Comparison of antidepressant classes and the risk and time course of suicide attempts in adults: propensity matched, retrospective cohort study.

BACKGROUND: Placebo-controlled clinical trials have led to concern over possible increased risk of suicide-related events in some populations exposed to antidepressants. AIMS: To evaluate the risk of suicide attempts by antidepressant drug class and the presence or absence of depression. METHOD: A retrospective propensity-matched new-user cohort study was used to compare participants with incident depression classified by antidepressant treatment with each other and with the general population. RESULTS: Among the treated group, the suicide attempt rate peaked in the month prior to diagnosis then decreased steadily over the next 6 months. Among the pharmacologically untreated group, the highest rate was seen in the second month after diagnosis. Cohorts with depression had significantly higher suicide attempt risk than the general population, but the treated group did not differ significantly from the untreated group. CONCLUSIONS: Patients on antidepressants did not have significantly higher risk compared with untreated patients. No significant differences were observed for patients treated with individual serotonin-noradrenaline reuptake inhibitors (SNRIs) or selective serotonin reuptake inhibitors (SSRIs) or by class (SSRI v. SNRI cohorts).

Evaluating Patient-Level Medication Regimen Complexity Over Time in Heart Transplant Recipients.

BACKGROUND: Medication regimen complexity describes multiple characteristics of a patient's prescribed drug regimen. Heart transplant recipients must comply with a lifelong regimen that consists of numerous medications. However, a systematic assessment of medication regimen complexity over time has not been conducted in this, or any other, transplant population. OBJECTIVE: The objective of this study was to quantify patient-level medication regimen complexity over time following primary heart transplantation and heart retransplantation, using the validated patient-level Medication Regimen Complexity Index (pMRCI) tool. METHODS: Medication lists were reviewed at transplant discharge and years 1, 3, and 5 post-primary heart transplant, and at transplant discharge and years 1 and 3 post-heart retransplantation. Medications were categorized as transplant-specific, other prescription, and over-the-counter (OTC). RESULTS: In primary heart transplant recipients (n = 60), mean total medication count was 14.3 ± 3.4 at transplant discharge and did not change significantly over time ( P = 0.64). Transplant-specific medication count decreased significantly from discharge (2.9 ± 0.4) to year 5 (2.3 ± 0.6); P = 0.02. However, 32% of patients were taking 16 or more total medications at year 5 posttransplant. More than 70% of the pMRCI score was attributed to other prescription and OTC medications, which was largely driven by dosing frequency in this cohort. Medication complexity did not differ significantly between heart retransplant recipients (n = 11) and matched primary heart transplant controls (n = 22). CONCLUSION: Together, these data highlight the substantial medication burden after heart transplantation and reveal opportunities to address medication regimen complexity in this, and other, transplant populations.

Patient-Level Medication Regimen Complexity in Patients With HIV.

BACKGROUND: Patients with HIV often have multiple medications besides antiretrovirals (ARV). Medication regimen complexity-formulations, dosing frequencies, and additional directions-expands pill burden by considering self-care demands. Studies show an inverse association between ARV adherence and medication complexity for ARVs only. Patient-level medication regimen complexity beyond ARV complexity is unknown. OBJECTIVE: To measure and characterize Patient-level Medication Regimen Complexity Index (pMRCI) and Antiretroviral Medication Regimen Complexity Index (ARCI) for patients in 2 HIV clinics. We hypothesized that an all-medication complexity metric will exceed disease-state-defined complexity metrics; for ARVs only, the pMRCI score will be smaller than the ARCI score by capturing fewer features of regimens. Associations between complexity and adherence were not assessed. METHOD: Electronic records supplied a retrospective, random sample of adult patients with HIV; medication lists were used to code the pMRCI (n=200). A random subsample (n=66) was coded using ARCI for ARV regimens only. RESULT: Medication counts ranged from 1 to 27; pMRCI scores ranged from 2 to 67.5. ARVs contributed roughly 25% to the pMRCI; other prescriptions contributed about 66%. Dosing frequency made the largest contribution of all components (62%) to the pMRCI. For ARVs, pMRCI and ARCI scores did not differ statistically. CONCLUSION: Unique dosing frequencies raised complexity and may provide opportunities for intervention. Other prescriptions drove pMRCI scores, suggesting that HIV management programs should review all medications. A patient-level approach added value to understanding the role of medications in patient complexity; future work can assess association of pMRCI with adherence and patient outcomes.

Characteristics and trends of low-dose quetiapine use in two western state Medicaid programs.

PURPOSE: Medicaid programs are concerned about inappropriate, potentially hazardous, and costly off-label use of second-generation antipsychotics (SGAs). Several states are exploring policies aimed at managing low-dose quetiapine, commonly prescribed for off-label conditions. This study aimed to characterize longitudinal trends and patient characteristics associated with low-dose quetiapine in two state Medicaid programs. We further aimed to quantify changes in the use of quetiapine associated with a legal settlement that curtailed off-label promotion of this product. METHODS: Using administrative data from two state Medicaid programs, Oregon and Colorado, we identified SGA initiators and determined patient level factors associated with receipt of low-dose SGAs. We evaluated changes in low-dose quetiapine initiation during and after a period in which quetiapine was being promoted illegally for off-label purposes. RESULTS: We identified 14,763 new SGA starts during the study period. Low-dose (versus therapeutic dose) SGA use was common in both states, representing 53% to 56% of initiators. Quetiapine was the most commonly used SGA in both states and both dose ranges. Diagnoses of schizophrenia, bipolar disorder, posttraumatic stress disorder, anxiety disorder, and use of newer sedative hypnotics were associated with lower likelihood of initiating low-dose quetiapine. Initiation of low-dose quetiapine as a proportion of all SGA initiation and of all quetiapine initiation significantly declined in Oregon following suspension of off-label promotional activities. CONCLUSIONS: Low-dose SGA and specifically low-dose quetiapine use remains common. Medicaid programs must set policies carefully to maximize the net safety of prescription use while optimizing disease management considering the potential for substitution effects.

Pharmacist-led telehealth deprescribing for people living with dementia and polypharmacy in primary care: A pilot study.

BACKGROUND: People living with dementia (PLWD) have complex medication regimens, exposing them to increased risk of harm. Pragmatic deprescribing strategies that align with patient-care partner goals are needed. METHODS: A pilot study of a pharmacist-led intervention to optimize medications with patient-care partner priorities, ran May 2021-2022 at two health systems. PLWD with ≥7 medications in primary care and a care partner were enrolled. After an introductory mailing, dyads were randomized to a pharmacist telehealth intervention immediately (intervention) or delayed by 3 months (control). Feasibility outcomes were enrollment, intervention completion, pharmacist time, and primary care provider (PCP) acceptance of recommendations. To refine pragmatic data collection protocols, we assessed the Medication Regimen Complexity Index (MRCI; primary efficacy outcome) and the Family Caregiver Medication Administration Hassles Scale (FCMAHS). RESULTS: 69 dyads enrolled; 27 of 34 (79%) randomized to intervention and 28 of 35 (80%) randomized to control completed the intervention. Most visits (93%) took more than 20 min and required multiple follow-up interactions (62%). PCPs responded to 82% of the pharmacists' first messages and agreed with 98% of recommendations. At 3 months, 22 (81%) patients in the intervention and 14 (50%) in the control had ≥1 medication discontinued; 21 (78%) and 12 (43%), respectively, had ≥1 new medication added. The mean number of medications decreased by 0.6 (3.4) in the intervention and 0.2 (1.7) in the control, reflecting a non-clinically meaningful 1.0 (±12.4) point reduction in the MRCI among intervention patients and a 1.2 (±12.9) point increase among control. FCMAHS scores decreased by 3.3 (±18.8) points in the intervention and 2.5 (±14.4) points in the control. CONCLUSION: Though complex, pharmacist-led telehealth deprescribing is feasible and may reduce medication burden in PLWD. To align with patient-care partner goals, pharmacists recommended deprescribing and prescribing. If scalable, such interventions may optimize goal-concordant care for PLWD.

Initial Antihypertensive Regimens in Newly Treated Patients: Real World Evidence From the OneFlorida+ Clinical Research Network.

Background Knowledge of real-world antihypertensive use is limited to prevalent hypertension, limiting our understanding of how treatment evolves and its contribution to persistently poor blood pressure control. We sought to characterize antihypertensive initiation among new users. Methods and Results Using Medicaid and Medicare data from the OneFlorida+ Clinical Research Consortium, we identified new users of ≥1 first-line antihypertensives (angiotensin-converting enzyme inhibitor, calcium channel blocker, angiotensin receptor blocker, thiazide diuretic, or ß-blocker) between 2013 and 2021 among adults with diagnosed hypertension, and no antihypertensive fill during the prior 12 months. We evaluated initial antihypertensive regimens by class and drug overall and across study years and examined variation in antihypertensive initiation across demographics (sex, race, and ethnicity) and comorbidity (chronic kidney disease, diabetes, and atherosclerotic cardiovascular disease). We identified 143 054 patients initiating 188 995 antihypertensives (75% monotherapy; 25% combination therapy), with mean age 59 years and 57% of whom were women. The most commonly initiated antihypertensive class overall was angiotensin-converting enzyme inhibitors (39%) followed by ß-blockers (31%), calcium channel blockers (24%), thiazides (19%), and angiotensin receptor blockers (11%). With the exception of ß-blockers, a single drug accounted for ≥75% of use of each class. ß-blocker use decreased (35%-26%), and calcium channel blocker use increased (24%-28%) over the study period, while initiation of most other classes remained relatively stable. We also observed significant differences in antihypertensive selection across demographic and comorbidity strata. Conclusions These findings indicate that substantial variation exists in initial antihypertensive prescribing, and there remain significant gaps between current guideline recommendations and real-world implementation in early hypertension care.

Economic differences in direct and indirect costs between people with epilepsy and without epilepsy.

OBJECTIVE: To provide generalizable estimates of economic burden in epilepsy and nonepilepsy populations and a comprehensive accounting for employment-based lost productivity associated with epilepsy in current US health care systems as compared with other chronic diseases. RESEARCH DESIGN: We use the nationally representative data source (Medical Expenditure Panel Survey) from 1998 to 2009 to create a retrospective cohort of people diagnosed with epilepsy by a health professional and a comparison cohort of people with no epilepsy. MEASURES: Health care utilization and direct costs for all components of treatment, including prescription medications, wages, employment, educational attainment, family income, and lost productivity were outcomes. RESULTS: We observed economic disparities associated with epilepsy in the United States despite high rates of modern treatments (89% on anticonvulsant therapies). Only 42% of the people with epilepsy over age 18 reported employment compared with 70% of people with no epilepsy; among those, people with epilepsy reported missing an average of 12 days of work because of illness or injury as compared with 4 days in the nonepilepsy cohort. Holding other variables constant, people with epilepsy had a loss of productivity of $9504 in 2011 dollars compared with people with no epilepsy. In comparison, diabetes was associated with annual average lost productivity valued at $3358 and depression at $3182. CONCLUSIONS: Lost wage-based productivity associated with epilepsy was nearly equal to combined wage losses associated with diabetes, depression, anxiety, and asthma together. To evaluate societal burden of illness, results illustrate the importance of indirect costs in addition to treated prevalence and direct medical costs.

Interventional radiologic treatment of hepatocellular carcinoma-a cost analysis from the payer perspective.

PURPOSE: To determine whether there is a cost advantage for one of the three commonly performed interventional radiology (IR) procedures (chemoembolization, selective internal radiation therapy [SIRT], radiofrequency ablation [RFA]) in the treatment of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: A cost analysis from the payer perspective was performed. Primary data were collected from a university hospital, and sensitivity testing was done by comparing coding information obtained at two other tertiary care medical facilities. Medicare allowable reimbursements were used to estimate costs. Decision analytic models using decision tree analysis and Monte Carlo simulations were used to compare alternatives. Simulations were performed comparing all three procedures, followed by a two-way comparison of chemoembolization and SIRT. RESULTS: Simple decision tree analyses showed that RFA was less expensive compared with chemoembolization and SIRT. Monte Carlo simulations showed average reimbursements for each of the three procedures that was largely dependent on the number of repeat procedures required ($9,362 vs $30,107 vs $35,629 for RFA, chemoembolization, and SIRT; P < .001). When comparing only chemoembolization and SIRT, chemoembolization was the lower cost strategy in most scenarios, but SIRT was lower in cost in more than one-third of the simulations. CONCLUSIONS: RFA was the least costly of the three IR strategies in nearly all scenarios studied in these models. Although chemoembolization was less expensive than SIRT in most instances, Monte Carlo simulation showed a preference for SIRT in more than one-third of all scenarios. Sensitivity analyses showed that the most important variables assessed were the need for repeat procedures.

Mentoring Underrepresented Minority Physician-Scientists to Success.

As the nation seeks to recruit and retain physician-scientists, gaps remain in understanding and addressing mitigatable challenges to the success of faculty from underrepresented minority (URM) backgrounds. The Doris Duke Charitable Foundation Fund to Retain Clinical Scientists program, implemented in 2015 at 10 academic medical centers in the United States, seeks to retain physician-scientists at risk of leaving science because of periods of extraordinary family caregiving needs, hardships that URM faculty-especially those who identify as female-are more likely to experience. At the annual Fund to Retain Clinical Scientists program directors conference in 2018, program directors-21% of whom identify as URM individuals and 13% as male-addressed issues that affect URM physician-scientists in particular. Key issues that threaten the retention of URM physician-scientists were identified through focused literature reviews; institutional environmental scans; and structured small- and large-group discussions with program directors, staff, and participants. These issues include bias and discrimination, personal wealth differential, the minority tax (i.e., service burdens placed on URM faculty who represent URM perspectives on committees and at conferences), lack of mentorship training, intersectionality and isolation, concerns about confirming stereotypes, and institutional-level factors. The authors present recommendations for how to create an environment in which URM physician-scientists can expect equitable opportunities to thrive, as institutions demonstrate proactive allyship and remove structural barriers to success. Recommendations include providing universal training to reduce interpersonal bias and discrimination, addressing the consequences of the personal wealth gap through financial counseling and benefits, measuring the service faculty members provide to the institution as advocates for URM faculty issues and compensating them appropriately, supporting URM faculty who wish to engage in national leadership programs, and sustaining institutional policies that address structural and interpersonal barriers to inclusive excellence.

Insights from an Intervention to Support Early Career Faculty with Extraprofessional Caregiving Responsibilities.

Background: Insufficient support for balancing career and family responsibilities hinders retention of physician-scientists. Programs to improve retention of this important group of faculty are crucial. Understanding the experiences of program implementers is key to refining and improving program offerings. Methods: We conducted an interpretive, descriptive, and qualitative study as part of an ongoing evaluation of the Doris Duke Charitable Foundation's Fund to Retain Clinical Scientists (FRCS) awards. We conducted telephone interviews with 12 program directors representing all 10 US medical schools who received the Doris Duke funding in 2016. Results: Of the 12 participants, 10 were women (83.3%). Participating program directors perceived the FRCS award as capable of producing paradigmatic changes regarding how responsibilities at home and work in academic medicine are viewed and integrated by early-career faculty members. The main qualitative themes that captured directors' experiences implementing the program were as follows: (1) championing a new paradigm of support, (2) lessons learned while implementing the new paradigm, (3) results of the new paradigm, and (4) sustaining the paradigm. Conclusions: These findings may help to inform development of similar programs to retain and support the career progress of physician-scientists with extraprofessional caregiving responsibilities. The interviews illuminate ways in which the Doris Duke FRCS award has driven institutional culture change by normalizing discussion and prompted reassessment of extraprofessional challenges and how best to aid early-career faculty members in overcoming these challenges.

Higher medication complexity in persons with HIV is associated with lower tenofovir diphosphate in dried blood spots.

STUDY OBJECTIVE: To assess the association between tenofovir diphosphate (TFV-DP) in dried blood spots (DBS), a measure of cumulative tenofovir-based antiretroviral (ART) adherence, with medication regimen complexity in persons with human immunodeficiency virus (PWH). DESIGN: Prospective clinical cohort (up to three visits over 48 weeks). SETTING: Academic-based HIV clinic. PATIENTS: PWH receiving tenofovir disoproxil fumarate (TDF)-based ART. MEASUREMENTS: DBS for TFV-DP were collected at every study visit. Baseline patient-level medication regimen complexity index (pMRCI) scores were calculated and categorized into three sub-scores (disease-specific [ART], non-ART, and over-the-counter [OTC]). The pMRCI scores were evaluated to assess the association with TFV-DP in DBS <350 fmol/punch after adjusting for clinical covariates. pMRCI scores were also categorized to estimate the adjusted relative risk (aRR) of having a TFV-DP <350 fmol/punch between pMRCI quartiles. MAIN RESULTS: Data from 525 participants (1,146 person-visits) were analyzed. Baseline median (interquartile range [IQR]) pMRCI scores for participants with TFV-DP in DBS <350 vs. ≥350 fmol/punch were 4 (3, 8) vs. 4 (2, 6) for ART, 27 (12, 31) vs. 12 (5, 22) for non-ART, and 0 (0, 1) vs. 0 (0, 2) for OTC, respectively. For the non-ART scores, the aRR for having a TFV-DP in DBS <350 fmol/punch was 6.4 (95% CI: 2.0, 20.6; P=0.002) when comparing participants in the highest pMRCI quartile with those in the lowest quartile. CONCLUSIONS: Higher pMRCI for non-ART medications is associated with lower adherence as measured by TFV-DP in DBS. Future research should investigate whether reducing non-ART medication complexity improves ART adherence and exposure in PWH.

Comparative effectiveness research in DARTNet primary care practices: point of care data collection on hypoglycemia and over-the-counter and herbal use among patients diagnosed with diabetes.

BACKGROUND: The Distributed Ambulatory Research in Therapeutics Network (DARTNet) is a federated network of electronic health record (EHR) data, designed as a platform for next-generation comparative effectiveness research in real-world settings. DARTNet links information from nonintegrated primary care clinics that use EHRs to deliver ambulatory care to overcome limitations with traditional observational research. OBJECTIVE: Test the ability to conduct a remote, electronic point of care study in DARTNet practices by prompting clinic staff to obtain specific information during a patient encounter. RESEARCH DESIGN: Prospective survey of patients identified through queries of clinical data repositories in federated network organizations. On patient visit, survey is triggered and data are relinked to the EHR, de-identified, and copied for evaluation. SUBJECTS: Adult patients diagnosed with diabetes mellitus that scheduled a clinic visit for any reason in a 2-week period in DARTNet primary care practices. MEASURES: Survey on hypoglycemic events (past month) and over-the-counter and herbal supplement use. RESULTS: DARTNet facilitated point of care data collection triggered by an electronic prompt for additional information at a patient visit. More than one-third of respondents (33% response rate) reported either mild (45%) or severe hypoglycemic events (5%) in the month before the survey; only 3 of those were also coded using the ICD-9 (a significant difference in detection rates 37% vs. 1%). Nearly one-quarter of patients reported taking an OTC/herbal, 4% specifically for the treatment of symptoms of diabetes. CONCLUSIONS: Prospective data collection is feasible in DARTNet and can enable comparative effectiveness and safety research.

Educating the Scientific Workforce on Sex and Gender Considerations in Research: A National Scan of the Literature and Building Interdisciplinary Research Careers in Women's Health Programs.

Background: This study was a national scan of education resources on integrating sex and gender considerations into research. The purpose was to assess capacity for educating researchers and to identify gaps, with implications for implementation of guidelines or mandates to consider sex and gender differences in research. Information sources were U.S. training programs in women's health and sex/gender difference research, Building Interdisciplinary Research Careers in Women's Health (BIRCWH), and published peer-reviewed biomedical literature. Materials and Methods: This descriptive study used multiple methods: a national survey and a comprehensive literature review. BIRCWH leaders responded to a survey regarding education on sex/gender difference research for BIRCWH scholars (response rate 100%, 20 of 20). A comprehensive literature review was conducted for 1993-2018. Results: Nearly half (45%) of BIRCWH institutions offered education on integrating sex or gender differences in clinical translational research; of those, roughly half (54%) offered in-person training and one-third (31%) offered content within existing for-credit courses. Respondents preferred online training (84%) to in-person offerings or reference materials (47% and 42% respectively). Published indexed literature on sex or gender differences has quadrupled since 1993, although growth in these publications remained flat in the most recent six years. Conclusions: Published resources to educate researchers on integrating sex and gender differences into medical research have increased, and BIRCWH programs connect scholars to national resources. Educational gaps remain due to limited access to curricula on applied research approaches, design, and methods for sex/gender difference research. BIRCWH programs desire curricula that are easily accessible online and asynchronously; sanctioned and supported by national thought leaders; linked to required training such as rigor and reproducibility; foster collaboration; and offer practical applications. Evidence-based, high-quality educational curricula and a dissemination plan are needed to enhance the adoption and integration of sex and gender into scientific endeavors.

Increases in Suicide Deaths Among Adolescents and Young Adults Following US Food and Drug Administration Antidepressant Boxed Warnings and Declines in Depression Care.

Objective: Studies show decreased depression diagnosis, psychotherapy, and medications and increased suicide attempts following US Food and Drug Administration antidepressant warnings regarding suicidality risk among youth. Effects on care spilled over to older adults. This study investigated whether suicide deaths increased following the warnings and declines in depression care. Methods: We conducted an interrupted time series study of validated death data (1990-2017) to estimate changes in trends of US suicide deaths per 100,000 adolescents (ages 10-19) and young adults (ages 20-24) after the warnings, controlling for baseline trends. Results: Before the warnings (1990-2002), suicide deaths decreased markedly. After the warnings (2005-2017) and abrupt declines in treatment, this downward trend reversed. There was an immediate increase of 0.49 suicides per 100,000 adolescents, 95% confidence interval [CI]: 0.12, 0.86) and a trend increase of 0.03 suicides per 100,000 adolescents per year (95% CI: 0.026, 0.031). Similarly, there was an immediate increase of 2.07 suicides per 100,000 young adults (95% CI: 1.04, 3.10) and a trend increase of 0.05 suicides per 100,000 young adults per year (95% CI: 0.04, 0.06). Assuming baseline trends continued, there may have been 5958 excess suicides nationally by 2010 among yearly cohorts of 43 million adolescents and 21 million young adults. Conclusions: We observed increases in suicide deaths among youth following the warnings and declines in depression care. Alternative explanations were explored, including substance use, economic recessions, smart phone use, and unintentional injury deaths. Additional factors may have contributed to continued increases in youth suicide during the last decade. Combined with previous research on declining treatment, these results call for re-evaluation of the antidepressant warnings.

Training Mentor-Mentee Pairs to Build a Robust Culture for Mentorship and a Pipeline of Clinical and Translational Researchers: The Colorado Mentoring Training Program.

The Colorado Mentoring Training program (CO-Mentor) was developed at the University of Colorado Anschutz Medical Campus in 2010, supported by the Colorado Clinical and Translational Sciences Institute. CO-Mentor represents a different paradigm in mentorship training by focusing equally on the development of mentees, who are valued as essential to institutional capacity for effective mentorship. The training model is unique among Clinical and Translational Science Award sites in that it engages mentors and mentees in an established relationship. Dyads participate in 4 day-long sessions scheduled throughout the academic year. Each session features workshops that combine didactic and experiential components. The latter provide structured opportunities to develop mentorship-related skills, including self-knowledge and goal setting, communication skills (including negotiation), "managing up," and the purposeful development of a mentorship support network. Mentors and mentees in 3 recent cohorts reported significant growth in confidence with respect to all mentorship-related skills assessed using a pre-post evaluation survey (P = .001). Mentors reported the most growth in relation to networking to engage social and professional support to realize goals as well as sharing insights regarding paths to success. Mentees reported the most growth with respect to connecting with potential/future mentors, knowing characteristics to look for in current/future mentors, and managing the work environment (e.g., prioritizing work most fruitful to advancing research/career objectives). CO-Mentor represents a novel approach to enhancing mentorship capacity by investing equally in the development of salient skills among mentees and mentors and in the mentorship relationship as an essential resource for professional development, persistence, and scholarly achievement.

From Stigma to Validation: A Qualitative Assessment of a Novel National Program to Improve Retention of Physician-Scientists with Caregiving Responsibilities.

Background: Research is needed to improve understanding of work-life integration issues in academic medicine and to guide the implementation of the Doris Duke Charitable Foundation's Fund to Retain Clinical Scientists (FRCS), a national initiative offering financial support to physician-scientists facing caregiving challenges. Materials and Methods: In 2018, as part of a prospective program evaluation, the authors conducted a qualitative study to examine FRCS program participants' initial impressions, solicit descriptions of their career and caregiving experiences, and inquire how such factors might influence their professional advancement. The authors invited all 33 awardees who had been granted FRCS funding in the first year of the program to participate in the study, of whom 28 agreed to complete an interview. Analysts evaluated de-identified transcripts and explicated the data using a thematic analysis approach. Results: While participants described aspects of a culture that harbor stigma against caregivers and impede satisfactory work-life integration, they also perceived an optimistic cultural shift taking place as a result of programs like the FRCS. Their comments indicated that the FRCS has the potential to influence culture if institutional leadership simultaneously fosters a community that validates individuals both as caregivers and as scientists. Conclusions: Insights garnered from this qualitative study suggest that there is a pressing need for institutional leaders to implement programs that can foster awareness and normalization of caregiving challenges. In addition to providing funding and other tangible resources, interventions should strive to reinforce a broader culture that affirms the presence of work-life integration challenges and openly embraces solutions.

The Most Valuable Resource Is Time: Insights From a Novel National Program to Improve Retention of Physician-Scientists With Caregiving Responsibilities.

PURPOSE: To enhance understanding of challenges related to work-life integration in academic medicine and to inform the ongoing implementation of an existing program and the development of other interventions to promote success of physician-scientists. METHOD: This study is part of a prospective analysis of the effects of the Fund to Retain Clinical Scientists (FRCS), a national program launched by the Doris Duke Charitable Foundation at 10 U.S. institutions, which provides financial support to physician-scientists facing caregiving challenges. In early 2018, 28 of 33 program awardees participated in semistructured interviews. Questions were about challenges faced by physician-scientists as caregivers and their early perceptions of the FRCS. Multiple analysts reviewed deidentified transcripts, iteratively revised the coding scheme, and interpreted the data using qualitative thematic analysis. RESULTS: Participants' rich descriptions illuminated 5 interconnected themes: (1) Time is a critical and limited resource, (2) timing is key, (3) limited time resources and timing conflicts may have a particularly adverse effect on women's careers, (4) flexible funds enable reclamation and repurposing of time resources, and (5) FRCS leaders should be cognizant of time and timing conflicts when developing program-related offerings. CONCLUSIONS: Programs such as the FRCS are instrumental in supporting individuals to delegate time-consuming tasks and to control how they spend their valuable time. Qualitative analysis suggests that access to and command of valuable time resources are crucial to career advancement, research productivity, and work-life flexibility, especially during critical time points along the physician-scientist trajectory.