Robin Wagner

Observations on emerging patterns of asthma in our society

Epidemiologic studies of temporal and geographic variation in asthma morbidity have identified asthma as an important public health concern. Knowledge gained from these studies has resulted in intense focus on this condition by agencies such as the National Institutes of Health and the World Health Organization. In this report, studies of recent asthma trends and patterns are explored. These studies show increases in US prevalence through 1994. Data on measures of morbidity show complex longitudinal patterns but are notable for large differences in emergency department services and hospitalizations by age and race. Very recent trends for US asthma mortality suggest widening of an existing racial gap. Limited comparisons are possible between these US trends and international trends but do suggest that US increases in prevalence and mortality rates may reflect world-wide patterns. Also, within the US, it is clear that geographic variation exists in asthma prevalence, morbidity, and mortality rates. Changes in certain environmental risk factors and exposures may contribute to recent trends, but little information is available relating specific risk factors to either longitudinal asthma trends, geographic variability, or high-risk populations.

CLER Pathways to Excellence: Expectations for an Optimal Clinical Learning Environment (Executive Summary).

T he Accreditation Council for Graduate Medical Education (ACGME) recognizes the public’s need for a physician workforce capable of meeting the challenges of a rapidly evolving health care environment. The ACGME has responded to this need by implementing the Clinical Learning Environment Review (CLER) program as a part of its Next Accreditation System. The CLER program is designed to provide US teaching hospitals, medical centers, health systems, and other clinical settings affiliated with ACGME-accredited institutions with periodic feedback that addresses the following 6 areas: patient safety, health care quality, transitions in care, supervision, duty hours and fatigue management and mitigation, and professionalism. The feedback provided by the CLER program is designed to improve how these clinical sites engage physician trainees in learning to provide safe, highquality patient care. To further the aim of the CLER program, the ACGME has developed the CLER Pathways to Excellence as a tool to promote discussions and actions that will optimize the clinical learning environment. The CLER pathways are designed as expectations rather than requirements. It is anticipated that by setting these expectations, clinical sites that provide training will strive to meet or exceed them in their efforts to provide the best care to patients and train the highest-quality physician workforce.

A simple and rapid DNA extraction method from whole blood for highly sensitive detection and quantitation of HIV-1 proviral DNA by real-time PCR.

Early diagnosis and access to treatment for infants with human immunodeficiency virus-1 (HIV-1) is critical to reduce infant mortality. The lack of simple point-of-care tests impedes the timely initiation of antiretroviral therapy. The development of FINA, filtration isolation of nucleic acids, a novel DNA extraction method that can be performed by clinic personnel in less than 2 min has been reported previously. In this report, significant improvements in the DNA extraction and amplification methods are detailed that allow sensitive quantitation of as little as 10 copies of HIV-1 proviral DNA and detection of 3 copies extracted from 100 μl of whole blood. An internal control to detect PCR inhibition was also incorporated. In a preliminary field evaluation of 61 South African infants, the FINA test demonstrated 100% sensitivity and specificity. The proviral copy number of the infant specimens was quantified, and it was established that 100 microliters of whole blood is required for sensitive diagnosis of infants.

Introducing the CLER Pathways to Excellence: A New Way of Viewing Clinical Learning Environments

I n January 2014, the Accreditation Council for Graduate Medical Education (ACGME) Clinical Learning Environment Review (CLER) program released ‘‘CLER Pathways to Excellence: expectations for an optimal clinical learning environment to achieve safe and highquality patient care’’ as guidance for the GME community, hospitals, medical centers, clinics, and other organizations that serve as sites for physician residency and fellowship programs. To launch this new resource, the ACGME held a conference ‘‘Preparing Doctors for 21st Century Practice’’ on January 27, 2014, at the Barbara Jordan Conference Center of the Kaiser Family Foundation in Washington, DC, and invited a variety of stakeholders from national health care organizations, graduate medical education (GME), and the media. The launch event focused attention on the clinical settings (inpatient hospitals and ambulatory clinics) where resident and fellow physicians learn to deliver patient care. Thomas Nasca, MD, MACP, chief executive officer, ACGME, opened the event with remarks that emphasized the clinical learning environment as an essential component to GME. Dr Nasca noted, ‘‘In the past decade there has been only modest progress in improving patient safety. Physicians need to be encouraged to interact more with hospitals, medical centers, and ambulatory sites to effect lasting improvements in patient care. It is critical to engage residents and fellows early in their careers as studies show there is a direct link between a physician’s performance in initial training and their clinical performance throughout their lifetime of practice.’’ John Duval, chief executive officer of Virginia Commonwealth University, provided the perspective of health care organizations and spoke to the value of enhancing resident and fellow physician involvement in efforts to improve care. The conference also included panel discussions moderated by Susan Dentzer, MA, senior policy adviser, Robert Wood Johnson Foundation, which further examined opportunities and challenges to enhancing GME engagement in patient safety and health care quality. In the final keynote, Kevin Weiss, MD, MPH, senior vice president, Institutional Accreditation, ACGME, and James P. Bagian, MD, director, Center for Health Engineering and Patient Safety, University of Michigan, highlighted the development and release of the CLER Pathways to Excellence. In his remarks, Dr Bagian emphasized that ‘‘this new document should be used as a tool to effect improvements in patient safety and health care quality for all health care organizations not only those that train physicians.’’ The text that follows is adapted from the introduction to the CLER Pathways to Excellence.

Detailed Findings from the CLER National Report of Findings 2016

For each of the 297 targeted institutions, the CLER teams visited one hospital or medical center that served as a clinical learning environment (CLE) for that SI They spent the majority of their time at inpatient settings, though where possible they also visited affiliated ambulatory care practices in close proximity The hospitals and medical centers varied in size from 41 to 2,396 acute care beds (median=520) The majority (69 4%) were nongovernment, not-for-profit organizations; 21 5% were government, nonfederal; 5 4% were investor-owned, for-profit; and 3 7% were government, federal As for location, approximately 30% of them were in the northeastern US, 29 3% in the south, 25 9% in the Midwest, and 14 1% in the west

A community-based study of near-fatal asthma

BACKGROUND The purpose of this study was to describe the community-based impact of near-fatal asthma within the District of Columbia (Washington, DC). METHODS The design was a prospective cohort study. Subjects included all persons in 1993 who presented to Washington, DC hospitals alive, requiring intubation for respiratory failure (including subjects who subsequently died in the hospital). Washington, DC hospitals were contacted on a biweekly basis to identify subjects. Patients were contacted by mail, followed by an interview with the subject or proxy. RESULTS Of the 35 case subjects identified, 31 (88.6%) were interviewed. Sixty-one percent of the subjects were female; 84% were African-American; and 45.2% were less than 18 years old. Forty-five percent had asthma for 10 or more years. Twenty-three percent reported the emergency department as their usual source of health care, and 32% saw a provider on a weekly basis. Fifty-two percent were taking four or more prescription medications, and 29% were taking no anti-inflammatory medications. In the 24 hours before the event, 77% reported difficulty breathing, but only 64% reported contacting a health care provider. CONCLUSIONS Community-based investigation of near-fatal asthma may lead to a better characterization of risk factors associated with this event. Findings from this study suggest that some of the factors associated with near-fatal events may be different from those associated with fatal asthma and that up to one third of the events may have been preventable.

Pursuing Excellence in Clinical Learning Environments

The Accreditation Council for Graduate Medical Education (ACGME) has launched a new shared learning collaborative as part of its larger Clinical Learning Environment Review (CLER) initiative. The collaboration, called Pursuing Excellence in Clinical Learning Environments, aims to improve teaching practices and patient care in the hospitals, medical centers, and ambulatory care sites where residents and fellows pursue their formal clinical training in a specialty or subspecialty. The Pursuing Excellence Initiative (PEI) builds on the 2015 report of findings of the CLER program. These findings demonstrate variability across the nations teaching hospitals in addressing 6 key focus areas. PEI sets up a shared system of collaborative learning among participating sites of ACGME-accredited institutions, in which early participants share advances that will be disseminated through an expanding circle of other participants. The ACGME will award funding to encourage participation in the first major component of PEI. The goal is to stimulate high-leverage changes that will broadly improve patient care and clinical learning environments across the nation.

The Overview of the CLER Program: CLER National Report of Findings 2016.

The ACGME’s mission is to improve health care and population health by assessing and advancing the quality of residents and fellows’ education through accreditation 1 Over the past few years it has become readily apparent the clinical setting in which residents and fellows learn directly impacts the quality of their training In order to better understand these environments, the ACGME established the Clinical Learning Environment Review (CLER) Program in 2012 2,3 The CLER Program is linked to accreditation only in that every institution must periodically complete a visit

The Methodology for the CLER National Report of Findings 2016

This report reflects the findings of the first set of visits of the Clinical Learning Environment Review (CLER) Program1,2 that were conducted from September 30, 2012 to March 20, 2015 These initial visits were aimed at collecting a comprehensive base of evidence on how the nation’s clinical learning environments (CLEs) approach the six CLER focus areas Specifically, the CLER Program explored issues related to the five key questions that were posed to the program at its outset 3 It also sought to enrich understanding of the nation’s CLEs and establish a benchmark for subsequent site visits Owing to these broad objectives, the CLER Program employed a mixed methods approach, utilizing both quantitative and qualitative information gathering and analysis methods It is the collective results of this effort that informed the aggregated findings in this report

Lessons Learned and Future Directions: CLER National Report of Findings 2016

The Clinical Learning Environment Review (CLER) Program is designed to provide formative feedback to the hospitals, medical centers, and ambulatory care sites that serve as clinical learning environments (CLEs) for ACGME-accredited residency and fellowship programs 1,2 While its main focus is to provide institutions with individual feedback, the aggregate data presented here offer an important overview of the environments where residents and fellows train—and thus can inform the national conversation on optimal attributes for a CLE The collective observations from this first set of CLER site visits portray a community of teaching hospitals, medical centers, and ambulatory care sites that has great capacity to shape the quality of the emerging physician workforce and drive improvements in patient care