The Feasibility of Blinding Residency Programs to USMLE Step 1 Scores During GME Application, Interview, and Match Processes.

BACKGROUND: With the recent announcement that Step 1 score reporting will soon change to pass/fail, residency programs will need to reconsider their recruitment processes. OBJECTIVE: We (1) evaluated the feasibility of blinding residency programs to applicants' Step 1 scores and their number of attempts throughout the recruitment process; (2) described the selection process that resulted from the blinding; and (3) reviewed if a program's initial rank list, created before scores were known, would be changed before submission for the Match. METHODS: During the 2018-2019 and 2019-2020 recruitment seasons, all programs at a single sponsoring institution were invited to develop selection criteria in the absence of Step 1 data, and to remain blinded to this data throughout recruitment. Participating programs were surveyed to determine factors affecting feasibility and metrics used for residency selection. Once unblinded to Step 1 scores, programs had the option to change their initial rank lists. RESULTS: Of 24 residency programs, 4 participated (17%) in the first year: emergency medicine, neurology, pediatrics, and psychiatry. The second year had the same participants, with the addition of family and community medicine and radiation oncology (n = 6, 25%). Each program was able to determine mission-specific qualities in the absence of Step 1 data. In both years, one program made changes to the final rank list. CONCLUSIONS: It was feasible for programs to establish metrics for residency recruitment in the absence of Step 1 data, and most programs made no changes to final rank lists after Step 1 scores were known.

Managing respiratory emergencies at school: A county-wide stock inhaler program.

BACKGROUND: A total of 15 states allow schools to manage respiratory emergencies among multiple students by using a single albuterol inhaler (stock inhaler) paired with a disposable holding chamber. OBJECTIVE: Our aim was to evaluate implementation barriers and facilitators, as well as satisfaction with a stock inhaler program across K through12 schools in Pima County, Arizona. METHODS: All public, charter, private, and parochial schools were offered supplies, web-based training, and technical assistance at no cost. The RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) framework was used to evaluate program implementation. School documentation logs were reviewed, school health personnel were surveyed, and a convenience sample of health personnel were interviewed. Chi-square tests evaluated categoric outcomes and Poisson hurdle regression examined stock inhaler use by school organization type, grade levels served, and type of school health personnel employed. RESULTS: In all, 229 schools (68%) participated, reaching 82% of students in the county. A total of 152 schools (66%) used a stock inhaler, accounting for 1038 events. The mean number of puffs administered was 2.7 (SD = 1.2) per event, and most events (79%) involved students with asthma. Although most events (83.9%) resulted in the student returning to class, 15.6% resulted in students being sent home. Only 6 events resulted in 911 calls, and 5 of these led to an ambulance transport. School health personnel reported high levels of satisfaction, and all schools renewed participation for a second year. Program costs were $156 per school. CONCLUSION: With technical assistance, stock inhaler programs can be feasibly implemented by schools in a wide range of settings, thereby increasing their capacity to safely manage respiratory emergencies.

School-supervised use of a once-daily inhaled corticosteroid regimen: A cluster randomized trial.

BACKGROUND: School-supervised use of a once-daily inhaled corticosteroid regimen (supervised therapy) can improve medication adherence and asthma control. OBJECTIVE: We sought to evaluate the effectiveness of supervised therapy in a unique setting and population. METHODS: We conducted a cluster randomized trial of supervised therapy in 20 elementary schools with a disproportionate enrollment of low-income Latino students. Schools were purposively selected, matched, and randomized to receive 9 months of supervised therapy with mometasone furoate or usual care. All English- or Spanish-speaking students with self-reported asthma were eligible. The Asthma Control Questionnaire (ACQ) was interviewer administered quarterly at school. Students in supervised therapy schools were hypothesized to have lower ACQ scores than students in usual-care schools. RESULTS: Of 393 enrolled students, 189 students receiving immediate intervention and 143 students receiving delayed intervention provided 1 or more ACQ data points, were between 6 and 10 years of age, and were included in the primary analysis. At baseline, 39% of students reported taking a controller medication, and 24% had well-controlled asthma. Eighty percent of students receiving immediate intervention were prescribed mometasone. Schools administered 98% of prescribed doses when students attended school. Absences, weekends, and holidays reduced calendar adherence to 53%. During the first year, the mean ACQ score for students receiving immediate and delayed intervention was 1.55 (95% CI, 1.41-1.70) and 1.64 (95% CI, 1.47-1.80), respectively. The estimated treatment effect was -0.08 (95% CI, -0.31 to 0.14). DISCUSSION: Compared with usual care, supervised therapy did not improve asthma control among this population of Latino students. Additional research is warranted to confirm these results.

Workforce Trends and Analysis of Selected Pediatric Subspecialties in the United States.

OBJECTIVE: To update pediatric subspecialty workforce data to support evidence-based legislation and public policy decisions by replicating the American Academy of Pediatrics' 1998 Future of Pediatric Education (FOPE II) workforce survey. METHODS: A descriptive and comparative analysis of survey responses from 9950 US pediatric subspecialists who completed an electronic survey. RESULTS: Pediatric subspecialists are working fewer hours and spending less of their time in direct patient care than they did in 1998 but the mean hours worked differs significantly according to subspecialty. Most subspecialists continue to be board-certified, white, non-Hispanic men, although the percentage who are women and from minority groups has increased. The proportion of subspecialists practicing in an academic medical center has increased since 1998. Thirty percent of pediatric subspecialists reported appointment wait times of >2 weeks and pediatric subspecialists in developmental pediatrics, endocrinology, and neurology identified much longer wait times than other subspecialists. CONCLUSION: The demographic and practice characteristics of pediatric subspecialists have changed since the FOPE II survey and access to subspecialty care in a family's community remains a challenge. However, pediatric subspecialties are not monolithic and solutions to workforce shortages will need to take into account these differences to improve access to subspecialty care.

Why parents use the emergency department during evening hours for nonemergent pediatric care.

BACKGROUND: Emergency departments (EDs) are commonly used by pediatric patients for nonemergent reasons. There is little information regarding how parents perceive their use of the ED and primary care availability during evening hours. METHODS: We conducted a survey of parental perspectives of ED use during evening hours. Participants were parents of pediatric patients (age 0-18 years) at a large quaternary medical center's ED presenting between 17:00 and 22:00 hours from January 15, 2013 to March 12, 2013. RESULTS: Most patients had a primary care pediatrician (98/102, 96.1%); 80% of their pediatricians (78/98) did not have evening hour availability. Overall, 46.7% of parents would have preferred to go to their primary care pediatrician. CONCLUSIONS: Many parents who expect outpatient treatment prefer to take their child to a primary care pediatrician during evening hours, but present to the ED because of lack of primary care access.

Effectiveness of gun-safety counseling and a gun lock giveaway in a Hispanic community.

OBJECTIVE: To evaluate the effectiveness of gun-safety counseling, a gun-safety brochure, and a free gun lock in subsequent gun removal and safe storage. METHODS: In a predominantly Hispanic pediatric clinic, gun-owning families were identified and assigned to either an intervention group (gun-safety counseling, gun-safety brochure, and a free gun lock) or a control group (usual anticipatory guidance). Families were resurveyed 1 month later for changes in the proportion of gun owners, changes in frequency of unloaded and locked gun storage, and changes to the use of locked storage. RESULTS: Two hundred six (7.8%) of the 2649 parents initially surveyed kept guns in their households. At follow-up, 16% of the control group removed all guns from their homes as compared with 22% of the intervention group (P = .41). Among the families who received the intervention, 61.6% either removed all guns from their homes or improved their gun storage safety practice in some way. Only 26.9% of the families in the control group showed similar types of improvement (P<.001). In those households still with guns at follow-up, 50.9% of the intervention group had some type of improvement in safe gun storage compared with 12.3% of the control group (P<.001). More specifically, 25.0% in the intervention group improved the frequency of locked storage of guns compared with 4.8% of those in the control group (P = .003). Twenty-six percent of the intervention group improved the use of locked storage compared with 3.1% in the control group (P<.001). CONCLUSIONS: A brief gun-safety counseling session supported with written information along with a gun lock giveaway resulted in significant improvements in safe gun storage behaviors. It did not significantly influence the removal of guns from the home. This study gives support to the recommendations of the American Academy of Pediatrics (Elk Grove Village, Ill) and other professional organizations to discuss gun safety with families and encourages research in this area. It also suggests that providing tools such as gun locks to enable the desired behavior may improve safe storage.

The development of a group B streptococcus prevention policy at a community hospital.

BACKGROUND AND OBJECTIVES: In 1996, the Centers for Disease Control (CDC) issued guidelines for antepartum antibiotic prophylaxis of group B streptococcal (GBS)-positive women. The objective of this study is to document results of a GBS prophylaxis policy at one nonacademically affiliated, community hospital and discern its effectiveness with regard to compliance as well as in decreasing the incidence of early onset GBS (EOGBS) disease. METHODS: The development of a GBS-prevention policy at the Women's Hospital of Greensboro (WHG) was documented by means of interviews and examination of minutes of meetings. Effectiveness of the policy was assessed by calculating the percentage of all GBS+ or unknown mothers who received antepartum antibiotics during a 1-year period. Additionally, all newborns with any positive GBS culture during the past 13 years at WHG were identified. RESULTS: The policy was formulated and distributed during a 6-month period by strong leadership, community "buy-in," and an educational seminar. A preprinted physician order was written so that all GBS-positive/unknown mothers would receive antepartum antibiotics. Additionally, a clinical pathway was used to track and monitor maternal GBS status. During October 1, 1999 to September 30, 2000, 1124 (23.1%) mothers were found to be GBS positive/unknown. Of those who delivered an infant >37 weeks' gestation and who could be linked to the pharmacy database, 777 (91.1%) received antepartum antibiotics. The incidence of EOGBS disease at WHG before 1996 was 1.93 +/- 0.7/1000 births compared to 0.4 +/- 0.05/1000 after the issuance of the guidelines (p = 0.002, t-test). CONCLUSIONS: Over 90% of GBS-positive mothers were treated with antibiotics at WHG. Associated with this high adherence rate to the CDC guidelines has been a five-fold decrease in the incidence of EOGBS disease. We attribute these results to the implementation of a preprinted physician order sheet to direct intrapartum antibiotics for women with GBS positive or unknown colonization and the use of a clinical pathway to track GBS colonization status.