Closing the hepatitis C treatment gap: United States strategies to improve retention in care.

The hepatitis C virus (HCV) treatment landscape is shifting given the advent of direct-acting antivirals and a global call to action by the World Health Organization. Eliminating HCV is now an issue of healthcare delivery. Treatment is limited by the complexity of the HCV care continuum, expensive therapy and competing health burdens experienced by an underserved HCV population. The objective of this literature review was to assess strategies to improve retention in HCV care, with particular focus on those implemented in the United States. We identified barriers in HCV care retention and propose solutions to increase HCV treatment delivery. The following recommendations are herein described: improving the cohesion of health services through localized care and integrated case management, expanding the supply of non-specialist HCV treatment providers, leveraging patient navigators and care coordinators, improving adherence through directly observed therapy and reducing cost barriers through value-based payment and pharmaceutical subscription models.

Emergency department versus community screening on hepatitis C follow-up care.

OBJECTIVES: Emergency department (ED) hepatitis C virus (HCV) screening programs are proliferating, and it is unknown whether EDs are more effective than traditional community screening at promoting HCV follow-up care. The objective of this study was to investigate whether patients screened HCV seropositive (HCV+) in the ED are linked to care and retained in treatment more successfully than patients screened HCV+ in the community. METHODS: A retrospective cohort study was performed including patients screened HCV+ at twelve screening facilities in New Orleans, LA from March 1, 2015 to July 31, 2017. Treatment outcomes, including retention and time to follow-up care, were assessed using the HCV continuum of care model. RESULTS: ED patients (n = 3008) were significantly more likely to achieve RNA confirmation (aRR = 1.91, 95% CI = 1.54-2.37), initiate HCV therapy (aRR = 2.23 [1.76-2.83]), complete HCV therapy (aRR = 1.77 [1.40-2.24]), and achieve HCV functional cure (aRR = 2.80 [1.09-7.23]) compared to community-screened patients (n = 322). ED screening was associated with decreased likelihood of fibrosis staging (aRR = 0.65 [0.51-0.82]) and no difference in linkage to specialty care (aRR = 1.03 [0.69-1.53]). In time to follow up, RNA confirmation occurred at faster rates in the ED (aHR = 2.26 [1.86-2.72]), although these patients completed fibrosis staging at slower rates (aHR = 0.49 [0.38-0.63]) than community patients. CONCLUSIONS: Compared to community screening, HCV screening in the ED was associated with higher rates of disease confirmation, treatment initiation/completion, and cure. Our findings provide new evidence that EDs may be the most effective setting to screen patients for HCV to promote follow-up care.

Research and Scholarly Projects.

The idea of doing a research or scholarly project can be very daunting, however, the satisfaction of seeing a project to its completion is very rewarding. In this article, we provide medical students with guidance on whether they should take on a research or scholarly project during medical school, and how to get started, publish, and then present their project. We also highlight how such a project can benefit an applicant applying for residency training.

Clinical Relevance and Role of Neuronal AT1 Receptors in ADAM17-Mediated ACE2 Shedding in Neurogenic Hypertension.

RATIONALE: Neurogenic hypertension is characterized by an increase in sympathetic activity and often resistance to drug treatments. We previously reported that it is also associated with a reduction of angiotensin-converting enzyme type 2 (ACE2) and an increase in a disintegrin and metalloprotease 17 (ADAM17) activity in experimental hypertension. In addition, while multiple cells within the central nervous system have been involved in the development of neurogenic hypertension, the contribution of ADAM17 has not been investigated. OBJECTIVE: To assess the clinical relevance of this ADAM17-mediated ACE2 shedding in hypertensive patients and further identify the cell types and signaling pathways involved in this process. METHODS AND RESULTS: Using a mass spectrometry-based assay, we identified ACE2 as the main enzyme converting angiotensin II into angiotensin-(1-7) in human cerebrospinal fluid. We also observed an increase in ACE2 activity in the cerebrospinal fluid of hypertensive patients, which was correlated with systolic blood pressure. Moreover, the increased level of tumor necrosis factor-α in those cerebrospinal fluid samples confirmed that ADAM17 was upregulated in the brain of hypertensive patients. To further assess the interaction between brain renin-angiotensin system and ADAM17, we generated mice lacking angiotensin II type 1 receptors specifically on neurons. Our data reveal that despite expression on astrocytes and other cells types in the brain, ADAM17 upregulation during deoxycorticosterone acetate-salt hypertension occurs selectively on neurons, and neuronal angiotensin II type 1 receptors are indispensable to this process. Mechanistically, reactive oxygen species and extracellular signal-regulated kinase were found to mediate ADAM17 activation. CONCLUSIONS: Our data demonstrate that angiotensin II type 1 receptors promote ADAM17-mediated ACE2 shedding in the brain of hypertensive patients, leading to a loss in compensatory activity during neurogenic hypertension.

Acute Optic Neuritis Diagnosed by Bedside Ultrasound in an Emergency Department.

BACKGROUND: Transorbital ultrasound was used to diagnose acute optic neuritis (AON) at bedside in an emergency department (ED). CASE REPORT: A 59-year-old female patient presented to an ED after 7 days of progressive unilateral visual loss while she was receiving outpatient treatment for relapsing-remitting multiple sclerosis. Transorbital ultrasound revealed a disparity between the optic nerve sheath diameters of the affected and nonaffected eyes and striking optic nerve edema in the affected eye. These findings led to a diagnosis of AON and early definitive treatment. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given an absence of reliable diagnostic criteria for AON, comorbidity with multiple sclerosis, and limitations inherent to magnetic resonance imaging, transorbital sonography may facilitate diagnosis of this condition in emergent presentations.

An evaluation study of the Becton-Dickinson ProbeTec Qx (BDQx) Trichomonas vaginalis trichomoniasis molecular diagnostic test in two large, urban STD services.

OBJECTIVES: The BASHH guidelines recommend molecular tests to aid diagnosis of Trichomonas vaginalis (TV) infection; however many clinics continue to use relatively insensitive techniques (pH, wet-prep microscopy (WPM) and culture). Our objectives were to establish a laboratory pathway for TV testing with the Becton-Dickinson Qx (BDQx) molecular assay, to determine TV prevalence and to identify variables associated with TV detection. METHODS: A prospective study of 901 women attending two urban sexual health services for STI testing was conducted. Women were offered TV BDQx testing in addition to standard of care. Data collected were demographics, symptoms, results of near-patient tests and BDQx results for TV, Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC). Women with any positive TV result were treated and followed up for test of cure (TOC). RESULTS: 901 women had a TV BDQx test. 472 (53%) were white, 143 (16%) black and 499 (55%) were symptomatic. Infections detected by BDQx were: 11 TV (1.2%), three GC (0.3%) and 44 CT (4.9%). Of the 11 BDQx-detected TV infections, 8 (73%) were in patients of black ethnicity. Of these, four of seven cases (57%) were WPM-positive. All patients received treatment and nine of nine (100%) were BDQx-negative at TOC. In univariate analysis, only black ethnicity was associated with likelihood of a positive TV BDQx result (relative risk (RR) 10.2 (95% CI 2.15 to 48.4)). CONCLUSIONS: The use of the BDQ enhanced detection of TV in asymptomatic and symptomatic populations. Cost-effective implementation of the test will rely on further work to reliably detect demographic and clinical variables that predict positivity.

Acute HIV Discovered During Routine HIV Screening With HIV Antigen-Antibody Combination Tests in 9 US Emergency Departments.

STUDY OBJECTIVE: Newer combination HIV antigen-antibody tests allow detection of HIV sooner after infection than previous antibody-only immunoassays because, in addition to HIV-1 and -2 antibodies, they detect the HIV-1 p24 antigen, which appears before antibodies develop. We determine the yield of screening with HIV antigen-antibody tests and clinical presentations for new diagnoses of acute and established HIV infection across US emergency departments (EDs). METHODS: This was a retrospective study of 9 EDs in 6 cities with HIV screening programs that integrated laboratory-based antigen-antibody tests between November 1, 2012, and December 31, 2015. Unique patients with newly diagnosed HIV infection were identified and classified as having either acute HIV infection or established HIV infection. Acute HIV infection was defined as a repeatedly reactive antigen-antibody test result, a negative HIV-1/HIV-2 antibody differentiation assay, or Western blot result, but detectable HIV ribonucleic acid (RNA); established HIV infection was defined as a repeatedly reactive antigen-antibody test result and a positive HIV-1/HIV-2 antibody differentiation assay or Western blot result. The primary outcomes were the number of new HIV diagnoses and proportion of patients with laboratory-defined acute HIV infection. Secondary outcomes compared reason for visit and the clinical presentation of acute HIV infection. RESULTS: In total, 214,524 patients were screened for HIV and 839 (0.4%) received a new diagnosis, of which 122 (14.5%) were acute HIV infection and 717 (85.5%) were established HIV infection. Compared with patients with established HIV infection, those with acute HIV infection were younger, had higher RNA and CD4 counts, and were more likely to have viral syndrome (41.8% versus 6.5%) or fever (14.3% versus 3.4%) as their reason for visit. Most patients with acute HIV infection displayed symptoms attributable to acute infection (median symptom count 5 [interquartile range 3 to 6]), with fever often accompanied by greater than or equal to 3 other symptoms (60.7%). CONCLUSION: ED screening using antigen-antibody tests identifies previously undiagnosed HIV infection at proportions that exceed the Centers for Disease Control and Prevention's screening threshold, with the added yield of identifying acute HIV infection in approximately 15% of patients with a new diagnosis. Patients with acute HIV infection often seek ED care for symptoms related to seroconversion.

New Zealand's emergency department target - did it reduce ED length of stay, and if so, how and when?

BACKGROUND: In 2009, the New Zealand government introduced a hospital emergency department (ED) target - 95% of patients seen, treated or discharged within 6 h - in order to alleviate crowding in public hospital EDs. While these targets were largely met by 2012, research suggests that such targets can be met without corresponding overall reductions in ED length-of-stay (LOS). Our research explores whether the NZ ED time target actually reduced ED LOS, and if so, how and when. METHODS: We adopted a mixed-methods approach with integration of data sources. After selecting four hospitals as case study sites, we collected all ED utilisation data for the period 2006 to 2012. ED LOS data was derived in two forms-reported ED LOS, and total ED LOS - which included time spent in short-stay units. This data was used to identify changes in the length of ED stay, and describe the timing of these changes to these indicators. Sixty-eight semi-structured interviews and two surveys of hospital clinicians and managers were conducted between 2011 and 2013. This data was then explored to identify factors that could account for ED LOS changes and their timing. RESULTS: Reported ED LOS reduced in all sites after the introduction of the target, and continued to reduce in 2011 and 2012. However, total ED LOS only decreased from 2008 to 2010, and did not reduce further in any hospital. Increased use of short-stay units largely accounted for these differences. Interview and survey data showed changes to improve patient flow were introduced in the early implementation period, whereas increased ED resources, better information systems to monitor target performance, and leadership and social marketing strategies mainly took throughout 2011 and 2012 when total ED LOS was not reducing. CONCLUSIONS: While the ED target clearly stimulated improvements in patient flow, our analysis also questions the value of ED targets as a long term approach. Increased use of short-stay units suggests that the target became less effective in 'standing for' improved timeliness of hospital care in response to increasing acute demand. As such, the overall challenges in managing demand for acute and urgent care in New Zealand hospitals remain.

Routine HIV screening in two health-care settings--New York City and New Orleans, 2011-2013.

Approximately 16% of the estimated 1.1 million persons living with human immunodeficiency virus (HIV) in the United States are unaware of their infection and thus unable to benefit from effective treatment that improves health and reduces transmission risk. Since 2006, CDC has recommended that health-care providers screen for HIV all patients aged 13-64 years unless prevalence of undiagnosed HIV infection in their patients has been documented to be <0.1%. This report describes novel HIV screening programs at the Urban Health Plan (UHP), Inc. in New York City and the Interim Louisiana Hospital (ILH) in New Orleans. Data were provided by the two programs. UHP screened a monthly average of 986 patients for HIV during January 2011-September 2013. Of the 32,534 patients screened, 148 (0.45%) tested HIV-positive, of whom 147 (99%) received their test result and 43 (29%) were newly diagnosed. None of the 148 patients with HIV infection were previously receiving medical care, and 120 (81%) were linked to HIV medical care. The ILH emergency department (ED) and the urgent-care center (UCC) screened a monthly average of 1,323 patients from mid-March to December 2013. Of the 12,568 patients screened, 102 (0.81%) tested HIV-positive, of whom 100 (98%) received their test result, 77 (75%) were newly diagnosed, and five (5%) had acute HIV infection. Linkage to HIV medical care was successful for 67 (74%) of 91 patients not already in care. Routine HIV screening identified patients with new and previously diagnosed HIV infection and facilitated their linkage to medical care. The two HIV screening programs highlighted in this report can serve as models that could be adapted by other health-care settings.

Emergency physicians perspectives of state continuing medical education requirements for medical licensure.

Objectives: This study aims to better understand the perspectives of emergency medicine physicians' on the role that state-mandated, topic-specific continuing medical education (CME) plays in addressing knowledge gaps, its relevance to current emergency practice, its reported burden and costs of CME activities to emergency physicians, and its perceived improvement in patient care. Methods: A cross-sectional survey was designed by the Coalition of Board-Certified Emergency Physicians (COBCEP) and distributed in February 2023 to all American Board of Emergency Medicine (ABEM)-certified physicians. Statistical tests of significance (Pearson's chi-square and Fisher's exact test) assessed the cost and time spent on CME as well as the perceived value placed on CME by ABEM-certified physicians to improve patient care. Data were summarized using descriptive statistics. Results: There were 5562 (13.0%) responses from the 43656 physicians who received the survey-5506 responses were included for analysis. Over half of the physicians (53.0%) had more than 15 years of post-residency practice experience. Most physicians (57.3%) spent less than $5,000 per year on obtaining CME. Most physicians practicing in states with state-mandated, topic-specific CME requirements believed that participation in ABEM continuing certification could be used to reduce the need for state-mandated, topic-specific CME requirements (83.6%) and state-mandated, topic-specific requirements were believed to be unlikely to improve patient care (70.8%). Conclusions: Although well-intended, state CME requirements may lack relevancy and can, at times, place an undue burden on emergency physicians. Tailoring CME requirements to increase relevance to their patient populations and reduce barriers to completing CME could enhance knowledge translation and improve patient outcomes.

Patient perceptions of barriers to the early diagnosis of lung cancer and advice for health service improvement.

BACKGROUND AND OBJECTIVE: Patient and systematic factors within primary and secondary care contribute to delay in timely diagnosis of lung cancer. This qualitative study aimed to explore New Zealand service users' experiences of the pathway to lung cancer diagnosis, identify factors contributing to delay and provide advice for service improvement. METHODS: Two samples were recruited. Patients who presented to a hospital emergency department with suspicious symptoms (n = 19) were interviewed individually. Those with confirmed lung cancer (n = 20) took part in a focus group. Similar semi-structured interview schedules were used. Interviews and focus groups were audiorecorded and thematic analyses performed. Evident commonality led to an integrated interpretation. RESULTS: Patient delay was common but most had seen a GP before referral. No ED participant had seen a respiratory specialist prior ED admission, but after that, most had a seamless pathway. This contrasts with long waits for outpatient participants. Two central themes, 'access to health services' and 'processes of care', described factors influencing delay. Subthemes highlighted issues relating to symptom interpretation, health beliefs, provider continuity, relationships and perceived expertise that contributed to patient and GP delay. System complexity, information systems and resourcing issues were identified as barriers at the primary-secondary care interface and within secondary care. CONCLUSION: Reasons for diagnostic delay are complex and multifactorial. Solutions include community initiatives to educate and resource at-risk patients to seek help, supporting and resourcing primary care to increase timely referral and implementing strategies to reduce system complexity for GPs and patients, and the employment of care coordinators.

Delays in fibrosis staging reduce the likelihood of achieving hepatitis C treatment and cure.

BACKGROUND: Updated 2021 hepatitis C virus (HCV) treatment guidelines no longer recommend fibrosis staging for treatment-naïve patients without cirrhosis; however, numerous US state Medicaid plans continue to restrict initiation of HCV therapy by fibrosis stage. The study objective was to determine whether delays from HCV diagnosis to fibrosis staging impact the likelihood of initiating/completing HCV treatment and achieving sustained virologic response (SVR). METHODS: A retrospective cohort study was performed among patients diagnosed with chronic HCV by an urban US emergency department who subsequently underwent fibrosis staging. Time elapsed from HCV diagnosis to hepatic fibrosis staging was evaluated on the likelihood of treatment initiation, treatment completion and SVR. RESULTS: Among fibrosis staging modalities, hepatic ultrasounds occurred more quickly following HCV diagnosis (3.5 months, IQR = 12.4 months), compared to FibroSure (8.5 months, IQR = 20.4 months) and FibroScan (9.9 months, IQR = 18.0 months) (p<.001). Each six-month delay in fibrosis staging decreased the likelihood of initiating treatment by 5% (adjusted relative risk (aRR)=0.95; 95% confidence interval (CI)=0.91-0.998; p=.04) and the likelihood of SVR by 7% (aRR = 0.93; 95% CI = 0.87-0.995; p=.04) after adjusting for insurance, race/ethnicity and history of HIV testing. CONCLUSIONS: Delays in hepatitis fibrosis staging were significantly associated with decreased likelihood of HCV treatment initiation and SVR.

New Zealand's Integration-Based Policy for Driving Local Health System Improvement - Which Conditions Underpin More Successful Implementation?

INTRODUCTION: The System Level Framework (SLMF) is a policy introduced by New Zealand's Ministry of Health in 2016 with the aim of improving health outcomes by stimulating inter-organisational integration at the local level. We sought to understand which conditions that vary at the local level are most important in shaping successful implementation of this novel and internationally significant policy initiative relevant to integrated care. STRATEGY AND METHODS: We conducted 50 interviews with managers and clinicians who were directly involved in SLM implementation during 2018. Interview data was supplemented with the SLM Improvement Plans of all districts over the first three years of implementation. We used Qualitative Comparative Analysis (QCA) to identify the combinations and configurations of necessary and sufficient conditions of successful implementation. RESULTS: We found that the strength of formal and informal organisational relationships at the local level were critical conditions for implementation success, and that while fidelity to the policy programme was necessary, it was not sufficient. Broader contextual features such as population size and complexity of the organisational environment were less important. The SLMF was able to deepen and widen inter-organisational collaboration where it already existed but could not mitigate the legacies of weaker relationships. DISCUSSION: The two dimensions of implementation success, 'Maturity of SLM Improvement Plan Processes' and 'Data Sophistication and Use' were closely related. Broadly, our findings support the contention that integrated approaches to health system improvement at the local level require collaborative, trust-based approaches with an emphasis on iterative learning, including the willingness to share data between organisations. CONCLUSION: In the context of integrated care, our findings support the need to focus on establishing the conditions that build collaborative governance in addition to strengthening it when it already exists.

Emergency Physician Survey on Firearm Injury Prevention: Where Can We Improve?

INTRODUCTION: Firearm injury and death is increasingly prevalent in the United States. Emergency physicians (EP) may have a unique role in firearm injury prevention. The aim of this study was to describe EPs' beliefs, attitudes, practices, and barriers to identifying risk of and counseling on firearm injury prevention with patients. A secondary aim was assessment of perceived personal vulnerability to firearm injury while working in the emergency department (ED). METHODS: We conducted a cross-sectional survey of a national convenience sample of EPs, using questions adapted from the American College of Surgeons' Committee on Trauma 2017 survey of surgeons. Descriptive statistics and chi-square tests were calculated as appropriate. RESULTS: A total of 1901 surveys were completed by EPs from across the United States. Among respondents, 42.9% had a firearm at home, and 56.0% had received firearm safety training. Although 51.4% of physicians in our sample were comfortable discussing firearm access with their high-risk patients, more than 70% agreed or strongly agreed that they wanted training on procedures to follow when they identify that a patient is at high risk of firearm injury. Respondents reported a variety of current practices regarding screening, counseling, and resource use for patients at high risk of firearm injury; the highest awareness and self-reported screening and counseling on firearm safety was with patients with suicidal ideation. Although 92.3% of EPs reported concerns about personal safety associated with firearms in the ED, 48.1% reported that there was either no protocol for dealing with a firearm in the ED, or if there was a protocol, they were not aware of it. Differences in demographics, knowledge, attitudes, and behavior were observed between respondents with a firearm in the home, and those without a firearm in the home. CONCLUSIONS: Among respondents to this national survey of a convenience sample of EPs, approximately 40% had a firearm at home. The majority reported wanting increased education and training to identify and counsel ED patients at high risk for firearm injury. Improved guidance on personal safety regarding firearms in the ED is also needed.

The prevalence of lesbian, gay, bisexual, and transgender health education and training in emergency medicine residency programs: Where are we now?

BACKGROUND: Despite identified inequities and disparities in lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ+) health, past studies have shown little or no education at the medical school or residency level for emergency physicians. With increased focus on health inequities and disparities, we sought to reexamine the status of sexual and gender minority health education in U.S. emergency medicine (EM) residencies. OBJECTIVES: Our primary objective was to determine how many EM residencies offer education on LGBTQ+ health. Secondary objectives included the number of actual versus preferred hours of LGBTQ+ training, identification of barriers to providing education, and correlation of education with program demographics. Finally, we compared our current data with past results of our 2013 study. METHODS: The initial survey that sought to examine LGBTQ+ training in 2013 was used and sent in 2020 via email to EM programs accredited by the American Council for Graduate Medical Education who had at least one full class of residents in 2019. Reminder emails and a reminder post on the Council of Residency Directors in Emergency Medicine listserv were used to increase participation. RESULTS: A total of 229 programs were eligible, with a 49.3% response rate (113/229). The majority (75%) offered education content on LGBTQ+ health, for a median (IQR) of 2 (1-3) hours and a range of 0 to 22 hours. Respondents preferred more hours of education than offered (median desired hours = 4, IQR = 2-5 hours; p < 0.001). The largest barrier identified was lack of time in curriculum (63%). The majority of programs had known LGBTQ+ faculty and residents. Inclusion and amount of education hours positively correlated with presence of LGBTQ+ faculty or residents; university- and county-based programs were more likely to deliver education content than private groups (p = 0.03). Awareness of known LGBTQ+ residents but not faculty differed by region, but there was no significant difference in actual or preferred content by region. CONCLUSION: The majority of respondents offer education in sexual and gender minority health, although there remains a gap between actual and preferred hours. This is a notable increase from 26% of responding programs providing education in 2013. Several barriers still exist, and the content, impact, and completeness of education remain areas for further study.

The World Health Organization Collaborating Center for Emergency and Trauma (WHO-CCET) in South East Asia, The World Academic Council of Emergency Medicine (WACEM), and The American College of Academic International Medicine (ACAIM) 2021 Framework for using Telemedicine Technology at Healthcare Institutions.

The coronavirus disease 2019 crisis has forced the world to integrate telemedicine into health delivery systems in an unprecedented way. To deliver essential care, lawmakers, physicians, patients, payers, and health systems have all adopted telemedicine and redesigned delivery processes with accelerated speed and coordination in a fragmented way without a long-term vision or uniformed standards. There is an opportunity to learn from the experiences gained by this pandemic to help shape a better health-care system that standardizes telemedicine to optimize the overall efficiency of remote health-care delivery. This collaboration focuses on four pillars of telemedicine that will serve as a framework to enable a uniformed, standardized process that allows for remote data capture and quality, aiming to improve ongoing management outside the hospital. In this collaboration, we recommend learning from this experience by proposing a telemedicine framework built on the following four pillars-patient safety and confidentiality; metrics, analytics, and reform; recording of audio-visual data as a health record; and reimbursement and accountability.

Gynaecologic cancer patients' needs and experiences of supportive health services in New Zealand.

BACKGROUND AND OBJECTIVES: Psychosocial care across the cancer continuum is a core component of quality gynaecologic cancer services. The purpose of this qualitative study was to identify needs for supportive care in a sample of New Zealand women and to understand to what extent they feel their needs are being met by health services. METHODS: Purposive sampling was used to recruit women (n=28) diagnosed with a gynaecologic cancer. Unstructured interviews were conducted and a thematic analysis was performed. RESULTS: Interviews revealed a range of shared and unique needs and support experiences. Three themes emerged reflecting participants' sense of control, need for validation of the cancer experience and organisation of their care. Findings suggest issues of continuity and coordination of care result in unmet support needs across the continuum of care, but primarily after treatment finishes. CONCLUSION: While broadly consistent with previous results, findings highlight the need for a patient-focused, comprehensive, integrated approach to supportive cancer care encompassing diagnosis, treatment and long-term recovery.

Like using a refrigerator to heat food: capacity and capability funding in primary care and the legacy of the Primary Health Organisation Performance Programme.

INTRODUCTION In 2016, the New Zealand Ministry of Health introduced the System Level Measures (SLM) framework as a new approach to health system improvement that emphasised quality improvement and integration. A funding stream that was a legacy of past primary care performance management was repurposed as 'capacity and capability' funding to support the implementation of the SLM framework. AIM This study explored how the capacity and capability funding has been used and the issues and challenges that have arisen from the funding implementation. METHODS Semi-structured interviews with 50 key informants from 18 of New Zealand's 20 health districts were conducted. Interview transcripts were coded using thematic analysis. RESULTS The capacity and capability funding was used in three different ways. Approximately one-third of districts used it to actively support quality improvement and integration initiatives. Another one-third tweaked existing performance incentive schemes and in the remaining one-third, the funding was passed directly on to general practices without strings attached. Three key issues were identified related to implementation of the capacity and capability funding: lack of clear guidance regarding the use of the funding; funding perceived as a barrier to integration; and funding seen as insufficient for intended purposes. DISCUSSION The capacity and capability funding was intended to support collaborative integration and quality improvement between health sector organisations at the district level. However, there is a mismatch between the purpose of the capacity and capability funding and its use in practice, which is primarily a product of incremental and inconsistent policy development regarding primary care improvement.

Advancing Diversity and Inclusion: An Organized Approach Through a Medical Specialty Academy.

BACKGROUND: The benefits of a diverse workforce in medicine have been previously described. While the population of the United States has become increasingly diverse, this has not occurred in the physician workforce. In academic medicine, underrepresented in medicine (URiM) faculty are less likely to be promoted or retained in academic institutions. Studies suggest that mentorship and engagement increase the likelihood of development, retention, and promotion. However, it is not clear what form of mentorship creates these changes. The Academy for Diversity and Inclusion in Emergency Medicine (ADIEM), an academy within the Society for Academic Emergency Medicine, is a group focused on advancing diversity and inclusion as well as promoting the development of its URiM students, residents, and faculty. The Academy serves many of the functions of a mentoring program. We assessed whether active involvement in ADIEM led to increased publications, promotion, or leadership advancement in the areas of diversity, equity, and inclusion. METHODS: We performed a survey of ADIEM members to determine if career development and productivity, defined as written scholarly products, presentations, and mentorship in the area of diversity, equity, and inclusion was enhanced by the establishment of the academy. To determine whether there were significant changes in academic accomplishments after the formation of ADIEM, two groups, ADIEM leaders and ADIEM nonleader members, were examined. RESULTS: Thirteen ADIEM leaders and 14 ADIEM nonleader members completed the survey. Academic productivity in the area of diversity, equity, and inclusion increased significantly among ADIEM leaders when compared to ADIEM nonleader members after the founding of ADIEM. In particular, in the ADIEM leader group, there were significant increases in manuscript publications (1.31 ± 1.6 to 5.5 ± 7.96, p = 0.12), didactic presentations (3.85 ± 7.36 to 23.46 ± 44.52, p < 0.01), grand rounds presentations (0.83 ± 1.75 to 8.6 ± 10.71, p < 0.05), and student/resident mentees (6.46 ± 9.36 to 25 ± 30.41, p = 0.02). CONCLUSION: The formation of a specialized academy within a national medical society has advanced academic accomplishments in diversity, equity, and inclusion in emergency medicine among ADIEM leadership. Involvement of URiM and lesbian, gay, bisexual, and transgender faculty in the academy fostered faculty development, mentoring, and educational scholarship.