Factors Associated With Health Care Professionals' Choice to Practice in Rural Minnesota.

Importance: Rural health inequities are due in part to a shortage of health care professionals in these areas. Objective: To determine the factors associated with health care professionals' decisions about where to practice. Design, Setting, and Participants: This prospective, cross-sectional survey study of health care professionals in Minnesota was administered by the Minnesota Department of Health from October 18, 2021, to July 25, 2022. Advanced practice registered nurses (APRNs), physicians, physician assistants (PAs), and registered nurses (RNs) renewing their professional licenses were eligible. Exposures: Individuals' ratings on survey items related to their choice of practice location. Main Outcomes and Measures: Rural or urban practice location as defined by the US Department of Agriculture's Rural-Urban Commuting Area typology. Results: A total of 32 086 respondents were included in the analysis (mean [SD] age, 44.4 [12.2] years; 22 728 identified as female [70.8%]). Response rates were 60.2% for APRNs (n = 2174), 97.7% for PAs (n = 2210), 95.1% for physicians (n = 11 019), and 61.6% for RNs (n = 16 663). The mean (SD) age of APRNs was 45.0 (10.3) years (1833 [84.3%] female); PAs, 39.0 (9.4) years (1648 [74.6%] female); physicians, 48.0 (11.9) years (4455 [40.4%] female); and RNs, 42.6 (12.3) years (14 792 [88.8%] female). Most respondents worked in urban (29 456 [91.8%]) vs rural (2630 [8.2%]) areas. Bivariate analysis suggested that family considerations are the most important determinant of practice location. Multivariate analysis revealed that having grown up in a rural area was the strongest factor associated with rural practice (odds ratio [OR] for APRNs, 3.44 [95% CI, 2.68-4.42]; OR for PAs, 3.75 [95% CI, 2.81-5.00]; OR for physicians, 2.44 [95% CI, 2.18-2.73]; OR for RNs, 3.77 [95% CI, 3.44-4.15]). When controlling for rural background, other associated factors included the availability of loan forgiveness (OR for APRNs, 1.42 [95% CI, 1.19-1.69]; OR for PAs, 1.60 [95% CI, 1.31-1.94]; OR for physicians, 1.54 [95% CI, 1.38-1.71]; OR for RNs, 1.20 [95% CI, 1.12-1.28]) and an educational program that prepared for rural practice (OR for APRNs, 1.44 [95% CI, 1.18-1.76]; OR for PAs. 1.70 [95% CI, 1.34-2.15]; OR for physicians, 1.31 [95% CI, 1.17-1.47]; OR for RNs, 1.23 [95% CI, 1.15-1.31]). Autonomy in one's work (OR for APRNs, 1.42 [95% CI, 1.08-1.86]; OR for PAs, 1.18 [95% CI, 0.89-1.58]; OR for physicians, 1.53 [95% CI, 1.31-1.78]; OR for RNs, 1.16 [95% CI, 1.07-1.25]) and a broad scope of practice (OR for APRNs, 1.46 [95% CI, 1.15-1.86]; OR for PAs, 0.96 [95% CI, 0.74-1.24]; OR for physicians, 1.62 [95% CI, 1.40-1.87]; OR for RNs, 0.96 [95% CI, 0.89-1.03]) were important factors associated with rural practice. Lifestyle and area considerations were not associated with rural practice; family considerations were associated with rural practice for RNs only (OR for APRNs, 0.97 [95% CI, 0.90-1.06]; OR for PAs, 0.95 [95% CI, 0.87-1.04]; OR for physicians, 0.92 [95% CI, 0.88-0.96]; OR for RNs, 1.05 [95% CI, 1.02-1.07]). Conclusions and Relevance: Understanding the interconnected factors involved in rural practice requires modeling relevant factors. The findings of this survey study suggest that loan forgiveness, rural training, autonomy, and a broad scope of practice are factors associated with rural practice for most health care professionals. Other factors associated with rural practice vary by profession, suggesting that there may not be a one-size-fits-all approach to recruitment of rural health care professionals.

Reimagining Nephrology Fellowship Education to Meet the Future Needs of Nephrology: A Report of the American Society of Nephrology Task Force on the Future of Nephrology.

The American Society of Nephrology (ASN) Task Force on the Future of Nephrology was established in April 2022 in response to requests from the American Board of Internal Medicine and the Accreditation Council for Graduate Medical Education regarding training requirements in nephrology. Given recent changes in kidney care, ASN also charged the task force with reconsidering all aspects of the specialty's future to ensure that nephrologists are prepared to provide high-quality care for people with kidney diseases. The task force engaged multiple stakeholders to develop 10 recommendations focused on strategies needed to promote: ( 1 ) just, equitable, and high-quality care for people living with kidney diseases; ( 2 ) the value of nephrology as a specialty to nephrologists, the future nephrology workforce, the health care system, the public, and government; and ( 3 ) innovation and personalization of nephrology education across the scope of medical training. This report reviews the process, rationale, and details (the "why" and the "what") of these recommendations. In the future, ASN will summarize the "how" of implementing the final report and its 10 recommendations.

Impact of the Rural Physician Associate Program on Workforce Outcomes.

BACKGROUND AND OBJECTIVES: The Rural Physician Associate Program (RPAP) at the University of Minnesota Medical School (UMMS) is a 9-month rural longitudinal integrated clerkship (LIC) for third-year medical students built on a foundation of family medicine. The purpose of this study was to examine the relationships between participation in the RPAP program and the desired workforce outcomes of practice in Minnesota, primary care specialty (particularly family medicine), and rural practice. METHODS: We analyzed workforce outcomes for UMMS graduates who completed postgraduate training between 1975 and 2017, comparing RPAP participants (n=1,217) to noparticipants (n=7,928). We identified graduates through internal UMMS databases linked to the American Medical Association (AMA) Physician Masterfile and the National Provider Identifier (NPI) registry. We identified workforce outcomes of rural practice, practice in Minnesota, primary care specialty, and family medicine specialty based on practice specialty and practice location data available through the AMA and NPI data sets. RESULTS: Proportionally, more RPAP graduates practice in state (65.7% vs 54.4%, P<.01), in primary care (69.0% vs 33.4%, P<.01), in family medicine (61.1% vs 17.3%, P<.01), and rurally (41.2% vs 13.9%, P<.01) than non-RPAP graduates. CONCLUSIONS: We demonstrate a significant association between participation in RPAP and a career in family medicine, rural practice, and primary care, all outcomes that promote meeting urgent rural workforce needs.

Presidential Address Kidney Week 2019: Winning the War on Kidney Diseases: The Time Is Now.

The American Society of Nephrology Presidential Address was delivered by Mark Rosenberg at Kidney Week 2019 on November 7, 2019 in Washington, DC. The Address describes a remarkable alignment-a syzygy of policy, science, innovation accelerators, clinical trials, clinical care delivery, and activated patients-that exists today in the kidney space. As a community, we must ensure that the strategies developed to take advantage of this alignment, such as Advancing American Kidney Health, succeed. We must overcome our current challenges to thrive as a meaningful specialty. We have an incredible opportunity to come together as a kidney community to ensure success that realigns the priorities and incentives in kidney medicine to better achieve kidney health for all people throughout the world. The time is now to act.

Building a Medical Education Outcomes Center: Development Study.

BACKGROUND: Medical education outcomes and clinical data exist in multiple unconnected databases, resulting in 3 problems: (1) it is difficult to connect learner outcomes with patient outcomes, (2) learners cannot be easily tracked over time through the education-training-practice continuum, and (3) no standard methodology ensures quality and privacy of the data. OBJECTIVE: The purpose of this study was to develop a Medical Education Outcomes Center (MEOC) to integrate education data and to build a framework to standardize the intake and processing of requests for using these data. METHODS: An inventory of over 100 data sources owned or utilized by the medical school was conducted, and nearly 2 dozen of these data sources have been vetted and integrated into the MEOC. In addition, the American Medical Association (AMA) Physician Masterfile data of the University of Minnesota Medical School (UMMS) graduates were linked to the data from the National Provider Identifier (NPI) registry to develop a mechanism to connect alumni practice data to education data. RESULTS: Over 160 data requests have been fulfilled, culminating in a range of outcomes analyses, including support of accreditation efforts. The MEOC received data on 13,092 UMMS graduates in the AMA Physician Masterfile and could link 10,443 with NPI numbers and began to explore their practice demographics. The technical and operational work to expand the MEOC continues. Next steps are to link the educational data to the clinical practice data through NPI numbers to assess the effectiveness of our medical education programs by the clinical outcomes of our graduates. CONCLUSIONS: The MEOC provides a replicable framework to allow other schools to more effectively operate their programs and drive innovation.

Treating and teaching: using publicly available data to explore the relationship between student and patient evaluations of teaching hospitals.

Introduction: Treating patients and teaching medical students are parallel activities that occur at teaching hospitals. However, the relationship between these activities is poorly understood. There have been multiple calls for assessing the quality of medical education by examining publicly available clinical data but there is minimal evidence linking these variables. Method: In this proof-of-principle study, the authors examined publicly available Hospital Consumer Assessment of Healthcare Providers and Systems (H-CAHPS)Ⓡ data collected during Calendar Year 2013 to explore the relationship between patient evaluations of their hospital experience and medical student evaluations of the educational experience at that site. Results: Pearson product-moment correlation coefficients were calculated for multiple variables. Patient ratings of doctor-patient communication correlated with student ratings of organization (R=0.882, p=0.048), educational value (R=0.882, p=0.048), teaching (R=0.963, p=0.008), and evaluation and feedback (R=0.920, p=0.027). Conclusion: These findings provide preliminary evidence for a relationship between patient experiences and the quality of education at that site. Further studies linking clinical and education outcomes are needed to explore this relationship in more depth. The contributions of specific hospital locations, providers, or clerkships need to be evaluated. Studies examining these relationships have the potential to improve both patient care and medical education.

AN OUTCOMES-BASED APPROACH ACROSS THE MEDICAL EDUCATION CONTINUUM.

The medical education continuum spans undergraduate medical education (i.e., medical school), graduate medical education (i.e., residency and fellowship), and continuing medical education. This article provides three examples across the medical education and practice continuum where an outcomes-based approach is being used. By focusing on outcomes instead of process, a more predictable product of undergraduate medical education will be a medical student capable on day 1 of performing the work required of residency. Assessing the quality of medical education by the quality of care a graduate delivers once they enter practice will allow more effective design of medical education to improve care. A more comprehensive assessment of lifelong physician competence will help ensure the health of patients, their health care experience, and the value of care are of the highest possible standard and are continually improving.

Telehealth by an Interprofessional Team in Patients With CKD: A Randomized Controlled Trial.

BACKGROUND: Telehealth and interprofessional case management are newer strategies of care within chronic disease management. We investigated whether an interprofessional team using telehealth was a feasible care delivery strategy and whether this strategy could affect health outcomes in patients with chronic kidney disease (CKD). STUDY DESIGN: Randomized clinical trial. SETTING & PARTICIPANTS: Minneapolis Veterans Affairs Health Care System (VAHCS), St. Cloud VAHCS, and affiliated clinics March 2012 to November 2013 in patients with CKD (estimated glomerular filtration rate < 60mL/min/1.73m(2)). INTERVENTIONS: Patients were randomly assigned to receive an intervention (n=451) consisting of care by an interprofessional team (nephrologist, nurse practitioner, nurses, clinical pharmacy specialist, psychologist, social worker, and dietician) using a telehealth device (touch screen computer with peripherals) or to usual care (n=150). OUTCOMES: The primary end point was a composite of death, hospitalization, emergency department visits, or admission to skilled nursing facilities, compared to usual care. RESULTS: Baseline characteristics of the overall study group: mean age, 75.1±8.1 (SD) years; men, 98.5%; white, 97.3%; and mean estimated glomerular filtration rate, 37±9mL/min/1.73m(2). Telehealth and interprofessional care were successfully implemented with meaningful engagement with the care system. One year after randomization, 208 (46.2%) patients in the intervention group versus 70 (46.7%) in the usual-care group had the primary composite outcome (HR, 0.98; 95% CI, 0.75-1.29; P=0.9). There was no difference between groups for any component of the primary outcome: all-cause mortality (HR, 1.46; 95% CI, 0.42-5.11), hospitalization (HR, 1.15; 95% CI, 0.80-1.63), emergency department visits (HR, 0.92; 95% CI, 0.68-1.24), or nursing home admission (HR, 3.07; 95% CI, 0.71-13.24). LIMITATIONS: Older population, mostly men, potentially underpowered/wide CIs. CONCLUSIONS: Telehealth by an interprofessional team is a feasible care delivery strategy in patients with CKD. There was no statistically significant evidence of superiority of this intervention on health outcomes compared to usual care.

Educational Tools: Thinking Outside the Box.

The understanding, study, and use of educational tools and their application to the education of adults in professional fields are increasingly important. In this review, we have compiled a description of educational tools on the basis of the teaching and learning setting: the classroom, simulation center, hospital or clinic, and independent learning space. When available, examples of tools used in nephrology are provided. We emphasize that time should be taken to consider the goals of the educational activity and the type of learners and use the most appropriate tools needed to meet the goals. Constant reassessment of tools is important to discover innovation and reforms that improve teaching and learning.

Inspiring innovation in medical education.

Traditionally, changes to medical education come from the top down, an approach that potentially misses important contributions from medical students, residents, faculty and staff. In order to provide an avenue for them to bring forward their ideas for educational improvements, the University of Minnesota Medical School sponsored the "What's the Bright Idea?" contest. Through the contest, we sought to foster a culture of innovation and collaboration among faculty, staff and students. The contest included five phases: launch, idea submission, online voting, follow-up and implementation. Seventy-six ideas were submitted, and 902 people participated in the online voting. When asked in a follow-up survey whether the submitter would have developed their idea without the contest, 27% of respondents answered "no" and 18% answered "maybe." Three-fourths stated the contest stimulated networking and collaboration. Four of the recommendations are now being implemented.

Cell-based therapies in kidney disease.

Cell-based therapy is an emerging field but one that has shown early promise for the treatment of human kidney diseases. The most widely used cell is the mesenchymal stem cell (MSC) given its ability to be harvested from bone marrow, expanded in culture, and used in allogeneic protocols. The beneficial effects of MSCs occur through differentiation-independent pathways that include increased cell survival and proliferation, decreased inflammation, and suppression of immune function. Acute kidney injury and kidney transplantation are the two conditions most frequently treated with MSC infusion. Although initial studies are promising, the long-term efficacy and safety of MSC infusion awaits further study.

Slowing progression of chronic kidney disease.

Early identification of chronic kidney disease (CKD) provides an opportunity to implement therapies to improve kidney function and slow progression. The goal of this article is to review established and developing clinical therapies directed at slowing progression. The importance of controlling blood pressure will be discussed along with the target blood pressure that should be achieved in CKD patients. Therapy directed at inhibiting the renin-angiotensin-aldosterone system remains the mainstay of treatment with single-agent inhibition of this system being as good as dual blockade with fewer adverse effects. Other therapies that may be used include correction of metabolic acidosis, dietary protein restriction, and new models for delivering care to patients with CKD. Emerging therapies targeting endothelin, uric acid, kidney fibrosis, and oxidant stress hold promise for the future.

Identification and characterization of Sall1-expressing cells present in the adult mouse kidney.

BACKGROUND: Sall1 is a transcription factor that best identifies stem cells present in the mouse embryonic kidney. Mutations in Sall1 gene in mice can lead to dysgenesis of kidney, while in humans it results in the Townes-Brocks syndrome, which is associated with the kidney agenesis. Unlike the embryonic kidney, Sall1 expression in the adult kidney is largely unknown. We hypothesized that similar to the embryonic kidney, Sall1 expression can identify stem cells present in the adult kidney. Accordingly in this study, we identified Sall1-expressing cells in the adult mouse kidney, determined their role in kidney regeneration following ischemia-reperfusion injury (IRI), and sought the effect of age on Sall1 expression. METHODS AND RESULTS: By immunofluorescence Sall1-expressing cells were identified in the proximal tubule at the cortico-medullary junction and constituted 0.5% of all tubular cells. Rare Sall1-positive cells were also identified in the outer cortex and distal tubules. Sall1 expression was not seen in the glomerular, interstitial, or vascular compartments. Following IRI, 90% of Sall1-expressing cells proliferated and 5% of Sall1-positive cells showed asymmetrical cell division with one of the two adjacent Sall1-positive cells incorporating chlorodeoxyuridine (CldU). Following IRI, there was an increase in Sall1 expression at 4 and 12 h, a decrease at 5 and 10 days, and baseline expression at day 30 by quantitative polymerase chain reaction (qRT-PCR) and Western blot analysis. There was no age-related change in Sall1 expression as determined by qRT-PCR, Western blot analysis, and immunofluorescence. CONCLUSIONS: We conclude that Sall1-expressing cells are present in the adult mouse kidney, predominantly in the proximal tubules. Sall1-expressing cells proliferate following IRI and some of the Sall1-positive cells undergo asymmetrical cell division. Therefore, Sall1 is a promising marker for identification of stem cells present in the adult mouse kidney.

Race disparities in U.S. nephrology fellowship training.

BACKGROUND AND OBJECTIVES: Renal disease disproportionately affects African-American patients. Trust has been implicated as an important factor in patient outcomes. Higher levels of trust and better interpersonal care have been reported when race of patient and physician are concordant. The purpose of this analysis was to examine trends in the racial background of U.S. medical school graduates, internal medicine residents, nephrology fellows, and patients with ESRD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Data for medical school graduates were obtained from the Association of American Medical Colleges and data for internal medicine and nephrology trainees from GME Track. ESRD data were obtained from U.S. Renal Data System (USRDS) annual reports. RESULTS: A significant disparity continues to exist between the proportional race makeup of African-American nephrology fellows (3.8%) and ESRD patients (32%). The low numbers of African-American nephrology fellows, and consequently new nephrologists, in light of the increase in ESRD patients has important implications for patient-centered nephrology care. CONCLUSIONS: Efforts are needed to increase minority recruitment into nephrology training programs, to more closely balance the racial background of trainees and patients in hopes of fostering improved trust between ESRD caregivers and patients, increasing access to care, alleviating ESRD health care disparities, and improving patient care.

Cellular therapy of kidney diseases.

The understanding of cellular sources of kidney regeneration has rapidly evolved in the last decade. It is now believed that regeneration occurs predominantly from cells that reside within the injured kidney, with minimal contribution from extra-renal cells. We now know that improved kidney regeneration seen following exogenous administration of stem cells occur predominantly by noncellular paracrine mechanisms. Of all extra-renal stem cells, mesenchymal stem cells (MSC) are the most promising stem cell type for treating kidney diseases. There is an ongoing clinical trial evaluating safety and efficacy of MSC in treating acute kidney injury (AKI). Results of this trial are expected to bring use of MSC closer to the clinical realm. An improved understanding of the small molecules that facilitate kidney regeneration and are secreted by MSC will likely result in the development of new therapies for treating AKI. Identification of adult stem cell markers will result in improved understanding of pathophysiology of kidney diseases and could lead to the development of new cellular therapies. Directed differentiation of stem cells into desired cell types such as erythropoietin producing cells will allow selective replacement of lost kidney function. Cell-based therapies for patients with chronic kidney disease are presently in proof-of-principle stage and are expected to evolve in the coming years with improved understanding of stem cell biology. Technological advancement in cellular therapy is expected to provide improved therapeutic options for patients with kidney diseases in the near future.