Evaluating maternal health capacity building in rural and underserved areas: a research protocol.

INTRODUCTION: The US is currently experiencing a maternal health crisis. Maternal morbidity and mortality in the US are higher than in other developed nations and continue to rise. Infant mortality, likewise, is higher in the US than in other developed nations. Limited availability of maternal health services, particularly in rural areas, contributes to this crisis. Maternal health outcomes are poorer, and maternal care workforce shortages are more severe in rural areas of the US. In rural areas where obstetric specialists are rare, many patients rely on family medicine physicians for maternity care. However, the number of family medicine physicians who provide maternal care services is decreasing, aggravating shortages. Calls have been made to build maternal care capacity in rural areas. The role family medicine will play in addressing the maternal health crisis is not clear. Maternal care shortages are complex issues resulting from multiple factors; likewise, efforts to build maternal health capacity are challenging and require multifaceted approaches. METHODS: With funding from the Health Resources and Services Administration (HRSA), the University of Utah seeks to address the shortage of quality maternity care in rural and underserved areas of Utah by strengthening partnerships, enhancing maternal care training of family medicine residents and obstetrics fellows, and improving the transition from training to rural practice for residents and fellows. This protocol describes the evaluation of the HRSA-funded project. The evaluation includes three components. Component 1 consists of qualitative interviews with a diverse group of maternal health providers, administrators, educators and academics, patients, and others. Interviews will be analyzed using qualitative content analysis. Component 2 is a survey of family medicine residents and obstetrics fellows, which aims to increase understanding of the factors and circumstances influencing intention to practice in rural or underserved areas and to provide maternal health services. Component 3 involves surveying fellowship alumni and tracking graduates to assess effectiveness of training programs in producing physicians who provide maternal health services in rural and underserved areas. Surveys will be analyzed with descriptive statistics including means, frequencies, and cross-tabulations. If sample size and participation provide sufficient power, statistical tests will be included in analyses. RESULTS: Evaluation results will help to fill an important gap in research literature concerning outcomes of projects and initiatives designed to build maternal care capacity in rural areas of the US. In addition, results will provide valuable information regarding effective practices for building capacity, which can be adopted elsewhere to address maternal care shortages. Finally, results will help to define the role of family medicine in addressing the maternal health crisis. Amid maternal care shortages, fewer and fewer family medicine physicians are providing maternal care in their practice. Evaluation results will clarify the role of training and preparation of family medicine residents in addressing workforce shortages. CONCLUSION: This evaluation will provide important contributions, but additional research is needed, including research protocols and studies of project outcomes, to understand how best to resolve the maternal care crisis in the US.

CT colonography: effect of computer-aided detection of colonic polyps as a second and concurrent reader for general radiologists with moderate experience in CT colonography.

OBJECTIVES: To assess the effectiveness of computer-aided detection (CAD) as a second reader or concurrent reader in helping radiologists who are moderately experienced in computed tomographic colonography (CTC) to detect colorectal polyps. METHODS: Seventy CTC datasets (34 patients: 66 polyps ≥6 mm; 36 patients: no abnormalities) were retrospectively reviewed by seven radiologists with moderate CTC experience. After primary unassisted evaluation, a CAD second read and, after a time interval of ≥4 weeks, a CAD concurrent read were performed. Areas under the receiver operating characteristic (ROC) curve (AUC), along with per-segment, per-polyp and per-patient sensitivities, and also reading times, were calculated for each reader with and without CAD. RESULTS: Of seven readers, 86% and 71% achieved a higher accuracy (segment-level AUC) when using CAD as second and concurrent reader respectively. Average segment-level AUCs with second and concurrent CAD (0.853 and 0.864) were significantly greater (p < 0.0001) than average AUC in the unaided evaluation (0.781). Per-segment, per-polyp, and per-patient sensitivities for polyps ≥6 mm were significantly higher in both CAD reading paradigms compared with unaided evaluation. Second-read CAD reduced readers' average segment and patient specificity by 0.007 and 0.036 (p = 0.005 and 0.011), respectively. CONCLUSIONS: CAD significantly improves the sensitivities of radiologists moderately experienced in CTC for polyp detection, both as second reader and concurrent reader. KEY POINTS: • CAD helps radiologists with moderate CTC experience to detect polyps ≥6 mm. • Second and concurrent read CAD increase the radiologist's sensitivity for detecting polyps ≥6 mm. • Second read CAD slightly decreases specificity compared with an unassisted read. • Concurrent read CAD is significantly more time-efficient than second read CAD.

Fall Risk Screening in Older Adult Patients on Chronic Opioid Therapy: A Quality Improvement Project.

ABSTRACT: Many older adults prescribed opioid pain medications may be at increased risk of falls. As a quality improvement (QI) initiative, the University of Utah Sugar House clinic initiated a 9-month fall risk screening pilot for older adult patients on chronic opioids. This QI project sought to determine the feasibility of adding screening to a busy clinical practice, examine risk of falls in this patient cohort, and examine whether there were significant clinical and demographic differences between the patients who did or did not receive screening. We observed whether conventionally understood fall risk factors, including higher opioid doses, concurrent benzodiazepine prescription, and age, correlate with high fall risk. After the screening initiative, we determined that it was possible to significantly increase fall risk screening rates with prompts in Electronic Health Record (EHR). This cohort's fall risk screening increased from 18% to 33%. In the patients who were screened, 43% were found to be at high risk of falls. We did not see a correlation with high fall risk and patients taking higher doses of opioids or concurrent benzodiazepine prescriptions. These findings emphasize the need for consistent screening in primary care because review of the medication list alone is not a reliable predictor of fall risk.

Protocol for the 2023 CERA General Membership Survey.

Introduction: CERA, the Council of Academic Family Medicine (CAFM) Educational Research Alliance, represents a unique collaboration between family medicine organizations, conducting annual surveys of distinct groups within family medicine. CERA's mission is to support family medicine educational research. This paper presents the methods and demographic results of the 2023 General Membership Survey. Methods: CERA's call for proposals for the annual General Membership Survey opened from June 2023 to July 2023. We received 16 proposals, and after a peer review process, five topics were accepted. Each author was assigned a research mentor. Because all the accepted proposals targeted physicians, the survey was distributed to select members of the CAFM organizations via SurveyMonkey from November 20, 2023 through December 22, 2023. We used χ2 and Fisher's exact tests for analysis. Results: The final pool size was 3,598. Eight-hundred thirty-three members completed the survey, for a response rate of 23.2% (833/3,598). Demographic data of potential survey respondents were compared with data of actual respondents. There were no significant differences in gender, location and underrepresented in medicine status. Actual survey respondents were slightly older, less likely Asian, and more likely to have a doctor of medicine (MD) or combined doctorate degree compared to potential survey respondents. Conclusion: This paper describes the methods of the 2023 CERA General Membership Survey. The 2023 survey focused on active physicians. The demographics of the survey respondents differed slightly from potential respondents. Authors of the five accepted survey topics are responsible for publishing their study findings.

Risk factors of undiagnosed and uncontrolled hypertension in primary care patients with hypertension: a cross-sectional study.

BACKGROUND: Hypertension is a common heart condition in the United States (US) and severely impacts racial and ethnic minority populations. While the understanding of hypertension has grown considerably, there remain gaps in US healthcare research. Specifically, there is a lack of focus on undiagnosed and uncontrolled hypertension in primary care settings. AIM: The present study investigates factors associated with undiagnosed and uncontrolled hypertension in primary care patients with hypertension. The study also examines whether Black/African Americans are at higher odds of undiagnosed and uncontrolled hypertension compared to White patients. METHODS: A cross-sectional study was conducted using electronic health records (EHR) data from the University of Utah primary care health system. The study included for analysis 24,915 patients with hypertension who had a primary care visit from January 2020 to December 2020. Multivariate logistic regression assessed the odds of undiagnosed and uncontrolled hypertension. RESULTS: Among 24,915 patients with hypertension, 28.6% (n = 7,124) were undiagnosed and 37.4% (n = 9,319) were uncontrolled. Factors associated with higher odds of undiagnosed hypertension included age 18-44 (2.05 [1.90-2.21]), Hispanic/Latino ethnicity (1.13 [1.03-1.23]),  Medicaid (1.43 [1.29-1.58]) or self-pay  (1.32 [1.13-1.53]) insurance, CCI 1-2 (1.79 [1.67-1.92]), and LDL-c ≥ 190 mg/dl (3.05 [1.41-6.59]). For uncontrolled hypertension, risk factors included age 65+ (1.11 [1.08-1.34]), male (1.24 [1.17-1.31]), Native-Hawaiian/Pacific Islander (1.32 [1.05-1.62])  or Black/African American race (1.24 [1.11-1.57]) , and self-pay insurance (1.11 [1.03-1.22]). CONCLUSION: The results of this study suggest that undiagnosed and uncontrolled hypertension is prevalent in primary care. Critical risk factors for undiagnosed hypertension include younger age, Hispanic/Latino ethnicity, very high LDL-c, low comorbidity scores, and self-pay or medicaid insurance. For uncontrolled hypertension, geriatric populations, males, Native Hawaiian/Pacific Islanders, and Black/African Americans, continue to experience greater burdens than their counterparts. Substantial efforts are needed to strengthen hypertension diagnosis and to develop tailored hypertension management programs in primary care, focusing on these populations.

Expanding Access to Contraceptive Services in a Family Medicine Residency Clinic: The Rapid Access to Contraception Clinic Model.

BACKGROUND AND OBJECTIVES: Learning to provide long-acting reversible contraception (LARC) during family medicine residency is an important step in building capacity for the primary care workforce to meet the reproductive health care needs of communities. We aimed to measure the impact of adding a contraceptive visit type (CVT) allowing for rapid access to contraception (RAC) on family medicine resident LARC procedure numbers. METHODS: Our program created a CVT in which patients were seen only for contraceptive services. We added the CVT to third-year family medicine resident continuity clinic schedules and a block of CVTs (the RAC clinic) to the third-year gynecology rotation. Residents self-reported LARC procedure numbers performed throughout residency, and the totals were compared for graduating residents from 2023 (post-RAC cohort) to 2022 graduates and 2018-2022 graduates (pre-RAC cohort). RESULTS: Post-RAC cohort residents reported a statistically significant increase in intrauterine device (IUD; P=.015) and contraceptive implant (P=.010) removals compared to the 2022 pre-RAC cohort. Insertions of IUDs and contraceptive implants were unchanged when compared to the pre-RAC cohort. IUD removals (P=.004) and insertions (P=.034), and contraceptive implant removals (P=.028) were significantly increased for post-RAC compared to 2022 graduates, with no difference in contraceptive implant insertions (P=.211). CONCLUSIONS: The addition of the CVT and RAC clinic contributed to an increase in LARC removals in both comparisons, and IUD insertions between 2022 and 2023. This clinic model offers an opportunity for other family medicine residency programs to improve access to contraceptive services and increase resident training in LARC management.

A cross-sectional and population-based study from primary care on post-COVID-19 conditions in non-hospitalized patients.

BACKGROUND: Current research on post-COVID-19 conditions (PCC) has focused on hospitalized COVID-19 patients, and often lacks a comparison group. This study assessed the prevalence of PCC in non-hospitalized COVID-19 primary care patients compared to primary care patients not diagnosed with COVID-19. METHODS: This cross-sectional, population-based study (n = 2539) analyzed and compared the prevalence of PCC in patients with a positive COVID-19 test (n = 1410) and patients with a negative COVID-19 test (n = 1129) never hospitalized for COVID-19 related conditions. Participants were identified using electronic health records and completed an electronic questionnaire, available in English and Spanish, including 54 potential post COVID-19 symptoms. Logistic regression was conducted to assess the association of PCC with COVID-19. RESULTS: Post-COVID-19 conditions are prevalent in both groups, and significantly more prevalent in patients with COVID-19. Strong significant differences exist for the twenty most reported conditions, except for anxiety. Common conditions are fatigue (59.5% (COVID-19 positive) vs. 41.3% (COVID-19 negative); OR 2.15 [1.79-2.60]), difficulty sleeping (52.1% (positive) vs. 41.9% (negative); OR 1.42 [1.18-1.71]) and concentration problems (50.6% (positive) vs 28.5% (negative); OR 2.64 [2.17-3.22]). Similar disparities in prevalence are also observed after comparing two groups (positive vs. negative) by age, sex, time since testing, and race/ethnicity. CONCLUSIONS: PCC is highly prevalent in non-hospitalized COVID-19 patients in primary care. However, it is important to note that PCC strongly overlaps with common health symptoms seen in primary care, including fatigue, difficulty sleeping, and headaches, which makes the diagnosis of PCC in primary care even more challenging.

Research on post-COVID-19 conditions (PCC), also known as Long COVID, has often involved hospitalized COVID-19 patients. However, many patients with COVID-19 were not hospitalized, therefore how commonly the condition affects individuals attending primary care services is not accounted for. Here, we assessed non-hospitalized primary care patients with and without COVID-19. Our results demonstrate that PCC is highly common among primary care patients with COVID-19 and often presents as fatigue, difficulty sleeping, and concentration problems. As these symptoms overlap with other non-COVID-related conditions, it is challenging to accurately diagnose PCC. This calls for improved diagnostics and management of PCC in primary care settings, which is often the first point of contact with the healthcare systems for many patients.

Cumulative Incidence of All-Cause Knee Injury, Concussion, and Stress Fracture among Transgender Patients on Gender-Affirming Hormone Therapy: An Exploratory Retrospective Cohort Study.

Previous research has shown a discrepancy in incidences of knee injuries, stress fractures, and concussions between cisgender men and women. Little is known regarding the incidence of musculoskeletal injuries among patients on gender-affirming hormone therapy (GAHT). This retrospective cohort study examines cumulative incidence of knee injuries, concussions, and stress fracture injuries among transgender patients on GAHT at one health system from 2011-2020. Using relevant ICD-9 and 10 codes, incidences of knee injury, concussion, and stress fracture were calculated. Cohorts included 1971 transgender and 3964 cisgender patients. Transgender patients had significantly higher incidence of all-cause knee injuries over the study period, 109 (5.5%) versus 175 (4.4%) (p < 0.001; OR: 2.14, 95% CI [1.17-3.92]). Subgroup analysis showed significantly higher incidence of knee injuries among cisgender men (5.6%) versus cisgender women (4.1%) (p = 0.042) and among transgender women (6.6%) versus cisgender women (4.1%) (p = 0.005). There were no significant differences between incidences of concussion and stress fracture between groups. This sample showed that patients on GAHT had increased cumulative incidences of all-cause knee injury compared to controls but similar cumulative incidences of concussion and bone-stress injuries. Transgender women on exogenous estrogen had significantly higher cumulative incidences of all-cause knee injuries compared to cisgender women.

Brain magnetic resonance imaging abnormalities following off-pump cardiac surgery.

BACKGROUND: Neurological and cognitive deficits are known complications after coronary artery bypass surgery (CABG) and are believed to be secondary to brain ischemia. Diffusion-weighted magnetic resonance imaging (DW-MRI) of the brain is especially sensitive and can depict ischemic areas that may not be evident clinically or with conventional MRI. Abnormalities found at brain MRI following CABG performed with cardiopulmonary bypass (ie, on pump) have been reported, but data are limited for CABG performed without use of cardiopulmonary bypass (ie, off pump). The objective of this study was to determine the rate of DW-MRI detection of brain lesions following off-pump CABG. METHODS AND RESULTS: Sixteen patients consecutively undergoing off-pump CABG underwent DW-MRI prior to and after surgery. A neuroradiologist blinded to patient data coded the location and size of lesions. Neurological function was assessed with the National Institutes of Health Stroke Scale. Five (31%) of the patients had new focal ischemic lesions found at postoperative DW-MRI. Risk factors for postoperative brain ischemic lesions were similar between patients with and those without lesions found at DW-MRI. No patient had a definite clinical stroke after surgery. CONCLUSIONS: Ischemic lesions found at DW-MRI are seen after off-pump CABG at a rate similar to that reported for CABG with cardiopulmonary bypass. This finding suggests that these lesions are not totally due to cardiopulmonary bypass. Further prospective clinical studies would be helpful for determining which factors are causally related to brain ischemia following CABG.