Increasing Pediatric Residency Class Diversity to Improve Patient Outcomes and Address Structural Racism.

PROBLEM: The racial and ethnic makeup of physicians in the United States does not reflect that of the communities they serve. Addressing this disparity may improve patient outcomes and combat structural racism. APPROACH: Starting in 2014, the pediatric residency program at Children's National Hospital deliberately worked to assemble residency classes with racial and ethnic diversity that was similar to that of the Washington, DC, community it served. This work consisted of 3 initiatives: the Minority Senior Scholarship Program (MSSP), a pipeline program for rising fourth-year underrepresented in medicine (UIM) medical students to expose them to careers in academic pediatrics; an enhanced applicant recruitment process for UIM applicants; and mechanisms like a diversity dinner series for UIM residents to find the support they need to succeed. OUTCOMES: Since its inception in 2015, 73 participants have completed the MSSP, with 26% (19/73) going on to match at Children's National Hospital. An additional 12 participants are completing the program during the 2022 Match cycle. The MSSP has also increased participants' self-reported interest in pursuing a career in academic pediatrics, from 70% (14/20) before participation to 95% (19/20) after participation. In addition, the enhanced recruitment efforts have proven fruitful. The percentage of UIM interns at Children's National Hospital has increased from 5% (2/40) in 2014 to 51% (21/41) in 2021. NEXT STEPS: The dimensions of diversity included in these initiatives will be expanded to include individuals from other marginalized populations, such as certain individuals of Southeast Asian descent, those who identify as LGBTQ+, and those with disabilities. An antiracism initiative has also been implemented in the residency program in collaboration with the hospital and partner medical schools.

Results of Testing Children for Severe Acute Respiratory Syndrome Coronavirus-2 Through a Community-based Testing Site.

OBJECTIVE: To describe the demographics, clinical features, and test results of children referred from their primary provider for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in the community setting. STUDY DESIGN: Retrospective cross-sectional study of children ≤22 years of age who were tested for SARS-CoV-2 at a community-based specimen collection site in Washington, DC, affiliated with a large children's hospital between March 21 and May 16, 2020. RESULTS: Of the 1445 patients tested at the specimen collection site for SARS-CoV-2 virus, 408 (28.2%) had a positive polymerase chain reaction test. The daily positivity rate increased over the study period, from 5.4% during the first week to a peak of 47.4% (Ptrend < .001). Patients with fever (aOR, 1.7; 95% CI, 1.3-2.3) or cough (aOR, 1.4; 95% CI, 1.1-1.9) and those with known contact with someone with confirmed SARS-CoV-2 infection (aOR, 1.6; 95% CI, 1.0-2.4.) were more likely have a positive test, but these features were not highly discriminating. CONCLUSIONS: In this cohort of mildly symptomatic or well children and adolescents referred to a community drive-through/walk-up SARS-CoV-2 testing site because of risk of exposure or clinical illness, 1 in 4 patients had a positive test. Children and young adults represent a considerable burden of SARS-CoV-2 infection. Assessment of their role in transmission is essential to implementing appropriate control measures.

Racial and/or Ethnic and Socioeconomic Disparities of SARS-CoV-2 Infection Among Children.

OBJECTIVES: To evaluate racial and/or ethnic and socioeconomic differences in rates of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among children. METHODS: We performed a cross-sectional study of children tested for SARS-CoV-2 at an exclusively pediatric drive-through and walk-up SARS-CoV-2 testing site from March 21, 2020, to April 28, 2020. We performed bivariable and multivariable logistic regression to measure the association of patient race and/or ethnicity and estimated median family income (based on census block group estimates) with (1) SARS-CoV-2 infection and (2) reported exposure to SARS-CoV-2. RESULTS: Of 1000 children tested for SARS-CoV-2 infection, 20.7% tested positive for SARS-CoV-2. In comparison with non-Hispanic white children (7.3%), minority children had higher rates of infection (non-Hispanic Black: 30.0%, adjusted odds ratio [aOR] 2.3 [95% confidence interval (CI) 1.2-4.4]; Hispanic: 46.4%, aOR 6.3 [95% CI 3.3-11.9]). In comparison with children in the highest median family income quartile (8.7%), infection rates were higher among children in quartile 3 (23.7%; aOR 2.6 [95% CI 1.4-4.9]), quartile 2 (27.1%; aOR 2.3 [95% CI 1.2-4.3]), and quartile 1 (37.7%; aOR 2.4 [95% CI 1.3-4.6]). Rates of reported exposure to SARS-CoV-2 also differed by race and/or ethnicity and socioeconomic status. CONCLUSIONS: In this large cohort of children tested for SARS-CoV-2 through a community-based testing site, racial and/or ethnic minorities and socioeconomically disadvantaged children carry the highest burden of infection. Understanding and addressing the causes of these differences are needed to mitigate disparities and limit the spread of infection.

Is There a Return on a Children's Hospital's Investment in a Pediatric Residency's Community Health Track? A Cost Analysis.

Academic Medical Centers incur significant expenses associated with training residents and caring for underserved populations. No previous studies have analyzed hospital-level graduate medical education economics for pediatric residency training. Using data from the 2010-2011 academic year, we quantified total direct costs per year for training 12 community health track (CHT) residents. Utilizing sensitivity analyses, we estimated revenues generated by residents in inpatient and outpatient settings. The total yearly direct cost of training 12 CHT residents was $922,640 including salaries, benefits, and administrative costs. The estimated additional yearly inpatient net revenue from attending-resident clinical teams compared to attendingonly service was $109,452. For primary care clinics, the estimated yearly revenue differential of resident-preceptor teams was $455,940, compared to attending-only clinics. The replacement cost of 12 CHT residents with advanced practitioners was $457,596 per year.This study suggests there is positive return on a children's hospital's investment in a CHT.

Strategies for Improving Vaccine Delivery: A Cluster-Randomized Trial.

OBJECTIVE: New emphasis on and requirements for demonstrating health care quality have increased the need for evidence-based methods to disseminate practice guidelines. With regard to impact on pediatric immunization coverage, we aimed to compare a financial incentive program (pay-for-performance [P4P]) and a virtual quality improvement technical support (QITS) learning collaborative. METHODS: This single-blinded (to outcomes assessor), cluster-randomized trial was conducted among unaffiliated pediatric practices across the United States from June 2013 to June 2014. Practices received either the P4P or QITS intervention. All practices received a Vaccinator Toolkit. P4P practices participated in a tiered financial incentives program for immunization coverage improvement. QITS practices participated in a virtual learning collaborative. Primary outcome was percentage of all needed vaccines received (PANVR). We also assessed immunization up-to-date (UTD) status. RESULTS: Data were analyzed from 3,147 patient records from 32 practices. Practices in the study arms reported similar QI activities (∼6 to 7 activities). We found no difference in PANVR between P4P and QITS (mean ± SE, 90.7% ± 1.1% vs 86.1% ± 1.3%, P = 0.46). Likewise, there was no difference in odds of being UTD between study arms (adjusted odds ratio 1.02, 95% confidence interval 0.68 to 1.52, P = .93). In within-group analysis, patients in both arms experienced nonsignificant increases in PANVR. Similarly, the change in adjusted odds of UTD over time was modest and nonsignificant for P4P but reached significance in the QITS arm (adjusted odds ratio 1.28, 95% confidence interval 1.02 to 1.60, P = .03). CONCLUSIONS: Participation in either a financial incentives program or a virtual learning collaborative led to self-reported improvements in immunization practices but minimal change in objectively measured immunization coverage.

Frequent vaccination missed opportunities at primary care encounters contribute to underimmunization.

OBJECTIVE: To examine missed opportunities to administer an eligible vaccination (MOs) and their contribution to underimmunization in contemporary pediatric practices. STUDY DESIGN: This study was a retrospective analysis from 42 diverse pediatric practices located throughout the US. Medical records of 50 randomly selected children 3-18 months of age per practice were reviewed in Spring 2013. Immunization status for age and MOs were assessed as of each encounter and as of March 1, 2013. RESULTS: Of 2076 eligible patients, 72.7% (95% CI 67.6-77.9) were up-to-date with receipt of standard vaccines. Most children (82.4%; 95% CI 78.3-85.9) had at least 1 MO, and 37.8% (95% CI 30.0-46.2) had at least one MO to administer an overdue vaccination. After adjustment, risk of underimmunization was 3.5 times greater for patients who had ever experienced an MO for an overdue vaccination compared with those who had not (adjusted relative risk = 3.5; 95% CI 2.8-4.3). If all age-appropriate vaccinations had been administered at the last recorded encounter, 45.5% (95% CI 36.8-54.5) of the underimmunized patients would have been up to date at the time of assessment. CONCLUSION: MOs were common and contributed substantially to underimmunization in this contemporary sample of diverse primary care practice settings.

Improving the quality of immunization delivery to an at-risk population: a comprehensive approach.

OBJECTIVE: Immunization quality improvement (QI) interventions are rarely tested as multicomponent interventions within the context of a theoretical framework proven to improve outcomes. Our goal was to study a comprehensive QI program to increase immunization rates for underserved children that relied on recommendations from the Centers for Disease Control and Prevention's Task Force on Community Preventive Services and the framework of the Chronic Care Model. METHODS: QI activities occurred from September 2007 to May 2008 at 6 health centers serving a low-income, minority population in Washington, DC. Interventions included family reminders, education, expanding immunization access, reminders and feedback for providers, and coordination of activities with community stakeholders. We determined project effectiveness in improving the 4:3:1:3:3:1:3 vaccination series (4 diphtheria-tetanus-pertussis vaccines, 3 poliovirus vaccines, 1 measles-mumps-rubella vaccine, 3 Haemophilus influenzae type b vaccines, 3 hepatitis B vaccines, 1 varicella vaccine, and three 7-valent pneumococcal conjugate vaccines) compliance. RESULTS: We found a 16% increase in immunization rates overall and a 14% increase in on-time immunization by 24 months of age. Improvement was achieved at all 6 health centers and maintained beyond 18 months. CONCLUSION: We were able to implement a comprehensive immunization QI program that was sustainable over time.

Minority faculty members' resilience and academic productivity: are they related?

PURPOSE: To explore whether there is a relationship between resilience and academic productivity of minority faculty members in U.S. academic health centers. For the purposes of the study, the authors defined academic productivity as peer-reviewed and non-peer-reviewed publications, grants, and academic promotion. METHOD: In 2007, the authors simultaneously collected quantitative and qualitative data by using a triangulation (mixed-method) design. Past participants in the Association of American Medical Colleges' Minority Faculty Career Development Seminar completed the Web-based 70-item Personal Resilience Questionnaire (PRQ). In addition, two focus groups were conducted with past seminar participants. RESULTS: Seventy-four minority faculty members completed the PRQ, and 15 participated in the two focus groups. The quantitative data showed a positive correlation between demographic, educational, and academic productivity variables and certain resilience subscale scores. Common themes that emerged from the qualitative data were categorized under four major domains: existing barriers to academic advancement, internal protective factors or cultural buffers, external institutional or environmental facilitators, and necessary attributes for ensuring academic productivity and advancement. CONCLUSIONS: Certain resilience subscales showed correlation with academic productivity of minority faculty members, and specific personal and/or cultural characteristics were identified as enablers. Minority faculty members may benefit from skill development and coaching that extends beyond the traditional scope of faculty development programs and that specifically targets modifiable resilience characteristics. Additional research is needed, but such nontraditional, resilience-centered intervention strategies may positively affect the advancement of minority faculty in academic medicine.

A cross-cultural pediatric residency program merger.

Academic health centers, health systems, and, to a lesser degree, medical schools and residency programs have merged, consolidated, or formed strategic alliances. There are few published reports of residency program mergers, and only one involving a merger between a historically black college and university (HBCU) and a predominantly white institution.This case study describes a merger between two dissimilar urban pediatric residency programs. The Howard University Hospital (HUH) pediatric residency program is affiliated with a HBCU, and the Children's National Medical Center (CNMC) pediatric residency program, is affiliated with a leading children's hospital which had relatively few underrepresented minority physicians or residents. The pediatric residency program merger between HUH and CNMC occurred in 2003 and presented organizational, cultural, and programmatic challenges and opportunities for both institutions. However, there was a sharp contrast between the opinions of the HUH and CNMC residents with respect to the perceived effect of the merger on residency training, patient care, and the individual institutions. Increasing the size and diversity of CNMC's resident pool and the granting of accreditation for the community health track were positive outcomes, but the magnitude of the institutional change process and the disruption to residents' routines and schedules were significant challenges. The merger served as an impetus to embed cultural competency guiding principles and expectations into the organizational fabric of the combined residency program.

Providing care for immigrant, homeless, and migrant children.

This policy statement, which replaces the retired statements "Health Care for Children of Immigrant Families" (1997) and "Health Needs of Homeless Children and Families" (1996), is a broader discussion and addresses not only immigrant but also homeless and migrant child populations. It provides pediatricians with the necessary framework for addressing underserved children: those who face substantial barriers that limit access to appropriate health care services. This statement supports a community-based approach to health care delivery to ensure that underserved children have a medical home.