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Peahl AF, Low LK, Langen ES, Moniz MH, Aaron B, Hu HM, Waljee J, Townsel C. Drivers of variation in postpartum opioid prescribing across hospitals participating in a statewide maternity care quality collaborative. Birth 2023. [PMID: 38158784 DOI: 10.1111/birt.12809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 10/06/2023] [Accepted: 12/04/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND We describe variation in postpartum opioid prescribing across a statewide quality collaborative and assess the proportion due to practitioner and hospital characteristics. METHODS We assessed postpartum prescribing data from nulliparous, term, singleton, vertex births between January 2020 and June 2021 included in the clinical registry of a statewide obstetric quality collaborative funded by Blue Cross Blue Shield of Michigan. Data were summarized using descriptive statistics. Mixed effect logistic regression and linear models adjusted for patient characteristics and assessed practitioner- and hospital-level predictors of receiving a postpartum opioid prescription and prescription size. Relative contributions of practitioner and hospital characteristics were assessed using the intraclass correlation coefficient. RESULTS Of 40,589 patients birthing at 68 hospitals, 3.0% (872/29,412) received an opioid prescription after vaginal birth and 87.8% (9812/11,177) received one after cesarean birth, with high variation across hospitals. In adjusted models, the strongest patient-level predictors of receiving a prescription were cesarean birth (aOR 899.1, 95% CI 752.8-1066.7) and third-/fourth-degree perineal laceration (aOR 25.7, 95% CI 17.4-37.9). Receiving care from a certified nurse-midwife (aOR 0.63, 95% CI 0.48-0.82) or family medicine physician (aOR 0.60, 95%CI 0.39-0.91) was associated with lower prescribing rates. Hospital-level predictors included receiving care at hospitals with <500 annual births (aOR 4.07, 95% CI 1.61-15.0). A positive safety culture was associated with lower prescribing rates (aOR 0.37, 95% CI 0.15-0.88). Much of the variation in postpartum prescribing was attributable to practitioners and hospitals (prescription receipt: practitioners 25.1%, hospitals 12.1%; prescription size: practitioners 5.4%, hospitals: 52.2%). DISCUSSION Variation in postpartum opioid prescribing after birth is high and driven largely by practitioner- and hospital-level factors. Opioid stewardship efforts targeted at both the practitioner and hospital level may be effective for reducing opioid prescribing harms.
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Affiliation(s)
- Alex F Peahl
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Lisa Kane Low
- School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
| | - Elizabeth S Langen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Michelle H Moniz
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Bryan Aaron
- Medical School, University of Michigan, Ann Arbor, Michigan, USA
| | - Hsou Mei Hu
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer Waljee
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Courtney Townsel
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
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Peahl AF, Morgan DM, Langen ES, Low LK, Brummett CM, Lai YL, Hu HM, Bauer M, Waljee J. Variation in Opioid Prescribing After Vaginal and Cesarean Birth: A Statewide Analysis. Womens Health Issues 2023; 33:182-90. [PMID: 36151029 DOI: 10.1016/j.whi.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 08/16/2022] [Accepted: 08/18/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Our aim was to evaluate variation in opioid prescribing rates and prescription size following childbirth across providers and hospitals. METHODS This retrospective cohort study analyzed claims data from a single-payer Preferred Provider Organization from June 2014 to May 2019 in 84 hospitals in a statewide quality collaborative. All patients aged 12-55 years, undergoing childbirth, with continuous enrollment in pregnancy were included. The primary outcome was the predicted rate of postpartum opioid fills from 7 days before birth to 3 days after discharge. Secondary outcomes included postpartum opioid prescription size in oral morphine equivalents, a standardized measure that includes the number of pills prescribed times the strength of the medication. Multilevel regression models accounted for clustering. We calculated attributable variation in opioid fills using the intraclass correlation coefficient. RESULTS Of 41,427 births, 15,459 patients (37.2%) filled a postpartum opioid prescription (vaginal, 4,624/27,536 [16.8%]; cesarean, 10,835/13,891 [78.0%]). The median postpartum prescription size was 150 oral morphine equivalents (interquartile range [IQR], 30) (vaginal, 135; [IQR, 45]; cesarean, 150 [IQR, 75]). In adjusted models, the rates of opioid prescribing after vaginal birth differed from cesarean birth (vaginal median, 12.1% [range, 1.1%-60.0%]; cesarean median, 80.4% [range, 43.6%-90.2%]). More variation in postpartum opioid fills was attributable to providers and hospitals for vaginal (provider, 29%; hospital, 24%) than cesarean birth (provider, 8%; hospital, 6%). Variation in prescription size was driven by providers for vaginal birth (provider, 27%; hospital, 6%) and providers and hospitals for cesarean birth (provider, 29%; hospital, 21%). CONCLUSIONS Across a statewide quality collaborative, variation in postpartum opioid prescribing is attributable to providers and hospitals. Future efforts at the provider and hospital levels are needed to implement best practices for postpartum opioid prescribing.
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Castaneda PR, Bethel E, Valora-Tapia H, Stuart Wolf J, Malaeb BS, Blair Y, Ambani SN. The Utility of Radiologic and Symptomatic Surveillance After Minimally-invasive Adult Pyeloplasty. Urology 2023; 174:179-184. [PMID: 36706869 DOI: 10.1016/j.urology.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To evaluate different types of failure after minimally-invasive pyeloplasty (MIP) when stratified by initial radiologic study and symptoms after ureteral stent removal. METHODS We retrospectively reviewed adults who underwent MIP (1996-2019) at a single academic center. Patients with at least 11 months of follow-up and patients who had a Mag3 scan as their initial postoperative imaging were included. Postprocedure, patients were categorized as having normal, equivocal, or obstructed imaging based on their initial radiologic test. Patients who were obstructed were excluded. Primary outcome was procedural failure, defined as the need for a procedure to treat recurrent obstruction. Secondary outcomes were radiologic failure and symptomatic failure. Groups were compared to assess for statistical significance (P <.05). RESULTS Overall, 122 patients met inclusion criteria. On initial postoperative imaging, 108 (89%) patients had no obstruction and 14 (11%) had equivocal findings. The procedural failure rate was 6.5% in the unobstructed group and 28.6% in the equivocal group (P = .023). Seven unobstructed patients (6.5%) and 2 equivocal patients (14.3%) eventually experienced radiologic failure (P = .275). Among patients who had no obstruction on initial imaging and remained asymptomatic, only one (0.9%) required a salvage procedure. CONCLUSION Recurrent obstruction after pyeloplasty varied based on the outcome of the initial radiologic study. These rates can be used to counsel patients and guide physicians' choice of surveillance schedules. The risk of future failure is very low in asymptomatic patients with normal initial imaging. The utility of routine radiologic surveillance in these patients may be limited.
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Affiliation(s)
- Peris R Castaneda
- Department of Urology, Cedars Sinai Medical Center, Los Angeles, CA.
| | - Emma Bethel
- Department of Urology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | | | - J Stuart Wolf
- Dell Medical School, University of Texas at Austin, Austin, TX
| | - Bahaa S Malaeb
- Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Yooni Blair
- Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Sapan N Ambani
- Department of Urology, University of Michigan Health System, Ann Arbor, MI
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Andersen BR, Ammitzbøll I, Hinrich J, Lehmann S, Ringsted CV, Løkkegaard ECL, Tolsgaard MG. Using machine learning to identify quality-of-care predictors for emergency caesarean sections: a retrospective cohort study. BMJ Open 2022; 12:e049046. [PMID: 35256439 PMCID: PMC8905885 DOI: 10.1136/bmjopen-2021-049046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Emergency caesarean sections (ECS) are time-sensitive procedures. Multiple factors may affect team efficiency but their relative importance remains unknown. This study aimed to identify the most important predictors contributing to quality of care during ECS in terms of the arrival-to-delivery interval. DESIGN A retrospective cohort study. ECS were classified by urgency using emergency categories one/two and three (delivery within 30 and 60 min). In total, 92 predictor variables were included in the analysis and grouped as follows: 'Maternal objective', 'Maternal psychological', 'Fetal factors', 'ECS Indication', 'Emergency category', 'Type of anaesthesia', 'Team member qualifications and experience' and 'Procedural'. Data was analysed with a linear regression model using elastic net regularisation and jackknife technique to improve generalisability. The relative influence of the predictors, percentage significant predictor weight (PSPW) was calculated for each predictor to visualise the main determinants of arrival-to-delivery interval. SETTING AND PARTICIPANTS Patient records for mothers undergoing ECS between 2010 and 2017, Nordsjællands Hospital, Capital Region of Denmark. PRIMARY OUTCOME MEASURES Arrival-to-delivery interval during ECS. RESULTS Data was obtained from 2409 patient records for women undergoing ECS. The group of predictors representing 'Team member qualifications and experience' was the most important predictor of arrival-to-delivery interval in all ECS emergency categories (PSPW 25.9% for ECS category one/two; PSPW 35.5% for ECS category three). In ECS category one/two the 'Indication for ECS' was the second most important predictor group (PSPW 24.9%). In ECS category three, the second most important predictor group was 'Maternal objective predictors' (PSPW 24.2%). CONCLUSION This study provides empirical evidence for the importance of team member qualifications and experience relative to other predictors of arrival-to-delivery during ECS. Machine learning provides a promising method for expanding our current knowledge about the relative importance of different factors in predicting outcomes of complex obstetric events.
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Affiliation(s)
- Betina Ristorp Andersen
- Department of Gynecology and Obstetrics, Nordsjællands Hospital & Department of Clinical Medicine, University of Copenhagen, Hillerod, Capital Region, Denmark
| | - Ida Ammitzbøll
- Department of Gynecology and Obstetrics, Nordsjællands Hospital & Department of Clinical Medicine, University of Copenhagen, Hillerod, Capital Region, Denmark
| | - Jesper Hinrich
- Cognitive Systems, Department of Applied Mathematics and Computer Science, Technical University of Denmark, Lyngby, Denmark
| | - Sune Lehmann
- Cognitive Systems, Department of Applied Mathematics and Computer Science, Technical University of Denmark, Lyngby, Denmark
| | | | - Ellen Christine Leth Løkkegaard
- Department of Gynecology and Obstetrics, Nordsjællands Hospital & Department of Clinical Medicine, University of Copenhagen, Hillerod, Capital Region, Denmark
| | - Martin G Tolsgaard
- Copenhagen Academy of Medical Education and Simulation, Rigshospitalet, Kobenhavn, Capital Region, Denmark
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Hsu I, Hsu L, Dorjee S, Hsu CC. Bacterial colonization at caesarean section defects in women of secondary infertility: an observational study. BMC Pregnancy Childbirth 2022; 22:135. [PMID: 35180844 PMCID: PMC8857828 DOI: 10.1186/s12884-022-04471-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 02/07/2022] [Indexed: 12/02/2022] Open
Abstract
Background Delayed childbearing has been noted in a high percentage of women with a previous Caesarean section (CS). Many women with CS scar defects (CSDs) present with clinical symptoms of irregular vaginal bleeding. The present study aimed to investigate bacterial colonies at CSDs in women suffering from secondary infertility. Methods This observational study included 363 women with secondary infertility who visited the Assisted Reproduction Unit between 2008 and 2013. Among them, 172 women with a previous CS and 191 women with no previous CS were approached. The women with a previous CS had their CS operations in the past 1 to 14 years, with a mean of 3.5 years. The presence of CSDs was detected by vaginal ultrasonography. Bacteriology cultures of specimens taken from the uterine niches in those with CSDs were collected during Day 7 to Day 10 of the follicular phase. Specimens were obtained from the endocervical canal for bacterial culture in those without CSDs. The main outcome measure was the detection of the growth of bacterial colonies. Results CSDs were found in 60.4% (96 of 159) of women with a previous CS. In women with a previous CS, bacterial colonies were identified in 89.6% (86 of 96) and 69.8% (44 of 63) of women with and without CSDs, respectively. In women with no previous CS, 49.7% (88 out of 177) of bacterial cultures of endocervical samples showed bacterial colony growth. Gram-positive cocci (P = 0.0017, odds ratio (OR) = 1.576, 95% confidence intervals (CI) -22.5 to − 5.4) and Gram-negative rods (P = 0.0016, OR = 1.74, CI − 20.8 to − 5.0) were the most commonly isolated bacteria and contributed to approximately 90% of all microorganisms found in those with a previous CS. In women with a previous CS, more Gram-negative rods were isolated (P = 0.01, OR = 1.765, CI − 27.2 to − 3.8), especially Pseudomonas species (P = 0.02, OR = 1.97, CI − 16.7 to − 1.0), in those with visible CSDs than in those without CSDs. Conclusions Bacterial colonization at CSDs was found in a high percentage of women with secondary infertility.
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Affiliation(s)
- Isabel Hsu
- Department of Obstetrics & Gynecology, National Taiwan University Hospital, Taipei, Taiwan
| | - Leonard Hsu
- Douglass Hanly Moir Pathology, Sydney, NSW, Australia
| | - Sonam Dorjee
- Taiwan United Birth-Promoting Experts Fertility Clinic, Tainan, Taiwan
| | - Chao-Chin Hsu
- Department of Obstetrics & Gynecology, National Taiwan University Hospital, Taipei, Taiwan. .,Taiwan United Birth-Promoting Experts Fertility Clinic, Tainan, Taiwan. .,Department of Obstetrics & Gynecology, National Cheng Kung University Hospital, Tainan, Taiwan.
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