Creating a health equity and inclusion office in an academic pediatric medical center: priorities addressed and lessons learned.

BACKGROUND: Over the last two decades, medical schools and academic health centers have acknowledged the persistence of health disparities in their patients and the lack of diversity in their faculty, leaders and extended workforce. We established an Office of Health Equity and Inclusion (OHEI) at our pediatric academic medical center after a thorough evaluation of prior diversity initiatives and review of faculty development data. OBJECTIVE: To describe the lessons learned at a pediatric academic medical center in prioritizing and implementing health equity, diversity and inclusion (EDI) initiatives in creating the OHEI. MATERIALS AND METHODS: We reviewed internal administrative data and faculty development data, including data related to faculty who are underrepresented in medicine, to understand the role of our EDI initiatives in the strategic priorities addressed and lessons learned in the creation of the OHEI. RESULTS: The intentional steps taken in our medical center's strategic approach in the creation of this office led to four important lessons to improve pediatric health equity: (1) board, senior executive and institutional prioritization of EDI initiatives; (2) multi-specialty and interprofessional collaboration; (3) academic approach to EDI programmatic development; and (4) intentionality with accountability in all EDI initiatives. CONCLUSION: The key lessons learned during the creation of an Office of Health Equity and Inclusion can provide guidance to other academic health centers committed to implementing institutional priorities that focus their EDI initiatives on the improvement of pediatric health equity.

Leadership in adolescent health: developing the next generation of maternal child health leaders through mentorship.

Leadership development is a core value of Maternal Child Health Bureau training programs. Mentorship, an MCH Leadership Competency, has been shown to positively affect career advancement and research productivity. Improving mentorship opportunities for junior faculty and trainees may increase pursuit of careers in areas such as adolescent health research and facilitate the development of new leaders in the field. Using a framework of Developmental Networks, a group of MCH Leadership Education in Adolescent Health training program faculty developed a pilot mentoring program offered at the Society for Adolescent Health and Medicine Annual Meeting (2011-2013). The program matched ten interdisciplinary adolescent health fellows and junior faculty with senior mentors at other institutions with expertise in the mentee's content area of study in 2011. Participants were surveyed over 2 years. Respondents indicated they were "very satisfied" with their mentor match, and all agreed or strongly agreed that the mentoring process in the session was helpful, and that the mentoring relationships resulted in several ongoing collaborations and expanded their Developmental Networks. These results demonstrate that MCH programs can apply innovative strategies to disseminate the MCH Leadership Competencies to groups beyond MCH-funded training programs through programs at scientific meetings. Such innovations may enhance the structure of mentoring, further the development of new leaders in the field, and expand developmental networks to provide support for MCH professionals transitioning to leadership roles.

Establishing a Pediatric Health Equity, Diversity, and Inclusion Research Review Process.

Equity, diversity, and inclusion (EDI) research is increasing, and there is a need for a more standardized approach for methodological and ethical review of this research. A supplemental review process for EDI-related human subject research protocols was developed and implemented at a pediatric academic medical center (AMC). The goal was to ensure that current EDI research principles are consistently used and that the research aligns with the AMC's declaration on EDI. The EDI Research Review Committee, established in January 2022, reviewed EDI protocols and provided recommendations and requirements for addressing EDI-related components of research studies. To evaluate this review process, the number and type of research protocols were reviewed, and the types of recommendations given to research teams were examined. In total, 78 research protocols were referred for EDI review during the 20-month implementation period from departments and divisions across the AMC. Of these, 67 were given requirements or recommendations to improve the EDI-related aspects of the project, and 11 had already considered a health equity framework and implemented EDI principles. Requirements or recommendations made applied to 1 or more stages of the research process, including design, execution, analysis, and dissemination. An EDI review of human subject research protocols can provide an opportunity to constructively examine and provide feedback on EDI research to ensure that a standardized approach is used based on current literature and practice.

Interprofessional provider educational needs and preferences regarding the provision of sexual and reproductive health care in cystic fibrosis.

BACKGROUND: Sexual and reproductive health (SRH) is an important disease-specific concern for adolescent and young adult (AYA) women that is not consistently addressed in cystic fibrosis (CF) centers. This study identifies educational needs and preferences of interprofessional CF providers regarding SRH in AYA women with CF. METHODS: Interprofessional CF providers participated in an anonymous survey regarding general and CF-specific SRH knowledge and skills, factors for optimizing SRH care, and preferred approaches for SRH training. We calculated descriptive statistics for all respondents and stratified by provider type. RESULTS: A total of 523 providers completed the survey (39% physicians/advanced practice providers, 19% nurses, 20% social workers, and 22% other disciplines). Half reported comfort responding to female AYA SRH concerns; however, only one-third were comfortable asking appropriate questions and confident taking a sexual history. Only 29% were comfortable with their current CF-specific SRH knowledge. Respondents' preferred SRH topics for further training included: pregnancy/parenthood planning, sexual functioning, urinary incontinence, intimate partner violence, and taking a sexual history. Nearly two-thirds felt having connection to women's health specialists familiar with CF would facilitate SRH care. Approximately one-third desired SRH educational materials for providers to view at point-of-care or through online case-based learning; <10% were interested in role playing SRH skills. CONCLUSION: Many interprofessional CF providers lack comfort and skills in addressing SRH with AYA women with CF. Provider training needs and approaches identified in this study can be used to develop tailored educational interventions to improve comprehensive CF care.

Sexual and Reproductive Health of Young Women With Cystic Fibrosis: A Concept Mapping Study.

OBJECTIVE: Adolescent and young adult (AYA) women with pediatric-onset chronic diseases, such as cystic fibrosis (CF), face disease-specific sexual and reproductive health (SRH) concerns. Using concept mapping (CM), this study aimed to identify the SRH topics and outcomes valued by AYA women with CF and their parents. METHODS: Women with CF who were 13 to 30years of age and parents of 13- to 30-year-old daughters with CF participated in an online CM study. Participants individually brainstormed, rated, and sorted SRH topics important for AYA women with CF. Using multidimensional scaling, hierarchical cluster analyses, and t tests to assess rating differences, multidisciplinary stakeholders interpreted results during in-person meetings. RESULTS: Twenty-four participants (13 AYAs and 11 parents) generated 109 statements around SRH in CF; 88% completed rating and sorting. Sixteen stakeholders named 6 main clusters of concepts: fertility and pregnancy, deciding to have children, birth control, navigating life, sex, and gynecologic concerns. Participants rated birth control as highest in importance for adolescent women (mean = 3.9 ± 0.1 on a 5-point scale) and fertility and pregnancy as highest for young adult women (mean = 4.2 ± 0.04). Parents provided higher importance ratings for all clusters than patient participants. Stakeholders identified patient-centered outcomes for each cluster and focused on how to improve SRH knowledge, decision making, and patient-provider communication in the subspecialty setting. CONCLUSIONS: Eliciting patient-centered outcomes using CM can inform improvements in the care of AYAs with pediatric-onset chronic diseases. The SRH topics and patient-centered outcomes identified in this study should inform enhancements to comprehensive clinical care delivery for these populations.

Whose personal control? Creating private, personally controlled health records for pediatric and adolescent patients.

Personally controlled health records (PCHRs) enable patients to store, manage, and share their own health data, and promise unprecedented consumer access to medical information. To deploy a PCHR in the pediatric population requires crafting of access and security policies, tailored to a record that is not only under patient control, but one that may also be accessed by parents, guardians, and third-party entities. Such hybrid control of health information requires careful consideration of both the PCHR vendor's access policies, as well as institutional policies regulating data feeds to the PCHR, to ensure that the privacy and confidentiality of each user is preserved. Such policies must ensure compliance with legal mandates to prevent unintended disclosures and must preserve the complex interactions of the patient-provider relationship. Informed by our own operational involvement in the implementation of the Indivo PCHR, we provide a framework for understanding and addressing the challenges posed by child, adolescent, and family access to PCHRs.

Gender differences in research grant applications and funding outcomes for medical school faculty.

PURPOSE: To evaluate whether there were differences in acquisition of research grant support between male and female faculty at eight Harvard Medical School-affiliated institutions. METHODS: Data were obtained from the participating institutions on all research grant applications submitted by full-time faculty from 2001 through 2003. Data were analyzed by gender and faculty rank of applicant, source of support (federal or nonfederal), funding outcome, amount of funding requested, and amount of funding awarded. RESULTS: Data on 6319 grant applications submitted by 2480 faculty applicants were analyzed. Women represented 29% of investigators and submitted 26% of all grant requests. There were significant gender differences in the mean number of submissions per applicant (women 2.3, men 2.7), success rate (women 41%, men 45%), number of years requested (women 3.1, men 3.4), median annual amount requested (women $115,325, men $150,000), mean number of years awarded (women 2.9, men 3.2), and median annual amount awarded (women $98,094, men $125,000). After controlling for academic rank, grant success rates were not significantly different between women and men, although submission rates by women were significantly lower at the lowest faculty rank. Although there was no difference in the proportion of money awarded to money requested, women were awarded significantly less money than men at the ranks of instructor and associate professor. More men than women applied to the National Institutes of Health, which awarded higher dollar amounts than other funding sources. CONCLUSIONS: Gender disparity in grant funding is largely explained by gender disparities in academic rank. Controlling for rank, women and men were equally successful in acquiring grants. However, gender differences in grant application behavior at lower academic ranks also contribute to gender disparity in grant funding for medical science.

Promoting Resident Professional Development Using Scholarly Academies.

Promoting professional development is a challenging but vital component of residency training. We created resident academies (scholarly homes) that aimed to develop academic skills, enhance mentorship, and create a sense of community based on scholarly interest.

Establishing Effective Mentoring Networks: Rationale and Strategies.

INTRODUCTION: Mentoring networks constitute an effective mentoring model in academic medicine and significantly add to the traditional dyadic mentor-mentee relationship. There is an unmet educational need for medical faculty to recognize the importance and characteristics of effective mentoring networks and to develop tools and strategies to appraise and construct strong, individualized mentoring networks. METHODS: An interactive educational session on developmental mentoring networks for physicians and scientists in an academic environment was designed. This session can be presented as part of a series on mentoring topics or as a stand-alone module. RESULTS: Using preassigned readings and a mentoring network mapping exercise, participants were able to describe their current mentoring relationships and identify strengths and opportunities for enhancing their effectiveness. CONCLUSION: A structured educational session is a useful approach towards advancing the ability of academic mentors to help create optimally effective mentoring networks. The learning environment is enhanced by the interactive nature of the session when used in an interdisciplinary cohort of faculty participants.

Pediatric Hospital Medicine: A Proposed New Subspecialty.

Over the past 20 years, hospitalists have emerged as a distinct group of pediatric practitioners. In August of 2014, the American Board of Pediatrics (ABP) received a petition to consider recommending that pediatric hospital medicine (PHM) be recognized as a distinct new subspecialty. PHM as a formal subspecialty raises important considerations related to: (1) quality, cost, and access to pediatric health care; (2) current pediatric residency training; (3) the evolving body of knowledge in pediatrics; and (4) the impact on both primary care generalists and existing subspecialists. After a comprehensive and iterative review process, the ABP recommended that the American Board of Medical Specialties approve PHM as a new subspecialty. This article describes the broad array of challenges and certain unique opportunities that were considered by the ABP in supporting PHM as a new pediatric subspecialty.

The Impact of a Junior Faculty Fellowship Award on Academic Advancement and Retention.

PURPOSE: Academic faculty experience barriers to career development and promotion. In 1996, Harvard Medical School (HMS) initiated an intramural junior faculty fellowship to address these obstacles. The authors sought to understand whether receiving a fellowship was associated with more rapid academic promotion and retention. METHOD: Junior faculty fellowship recipients and all other instructor and assistant professors at HMS between 1996 and 2011 were identified. Using propensity score modeling, the authors created a matched comparison group for the fellowship recipients based on educational background, training, academic rank, department, hospital affiliation, and demographics. Time to promotion and time to leaving were assessed by Kaplan-Meier curves. RESULTS: A total of 622 junior faculty received fellowships. Faculty who received fellowships while instructors (n = 480) had shorter times to promotion to assistant professor (P < .0001) and longer retention times (P < .0001) than matched controls. There were no significant differences in time to promotion for assistant professors who received fellowships (n = 142) compared with matched controls, but assistant professor fellowship recipients were significantly more likely to remain longer on the faculty (P = .0005). Women instructors advanced more quickly than matched controls, while male instructors' rates of promotions did not differ. CONCLUSIONS: Fellowships to support junior faculty were associated with shorter times to promotion for instructors and more sustained faculty retention for both instructors and assistant professors. This suggests that relatively small amounts of funding early in faculty careers can play a critical role in supporting academic advancement and retention.

Sense of Mission and Sexual Health Outcomes Among Young Adult Women.

STUDY OBJECTIVE: To examine the association between self-reported sense of mission and sexual health behaviors in a geographically diverse cohort of U.S. young adult females in the Growing Up Today Study (GUTS). DESIGN: We conducted a cross-sectional analysis of the 2007 wave of GUTS data from self-reported online or mailed surveys. Outcomes were early sex initiation and history of sexually transmitted infection (STI), which were analyzed as a binary outcome using logit link, and number of sex partners, which was analyzed as a continuous outcome. Models for number of sex partners and history of STIs were adjusted for age. PARTICIPANTS: There were 5,624 young women aged 20 to 25 years who participate in GUTS and who answered the question on "sense of mission." MAIN OUTCOME MEASURES: Age at sexual initiation, history of STIs, and number of lifetime partners. RESULTS: When asked whether they had a sense of mission in their life, 28.1% of women strongly agreed, 54.9% agreed, and 17% disagreed. Women with a low sense of mission had higher odds of reporting a history of STI (odds ratio 1.35, 95% confidence interval 1.08 to 1.70), and more lifetime sexual partners (ß = .83, P < .001). CONCLUSIONS: Having a high sense of mission is associated with lower sexual risk in young women. Interventions to increase sense of mission among young women may improve sexual health outcomes.

Total Direct Medical Expenses and Characteristics of Privately Insured Adolescents Who Incur High Costs.

IMPORTANCE: Accountable care payment models aim to reduce total direct medical expenses for high-cost patients through improved quality of care and preventive health services. Little is known about health care expenditures of privately insured adolescents, especially those who incur high costs. OBJECTIVES: To assess health care expenditures for high-cost adolescents and to describe the patient characteristics associated with high medical costs. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort analysis was conducted of data from January 1 to December 31, 2012, of 13,103 privately insured adolescents aged 13 to 21 years (mean [SD] age, 16.3 [2.4] years; 6764 [51.6%] males) at 82 independent pediatric primary care practices in Massachusetts. Analysis was conducted from April 1, 2014, to April 1, 2015. MAIN OUTCOMES AND MEASURES: We compared demographic (age, sex, median income by zip code) and clinical (obesity, behavioral health problem, complex chronic condition) characteristics between high-cost (top 1%) and non-high-cost adolescents. We assigned high-cost adolescents to clinical categories using software from the Agency for Healthcare Research and Quality to describe clinically relevant patterns of spending. RESULTS: Total direct medical expenses were $41.2 million for the entire cohort and a median $1167 per patient. A total of 132 (1.0%) patients with the highest costs accounted for 23.6% of expenses of the cohort, with a median $52,577 per patient. Mental health disorders were the most common diagnosis in high-cost patients; 78 (59.1%) of these patients had at least 1 behavioral health diagnosis. Pharmacy costs accounted for 28.4% of total direct medical expenses of high-cost patients; primary care accounted for 1.0%. Characteristics associated with being a high-cost patient included having 1 complex chronic condition (relative risk [RR], 6.5; 95% CI, 4.7-9.0), having 2 or more complex chronic conditions (RR, 23.5; 95% CI, 14.2-39.1), having any behavioral health diagnosis (RR, 3.6; 95% CI, 2.6-5.1), and obesity (RR, 2.0; 95% CI, 1.3-3.0). CONCLUSIONS AND RELEVANCE: Total direct medical expenses for privately insured high-cost adolescents are associated with medical complexity, mental health conditions, and obesity. Cost reduction strategies in similar populations should be tailored to these cost drivers.

Screening for abnormal glucose tolerance in adolescents with polycystic ovary syndrome.

Insulin resistance is common in adults with polycystic ovary syndrome (PCOS). Although recent data demonstrate that insulin resistance is present in the early stages of PCOS, the prevalence of insulin resistance in adolescents with PCOS has not been determined. Likewise, the prevalence of impaired glucose tolerance (IGT) or type 2 diabetes mellitus (DM) in adolescent cohorts has not been established. In this study we sought to obtain preliminary data regarding the prevalence of IGT and DM in adolescents with PCOS and to assess the ability of screening tests to predict these abnormalities within this population. Twenty-seven adolescents with PCOS underwent oral glucose tolerance tests. Plasma glucose and insulin levels were obtained at baseline, and glucose was measured 2 h after a 75-g glucose challenge. The 2-h plasma glucose level was used to categorize subjects as having IGT or the provisional diagnosis of DM. Eight of our 27 subjects had IGT, and 1 had previously undiagnosed DM. These abnormalities were seen among lean and obese subjects. Fasting plasma glucose levels and simple measures of insulin resistance were suboptimal predictors of IGT and DM within our cohort. As in adults, our results indicate that adolescents with PCOS are at increased risk for IGT and DM and that the 2-h plasma glucose level after an oral glucose challenge appears to be the most reliable screening test for these abnormalities. Our results need to be corroborated by future studies that determine the prevalence of abnormalities in glucose tolerance among large populations of adolescents, both with and without PCOS. However, as DM may be preventable by lifestyle modifications, we would recommend that adolescents with PCOS undergo periodic screening for abnormal glucose tolerance using 2-h postchallenge plasma glucose levels.

Effects of oral dehydroepiandrosterone on bone density in young women with anorexia nervosa: a randomized trial.

Young women with anorexia nervosa (AN) have subnormal levels of dehydroepiandrosterone (DHEA) and estrogen that may be mechanistically linked to the bone loss seen in this disease. The purpose of this study was to compare the effects of a 1-yr course of oral DHEA treatment vs. conventional hormonal replacement therapy (HRT) in young women with AN. Sixty-one young women were randomly assigned to receive oral DHEA (50 mg/d) or HRT (20 micro g ethinyl estradiol/0.1 mg levonorgestrel). Anthropometric, nutrition, and exercise data were acquired every 3 months, and bone mineral density (BMD) and body composition were measured by dual energy x-ray absorptiometry (DXA) every 6 months over 1 yr. Serum samples were obtained for measurements of hormones, proresorptive cytokines, and bone formation markers, and urine was collected for determinations of bone resorption markers at each visit. In initial analyses, total hip BMD increased significantly and similarly (+1.7%) in both groups. Hip BMD increases were positively correlated with increases in IGF-I (r = 0.44; P = 0.030) and the bone formation marker, bone-specific alkaline phosphatase increased significantly only in the DHEA treatment group (P = 0.003). However, both groups gained significant amounts of weight over the year of therapy, and after controlling for weight gain, no treatment effect was detectable. There was no significant change in lumbar BMD in either group. Both bone formation markers, bone-specific alkaline phosphatase and osteocalcin, increased transiently at 6-9 months in those subjects receiving DHEA compared with the estrogen-treated group (P < 0.05). Both DHEA and HRT significantly reduced levels of the bone resorption markers, urinary N-telopeptides (P < 0.05). There was a positive correlation between changes in IGF-I and changes in weight, body fat determined by DXA, and estradiol for both groups. In addition, patients receiving DHEA exhibited improvement on three validated psychological instruments (Eating Attitudes Test, Anorexia Nervosa Subtest, and Spielberger Anxiety Inventory). Both DHEA and HRT had similar effects on hip and spinal BMD. Over the year of treatment, maintenance of both hip and spinal BMD was seen, but there was no significant increase after accounting for weight gain. Compared with HRT, DHEA appeared to have anabolic effects, evidenced by the positive correlation between increases in hip DXA measurements and IGF-I and significant increases in bone formation markers. Both therapies significantly decreased bone resorption. Replicating results from studies of the elderly, DHEA resulted in improvements in specific psychological parameters in these young women.

Prevalence of vitamin D deficiency among healthy adolescents.

BACKGROUND: Although vitamin D deficiency has been documented as a frequent problem in studies of young adults, elderly persons, and children in other countries, there are limited data on the prevalence of this nutritional deficiency among healthy US teenagers. OBJECTIVE: To determine the prevalence of vitamin D deficiency in healthy adolescents presenting for primary care. DESIGN: A cross-sectional clinic-based sample. SETTING: An urban hospital in Boston. PARTICIPANTS: Three hundred seven adolescents recruited at an annual physical examination to undergo a blood test and nutritional and activity assessments. MAIN OUTCOME MEASURES: Serum levels of 25-hydroxyvitamin D (25OHD) and parathyroid hormone, anthropometric data, nutritional intake, and weekly physical activity and lifestyle variables that were potential risk factors for hypovitaminosis D. RESULTS: Seventy-four patients (24.1%) were vitamin D deficient (serum 25OHD level,

Predictors of Papanicolaou smear return in a hospital-based adolescent and young adult clinic.

OBJECTIVE: Sexually active young women have relatively high rates of abnormal cervical cytology, yet compliance with return for Papanicolaou smear screening and follow-up appointments is poor. The aim of this study was to determine whether a theory-based model could explain compliance with return visits. METHODS: Participants in this longitudinal cohort study were sexually active young women 12-24 years of age presenting to a hospital-based adolescent clinic. Participants completed self-administered surveys and were then followed for up to 15 months to assess for the outcome measure, return. Logistic regression modeling was used to determine variables independently associated with return. RESULTS: The outcome measure, return, was available for 439 of 490 participants (90%). Mean participant age (+/- standard deviation) was 18.3 (+/- 2.2) years, 49% were black, 23% were Hispanic, and 51% had Medicaid health insurance. Variables independently associated with return included belief that the Papanicolaou smear will not be painful (odds ratio [OR] 1.73, 95% confidence interval [CI] 1.08, 2.83), belief that return for follow-up will prevent cervical cancer (OR 1.83, 95% CI 1.12, 3.07), likelihood that the doctor will be honest (OR 4.07, 95% CI 1.37, 17.5), and low self-reported impulsivity (OR 1.66, 95% CI 1.06, 2.63). Family history of cervical cancer was associated with decreased likelihood of return (OR 0.28, 95% CI 0.08, 0.78). CONCLUSION: Specific beliefs about Papanicolaou smears and providers, low self-reported impulsivity, and no family history of cervical cancer are associated with return for Papanicolaou smear screening and follow-up visits. These findings may guide the design of interventions to increase compliance with recommendations for Papanicolaou smear return.

Perspectives of patients with cystic fibrosis on preventive counseling and transition to adult care.

The purpose of this study was to investigate how adolescents and adults with cystic fibrosis (CF) view preventive counseling and their transition to adult-centered care within a children's hospital. Thirty-two patients >/=16 years old diagnosed with CF were recruited from a pediatric tertiary care setting. During face-to-face interviews, patients were asked 27 structured questions and completed a 30-item self-administered questionnaire on preventive counseling by healthcare providers and on transition issues. The median age of patients was 25.5 years (range, 16-43 years); 69% of patients identified a pulmonologist as their "main doctor," even though 78% had a primary care provider. Participants felt that 13-16 years of age was the best time for them to begin spending time alone with their main doctor. Less than half of the participants recalled receiving preventive counseling during the previous 12 months, and more patients wanted to discuss issues than actually did. Qualitative data emphasized the importance of independence in making decisions in healthcare and establishing relationships with providers, and many patients did not desire to transfer care to an adult hospital. Participants identified adult-focused services such as inpatient rooms, discussion groups, work options, and social service support that would enhance care. In conclusion, the majority of adolescent/young adult patients with CF receiving care in a pediatric institution reported satisfaction with their healthcare. However, patients identified preventive issues that they desired to be more regularly addressed, starting in early adolescence, and changes in the delivery of services to enhance transition to adult-oriented care. This study underscored the understanding of the integration of transition planning into the facilitation of healthcare decision-making by the adolescent in issues of self-care, sexuality, education, and finances. Future initiatives to enhance the care of patients with CF should provide training of pulmonologists in preventive care and increased attention to helping patients utilize appropriate primary-care services during the adult years. In addition, prospective studies are needed to compare outcomes of CF patients who have transitioned and transferred to adult hospitals and those transitioning to adult-oriented services in a pediatric institution.