Update on workforce diversity in vascular surgery.

OBJECTIVE: Creating a diverse workforce is paramount to the success of the surgical field. A diverse workforce allows us to meet the health needs of an increasingly diverse population and to bring new ideas to spur technical innovation. The purpose of this study was to assess trends in workforce diversity within vascular surgery (VS) and general surgery (GS) as compared with orthopedic surgery (OS)-a specialty that instituted a formal diversity initiative over a decade ago. METHODS: Data on the trainee pool for VS (fellowships and integrated residencies), GS, and OS were obtained from the U.S. Graduate Medical Education reports for 1999 through 2017. Medical student demographic data were obtained from the Association of American Medical Colleges U.S. medical school enrollment reports. The representation of surgical trainee populations (female, Hispanic, and black) was normalized by their representation in medical school. We also performed the χ2 test to compare proportions of residents over dichotomized time periods (1999-2005 and 2013-2017) as well as a more sensitive trend of proportions test. RESULTS: The proportion of female trainees increased significantly between the time periods for the three surgical disciplines examined (P < .001). Hispanic trainees also represented an increasing proportion of all three disciplines (P ≤ .001). The proportion of black trainees did not significantly change in any discipline between the two periods. Relative to their proportion in medical school, Hispanic trainees were well represented in all surgical specialties studied (normalized ratio [NR], 0.95-1.52: 0.95 OS, 1.00 GS, 1.53 VS fellowship, and 1.23 VS residency). Compared with their representation in medical school, women were under-represented as surgical trainees (NR: 0.32 OS, 0.82 GS, 0.56 VS fellowship, and 0.78 VS residency) as were black trainees (NR: 0.63 OS, 0.90 GS, 0.99 VS fellowship, and 0.81 VS residency). CONCLUSIONS: Although there were significant increases in the number of women and Hispanic trainees in these three surgical disciplines, only Hispanic trainees enter the surgical field at a rate higher than their proportion in medical school. The lack of an increase in black trainees across all specialties was particularly discouraging. Women and black trainees were under-represented in all specialties as compared with their representation in medical school. The data presented suggest potential problems with recruitment at multiple levels of the pipeline. Particular attention should be paid to increasing the pool of minority medical school graduates who are both interested in and competitive for surgical specialties.

Emergency Department/Urgent Care as Usual Source of Care and Clinical Outcomes in CKD: Findings From the Chronic Renal Insufficiency Cohort Study.

Rationale & Objective: Having a usual source of care increases use of preventive services and is associated with improved survival in the general population. We evaluated this association in adults with chronic kidney disease (CKD). Study Design: Prospective, observational cohort study. Setting & Participants: Adults with CKD enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study. Predictor: Usual source of care was self-reported as: 1) clinic, 2) emergency department (ED)/urgent care, 3) other. Outcomes: Primary outcomes included incident end-stage kidney disease (ESKD), atherosclerotic events (myocardial infarction, stroke, or peripheral artery disease), incident heart failure, hospitalization events, and all-cause death. Analytical Approach: Multivariable regression analyses to evaluate the association between usual source of care (ED/urgent care vs clinic) and primary outcomes. Results: Among 3,140 participants, mean age was 65 years, 44% female, 45% non-Hispanic White, 43% non-Hispanic Black, and 9% Hispanic, mean estimated glomerular filtration rate 50 mL/min/1.73 m2. Approximately 90% identified clinic as usual source of care, 9% ED/urgent care, and 1% other. ED/urgent care reflected a more vulnerable population given lower baseline socioeconomic status, higher comorbid condition burden, and poorer blood pressure and glycemic control. Over a median follow-up time of 3.6 years, there were 181 incident end-stage kidney disease events, 264 atherosclerotic events, 263 incident heart failure events, 288 deaths, and 7,957 hospitalizations. Compared to clinic as usual source of care, ED/urgent care was associated with higher risk for all-cause death (HR, 1.53; 95% CI, 1.05-2.23) and hospitalizations (RR, 1.41; 95% CI, 1.32-1.51). Limitations: Cannot be generalized to all patients with CKD. Causal relationships cannot be established. Conclusions: In this large, diverse cohort of adults with moderate-to-severe CKD, those identifying ED/urgent care as usual source of care were at increased risk for death and hospitalizations. These findings highlight the need to develop strategies to improve health care access for this high-risk population.

If you build it, they may not come: modifiable barriers to patient portal use among pre- and post-kidney transplant patients.

BACKGROUND: Patient access to health information using electronic patient portals is increasingly common. Portal use has the potential to improve patients' engagement with their health and is particularly important for patients with chronic illness; however, patients' abilities, attitudes, and use of portals are poorly understood. METHODS: A single-center, cross-sectional survey was conducted of 240 consecutive pre- and post-kidney transplant patients of all levels of technological proficiency who presented to an urban transplant center in the United States. The investigator-developed Patient Information and Technology Assessment-Patient Portal was used to assess patients' attitudes towards the use of patient portals. RESULTS: Most patients surveyed did not use the patient portal (n = 176, 73%). Patients were more likely to use the patient portal if they were White, highly educated, in the post-transplant period, more comfortable with technology, and reported being a frequent internet user (P < .05). The most common reasons for not using the patient portal included: (1) preference for traditional communication, (2) not being aware of the portal, (3) low technological proficiency, and (4) poor interoperability between the portal at the transplant center and the patient's primary care center. CONCLUSIONS: We identified several modifiable barriers to patient portal use. Some barriers can be addressed by patient education and training on portal use, and federal initiatives are underway to improve interoperability; however, a preference for traditional communications represents the most prominent barrier. Additional strategies are needed to improve portal adoption by encouraging acceptance of technologies as a way of clinical communication.