Quality adjusted coverage of family planning services in low- and middle-income countries: Analysis of 33 countries using Demographic and Health Survey data.

Background: Monitoring service quality for family planning programmes in low- and middle-income countries (LMICs) has been challenging due to data availability. Self-reported service quality from Demographic and Health Surveys (DHS) can provide additional information on quality beyond simple service contact. Methods: The DHS collects need, use and counselling for contraceptives. We used this data from 33 LMICs to develop quality-adjusted demand for modern family planning satisfied indicator (DFPSq). We compared it with the crude indicator (demand for family planning satisfied (DFPS)) and performed an equity analysis. Median, interquartile ranges (IQR) and the absolute and relative gap by country were used to describe the findings. Results: The median DFPS was 49% (IQR = 41-57%) and the median DPFSq was 19% (IQR = 14-27%). We found similar relative differences in the gap stratified by SES indicating quality was universally low. One exception is that adolescents had a higher relative gap (70%, IQR = 57-79%) compared to adults (54%, IQR = 46-68%), indicating lower quality access. Conclusions: Severe and pervasive quality gaps exist in family planning services across most LMICs. Our novel DFPSq indicator is one additional tool for monitoring access and quality of service that is critical to meet the family planning needs of women.

Assessment of Differences in Academic Rank and Compensation by Gender and Race/Ethnicity Among Academic Radiation Oncologists in the United States.

Purpose: Advancing equity, diversity, and inclusion in the physician workforce is essential to providing high-quality and culturally responsive patient care and has been shown to improve patient outcomes. To better characterize equity in the field of radiation oncology, we sought to describe the current academic radiation oncology workforce, including any contemporary differences in compensation and rank by gender and race/ethnicity. Methods and Materials: We conducted a retrospective cohort study using data from the Society of Chairs of Academic Radiation Oncology Programs (SCAROP) 2018 Financial Survey. Multivariable logistic regression models were used to identify factors associated with associate or full professor rank. Compensation was compared by gender and race/ethnicity overall and stratified by rank and was further analyzed using multivariable linear regression models. Results: Of the 858 academic radiation oncologists from 63 departments in the United States in the sample, 33.2% were female, 65.2% were White, 27.2% were Asian, and 7.6% were underrepresented in medicine (URiM). There were 44.0% assistant professors, 32.0% associate professors, and 22.8% full professors. Multivariable logistic regression analysis for factors associated with associate or full professor rank did not reveal statistically significant associations between gender or race/ethnicity with academic rank (odds ratio [OR], 0.86; 95% confidence interval [CI], 0.56-1.32; P = .48 for gender; OR, 0.81; 95% CI, 0.5-1.30; P = .37 for Asian vs White; and OR, 0.69; 95% CI, 0.31-1.55; P = .37 for URiM vs White), but CIs were wide due to sample size, and point estimates were <1. Similarly, multivariable linear regression analysis modeling the log relative total compensation did not detect statistically significant differences between radiation oncologists by gender (-1.7%; 95% CI, -6.8% to 3.4%; P = .51 for female vs male) or race/ethnicity (-1.6%; 95% CI, -7.3% to 4.0%; P = .57 for Asian vs White and -3.0%; 95% CI, -12.1% to 6.0%; P = .51 for URiM vs White). Conclusions: The low numbers of women and faculty with URiM race/ethnicity in this radiation oncology faculty sample limits the ability to compare career trajectory and compensation by those characteristics. Given that point estimates were <1, our findings do not contradict larger multispecialty studies that suggest an ongoing need to monitor equity.

Design, development and preliminary assessment in a porcine model of a novel peripheral intravenous catheter aimed at reducing early failure rates.

BACKGROUND: Peripheral intravenous catheters (PIVCs) are the most commonly used invasive medical device, yet despite best efforts by end-users, PIVCs experience unacceptably high early failure rates. We aimed to design a new PIVC that reduces the early failure rate of in-dwelling PIVCs and we conducted preliminary tests to assess its efficacy and safety in a porcine model of intravenous access. METHODS: We used computer-aided design and simulation to create a PIVC with a ramped tip geometry, which directs the infused fluid away from the vein wall; we called the design the FloRamp™. We created FloRamp prototypes (test device) and tested them against a market-leading device (BD Insyte™; control device) in a highly-controlled setting with five insertion sites per device in four pigs. We measured resistance to infusion and visual infusion phlebitis (VIP) every 6 h and terminated the experiment at 48 h. Veins were harvested for histology and seven pathological markers were assessed. RESULTS: Computer simulations showed that the optimum FloRamp tip reduced maximum endothelial shear stress by 60%, from 12.7 Pa to 5.1 Pa, compared to a typical PIVC tip and improved the infusion dynamics of saline in the blood stream. In the animal study, we found that 2/5 of the control devices were occluded after 24 h, whereas all test devices remained patent and functional. The FloRamp created less resistance to infusion (0.73 ± 0.81 vs 0.47 ± 0.50, p = 0.06) and lower VIP scores (0.60 ± 0.93 vs 0.31 ± 0.70, p = 0.09) than the control device, although neither findings were significantly different. Histopathology revealed that 5/7 of the assessed markers were lower in veins with the FloRamp. CONCLUSIONS: Herein we report preliminary assessment of a novel PIVC design, which could be advantageous in clinical settings through decreased device occlusion and reduced early failure rates.

The RADAR coverage tool: developing a toolkit for rigorous household surveys for reproductive, maternal, newborn, and child health & nutrition indicators.

Population-based intervention coverage data are used to inform the design of projects, programs, and policies and to evaluate their impact. In low- and middle-income countries (LMICs), household surveys are the primary source of coverage data. Many coverage surveys are implemented by organizations with limited experience or resources in population-based data collection. We developed a streamlined survey and set of supporting materials to facilitate rigorous survey design and implementation. The RADAR coverage survey tool aimed to 1) rigorously measure priority reproductive, maternal, newborn, child health & nutrition coverage indicators, and allow for equity and gender analyses; 2) use standard, valid questions, to the extent possible; 3) be as light as possible; 4) be flexible to address users' needs; and 5) be compatible with the Lives Saved Tool for analysis of program impact. Early interactions with stakeholders also highlighted survey planning, implementation, and analysis as challenging areas. We therefore developed a suite of resources to support implementers in these areas. The toolkit was piloted by implementers in Tanzania and in Burkina Faso. Although the toolkit was successfully implemented in these settings and facilitated survey planning and implementation, we found that implementers must still have access to sufficient resources, time, and technical expertise in order to use the tool appropriately. This potentially limits the use of the tool to situations where high-quality surveys or evaluations have been prioritized and adequately resourced.

Prevalence, Characteristics, and Outcomes of Emergency Department Discharge Among Patients With Sepsis.

Importance: Sepsis guidelines and research have focused on patients with sepsis who are admitted to the hospital, but the scope and implications of sepsis that is managed in an outpatient setting are largely unknown. Objective: To identify the prevalence, risk factors, practice variation, and outcomes for discharge to outpatient management of sepsis among patients presenting to the emergency department (ED). Design, Setting, and Participants: This cohort study was conducted at the EDs of 4 Utah hospitals, and data extraction and analysis were performed from 2017 to 2021. Participants were adult ED patients who presented to a participating ED from July 1, 2013, to December 31, 2016, and met sepsis criteria before departing the ED alive and not receiving hospice care. Exposures: Patient demographic and clinical characteristics, health system parameters, and ED attending physician. Main Outcomes and Measures: Information on ED disposition was obtained from electronic medical records, and 30-day mortality data were acquired from Utah state death records and the US Social Security Death Index. Factors associated with ED discharge rather than hospital admission were identified using penalized logistic regression. Variation in ED discharge rates between physicians was estimated after adjustment for potential confounders using generalized linear mixed models. Inverse probability of treatment weighting was used in the primary analysis to assess the noninferiority of outpatient management for 30-day mortality (noninferiority margin of 1.5%) while adjusting for multiple potential confounders. Results: Among 12 333 ED patients with sepsis (median [IQR] age, 62 [47-76] years; 7017 women [56.9%]) who were analyzed in the study, 1985 (16.1%) were discharged from the ED. After penalized regression, factors associated with ED discharge included age (adjusted odds ratio [aOR], 0.90 per 10-y increase; 95% CI, 0.87-0.93), arrival to ED by ambulance (aOR, 0.61; 95% CI, 0.52-0.71), organ failure severity (aOR, 0.58 per 1-point increase in the Sequential Organ Failure Assessment score; 95% CI, 0.54-0.60), and urinary tract (aOR, 4.56 [95% CI, 3.91-5.31] vs pneumonia), intra-abdominal (aOR, 0.51 [95% CI, 0.39-0.65] vs pneumonia), skin (aOR, 1.40 [95% CI, 1.14-1.72] vs pneumonia) or other source of infection (aOR, 1.67 [95% CI, 1.40-1.97] vs pneumonia). Among 89 ED attending physicians, adjusted ED discharge probability varied significantly (likelihood ratio test, P < .001), ranging from 8% to 40% for an average patient. The unadjusted 30-day mortality was lower in discharged patients than admitted patients (0.9% vs 8.3%; P < .001), and their adjusted 30-day mortality was noninferior (propensity-adjusted odds ratio, 0.21 [95% CI, 0.09-0.48]; adjusted risk difference, 5.8% [95% CI, 5.1%-6.5%]; P < .001). Alternative confounder adjustment strategies yielded odds ratios that ranged from 0.21 to 0.42. Conclusions and Relevance: In this cohort study, discharge to outpatient treatment of patients who met sepsis criteria in the ED was more common than previously recognized and varied substantially between ED physicians, but it was not associated with higher mortality compared with hospital admission. Systematic, evidence-based strategies to optimize the triage of ED patients with sepsis are needed.

The complex audio visual emotion assessment task (CAVEAT): development of a shorter version for clinical use.

PURPOSE: The Complex Audio Visual Emotion Assessment Task (CAVEAT) is a measure of emotion recognition using dynamic, naturalistic videos to assess recognition of 22 different emotional states (11 positive, 11 negative). It has established construct validity and demonstrated sensitivity to emotion perception impairments in those with moderate-severe traumatic brain injury (TBI). Despite this, its lengthy administration has limited its use in clinical practice and rehabilitation. The current paper aimed to develop shortened versions of the CAVEAT and examine their psychometric properties. METHODS: The CAVEAT-S A and CAVEAT-S B (22 items each) and the CAVEAT-S AB (44 items) were developed using the original data. Comparability, reliability, construct and predictive validity were examined in the original sample (Study 1: 32 people with TBI and 32 demographically matched control participants) and a replication sample (Study 2: 18 adults with TBI and 21 demographically matched controls). RESULTS: All short forms produced comparable accuracy ratings to the full measure, as well as discriminating between people with or without a TBI. Shortened forms all correlated with other measures of emotion perception and social cognition and also predicted psychosocial outcomes in terms of self-reported interpersonal relationships. Internal reliability of the short forms was low relative to the longer forms, especially for the two very short measures. CONCLUSIONS: The new shortened forms of the CAVEAT are promising tools that are sensitive and valid for assessing emotion perception in people with TBI for clinical purposes. Their application in other clinical disorders is yet to be examined.Implications for rehabilitationEmotion perception deficits are present in many clinical populations and an important target for rehabilitation.CAVEAT Short provides ecologically valid emotional stimuli. Such stimuli are important for assessing real world function and to set rehabilitation targets.By having parallel versions of CAVEAT, there is the opportunity to test pre and post intervention while minimising practice effects.Alternatively, one version of CAVEAT-S can be used for assessment, while the other is used for training purposes during remediation.

Experiences of menstruation in high income countries: A systematic review, qualitative evidence synthesis and comparison to low- and middle-income countries.

BACKGROUND: There is growing recognition of the importance of menstruation in achieving health, education, and gender equality for all. New policies in high income countries (HICs) have responded to anecdotal evidence that many struggle to meet their menstrual health needs. Qualitative research has explored lived experiences of menstruating in HICs and can contribute to designing intervention approaches. To inform the growing policy attention to support people who menstruate, here we review and synthesise the existing research. METHODS AND FINDINGS: Primary, qualitative studies capturing experiences of menstruation in HICs were eligible for inclusion. Systematic database and hand searching identified 11485 records. Following screening and quality appraisal using the EPPI-Centre checklist, 104 studies (120 publications) detailing the menstrual experiences of over 3800 individuals across sixteen countries were included. We used the integrated model of menstrual experiences developed from studies in low- and middle-income countries (LMICs) as a starting framework and deductively and inductively identified antecedents contributing to menstrual experiences; menstrual experiences themselves and impacts of menstrual experiences. Included studies described consistent themes and relationships that fit well with the LMIC integrated model, with modifications to themes and model pathways identified through our analysis. The socio-cultural context heavily shaped menstrual experiences, manifesting in strict behavioural expectations to conceal menstruation and limiting the provision of menstrual materials. Resource limitations contributed to negative experiences, where dissatisfaction with menstrual practices and management environments were expressed along with feelings of disgust if participants felt they failed to manage their menstruation in a discrete, hygienic way. Physical menstrual factors such as pain were commonly associated with negative experiences, with mixed experiences of healthcare reported. Across studies participants described negative impacts of their menstrual experience including increased mental burden and detrimental impacts on participation and personal relationships. Positive experiences were more rarely reported, although relationships between cis-women were sometimes strengthened by shared experiences of menstrual bleeding. Included studies reflected a broad range of disciplines and epistemologies. Many aimed to understand the constructed meanings of menstruation, but few were explicitly designed to inform policy or practice. Few studies focused on socioeconomically disadvantaged groups relevant to new policy efforts. CONCLUSIONS: We developed an integrated model of menstrual experience in HICs which can be used to inform research, policy and practice decisions by emphasising the pathways through which positive and negative menstrual experiences manifest. REVIEW PROTOCOL REGISTRATION: The review protocol registration is PROSPERO: CRD42019157618.

The role of gender power relations on women's health outcomes: evidence from a maternal health coverage survey in Simiyu region, Tanzania.

BACKGROUND: Gender is a crucial consideration of human rights that impacts many priority maternal health outcomes. However, gender is often only reported in relation to sex-disaggregated data in health coverage surveys. Few coverage surveys to date have integrated a more expansive set of gender-related questions and indicators, especially in low- to middle-income countries that have high levels of reported gender inequality. Using various gender-sensitive indicators, we investigated the role of gender power relations within households on women's health outcomes in Simiyu region, Tanzania. METHODS: We assessed 34 questions around gender dynamics reported by men and women against 18 women's health outcomes. We created directed acyclic graphs (DAGs) to theorize the relationship between indicators, outcomes, and sociodemographic covariates. We grouped gender variables into four categories using an established gender framework: (1) women's decision-making, (2) household labor-sharing, (3) women's resource access, and (4) norms/beliefs. Gender indicators that were most proximate to the health outcomes in the DAG were tested using multivariate logistic regression, adjusting for sociodemographic factors. RESULTS: The overall percent agreement of gender-related indicators within couples was 68.6%. The lowest couple concordance was a woman's autonomy to decide to see family/friends without permission from her husband/partner (40.1%). A number of relationships between gender-related indicators and health outcomes emerged: questions from the decision-making domain were found to play a large role in women's health outcomes, and condoms and contraceptive outcomes had the most robust relationship with gender indicators. Women who reported being able to make their own health decisions were 1.57 times (95% CI: 1.12, 2.20) more likely to use condoms. Women who reported that they decide how many children they had also reported high contraception use (OR: 1.79, 95% CI: 1.34, 2.39). Seeking care at the health facility was also associated with women's autonomy for making major household purchases (OR: 1.35, 95% CI: 1.13, 1.62). CONCLUSIONS: The association between decision-making and other gender domains with women's health outcomes highlights the need for heightened attention to gender dimensions of intervention coverage in maternal health. Future studies should integrate and analyze gender-sensitive questions within coverage surveys.

Assessment of von Willebrand disease and pregnancy outcomes at regional Australian hospitals.

BACKGROUND: von Willebrand disease (vWD) is a heterogeneous hereditary bleeding disorder and is associated with risk of primary postpartum haemorrhage (PPH). DESIGN AND METHODS: An observational study at a tertiary referral centre in Australia of 16 women with 23 deliveries with a median age of 27.5 years (range, 21-39; IQR = 9). Median gestational age at delivery was 39 weeks (range, 35-41; IQR = 1.1). RESULTS: All cases had type 1 vWD, apart from one case with type 2. Patients were managed in combined obstetrics and haematology clinics. PPH occurred in ten deliveries (44%). Intravenous desmopressin was administered in 6 cases, and IV human vWF was administered in 4 cases. Two cases with mild vWD had received oral tranexamic acid. The median Apgar score at 1 and 5 min was 9 (IQR = 1.0), while the median Apgar score at 10 min was 10.0 (IQR = 0.0). One case required transfusion of blood products postdelivery. There were no other significant complications observed. CONCLUSIONS: vWD was associated with a high incidence of primary PPH. Individualised treatment to restore haemostasis, according to the severity of the disease, could achieve as possible, normal haemostasis with favourable outcomes for both mothers and their infants. Further studies to confirm our findings are warranted.

Basic maternal health care coverage among adolescents in 22 sub-Saharan African countries with high adolescent birth rate.

BACKGROUND: In the sub-Saharan Africa region, the adolescent birth rate is the highest in the world, estimated at 100.5 births per 1000 women aged 15 to 19 years, and 2.4 times greater than the global average. This analysis examines coverage levels and gaps in basic maternal health care for adolescent mothers living in this region. METHODS: We used data from national Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) conducted between 2010 and 2016 in 22 of the sub-Saharan African Countdown to 2030 priority countries with adolescent birth rates above 100 in 2016. We analyzed 11 indicators of coverage of key services provided during the pre-pregnancy, pregnancy, delivery and postnatal period. We described the coverage level among adolescent girls aged 15-19 and women aged 20-49 for basic indicators in the continuum of care. We conducted a multilevel random effect logistic regression to quantify the association between the receipt of basic package of maternal care and woman's socio-demographic and socio-economic characteristics. RESULTS: The median coverage of the basic package of maternal care among adolescents was extremely low, at 9.3%. Adolescent mothers who were in the highest household wealth quintile (odds ratio OR = 2.44, 95% confidence interval (CI) = 2.23-2.68), living in an urban area (OR = 1.25, 95% CI = 1.18-1.33) and having secondary education (OR = 1.61, 95% CI = 1.50-1.73) had greater odds of receiving the basic package of maternal health care as compared to those in the lowest wealth quintile, living in rural areas, and with no education respectively. Adolescent girls aged 15-17 and 18-19 had respectively 26% (OR = 0.74, 95% CI = 0.67-0.82) and 9% (OR = 0.91, 95% CI = 0.84-0.98) lower odds of receiving the basic package compared to women 20-49 years old. Child brides had 12% (OR = 0.88, 95% CI = 0.84-0.93) lower odds of receiving the basic package compared to women who were married after the age of 18. CONCLUSION: Coverage of basic maternal health care for adolescent mothers is inadequate in the countries with the highest adolescent birth rates in the world. Addressing the reproductive and maternal health needs of adolescents in sub-Saharan Africa is of critical importance, especially given projections that this region will experience the highest increases in adolescent births in the coming decades.

Psychometric properties of the Intolerance of Uncertainty Scale-12 in generalized anxiety disorder: Assessment of factor structure, measurement properties and clinical utility.

Intolerance of uncertainty is a psychological vulnerability implicated in the development and maintenance of generalized anxiety disorder (GAD). The Intolerance of Uncertainty Scale-12 (IUS-12) is a widely used measure, however no studies have thoroughly tested the psychometric properties in a clinically diagnosed GAD sample. This study aimed to evaluate the factor structure, measurement properties and clinical utility of the IUS-12 in clinical and non-clinical samples. Participants were screened using the Anxiety Disorders Interview Schedule for DSM-IV to ascertain clinical (n = 136: principal diagnosis of GAD) or non-clinical status (n = 76). Confirmatory factor analysis determined that the bifactor type (two-factor testlet) model demonstrated significantly better fit in comparison to the unidimensional model for the clinical sample. The IUS-12 exhibited limited multidimensionality indicating that only the total score provides meaningful interpretation. The IUS-12 demonstrated good construct validity (with DASS-21, MCQ-30, and PSWQ), good internal consistency, as well as good test-retest reliability over 12-weeks. The IUS-12 demonstrated responsivity to treatment following cognitive behavioral therapy and mindfulness based psychological interventions. Receiver operating characteristic curve analysis indicated an optimal cut-off score of 28 for distinguishing individuals with GAD from non-clinical cases. Overall, the IUS-12 is a valid, reliable and clinically useful instrument for individuals with GAD.

Depression and Change in Caregiver Burden Among Family Members of Intensive Care Unit Survivors.

BACKGROUND: Family members of patients in intensive care units may experience psychological distress and substantial caregiver burden. OBJECTIVE: To evaluate whether change in caregiver burden from intensive care unit admission to 3-month follow-up is associated with caregiver depression at 3 months. METHODS: Caregiver burden was assessed at enrollment and 3 months later, and caregiver depression was assessed at 3 months. Depression was measured with the Hospital Anxiety and Depression Score. The primary analysis was the association between depression at 3 months and change in caregiver burden, controlling for a history of caregiver depression. RESULTS: One hundred one participants were enrolled; 65 participants had a surviving loved one and completed 3-month follow-up. At 3-month follow-up, 12% of participants met criteria for depression. Increased caregiver burden over time was significantly associated with depression at follow-up (Fisher exact test, P = .004), although this association was not significant after controlling for self-reported history of depression at baseline (Cochran-Mantel-Haenszel test, P = .23). CONCLUSIONS: Family members are increasingly recognized as a vulnerable population susceptible to negative psychological outcomes after a loved one's admission to the intensive care unit. In this small sample, no significant association was found between change in caregiver burden and depression at 3 months after controlling for baseline depression.

Comparative evaluation of the clinical laboratory-based Intermountain risk score with the Charlson and Elixhauser comorbidity indices for mortality prediction.

BACKGROUND: The Charlson and Elixhauser comorbidity indices are mortality predictors often used in clinical, administrative, and research applications. The Intermountain Mortality Risk Scores (IMRS) are validated mortality predictors that use all factors from the complete blood count and basic metabolic profile. How IMRS, Charlson, and Elixhauser relate to each other is unknown. METHODS: All inpatient admissions except obstetric patients at Intermountain Healthcare's 21 adult care hospitals from 2010-2014 (N = 197,680) were examined in a observational cohort study. The most recent admission was a patient's index encounter. Follow-up to 2018 used hospital death records, Utah death certificates, and the Social Security death master file. Three Charlson versions, 8 Elixhauser versions, and 3 IMRS formulations were evaluated in Cox regression and the one of each that was most predictive was used in dual risk score mortality analyses (in-hospital, 30-day, 1-year, and 5-year mortality). RESULTS: Indices with the strongest mortality associations and selected for dual score study were the age-adjusted Charlson, the van Walraven version of the acute Elixhauser, and the 1-year IMRS. For in-hospital mortality, Charlson (c = 0.719; HR = 4.75, 95% CI = 4.45, 5.07), Elixhauser (c = 0.783; HR = 5.79, CI = 5.41, 6.19), and IMRS (c = 0.821; HR = 17.95, CI = 15.90, 20.26) were significant predictors (p<0.001) in univariate analyses. Dual score analysis of Charlson (HR = 1.79, CI = 1.66, 1.92) with IMRS (HR = 13.10, CI = 11.53, 14.87) and of Elixhauser (HR = 3.00, CI = 2.80, 3.21) with IMRS (HR = 11.42, CI = 10.09, 12.92) found significance for both scores in each model. Results were similar for 30-day, 1-year, and 5-year mortality. CONCLUSIONS: IMRS provided the strongest ability to predict mortality, adding to and attenuating the predictive ability of the Charlson and Elixhauser indices whose mortality associations remained statistically significant. IMRS uses common, standardized, objective laboratory data and should be further evaluated for integration into mortality risk evaluations.

Impact of Critical Illness on Resource Utilization: A Comparison of Use in the Year Before and After ICU Admission.

OBJECTIVES: Increasingly, patients admitted to an ICU survive to hospital discharge; many with ongoing medical needs. The full impact of an ICU admission on an individual's resource utilization and survivorship trajectory in the United States is not clear. We sought to compare healthcare utilization among ICU survivors in each year surrounding an ICU admission. DESIGN: Retrospective cohort of patients admitted to an ICU during one calendar year (2012) in a multipayer healthcare system. We assessed mortality, hospital readmissions (categorized by ambulatory care sensitive conditions and emergency department), and outpatient visits. We compared the proportion of patients with visits during the pre-ICU year versus the post-ICU year. PATIENTS: People admitted to an Intermountain healthcare ICU for greater than 48 hours in the year 2012 INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS: Among 4,074 ICU survivors, 45% had increased resource utilization. Readmission rates at 30-day, 90-day, and 1-year were 15%, 26%, and 43%. The proportion of patients with a hospital admission increased significantly in the post-ICU period (43% vs 29%; p < 0.001). Of patients with a readmission in the post-ICU period, 24% were ambulatory care sensitive condition. Patients with increased utilization differed by socioeconomic status, insurance type, and severity of illness. Sixteen percent of patients had either an emergency department or inpatient admission, but no outpatient visits during the post-ICU period. CONCLUSIONS: An ICU admission is associated with increased resource utilization including hospital readmissions, with many due to an ambulatory care sensitive condition. Lower socioeconomic status and higher severity of illness are associated with increased resource utilization. After an ICU visit patients seem to use hospital resources over outpatient resources. Interventions to improve and coordinate care after ICU discharge are needed.

Gender, Professional Experiences, and Personal Characteristics of Academic Radiation Oncology Chairs: Data to Inform the Pipeline for the 21st Century.

PURPOSE: Understanding the pathways and gateways to leadership and challenges faced by individuals in such roles can inform efforts to promote diversity and equity. We sought to describe the professional experiences and personal characteristics of academic radiation oncology (RO) chairs and to evaluate whether differences exist by gender. METHODS AND MATERIALS: Anonymous surveys were distributed to 95 chairs of RO departments during the 2016 annual meeting of the Society of Chairs of Academic Radiation Oncology Programs. The surveys included 28 closed-ended questions and the Leadership Practices Inventory. Results were analyzed by gender using χ2 tests, rank-sum, and t tests (significance P < .05). RESULTS: A total of 72 chairs responded (61 male, 10 female, 1 declined to identify gender) for a response rate of 76%. There were no significant gender differences in age, academic rank, publications, or prior leadership positions held at the time of the first chair appointment, but female respondents held significantly greater total direct funding from extramural grants than their male counterparts (median, $1.89 million [interquartile range, $0.5-$5 million] vs $0.25 million [interquartile range, $0-$1.0 million]; P = .006). Women were more likely to have spouses employed outside the home at time of their first chair appointment than men were, with a trend toward women experiencing greater difficulty relocating. Men and women identified budgeting and resource allocation as their greatest professional challenges. There were no gender differences in the Leadership Practices Inventory-identified leadership domains or professional goals. CONCLUSIONS: Female RO chairs are as equally qualified as men in terms of productivity or leadership skills, but they face distinct challenges in the context of a gender-structured society. The observation of higher grant funding among women at the time of chair appointment suggests a possible need for interventions such as unconscious bias training to ensure that selection processes do not unnecessarily hold women to a higher standard.

Methods for analysis of complex survey data: an application using the Tanzanian 2015 Demographic and Health Survey and Service Provision Assessment.

BACKGROUND: Low-income and middle-income countries (LMICs) seek to better utilize household and health facility survey data for monitoring and evaluation, as well as for health program planning. However, analysis of this complex survey data are complicated. In Tanzania, the National Evaluation Platform project sought to analyze Demographic and Health Survey (DHS) data and Service Provision Assessment (SPA) data as part of an evaluation of the national One Plan for Maternal and Child Health. To support this evaluation, we used this survey data to answer two key methodological questions: 1) what are the benefits and costs of using sampling weights in rate estimation; and 2) what is the best method for calculating standard errors in these two surveys? METHODS: We conducted a simulation study for each methodologic question. The first simulation study assessed the benefits and costs of using sampling weights in rate estimation. This simulation used weighted and unweighted estimates and examined bias, variance, and the mean squared error (MSE). The second simulation study assessed the best method for calculating standard errors comparing cluster bootstrapped variance estimation, design based asymptotic variance with one level (svy1), and design based asymptotic variance with three levels (svy3). We compared coverage probability and confidence interval length. RESULTS: Our results showed that although weighted estimates were less biased, unweighted estimates were less variable. The weighted estimates had a lower MSE, indicating that the effect of the bias trade-off was greater than the effect of the variance trade-off for most indicators assessed. The best performer for variance estimation was the cluster bootstrap method, followed by the svy3 method. The svy1 method was the worst performer for most indicators assessed. CONCLUSIONS: As complex survey data become more widely used for policymaking in LMICs, there is a need for guidance on the best methods for analyzing this data. The standard of practice has been a design-based analysis using survey weights and the single-level svy method for calculating standard errors. This study puts forth an alternative approach to analysis. In addition, this study offers practical guidance on determining the best method for analysis of complex survey data.