Optimizing allocation of curricular content across the undergraduate & graduate medical education continuum

BACKGROUND: Medical educators struggle to incorporate socio-cultural topics into crowded curricula. The continuum of learning includes undergraduate and graduate medical education. Utilizing an exemplar socio-cultural topic, we studied the feasibility of achieving expert consensus among two groups of faculty (experts in medical education and experts in social determinants of health) on which aspects of the topic could be taught during undergraduate versus graduate medical education. METHODS: A modified Delphi method was used to generate expert consensus on which learning objectives of social determinants of health are best taught at each stage of medical education. Delphi respondents included experts in medical education or social determinants of health. A survey was created using nationally published criteria for social determinants of health learning objectives. Respondents were asked 1) which learning objectives were necessary for every physician (irrespective of specialty) to develop competence upon completion of medical training and 2) when the learning objective should be taught. Respondents were also asked an open-ended question on how they made the determination of when in the medical education continuum the learning objective should be taught. RESULTS: 26 out of 55 experts (13 social determinants of health and 13 education experts) responded to all 3 Delphi rounds. Experts evaluated a total of 49 learning objectives and were able to achieve consensus for at least one of the two research questions for 45 of 49 (92%) learning objectives. 50% more learning objectives reached consensus for inclusion in undergraduate (n = 21) versus graduate medical education (n = 14). CONCLUSIONS: A modified Delphi technique demonstrated that experts could identify key learning objectives of social determinants of health needed by all physicians and allocate content along the undergraduate and graduate medical education continuum. This approach could serve as a model for similar socio-cultural content. Future work should employ a qualitative approach to capture principles utilized by experts when making these decisions

Perceived Discrimination During the Childbirth Hospitalization and Postpartum Visit Attendance and Content: Evidence From the Listening to Mothers in California Survey

Objective Postpartum visits are an important opportunity to address ongoing maternal health. Experiences of discrimination in healthcare can impact healthcare use, including postpartum visits. However, it is unknown whether discrimination is associated with postpartum visit content. This study aimed to examine the relationship between perceived discrimination during the childbirth hospitalization and postpartum visit attendance and content. Research design Data were from Listening to Mothers in California, a population-based survey of people with a singleton hospital birth in California in 2016. Adjusted logistic regression models estimated the association between perceived discrimination during the childbirth hospitalization and 1) postpartum visit attendance, and 2) topics addressed at the postpartum visit (birth control, depression and breastfeeding) for those who attended. Results 90.6% of women attended a postpartum visit, and 8.6% reported discrimination during the childbirth hospitalization. In adjusted models, any discrimination and insurance-based discrimination were associated with 7 and 10 percentage point (pp) lower predicted probabilities of attending a postpartum visit, respectively. There was a 7pp lower predicted probability of discussing birth control for women who had experienced discrimination (81% vs. 88%), a 15pp lower predicted probability of being asked about depression (64% vs. 79%), and a 9 pp lower predicted probability of being asked about breastfeeding (57% vs. 66%). Conclusions Amid heightened attention to the importance of postpartum care, there is a need to better understand determinants of postpartum care quality. Our findings highlight the potential consequences of healthcare discrimination in the perinatal period, including lower quality of postpartum care

Transitions in health insurance among continuously insured patients with schizophrenia

Abstract Changes in health insurance coverage may disrupt access to and continuity of care, even for those who remain insured. Continuity of care is especially important in schizophrenia, which requires ongoing medical and pharmaceutical treatment. However, little is known about continuity of insurance coverage among those with schizophrenia. The objective was to examine the probability of insurance transitions for individuals with schizophrenia who were continuously insured and whether this varied across insurance types. The Massachusetts All-Payer Claims Database identified individuals with schizophrenia aged 18–64 who were continuously insured during a two-year period between 2014 and 2018. A logistic regression estimated the association of having an insurance transition – defined as having a change in insurance type – with insurance type at the start of the period, adjusting for age, sex, ZIP code in the lowest quartile of median income, and ZIP code with concentrated poverty. Overall, 15.1% had at least one insurance transition across a 24-month period. Insurance transitions were most frequent among those with plans from the Marketplace. In regression adjusted results, individuals covered by the traditional Medicaid program were 20.2 percentage points [pp] (95% confidence interval [CI]: 24.6 pp, 15.9 pp) less likely to have an insurance transition than those who were insured by a Marketplace plan. Insurance transitions among individuals with schizophrenia were common, with more than one in six people having at least one transition in insurance type during a two-year period. Given that even continuously insured individuals with schizophrenia commonly experience insurance transitions, attention to insurance transitions as a barrier to care access and continuity is warranted