Effect of postpartum family planning intervention and associated factors during child immunization in Addis Ababa, Ethiopia.

Introduction: World Health Organization (WHO) recommends postpartum family planning (PPFP) as a critical component of health care that has the potential to save millions of maternal and infant lives in low- and middle-income countries. Methods: participants in our randomized, controlled trial were mothers coming for vaccination of their child in three selected health centers in Addis Ababa during the first 10 weeks postpartum. Eligible mothers were randomly assigned to intervention (pamphlet-supported counseling about the benefits of family planning) and non-intervention (routine care) arms. Data were collected when mothers came with their infants for a routine measles vaccination at nine months of life. Family planning (FP) use was compared between the groups using logistic regression, and bivariate and multivariate analyses. The study also used Kaplan Meier and Cox regressions to compare the median time of PPFP use and its correlation using SPSS version 26. The research was undertaken from December 2019 to June 2021. Results: a total of 347 women (177 control, 170 intervention) enrolled in the study. Fifty-eight percent were 24-30 years old. Young age, knowledge about FP, previous use of an FP method, and being married were found to be independent predictors for PPFP use. When comparing intervention and non-intervention groups, there was no significant effect on contraceptive use (adjusted OR 0.633 [95% CI 0.385-1.040]). Conclusion: pamphlet-supported counseling of mothers in the first 10 weeks postpartum did not increase PPFP at nine months postpartum. Successful interventions will likely require holistic strategies, especially in resource-limited settings. The trial had been registered with clinicaltrials.gov (NCT04521517) on September 24, 2019.

Disability Evaluations: Common Questions and Answers.

Disability is a physical or mental impairment that substantially limits at least one major life activity. Family physicians are often asked to assess patients with disabling conditions that can impact insurance benefits, employment, and ability to access needed accommodations. Disability evaluations are needed for short-term work restrictions following a simple injury or illness and for more complex cases involving Social Security Disability Insurance, Supplemental Security Income, Family and Medical Leave Act, workers' compensation, and personal/private disability insurance claims. Using a stepwise approach built on awareness of the biologic, psychological, and social elements of disability assessment may facilitate this evaluation. Step 1 establishes the role of the physician in the disability evaluation process and the context of the request. In Step 2, the physician assesses impairments and establishes a diagnosis based on findings from an examination and validated diagnostic tools. In Step 3, the physician identifies specific participation restrictions by assessing the patient's ability to perform specific movements or activities and reviewing the employment environment and tasks. Steps 4 and 5 ensure proper documentation, billing, and coding. In complex cases, consultants such as psychiatrists and physical therapists may assist by providing insight into a patient's mental and physical impairments, activity limitations, and response to treatment.

Health facility assessments of cervical cancer prevention, early diagnosis, and treatment services in Gulu, Uganda.

BACKGROUND: Cervical cancer is ranked globally in the top three cancers for women younger than 45 years, with the average age of death at 59 years of age. The highest burden of disease is in low-to-middle income countries (LMICs), responsible for 90% of the 311,000 cervical cancer deaths in 2018. This growing health disparity is due to the lack of quality screening and treatment programs, low human papillomavirus (HPV) vaccination rates, and high human immunodeficiency virus (HIV) co-infection rates. To address these gaps in care, we need to develop a clear understanding of the resources and capabilities of LMICs' health care facilities to provide prevention, early diagnosis through screening, and treatment for cervical cancer. OBJECTIVES: This project aimed to assess baseline available cervical cancer prevention, early diagnosis, and treatment resources, at facilities designated as Health Center III or above, in Gulu, Uganda. METHODS: We adapted the World Health Organization's Harmonized Health Facility Assessment for our own HFA and grading scale, deploying it in October 2021 for a cross-sectional analysis of 21 health facilities in Gulu. RESULTS: Grading of Health Center IIIs (n = 16) concluded that 37% had "excellent" or "good" resources available, and 63% of facilities had "poor" or "fair" resources available. Grading of Health Center IVs and above (n = 5) concluded that 60% of facilities had "excellent" or "good" resources, and 40% had "fair" resources available. DISCUSSION: The analysis of health facilities in Gulu demonstrated subpar resources available for cervical cancer prevention, early diagnosis, and treatment. Focused efforts are needed to expand health centers' resources and capability to address rising cervical cancer rates and related health disparities in LMICs. The development process for this project's HFA can be applied to global cervical cancer programming to determine gaps in resources and indicate areas to target improved health equity.

Trainee Perspectives Regarding Advanced Clinical Global Health Fellowships in North America.

Postgraduate clinical global health (GH) training is a rapidly evolving field. To understand and improve training opportunities, we sought the perspectives of current and former trainees related to their advanced clinical training or global health fellowships and the anticipated impact on their careers. Clinical GH fellowships across North America were identified through websites and previous studies. An e-mail was sent to program directors to invite all current and former GH fellows to complete a web-based questionnaire. We contacted 100 GH fellowship programs. Fifty-two fellows from 10 different specialties completed the survey. The median fellowship length was 23.3 months, with an annual median of 4.8 months spent in low-income and middle-income countries, which was less than their reported ideal of 6 months. The majority reported satisfaction, the anticipation of career benefits, and that they would recommend fellowship training to others. Challenges included insufficient funding, mentorship, and formal curricula. Conducting research in high-income countries was a significant negative predictor of fellowship satisfaction. Most fellows (73.1%) were not at all or only a little concerned about the absence of fellowship accreditation, with only 17.3% desiring accreditation. Survey respondents were largely satisfied with their training and valued program flexibility and educational opportunities, including advanced tropical medicine certificates or diplomas. However, to improve fellowship training, improvements are needed in mentorship, standardized curricula, institutional support, and funding. For GH fellowship training to be effective and sustainable, institutions will need to balance the needs of fellows, training programs, and the communities (low-, middle-, and high-income countries) where the fellows serve.

Status of global health fellowship training in the United States and Canada.

BACKGROUND: Increasing numbers of residency graduates desire global health (GH) fellowship training. However, the full extent of training options is not clear. OBJECTIVE: To identify clinical GH fellowships in all specialties in the U.S. and Canada and to describe their demographics, innovative features, and challenges. METHODS: The authors surveyed program directors or designees from GH fellowships with a web-based tool in 2017. RESULTS: The authors identified 85 programs. Fifty-four programs (63.5%) responded confirming 50 fellowships. One- third of fellowships accepted graduates from more than one specialty, and the most common single-specialty programs were Emergency Medicine and Family Medicine. Fellowships most commonly were 24 months in duration with a median size of one fellow per year. Funding and lack of qualified applicants were significant challenges. Most programs were funded through fellow billing for patient care or other self-support. CONCLUSION: The number of U.S. and Canadian GH fellowship programs has nearly doubled since 2010. Challenges include lack of funding and qualified applicants. Further work is needed to understand how best to identify and disseminate fellowship best practices to meet the diverse needs of international partners, fellows, and the patients they serve and to determine if consensus regarding training requirements would be beneficial.

CONTEXTE: Un nombre croissant de diplômés des programmes de résidence optent pour une formation complémentaire en santé mondiale. Cependant, la pleine mesure des possibilités de formation n'est pas claire. OBJECTIF: Identifier les formations cliniques complémentaires en santé mondiale pour toutes les spécialités aux États- Unis et au Canada et décrire leur démographie, leurs caractéristiques novatrices, et leurs défis. MÉTHODES: En 2017, les auteurs ont interrogé les directeurs de programmes de formation complémentaire en santé mondiale ou leur représentant à l'aide d'un outil en ligne. RÉSULTATS: Les auteurs ont identifié 85 programmes. 54 programmes (63,5 %) ont répondu et confirmé 50 programmes de formation. Un tiers des programmes acceptaient des diplômés provenant de plusieurs spécialités, et les programmes offerts à des spécialités uniques étaient plus fréquemment ceux en médecine d'urgence et en médecine familiale. Les programmes étaient généralement d'une durée de 24 mois avec une capacité d'accueil d'un moniteur (fellow) par année. Le financement et le manque de candidats qualifiés étaient des défis de taille. La plupart des programmes étaient financés par la rémunération des moniteurs (fellows) pour les soins qu'ils prodiguaient aux patients ou via d'autres aides financières individuelles. CONCLUSIONS: Le nombre de programmes de formation complémentaire en santé mondiale a presque doublé depuis 2010. Les défis sont notamment le manque de financement et de candidats qualifiés. Il est nécessaire de poursuivre le travail pour pouvoir bien identifier et transmettre les meilleures pratiques en matière de formation complémentaire afin de répondre aux divers besoins des partenaires internationaux, des moniteurs (fellows) et des patients qu'ils soignent, et déterminer si un consensus concernant les exigences de formation serait bénéfique.

Family Medicine in Ethiopia: Lessons from a Global Collaboration.

BACKGROUND: Building the capacity of local health systems to provide high-quality, self-sustaining medical education and health care is the central purpose for many global health partnerships (GHPs). Since 2001, our global partner consortium collaborated to establish Family Medicine in Ethiopia; the first Ethiopian family physicians graduated in February 2016. METHODS: The authors, representing the primary Ethiopian, Canadian, and American partners in the GHP, identified obstacles, accomplishments, opportunities, errors, and observations from the years preceding residency launch and the first 3 years of the residency. RESULTS: Common themes were identified through personal reflection and presented as lessons to guide future GHPs. LESSON 1: Promote Family Medicine as a distinct specialty. LESSON 2: Avoid gaps, conflict, and redundancy in partner priorities and activities. LESSON 3: Building relationships takes time and shared experiences. LESSON 4: Communicate frequently to create opportunities for success. LESSON 5: Engage local leaders to build sustainable, long-lasting programs from the beginning of the partnership. CONCLUSIONS: GHPs can benefit individual participants, their organizations, and their communities served. Engaging with numerous partners may also result in challenges-conflicting expectations, misinterpretations, and duplication or gaps in efforts. The lessons discussed in this article may be used to inform GHP planning and interactions to maximize benefits and minimize mishaps.

Faculty development in family medicine education: what is needed?

A growing number of countries are embracing graduate training in the specialty of Family Medicine as a core component of global health systems reform. One significant challenge for new programs is to adequately prepare for educational excellence and leadership. Promising residents are often encouraged to remain in their program as faculty, but may not have had the benefit of specific training in teaching, curriculum development, learner assessment or educational leadership. Faculty Development is a potential avenue to providing these skills to new Family Medicine Faculty and to encourage new graduates to consider teaching. We are currently seeking to further clarify what the current needs and future possibilities are for Family Medicine Faculty Development in Sub-Saharan Africa.

Postpartum Hemorrhage: Prevention and Treatment.

Postpartum hemorrhage is common and can occur in patients without risk factors for hemorrhage. Active management of the third stage of labor should be used routinely to reduce its incidence. Use of oxytocin after delivery of the anterior shoulder is the most important and effective component of this practice. Oxytocin is more effective than misoprostol for prevention and treatment of uterine atony and has fewer adverse effects. Routine episiotomy should be avoided to decrease blood loss and the risk of anal laceration. Appropriate management of postpartum hemorrhage requires prompt diagnosis and treatment. The Four T's mnemonic can be used to identify and address the four most common causes of postpartum hemorrhage (uterine atony [Tone]; laceration, hematoma, inversion, rupture [Trauma]; retained tissue or invasive placenta [Tissue]; and coagulopathy [Thrombin]). Rapid team-based care minimizes morbidity and mortality associated with postpartum hemorrhage, regardless of cause. Massive transfusion protocols allow for rapid and appropriate response to hemorrhages exceeding 1,500 mL of blood loss. The National Partnership for Maternal Safety has developed an obstetric hemorrhage consensus bundle of 13 patient- and systems-level recommendations to reduce morbidity and mortality from postpartum hemorrhage.

Current Status of Family Medicine Faculty Development in Sub-Saharan Africa.

BACKGROUND AND OBJECTIVES: Reducing the shortage of primary care physicians in sub-Saharan Africa requires expansion of training programs in family medicine. Challenges remain in preparing, recruiting, and retaining faculty qualified to teach in these pioneering programs. Little is known about the unique faculty development needs of family medicine faculty within the sub-Saharan African context. The purpose of this study was to assess the current status and future needs for developing robust family medicine faculty in sub-Saharan Africa. The results are reported in two companion articles. METHODS: A cross-sectional study design was used to conduct a qualitative needs assessment comprising 37 in-depth, semi-structured interviews of individual faculty trainers from postgraduate family medicine training programs in eight sub-Saharan African countries. Data were analyzed according to qualitative description. RESULTS: While faculty development opportunities in sub-Saharan Africa were identified, current faculty note many barriers to faculty development and limited participation in available programs. Faculty value teaching competency, but institutional structures do not provide adequate support. CONCLUSIONS: Sub-Saharan African family physicians and postgraduate trainee physicians value good teachers and recognize that clinical training alone does not provide all of the skills needed by educators. The current status of limited resources of institutions and individuals constrain faculty development efforts. Where faculty development opportunities do exist, they are too infrequent or otherwise inaccessible to provide trainers the necessary skills to help them succeed as educators.

Future of Family Medicine Faculty Development in Sub-Saharan Africa.

BACKGROUND AND OBJECTIVES: High-quality family medicine education is needed in sub-Saharan Africa to facilitate the future growth of primary care health systems. Current faculty educators recognize the value of dedicated teacher training and ongoing faculty development. However, they are constrained by inadequate faculty development program availability and institutional support. METHODS: A cross-sectional study design was used to conduct a qualitative needs assessment comprised of 37 in-depth, semi-structured interviews of individual faculty trainers from postgraduate family medicine training programs in eight sub-Saharan African countries. Data were analyzed according to qualitative description. RESULTS: Informants described desired qualities for a family medicine educator in sub-Saharan Africa: (1) pedagogical expertise in topics and perspectives unique to family medicine, (2) engagement in self-directed, lifelong learning, and (3) exemplary character and behavior that inspires others. Informant recommendations to guide the development of faculty development programs include: (1) sustainability, partnership, and responsiveness to the needs of the institution, (2) intentional faculty development must begin early and be supported with high-quality mentorship, (3) presumptions of teaching competence based on clinical training must be overcome, and (4) evaluation and feedback are critical components of faculty development. CONCLUSIONS: High-quality faculty development in family medicine is critically important to the primary care workforce in sub-Saharan Africa. Our study describes specific needs and recommendations for family medicine faculty development in sub-Saharan Africa. Next steps include piloting and evaluating innovative models of faculty development that respond to specific institutional or regional needs.

Travel During Pregnancy: Considerations for the Obstetric Provider.

IMPORTANCE: Travel among US citizens is becoming increasingly common, and travel during pregnancy is also speculated to be increasingly common. During pregnancy, the obstetric provider may be the first or only clinician approached with questions regarding travel. OBJECTIVE: In this review, we discuss the reasons women travel during pregnancy, medical considerations for long-haul air travel, destination-specific medical complications, and precautions for pregnant women to take both before travel and while abroad. To improve the quality of pretravel counseling for patients before or during pregnancy, we have created 2 tools: a guide for assessing the pregnant patient's risk during travel and a pretravel checklist for the obstetric provider. EVIDENCE ACQUISITION: A PubMed search for English-language publications about travel during pregnancy was performed using the search terms "travel" and "pregnancy" and was limited to those published since the year 2000. Studies on subtopics were not limited by year of publication. RESULTS: Eight review articles were identified. Three additional studies that analyzed data from travel clinics were found, and 2 studies reported on the frequency of international travel during pregnancy. Additional publications addressed air travel during pregnancy (10 reviews, 16 studies), high-altitude travel during pregnancy (5 reviews, 5 studies), and destination-specific illnesses in pregnant travelers. CONCLUSIONS AND RELEVANCE: Travel during pregnancy including international travel is common. Pregnant travelers have unique travel-related and destination-specific risks. We review those risks and provide tools for obstetric providers to use in counseling pregnant travelers.

An Assessment of International Family Medicine Faculty Development Priorities: Perspectives From the American Academy of Family Physicians Global Health Workshop.

INTRODUCTION: The proliferation of new family medicine training programs across the globe has increased the demand for faculty development (FD) opportunities in international settings. US-based faculty may partner with international colleagues to support FD. In 2016, the Society of Teachers of Family Medicine Global Health Educators Collaborative (STFM-GHEC) began to develop a toolkit of low-cost FD resources for this purpose. To ensure that the resources appropriately target current FD needs, STFM-GHEC organized a session at the 2016 American Academy of Family Physicians (AAFP) Global Health Workshop (GHW) to collect feedback from internationally-based and US-based faculty. METHODS: The authors presented a list of faculty development topics to attendees of an AAFP GHW session entitled "Global Faculty Development Tool Kit" on September 8, 2016, in Atlanta, Georgia. Workshop participants voted up to five times each using sticky notes for the topics they felt were of greatest need. RESULTS: Forty-five participants cast 157 votes (34 from internationally-based faculty, 123 from US-based faculty). The combined group ranked curriculum development, program evaluation, and teaching methods as the most important FD needs. Both groups identified assessment strategy and time management among the least important FD needs. Other topics such as technology training and research design varied widely between the two groups in relative importance. CONCLUSIONS: This pilot demonstrates that US-based and internationally-based family medicine faculty may differ in their perceived FD needs. This exercise may be utilized by future members in global health partnerships to understand and prioritize faculty development needs.

Resident Competency in Pelvic Exam Skills Not Predicted by Early Assessment.

INTRODUCTION: Pelvic examination training and competency-based assessment are expensive and time consuming. Our goal was to use the results of skill evaluation early in residency to identify residents who required training. METHODS: Incoming residents performed pelvic examinations with gynecological teaching assistants. Faculty observed residents performing examinations with clinic patients to assess for competency. Written assessment of residents by teaching assistants and faculty were completed. A regression-based software tool was used to determine items in early resident performance to best predict subsequent competency. RESULTS: Sixty-eight residents were evaluated. Thirty-eight (56%) residents were not able to demonstrate competency in three clinical exams and therefore received more observation. One third of evaluations were completed by faculty performing ≤1 evaluation per year. Two items were found most likely to identify a resident who required further training ("identifies cervix" and "properly assembles equipment"). The model based on these items had a sensitivity of 100% (95% confidence interval [CI]=86-100%) and specificity of 36.8% (95% CI=22-54%). CONCLUSIONS: A model using early skills assessments was not sufficiently specific to identify residents who needed more training. Next steps include limiting the number of faculty assessors, faculty development to improve discriminatory capacity, and creating separate processes for (1) providing feedback and identifying learning needs in new residents, and (2) documenting competency in performance of pelvic exams.

Characteristics and outcomes of women using emergency medical services for third-trimester pregnancy-related problems in India: a prospective observational study.

OBJECTIVES: Characterise the demographics, management and outcomes of obstetric patients transported by emergency medical services (EMS). DESIGN: Prospective observational study. SETTING: Five Indian states using a centralised EMS agency that transported 3.1 million pregnant women in 2014. PARTICIPANTS: This study enrolled a convenience sample of 1684 women in third trimester of pregnancy calling with a 'pregnancy-related' problem for free-of-charge ambulance transport. Calls were deemed 'pregnancy related' if categorised by EMS dispatchers as 'pregnancy', 'childbirth', 'miscarriage' or 'labour pains'. Interfacility transfers, patients absent on ambulance arrival and patients refusing care were excluded. MAIN OUTCOME MEASURES: Emergency medical technician (EMT) interventions, method of delivery and death. RESULTS: The median age enrolled was 23 years (IQR 21-25). Women were primarily from rural or tribal areas (1550/1684 (92.0%)) and lower economic strata (1177/1684 (69.9%)). Time from initial call to hospital arrival was longer for rural/tribal compared with urban patients (66 min (IQR 51-84) vs 56 min (IQR 42-73), respectively, p<0.0001). EMTs assisted delivery in 44 women, delivering the placenta in 33/44 (75%), performing transabdominal uterine massage in 29/33 (87.9%) and administering oxytocin in none (0%). There were 1411 recorded deliveries. Most women delivered at a hospital (1212/1411 (85.9%)), however 126/1411 (8.9%) delivered at home following hospital discharge. Follow-up rates at 48 hours, 7 days and 42 days were 95.0%, 94.4% and 94.1%, respectively. Four women died, all within 48 hours. The caesarean section rate was 8.2% (116/1411). On multivariate regression analysis, women transported to private hospitals versus government primary health centres were less likely to deliver by caesarean section (OR 0.14 (0.05-0.43)) CONCLUSIONS: Pregnant women from vulnerable Indian populations use free-of-charge EMS for impending delivery, making it integral to the healthcare system. Future research and health system planning should focus on strengthening and expanding EMS as a component of emergency obstetric and newborn care (EmONC).

Emergence of family medicine in Ethiopia [corrected]: an international collaborative education model.

Family Medicine (FM) is a new specialty in Ethiopia. The first seven family physicians graduated in February 2016 from the inaugural residency programme at Addis Ababa University. Cooperation amongst Ethiopian and expatriate decision-makers and physicians was needed to begin the programme. Intentional replacement of expatriates with Ethiopian family physicians has begun. Barriers include lack of understanding of FM and the human and financial resources needed for scaling up the programme. Regular programme review with resident physician involvement has allowed the FM training programme to adapt and fit the Ethiopian context. Further successes will result from ongoing support and advocacy from the Federal Ministry of Health and other Ethiopian, African, and international primary care organisations.

Preexposure Prophylaxis (PrEP) for HIV Prevention: The Primary Care Perspective.

Until recently there have been few primary care office-based strategies to reduce the transmission of HIV. In May 2014 the Centers for Disease Control and Prevention published updated practice guidelines recommending the use of preexposure prophylaxis (PrEP) with daily oral dosing of tenofovir/emtricitabine to help prevent HIV infection in high-risk individuals (strength of recommendation, A). Knowledge of PrEP among primary care providers is low, however, and this intervention is likely reaching only a small fraction of eligible patients. PrEP is recommended for certain injection drug users, nonmonogamous men who have sex with men, heterosexual women who have sex with men who have sex with men or injection drug users, and those in HIV serodiscordant relationships. Providers should obtain baseline laboratory values and provide initial counseling before prescribing PrEP. Regular office visits are necessary to ensure adherence, provide ongoing counseling, and monitor for side effects, including nausea, abdominal pain, headache, and, less commonly, increased creatinine. Guidelines and toolkits have been developed to assist in incorporating PrEP into primary care practice. PrEP is gaining widespread acceptance and has become a crucial tool in the fight to stop the spread of HIV.

The impact of Advanced Life Support in Obstetrics (ALSO) training in low-resource countries.

OBJECTIVE: To examine the effects of the Advanced Life Support in Obstetrics (ALSO) program on maternal outcomes in four low-income countries. METHODS: Data were obtained from single-center, longitudinal cohort studies in Colombia, Guatemala, and Honduras, and from an uncontrolled prospective trial in Tanzania. RESULTS: In Colombia, maternal morbidity and the number of near misses increased after ALSO training, but maternal mortality decreased. In Guatemala, sustained reductions in overall maternal mortality and mortality from postpartum hemorrhage (PPH) were recorded after ALSO implementation. In Honduras, there was a significant decrease in episiotomy rates, and increases in active management of the third stage of labor (AMTSL), vacuum-assisted delivery, and reported comfort managing obstetric emergencies. In Tanzania, the frequency of PPH and severe PPH decreased after training, while management improved. CONCLUSION: In low-income countries, ALSO training was associated with decreased in-hospital maternal mortality, episiotomy use, and PPH. AMTSL and vacuum-assisted vaginal delivery increased in frequency after ALSO training.

Increased patient communication using a process supplementing an electronic medical record.

BACKGROUND: Importance: Patients with cervical cytology abnormalities may require surveillance for many years, which increases the risk of management error, especially in clinics with multiple managing clinicians. National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home (PCMH) certification requires tracking of abnormal results and communicating effectively with patients. OBJECTIVES: The purpose of this study was to determine whether a computer-based tracking system that is not embedded in the electronic medical record improves (1) accurate and timely communication of results and (2) patient adherence to follow-up recommendations. METHODS: Design: Pre/post study using data from 2005-2012. Intervention implemented in 2008. Data collected via chart review for at least 18 months after index result. Participants: Pre-intervention: all women (N = 72) with first abnormal cytology result from 2005-2007. Post-intervention: all women (N = 128) with first abnormal cytology result from 2008-2010. Patients were seen at a suburban, university-affiliated, family medicine residency clinic. Intervention: Tracking spreadsheet reviewed monthly with reminders generated for patients not in compliance with recommendations. Main Outcome and Measures: (1) rates of accurate and timely communication of results and (2) rates of patient adherence to follow-up recommendations. RESULTS: Intervention decreased absent or erroneous communication from clinician to patient (6.4% pre- vs 1.6% post-intervention [P = 0.04]), but did not increase patient adherence to follow-up recommendations (76.1% pre- vs 78.0% post-intervention [ P= 0.78]). CONCLUSIONS: Use of a spreadsheet tracking system improved communication of abnormal results to patients, but did not significantly improve patient adherence to recommended care. Although the tracking system complies with NCQA PCMH requirements, it was insufficient to make meaningful improvements in patient-oriented outcomes.

Update on gestational diabetes mellitus.

The incidence of gestational diabetes mellitus (GDM) is increasing in the United States. Universal GDM screening is recommended, although evidence of benefit is lacking. Treatment of GDM reduces the risk of shoulder dystocia, preeclampsia, and macrosomia. Intensive treatment is more effective than less-intensive treatment. Traditional management includes diet, exercise, and short- and intermediate-acting insulin regimens. Use of metformin and glyburide is controversial, but evidence supporting safety and efficacy is accumulating. Postpartum screening with a glucose tolerance test rather than a fasting blood glucose level should be performed 6 weeks after delivery.

Clinical inquiries. Which patients benefit from lowering LDL to <100 mg/dL?

Patients who have coronary heart disease (CHD) or are at high risk for CHD should aim for a low-density lipoprotein (LDL) target of <100 mg/dL. An LDL target of <70 mg/dL is an option for very-high-risk patients (strength of recommendation [SOR]: C, expert opinion). The evidence also indicates that high-risk patients benefit from a statin-preferably in high doses-regardless of their baseline LDL or degree of LDL reduction with treatment (SOR: A, a large randomized controlled trial [RCT] and meta-analyses).