Evaluating Leadership Development Competencies of Clinicians to Build Health Equity in America.

INTRODUCTION: To achieve more equitable health, health care must be grounded in an understanding of social determinants of health. Clinicians need hands-on, equity-centered training in interdisciplinary settings where they can further develop leadership skills and apply learnings in real-time. The Clinical Scholars program trained five cohorts of health care professionals in 25 leadership development competencies to contribute toward advancing health equity within the organizations and communities where they work. This study describes the self-reported ratings of three dimensions of competencies within four domains. METHODS: Data from 169 Fellows were collected at three time-points during the three-year training program using Qualtrics and Research Electronic Data Captrue software. Analysis was conducted in R and included descriptive statistics, fitting a linear mixed-effects model using random intercepts, and paired-sample t tests to assess significance between baseline and endpoint ratings. RESULTS: We found improved ratings over time for each of the three competency dimensions (knowledge, self-efficacy, use) and significant differences in ratings from baseline to endpoint, by domain (personal, interpersonal, organizational, community, and systems). DISCUSSION: These findings support the effectiveness of an equity-centered leadership development curriculum in training health care professionals to address health challenges in their communities and organizations, thereby furthering the broader goal of achieving more equitable health for all.

Comparison of ZETA Fast (PTS) (Optopol Technology) and Humphrey SITA Fast (SFA) (Carl Zeiss Meditec) Perimetric Strategies.

PURPOSE: To compare two threshold strategies for visual field assessment, ZETA Fast (Optopol Technology) and Humphrey SITA Fast (Carl Zeiss Meditec), in controls and subjects with glaucoma. Patients and Methods. A prospective case-control study was carried out in which the clinical practice study included 26 controls and 26 glaucoma subjects. Testing for each strategy was monocular. Quantitative comparisons of mean deviation (MD), pattern standard deviation (PSD), visual field index (VFI), and test duration were made using two one-sided t-tests and Wilcoxon signed-rank tests. Confusion matrices were constructed to assess Optopol's detection as a proxy for Zeiss's detection of early glaucomatous defects. Receiver operating characteristic (ROC) curves were used to assess MD and PSD's discriminability. RESULTS: The difference in MD values (Optopol-Zeiss) was within the margin for controls (difference = 0.36, p=0.06), but not for glaucomatous subjects (difference = 2.16, p=1.0). The Optopol strategy took longer than the Zeiss strategy in both controls (difference = 23 seconds, p=0.001) and glaucomatous subjects (difference = 49 seconds, p < 0.001). PSD values were higher and VFI values were lower from Optopol in glaucomatous subjects (p < 0.001 and p=0.002). Optopol was 92% sensitive in capturing early glaucomatous defects with MD <-2 when compared to Zeiss (p < 0.001). ROC analysis shows Optopol yields higher discriminability than Zeiss for MD/PSD indices. CONCLUSIONS: Both strategies enable effective identification of glaucomatous defects within 6 minutes; they also offer high sensitivity with a high correlation in global indices between the two strategies. The Optopol strategy is an alternative to the Zeiss counterpart with the limitation of a marginally longer testing protocol but a higher sensitivity of detecting glaucomatous defects.

Changes in Neurodevelopmental Outcomes From Age 2 to 10 Years for Children Born Extremely Preterm.

OBJECTIVES: Evidence-based care of extremely preterm infants (<28 weeks' gestation) depends heavily on research in which a primary outcome is infant neurodevelopmental impairment (NDI), yet it is unclear how well NDI in infancy predicts long-term NDI. In this study, we aim to assess the relationship between 2- and 10-year neurodevelopment using a well-known 2-year definition and a 10-year definition developed by an expert panel. METHODS: Using data from the Extremely Low Gestational Age Newborn Study cohort, we classified 2-year NDI using definitions developed by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. We classified 10-year NDI using definitions developed by an expert panel, which added epilepsy and ASD at 10 years. RESULTS: Of 1506 infants, 80% survived. Data sufficient to classify severity of NDI at both 2 and 10 years were available for 67% of survivors (n = 802). Among children classified as having moderate to severe NDI at 2 years, 63% had none to mild NDI at 10 years; among children classified as having profound NDI at 2 years, 36% had none to mild NDI at 10 years. Cohen's κ statistic indicated minimal to fair agreement between NDI at 2 and 10 years (0.34, P < .001). CONCLUSIONS: NDI in infancy, as defined in this study, only weakly predicts NDI in middle childhood. For the parents at risk for delivery of an extremely preterm infant, a hopeful message can be taken from our findings that one-third of surviving children classified as having profound NDI and nearly two-thirds of those classified as having moderate to severe NDI at 2 years had none to mild NDI at 10 years.

Enhancing Advance Care Planning Communication: An Interactive Workshop With Role-Play for Students and Primary Care Clinicians.

Introduction: Increased clinician training on advance care planning (ACP) is needed. Common barriers to ACP include perceived lack of confidence, skills, and knowledge necessary to engage in these discussions. Furthermore, many clinicians feel inadequately trained in prognostication. Evidence exists that multimodality curricula are effective in teaching ACP and can be simultaneously targeted to trainees and practicing clinicians with success. Methods: We developed a 3-hour workshop incorporating lecture, patient-oriented decision aids, prognostication tools, small-group discussion, and case-based role-play to communicate a values-based approach to ACP. Cases included discussion of care goals for a patient with severe chronic obstructive pulmonary disease and one with mild cognitive impairment. The workshop was delivered to fourth-year medical students, then adapted in two primary care clinics. In the clinics, we added an interprofessional case applying ACP to management of dental pain in advanced dementia. We evaluated the workshops using pre-post surveys. Results: Thirty-four medical students and 14 primary care providers participated. Self-reported knowledge and comfort regarding ACP significantly improved; attitudes toward ACP were strongly positive both before and after. The workshop was well received. On a 7-point Likert scale (1 = unacceptable, 7 = outstanding), the median overall rating was 6 (excellent). Discussion: We developed an ACP workshop applicable to students and primary clinicians and saw improvements in self-reported knowledge and comfort regarding ACP. Long-term effects were not studied. Participants found the role-play especially valuable. Modifications for primary care clinics focused on duration rather than content. Future directions include expanding the workshop's content.

Persistently Elevated PTH After Parathyroidectomy at One Year: Experience in a Tertiary Referral Center.

CONTEXT/OBJECTIVE: Increased PTH after successful parathyroid surgery represents a clinical conundrum. We aimed to determine the prevalence of persistently elevated PTH (PePTH) postsurgery, along with predisposing factors. DESIGN: and Setting: Patients ≥ age 18 with parathyroidectomy performed at University of North Carolina Hospitals for primary hyperparathyroidism (PHPT) over a 12-year period were identified from the Carolina Data Warehouse. Clinical and demographic characteristics were collected, transformed, and analyzed. RESULTS: Five hundred seventy patients met initial criteria for PHPT, and of those 407 had postoperative values. One hundred forty-four had laboratory results within 3 to 18 months post operatively. There was no clinical difference between those with and without long-term laboratory follow-up. Presurgery, patients had average calcium of 11 mg/dL and PTH 125.4 pg/mL. Ninety-seven percent of patients had normalized calcium after surgery, but 30% had PePTH, which can be predicted at 3 months. Patients with PePTH (persistent elevation of PTH) after surgery did not differ from those with normalized PTH in terms of sex, age, body mass index, or excised gland weight; presurgery 25-vitamin D was slightly lower, but not abnormal (26 ± 15 vs 36 ± 11). The presurgical PTH was significantly higher (P < 0.001) in those with PePTH (156.5 pg/mL compared with presurgical level of 102.5 in those whose PTH normalized). CONCLUSIONS: Nearly one-third of PHPT patients have elevated PTH levels postsurgery in a tertiary hospital setting. At presentation, patients with PePTH tend to have higher PTH relative to calcium levels. Whether PePTH after surgical treatment of PHPT has pathological consequences is unknown.

Missed hepatitis B birth dose vaccine is a risk factor for incomplete vaccination at 18 and 24 months.

OBJECTIVES: To determine whether missing the HepB birth dose vaccine is a risk factor for incomplete vaccination later in childhood. METHODS: This was a retrospective cohort study of infants born over one year at an academic medical center. The "not vaccinated at birth" group consisted of all infants who did not receive the HepB birth dose vaccine by seven days of life, while the "vaccinated at birth" group included infants who did receive the birth dose. The primary outcome was vaccination status at 18 months of age, determined from the state vaccination registry. RESULTS: Infants "not vaccinated at birth" had lower vaccination rates. At 18 months, 44% of the "vaccinated at birth" group received all recommended vaccines, compared with 23% of the "not vaccinated at birth" group (p < 0.001); at 24 months, rates were 65% and 45%, respectively (p < 0.001). Over 80% of the variability in vaccination completions were related to a single latent variable, which is most likely vaccine hesitancy/refusal. CONCLUSIONS: Infants who miss the HepB birth dose vaccine are at risk for under-immunization by 18 and 24 months of age. This suggests that parents likely form opinions about vaccines long before the birth of their child; therefore, efforts to influence attitudes must begin earlier.