Use of Patient Identifiers at the University of Washington School of Medicine: Building Institutional Consensus to Reduce Bias and Stigma.

BACKGROUND AND OBJECTIVES: Patient identifiers are used in the opening lines of case presentations and written documentation in health care and medical education settings. These identifiers can reflect physicians' implicit biases, which are known to impact patient care. Yet, no clear recommendations for the use of patient identifiers to reduce bias and stigma in patient care and medical education learning environments currently exist. We describe a process and outcomes for articulating such recommendations. METHODS: The University of Washington School of Medicine convened a group of diverse stakeholders to create patient identifier recommendations for use in the undergraduate medical education program. After a literature review, 22 recommendations for the use of patient identifiers were articulated. These underwent public comment periods reaching 11,150 potential respondents across our 5-state institution. Feedback from 437 respondents informed modifications to the recommendations. We used consensus methodology with three rounds of surveys and an expert group of 27 stakeholders to adopt recommendations with an a priori threshold of 90% agreeing the recommendation should be used. RESULTS: We adopted 12 recommendations for patient identifiers for age, gender/sex, race/ethnicity, sexual orientation, ability, size, and stigma; nine in round one, three in round two, and none in the third round. DISCUSSION: Our institution vetted these patient identifier recommendations via public comment and consensus methodology. Next steps include implementation across the undergraduate medical education program, including classroom and clinical settings. Other institutions could consider similar processes as key steps to reduce bias and stigma in their medical education programs.

Effectiveness of Mobile Apps to Promote Health and Manage Disease: Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Interventions aimed at modifying behavior for promoting health and disease management are traditionally resource intensive and difficult to scale. Mobile health apps are being used for these purposes; however, their effects on health outcomes have been mixed. OBJECTIVE: This study aims to summarize the evidence of rigorously evaluated health-related apps on health outcomes and explore the effects of features present in studies that reported a statistically significant difference in health outcomes. METHODS: A literature search was conducted in 7 databases (MEDLINE, Scopus, PsycINFO, CINAHL, Global Index Medicus, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews). A total of 5 reviewers independently screened and extracted the study characteristics. We used a random-effects model to calculate the pooled effect size estimates for meta-analysis. Sensitivity analysis was conducted based on follow-up time, stand-alone app interventions, level of personalization, and pilot studies. Logistic regression was used to examine the structure of app features. RESULTS: From the database searches, 8230 records were initially identified. Of these, 172 met the inclusion criteria. Studies were predominantly conducted in high-income countries (164/172, 94.3%). The majority had follow-up periods of 6 months or less (143/172, 83.1%). Over half of the interventions were delivered by a stand-alone app (106/172, 61.6%). Static/one-size-fits-all (97/172, 56.4%) was the most common level of personalization. Intervention frequency was daily or more frequent for the majority of the studies (123/172, 71.5%). A total of 156 studies involving 21,422 participants reported continuous health outcome data. The use of an app to modify behavior (either as a stand-alone or as part of a larger intervention) confers a slight/weak advantage over standard care in health interventions (standardized mean difference=0.38 [95% CI 0.31-0.45]; I2=80%), although heterogeneity was high. CONCLUSIONS: The evidence in the literature demonstrates a steady increase in the rigorous evaluation of apps aimed at modifying behavior to promote health and manage disease. Although the literature is growing, the evidence that apps can improve health outcomes is weak. This finding may reflect the need for improved methodological and evaluative approaches to the development and assessment of health care improvement apps. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42018106868; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=106868.

Gender-related barriers and delays in accessing tuberculosis diagnostic and treatment services: a systematic review of qualitative studies.

Background. Tuberculosis (TB) remains a significant global public health problem with known gender-related (male versus female) disparities. We reviewed the qualitative evidence (written/spoken narrative) for gender-related differences limiting TB service access from symptom onset to treatment initiation. Methods. Following a systematic process, we searched 12 electronic databases, included qualitative studies that assessed gender differences in accessing TB diagnostic and treatment services, abstracted data, and assessed study validity. Using a modified "inductive coding" system, we synthesized emergent themes within defined barriers and delays limiting access at the individual and provider/system levels and examined gender-related differences. Results. Among 13,448 studies, 28 studies were included. All were conducted in developing countries and assessed individual-level barriers; 11 (39%) assessed provider/system-level barriers, 18 (64%) surveyed persons with suspected or diagnosed TB, and 7 (25%) exclusively surveyed randomly sampled community members or health care workers. Each barrier affected both genders but had gender-variable nature and impact reflecting sociodemographic themes. Women experienced financial and physical dependence, lower general literacy, and household stigma, whereas men faced work-related financial and physical barriers and community-based stigma. Conclusions. In developing countries, barriers limiting access to TB care have context-specific gender-related differences that can inform integrated interventions to optimize TB services.

The effectiveness of prophylactic inferior vena cava filters in trauma patients: a systematic review and meta-analysis.

IMPORTANCE: Trauma is known to be one of the strongest risk factors for pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin therapy for prevention of PE, but trauma places some patients at risk of excess bleeding. Experts are divided on the role of prophylactic inferior vena cava (IVC) filters to prevent PE. OBJECTIVE: To perform a systematic review and meta-analysis examining the comparative effectiveness of prophylactic IVC filters in trauma patients, particularly in preventing PE, fatal PE, and mortality. DATA SOURCES: We searched the following databases for primary studies: MEDLINE, EMBASE, Scopus, CINAHL, International Pharmaceutical Abstracts, clinicaltrial.gov, and the Cochrane Library (all through July 31, 2012). We developed a search strategy using medical subject headings terms and text words of key articles that we identified a priori. We reviewed the references of all included articles, relevant review articles, and related systematic reviews to identify articles the database searches might have missed. STUDY SELECTION: We reviewed titles followed by abstracts to identify randomized clinical trials or observational studies with comparison groups reporting on the effectiveness and/or safety of IVC filters for prevention of venous thromboembolism in trauma patients. DATA EXTRACTION AND SYNTHESIS: Two investigators independently reviewed abstracts and abstracted data. For studies amenable to pooling with meta-analysis, we pooled using the random-effects model to analyze the relative risks. We graded the quantity, quality, and consistency of the evidence by adapting an evidence-grading scheme recommended by the Agency for Healthcare Research and Quality. RESULTS: Eight controlled studies compared the effectiveness of no IVC filter vs IVC filter on PE, fatal PE, deep vein thrombosis, and/or mortality in trauma patients. Evidence showed a consistent reduction of PE (relative risk, 0.20 [95% CI, 0.06-0.70]; I(2)=0%) and fatal PE (0.09 [0.01-0.81]; I(2)=0%) with IVC filter placement, without any statistical heterogeneity. We found no significant difference in the incidence of deep vein thrombosis (relative risk, 1.76 [95% CI, 0.50-6.19]; P=.38; I(2)=56.8%) or mortality (0.70 [0.40-1.23]; I(2)=6.7%). The number needed to treat to prevent 1 additional PE with IVC filters is estimated to range from 109 (95% CI, 93-190) to 962 (819-2565), depending on the baseline PE risk. CONCLUSIONS AND RELEVANCE: The strength of evidence is low but supports the association of IVC filter placement with a lower incidence of PE and fatal PE in trauma patients. Which patients experience benefit enough to outweigh the harms associated with IVC filter placement remains unclear. Additional well-designed observational or prospective cohort studies may be informative.

Barriers and delays in tuberculosis diagnosis and treatment services: does gender matter?

Background. Tuberculosis (TB) remains a global public health problem with known gender-related disparities. We reviewed the quantitative evidence for gender-related differences in accessing TB services from symptom onset to treatment initiation. Methods. Following a systematic review process, we: searched 12 electronic databases; included quantitative studies assessing gender differences in accessing TB diagnostic and treatment services; abstracted data; and assessed study validity. We defined barriers and delays at the individual and provider/system levels using a conceptual framework of the TB care continuum and examined gender-related differences. Results. Among 13,448 articles, 137 were included: many assessed individual-level barriers (52%) and delays (42%), 76% surveyed persons presenting for care with diagnosed or suspected TB, 24% surveyed community members, and two-thirds were from African and Asian regions. Many studies reported no gender differences. Among studies reporting disparities, women faced greater barriers (financial: 64% versus 36%; physical: 100% versus 0%; stigma: 85% versus 15%; health literacy: 67% versus 33%; and provider-/system-level: 100% versus 0%) and longer delays (presentation to diagnosis: 45% versus 0%) than men. Conclusions. Many studies found no quantitative gender-related differences in barriers and delays limiting access to TB services. When differences were identified, women experienced greater barriers and longer delays than men.