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Asian Americans Pacific Islanders (AAPI) share a disproportionate burden of chronic hepatitis B (CHB) in both the United States and New York State. Current hepatitis B virus (HBV) screening and research efforts have focused on urban communities. We administered a cross-sectional survey to 64 attendants at two free health fairs hosted by AAPI organizations on suburban Long Island, New York. We report the demographic make-up, healthcare attitudes, and HBV-related health histories of event attendees in Nassau and Suffolk Counties. Participants in Nassau County generally had more access to healthcare (97.1% vs 74.1% insured, 91.4% vs. 63.0% annual physician visit) and more familiarity with HBV screening (57.1% vs 17.2% history of HBV screening, 42.9% vs 3.9% physician recommendation for HBV screening). AAPI are a heterogenous population. Communities in close proximity may be demographically distinct and efforts to screen for HBV should be tailored to individual communities.

Background Diagnostic reasoning is an important topic in medical education, and diagnostic errors are increasingly recognized as large contributors to patient morbidity and mortality. One way to improve learner understanding of the diagnostic process is to teach the concepts of Bayesian reasoning and to make these concepts practical for clinical use. Many clinician educators do not fully understand Bayesian concepts and they lack the tools to incorporate Bayesian reasoning into clinical practice and teaching. Methods The authors developed an interactive workshop using visual models of probabilities and thresholds, clinical cases, and available smartphone apps to teach learners about Bayesian concepts. Results Evaluations from 3 years of workshops at a national internal medicine chief resident conference showed high satisfaction, with narrative comments suggesting learners found the visual and smartphone tools useful for applying the concepts with future learners. Conclusions Visual models, clinical cases, and smartphone apps were well received by chief residents as a way to learn and teach Bayesian reasoning. Further study will be needed to understand if these tools can improve diagnostic accuracy or patient outcomes.

Background Assessment using entrustable professional activities (EPAs) is currently under study as a joint effort of the American Board of Pediatrics and program director community. However, limited evidence exists for the feasibility of EPA-based assessment in pediatrics. Aim Among pediatric residency programs that implemented EPA-based assessment over 3 academic years (2015-16, 2016-17, 2017-18), determine how often programs were “unable to assess” a resident on a given EPA. Methods 23 programs reported clinical competency committee (CCC) determined EPA supervision level assignments for all residents in their program for a subset of 5-6 of the 17 general pediatrics EPAs biannually (Fall and Spring), except interns who were only assessed at the end of the academic year (Spring). They indicated “unable to assess” whenever applicable. Results Across the 5 data collection cycles, there were 29,643 opportunities to assign an EPA supervision level to 1987 residents from all three post-graduate years. Of these, 4140 assignments (14%) were deemed “unable to assess.” Across all EPAs, this determination was made less often in mid-year reports than year-end reports (p=.005). Post-graduate year 3 (PGY3) residents and PGY2 residents had significantly lower frequencies of “unable to assess” assignments when compared with PGY1 residents (Figure). EPAs with the lowest rates of “unable to assess” included: EPA 4 (patients with acute, common dx) at 0.4%, EPAs 10 (initial resuscitation/stabilization) and 16 (handovers) at 0.9%, EPA 11 (manage information) at 4%, and EPA 13 (practice management) at 5%. EPAs with the highest rates of “unable to assess” included EPA 8 (transition to adult care) at 43%, EPA 17 (procedures) at 27%, EPA 14 (quality improvement) at 20%, and EPAs 12 (make referrals) and 9 (behavioral and mental health) at 14%. Conclusions “Unable to assess” assignments are related to the given EPA, training year, and timing of assessment within the academic year. CCCs may be less likely to assign EPA supervision levels at timepoints viewed as higher stakes, such as transition from one training year to the next. Future work should explore this further and consider the etiology behind high levels of inability to assess some EPAs in particular.

Importance Entrustable professional activities (EPAs) are an emerging workplace-based, patient-oriented assessment approach with limited empirical evidence. Objective To measure the development of pediatric trainees’ clinical skills over time using EPA-based assessment data. Design, Setting, and Participants Prospective cohort study of categorical pediatric residents over 3 academic years (2015-2016, 2016-2017, and 2017-2018) assessed on 17 American Board of Pediatrics EPAs. Residents in training at 23 pediatric residency programs in the Association of Pediatric Program Directors Longitudinal Educational Assessment Research Network were included. Assessment was conducted by clinical competency committee members, who made summative assessment decisions regarding levels of supervision required for each resident and each EPA. Data were collected from May 2016 to November 2018 and analyzed from November to December 2018. Interventions Longitudinal, prospective assessment using EPAs. Main Outcomes and Measures Trajectories of supervision levels by EPA during residency training and how often graduating residents were deemed ready for unsupervised practice in each EPA. Results Across the 5 data collection cycles, 1987 residents from all 3 postgraduate years in 23 residency programs were assigned 25 503 supervision level reports for the 17 general pediatrics EPAs. The 4 EPAs that required the most supervision across training were EPA 14 (quality improvement) on the 5-level scale (estimated mean level at graduation, 3.7; 95% CI, 3.6-3.7) and EPAs 8 (transition to adult care; mean, 7.0; 95% CI, 7.0-7.1), 9 (behavioral and mental health; mean, 6.6; 95% CI, 6.5-6.6), and 10 (resuscitate and stabilize; mean, 6.9; 95% CI, 6.8-7.0) on the expanded 5-level scale. At the time of graduation (36 months), the percentage of trainees who were rated at a supervision level corresponding to “unsupervised practice” varied by EPA from 53% to 98%. If performance standards were set to align with 90% of trainees achieving the level of unsupervised practice, this standard would be met for only 8 of the 17 EPAs (although 89% met this standard for EPA 17, performing the common procedures of the general pediatrician). Conclusions and Relevance This study presents initial evidence for empirically derived practice readiness and sets the stage for identifying curricular gaps that contribute to discrepancy between observed practice readiness and standards needed to produce physicians able to meet the health needs of the patient populations they serve. Future work should compare these findings with postgraduation outcomes data as a means of seeking validity evidence.

BACKGROUND: Surveys have been instrumental in describing adolescent use of tobacco, electronic cigarettes (e-cigarettes), and marijuana. However, objective biomarker data are lacking. We compared adolescent self-reported use to urinary biomarkers. METHODS: From April 2017 to April 2018, adolescents 12 to 21 years old completed an anonymous questionnaire regarding tobacco, e-cigarette, and marijuana use and provided a urine sample. Urine was analyzed for biomarkers cotinine, total 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol, and tetrahydrocannabinolic acid (THCA). RESULTS: Of 517 participants, 2.9% reported using tobacco, 14.3% e-cigarettes, and 11.4% marijuana in the past week. Only 2% reporting no smoking had total 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol levels above cutoff (14.5 pg/mL); 2% of non–e-cigarette users had cotinine above cutoff (10 ng/mL); 2% of those denying marijuana use had THCA above cutoff (10 ng/mL). Daily e-cigarette users showed significantly higher median cotinine than nondaily users (315.4 [interquartile range (IQR) 1375.9] vs 1.69 ng/mL [IQR 28.2]; P 10 ng/mL. Pod users9 median cotinine was significantly higher than in nonpod users (259.03 [IQR 1267.69] vs 1.61 ng/mL [IQR 16.3]; P 10 ng/mL vs 39% of those with cotinine 10 ng/mL (P CONCLUSIONS: Adolescents’ self-report correlated with measured urinary biomarkers, but subjects were unaware of their nicotine exposure. More frequent e-cigarette and pod use correlated with elevated biomarkers. Co-use of tobacco, e-cigarettes, and marijuana was corroborated by higher THCA in those with higher cotinine.

Entrustable Professional Activities (EPAs) and the Next Accreditation System reporting milestones reduce general competencies into smaller evaluable parts. However, some EPAs and reporting milestones may be too broad to use as direct assessment tools. We describe our internal medicine residency curriculum and assessment system, which uses entrustment and mapping of observable practice activities (OPAs) for resident assessment. We created discrete OPAs for each resident rotation and learning experience. In combination, these serve as curricular foundation and tools for assessment. OPA performance is measured via a 5-point entrustment scale, and mapped to milestones and EPAs. Entrustment ratings of OPAs provide an opportunity for immediate structured feedback of specific clinical skills, and mapping OPAs to milestones and EPAs can be used for longitudinal assessment, promotion decisions, and reporting. Direct assessment and demonstration of progressive entrustment of trainee skill over time are important goals for all training programs. Systems that use OPAs mapped to milestones and EPAs provide the opportunity for achieving both, but require validation.

Managing costs and improving care associated with type 1 and type 2 diabetes has proven to be as difficult as managing the disease itself. Diabetes care is costly, complications are common, and prevalence is growing. In addition, the need for improved coordination and management of care is hindered by barriers in the monitoring and tracking of diabetes care across multiple clinical settings.1–7 To better manage patients and improve care, many hospitals and primary care practices have adopted electronic health records (EHRs), many with clinical decision support (CDS) functionality that facilitates closer monitoring of A1C, LDL cholesterol, blood pressure, and eye and foot exams.8 The use of EHRs with CDS has been associated with improved outcomes for patients with diabetes; decreased use of outpatient, specialist, and inpatient services; and reduced overall costs, particularly when integrated into quality improvement (QI) activities.9,10 However, a sizeable proportion of primary care providers (PCPs) and emergency departments (EDs) do not have or adequately leverage EHRs, and many communities are just beginning to develop the health information exchange (HIE) infrastructure necessary to share meaningful clinical information across care settings.6,11 Without EHRs and more advanced HIE infrastructure, providers often lack the resources to capture QI data and communicate clinical patient information across care settings. The alternatives—phone, mail, or fax communication—can lead to inefficiencies, opportunities for error, and misplacement of records.12 In September 2010, the Greater Cincinnati Beacon Collaboration (GCBC), a group of six organizations in Cincinnati, Ohio, representing different stakeholders in the health care system, was awarded a Beacon Community cooperative agreement grant from the Office of the National Coordinator for Health Information Technology (IT). The purpose of the Beacon Community program is to develop and test health information technology and QI innovations to improve health outcomes …

Competency-based medical education and milestone reporting have led to increased interest in work-based assessments using entrustment over time as an assessment framework. Little is known about data collected from these assessments during residency. This study describes the results of entrustment of discrete work-based skills over 36 months in the University of Cincinnati internal medicine (IM) residency program. Attending physician and peer/allied health assessors provided entrustment ratings of resident performance on work-based observable practice activities (OPAs) mapped to Accreditation Council for Graduate Medicine Education/American Board of Internal Medicine reporting milestones for IM. These data were translated into milestones data and tracked longitudinally. The authors analyzed data from this new entrustment system’s first 36 months (July 2012–June 2015). During the 36-month period, assessors made 364,728 milestone assessments (mapped from OPAs) of 189 residents. Residents received an annualized average of 83 assessment encounters, producing means of 3,987 milestone assessments and 4,325 words of narrative assessment. Mean entrustment ratings (range 1–5) from all assessors for all milestones rose from 2.46 for first-month residents to 3.92 for 36th-month residents (r2 = 0.9252, P < .001). Attending physicians’ entrustment ratings were lower than peer/allied health assessors’ ratings. Medical knowledge and patient care milestones were rated lower than professionalism and interpersonal and communication skills milestones. Entrustment of milestones appears to rise progressively over time, with differences by assessor type, competency, milestone, and resident. Further research is needed to elucidate the validity of these data in promotion, remediation, and reporting decisions.