Monica B. Vela

Innovative Health Care Disparities Curriculum for Incoming Medical Students

Purpose1) To pilot a health disparities curriculum for incoming first year medical students and evaluate changes in knowledge. 2) To help students become aware of personal biases regarding racial and ethnic minorities. 3) To inspire students to commit to serving indigent populations.MethodsFirst year students participated in a 5-day elective course held before orientation week. The course used the curricular goals that had been developed by the Society of General Internal Medicine Health Disparities Task Force. Thirty-two faculty members from multiple institutions and different disciplinary backgrounds taught the course. Teaching modalities included didactic lectures, small group discussions, off-site expeditions to local free clinics, community hospitals and clinics, and student-led poster session workshops. The course was evaluated by pre-post surveys.ResultsSixty-four students (60% of matriculating class) participated. Survey response rates were 97–100%. Students’ factual knowledge (76 to 89%, p < .0009) about health disparities and abilities to address disparities issues improved after the course. This curriculum received the highest rating of any course at the medical school (overall mean 4.9, 1 = poor, 5 = excellent).ConclusionsThis innovative course provided students an opportunity for learning and exploration of a comprehensive curriculum on health disparities at a critical formative time.

Improving underrepresented minority medical student recruitment with health disparities curriculum.

ABSTRACTBACKGROUNDDiversity improves all students’ academic experiences and their abilities to work with patients from differing backgrounds. Little is known about what makes minority students select one medical school over another.PURPOSETo measure the impact of the existence of a health disparities course in the medical school curriculum on recruitment of underrepresented minority (URM) college students to the University of Chicago Pritzker School of Medicine.METHODSAll medical school applicants interviewed in academic years 2007 and 2008 at the University of Chicago Pritzker School of Medicine (PSOM) attended an orientation that detailed a required health care disparities curriculum introduced in 2006. Matriculants completed a precourse survey measuring the impact of the existence of the course on their decision to attend PSOM. URM was defined by the American Association of Medical Colleges as Black, American Indian/Alaskan Native, Native Hawaiian, Mexican American, and Mainland Puerto Rican.RESULTSPrecourse survey responses were 100% and 96% for entering classes of 2007 and 2008, respectively. Among those students reporting knowledge of the course (128/210, 61%), URM students (27/37, 73%) were more likely than non-URM students (38/91, 42%) to report that knowledge of the existence of the course influenced their decision to attend PSOM (p = 0.002). Analysis of qualitative responses revealed that students felt that the curriculum gave the school a reputation for placing importance on health disparities and social justice issues. URM student enrollment at PSOM, which had remained stable from years 2005 and 2006 at 12% and 11% of the total incoming classes, respectively, increased to 22% of the total class size in 2007 (p = 0.03) and 19 percent in 2008.CONCLUSIONThe required health disparities course may have contributed to the increased enrollment of URM students at PSOM in 2007 and 2008.

“URM Candidates Are Encouraged to Apply”: A National Study to Identify Effective Strategies to Enhance Racial and Ethnic Faculty Diversity in Academic Departments of Medicine

Purpose There is little evidence regarding which factors and strategies are associated with high proportions of underrepresented minority (URM) faculty in academic medicine. The authors conducted a national study of U.S. academic medicine departments to better understand the challenges, successful strategies, and predictive factors for enhancing racial and ethnic diversity among faculty (i.e., physicians with an academic position or rank). Method This was a mixed-methods study using quantitative and qualitative methods. The authors conducted a cross-sectional study of eligible departments of medicine in 125 accredited U.S. medical schools, dichotomized into low-URM (bottom 50%) versus high-URM rank (top 50%). They used t tests and chi-squared tests to compare departments by geographic region, academic school rank, city type, and composite measures of “diversity best practices.” The authors also conducted semistructured in-depth interviews with a subsample from the highest- and lowest-quartile medical schools in terms of URM rank. Results Eighty-two medical schools responded (66%). Geographic region and academic rank were statistically associated with URM rank, but not city type or composite measures of diversity best practices. Key themes emerged from interviews regarding successful strategies for URM faculty recruitment and retention, including institutional leadership, the use of human capital and social relationships, and strategic deployment of institutional resources. Conclusions Departments of medicine with high proportions of URM faculty employ a number of successful strategies and programs for recruitment and retention. More research is warranted to identify new successful strategies and to determine the impact of specific strategies on establishing and maintaining workforce diversity.

The Chicago Breathe Project: a regional approach to improving education on asthma inhalers for resident physicians and minority patients.

BACKGROUND Asthma affects minority citizens in Chicago disproportionately. Policy changes introducing hydrofluroalkane (HFA) inhalers may worsen already-existing health disparities related to asthma. AIMS To teach internal medicine residents about the transition to HFAs so they can better counsel their patients on asthma self-management. To provide minority community members with interactive educational sessions. SETTING Internal medicine residents at 5 Chicago programs. Community workshops in primarily Spanish-speaking (Cicero) Latino population and a primarily African American population from the south side of Chicago. PROGRAM DESCRIPTION The Chicago Breathe Project provides residents with education and tools necessary to counsel patients with asthma on inhaler use and provides minority community members with interactive educational sessions on asthma and inhaler use. PROGRAM EVALUATION Eleven workshops were held across 5 academic institutions, with a total of 161 residents. Resident knowledge regarding HFA inhalers improved dramatically (5% pre vs. 91% post, p < .001). Six months post education, residents were more likely to assess inhaler technique (44% vs. 11%, p = .046) and discuss new HFA inhalers (69% vs. 24%, p = .011) with their asthma patients. Community members provided feedback after the workshops that they would come again, found the session helpful ,and enjoyed the session. DISCUSSION The Chicago Breathe Project resulted in improved resident knowledge and skill on inhaler use during HFA transition. Regional educational approaches targeting internal medicine residencies in urban areas may be helpful to address future changes in chronic disease management. This training can be taken into minority communities to provide high-quality interactive educational workshops directly to patients and their families.

Screening for Chronic Kidney Disease

of the Clinical Problem Chronic kidneydisease is an important health issue associatedwith increased morbidity, mortality, and health care costs. Chronic kidney disease is defined as greater than 3 months of decreased kidney function, identified by a reduced estimated glomerular filtration rate (eGFR) of less than 60mL/min/1.73 m2 or by blood orurinemarkers of kidneydamage regardless of eGFR.1 Using this definition, aboutwhich there remains some controversy,more than 14% of the US population has CKD and 6% have stage 3 CKD or higher.2,3 Stage 3CKDconfers a greater risk of CKD-related complications and progression to end-stage renal disease (ESRD).3 Because CKD has a long asymptomatic phase, there are acceptable screening tests, and the health consequences associated with the diseasearehigh, it is adisease that is amenable toscreening.Screening could also be beneficial because only 10% of people with CKD knowtheyhave thedisease, and treatmentsexist thatdelay theprogression of CKD.4

Health Literacy During Aging.

To the Editors We appreciate Mattiesen et al.’s valuable letter regarding our paper. We agree that poor vision is an important risk factor for low health literacy when health information is provided in written or visual format. Hence, the effect of vision on health literacy is contextual. In our study, a medicine label printed at A4 size was used to assess health literacy; therefore, vision was important in this testing context (and in most others in health literacy research). Unlike in other instruments for assessing health literacy (e.g. the TOFHLA), vision was not formally tested as part of the English Longitudinal Study of Ageing (ELSA), and participants with poor vision were not a priori excluded from the study. However, participants could refuse the health literacy assessment if they either could not or chose not to complete it due to poor vision. At wave 2, 1.5 % (132/8780) and at wave 5, 1.6 % (96/5840) of respondents refused the health literacy test due to poor vision. Please note that the proportion of refusals due to poor vision is not the same as the proportion of participants in the study who had poor vision. Self-rated vision was assessed in the ELSA study interviews, and was distributed as follows: at wave 2, 15 % of our sample (803/5256) had ‘excellent’ vision, 36 % (1877/5256) had ‘very good’ vision, 39 % (2045/5256) had ‘good’ vision, 9 % (454/5256) had ‘fair vision’, and 1 % (76/ 5256) had ‘poor’ vision. The corresponding proportions for wave 5 were similar, at 14 % (727/5256), 35 % (1814/5256), 39 % (2050/5256), 10 % (538/5256), and 2 % (126/5256), respectively. When self-rated vision at wave 2 is added to our final multivariable model from the paper, having ‘fair’/‘poor’ vision is significantly associated with increased odds of health literacy decline over the follow-up (adjusted OR=1.38; 95 % CI: 1.11-1.72; vs. ‘excellent’/’very good’/‘good’ vision). The inclusion of self-rated vision in the model does not change the observed ORs between age, any cognitive variables, and health literacy decline. Hence, self-rated vision does not appear to be a mediator or confounder of the relationships between age and health literacy decline, and between cognitive function/decline and health literacy decline. We agree that future work on health literacy should not exclude older adults with poor vision. Adults with poor vision are at risk of low health literacy when information is provided in visual formats and appear to be vulnerable to ageing-related decline in health literacy skills.

Patient factors associated with lung transplant referral and waitlist for patients with cystic fibrosis and pulmonary fibrosis

BACKGROUND Since 2005, the Lung Allocation Score (LAS) has prioritized patient benefit and post-transplant survival, reducing waitlist to transplant time to <200 days and decreasing mortality on the waitlist. A current challenge is the wait for the waitlist-the time between the patients transplant-eligible diagnosis and waitlist registration. METHODS We investigated whether sociodemographic (age, sex, race, insurance, marital status, median household income) and clinical (forced expiratory volume in 1 second [FEV1] percent of predicted, body mass index, depression/anxiety, alcohol/substance misuse, absolute/relative contraindications) factors influenced referral and waitlist registration. We conducted a retrospective cohort study through chart review of hospitalized patients on the University of Chicago general medicine service from 2006 to 2014 who met transplant-eligible criteria and ICD-9 billing codes for cystic fibrosis (CF) and pulmonary fibrosis (PF). We analyzed the times from transplant eligibility to referral, work-up and waitlisting using Kaplan-Meier curves and log-rank tests. RESULTS Overall, the referral rate for transplant-eligible patients was 64%. Of those referred, approximately 36% reach the lung transplant waitlist. Referred CF patients were significantly more likely to reach the transplant waitlist than PF patients (CF 60% vs PF 22%, p < 0.05). In addition, CF patients had a shorter wait from transplant eligibility to waitlist than PF patients (329 vs 2,369 days, respectively [25th percentile], p < 0.05). Patients with PF and CF both faced delays from eligibility to referral and waitlist. CONCLUSIONS Quality improvement efforts are needed to better identify and refer appropriate patients for lung transplant evaluation. Targeted interventions may facilitate more efficient evaluation completion and waitlist appearance.

A qualitative study of parent perspectives on barriers, facilitators and expectations for school asthma care among urban, African-American children

Abstract Objectives: Minority children experience the disproportionate burden of asthma and its consequences. Studies suggest ethnic groups may experience asthma differently with varied perceptions and expectations among parents of African-American and Latino children. Because parents coordinate asthma care with the school, where children spend a significant amount of their day, this study’s goal was to determine parents’ perspectives on school asthma management. Methods: Focus groups were conducted with parents of children with asthma at four urban schools whose student population is predominantly African-American. A semi-structured guide was utilized focusing on barriers, facilitators and expectations for asthma care at school. Grounded theory principles were applied in this study. Results: Twenty-two parents (91% females) representing 13 elementary and 10 middle school children with asthma (61% boys) participated in four focus groups. Most children (87%) had persistent asthma. The identified barriers to effective school-based asthma care included limited awareness of children with asthma by teachers/staff, communication issues (e.g. school/parent, within school), inadequate education and lack of management plans or systems in place. In contrast, the identified facilitators included steps that fostered education, communication and awareness, as supported by management plans and parent initiative. Parents described their expectations for increased communication and education about asthma, better systems for identifying children with asthma, and a trained asthma point person for school-based asthma care. Conclusions: Parents of children with asthma identified important barriers, facilitators and expectations that must be considered to advance school asthma management. Improved school-based asthma care could lead to better health and academic outcomes.

Use of Interpreters by Physicians

D ear Editors, We read with interest Lopez et al.s recent article. Patient–provider communication during hospitalization and at the time of discharge is increasingly recognized as important to quality of care and safety for all patients. This field of inquiry is of importance as the number of limited English proficiency (LEP) patients in our country grows, and as the authors document once again, interpreters are greatly underutilized in health care. The question asked by the authors is of great import—how does the use of an interpreter impact length of hospital stays (LOS) and post-discharge outcomes? However, we question the interpretation and importance of their findings, given the significant limitations of their measure of LEP, the fact that there is no measure of the providers’ use of non-English language, and the very weak measure of interpreter use. The authors’ measure of LEP was based on patients’ documented language preference at the time of hospital admission. Karliner et al. document well that the optimal method of identifying LEP patients should be a two part process. Patients should be asked how well they can discuss their symptoms in English and this should be followed by a language preference question. Lower specificity of the language preference question alone could lead to misclassification of some patients as LEP who are, in fact, able to effectively communicate in English with their physicians. Further, the authors did not consider the possibility that some of the patients in the study may have had physicians who spoke their language. This language-concordant care could have resulted in better communication and shorter length of stay. There was also no documentation of the presence or absence of English proficient family members or use of phone interpretation. Finally, as we understand it, patients were included in the interpreter service utilized group if patients received interpreter services as little as one time. As LOS was, on average, more than 5 days, it would be highly unlikely that one-time use of an interpreter would have any impact on LOS or other outcomes. We recognize that many of these limitations were a consequence of conducting a retrospective study. These results should be interpreted within the context of these limitations and within the greater context of the existing literature, which overwhelmingly supports the use of professional interpreters as important to the quality of care delivered to LEP patients.

Reducing Language Barriers in Health Care: Is Technology the Answer?

In this issueof JAMAPediatrics, Lionandcolleagues1 describe findings from their well-designed randomized clinical trial of videovstelephonicmodesofdeliveringSpanish-language interpretation in the pediatric emergency department (ED). They foundthatparentswhowererandomizedtoreceivevideo interpretationduring their child’s ED stayweremore likely toname their child’s diagnosis correctly than those who received telephonic interpretation (74.6% vs 60.0%, respectively) and reported a lower percentage of frequent lapses in interpreter use (1.7%%vs7.7%,respectively);videointerpretationwasalsomore costly by amean of