Association between Gaps in Care Coordination and Emergency Department Visits Among Children without Chronic Conditions or Special Needs.

OBJECTIVE: Prior studies and have shown that gaps in care coordination (CC) increase the risk of emergency department (ED) visits among children with special healthcare needs. This study aims to determine if gaps in CC are associated with an increased risk of ED visits among children without special needs (non-CSHCN). STUDY DESIGN: We conducted a cross-sectional study using the National Survey of Children's Health (2018-2019), representing children up to age 17. A "gap" in CC occurs if the adult proxy reported dissatisfaction with communication between providers or difficulty getting the help needed to coordinate care for the child. Using logistic regression models adjusting for age and sex, we measured the association between a gap in CC and 1 or more ED visits during the past 12 months overall and stratified by any special needs. Adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) were calculated. RESULTS: Between 2018 and 2019, 15% of respondents reported a gap in CC and 19.4% of children had at least one ED visit. Among non-CSHCN, these rates were 11% and 17%. In this population, a gap in CC was independently associated with an increased odds of ED use (AOR: 2.14; 95% CI 1.82, 2.52). CONCLUSIONS FOR PRACTICE: Self-reported gaps in ambulatory CC were associated with increased odds of ED visits even among non-CSHCN children with minor illnesses, suggesting that providers need to be aware of potential pitfalls in CC for all children, and ensure that pertinent information is available where needed.

Scholarly Activity during Neonatal-Perinatal Medicine Fellowship.

OBJECTIVE: This study aimed to describe scholarly activity training during neonatal-perinatal medicine (NPM) fellowship and factors associated with scholarship productivity. STUDY DESIGN: NPM fellowship program directors (FPDs) were surveyed between March and October 2019, as part of a larger study of all pediatric subspecialty programs, to define barriers, resources, and productivity for fellow scholarly activity. High productivity was defined as >75% of fellows in a program in the last 5 years having a manuscript accepted for publication based on fellowship scholarly work. RESULTS: Fifty-four percent (54/100) of NPM FPDs completed the survey. Nineteen fellowship programs (35%, 19/54) met the definition for high productivity. High productivity in scholarly activity was associated with a greater likelihood of having funds to conduct scholarship (p = 0.011), more protected months dedicated to scholarly activity (p = 0.03), and fellow extramural grant applications (submitted or accepted, p = 0.047). FPDs of productive programs were less likely to report lack of an adequate core research curriculum (p = 0.018), lack of adequate expertise on the fellowship scholarly oversight committee (p = 0.048), and lack of sufficient divisional mentorship (p = 0.048) as barriers to completion of scholarly activity during fellowship. CONCLUSION: Research funding, protected research time, established research mentors, and a research curriculum are associated with higher scholarly activity productivity among NPM fellowship programs. Further investment in these resources may improve scholarly activity productivity during fellowship training. KEY POINTS: · Fellow productivity depends on protected time.. · Inadequate funding impacts fellow productivity.. · Mentorship is important for fellow scholarship.. · A research curriculum impacts research outcomes..

Cost-Effectiveness of Smoking Cessation Interventions in Patients With Ischemic Stroke and Transient Ischemic Attack.

BACKGROUND: Smoking cessation rates after stroke and transient ischemic attack are suboptimal, and smoking cessation interventions are underutilized. We performed a cost-effectiveness analysis of smoking cessation interventions in this population. METHODS: We constructed a decision tree and used Markov models that aimed to assess the cost-effectiveness of varenicline, any pharmacotherapy with intensive counseling, and monetary incentives, compared with brief counseling alone in the secondary stroke prevention setting. Payer and societal costs of interventions and outcomes were modeled. The outcomes were recurrent stroke, myocardial infarction, and death using a lifetime horizon. Estimates and variance for the base case (35% cessation), costs and effectiveness of interventions, and outcome rates were imputed from the stroke literature. We calculated incremental cost-effectiveness ratios and incremental net monetary benefits. An intervention was considered cost-effective if the incremental cost-effectiveness ratio was less than the willingness-to-pay threshold of $100 000 per quality-adjusted life-year (QALY) or when the incremental net monetary benefit was positive. Probabilistic Monte Carlo simulations modeled the impact of parameter uncertainty. RESULTS: From the payer perspective, varenicline and pharmacotherapy with intensive counseling were associated with more QALYs (0.67 and 1.00, respectively) at less total lifetime costs compared with brief counseling alone. Monetary incentives were associated with 0.71 more QALYs at an additional cost of $120 compared with brief counseling alone, yielding an incremental cost-effectiveness ratio of $168/QALY. From the societal perspective, all 3 interventions provided more QALYs at less total costs compared with brief counseling alone. In 10 000 Monte Carlo simulations, all 3 smoking cessation interventions were cost-effective in >89% of runs. CONCLUSIONS: For secondary stroke prevention, it is cost-effective and potentially cost-saving to deliver smoking cessation therapy beyond brief counseling alone.

COVID-19 is Observed in Older Children During the Omicron Wave in New York City.

BACKGROUND: The Omicron variant of SARS-CoV-2 has a predilection for the upper airways, causing symptoms such as sore throat, hoarse voice, and stridor. OBJECTIVE: We describe a series of children with COVID-19-associated croup in an urban multicenter hospital system. METHODS: We conducted a cross-sectional study of children ≤18 years of age presenting to the emergency department during the COVID-19 pandemic. Data were extracted from an institutional data repository comprised of all patients who were tested for SARS-CoV-2. We included patients with a croup diagnosis by International Classification of Diseases, 10th revision code and a positive SARS-CoV-2 test within 3 days of presentation. We compared demographics, clinical characteristics, and outcomes for patients presenting during a pre-Omicron period (March 1, 2020-December 1, 2021) to the Omicron wave (December 2, 2021-February 15, 2022). RESULTS: We identified 67 children with croup, 10 (15%) pre-Omicron and 57 (85%) during the Omicron wave. The prevalence of croup among SARS-CoV-2-positive children increased by a factor of 5.8 (95% confidence interval 3.0-11.4) during the Omicron wave compared to prior. More patients were ≥6 years of age in the Omicron wave than prior (19% vs. 0%). The majority were not hospitalized (77%). More patients ≥6 years of age received epinephrine therapy for croup during the Omicron wave (73% vs. 35%). Most patients ≥6 years of age had no croup history (64%) and only 45% were vaccinated against SARS-CoV-2. CONCLUSION: Croup was prevalent during the Omicron wave, atypically affecting patients ≥6 years of age. COVID-19-associated croup should be added to the differential diagnosis of children with stridor, regardless of age. © 2022 Elsevier Inc.

Patients' and Providers' Views on Causes and Consequences of Healthcare Fragmentation in the Ambulatory Setting: a Qualitative Study.

BACKGROUND: Patients with chronic conditions routinely see multiple outpatient providers, who may or may not communicate with each other. Gaps in information across providers caring for the same patient can lead to harm for patients. However, the exact causes and consequences of healthcare fragmentation are not understood well enough to design interventions to address them. OBJECTIVE: We sought to elicit patients' and providers' views on the causes and consequences of healthcare fragmentation. DESIGN AND PARTICIPANTS: We conducted a qualitative study with focus groups of patients and, separately, of providers (attending physicians and nurse practitioners) at an academic hospital-based primary care practice in New York City in June-August 2017. Patient participants were English-speaking adults with ≥ 2 chronic conditions. APPROACH: Each focus group lasted 1 h and asked the same two questions: "Why do you think some patients receive care from many different providers and others do not?" and "What do you think happens as a result of patients receiving care from many different providers?" Data collection continued until a point of data saturation was reached. Thematic analysis was used to identify themes and subthemes. KEY RESULTS: We conducted 6 focus groups with a total of 46 participants (25 patients and 21 providers). Study participants identified 41 unique causes of fragmentation, which originate from 4 different levels of the healthcare system (patient, provider, healthcare organization, and healthcare environment); most causes were not related to medical need. Participants also identified 24 unique consequences of fragmentation, of which 3 were desirable and 21 were undesirable. CONCLUSIONS: The results of this study offer a granular roadmap for how to decrease healthcare fragmentation. The large number and severity of negative consequences (including medical errors, misdiagnosis, increased cost, and provider burnout) underscore the urgent need for interventions to address this problem directly.

Predicting frequent emergency department use among children with epilepsy: A retrospective cohort study using electronic health data from 2 centers.

OBJECTIVE: Among children with epilepsy, to develop and evaluate a model to predict emergency department (ED) use, an indicator of poor disease control and/or poor access to care. METHODS: We used electronic health record data from 2013 to predict ED use in 2014 at 2 centers, benchmarking predictive performance against machine learning algorithms. We evaluated algorithms by calculating the expected yearly ED visits among the 5% highest risk individuals. We estimated the breakeven cost per patient per year for an intervention that reduced ED visits by 10%. We estimated uncertainty via cross-validation and bootstrapping. RESULTS: Bivariate analyses showed multiple potential predictors of ED use (demographics, social determinants of health, comorbidities, insurance, disease severity, and prior health care utilization). A 3-variable model (prior ED use, insurance, number of antiepileptic drugs [AEDs]) performed as well as the best machine learning algorithm at one center (N = 2730; ED visits among top 5% highest risk, 3-variable model, mean = 2.9, interquartile range [IQR] = 2.7-3.1 vs Random Forest, mean = 2.9, IQR = 2.7-3.1), and superior at the second (N = 784; mean = 2.5, IQR = 2.2-2.9 vs mean = 1.9, IQR = 1.6-2.5). The per-patient-per-year breakeven point using this model to identify high-risk individuals was $958 (95% confidence interval [CI] = $568-$1390) at one center and $1086 (95% CI = $886-$1320) at the second. SIGNIFICANCE: Prior ED use, insurance status, and number of AEDs, taken together, predict future ED use for children with epilepsy. Our estimates suggest a program targeting high-risk children with epilepsy that reduced ED visits by 10% could spend approximately $1000 per patient per year and break even. Further work is indicated to develop and evaluate such programs.

The Expanding Role of Antimicrobial Stewardship Programs in Hospitals in the United States: Lessons Learned from a Multisite Qualitative Study.

BACKGROUND: Misuse of antibiotics can lead to the development of antibiotic resistance, which adversely affects morbidity, mortality, length of stay, and cost. To combat the threat of antimicrobial resistance, The Joint Commission and the Centers for Medicare & Medicaid Services have initiated or proposed requirements for hospitals to have antimicrobial stewardship programs (ASPs), but implementation remains challenging. A key-informant interview study was conducted to describe the characteristics and innovative strategies of leading ASPs. METHODS: Semistructured interviews were conducted with 12 program leaders at four ASPs in the United States, chosen by purposive sampling on the basis of national reputation, scholarship, and geography. Questions focused on ASP implementation, program structure, strengths, weaknesses, lessons learned, and future directions. Content analysis was used to identify dominant themes. RESULTS: Three major themes were identified. The first was evolution of ASPs from a top-down structure to a more diffuse approach involving unit-based pharmacists, multidisciplinary staff, and shared responsibility for antimicrobial prescribing under the ASPs' leadership. The second theme was integration of information technology (IT) systems, which enabled real-time interventions to optimize antimicrobial therapy and patient management. The third was barriers to technology integration, including limited resources for data analysis and poor interoperability between software systems. CONCLUSION: The study provides valuable insights on program implementation at a sample of leading ASPs across the United States. These ASPs used expansion of personnel to amplify the ASP's impact and integrated IT resources into daily work flow to improve efficiency. These findings can be used to guide implementation at other hospitals and aid in future policy development.

Hospital crossover increases utilization for people with epilepsy: a retrospective cohort study.

OBJECTIVES: "Hospital crossover" occurs when people visit multiple hospitals for care, which may cause gaps in electronic health records. Although crossover is common among people with epilepsy, the effect on subsequent use of health services is unknown. Understanding this effect will help prioritize health care delivery innovations targeted for this population. METHODS: We collected de-identified information from a health information exchange network describing 7,836 people with epilepsy who visited any of seven hospitals in New York, NY from 2009-2012. Data included demographics, comorbidities, and 2 years of visit information from ambulatory, inpatient, emergency department (ED), and radiology settings. We performed two complementary retrospective cohort analyses, in order to (1) illustrate the effect on a carefully selected subgroup, and (2) confirm the effect across the study population. First, we performed a matched cohort analysis on 410 pairs of individuals with and without hospital crossover in the baseline year. Second, we performed a propensity score odds weighted ordinal logistic regression analysis to estimate the effect across all 7,836 individuals. The outcomes were the use of six health services in the follow-up year. RESULTS: In the matched pair analysis, baseline hospital crossover increased the odds of more visits in the ED (odds ratio 1.42, 95% confidence interval [CI] 1.05-1.95) and radiology settings (1.7, 1.22-2.38). The regression analysis confirmed the ED and radiology findings, and also suggested that crossover led to more inpatient admissions (1.35, 1.11-1.63), head CTs (1.44, 1.04-2), and brain MRIs (2.32, 1.59-3.37). SIGNIFICANCE: Baseline hospital crossover is an independent marker for subsequent increased health service use in multiple settings among people with epilepsy. Health care delivery innovations targeted for people with epilepsy who engage in hospital crossover should prioritize (1) sharing radiology images and reports (to reduce unnecessary radiology use, particularly head CTs), and (2) improving coordination of care (to reduce unnecessary ED and inpatient use).

People with epilepsy who use multiple hospitals; prevalence and associated factors assessed via a health information exchange.

OBJECTIVE: Hospital crossover occurs when people seek care at multiple hospitals, creating information gaps for physicians at the time of care. Health information exchange (HIE) is technology that fills these gaps, by allowing otherwise unaffiliated physicians to share electronic medical information. However, the potential value of HIE is understudied, particularly for chronic neurologic conditions like epilepsy. We describe the prevalence and associated factors of hospital crossover among people with epilepsy, in order to understand the epidemiology of who may benefit from HIE. METHODS: We used a cross-sectional study design to examine the bivariate and multivariable association of demographics, comorbidity, and health service utilization variables with hospital crossover, among people with epilepsy. We identified 8,074 people with epilepsy from the International Classification of Diseases, Ninth Revision (ICD-9) codes, obtained from an HIE that linked seven hospitals in Manhattan, New York. We defined hospital crossover as care from more than one hospital in any setting (inpatient, outpatient, emergency, or radiology) over 2 years. RESULTS: Of 8,074 people with epilepsy, 1,770 (22%) engaged in hospital crossover over 2 years. Crossover was associated with younger age (children compared with adults, adjusted odds ratio [OR] 1.4, 95% confidence interval [CI] 1.2-1.7), living near the hospitals (Manhattan vs. other boroughs of New York City, adjusted OR 1.6, 95% CI 1.4-1.8), more visits in the emergency, radiology, inpatient, and outpatient settings (p < 0.001 for each), and more head computerized tomography (CT) scans (p < 0.01). The diagnosis of "encephalopathy" was consistently associated with crossover in bivariate and multivariable analyses (adjusted OR 2.66, 95% CI 2.14-3.29), whereas the relationship between other comorbidities and crossover was less clear. SIGNIFICANCE: Hospital crossover is common among people with epilepsy, particularly among children, frequent users of medical services, and people living near the study hospitals. HIE should focus on these populations. Further research should investigate why hospital crossover occurs, how it affects care, and how HIE can most effectively mitigate the resultant fragmentation of medical records.

Meaningful Use Status and Participation in Health Information Exchange Among New York State Hospitals: A Longitudinal Assessment.

BACKGROUND: Billions of dollars is being utilized to promote electronic health record (EHR) adoption and electronic health information exchange (HIE). Monitoring trends over time is critical to understanding the success of policies initiatives. New York State is a leader in state-based initiatives promoting health information technology (HIT), and its experiences can provide valuable lessons to inform ongoing state and federal efforts. METHODS: All hospitals in New York State were previously surveyed in 2009 to determine rates of EHR adoption, preparedness to meet meaningful use criteria, and participation in HIE. A follow-up survey was conducted from November 2012 through February 2013 to evaluate progress over time. RESULTS: Responses were received from 129 of 210 hospitals (61% response rate). Some 98% of responding hospitals (n = 126) had implemented or begun implementing an EHR-greater than a fourfold increase in three years. Nearly three-quarters had already attested to Stage 1 meaningful use for Medicaid (74.8%, n = 86) and Medicare (70.8%, n = 85), although only 10.7% (n = 13) anticipated it would be easy to achieve Stage 2 meaningful use. Seventy-nine percent of respondents (n = 92) reported exchanging electronic patient-level clinical data with other partners, and 89.9% (n = 116) reported participation in regional arrangements to share data. Lack of architecture and cost remain major barriers to achieving robust HIE. DISCUSSION: Although much progress has been made since 2009, careful attention must be paid to helping hospitals meet the stricter Stage 2 meaningful use requirements and to supporting robust HIE to help fulfill HIT's promise of achieving higher-quality, lower-cost health care.

Importance of medical home domains on emergency visits using a cross-sectional national survey of US children.

BACKGROUND AND OBJECTIVES: Receiving care at patient-centred medical homes (PCMH) is associated with reduced emergency department (ED) visits among children. Adverse social determinants of health (SDoH), such as lower socioeconomic status and household poverty, are associated with increased ED visits in children. The objective of this study is to use machine learning techniques to understand the relative importance of each PCMH component among different populations with adverse SDoH on the outcome of ED visits. METHODS DESIGN, SETTING AND PARTICIPANTS: This study used the 2018-2019 pooled data from the National Survey of Children's Health (NSCH), an annual survey of parents and caregivers of US children from birth to 17 years. PCMH components were operationalised by classifying parent/caregiver responses into five domains: care coordination (CC), having a personal doctor or nurse, having a usual source of care, family-centred care and ease of getting referrals. SDoH included five categories: (1) social and community context, (2) economic stability, (3) education access and quality, (4) healthcare access and quality and (5) neighbourhood and built environment. PRIMARY OUTCOME MEASURE: We used a split-improvement variable importance measure based on random forests to determine the importance of PCMH domains on ED visits overall and stratified by SDoH. RESULTS: Overall, between 3% and 28% experienced one or more gaps in PCMH domains. Models show that problems with referrals (rank, 2; Gini, 83.5) and gaps in CC (rank, 3; Gini, 81.0) were the two most important domains of PCMH associated with ED visits in children. This result was consistent among black and Hispanic children and among children with lower socioeconomic status. CONCLUSIONS: Our study findings underscore the importance of poor CC and referrals on ED visits for all children and those from disadvantaged populations. Initiatives for expanding the reach of PCMH should consider prioritising these two domains, especially in areas with significant minority populations.

PICC Your Poison: Resident Beliefs and Attitudes Regarding Discharge Parenteral Antibiotics for Patients Who Inject Drugs.

Background: Serious injection-related infections (SIRIs) in people who inject drugs often lead to prolonged hospitalizations or premature discharges. This may be in part due to provider reluctance to place peripherally inserted central catheters (PICCs) for outpatient parenteral antibiotic therapy in this population. Because internal medicine (IM) residents are often frontline providers in academic centers, understanding their perspectives on SIRI care is important to improve outcomes. Methods: We surveyed IM residents in a large urban multicenter hospital system about SIRI care with a novel case-based survey that elicited preferences, comfort, experience, and stigma. The survey was developed using expert review, cognitive interviewing, and pilot testing. Results are reported with descriptive statistics and linear regression. Results: Of 116 respondents (response rate 34%), most (73%) were uncomfortable discharging a patient with active substance use home with a PICC, but comfortable (87%) with discharge to postacute facilities. Many (∼40%) endorsed high levels of concern for PICC misuse or secondary line infections, but larger numbers cited concerns about home environment (50%) or loss to follow-up (68%). While overall rates were low, higher stigma was associated with more concerns around PICC use (r = -0.3, P = .002). A majority (58%) believed hospital policies against PICC use in SIRI may act as a barrier to discharge, and 74% felt initiation of medications for opioid use disorder (MOUD) would increase their comfort discharging with a PICC. Conclusions: Most IM residents endorsed high levels of concern about PICC use for SIRI, related to patient outcomes and perceived institutional barriers, but identified MOUD as a mitigating factor.

The effects of electronic prescribing by community-based providers on ambulatory medication safety.

BACKGROUND: US federal policies are incentivizing use of electronic prescribing (e-prescribing) to improve safety. However, little is known about e-prescribing's actual impact on medication safety over time. A study was conducted to assess the effect of implementing a commercial electronic health record (EHR) with e-prescribing on rates and types of prescribing errors. Understanding safety effects from e-prescribing will be important as providers increasingly e-prescribe. METHODS: Prescriptions written by 20 community-based primary care providers in the Hudson Valley region of New York from November 2008 to November 2009 were retrospectively studied. All providers adopted a commercial EHR with robust clinical decision support and extensive technical support to aid in prescribing. Errors were identified by standardized prescription and chart review. RESULTS: Some 1,629 prescriptions were analyzed at three months postimplementation, and 1,738 prescriptions were analyzed at one year postimplementation. Use of e-prescribing resulted in relatively low error rates (6.0 errors per 100 prescriptions). These rates were sustained over time but without further improvement (6.0 versus 4.5 errors per 100 prescriptions, p = .15). Antibiotics were the class of medications most frequently involved (12.7% of overall errors), and direction errors were most common (24% of errors). CONCLUSIONS: This study is the first, as far as known, to quantitatively evaluate prescribing errors early after EHR implementation and after sustained use among community-based primary care providers. Relatively low rates of errors with e-prescribing were found early and after prolonged use. Extensive support for providers before, during, and after implementation may mitigate potential safety threats from implementation of an EHR system and result in sustained safety benefits over the long-term.

Using an experiential learning model to teach clinical reasoning theory and cognitive bias: an evaluation of a first-year medical student curriculum.

BACKGROUND: Most medical students entering clerkships have limited understanding of clinical reasoning concepts. The value of teaching theories of clinical reasoning and cognitive biases to first-year medical students is unknown. This study aimed to evaluate the value of explicitly teaching clinical reasoning theory and cognitive bias to first-year medical students. METHODS: Using Kolb's experiential learning model, we introduced dual process theory, script theory, and cognitive biases in teaching clinical reasoning to first-year medical students at an academic medical center in New York City between January and June 2020. Due to the COVID-19 pandemic, instruction was transitioned to a distance learning format in March 2020. The curriculum included a series of written clinical reasoning examinations with facilitated small group discussions. Written self-assessments prompted each student to reflect on the experience, draw conclusions about their clinical reasoning, and plan for future encounters involving clinical reasoning. We evaluated the value of the curriculum using mixed-methods to analyze faculty assessments, student self-assessment questionnaires, and an end-of-curriculum anonymous questionnaire eliciting student feedback. RESULTS: Among 318 total examinations of 106 students, 254 (80%) had a complete problem representation, while 199 (63%) of problem representations were considered concise. The most common cognitive biases described by students in their clinical reasoning were anchoring bias, availability bias, and premature closure. Four major themes emerged as valuable outcomes of the CREs as identified by students: (1) synthesis of medical knowledge; (2) enhanced ability to generate differential diagnoses; (3) development of self-efficacy related to clinical reasoning; (4) raised awareness of personal cognitive biases. CONCLUSIONS: We found that explicitly teaching clinical reasoning theory and cognitive biases using an experiential learning model provides first-year medical students with valuable opportunities for developing knowledge, skills, and self-efficacy related to clinical reasoning.

Pediatric Mental Health Emergencies During 5 COVID-19 Waves in New York City.

OBJECTIVES: To describe the proportion of pediatric mental health emergency department (MH-ED) visits across 5 COVID-19 waves in New York City (NYC) and to examine the relationship between MH-ED visits, COVID-19 prevalence, and societal restrictions. METHODS: We conducted a time-series analysis of MH-ED visits among patients ages 5 to 17 years using the INSIGHT Clinical Research Network, a database from 5 medical centers in NYC from January 1, 2016, to June 12, 2022. We estimated seasonally adjusted changes in MH-ED visit rates during the COVID-19 pandemic, compared with predicted prepandemic levels, specific to each COVID-19 wave and stratified by mental health diagnoses and sociodemographic characteristics. We estimated associations between MH-ED visit rates, COVID-19 prevalence, and societal restrictions measured by the Stringency Index. RESULTS: Of 686 500 ED visits in the cohort, 27 168 (4.0%) were MH-ED visits. The proportion of MH-ED visits was higher during each COVID-19 wave compared with predicted prepandemic trends. Increased MH-ED visits were seen for eating disorders across all waves; anxiety disorders in all except wave 3; depressive disorders and suicidality/self-harm in wave 2; and substance use disorders in waves 2, 4, and 5. MH-ED visits were increased from expected among female, adolescent, Asian race, high Child Opportunity Index patients. There was no association between MH-ED visits and NYC COVID-19 prevalence or NY State Stringency Index. CONCLUSIONS: The proportion of pediatric MH-ED visits during the COVID-19 pandemic was higher during each wave compared with the predicted prepandemic period, with varied increases among diagnostic and sociodemographic subgroups. Enhanced pediatric mental health resources are essential to address these findings.

COVID-19 Pandemic Impact on Pediatricians Entering the Pediatric Workforce.

OBJECTIVE: Determine extent of impact of coronavirus disease 2019 (COVID-19) pandemic on career choice and employment of pediatricians entering pediatric workforce. METHODS: A national, cross-sectional electronic survey of pediatricians registering for the 2021 American Board of Pediatrics initial general certifying examination on the impact of the COVID-19 pandemic on 3 aspects of career (career choice, employment search, employment offers) was performed. Data were analyzed using descriptive statistics and multivariate logistic regression to determine factors associated with the pandemic's impact on career. Thematic analysis was used to generate themes for open-ended survey questions. RESULTS: Over half (52.3%, 1767 of 3380) of pediatricians responded. Overall, 29.1% reported that the pandemic impacted their career (career choice [10.4%], employment search [15.6%], or employment offers [19.0%]); applicants to general pediatrics (GP) (52.9%) or pediatric hospitalist (PH) positions (49.3%) were most affected. Multivariate logistic regression modeling found those applying to GP (odds ratio [OR]: 3.83, 95% confidence interval [CI]: 2.22-6.60), PH (OR: 9.02, 95% CI: 5.60-14.52), and International Medical Graduates (IMGs) (OR: 1.90; 95% CI: 1.39-2.59) most likely to experience any career impact. CONCLUSIONS: Almost one third of pediatricians registering for the initial general pediatrics certifying examination reported their careers were impacted by the COVID-19 pandemic, with 10% of respondents reporting the pandemic impacted their career choice. Half of new pediatricians seeking employment reported being impacted by the pandemic, particularly IMGs. As the pandemic evolves, career advising will continue to be critical to support trainees in their career choices and employment.

The Early Effects of the Coronavirus Disease-19 Pandemic on Pediatric Resident Education: A National Assessment.

PURPOSE: Residency programs must ensure resident competence for independent practice. The coronavirus disease-19 (COVID-19) pandemic disrupted health care delivery, impacting pediatric residencies. This study examines the impact on pediatric resident education. METHODS: The authors conducted a mixed methods national survey of pediatric residency program directors (PDs) from May 2020 to July 2020. Data analysis included descriptive statistics, chi-square, and Wilcoxon rank sum tests. Multivariable modeling identified factors associated with resident preparation for more senior roles. Thematic analysis was performed on open-ended questions about PD COVID-19 pandemic recommendations to peers, Accreditation Council for Graduate Medical Education and American Board of Pediatrics. RESULTS: Response rate was 55% (110/199). PDs reported the COVID-19 pandemic negatively affected inpatient (n = 86, 78.2%), and outpatient education (n = 104, 94.5%), procedural competence (n = 64; 58.2%), and resident preparation for more senior roles (n = 50, 45.5%). In bivariate analyses, increasingly negative impacts on inpatient and outpatient education were associated with an increasingly negative impact on resident preparation for more senior roles (P = .03, P = .008), these relationships held true in multivariable analysis. Qualitative analysis identified 4 themes from PD recommendations: 1) Clear communication from governing bodies and other leaders; 2) Flexibility within programs and from governing bodies; 3) Clinical exposure is key for competency development; 4) Online platforms are important for education, communication, and support. CONCLUSIONS: The COVID-19 pandemic negatively impacted inpatient and outpatient education. When these were more negatively impacted, resident preparation for more senior roles was worse, highlighting the importance of competency based medical education to tailor experiences ensuring each resident is competent for independent practice.

An Instrument for Measuring Critical Appraisal Self-Efficacy in Rheumatology Trainees.

OBJECTIVE: Self-efficacy, the internal belief that one can perform a specific task successfully, influences behavior. To promote critical appraisal of medical literature, rheumatology training programs should foster both competence and self-efficacy for critical appraisal. This study aimed to investigate whether select items from the Clinical Research Appraisal Inventory (CRAI), an instrument measuring clinical research self-efficacy, could be used to measure critical appraisal self-efficacy (CASE). METHODS: One hundred twenty-five trainees from 33 rheumatology programs were sent a questionnaire that included two sections of the CRAI. Six CRAI items relevant to CASE were identified a priori; responses generated a CASE score (total score range 0-10; higher = greater confidence in one's ability to perform a specific task successfully). CASE scores' internal structure and relation to domain-concordant variables were analyzed. RESULTS: Questionnaires were completed by 112 of 125 (89.6%) trainees. CASE scores ranged from 0.5 to 8.2. The six CRAI items contributing to the CASE score demonstrated high internal consistency (Cronbach's α = 0.95) and unidimensionality. Criterion validity was supported by the findings that participants with higher CASE scores rated their epidemiology and biostatistics understanding higher than that of peers (P < 0.0001) and were more likely to report referring to studies to answer clinical questions (odds ratio 2.47, 95% confidence interval 1.41-4.33; P = 0.002). The correlation of CASE scores with percentage of questions answered correctly was only moderate, supporting discriminant validity. CONCLUSION: The six-item CASE instrument demonstrated content validity, internal consistency, discriminative capability, and criterion validity, including correlation with self-reported behavior, supporting its potential as a useful measure of critical appraisal self-efficacy.

Assessing Usability and Ambulatory Clinical Staff Satisfaction with Two Electronic Health Records.

BACKGROUND: A growing body of literature has linked usability limitations within electronic health records (EHRs) to adverse outcomes which may in turn affect EHR system transitions. NewYork-Presbyterian Hospital, Columbia University College of Physicians and Surgeons (CU), and Weill Cornell Medical College (WC) are a tripartite organization with large academic medical centers that initiated a phased transition of their EHRs to one system, EpicCare. OBJECTIVES: This article characterizes usability perceptions stratified by provider roles by surveying WC ambulatory clinical staff already utilizing EpicCare and CU ambulatory clinical staff utilizing iterations of Allscripts before the implementation of EpicCare campus-wide. METHODS: A customized 19-question electronic survey utilizing usability constructs based on the Health Information Technology Usability Evaluation Scale was anonymously administered prior to EHR transition. Responses were recorded with self-reported demographics. RESULTS: A total of 1,666 CU and 1,065 WC staff with ambulatory self-identified work setting were chosen. Select demographic statistics between campus staff were generally similar with small differences in patterns of clinical and EHR experience. Results demonstrated significant differences in EHR usability perceptions among ambulatory staff based on role and EHR system. WC staff utilizing EpicCare accounted for more favorable usability metrics than CU across all constructs. Ordering providers (OPs) denoted less usability than non-OPs. The Perceived Usefulness and User Control constructs accounted for the largest differences in usability perceptions. The Cognitive Support and Situational Awareness construct was similarly low for both campuses. Prior EHR experience demonstrated limited associations. CONCLUSION: Usability perceptions can be affected by role and EHR system. OPs consistently denoted less usability overall and were more affected by EHR system than non-OPs. While there was greater perceived usability for EpicCare to perform tasks related to care coordination, documentation, and error prevention, there were persistent shortcomings regarding tab navigation and cognitive burden reduction, which have implications on provider efficiency and wellness.