Variation in Hospital Neuraxial Labor Analgesia Rates in California.

BACKGROUND: Neuraxial analgesia provides effective pain relief during labor. However, it is unclear whether neuraxial analgesia prevalence differs across U.S. hospitals. The aim of this study was to assess hospital variation in neuraxial analgesia prevalence in California. METHODS: A retrospective cross-sectional study analyzed birthing patients who underwent labor in 200 California hospitals from 2016 to 2020. The primary exposure was the delivery hospital. The outcomes were hospital neuraxial analgesia prevalence and between-hospital variability, before and after adjustment for patient and hospital factors. Median odds ratio and intraclass correlation coefficients quantified between-hospital variability. The median odds ratio estimated the odds of a patient receiving neuraxial analgesia when moving between hospitals. The intraclass correlation coefficients quantified the proportion of the total variance in neuraxial analgesia use due to variation between hospitals. RESULTS: Among 1,510,750 patients who underwent labor, 1,040,483 (68.9%) received neuraxial analgesia. Both unadjusted and adjusted hospital prevalence exhibited a skewed distribution characterized by a long left tail. The unadjusted and adjusted prevalences were 5.4% and 6.0% at the 1st percentile, 21.0% and 21.2% at the 5th percentile, 70.6% and 70.7% at the 50th percentile, 75.8% and 76.6% at the 95th percentile, and 75.9% and 78.6% at the 99th percentile, respectively. The adjusted median odds ratio (2.3; 95% CI, 2.1 to 2.5) indicated substantially increased odds of a patient receiving neuraxial analgesia if they moved from a hospital with a lower odds of neuraxial analgesia to one with higher odds. The hospital explained only a moderate portion of the overall variability in neuraxial analgesia (intraclass correlation coefficient, 19.1%; 95% CI, 18.8 to 20.5%). CONCLUSIONS: A long left tail in the distribution and wide variation exist in the neuraxial analgesia prevalence across California hospitals that is not explained by patient and hospital factors. Addressing the low prevalence among hospitals in the left tail requires exploration of the interplay between patient preferences, staffing availability, and care providers' attitudes toward neuraxial analgesia.

Postpartum care visits among commercially insured women in the United States.

BACKGROUND: To reduce postpartum morbidity and mortality, optimizing routine outpatient postpartum care has become a focus of national attention and a healthcare priority. OBJECTIVE: This study aimed to examine the timing, content, and predictors of routine outpatient postpartum visit attendance within a large, commercially insured patient population. STUDY DESIGN: We performed a retrospective cohort study using a national US database of commercial insurance beneficiaries with a delivery hospitalization between 2011 and 2015. We calculated the proportion of patients who had an outpatient postpartum visit within 8 weeks of hospital discharge. Using a multivariable logistic regression model, we identified independent predictors of an outpatient postpartum visit. To gain insight into the nature and extent of any postpartum medical or surgical morbidity, we also identified the most frequent International Classification of Diseases, Ninth Revision, Clinical Modification codes associated with postpartum visits. RESULTS: The study cohort comprised 431,969 patients who underwent delivery hospitalization, of whom 257,727 (59.7%; 95% confidence interval, 59.5-59.8) had at least 1 outpatient postpartum visit within 8 weeks of hospital discharge. The distribution of postpartum visits was bimodal, occurring most frequently in the first week (23.2%) and sixth week (21.7%) after hospital discharge. The median period between hospital discharge and the postpartum visit was 28 days (interquartile range, 8-41 days). In our multivariable model, patient-level factors that were most strongly associated with a postpartum visit were preexisting medical morbidities, which included: thyroid disease (adjusted odds ratio, 1.62; 95% confidence interval, 1.40-1.52), seizure disorder (adjusted odds ratio, 1.50; 95% confidence interval, 1.33-1.70), chronic hypertension (adjusted odds ratio, 1.46; 95% confidence interval, 1.58-1.67), and psychiatric disease (adjusted odds ratio, 1.41; 95% confidence interval, 1.36-1.47). Between 29% and 42% of patients with preexisting medical morbidity and between 35% and 41% of patients who experienced peri- or postpartum complications did not attend a postpartum visit. CONCLUSION: Our findings indicate that among a large, commercially-insured patient population, postpartum visit attendance was suboptimal. A high proportion with preexisting medical and peripartum morbidities was not evaluated within 8 weeks of hospital discharge. Multifaceted interventions and healthcare reform are suggested to address patients' concerns and healthcare needs after delivery.

Hospital-level variation in rates of postpartum hemorrhage in California.

BACKGROUND: To examine the extent of hospital-level variation in risk-adjusted rates of postpartum hemorrhage (PPH). STUDY DESIGN AND METHODS: We performed a cross-sectional study examining live births in 257 California hospitals between 2011 and 2015 using linked birth certificate and maternal discharge data. PPH was measured using International Classification of Diseases Codes version 9. Mixed-effects logistic regression models were used to examine the presence and extent of hospital-level variation in PPH before and after adjustment for patient-level risk factors and select hospital characteristics (teaching status and annual delivery volume). Risk-adjusted rates of PPH were estimated for each hospital. The extent of hospital variation was evaluated using the median odds ratio (MOR) and intraclass correlation coefficient (ICC). RESULTS: Our study cohort comprised 1,904,479 women who had a live birth delivery hospitalization at 247 hospitals. The median, lowest, and highest hospital-specific rates of PPH were 3.48%, 0.54%, and 12.0%, respectively. Similar rates were observed after adjustment for patient and hospital factors (3.44%, 0.60%, and 11.48%). After adjustment, the proportion of the total variation in PPH rates attributable to the hospital was low, with a MOR of 2.02 (95% confidence interval [CI]: 1.89-2.15) and ICC of 14.3% (95% CI: 11.9%-16.3%). DISCUSSION: Wide variability exists in the rate of PPH across hospitals in California, not attributable to patient factors, hospital teaching status, and hospital annual delivery volume. Determining whether differences in hospital quality of care explain the unaccounted-for variation in hospital-level PPH rates should be a public health priority.

Feasibility and thematic analysis of narrative visualization materials with physical activity monitoring among breast cancer survivors.

BACKGROUND: Breast cancer survivors have a unique risk for negative health outcomes. Engaging in routine physical activity (PA) can reduce these risks. However, PA levels are low among this population. Narrative visualization (NV) is a technique that uses drawings, photographs, and text to contextualize data, which may increase integrated regulation, or motivation related to personal values and identity. A PA intervention targeting breast cancer survivors using an NV strategy may improve PA behavior. The purpose of this study was to determine whether scrapbooking activities could successfully be used as an NV strategy for older (55+) breast cancer survivors. METHODS: Breast cancer survivors were given workbooks, wearable electronic activity monitors, instant cameras, and art supplies including a variety of stickers (e.g., emojis, affirmations). Participants were instructed to use these materials for 7 days. The workbook pages prompted participants to re-draw their daily activity graphs from the wearable's mobile app, then annotate them with text, photographs, stickers, etc. to reflect what the data meant to them. Hybrid thematic analysis was used to analyze the photographs, drawings, and written content to identify emergent themes. Content analysis was also used to investigate use of stickers and photographs. RESULTS: Of the 20 consented women (mean age 67 ± 5 years, 45% non-Hispanic white), 3 participants were lost to follow-up or unable to complete the procedures. The NV procedures were successfully utilized by the remaining 17 participants, who collectively used 945 stickers over 7 days, most of which were emojis. Emojis were both positively and negatively valanced. Participants took a mean of 9 photos over 7 days and completed workbook questions regarding current PA and PA goals. Themes within the photos included family, specific locations, everyday objects, religion, and friends. Themes within the written portions of the workbook included family, chores and obligations, health, personal reflection, hobbies, and shopping. CONCLUSIONS: The materials provided allowed breast cancer survivors to successfully use NV techniques to reflect on their PA data and behavior. These techniques show promise for promoting integrated regulation in activity monitoring interventions. TRIAL REGISTRATION: This study was funded by the National Cancer Institute ( R21CA218543 ) beginning July 1, 2018.

A Photography-based, Social Media Walking Intervention Targeting Autonomous Motivations for Physical Activity: Semistructured Interviews With Older Women.

BACKGROUND: Older adult women are at risk for negative health outcomes that engaging in sustained physical activity can help prevent. However, promoting long-term maintenance of physical activity in this population has proven to be a challenge. Increasing autonomous motivations (ie, intrinsic, integrated, and identified regulations) for physical activity may facilitate enduring behavior change. Digitally delivered games for health that take a celebratory technology approach, that is, using technology to create new ways to experience valued behaviors and express valued beliefs, may be a useful way to target autonomous motivations for physical activity. Formative research with the target population is needed to design compelling intervention content. OBJECTIVE: The objective of this study is to investigate older adult women's reactions to and thoughts about a photography-based, social media walking game targeting autonomous motivations for physical activity. METHODS: During an individual semistructured interview, a moderator solicited feedback from 20 older adult women (age range 65-74 years) as part of formative research to develop a social media game featuring weekly walking challenges. The challenges were designed to target autonomous motivations for physical activity. Interviews were audio-recorded and transcribed verbatim. Two reviewers conducted thematic content analysis on interview transcripts. RESULTS: We identified 3 overarching themes in qualitative data analysis. These reflected the playful experiences, value, and acceptability associated with the intervention challenges. Generally, participants understood what the challenges were asking them to do, proffered appropriate example responses, and indicated that the challenges would be enjoyable. Participants reported that the intervention content afforded many and varied playful experiences (eg, competition, discovery, exploration, expression, fellowship, humor, nurture, sensation). Further, participants indicated that the intervention increased their motivation for physical activity, occasioned meaningful shifts in perspective, increased their knowledge of various topics of interest, provided an opportunity to create valued connection with others, and provided health-related benefits. Participants suggested the intervention emphasize local history, nature, and cultural events. CONCLUSIONS: The photography-based, social media walking game with relatively simple game mechanics was well received and judged to be apt to bring about a wide variety of emotive experiences. A clear, geographically specific identity emerged as a key driver of interest for intervention content. Taking a celebratory technology approach holds promise for targeting autonomous motivations for physical activity in older adult women.

Association of Medicaid Expansion With Neuraxial Labor Analgesia Use in the United States: A Retrospective Cross-Sectional Analysis.

BACKGROUND: The Affordable Care Act has been associated with increased Medicaid coverage for childbirth among low-income US women. We hypothesized that Medicaid expansion was associated with increased use of labor neuraxial analgesia. METHODS: We performed a cross-sectional analysis of US women with singleton live births who underwent vaginal delivery or intrapartum cesarean delivery between 2009 and 2017. Data were sourced from births in 26 US states that used the 2003 Revised US Birth Certificate. Difference-in-difference linear probability models were used to compare changes in the prevalence of neuraxial labor analgesia in 15 expansion and 11 nonexpansion states before and after Medicaid expansion. Models were adjusted for potential maternal and obstetric confounders with standard errors clustered at the state level. RESULTS: The study sample included 5,703,371 births from 15 expansion states and 5,582,689 births from 11 nonexpansion states. In the preexpansion period, the overall rate of neuraxial analgesia in expansion and nonexpansion states was 73.2% vs 76.3%. Compared with the preexpansion period, the rate of neuraxial analgesia increased in the postexpansion period by 1.7% in expansion states (95% CI, 1.6-1.8) and 0.9% (95% CI, 0.9-1.0) in nonexpansion states. The adjusted difference-in-difference estimate comparing expansion and nonexpansion states was 0.47% points (95% CI, -0.63 to 1.57; P = .39). CONCLUSIONS: Medicaid expansion was not associated with an increase in the rate of neuraxial labor analgesia in expansion states compared to the change in nonexpansion states over the same time period. Increasing Medicaid eligibility alone may be insufficient to increase the rate of neuraxial labor analgesia.

Trends in eclampsia in the United States, 2009-2017: a population-based study.

BACKGROUND: Reducing the prevalence of eclampsia, a major cause of maternal and perinatal morbidity, is a maternal health priority. However, sparse data exist examining trends in the USA prevalence of eclampsia. OBJECTIVE: The aim of this study was to assess temporal trends in the prevalence of eclampsia among live births in the United States from 2009 to 2017. STUDY DESIGN: This population-based cross-sectional study included live births in 41 USA states and the District of Columbia between 2009 and 2017. The prevalence of eclampsia among all women, women with chronic hypertension and hypertensive disorders of pregnancy were reported by 1000 live births. Risk ratios adjusted for maternal characteristics were used to assess temporal trends. RESULTS: Of 27 866 714 live births between 2009 and 2017, 83 000 (0.30%) were associated with eclampsia. The adjusted risk of eclampsia decreased 10% during the 7 most recent years of the cohort, with an adjusted risk ratio of 0.90 [95% confidence interval (95% CI): 0.87-0.93] in 2017 relative to 2009. Relative to 2009, the adjusted risk of eclampsia in 2017 was substantially lower among women with chronic hypertension (adjusted risk ratio: 0.51; 95% CI: 0.46-0.57) and women with hypertensive pregnancy disorders (adjusted risk ratio: 0.43; 95% CI: 0.40-0.47). Among nonhypertensive women, there was a slight increase in the adjusted risk of eclampsia in 2017 relative to 2009 (adjusted risk ratio: 1.14; 95% CI: 1.10-1.17). CONCLUSION: Despite reductions in the eclampsia prevalence among women with chronic hypertension and hypertensive disorders of pregnancy, public health initiatives are needed to reduce the overall eclampsia prevalence, especially in nonhypertensive women.

Alternatives to low birthweight as a population-level indicator of infant and child health.

BACKGROUND: Low birthweight (<2500 g) is often used as a population-level indicator of maternal-child health, as it is easy to measure and correlates with poorer infant health outcomes. However, it conflates preterm birth and intrauterine growth restriction, which have different causal pathways and require different approaches to prevention. Small for gestational age (SGA) (a proxy for growth restriction) and preterm birth may be more informative measures. We evaluated low birthweight as a population-level indicator. METHODS: We conducted a population-based cohort study of singleton live births in New South Wales (NSW), Australia, using linked data from 1994-2006 birth, hospital, death and educational records, with follow-up until 2014. Outcomes of babies born of low birthweight, preterm and SGA were compared with well-grown term infants (i.e. not low birthweight or SGA). Overlap between groups and temporal trends were also examined. RESULTS: Of 1 093 765 singleton live births, 47 946 (4.4%) infants were low birthweight and had poorer outcomes than well-grown term infants (2.7% vs. 0.1% infant mortality; 13% vs. 6% below national minimum numeracy standard). SGA and preterm infants also had poorer outcomes (0.5%, 2.3% infant mortality respectively; 10%, 11% below numeracy standard) but 80% of SGA and 47% of preterm infants were not low birthweight. For all outcomes, low birthweight identified a smaller proportion of infants with poor outcomes than preterm birth and than either SGA or low birthweight at term. The proportion of low-birthweight births remained constant over time, while the proportion of births that were preterm increased and proportion of SGA decreased. CONCLUSIONS: Low birthweight, SGA and preterm infants are all at higher risk of poorer outcomes but low birthweight inadequately captures, and masks trends in, both preterm births and births that are SGA. Reporting preterm births and an indicator of growth restriction at term will identify vulnerable groups better than using the measure of low birthweight.

Implementing health communication tools at scale: mobile audio messaging and paper-based job aids for front-line workers providing community health education to mothers in Bihar, India.

INTRODUCTION: As part of an investment by the Bill & Melinda Gates Foundation to support the Government of Bihar to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) statewide, BBC Media Action implemented multiple communication tools to support front-line worker (FLW) outreach. We analyse the impacts of a package of mHealth audio messaging and paper-based job aids used by FLWs during government-sponsored village health, sanitation and nutrition days (VHSNDs) on knowledge and practices of childbearing women across the RMNCHN continuum of care. METHODS: Data from two surveys collected between July and September 2016 were analysed using logistic regression to compare health-related knowledge and behaviours between women who had been exposed at VHSNDs to the mHealth GupShup Potli (GSP) audio recordings or interpersonal communication (IPC) tools versus those who were unexposed. RESULTS: Exposure to GSP recordings (n=2608) was associated with improved knowledge across all continuum-of-care domains, as well as improved health-related behaviours in some domains. The odds of having taken iron-folic acid (IFA) tablets were significantly higher in exposed women (OR 1.5, 95% CI 1.1 to 2.2), as was contraceptive use (OR 2.0, 95% CI 1.2 to 3.2). There were no differences in birth preparedness or complementary feeding practices between groups. Exposure to IPC paper-based tools (n=2002) was associated with a twofold increased odds of IFA consumption (OR 2.3, 95% CI 1.7 to 3.2) and contraceptive use (OR 1.8, 95% CI 1.2 to 2.8). Women exposed to both tools were generally at least twice as likely to subsequently discuss the messages with others. CONCLUSION: BBC Media Action's mHealth audio messaging job aids and paper-based IPC tools were associated with improved knowledge and practices of women who were exposed to them across multiple domains, suggesting their important potential for improving health outcomes for beneficiaries at scale in low-resource settings. TRIAL REGISTRATION NUMBER: NCT02726230.

Defining and describing treatment heterogeneity in new-onset idiopathic lower back and extremity pain through reconstruction of longitudinal care sequences.

BACKGROUND CONTEXT: Despite established guidelines, long-term management of surgically-treated low back pain (LBP) and lower extremity pain (LEP) remains heterogeneous. Understanding care heterogeneity could inform future approaches for standardization of practices. PURPOSE: To describe treatment heterogeneity in surgically-managed LBP and LEP. STUDY DESIGN/SETTING: Retrospective study of a nationwide commercial database spanning inpatient and outpatient encounters for enrollees of eligible employer-supplied healthcare plans (2007-2016). PATIENT SAMPLE: A population-based sample of opioid-naïve adult patients with newly-diagnosed LBP or LEP were identified. Inclusion required at least 12-months of pre-diagnosis and post-diagnosis continuous follow-up. EXPOSURE: Included treatments/evaluations include conservative management (chiropractic manipulative therapy, physical therapy, epidural steroid injections), imaging (x-ray, MRI, CT), pharmaceuticals (opioids, benzodiazepines), and spine surgery (decompression, fusion). OUTCOME MEASURES: Primary outcomes-of-interest were 12-month net healthcare expenditures (inpatient and outpatient) and 12-month opioid usage. METHODS: Analyses include interrogation of care sequence heterogeneity and temporal trends in sequence-initiating services. Comparisons were conducted in the framework of sequence-specific treatment sequences, which reflect the personalized order of healthcare services pursued by each patient. Outlier sequences characterized by high opioid use and costs were identified from frequently observed surgical treatment sequences using Mahalanobis distance. RESULTS: A total of 2,496,908 opioid-naïve adult patients with newly-diagnosed LBP or LEP were included (29,519 surgical). In the matched setting, increased care sequence heterogeneity was observed in surgical patients (0.51 vs. 0.12 previously-unused interventions/studies pursued per month). Early opioid and MRI use has decreased between 2008 and 2015 but is matched by increases in early benzodiazepine and x-ray use. Outlier sequences, characterized by increased opioid use and costs, were found in 5.8% of surgical patients. Use of imaging prior to conservative management was common in patients pursuing outlier sequences compared to non-outlier sequences (96.5% vs. 63.8%, p<.001). Non-outlier sequences were more frequently characterized by early conservative interventions (31.9% vs. 7.4%, p<.001). CONCLUSIONS: Surgically-managed LBP and LEP care sequences demonstrate high heterogeneity despite established practice guidelines. Outlier sequences associated with high opioid usage and costs can be identified and are characterized by increased early imaging and decreased early conservative management. Elements that may portend suboptimal longitudinal management could provide opportunities for standardization of patient care.

Breastfeeding patterns and effects of minimal supplementation on breastfeeding exclusivity and duration in term infants: A prospective sub-study of a randomised controlled trial.

AIM: Despite international recommendations, less than one-third of Australian women exclusively breastfeed for 6 months. The aims of this study were to prospectively determine rates and factors associated with the type and duration of breastfeeding in the first year and examine the effect of minimal supplementation. METHODS: We conducted a sub-study of a randomised controlled trial in Sydney, Australia, which included 635 women with uncomplicated term births who intended to breastfeed. Data were collected daily for 56 days, and then at 2, 6 and 12 months post-partum. RESULTS: Breastfeeding outcomes were evaluated for 553 (87%), 480 (76%) and 392 (62%) women at 2, 6 and 12 months. Exclusive breastfeeding was 81% at 2 months and 8% at 6 months. Partial breastfeeding was 75% at 6 months and 54% at 12 months. Factors associated with breastfeeding cessation included caesarean birth, low milk supply, problems latching, increased time to breastfeed, use of formula >7 days in the first 2 months, return to work and early introduction of solids. Breast pain in the first week was associated with a 10% decrease in exclusive breastfeeding. Cracked nipples and no previous breastfeeding experience were associated with supplementation of ≤7 days but had no effect on long-term breastfeeding duration. CONCLUSIONS: Exclusive breastfeeding declined significantly between 2 and 6 months post-partum. Early intervention and education to prolong breastfeeding duration should include strategies to manage breast pain and nipple damage to minimise prolonged supplementation. Consistent guidelines about introduction of complementary foods, improved maternity leave and workplace incentives could be effective in prolonging breastfeeding.

Association of Gestational Age with Postpartum Hemorrhage: An International Cohort Study.

BACKGROUND: Risk factors for postpartum hemorrhage, such as chorioamnionitis and multiple gestation, have been identified in previous epidemiologic studies. However, existing data describing the association between gestational age at delivery and postpartum hemorrhage are conflicting. The aim of this study was to assess the association between gestational age at delivery and postpartum hemorrhage. METHODS: The authors conducted a population-based retrospective cohort study of women who underwent live birth delivery in Sweden between 2014 and 2017 and in California between 2011 and 2015. The primary exposure was gestational age at delivery. The primary outcome was postpartum hemorrhage, classified using International Classification of Diseases, Ninth Revision-Clinical Modification codes for California births and a blood loss greater than 1,000 ml for Swedish births. The authors accounted for demographic and obstetric factors as potential confounders in the analyses. RESULTS: The incidences of postpartum hemorrhage in Sweden (23,323/328,729; 7.1%) and in California (66,583/2,079,637; 3.2%) were not comparable. In Sweden and California, the incidence of postpartum hemorrhage was highest for deliveries between 41 and 42 weeks' gestation (7,186/75,539 [9.5%] and 8,921/160,267 [5.6%], respectively). Compared to deliveries between 37 and 38 weeks, deliveries between 41 and 42 weeks had the highest adjusted odds of postpartum hemorrhage (1.62 [95% CI, 1.56 to 1.69] in Sweden and 2.04 [95% CI, 1.98 to 2.09] in California). In both cohorts, the authors observed a nonlinear (J-shaped) association between gestational age and postpartum hemorrhage risk, with 39 weeks as the nadir. In the sensitivity analyses, similar findings were observed among cesarean deliveries only, when postpartum hemorrhage was classified only by International Classification of Diseases, Tenth Revision-Clinical Modification codes, and after excluding women with abnormal placentation disorders. CONCLUSIONS: The postpartum hemorrhage incidence in Sweden and California was not comparable. When assessing a woman's risk for postpartum hemorrhage, clinicians should be aware of the heightened odds in women who deliver between 41 and 42 weeks' gestation.

Inpatient Observation After Transition From Intravenous to Oral Antibiotics.

OBJECTIVES: Children hospitalized with infections are commonly transitioned from intravenous (IV) to enteral (per os [PO]) antibiotics before discharge, after which they may be observed in the hospital to ensure tolerance of PO therapy and continued clinical improvement. We sought to describe the frequency and predictors of in-hospital observation after transition from IV to PO antibiotics in children admitted for skin and soft tissue infections (SSTIs). METHODS: We conducted a retrospective cohort study of children with SSTIs discharged between January 1, 2016, and June 30, 2018, using the Pediatric Health Information System database. Children were classified as observed if hospitalized ≥1 day after transitioning from IV to PO antibiotics. We calculated the proportion of observed patients and used logistic regression with random intercepts to identify predictors of in-hospital observation. RESULTS: Overall, 15% (558 of 3704) of hospitalizations for SSTIs included observation for ≥1 hospital day after the transition from IV to PO antibiotics. The proportion of children observed differed significantly between hospitals (range of 4%-27%; P < .001). Observation after transition to PO antibiotics was less common in older children (adjusted odds ratio [aOR] = 0.69; 95% confidence interval [CI] 0.52-0.90; P = .045). Children initially prescribed vancomycin (aOR = 1.36; 95% CI 1.03-1.79; P = .032) or with infections located on the neck (aOR = 1.72; 95% CI 1.32-2.24; P < .001) were more likely to be observed. CONCLUSIONS: Children hospitalized for SSTIs are frequently observed after transitioning from IV to PO antibiotics, and there is substantial variability in the observation rate between hospitals. Specific factors predict in-hospital observation and should be investigated as part of future studies aimed at improving the care of children hospitalized with SSTIs.

Timing and Predictors of Subspecialty Career Choice Among Internal Medicine Residents: A Retrospective Cohort Study.

BACKGROUND: Internal medicine residents face numerous career options after residency training. Little is known about when residents make their final career choice. OBJECTIVE: We assessed the timing and predictive factors of final career choices among internal medicine residents at graduation, including demographics, pre-residency career preferences, and rotation scheduling. METHODS: We conducted a retrospective study of graduates of an academic internal medicine residency program from 2014 to 2017. Main measures included demographics, rotation schedules, and self-reported career choices for residents at 5 time points: recruitment day, immediately after Match Day, end of postgraduate year 1 (PGY-1), end of PGY-2, and at graduation. RESULTS: Of the 138 residents eligible for the study, 5 were excluded based on participation in a fast-track program for an Accreditation Council for Graduate Medical Education subspecialty fellowship. Among the remaining 133 residents, 48 (36%) pursued general internal medicine fields and 78 (59%) pursued fellowship training. Career choices from recruitment day, Match Day, and PGY-1 were only weakly predictive of the career choice. Many choices demonstrated low concordance throughout training, and general medicine fields (primary care, hospital medicine) were frequently not decided until after PGY-2. Early clinical exposure to subspecialty rotations did not predict final career choice. CONCLUSIONS: Early career choices before and during residency training may have low predictability toward final career choices upon graduation in internal medicine. These choices may continue to have low predictability beyond PGY-2 for many specialties. Early clinical exposure may not predict final career choice for subspecialties.

Epigenetic clock measuring age acceleration via DNA methylation levels in blood is associated with decreased oocyte yield.

PURPOSE: To investigate how biologic age (phenotypic age at which your body functions) greater than chronologic age, (age acceleration (AgeAccel)), correlates with oocyte yield. METHODS: Thirty-nine women undergoing ovarian stimulation, inclusive of all infertility diagnoses, were included in this pilot study. Methylome analysis of peripheral blood was utilized to determine biologic age. AgeAccel was defined as biologic age > 2 years older than chronologic age. A negative binomial model was used to obtain the crude association of AgeAccel with number of oocytes. A parsimonious adjusted model for the number of oocytes was obtained using backwards selection (p < 0.05). RESULTS: Measures of age were negatively correlated with number of oocytes (chronological age Pearson ρ = - 0.45, biologic age Pearson ρ = - 0.46) and AMH was positively correlated with number of oocytes (Pearson ρ = 0.91). Patients with AgeAccel were noted to have lower AMH values (1.29 ng/mL vs. 2.29, respectively (p = 0.049)) and lower oocyte yield (5.50 oocytes vs. 14.50 oocytes, respectively (p = 0.0030)). A crude association of a 7-oocyte reduction in the age-accelerated group was found (- 6.9 oocytes (CI - 11.6, - 2.4)). In a model with AMH and antral follicle count, AgeAccel was associated with a statistically significant 3.3 reduction in the number of oocytes (- 3.1; 95% CI - 6.5, - 0.1; p = 0.036). CONCLUSIONS: In this small pilot study, AgeAccel is associated with a lower AMH and lower oocyte yield providing preliminary evidence that biologic age, specifically AgeAccel, may serve as an epigenetic biomarker to improve the ability of predictive models to assess ovarian reserve.

Portable Ultrasound Device Usage and Learning Outcomes Among Internal Medicine Trainees: A Parallel-Group Randomized Trial.

BACKGROUND: Little is known about how to effectively train residents with point-of-care ultrasonography (POCUS) despite increasing usage. OBJECTIVE: This study aimed to assess whether handheld ultrasound devices (HUDs), alongside a year-long lecture series, improved trainee image interpretation skills with POCUS. METHODS: Internal medicine intern physicians (N = 149) at a single academic institution from 2016 to 2018 participated in the study. The 2017 interns (n = 47) were randomized 1:1 to receive personal HUDs (n = 24) for patient care vs no-HUDs (n = 23). All 2017 interns received a repeated lecture series regarding cardiac, thoracic, and abdominal POCUS. Interns were assessed on their ability to interpret POCUS images of normal/abnormal findings. The primary outcome was the difference in end-of-the-year assessment scores between interns randomized to receive HUDs vs not. Secondary outcomes included trainee scores after repeating lectures and confidence with POCUS. Intern scores were also compared with historical (2016, N = 50) and contemporaneous (2018, N = 52) controls who received no lectures. RESULTS: Interns randomized to HUDs did not have significantly higher image interpretation scores (median HUD score: 0.84 vs no-HUD score: 0.84; P = .86). However, HUD interns felt more confident in their abilities. The 2017 cohort had higher scores (median 0.84), compared with the 2016 historical control (median 0.71; P = .001) and 2018 contemporaneous control (median 0.48; P < .001). Assessment scores improved after first-time exposure to the lecture series, while repeated lectures did not improve scores. CONCLUSIONS: Despite feeling more confident, personalized HUDs did not improve interns' POCUS-related knowledge or interpretive ability. Repeated lecture exposure without further opportunities for deliberate practice may not be beneficial for mastering POCUS.

Improving primary health care delivery in Bihar, India: Learning from piloting and statewide scale-up of Ananya.

In 2010, the Bill and Melinda Gates Foundation (BMGF) partnered with the Government of Bihar (GoB), India to launch the Ananya program to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) outcomes. The program sought to address supply- and demand-side barriers to the adoption, coverage, quality, equity and health impact of select RMNCHN interventions. Approaches included strengthening frontline worker service delivery; social and behavior change communications; layering of health, nutrition and sanitation into women's self-help groups (SHGs); and quality improvement in maternal and newborn care at primary health care facilities. Ananya program interventions were piloted in approximately 28 million population in eight innovation districts from 2011-2013, and then beginning in 2014, were scaled up by the GoB across the rest of the state's population of 104 million. A Bihar Technical Support Program provided techno-managerial support to governmental Health as well as Integrated Child Development Services, and the JEEViKA Technical Support Program supported health layering and scale-up of the GoB's SHG program. The level of support at the block level during statewide scale-up in 2014 onwards was approximately one-fourth that provided in the pilot phase of Ananya in 2011-2013. This paper - the first manuscript in an 11-manuscript and 2-viewpoint collection on Learning from Ananya: Lessons for primary health care performance improvement - seeks to provide a broad description of Ananya and subsequent statewide adaptation and scale-up, and capture the background and context, key objectives, interventions, delivery approaches and evaluation methods of this expansive program. Subsequent papers in this collection focus on specific intervention delivery platforms. For the analyses in this series, Stanford University held key informant interviews and worked with the technical support and evaluation grantees of the Ananya program, as well as leadership from the India Country Office of the BMGF, to analyse and synthesise data from multiple sources. Capturing lessons from the Ananya pilot program and statewide scale-up will assist program managers and policymakers to more effectively design and implement RMNCHN programs at scale through technical assistance to governments.

Trends in reproductive, maternal, newborn and child health and nutrition indicators during five years of piloting and scaling-up of Ananya interventions in Bihar, India.

BACKGROUND: The Ananya program in Bihar implemented household and community-level interventions to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) in two phases: a first phase of intensive ancillary support to governmental implementation and innovation testing by non-government organisation (NGO) partners in eight focus districts (2012-2014), followed by a second phase of state-wide government-led implementation with techno-managerial assistance from NGOs (2014 onwards). This paper examines trends in RMNCHN indicators in the program's implementation districts from 2012-2017. METHODS: Eight consecutive rounds of cross-sectional Community-based Household Surveys conducted by CARE India in 2012-2017 provided comparable data on a large number of indicators of frontline worker (FLW) performance, mothers' behaviours, and facility-based care and outreach service delivery across the continuum of maternal and child care. Logistic regression, considering the complex survey design and sample weights generated by that design, was used to estimate trends using survey rounds 2-5 for the first phase in the eight focus districts and rounds 6-9 for the second phase in all 38 districts statewide, as well as the overall change from round 2-9 in focus districts. To aid in contextualising the results, indicators were also compared amongst the formerly focus and the non-focus districts at the beginning of the second phase. RESULTS: In the first phase, the levels of 34 out of 52 indicators increased significantly in the focus districts, including almost all indicators of FLW performance in antenatal and postnatal care, along with mother's birth preparedness, some breastfeeding practices, and immunisations. Between the two phases, 33 of 52 indicators declined significantly. In the second phase, the formerly focus districts experienced a rise in the levels of 14 of 50 indicators and a decline in the levels of 14 other indicators. There was a rise in the levels of 22 out of 50 indicators in the non-focus districts in the second phase, with a decline in the levels of 13 other indicators. CONCLUSIONS: Improvements in indicators were conditional on implementation support to program activities at a level of intensity that was higher than what could be achieved at scale so far. Successes during the pilot phase of intensive support suggests that RMNCHN can be improved statewide in Bihar with sufficient investments in systems performance improvements. STUDY REGISTRATION: ClinicalTrials.gov number NCT02726230.

Impact of the Ananya program on reproductive, maternal, newborn and child health and nutrition in Bihar, India: early results from a quasi-experimental study.

BACKGROUND: The Government of Bihar (GoB) in India, the Bill and Melinda Gates Foundation and several non-governmental organisations launched the Ananya program aimed to support the GoB to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) statewide. Here we summarise changes in indicators attained during the initial two-year pilot phase (2012-2013) of implementation in eight focus districts of approximately 28 million population, aimed to inform subsequent scale-up. METHODS: The quasi-experimental impact evaluation included statewide household surveys at two time points during the pilot phase: January-April 2012 ("baseline") including an initial cohort of beneficiaries and January-April 2014 ("midline") with a new cohort. The two arms were: 1) eight intervention districts, and 2) a comparison arm comprised of the remaining 30 districts in Bihar where Ananya interventions were not implemented. We analysed changes in indicators across the RMNCHN continuum of care from baseline to midline in intervention and comparison districts using a difference-in-difference analysis. RESULTS: Indicators in the two arms were similar at baseline. Overall, 40% of indicators (20 of 51) changed significantly from baseline to midline in the comparison districts unrelated to Ananya; two-thirds (n = 13) of secular indicator changes were in a direction expected to promote health. Statistically significant impact attributable to the Ananya program was found for 10% (five of 51) of RMNCHN indicators. Positive impacts were most prominent for mother's behaviours in contraceptive utilisation. CONCLUSIONS: The Ananya program had limited impact in improving health-related outcomes during the first two-year period covered by this evaluation. The program's theories of change and action were not powered to observe statistically significant differences in RMNCHN indicators within two years, but rather aimed to help inform program improvements and scale-up. Evaluation of large-scale programs such as Ananya using theory-informed, equity-sensitive (including gender), mixed-methods approaches can help elucidate causality and better explain pathways through which supply- and demand-side interventions contribute to changes in behaviour among the actors involved in the production of population-level health outcomes. Evidence from Bihar indicates that deep structural constraints in health system organisation and delivery of interventions pose substantial limitations on behaviour change among health care providers and beneficiaries. STUDY REGISTRATION: ClinicalTrials.gov number NCT02726230.

Impact of mHealth interventions for reproductive, maternal, newborn and child health and nutrition at scale: BBC Media Action and the Ananya program in Bihar, India.

BACKGROUND: Mobile health (mHealth) tools have potential for improving the reach and quality of health information and services through community health workers in low- and middle-income countries. This study evaluates the impact of an mHealth tool implemented at scale as part of the statewide reproductive,maternal, newborn and child health and nutrition (RMNCHN) program in Bihar, India. METHODS: Three survey-based data sets were analysed to compare the health-related knowledge, attitudes and behaviours amongst childbearing women exposed to the Mobile Kunji and Dr. Anita mHealth tools during their visits with frontline workers compared with those who were unexposed. RESULTS: An evaluation by Mathematica (2014) revealed that exposure to Mobile Kunji and Dr. Anita recordings were associated with significantly higher odds of consuming iron-folic acid tablets (odds ratio (OR) = 2.3, 95% confidence interval (CI) = 1.8-3.1) as well as taking a set of three measures for delivery preparedness (OR = 2.8, 95% CI = 1.9-4.2) and appropriate infant complementary feeding (OR = 1.9, 95% CI = 1.0-3.5). CARE India's Community-based Household Surveys (2012-2017) demonstrated significant improvements in early breastfeeding (OR = 1.64, 95% CI = 1.5-1.78) and exclusive breastfeeding (OR = 1.46, 95% CI = 1.33-1.62) in addition to birth preparedness practices. BBC Media Action's Usage & Engagement Survey (2014) demonstrated a positive association between exposure to Mobile Kunji and Dr. Anita and exclusive breastfeeding (58% exposed vs 43% unexposed, P < 0.01) as well as maternal respondents' trust in their frontline worker. CONCLUSIONS: Significant improvements in RMNCHN-related knowledge and behaviours were observed for Bihari women who were exposed to Mobile Kunji and Dr. Anita. This analysis is unique in its rigorous evaluation across multiple data sets of mHealth interventions implemented at scale. These results can help inform global understanding of how best to use mHealth tools, for whom, and in what contexts. STUDY REGISTRATION: ClinicalTrials.gov number NCT02726230.