Adverse Social Determinants of Health and Gaps in Care Coordination Among Children

Gaps in care coordination (CC) can have detrimental impacts on children's health. It is unclear how much adverse social determinants of health (SDoH) may affect CC gaps. We determined whether exposure to adverse SDoH is associated with experiencing more gaps in CC using a representative national sample of children. Children with inadequate or no health insurance (adjusted odds ratio [aOR] = 2.41; 95% confidence interval [CI], 2.19-2.66) and living in disadvantaged neighborhoods (aOR = 1.53; 95% CI, 1.33-1.75) have a higher likelihood of having gaps in CC, as do those with higher counts of adverse SDoH (aOR = 2.17; 95% CI, 1.85-2.53). Thus, interventions to improve CC for children should consider adverse SDoH.

Using an experiential learning model to teach clinical reasoning theory and cognitive bias: an evaluation of a first-year medical student curriculum

BACKGROUND

Most medical students entering clerkships have limited understanding of clinical reasoning concepts. The value of teaching theories of clinical reasoning and cognitive biases to first-year medical students is unknown. This study aimed to evaluate the value of explicitly teaching clinical reasoning theory and cognitive bias to first-year medical students.

METHODS

Using Kolb's experiential learning model, we introduced dual process theory, script theory, and cognitive biases in teaching clinical reasoning to first-year medical students at an academic medical center in New York City between January and June 2020. Due to the COVID-19 pandemic, instruction was transitioned to a distance learning format in March 2020. The curriculum included a series of written clinical reasoning examinations with facilitated small group discussions. Written self-assessments prompted each student to reflect on the experience, draw conclusions about their clinical reasoning, and plan for future encounters involving clinical reasoning. We evaluated the value of the curriculum using mixed-methods to analyze faculty assessments, student self-assessment questionnaires, and an end-of-curriculum anonymous questionnaire eliciting student feedback.

RESULTS

Among 318 total examinations of 106 students, 254 (80%) had a complete problem representation, while 199 (63%) of problem representations were considered concise. The most common cognitive biases described by students in their clinical reasoning were anchoring bias, availability bias, and premature closure. Four major themes emerged as valuable outcomes of the CREs as identified by students: (1) synthesis of medical knowledge; (2) enhanced ability to generate differential diagnoses; (3) development of self-efficacy related to clinical reasoning; (4) raised awareness of personal cognitive biases.

CONCLUSIONS

We found that explicitly teaching clinical reasoning theory and cognitive biases using an experiential learning model provides first-year medical students with valuable opportunities for developing knowledge, skills, and self-efficacy related to clinical reasoning.

Pediatric Mental Health Emergencies During 5 COVID-19 Waves in New York City

OBJECTIVES

To describe the proportion of pediatric mental health emergency department (MH-ED) visits across 5 COVID-19 waves in New York City (NYC) and to examine the relationship between MH-ED visits, COVID-19 prevalence, and societal restrictions.

METHODS

We conducted a time-series analysis of MH-ED visits among patients ages 5 to 17 years using the INSIGHT Clinical Research Network, a database from 5 medical centers in NYC from January 1, 2016, to June 12, 2022. We estimated seasonally adjusted changes in MH-ED visit rates during the COVID-19 pandemic, compared with predicted prepandemic levels, specific to each COVID-19 wave and stratified by mental health diagnoses and sociodemographic characteristics. We estimated associations between MH-ED visit rates, COVID-19 prevalence, and societal restrictions measured by the Stringency Index.

RESULTS

Of 686 500 ED visits in the cohort, 27 168 (4.0%) were MH-ED visits. The proportion of MH-ED visits was higher during each COVID-19 wave compared with predicted prepandemic trends. Increased MH-ED visits were seen for eating disorders across all waves; anxiety disorders in all except wave 3; depressive disorders and suicidality/self-harm in wave 2; and substance use disorders in waves 2, 4, and 5. MH-ED visits were increased from expected among female, adolescent, Asian race, high Child Opportunity Index patients. There was no association between MH-ED visits and NYC COVID-19 prevalence or NY State Stringency Index.

CONCLUSIONS

The proportion of pediatric MH-ED visits during the COVID-19 pandemic was higher during each wave compared with the predicted prepandemic period, with varied increases among diagnostic and sociodemographic subgroups. Enhanced pediatric mental health resources are essential to address these findings.

Assessing Usability and Ambulatory Clinical Staff Satisfaction with Two Electronic Health Records

BACKGROUND

A growing body of literature has linked usability limitations within electronic health records (EHRs) to adverse outcomes which may in turn affect EHR system transitions. NewYork-Presbyterian Hospital, Columbia University College of Physicians and Surgeons (CU), and Weill Cornell Medical College (WC) are a tripartite organization with large academic medical centers that initiated a phased transition of their EHRs to one system, EpicCare.

OBJECTIVES

This article characterizes usability perceptions stratified by provider roles by surveying WC ambulatory clinical staff already utilizing EpicCare and CU ambulatory clinical staff utilizing iterations of Allscripts before the implementation of EpicCare campus-wide.

METHODS

A customized 19-question electronic survey utilizing usability constructs based on the Health Information Technology Usability Evaluation Scale was anonymously administered prior to EHR transition. Responses were recorded with self-reported demographics.

RESULTS

A total of 1,666 CU and 1,065 WC staff with ambulatory self-identified work setting were chosen. Select demographic statistics between campus staff were generally similar with small differences in patterns of clinical and EHR experience. Results demonstrated significant differences in EHR usability perceptions among ambulatory staff based on role and EHR system. WC staff utilizing EpicCare accounted for more favorable usability metrics than CU across all constructs. Ordering providers (OPs) denoted less usability than non-OPs. The Perceived Usefulness and User Control constructs accounted for the largest differences in usability perceptions. The Cognitive Support and Situational Awareness construct was similarly low for both campuses. Prior EHR experience demonstrated limited associations.

CONCLUSION

Usability perceptions can be affected by role and EHR system. OPs consistently denoted less usability overall and were more affected by EHR system than non-OPs. While there was greater perceived usability for EpicCare to perform tasks related to care coordination, documentation, and error prevention, there were persistent shortcomings regarding tab navigation and cognitive burden reduction, which have implications on provider efficiency and wellness.

Cost-Effectiveness of Smoking Cessation Interventions in Patients With Ischemic Stroke and Transient Ischemic Attack

BACKGROUND

Smoking cessation rates after stroke and transient ischemic attack are suboptimal, and smoking cessation interventions are underutilized. We performed a cost-effectiveness analysis of smoking cessation interventions in this population.

METHODS

We constructed a decision tree and used Markov models that aimed to assess the cost-effectiveness of varenicline, any pharmacotherapy with intensive counseling, and monetary incentives, compared with brief counseling alone in the secondary stroke prevention setting. Payer and societal costs of interventions and outcomes were modeled. The outcomes were recurrent stroke, myocardial infarction, and death using a lifetime horizon. Estimates and variance for the base case (35% cessation), costs and effectiveness of interventions, and outcome rates were imputed from the stroke literature. We calculated incremental cost-effectiveness ratios and incremental net monetary benefits. An intervention was considered cost-effective if the incremental cost-effectiveness ratio was less than the willingness-to-pay threshold of $100 000 per quality-adjusted life-year (QALY) or when the incremental net monetary benefit was positive. Probabilistic Monte Carlo simulations modeled the impact of parameter uncertainty.

RESULTS

From the payer perspective, varenicline and pharmacotherapy with intensive counseling were associated with more QALYs (0.67 and 1.00, respectively) at less total lifetime costs compared with brief counseling alone. Monetary incentives were associated with 0.71 more QALYs at an additional cost of $120 compared with brief counseling alone, yielding an incremental cost-effectiveness ratio of $168/QALY. From the societal perspective, all 3 interventions provided more QALYs at less total costs compared with brief counseling alone. In 10 000 Monte Carlo simulations, all 3 smoking cessation interventions were cost-effective in >89% of runs.

CONCLUSIONS

For secondary stroke prevention, it is cost-effective and potentially cost-saving to deliver smoking cessation therapy beyond brief counseling alone.

COVID-19 is Observed in Older Children During the Omicron Wave in New York City

BACKGROUND

The Omicron variant of SARS-CoV-2 has a predilection for the upper airways, causing symptoms such as sore throat, hoarse voice, and stridor.

OBJECTIVE

We describe a series of children with COVID-19-associated croup in an urban multicenter hospital system.

METHODS

We conducted a cross-sectional study of children ≤18 years of age presenting to the emergency department during the COVID-19 pandemic. Data were extracted from an institutional data repository comprised of all patients who were tested for SARS-CoV-2. We included patients with a croup diagnosis by International Classification of Diseases, 10th revision code and a positive SARS-CoV-2 test within 3 days of presentation. We compared demographics, clinical characteristics, and outcomes for patients presenting during a pre-Omicron period (March 1, 2020-December 1, 2021) to the Omicron wave (December 2, 2021-February 15, 2022).

RESULTS

We identified 67 children with croup, 10 (15%) pre-Omicron and 57 (85%) during the Omicron wave. The prevalence of croup among SARS-CoV-2-positive children increased by a factor of 5.8 (95% confidence interval 3.0-11.4) during the Omicron wave compared to prior. More patients were ≥6 years of age in the Omicron wave than prior (19% vs. 0%). The majority were not hospitalized (77%). More patients ≥6 years of age received epinephrine therapy for croup during the Omicron wave (73% vs. 35%). Most patients ≥6 years of age had no croup history (64%) and only 45% were vaccinated against SARS-CoV-2.

CONCLUSION

Croup was prevalent during the Omicron wave, atypically affecting patients ≥6 years of age. COVID-19-associated croup should be added to the differential diagnosis of children with stridor, regardless of age. © 2022 Elsevier Inc.

An Instrument for Measuring Critical Appraisal Self-Efficacy in Rheumatology Trainees

OBJECTIVE

Self-efficacy, the internal belief that one can perform a specific task successfully, influences behavior. To promote critical appraisal of medical literature, rheumatology training programs should foster both competence and self-efficacy for critical appraisal. This study aimed to investigate whether select items from the Clinical Research Appraisal Inventory (CRAI), an instrument measuring clinical research self-efficacy, could be used to measure critical appraisal self-efficacy (CASE).

METHODS

One hundred twenty-five trainees from 33 rheumatology programs were sent a questionnaire that included two sections of the CRAI. Six CRAI items relevant to CASE were identified a priori; responses generated a CASE score (total score range 0-10; higher = greater confidence in one's ability to perform a specific task successfully). CASE scores' internal structure and relation to domain-concordant variables were analyzed.

RESULTS

Questionnaires were completed by 112 of 125 (89.6%) trainees. CASE scores ranged from 0.5 to 8.2. The six CRAI items contributing to the CASE score demonstrated high internal consistency (Cronbach's α = 0.95) and unidimensionality. Criterion validity was supported by the findings that participants with higher CASE scores rated their epidemiology and biostatistics understanding higher than that of peers (P < 0.0001) and were more likely to report referring to studies to answer clinical questions (odds ratio 2.47, 95% confidence interval 1.41-4.33; P = 0.002). The correlation of CASE scores with percentage of questions answered correctly was only moderate, supporting discriminant validity.

CONCLUSION

The six-item CASE instrument demonstrated content validity, internal consistency, discriminative capability, and criterion validity, including correlation with self-reported behavior, supporting its potential as a useful measure of critical appraisal self-efficacy.

COVID-19 Pandemic Impact on Pediatricians Entering the Pediatric Workforce

OBJECTIVE

Determine extent of impact of coronavirus disease 2019 (COVID-19) pandemic on career choice and employment of pediatricians entering pediatric workforce.

METHODS

A national, cross-sectional electronic survey of pediatricians registering for the 2021 American Board of Pediatrics initial general certifying examination on the impact of the COVID-19 pandemic on 3 aspects of career (career choice, employment search, employment offers) was performed. Data were analyzed using descriptive statistics and multivariate logistic regression to determine factors associated with the pandemic's impact on career. Thematic analysis was used to generate themes for open-ended survey questions.

RESULTS

Over half (52.3%, 1767 of 3380) of pediatricians responded. Overall, 29.1% reported that the pandemic impacted their career (career choice [10.4%], employment search [15.6%], or employment offers [19.0%]); applicants to general pediatrics (GP) (52.9%) or pediatric hospitalist (PH) positions (49.3%) were most affected. Multivariate logistic regression modeling found those applying to GP (odds ratio [OR]: 3.83, 95% confidence interval [CI]: 2.22-6.60), PH (OR: 9.02, 95% CI: 5.60-14.52), and International Medical Graduates (IMGs) (OR: 1.90; 95% CI: 1.39-2.59) most likely to experience any career impact.

CONCLUSIONS

Almost one third of pediatricians registering for the initial general pediatrics certifying examination reported their careers were impacted by the COVID-19 pandemic, with 10% of respondents reporting the pandemic impacted their career choice. Half of new pediatricians seeking employment reported being impacted by the pandemic, particularly IMGs. As the pandemic evolves, career advising will continue to be critical to support trainees in their career choices and employment.

The Early Effects of the COVID-19 Pandemic on Pediatric Resident Education: A National Assessment

PURPOSE

Residency programs must ensure resident competence for independent practice. The COVID-19 pandemic disrupted healthcare delivery, impacting pediatric residencies. This study examines the impact on pediatric resident education.

METHODS

The authors conducted a mixed methods national survey of pediatric residency program directors (PDs) from May- July 2020. Data analysis included descriptive statistics, χ², Wilcox rank sum tests. Multivariable modeling identified factors associated with resident preparation for more senior roles. Thematic analysis was performed on open-ended questions about PD COVID-19 pandemic recommendations to peers, Accreditation Council for Graduate Medical Education and American Board of Pediatrics.

RESULTS

Response rate was 55% (110/199). PDs reported the COVID-19 pandemic negatively affected inpatient (n= 86, 78.2%), and outpatient education (n=104, 94.5%), procedural competence (n=64; 58.2%), and resident preparation for more senior roles (n= 50, 45.5%). In bivariate analyses, increasingly negative impacts on inpatient and outpatient education were associated with an increasingly negative impact on resident preparation for more senior roles (p=0.03, p=0.008), these relationships held true in multivariable analysis. Qualitative analysis identified 4 themes from PD recommendations: 1) Clear communication from governing bodies and other leaders; 2) Flexibility within programs and from governing bodies; 3) Clinical exposure is key for competency development; 4) Online platforms are important for education, communication, and support.

CONCLUSIONS

The COVID-19 pandemic negatively impacted inpatient and outpatient education. When these were more negatively impacted, resident preparation for more senior roles was worse. Highlighting the importance of competency based medical education to tailor experiences ensuring each resident is competent for independent practice.

WHAT'S NEW

The COVID-19 pandemic negatively impacted inpatient and outpatient clinical education which negatively impacted resident preparation for more senior roles. This highlights the importance of competency based medical education to ensure each graduating resident is competent for independent practice.

Indications for Hospitalization in Children with SARS-CoV-2 Infection during the Omicron Wave in New York City

The emergence of the Omicron variant was accompanied by an acute increase in COVID-19 cases and hospitalizations in New York City. An increased incidence of COVID-19-associated croup in children during the Omicron wave has been recognized, suggesting that there may be other changes in clinical symptoms and severity. To better understand clinical outcomes and health care utilization in children infected with SARS-CoV-2 during the Omicron wave, we performed a cross-sectional study in pediatric patients aged ≤18 years who were tested for SARS-CoV-2 in pediatric emergency departments within a large medical system in New York City from 2 December 2021 to 23 January 2022. We described the clinical characteristics and outcomes of pediatric patients who presented to the pediatric emergency department and were hospitalized with SARS-CoV-2 infection during the Omicron wave in New York City. There were 2515 children tested in the ED for SARS-CoV-2 of whom 794 (31.6%) tested positive. Fifty-eight children were hospitalized for a COVID-19-related indication, representing 7.3% of all COVID-19-positive children and 72% of hospitalized COVID-19-positive children. Most (64%) children hospitalized for a COVID-19-related indication were less than 5 years old. Indications for hospitalization included respiratory symptoms, clinical monitoring of patients with comorbid conditions, and exacerbations of underlying disease. Eleven (19%) hospitalized children were admitted to the ICU and six (10%) required mechanical ventilation. Children infected with COVID-19 during the Omicron wave, particularly those less than 5 years old, were at risk for hospitalization. A majority of hospitalizations were directly related to COVID-19 infection although clinical indications varied with less than a half being admitted for respiratory diseases including croup. Our findings underscore the need for an effective COVID-19 vaccine in those less than 5 years old, continued monitoring for changes in clinical outcomes and health care utilization in children as more SARS-CoV-2 variants emerge, and understanding that children are often admitted for non-respiratory diseases with COVID-19.

Students as Community Vaccinators: Implementation of A Service-Learning COVID-19 Vaccination Program

While the COVID-19 pandemic has caused major educational disruptions, it has also catalyzed innovation in service-learning as a real-time response to pandemic-related problems. The limited number of qualified providers was primed to restrict SARS-CoV-2 vaccination efforts. Thus, New York State temporarily allowed healthcare professional trainees to vaccinate, enabling medical students to support an overwhelmed healthcare system and contribute to the public health crisis. Here, we describe a service-learning vaccination program directed towards underserved communities. A faculty-led curriculum prepared medical students to communicate with patients about COVID-19 vaccines and to administer intramuscular injections. Qualified students were deployed to public vaccination clinics located in under-served neighborhoods in collaboration with an established community partner. Throughout the program, 128 students worked at 103 local events, helping to administer 26,889 vaccine doses. Analysis of a retrospective survey administered to participants revealed the program taught fundamental clinical skills and was a transformative service-learning experience. As new virus variants emerge and nations battle recurrent waves of infection, the need for effective vaccination plans continues to grow. The program described here offers a novel framework that academic medical centers could adapt to increase vaccine access in their local community and provide students with a uniquely meaningful educational experience.

Scholarly activity training in pediatric pulmonology fellowship programs

BACKGROUND

Scholarly activity training is a required component of pediatric pulmonology fellowship programs. However, there are no data on resources and barriers to training and factors associated with fellow productivity.

METHODS

We surveyed US pediatric pulmonology fellowship program directors (FPDs) between March and October 2019. Our primary outcome was fellow productivity (>75% of fellows in the past 5 years had a manuscript accepted in a peer-reviewed journal). Analyses included descriptive statistics, χ² and Fisher's exact tests for categorical values, and t-test or Wilcoxon rank-sum test for numerical values.

RESULTS

Sixty-one percent (33/54) of FPDs completed the survey. Seventy-nine percent reported that most fellows completed clinical, basic science, or translational research. However, only 21% reported that most fellows pursued research positions after graduation; academic clinical positions were more common. For 21%, lack of funding and competing clinical responsibilities were barriers to completing the scholarly activity. Only 39% had highly productive programs; those FPDs were more likely to be highly satisfied with fellow scholarly activity products (p = 0.049) and have >6 publications in the previous 3 years (p = 0.03). Fifty-two percent of FPDs believed that pediatric pulmonary training should be shortened to 2 years for those pursuing clinical or clinician-educator careers.

CONCLUSIONS

Barriers to scholarly activity training in pediatric pulmonology programs threaten the pipeline of academic pediatric pulmonologists and physician-investigators. Aligning fellow scholarly activity and clinical training with the skills required in their postgraduate positions could optimize the utilization of limited resources and better support career development.

Transitioning preclinical students into clerkships amidst curricular disruptions from the COVID-19 pandemic

The COVID-19 pandemic resulted in significant disruptions to medical education. The patient care space was unavailable as a learning environment, which compounded the complexity of preparing students for clerkships with a traditional transition to clerkship (TTC) curriculum. We developed a multimodal, structured approach to re-introduce students to the clinical space prior to the start of clerkships. 105 second year medical students completed a 4-week clinical enhancement course. A modified Delphi method was used to select core topics, which were then anchored to key Entrustable Professional Activities (EPAs). Students participated in 9 virtual problem-based cases, workshops and multiple supervised patient encounters. Students were surveyed before, during, and after the course; responses were compared with paired t-tests. 25.9% rated the course as excellent, 44.2% as very good, and 19.5% as good. Compared to baseline, self-perceived efficacy grew significantly (P < 0.05) across all EPAs. Improvements in key competencies were sustained when students were surveyed 2 weeks into their first clerkship. This was a well-received, novel course, focused on helping students transition back into the clinical space through a multimodal teaching approach. This framework may be used by other institutions seeking to restructure their TTC initiatives.

Factorial Analysis Quantifies the Effects of Pediatric Discharge Bundle on Hospital Readmission

BACKGROUND AND OBJECTIVES

Factorial design of a natural experiment was used to quantify the benefit of individual and combined bundle elements from a 4-element discharge transition bundle (checklist, teach-back, handoff to outpatient providers, and postdischarge phone call) on 30-day readmission rates (RRs).

METHODS

A 2⁴ factorial design matrix of 4 bundle element combinations was developed by using patient data (N = 7725) collected from January 2014 to December 2017 from 4 hospitals. Patients were classified into 3 clinical risk groups (CRGs): no chronic disease (CRG1), single chronic condition (CRG2), and complex chronic condition (CRG3). Estimated main effects of each bundle element and their interactions were evaluated by using Study-It software. Because of variation in subgroup size, important effects from the factorial analysis were determined by using weighted effect estimates.

RESULTS

RR in CRG1 was 3.5% (n = 4003), 4.1% in CRG2 (n = 1936), and 17.6% in CRG3 (n = 1786). Across the 3 CRGs, the number of subjects in the factorial groupings ranged from 16 to 674. The single most effective element in reducing RR was the checklist in CRG1 and CRG2 (reducing RR by 1.3% and 3.0%) and teach-back in CRG3 (by 4.7%) The combination of teach-back plus a checklist had the greatest effect on reducing RR in CRG3 by 5.3%.

CONCLUSIONS

The effect of bundle elements varied across risk groups, indicating that transition needs may vary on the basis of population. The combined use of teach-back plus a checklist had the greatest impact on reducing RR for medically complex patients.

Scholarly Activity During Pediatric Fellowship

BACKGROUND AND OBJECTIVES

The educational requirements for pediatric fellows include at least 12 months of scholarly activity and generation of a work product. Yet there lacks detailed guidance on how programs can best integrate scholarly activity training into fellowships. Our objectives were to understand the resources and barriers to training and identify factors associated with productivity.

METHODS

We surveyed pediatric fellowship program directors (FPDs) nationally in 2019. Data analysis included descriptive statistics, χ² and Fisher's exact tests, and multivariable modeling to identify factors associated with high productivity (>75% of fellows in the past 5 years had an article from their fellowship accepted).

RESULTS

A total of 499 of 770 FPDs responded (65%). A total of 174 programs (35%) were highly productive. The most frequent major barriers were a lack of funding for fellows to conduct scholarship (21%, n = 105) and lack of sufficient divisional faculty mentorship (16%, n = 79). The median number of months for scholarship with reduced clinical obligations scholarship was 17. A total of 40% (n = 202) of FPDs believed training should be shortened to 2 years for clinically oriented fellows. Programs with a T32 and a FPD with >5 publications in the past 3 years were twice as likely to be productive. Not endorsing lack of adequate Scholarship Oversight Committee expertise and a research curriculum as barriers was associated with increased productivity (odds ratio = 1.83-1.65).

CONCLUSIONS

Despite significant protected fellow research time, most fellows do not publish. Ensuring a program culture of research may provide the support needed to take projects to publication. The fellowship community may consider reevaluating the fellowship duration, particularly for those pursing nonresearch focused careers.

"How did you get to this number?" Stakeholder needs for implementing predictive analytics: a pre-implementation qualitative study

OBJECTIVE

Predictive analytics are potentially powerful tools, but to improve healthcare delivery, they must be carefully integrated into healthcare organizations. Our objective was to identify facilitators, challenges, and recommendations for implementing a novel predictive algorithm which aims to prospectively identify patients with high preventable utilization to proactively involve them in preventative interventions.

MATERIALS AND METHODS

In preparation for implementing the predictive algorithm in 3 organizations, we interviewed 3 stakeholder groups: health systems operations (eg, chief medical officers, department chairs), informatics personnel, and potential end users (eg, physicians, nurses, social workers). We applied thematic analysis to derive key themes and categorize them into the dimensions of Sittig and Singh's original sociotechnical model for studying health information technology in complex adaptive healthcare systems. Recruiting and analysis were conducted iteratively until thematic saturation was achieved.

RESULTS

Forty-nine interviews were conducted in 3 healthcare organizations. Technical components of the implementation (hardware and software) raised fewer concerns than alignment with sociotechnical factors. Stakeholders wanted decision support based on the algorithm to be clear and actionable and incorporated into current workflows. However, how to make this disease-independent classification tool actionable was perceived as a challenge, and appropriate patient interventions informed by the algorithm appeared likely to require substantial external and institutional resources. Stakeholders also described the criticality of trust, credibility, and interpretability of the predictive algorithm.

CONCLUSIONS

Although predictive analytics can classify patients with high accuracy, they cannot advance healthcare processes and outcomes without careful implementation that takes into account the sociotechnical system. Key stakeholders have strong perceptions about facilitators and challenges to shape successful implementation.

Funding sources and effects of limited funding in pediatric pulmonology fellowship programs

BACKGROUND

The pediatric pulmonology workforce is at risk. Access to pediatric pulmonologists to meet patient needs is limited and recruitment of new trainees to replace the aging, retiring physician population may be inadequate. Furthermore, sources of funding for graduate medical education are insecure. However, no prior studies have identified the funding sources of pediatric pulmonology fellowships or the effects of funding constraints.

METHODS

We conducted a national survey of pediatric pulmonology training directors (PPTD) in the United States between 1 November, 2016 and 9 February, 2017 to examine the sources of funding for pediatric pulmonary fellows and the effect of funding limitations.

RESULTS

We obtained data from 48 PPTD, representing 89% of pediatric pulmonology programs (N = 54). Limitations in funding restricted program size in 31% of programs. A significant number of programs had no funding to cover educational resources such as advanced degrees (38%), courses (23%), society membership (25%), and journals and books (15%). Twenty seven percent of PPTD perceived their program as financially insecure for academic year 2019 and beyond.

CONCLUSIONS

Insufficient funding has limited the size of pediatric pulmonology programs and access to important educational resources. It is critical to ensure that there is adequate funding for pediatric pulmonology fellowship programs, as insecurity further endangers the pediatric pulmonology workforce and future provision of care for children with respiratory diseases.

Comparison of Attention-Deficit/Hyperactivity Disorder Care Between School-Based Health Centers and a Continuity Clinic

BACKGROUND

School-based health centers (SBHC) are in a unique position to provide guideline-driven attention-deficit/hyperactivity disorder (ADHD) care. In this study, we compared adherence to 2 components of ADHD guidelines in SBHC versus a continuity clinic.

METHODS

We compared proportions of ADHD visits that had a structured symptom report available and timely follow-up in SBHC to a continuity clinic using chart review. We used multiple logistic regression to estimate the association between guideline adherence and clinic type.

RESULTS

Participants who had a medication dose change were 3.9 times more likely (relative risk [RR] = 3.9, 95% confidence interval [CI] 3.0-5.1) to have a structured report present and 1.7 times more likely (RR = 1.7, 95% CI 1.2-2.2) to have follow-up within 30 days if they were seen in SBHC versus continuity clinic. Participants who were stable on their medication dose were 18 times more likely (RR = 18.0, 95% CI 11.3-29.0) to have a structured report present and 1.4 times more likely (RR = 1.4, 95% CI 1.3-1.6) to have follow-up within 100 days if they were seen in SBHC versus continuity clinic.

CONCLUSIONS

Care provided in SBHC was associated with improved adherence to guidelines and has the potential to the improve pediatric ADHD outcomes.

Scholarly Collaboration, Mentorship, and Friendship: A New Model for Success in Academic Medicine

Mentorship can be one of the most important factors in helping faculty members successfully advance academic careers. Finding effective mentorship, however, is extremely challenging and lack of mentorship may negatively impact productivity, promotion, and retention. Women, in particular, identify lack of mentorship as a major factor inhibiting career advancement, which in turn may be one element contributing to the significant gender gaps existing in academic medicine. Here, we describe a model of mentoring drawn from our personal experiences as 4 female faculty that has resulted in a successful collaboration spanning nearly a decade. This model combines different elements of mentoring models previously described in the literature into a single model of network mentoring. Our model aims to promote longitudinal, collaborative scholarship around a broad common research theme, provide long-term mentorship focused on successfully navigating personal and academic hurdles, and create a forum of mentorship for faculty at all academic ranks. Keys to the success of our model, The Accelerate Scholarship through Personal Engagement with a Collaborative Team (ASPECT) Model, are: 1) a shared overarching research goal that allows for multiple projects to be worked on over time; 2) regular, structured meetings; 3) a collaborative yet flexible arrangement with "group accountability"; and 4) a focus on the human connection. Our goal in writing this paper is to describe, in detail, lessons learned from our experiences and reflect on why and how this model may be effective in addressing mentoring gaps many faculty members, particularly women, experience.

Funding Sources and Perceived Financial Insecurity in Pediatric Subspecialty Fellowship Programs

OBJECTIVE

Shortages of pediatric subspecialists exist in many fields with insufficient recruitment of new fellows. The current system of funding graduate medical education is inadequate. We examined funding sources for trainee salary and educational expenses in pediatric fellowship programs, effects of funding constraints, and program characteristics associated with financial insecurity as reported by fellowship program directors (FPD).

METHODS

We conducted a national survey of FPD between November 1, 2016 and February 9, 2017. We used multivariable logistic regression to examine the association between perceived financial insecurity, program characteristics, and funding sources for fellow salary.

RESULTS

We obtained data from 519 FPD, representing 14 different pediatric subspecialties. FPD reported that funding limitations restricted program size and educational resources in 22% and 36% of programs, respectively. Nineteen percent of FPD perceived funding of their program to be insecure. Programs with 7 or more fellows (OR .50 [95% CI .27-.90], P = .03) or hospital or graduate medical education/Children's Hospital graduate medical education funding (OR .58 [95% CI .35-.96], P = .04) were less likely to be perceived as insecure. Conversely, programs with extramural (OR 1.74 [95% CI 1.07-2.81], P = .03) or division funding (OR 1.70 [95% CI 1.02-2.82], P = .04) or in subspecialties with more than 25% unfilled positions or programs (OR 1.86 [95% CI 1.11-3.09], P = .02) were more likely to be perceived as insecure.

CONCLUSIONS

Perceived financial insecurity of fellowship programs was strongly associated with program size, funding source, and unfilled positions, limiting recruitment and resources. Stable funding of fellowship programs is critical to maintain an adequate pediatric subspecialty workforce.

What is new in paediatric medication safety?

Medication-related errors are among the most common medical errors, and studies have shown that the paediatric population is particularly vulnerable. Errors can occur during any step in the medication process. This review article seeks to highlight new advancements in the field of paediatric medication safety at each stage of the medication process, from ordering and transcribing to medication dispensing and administration. We will focus on interventions that are increasingly widely used, such as computerised provider order entry with clinical decision support, barcoding technologies and safe medication administration through technologies pumps (SMART pumps), as well as innovative mobile application devices and workflow management systems that are being piloted at single institutions. By highlighting what is new in paediatric medication safety, as well as the gaps that remain, we hope to continue to foster focus on this critically important area in order to create the safest possible environment for children.

Enhancing Educational Scholarship Through Conceptual Frameworks: A Challenge and Roadmap for Medical Educators

Historically, health sciences education has been guided by tradition and teacher preferences rather than by the application of practices supported by rigorous evidence of effectiveness. Although often underutilized, conceptual frameworks-theories that describe the complexities of educational and social phenomenon-are essential foundations for scholarly work in education. Conceptual frameworks provide a lens through which educators can develop research questions, design research studies and educational interventions, assess outcomes, and evaluate the impact of their work. Given this vital role, conceptual frameworks should be considered at the onset of an educational initiative. Use of different conceptual frameworks to address the same topic in medical education may provide distinctive approaches. Exploration of educational issues by employing differing, theory-based approaches advances the field through the identification of the most effective educational methods. Dissemination of sound educational research based on theory is similarly essential to spark future innovation. Ultimately, this rigorous approach to medical education scholarship is necessary to allow us to establish how our educational interventions impact the health and well-being of our patients.

Scholarly Activity Training During Residency: Are We Hitting the Mark? A National Assessment of Pediatric Residents

OBJECTIVE

Participation in scholarly activity (SA) is an Accreditation Council for Graduate Medical Education requirement. Our previous research with program directors (PDs) suggests that pediatric SA training is variable and suboptimal. To help programs better meet requirements, our objective was to understand the resident perspective regarding SA training, including factors associated with satisfaction and productivity.

METHODS

We conducted cross-sectional surveys of second- and third-year pediatric residents and PDs at 22 diverse programs in 2016. Surveys assessed resident demographics, career intentions, program characteristics, beliefs, barriers, satisfaction, and productivity, defined as SA accepted at a regional or national meeting, for publication, or grant funding. Data were analyzed using descriptive statistics and multivariable logistic regression.

RESULTS

A total of 464 (60.2%) of 771 residents and 22 PDs (100%) responded. Most residents believed that residents should participate in SA (n = 380, 81.9%). However, only 37.9% (n = 175) were extremely or very satisfied with their training. Residents who reported that training to conduct research (adjusted odds ratio [AOR]  = 1.9, 95% confidence interval [CI] 1.1-3.5), availability of a research curriculum (AOR = 1.9, 95% CI 1.2-3.1), and adequate faculty mentorship (AOR = 2.5, 95% CI 1.6-4.1) were not barriers were more satisfied. Protected time was associated with satisfaction (AOR = 1.7, 95% CI 1.1-2.7). A total of 43.8% of residents (n = 203) were productive. Productivity was associated with future plans to conduct research (AOR = 3.3, 95% CI 2.1-5.1).

CONCLUSIONS

Residents believe SA training is important. Dedicated program infrastructure, protected time, and adequate mentorship appear to be crucial to improving quality perceptions.

Conducting Quantitative Medical Education Research: From Design to Dissemination

Rigorous medical education research is critical to effectively develop and evaluate the training we provide our learners. Yet many clinical medical educators lack the training and skills needed to conduct high-quality medical education research. We offer guidance on conducting sound quantitative medical education research. Our aim is to equip readers with the key skills and strategies necessary to conduct successful research projects, highlighting new concepts and controversies in the field. We utilize Glassick's criteria for scholarship as a framework to discuss strategies to ensure that the research question of interest is worthy of further study and how to use existing literature and conceptual frameworks to strengthen a research study. Through discussions of the strengths and limitations of commonly used study designs, we expose the reader to particular nuances of these decisions in medical education research and discuss outcomes generally focused on, as well as strategies for determining the significance of consequent findings. We conclude with information on critiquing research findings and preparing results for dissemination to a broad audience. Practical planning worksheets and comprehensive tables illustrating key concepts are provided in order to guide researchers through each step of the process. Medical education research provides wonderful opportunities to improve how we teach our learners, to satisfy our own intellectual curiosity, and ultimately to enhance the care provided to patients.

The Expanding Role of Antimicrobial Stewardship Programs in Hospitals in the United States: Lessons Learned from a Multisite Qualitative Study

BACKGROUND

Misuse of antibiotics can lead to the development of antibiotic resistance, which adversely affects morbidity, mortality, length of stay, and cost. To combat the threat of antimicrobial resistance, The Joint Commission and the Centers for Medicare & Medicaid Services have initiated or proposed requirements for hospitals to have antimicrobial stewardship programs (ASPs), but implementation remains challenging. A key-informant interview study was conducted to describe the characteristics and innovative strategies of leading ASPs.

METHODS

Semistructured interviews were conducted with 12 program leaders at four ASPs in the United States, chosen by purposive sampling on the basis of national reputation, scholarship, and geography. Questions focused on ASP implementation, program structure, strengths, weaknesses, lessons learned, and future directions. Content analysis was used to identify dominant themes.

RESULTS

Three major themes were identified. The first was evolution of ASPs from a top-down structure to a more diffuse approach involving unit-based pharmacists, multidisciplinary staff, and shared responsibility for antimicrobial prescribing under the ASPs' leadership. The second theme was integration of information technology (IT) systems, which enabled real-time interventions to optimize antimicrobial therapy and patient management. The third was barriers to technology integration, including limited resources for data analysis and poor interoperability between software systems.

CONCLUSION

The study provides valuable insights on program implementation at a sample of leading ASPs across the United States. These ASPs used expansion of personnel to amplify the ASP's impact and integrated IT resources into daily work flow to improve efficiency. These findings can be used to guide implementation at other hospitals and aid in future policy development.

Predicting frequent emergency department visits among children with asthma using EHR data

OBJECTIVE

For children with asthma, emergency department (ED) visits are common, expensive, and often avoidable. Though several factors are associated with ED use (demographics, comorbidities, insurance, medications), its predictability using electronic health record (EHR) data is understudied.

METHODS

We used a retrospective cohort study design and EHR data from one center to examine the relationship of patient factors in 1 year (2013) and the likelihood of frequent ED use (≥2 visits) in the following year (2014), using bivariate and multivariable statistics. We applied and compared several machine-learning algorithms to predict frequent ED use, then selected a model based on accuracy, parsimony, and interpretability.

RESULTS

We identified 2691 children. In bivariate analyses, future frequent ED use was associated with demographics, co-morbidities, insurance status, medication history, and use of healthcare resources. Machine learning algorithms had very good AUC (area under the curve) values [0.66-0.87], though fair PPV (positive predictive value) [48-70%] and poor sensitivity [16-27%]. Our final multivariable logistic regression model contained two variables: insurance status and prior ED use. For publicly insured patients, the odds of frequent ED use were 3.1 [2.2-4.5] times that of privately insured patients. Publicly insured patients with 4+ ED visits and privately insured patients with 6+ ED visits in a year had ≥50% probability of frequent ED use the following year. The model had an AUC of 0.86, PPV of 56%, and sensitivity of 23%.

CONCLUSION

Among children with asthma, prior frequent ED use and insurance status strongly predict future ED use.

Research in Pediatric Residency: National Experience of Pediatric Chief Residents

OBJECTIVE

To determine factors associated with increased research productivity, satisfaction, and perceived barriers to research within residency from the experience of pediatric chief residents.

METHODS

An online cross-sectional survey was administered to academic year 2014-15 chief residents. Topics assessed included program demographic characteristics, career intentions, research productivity, satisfaction with research training and opportunities, and research barriers. Chi-square and Fisher exact tests were used for descriptive statistics. Multivariable logistic regression analysis was used to determine factors associated with productivity and research satisfaction.

RESULTS

The response rate was 63% (165 of 261). Half (82 of 165) were productive in research. Most were satisfied with their quality of research training (55%; 90 of 165) and research opportunities (69%; 114 of 165). Chiefs reporting interest in research were 5 times more likely to be productive than those who did not (odds ratio [OR] = 5.2; 95% confidence interval [CI], 2.3-11.8). Productive chiefs were more likely to report including research time in future careers (P = .003). Most (83%; 137 of 165) thought their programs were supportive of resident research, but lack of time was frequently cited as a major barrier. Those satisfied with research opportunities were less likely to find lack of training (OR = 0.3; 95% CI, 0.1-0.7) or faculty mentorship (OR = 0.2; 95% CI, 0.0-0.9) as a major barrier.

CONCLUSIONS

Pediatric chief resident interest in research is strongly associated with research productivity during residency, and research productivity is strongly associated with career plans including research time. By cultivating research interest through faculty mentorship, research training, and dedicated time, pediatric residency programs might help foster early research success and, potentially lead to continued engagement with research in trainees' future careers.

Increasing Scholarly Activity Productivity During Residency: A Systematic Review

PURPOSE

Although resident participation in scholarly activity is mandated by the Accreditation Council for Graduate Medical Education, programmatic factors associated with success are not defined. This systematic review's objective was to determine which interventions are effective in increasing resident scholarly activity productivity (RSAP), as measured by participation in scholarly activity, presentations, or publications.

METHOD

The PubMed, MEDLINE, Cochrane Library of Systematic Reviews, PsycINFO, CINAHL, and ERIC databases were searched through October 2013. English-language articles evaluating interventions to increase RSAP in U.S. or Canadian residency programs were included, without date limits. Two independent reviewers selected articles for inclusion and extracted data. Discrepancies were resolved by consensus.

RESULTS

Of the 6,248 records screened, 80 studies underwent data abstraction. Twenty-six described outcomes without a comparison group, leaving 54 studies representing 13 medical and surgical specialties. Interventions included required scholarly activity participation, protected research time, research curricula, research directors, dedicated research days, and research tracks. Focusing on the 35 studies reporting statistical analysis, RSAP was associated with all interventions. There were some differences in intervention effectiveness between medical and surgical specialties.

CONCLUSIONS

Interventions, including protected time, research curricula, or specialized research tracks, generally result in increased participation in scholarly activity in residency programs, with mixed effects on resident presentations or publications. In many studies, interventions were bundled, suggesting that programs may need to provide increased structure and rigor through multiple pathways. The findings highlight the need for a clear definition of resident scholarly activity success aligned specifically to individual program and resident aims.

How Physician Perspectives on E-Prescribing Evolve over Time. A Case Study Following the Transition between EHRs in an Outpatient Clinic

BACKGROUND

Physicians are expending tremendous resources transitioning to new electronic health records (EHRs), with electronic prescribing as a key functionality of most systems. Physician dissatisfaction post-transition can be quite marked, especially initially. However, little is known about how physicians' experiences using new EHRs for e-prescribing evolve over time. We previously published a qualitative case study about the early physician experience transitioning from an older to a newer, more robust EHR, in the outpatient setting, focusing on their perceptions of the electronic prescribing functionality.

OBJECTIVE

Our current objective was to examine how perceptions about using the new HER evolved over time, again with a focus on electronic prescribing.

METHODS

We interviewed thirteen internists at an academic medical center-affiliated ambulatory care clinic who transitioned to the new EHR two years prior. We used a grounded theory approach to analyze semi-structured interviews and generate key themes.

RESULTS

We identified five themes: efficiency and usability, effects on safety, ongoing training requirements, customization, and competing priorities for the EHR. We found that for even experienced e-prescribers, achieving prior levels of perceived prescribing efficiency took nearly two years. Despite the fact that speed in performing prescribing-related tasks was highly important, most were still not utilizing system short cuts or customization features designed to maximize efficiency. Alert fatigue remained common. However, direct transmission of prescriptions to pharmacies was highly valued and its benefits generally outweighed the other features considered poorly designed for physician workflow.

CONCLUSIONS

Ensuring that physicians are able to do key prescribing tasks efficiently is critical to the perceived value of e-prescribing applications. However, successful transitions may take longer than expected and e-prescribing system features that do not support workflow or require constant upgrades may further prolong the process. Additionally, as system features continually evolve, physicians may need ongoing training and support to maintain efficiency.

Effects of health information technology on patient outcomes: a systematic review

OBJECTIVE

To systematically review studies assessing the effects of health information technology (health IT) on patient safety outcomes.

MATERIALS AND METHODS

The authors employed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement methods. MEDLINE, Cumulative Index to Nursing Allied Health (CINAHL), EMBASE, and Cochrane Library databases, from 2001 to June 2012, were searched. Descriptive and comparative studies were included that involved use of health IT in a clinical setting and measured effects on patient safety outcomes.

RESULTS

Data on setting, subjects, information technology implemented, and type of patient safety outcomes were all abstracted. The quality of the studies was evaluated by 2 independent reviewers (scored from 0 to 10). A total of 69 studies met inclusion criteria. Quality scores ranged from 1 to 9. There were 25 (36%) studies that found benefit of health IT on direct patient safety outcomes for the primary outcome measured, 43 (62%) studies that either had non-significant or mixed findings, and 1 (1%) study for which health IT had a detrimental effect. Neither the quality of the studies nor the rate of randomized control trials performed changed over time. Most studies that demonstrated a positive benefit of health IT on direct patient safety outcomes were inpatient, single-center, and either cohort or observational trials studying clinical decision support or computerized provider order entry.

DISCUSSION AND CONCLUSION

Many areas of health IT application remain understudied and the majority of studies have non-significant or mixed findings. Our study suggests that larger, higher quality studies need to be conducted, particularly in the long-term care and ambulatory care settings.

Predicting frequent ED use by people with epilepsy with health information exchange data

OBJECTIVES

To describe (1) the predictability of frequent emergency department (ED) use (a marker of inadequate disease control and/or poor access to care), and (2) the demographics, comorbidities, and use of health services of frequent ED users, among people with epilepsy.

METHODS

We obtained demographics, comorbidities, and 2 years of encounter data for 8,041 people with epilepsy from a health information exchange in New York City. Using a retrospective cohort design, we explored bivariate relationships between baseline characteristics (year 1) and subsequent frequent ED use (year 2). We then built, evaluated, and compared predictive models to identify frequent ED users (≥4 visits year 2), using multiple techniques (logistic regression, lasso, elastic net, CART [classification and regression trees], Random Forests, AdaBoost, support vector machines). We selected a final model based on performance and simplicity.

RESULTS

People with epilepsy who, in year 1, were adults (rather than children or seniors), male, Manhattan residents, frequent users of health services, users of multiple health systems, or had medical, neurologic, or psychiatric comorbidities, were more likely to frequently use the ED in year 2. Predictive techniques identified frequent ED visitors with good positive predictive value (approximately 70%) but poor sensitivity (approximately 20%). A simple strategy, selecting individuals with 11+ ED visits in year 1, performed as well as more sophisticated models.

CONCLUSIONS

People with epilepsy with 11+ ED visits in a year are at highest risk of continued frequent ED use and may benefit from targeted intervention to avoid preventable ED visits. Future work should focus on improving the sensitivity of predictions.

Causes and consequences of e-prescribing errors in community pharmacies

Major national policy forces are promoting the adoption and use of health information technology (health IT) to improve the quality, safety, and efficiency of health care delivery. One such health IT is electronic prescribing (e-prescribing), which is the direct transmission of prescription information from a provider to a pharmacy. Given research showing that handwritten prescriptions are unsafe and associated errors can lead to tremendous inefficiency for patients and pharmacists, e-prescribing has many potential benefits. However, as with the introduction of any new technology, unintended, adverse consequences may result. The purpose of this review is to explore the causes and consequences of e-prescribing errors in community pharmacies, which are pharmacies not affiliated with a hospital or clinic. Many new types of errors - including provider order entry errors, transcription errors, and dispensing errors - appear to result from e-prescribing. These lead to important consequences for pharmacies, including safety threats to patients, reduced efficiency for pharmacists, processing delays, and increased pharmacy cost. Increased attention to system design and pharmacist training, as well as additional research in this area, will be critical to realize the full benefits of e-prescribing.

Hospital crossover increases utilization for people with epilepsy: a retrospective cohort study

OBJECTIVES

"Hospital crossover" occurs when people visit multiple hospitals for care, which may cause gaps in electronic health records. Although crossover is common among people with epilepsy, the effect on subsequent use of health services is unknown. Understanding this effect will help prioritize health care delivery innovations targeted for this population.

METHODS

We collected de-identified information from a health information exchange network describing 7,836 people with epilepsy who visited any of seven hospitals in New York, NY from 2009-2012. Data included demographics, comorbidities, and 2 years of visit information from ambulatory, inpatient, emergency department (ED), and radiology settings. We performed two complementary retrospective cohort analyses, in order to (1) illustrate the effect on a carefully selected subgroup, and (2) confirm the effect across the study population. First, we performed a matched cohort analysis on 410 pairs of individuals with and without hospital crossover in the baseline year. Second, we performed a propensity score odds weighted ordinal logistic regression analysis to estimate the effect across all 7,836 individuals. The outcomes were the use of six health services in the follow-up year.

RESULTS

In the matched pair analysis, baseline hospital crossover increased the odds of more visits in the ED (odds ratio 1.42, 95% confidence interval [CI] 1.05-1.95) and radiology settings (1.7, 1.22-2.38). The regression analysis confirmed the ED and radiology findings, and also suggested that crossover led to more inpatient admissions (1.35, 1.11-1.63), head CTs (1.44, 1.04-2), and brain MRIs (2.32, 1.59-3.37).

SIGNIFICANCE

Baseline hospital crossover is an independent marker for subsequent increased health service use in multiple settings among people with epilepsy. Health care delivery innovations targeted for people with epilepsy who engage in hospital crossover should prioritize (1) sharing radiology images and reports (to reduce unnecessary radiology use, particularly head CTs), and (2) improving coordination of care (to reduce unnecessary ED and inpatient use).

Research training among pediatric residency programs: a national assessment

PURPOSE

The Accreditation Council for Graduate Medical Education (ACGME) states that "residents should participate in scholarly activity." However, there is little guidance for effectively integrating scholarly activity into residency. This study was conducted to understand how pediatric residency programs meet ACGME requirements and to identify characteristics of successful programs.

METHOD

The authors conducted an online cross-sectional survey of all pediatric residency program directors in October 2012, assessing program characteristics, resident participation in scholarly activity, program infrastructure, barriers, and outcomes. Multivariate logistic regression was used to identify characteristics of programs in the top quartile for resident scholarly activity participation.

RESULTS

The response rate was 52.8% (105/199 programs). Seventy-seven (78.6%) programs required scholarly activity, although definitions were variable. When including only original research, systematic reviews or meta-analyses, and case reports or series with references, resident participation averaged 56% (range 0%-100%). Characteristics associated with high-participation programs included a scholarly activity requirement (odds ratio [OR] = 5.5, 95% confidence interval [CI] = 1.03-30.0); program director belief that all residents should present work regionally or nationally (OR = 4.7, 95% CI = 1.5-15.1); and mentorship by >25% of faculty (OR = 3.6, CI = 1.2-11.4). Only 47.1% (41) of program directors were satisfied with resident participation, and only 30.7% (27) were satisfied with the quality of research training provided.

CONCLUSIONS

The findings suggest that resident scholarly activity experience is highly variable and suboptimal. Identifying characteristics of successful programs can improve the resident research training experience.

Trending health information technology adoption among New York nursing homes

OBJECTIVES

Federal policies are incentivizing hospitals and providers to adopt and meaningfully use electronic health records (EHRs). Nursing homes are not eligible for incentives. However, understanding health information technology (HIT) adoption among nursing homes will be critical to developing HIT policies for this sector. Our objective was to assess the pace of EHR adoption, changes in computerized function adoption, and participation in health information exchange by New York state nursing homes over time.

STUDY DESIGN

We used a repeated, cross-sectional study design.

METHODS

We surveyed all New York state nursing homes between February and May 2013, comparing results to the same survey administered in 2012.

RESULTS

We received responses from 472 of 630 nursing homes (74.9%). Rates of EHR adoption increased from 48.6% to 56.3% (P = .03). Participation in health information exchange remained unchanged (54.5% to 55.3%, P = .8). The top barriers to EHR adoption cited were: a) the initial cost of HIT investment (67.9%, n = 133), b) lack of technical IT staff (46.4%, n = 91), and c) lack of fiscal incentives (45.8%, n = 88). Comparing nursing homes with EHRs in 2012 to nursing homes with EHRs in 2013, the availability of many types of computerized functionalities significantly increased, although no gains were seen for order entry or clinical tools.

CONCLUSIONS

While some gains are being made by nursing homes, HIT adoption generally lags behind that of other sectors. Public policy focusing on building HIT infrastructure is essential to ensure that nursing homes keep up with other healthcare segments.

Meaningful Use Status and Participation in Health Information Exchange Among New York State Hospitals: A Longitudinal Assessment

BACKGROUND

Billions of dollars is being utilized to promote electronic health record (EHR) adoption and electronic health information exchange (HIE). Monitoring trends over time is critical to understanding the success of policies initiatives. New York State is a leader in state-based initiatives promoting health information technology (HIT), and its experiences can provide valuable lessons to inform ongoing state and federal efforts.

METHODS

All hospitals in New York State were previously surveyed in 2009 to determine rates of EHR adoption, preparedness to meet meaningful use criteria, and participation in HIE. A follow-up survey was conducted from November 2012 through February 2013 to evaluate progress over time.

RESULTS

Responses were received from 129 of 210 hospitals (61% response rate). Some 98% of responding hospitals (n = 126) had implemented or begun implementing an EHR-greater than a fourfold increase in three years. Nearly three-quarters had already attested to Stage 1 meaningful use for Medicaid (74.8%, n = 86) and Medicare (70.8%, n = 85), although only 10.7% (n = 13) anticipated it would be easy to achieve Stage 2 meaningful use. Seventy-nine percent of respondents (n = 92) reported exchanging electronic patient-level clinical data with other partners, and 89.9% (n = 116) reported participation in regional arrangements to share data. Lack of architecture and cost remain major barriers to achieving robust HIE.

DISCUSSION

Although much progress has been made since 2009, careful attention must be paid to helping hospitals meet the stricter Stage 2 meaningful use requirements and to supporting robust HIE to help fulfill HIT's promise of achieving higher-quality, lower-cost health care.

Expert panel evaluation of health information technology effects on adverse events

RATIONALE, AIMS AND OBJECTIVES

Adverse events (AEs) among hospitalized patients occur frequently and result in significant sequelae. Federal policy is incentivizing health information technology (HIT) use, although research demonstrating safety benefits from HIT is mixed. Our objective was to evaluate the potential effects of HIT on reducing 21 different inpatient AEs. Identifying AEs most likely to be reduced by HIT can inform the design of future studies evaluating its effectiveness.

METHODS

We conducted a modified Delphi panel of national experts in HIT and safety. We conducted a focused literature review to inform the experts. Using a novel framework, experts rated each AE as 'definitely reduced by health IT,' 'possibly reduced by health IT' and 'not likely to be reduced by health IT'.

RESULTS

From our panel discussion, experts identified six AEs as 'definitely reduced by health IT': (1) adverse drug events (ADEs) associated with digoxin; (2) ADE associated with IV heparin; (3) ADE associated with hypoglycaemic agents; (4) ADE associated with low molecular weight heparin and factor Xa inhibitor; (5) contrast nephropathy associated with catheter angiography; and (6) ADE hospital-acquired antibiotic-associated Clostridium difficile.

CONCLUSIONS

Understanding the effects of HIT on patient outcomes will be essential to ensuring that the significant federal investment results in anticipated improvements. This study serves as an important early step in helping with the design of future work evaluating level of HIT infrastructure and rates of inpatient AEs.

Consumer perspectives on personal health records: a 4-community study

OBJECTIVES

To characterize consumer attitudes toward personal health records (PHRs) in 4 diverse communities across New York state (NYS).

STUDY DESIGN

Combined analysis from four separate cross-sectional studies.

METHODS

We analyzed pooled data from surveys separately administered to 4 NYS communities. Results from individual communities have been previously published. However, pooling the data allowed us to conduct multivariable regression analyses that identified key factors associated with potential usage among a broad group of consumers.

RESULTS

We received responses from 701 consumers. A majority (74%) of respondents (n = 494) reported that they would use a PHR and the majority wanted a broad array of functionalities available. We found that potential PHR use was significantly associated with Internet use at least monthly (odds ratio [OR] = 5.8, 95% confidence interval [CI] = 3.3-10.2), a belief that PHRs may improve the security of health information (OR = 2.6, 95% CI = 1.5-4.7), and a belief that PHRs may improve quality of care (OR = 4.1, 95% CI = 2.6-6.6).

CONCLUSIONS

As federal initiatives aim to improve healthcare, which includes making care more patient centered, PHRs will likely play an increasing role. Our results provide critical information to inform policy efforts, suggesting that PHRs must offer a broad range of patient-centered functionalities while maintaining high privacy and security standards to narrow the gap between reported interest and actual use. Ensuring widespread access to and frequent use of the internet among consumers will also be critical to avoid creating healthcare disparities through PHR use.

People with epilepsy who use multiple hospitals; prevalence and associated factors assessed via a health information exchange

OBJECTIVE

Hospital crossover occurs when people seek care at multiple hospitals, creating information gaps for physicians at the time of care. Health information exchange (HIE) is technology that fills these gaps, by allowing otherwise unaffiliated physicians to share electronic medical information. However, the potential value of HIE is understudied, particularly for chronic neurologic conditions like epilepsy. We describe the prevalence and associated factors of hospital crossover among people with epilepsy, in order to understand the epidemiology of who may benefit from HIE.

METHODS

We used a cross-sectional study design to examine the bivariate and multivariable association of demographics, comorbidity, and health service utilization variables with hospital crossover, among people with epilepsy. We identified 8,074 people with epilepsy from the International Classification of Diseases, Ninth Revision (ICD-9) codes, obtained from an HIE that linked seven hospitals in Manhattan, New York. We defined hospital crossover as care from more than one hospital in any setting (inpatient, outpatient, emergency, or radiology) over 2 years.

RESULTS

Of 8,074 people with epilepsy, 1,770 (22%) engaged in hospital crossover over 2 years. Crossover was associated with younger age (children compared with adults, adjusted odds ratio [OR] 1.4, 95% confidence interval [CI] 1.2-1.7), living near the hospitals (Manhattan vs. other boroughs of New York City, adjusted OR 1.6, 95% CI 1.4-1.8), more visits in the emergency, radiology, inpatient, and outpatient settings (p < 0.001 for each), and more head computerized tomography (CT) scans (p < 0.01). The diagnosis of "encephalopathy" was consistently associated with crossover in bivariate and multivariable analyses (adjusted OR 2.66, 95% CI 2.14-3.29), whereas the relationship between other comorbidities and crossover was less clear.

SIGNIFICANCE

Hospital crossover is common among people with epilepsy, particularly among children, frequent users of medical services, and people living near the study hospitals. HIE should focus on these populations. Further research should investigate why hospital crossover occurs, how it affects care, and how HIE can most effectively mitigate the resultant fragmentation of medical records.

The effects of electronic prescribing by community-based providers on ambulatory medication safety

BACKGROUND

US federal policies are incentivizing use of electronic prescribing (e-prescribing) to improve safety. However, little is known about e-prescribing's actual impact on medication safety over time. A study was conducted to assess the effect of implementing a commercial electronic health record (EHR) with e-prescribing on rates and types of prescribing errors. Understanding safety effects from e-prescribing will be important as providers increasingly e-prescribe.

METHODS

Prescriptions written by 20 community-based primary care providers in the Hudson Valley region of New York from November 2008 to November 2009 were retrospectively studied. All providers adopted a commercial EHR with robust clinical decision support and extensive technical support to aid in prescribing. Errors were identified by standardized prescription and chart review.

RESULTS

Some 1,629 prescriptions were analyzed at three months postimplementation, and 1,738 prescriptions were analyzed at one year postimplementation. Use of e-prescribing resulted in relatively low error rates (6.0 errors per 100 prescriptions). These rates were sustained over time but without further improvement (6.0 versus 4.5 errors per 100 prescriptions, p = .15). Antibiotics were the class of medications most frequently involved (12.7% of overall errors), and direction errors were most common (24% of errors).

CONCLUSIONS

This study is the first, as far as known, to quantitatively evaluate prescribing errors early after EHR implementation and after sustained use among community-based primary care providers. Relatively low rates of errors with e-prescribing were found early and after prolonged use. Extensive support for providers before, during, and after implementation may mitigate potential safety threats from implementation of an EHR system and result in sustained safety benefits over the long-term.

A statewide assessment of electronic health record adoption and health information exchange among nursing homes

OBJECTIVE

To determine rates of electronic health record (EHR) adoption and health information exchange (HIE) among New York State (NYS) nursing homes.

DATA SOURCES/STUDY SETTING

Primary data collected from a novel survey administered between November 2011 and March 2012 to all NYS nursing homes.

STUDY DESIGN

We used a cross-sectional study design to assess level of EHR implementation, automation of key functionalities, participation in HIE, and barriers to adoption.

DATA COLLECTION/EXTRACTION METHODS

We used descriptive statistics to characterize rates of EHR adoption and participation in HIE and logistic regression to identify nursing home characteristics associated with EHR adoption and HIE.

PRINCIPAL FINDINGS

We received responses from 375 of 632 nursing homes (59.3 percent). Of respondents, almost one in five (n=66, 18.0 percent) reported having a fully implemented and operational EHR and a majority (n=192, 54.4 percent) reported electronically exchanging information. Nursing homes with 100-159 beds were significantly less likely than other facilities to have implemented or be in the process of implementing an EHR (p=.011).

CONCLUSIONS

Our findings present an important systematic look at EHR adoption and HIE by NYS nursing homes. Although the nursing home sector has been reported to lag in health information technology adoption, our results are encouraging. However, they suggest much room for growth and highlight the need for targeted initiatives to achieve more widespread adoption in this important health care sector.

Potential value of health information exchange for people with epilepsy: crossover patterns and missing clinical data

CONTEXT

For people with epilepsy, the potential value of health information exchange (HIE) is unknown.

METHODS

We reviewed two years of clinical encounters for 8055 people with epilepsy from seven Manhattan hospitals. We created network graphs illustrating crossover among these hospitals for multiple encounter types, and calculated a novel metric of care fragmentation: "encounters at risk for missing clinical data."

RESULTS

Given two hospitals, a median of 109 [range 46 - 588] patients with epilepsy had visited both. Due to this crossover, recent, relevant clinical data may be missing at the time of care frequently (44.8% of ED encounters, 34.5% inpatient, 24.9% outpatient, and 23.2% radiology). Though a smaller percentage of outpatient encounters were at risk for missing data than ED encounters, the absolute number of outpatient encounters at risk was three times higher (14,579 vs. 5041).

CONCLUSION

People with epilepsy may benefit from HIE. Future HIE initiatives should prioritize outpatient access.

A long-term follow-up evaluation of electronic health record prescribing safety

OBJECTIVE

To be eligible for incentives through the Electronic Health Record (EHR) Incentive Program, many providers using older or locally developed EHRs will be transitioning to new, commercial EHRs. We previously evaluated prescribing errors made by providers in the first year following transition from a locally developed EHR with minimal prescribing clinical decision support (CDS) to a commercial EHR with robust CDS. Following system refinements, we conducted this study to assess the rates and types of errors 2 years after transition and determine the evolution of errors.

MATERIALS AND METHODS

We conducted a mixed methods cross-sectional case study of 16 physicians at an academic-affiliated ambulatory clinic from April to June 2010. We utilized standardized prescription and chart review to identify errors. Fourteen providers also participated in interviews.

RESULTS

We analyzed 1905 prescriptions. The overall prescribing error rate was 3.8 per 100 prescriptions (95% CI 2.8 to 5.1). Error rates were significantly lower 2 years after transition (p<0.001 compared to pre-implementation, 12 weeks and 1 year after transition). Rates of near misses remained unchanged. Providers positively appreciated most system refinements, particularly reduced alert firing.

DISCUSSION

Our study suggests that over time and with system refinements, use of a commercial EHR with advanced CDS can lead to low prescribing error rates, although more serious errors may require targeted interventions to eliminate them. Reducing alert firing frequency appears particularly important. Our results provide support for federal efforts promoting meaningful use of EHRs.

CONCLUSIONS

Ongoing error monitoring can allow CDS to be optimally tailored and help achieve maximal safety benefits.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov, Identifier: NCT00603070.

Electronic health record adoption and health information exchange among hospitals in New York State

RATIONALE, AIMS AND OBJECTIVES

Unprecedented national and state initiatives are underway to promote adoption and meaningful use of electronic health records (EHRs) with health information exchange (HIE). New York State leads the nation in state initiatives and is conducting ongoing surveillance of its investments. Lessons learned from studying states like New York can inform federal policies and will be essential to evaluate the effectiveness of these initiatives. We undertook this first in a series of planned surveys to assess EHR adoption and HIE activities by New York State hospitals.

METHODS

Between May and December 2009, we surveyed all New York State hospitals to determine rates of EHR adoption, participation in HIE and implementation of functionalities associated with nine core meaningful use criteria.

RESULTS

We received responses from 148 (72.2%) of 205 hospitals surveyed and found that 23 (15.5%) had adopted an EHR and 29 (23.2%) were participating in HIE. Two hospitals (1.4%) reported full implementation of the meaningful use functionalities surveyed. Public hospitals were ahead of private hospitals and notable regional differences were found.

DISCUSSION

EHR adoption rates and participation in HIE are higher among New York hospitals than hospitals nationwide, suggesting that state initiatives funding community EHR implementation may influence these efforts by hospitals. However, overall rates of adoption and preparedness to meet meaningful use remain low. Direct support for hospitals, such as that provided through the national EHR Incentive Program, will likely be critical for rates of EHR adoption and HIE to significantly rise, even in advanced states.