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Introduction: Cardiovascular disease (CVD) is the leading cause of death worldwide. However, the lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) population experiences significant disparities in CVD risk factors, placing them at higher risk for developing CVD. Assessing and addressing risk factors (RF) in this population requires identifying and addressing modifiable barriers in a timely fashion. We aimed to evaluate trainee assessment of CVD RF in the LGBTQ community while identifying potential barriers as opportunities for intervention. Methods: This was a multi-institutional study performed at three academic training programs in Georgia. An anonymous questionnaire was used to assess trainees' (interns, residents, and medical students) identification and perception of CVD RF in the LGBTQ community. The data was compiled and analyzed to identify perceived barriers to LGBTQ CVD RF assessment by medical trainees. Results: A total of 168 surveys were returned. More than a third (37%; 62/168) of trainees noted that the LGBTQ community is at increased risk of developing CVD compared to their cisgender heterosexual peers. Only 3.6% (6/168) reported complete confidence in assessing CVD risk factors in the LGBTQ community. The most identified (90%; 152/168) RF was environmental stress such as discrimination, rejection, and violence followed by HIV/AIDs (83%; 139/168) and hormone replacement therapies (81%; 136/168). Almost half (48%; 77/161) of trainees noted that they address risk factors for CVD in the LGBTQ community less than 25% of the time, listing a lack of knowledge of the unique risk factors in the LGBTQ community 45% (69/152) as the most significant barrier. Conclusion: Identifying and addressing unique CVD RF in LGBTQ populations is pivotal to improving overall CVD outcomes. Medical teaching teams and training programs can play a leading role in educating trainees about these unique risk factors and helping to address knowledge barriers. Our study demonstrates that medical trainees are largely unaware that the LGBTQ community is at increased risk for CVD, presenting a significant opportunity to address cardiovascular health disparities in this community through intentional changes in the structure of medical education.

Background: Racial and ethnic healthcare disparities contribute to significant morbidity, mortality, and healthcare costs in cardiovascular disease. As one of the primary reasons for emergency department (ED) presentation, rapid assessment of patients with chest pain is necessary to guide further intervention and disposition. However, even with continued efforts to achieve health equity and eliminate disparities, Hispanics continue to face significant barriers to healthcare. Our goal was to assess the characteristics, and disposition, of Hispanic patients presenting to the ED with chest pain to identify potential targets for intervention to improve healthcare delivery. Methods: Data was obtained from the electronic medical record warehouse of a large, safety-net, academic hospital from January to December 2020. Patients who presented to the emergency department with a chief complaint of “chest pain” were identified and medical records were reviewed. Bivariate analyses were performed to identify the relationship between Hispanic ethnicity and ED disposition. Results: Hispanic patients who presented with chest pain represented only 4.78% (530 of 11095). Hispanics were of younger age (43.4 vs 48.5) and had lower BP (128.8/77.8 vs 134.5/81.5), but were 2.93 times more likely to be uninsured (2.44-3.51, 95% CI, p Discussion: Our study suggests that Hispanics with chest pain may experience delays in triage and disposition from the ED. Contributing factors may be due to higher prevalence of undocumented status, lack of insurance, language barriers, and a lack of Hispanic providers who promote healthcare equity. Our next steps are to begin a focused educational program for residents to demonstrate that physician driven interventions are an effective way to promote the elimination of racial and ethnic healthcare disparities.

Introduction: Non-adherence to guideline directed medical therapies (GDMT) is responsible for significant health care costs, morbidity, and mortality in heart failure (HF) patients. Assessing and improving medication adherence (MA) is challenging in this patient population given its multifactorial nature. We aimed to evaluate trainee assessment of MA in HF patients while identifying potential barriers to addressing MA during patient encounters. Methods: This was a single-institution study performed at a large safety net hospital in Atlanta. An anonymous questionnaire was used to assess MA strategies of interns, residents, and medical students for HF patients. This data was compiled and analyzed to identify the most commonly perceived barriers to medication non-adherence. Results: 100 surveys were returned. 99% (99/100) noted that addressing MA is important in HF patients. However, only 83% (83/100) reported that they discussed the specific reasons for non-adherence with their HF patients, with 9%, 12%, and 78% addressing MA in the outpatient, inpatient, and both settings, respectively; the lack of time was reported as the most common contributor in all settings. The most common reasons reported by trainees for patient non-adherence include misunderstanding of their regimen (71%), cost (62%), and polypharmacy (57%). Although, 40% (40/100) of survey responders believed that ≥50% of their HF patients were nonadherent, strikingly, only 12% (12/100) discussed these MA barriers at all HF patient visits. Conclusion: Improving outcomes in HF patients is multifactorial. Medicine teaching teams can play a crucial role in this process by recognizing and addressing the specific barriers to MA in HF patients while promoting GDMT adherence. Our study demonstrates that although trainees recognize the importance of MA, the unique patient characteristics that contribute to non-adherence are under appreciated. Our long-term goal is to not only identify these barriers, but to implement educational interventions, then re-assess trainee comfort level with discussing MA, to demonstrate that trainee driven interventions can improve MA in HF patients while simultaneously reducing HF related re-admissions and hospital costs.

BACKGROUND: An estimated two-thirds of the world's 2.7 million newborn deaths could be prevented with quality care at birth and during the postnatal period. Basic Newborn Care (BNC) is part of the solution and includes hygienic birth and newborn care practices including cord care, thermal care, and early and exclusive breastfeeding. Timely provision of resuscitation if needed is also critical to newborn survival. This paper describes health system barriers to BNC and neonatal resuscitation and proposes solutions to scale up evidence-based strategies. METHODS: The maternal and newborn bottleneck analysis tool was applied by 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops engaged technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks" that hinder the scale up of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for BNC and neonatal resuscitation. RESULTS: Eleven of the 12 countries provided grading data. Overall, bottlenecks were graded more severely for resuscitation. The most severely graded bottlenecks for BNC were health workforce (8 of 11 countries), health financing (9 out of 11) and service delivery (7 out of 9); and for neonatal resuscitation, workforce (9 out of 10), essential commodities (9 out of 10) and service delivery (8 out of 10). Country teams from Africa graded bottlenecks overall more severely. Improving workforce performance, availability of essential commodities, and well-integrated health service delivery were the key solutions proposed. CONCLUSIONS: BNC was perceived to have the least health system challenges among the seven maternal and newborn intervention packages assessed. Although neonatal resuscitation bottlenecks were graded more severe than for BNC, similarities particularly in the workforce and service delivery building blocks highlight the inextricable link between the two interventions and the need to equip birth attendants with requisite skills and commodities to assess and care for every newborn. Solutions highlighted by country teams include ensuring more investment to improve workforce performance and distribution, especially numbers of skilled birth attendants, incentives for placement in challenging settings, and skills-based training particularly for neonatal resuscitation.

BACKGROUND: The Every Newborn Action Plan (ENAP) and Ending Preventable Maternal Mortality targets cannot be achieved without high quality, equitable coverage of interventions at and around the time of birth. This paper provides an overview of the methodology and findings of a nine paper series of in-depth analyses which focus on the specific challenges to scaling up high-impact interventions and improving quality of care for mothers and newborns around the time of birth, including babies born small and sick. METHODS: The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the ENAP process. Country workshops engaged technical experts to complete a tool designed to synthesise "bottlenecks" hindering the scale up of maternal-newborn intervention packages across seven health system building blocks. We used quantitative and qualitative methods and literature review to analyse the data and present priority actions relevant to different health system building blocks for skilled birth attendance, emergency obstetric care, antenatal corticosteroids (ACS), basic newborn care, kangaroo mother care (KMC), treatment of neonatal infections and inpatient care of small and sick newborns. RESULTS: The 12 countries included in our analysis account for the majority of global maternal (48%) and newborn (58%) deaths and stillbirths (57%). Our findings confirm previously published results that the interventions with the most perceived bottlenecks are facility-based where rapid emergency care is needed, notably inpatient care of small and sick newborns, ACS, treatment of neonatal infections and KMC. Health systems building blocks with the highest rated bottlenecks varied for different interventions. Attention needs to be paid to the context specific bottlenecks for each intervention to scale up quality care. Crosscutting findings on health information gaps inform two final papers on a roadmap for improvement of coverage data for newborns and indicate the need for leadership for effective audit systems. CONCLUSIONS: Achieving the Sustainable Development Goal targets for ending preventable mortality and provision of universal health coverage will require large-scale approaches to improving quality of care. These analyses inform the development of systematic, targeted approaches to strengthening of health systems, with a focus on overcoming specific bottlenecks for the highest impact interventions.

BACKGROUND: Around one-third of the world's 2.8 million neonatal deaths are caused by infections. Most of these deaths are preventable, but occur due to delays in care-seeking, and access to effective antibiotic treatment with supportive care. Understanding variation in health system bottlenecks to scale-up of case management of neonatal infections and identifying solutions is essential to reduce mortality, and also morbidity. METHODS: A standardised bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the development of the Every Newborn Action Plan. Country workshops involved technical experts to complete a survey tool, to grade health system "bottlenecks" hindering scale up of maternal-newborn intervention packages. Quantitative and qualitative methods were used to analyse the data, combined with literature review, to present priority bottlenecks and synthesise actions to improve case management of newborn infections. RESULTS: For neonatal infections, the health system building blocks most frequently graded as major or significant bottlenecks, irrespective of mortality context and geographical region, were health workforce (11 out of 12 countries), and community ownership and partnership (11 out of 12 countries). Lack of data to inform decision making, and limited funding to increase access to quality neonatal care were also major challenges. CONCLUSIONS: Rapid recognition of possible serious bacterial infection and access to care is essential. Inpatient hospital care remains the first line of treatment for neonatal infections. In situations where referral is not possible, the use of simplified antibiotic regimens for outpatient management for non-critically ill young infants has recently been reported in large clinical trials; WHO is developing a guideline to treat this group of young infants. Improving quality of care through more investment in the health workforce at all levels of care is critical, in addition to ensuring development and dissemination of national guidelines. Improved information systems are needed to track coverage and adequately manage drug supply logistics for improved health outcomes. It is important to increase community ownership and partnership, for example through involvement of community groups.