Adjuvant misoprostol or mifepristone for cervical preparation with osmotic dilators before dilation and evacuation.

OBJECTIVES: This study aimed to compare effectiveness and safety of cervical preparation with osmotic dilators plus same-day misoprostol or overnight mifepristone prior to dilation and evacuation (D&E). STUDY DESIGN: We conducted a retrospective cohort analysis of 664 patients initiating abortion between 18 and 22 weeks at an ambulatory health center. We abstracted medical record data from two consecutive 12-month periods in 2017 to 2019. All patients received overnight dilators plus: 600 mcg buccal misoprostol 90 minutes before D&E (period 1); 200 mg oral mifepristone at time of dilators (period 2). Our primary outcome was procedure time. We report frequency of patients experiencing any acute complication, defined as unplanned procedure (i.e., reaspiration, cervical laceration repair, uterine balloon tamponade) or hospital transfer and bleeding complications. RESULTS: We observed higher mean procedure time in the mifepristone group (9.7 ± 5.3 minutes vs 7.9 ± 4.4, p = 0.004). After adjusting for race, ethnicity, insurance, body mass index, parity, prior cesarean, prior uterine surgery, gestational age, provider, trainee participation, and long-acting reversible contraception initiation, the difference remained statistically significant (relative change 1.09, 95% CI 1.01, 1.17) but failed to reach our threshold for clinical significance. The use of additional misoprostol was more common in the mifepristone group, but the use of an additional set of dilators was not different between groups. Acute complications occurred at a frequency of 4.1% in misoprostol group and 4.3% in mifepristone group (p = 0.90). CONCLUSIONS: We found procedure time to be longer with adjunctive mifepristone compared to misoprostol; however, this difference is unlikely to be clinically meaningful. Furthermore, the frequency of acute complications was similar between groups. IMPLICATIONS: Overnight mifepristone at the time of cervical dilator placement is a safe and effective alternative to adjuvant same-day misoprostol for cervical preparation prior to D&E and may offer benefits for clinic flow and patient experience.

Provision of contraceptive implants in school-based health centers: A cost-effectiveness analysis.

OBJECTIVE: To evaluate the cost-effectiveness of providing contraceptive implants in school-based health centers (SBHCs) compared to the practice of referring adolescents to non-SBHCs in New York City. STUDY DESIGN: We developed a microsimulation model of teen pregnancy to estimate the cost-effectiveness of immediate provision of contraceptive implants at SBHCs over a 3-year time horizon. Model parameters were derived from both a retrospective chart review of patient data and published literature. The model projected the number of pregnancies as well as the total costs for each intervention scenario. The incremental cost-effectiveness ratio was calculated using the public payer perspective, using direct costs only. RESULTS: The health care cost of immediate provision of contraceptive implants at SBHCs was projected to be $13,719 per person compared to $13,567 per person for delayed provision at the referral appointment over 3 years. However, immediate provision would prevent 78 more pregnancies per 1000 adolescents over 3 years. The incremental cost-effectiveness ratio for implementing in-school provision was $1940 per additional pregnancy prevented, which was less than the $4206.41 willingness-to-pay threshold. Sensitivity analyses showed that the cost-effectiveness conclusion was robust over a wide range of key model inputs. CONCLUSION: Provision of contraceptive implants in SBHCs compared to non-SBHCs is cost-effective for preventing unintended teen pregnancy. Health care providers and policymakers should consider expanding this model of patient-centered health care delivery to other locations.

An evaluation study of the implementation of stroke best practice guidelines using a Knowledge Transfer Team approach.

INTRODUCTION: Strokes will become an increasing burden on the Canadian health care and social systems in coming years. Caring for people who have experienced a stroke is a challenging issue. The Registered Nurses Association of Ontario (RNAO) developed Stroke Assessment Across the Continuum Best Practice Guidelines (BPGs) to support the best possible care for this population. This article reports the findings of an evaluation of the implementation of recommendations from the stroke BPGs using a Knowledge Transfer Team (KTT) at Mackenzie Health's Integrated Stroke Unit in Richmond Hill, Ontario. METHODS: Over a 12-month period, an evaluation of the implementation activities using structure, process, and outcome indicators, as well as identifying effective strategies for system-wide dissemination of BPG implementation and outcomes was completed. Data were collected from the staff, KTT members, and patients and their providers. RESULTS: The results clearly illustrate that all of the health care professionals involved in the study felt the KT approach was an effective method of implementing and disseminating the stroke BPGs. The main limitations perceived by staff and KTT members were time constraints, difficulty recruiting a larger sample size, competing priorities, lack of compliance, changes to charting, staff attrition, and a lack of financial support. CONCLUSION: The KTT approach resulted in improved patient care and outcomes, as illustrated by the high patient satisfaction levels.

Effect of an atraumatic vulsellum versus a single-tooth tenaculum on pain perception during intrauterine device insertion: a randomized controlled trial.

INTRODUCTION: Intrauterine devices (IUDs) are used by only 5.6% of contraceptive users in the United States. One barrier to IUD uptake is fear of pain during insertion, particularly among nulliparous women. Many interventions to reduce pain during IUD insertion have proven unsuccessful. Comparisons of different tenaculae have not been previously reported. METHODS: This was a single-blinded, randomized control trial of 80 women randomized to the use of a vulsellum or a single-tooth tenaculum during IUD insertion. The primary outcome was reported pain on a 100-mm visual analog scale at the time of vulsellum placement. Secondary outcomes included pain at other intervals during IUD insertion and bleeding from the tenaculum site. Pain scores were analyzed with a Mann-Whitney test because they were not normally distributed. RESULTS: Pain scores at the time of single-tooth tenaculum (33.3 mm) and vulsellum (35.0 mm) placement were the same in both groups (p=0.58). It took longer to control bleeding in the single-tooth tenaculum versus the vulsellum group (1.1 vs. 0.4 min, p=0.001), although there was no statistically significant difference in the number of maneuvers required to control bleeding at the tenaculum site between the two groups. Preprocedure anxiety appeared to correlate with more pain during IUD insertion. CONCLUSION: This is the first randomized trial comparing tenaculae. There was no difference in reported pain, but the vulsellum may be associated with less bleeding than a single-tooth tenaculum. Women with higher preprocedure anxiety may experience more pain during IUD insertion. Future research could investigate an anxiolytic's effect on pain during IUD insertion.

Routine training is not enough: structured training in family planning and abortion improves residents' competency scores and intentions to provide abortion after graduation more than ad hoc training.

BACKGROUND: Abortion provision remains threatened by the paucity of physicians trained to provide them. Lack of training during residency has been cited by obstetrician and gynecologist (ob-gyn) physicians as a reason for not including abortion in their practice. STUDY DESIGN: We administered surveys on interest, competency and intention to provide abortions to two groups of ob-gyn residents: one experiencing a new comprehensive and structured family planning rotation, and another group at our affiliate hospital's residency program receiving "ad hoc" training during their routine gynecology rotations. Surveys were anonymous and blinded to investigator. RESULTS: The structured family planning rotation group compared to the ad hoc group reported significantly increased competency score using a Likert scale in manual vacuum aspiration (MVA) (4.5 vs. 1; p=.003) and had a higher proportion reporting intent to provide office MVA postresidency (100% vs. 39%; p=.01) and being trained to 22.5 weeks' vs. 12 weeks' gestation (p=.005). In bivariate analysis, competency in MVA was associated with higher intentions to provide MVA after residency (p=.007). CONCLUSIONS: A structured rotation in family planning and abortion for obstetrics/gynecology residents results in increases in competency and intentions to provide abortion, and an association between the two. In-hospital structured training proved to be superior to ad hoc training in our affiliate institution in improving competency and intention to provide abortion after residency.

Supportive care needs after an acute stroke: a descriptive enquiry of caregivers' perspective.

This mixed-methods study explored the use of the Supportive Care Needs Framework (M. Fitch, 1998; M. Fitch, H. B. Porter, & B. D. Page, 2008) as an overall guide to identify the wide spectrum of needs of the family caregivers of patients with stroke. Within this framework, a needs assessment survey developed for a different complex medical population was modified and administered to 10 caregivers of patients recently diagnosed with stroke to identify the specific needs of this population. The applicability of the tool was further evaluated through a focus group of nurses working in acute stroke care. The Supportive Care Needs Framework provides a useful and comprehensive framework for the assessment of caregiver need. Results suggest that although additional validation is needed, the modified survey may aid nurses in early identification of caregiver needs.

Supportive care needs of caregivers of individuals following stroke: a synopsis of research.

Approximately 75% of stroke survivors are discharged from hospital to the community with varying degrees of residual neurological deficits (Heart & Stroke Foundation of Ontario, 2003). As a part of a masters' thesis, a systematic review was conducted to synthesize the research related to the identification of family needs during the acute phase of stroke in order to facilitate successful transition into the role of caregiver. Relevant articles were identified using: CINAHL, MEDLINE, All EBM Reviews, Psych Info, Embase, and AARP Ageline (1978 to December 2007). A Supportive Care Needs Framework (SCNF) (Fitch, 1994; 2008) was used to collect and analyze data. The utility of this framework was evaluated in capturing the spectrum of needs of the family caregivers of patients with stroke. Ten qualitative studies and seven quantitative studies were identified and analyzed by the author. The studies were equivocal in their reports of needs not being identified and addressed during hospitalization. The SCNF provided a comprehensive means of organizing the broad spectrum of needs of this population reported in the literature. No new domains were uncovered in the review.

Intrauterine contraception: the pendulum swings back.

Intrauterine contraception is the most widely used method of reversible fertility regulation in the world. Finally, IUC is undergoing a renaissance in the US and it's role will expand as new devices and systems are developed and as old biases among clinicians and women are erased. Successful fertility regulation is a defining factor of the overall health of a population; the expanded use of IUC can help achieve that public health success.