UpToDate Use as a Predictor of Medical Student Success

Background Both practicing physicians and student learners prioritize speed of access and ease of use over most other criteria in choosing how to look up clinical information, with electronic resources far outpacing books for these reasons. While there are many variations of electronic reference materials available, UpToDate is one of, if not the most, frequently referenced clinical knowledge resources. It is professionally written and edited by practicing clinicians with frequent updates as new information or studies become available to inform care, allowing the learner to answer clinical questions rapidly, correctly, and fully. Given its proven popularity, the usefulness of UpToDate as a teaching tool must now be assessed against commonly agreed upon measures of medical student clinical competency. Methods We will measure the relationship between UpToDate usage, tracked as time logged as well as mouse clicks during each third-year clerkship, and several benchmarks commonly used to indicate medical student clinical competence. The four measures that will be used are (1) NBME clinical subject exam scores for each clerkship, reported as percent correct; (2) RIME score assigned at the end of each clerkship, which rate clinical skills on a scale from R (reporter) to I (interpreter) to M (manager) to E (educator); (3) USMLE Step 2 Clinical Skills score (if available), reported as pass/fail; and (4) USMLE Step 2 Clinical Knowledge score, reported on a scale from 1 to 300. We will control for pre-existing biomedical knowledge by using USMLE STEP 1 score as a control variable. UpToDate usage data is currently being matched to these datapoints for each student and anonymized before further analysis. Conclusion Assessing the utility of UpToDate as a teaching tool to reach validated endpoints of clinical skill will assist in curriculum design and instruction in medical schools and lead to a better prepared future physician workforce, thus benefiting both medical educators and society more broadly

Income Diversity Within Neighborhoods and Very Low-Income Families

The past decades have witnessed increasing concern over the family ills engendered by neighborhoods inhabited overwhelmingly by families with limited resources. This study focuses on a different sort of residential context—neighborhoods with substantial income mixing—and the extent to which very low-income (VLI) families—those earning less than 50 percent of the area median income (AMI)—live in them. The study’s primary units of analysis are the 100 largest metropolitan areas in the United States, according to the 2000 Census, and the secondary units of analysis are census tracts. The study specifies six mutually exclusive income groups based on the ratios relative to AMI, as defined by the U.S. Department of Housing and Urban Development. It also specifies four groups of neighborhoods according to their diversity of the six income groups, as measured by an entropy index. The descriptive results show that in 2000 (1) most neighborhoods had high diversity, although a decline is apparent in the overall income diversity of neighborhoods and in the share comprising high-diversity neighborhoods; (2) no neighborhoods with median incomes of less than 50 percent of AMI had high diversity; (3) 19 percent of all high-diversity neighborhoods (on average) consist of VLI families and 65 percent of all VLI families live in high-diversity neighborhoods, although both percentages have declined since 1970; (4) 5 percent of VLI families live in neighborhoods with median incomes of less than 50 percent of AMI, twice the percentage of 1970 but lower than in 1990; and (5) exposure of VLI families to other VLI families and moderate-income groups has steadily fallen since 1970 and concomitantly increased for families that have very high incomes (VHIs); indeed, the exposure to VHI families is approximately the same as exposure to other VLI families. This article addresses the mixed implications of these trends for the potential socioeconomic mobility of VLI families. This research was presented at Wayne State University\u27s 2010 Sociology Student Research & Awards Day. Presentation slides are included as supplemental materials. This research was supported by a grant from the U.S. Department of Housing and Urban Development, Office of Policy Development and Research. The opinions expressed in this article are those of the authors and do not necessarily reflect those of the Department

Racial Differences in the Use of Adjuvant Chemotherapy for Breast Cancer in a Large Urban Integrated Health System

Background. Racial differences in breast cancer survival may be in part due to variation in patterns of care. To better understand factors influencing survival disparities, we evaluated patterns of receipt of adjuvant chemotherapy among 2,234 women with invasive, nonmetastatic breast cancer treated at the Henry Ford Health System (HFHS) from 1996 through 2005. Methods. Sociodemographic and clinical information were obtained from linked datasets from the HFHS, Metropolitan Detroit Cancer Surveillance Systems, and U.S. Census. Comorbidity was measured using the Charlson comorbidity index (CCI), and economic deprivation was categorized using a neighborhood deprivation index. Results. African American (AA) women were more likely than whites to have advanced tumors with more aggressive clinical features, to have more comorbidity and to be socioeconomically deprived. While in the unadjusted model, AAs were more likely to receive chemotherapy (odds ratio (OR) 1.22, 95% confidence interval (CI) 1.02–1.46) and to have a delay in receipt of chemotherapy beyond 60 days (OR 1.68, 95% CI, 1.26–1.48), after multivariable adjustment there were no racial differences in receipt (odds ratio (OR) 1.02, 95% confidence interval (CI) 0.73–1.43), or timing of chemotherapy (OR 1.18, 95 CI, 0.8–1.74). Conclusions. Societal factors and not race appear to have an impact on treatment delay among African American women with early breast cancer

Racial Differences in the Use of Adjuvant Chemotherapy for Breast Cancer in a Large Urban Integrated Health System

Background. Racial differences in breast cancer survival may be in part due to variation in patterns of care. To better understand factors influencing survival disparities, we evaluated patterns of receipt of adjuvant chemotherapy among 2,234 women with invasive, nonmetastatic breast cancer treated at the Henry Ford Health System (HFHS) from 1996 through 2005. Methods. Sociodemographic and clinical information were obtained from linked datasets from the HFHS, Metropolitan Detroit Cancer Surveillance Systems, and U.S. Census. Comorbidity was measured using the Charlson comorbidity index (CCI), and economic deprivation was categorized using a neighborhood deprivation index. Results. African American (AA) women were more likely than whites to have advanced tumors with more aggressive clinical features, to have more comorbidity and to be socioeconomically deprived. While in the unadjusted model, AAs were more likely to receive chemotherapy (odds ratio (OR) 1.22, 95% confidence interval (CI) 1.02-1.46) and to have a delay in receipt of chemotherapy beyond 60 days (OR 1.68, 95% CI, 1.26-1.48), after multivariable adjustment there were no racial differences in receipt (odds ratio (OR) 1.02, 95% confidence interval (CI) 0.73-1.43), or timing of chemotherapy (OR 1.18, 95 CI,. Conclusions. Societal factors and not race appear to have an impact on treatment delay among African American women with early breast cancer. Background Despite improvements in available options for breast cancer treatment, there continues to be a considerable gap in survival between African American (AA) and white women with breast cancer Adjuvant chemotherapy and hormonal therapy have had a dramatic impact on breast cancer survival, and in order to optimize longevity, it is critical for patients to receive treatment according to standard clinical guidelines International Journal of Breast Cancer Previous reports on patterns of care have indicated that AA women are less likely to receive standard breast cancer treatment compared with white women We hypothesized that racial disparities in breast cancer survival may be at least in part due to differences in the receipt of standard adjuvant chemotherapy as defined by national treatment guidelines. In order to address this question, we evaluated patterns of breast cancer care provided at the Henry Ford Health System (HFHS), a large integrated health system serving southeastern MI. The goal of this study was to assess patterns of adjuvant chemotherapy administration among women with invasive, nonmetastatic breast cancer comparing AA and white women, and focusing on receipt of standard chemotherapy, duration of treatment, and timing of treatment in relationship to diagnosis. Methods Study Design. This study consisted of a descriptive analysis of adjuvant chemotherapy received by AA and white women diagnosed with invasive, nonmetastatic breast cancer at the HFHS between January 1, 1996 and December 31, 2005. HFHS is a large urban integrated health system located in southeast Michigan founded in 1915 to provide for the health care needs of the city of Detroit and surrounding metropolitan area. HFHS currently consists of 5 hospitals, anchored by Henry Ford Hospital, a 903 bed tertiary care, research and teaching facility; and 36 ambulatory care facilities including 5 sites located within the city of Detroit, and 31 sites located in Wayne (outside of Detroit), Macomb, Oakland, and Washtenaw counties. A single lifetime medical record number (MRN) is used throughout the system to provide continuity of record keeping and medical care. For the purposes of this project, patient sociodemographic, clinical, and treatment information was derived through analyses of linked datasets using the HFHS administrative databases, the Metropolitan Detroit Cancer Surveillance System (MDCSS), and the U.S. Census Bureau. The MDCSS is home for the Detroit SEER registry, which registers all cancers of residents from Wayne, Oakland, and Macomb counties. In the current study, case records were matched from the SEER and HFHS databases using MRN, social security number (SSN), last name, and date of birth. Records that matched for only one variable were manually reviewed to look for character or punctuation errors in other nonmatched fields. Matching resulted in 3,630 record matches. We excluded matches with unknown American Joint Cancer Committee (AJCC) stage (n = 51); first breast surgery at another institution (n = 147); history of a prior malignancy within 6 months of breast cancer diagnosis (n = 52); duplicate records (n = 3); histology code indicating non-breast origin (n = 1); stage IV disease (n = 978), other race (n = 45); no definitive breast surgery (n = 52); and receipt of neoadjuvant chemotherapy (n = 67). These exclusions resulted in a study population of 2,234 (61.5%) white and AA women treated for invasive, nonmetastatic breast cancer at the HFHS. Measurement of Variables. Detailed information on breast cancer treatment, clinical, and socio-demographic data were derived from the HFHS and SEER database and information on neighborhood-level economic deprivation (see deprivation index below) was obtained form the U.S. Census Bureau. All primary breast surgery consisting of lumpectomy (partial mastectomy) or mastectomy (modified radical mastectomy, radical mastectomy, or simple mastectomy) and standard axillary lymph node dissection was performed at the HFHS. Guidelines from the National Comprehensive Cancer Network (NCCN) corresponding to the years of diagnosis were used to define standard adjuvant chemotherapy treatment recommendations according to AJCC stage Patient and clinical characteristics included race (from the medical record listing), age at diagnosis, tumor size, lymph node positivity, histology, grade, and estrogen and progesterone receptor (ER and PR) status. Insurance status was available from the HFHS records and was classified based on the most frequent insurance charged for each treatment visit, and categorized into 3 groups (private, Medicare, and other, including uninsured). Comorbidity was assessed using the Charlson comorbidity index (CCI) a prospectively verified method for classifying comorbid medical conditions which could affect the risk of mortality in longitudinal studies Statistical Analysis. The clinical and sociodemographic characteristics of AA and white women with invasive, nonmetastatic breast cancer were compared by chi-square tests for categorical variables and Student's t-tests for continuous variables. Separate analyses were conducted to determine racial differences in the use of standard chemotherapy (yes versus no), timing of chemotherapy as determined by the date of diagnosis and the date of chemotherapy initiation (dichotomized using the sample median, 60 days) for cases where detailed chemotherapy records were available and completion of standard chemotherapy (i.e., completing the NCCN recommended number of cycles of treatment). Odds ratios (ORs) for receipt of chemotherapy for AA versus white women and 95% confidence intervals (CIs) were estimated using unconditional logistic regression analyses. Race, age at diagnosis, tumor size, lymph node positivity, hormone receptor status, tumor grade, CCI, deprivation index, and insurance status were assessed individually and in multivariable adjusted models. Unconditional logistic regression was also used to estimate the odds of beginning chemotherapy within 60 days of the date of diagnosis. The analyses consisted of three models, first adjusting for clinical factors only (race, age, tumor size, lymph node positivity, hormone receptor status, tumor grade, and CCI), second adjusting for societal factors (race, deprivation index, and insurance status), and third adjusting for all listed variables. The purpose of performing three different models was to determine whether clinical versus societal factors had a greater impact on racial differences in receipt of adjuvant chemotherapy or in timing of chemotherapy. All regression models were run with and without a clustering correction for census tract. Results There were no significant racial differences in age at diagnosis adjuvant chemotherapy for AA women compared with white women. The average time from diagnosis to initiation of chemotherapy for white women was 67.9 days (S.D. 38.6) compared to 73.2 (S.D. 36.4) for AA women, P = 0.049. When time to adjuvant chemotherapy was stratified at 60 days (the sample median), white women were more likely to be treated prior to 60 days (55%) compared to AA women (43%), P < 0.001. Discussion While breast cancer survival rates continue to improve over time http://seer.cancer.gov/csr/1975 2008/, there remains a marked discrepancy in survival by race, Strengths of this study include the inclusion of women enrolled in a large integrated urban heath care system which provides uniform access to high-quality medical care. In addition, the linked HFHS and SEER database allowed for availability of detailed and accurate clinical, demographic, and treatment data including details on adjuvant chemotherapy received. Our measure of socioeconomic deprivation was a sophisticated measure developed through the linkage with U.S. Census data, however, the derived deprivation index was not based on factors specific to the individual patient such as income, education, or family support, and may therefore be subject to misclassification. In conclusion, race had no direct impact on receipt of adjuvant chemotherapy or timing of chemotherapy among a cohort of women treated at a large urban integrated health care system in Detroit. The fact that AA women were more likely to receive adjuvant chemotherapy in the unadjusted model was largely explained by the more advanced stage at diagnosis among AAs that suggests the need for better screening and access to early treatment interventions. Delay in receipt of chemotherapy among AA women was largely explained by societal factors which likely have a direct effect on access to care. However, the delay was on average less than one week and may not have had significant clinical impact. Nevertheless, it serves to remind health care providers of the importance of making health care accessible to all

Geospatial relationships of air pollution and acute asthma events across the Detroit–Windsor international border: Study design and preliminary results

The Geospatial Determinants of Health Outcomes Consortium (GeoDHOC) study investigated ambient air quality across the international border between Detroit, Michigan, USA and Windsor, Ontario, Canada and its association with acute asthma events in 5- to 89-year-old residents of these cities. NO2, SO2, and volatile organic compounds (VOCs) were measured at 100 sites, and particulate matter (PM) and polycyclic aromatic hydrocarbons (PAHs) at 50 sites during two 2-week sampling periods in 2008 and 2009. Acute asthma event rates across neighborhoods in each city were calculated using emergency room visits and hospitalizations and standardized to the overall age and gender distribution of the population in the two cities combined. Results demonstrate that intra-urban air quality variations are related to adverse respiratory events in both cities. Annual 2008 asthma rates exhibited statistically significant positive correlations with total VOCs and total benzene, toluene, ethylbenzene and xylene (BTEX) at 5-digit zip code scale spatial resolution in Detroit. In Windsor, NO2, VOCs, and PM10 concentrations correlated positively with 2008 asthma rates at a similar 3-digit postal forward sortation area scale. The study is limited by its coarse temporal resolution (comparing relatively short term air quality measurements to annual asthma health data) and interpretation of findings is complicated by contrasts in population demographics and health-care delivery systems in Detroit and Windsor

Studying the Multilingual City : a GIS-based approach

Work in two distinct disciplines, urban geography and sociolinguistics, readilypoints out the multiethnic and multilingual character of metropolitan areas.However, there is still demand for studies which establish the language structure of modern cities. For the purposes of this pilot study, we focus on the Detroit Metropolitan Area (DMA), Michigan. GIS technology together with census data were used to arrive at an adequate description of the spatial distribution of languages currently spoken in Detroit and its immediate surroundings. Data from the 2000 US Census are entered into a GIS system and presented visually with a subsequent analysis of the emerging spatial patterns. Due to limitations of the data, we had to restrict the mapping to languages used at home. The study suggests one possible model for the initial stages of mapping the multilingual city; moreover, the data analysed here provide the infra-structure necessary for further research on phenomena such as language shift and language death as well as other aspects of a dynamic multilingual situation

Are home and auto insurance policies excessively priced in cities? : recent evidence from Michigan

Our study contributes to the growing literature on how insurance industry practices vary across space in ways that may unfairly penalize central cities. We utilize a unique, comprehensive database that allows us to examine the spatial patterns of premiums collected and claims paid out to policyholders for all home and auto insurance companies in Michigan during 2001-2002. As a result, we can test whether higher premiums typically charged in urban areas are justified by the higher claims losses incurred there. Territories that persistently evince low ratios of losses to premiums for a given policy type, all else equal, provide prima facie evidence of excessive premium-setting. We analyze three groups of homeowners' policies, delineated by the comprehensiveness of perils covered and the nature and level of compensation provided in case of loss, and three auto policy types - mandatory, collision, and comprehensive coverage. We find that both premiums and claims losses are higher in urban than suburban areas of Michigan, on average. However, the mean loss ratios for all segments of the home insurance market are not systematically lower in urban areas, even after a host of proxies for transactions costs are employed as controls. The same results appertain in the case of auto insurance across all but one policy type, comprehensive, where loss ratios are 16% lower in urban compared to suburban territories statewide, all else equal

Information Seeking Behavior of Students Studying for USMLE Step 1

Background: While the USMLE Step 1 has not changed significantly in content over the past 20 years, the context in which the exam is offered has changed drastically. In fact, a 2016 survey of Program Directors cited USMLE Step 1 as one of the most important factors in selecting applicants for interviews1. Though medical institutions provide evidence-based preparatory materials, online resources have become more available and accessible. Much of the current literature regarding the USMLE Step 1 exam is dedicated to content resources and their efficacy. Less is known, however, about students’ information-seeking behaviors. At our urban, large campus medical school, students rely on a variety of resources for assistance with content, test-taking strategies, and score prediction tools. These resources include school provided evidence-based curriculums, peers who have previously taken the exam, and online anonymous platforms like Reddit and Student Doctor Network (SDN)3. We sought to analyze students’ information-seeking behavior and identify patterns within this behavior. We hypothesize that students are turning increasingly more frequently to anonymous online platforms like Reddit and SDN. This poses a challenge to medical education institutions, as these platforms may lack regulation and monitoring for accuracy. Methods: Our 19-question online survey was sent out via email. The survey inquired about resources used for information about the exam (not content sources), perceived advantages and disadvantages of online vs. university sources, and exam scores. Primary outcomes were the perceived strengths and weaknesses of university provided and online resources as well as prevalence and reasons of online resource use. Secondary outcomes were Comprehensive Basic Science Exam (CBSE) score at the beginning of the dedicated study period, target score, and USMLE Step 1 score. Results: 51 students responded and answered all questions, giving a response rate of 17.33%. Average dedicated study time was 6 weeks. Mean CBSE score was 200 while the class mean was 211 (p=0.018) and mean Step 1 score was 236 while class mean was 232 (p=0.047). Students reported getting information from peers (80.77%), online platforms (80.77%), and university-provided information (69.23%). They rated the most useful resource as their peers (50%) and online platforms (17.3%). When asked what made online resources appealing, study advice (33.3%), score predication tools (15.4%), and freedom to discuss test scores anonymously (20.6%) were most common. Reasons students used university information included convenience (45.9%), tailored to curriculum (25%), and ability to meet in person (16.7%). Conclusions: Anonymity, score prediction, and review of practice exam questions led most students to utilize online resources. However, despite this changing dynamic, university provided information remains valued for its evidence based nature, convenience, and tailoring to curriculum. Medical schools need to use the changing medical education climate to improve their USMLE exam information to provide students with evidence based approaches to the current desired attributes of online platforms. Resources: 1 National Residency Matching Program. Results of the 2016 NRMP Program Director Survey. http://www.nrmp.org/wp-content/uploads/2019/09/NRMP-2016-Program-Director-Survey.pdf. Accessed January 13, 2020. 2 Burk-Rafel, J., Santen, S.A., & Purkiss, J.A. (2017). Study Behaviors and USMLE Step 1 Performance: Implications of a Student Self-Directed Parallel Curriculum. Academic Medicine, 92, S67–S74. 3Ajayi N. Library use and information-seeking behavior of medical students. Anthropologist. 2004;6(3):209–213

Income Diversity Within Neighborhoods and Very Low-Income Families

Development and Research. The opinions expressed in this article are those of the authors and do not necessarily reflect those of the Department. The past decades have witnessed increasing concern over the family ills engendered by neighborhoods inhabited overwhelmingly by families with limited resources. This study focuses on a different sort of residential context—neighborhoods with substantial income mixing—and the extent to which very low-income (VLI) families—those earning less than 50 percent of the area median income (AMI)—live in them. The study’s primary units of analysis are the 100 largest metropolitan areas in the United States, according to the 2000 Census, and the secondary units of analysis are census tracts. The study specifies six mutually exclusive income groups based on the ratios relative to AMI, as defined by the U.S. Department of Housing and Urban Development. It also specifies four groups of neighborhoods according to their diversity of the six income groups, as measured by an entropy index. The descriptive results show that in 2000 (1) most neighborhoods had high diversity, although a decline is apparent in the overall incom