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Adoption of Choosing Wisely Recommendations Slow to Catch On
Clinical question: Have the Choosing Wisely campaign recommendations led to changes in practice?
Background: The Choosing Wisely campaign aims to reduce the incidence of low-value care by providing evidence-based recommendations for common clinical situations. The rate of adoption of these recommendations is unknown.
Study design: Retrospective review.
Setting: Anthem insurance members.
Synopsis: The study examined the claims data from 25 million Anthem insurance members to compare the rate of services that were targeted by seven Choosing Wisely campaign recommendations before and after the recommendations were published in 2012.
Investigators found the incidence of two of the services declined after the Choosing Wisely recommendations were published; the other five services remained stable or increased slightly. Furthermore, the declines were statistically significant but not a marked absolute difference, with the incidence of head imaging in patients with uncomplicated headaches going down to 13.4% from 14.9% and the use of cardiac imaging in the absence of cardiac disease declining to 9.7% from 10.8%.
The main limitations are the narrow population of Anthem insurance members and the lack of specific data that could help answer why clinical practice has not changed, but that could be the aim of future studies.
Bottom line: Choosing Wisely recommendations have not been adopted on a population level; widespread implementation likely will require financial incentives, provider-level data feedback, and systems interventions.
Citation: Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med. 2015;175(12):1913-1920. doi:10.1001/jamainternmed.2015.5441.
Clinical question: Have the Choosing Wisely campaign recommendations led to changes in practice?
Background: The Choosing Wisely campaign aims to reduce the incidence of low-value care by providing evidence-based recommendations for common clinical situations. The rate of adoption of these recommendations is unknown.
Study design: Retrospective review.
Setting: Anthem insurance members.
Synopsis: The study examined the claims data from 25 million Anthem insurance members to compare the rate of services that were targeted by seven Choosing Wisely campaign recommendations before and after the recommendations were published in 2012.
Investigators found the incidence of two of the services declined after the Choosing Wisely recommendations were published; the other five services remained stable or increased slightly. Furthermore, the declines were statistically significant but not a marked absolute difference, with the incidence of head imaging in patients with uncomplicated headaches going down to 13.4% from 14.9% and the use of cardiac imaging in the absence of cardiac disease declining to 9.7% from 10.8%.
The main limitations are the narrow population of Anthem insurance members and the lack of specific data that could help answer why clinical practice has not changed, but that could be the aim of future studies.
Bottom line: Choosing Wisely recommendations have not been adopted on a population level; widespread implementation likely will require financial incentives, provider-level data feedback, and systems interventions.
Citation: Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med. 2015;175(12):1913-1920. doi:10.1001/jamainternmed.2015.5441.
Clinical question: Have the Choosing Wisely campaign recommendations led to changes in practice?
Background: The Choosing Wisely campaign aims to reduce the incidence of low-value care by providing evidence-based recommendations for common clinical situations. The rate of adoption of these recommendations is unknown.
Study design: Retrospective review.
Setting: Anthem insurance members.
Synopsis: The study examined the claims data from 25 million Anthem insurance members to compare the rate of services that were targeted by seven Choosing Wisely campaign recommendations before and after the recommendations were published in 2012.
Investigators found the incidence of two of the services declined after the Choosing Wisely recommendations were published; the other five services remained stable or increased slightly. Furthermore, the declines were statistically significant but not a marked absolute difference, with the incidence of head imaging in patients with uncomplicated headaches going down to 13.4% from 14.9% and the use of cardiac imaging in the absence of cardiac disease declining to 9.7% from 10.8%.
The main limitations are the narrow population of Anthem insurance members and the lack of specific data that could help answer why clinical practice has not changed, but that could be the aim of future studies.
Bottom line: Choosing Wisely recommendations have not been adopted on a population level; widespread implementation likely will require financial incentives, provider-level data feedback, and systems interventions.
Citation: Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med. 2015;175(12):1913-1920. doi:10.1001/jamainternmed.2015.5441.
Overall Patient Satisfaction Better on Hospitalist Teams Compared with Teaching Teams
Clinical question: Is there a difference in patient experience on hospitalist teams compared with teaching teams?
Background: Hospitalist-intensive hospitals tend to perform better on patient-satisfaction measures on HCAHPS survey; however, little is known about the difference in patient experience between patients cared for by hospitalist and trainee teams.
Study design: Retrospective cohort analysis.
Setting: University of Chicago Medical Center.
Synopsis: A 30-day post-discharge survey was sent to 14,855 patients cared for by hospitalist and teaching teams, with 57% of teaching and 31% of hospitalist team patients returning fully completed surveys. A higher percentage of hospitalist team patients reported satisfaction with their overall care (73% vs. 67%; P<0.001; regression model odds ratio = 1.33; 95% CI, 1.15–1.47). There was no statistically significant difference in patient satisfaction with the teamwork of their providers, confidence in identifying their provider, or ability to understand the role of their provider.
Other than the inability to mitigate response-selection bias, the main limitation of this study is the single-center setting, which impacts the generalizability of the findings. Hospital-specific factors like different services and structures (hospitalists at their institution care for renal and lung transplant and oncology patients) could influence patients’ perception of their care. More research needs to be done to determine the specific factors that lead to a better patient experience.
Bottom line: At a single academic center, overall patient satisfaction was higher on a hospitalist service compared with teaching teams.
Citation: Wray CM, Flores A, Padula WV, Prochaska MT, Meltzer DO, Arora VM. Measuring patient experiences on hospitalist and teaching services: patient responses to a 30-day postdischarge questionnaire [published online ahead of print September 18, 2015]. J Hosp Med. doi:10.1002/jhm.2485.
Clinical question: Is there a difference in patient experience on hospitalist teams compared with teaching teams?
Background: Hospitalist-intensive hospitals tend to perform better on patient-satisfaction measures on HCAHPS survey; however, little is known about the difference in patient experience between patients cared for by hospitalist and trainee teams.
Study design: Retrospective cohort analysis.
Setting: University of Chicago Medical Center.
Synopsis: A 30-day post-discharge survey was sent to 14,855 patients cared for by hospitalist and teaching teams, with 57% of teaching and 31% of hospitalist team patients returning fully completed surveys. A higher percentage of hospitalist team patients reported satisfaction with their overall care (73% vs. 67%; P<0.001; regression model odds ratio = 1.33; 95% CI, 1.15–1.47). There was no statistically significant difference in patient satisfaction with the teamwork of their providers, confidence in identifying their provider, or ability to understand the role of their provider.
Other than the inability to mitigate response-selection bias, the main limitation of this study is the single-center setting, which impacts the generalizability of the findings. Hospital-specific factors like different services and structures (hospitalists at their institution care for renal and lung transplant and oncology patients) could influence patients’ perception of their care. More research needs to be done to determine the specific factors that lead to a better patient experience.
Bottom line: At a single academic center, overall patient satisfaction was higher on a hospitalist service compared with teaching teams.
Citation: Wray CM, Flores A, Padula WV, Prochaska MT, Meltzer DO, Arora VM. Measuring patient experiences on hospitalist and teaching services: patient responses to a 30-day postdischarge questionnaire [published online ahead of print September 18, 2015]. J Hosp Med. doi:10.1002/jhm.2485.
Clinical question: Is there a difference in patient experience on hospitalist teams compared with teaching teams?
Background: Hospitalist-intensive hospitals tend to perform better on patient-satisfaction measures on HCAHPS survey; however, little is known about the difference in patient experience between patients cared for by hospitalist and trainee teams.
Study design: Retrospective cohort analysis.
Setting: University of Chicago Medical Center.
Synopsis: A 30-day post-discharge survey was sent to 14,855 patients cared for by hospitalist and teaching teams, with 57% of teaching and 31% of hospitalist team patients returning fully completed surveys. A higher percentage of hospitalist team patients reported satisfaction with their overall care (73% vs. 67%; P<0.001; regression model odds ratio = 1.33; 95% CI, 1.15–1.47). There was no statistically significant difference in patient satisfaction with the teamwork of their providers, confidence in identifying their provider, or ability to understand the role of their provider.
Other than the inability to mitigate response-selection bias, the main limitation of this study is the single-center setting, which impacts the generalizability of the findings. Hospital-specific factors like different services and structures (hospitalists at their institution care for renal and lung transplant and oncology patients) could influence patients’ perception of their care. More research needs to be done to determine the specific factors that lead to a better patient experience.
Bottom line: At a single academic center, overall patient satisfaction was higher on a hospitalist service compared with teaching teams.
Citation: Wray CM, Flores A, Padula WV, Prochaska MT, Meltzer DO, Arora VM. Measuring patient experiences on hospitalist and teaching services: patient responses to a 30-day postdischarge questionnaire [published online ahead of print September 18, 2015]. J Hosp Med. doi:10.1002/jhm.2485.
Caprini Score Accurately Predicts Risk of Venous Thromboembolism in Critically Ill Surgical Patients
Clinical question: Is the Caprini risk assessment model (RAM) a valid tool to predict venous thromboembolism (VTE) risk in critically ill surgical patients?
Background: VTE is a major source of morbidity and mortality among hospitalized patients; prevention is critical to reduce morbidity and cut healthcare costs. Risk assessment is important to determine thromboprophylaxis, yet data are lacking regarding an appropriate tool for risk stratification in the critically ill.
Study design: Retrospective cohort.
Setting: University of Michigan Health System; 20-bed surgical ICU at an academic hospital.
Synopsis: This study included 4,844 surgical ICU patients. Primary outcome was VTE during the patient’s hospital admission. A retrospective risk scoring method based on the 2005 Caprini RAM was used to calculate the risk for all patients at the time of ICU admission. Patients were divided into low (Caprini score 0–2), moderate, high, highest, and super-high (Caprini score > 8) risk levels. The incidence of VTE increased in linear fashion with increasing Caprini score.
This study was limited to one academic medical center. The retrospective scoring model limits the ability to identify all patient risk factors. VTE outcomes were reported only for the length of hospitalization and did not include post-discharge follow-up. Replicating this study across a larger patient population and performing a prospective study with follow-up after discharge would address these limitations.
Bottom line: The Caprini risk assessment model is a valid instrument to assess VTE risk in critically ill surgical patients.
Citation: Obi AT, Pannucci CJ, Nackashi A, et al. Validation of the Caprini venous thromboembolism risk assessment model in critically ill surgical patients. JAMA Surg. 2015;150(10):941-948.
Clinical question: Is the Caprini risk assessment model (RAM) a valid tool to predict venous thromboembolism (VTE) risk in critically ill surgical patients?
Background: VTE is a major source of morbidity and mortality among hospitalized patients; prevention is critical to reduce morbidity and cut healthcare costs. Risk assessment is important to determine thromboprophylaxis, yet data are lacking regarding an appropriate tool for risk stratification in the critically ill.
Study design: Retrospective cohort.
Setting: University of Michigan Health System; 20-bed surgical ICU at an academic hospital.
Synopsis: This study included 4,844 surgical ICU patients. Primary outcome was VTE during the patient’s hospital admission. A retrospective risk scoring method based on the 2005 Caprini RAM was used to calculate the risk for all patients at the time of ICU admission. Patients were divided into low (Caprini score 0–2), moderate, high, highest, and super-high (Caprini score > 8) risk levels. The incidence of VTE increased in linear fashion with increasing Caprini score.
This study was limited to one academic medical center. The retrospective scoring model limits the ability to identify all patient risk factors. VTE outcomes were reported only for the length of hospitalization and did not include post-discharge follow-up. Replicating this study across a larger patient population and performing a prospective study with follow-up after discharge would address these limitations.
Bottom line: The Caprini risk assessment model is a valid instrument to assess VTE risk in critically ill surgical patients.
Citation: Obi AT, Pannucci CJ, Nackashi A, et al. Validation of the Caprini venous thromboembolism risk assessment model in critically ill surgical patients. JAMA Surg. 2015;150(10):941-948.
Clinical question: Is the Caprini risk assessment model (RAM) a valid tool to predict venous thromboembolism (VTE) risk in critically ill surgical patients?
Background: VTE is a major source of morbidity and mortality among hospitalized patients; prevention is critical to reduce morbidity and cut healthcare costs. Risk assessment is important to determine thromboprophylaxis, yet data are lacking regarding an appropriate tool for risk stratification in the critically ill.
Study design: Retrospective cohort.
Setting: University of Michigan Health System; 20-bed surgical ICU at an academic hospital.
Synopsis: This study included 4,844 surgical ICU patients. Primary outcome was VTE during the patient’s hospital admission. A retrospective risk scoring method based on the 2005 Caprini RAM was used to calculate the risk for all patients at the time of ICU admission. Patients were divided into low (Caprini score 0–2), moderate, high, highest, and super-high (Caprini score > 8) risk levels. The incidence of VTE increased in linear fashion with increasing Caprini score.
This study was limited to one academic medical center. The retrospective scoring model limits the ability to identify all patient risk factors. VTE outcomes were reported only for the length of hospitalization and did not include post-discharge follow-up. Replicating this study across a larger patient population and performing a prospective study with follow-up after discharge would address these limitations.
Bottom line: The Caprini risk assessment model is a valid instrument to assess VTE risk in critically ill surgical patients.
Citation: Obi AT, Pannucci CJ, Nackashi A, et al. Validation of the Caprini venous thromboembolism risk assessment model in critically ill surgical patients. JAMA Surg. 2015;150(10):941-948.
Total Knee Replacement Superior to Non-Surgical Intervention
Clinical question: Does total knee replacement followed by a 12-week non-surgical treatment program provide greater pain relief and improvement in function and quality of life than non-surgical treatment alone?
Background: The number of total knee replacements in the U.S. has increased dramatically since the 1970s and is expected to continue to rise. To date, evidence to support the effectiveness of surgical intervention compared to non-surgical intervention is lacking.
Study design: Randomized, controlled trial.
Setting: Aalborg University Hospital Outpatient Clinics, Denmark.
Synopsis: One hundred patients with osteoarthritis were randomly assigned to undergo total knee replacement followed by 12 weeks of non-surgical treatment or to receive only 12 weeks of non-surgical treatment. The non-surgical treatment program consisted of exercise, education, dietary advice, insoles, and pain medication. Change from baseline to 12 months was assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS).
The total knee replacement group had a significantly greater improvement in the KOOS score than did the non-surgical group. Serious adverse events were more common in the total knee replacement group.
The study did not include a sham-surgery control group. It is unknown whether the KOOS pain subscale is generalizable to patients with severe pain. Additionally, the intensity of non-surgical treatment may have differed between groups.
Bottom line: Total knee replacement followed by non-surgical treatment is more efficacious than non-surgical treatment alone in providing pain relief and improving function and quality of life, but it is associated with higher number of adverse events.
Citation: Skou ST, Roos EM, Laursen MB, et al. A randomized, controlled trial of total knee replacement. N Engl J Med. 2015;373(17):1597-1606.
Clinical question: Does total knee replacement followed by a 12-week non-surgical treatment program provide greater pain relief and improvement in function and quality of life than non-surgical treatment alone?
Background: The number of total knee replacements in the U.S. has increased dramatically since the 1970s and is expected to continue to rise. To date, evidence to support the effectiveness of surgical intervention compared to non-surgical intervention is lacking.
Study design: Randomized, controlled trial.
Setting: Aalborg University Hospital Outpatient Clinics, Denmark.
Synopsis: One hundred patients with osteoarthritis were randomly assigned to undergo total knee replacement followed by 12 weeks of non-surgical treatment or to receive only 12 weeks of non-surgical treatment. The non-surgical treatment program consisted of exercise, education, dietary advice, insoles, and pain medication. Change from baseline to 12 months was assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS).
The total knee replacement group had a significantly greater improvement in the KOOS score than did the non-surgical group. Serious adverse events were more common in the total knee replacement group.
The study did not include a sham-surgery control group. It is unknown whether the KOOS pain subscale is generalizable to patients with severe pain. Additionally, the intensity of non-surgical treatment may have differed between groups.
Bottom line: Total knee replacement followed by non-surgical treatment is more efficacious than non-surgical treatment alone in providing pain relief and improving function and quality of life, but it is associated with higher number of adverse events.
Citation: Skou ST, Roos EM, Laursen MB, et al. A randomized, controlled trial of total knee replacement. N Engl J Med. 2015;373(17):1597-1606.
Clinical question: Does total knee replacement followed by a 12-week non-surgical treatment program provide greater pain relief and improvement in function and quality of life than non-surgical treatment alone?
Background: The number of total knee replacements in the U.S. has increased dramatically since the 1970s and is expected to continue to rise. To date, evidence to support the effectiveness of surgical intervention compared to non-surgical intervention is lacking.
Study design: Randomized, controlled trial.
Setting: Aalborg University Hospital Outpatient Clinics, Denmark.
Synopsis: One hundred patients with osteoarthritis were randomly assigned to undergo total knee replacement followed by 12 weeks of non-surgical treatment or to receive only 12 weeks of non-surgical treatment. The non-surgical treatment program consisted of exercise, education, dietary advice, insoles, and pain medication. Change from baseline to 12 months was assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS).
The total knee replacement group had a significantly greater improvement in the KOOS score than did the non-surgical group. Serious adverse events were more common in the total knee replacement group.
The study did not include a sham-surgery control group. It is unknown whether the KOOS pain subscale is generalizable to patients with severe pain. Additionally, the intensity of non-surgical treatment may have differed between groups.
Bottom line: Total knee replacement followed by non-surgical treatment is more efficacious than non-surgical treatment alone in providing pain relief and improving function and quality of life, but it is associated with higher number of adverse events.
Citation: Skou ST, Roos EM, Laursen MB, et al. A randomized, controlled trial of total knee replacement. N Engl J Med. 2015;373(17):1597-1606.
Patients with Postoperative Myocardial Infarction May Benefit from Higher Transfusion Threshold
Clinical question: Is there an improved 30-day mortality rate if patients receive blood transfusion at higher hematocrit values after postoperative myocardial infarction (MI)?
Background: Prior studies evaluating patients with a history of coronary artery disease (CAD) who undergo non-cardiac surgery have shown similar mortality outcomes with liberal and restrictive transfusion strategies. Data are lacking for transfusion strategies in patients with CAD who experience postoperative MI after non-cardiac surgeries.
Study design: Retrospective cohort.
Setting: Veterans Affairs health system.
Synopsis: The study included 7,361 patients with a history of CAD who underwent non-cardiac surgery whose postoperative hematocrit was between 20% and 30%. Patients were stratified by postoperative hematocrit nadir and presence of postoperative MI. In patients with postoperative MI, transfusion was associated with lower mortality with hematocrit nadir of 20%–24% but not with hematocrit of 24%–27% or 27%–30%. In patients without postoperative MI, transfusion was associated with higher mortality in patients with hematocrit of 27%–30%.
This retrospective study was limited to the VA population of mostly male patients. The sample size was limited. The study was unable to determine if postoperative blood transfusion is a risk for developing MI.
Bottom line: Patients with a history of CAD and MI who have a postoperative MI following non-cardiac surgery may benefit from higher blood transfusion thresholds; however, further controlled studies are needed.
Citation: Hollis RH, Singeltary BA, McMurtrie JT, et al. Blood transfusion and 30-day mortality in patients with coronary artery disease and anemia following noncardiac surgery [published online ahead of print October 7, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.3420.
Clinical question: Is there an improved 30-day mortality rate if patients receive blood transfusion at higher hematocrit values after postoperative myocardial infarction (MI)?
Background: Prior studies evaluating patients with a history of coronary artery disease (CAD) who undergo non-cardiac surgery have shown similar mortality outcomes with liberal and restrictive transfusion strategies. Data are lacking for transfusion strategies in patients with CAD who experience postoperative MI after non-cardiac surgeries.
Study design: Retrospective cohort.
Setting: Veterans Affairs health system.
Synopsis: The study included 7,361 patients with a history of CAD who underwent non-cardiac surgery whose postoperative hematocrit was between 20% and 30%. Patients were stratified by postoperative hematocrit nadir and presence of postoperative MI. In patients with postoperative MI, transfusion was associated with lower mortality with hematocrit nadir of 20%–24% but not with hematocrit of 24%–27% or 27%–30%. In patients without postoperative MI, transfusion was associated with higher mortality in patients with hematocrit of 27%–30%.
This retrospective study was limited to the VA population of mostly male patients. The sample size was limited. The study was unable to determine if postoperative blood transfusion is a risk for developing MI.
Bottom line: Patients with a history of CAD and MI who have a postoperative MI following non-cardiac surgery may benefit from higher blood transfusion thresholds; however, further controlled studies are needed.
Citation: Hollis RH, Singeltary BA, McMurtrie JT, et al. Blood transfusion and 30-day mortality in patients with coronary artery disease and anemia following noncardiac surgery [published online ahead of print October 7, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.3420.
Clinical question: Is there an improved 30-day mortality rate if patients receive blood transfusion at higher hematocrit values after postoperative myocardial infarction (MI)?
Background: Prior studies evaluating patients with a history of coronary artery disease (CAD) who undergo non-cardiac surgery have shown similar mortality outcomes with liberal and restrictive transfusion strategies. Data are lacking for transfusion strategies in patients with CAD who experience postoperative MI after non-cardiac surgeries.
Study design: Retrospective cohort.
Setting: Veterans Affairs health system.
Synopsis: The study included 7,361 patients with a history of CAD who underwent non-cardiac surgery whose postoperative hematocrit was between 20% and 30%. Patients were stratified by postoperative hematocrit nadir and presence of postoperative MI. In patients with postoperative MI, transfusion was associated with lower mortality with hematocrit nadir of 20%–24% but not with hematocrit of 24%–27% or 27%–30%. In patients without postoperative MI, transfusion was associated with higher mortality in patients with hematocrit of 27%–30%.
This retrospective study was limited to the VA population of mostly male patients. The sample size was limited. The study was unable to determine if postoperative blood transfusion is a risk for developing MI.
Bottom line: Patients with a history of CAD and MI who have a postoperative MI following non-cardiac surgery may benefit from higher blood transfusion thresholds; however, further controlled studies are needed.
Citation: Hollis RH, Singeltary BA, McMurtrie JT, et al. Blood transfusion and 30-day mortality in patients with coronary artery disease and anemia following noncardiac surgery [published online ahead of print October 7, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.3420.
Beta-Blockers May Increase Risk of Perioperative MACEs in Patients with Uncomplicated Hypertension
Clinical question: Does taking a perioperative beta-blocker increase the risk of major adverse cardiovascular events (MACEs) and all-cause mortality in low-risk patients with essential hypertension (HTN)?
Background: Guidelines for the use of perioperative beta-blockers are being reevaluated due to concerns about validity of prior studies that supported the use of perioperative beta-blockers. This study sought to evaluate effectiveness and safety of beta-blockers in patients with uncomplicated HTN.
Study design: Observational cohort study.
Setting: Denmark.
Synopsis: This study included 55,320 hypertensive patients using at least two antihypertensive drugs who underwent non-cardiac surgery. Of these, 14,644 patients were treated with a beta-blocker. Patients with secondary cardiovascular conditions, renal disease, or liver disease were excluded; 30-day MACEs and all-cause mortality were analyzed.
In patients treated with a beta-blocker, the incidence of 30-day MACEs was 1.32% compared with 0.84% in the non-beta-blockers group; 30-day mortality in those treated with beta-blocker was 1.9% compared with 1.3% in the non-beta-blocker group. Risk of beta-blocker-associated MACEs was higher in patients 70 and older. Causality cannot be concluded based on observational data.
Bottom line: In patients with uncomplicated HTN, treatment with a beta-blocker may be associated with increased 30-day risk of perioperative MACEs after non-cardiac surgery.
Citation: Jorgensen ME, Hlatky MA, Kober L, et al. Beta-blocker-associated risks in patients with uncomplicated hypertension undergoing noncardiac surgery. JAMA Intern Med. 2015;175(12):1923-1931.
Clinical question: Does taking a perioperative beta-blocker increase the risk of major adverse cardiovascular events (MACEs) and all-cause mortality in low-risk patients with essential hypertension (HTN)?
Background: Guidelines for the use of perioperative beta-blockers are being reevaluated due to concerns about validity of prior studies that supported the use of perioperative beta-blockers. This study sought to evaluate effectiveness and safety of beta-blockers in patients with uncomplicated HTN.
Study design: Observational cohort study.
Setting: Denmark.
Synopsis: This study included 55,320 hypertensive patients using at least two antihypertensive drugs who underwent non-cardiac surgery. Of these, 14,644 patients were treated with a beta-blocker. Patients with secondary cardiovascular conditions, renal disease, or liver disease were excluded; 30-day MACEs and all-cause mortality were analyzed.
In patients treated with a beta-blocker, the incidence of 30-day MACEs was 1.32% compared with 0.84% in the non-beta-blockers group; 30-day mortality in those treated with beta-blocker was 1.9% compared with 1.3% in the non-beta-blocker group. Risk of beta-blocker-associated MACEs was higher in patients 70 and older. Causality cannot be concluded based on observational data.
Bottom line: In patients with uncomplicated HTN, treatment with a beta-blocker may be associated with increased 30-day risk of perioperative MACEs after non-cardiac surgery.
Citation: Jorgensen ME, Hlatky MA, Kober L, et al. Beta-blocker-associated risks in patients with uncomplicated hypertension undergoing noncardiac surgery. JAMA Intern Med. 2015;175(12):1923-1931.
Clinical question: Does taking a perioperative beta-blocker increase the risk of major adverse cardiovascular events (MACEs) and all-cause mortality in low-risk patients with essential hypertension (HTN)?
Background: Guidelines for the use of perioperative beta-blockers are being reevaluated due to concerns about validity of prior studies that supported the use of perioperative beta-blockers. This study sought to evaluate effectiveness and safety of beta-blockers in patients with uncomplicated HTN.
Study design: Observational cohort study.
Setting: Denmark.
Synopsis: This study included 55,320 hypertensive patients using at least two antihypertensive drugs who underwent non-cardiac surgery. Of these, 14,644 patients were treated with a beta-blocker. Patients with secondary cardiovascular conditions, renal disease, or liver disease were excluded; 30-day MACEs and all-cause mortality were analyzed.
In patients treated with a beta-blocker, the incidence of 30-day MACEs was 1.32% compared with 0.84% in the non-beta-blockers group; 30-day mortality in those treated with beta-blocker was 1.9% compared with 1.3% in the non-beta-blocker group. Risk of beta-blocker-associated MACEs was higher in patients 70 and older. Causality cannot be concluded based on observational data.
Bottom line: In patients with uncomplicated HTN, treatment with a beta-blocker may be associated with increased 30-day risk of perioperative MACEs after non-cardiac surgery.
Citation: Jorgensen ME, Hlatky MA, Kober L, et al. Beta-blocker-associated risks in patients with uncomplicated hypertension undergoing noncardiac surgery. JAMA Intern Med. 2015;175(12):1923-1931.
Pharmacist Involvement in Transitional Care Can Reduce Return ED Visits, Inpatient Readmissions
Clinical question: Does pharmacist involvement in transitions of care decrease medication errors (MEs), adverse drug events (ADEs), and 30-day ED visits and inpatient readmissions?
Background: Previous studies show pharmacist involvement in discharge can reduce ADEs and improve patient satisfaction, but there have been inconsistent data on the impact of pharmacist involvement on readmissions, ADEs, and MEs.
Study design: Prospective, randomized, single-period, longitudinal study.
Setting: Northwestern Memorial Hospital, Chicago.
Synopsis: Investigators included 278 patients (137 in study arm, 141 in control arm) in the final analysis. The study arm received intensive pharmacist involvement on admission and discharge, followed by phone calls at three, 14, and 30 days post-discharge. The study arm had lower composite 30-day ED visits and inpatient readmission rates compared to the control group (25% vs. 39%; P=0.001) but did not have lower isolated inpatient readmission rates (20% vs. 24%; P=0.43). ADEs and MEs were not significantly different between the two groups.
This study had extensive exclusion criteria, limiting the patient population to which these results can be applied. It was underpowered, which could have prevented the detection of a significant improvement in readmission rates.
Care transitions are high-risk periods in patient care, and there is benefit to continuity of care of an interdisciplinary team, including pharmacists.
Bottom line: Pharmacist involvement in transitions of care was shown to reduce the composite of ED visits and inpatient readmissions.
Citation: Phatak A, Prusi R, Ward B, et al. Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study). J Hosp Med. 2016;11(1):39-44. doi:10.1002/jhm.2493.
Clinical question: Does pharmacist involvement in transitions of care decrease medication errors (MEs), adverse drug events (ADEs), and 30-day ED visits and inpatient readmissions?
Background: Previous studies show pharmacist involvement in discharge can reduce ADEs and improve patient satisfaction, but there have been inconsistent data on the impact of pharmacist involvement on readmissions, ADEs, and MEs.
Study design: Prospective, randomized, single-period, longitudinal study.
Setting: Northwestern Memorial Hospital, Chicago.
Synopsis: Investigators included 278 patients (137 in study arm, 141 in control arm) in the final analysis. The study arm received intensive pharmacist involvement on admission and discharge, followed by phone calls at three, 14, and 30 days post-discharge. The study arm had lower composite 30-day ED visits and inpatient readmission rates compared to the control group (25% vs. 39%; P=0.001) but did not have lower isolated inpatient readmission rates (20% vs. 24%; P=0.43). ADEs and MEs were not significantly different between the two groups.
This study had extensive exclusion criteria, limiting the patient population to which these results can be applied. It was underpowered, which could have prevented the detection of a significant improvement in readmission rates.
Care transitions are high-risk periods in patient care, and there is benefit to continuity of care of an interdisciplinary team, including pharmacists.
Bottom line: Pharmacist involvement in transitions of care was shown to reduce the composite of ED visits and inpatient readmissions.
Citation: Phatak A, Prusi R, Ward B, et al. Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study). J Hosp Med. 2016;11(1):39-44. doi:10.1002/jhm.2493.
Clinical question: Does pharmacist involvement in transitions of care decrease medication errors (MEs), adverse drug events (ADEs), and 30-day ED visits and inpatient readmissions?
Background: Previous studies show pharmacist involvement in discharge can reduce ADEs and improve patient satisfaction, but there have been inconsistent data on the impact of pharmacist involvement on readmissions, ADEs, and MEs.
Study design: Prospective, randomized, single-period, longitudinal study.
Setting: Northwestern Memorial Hospital, Chicago.
Synopsis: Investigators included 278 patients (137 in study arm, 141 in control arm) in the final analysis. The study arm received intensive pharmacist involvement on admission and discharge, followed by phone calls at three, 14, and 30 days post-discharge. The study arm had lower composite 30-day ED visits and inpatient readmission rates compared to the control group (25% vs. 39%; P=0.001) but did not have lower isolated inpatient readmission rates (20% vs. 24%; P=0.43). ADEs and MEs were not significantly different between the two groups.
This study had extensive exclusion criteria, limiting the patient population to which these results can be applied. It was underpowered, which could have prevented the detection of a significant improvement in readmission rates.
Care transitions are high-risk periods in patient care, and there is benefit to continuity of care of an interdisciplinary team, including pharmacists.
Bottom line: Pharmacist involvement in transitions of care was shown to reduce the composite of ED visits and inpatient readmissions.
Citation: Phatak A, Prusi R, Ward B, et al. Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study). J Hosp Med. 2016;11(1):39-44. doi:10.1002/jhm.2493.
Displaying Prices to Providers May Reduce Overall Ordering Costs
Clinical question: Does price display impact order costs and volume as well as patient safety outcomes, and is it acceptable to providers?
Background: Up to one-third of national healthcare expenditures are wasteful, with physicians playing a central role in overall cost, purchasing almost all tests and therapies for patients. Increasing the transparency of costs for physicians is one strategy to reduce unnecessary spending.
Study design: Systematic review.
Setting: Yale School of Medicine, New Haven, Conn.
Synopsis: Nineteen publications were selected for final analysis. Thirteen studies reported the impact of price display on costs, nine of which showed a statistically significant decrease in order costs. Only three of eight studies reporting the impact of price display on order volume showed statistically significant decreases in order volume. One study showed adverse safety findings in the form of higher rates of unscheduled follow-up care in a pediatric ED. Physicians were overall satisfied with price display in the five studies reporting this.
There was high heterogeneity among studies, which did not allow for pooling of data. Furthermore, more than half of the studies were conducted more than 15 years ago, limiting their generalizability to the modern era of electronic health records (EHRs).
Overall, this review supports the conclusion that price display has a modest effect on order costs. Additional studies utilizing EHR systems are required to more definitively confirm these findings.
Bottom line: Displaying prices to physicians can have a modest effect on overall order costs.
Citation: Silvestri MT, Bongiovanni TR, Glover JG, Gross CP. Impact of price display on provider ordering: a systematic review. J Hosp Med. 2016;11(1):65-76. doi:10.1002/jhm.2500.
Clinical question: Does price display impact order costs and volume as well as patient safety outcomes, and is it acceptable to providers?
Background: Up to one-third of national healthcare expenditures are wasteful, with physicians playing a central role in overall cost, purchasing almost all tests and therapies for patients. Increasing the transparency of costs for physicians is one strategy to reduce unnecessary spending.
Study design: Systematic review.
Setting: Yale School of Medicine, New Haven, Conn.
Synopsis: Nineteen publications were selected for final analysis. Thirteen studies reported the impact of price display on costs, nine of which showed a statistically significant decrease in order costs. Only three of eight studies reporting the impact of price display on order volume showed statistically significant decreases in order volume. One study showed adverse safety findings in the form of higher rates of unscheduled follow-up care in a pediatric ED. Physicians were overall satisfied with price display in the five studies reporting this.
There was high heterogeneity among studies, which did not allow for pooling of data. Furthermore, more than half of the studies were conducted more than 15 years ago, limiting their generalizability to the modern era of electronic health records (EHRs).
Overall, this review supports the conclusion that price display has a modest effect on order costs. Additional studies utilizing EHR systems are required to more definitively confirm these findings.
Bottom line: Displaying prices to physicians can have a modest effect on overall order costs.
Citation: Silvestri MT, Bongiovanni TR, Glover JG, Gross CP. Impact of price display on provider ordering: a systematic review. J Hosp Med. 2016;11(1):65-76. doi:10.1002/jhm.2500.
Clinical question: Does price display impact order costs and volume as well as patient safety outcomes, and is it acceptable to providers?
Background: Up to one-third of national healthcare expenditures are wasteful, with physicians playing a central role in overall cost, purchasing almost all tests and therapies for patients. Increasing the transparency of costs for physicians is one strategy to reduce unnecessary spending.
Study design: Systematic review.
Setting: Yale School of Medicine, New Haven, Conn.
Synopsis: Nineteen publications were selected for final analysis. Thirteen studies reported the impact of price display on costs, nine of which showed a statistically significant decrease in order costs. Only three of eight studies reporting the impact of price display on order volume showed statistically significant decreases in order volume. One study showed adverse safety findings in the form of higher rates of unscheduled follow-up care in a pediatric ED. Physicians were overall satisfied with price display in the five studies reporting this.
There was high heterogeneity among studies, which did not allow for pooling of data. Furthermore, more than half of the studies were conducted more than 15 years ago, limiting their generalizability to the modern era of electronic health records (EHRs).
Overall, this review supports the conclusion that price display has a modest effect on order costs. Additional studies utilizing EHR systems are required to more definitively confirm these findings.
Bottom line: Displaying prices to physicians can have a modest effect on overall order costs.
Citation: Silvestri MT, Bongiovanni TR, Glover JG, Gross CP. Impact of price display on provider ordering: a systematic review. J Hosp Med. 2016;11(1):65-76. doi:10.1002/jhm.2500.
Hospitalist Minority Mentoring Program
The fraction of the US population identifying themselves as ethnic minorities was 36% in 2010 and will exceed 50% by 2050.[1, 2] This has resulted in an increasing gap in healthcare, as minorities have well‐documented disparities in access to healthcare and a disproportionately high morbidity and mortality.[3] In 2008, only 12.3% of US physicians were from under‐represented minority (URM) groups (see Figure in Castillo‐Page 4) (ie, those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population as defined by the American Association of Medical Colleges[4, 5]). Diversifying the healthcare workforce may be an effective approach to reducing healthcare disparities, as URM physicians are more likely to choose primary care specialties,[6] work in underserved communities with socioeconomic or racial mixes similar to their own, thereby increasing access to care,[6, 7, 8] increasing minority patient satisfaction, and improving the quality of care received by minorities.[9, 10, 11]
The number of URM students attending medical school is slowly increasing, but in 2011, only 15% of the matriculating medical school students were URMs (see Figure 12 and Table 10 in Castillo‐Page[12]), and medical schools actively compete for this limited number of applicants. To increase the pool of qualified candidates, more URM students need to graduate college and pursue postgraduate healthcare training.[12]
URM undergraduate freshmen with intentions to enter medical school are 50% less likely to apply to medical school by the time they are seniors than their non‐Latino, white, and Asian counterparts.[13] Higher attrition rates have been linked to students having negative experiences in the basic science courses and with a lack of role models and exposure to careers in healthcare.[13, 14, 15, 16] We developed a hospitalist‐led mentoring program that was focused on overcoming these perceived limitations. This report describes the program and follow‐up data from our first year cohort documenting its success.
METHODS
The Healthcare Interest Program (HIP) was developed by 2 hospitalists (L. C., E. C.) and a physician's assistant (C. N.) who worked at Denver Health (DH), a university‐affiliated public hospital. We worked in conjunction with the chief diversity officer of the University of Colorado, Denver (UCD), primarily a commuter university in metropolitan Denver, where URMs composed 51% of the 2011 freshmen class. We reviewed articles describing mentoring programs for undergraduate students, and by consensus, designed a 7‐component program, each of which was intended to address a specific barrier identified in the literature as possibly contributing to reduced interest of minority students in pursuing medical careers (Table 1).[13, 14, 15, 16]
| Component | Goal |
|---|---|
| Clinical shadowing | |
| Student meets with their mentor and/or with other healthcare providers (eg, pharmacist, nurse) 4 hours per day, 1 or 2 times per month. | Expose students to various healthcare careers and to care for underserved patients. |
| Mentoring | |
| Student meets with their mentor for life coaching, career counseling, and to learn interviewing techniques 4 hours per month | Expand ideas of opportunity, address barriers or concerns before they affect grades, write letter of recommendation |
| Books to Bedside lectures | |
| One lecture per month designed to integrate clinical medicine with the undergraduate basic sciences. Sample lectures include: The Physics of Electrocardiograms and The Biochemistry of Diabetic Ketoacidosis | Improve the undergraduate experience in the basic science courses |
| Book club | |
| Group discussions of books selected for their focus on healthcare disparities and cultural diversity; 2 or 3 books per year (eg, The Spirit Catches You and You Fall Down by Ann Fadiman, Just Like Us by Helen Thorpe) | Socialize, begin to understand and discuss health disparities and caring for the underserved. |
| Diversity lectures | |
| Three speakers per term, each discussing different aspects of health disparities research being conducted in the Denver metropolitan area | Understand the disparities affecting the students' communities. Inspire interest in becoming involved with research. |
| Social events | |
| Kickoff, winter, and end‐of‐year gatherings | Socializing, peer group support |
| Journaling and reflection essay | |
| Summary of hospital experience with mentor and thoughts regarding healthcare career goals and plans. | Formalize career goals |
During the 2009 to 2010 academic year, information about the program, together with an application, was e‐mailed to all students at UCD who self‐identified as having interest in healthcare careers. This information was also distributed at all prehealth clubs and gatherings (ie, to students expressing interest in graduate and professional programs in healthcare‐related fields). All sophomore and junior students who submitted an application and had grade point averages (GPA) 2.8 were interviewed by the program director. Twenty‐three students were selected on the basis of their GPAs (attempting to include those with a range of GPAs), interviews, and the essays prepared as part of their applications.
An e‐mail soliciting mentors was sent to all hospitalists physicians and midlevels working at DH; 25/30 volunteered, and 20 were selected on the basis of their gender (as mentors were matched to students based on gender). The HIP director met with the mentors in person to introduce the program and its goals. All mentors had been practicing hospital medicine for 10 years after their training, and all but 3 were non‐Latino white. Each student accepted into the program was paired with a hospitalist who served as their mentor for the year.
The mentors were instructed in life coaching in both e‐mails and individual discussions. Every 2 or 3 months each hospitalist was contacted by e‐mail to see if questions or problems had arisen and to emphasize the need to meet with their mentees monthly.
Students filled out a written survey after each Books‐to‐Bedside (described in Table 1) discussion. The HIP director met with each student for at least 1 hour per semester and gathered feedback regarding mentor‐mentee success, shadowing experience, and the quality of the book club. At the end of the academic year, students completed a written, anonymous survey assessing their impressions of the program and their intentions of pursuing additional training in healthcare careers (Table 2). We used descriptive statistics to analyze the data including frequencies and mean tests.
|
| Open‐ended questions: |
| 1. How did HIP or your HIP mentor affect your application to your healthcare field of interest (eg, letter of recommendation, clinical hours, change in healthcare career of interest)? |
| 2. How did the Books to Bedside presentation affect you? |
| 3. My healthcare professional school of interest is (eg, medical school, nursing school, physician assistant school, pharmacy school, physical therapy school, dental school). |
| 4. How many times per month were you able to shadow at Denver Health? |
| 5. How would you revise the program to improve it? |
| Yes/no questions: |
| 1. English is my primary language. |
| 2. I am the first in my immediate family to attend college |
| 3. Did you work while in school? |
| 4. Did you receive scholarships while in school? |
| 5. Prior to participating in this program, I had a role model in my healthcare field of interest. |
| 6. My role model is my HIP mentor. |
| 7. May we contact you in 2 to 3 years to obtain information regarding your acceptance into your healthcare field of interest? |
| Likert 5‐point questions: |
| 1. Participation in HIP expanded my perceptions of what I could accomplish in the healthcare field. |
| 2. Participation in HIP has increased my confidence that I will be accepted into my healthcare field of choice. |
| 3. I intend to go to my healthcare school in the state of Colorado. |
| 4. One of my long‐term goals is to work with people with health disparities (eg, underserved). |
| 5. One of my long‐term goals is to work in a rural environment. |
| 6. I have access to my prehealth advisors. |
| 7. I have access to my HIP mentor. |
| 8. Outside of the HIP, I have had access to clinical experience shadowing with a physician or physician assistant. |
| 9. If not accepted the first time, I will reapply to my healthcare field of interest. |
| 10. I would recommend HIP to my colleagues. |
Two years after completing the program, each student was contacted via e‐mail and/or phone to determine whether they were still pursuing healthcare careers.
RESULTS
Twenty‐three students were accepted into the program (14 female, 9 male, mean age 19 [standard deviation1]). Their GPAs ranged from 2.8 to 4.0. Eleven (48%) were the first in their family to attend college, 6 (26%) indicated that English was not their primary language, and 16 (70%) were working while attending school. All 23 students stayed in the HIP program for the full academic year.
Nineteen of the 23 students (83%) completed the survey at the end of the year. Of these, 19 (100%) strongly agreed that the HIP expanded their perceptions of what they might accomplish and increased their confidence in being able to succeed in a healthcare profession. All 19 (100%) stated that they hoped to care for underserved minority patients in the future. Sixteen (84%) strongly agreed that their role model in life was their HIP mentor. These findings suggest that many of the HIP components successfully accomplished their goals (Table 1).
Two‐year follow‐up was available for 21 of the 23 students (91%). Twenty (95%) remained committed to a career in healthcare, 18 (86%) had graduated college, 6 (29%) were enrolled in graduate training in the healthcare professions (2 in medical school, 1 in nursing school, and 3 in a master's programs in public health, counseling, and medical science, respectively), and 9 (43%) were in the process of applying to postgraduate healthcare training programs (7 to medical school, 1 to dental school, and 1 to nursing school, respectively). Five students were preparing to take the Medical College Admissions Test, and 7 were working at various jobs in the healthcare field (eg, phlebotomists, certified nurse assistants, research assistants). Of the 16 students who expressed an interest in attending medical school at the beginning of the program, 15 (94%) maintained that interest.
DISCUSSION
HIP was extremely well‐received by the participating students, the majority graduated college and remained committed to a career in healthcare, and 29% were enrolled in postgraduate training in healthcare professions 2 years after graduation.
The 86% graduation rate that we observed compares highly favorably to the UCD campus‐wide graduation rates for minority students of 12.5% at 4 years and 30.8% at 5 years. Although there may be selection bias in the students participating in HIP, the extremely high graduation rate is consistent with HIP meeting 1 or more of its stated objectives.
Many universities have prehealthcare pipeline programs that are designed to provide short‐term summer medical experiences, research opportunities, and assistance with the Medical College Admissions Test.[17, 18, 19] We believe, however, that several aspects of our program are unique. First, we designed HIP to be year‐long, rather than a summertime program. Continuing the mentoring and life coaching throughout the year may allow stronger relationships to develop between the mentor and the student. In addition, ongoing student‐mentor interactions during the time when a student may be encountering problems with their undergraduate basic science courses may be beneficial. Second, the Books‐to‐Bedside lectures series, which was designed to link the students' basic science training with clinical medicine, has not previously been described and may contribute to a higher rate of completion of their basic science training. Third, those aspects of the program resulting in increased peer interactions (eg, book club discussions, diversity lectures, and social gatherings) provided an important venue for students with similar interests to interact, an opportunity that is limited at UCD as it is primarily a commuter university.
A number of lessons were learned during the first year of the program. First, a program such as ours must include rigorous evaluation from the start to make a case for support to the university and key stakeholders. With this in mind, it is possible to obtain funding and ensure long‐term sustainability. Second, by involving UCD's chief diversity officer in the development, the program fostered a strong partnership between DH and UCD and facilitated growing the program. Third, the hospitalists who attended the diversity‐training aspects of the program stated through informal feedback that they felt better equipped to care for the underserved and felt that providing mentorship increased their personal job satisfaction. Fourth, the students requested more opportunities for them to participate in health disparities research and in shadowing in subspecialties in addition to internal medicine. In response to this feedback, we now offer research opportunities, lectures on health disparities research, and interactions with community leaders working in improving healthcare for the underserved.
Although influencing the graduation rate from graduate level schooling is beyond the scope of HIP, we can conclude that the large majority of students participating in HIP maintained their interest in the healthcare professions, graduated college, and that many went on to postgraduate healthcare training. The data we present pertain to the cohort of students in the first year of the HIP. As the program matures, we will continue to evaluate the long‐term outcomes of our students and hospitalist mentors. This may provide opportunities for other academic hospitalists to replicate our program in their own communities.
ACKNOWLEDGMENTS
Disclosure: The authors report no conflicts of interest.
- United States Census Bureau. An older and more diverse nation by midcentury. Available at: https://www.census.gov/newsroom/releases/archives/population/cb08–123.html. Accessed February 28, 2013.
- United States Census Bureau. State and county quick facts. Available at: http://quickfacts.census.gov/qfd/states/00000.html. Accessed February 28, 2013.
- Centers for Disease Control and Prevention. Surveillance of health status in minority communities—racial and ethnic approaches to community health across the U.S. (REACH US) risk factor survey, United States, 2009. Available at: http://cdc.gov/mmwr/preview/mmwrhtml/ss6006a1.htm. Accessed February 28, 2013.
- Association of American Medical Colleges. Diversity in the physician workforce: facts and figures 2010. Available at: https://members.aamc.org/eweb/upload/Diversity%20in%20the%20 Physician%20Workforce%20Facts%20and%20Figures%202010.pdf. Accessed April 29, 2014.
- Association of American Medical Colleges Executive Committee. The status of the new AAMC definition of “underrepresented in medicine” following the Supreme Court's decision in Grutter. Available at: https://www.aamc.org/download/54278/data/urm.pdf. Accessed May 25, 2014.
- . Physician Characteristics and Distribution in the US. 2013 ed. Chicago, IL: American Medical Association; 2013.
- , , , et al. The role of black and Hispanic physicians in providing health care for underserved populations. N Engl J Med. 1996;334:1305–1310.
- , , . The association among specialty, race, ethnicity, and practice location among California physicians in diverse Specialties. J Natl Med Assoc. 2012;104:46–52.
- , , , , Patient‐physician racial concordance and the perceived quality and use of health care. Arch Intern Med. 1999;159:997–1004.
- , . Race of physician and satisfaction with care among African‐American patients. J Natl Med Assoc. 2002;94:937–943.
- U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions. The rational for diversity in health professions: a review of the evidence. 2006. Available at: http://bhpr.hrsa.gov/healthworkforce/reports/diversityreviewevidence.pdf. Accessed March 30, 2014.
- . Association of American Medical Colleges. Diversity in medical education: facts and figures 2012. Available at: https://members.aamc.org/eweb/upload/Diversity%20in%20Medical%20Ed ucation%20Facts%20and%20Figures%202012.pdf. Accessed February 28, 2013.
- , , . The leaky pipeline: factors associated with early decline in interest in premedical studies among underrepresented minority undergraduate students. Acad Med. 2008;83:503–511.
- , . Perspective: adopting an asset bundles model to support and advance minority students' careers in academic medicine and the scientific pipeline. Acad Med. 2012;87:1488–1495.
- , , , . Contributors of black men's success in admission to and graduation from medical school. Acad Med. 2011;86:892–900.
- , . Premed survival: understanding the culling process in premedical undergraduate education. Acad Med. 2002;77:719–724.
- , , , . A novel enrichment program using cascading mentorship to increase diversity in the health care professions. Acad Med. 2013;88:1232–1238.
- , . A social and academic enrichment program promotes medical school matriculation and graduation for disadvantaged students. Educ Health. 2012;25:55–63.
- , , , . Addressing medical school diversity through an undergraduate partnership at Texas A83:512–515.
The fraction of the US population identifying themselves as ethnic minorities was 36% in 2010 and will exceed 50% by 2050.[1, 2] This has resulted in an increasing gap in healthcare, as minorities have well‐documented disparities in access to healthcare and a disproportionately high morbidity and mortality.[3] In 2008, only 12.3% of US physicians were from under‐represented minority (URM) groups (see Figure in Castillo‐Page 4) (ie, those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population as defined by the American Association of Medical Colleges[4, 5]). Diversifying the healthcare workforce may be an effective approach to reducing healthcare disparities, as URM physicians are more likely to choose primary care specialties,[6] work in underserved communities with socioeconomic or racial mixes similar to their own, thereby increasing access to care,[6, 7, 8] increasing minority patient satisfaction, and improving the quality of care received by minorities.[9, 10, 11]
The number of URM students attending medical school is slowly increasing, but in 2011, only 15% of the matriculating medical school students were URMs (see Figure 12 and Table 10 in Castillo‐Page[12]), and medical schools actively compete for this limited number of applicants. To increase the pool of qualified candidates, more URM students need to graduate college and pursue postgraduate healthcare training.[12]
URM undergraduate freshmen with intentions to enter medical school are 50% less likely to apply to medical school by the time they are seniors than their non‐Latino, white, and Asian counterparts.[13] Higher attrition rates have been linked to students having negative experiences in the basic science courses and with a lack of role models and exposure to careers in healthcare.[13, 14, 15, 16] We developed a hospitalist‐led mentoring program that was focused on overcoming these perceived limitations. This report describes the program and follow‐up data from our first year cohort documenting its success.
METHODS
The Healthcare Interest Program (HIP) was developed by 2 hospitalists (L. C., E. C.) and a physician's assistant (C. N.) who worked at Denver Health (DH), a university‐affiliated public hospital. We worked in conjunction with the chief diversity officer of the University of Colorado, Denver (UCD), primarily a commuter university in metropolitan Denver, where URMs composed 51% of the 2011 freshmen class. We reviewed articles describing mentoring programs for undergraduate students, and by consensus, designed a 7‐component program, each of which was intended to address a specific barrier identified in the literature as possibly contributing to reduced interest of minority students in pursuing medical careers (Table 1).[13, 14, 15, 16]
| Component | Goal |
|---|---|
| Clinical shadowing | |
| Student meets with their mentor and/or with other healthcare providers (eg, pharmacist, nurse) 4 hours per day, 1 or 2 times per month. | Expose students to various healthcare careers and to care for underserved patients. |
| Mentoring | |
| Student meets with their mentor for life coaching, career counseling, and to learn interviewing techniques 4 hours per month | Expand ideas of opportunity, address barriers or concerns before they affect grades, write letter of recommendation |
| Books to Bedside lectures | |
| One lecture per month designed to integrate clinical medicine with the undergraduate basic sciences. Sample lectures include: The Physics of Electrocardiograms and The Biochemistry of Diabetic Ketoacidosis | Improve the undergraduate experience in the basic science courses |
| Book club | |
| Group discussions of books selected for their focus on healthcare disparities and cultural diversity; 2 or 3 books per year (eg, The Spirit Catches You and You Fall Down by Ann Fadiman, Just Like Us by Helen Thorpe) | Socialize, begin to understand and discuss health disparities and caring for the underserved. |
| Diversity lectures | |
| Three speakers per term, each discussing different aspects of health disparities research being conducted in the Denver metropolitan area | Understand the disparities affecting the students' communities. Inspire interest in becoming involved with research. |
| Social events | |
| Kickoff, winter, and end‐of‐year gatherings | Socializing, peer group support |
| Journaling and reflection essay | |
| Summary of hospital experience with mentor and thoughts regarding healthcare career goals and plans. | Formalize career goals |
During the 2009 to 2010 academic year, information about the program, together with an application, was e‐mailed to all students at UCD who self‐identified as having interest in healthcare careers. This information was also distributed at all prehealth clubs and gatherings (ie, to students expressing interest in graduate and professional programs in healthcare‐related fields). All sophomore and junior students who submitted an application and had grade point averages (GPA) 2.8 were interviewed by the program director. Twenty‐three students were selected on the basis of their GPAs (attempting to include those with a range of GPAs), interviews, and the essays prepared as part of their applications.
An e‐mail soliciting mentors was sent to all hospitalists physicians and midlevels working at DH; 25/30 volunteered, and 20 were selected on the basis of their gender (as mentors were matched to students based on gender). The HIP director met with the mentors in person to introduce the program and its goals. All mentors had been practicing hospital medicine for 10 years after their training, and all but 3 were non‐Latino white. Each student accepted into the program was paired with a hospitalist who served as their mentor for the year.
The mentors were instructed in life coaching in both e‐mails and individual discussions. Every 2 or 3 months each hospitalist was contacted by e‐mail to see if questions or problems had arisen and to emphasize the need to meet with their mentees monthly.
Students filled out a written survey after each Books‐to‐Bedside (described in Table 1) discussion. The HIP director met with each student for at least 1 hour per semester and gathered feedback regarding mentor‐mentee success, shadowing experience, and the quality of the book club. At the end of the academic year, students completed a written, anonymous survey assessing their impressions of the program and their intentions of pursuing additional training in healthcare careers (Table 2). We used descriptive statistics to analyze the data including frequencies and mean tests.
|
| Open‐ended questions: |
| 1. How did HIP or your HIP mentor affect your application to your healthcare field of interest (eg, letter of recommendation, clinical hours, change in healthcare career of interest)? |
| 2. How did the Books to Bedside presentation affect you? |
| 3. My healthcare professional school of interest is (eg, medical school, nursing school, physician assistant school, pharmacy school, physical therapy school, dental school). |
| 4. How many times per month were you able to shadow at Denver Health? |
| 5. How would you revise the program to improve it? |
| Yes/no questions: |
| 1. English is my primary language. |
| 2. I am the first in my immediate family to attend college |
| 3. Did you work while in school? |
| 4. Did you receive scholarships while in school? |
| 5. Prior to participating in this program, I had a role model in my healthcare field of interest. |
| 6. My role model is my HIP mentor. |
| 7. May we contact you in 2 to 3 years to obtain information regarding your acceptance into your healthcare field of interest? |
| Likert 5‐point questions: |
| 1. Participation in HIP expanded my perceptions of what I could accomplish in the healthcare field. |
| 2. Participation in HIP has increased my confidence that I will be accepted into my healthcare field of choice. |
| 3. I intend to go to my healthcare school in the state of Colorado. |
| 4. One of my long‐term goals is to work with people with health disparities (eg, underserved). |
| 5. One of my long‐term goals is to work in a rural environment. |
| 6. I have access to my prehealth advisors. |
| 7. I have access to my HIP mentor. |
| 8. Outside of the HIP, I have had access to clinical experience shadowing with a physician or physician assistant. |
| 9. If not accepted the first time, I will reapply to my healthcare field of interest. |
| 10. I would recommend HIP to my colleagues. |
Two years after completing the program, each student was contacted via e‐mail and/or phone to determine whether they were still pursuing healthcare careers.
RESULTS
Twenty‐three students were accepted into the program (14 female, 9 male, mean age 19 [standard deviation1]). Their GPAs ranged from 2.8 to 4.0. Eleven (48%) were the first in their family to attend college, 6 (26%) indicated that English was not their primary language, and 16 (70%) were working while attending school. All 23 students stayed in the HIP program for the full academic year.
Nineteen of the 23 students (83%) completed the survey at the end of the year. Of these, 19 (100%) strongly agreed that the HIP expanded their perceptions of what they might accomplish and increased their confidence in being able to succeed in a healthcare profession. All 19 (100%) stated that they hoped to care for underserved minority patients in the future. Sixteen (84%) strongly agreed that their role model in life was their HIP mentor. These findings suggest that many of the HIP components successfully accomplished their goals (Table 1).
Two‐year follow‐up was available for 21 of the 23 students (91%). Twenty (95%) remained committed to a career in healthcare, 18 (86%) had graduated college, 6 (29%) were enrolled in graduate training in the healthcare professions (2 in medical school, 1 in nursing school, and 3 in a master's programs in public health, counseling, and medical science, respectively), and 9 (43%) were in the process of applying to postgraduate healthcare training programs (7 to medical school, 1 to dental school, and 1 to nursing school, respectively). Five students were preparing to take the Medical College Admissions Test, and 7 were working at various jobs in the healthcare field (eg, phlebotomists, certified nurse assistants, research assistants). Of the 16 students who expressed an interest in attending medical school at the beginning of the program, 15 (94%) maintained that interest.
DISCUSSION
HIP was extremely well‐received by the participating students, the majority graduated college and remained committed to a career in healthcare, and 29% were enrolled in postgraduate training in healthcare professions 2 years after graduation.
The 86% graduation rate that we observed compares highly favorably to the UCD campus‐wide graduation rates for minority students of 12.5% at 4 years and 30.8% at 5 years. Although there may be selection bias in the students participating in HIP, the extremely high graduation rate is consistent with HIP meeting 1 or more of its stated objectives.
Many universities have prehealthcare pipeline programs that are designed to provide short‐term summer medical experiences, research opportunities, and assistance with the Medical College Admissions Test.[17, 18, 19] We believe, however, that several aspects of our program are unique. First, we designed HIP to be year‐long, rather than a summertime program. Continuing the mentoring and life coaching throughout the year may allow stronger relationships to develop between the mentor and the student. In addition, ongoing student‐mentor interactions during the time when a student may be encountering problems with their undergraduate basic science courses may be beneficial. Second, the Books‐to‐Bedside lectures series, which was designed to link the students' basic science training with clinical medicine, has not previously been described and may contribute to a higher rate of completion of their basic science training. Third, those aspects of the program resulting in increased peer interactions (eg, book club discussions, diversity lectures, and social gatherings) provided an important venue for students with similar interests to interact, an opportunity that is limited at UCD as it is primarily a commuter university.
A number of lessons were learned during the first year of the program. First, a program such as ours must include rigorous evaluation from the start to make a case for support to the university and key stakeholders. With this in mind, it is possible to obtain funding and ensure long‐term sustainability. Second, by involving UCD's chief diversity officer in the development, the program fostered a strong partnership between DH and UCD and facilitated growing the program. Third, the hospitalists who attended the diversity‐training aspects of the program stated through informal feedback that they felt better equipped to care for the underserved and felt that providing mentorship increased their personal job satisfaction. Fourth, the students requested more opportunities for them to participate in health disparities research and in shadowing in subspecialties in addition to internal medicine. In response to this feedback, we now offer research opportunities, lectures on health disparities research, and interactions with community leaders working in improving healthcare for the underserved.
Although influencing the graduation rate from graduate level schooling is beyond the scope of HIP, we can conclude that the large majority of students participating in HIP maintained their interest in the healthcare professions, graduated college, and that many went on to postgraduate healthcare training. The data we present pertain to the cohort of students in the first year of the HIP. As the program matures, we will continue to evaluate the long‐term outcomes of our students and hospitalist mentors. This may provide opportunities for other academic hospitalists to replicate our program in their own communities.
ACKNOWLEDGMENTS
Disclosure: The authors report no conflicts of interest.
The fraction of the US population identifying themselves as ethnic minorities was 36% in 2010 and will exceed 50% by 2050.[1, 2] This has resulted in an increasing gap in healthcare, as minorities have well‐documented disparities in access to healthcare and a disproportionately high morbidity and mortality.[3] In 2008, only 12.3% of US physicians were from under‐represented minority (URM) groups (see Figure in Castillo‐Page 4) (ie, those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population as defined by the American Association of Medical Colleges[4, 5]). Diversifying the healthcare workforce may be an effective approach to reducing healthcare disparities, as URM physicians are more likely to choose primary care specialties,[6] work in underserved communities with socioeconomic or racial mixes similar to their own, thereby increasing access to care,[6, 7, 8] increasing minority patient satisfaction, and improving the quality of care received by minorities.[9, 10, 11]
The number of URM students attending medical school is slowly increasing, but in 2011, only 15% of the matriculating medical school students were URMs (see Figure 12 and Table 10 in Castillo‐Page[12]), and medical schools actively compete for this limited number of applicants. To increase the pool of qualified candidates, more URM students need to graduate college and pursue postgraduate healthcare training.[12]
URM undergraduate freshmen with intentions to enter medical school are 50% less likely to apply to medical school by the time they are seniors than their non‐Latino, white, and Asian counterparts.[13] Higher attrition rates have been linked to students having negative experiences in the basic science courses and with a lack of role models and exposure to careers in healthcare.[13, 14, 15, 16] We developed a hospitalist‐led mentoring program that was focused on overcoming these perceived limitations. This report describes the program and follow‐up data from our first year cohort documenting its success.
METHODS
The Healthcare Interest Program (HIP) was developed by 2 hospitalists (L. C., E. C.) and a physician's assistant (C. N.) who worked at Denver Health (DH), a university‐affiliated public hospital. We worked in conjunction with the chief diversity officer of the University of Colorado, Denver (UCD), primarily a commuter university in metropolitan Denver, where URMs composed 51% of the 2011 freshmen class. We reviewed articles describing mentoring programs for undergraduate students, and by consensus, designed a 7‐component program, each of which was intended to address a specific barrier identified in the literature as possibly contributing to reduced interest of minority students in pursuing medical careers (Table 1).[13, 14, 15, 16]
| Component | Goal |
|---|---|
| Clinical shadowing | |
| Student meets with their mentor and/or with other healthcare providers (eg, pharmacist, nurse) 4 hours per day, 1 or 2 times per month. | Expose students to various healthcare careers and to care for underserved patients. |
| Mentoring | |
| Student meets with their mentor for life coaching, career counseling, and to learn interviewing techniques 4 hours per month | Expand ideas of opportunity, address barriers or concerns before they affect grades, write letter of recommendation |
| Books to Bedside lectures | |
| One lecture per month designed to integrate clinical medicine with the undergraduate basic sciences. Sample lectures include: The Physics of Electrocardiograms and The Biochemistry of Diabetic Ketoacidosis | Improve the undergraduate experience in the basic science courses |
| Book club | |
| Group discussions of books selected for their focus on healthcare disparities and cultural diversity; 2 or 3 books per year (eg, The Spirit Catches You and You Fall Down by Ann Fadiman, Just Like Us by Helen Thorpe) | Socialize, begin to understand and discuss health disparities and caring for the underserved. |
| Diversity lectures | |
| Three speakers per term, each discussing different aspects of health disparities research being conducted in the Denver metropolitan area | Understand the disparities affecting the students' communities. Inspire interest in becoming involved with research. |
| Social events | |
| Kickoff, winter, and end‐of‐year gatherings | Socializing, peer group support |
| Journaling and reflection essay | |
| Summary of hospital experience with mentor and thoughts regarding healthcare career goals and plans. | Formalize career goals |
During the 2009 to 2010 academic year, information about the program, together with an application, was e‐mailed to all students at UCD who self‐identified as having interest in healthcare careers. This information was also distributed at all prehealth clubs and gatherings (ie, to students expressing interest in graduate and professional programs in healthcare‐related fields). All sophomore and junior students who submitted an application and had grade point averages (GPA) 2.8 were interviewed by the program director. Twenty‐three students were selected on the basis of their GPAs (attempting to include those with a range of GPAs), interviews, and the essays prepared as part of their applications.
An e‐mail soliciting mentors was sent to all hospitalists physicians and midlevels working at DH; 25/30 volunteered, and 20 were selected on the basis of their gender (as mentors were matched to students based on gender). The HIP director met with the mentors in person to introduce the program and its goals. All mentors had been practicing hospital medicine for 10 years after their training, and all but 3 were non‐Latino white. Each student accepted into the program was paired with a hospitalist who served as their mentor for the year.
The mentors were instructed in life coaching in both e‐mails and individual discussions. Every 2 or 3 months each hospitalist was contacted by e‐mail to see if questions or problems had arisen and to emphasize the need to meet with their mentees monthly.
Students filled out a written survey after each Books‐to‐Bedside (described in Table 1) discussion. The HIP director met with each student for at least 1 hour per semester and gathered feedback regarding mentor‐mentee success, shadowing experience, and the quality of the book club. At the end of the academic year, students completed a written, anonymous survey assessing their impressions of the program and their intentions of pursuing additional training in healthcare careers (Table 2). We used descriptive statistics to analyze the data including frequencies and mean tests.
|
| Open‐ended questions: |
| 1. How did HIP or your HIP mentor affect your application to your healthcare field of interest (eg, letter of recommendation, clinical hours, change in healthcare career of interest)? |
| 2. How did the Books to Bedside presentation affect you? |
| 3. My healthcare professional school of interest is (eg, medical school, nursing school, physician assistant school, pharmacy school, physical therapy school, dental school). |
| 4. How many times per month were you able to shadow at Denver Health? |
| 5. How would you revise the program to improve it? |
| Yes/no questions: |
| 1. English is my primary language. |
| 2. I am the first in my immediate family to attend college |
| 3. Did you work while in school? |
| 4. Did you receive scholarships while in school? |
| 5. Prior to participating in this program, I had a role model in my healthcare field of interest. |
| 6. My role model is my HIP mentor. |
| 7. May we contact you in 2 to 3 years to obtain information regarding your acceptance into your healthcare field of interest? |
| Likert 5‐point questions: |
| 1. Participation in HIP expanded my perceptions of what I could accomplish in the healthcare field. |
| 2. Participation in HIP has increased my confidence that I will be accepted into my healthcare field of choice. |
| 3. I intend to go to my healthcare school in the state of Colorado. |
| 4. One of my long‐term goals is to work with people with health disparities (eg, underserved). |
| 5. One of my long‐term goals is to work in a rural environment. |
| 6. I have access to my prehealth advisors. |
| 7. I have access to my HIP mentor. |
| 8. Outside of the HIP, I have had access to clinical experience shadowing with a physician or physician assistant. |
| 9. If not accepted the first time, I will reapply to my healthcare field of interest. |
| 10. I would recommend HIP to my colleagues. |
Two years after completing the program, each student was contacted via e‐mail and/or phone to determine whether they were still pursuing healthcare careers.
RESULTS
Twenty‐three students were accepted into the program (14 female, 9 male, mean age 19 [standard deviation1]). Their GPAs ranged from 2.8 to 4.0. Eleven (48%) were the first in their family to attend college, 6 (26%) indicated that English was not their primary language, and 16 (70%) were working while attending school. All 23 students stayed in the HIP program for the full academic year.
Nineteen of the 23 students (83%) completed the survey at the end of the year. Of these, 19 (100%) strongly agreed that the HIP expanded their perceptions of what they might accomplish and increased their confidence in being able to succeed in a healthcare profession. All 19 (100%) stated that they hoped to care for underserved minority patients in the future. Sixteen (84%) strongly agreed that their role model in life was their HIP mentor. These findings suggest that many of the HIP components successfully accomplished their goals (Table 1).
Two‐year follow‐up was available for 21 of the 23 students (91%). Twenty (95%) remained committed to a career in healthcare, 18 (86%) had graduated college, 6 (29%) were enrolled in graduate training in the healthcare professions (2 in medical school, 1 in nursing school, and 3 in a master's programs in public health, counseling, and medical science, respectively), and 9 (43%) were in the process of applying to postgraduate healthcare training programs (7 to medical school, 1 to dental school, and 1 to nursing school, respectively). Five students were preparing to take the Medical College Admissions Test, and 7 were working at various jobs in the healthcare field (eg, phlebotomists, certified nurse assistants, research assistants). Of the 16 students who expressed an interest in attending medical school at the beginning of the program, 15 (94%) maintained that interest.
DISCUSSION
HIP was extremely well‐received by the participating students, the majority graduated college and remained committed to a career in healthcare, and 29% were enrolled in postgraduate training in healthcare professions 2 years after graduation.
The 86% graduation rate that we observed compares highly favorably to the UCD campus‐wide graduation rates for minority students of 12.5% at 4 years and 30.8% at 5 years. Although there may be selection bias in the students participating in HIP, the extremely high graduation rate is consistent with HIP meeting 1 or more of its stated objectives.
Many universities have prehealthcare pipeline programs that are designed to provide short‐term summer medical experiences, research opportunities, and assistance with the Medical College Admissions Test.[17, 18, 19] We believe, however, that several aspects of our program are unique. First, we designed HIP to be year‐long, rather than a summertime program. Continuing the mentoring and life coaching throughout the year may allow stronger relationships to develop between the mentor and the student. In addition, ongoing student‐mentor interactions during the time when a student may be encountering problems with their undergraduate basic science courses may be beneficial. Second, the Books‐to‐Bedside lectures series, which was designed to link the students' basic science training with clinical medicine, has not previously been described and may contribute to a higher rate of completion of their basic science training. Third, those aspects of the program resulting in increased peer interactions (eg, book club discussions, diversity lectures, and social gatherings) provided an important venue for students with similar interests to interact, an opportunity that is limited at UCD as it is primarily a commuter university.
A number of lessons were learned during the first year of the program. First, a program such as ours must include rigorous evaluation from the start to make a case for support to the university and key stakeholders. With this in mind, it is possible to obtain funding and ensure long‐term sustainability. Second, by involving UCD's chief diversity officer in the development, the program fostered a strong partnership between DH and UCD and facilitated growing the program. Third, the hospitalists who attended the diversity‐training aspects of the program stated through informal feedback that they felt better equipped to care for the underserved and felt that providing mentorship increased their personal job satisfaction. Fourth, the students requested more opportunities for them to participate in health disparities research and in shadowing in subspecialties in addition to internal medicine. In response to this feedback, we now offer research opportunities, lectures on health disparities research, and interactions with community leaders working in improving healthcare for the underserved.
Although influencing the graduation rate from graduate level schooling is beyond the scope of HIP, we can conclude that the large majority of students participating in HIP maintained their interest in the healthcare professions, graduated college, and that many went on to postgraduate healthcare training. The data we present pertain to the cohort of students in the first year of the HIP. As the program matures, we will continue to evaluate the long‐term outcomes of our students and hospitalist mentors. This may provide opportunities for other academic hospitalists to replicate our program in their own communities.
ACKNOWLEDGMENTS
Disclosure: The authors report no conflicts of interest.
- United States Census Bureau. An older and more diverse nation by midcentury. Available at: https://www.census.gov/newsroom/releases/archives/population/cb08–123.html. Accessed February 28, 2013.
- United States Census Bureau. State and county quick facts. Available at: http://quickfacts.census.gov/qfd/states/00000.html. Accessed February 28, 2013.
- Centers for Disease Control and Prevention. Surveillance of health status in minority communities—racial and ethnic approaches to community health across the U.S. (REACH US) risk factor survey, United States, 2009. Available at: http://cdc.gov/mmwr/preview/mmwrhtml/ss6006a1.htm. Accessed February 28, 2013.
- Association of American Medical Colleges. Diversity in the physician workforce: facts and figures 2010. Available at: https://members.aamc.org/eweb/upload/Diversity%20in%20the%20 Physician%20Workforce%20Facts%20and%20Figures%202010.pdf. Accessed April 29, 2014.
- Association of American Medical Colleges Executive Committee. The status of the new AAMC definition of “underrepresented in medicine” following the Supreme Court's decision in Grutter. Available at: https://www.aamc.org/download/54278/data/urm.pdf. Accessed May 25, 2014.
- . Physician Characteristics and Distribution in the US. 2013 ed. Chicago, IL: American Medical Association; 2013.
- , , , et al. The role of black and Hispanic physicians in providing health care for underserved populations. N Engl J Med. 1996;334:1305–1310.
- , , . The association among specialty, race, ethnicity, and practice location among California physicians in diverse Specialties. J Natl Med Assoc. 2012;104:46–52.
- , , , , Patient‐physician racial concordance and the perceived quality and use of health care. Arch Intern Med. 1999;159:997–1004.
- , . Race of physician and satisfaction with care among African‐American patients. J Natl Med Assoc. 2002;94:937–943.
- U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions. The rational for diversity in health professions: a review of the evidence. 2006. Available at: http://bhpr.hrsa.gov/healthworkforce/reports/diversityreviewevidence.pdf. Accessed March 30, 2014.
- . Association of American Medical Colleges. Diversity in medical education: facts and figures 2012. Available at: https://members.aamc.org/eweb/upload/Diversity%20in%20Medical%20Ed ucation%20Facts%20and%20Figures%202012.pdf. Accessed February 28, 2013.
- , , . The leaky pipeline: factors associated with early decline in interest in premedical studies among underrepresented minority undergraduate students. Acad Med. 2008;83:503–511.
- , . Perspective: adopting an asset bundles model to support and advance minority students' careers in academic medicine and the scientific pipeline. Acad Med. 2012;87:1488–1495.
- , , , . Contributors of black men's success in admission to and graduation from medical school. Acad Med. 2011;86:892–900.
- , . Premed survival: understanding the culling process in premedical undergraduate education. Acad Med. 2002;77:719–724.
- , , , . A novel enrichment program using cascading mentorship to increase diversity in the health care professions. Acad Med. 2013;88:1232–1238.
- , . A social and academic enrichment program promotes medical school matriculation and graduation for disadvantaged students. Educ Health. 2012;25:55–63.
- , , , . Addressing medical school diversity through an undergraduate partnership at Texas A83:512–515.
- United States Census Bureau. An older and more diverse nation by midcentury. Available at: https://www.census.gov/newsroom/releases/archives/population/cb08–123.html. Accessed February 28, 2013.
- United States Census Bureau. State and county quick facts. Available at: http://quickfacts.census.gov/qfd/states/00000.html. Accessed February 28, 2013.
- Centers for Disease Control and Prevention. Surveillance of health status in minority communities—racial and ethnic approaches to community health across the U.S. (REACH US) risk factor survey, United States, 2009. Available at: http://cdc.gov/mmwr/preview/mmwrhtml/ss6006a1.htm. Accessed February 28, 2013.
- Association of American Medical Colleges. Diversity in the physician workforce: facts and figures 2010. Available at: https://members.aamc.org/eweb/upload/Diversity%20in%20the%20 Physician%20Workforce%20Facts%20and%20Figures%202010.pdf. Accessed April 29, 2014.
- Association of American Medical Colleges Executive Committee. The status of the new AAMC definition of “underrepresented in medicine” following the Supreme Court's decision in Grutter. Available at: https://www.aamc.org/download/54278/data/urm.pdf. Accessed May 25, 2014.
- . Physician Characteristics and Distribution in the US. 2013 ed. Chicago, IL: American Medical Association; 2013.
- , , , et al. The role of black and Hispanic physicians in providing health care for underserved populations. N Engl J Med. 1996;334:1305–1310.
- , , . The association among specialty, race, ethnicity, and practice location among California physicians in diverse Specialties. J Natl Med Assoc. 2012;104:46–52.
- , , , , Patient‐physician racial concordance and the perceived quality and use of health care. Arch Intern Med. 1999;159:997–1004.
- , . Race of physician and satisfaction with care among African‐American patients. J Natl Med Assoc. 2002;94:937–943.
- U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions. The rational for diversity in health professions: a review of the evidence. 2006. Available at: http://bhpr.hrsa.gov/healthworkforce/reports/diversityreviewevidence.pdf. Accessed March 30, 2014.
- . Association of American Medical Colleges. Diversity in medical education: facts and figures 2012. Available at: https://members.aamc.org/eweb/upload/Diversity%20in%20Medical%20Ed ucation%20Facts%20and%20Figures%202012.pdf. Accessed February 28, 2013.
- , , . The leaky pipeline: factors associated with early decline in interest in premedical studies among underrepresented minority undergraduate students. Acad Med. 2008;83:503–511.
- , . Perspective: adopting an asset bundles model to support and advance minority students' careers in academic medicine and the scientific pipeline. Acad Med. 2012;87:1488–1495.
- , , , . Contributors of black men's success in admission to and graduation from medical school. Acad Med. 2011;86:892–900.
- , . Premed survival: understanding the culling process in premedical undergraduate education. Acad Med. 2002;77:719–724.
- , , , . A novel enrichment program using cascading mentorship to increase diversity in the health care professions. Acad Med. 2013;88:1232–1238.
- , . A social and academic enrichment program promotes medical school matriculation and graduation for disadvantaged students. Educ Health. 2012;25:55–63.
- , , , . Addressing medical school diversity through an undergraduate partnership at Texas A83:512–515.