Utilization, quality, and spending for pediatric Medicaid enrollees with primary care in health centers vs non-health centers.

BACKGROUND: Limited research has explored the performance of health centers (HCs) compared to other primary care settings among children in the United States. We evaluated utilization, quality, and expenditures for pediatric Medicaid enrollees receiving care in HCs versus non-HCs. METHODS: This national cross-sectional study utilized 2012 Medicaid Analytic eXtract (MAX) claims to examine children 0-17 years with a primary care visit, stratified by whether majority (> 50%) of primary care visits were at HCs or non-HCs. Outcome measures include utilization (primary care visits, non-primary care outpatient visits, prescription claims, Emergency Department (ED) visits, hospitalizations) and quality (well-child visits, avoidable ED visits, avoidable hospitalizations). For children enrolled in fee-for-service Medicaid, we also measured expenditures. Propensity score-based overlap weighting was used to balance covariates. RESULTS: A total of 2,383,270 Medicaid-enrolled children received the majority of their primary care at HCs, while 18,540,743 did at non-HCs. In adjusted analyses, HC patients had 20% more primary care visits, 15% less non-primary care outpatient visits, and 21% less prescription claims than non-HC patients. ED visits were similar across the two groups, while HC patients had 7% lower chance of hospitalization than non-HC. Quality of care outcomes favored HC patients in main analyses, but results were less robust when excluding managed care beneficiaries. Total expenditures among the fee-for-service subpopulation were lower by $239 (8%) for HC patients. CONCLUSIONS: In this study of nationwide claims data to evaluate healthcare utilization, quality, and spending among Medicaid-enrolled children who receive primary care at HCs versus non-HCs, findings suggest primary care delivery in HCs may be associated with a more cost-effective model of healthcare for children.

The ACHIEVE Program: Bringing Chicago Youth and Community Organizations Together to Impact Local Disparities.

To evaluate the Advancing Community Health and Individual leadership through a noVel Educational (ACHIEVE) program uniting Chicago high school and undergraduate students (scholars) and community organizations to empower youth to meaningfully impact communities while enhancing organizational capacity. Between 2020 and 2022, the ACHIEVE program engaged cohorts of youth in classroom-based learning and community-based projects targeting health and education disparities. Pre and post-program surveys were administered to scholars to assess knowledge about disparities, skills, and self-efficacy. Semi-structured interviews were conducted with community organization leaders to examine programmatic impact. Descriptive and thematic analyses were performed. Across four cohorts (March 2020; September 2020-May 2021; September-November 2021; March-May 2022), 85 students participated in the ACHIEVE program. Scholars supported 19 community-based projects that increased awareness of local issues and resources and evaluated programs. Scholars reported advancement in their knowledge and skills as well as interest in sustaining their community engagement. Leaders shared several benefits at the organizational and community levels from collaborating with scholars. The ACHIEVE program enabled bidirectional learning between scholars and organizations. It also demonstrated that youth can contribute positively to addressing disparities while supporting local organizations and communities.

Analysis of narrative assessments of internal medicine resident performance: are there differences associated with gender or race and ethnicity?

BACKGROUND: Equitable assessment is critical in competency-based medical education. This study explores differences in key characteristics of qualitative assessments (i.e., narrative comments or assessment feedback) of internal medicine postgraduate resident performance associated with gender and race and ethnicity. METHODS: Analysis of narrative comments included in faculty assessments of resident performance from six internal medicine residency programs was conducted. Content analysis was used to assess two key characteristics of comments- valence (overall positive or negative orientation) and specificity (detailed nature and actionability of comment) - via a blinded, multi-analyst approach. Differences in comment valence and specificity with gender and race and ethnicity were assessed using multilevel regression, controlling for multiple covariates including quantitative competency ratings. RESULTS: Data included 3,383 evaluations with narrative comments by 597 faculty of 698 residents, including 45% of comments about women residents and 13.2% about residents who identified with race and ethnicities underrepresented in medicine. Most comments were moderately specific and positive. Comments about women residents were more positive (estimate 0.06, p 0.045) but less specific (estimate - 0.07, p 0.002) compared to men. Women residents were more likely to receive non-specific, weakly specific or no comments (adjusted OR 1.29, p 0.012) and less likely to receive highly specific comments (adjusted OR 0.71, p 0.003) or comments with specific examples of things done well or areas for growth (adjusted OR 0.74, p 0.003) than men. Gendered differences in comment specificity and valence were most notable early in training. Comment specificity and valence did not differ with resident race and ethnicity (specificity: estimate 0.03, p 0.32; valence: estimate - 0.05, p 0.26) or faculty gender (specificity: estimate 0.06, p 0.15; valence: estimate 0.02 p 0.54). CONCLUSION: There were significant differences in the specificity and valence of qualitative assessments associated with resident gender with women receiving more praising but less specific and actionable comments. This suggests a lost opportunity for well-rounded assessment feedback to the disadvantage of women.

Asthma policy in Illinois: A survey of school nursing and staff knowledge and implementation patterns.

OBJECTIVE: Our goal is to examine gaps in self-carry, asthma emergency protocol, and stock inhaler policy knowledge in Illinois schools. DESIGN: A 30-item REDCap cross-sectional survey developed by a team of stakeholders was disseminated. Questions assessed policy knowledge, awareness, and practices regarding asthma emergency protocols, self-carry, and stock inhalers. SAMPLE: Participants were Illinois school nurses belonging to a governmental organization listserv. MEASUREMENTS: Analysis utilized Chi-square tests, descriptive statistics, and t-tests. RESULTS: Nurses reported 36% of students on average self-carried asthma medication. Thirty percent of nurses were not aware of their emergency asthma policy and only 60% reported having an emergency asthma protocol in their school(s). Fifty-four percent of nurses were aware of stock inhaler programming. Of the 10.3% who reported a stock inhaler program, a lower frequency reported calling 911 for asthma emergencies. Perceived school asthma prevalence varied from 0%-87%. CONCLUSIONS: Our survey demonstrates large variation in knowledge and implementation of school-based asthma health policy. This is likely due to variations in health policy education dissemination. Future efforts should focus on the dissemination and implementation of school-based asthma health policies to improve their more universal adoption and better support school-based asthma management.

Evaluating inhaler education interventions for hospitalized children with asthma: A randomized controlled trial.

BACKGROUND: Most children with asthma have poor inhaler technique, with detrimental morbidity effects. Guidelines recommend clinicians provide inhaler education at every opportunity, yet resources are limited. A low-cost, technology-based intervention-Virtual Teach-to-Goal (V-TTG)-was developed to deliver tailored inhaler technique education with high fidelity. OBJECTIVE: To evaluate whether V-TTG leads to less inhaler misuse among children with asthma who are hospitalized vs brief intervention (BI, reading steps aloud). METHODS: A single-center randomized controlled trial of V-TTG vs BI was conducted with 5-to-10-year-old children with asthma hospitalized between January 2019 and February 2020. Inhaler technique was assessed pre- and post-education using 12-step validated checklists (misuse: < 10 steps correct). RESULTS: Among 70 children enrolled, mean age was 7.8 years (SD = 1.6). Most (86%) were Black. Most had an emergency department visit (94%) or hospitalization (90%) in the previous year. At baseline, nearly all children misused inhalers (96%). The proportion of children with inhaler misuse decreased significantly in V-TTG (100%→74%, P = .002) and BI (92%→69%, P = .04) groups, with no difference between groups at both time points (P = .2 and .9). On average, children performed 1.5 more steps correctly (SD = 2.0), with greater improvement with V-TTG (mean [SD] = 1.7 [1.6]) vs BI (mean [SD] = 1.4 [2.3]), though not significant (P = .6). Concerning pre and post technique, older children were significantly more likely than younger children to show more correct steps (mean change = 1.9 vs 1.1, P = .002). CONCLUSION: A technology-based intervention for tailored inhaler education led to improved technique among children, similarly to reading steps aloud. Older children saw greater benefits. Future studies should evaluate the V-TTG intervention across diverse populations and disease severities to identify the greatest impact. CLINICAL TRIAL REGISTRATION: NCT04373499.

Appropriate inhaler use in children with asthma: barriers and opportunities through the lens of the socio-ecological model.

Objective: Proper use of inhaled medications is essential for management of asthma, as inhaled therapies are recommended as first-line for both prevention and treatment of asthma symptoms. Optimizing adherence requires identifying and understanding multiple layers of systemic complexity to obtaining and using these therapies and offering specific solutions to address these barriers. Bronfenbrenner's socio-ecological model provides a framework for examining multilevel systems - both internal and external - that contribute to the management of childhood asthma. The four levels in this model consist of factors related to the individual, interpersonal relationships, organizational entities, and societal structures and rules. This narrative review identifies influences and factors related to asthma inhaler adherence by each level and offers evidence-based solutions to each obstacle.Data Sources: We conducted PubMed searches to identify relevant articles for barriers and solutions impacting asthma control at each level of the socio-ecological model.Study Selection: Common barriers to asthma control at each model level were identified. Pertinent studies for each barrier were identified and reviewed by the writing group for inclusion into the narrative review.Results: For each level of the socio-ecological model, three primary issues were identified based on the literature review. Approaches for addressing each issue in an evidence-based, systematic fashion are presented.Conclusion: Understanding the obstacles and potential interventions to achieve proper use of inhaled medications is a critical step necessary to develop and implement systematic solutions aimed at improving asthma control and morbidity for the more than 6 million affected children in the United States.

Student knowledge gains among first-time and repeat attendees of school-based asthma education program.

BACKGROUND: Because children spend much of their time in schools, schools can play an important role in asthma education for the one in 12 affected children in the United States. School-based asthma education programs are commonly repeated annually, however few studies have evaluated the impact of repeated participation in asthma education in school-based programs. METHODS: This observational study evaluated the impact of Fight Asthma Now© (FAN), a school-based asthma education program for children in Illinois schools. Participants completed a survey at the start and end of the program, including demographics, prior asthma education, and 11 asthma knowledge questions (maximum knowledge score = 11). RESULTS: Among 4,951 youth participating in the school-based asthma education program, mean age was 10.75 years. Approximately half were male and Black. Over half reported no prior asthma education (54.6%). At baseline, repeat attendees had significantly higher knowledge versus first-time attendees (mean: 7.45 versus 5.92; p < 0.001). After the program, both first-time and repeat attendees had significant knowledge improvements (first-time: mean = 5.92◊9.32; p < 0.001; repeat: mean = 7.45◊9.62; p < 0.001). CONCLUSIONS: School-based asthma education is effective for increasing asthma knowledge. Notably, repeated asthma education in school leads to incremental benefits for knowledge. Future studies are needed to understand the effects of repeated asthma education on morbidity.

Video-Based Educational Interventions for Patients With Chronic Illnesses: Systematic Review.

BACKGROUND: With rising time constraints, health care professionals increasingly depend on technology to provide health advice and teach patients how to manage chronic disease. The effectiveness of video-based tools in improving knowledge, health behaviors, disease severity, and health care use for patients with major chronic illnesses is not well understood. OBJECTIVE: The aim of this study was to assess the current literature regarding the efficacy of video-based educational tools for patients in improving process and outcome measures across several chronic illnesses. METHODS: A systematic review was conducted using CINAHL and PubMed with predefined search terms. The search included studies published through October 2021. The eligible studies were intervention studies of video-based self-management patient education for an adult patient population with the following chronic health conditions: asthma, chronic kidney disease, chronic obstructive pulmonary disease, chronic pain syndromes, diabetes, heart failure, HIV infection, hypertension, inflammatory bowel disease, and rheumatologic disorders. The eligible papers underwent full extraction of study characteristics, study design, sample demographics, and results. Bias was assessed with the Cochrane risk-of-bias tools. Summary statistics were synthesized in Stata SE (StataCorp LLC). Data reporting was conducted per the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist. RESULTS: Of the 112 studies fully extracted, 59 (52.7%) were deemed eligible for inclusion in this review. The majority of the included papers were superiority randomized controlled trials (RCTs; 39/59, 66%), with fewer pre-post studies (13/59, 22%) and noninferiority RCTs (7/59, 12%). The most represented conditions of interest were obstructive lung disease (18/59, 31%), diabetes (11/59, 19%), and heart failure (9/59, 15%). The plurality (28/59, 47%) of video-based interventions only occurred once and occurred alongside adjunct interventions that included printed materials, in-person counseling, and interactive modules. The most frequently studied outcomes were disease severity, health behavior, and patient knowledge. Video-based tools were the most effective in improving patient knowledge (30/40, 75%). Approximately half reported health behavior (21/38, 56%) and patient self-efficacy (12/23, 52%) outcomes were improved by video-based tools, and a minority of health care use (11/28, 39%) and disease severity (23/69, 33%) outcomes were improved by video-based tools. In total, 48% (22/46) of the superiority and noninferiority RCTs and 54% (7/13) of the pre-post trials had moderate or high risk of bias. CONCLUSIONS: There is robust evidence that video-based tools can improve patient knowledge across several chronic illnesses. These tools less consistently improve disease severity and health care use outcomes. Additional study is needed to identify features that maximize the efficacy of video-based interventions for patients across the spectrum of digital competencies to ensure optimized and equitable patient education and outcomes.

Exploring gender and thematic differences in qualitative assessments of internal medicine resident performance.

INTRODUCTION: Evidence suggests gender disparities in medical education assessment, including differences in ratings of competency and narrative comments provided in resident performance assessments. This study explores how gender manifests within the content of qualitative assessments (i.e., narrative comments or performance feedback) of resident performance. METHODS: Qualitative content analysis was used to explore gender-based differences in narrative comments included in faculty assessments of resident performance during inpatient medicine rotations at six Internal Medicine residency programs, 2016-2017. A blinded, multi-analyst approach was employed to identify themes across comments. Patterns in themes with resident gender and post-graduate year (PGY) were explored, focusing on PGY2 and PGY3 when residents are serving in the team leader role. RESULTS: Data included 3,383 evaluations with narrative comments of 385 men (55.2%) and 313 women residents (44.8%). There were thematic differences in narrative comments received by men and women residents and how these themes manifested within comments changed with training time. Compared to men, comments about women had a persistent relationship-orientation and emphasized confidence over training including as interns and in PGY2 and PGY3, when serving as team leader. The relationship-orientation was characterized not only by the residents' communal attributes but also their interpersonal and communication skills, including efforts supporting others and establishing the tone for the team. Comments about women residents often highlighted confidence, including recommendations around behaviors that convey confidence in decision-making and team leadership. DISCUSSION: There were gender-based thematic differences in qualitative assessments. Comments about women resident team leaders highlight relationship building skills and urge confidence and actions that convey confidence as team leader. Persistent attention to communal skills suggests gendered expectations for women resident team leaders and a lost opportunity for well-rounded feedback to the disadvantage of women residents. These findings may inform interventions to promote equitable assessment, such as providing feedback across the competencies.

Association of Gender and Race/Ethnicity with Internal Medicine In-Training Examination Performance in Graduate Medical Education.

BACKGROUND: Disparities in objective assessments in graduate medical education such as the In-Training Examination (ITE) that disadvantage women and those self-identifying with race/ethnicities underrepresented in medicine (URiM) are of concern. OBJECTIVE: Examine ITE trends longitudinally across post-graduate year (PGY) with gender and race/ethnicity. DESIGN: Longitudinal analysis of resident ITE metrics at 7 internal medicine residency programs, 2014-2019. ITE trends across PGY of women and URiM residents compared to non-URiM men assessed via ANOVA. Those with ITE scores associated with less than 90% probability of passing the American Board of Internal Medicine certification exam (ABIM-CE) were identified and odds of being identified as at-risk between groups were assessed with chi square. PARTICIPANTS: A total of 689 IM residents, including 330 women and URiM residents (48%). MAIN MEASURES: ITE score KEY RESULTS: There was a significant difference in ITE score across PGY for women and URiM residents compared to non-URiM men (F(2, 1321) 4.46, p=0.011). Adjusting for program, calendar year, and baseline ITE, women and URiM residents had smaller ITE score gains (adjusted mean change in score between PGY1 and PGY3 (se), non-URiM men 13.1 (0.25) vs women and URiM residents 11.4 (0.28), p<0.001). Women and URiM residents had greater odds of being at potential risk for not passing the ABIM-CE (OR 1.75, 95% CI 1.10 to 2.78) with greatest odds in PGY3 (OR 3.13, 95% CI 1.54 to 6.37). CONCLUSION: Differences in ITE over training were associated with resident gender and race/ethnicity. Women and URiM residents had smaller ITE score gains across PGY translating into greater odds of potentially being seen as at-risk for not passing the ABIM-CE. Differences in ITE over training may reflect differences in experiences of women and URiM residents during training and may lead to further disparities.

Primary Care Practice Transformation in the Era of COVID-19 and Beyond: Key Principles for General Internal Medicine Practitioners.

As members of the Clinical Practice Committee (CPC) of the Society for General Internal Medicine (SGIM), we support practice innovation and transformation to achieve a more just system by which all people can achieve and maintain optimal health. The COVID-19 pandemic has tested the US healthcare delivery system and sharpened our national awareness of long-standing and ingrained system shortcomings. In the face of crisis, SGIM members innovated and energetically mobilized to focus on the immediate needs of our patients and communities. Reflecting on these experiences, we are called to consider what was learned from the pandemic that applies to the future of healthcare delivery. CPC members include leaders in primary care delivery, practice finance, quality of care, patient safety, hospital practice, and health policy. CPC members provide expertise in clinical practice, serving as primary care doctors, hospitalists, and patient advocates who understand the intensity of care needed for those with severe COVID-19 infections, the disproportionate impact of the pandemic on Black and Brown communities, the struggles created for those with poor access to care, and the physical and emotional impact it has placed on patients, families, and clinicians. In this consensus statement, we summarize lessons learned from the 2020-2021 pandemic and their broader implications for reform in healthcare delivery. We provide a platform for future work by identifying many interactive elements of healthcare delivery that must be simultaneously addressed in order to ensure that care is accessible, equitably provided, patient-centered, and cost-effective.

Ensuring Access to Albuterol in Schools: From Policy to Implementation. An Official ATS/AANMA/ALA/NASN Policy Statement.

Rationale: For children with asthma, access to quick-relief medications is critical to minimizing morbidity and mortality. An innovative and practical approach to ensure access at school is to maintain a supply of stock albuterol that can be used by any student who experiences respiratory distress. To make this possible, state laws allowing for stock albuterol are needed to improve medication access.Objectives: To provide policy recommendations and outline steps for passing and implementing stock albuterol laws.Methods: We assembled a diverse stakeholder group and reviewed guidelines, literature, statutes, regulations, and implementation documents related to school-based medication access. Stakeholders were divided into two groups-legislation and implementation-on the basis of expertise. Each group met virtually to review documents and draft recommendations. Recommendations were compiled and revised in iterative remote meetings with all stakeholders.Main Results: We offer several recommendations for crafting state legislation and facilitating program implementation. 1) Create a coalition of stakeholders to champion legislation and implement stock albuterol programs. The coalition should include school administrators, school nurses and health personnel, parents, or caregivers of children with asthma, pediatric primary care and subspecialty providers (e.g., pulmonologists/allergists), pharmacists, health department staff, and local/regional/national advocacy organizations. 2) Legislative components critical for effective implementation of stock albuterol programs include specifying that medication can be administered in good faith to any child in respiratory distress, establishing training requirements for school staff, providing immunity from civil liability for staff and prescribers, ensuring pharmacy laws allow prescriptions to be dispensed to schools, and suggesting inhalers with valved holding chambers/spacers for administration. 3) Select an experienced and committed legislator to sponsor legislation and guide revisions as needed during passage and implementation. This person should be from the majority party and serve on the legislature's health or education committee. 4) Develop plans to disseminate legislation and regulations/policies to affected groups, including school administrators, school nurses, pharmacists, emergency responders, and primary/subspecialty clinicians. Periodically evaluate implementation effectiveness and need for adjustments.Conclusions: Stock albuterol in schools is a safe, practical, and potentially life-saving option for children with asthma, whether asthma is diagnosed or undiagnosed, who lack access to their personal quick-relief medication. Legislation is imperative for aiding in the adoption and implementation of school stock albuterol policies, and key policy inclusions can lay the groundwork for success. Future work should focus on passing legislation in all states, implementing policy in schools, and evaluating the impact of such programs on academic and health outcomes.

Association between dispensing of low-value oral albuterol and removal from Medicaid preferred drug lists.

BACKGROUND: Oral albuterol has worse efficacy and side effects compared with inhaled albuterol, and thus its use has been discouraged for decades. Drug inclusion or exclusion on formularies have been associated with reductions in low-value care. This study examines dispensing of oral albuterol and inclusion of oral albuterol on state Medicaid drug formularies--Preferred Drug Lists (PDLs). It also evaluates the association between removal of oral albuterol from the PDL and dispensing levels. METHODS: This quasi-experimental study determined oral albuterol inclusion on PDLs and dispensing between 2011 and 2018, using Medicaid program websites and the State Drug Utilization Database. Using a difference-in-differences model, we examine the association between removal of oral albuterol from Arkansas' Medicaid PDL in 2014 and dispensing of this drug through Medicaid, with Iowa as a control state. The outcome measure was the percent of all albuterol prescriptions that were for oral albuterol. RESULTS: A total of 28 state Medicaid PDLs included at least one formulation of oral albuterol in 2018. In 2018, 179,446 oral albuterol prescriptions were dispensed to Medicaid beneficiaries nationally. Medicaid programs paid approximately $3.0 million for oral albuterol prescriptions in 2018. Removal of oral albuterol syrup from the Arkansas PDL in March 2014 was associated with a more rapid decline in dispensing compared with Iowa which maintained this medication on their PDL. CONCLUSIONS: Findings suggest that removal of low-value medications, such as oral albuterol, from PDLs may be one avenue by which state Medicaid programs can reduce wasteful spending while improving guideline-based care.

Parental quality of life and self-efficacy in pediatric asthma.

Objective: Self-efficacy is the personal belief that a behavior can produce a desired result; and in asthma, self-efficacy in asthma care has been related to improvements in asthma outcomes and children's quality of life. To appreciate the full burden of asthma on families, the relationship between parental self-efficacy and quality of life also needs further study. We aim to characterize this relationship.Methods: Secondary analysis of measurements of parents of children with persistent asthma (n = 252; ages 4-17 years) from a large urban area were identified from a randomized trial; the association between baseline assessments of parental quality of life, measured by the Pediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ), and parental self-efficacy, measured through the Parental Asthma Management Self-Efficacy Scale (PAMSES), were examined through multivariable linear regression.Results: Parental self-efficacy in asthma was positively associated with quality of life among parents of racially and ethnically diverse children (p = 0.01). Confidence in using medications correctly (p = 0.03), having inhalers during a child's serious breathing problem (p = 0.02), and knowing which medications to use during a child's serious breathing problem (p = 0.04) were associated with a clinically meaningful difference in parental quality of life. Other significant factors associated with parental quality of life included Hispanic/Latino ethnicity (p < 0.01) of the child and Asthma Control Test scores (p < 0.01).Conclusion: The findings suggest that improving parental confidence on when and how to use their child's asthma medications, particularly during an asthma attack, might be clinically meaningful in enhancing parent's quality of life.

A Mixed-methods Study Examining Inhaler Carry and Use among Children at School.

Objective: Asthma self-management depends partly on access to inhalers; for children, this includes independent inhaler carry and use at school ("self-carry"). Although laws and policies support self-carry, little is known about practices within schools. This study aimed to identify factors associated with inhaler self-carry among children and examine barriers and facilitators to self-carry.Methods: This mixed-methods observational study included child-parent dyads and nurses from four Chicago schools. Children and parents answered questions about asthma care and morbidity, confidence in self-carry skills, and facilitators and barriers to self-carry. Nurses reported asthma documentation on file and their confidence in children's self-carry skills. Analysis utilized logistic regression. Thematic analysis was performed for open-ended questions.Results: Of 65 children enrolled (mean = 10.66 years), 45 (69.2%) reported having quick-relief medication at school, primarily inhalers, and 35 (53.8%) reported self-carry. Inhaler self-carry was associated with controller medication use and parent confidence in child's self-carry skills. Children and parents identified several facilitators to self-carry: child's asthma knowledge, inhaler characteristics, and need for easy inhaler access. Barriers included child's limited understanding of asthma and inhalers, perception that inhaler is not needed, and limited inhaler access. Children also emphasized social relationships as facilitators and barriers, while parents described children's responsibility as a facilitator and inconsistent policy implementation as a barrier.Conclusions: Efforts to improve inhaler self-carry at school should focus on educating children about asthma and inhaler use, creating supportive environments for self-carry among peers and teachers, and fostering consistent implementation and communication about asthma policy among schools and families.

Gender Bias in Resident Assessment in Graduate Medical Education: Review of the Literature.

BACKGROUND: Competency-based medical education relies on meaningful resident assessment. Implicit gender bias represents a potential threat to the integrity of resident assessment. We sought to examine the available evidence of the potential for and impact of gender bias in resident assessment in graduate medical education. METHODS: A systematic literature review was performed to evaluate the presence and influence of gender bias on resident assessment. We searched Medline and Embase databases to capture relevant articles using a tiered strategy. Review was conducted by two independent, blinded reviewers. We included studies with primary objective of examining the impact of gender on resident assessment in graduate medical education in the USA or Canada published from 1998 to 2018. RESULTS: Nine studies examined the existence and influence of gender bias in resident assessment and data included rating scores and qualitative comments. Heterogeneity in tools, outcome measures, and methodologic approach precluded meta-analysis. Five of the nine studies reported a difference in outcomes attributed to gender including gender-based differences in traits ascribed to residents, consistency of feedback, and performance measures. CONCLUSION: Our review suggests that gender bias poses a potential threat to the integrity of resident assessment in graduate medical education. Future study is warranted to understand how gender bias manifests in resident assessment, impact on learners and approaches to mitigate this bias.

A qualitative study of parent perspectives on barriers, facilitators and expectations for school asthma care among urban, African-American children.

Objectives: Minority children experience the disproportionate burden of asthma and its consequences. Studies suggest ethnic groups may experience asthma differently with varied perceptions and expectations among parents of African-American and Latino children. Because parents coordinate asthma care with the school, where children spend a significant amount of their day, this study's goal was to determine parents' perspectives on school asthma management. Methods: Focus groups were conducted with parents of children with asthma at four urban schools whose student population is predominantly African-American. A semi-structured guide was utilized focusing on barriers, facilitators and expectations for asthma care at school. Grounded theory principles were applied in this study. Results: Twenty-two parents (91% females) representing 13 elementary and 10 middle school children with asthma (61% boys) participated in four focus groups. Most children (87%) had persistent asthma. The identified barriers to effective school-based asthma care included limited awareness of children with asthma by teachers/staff, communication issues (e.g. school/parent, within school), inadequate education and lack of management plans or systems in place. In contrast, the identified facilitators included steps that fostered education, communication and awareness, as supported by management plans and parent initiative. Parents described their expectations for increased communication and education about asthma, better systems for identifying children with asthma, and a trained asthma point person for school-based asthma care. Conclusions: Parents of children with asthma identified important barriers, facilitators and expectations that must be considered to advance school asthma management. Improved school-based asthma care could lead to better health and academic outcomes.

Student perspectives on asthma management in schools: a mixed-methods study examining experiences, facilitators, and barriers to care.

Objective: Children spend nearly a third of their day at school, making it a critical point of intervention for those with asthma. This study aimed to illuminate minority students' experiences with asthma at school and perceptions of facilitators and barriers to care. Methods: A mixed-methods study was conducted with elementary students with asthma. Participants completed a 24-question survey, drawing exercise to depict experiences caring for their asthma at school, and focus group discussion. Drawings were analyzed for narrative and pictorial themes. Discussions were audio-recorded, transcribed, and independently coded for themes. Results: Fifteen children with asthma (8-11 years) participated from two Chicago schools with predominately African-American populations. Most students (79%) indicated they had control of asthma at school, while 85% identified asthma as a problem when exercising. Half (53%) received help with asthma care at school. Drawings depicted cooperative management with adults or peers and the central role of inhalers as part of everyday asthma care in school. Finally, focus groups produced six key themes within the domains of facilitators: 1) support of others, 2) self-efficacy; 3) perception of being normal; and barriers: 4) lack of support from others; 5) difficulty accessing inhaler; 6) perception of being different. Conclusions: This study suggests asthma care plays an important role in students' school experiences. Stigma around inhaler use, lack of concern by school staff, and limited access to medications remain as barriers to school-based asthma management. Although facilitators, such as support from teachers and peers, do exist, future interventions must address existing barriers.

A pilot study of team-based learning in one-hour pediatrics residency conferences.

BACKGROUND: Active learning has been shown to improve knowledge retention, facilitate feedback, and motivate learners. Despite this evidence, lecture, a passive mode of instruction, is the most widely utilized instructional method for residency educational conferences. Team-based learning fosters active learning but is infrequently used during residency training. METHODS: Three team-based learning sessions (one introductory and two content-based) were held during noon conferences in a pediatrics residency program. A pre-post static-group design was used to evaluate learner satisfaction and knowledge gains. Additional data was collected about facilitator preparation, session attendance, and readiness assurance test scores. Descriptive statistics and qualitative content analyses were conducted. RESULTS: Forty-seven residents and students participated (81%, 47 of 58). Prior to the introductory session, the majority of participants (55%) were not familiar with team-based learning. After the three sessions, 65% of residents and students reported high levels of satisfaction with team-based learning. When compared to traditional, lecture-based noon conferences, 76% of participants reported more engagement and 48% perceived more learning in team-based learning sessions. Challenges included low completion rates of the assigned reading prior to the session and abridged discussions due to time limitations during sessions. Each session required 10 hours of preparation for curriculum development. CONCLUSIONS: Team-based learning resulted in greater satisfaction and engagement among learners when compared to lecture-based formats. However, it did not prove to be a feasible instructional method during one-hour residency conferences. Adaptations that promote learner preparation for sessions and overcome time limitations during sessions may improve the feasibility and impact of team-based learning during one-hour conferences. TRIAL REGISTRATION: Not applicable.