The impact of fetal surgical procedures on perinatal anxiety and depression

BACKGROUND

Perinatal mental illness presents a significant health burden to both patients and families. Many factors are hypothesized to increase the incidence of perinatal depression and anxiety in the fetal surgical population, including uncertain fetal prognosis and inherent risks of surgery and preterm delivery.

OBJECTIVE

This study aimed to determine the incidence and disease course of postpartum depression and anxiety in the fetal surgery population.

STUDY DESIGN

A retrospective medical record review study was conducted of fetal surgery patients delivering between November 2016 and November 2021 at an academic level IV perinatal healthcare center. Demographics and surgical, obstetrical, and psychiatric diagnoses were abstracted. Standard descriptive analyses were performed.

RESULTS

Eligible patients were identified (N=119). Fetal surgery was performed at a mean gestational age of 22.8 weeks (standard deviation, 4.11). Laser ablation of placental anastomoses (n=51) and in utero myelomeningocele repair (n=22) were the most common procedures. Of 119 patients, 34 (28.6%) were diagnosed with preexisting depression or anxiety, with 19 (55.9%) and 17 (50.0%) on baseline medication for depression or anxiety, respectively, before surgery. Of 85 patients, 23 (27.1%) without a history of anxiety or depression had new identification of one or both after delivery. Of note, 2 patients experienced suicidal ideation after delivery. Of the 119 patients, 8 (6.7%) and 12 (10.1%) initiated a new psychiatric medication during or after pregnancy, respectively, and 19 (16.0%) received a therapy referral. Among patients with baseline anxiety or depression, 20 of 34 patients (58.8%) experienced an exacerbation after delivery, 9 of 34 patients (26.5%) were referred for therapy, 9 of 34 patients (26.5%) were changing dose or medication for anxiety, and 11 of 34 patients (32.4%) were changing dose or medication for depression. Of the 119 patients, 24 (20.2%) experienced new or worsening depression or anxiety after the standard 6-week postpartum visit.

CONCLUSION

Among patients undergoing fetal surgery, a high incidence of postpartum depression and anxiety was identified, with most patients with prepregnancy anxiety or depression experiencing exacerbation after delivery. The timeframe to clinical presentation with depression or anxiety symptoms may be delayed beyond the traditional 6-week postpartum period and into the first postpartum year. This observation could be attributed to de novo postpartum exacerbation or a lack of standardized treatment approaches earlier in the disease course or antepartum period. Understanding effective longitudinal supportive interventions is an essential next step.

Use of Obstetric and Gynecologic Hospitalists Is Associated With Decreased Severe Maternal Morbidity in the United States

OBJECTIVES

This study aimed to evaluate the prevalence of obstetric and gynecologic (Ob/Gyn) hospitalists and determine if an association exists between the presence of Ob/Gyn hospitalists and severe maternal morbidity (SMM).

METHODS

This observational study included data from hospitals listed in the USA TODAY 's 2019 article titled, "Deadly deliveries: Childbirth complication rates at maternity hospitals." Telephone and email surveys of staff in these hospitals identified the presence or absence of continuous providers in the hospital 24 hours, 7 days a week (24/7 coverage) and the types of providers who are employed, then compared these responses with the SMM cited by USA TODAY .

RESULTS

Eight hundred ten hospitals were contacted, with participation from 614 labor and delivery units for a response rate of 75.8%. Fifty-seven percent of units were staffed with 24/7 coverage, with 46% of hospitals' coverage primarily provided by an Ob/Gyn hospitalist and 54% primarily by a nonhospitalist OB/Gyn provider. The SMM and presence of 24/7 coverage increased with the level of neonatal care and delivery volume. Of hospitals with 24/7 coverage, those that primarily used Ob/Gyn hospitalists had a lower SMM for all mothers (1.7 versus 2.0, P = 0.014) and for low-income mothers (1.9 versus 2.30, P = 0.007) than those who primarily used nonhospitalist OB/Gyn providers.

CONCLUSIONS

Severe maternal morbidity increases with delivery volume, level of neonatal care, and 24/7 coverage. Of hospitals with 24/7 coverage, units that staff with Ob/Gyn hospitalists have lower levels of SMM than those that use nonhospitalist Ob/Gyn providers.

Focal-occult placenta accreta: A clandestine source of maternal morbidity

INTRODUCTION

Focal-occult placenta accreta spectrum (PAS) is known to lead to adverse obstetric morbidity outcomes, however direct comparisons with previa-associated PAS morbidity are lacking.

OBJECTIVE

We sought to compare baseline characteristics, surgical and obstetric morbidity, and subsequent pregnancy outcomes of patients with focal occult PAS compared to patients with previa associated accreta.

STUDY DESIGN

A retrospective review was conducted of all pathologically confirmed PAS from 2018-2022 at a tertiary care center. Baseline characteristics, surgical, obstetric, and subsequent pregnancy outcomes were recorded. Focal-occult PAS was compared with previa-associated PAS across a range of morbidity characteristics including hemorrhagic factors, interventions, post-delivery re-operations, infections, and ICU admission. Statistical comparison was performed using Kruskal-Wallis/Chi-Square tests, and p <0.05 was considered significant.

RESULTS

74 cases were identified; 43 focal-occult and 31 previa-associated PAS. 25.6% focal-occult vs 100% previa-associated PAS underwent hysterectomy. 1 focal-occult and 29 previa-associated PAS were diagnosed antenatally. Patients with focal-occult PAS did not differ from previa-associated PAS in mean maternal age (33.0 vs 33.1 years), BMI (Body Mass Index), or presence of previous dilation & curettage procedure (16.3% vs 25.8%) when compared to previa-associated PAS. Focal-occult PAS patients were significantly more likely to have a lower mean parity (1.5 vs 3.6 gestations), higher gestational age at delivery (36.1 vs 33.9 weeks), were less likely to have had a previous cesarean (12/43, 27.9% vs 30/31, 96.8%). Additionally, focal-occult PAS patients had fewer number of previous cesareans (mean 0.5 vs 2.3), were more likely to have had in-vitro fertilization (IVF) (20.9% vs 3.2%) and less likely to have anterior placentation. When contrasting clinical outcomes of focal-occult to previa-associated PAS, postpartum hemorrhage rates (71.0% vs 67.4%), mean quantitative blood loss 2099 mL (range 500-9516mL) vs 2119 mL (range 350-12,220 mL), mean units red blood cells transfused (1.4 vs 1.7), massive transfusion rate (9.3% vs 3.2%), ICU admission (11.6% vs 6.5%), were not significantly different, with a non-significant trend towards higher morbidity in focal-occult accreta patients. Focal occult accreta had higher incidence of reoperation/return to the OR (30.2 vs 6.5%, p=0.01). When comparing focal-occult to previa-associated PAS, the composite outcomes, including hemorrhagic morbidity (77.4% vs 74.4%), any maternal morbidity (83.9% vs 76.7%) and severe maternal morbidity (64.5% vs 65.1%) were not significantly different between groups. Nine focal-occult PAS patients had a subsequent pregnancy, and three of those had recurrent PAS.

CONCLUSION/IMPLICATIONS

Focal-occult PAS presents with fewer identifiable risk factors than placenta previa-associated PAS but may be associated with IVF pregnancy. Focal-occult PAS was observed to have higher incidence of reoperation when compared to previa-associated PAS, and no other statistically significant differences in morbidity outcomes were observed. The absence of different morbidity outcomes may be attributable to a lack of antenatal detection of focal occult accreta, and merits further investigation.

Shared Decision Making in Cardiac Electrophysiology Procedures and Arrhythmia Management

Shared decision making (SDM) has been advocated to improve patient care, patient decision acceptance, patient-provider communication, patient motivation, adherence, and patient reported outcomes. Documentation of SDM is endorsed in several society guidelines and is a condition of reimbursement for selected cardiovascular and cardiac arrhythmia procedures. However, many clinicians argue that SDM already occurs with clinical encounter discussions or the process of obtaining informed consent and note the additional imposed workload of using and documenting decision aids without validated tools or evidence that they improve clinical outcomes. In reality, SDM is a process and can be done without decision tools, although the process may be variable. Also, SDM advocates counter that the low-risk process of SDM need not be held to the high bar of demonstrating clinical benefit and that increasing the quality of decision making should be sufficient. Our review leverages a multidisciplinary group of experts in cardiology, cardiac electrophysiology, epidemiology, and SDM, as well as a patient advocate. Our goal is to examine and assess SDM methodology, tools, and available evidence on outcomes in patients with heart rhythm disorders to help determine the value of SDM, assess its possible impact on electrophysiological procedures and cardiac arrhythmia management, better inform regulatory requirements, and identify gaps in knowledge and future needs.

Dermatologic Research Potential of the Observational Health Data Sciences and Informatics (OHDSI) Network

BACKGROUND

The Observational Health Data Sciences and Informatics (OHDSI) network enables access to billions of deidentified, standardized health records and built-in analytics software for observational health research, with numerous potential applications to dermatology. While the use of the OHDSI has increased steadily over the past several years, review of the literature reveals few studies utilizing OHDSI in dermatology. To our knowledge, the University of Colorado School of Medicine is unique in its use of OHDSI for dermatology big data research.

SUMMARY

A PubMed search was conducted in August 2020, followed by a literature review, with 24 of the 72 screened articles selected for inclusion. In this review, we discuss the ways OHDSI has been used to compile and analyze data, improve prediction and estimation capabilities, and inform treatment guidelines across specialties. We also discuss the potential for OHDSI in dermatology - specifically, ways that it could reveal adherence to available guidelines, establish standardized protocols, and ensure health equity. Key Messages: OHDSI has demonstrated broad utility in medicine. Adoption of OHDSI by the field of dermatology would facilitate big data research, allow for examination of current prescribing and treatment patterns without clear best practice guidelines, improve the dermatologic knowledge base and, by extension, improve patient outcomes.

Shared medical appointments: Translating research into practice for patients treated with ablation therapy for atrial fibrillation

Background

People with atrial fibrillation (AF) have lower reported quality of life and increased risk of heart attack, death, and stroke. Lifestyle modifications can improve arrhythmia-free survival/symptom severity. Shared medical appointments (SMAs) have been effective at targeting lifestyle change in other chronic diseases and may be beneficial for patients with AF.

Objective

To determine if perceived self-management and satisfaction with provider communication differed between patients who participated in SMAs compared to patients in standard care. Secondary objectives were to examine differences between groups for knowledge about AF, symptom severity, and healthcare utilization.

Methods

We conducted a retrospective analysis of data collected where patients were assigned to either standard care (n = 62) or a SMA (n = 59). Surveys were administered at pre-procedure, 3, and 6 months.

Results

Perceived self-management was not significantly different at baseline (p = 0.95) or 6 months (p = 0.21). Patients in SMAs reported more knowledge gain at baseline (p = 0.01), and higher goal setting at 6 months (p = 0.0045). Symptom severity for both groups followed similar trends.

Conclusion

Patients with AF who participated in SMAs had similar perceived self-management, patient satisfaction with provider communication, symptom severity, and healthcare utilization with their counterparts, but had a statistically significant improvement in knowledge about their disease.

Validation of prognostic indices for short term mortality in an incident dialysis population of older adults >75

Rational and objective

Prognosis provides critical knowledge for shared decision making between patients and clinicians. While several prognostic indices for mortality in dialysis patients have been developed, their performance among elderly patients initiating dialysis is unknown, despite great need for reliable prognostication in that context. To assess the performance of 6 previously validated prognostic indices to predict 3 and/or 6 months mortality in a cohort of elderly incident dialysis patients.

Study design

Validation study of prognostic indices using retrospective cohort data. Indices were compared using the concordance (“c”)-statistic, i.e. area under the receiver operating characteristic curve (ROC). Calibration, sensitivity, specificity, positive and negative predictive values were also calculated.

Setting & participants

Incident elderly (age ≥75 years; n = 349) dialysis patients at a tertiary referral center.

Established predictors

Variables for six validated prognostic indices for short term (3 and 6 month) mortality prediction (Foley, NCI, REIN, updated REIN, Thamer, and Wick) were extracted from the electronic medical record. The indices were individually applied as per each index specifications to predict 3- and/or 6-month mortality.

Results

In our cohort of 349 patients, mean age was 81.5±4.4 years, 66% were male, and median survival was 351 days. The c-statistic for the risk prediction indices ranged from 0.57 to 0.73. Wick ROC 0.73 (0.68, 0.78) and Foley 0.67 (0.61, 0.73) indices performed best. The Foley index was weakly calibrated with poor overall model fit (p <0.01) and overestimated mortality risk, while the Wick index was relatively well-calibrated but underestimated mortality risk.

Limitations

Small sample size, use of secondary data, need for imputation, homogeneous population.

Conclusion

Most predictive indices for mortality performed moderately in our incident dialysis population. The Wick and Foley indices were the best performing, but had issues with under and over calibration. More accurate indices for predicting survival in older patients with kidney failure are needed.

Changing conversations in primary care for patients living with chronic conditions: pilot and feasibility study of the ICAN Discussion Aid

PURPOSE

To pilot test the impact of the ICAN Discussion Aid on clinical encounters.

METHODS

A pre-post study involving 11 clinicians and 100 patients was conducted at two primary care clinics within a single health system in the Midwest. The study examined clinicians' perceptions about ICAN feasibility, patients' and clinicians' perceptions about encounter success, videographic differences in encounter topics, and medication adherence 6 months after an ICAN encounter.

RESULTS

39/40 control encounters and 45/60 ICAN encounters yielded usable data. Clinicians reported ICAN use was feasible. In ICAN encounters, patients discussed diet, being active and taking medications more. Clinicians scored themselves poorer regarding visit success than their patients scored them; this effect was more pronounced in ICAN encounters. ICAN did not improve 6-month medication adherence or lengthen visits.

CONCLUSION

This pilot study suggests that using ICAN in primary care is feasible, efficient and capable of modifying conversations. With lessons learned in this pilot, we are conducting a randomised trial of ICAN versus usual care in diverse clinical settings.

TRIAL REGISTRATION NUMBER

NCT02390570.

Conversations About Financial Issues in Routine Oncology Practices: A Multicenter Study

PURPOSE

To describe the frequency, content, dynamics, and patterns of cost conversations in academic medical oncology across tumor types.

PATIENTS AND METHODS

We reviewed 529 audio recordings between May 3, 2012, to September 23, 2014, from a prospective three-site communication study in which patients at any stage of management for any solid tumor malignancy were seen in routine oncology appointments. Recordings were deidentified, transcribed, and flagged for any mention of cost. We coded encounters and used qualitative thematic analysis.

RESULTS

Financial issues were discussed in 151 (28%) of 529 recordings. Conversations lasted shorter than 2 minutes on average. Patients/caregivers raised a majority of discussions (106 of 151), and 40% of cost concerns raised by patients/caregivers were not verbally acknowledged by clinicians. Social service referrals were made only six times. Themes from content analysis were related to insurance eligibility/process, work insecurity, cost of drugs, cost used as tool to influence medical decision making, health care-specific costs, and basic needs. Financial concerns influenced oncology work processes via test or medication coverage denials, creating paperwork for clinicians, potentially influencing patient involvement in trials, and leading to medication self-rationing or similar behaviors. Typically, financial concerns were associated with negative emotions.

CONCLUSION

Financial issues were raised in approximately one in four academic oncology visits. These brief conversations were usually initiated by patients/caregivers, went frequently unaddressed by clinicians, and seemed to influence medical decision making and work processes and contribute to distress. Themes identified shed light on the kinds of gaps that must be addressed to help patients with cancer cope with the rising cost of care.

Patient capacity for self-care in the medical record of patients with chronic conditions: a mixed-methods retrospective study

BACKGROUND

Patients with chronic conditions must mobilize capacity to access and use healthcare and enact self-care. In order for clinicians to create feasible treatment plans with patients, they must appreciate the limits and possibilities of patient capacity. This study seeks to characterize the amount, nature, and comprehensiveness of the information about patient capacity documented in the medical record.

METHODS

In this mixed-methods study, we extracted notes about 6 capacity domains from the medical records of 100 patients receiving care from 15 primary care clinicians at a single practice. Using a generalized linear model to account for repeated measures across multiple encounters, we calculated the rate of documented domains per encounter per patient adjusted for appointment type and number. Following quantitative analyses, we purposefully selected records to conduct inductive content analysis.

RESULTS

After adjusting for number of appointments and appointment type, primary care notes contained the most mentions of capacity. Physical capacity was most noted, followed by personal, emotional, social, financial, and environmental. Qualitatively, we found three documentation patterns: patients with broad capacity notes, patients with predominantly physical domain capacity notes, and patients with capacity notes mostly in domains other than physical. Records contained almost no mention of patients' environmental or financial capacity, or of how they coped with capacity limitations. Rarely, did notes ever mention how well patients interacted with their social network or what support they provided to the patient in managing their health.

CONCLUSION

Medical records scarcely document patient capacity. This may impair the ability of clinicians to determine how patients can handle patient work, at what point patient capacity might become overwhelmed leading to poor adherence and health outcomes, and how best to craft feasible treatment programs that patients can implement with high fidelity.

The impact of obesity on perceived patient-centred communication

OBJECTIVE

Patient-provider communication has been found to be less patient centred, on average, with patients who are members of stigmatized or minority groups. Obesity is a stigmatized condition, and thus, people with obesity may experience less patient-centred communication (PCC). The objective of this study was to assess the association between patient body mass index (BMI) and self-reported quality of PCC experienced over a 12-month period and whether that relationship differed for men and women.

METHODS

Data collected for the National Cancer Institute's Health Information National Trends Survey were analysed. Respondents who reported a BMI ≥ 18.5 kg/m2 and indicated having seen a healthcare provider outside of an emergency room in the last 12 months were included. PCC was measured using a validated six-item scale. Multivariate logistic regression was used to model the odds of reporting PCC greater than the sample median.

RESULTS

Compared with people with normal weight BMIs, no associations were found between overweight (odds ratio [OR] = 0.84, p = 0.17), class I & II obesity (OR = 0.94, p = 0.68) or class III obesity (OR = 0.86, p = 0.47) and PCC. There was a significant interaction (p = 0.015) such that for men, but not women, higher BMI was associated with less PCC.

CONCLUSION

Unlike evidence that women experience more weight stigma, in the healthcare domain, men may be at elevated risk of experiencing communication influenced by weight stigma.

Integrating community-based health promotion programs and primary care: a mixed methods analysis of feasibility

BACKGROUND

Implementation of evidence-based programs (EBPs) for disease self-management and prevention is a policy priority. It is challenging to implement EBPs offered in community settings and to integrate them with healthcare. We sought to understand, categorize, and richly describe key challenges and opportunities related to integrating EBPs into routine primary care practice in the United States.

METHODS

As part of a parent, participatory action research project, we conducted a mixed methods evaluation guided by the PRECEDE implementation planning model in an 11-county region of Southeast Minnesota. Our community-partnered research team interviewed and surveyed 15 and 190 primary care clinicians and 15 and 88 non-clinician stakeholders, respectively. We coded interviews according to pre-defined PRECEDE factors and by participant type and searched for emerging themes. We then categorized survey items-before looking at participant responses-according to their ability to generate further evidence supporting the PRECEDE factors and emerging themes. We statistically summarized data within and across responder groups. When consistent, we merged these with qualitative insight.

RESULTS

The themes we found, "Two Systems, Two Worlds," "Not My Job," and "Seeing is Believing," highlighted the disparate nature of prescribed activities that different stakeholders do to contribute to health. For instance, primary care clinicians felt pressured to focus on activities of diagnosis and treatment and did not imagine ways in which EBPs could contribute to either. Quantitative analyses supported aspects of all three themes, highlighting clinicians' limited trust in community-placed activities, and the need for tailored education and system and policy-level changes to support their integration with primary care.

CONCLUSIONS

Primary care and community-based programs exist in disconnected worlds. Without urgent and intentional efforts to bridge well-care and sick-care, interventions that support people's efforts to be and stay well in their communities will remain outside of-if not at odds with-healthcare.

How do patients describe their disabilities? A coding system for categorizing patients' descriptions

BACKGROUND

To provide care that meets the values and preferences of patients with disabilities, health care providers need to understand patients' perceptions and understanding of their disability. No studies have explored patients' definitions of disability within the healthcare setting.

OBJECTIVE

The aim of the study was to understand how patients' define their disability in the healthcare setting and to develop a coding system for categorizing how they describe their disability.

METHODS

In 2000 all new outpatients at Mayo Clinic, Rochester, MN completed a form that inquired if they had a disability and if so, to write in the disability. The research team categorized the responses by disability type (e.g.: visual or physical) and how the patient described his disability or "disability narrative" (e.g.: diagnosis or activity).

RESULTS

Within 128,636 patients, 14,908 reported a disability. For adults, lower limb (26%) and chronic conditions (24%) were the most frequent disability type and activity limitations (56%) were the most frequent disability narrative category. For pediatric patients, developmental disabilities (43%) were the most frequently reported disability type and diagnoses (83%) were the most frequent disability narrative category. Patients used different disability narrative categories to describe different disability types. For example, most adults reporting a mental health listed a diagnosis (97%), compared to only 13% of those with lower limb disabilities.

CONCLUSIONS

Patients had diverse descriptions of their disabilities. In order for providers and healthcare organizations to provide high-quality care, they should engage patients in developing a consistent, patient-centered language around disability.

PCI Choice Decision Aid for Stable Coronary Artery Disease

Background—

Percutaneous coronary intervention (PCI) for stable coronary artery disease does not reduce the risk of death and myocardial infarction compared with optimal medical therapy (OMT), but many patients think otherwise. PCI Choice, a decision aid (DA), was designed for use during the clinical visit and includes information on quality of life and mortality outcomes for PCI with OMT versus OMT alone for stable coronary artery disease.

Methods and Results—

We conducted a randomized trial to assess the impact of the PCI Choice DA compared with usual care when there is a choice between PCI and optimal medical therapy. Primary outcomes were patient knowledge and decisional conflict, and the secondary outcome was an objective measure of shared decision making. A total of 124 patients were eligible for final analysis. Knowledge was higher among patients receiving the DA compared with usual care (60% DA; 40% usual care; P =0.034), and patients felt more informed ( P =0.043). Other measures of decisional quality were not improved, and engagement of the patient by the clinician in shared decision making did not change with use of the DA. There was evidence that clinicians used the DA as an educational tool.

Conclusions—

The PCI Choice DA improved patient knowledge but did not significantly impact decisional quality. Further work is needed to effectively address clinician knowledge gaps in shared decision-making skills, even in the context of carefully designed DAs.

Clinical Trial Registration—

URL: https://www.clinicaltrials.gov/ . Unique identifier: NCT01771536.

Communication predictors and consequences of Complementary and Alternative Medicine (CAM) discussions in oncology visits

OBJECTIVE

Cancer patients use complementary and alternative medicine (CAM), but do not routinely talk about it with their clinicians. This study describes CAM discussions in oncology visits, the communication patterns that facilitate these discussions and their association with visit satisfaction.

METHODS

327 patients (58% female; average age 61) and 37 clinicians were recorded during an oncology visit and completed post-visit questionnaires. All CAM discussions were tagged and the Roter Interaction Analysis System (RIAS) was used to code visit dialogue.

RESULTS

CAM was discussed in 36 of 327 visits; discussions were brief (

CONCLUSIONS

CAM discussions do not occur at random; they take place in visits characterized by patient-centered communication and are associated with higher visit satisfaction.

PRACTICE IMPLICATIONS

CAM discussions are perceived positively by both patients and clinicians and are facilitated by patient-centered visit communication.

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Key Words

• Clinician satisfaction
• Complimentary and Alternative Medicine (CAM)
• Patient satisfaction
• Patient-physician communication
• Roter Interaction Analysis System (RIAS)

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MESH Headings

• Adult
• Aged
• Attitude of Health Personnel
• Communication
• Complementary Therapies
• Female
• Health Care Surveys
• Humans
• Male
• Medical Oncology
• Middle Aged
• Neoplasms/therapy
• Office Visits
• Oncologists/psychology
• Patient Satisfaction
• Physician-Patient Relations
• Surveys and Questionnaires
• Tape Recording

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Grants

• R01 AT006515 NCCIH NIH HHS
• UL1 TR000135 NCATS NIH HHS

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Affiliation(s)

Debra L Roter Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
Kathleen J Yost Mayo Clinic, Rochester, MN, USA
Thomas O'Byrne Mayo Clinic, Rochester, MN, USA
Megan Branda Mayo Clinic, Rochester, MN, USA
Aaron Leppin Mayo Clinic, Rochester, MN, USA
Brittany Kimball Mayo Clinic, Rochester, MN, USA
Cara Fernandez Mayo Clinic, Rochester, MN, USA
Aminah Jatoi Mayo Clinic, Rochester, MN, USA
Ashok Kumbamu Mayo Clinic, Rochester, MN, USA
Victor Montori Mayo Clinic, Rochester, MN, USA
Barbara Koenig University of California San Francisco, San Francisco, CA, USA
Gail Geller Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
Susan Larson Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
Jon Tilburt Mayo Clinic, Rochester, MN, USA.

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Implementation of a new prenatal care model to reduce office visits and increase connectivity and continuity of care: protocol for a mixed-methods study

Background

Most low-risk pregnant women receive the standard model of prenatal care with frequent office visits. Research suggests that a reduced schedule of visits among low-risk women could be implemented without increasing adverse maternal or fetal outcomes, but patient satisfaction with these models varies. We aim to determine the effectiveness and feasibility of a new prenatal care model (OB Nest) that enhances a reduced visit model by adding virtual connections that improve continuity of care and patient-directed access to care.

Methods and design

This mixed-methods study uses a hybrid effectiveness-implementation design in a single center randomized controlled trial (RCT). Embedding process evaluation in an experimental design like an RCT allows researchers to answer both “Did it work?” and “How or why did it work (or not work)?” when studying complex interventions, as well as providing knowledge for translation into practice after the study. The RE-AIM framework was used to ensure attention to evaluating program components in terms of sustainable adoption and implementation.

Low-risk patients recruited from the Obstetrics Division at Mayo Clinic (Rochester, MN) will be randomized to OB Nest or usual care. OB Nest patients will be assigned to a dedicated nursing team, scheduled for 8 pre-planned office visits with a physician or midwife and 6 telephone or online nurse visits (compared to 12 pre-planned physician or midwife office visits in the usual care group), and provided fetal heart rate and blood pressure home monitoring equipment and information on joining an online care community.

Quantitative methods will include patient surveys and medical record abstraction. The primary quantitative outcome is patient-reported satisfaction. Other outcomes include fidelity to items on the American Congress of Obstetricians and Gynecologists standards of care list, health care utilization (e.g. numbers of antenatal office visits), and maternal and fetal outcomes (e.g. gestational age at delivery), as well as validated patient-reported measures of pregnancy-related stress and perceived quality of care. Quantitative analysis will be performed according to the intention to treat principle. Qualitative methods will include interviews and focus groups with providers, staff, and patients, and will explore satisfaction, intervention adoption, and implementation feasibility. We will use methods of qualitative thematic analysis at three stages. Mixed methods analysis will involve the use of qualitative data to lend insight to quantitative findings.

Discussion

This study will make important contributions to the literature on reduced visit models by evaluating a novel prenatal care model with components to increase patient connectedness (even with fewer pre-scheduled office visits), as demonstrated on a range of patient-important outcomes. The use of a hybrid effectiveness-implementation approach, as well as attention to patient and provider perspectives on program components and implementation, may uncover important information that can inform long-term feasibility and potentially speed future translation.

Trial registration

Trial registration identifier: NCT02082275

Submitted: March 6, 2014

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-015-0762-2) contains supplementary material, which is available to authorized users.

Long-term Outcomes After Stepping Down Asthma Controller Medications: A Claims-Based, Time-to-Event Analysis

BACKGROUND

Long-term outcomes after stepping down asthma medications are not well described.

METHODS

This study was a retrospective time-to-event analysis of individuals diagnosed with asthma who stepped down their asthma controller medications using a US claims database spanning 2000 to 2012. Four-month intervals were established and a step-down event was defined by a ≥ 50% decrease in days-supplied of controller medications from one interval to the next; this definition is inclusive of step-down that occurred without health-care provider guidance or as a consequence of a medication adherence lapse. Asthma stability in the period prior to step-down was defined by not having an asthma exacerbation (inpatient visit, ED visit, or dispensing of a systemic corticosteroid linked to an asthma visit) and having fewer than two rescue inhaler claims in a 4-month period. The primary outcome in the period following step-down was time-to-first asthma exacerbation.

RESULTS

Thirty-two percent of the 26,292 included individuals had an asthma exacerbation in the 24-month period following step-down of asthma controller medication, though only 7% had an ED visit or hospitalization for asthma. The length of asthma stability prior to stepping down asthma medication was strongly associated with the risk of an asthma exacerbation in the subsequent 24-month period: < 4 months' stability, 44%; 4 to 7 months, 34%; 8 to 11 months, 30%; and ≥ 12 months, 21% (P < .001).

CONCLUSIONS

In a large, claims-based, real-world study setting, 32% of individuals have an asthma exacerbation in the 2 years following a step-down event.

Effect of Laparoscopic-Assisted Resection vs Open Resection of Stage II or III Rectal Cancer on Pathologic Outcomes: The ACOSOG Z6051 Randomized Clinical Trial

IMPORTANCE

Evidence about the efficacy of laparoscopic resection of rectal cancer is incomplete, particularly for patients with more advanced-stage disease.

OBJECTIVE

To determine whether laparoscopic resection is noninferior to open resection, as determined by gross pathologic and histologic evaluation of the resected proctectomy specimen.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter, balanced, noninferiority, randomized trial enrolled patients between October 2008 and September 2013. The trial was conducted by credentialed surgeons from 35 institutions in the United States and Canada. A total of 486 patients with clinical stage II or III rectal cancer within 12 cm of the anal verge were randomized after completion of neoadjuvant therapy to laparoscopic or open resection.

INTERVENTIONS

Standard laparoscopic and open approaches were performed by the credentialed surgeons.

MAIN OUTCOMES AND MEASURES

The primary outcome assessing efficacy was a composite of circumferential radial margin greater than 1 mm, distal margin without tumor, and completeness of total mesorectal excision. A 6% noninferiority margin was chosen according to clinical relevance estimation.

RESULTS

Two hundred forty patients with laparoscopic resection and 222 with open resection were evaluable for analysis of the 486 enrolled. Successful resection occurred in 81.7% of laparoscopic resection cases (95% CI, 76.8%-86.6%) and 86.9% of open resection cases (95% CI, 82.5%-91.4%) and did not support noninferiority (difference, -5.3%; 1-sided 95% CI, -10.8% to ∞; P for noninferiority = .41). Patients underwent low anterior resection (76.7%) or abdominoperineal resection (23.3%). Conversion to open resection occurred in 11.3% of patients. Operative time was significantly longer for laparoscopic resection (mean, 266.2 vs 220.6 minutes; mean difference, 45.5 minutes; 95% CI, 27.7-63.4; P < .001). Length of stay (7.3 vs 7.0 days; mean difference, 0.3 days; 95% CI, -0.6 to 1.1), readmission within 30 days (3.3% vs 4.1%; difference, -0.7%; 95% CI, -4.2% to 2.7%), and severe complications (22.5% vs 22.1%; difference, 0.4%; 95% CI, -4.2% to 2.7%) did not differ significantly. Quality of the total mesorectal excision specimen in 462 operated and analyzed surgeries was complete (77%) and nearly complete (16.5%) in 93.5% of the cases. Negative circumferential radial margin was observed in 90% of the overall group (87.9% laparoscopic resection and 92.3% open resection; P = .11). Distal margin result was negative in more than 98% of patients irrespective of type of surgery (P = .91).

CONCLUSIONS AND RELEVANCE

Among patients with stage II or III rectal cancer, the use of laparoscopic resection compared with open resection failed to meet the criterion for noninferiority for pathologic outcomes. Pending clinical oncologic outcomes, the findings do not support the use of laparoscopic resection in these patients.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00726622.

Abstract 13: The PCI Choice Decision Aid for Stable Angina: A Randomized Trial

Background: Although percutaneous coronary intervention (PCI) has not been shown to reduce the risk of death and myocardial infarction (MI) for stable coronary artery disease (CAD), many patients believe that PCI is a life-saving procedure. PCI for stable CAD is known to improve patients’ quality of life more rapidly than medications alone. We conducted a randomized trial to assess the impact of a decision aid (DA) compared to usual care (UC) for the treatment of stable CAD when there is a choice between PCI and optimal medical therapy (OMT).

Methods: The PCI Choice trial was a prospective, randomized trial comparing the effects of DA versus UC. The DA was designed with a user-centered approach for an in-visit consultation, involving patients and clinicians throughout the development process. The final DA included information on myocardial infarction (MI), death and quality of life outcomes for PCI with OMT vs. OMT alone in the treatment of stable angina, stratified by angina type. Risks of procedure, bleeding, stent thrombosis, and need for future procedures were also depicted. The primary outcome was patient knowledge, measured by pre- and post-visit surveys. Additional outcomes included decisional conflict, patient satisfaction, preferred decision making style, and treatment decision.

Results: A total of 110 patients were enrolled; mean age was 68.3 years and 26% of patients were women. At baseline, most patients had CCS Class I/II angina and were on a mean of two anti-anginal medications (2.3, SD 1.2). Knowledge increased among patients receiving DA compared to UC (63% vs. 44% p=0.0003). Specific knowledge about the impact of PCI for stable angina on death and MI was higher in both groups compared to prior studies (54% DA, 46% UC, p=0.45; 12% prior). Patient satisfaction was significantly higher in the DA group vs. UC (72% vs 40%, p=0.004). Decisional conflict was greater than in non-procedural DA trials, and was not different between the two arms (p=.43). Following exposure to DA, patients’ preference for sharing decision making tended to change more with DA (55% to 65%) than with UC (56% to 59%). While the proportion of patients choosing PCI over OMT was nearly half in both groups, there were fewer patients that remained undecided with DA (18% vs. 4%; p=0.14 overall difference).

Conclusions: Exposure to a DA for the choice of PCI vs. optimal medical therapy in stable CAD improved patient knowledge and satisfaction and decreased uncertainty, without reducing the rate of PCI. Use of the DA in a larger patient population may further delineate impact on outcomes such as treatment choice, geographic variation and cost.

Effectiveness of the head CT choice decision aid in parents of children with minor head trauma: study protocol for a multicenter randomized trial

Background

Blunt head trauma is a common cause of death and disability in children worldwide. Cranial computed tomography (CT), the reference standard for the diagnosis of traumatic brain injury (TBI), exposes children to ionizing radiation which has been linked to the development of brain tumors, leukemia, and other cancers. We describe the methods used to develop and test the effectiveness of a decision aid to facilitate shared decision-making with parents regarding whether to obtain a head CT scan or to further observe their child at home.

Methods/Design

This is a protocol for a multicenter clinician-level parallel randomized trial to compare an intervention group receiving a decision aid, ‘Head CT Choice’, to a control group receiving usual care. The trial will be conducted at five diverse emergency departments (EDs) in Minnesota and California. Clinicians will be randomized to decision aid or usual care. Parents visiting the ED with children who are less than 18-years-old, have experienced blunt head trauma within 24 hours, and have one or two risk factors for clinically-important TBI (ciTBI) from the Pediatric Emergency Care Applied Research Network head injury clinical prediction rules will be eligible for enrollment. We will measure the effect of Head CT Choice on: (1) parent knowledge regarding their child’s risk of ciTBI, the available diagnostic options, and the risks of radiation exposure associated with a cranial CT scan (primary outcome); (2) parent engagement in the decision-making process; (3) the degree of conflict parents experience related to feeling uninformed; (4) patient and clinician satisfaction with the decision made; (5) the rate of ciTBI at seven days; (6) the proportion of patients in whom a cranial CT scan is obtained; and (7) seven-day healthcare utilization. To capture these outcomes, we will administer parent and clinician surveys immediately after each clinical encounter, obtain video recordings of parent-clinician discussions, administer parent healthcare utilization diaries, analyze hospital billing records, review the electronic medical record, and conduct telephone follow-up.

Discussion

This multicenter trial will robustly assess the effectiveness of a decision aid on patient-centered outcomes, safety, and healthcare utilization in parents of children with minor head trauma in five diverse EDs.

Trial registration

ClinicalTrials.gov registration number: NCT02063087. Registration date February 13, 2014.

Impact of sociodemographic patient characteristics on the efficacy of decision AIDS: a patient-level meta-analysis of 7 randomized trials

BACKGROUND

Decision aids (DAs) increase patient knowledge, reduce decisional conflict, and promote shared decision making (SDM). The extent to which they do so across diverse sociodemographic patient groups is unknown.

METHODS AND RESULTS

We conducted a patient-level meta-analysis of 7 randomized trials of DA versus usual care comprising 771 encounters between patients and clinicians discussing treatment options for chest pain, myocardial infarction, diabetes mellitus, and osteoporosis. Using a random effects model, we examined the impact of sociodemographic patient characteristics (age, sex, education, income, and insurance status) on the outcomes of knowledge transfer, decisional conflict, and patient involvement in SDM. Because of small numbers of people of color in the study population, we were not powered to investigate the role of race. Most patients were aged ≥65 years (61%), white (94%), and women (59%); two thirds had greater than a high school education. Compared with usual care, DA patients gained knowledge, were more likely to know their risk, and had less decisional conflict along with greater involvement in SDM. These gains were largely consistent across sociodemographic patient groups, with DAs demonstrating similar efficacy when used with vulnerable patients such as the elderly and those with less income and less formal education. Differences in efficacy were found only in knowledge of risk in 1 subgroup, with greater efficacy among those with higher education (35% versus 18%; P=0.02).

CONCLUSIONS

In this patient-level meta-analysis of 7 randomized trials, DAs were efficacious across diverse sociodemographic groups as measured by knowledge transfer, decisional conflict, and patient involvement in SDM. To the extent that DAs increase patient knowledge and participation in SDM, they have potential to impact health disparities related to these factors.

Effectiveness of the Chest Pain Choice decision aid in emergency department patients with low-risk chest pain: study protocol for a multicenter randomized trial

Background

Chest pain is the second most common reason patients visit emergency departments (EDs) and often results in very low-risk patients being admitted for prolonged observation and advanced cardiac testing. Shared decision-making, including educating patients regarding their 45-day risk for acute coronary syndrome (ACS) and management options, might safely decrease healthcare utilization.

Methods/Design

This is a protocol for a multicenter practical patient-level randomized trial to compare an intervention group receiving a decision aid, Chest Pain Choice (CPC), to a control group receiving usual care. Adults presenting to five geographically and ethnically diverse EDs who are being considered for admission for observation and advanced cardiac testing will be eligible for enrollment. We will measure the effect of CPC on (1) patient knowledge regarding their 45-day risk for ACS and the available management options (primary outcome); (2) patient engagement in the decision-making process; (3) the degree of conflict patients experience related to feeling uninformed (decisional conflict); (4) patient and clinician satisfaction with the decision made; (5) the rate of major adverse cardiac events at 30 days; (6) the proportion of patients admitted for advanced cardiac testing; and (7) healthcare utilization. To assess these outcomes, we will administer patient and clinician surveys immediately after each clinical encounter, obtain video recordings of the patient-clinician discussion, administer a patient healthcare utilization diary, analyze hospital billing records, review the electronic medical record, and conduct telephone follow-up.

Discussion

This multicenter trial will robustly assess the effectiveness of a decision aid on patient-centered outcomes, safety, and healthcare utilization in low-risk chest pain patients from a variety of geographically and ethnically diverse EDs.

Trial registration

NCT01969240.

Impact of a palliative care consult service

Established hospital palliative care consult services (PCCS) have been associated with reduced costs and length of stay, decreased symptom burden, and increased satisfaction with care. Using a retrospective case-control design, we analyzed administrative data of patients seen by PCCS while hospitalized at the Rochester, Minnesota Mayo Clinic hospitals from 2003 to 2008. The PCCS patients were matched to 3:1. A total of 1477 patients seen by the PCCS were matched with 4431 patients not seen. Costs for patients seen and discharged alive were US $35,449 (95% confidence interval [CI] US $34,157-US $36,686) compared to US $37,447 (95% CI US $36,734-US $38,126), without PCCS consultation. Costs for PCCS patients that died during hospitalization were US $54,940 (95% CI US $51,483-US $58,576) and non-PCCS patients were US $79,660 (95% CI US $76,614-US $83,398).

Standardization of surgical and pathologic variables is needed in multicenter trials of adjuvant therapy for pancreatic cancer: results from the ACOSOG Z5031 trial

BACKGROUND

Standardization of surgical and pathologic techniques is crucial to the interpretation of studies evaluating adjuvant therapies for pancreatic cancer (PC).

METHODS

To assess the degree to which treatment administered prior to enrollment of patients in trials of adjuvant therapy is quality controlled, the operative and pathology reports of patients in American College of Surgeons Oncology Group (ACOSOG) Z5031-a national trial of chemoradiation following pancreaticoduodenectomy (PD)-were rigorously evaluated. We analyzed variables with the potential to influence staging or outcome.

RESULTS

80 patients reported to have undergone R0 (75%) or R1 (25%) pylorus-preserving (38%) or standard (62%) PD were evaluated. A search for metastases was documented in 96% of cases. The proximity of the tumor to the superior mesenteric vein was reported in 69%; vein resection was required in 9% and lateral venorrhaphy in 14%. The method of dissection along the superior mesenteric artery (SMA) was described in 68%, being ultrasonic dissection (17%), stapler (24%), and clamp and cut (59%). SMA skeletonization was described in 25%, and absence of disease following resection was documented in 24%. The surgeon reported marking the critical SMA margin in 25%; inking was documented in 65% of cases and evaluation of the SMA margin was reported in 47%. A range of 1-49 lymph nodes was evaluated. Only 34% of pathology reports met College of American Pathologists criteria.

CONCLUSIONS

Trials of adjuvant therapy following PD suffer from a lack of standardization and quality control prior to patient enrollment. These data suggest areas for improvement in the design of multidisciplinary treatment protocols.