Accelerating Climate Action Through Academic Health Systems: Leadership's Call to Duty.

This Viewpoint makes the case for academic health systems to lead the way on climate change action in the US, including planning to reduce greenhouse gas emissions, educating current and future clinicians, and communicating with their patients and communities.

Developing a Workforce for Health in North Carolina: Planning for the Future.

Among the many trends influencing health and health care delivery over the next decade, three are particularly important: the transition to value-based care and increased focus on population health; the shift of care from acute to community-based settings; and addressing the vulnerability of rural health care systems in North Carolina.

Implementing Community Engagement as a Mission at the David Geffen School of Medicine at the University of California, Los Angeles.

This manuscript describes the development and implementation of community engagement as a mission at UCLA's David Geffen School of Medicine (DGSOM) and UCLA Health System, and summarizes survey results documenting existing community-engaged projects and interest between 2010 to 2013.

Implementing Community Engagement as a Mission at the David Geffen School of Medicine at the University of California, Los Angeles.

This manuscript describes the development and implementation of community engagement as a mission at UCLA's David Geffen School of Medicine (DGSOM) and UCLA Health System, and summarizes survey results documenting existing community-engaged projects and interest between 2010 to 2013.

Contributions of hysterectomy and uterus-preserving surgery to health-related quality of life.

OBJECTIVE: To document the long-term effect of surgical interventions for noncancerous uterine conditions on health-related quality of life. METHODS: The Study of Pelvic Problems, Hysterectomy and Intervention Alternatives, conducted between 1998 and 2008, was a longitudinal study of 1,503 women with intact uteri experiencing abnormal uterine bleeding with or without leiomyomas, chronic pelvic pain, or pressure resulting from leiomyomas. Baseline and follow-up questionnaires included three condition-specific measures (Pelvic Problem Resolution, Pelvic Problem Impact Overall, and Pelvic Problem Impact on Sex) and five generic measures (Short Form-12 Mental and Physical Component Summaries, Current Health Utility, Feelings about Heath, and Satisfaction with Sex). We modeled changes over time in these patient-reported outcomes stratified by the most invasive treatment undergone (hysterectomy [13.7%], uterus-preserving surgery [9.0%], or nonsurgical therapy [77.3%]). RESULTS: Participants in all three groups reported significant improvement on all condition-specific measures and two of the five generic measures (Current Health Utility and Feelings about Health) from enrollment to final interview (all P values <.01). In general, greater improvements were experienced by women who had surgery. Trajectories modeled around the dates of surgery showed dramatic improvements after hysterectomy and, to a lesser degree, after uterus-preserving surgery. Although women who underwent uterus-preserving surgery tended to show immediate improvement, women who underwent hysterectomy experienced a 6-month delay in improvement in some outcomes with trajectories converging by 4 years postsurgery. CONCLUSION: Women seeking care for noncancerous uterine conditions can expect to experience improvement over time. Those who opt for surgery may experience most improvement. Understanding health-related quality-of-life trajectories may enhance counseling for women deciding between hysterectomy and alternative interventions. LEVEL OF EVIDENCE: II.

Using visual displays to communicate risk of cancer to women from diverse race/ethnic backgrounds.

OBJECTIVE: This study evaluated how well women from diverse race/ethnic groups were able to take a quantitative cancer risk statistic verbally provided to them and report it in a visual format. METHODS: Cross-sectional survey was administered in English, Spanish or Chinese, to women aged 50-80 (n=1160), recruited from primary care practices. The survey contained breast, colorectal or cervical cancer questions regarding screening and prevention. Women were told cancer-specific lifetime risk then shown a visual display of risk and asked to indicate the specific lifetime risk. Correct indication of risk was the main outcome. RESULTS: Correct responses on icon arrays were 46% for breast, 55% for colon, and 44% for cervical; only 25% correctly responded to a magnifying glass graphic. Compared to Whites, African American and Latina women were significantly less likely to use the icon arrays correctly. Higher education and higher numeracy were associated with correct responses. Lower education was associated with lower numeracy. CONCLUSIONS: Race/ethnic differences were associated with women's ability to take a quantitative cancer risk statistic verbally provided to them and report it in a visual format. PRACTICE IMPLICATIONS: Systematically considering the complexity of intersecting factors such as race/ethnicity, educational level, poverty, and numeracy in most health communications is needed.

Racial and ethnic disparities in benign gynecologic conditions and associated surgeries.

Common gynecologic conditions and surgeries may vary significantly by race or ethnicity. Uterine fibroid tumors are more prevalent in black women, and black women may have larger, more numerous fibroid tumors that cause worse symptoms and greater myomectomy complications. Some, but not all, studies have found a higher prevalence of endometriosis among Asian women. Race and ethnicity are also associated with hysterectomy rate, route, and complications. Overall, the current literature has significant deficits in the identification of racial and ethnic disparities in the incidence of fibroid tumors, endometriosis, and hysterectomy. Further research is needed to better define racial and ethnic differences in these conditions and to examine the complex mechanisms that may result in associated health disparities.

Maternal and paternal race/ethnicity are both associated with gestational diabetes.

OBJECTIVE: The objective of the study was to examine the rates of gestational diabetes mellitus (GDM) associated with both maternal and paternal race/ethnicity. STUDY DESIGN: This was a retrospective cohort study of all women delivered within a managed care network. Rates of GDM were calculated for maternal, paternal, and combined race/ethnicity. RESULTS: Among the 139,848 women with identified race/ethnicity, Asians had the highest rate (P < .001) of GDM (6.8%) as compared with whites (3.4%), African Americans (3.2%), and Hispanics (4.9%). When examining race/ethnicity controlling for potential confounders, we found that the rates of GDM were higher among Asian (adjusted odds ratio [aOR], 1.5; 95% confidence interval [CI], 1.4-1.6) and Hispanic (aOR, 1.2; 95% CI, 1.1-1.4) women as well as Asian (aOR, 1.4; 95% CI, 1.3-1.5) and Hispanic (aOR, 1.3; 95% CI, 1.2-1.4) men as compared with their white counterparts. CONCLUSION: We found that rates of GDM are affected by both maternal and paternal race/ethnicity. In both Asians and Hispanics, maternal and paternal race are equally associated with an increase in GDM. These differences may inform further investigation of the pathophysiology of GDM.

Predictors of hysterectomy use and satisfaction.

OBJECTIVE: To identify static and time-varying sociodemographic, clinical, health-related quality-of-life and attitudinal predictors of use and satisfaction with hysterectomy for noncancerous conditions. METHODS: The Study of Pelvic Problems, Hysterectomy, and Intervention Alternatives (SOPHIA) was conducted from 1998 to 2008. English-, Spanish-, or Chinese-speaking premenopausal women (n=1,420) with intact uteri who had sought care for pelvic pressure, bleeding, or pain from an academic medical center, county hospital, closed-panel health maintenance organization, or one of several community-based practices in the San Francisco Bay area were interviewed annually for up to 8 years. Primary outcomes were use of and satisfaction with hysterectomy. RESULTS: A total of 207 women (14.6%) underwent hysterectomy. In addition to well-established clinical predictors (entering menopause, symptomatic leiomyomas, prior treatment with gonadotropin-releasing hormone agonist, and less symptom resolution), greater symptom impact on sex (P=.001), higher 12-Item Short Form Health Survey mental component summary scores (P=.010), and higher scores on an attitude measure describing "benefits of not having a uterus" and lower "hysterectomy concerns" scores (P<.001 for each) were predictive of hysterectomy use. Most participants who underwent hysterectomy were very (63.9%) or somewhat (21.4%) satisfied in the year after the procedure, and we observed significant variations in posthysterectomy satisfaction across the clinical sites (omnibus P=.036). Other determinants of postsurgical satisfaction included higher pelvic problem impact (P=.035) and "benefits of not having a uterus" scores (P=.008) before surgery and greater posthysterectomy symptom resolution (P=.001). CONCLUSION: Numerous factors beyond clinical symptoms predict hysterectomy use and satisfaction. Providers should discuss health-related quality of life, sexual function, and attitudes with patients to help identify those who are most likely to benefit from this procedure.

Racial/ethnic disparities in obstetric outcomes and care: prevalence and determinants.

Wide disparities in obstetric outcomes exist between women of different race/ethnicities. The prevalence of preterm birth, fetal growth restriction, fetal demise, maternal mortality, and inadequate receipt of prenatal care all vary by maternal race/ethnicity. These disparities have their roots in maternal health behaviors, genetics, the physical and social environments, and access to and quality of health care. Elimination of the health inequities because of sociocultural differences or access to or quality of health care will require a multidisciplinary approach. We aim to describe these obstetric disparities, with an eye toward potential etiologies, thereby improving our ability to target appropriate solutions.

Who is at risk for prolonged and postterm pregnancy?

OBJECTIVE: The objective of the study was to examine risk factors for postterm (gestational age >or= 42 weeks) or prolonged (gestational age >or= 41 weeks) pregnancy. STUDY DESIGN: We conducted a retrospective cohort study of all term, singleton pregnancies delivered at a mature, managed care organization. The primary outcome measures were the rates of pregnancies greater than 41 or 42 weeks' gestation. Multivariable logistic regression models were used to control for potential confounding and interaction. RESULTS: Specific risk factors for pregnancy beyond 41 weeks of gestation include obesity (adjusted odds ratio [aOR], 1.26; 95% confidence interval [CI], 1.16-1.37), nulliparity (aOR, 1.46; 95% CI 1.42-1.51), and maternal age 30-39 years (aOR, 1.06; 95% CI, 1.02-1.10) and 40 years or older (aOR, 1.07; 95% CI, 1.02-1.12). Additionally, African American, Latina, and Asian race/ethnicity were all associated with a lower risk of reaching 41 or 42 weeks of gestation. CONCLUSION: Our findings suggest that there may be biological differences that underlie the risk for women to progress to 41 or 42 weeks of gestation. In particular, obesity is a modifiable risk factor and could potentially be prevented with prepregnancy or interpregnancy interventions.

Ending cervical cancer screening: attitudes and beliefs from ethnically diverse older women.

OBJECTIVE: Guidelines support ending cervical cancer screening in women aged 65-70 years and older with previous normal testing, but little is known about older women's attitudes and beliefs about ending screening. STUDY DESIGN: We conducted face-to-face interviews with 199 women aged 65 and older in English, Spanish, Cantonese, or Mandarin. RESULTS: Most interviewees were nonwhite (44.7% Asian, 18.1% Latina, and 11.6% African American). Most (68%) thought lifelong screening was either important or very important, a belief held more strongly by African American (77%) and Latina (83%) women compared with women in other ethnic groups (P < .01). Most (77%) had no plans to discontinue screening or had ever thought of discontinuing (69%). When asked if they would end screening if recommended by their physician, 68% responded "yes." CONCLUSION: The majority of these women believe that lifelong cervical cancer screening is important. Many women, however, reported that they would end screening if recommended by their physician.

Computerized prenatal genetic testing decision-assisting tool: a randomized controlled trial.

OBJECTIVE: Guidelines for fetal aneuploidy testing recommend that screening and diagnostic testing be made available to pregnant women of all ages and that providers explain the differences between these tests to help their patients make informed testing decisions. We sought to estimate the effect of a computerized, interactive prenatal testing decision tool on prenatal testing decision making. METHODS: Four hundred ninety-six English- or Spanish-speaking women at 20 or fewer weeks of gestation were randomly assigned to view the interactive prenatal testing decision tool or the California Department of Health Services' educational booklet. Primary outcomes were knowledge, risk awareness, intervention satisfaction, decisional conflict, and among women aged at least 35 years, use of invasive diagnostic testing. RESULTS: Women assigned to the interactive prenatal testing decision tool had higher knowledge scores (79.5% compared with 64.9%, P<.001), were more likely to correctly estimate their risk of procedure-related miscarriage (64.9% compared with 48.1%, P=.002) and carrying a Down syndrome-affected fetus (63.5% compared with 15.1%, P<.001), were more satisfied with the intervention (P<.001), and had less decision uncertainty (P<.001) than controls after viewing the intervention. Most of these differences persisted over time. Among women aged at least 35 years, the interactive prenatal testing decision tool viewers who were originally less inclined to undergo invasive testing were ultimately more likely than similarly inclined controls to have amniocentesis or chorionic villus sampling (44.8% compared with 29.2%), whereas those who were originally more inclined to undergo an invasive procedure ultimately were less likely than similarly inclined controls to have a diagnostic procedure (84.6% compared with 94.9%; P=.015 for interaction). CONCLUSION: Using an interactive prenatal testing decision tool results in more informed prenatal genetic testing decisions than viewing standard educational booklets. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, www.clinicaltrials.gov, NCT00686062 LEVEL OF EVIDENCE: I.

Perinatal outcomes in low-risk term pregnancies: do they differ by week of gestation?

OBJECTIVE: The objective of the study was to examine whether the risk of perinatal complications increases with increasing gestational age among term pregnancies. STUDY DESIGN: This is a retrospective cohort study of low-risk women with term, singleton births in 2003 in the United States. Gestational age was subgrouped into 37, 38, 39, 40, and 41 completed weeks. Statistical comparison was performed using chi(2) test and multivariable logistic regression models, with 39 weeks' gestation as the referent. RESULTS: There were 2,527,766 women meeting study criteria. Compared with 39 weeks, delivery at 37 or 38 weeks had lower risk of febrile morbidity but slightly higher risk of cesarean delivery. Delivery at 40 or 41 weeks was also associated with higher overall maternal morbidity. For neonates, delivery at 40 or 41 weeks had higher risk of birthweight greater than 4500 g, neonatal injury (40 weeks: adjusted odds ratio [aOR] 1.11 [95% confidence interval (CI), 1.05-1.18]; 41 weeks: aOR 1.27 [95% CI, 1.17-1.37]) and meconium aspiration (40 weeks: aOR 1.55 [95% CI, 1.43-1.69]; 41 weeks: aOR 2.12 [95% CI, 1.91-2.35]). Delivery at 37 or 38 weeks had higher risk of hyaline membrane disease (37 weeks: aOR 3.12 [95% CI, 2.90-3.38]); 38 weeks: aOR 1.30 [95% CI, 1.19-1.43]) but lower risk of meconium aspiration. CONCLUSION: The risk of cesarean delivery and neonatal morbidity in low-risk women increases at 40 weeks and beyond, whereas the odds of serious neonatal pulmonary disease were highest at 37 weeks. Recognition of such variation in term outcomes should lead providers to avoid iatrogenic morbidity and consider interventions to prevent complications of late-term pregnancy.

First- vs second-trimester ultrasound: the effect on pregnancy dating and perinatal outcomes.

OBJECTIVE: The objective of the study was to examine the effect of first-trimester obstetric ultrasound (OBUS) on the measurement of the effect of complications ascribed to postterm pregnancies. STUDY DESIGN: We conducted a retrospective cohort study of all term, singleton pregnancies delivered at our institution who had an OBUS at a gestation of 24 weeks or less. Those women who underwent an OBUS at a gestation of 12 weeks or less (OBUS12) were compared with those who had an OBUS at 13-24 weeks of gestation (OBUS13-24). The primary outcome measures were the rates of postterm pregnancies greater than 41 or 42 weeks' gestation. Secondary outcomes were the differences between the postterm and term gestations in maternal and neonatal outcomes. RESULTS: In the OBUS12 group, the rate of postterm pregnancy 42 weeks or longer was lower (2.7%) as compared with the OBUS13-24 group (3.7%, P = .022). With regard to reaching 41 weeks of gestation, the OBUS12 group was again lower (18.2%) as compared with the OBUS13-24 group (22.1%, P < .001). There were also fewer postterm inductions at 42 weeks or longer in the OBUS12 group (1.8%) as compared with the OBUS13-24 group (2.6%, P = .017). When comparing perinatal outcomes between those women who reached 41 weeks of gestation and those prior to 41 weeks of gestation, the OBUS12 group demonstrated greater differences between these 2 groups. CONCLUSION: Our findings suggest that earlier obstetric ultrasound, which leads to better pregnancy dating, reduces the rate of estimated postterm pregnancies. This may, in turn, reduce unnecessary intervention and lead to better identification of postterm pregnancies at greater risk of complications.

Time of delivery and neonatal morbidity and mortality.

OBJECTIVE: The objective of the study was to examine the association between time of delivery and neonatal outcomes in term deliveries. STUDY DESIGN: We conducted a retrospective cohort study of all term pregnancies delivered at an academic institution with 24-hour in-house obstetric and anesthesia coverage. Time of delivery was categorized as day (7 am to 6 pm), evening (6 pm to 12 midnight), and late night (12 midnight to 7 am). Outcomes included 5-minute Apgar less than 7, umbilical artery pH less than 7.0, base excess less than -12, admission to the neonatal intensive care unit (NICU), and neonatal death. We excluded patients delivered via cesarean delivery not in labor. We had greater than 80% power to detect a 25% difference in Apgar score, base excess, and admission to the NICU and 80% power to detect a 50% difference in umbilical artery pH less than 7.0. RESULTS: Among the 34,424 deliveries meeting inclusion criteria, 15,664 were during the day, 8495 were during the evening, and 10,265 were during the night. In univariate comparisons, there were no statistically significant differences in neonatal outcomes. For example, the rate of pH less than 7.0 was 0.7% during the day, 1.0% in the evening, and 0.6% at night (P = .12). Admissions to the NICU were 3.6% during the day, 3.7% in the evening, and 3.5% at night (P = .81). When we controlled for obstetric history, demographic factors, and labor characteristics, there were still no differences in rates of either neonatal morbidity or mortality by time of delivery. CONCLUSION: At our institution, we could not demonstrate any significant differences in neonatal morbidity or mortality by time of day among neonates delivered at term. These data can be used to counsel patients and families concerned about differences in time of delivery and potential impact on their infant's health. Future research should include time of delivery in relation to maternal and neonatal outcomes in various types of inpatient settings.