Clinician care priorities and practices in the fourth trimester: perspective from a California survey.

BACKGROUND: Professional societies such as the American College of Obstetricians and Gynecologists (ACOG) promote the idea that postpartum care is an ongoing process where there is adequate opportunity to provide services and support. Nonetheless, in practice, the guidelines ask clinicians to perform more clinical responsibilities than they might be able to do with limited time and resources. METHODS: We conducted an online survey among practicing obstetric clinicians (obstetrician/gynecologists (OB/GYNs), midwives, and family medicine doctors) in California about their priorities and care practices for the first postpartum visit and explored how they prioritize multiple clinical responsibilities within existing time and resources. Between September 2023 and February 2024, 174 out of 229 eligible participants completed the survey, a 76% response rate. From a list of care components, we used descriptive statistics to identify those that were highly prioritized by most clinicians and those that were considered a priority by very few and examined the alignment between prioritized components and recommended care practices. RESULTS: Clinicians were highly invested in the care components that they rated as most important, indicating that they always check these components or assess them when they perceive patient need. Depression and anxiety, breast health/breast feeding issues, vaginal birth complications and family planning counseling were highly ranked components by all clinicians. In contrast, clinicians more often did not assess those care components that infrequently ranked highly among the priority listing, consisting mainly of social drivers of health such as screening and counseling for intimate partner violence, working conditions and food/housing insecurity. In both instances, we found little discordance between priorities and care practices. However, OB/GYNs and midwives differed in some care components that they prioritized highly. CONCLUSIONS: While there is growing understanding of how important professional society recommendations are for maternal-infant health, clinicians face barriers completing all recommendations, especially those components related to social drivers of health. However, what the clinicians do prioritize highly, they are likely to perform. Now that Medi-Cal (Medicaid) insurance is available in California for up to 12 months postpartum, there is a need to understand what care clinicians provide and what gaps remain.

Association between SARS-CoV-2 Infection and Adverse Perinatal Outcomes by Race/Ethnicity in a Large Integrated Health Care System.

OBJECTIVE: Recent studies have reported associations between severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection during pregnancy and adverse perinatal outcomes but the extent to which these associations vary by race/ethnicity remains uncertain. Therefore, we examined how the association between prenatal SARS-CoV-2 infection and adverse perinatal outcomes may be modified by race/ethnicity. STUDY DESIGN: A retrospective cohort study was performed using data on 67,986 pregnant women extracted from the Kaiser Permanente Southern California electronic health records between April 6, 2020, and December 31, 2021. Upon admission to labor and delivery, all women were routinely tested for coronavirus disease 2019 (COVID-19) using real-time reverse-transcriptase polymerase chain reaction test. Adjusted odds ratios (aORs) were used to estimate associations. RESULTS: During the study period, COVID-19 was diagnosed in 4,960 (7%) of singleton pregnancies, with the highest rates observed among Hispanics (9.4%) and non-Hispanic Blacks (6.2%). Compared with non-Hispanic Whites, Hispanics (aOR: 1.12, 95% CI: 1.03, 1.21) with SARS-CoV-2 infection had the highest odds of a pregnancy associated with nonreassuring fetal heart rate tracing. Neonates of all races/ethnicities, except for non-Hispanic Blacks, showed significantly increased odds of SARS-CoV-2 infection, with the highest risk observed among Asians/Pacific Islanders (aOR: 10.88, 95% CI: 1.33, 89.04). Non-Hispanic White mothers who tested positive were admitted to intensive care unit (ICU) at a higher rate at delivery and within 7 days of delivery (aOR: 34.77, 95% CI: 11.3, 107.04; aOR: 26.48, 95% CI: 9.55, 73.46, respectively). Hispanics were also at a significantly higher odds of admission to ICU (aOR: 4.62, 95% CI: 2.69, 7.94; aOR: 4.42, 95% CI: 2.58, 7.56, respectively). Non-Hispanic Black, Hispanic, and Asian/Pacific Islander mothers who tested positive for SARS-CoV-2 prenatally, were at increased risk for preeclampsia/eclampsia, and preterm birth as compared to non-Hispanic White mothers. CONCLUSION: The findings highlight racial/ethnic disparities in the association between SARS-CoV-2 infection and adverse perinatal outcomes. The risk of neonatal SARS-CoV-2 infection was highest for Asian/Pacific Islanders. We also observed a remarkably high risk of ICU admission for non-Hispanic White mothers infected with SARS-CoV-2. KEY POINTS: · Race/ethnicity influences perinatal outcomes in pregnancies impacted by SARS-CoV-2.. · The risk of neonatal SARS-CoV-2 infection was highest for Asian/Pacific Islanders.. · White mothers had a notably high risk of ICU admission at delivery following SARS-CoV-2 infection..

Association between SARS-CoV-2 Infection and Adverse Perinatal Outcomes in a Large Health Maintenance Organization.

OBJECTIVE: This study aimed to examine whether severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection during pregnancy is associated with increased odds of perinatal complications and viral transmission to the infant. STUDY DESIGN: A retrospective cohort study of women who delivered at Kaiser Permanente Southern California hospitals (April 6, 2020-February 28, 2021) was performed using data extracted from electronic health records (EHRs). During this time polymerize chain reaction (PCR)-based tests for SARS-CoV-2 was universally offered to all pregnant women at labor and delivery admission, as well as earlier in the pregnancy, if they were displaying symptoms consistent with SARS-CoV-2 infection or a possible exposure to the virus. Adjusted odds ratio (aOR) was used to estimate the strength of associations between positive test results and adverse perinatal outcomes. RESULTS: Of 35,123 women with a singleton pregnancy, 2,203 (6%) tested positive for SARS-CoV-2 infection with 596 (27%) testing positive during the first or second trimester and 1,607 (73%) during the third trimester. Women testing positive were younger than those who tested negative (29.7 [5.4] vs. 31.1 [5.3] years; mean [standard deviation (SD)]; p < .001). The SARS-CoV-2 infection tended to increase the odds of an abnormal fetal heart rate pattern (aOR: 1.10; 95% confidence interval [CI]: 1.00, 1.21; p = 0.058), spontaneous preterm birth (aOR: 1.28; 95% CI: 1.03, 1.58; p = 0.024), congenital anomalies (aOR: 1.69; 95% CI: 1.15, 2.50; p = 0.008), and maternal intensive care unit admission at delivery (aOR: 7.44; 95% CI: 4.06, 13.62; p < 0.001) but not preeclampsia/eclampsia (aOR: 1.14; 95% CI: 0.98, 1.33; p = 0.080). Eighteen (0.8%) neonates of mothers who tested positive also had a positive SARS-CoV-2 test after 24 hours of birth, but all were asymptomatic during the neonatal period. CONCLUSION: These findings suggest that prenatal SARS-CoV-2 infection increases the odds of some adverse perinatal outcomes. The likelihood of vertical transmission from the mother to the fetus was low (0.3%), suggesting that pregnancy complications resulting from SARS-CoV-2 infection pose more risk to the baby than transplacental viral transmission. KEY POINTS: · SARS-CoV-2 infection is associated with increased odds of adverse perinatal outcomes.. · The odds of specific adverse outcomes were greater when a mother was infected earlier in pregnancy.. · The proportion of vertical transmission from mother to fetus was 0.3%.

Universal SARS-Cov-2 Screening in Women Admitted for Delivery in a Large Managed Care Organization.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has created a need for data regarding the prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pregnant women. After implementing universal screening for COVID-19 in women admitted for delivery, we sought to describe the characteristics of COVID-19 in this large cohort of women. STUDY DESIGN: An observational study of women admitted to labor and delivery units in Kaiser Permanente Southern California (KPSC) hospitals between April 6 and May 11, 2020 who were universally offered testing for SARS-CoV-2 infection (n = 3,963). Hospital inpatient and outpatient physician encounter, and laboratory records were used to ascertain universal testing levels, test results, and medical and obstetrical histories. The prevalence of SARS-CoV-2 infection was estimated from the number of women who tested positive during labor per 100 women delivered. RESULTS: Of women delivered during the study period, 3,923 (99.0%) underwent SARS-CoV-2 testing. A total of 17 (0.43%; 95% confidence interval: 0.23-0.63%) women tested positive, and none of them were symptomatic on admission. There was no difference in terms of characteristics between SARS-CoV-2 positive and negative tested women. One woman developed a headache attributed to COVID-19 3 days postpartum. No neonates had a positive test at 24 hours of life. CONCLUSION: The findings suggest that in pregnant women admitted for delivery between April 6 and May 11, 2020 in this large integrated health care system in Southern California, prevalence of SARS-CoV-2 test positive was very low and all patients were asymptomatic on admission. KEY POINTS: · The prevalence of SARS-CoV-2 infection in a large diverse cohort of term pregnant women was 0.43%.. · 99% of women accepted SARS-CoV-2 screening on admission to labor and delivery.. · All women with positive test results were asymptomatic at the time of testing..

The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy.

Solving diagnostic errors is difficult and progress on preventing those errors has been slow since the 2015 National Academy of Medicine report. There are several methods used to improve diagnostic and other errors including voluntary reporting; malpractice claims; patient complaints; physician surveys, random quality reviews and audits, and peer review data which usually evaluates single cases and not the systems that allowed the error. Additionally, manual review of charts is often labor intensive and reviewer dependent. In 2010 we developed an e-Autopsy/e-Biopsy (eA/eB) methodology to aggregate cases with quality/safety/diagnostic issues, focusing on a specific population of patients and conditions. By performing a hybrid review process (cases are first filtered using administrative data followed by standardized manual chart reviews) we can efficiently identify patterns of medical and diagnostic error leading to opportunities for system improvements that have improved care for future patients. We present a detailed methodology for eA/eB studies and describe results from three successful studies on different diagnoses (ectopic pregnancy, abdominal aortic aneurysms, and advanced colon cancer) that illustrate our eA/eB process and how it reveals insights into creating systems that reduce diagnostic and other errors. The eA/eB process is innovative and transferable to other healthcare organizations and settings to identify trends in diagnostic error and other quality issues resulting in improved systems of care.

Real world outcomes related to providing an annual supply of short-acting hormonal contraceptives.

OBJECTIVE: To compare pregnancy rates among women provided a 12-month supply or less than a 12-month supply of short-acting hormonal contraceptives. STUDY DESIGN: This retrospective cohort study examined data from an integrated health plan in California, collected about people aged 10-50 years, who filled at least one contraceptive prescription between January 2017 and September 2018. We examined outcomes following index contraceptive prescriptions for up to 15 months, end of membership, initiation of a long-acting contraceptive, or death, whichever occurred first. We compared rates per 100 person years of observation of: pregnancy, receipt of emergency contraception (EC), and contraceptive refills more than 12 months after the index prescription. We used multivariable logistic regression to control for demographics and baseline clinical variables when comparing provision of a 12-month to a smaller supply. RESULTS: We identified 1689 members who received a 12-month supply of short-acting hormonal contraception and 352,624 women who received less than a 12-month supply. Those who received a 12-month supply were less likely to receive EC (1.3 vs 2.1 per 100 person years, p = 0.04) or have documentation of pregnancy (1.7 vs 2.7 per 100 person-years, p = 0.02), and more likely to refill the contraceptive more than 1 year after the index prescription (99.4% vs 63.9%, p < 0.01). Among new starts, the adjusted odds ratio (OR) of pregnancy was 0.50 (95% CI 0.27-0.94) among women who received a 12-month supply vs. those were not. CONCLUSION: Members of an integrated healthcare system who received a 12-month supply of short-acting hormonal contraceptives are less likely to become pregnant within the following year. IMPLICATIONS: Offering a 12-month supply of short-acting hormonal contraceptives may reduce rates of undesired pregnancy.

Self-Reported Learning (SRL), a Voluntary Incident Reporting System Experience Within a Large Health Care Organization.

BACKGROUND: In aviation, significant improvements in safety have been attributed to a system of voluntary reporting of errors and hazards by pilots and other frontline personnel. Such a system is lacking in health care. METHODS: A system to allow physicians to self-report their clinical care errors along with insights to prevent recurrence ("self-reported learning [SRL] system") was established in three hospitals and used for four years in one center and for two years in two others. Clinicians were educated in how to use the system and encouraged to report deviations from standard care by secure e-mail, a telephone hotline, or the institutional incident reporting system. Events were included in the SRL system only if clinicians self-reported them prior to others doing so. Submissions were analyzed for evidence of primary insight, recognition of error, and secondary insight. Physicians were surveyed afterward about their attitudes toward clinical peer review, the physician's role in errors, and the SRL program. RESULTS: There were 117 SRL submissions (less than 5% of clinical peer review cases); 86 had complete information available. Of these, there was agreement among two reviewers that secondary insight was present in 52.2%, and several were novel submissions that otherwise would have not been identified. Survey response rate was 18.3%; 31.1% of respondents had never been involved in clinical peer review before, a majority had an overall favorable impression of clinical peer review, and 47.2% reported not having made "any mistakes worth reporting." CONCLUSION: An SRL system modeled after the aviation reporting system elicited a low number of reports and did not decrease the number of clinical peer review reports. In a high proportion of SRL reports reporting physicians demonstrated secondary insight. Benefits to SRL reporting could be seen despite low number of self-reports.