Diversity, equity and inclusion: a survey of pediatric radiology fellowship graduates from 1996 to 2020.

BACKGROUND: Understanding the sociodemographic diversity and the experiences of trainees is imperative for developing an inclusive pediatric radiology workforce and improving patient outcomes. OBJECTIVE: To describe the sociodemographics of a pediatric radiology fellowship program over 25 years and examine potential associations with (a) a trainee's sense of inclusion and belonging during training and (b) graduates' ultimate choice/type of practice, progression to positions of leadership and mentorship of others. MATERIALS AND METHODS: We designed and administered an online survey of sociodemographic diversity to graduates of one of the largest pediatric radiology fellowship programs in North America who graduated over the last 25 years. Respondents answered questions regarding (a) racial/ethnic identity, gender identity, sexual orientation, disability and other sociodemographics; (b) their sense of inclusion and belonging during fellowship training; and (c) their current type of practice, leadership and mentorship of others. Univariate analysis of variance (ANOVA) tests determined whether sociodemographic background was associated with inclusion/belonging during training, and with current type of radiology practice, leadership and mentorship. We assessed associations with covariates of interest and current leadership and mentorship roles using chi-square or Fisher exact tests. A heat map assessed individual and overall Likert scores across covariates. RESULTS: Seventy-six graduates completed the survey (46% response rate). Three percent of respondents identified as Black/African American, 7% as Latino/a/x, 45% as female, 4% as LGBTQ (lesbian, gay, bisexual, transgender, queer/questioning) and 5% as living with a disability at the time of fellowship. Graduates of international medical schools (P = 0.09) and osteopathic medical (DO) schools (P = 0.09), first-generation college graduates (P = 0.023), those with a first language other than English (P = 0.02) and U.S. military veterans (P = 0.048) reported significantly lower feelings of inclusion and belonging during training. Gender identity and sexual orientation did not correlate with feelings of exclusion or inequity. Graduates between 1996 and 2010 were significantly more likely to have filled a leadership role than those graduating after 2011 (P = 0.004) and were also significantly more likely to have mentored individuals underrepresented in medicine/pediatric radiology than those who graduated after 2011 (P = 0.04). None of the other sociodemographic variables demonstrated an association with leadership or mentorship, although 92.3% of those with a first language other than English served as a mentor compared to 68.2% of native English speakers (P = 0.097). CONCLUSION: Efforts to promote a more diverse and inclusive workforce in pediatric radiology should be directed toward increasing numbers of fellows who are underrepresented in medicine (Black/African American, Hispanic/Latino/a/x) and providing a more inclusive training environment for first-generation college graduates, graduates of international and DO medical schools, fellows whose first language is not English, and veterans of the U.S. Armed Forces.

Creating a health equity and inclusion office in an academic pediatric medical center: priorities addressed and lessons learned.

BACKGROUND: Over the last two decades, medical schools and academic health centers have acknowledged the persistence of health disparities in their patients and the lack of diversity in their faculty, leaders and extended workforce. We established an Office of Health Equity and Inclusion (OHEI) at our pediatric academic medical center after a thorough evaluation of prior diversity initiatives and review of faculty development data. OBJECTIVE: To describe the lessons learned at a pediatric academic medical center in prioritizing and implementing health equity, diversity and inclusion (EDI) initiatives in creating the OHEI. MATERIALS AND METHODS: We reviewed internal administrative data and faculty development data, including data related to faculty who are underrepresented in medicine, to understand the role of our EDI initiatives in the strategic priorities addressed and lessons learned in the creation of the OHEI. RESULTS: The intentional steps taken in our medical center's strategic approach in the creation of this office led to four important lessons to improve pediatric health equity: (1) board, senior executive and institutional prioritization of EDI initiatives; (2) multi-specialty and interprofessional collaboration; (3) academic approach to EDI programmatic development; and (4) intentionality with accountability in all EDI initiatives. CONCLUSION: The key lessons learned during the creation of an Office of Health Equity and Inclusion can provide guidance to other academic health centers committed to implementing institutional priorities that focus their EDI initiatives on the improvement of pediatric health equity.

Sociodemographic Missed-care Predictors for Pediatric Orthopaedic Telemedicine During COVID-19.

BACKGROUND: Increased telehealth services may not benefit communities already lacking access to care. Race, socioeconomic status, and insurance type are known to predict missed-care opportunities (MCO) in health care. We examined differences in pediatric orthopaedic telemedicine MCOs during the COVID-19 pandemic, compared with MCOs of in-person visits in a prepandemic time frame. We hypothesized that groups with known health disparities would experience higher rates of pediatric orthopedic telemedicine MCOs. METHODS: We retrospectively analyzed pediatric orthopaedic telemedicine MCOs during the COVID-19 pandemic lockdown (March-May 2020) and in-person pediatric orthopaedic visit MCOs during a nonpandemic timeframe (March-May 2019). We examined predictors of MCOs including race, ethnicity, language, insurance status, and other socioeconomic determinants of health. RESULTS: There were 1448 telemedicine appointments in the pandemic cohort and 8053 in-person appointments in the prepandemic cohort. Rates of telemedicine MCOs (12.5%; n=181) were significantly lower than in-person MCOs (19.5%; n=1566; P<0.001). Telemedicine appointments with public insurance or without insurance (P<0.001) and being Black or Hispanic/Latinx (P=0.003) were associated with MCOs. There were significant differences between in-person MCOs and telemedicine MCOs among all predictors studied, except for orthopaedic subspecialty team and patient's social vulnerability index. CONCLUSIONS: Patients with telemedicine appointments during the COVID-19 pandemic were less likely to experience MCOs than patients with in-person visits during the nonpandemic timeframe. However, when controlling for socioeconomic factors including race, ethnicity, and insurance type, disparities found for in-person visits persisted with the shift to telemedicine. Pediatric orthopaedists should be aware that the use of telemedicine does not necessarily improve access for our most vulnerable patients. LEVEL OF EVIDENCE: Level III.

Sociodemographic and Appointment Factors Affecting Missed Opportunities to Provide Neonatal Ultrasound Imaging.

PURPOSE: The aim of this study was to assess disparities in outpatient imaging missed care opportunities (IMCOs) for neonatal ultrasound by sociodemographic and appointment factors at a large urban pediatric hospital. METHODS: A retrospective review was performed among patients aged 0 to 28 days receiving one or more outpatient appointments for head, hip, renal, or spine ultrasound at the main hospital or satellite sites from 2008 to 2018. An IMCO was defined as a missed ultrasound or cancellation <24 hours in advance. Population-average correlated logistic regression modeling estimated the odds of IMCOs for six sociodemographic (age, sex, race/ethnicity, language, insurance, and region of residence) and seven appointment (type of ultrasound, time, day, season, site, year, and distance to appointment) factors. The primary analysis included unknown values as a separate category, and the secondary analysis used multiple imputation to impute genuine categories from unknown variables. RESULTS: The data set comprised 5,474 patients totaling 6,803 ultrasound appointments. IMCOs accounted for 4.4% of appointments. IMCOs were more likely for Black (odds ratio [OR], 3.31; P < .001) and other-race neonates (OR, 2.66; P < .001) and for patients with public insurance (OR, 1.78; P = .002). IMCOs were more likely for appointments at the main hospital compared with satellites (P < .001), during work hours (P = .021), and on weekends (P < .001). Statistical significance for primary and secondary analyses was quantitatively similar and qualitatively identical. CONCLUSIONS: Marginalized racial groups and those with public insurance had a higher rate of IMCOs in neonatal ultrasound. This likely represents structural inequities faced by these communities, and more research is needed to identify interventions to address these inequities in care delivery for vulnerable neonatal populations.

Safety Protocols for Adolescent Substance Use Research in Clinical Settings.

PURPOSE: Research involving adolescent risk behaviors must balance data confidentiality with participant safety when risky behaviors are revealed. This report details a safety protocol and reports the experience of two contemporaneous studies that used it with variant safety thresholds. METHODS: We developed a safety protocol for research with adolescent patients and used it in two concurrent studies of adolescent patients, aged 14-18 years. Study "PC" recruited participants from a primary care adolescent medical clinic (N = 490), and Study "SP" recruited participants from subspecialty pediatric clinics (N = 434); both studies involved a similar self-administered assessment of health behaviors. The protocol sets thresholds for clinical intervention (positive safety flags) for past 3-month heavy alcohol consumption (Study PC: 10 or more drinks and Study SP: "binge-"level drinking), illicit drug use other than marijuana and alcohol in combination with a substance other than marijuana, and sets a positive screen for depression. We examined the rates of positive safety flags in both protocol settings, used significance testing to describe demographic differences between participants with and without positive flags in both studies, and described clinician experiences with protocol implementation. RESULTS: In studies PC/SP, .6%/8.8% of participants were flagged for heavy alcohol consumption, respectively; .2%/0% for illicit drug use, 2.2%/.7% for combination substance use, and 14.9%/4.8% for depression. Some clinicians found managing positive flags challenging, although both studies completed recruitment on time and without serious adverse events. CONCLUSIONS: The protocol was feasible in clinical settings. The findings and experiences documented in this report could be useful for future protocols.