost, technology-based intervention-Virtual Teach-to-Goal (V-TTG)-was developed to deliver tailored inhaler technique education with high fidelity.

OBJECTIVE

To evaluate whether V-TTG leads to less inhaler misuse among children with asthma who are hospitalized vs brief intervention (BI, reading steps aloud).

METHODS

A single-center randomized controlled trial of V-TTG vs BI was conducted with 5-to-10-year-old children with asthma hospitalized between January 2019 and February 2020. Inhaler technique was assessed pre- and post-education using 12-step validated checklists (misuse: < 10 steps correct).

RESULTS

Among 70 children enrolled, mean age was 7.8 years (SD = 1.6). Most (86%) were Black. Most had an emergency department visit (94%) or hospitalization (90%) in the previous year. At baseline, nearly all children misused inhalers (96%). The proportion of children with inhaler misuse decreased significantly in V-TTG (100%→74%, P = .002) and BI (92%→69%, P = .04) groups, with no difference between groups at both time points (P = .2 and .9). On average, children performed 1.5 more steps correctly (SD = 2.0), with greater improvement with V-TTG (mean [SD] = 1.7 [1.6]) vs BI (mean [SD] = 1.4 [2.3]), though not significant (P = .6). Concerning pre and post technique, older children were significantly more likely than younger children to show more correct steps (mean change = 1.9 vs 1.1, P = .002).

CONCLUSION

A technology-based intervention for tailored inhaler education led to improved technique among children, similarly to reading steps aloud. Older children saw greater benefits. Future studies should evaluate the V-TTG intervention across diverse populations and disease severities to identify the greatest impact.

CLINICAL TRIAL REGISTRATION

NCT04373499.

Video-Based Educational Interventions for Patients With Chronic Illnesses: Systematic Review

BACKGROUND

With rising time constraints, health care professionals increasingly depend on technology to provide health advice and teach patients how to manage chronic disease. The effectiveness of video-based tools in improving knowledge, health behaviors, disease severity, and health care use for patients with major chronic illnesses is not well understood.

OBJECTIVE

The aim of this study was to assess the current literature regarding the efficacy of video-based educational tools for patients in improving process and outcome measures across several chronic illnesses.

METHODS

A systematic review was conducted using CINAHL and PubMed with predefined search terms. The search included studies published through October 2021. The eligible studies were intervention studies of video-based self-management patient education for an adult patient population with the following chronic health conditions: asthma, chronic kidney disease, chronic obstructive pulmonary disease, chronic pain syndromes, diabetes, heart failure, HIV infection, hypertension, inflammatory bowel disease, and rheumatologic disorders. The eligible papers underwent full extraction of study characteristics, study design, sample demographics, and results. Bias was assessed with the Cochrane risk-of-bias tools. Summary statistics were synthesized in Stata SE (StataCorp LLC). Data reporting was conducted per the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist.

RESULTS

Of the 112 studies fully extracted, 59 (52.7%) were deemed eligible for inclusion in this review. The majority of the included papers were superiority randomized controlled trials (RCTs; 39/59, 66%), with fewer pre-post studies (13/59, 22%) and noninferiority RCTs (7/59, 12%). The most represented conditions of interest were obstructive lung disease (18/59, 31%), diabetes (11/59, 19%), and heart failure (9/59, 15%). The plurality (28/59, 47%) of video-based interventions only occurred once and occurred alongside adjunct interventions that included printed materials, in-person counseling, and interactive modules. The most frequently studied outcomes were disease severity, health behavior, and patient knowledge. Video-based tools were the most effective in improving patient knowledge (30/40, 75%). Approximately half reported health behavior (21/38, 56%) and patient self-efficacy (12/23, 52%) outcomes were improved by video-based tools, and a minority of health care use (11/28, 39%) and disease severity (23/69, 33%) outcomes were improved by video-based tools. In total, 48% (22/46) of the superiority and noninferiority RCTs and 54% (7/13) of the pre-post trials had moderate or high risk of bias.

CONCLUSIONS

There is robust evidence that video-based tools can improve patient knowledge across several chronic illnesses. These tools less consistently improve disease severity and health care use outcomes. Additional study is needed to identify features that maximize the efficacy of video-based interventions for patients across the spectrum of digital competencies to ensure optimized and equitable patient education and outcomes.

Student knowledge gains among first-time and repeat attendees of school-based asthma education program

BACKGROUND

Because children spend much of their time in schools, schools can play an important role in asthma education for the one in 12 affected children in the United States. School-based asthma education programs are commonly repeated annually, however few studies have evaluated the impact of repeated participation in asthma education in school-based programs.

METHODS

This observational study evaluated the impact of Fight Asthma Now© (FAN), a school-based asthma education program for children in Illinois schools. Participants completed a survey at the start and end of the program, including demographics, prior asthma education, and 11 asthma knowledge questions (maximum knowledge score = 11).

RESULTS

Among 4,951 youth participating in the school-based asthma education program, mean age was 10.75 years. Approximately half were male and Black. Over half reported no prior asthma education (54.6%). At baseline, repeat attendees had significantly higher knowledge versus first-time attendees (mean: 7.45 versus 5.92; p < 0.001). After the program, both first-time and repeat attendees had significant knowledge improvements (first-time: mean = 5.92◊9.32; p < 0.001; repeat: mean = 7.45◊9.62; p < 0.001).

CONCLUSIONS

School-based asthma education is effective for increasing asthma knowledge. Notably, repeated asthma education in school leads to incremental benefits for knowledge. Future studies are needed to understand the effects of repeated asthma education on morbidity.

Community health workers' perspectives on integrating into school settings to support student health

Introduction

While schools represent key venues for supporting health, they continue to experience gaps in health resources. The integration of community health workers (CHWs) into schools has the potential to supplement these resources but has been underexplored. This study is the first to examine perspectives of experienced CHWs about how CHWs can be applied in school settings to support student health.

Methods

This qualitative study involved conducting semi-structured interviews focused on implementation of CHWs in schools with individuals who held positions aligned with the CHW scope of work. De-identified transcripts were analyzed, and codes were organized into domains and themes.

Results

Among 14 participants, seven domains emerged about the implementation of CHWs in schools: roles and responsibilities, collaborations, steps for integration, characteristics of successful CHWs, training, assessment, and potential challenges. Participants shared various potential responsibilities of school-based CHWs, including educating on health topics, addressing social determinants of health, and supporting chronic disease management. Participants emphasized the importance of CHWs building trusting relationships with the school community and identified internal and external collaborations integral to the success of CHWs. Specifically, participants indicated CHWs and schools should together determine CHWs' responsibilities, familiarize CHWs with the school population, introduce CHWs to the school community, and establish support systems for CHWs. Participants identified key characteristics of school-based CHWs, including having familiarity with the broader community, relevant work experience, essential professional skills, and specific personal qualities. Participants highlighted trainings relevant to school-based CHWs, including CHW core skills and health topics. To assess CHWs' impact, participants proposed utilizing evaluation tools, documenting interactions with students, and observing indicators of success within schools. Participants also identified challenges for school-based CHWs to overcome, including pushback from the school community and difficulties related to the scope of work.

Discussion

This study identified how CHWs can have a valuable role in supporting student health and the findings can help inform models to integrate CHWs to ensure healthy school environments.

Validity of the Childhood Asthma Control Test in diverse populations: A systematic review

PURPOSE

We examined the validity of the Childhood Asthma Control Test (C-ACT) and identified recommended thresholds for uncontrolled asthma in children from varying backgrounds.

METHODS

A systematic literature review was performed utilizing PubMed, Ovid Medline, SCOPUS, CINAHL, and conference proceedings. Studies were included if they enrolled children, had a primary outcome of asthma control, examined test validity or psychometrics, and utilized the C-ACT. Along with study design and demographic data, we extracted all outcomes and comparisons used to validate the C-ACT. We evaluated risk of bias using the COSMIN Risk of Bias tool. Our protocol was registered with PROSPERO (CRD42020211119).

RESULTS

Of 4924 records screened, 28 studies were included. Studies were conducted internationally and published between 2007 and 2018. Average number of enrolled participants was 193 (SD = 155, range = 22-671). Ten studies calculated Cronbach's α (mean [SD] = 0.78(0.05), range = 0.677-0.83). Thirteen studies recommended cut-offs for uncontrolled asthma (≤18-≤24). Nine studies found significant agreement or correlation between C-ACT and Global Initiative for Asthma guidelines/physician assessment of asthma control (correlation coefficients range = 0.219-0.65). Correlation coefficients between C-ACT and spirometry were <0.6 in five of six studies that included spirometry. Kappa values for C-ACT and various spirometry measurements ranged 0.00-0.34.

CONCLUSIONS

The C-ACT showed good internal consistency and mixed levels of agreement and correlation with various clinical asthma measures. Recommended cut-offs for asthma control varied and had no consistent relationship with nationality, race, ethnicity, or language. Few studies examined cross-cultural validity and multiple populations remain under-studied.

Applying Lessons from the COVID-19 Pandemic to Improve Pediatric Asthma Care

Asthma is the most common chronic childhood condition and is a risk factor for severe respiratory viral infections. Thus, early during the coronavirus disease 2019 (COVID-19) pandemic there was concern that children with asthma would be at risk for severe COVID-19 illness and that asthma control could worsen as a result of the pandemic. This article seeks to summarize what was learned in the early stages of the pandemic about the impact of COVID-19 on children with asthma. We review evidence from several studies that demonstrated a significant decline in asthma morbidity in the first year of the pandemic. Additionally, we describe several potential mechanisms that may explain the reduced frequency in childhood asthma exacerbations as well as review lessons learned for future management of childhood asthma. While the COVID-19 pandemic initially brought uncertainty, it soon became clear that the pandemic had several positive effects for children with asthma. Now we can apply the lessons that were learned during the pandemic to re-examine asthma care practices as well as advocate for best approaches for asthma management.

Supporting Breastfeeding Physicians Across the Educational and Professional Continuum: A Call to Action

The benefits of breastmilk and lactation are well established for both infants and women. National organizations recommend exclusively breastfeeding for the first 6 months of life and continued breastfeeding for the first 1-2 years of life. For physicians, childbearing years often coincide with key periods of training and their early career. Physician mothers have high rates of initiating breastfeeding but low success in maintaining breastfeeding. Breastfeeding discontinuation among physicians is a well-described, multifactorial issue that has persisted for decades. Reasons for discontinuation include inadequate access to pumping rooms, insufficient workplace and coworker support, and constrained schedules. Pumping is viewed as a burden to teammates and superiors, and physicians are often required to make up time spent pumping. Vague or absent policies to support breastfeeding by accreditation organizations and institutions create workplace conflict and impose additional stress on breastfeeding physicians, who devote significant time, energy, and mental reserves navigating clinical responsibilities, workplace relationships, and licensing requirements to pump. The authors propose several recommendations to improve the environment, support, and resources for breastfeeding physicians with a focus on what individuals, institutions, and professional organizations can do. Creating lactation policies that allow breastfeeding physicians equitable participation in the workplace is a matter of reproductive justice. Improving the collective awareness and support for breastfeeding trainees and physicians is a critical step in recruiting, retaining, and supporting women in medicine.

Community Health Workers in Schools: A Systematic Review

BACKGROUND

Community health workers (CHWs) are trusted community members who provide health education and care. However, no consensus exists regarding whether community health worker-based interventions are effective within the school setting.

OBJECTIVE

To determine outcomes and best practices of school-based community health worker interventions.

DATA SOURCES

PubMed, CINAHL, and SCOPUS databases.

STUDY ELIGIBILITY CRITERIA

This systematic literature review examined articles that described an intervention led by community health workers, targeted children and/or parents, and took place primarily within a Kindergarten-12th grade school setting. Articles were excluded if they described an intervention outside the United States.

PARTICIPANTS

Community health workers, children, and/or their parents INTERVENTIONS: School-based community health worker programs RESULTS: Of 1875 articles identified, 13 met inclusion criteria and were included in the final analysis. Of these, 5 described a statistically significant primary outcome. Seven articles provided details regarding community health worker recruitment, training, and roles that would enable reproduction of the intervention.

LIMITATIONS

This review focused on interventions in the United States. Bias of individual studies had a wide range of scores (9-21). Heterogeneity of studies also precluded a meta-analysis of primary outcomes.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

The utilization of Community health workers in school-based interventions for children and/or parents is promising. This review identified a lack of detail and uniformity in program presentation, specifically with Community health worker recruitment, training, and roles. A standardized reporting mechanism for Community health worker interventions in schools would better allow for reproducibility and scalability of existing studies.

Appropriate inhaler use in children with asthma: barriers and opportunities through the lens of the socio-ecological model

Objective: Proper use of inhaled medications is essential for management of asthma, as inhaled therapies are recommended as first-line for both prevention and treatment of asthma symptoms. Optimizing adherence requires identifying and understanding multiple layers of systemic complexity to obtaining and using these therapies and offering specific solutions to address these barriers. Bronfenbrenner's socio-ecological model provides a framework for examining multilevel systems - both internal and external - that contribute to the management of childhood asthma. The four levels in this model consist of factors related to the individual, interpersonal relationships, organizational entities, and societal structures and rules. This narrative review identifies influences and factors related to asthma inhaler adherence by each level and offers evidence-based solutions to each obstacle.Data Sources: We conducted PubMed searches to identify relevant articles for barriers and solutions impacting asthma control at each level of the socio-ecological model.Study Selection: Common barriers to asthma control at each model level were identified. Pertinent studies for each barrier were identified and reviewed by the writing group for inclusion into the narrative review.Results: For each level of the socio-ecological model, three primary issues were identified based on the literature review. Approaches for addressing each issue in an evidence-based, systematic fashion are presented.Conclusion: Understanding the obstacles and potential interventions to achieve proper use of inhaled medications is a critical step necessary to develop and implement systematic solutions aimed at improving asthma control and morbidity for the more than 6 million affected children in the United States.

Association Between Resident Race and Ethnicity and Clinical Performance Assessment Scores in Graduate Medical Education

PURPOSE

To assess the association between internal medicine (IM) residents' race/ethnicity and clinical performance assessments.

METHOD

The authors conducted a cross-sectional analysis of clinical performance assessment scores at 6 U.S. IM residency programs from 2016 to 2017. Residents underrepresented in medicine (URiM) were identified using self-reported race/ethnicity. Standardized scores were calculated for Accreditation Council for Graduate Medical Education core competencies. Cross-classified mixed-effects regression assessed the association between race/ethnicity and competency scores, adjusting for rotation time of year and setting; resident gender, postgraduate year, and IM In-Training Examination percentile rank; and faculty gender, rank, and specialty.

RESULTS

Data included 3,600 evaluations by 605 faculty of 703 residents, including 94 (13.4%) URiM residents. Resident race/ethnicity was associated with competency scores, with lower scores for URiM residents (difference in adjusted standardized scores between URiM and non-URiM residents, mean [standard error]) in medical knowledge (-0.123 [0.05], P = .021), systems-based practice (-0.179 [0.05], P = .005), practice-based learning and improvement (-0.112 [0.05], P = .032), professionalism (-0.116 [0.06], P = .036), and interpersonal and communication skills (-0.113 [0.06], P = .044). Translating this to a 1 to 5 scale in 0.5 increments, URiM resident ratings were 0.07 to 0.12 points lower than non-URiM resident ratings in these 5 competencies. The interaction with faculty gender was notable in professionalism (difference between URiM and non-URiM for men faculty -0.199 [0.06] vs women faculty -0.014 [0.07], P = .01) with men more than women faculty rating URiM residents lower than non-URiM residents. Using the 1 to 5 scale, men faculty rated URiM residents 0.13 points lower than non-URiM residents in professionalism.

CONCLUSIONS

Resident race/ethnicity was associated with assessment scores to the disadvantage of URiM residents. This may reflect bias in faculty assessment, effects of a noninclusive learning environment, or structural inequities in assessment.

Association of Gender and Race/Ethnicity with Internal Medicine In-Training Examination Performance in Graduate Medical Education

BACKGROUND

Disparities in objective assessments in graduate medical education such as the In-Training Examination (ITE) that disadvantage women and those self-identifying with race/ethnicities underrepresented in medicine (URiM) are of concern.

OBJECTIVE

Examine ITE trends longitudinally across post-graduate year (PGY) with gender and race/ethnicity.

DESIGN

Longitudinal analysis of resident ITE metrics at 7 internal medicine residency programs, 2014-2019. ITE trends across PGY of women and URiM residents compared to non-URiM men assessed via ANOVA. Those with ITE scores associated with less than 90% probability of passing the American Board of Internal Medicine certification exam (ABIM-CE) were identified and odds of being identified as at-risk between groups were assessed with chi square.

PARTICIPANTS

A total of 689 IM residents, including 330 women and URiM residents (48%).

MAIN MEASURES

ITE score KEY RESULTS: There was a significant difference in ITE score across PGY for women and URiM residents compared to non-URiM men (F_{(2, 1321)} 4.46, p=0.011). Adjusting for program, calendar year, and baseline ITE, women and URiM residents had smaller ITE score gains (adjusted mean change in score between PGY1 and PGY3 (se), non-URiM men 13.1 (0.25) vs women and URiM residents 11.4 (0.28), p<0.001). Women and URiM residents had greater odds of being at potential risk for not passing the ABIM-CE (OR 1.75, 95% CI 1.10 to 2.78) with greatest odds in PGY3 (OR 3.13, 95% CI 1.54 to 6.37).

CONCLUSION

Differences in ITE over training were associated with resident gender and race/ethnicity. Women and URiM residents had smaller ITE score gains across PGY translating into greater odds of potentially being seen as at-risk for not passing the ABIM-CE. Differences in ITE over training may reflect differences in experiences of women and URiM residents during training and may lead to further disparities.

Association between dispensing of low-value oral albuterol and removal from Medicaid preferred drug lists

Background

Oral albuterol has worse efficacy and side effects compared with inhaled albuterol, and thus its use has been discouraged for decades. Drug inclusion or exclusion on formularies have been associated with reductions in low-value care. This study examines dispensing of oral albuterol and inclusion of oral albuterol on state Medicaid drug formularies--Preferred Drug Lists (PDLs). It also evaluates the association between removal of oral albuterol from the PDL and dispensing levels.

Methods

This quasi-experimental study determined oral albuterol inclusion on PDLs and dispensing between 2011 and 2018, using Medicaid program websites and the State Drug Utilization Database. Using a difference-in-differences model, we examine the association between removal of oral albuterol from Arkansas’ Medicaid PDL in 2014 and dispensing of this drug through Medicaid, with Iowa as a control state. The outcome measure was the percent of all albuterol prescriptions that were for oral albuterol.

Results

A total of 28 state Medicaid PDLs included at least one formulation of oral albuterol in 2018. In 2018, 179,446 oral albuterol prescriptions were dispensed to Medicaid beneficiaries nationally. Medicaid programs paid approximately $3.0 million for oral albuterol prescriptions in 2018. Removal of oral albuterol syrup from the Arkansas PDL in March 2014 was associated with a more rapid decline in dispensing compared with Iowa which maintained this medication on their PDL.

Conclusions

Findings suggest that removal of low-value medications, such as oral albuterol, from PDLs may be one avenue by which state Medicaid programs can reduce wasteful spending while improving guideline-based care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07955-x.

School Stock Inhaler Statutes and Regulations in the United States: A Systematic Review

BACKGROUND

Children with asthma should have immediate access to rescue medication. Yet, <15% of children have access to this life-saving drug while at school.

METHODS

A search was conducted in the all states database of Westlaw to identify which the US states, territories, and the District of Columbia have a law for K-12 schools. Terms searched included (inhaler or asthma/s medic!) and school and (prescription or order) from conception to December 2020. Demographic data from states with and without a policy were compared. All policies were examined for the following components: (1) type of law (statute or regulation); (2) type of school (charter, private/parochial or public); (3) training requirements; (4) devices; (5) prescriptive authority/safe harbor; (6) medication requirements; and (7) mandated documentation, reporting and funding.

RESULTS

Our systematic search revealed 15 locations with existing laws. States with a law had a higher percentage of children under 17-years than states without a law (p = .02). Common components described were the applicability to various types of schools, training requirements for those empowered to administer, and civil liability protections for trained school personnel.

CONCLUSIONS

Existing stock inhaler laws differ vastly across the United States that may impact access to stock albuterol for children at their schools.

A National Review of State Laws for Stock Epinephrine in Schools

BACKGROUND

Anaphylaxis is a life-threatening allergic reaction with significant risk for children with allergies. Access to potentially life-saving medication is critical for these children. This review aims to describe state laws and policies guiding stock epinephrine in schools for allergic or anaphylactic events and detail recommendations for best practices.

METHODS

This paper is a comprehensive review of the 50 states and the District of Columbia's (DC) laws and policies for stock epinephrine at schools for children in pre-kindergarten through 12th grade.

RESULTS

All 50 states and DC allow undesignated epinephrine in schools to use for allergic or anaphylactic reactions. A key difference arises in whether states allow (N = 37) or mandate (N = 14) that schools stock epinephrine. States exhibit differences in the body responsible for developing stock epinephrine policy (N = 48), along with stakeholders responsible for developing procedures (N = 30) and implementing them (N = 19). Differences also exist in state epinephrine procurement, administration, training, and liability.

CONCLUSIONS

This review of stock epinephrine laws and policies highlights the significant variation in state legislation despite widespread adoption. Only one-quarter of states mandate that schools have stock epinephrine available for emergency use, underscoring need for a more unified approach with consistent guidelines, comprehensive training, and possible funding for implementation.

Association Of Neighborhood Disadvantage With Racial Disparities In COVID-19 Positivity In Chicago

Racial health inequities exemplified during the COVID-19 crisis have awakened a sense of urgency among public health and policy experts to examine contributing factors. One potential factor includes the socioeconomic disadvantage of racially segregated neighborhoods. This study quantified associations of neighborhood socioeconomic disadvantage in Chicago, Illinois, as measured by the Area Deprivation Index (ADI), with racial disparities in COVID-19 positivity. A retrospective cohort included 16,684 patients tested for COVID-19 at an academic medical center and five community-based testing sites during Chicago's "first wave" (March 12, 2020-June 25, 2020). Patients living in Black majority neighborhoods had two times higher odds of COVID-19 positivity relative to those in White majority neighborhoods. The ADI accounted for 20 percent of the racial disparity; however, COVID-19 positivity remained substantially higher at every decile of the ADI in Black relative to White neighborhoods. The remaining disparities (80 percent) suggest a large, cumulative effect of other structural disadvantages in urban communities of color.

Ensuring Access to Albuterol in Schools: From Policy to Implementation. An Official ATS/AANMA/ALA/NASN Policy Statement

Rationale: For children with asthma, access to quick-relief medications is critical to minimizing morbidity and mortality. An innovative and practical approach to ensure access at school is to maintain a supply of stock albuterol that can be used by any student who experiences respiratory distress. To make this possible, state laws allowing for stock albuterol are needed to improve medication access.

Objectives: To provide policy recommendations and outline steps for passing and implementing stock albuterol laws.

Methods: We assembled a diverse stakeholder group and reviewed guidelines, literature, statutes, regulations, and implementation documents related to school-based medication access. Stakeholders were divided into two groups—legislation and implementation—on the basis of expertise. Each group met virtually to review documents and draft recommendations. Recommendations were compiled and revised in iterative remote meetings with all stakeholders.

Main Results: We offer several recommendations for crafting state legislation and facilitating program implementation. 1) Create a coalition of stakeholders to champion legislation and implement stock albuterol programs. The coalition should include school administrators, school nurses and health personnel, parents, or caregivers of children with asthma, pediatric primary care and subspecialty providers (e.g., pulmonologists/allergists), pharmacists, health department staff, and local/regional/national advocacy organizations. 2) Legislative components critical for effective implementation of stock albuterol programs include specifying that medication can be administered in good faith to any child in respiratory distress, establishing training requirements for school staff, providing immunity from civil liability for staff and prescribers, ensuring pharmacy laws allow prescriptions to be dispensed to schools, and suggesting inhalers with valved holding chambers/spacers for administration. 3) Select an experienced and committed legislator to sponsor legislation and guide revisions as needed during passage and implementation. This person should be from the majority party and serve on the legislature’s health or education committee. 4) Develop plans to disseminate legislation and regulations/policies to affected groups, including school administrators, school nurses, pharmacists, emergency responders, and primary/subspecialty clinicians. Periodically evaluate implementation effectiveness and need for adjustments.

Conclusions: Stock albuterol in schools is a safe, practical, and potentially life-saving option for children with asthma, whether asthma is diagnosed or undiagnosed, who lack access to their personal quick-relief medication. Legislation is imperative for aiding in the adoption and implementation of school stock albuterol policies, and key policy inclusions can lay the groundwork for success. Future work should focus on passing legislation in all states, implementing policy in schools, and evaluating the impact of such programs on academic and health outcomes.

Prescription Drug Dispensing to US Children During the COVID-19 Pandemic

BACKGROUND

After the US coronavirus disease 2019 outbreak, overall prescription dispensing declined but then rebounded. Whether these same trends occurred for children is unknown.

METHODS

Using the IQVIA National Prescription Audit, which contains monthly dispensing counts from 92% of US retail pharmacies, we assessed changes in the monthly number of prescriptions dispensed to US children aged 0 to 19 years during 2018-2020. We compared dispensing totals in April to December 2020 and April to December 2019 overall, by drug class, and among drug classes that typically treat acute infections (eg, antibiotics) or chronic diseases (eg, antidepressants).

RESULTS

Between January 2018 and February 2020, the median monthly number of prescriptions dispensed to children was 25 744 758. Dispensing totals declined from 25 684 219 to 16 742 568 between March and April 2020, increased to 19 657 289 during October 2020, and decreased to 15 821 914 during December 2020. Dispensing totals during April to December 2020 (160 630 406) were 27.1% lower compared with April to December 2019 (220 284 613). Among the 3 drug classes accounting for the most prescriptions in 2019, the corresponding percentage changes were -55.6% for antibiotics, -11.8% for attention-deficit/hyperactivity disorder medications, and 0.1% for antidepressants. Among drug classes that typically treat acute infections and chronic diseases, percentage changes were -51.3% and -17.4%, respectively.

CONCLUSIONS

Prescription dispensing to children declined by one-quarter in April to December 2020 compared with April to December 2019. Declines were greater for infection-related drugs than for chronic disease drugs. Decreased dispensing of the latter is potentially concerning and warrants further investigation. Whether reductions in dispensing of infection-related drugs are temporary or sustained will be important to monitor going forward.

Strategies for Improving Inhalation Technique in Children: A Narrative Review

Inhaled medicines are commonly utilized by children for various respiratory conditions and must be used effectively for the medication to reach the airways. Poor inhaler technique contributes to poorly controlled asthma with significant associated morbidity. Given the significant consequences of improper inhaler use in children, the goal of this review is to comprehensively describe existing and potential solutions to improve inhaler technique. Because children move through various settings, including clinical practices, schools, pharmacies, and homes, in their daily routine, there is great opportunity to teach and reinforce proper inhaler technique across settings. Within each setting, in-person and technology-based interventions have shown promise to improve technique. These solutions need to be more broadly adopted to deliver tailored education with support for provider training, team-based care, communication structures, and reimbursement. Such solutions hold the potential to improve inhaler use among children, with potential for decreasing morbidity and costs.

A National Analysis of State Policies on Lesbian, Gay, Bisexual, Transgender, and Questioning/Queer Inclusive Sex Education

BACKGROUND

Many youth engage in risky sexual behaviors that are associated with adverse sexual health outcomes. Lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ) youth are disproportionately affected. Comprehensive sex education is instrumental to minimize these outcomes; however, each state varies in the topics taught.

METHODS

This paper is a comprehensive review of all 50 states and the District of Columbia's policies, including laws and education standards, for LGBTQ inclusive material in school-based sex education for youth in K-12.

RESULTS

Overall, 48 states have policies that mandate sex education in the public schools. This review describes policy differences relevant to students who identify as LGBTQ, by comparing required topics, parental/guardian permission, LGBTQ inclusion, and normative language requirements.

CONCUSIONS

There is a lack of uniformity and presence of discrimination in school-based sex education policies in the United States, particularly related to LGBTQ topics. Therefore, young people, especially LGBTQ students, face geographical barriers to accessing sexual health information and schools are limited in implementing curriculum essential for students to optimize sexual health outcomes. State policymakers, school administrators, child health advocates, and parents should work to eliminate barriers for comprehensive sex education.

Representation of Women on National Institutes of Health Study Sections

This cross-sectional study examines the proportion of women represented on National Institutes of Health study sections and whether there is an association with research funding levels.

Association between inhaler technique and confidence among hospitalized children with asthma

OBJECTIVE

Proper use of respiratory inhalers is crucial to asthma self-management and associated with improved outcomes. Previous studies conducted in outpatient and community settings show parents and children are overconfident in children's ability to use inhalers properly, which may lead healthcare providers to not teach or review inhaler technique. This study examined whether children and parents' confidence were associated with proper inhaler technique among children hospitalized with asthma.

METHODS

Children between 5 and 10 years old hospitalized with asthma at an urban academic medical center demonstrated inhaler technique using metered dose inhalers and spacers. Technique was scored based on a validated 12-step scale. Confidence was measured using three items assessing 1. Knowledge to use inhaler, 2. Skills to use inhaler, and 3. Ability to independently use inhaler. These items were five-point scales and analyzed as binary variables. Independent t-tests were used to measure associations between confidence and number of steps performed correctly.

RESULTS

None of the confidence items, when asked to parents or children (n = 70), were associated with the number of steps performed correctly. Further, while the majority of children and parents (59-70%) were confident based on each item, the mean number of steps correctly completed was 6.4 out of 12.

CONCLUSIONS

Children and parents' confidence in children's knowledge, skills, and ability to independently use an inhaler were all poor proxies for proper inhaler technique. Inpatient healthcare professionals should objectively evaluate technique and teach proper inhaler use to all children with asthma to optimize outcomes.

Association of Gender With Learner Assessment in Graduate Medical Education

IMPORTANCE

Gender bias may affect assessment in competency-based medical education.

OBJECTIVE

To evaluate the association of gender with assessment of internal medicine residents.

DESIGN, SETTING, AND PARTICIPANTS

This multisite, retrospective, cross-sectional study included 6 internal medicine residency programs in the United States. Data were collected from July 1, 2016, to June 30, 2017, and analyzed from June 7 to November 6, 2019.

EXPOSURES

Faculty assessments of resident performance during general medicine inpatient rotations.

MAIN OUTCOMES AND MEASURES

Standardized scores were calculated based on rating distributions for the Accreditation Council for Graduate Medical Education's core competencies and internal medicine Milestones at each site. Standardized scores are expressed as SDs from the mean. The interaction of gender and postgraduate year (PGY) with standardized scores was assessed, adjusting for site, time of year, resident In-Training Examination percentile rank, and faculty rank and specialty.

RESULTS

Data included 3600 evaluations for 703 residents (387 male [55.0%]) by 605 faculty (318 male [52.6%]). Interaction between resident gender and PGY was significant in 6 core competencies. In PGY2, female residents scored significantly higher than male residents in 4 of 6 competencies, including patient care (mean standardized score [SE], 0.10 [0.04] vs 0.22 [0.05]; P = .04), systems-based practice (mean standardized score [SE], -0.06 [0.05] vs 0.13 [0.05]; P = .003), professionalism (mean standardized score [SE], -0.04 [0.06] vs 0.21 [0.06]; P = .001), and interpersonal and communication skills (mean standardized score [SE], 0.06 [0.05] vs 0.32 [0.06]; P < .001). In PGY3, male residents scored significantly higher than female patients in 5 of 6 competencies, including patient care (mean standardized score [SE], 0.47 [0.05] vs 0.32 [0.05]; P = .03), medical knowledge (mean standardized score [SE], 0.47 [0.05] vs 0.24 [0.06]; P = .003), systems-based practice (mean standardized score [SE], 0.30 [0.05] vs 0.12 [0.06]; P = .02), practice-based learning (mean standardized score [SE], 0.39 [0.05] vs 0.16 [0.06]; P = .004), and professionalism (mean standardized score [SE], 0.35 [0.05] vs 0.18 [0.06]; P = .03). There was a significant increase in male residents' competency scores between PGY2 and PGY3 (range of difference in mean adjusted standardized scores between PGY2 and PGY3, 0.208-0.391; P ≤ .002) that was not seen in female residents' scores (range of difference in mean adjusted standardized scores between PGY2 and PGY3, -0.117 to 0.101; P ≥ .14). There was a significant increase in male residents' scores between PGY2 and PGY3 cohorts in 6 competencies with female faculty and in 4 competencies with male faculty. There was no significant change in female residents' competency scores between PGY2 to PGY3 cohorts with male or female faculty. Interaction between faculty-resident gender dyad and PGY was significant in the patient care competency (β estimate [SE] for female vs male dyad in PGY1 vs PGY3, 0.184 [0.158]; β estimate [SE] for female vs male dyad in PGY2 vs PGY3, 0.457 [0.181]; P = .04).

CONCLUSIONS AND RELEVANCE

In this study, resident gender was associated with differences in faculty assessments of resident performance, and differences were linked to PGY. In contrast to male residents' scores, female residents' scores displayed a peak-and-plateau pattern whereby assessment scores peaked in PGY2. Notably, the peak-and-plateau pattern was seen in assessments by male and female faculty. Further study of factors that influence gender-based differences in assessment is needed.

What can be done to impact respiratory inhaler misuse: exploring the problem, reasons, and solutions

INTRODUCTION

Respiratory inhalers, when used correctly, provide critical treatments for managing pulmonary conditions. However, many patients misuse inhalers, negatively affecting disease control, quality of life, healthcare utilization, and costs. Numerous factors are associated with misuse and are nested within four levels of influence: individual, interpersonal, organizational/institutional, and policy.

AREAS COVERED

This review analyzed published literature and identified the most salient factors at each socio-ecological framework level. English language articles from any year were identified from PubMed, Google Scholar, and Embase databases. Misuse exists across clinical settings, patient populations, and device types. Several potential solutions are highlighted. Published interventions to improve inhaler technique have utilized handouts, in-person, virtual, and biofeedback approaches both inside and outside of healthcare settings with varied effectiveness. However, some interventions have superior effectiveness for improving technique and reducing acute care utilization.

EXPERT OPINION

To robustly address inhaler misuse, future solutions should focus on multi-level approaches to account for the myriad of factors contributing to inhaler misuse. Solutions should also streamline inhaler equipment, identify innovative technology-based solutions, support collaborations across healthcare and non-healthcare settings, and ensure reimbursement to healthcare professionals for inhaler education. Rigorous research studies must be funded and supported to identify and disseminate solutions.

Pediatric Orphan Drug Indications: 2010-2018

BACKGROUND

Orphan drug development is crucial for children, who are disproportionately affected by rare diseases. Data are lacking on the number, nature, and benefit of recently approved pediatric orphan indications.

METHODS

We classified the 402 orphan indications the US Food and Drug Administration approved between 2010 and 2018 as "pediatric" if they were approved for children only or targeted pediatric diseases. We determined the number of unique diseases targeted by pediatric orphan indications and calculated the proportion that were for (1) novel drugs, (2) non-novel drugs approved to treat ≥1 common disease, and (3) non-novel drugs approved only to treat rare diseases. Among pediatric orphan indications eligible for US Food and Drug Administration breakthrough designation (granted to drugs potentially representing major therapeutic advances), we calculated the proportion receiving this designation.

RESULTS

Of the 402 orphan indications, 136 (33.8%) were pediatric. These 136 indications targeted 87 unique diseases; 21 diseases were targeted by ≥1 indication. Of the 136 pediatric orphan indications, 60 (44.1%) were for novel drugs, 45 (33.1%) were for non-novel drugs approved to treat ≥1 common disease, and 31 (22.8%) were for non-novel drugs approved only to treat rare diseases. Among 97 indications eligible for breakthrough designation, 20 (20.6%) received this designation.

CONCLUSIONS

Recent orphan drug development has increased the availability of treatments for pediatric rare diseases. Most pediatric orphan indications expanded use of existing drugs, and many targeted the same disease. Some indications may represent breakthroughs, but substantial unmet need for treatments remains for most pediatric rare diseases.

Parental quality of life and self-efficacy in pediatric asthma

Objective: Self-efficacy is the personal belief that a behavior can produce a desired result; and in asthma, self-efficacy in asthma care has been related to improvements in asthma outcomes and children's quality of life. To appreciate the full burden of asthma on families, the relationship between parental self-efficacy and quality of life also needs further study. We aim to characterize this relationship.Methods: Secondary analysis of measurements of parents of children with persistent asthma (n = 252; ages 4-17 years) from a large urban area were identified from a randomized trial; the association between baseline assessments of parental quality of life, measured by the Pediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ), and parental self-efficacy, measured through the Parental Asthma Management Self-Efficacy Scale (PAMSES), were examined through multivariable linear regression.Results: Parental self-efficacy in asthma was positively associated with quality of life among parents of racially and ethnically diverse children (p = 0.01). Confidence in using medications correctly (p = 0.03), having inhalers during a child's serious breathing problem (p = 0.02), and knowing which medications to use during a child's serious breathing problem (p = 0.04) were associated with a clinically meaningful difference in parental quality of life. Other significant factors associated with parental quality of life included Hispanic/Latino ethnicity (p < 0.01) of the child and Asthma Control Test scores (p < 0.01).Conclusion: The findings suggest that improving parental confidence on when and how to use their child's asthma medications, particularly during an asthma attack, might be clinically meaningful in enhancing parent's quality of life.

Differences in the Receipt of Low-Value Services Between Publicly and Privately Insured Children

BACKGROUND

Children frequently receive low-value services that do not improve health, but it is unknown whether the receipt of these services differs between publicly and privately insured children.

METHODS

We analyzed 2013-2014 Medicaid Analytic eXtract and IBM MarketScan Commercial Claims and Encounters databases. Using 20 measures of low-value care (6 diagnostic testing measures, 5 imaging measures, and 9 prescription drug measures), we compared the proportion of publicly and privately insured children in 12 states who received low-value services at least once or twice in 2014; the proportion of publicly and privately insured children who received low-value diagnostic tests, imaging tests, and prescription drugs at least once; and the proportion of publicly and privately insured children eligible for each measure who received the service at least once.

RESULTS

Among 6 951 556 publicly insured children and 1 647 946 privately insured children, respectively, 11.0% and 8.9% received low-value services at least once, 3.9% and 2.8% received low-value services at least twice, 3.2% and 3.8% received low-value diagnostic tests at least once, 0.4% and 0.4% received low-value imaging tests at least once, and 8.4% and 5.5% received low-value prescription drug services at least once. Differences in the proportion of eligible children receiving each service were typically small (median difference among 20 measures, public minus private: +0.3 percentage points).

CONCLUSIONS

In 2014, 1 in 9 publicly insured and 1 in 11 privately insured children received low-value services. Differences between populations were modest overall, suggesting that wasteful care is not highly associated with payer type. Efforts to reduce this care should target all populations regardless of payer mix.

Supporting New Physicians and New Parents: A Call to Create a Standard Parental Leave Policy for Residents

Parents taking leave after the birth of a child is associated with significant benefits for infants, mothers, and fathers. Although nearly 40% of residents have or plan to have children during residency, there is no standard parental leave policy for these trainees. In this Perspective, the authors discuss the benefits of parental leave, synthesize findings about maternity bias and other negative effects of the current variable approaches to parental leave during residency, and explore underlying causes of the lack of a standard parental leave policy for residents. They also call on the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties to work together to address this issue, recommending a standard parental leave policy that ensures a minimum of 8 weeks of paid leave for all residents without requiring them to extend training or making them ineligible to sit for board certification exams. Creating evidence-based and family-friendly guidelines for parental leave is important to the progress of academic medicine in the modern era, as it supports parental and child health, promotes resident wellness, and reduces gender disparities in medicine to the benefit of all.

A pilot study of team-based learning in one-hour pediatrics residency conferences

BACKGROUND

Active learning has been shown to improve knowledge retention, facilitate feedback, and motivate learners. Despite this evidence, lecture, a passive mode of instruction, is the most widely utilized instructional method for residency educational conferences. Team-based learning fosters active learning but is infrequently used during residency training.

METHODS

Three team-based learning sessions (one introductory and two content-based) were held during noon conferences in a pediatrics residency program. A pre-post static-group design was used to evaluate learner satisfaction and knowledge gains. Additional data was collected about facilitator preparation, session attendance, and readiness assurance test scores. Descriptive statistics and qualitative content analyses were conducted.

RESULTS

Forty-seven residents and students participated (81%, 47 of 58). Prior to the introductory session, the majority of participants (55%) were not familiar with team-based learning. After the three sessions, 65% of residents and students reported high levels of satisfaction with team-based learning. When compared to traditional, lecture-based noon conferences, 76% of participants reported more engagement and 48% perceived more learning in team-based learning sessions. Challenges included low completion rates of the assigned reading prior to the session and abridged discussions due to time limitations during sessions. Each session required 10 hours of preparation for curriculum development.

CONCLUSIONS

Team-based learning resulted in greater satisfaction and engagement among learners when compared to lecture-based formats. However, it did not prove to be a feasible instructional method during one-hour residency conferences. Adaptations that promote learner preparation for sessions and overcome time limitations during sessions may improve the feasibility and impact of team-based learning during one-hour conferences.

TRIAL REGISTRATION

Not applicable.

A Mixed-methods Study Examining Inhaler Carry and Use among Children at School

Objective: Asthma self-management depends partly on access to inhalers; for children, this includes independent inhaler carry and use at school ("self-carry"). Although laws and policies support self-carry, little is known about practices within schools. This study aimed to identify factors associated with inhaler self-carry among children and examine barriers and facilitators to self-carry.Methods: This mixed-methods observational study included child-parent dyads and nurses from four Chicago schools. Children and parents answered questions about asthma care and morbidity, confidence in self-carry skills, and facilitators and barriers to self-carry. Nurses reported asthma documentation on file and their confidence in children's self-carry skills. Analysis utilized logistic regression. Thematic analysis was performed for open-ended questions.Results: Of 65 children enrolled (mean = 10.66 years), 45 (69.2%) reported having quick-relief medication at school, primarily inhalers, and 35 (53.8%) reported self-carry. Inhaler self-carry was associated with controller medication use and parent confidence in child's self-carry skills. Children and parents identified several facilitators to self-carry: child's asthma knowledge, inhaler characteristics, and need for easy inhaler access. Barriers included child's limited understanding of asthma and inhalers, perception that inhaler is not needed, and limited inhaler access. Children also emphasized social relationships as facilitators and barriers, while parents described children's responsibility as a facilitator and inconsistent policy implementation as a barrier.Conclusions: Efforts to improve inhaler self-carry at school should focus on educating children about asthma and inhaler use, creating supportive environments for self-carry among peers and teachers, and fostering consistent implementation and communication about asthma policy among schools and families.