Effect of Access to Obstetrical Care in Rural Alabama on Perinatal, Neonatal, and Infant Outcomes: 2003-2017.

PURPOSE: To evaluate differential mortality outcomes in rural Alabama counties with or without access to a local labor and delivery (L&D) unit. METHODS: This retrospective cohort study used county-level data from the Alabama Department of Public Health. Rural counties in Alabama were categorized into those with an L&D unit and those without. The 2 groups were compared based on infant mortality rate, perinatal mortality rate, neonatal mortality rate, and low birth weight. RESULTS: The infant mortality rate from 2003-2017 in the rural counties in Alabama with no local obstetrical care was 9.23 per 1,000 live births, whereas the infant mortality rate during the same period in the rural counties with continuous access to local obstetrical units was 7.89 (relative risk [RR] = 1.1679; 95% CI, 1.0643-1.2817, P = 0.0011). The percentage of low birth weight babies from the time period 2003-2014 in the rural counties in Alabama with no local obstetrical care was 10.61%, compared with 9.86% in the rural counties with continuous access to local L&D services (RR = 1.0756; 95% CI, 1.0424-1.1098, P <.0001). The perinatal mortality rate in counties with no active L&D was 10.82 per 1,000 still + live births compared with 8.89 in counties with an active L&D (RR = 1.2149; 95% CI, 1.1147-1.3242; P <.0001). The neonatal mortality rate during this period was 5.67 per 1,000 live births in counties with no active L&D, vs 4.74 in those counties with L&D services (RR = 1.1953; 95% CI, 1.0609-1.3466; P = 0.0034). CONCLUSION: Access to local obstetrical care in a rural area is associated with better infant outcomes.

Evaluation of Family Medicine Residency Programs for Diversity, Equity, and Inclusion Milestones.

BACKGROUND AND OBJECTIVES: In 2020, the Association of Family Medicine Residency Directors (AFMRD) Diversity and Health Equity (DHE) Task Force developed and piloted a framework to measure diversity, equity, and inclusion (DEI) initiatives in medical residencies across five domains: curriculum, evaluation, institution, resident pathway, and faculty pathway. The objectives were (1) to measure DEI initiatives across multiple domains in family medicine residencies using the DEI milestones and (2) to obtain current national baseline data providing criteria against which to measure effectiveness of initiatives and create tailored benchmarks. METHODS: We developed a cross-sectional survey of 12 quantitative residency characteristic items and the five DEI milestone ratings, and distributed the survey to program directors of family medicine residencies accredited by the Accreditation Council for Graduate Medical Education in the spring of 2022. We generated descriptive statistics, including item frequencies and cross-tabulations, and completed subgroup comparisons with analysis of variance. RESULTS: We collected aggregate milestone data for 194 family medicine residencies of 588 eligible programs (33% response rate). Respondents represented 48 states and US territories: 107 community-based, university-affiliated; 48 community-based; 34 university-based; and 5 military/other programs. Overall, the curriculum milestone was rated the highest (mean=2.54, SD=1.03), whereas the faculty pathway (mean=1.94, SD=1.04) and resident pathway (mean=2.02, SD=1.06) milestones were rated lowest. CONCLUSIONS: DEI milestone data may support residency programs as they assess their institution's developmental progress across five key domains. Additionally, aggregate data may shed light on collective strengths and areas for improvement.

Enhancing Examination Success: the Cumulative Benefits of Self-Assessment Questions and Virtual Patient Cases.

Purpose: Research on the learning benefits of the feedback-rich formative assessment environment of virtual patient cases (VPCs) has largely been limited to single institutions and focused on discrete clinical skills or topical knowledge. To augment current understanding, we designed a multi-institutional study to explore the distinct and cumulative effects of VPC formative assessments and optional self-assessment questions (SAQs) on exam performance. Method: In this correlational study, we examined the records of 1,692 students on their family medicine (FM) clerkship at 20 medical schools during the 2014-2015 academic year. Schools utilized an established online curriculum, which included family medicine VPCs, embedded formative assessments, context-rich SAQs corresponding with each VPC, and an associated comprehensive family medicine exam. We used mixed-effects modeling to relate the student VPC composite formative assessment score, SAQ completion, and SAQ performance to students' scores on the FM final examination. Results: Students scored higher on the final exam when they performed better on the VPC formative assessments, completed associated SAQs, and scored higher on those SAQs. Students' SAQ completion enhanced examination performance above that explained by engagement with the VPC formative assessments alone. Conclusions: This large-scale, multi-institutional study furthers the body of research on the effect of formative assessments associated with VPCs on exam performance and demonstrates the added benefit of optional associated SAQs. Findings highlight opportunities for future work on the broader impact of formative assessments for learning, exploring the benefits of integrating VPCs and SAQs, and documenting effects on clinical performance and summative exam scores.

Rational use of laboratory testing in the initial evaluation of soft tissue and joint complaints.

The rational use of laboratory testing to investigate early, undifferentiated joint pain depends heavily on a detailed history and careful physical examination. Nevertheless, several diagnostic tests have some discriminatory function in the initial evaluation of soft tissues and joint complaints, given the correct clinical context. Arthrocentesis frequently gives the best results when compared with other tests in the differential diagnosis of monoarticular and polyarticular joint pain. There is also a role for radiographs, and less frequently, magnetic resonance imaging. Although overuse of an arthritis panel is not recommended, for an appropriately chosen patient, complete blood cell count, serum uric acid, C-reactive protein (or erythrocyte sedimentation rate), rheumatoid factor, antiecyclic citrullinated peptide, and antinuclear antibody titers form a reasonable screening panel when rheumatic disease is suspected based on the clinical condition. Other tests might include a purified protein derivative, anti-Borrelia titers, and antibodies for antistreptolysin O. However, many rheumatic conditions can be diagnosed or at least suspected on clinical grounds alone, and a careful history and physical examination are absolutely essential for the appropriate use of any laboratory testing.