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OBJECTIVES: To describe the experience of caregivers and their perceptions of disparate care in the NICU, and (2) explore inter-professional NICU provider perspectives on potential biases and perceptions of disparate care. METHODS: This qualitative study was conducted in one southeastern level IV NICU. Semi-structured interviews assessed caregiver and provider perspectives on NICU care. Purposive sampling ensured ≥50% of caregivers self-identified as racial and/or ethnic minorities. Interviews were recorded, transcribed verbatim, and audio verified. A coding scheme was developed, raw data were systematically coded, and emerging themes were identified using thematic analyses. RESULTS: 23 caregivers and 14 providers were interviewed, including 5 neonatologists, 6 nurses, and 3 residents. Caregivers were predominantly English-speaking (85%); 96% were mothers with a mean age of 32 years. Neonates were predominantly racial and ethnic minorities (62%). Providers were predominantly White (71%) and female (71%). Five themes emerged: (1) ineffective, biased communication between caregivers, providers, and healthcare team may contribute to disparities (2) language barriers and lack of interpreter access play a significant role in perceived negative care; (3) lack of caregiver involvement and role in decision-making may negatively influence NICU outcomes, especially for those not able to be present at the bedside; and (4) multiple biases may affect neonatal health disparities. CONCLUSION: Our study highlights the importance of considering both provider and racial and/or ethnic minority caregiver perceptions disparities in NICU care delivery. It adds to the literature as one of the few qualitative studies comparing perceptions of disparate NICU care among both caregivers and providers.
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BACKGROUND AND OBJECTIVES: Race-based medicine, which falsely assumes that race is biological, is common in the published medical literature. We analyzed trends in the use of race in Pediatrics articles over a 75-year period. METHODS: We analyzed a random sample of 50 original research articles published each decade in Pediatrics from 1948 to 2022. RESULTS: Of 375 articles, 39% (n = 147) included race. Among articles, 85% (n = 116) used race only to describe study subjects, 7% (n = 9) described race as a social construct, and 11% (n = 15) described race as a biological construct. Only 7% (n = 10) of studies provided a reason for including race. Statements reflective of racial bias or discrimination were identified in 22% (n = 30) of the articles that mentioned race. Although statements concerning for explicit racial bias were uncommon, with none identified in the most recent decade, statements suggestive of implicit racial bias still occurred (22%, 5 of 23). Race was presented as a dichotomy, such as "white/nonwhite," in 9% of studies (n = 12). Regarding currently nonrecommended terminology, the term "minorities" was used in 13% of studies (n = 18); 25% of studies used the term "others" (n = 34), and among these, 91% (n = 31 of 34) did not provide any definition, an occurrence that increased over time at a rate of 0.9%/year. CONCLUSIONS: Although there has been improvement over the past 75 years in the reporting of race in published studies in Pediatrics, significant opportunities for further improvement remain.
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Pediatría , Grupos Raciales , Racismo , Humanos , Pediatría/tendencias , Publicaciones Periódicas como Asunto/tendenciasRESUMEN
Objectives: Participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has numerous benefits, yet many eligible children remain unenrolled. This qualitative study sought to explore perceptions of a novel electronic health record (EHR) intervention to facilitate referrals to WIC and improve communication/coordination between WIC staff and healthcare professionals. Methods: WIC staff in three counties were provided EHR access and recruited to participate. An automated, EHR-embedded WIC participation screening and referral tool was implemented within 8 healthcare clinics; healthcare professionals within these clinics were eligible to participate. The interview guide was developed using the Consolidated Framework for Implementation Research to elicit perceptions of this novel EHR-based intervention. Semi-structured interviews were conducted via telephone. Interviews were recorded, transcribed, coded, and analyzed using thematic analysis. Results: Twenty semi-structured interviews were conducted with eight WIC staff, seven pediatricians, four medical assistants, and one registered nurse. Most participants self-identified as female (95%) and White (55%). We identified four primary themes: (1) healthcare professionals had a positive view of WIC but communication and coordination between WIC and healthcare professionals was limited prior to WIC having EHR access; (2) healthcare professionals favored WIC screening using the EHR but workflow challenges existed; (3) EHR connections between WIC and the healthcare system can streamline referrals to and enrollment in WIC; and (4) WIC staff and healthcare professionals recommended that WIC have EHR access. Conclusions: A novel EHR-based intervention has potential to facilitate healthcare referrals to WIC and improve communication/coordination between WIC and healthcare systems.
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This Viewpoint discusses a report from the National Academies of Science, Engineering, and Medicine on how to address intergenerational poverty.
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Pobreza , Humanos , Estados Unidos , Pobreza/prevención & control , National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine DivisionRESUMEN
Using multiple metrics, the diversity of the pediatric population in the United States is increasing. However, recent data suggest significant disparities in both the prevalence and management of child health conditions cared for by pediatric subspecialists. These inequities occur across multiple dimensions of diversity, including race and ethnicity, country of origin, socioeconomic status, sex and gender, and disability. Research also suggests that attending to diversity, equity, and inclusion in the medical workforce may positively affect health outcomes. High-quality pediatric subspecialty care thus requires knowledge of these data, attention to the effects of social drivers, including racism and discrimination, on health and wellbeing, and interventions to improve pediatric health equity through educational, practice, policy, and research innovations. In this article, we review data on the diversity of the pediatric population and pediatric subspecialty workforce, suggest potential strengths, weaknesses, opportunities, and threats of current diversity, equity, and inclusion initiatives in academic pediatrics, and provide recommendations across 4 domains: education and training, practice, policy, and future research. The ultimate goal of pediatrics is to improve health equity for all infants, children, adolescents, and young adults cared for in the United States by pediatric subspecialists.
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Salud Infantil , Diversidad, Equidad e Inclusión , Adolescente , Lactante , Femenino , Masculino , Adulto Joven , Humanos , Niño , Escolaridad , Benchmarking , Recursos HumanosRESUMEN
OBJECTIVE: In medicine, women have lower lifetime earnings than men. To our knowledge, an in-depth examination of academic general pediatric faculty compensation by gender, race, and ethnicity has not been conducted. We aimed to 1) explore full-time academic general pediatric faculty salary differences by race and ethnicity; 2) explore these differences among all full-time pediatric faculty. METHODS: We performed a cross-sectional study using data on median full-time academic general pediatric faculty compensation for the academic year of 2020-2021 from the Association of American Medical Colleges Medical School Faculty Salary Survey report. Pearson's chi-square tests were used to evaluate the association of faculty rank with gender, race, ethnicity, and degree. We used hierarchical generalize linear models with a log link and a gamma distribution to model to assess the association of median salary with faculty race and ethnicity, adjusting for degree, rank, and gender. RESULTS: Men academic general pediatric faculty consistently had higher median salaries than women faculty even after adjusting for degree, rank, race, and ethnicity. Underrepresented in medicine academic general pediatric faculty had a lower median salary when compared to White faculty, and this was similar when adjusted for degree, rank, race, and ethnicity. CONCLUSIONS: Our results demonstrated broad disparities in general academic pediatric compensation by both gender and race and ethnicity. Academic medical centers must identify, acknowledge, and address inequities in compensation models.
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Etnicidad , Salarios y Beneficios , Masculino , Humanos , Femenino , Niño , Estados Unidos , Estudios Transversales , Encuestas y Cuestionarios , Docentes MédicosRESUMEN
Physicians serve as crucial advocates for their patients. Undergraduate medical education (UME) must move beyond the biomedical model, built upon the perception that health is defined purely in the absence of illness, to also incorporate population health through health policy, advocacy, and community engagement to account for structural and social determinants of health. Currently, the US guidelines for UME lack structured training in health policy or advocacy, leaving trainees ill-equipped to assume their role as physician-advocates or to engage with communities. There is an undeniable need to educate future physicians on legislative advocacy toward improving the social determinants of health through the creation of evidence-based health policy, in addition to training in effective techniques to engage in partnership with the communities in which physicians serve. The authors of this article also present curricular case studies around two programs at their institution that could be used to implement similar programs at other US medical schools.
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BACKGROUND AND OBJECTIVES: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides food and other resources to mitigate the harmful effects of food insecurity on child and maternal health. From a 2009 peak, nationwide WIC participation declined through 2020. Our objectives were to understand factors influencing WIC engagement and improve WIC enrollment through novel, primary care-based quality improvement interventions. METHODS: Plan-do-study-act cycles were implemented at a majority Medicaid-insured pediatric primary care clinic. Universal WIC screening at <5-year-old well-child visits was initiated, with counseling and referrals offered to nonparticipants. Clinic providers received WIC education. WIC screening, counseling reminders, and referrals were streamlined via the electronic health record. Families were surveyed on WIC participation barriers. Patient demographic data were analyzed for predictors of WIC participation. RESULTS: Mean new WIC enrollments increased significantly (42%) compared with baseline, with sustained special cause variation after study interventions. Provider WIC knowledge improved significantly at study end (P <.001). Rates of WIC screening, counseling, and referrals remained stable for >1 year after study interventions. The most common family-reported barriers to WIC participation were "Access problems" and "WIC knowledge gap." Factors associated with decreased WIC participation in multivariable analysis were increasing age (P <.001), and non-Medicaid insurance status (P = .03). CONCLUSIONS: We demonstrate feasible primary care-based screening, education, and referral interventions that appear to improve WIC enrollment. We identify knowledge gap and access problems as major potentially modifiable barriers to WIC participation. The expansion of similar low-cost interventions into other settings has the potential to benefit under-resourced children and families.
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Servicios de Salud del Niño , Asistencia Alimentaria , Lactante , Niño , Humanos , Femenino , Preescolar , Medicaid , Consejo , Estado Nutricional , Atención Primaria de SaludRESUMEN
INTRODUCTION: On July 1, 2021, North Carolina's Medicaid Transformation mandatorily switched 1.6 million Medicaid beneficiaries from fee-for-service to managed care plans. We examined the early enrollee experience in terms of engagement in plan selection, provider continuity, use of primary care visits, and assistance with social needs. METHODS: Using electronic health records (EHR) covering pre- and post-transition periods (1/1/2019-5/31/2022) from the largest provider network in western North Carolina, we identified all children and adults under age 65 with continuous Medicaid or private coverage. We conducted primary surveys of a random sample of Medicaid-covered enrollees and obtained self-reported rates of engagement in plan selection, continuity of provider access, and receipt of social need assistance. We used comparative interrupted time series models to estimate the relative change in primary care visits associated with the transition. RESULTS: Our EHR-based study cohorts included 4859 Medicaid and 5137 privately insured enrollees, with 398 Medicaid enrollees in the primary surveys. We found that 77.3% of survey participants reported that the managed care plan they were on was not chosen but automatically assigned to them, 13.1% reported insufficient information about the transition, and 19.2% reported lacking assistance with plan choice. We found that 5.9% were assigned to a different primary care provider. Over 29% reported not receiving any additional social need assistance. The transition was associated with a 7.1% reduction (95% CI, -11.5 to -2.7%) in the volume of primary care visits among Medicaid enrollees relative to privately insured enrollees. CONCLUSIONS: Medicaid enrollees in North Carolina may have had limited awareness and engagement in the transition process and experienced a reduction in primary care visits. As the state's transition process gains a foothold, future policy needs to improve enrollee engagement and develop evidence on healthcare utilization and patient outcomes.
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Programas Controlados de Atención en Salud , Medicaid , Niño , Adulto , Estados Unidos , Humanos , Anciano , North Carolina , Planes de Aranceles por Servicios , Encuestas y CuestionariosRESUMEN
This Viewpoint discusses proposed pathways of modifying the medical education timeline that would aid in producing US physicians in a timelier manner.
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Educación Médica , Médicos , Humanos , Estados UnidosRESUMEN
BACKGROUND: In 2021, North Carolina switched 1.6 million beneficiaries from a fee-for-service Medicaid model to a managed care system. The state prepared beneficiaries with logistical planning and a communications plan. However, the rollout occurred during the COVID-19 pandemic, creating significant challenges. Little is known about how Medicaid Transformation impacted the experience of Medicaid enrollees. METHODS: We conducted four focus groups (N = 22) with Medicaid beneficiaries from January to March 2022 to gain insight into their experience with Medicaid Transformation. A convenience sample was recruited. Focus groups were recorded, transcribed verbatim, and verified. A codebook was developed using inductive and deductive codes. Two study team members independently coded the transcripts; discrepancies were resolved among the research team. Themes were derived by their prevalence and salience within the data. RESULTS: We identified four major themes: 1) Participants expressed confusion about the signup process; 2) Participants had a limited understanding of their new plans; 3) Participants expressed difficulty accessing services through their plans; and 4) Participants primarily noted negative changes to their care. These findings suggest that Medicaid enrollees felt unsupported during the enrollment process and had difficulty accessing assistance to gain a better understanding of their plans and new services. LIMITATIONS: Participants were recruited from a single institution in the Southeastern United States; results may not be transferable to other institutions. Participants were likely not representative of all Medicaid Transformation beneficiaries; only English-speaking participants were included. CONCLUSION: As the transition process continues, the North Carolina Medicaid program can benefit from integrating recommendations identified by member input to guide strategies for addressing whole-person care.
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This qualitative study aimed to elicit the perspectives of individuals with food insecurity (FI) who were enrolled in a Fresh Food Prescription (FFRx) delivery program through a collaboration between an academic medical center and multiple community partners in the southeastern United States. Semi-structured interviews and open-ended survey responses explored the experiences of participants enrolled in a FFRx delivery program during the COVID-19 pandemic. The interviews probed the shopping habits, food security, experience, and impact of the program on nutrition, health, and well-being; the surveys explored the perceptions of and satisfaction with the program. A coding scheme was developed inductively, and a thematic analysis was conducted on raw narrative data using Atlas.ti 8.4 to sort and manage the data. The themes included that the program promoted healthy dietary habits, improved access to high-quality foods, improved well-being, enhanced financial well-being, and alleviated logistical barriers to accessing food and cooking. Participants provided suggestions for FFRx improvement. Future studies may facilitate improved clinical-community partnerships to address FI.
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COVID-19 , COVID-19/epidemiología , Inseguridad Alimentaria , Abastecimiento de Alimentos , Humanos , Pandemias , PrescripcionesRESUMEN
Objective: Food insecurity (FI) is a growing public health problem. Produce prescriptions are known to improve healthy eating and decrease FI; however, few studies have incorporated community voice prior to its implementation. In this study, we aimed to elicit perspectives of individuals at risk for FI and the potential impact of a fresh food prescription (FFRx) program. Methods: We conducted this qualitative descriptive study through an academic medical center in collaboration with community partners. We conducted focus groups involving Latinx (N = 16) and African-American (N = 8) adults in community settings. Data were interpreted using an inductive thematic analysis. Results: Three overarching themes emerged: (1) fresh food accessibility was limited by cost, household size, and transportation but enhanced by food pantries, budgeting, and education; (2) cooking behaviors were curbed by time constraints and unfamiliarity but propagated by passion, traditions, and communal practices; and (3) health and wellness deterrents included unhealthy diets driven by cultural and familial norms; however, weight loss and awareness of comorbidities were positive motivators. Participants shared their preference for local produce and cooking classes as components of a FFRx program while raising concerns about low participation due to the stigma of receiving aid. Conclusions: Our findings illuminated interest in engaging in a FFRx program and learning ways to prepare healthy foods. A program distributing fresh produce and healthy lifestyle education could close gaps identified in African-American and Latinx communities at risk for FI.
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OBJECTIVE: Academic medicine diversity is important for addressing health disparities and training the next generation. A recent study highlighted the lack of diversity among pediatric trainees over time. However, trends in US pediatric faculty diversity have not been clearly illuminated. The aim of this study is to evaluate pediatric faculty diversity trends and compare racial/ethnic representation between pediatric faculty and the US population. METHODS: Repeat cross-sectional study of the Association of American Medical Colleges Faculty Roster of pediatric faculty from 2000 to 2020. Trends in sex, race, ethnicity, and rank were compared with the Cochran-Armitage test. Data on faculty race/ethnicity were compared with the general and child population by using US Census Bureau data. RESULTS: Trends in underrepresented in medicine (URiM) faculty representation significantly increased at all ranks: professor (+3.5%, P < .0001), associate professor (+3.0%, P = .0001), and assistant professor (+2.5%, P = .0001). URiM male representation remained unchanged (P = .14), whereas significantly increased trends occurred in URiM female representation (+3.4%, P < .0001). African American/Black males significantly decreased representation at associate (-0.4%, P = .04) and assistant professor levels (-0.6%, P < .0001), and American Indian/Alaska Native males significantly decreased representation at the assistant professor rank (-0.1%, P < .0001). The percentage of URiM pediatric faculty representation was considerably lower compared with 2020 US overall and longitudinal child population representation. CONCLUSION: The stagnation of URiM male representation and lack of faculty diversity reflective of the US population may have a critical impact on the ability to recruit/retain a diverse pediatric workforce and promote equitable care.
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Diversidad Cultural , Etnicidad , Negro o Afroamericano , Niño , Estudios Transversales , Docentes Médicos , Femenino , Humanos , Masculino , Grupos Minoritarios , Estados UnidosRESUMEN
OBJECTIVE: To characterize the association of children's social risk factors with total number of emergency department (ED) visits or hospitalization and time to first subsequent ED or hospitalization. STUDY DESIGN: This was a retrospective cohort study of patients seen at a general pediatric clinic between 2017 and 2021 with documented ≥1 social risk factors screened per visit. Negative binomial or Poisson regression modeled ED utilization and hospitalizations as functions of the total number of risk factors or each unique risk factor. Time-varying Cox models were used to evaluate differences between those who screened positive and those who screened negative, controlling for demographic and clinical covariates. RESULTS: Overall, 4674 patients (mean age, 6.6 years; 49% female; 64% Hispanic; 21% Black) were evaluated across a total of 20â927 visits. Children with risk factors had higher rates of attention-deficit hyperactivity disorder, failure to gain weight, asthma, and prematurity compared with children with no risk (all P < .01). Adjusted models show a positive association between increased total number of factors and ED utilization (incidence rate ratio [IRR], 1.18; 95% CI, 1.12-1.23) and hospitalizations (IRR, 1.36; 95% CI, 1.26-1.47). There were no associations between a positive screen and time to first ED visit (hazard ratio [HR], 0.95; 95% CI, 0.85-1.06; P = .36) or hospitalization (HR, 1.15; 95% CI, 0.84-1.59; P = .40). CONCLUSIONS: Social risk factors were associated with increased ED utilization and hospitalizations at the patient level but were not significantly associated with time to subsequent acute care use. Future research should evaluate the effect of focused interventions on health care utilization, such as those addressing food insecurity and transportation challenges.