There's no place like home: optimizing the antepartum inpatient experience.

BACKGROUND: To characterize the demographics of a modern hospitalized antepartum population, compare the morbidities of this subset to national morbidity trends, and identify predictors of satisfaction during hospitalization to inform opportunities to enhance equitable antepartum care. METHODS: Pregnant people admitted to the antepartum service of a large university hospital between 2011 and 2019 were surveyed about their hospitalization, pregnancy outcomes, provider interactions, perceived needs, and resource use. Multiple correspondence analysis was used to group patient responses based on latent relationships among demographic, medical, and psychosocial variables. Multivariate analyses were conducted to identify predictors of patient experience rating. Patient free text responses were qualitatively analyzed for common themes. RESULTS: Of 740 pregnant people invited to participate, 298 surveys met criteria for analysis. 25.2% of these pregnant people identified as non-white and 20.8% were admitted for the management of a chronic medical condition. Patient responses clustered into three representative groups: (1) working pregnant people facing resource limitations, (2) first-time pregnant people with college educations, and (3) pregnant people with medical problems and limited partner support. The mean overall patient admission experience rating was 8.4 ± 1.7 out of 10. Variables represented in Cluster 1 (working and resource limitations) were associated with lower patient experience rating (p < 0.01). There was no significant variation in experience rating with indication for admission (P = 0.14) or outcome of the pregnancy (P = 0.32). Conversely, feeling supported by partners (P < 0.01) and providers (P < 0.01) directly correlated with a better experience. CONCLUSION: Black pregnant people and those with chronic medical conditions are overrepresented in this antepartum population when compared to the demographics of those not requiring hospitalization in pregnancy, where these groups also have higher rates of maternal morbidity and mortality at the national level. The most important contributors to patients' satisfaction with their antepartum experience are feeling listened to by providers and supported by partners. Improving patient-provider communication and partner engagement during antepartum admissions should be a focus of inpatient high-risk obstetric care.

Trends in Reporting of Nuchal Translucency Measurements After the Clinical Introduction of Cell-Free DNA Screening.

Nuchal translucency (NT) measurement in conjunction with serum analytes has been used for first-trimester aneuploidy screening in the United States since 2005. We sought to analyze the trends in reporting of NT measurements to the Nuchal Translucency Quality Review program in all pregnancies beginning after the clinical introduction of cell-free DNA (cfDNA) screening for fetal aneuploidy in 2011. Overall, reported NT measurements decreased 74.3% from 2012 to 2022. A similar decline was noted among individuals with pregnancies at increased risk for aneuploidy based on patient age and twin gestations. The decrease in reporting aligns temporally with the availability of cfDNA screening and the coronavirus disease 2019 (COVID-19) pandemic.

The Impact of Spontaneous versus Indicated Preterm Birth on Neonatal Outcomes among Extremely Premature Neonates.

OBJECTIVE: This study aimed to investigate whether neonatal morbidity differs in spontaneous compared with indicated preterm births in extremely premature neonates. STUDY DESIGN: This is a retrospective cohort study including births ≤28 weeks at a single institution from 2011 to 2020. Births were categorized as either medically indicated or spontaneous preterm deliveries. The primary outcome was inhospital mortality and serious morbidity in survivors. t-tests, Fisher's exact tests, chi-square tests, and logistic regression models were utilized as appropriate. p < 0.05 was significant. RESULTS: Two hundred and twenty-seven births were included, with two-thirds representing spontaneous births (65.6%, 149/227) and one-third categorized as medically indicated births (34.4%, 78/227). Inhospital mortality was more common in the spontaneous preterm birth group (p = 0.04), while inhospital morbidity did not significantly vary between the medically indicated and spontaneous birth groups (p = 0.32). There was no difference in inhospital morbidity or mortality by maternal race. In multivariate models of inhospital morbidity and mortality, gestational age was the only significant predictor of adverse outcomes. CONCLUSION: Despite inhospital mortality being more common in spontaneous preterm births, inhospital mortality and significant morbidity are best accounted for by gestational age alone. KEY POINTS: · Inhospital death is more common in spontaneous preterm births.. · Perinatal outcomes do not differ on the basis of racial/ethnic group.. · Gestational age is the best predictor of inhospital morbidity and mortality..

Placental transcriptome analysis of hypertensive pregnancies identifies distinct gene expression profiles of preeclampsia superimposed on chronic hypertension.

BACKGROUND: The pathogenesis of preeclampsia superimposed on chronic hypertension (SI) is poorly understood relative to preeclampsia (PreE) occurring in pregnant people without chronic hypertension. Placental transcriptomes in pregnancies complicated by PreE and SI have not been previously compared. METHODS: We identified pregnant people in the University of Michigan Biorepository for Understanding Maternal and Pediatric Health with hypertensive disorders affecting singleton, euploid gestations (N = 36) along with non-hypertensive control subjects (N = 12). Subjects were grouped as: (1) normotensive (N = 12), (2) chronic hypertensive (N = 13), (3) preterm PreE with severe features (N = 5), (4) term PreE with severe features (N = 11), (5) preterm SI (N = 3), or (6) term SI (N = 4). Bulk RNA sequencing of paraffin-embedded placental tissue was performed. The primary analysis assessed differential gene expression relative to normotensive and chronic hypertensive placentas, where Wald adjusted P values < 0.05 were considered significant. Unsupervised clustering analyses and correlation analyses were performed between conditions of interest, and a gene ontology was constructed. RESULTS: Comparing samples from pregnant people with hypertensive diseases to non-hypertensive controls, there were 2290 differentially expressed genes. The log2-fold changes in genes differentially expressed in chronic hypertension correlated better with term (R = 0.59) and preterm (R = 0.63) PreE with severe features than with term (R = 0.21) and preterm (R = 0.22) SI. A relatively poor correlation was observed between preterm SI and preterm PreE with severe features (0.20) as well as term SI and term PreE with severe features (0.31). The majority of significant genes were downregulated in term and preterm SI versus normotensive controls (92.1%, N = 128). Conversely, most term and preterm PreE with severe features genes were upregulated compared to the normotensive group (91.8%, N = 97). Many of the upregulated genes in PreE with the lowest adjusted P values are known markers of abnormal placentation (e.g., PAAPA, KISS1, CLIC3), while the downregulated genes with the greatest adjusted P values in SI have fewer known pregnancy-specific functions. CONCLUSIONS: We identified unique placental transcriptional profiles in clinically relevant subgroups of individuals with hypertension in pregnancy. Preeclampsia superimposed on chronic hypertension was molecularly distinct from preeclampsia in individuals without chronic hypertension, and chronic hypertension without preeclampsia, suggesting that preeclampsia superimposed on hypertension may represent a distinct entity.

Urinary metabolites as a predictive marker for perinatal depression: A secondary analysis of the mothers, Omega-3 & Mental Health Study.

Background: Perinatal depression has been associated with unfavorable pregnancy and childhood development outcomes; however, no objective markers exist to identify perinatal mood disorders. We investigated whether metabolites in maternal urine during pregnancy can predict increased depressive symptoms in late pregnancy and postpartum among pregnant women at risk for perinatal depression. Methods: We evaluated metabolomic markers in urine collected at 12-20 and 34-36 weeks' gestation. We analyzed 49 urinary metabolites using ion pairing reversed-phase liquid chromatography-mass spectrometry. Depressive symptom severity was identified using Beck Depression Inventory (BDI) scores from 105 participants at 12-20 and 34-36 weeks' gestation, and 6-8 weeks' postpartum. Mixed model repeated measures analysis evaluated associations between changes in maternal urinary metabolites and BDI scores across pregnancy. Results: Increases in urinary xanthine and hypoxanthine were positively associated with increases in maternal depressive symptoms throughout pregnancy (p = 0.03 and 0.02, respectively). This finding did not persist after false discovery rate correction. None of the urinary metabolites examined were significantly associated with development of postpartum depressive symptoms. Limitations: This study is an exploratory secondary biologic sample analysis from a trial whose sample size was determined by a different primary outcome and expected effect size, which may have limited statistical power to detect associations between urinary metabolites, depressive symptoms, and mood trajectory over time. Conclusions: Increasing concentrations of xanthine and hypoxanthine were associated with increasing depressive symptoms throughout pregnancy. Further research is needed to evaluate the utility of these metabolic markers in identifying women at risk for perinatal depressive symptoms.

Delivering equity: preterm birth by socioeconomic class before and after coverage of 17-hydroxyprogesterone caproate.

OBJECTIVE: We compare the preterm birth rate across socioeconomic strata in Michigan before and after the decision by Michigan Medicaid to provide coverage for 17-hydroxyprogesterone caproate (17-OHP), a costly medication for recurrent preterm birth prevention. STUDY DESIGN: We retrospectively analyzed births recorded in the Michigan Department of Health & Human Services database from 2008-2016, comparing the rate of preterm birth stratified by standardized US Census Bureau socioeconomic levels (affluent, higher-middle class, lower-middle class, and poverty) across three time periods: pre-Federal Drug Administration approval of 17-OHP (2008-2011), pre-Medicaid coverage (2012-2014), and post-Medicaid coverage (2015-2016). RESULTS: Of 1,034,901 total live births, 10% (N = 103,869) were premature. An ANOVA with post-hoc testing showed the preterm birth rate was highest for those living in poverty, lower for the lower-middle class, and lowest for the collective higher-middle and affluent classes. The preterm birth rate dropped for all classes after Michigan Medicaid began paying for 17-OHP, but inter-class gaps remained. CONCLUSION: Extended financial coverage for 17-OHP may have contributed to modest decreases in preterm birth rates, but this policy did not equalize outcomes between those with disparate resources.

The prevalence of self-reported medical comorbidities in patients with vulvar lichen sclerosus: A single-center retrospective study.

OBJECTIVE: To compare the demographics and self-reported medical comorbidities of patients with vulvar lichen sclerosus (VLS) with those of women with other vulvar conditions. METHODS: Intake questionnaires for patients presenting to the University of Michigan Center for Vulvar Diseases between 1996 and 2019 were entered into a de-identified database (n = 1983). Responses to questions about thyroid disease, urinary symptoms and signs, gastrointestinal conditions, and pain conditions were collected. RESULTS: A total of 1983 women, including 865 patients with VLS and 1118 patients without VLS were enrolled. Pearson's χ2 analysis showed that age, hypertension, anorectal fissures, peptic ulcer disease/gastroesophageal reflux disease, urinary incontinence, fibromyalgia, thyroid disease, kidney problems, liver problems, and cancer were significantly associated with VLS when compared between the VLS and non-VLS groups (P < 0.01). However, multiple regression analysis demonstrated that only age, thyroid disease, and anorectal fissures were strongly associated with VLS (P < 0.01). CONCLUSION: Increasing age, thyroid disease, and anorectal fissures were significantly associated with VLS. The association between anorectal fissures and VLS likely represents a sequela of the disease rather than a true comorbidity.

A randomized-controlled trial to assess the effect of ibuprofen on postpartum blood pressure in women with hypertensive disorders of pregnancy.

OBJECTIVES: To test the hypothesis that ibuprofen is equivalent to acetaminophen in its effect on postpartum blood pressure in women with gestational hypertension or preeclampsia without severe features. STUDY DESIGN: Single-center randomized, crossover, equivalence trial among women with hypertensive disorders of pregnancy without severe features after vaginal delivery. Participants were assigned in a double-blind fashion to ibuprofen 600 mg or acetaminophen 650 mg every 6 h for 24 h followed by crossover to the other drug. We assessed clinical blood pressures and ambulatory blood pressure monitor measurements. Intention-to-treat analyses were performed using a linear mixed model adjusted for time period. MAIN OUTCOME MEASURES: The mean difference in systolic blood pressure through 24 h of drug exposure with an equivalence margin of 10 mmHg. RESULTS: Of 185 screened women, 74 enrolled prior to delivery. Forty-three women remained eligible and were randomized to ibuprofen first (n = 20, 46.5%) or acetaminophen first (n = 23, 53.5%). A total of 37 women (86.0%) received study drug (ibuprofen first n = 19, acetaminophen first n = 18). Most participants were white (91.9%) and had gestational hypertension (86.5%); mean (SD) age was 31.0 (6.5) years. The mean adjusted difference in systolic blood pressure was 1.0 mmHg (95% CI, -3.7 to 5.7 mmHg), which was within the equivalence margin. A linear mixed model did not demonstrate a main effect of group assignment, nor did it show an interaction effect with time period. CONCLUSIONS: Among women with gestational hypertension and preeclampsia without severe features, ibuprofen is an equally safe option as acetaminophen with respect to postpartum blood pressure concerns.

The gender authorship gap in gynecologic oncology research.

Female first authorship and senior authorship in academic obstetrics and gynecology has increased over time but gender-specific publishing data are lacking within gynecologic oncology. We examined contribution by gender to the subspecialty's flagship journal, Gynecologic Oncology, over five decades, from 1972 to 2014, to identify trends in gender representation. Chi-square tests were used to compare gender distributions within and between the first and last years studied (1972-73 and 2014) as well as linear regression to model trends over time. Female first and senior authorship increased significantly from 1972 to 2014 (first: χ2 = 20.9, p < .01; senior: χ2 = 9.9, p < .01). The number of female first authors increased markedly after 2000. Male senior authors still outnumber female senior authors. Papers with senior female authors were more likely to have female first authors, suggesting a mentorship role. Subspecialty-wide gender equity initiatives should encourage continued mentorship of women by female colleagues.

Outcomes in oligohydramnios: the role of etiology in predicting pulmonary morbidity/mortality.

Objective Early-onset oligohydramnios is typically secondary to renal-urinary anomalies (RUA) or preterm premature rupture of membranes (PPROM). We compared neonatal pulmonary outcomes between these etiologies. Methods We conducted a retrospective cohort study of women with oligohydramnios identified before 24 completed weeks of gestation attributed to either PPROM or RUA. Patients were excluded if other fetal anomalies were noted. Respiratory morbidity was assessed by the need for oxygen at 36 corrected weeks or at hospital discharge. Results Of 116 eligible patients, 54 chose elective pregnancy termination. A total of 39.5% of PPROM (n=17/43) and 36.8% of RUA (n=7/19) pregnancies experienced pre-viable loss (P=1.00). Significantly fewer PPROM live births resulted in neonatal mortality (26.9% vs. 75.0%, P<0.01). There was no difference in respiratory morbidity (57.9% vs. 66.6%, P=1.00). The collective incidence of respiratory mortality and morbidity was not different between etiologies (P=0.06). Conclusion This analysis suggests that the prognoses for oligohydramnios due to pre-viable PPROM vs. renal anomalies are similarly grave, though RUA infants experienced a higher rate of neonatal respiratory mortality.

Breaking Down Barriers in Pediatric Mental Health Consultations: Understanding Patients' Use of I DON'T KNOW.

Barriers to effective provider-patient communication take many forms that can be difficult to recognize and appropriately address. This paper offers probabilistic indicators for one such form, patient-produced "I don't know" (IDK), distinguishing its use as a cognitive claim and its use as a strategy for resisting discussion of sensitive topics. A total of 95 audio-recorded psychiatrist-child interactions are drawn from a US-wide corpus of physician-patient consultations. From these, 376 patient-produced IDKs are extracted and coded for linguistic/social factors, including form, function, prosody, age, gender, and primary diagnosis. Two multiple logistic regressions are performed to determine the predictors of cognitive and resistive IDK functions respectively. Cognitive IDK uses are associated with the full form (p < 0.01) and unstressed prosody (p < 0.01). Use of resistive IDK is correlated with decreasing patient age (p < 0.01) and emotionally labile mental health diagnoses (p < 0.01). Cognitive and resistive IDK uses have distinctive linguistic and social distributions in psychiatrist-child interactions, where cognitive uses have two objectively identifiable linguistic characteristics and resistive uses are associated with certain patient types. Providers may learn to recognize cognitive and resistive IDK uses, thus acquiring the ability to correctly interpret interactional cues relevant to the diagnosis and treatment of pediatric mental health conditions.

Discussing Health Care Expenses in the Oncology Clinic: Analysis of Cost Conversations in Outpatient Encounters.

PURPOSE: ASCO identified oncologist-patient conversations about cancer costs as an important component of high-quality care. However, limited data exist characterizing the content of these conversations. We sought to provide novel insight into oncologist-patient cost conversations by determining the content of cost conversations in breast cancer clinic visits. METHODS: We performed content analysis of transcribed dialogue from 677 outpatient appointments for breast cancer management. Encounters featured 677 patients with breast cancer visiting 56 oncologists nationwide from 2010 to 2013. RESULTS: Cost conversations were identified in 22% of visits (95% CI, 19 to 25) and had a median duration of 33 seconds (interquartile range, 19 to 62). Fifty-nine percent of cost conversations were initiated by oncologists (95% CI, 51 to 67), who most commonly brought up costs for antineoplastic agents. By contrast, patients most frequently brought up costs for diagnostic tests. Thirty-eight percent of cost conversations mentioned cost-reducing strategies (95% CI, 30 to 46), which most commonly sought to lower patient costs for endocrine therapies and symptom-alleviating treatments. The three most commonly discussed cost-reducing strategies were: switching to a lower-cost therapy/diagnostic, changing logistics of the intervention, and facilitating copay assistance. CONCLUSION: We identified cost conversations in approximately one in five breast cancer visits. Cost conversations were mostly oncologist initiated, lasted < 1 minute, and dealt with a wide range of health care expenses. Cost-reducing strategies were mentioned in more than one third of cost conversations and often involved switching antineoplastic agents for lower-cost alternatives or altering logistics of diagnostic tests.

Meta-analysis of randomized controlled trials comparing 17α-hydroxyprogesterone caproate and vaginal progesterone for the prevention of recurrent spontaneous preterm delivery.

BACKGROUND: Vaginal progesterone and 17α-hydroxyprogesterone (17α-OHP) are both used to prevent preterm delivery in women who have experienced spontaneous preterm delivery (SPTD) previously. Randomized trial data of the comparative effectiveness of these interventions have been mixed. OBJECTIVES: To compare the efficacy of intramuscular 17α-OHP and vaginal progesterone in the prevention of recurrent SPTD. SEARCH STRATEGY: Cochrane Central Register of Controlled Trials, African Journals Online, Embase, Google Scholar, ISI Web of Science, LILACS, CINAHL, PubMed, and registers of ongoing trials were searched using keywords related to 17α-OHP, vaginal progesterone, and preterm delivery. SELECTION CRITERIA: Randomized controlled trials published between January 1, 1966, and November 30, 2016, comparing 17α-OHP and vaginal progesterone for the prevention of recurrent SPTD during singleton pregnancies were included. DATA COLLECTION AND ANALYSIS: Study data were extracted and meta-analyses were performed when outcomes were comparable. MAIN RESULTS: The meta-analyses included data from three randomized trials. Lower rates of SPTD before 34 weeks (relative risk 0.71, 95% confidence interval 0.53-0.95) and before 32 weeks (relative risk 0.62, 95% confidence interval 0.40-0.94) of pregnancy were observed among patients treated with vaginal progesterone. CONCLUSIONS: Vaginal progesterone and 17α-OHP were comparable for the prevention of recurrent SPTD in singleton pregnancies; vaginal progesterone could be superior.

Discussing Out-of-Pocket Expenses During Clinical Appointments: An Observational Study of Patient-Psychiatrist Interactions.

OBJECTIVE: High out-of-pocket expenses for medical treatment have been associated with worse quality of life, decreased treatment adherence, and increased risk of adverse health outcomes. Treatment of depression potentially has high out-of-pocket expenses. Limited data characterize psychiatrist-patient conversations about health care costs. METHODS: The authors conducted content analysis from 422 outpatient psychiatrist-patient visits for medication management of major depressive disorder in community-based private practices nationwide from 2010 to 2014. RESULTS: Patients' health care expenses were discussed in 38% of clinic visits (95% confidence interval [CI]= 33%-43%). Uninsured patients were significantly more likely to discuss expenses than were patients enrolled in private or public plans (64%, 44%, and 30%, respectively; p<.001). Sixty-nine percent of cost conversations lasted less than one minute (median=36 seconds; interquartile range [IQR]=16-81 seconds). Cost conversations most frequently addressed psychotropic medications (51%). Physicians initiated 50% of cost conversations and brought up costs for psychotropic medications more often than did patients (62% versus 38%, p=.009). Conversely, a greater percentage of patient-initiated cost conversations addressed provider visit costs (27% versus 10%, p=.008). Overall, 45% of cost conversations mentioned cost-reducing strategies (CI=37%-53%). The most frequently discussed cost-reducing strategies were lowering cost by changing the source or timing of an intervention (for example, changing pharmacies), providing free samples, and switching to a lower-cost therapy or diagnostic test. CONCLUSIONS: Psychiatrists and patients regularly discuss patients' health care costs in visits for depression. These discussions cover a variety of clinical topics and frequently include strategies to lower patients' costs.

Interpreting "I don't know" use by persons living with dementia in Mini-Mental State Examinations.

OBJECTIVE: We investigate dementia patients' use of "I don't know" (IDK) in Mini-Mental State Exams (MMSEs) using objective linguistic indicators to differentiate IDK signalling lack of knowledge (LOK) from IDK used to hedge responses, affect exam progression etc. We hypothesize that increased proportional use of LOK-IDK correlates with worsening dementia severity. METHODS: 189 IDK tokens were extracted from 72 MMSE interactions and coded for linguistic/social characteristics. A data-driven, discourse position/relation-based functional taxonomy for IDK in MMSE was developed and the resulting functional distribution was subjected to multiple logistic regression. RESULTS: Use of LOK-IDK (vs. non-LOK-IDK) is significantly correlated (p=0.01) with clinicians' subjective ratings of patients' dementia as 'severe' vs. 'mild'/'moderate', indicating that objective sociolinguistic criteria approximate physician judgments. 92% of 'severe' patients' IDKs signalled LOK, compared to only 68% of 'mild' patients', suggesting that uncritical interpretation of IDK as signalling LOK would result in 8-32% of IDK responses being mis-scored. CONCLUSION: LOK and non-LOK uses distinguished on the basis of reliable, objective usage patterns are differentially distributed among dementia severity groups. PRACTICE IMPLICATIONS: LOK-IDK serves as a supplemental indicator of dementia severity. Correct interpretation may improve diagnostic accuracy and allow clinicians to respond supportively during cognitive assessment.

Patient-physician discussions about costs: definitions and impact on cost conversation incidence estimates.

BACKGROUND: Nearly one in three Americans are financially burdened by their medical expenses. To mitigate financial distress, experts recommend routine physician-patient cost conversations. However, the content and incidence of these conversations are unclear, and rigorous definitions are lacking. We sought to develop a novel set of cost conversation definitions, and determine the impact of definitional variation on cost conversation incidence in three clinical settings. METHODS: Retrospective, mixed-methods analysis of transcribed dialogue from 1,755 outpatient encounters for routine clinical management of breast cancer, rheumatoid arthritis, and depression, occurring between 2010-2014. We developed cost conversation definitions using summative content analysis. Transcripts were evaluated independently by at least two members of our multi-disciplinary team to determine cost conversation incidence using each definition. Incidence estimates were compared using Pearson's Chi-Square Tests. RESULTS: Three cost conversation definitions emerged from our analysis: (a) Out-of-Pocket (OoP) Cost--discussion of the patient's OoP costs for a healthcare service; (b) Cost/Coverage--discussion of the patient's OoP costs or insurance coverage; (c) Cost of Illness- discussion of financial costs or insurance coverage related to health or healthcare. These definitions were hierarchical; OoP Cost was a subset of Cost/Coverage, which was a subset of Cost of Illness. In each clinical setting, we observed significant variation in the incidence of cost conversations when using different definitions; breast oncology: 16, 22, 24% of clinic visits contained cost conversation (OOP Cost, Cost/Coverage, Cost of Illness, respectively; P < 0.001); depression: 30, 38, 43%, (P < 0.001); and rheumatoid arthritis, 26, 33, 35%, (P < 0.001). CONCLUSIONS: The estimated incidence of physician-patient cost conversation varied significantly depending on the definition used. Our findings and proposed definitions may assist in retrospective interpretation and prospective design of investigations on this topic.

Study Of Physician And Patient Communication Identifies Missed Opportunities To Help Reduce Patients' Out-Of-Pocket Spending.

Some experts contend that requiring patients to pay out of pocket for a portion of their care will bring consumer discipline to health care markets. But are physicians prepared to help patients factor out-of-pocket expenses into medical decisions? In this qualitative study of audiorecorded clinical encounters, we identified physician behaviors that stand in the way of helping patients navigate out-of-pocket spending. Some behaviors reflected a failure to fully engage with patients' financial concerns, from never acknowledging such concerns to dismissing them too quickly. Other behaviors reflected a failure to resolve uncertainty about out-of-pocket expenses or reliance on temporary solutions without making long-term plans to reduce spending. Many of these failures resulted from systemic barriers to health care spending conversations, such as a lack of price transparency. For consumer health care markets to work as intended, physicians need to be prepared to help patients navigate out-of-pocket expenses when financial concerns arise during clinical encounters.

What Strategies Do Physicians and Patients Discuss to Reduce Out-of-Pocket Costs? Analysis of Cost-Saving Strategies in 1,755 Outpatient Clinic Visits.

BACKGROUND: More than 1 in 4 Americans report difficulty paying medical bills. Cost-reducing strategies discussed during outpatient physician visits remain poorly characterized. OBJECTIVE: We sought to determine how often patients and physicians discuss health care costs during outpatient visits and what strategies, if any, they discussed to lower patient out-of-pocket costs. DESIGN: Retrospective analysis of dialogue from 1,755 outpatient visits in community-based practices nationwide from 2010 to 2014. The study population included 677 patients with breast cancer, 422 with depression, and 656 with rheumatoid arthritis visiting 56 oncologists, 36 psychiatrists, and 26 rheumatologists, respectively. RESULTS: Thirty percent of visits contained cost conversations (95% confidence interval [CI], 28 to 32). Forty-four percent of cost conversations involved discussion of cost-saving strategies (95% CI, 40 to 48; median duration, 68 s). We identified 4 strategies to lower costs without changing the care plan. They were, in order of overall frequency: 1) changing logistics of care, 2) facilitating co-pay assistance, 3) providing free samples, and 4) changing/adding insurance plans. We also identified 4 strategies to reduce costs by changing the care plan: 1) switching to lower-cost alternative therapy/diagnostic, 2) switching from brand name to generic, 3) changing dosage/frequency, and 4) stopping/withholding interventions. Strategies were relatively consistent across health conditions, except for switching to a lower-cost alternative (more common in breast oncology) and providing free samples (more common in depression). LIMITATION: Focus on 3 conditions with potentially high out-of-pocket costs. CONCLUSIONS: Despite price opacity, physicians and patients discuss a variety of out-of-pocket cost reduction strategies during clinic visits. Almost half of cost discussions mention 1 or more cost-saving strategies, with more frequent mention of those not requiring care-plan changes.

Patient understanding of medical jargon: a survey study of U.S. medical students.

OBJECTIVE: With increasing exposure, medical students may forget that technical jargon is unfamiliar to laypeople. To investigate this possibility, authors assessed student perceptions of patient understanding across different years in medical school. METHODS: 533 students at 4 U.S. medical schools rated the proportion of patients likely to understand each of twenty-one different jargon terms. Students were either in the first month of their first year, the middle of their first year, or the middle of their fourth year of medical school. RESULTS: Fourth-year students were slightly more pessimistic about patients' understanding compared to new first-year students (mean percent understanding of 55.1% vs. 58.6%, p=0.004). Students both over- and under-estimated patient understanding of specific words compared to published estimates. In a multivariate model, other factors did not explain these differences. CONCLUSION: Students do not generally presume that patients understand medical jargon. In many cases they actually underestimate patients' understanding, and these estimates may become more pessimistic longitudinally. Jargon use in communication with patients does not appear to stem from unrealistic presumptions about patients' understanding or from desensitization to jargon during medical school. PRACTICE IMPLICATIONS: Training about patient knowledge of medical jargon may be a useful addition to communication skills curricula.

Patient-centered interviewing is associated with decreased responses to painful stimuli: an initial fMRI study.

OBJECTIVE: To identify the functional magnetic resonance imaging (fMRI) changes associated with a patient-centered interview (PCI) and a positive provider-patient relationship (PPR). METHODS: Nine female patients participated, five randomly selected to undergo a replicable, evidence-based PCI, the other four receiving standard clinician-centered interviews (CCI). To verify that PCI differed from CCI, we rated the interviews and administered a patient satisfaction with the provider-patient relationship (PPR) questionnaire. Patients were then scanned as they received painful stimulation while viewing pictures of the interviewing doctor and control images (unknown doctor). RESULTS: Interview ratings and questionnaire results confirmed that PCIs and CCIs were performed as planned and PCIs led to a much more positive PPR. We found significantly reduced pain-related neural activation in the left anterior insula region in the PCI group when the interviewing doctor's picture was shown. CONCLUSION: This study identifies an association between a PCI that produced a positive PPR and reduced pain-related neural responses in the anterior insula. This is an initial step in understanding the neural underpinnings of a PCI. PRACTICE IMPLICATIONS: If confirmed, our results indicate one neurobiological underpinning of an effective PCI, providing an additional scientific rationale for its use clinically.