Capacity-Building for Collecting Patient-Reported Outcomes and Experiences (PRO) Data Across Hospitals.

PURPOSE: Patient-reported outcomes and experiences (PRO) data are an integral component of health care quality measurement and PROs are now being collected by many healthcare systems. However, hospital organizational capacity-building for the collection and sharing of PROs is a complex process. We sought to identify the factors that facilitated capacity-building for PRO data collection in a nascent quality improvement learning collaborative of 16 hospitals that has the goal of improving the childbirth experience. DESCRIPTION: We used standard qualitative case study methodologies based on a conceptual framework that hypothesizes that adequate organizational incentives and capacities allow successful achievement of project milestones in a collaborative setting. The 4 project milestones considered in this study were: (1) Agreements; (2) System Design; (3) System Development and Operations; and (4) Implementation. To evaluate the success of reaching each milestone, critical incidents were logged and tracked to determine the capacities and incentives needed to resolve them. ASSESSMENT: The pace of the implementation of PRO data collection through the 4 milestones was uneven across hospitals and largely dependent on limited hospital capacities in the following 8 dimensions: (1) Incentives; (2) Leadership; (3) Policies; (4) Operating systems; (5) Information technology; (6) Legal aspects; (7) Cross-hospital collaboration; and (8) Patient engagement. From this case study, a trajectory for capacity-building in each dimension is discussed. CONCLUSION: The implementation of PRO data collection in a quality improvement learning collaborative was dependent on multiple organizational capacities for the achievement of project milestones.

Using Potentially Preventable Severe Maternal Morbidity to Monitor Hospital Performance.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) measure of severe maternal morbidity (SMM) quantifies the burden of SMM but is not restricted to potentially preventable SMM. The authors adapted the CDC SMM measure for this purpose and evaluated it for use as a hospital performance measure. METHODS: Guidelines for defining performance SMM (pSMM) were (1) exclusion of preexisting conditions from outcome; (2) exclusion of inconsistently documented outcomes; and (3) risk adjustment for conditions that preceded hospitalization. California maternal hospital discharge data from 2016 to 2017 were used for model development, and 2018 data were used for model testing and evaluation of hospital performance. Separate models were developed for hospital types (Community, Teaching, Integrated Delivery System [IDS], and IDS Teaching), generating model-based expected pSMM values. Observed-to-expected (O/E) ratios were calculated for hospitals and used to categorize them as overperforming, average performing, or underperforming using 95% confidence intervals. Performance categories were compared for pSMM vs. CDC SMM (excluding blood transfusion). RESULTS: The overall 2016-2018 pSMM rate was 0.44%. All hospital types had over- and underperformers, and the proportions of Community, Teaching, IDS, and IDS Teaching hospitals whose performance differed from their performance on the CDC SMM measure were 12.1%, 25.0%, 38.9%, and 66.7%, respectively. CONCLUSION: The rate of potentially preventable SMM as defined by pSMM (0.44%) was less than half the previously published rate of CDC SMM (1.03%). pSMM identified differences in performance across hospitals, and pSMM and CDC SMM classified hospitals' performances differently. pSMM may be suitable for hospital comparisons because it identifies potentially preventable, hospital-acquired SMM that should be responsive to quality improvement activities.

Patient perceptions of virtual reality for pain relief in labor: A qualitative study.

Introduction: Labor represents the most common reason for hospitalization, and most patients will use some form of pain management during their labor. While some studies have suggested that virtual reality (VR) may be an effective option for managing pain, more study is necessary to understand the patient experience of VR. The aim of this study is to characterize the effect of VR on patient perceptions of coping in labor and their descriptions of the VR experience. Methodology: A nested prospective, descriptive study within a randomized controlled trial of VR in laboring patients. We included nulliparous, term patients, having contractions at least every 5 min, a pain score on the Wong-Baker pain scale of 4-7, and who had been randomized to receive the 30 min virtual reality intervention in the trial. Subjects completed a childbirth self-efficacy inventory prior to the intervention. After the intervention, they completed a modified childbirth self-efficacy inventory related to VR and underwent a structured interview. Self-efficacy scores were compared using t-tests and qualitative, thematic analysis was performed using Dedoose. Results: Twenty-one subjects received the VR intervention. Twenty subjects completed the post-intervention survey and structured interview; one declined due to discomfort. Subjects noted a significant increase in perceived degree to which VR could improve their self-efficacy in managing pain during labor. Thematic analysis revealed that subjects described the VR experience as allowing them to connect with their breathing, feeling more relaxed, and being distracted from pain. In total, 70% believed VR reduced their pain, 60% felt it reduced their anxiety, and 100% would recommend VR availability for laboring patients. Conclusion: VR can improve patient self-efficacy for managing pain in labor. Future studies should focus on the content of the visualizations, optimized user experience and design, and effectiveness with ongoing exposure to VR content in labor.

Association of Primary Cesarean Delivery Rate With Dissemination of Nurse-Specific Cesarean Delivery Rates.

Strategies to safely reduce the rate of nulliparous, term, singleton, vertex (NTSV) cesarean deliveries have thus far largely ignored the contribution that labor and delivery nurses make to the delivery mode. We used a recently developed method to calculate nurse-specific cesarean delivery rates and provide these to labor and delivery nursing leadership, who shared the rates with labor and delivery nurses beginning in September 2020. We performed a 3-year interrupted time series analysis comparing our NTSV cesarean delivery rates before and after nurse-specific rates were released. On release of nurse-specific rates, our labor and delivery unit's NTSV cesarean delivery rate declined from 25.7% to 22.0%. Further work to find strategies to sustain nurse engagement is warranted.

Preventing Obesity in Midlife Women: A Recommendation From the Women's Preventive Services Initiative.

DESCRIPTION: The Women's Preventive Services Initiative (WPSI), a national coalition of women's health professional organizations and patient advocacy representatives, developed a recommendation for counseling midlife women aged 40 to 60 years with normal or overweight body mass index (BMI; 18.5 to 29.9 kg/m2) to maintain weight or limit weight gain to prevent obesity with the long-term goals of optimizing health, function, and well-being. This recommendation is intended to guide clinical practice and coverage of clinical preventive health services for the Health Resources and Services Administration and other stakeholders. Clinicians providing preventive health care to women in primary care settings are the target audience for this recommendation. METHODS: The WPSI developed this recommendation after evaluating results of a systematic review of the effectiveness and harms of interventions to prevent weight gain and obesity in women aged 40 to 60 years without obesity. Seven randomized clinical trials including 51 638 participants and using various counseling and behavioral interventions were included. Trials indicated favorable weight changes with interventions that were statistically significantly different from control groups in 4 of 5 trials of counseling, but not in 2 trials of exercise. Few harms were reported. RECOMMENDATION: The WPSI recommends counseling midlife women aged 40 to 60 years with normal or overweight BMI (18.5 to 29.9 kg/m2) to maintain weight or limit weight gain to prevent obesity. Counseling may include individualized discussion of healthy eating and physical activity.

Geotemporal analysis of perinatal care changes and maternal mental health: an example from the COVID-19 pandemic.

Our primary objective was to document COVID-19 induced changes to perinatal care across the USA and examine the implication of these changes for maternal mental health. We performed an observational cross-sectional study with convenience sampling using direct patient reports from 1918 postpartum and 3868 pregnant individuals collected between April 2020 and December 2020 from 10 states across the USA. We leverage a subgroup of these participants who gave birth prior to March 2020 to estimate the pre-pandemic prevalence of specific birthing practices as a comparison. Our primary analyses describe the prevalence and timing of perinatal care changes, compare perinatal care changes depending on when and where individuals gave birth, and assess the linkage between perinatal care alterations and maternal anxiety and depressive symptoms. Seventy-eight percent of pregnant participants and 63% of postpartum participants reported at least one change to their perinatal care between March and August 2020. However, the prevalence and nature of specific perinatal care changes occurred unevenly over time and across geographic locations. The separation of infants and mothers immediately after birth and the cancelation of prenatal visits were associated with worsened depression and anxiety symptoms in mothers after controlling for sociodemographic factors, mental health history, number of pregnancy complications, and general stress about the COVID-19 pandemic. Our analyses reveal widespread changes to perinatal care across the US that fluctuated depending on where and when individuals gave birth. Disruptions to perinatal care may also exacerbate mental health concerns, so focused treatments that can mitigate the negative psychiatric sequelae of interrupted care are warranted.

The transition to parenthood in obstetrics: enhancing prenatal care for 2-generation impact.

Obstetrics, the specialty overseeing infant and parent health before birth, could be expanded to address the interrelated areas of parents' prenatal impact on children's brain development and their own psychosocial needs during a time of immense change and neuroplasticity. Obstetrics is primed for the shift that is happening in pediatrics, which is moving from its traditional focus on physical health to a coordinated, whole-child, 2- or multigeneration approach. Pediatric care now includes developmental screening, parenting education, parent coaching, access to developmental specialists, brain-building caregiving skills, linkages to community resources, and tiered interventions with psychologists. Drawing on decades of developmental origins of health and disease research highlighting the prenatal beginnings of future health and new studies on the transition to parenthood describing adult development from pregnancy to early postpartum, we have proposed that, similar to pediatrics, the integration of education and intervention strategies into the prenatal care ecosystem should be tested for its potential to improve child cognitive and social-emotional development and parental mental health. Pediatric care programs can serve as models of change for the systematic development, testing and, incorporation of new content into prenatal care as universal, first-tier treatment and evidenced-based, triaged interventions according to the level of need. To promote optimal beginnings for the whole family, we have proposed an augmented prenatal care ecosystem that aligns with, and could build on, current major efforts to enhance perinatal care individualization through consideration of medical, social, and structural determinants of health.

Applying Automated Machine Learning to Predict Mode of Delivery Using Ongoing Intrapartum Data in Laboring Patients.

OBJECTIVE: This study aimed to develop and validate a machine learning (ML) model to predict the probability of a vaginal delivery (Partometer) using data iteratively obtained during labor from the electronic health record. STUDY DESIGN: A retrospective cohort study of deliveries at an academic, tertiary care hospital was conducted from 2013 to 2019 who had at least two cervical examinations. The population was divided into those delivered by physicians with nulliparous term singleton vertex (NTSV) cesarean delivery rates <23.9% (Partometer cohort) and the remainder (control cohort). The cesarean rate among this population of lower risk patients is a standard metric by which to compare provider rates; <23.9% was the Healthy People 2020 goal. A supervised automated ML approach was applied to generate a model for each population. The primary outcome was accuracy of the model developed on the Partometer cohort at 4 hours from admission to labor and delivery. Secondary outcomes included discrimination ability (receiver operating characteristics-area under the curve [ROC-AUC]), precision-recall AUC, and calibration of the Partometer. To assess generalizability, we compared the performance and clinical predictors identified by the Partometer to the control model. RESULTS: There were 37,932 deliveries during the study period; after exclusions, 9,385 deliveries were included in the Partometer cohort and 19,683 in the control cohort. Accuracy of predicting vaginal delivery at 4 hours was 87.1% for the Partometer (ROC-AUC: 0.82). Clinical predictors of greatest importance in the stacked Intrapartum Partometer Model included the Admission Model prediction and ongoing measures of dilatation and station which mirrored those found in the control population. CONCLUSION: Using automated ML and intrapartum factors improved the accuracy of prediction of probability of a vaginal delivery over both previously published models based on logistic regression. Harnessing real-time data and ML could represent the bridge to generating a truly prescriptive tool to augment clinical decision-making, predict labor outcomes, and reduce maternal and neonatal morbidity. KEY POINTS: · Our ML-based model yielded accurate predictions of mode of delivery early in labor.. · Predictors for models created on populations with high and low cesarean rates were the same.. · A ML-based model may provide meaningful guidance to clinicians managing labor..

Behavioral coping phenotypes and associated psychosocial outcomes of pregnant and postpartum women during the COVID-19 pandemic.

The impact of COVID-19-related stress on perinatal women is of heightened public health concern given the established intergenerational impact of maternal stress-exposure on infants and fetuses. There is urgent need to characterize the coping styles associated with adverse psychosocial outcomes in perinatal women during the COVID-19 pandemic to help mitigate the potential for lasting sequelae on both mothers and infants. This study uses a data-driven approach to identify the patterns of behavioral coping strategies that associate with maternal psychosocial distress during the COVID-19 pandemic in a large multicenter sample of pregnant women (N = 2876) and postpartum women (N = 1536). Data was collected from 9 states across the United States from March to October 2020. Women reported behaviors they were engaging in to manage pandemic-related stress, symptoms of depression, anxiety and global psychological distress, as well as changes in energy levels, sleep quality and stress levels. Using latent profile analysis, we identified four behavioral phenotypes of coping strategies. Critically, phenotypes with high levels of passive coping strategies (increased screen time, social media, and intake of comfort foods) were associated with elevated symptoms of depression, anxiety, and global psychological distress, as well as worsening stress and energy levels, relative to other coping phenotypes. In contrast, phenotypes with high levels of active coping strategies (social support, and self-care) were associated with greater resiliency relative to other phenotypes. The identification of these widespread coping phenotypes reveals novel behavioral patterns associated with risk and resiliency to pandemic-related stress in perinatal women. These findings may contribute to early identification of women at risk for poor long-term outcomes and indicate malleable targets for interventions aimed at mitigating lasting sequelae on women and children during the COVID-19 pandemic.

Elevated blood pressures during epidural placement are associated with increased risk of hypertensive disorders of pregnancy.

BACKGROUND: Many providers ignore hypertensive blood pressures (BPs) during epidural placement, attributing them to patient pain or malposition. We aimed to determine if an elevated BP during epidural placement was associated with increased risk for developing a hypertensive disorder of pregnancy (HDP). METHODS: Cohort study of previously normotensive nulliparous, singleton, term patients who received neuraxial analgesia and delivered at our institution in 2016. Primary exposure was BP during epidural window (one hour before and after epidural procedure start time). Primary outcome was HDP (gestational hypertension, preeclampsia, eclampsia, or HELLP syndrome) prior to discharge. Statistics included χ2, t-test, and multivariable logistic regression; α = 0.05. RESULTS: One thousand and eight hundred patients met study criteria. Patients with elevated BP during epidural window (n = 566, 31.4%) were more likely to develop HDP than patients who remained normotensive during epidural window (20.1% vs. 6.4%, adjusted OR 3.57 [95% CI 2.61-4.89]). The incidence of HDP increased in association with BP severity during epidural window: 7.3% for maximum systolic blood pressure (SBP) <140 mmHg; 18.4% for maximum SBP 140-159 mmHg (OR 2.9, 95% CI 2.0-4.0); and 29.9% for maximum SBP ≥160 mmHg (OR 5.4, 95% CI 2.9-9.8). The trend was similar for maximum diastolic BP. The magnitude of increased odds for HDP was highest for Black patients with elevated BP during epidural window (40.9% vs. 10.1%, OR 6.1, 95% CI 2.4-16). CONCLUSIONS: Previously normotensive patients with an elevated BP during labor epidural placement are significantly more likely to develop HDP than patients who remain normotensive. Elevated BP during epidural placement should not be disregarded to ensure timely diagnosis and treatment.

Comparing Methods of Identifying Outlying Nurses in Audits of Low-Risk Cesarean Delivery Rates.

BACKGROUND: The low-risk cesarean delivery (CD) rate is an established performance indicator for providers in maternity care for quality improvement purposes. PURPOSE: Our objectives were to assess nurse performance using adjusted nurse-level CD rates and to compare methods of identifying nurse outliers. METHODS: We conducted a retrospective, cohort study of 6970 births attended by 181 registered nurses in one hospital's maternity unit. Adjusted and unadjusted nurse-level CD rates were compared and agreement between 3 definitions (statistical, top decile, over a benchmark) of outliers calculated. RESULTS: Adjusted nurse-level CD rates varied from 5.5% to 53.2%, and the unadjusted rates varied from 5% to 50%. Risk adjustment had little impact on the ranking of nurses, and outliers were consistently identified by 3 definitions. CONCLUSIONS: Trade-offs between statistical certainty and feasibility need to be considered when classifying nurse outliers. Findings can help target interventions to improve nurse performance.

Severe Maternal Morbidity in California Hospitals: Performance Based on a Validated Multivariable Prediction Model.

BACKGROUND: Severe maternal morbidity (SMM) is under development as a quality indicator for maternal health care. The aim of this study is to evaluate California hospital performance based on a standardized SMM measure. METHODS: California maternal hospital delivery discharge data from 2016 to 2017 were used to develop logistic regression models for SMM, adjusted for clinical risk factors at admission. Data from 2018 were used to test the models and evaluate hospital performance. SMM was defined per the Centers for Disease Control and Prevention, including (excluding) blood transfusion. Independent models were developed for each hospital type: community, teaching, integrated delivery system (IDS), and IDS teaching. Within each type, model-based expected SMM values and observed-to-expected (O/E) ratios were calculated for each hospital. For each hospital type, hospitals were ranked by O/E ratio, and over- and underperforming hospitals were identified using 95% confidence intervals. RESULTS: Rates of SMM including (excluding) transfusion by hospital type were 1.7% (0.9%) for community, 2.7% (1.5%) for teaching, 2.3% (1.2%) for IDS, and 3.0% (1.6%) for IDS teaching hospitals. In higher-volume community hospitals (≥ 500 births/year), the proportion of underperformers including (excluding) transfusion was 20.7% (11.0%). Summing over all hospital types, 25.3% (14.9%) of hospitals were identified as underperformers in that they experienced significantly more SMM events than expected including (excluding) transfusion. CONCLUSION: California hospital discharge data demonstrated significant hospital variation in standardized childbirth SMM. These data suggest that a standardized SMM measure may help guide and monitor statewide quality improvement efforts.

How is the COVID-19 pandemic shaping transportation access to health care?

The Coronavirus disease 19 (COVID-19) pandemic has disrupted both transportation and health systems. While about 40% of Americans have delayed seeking medical care during the pandemic, it remains unclear to what extent transportation is contributing to missed care. To understand the relationship between transportation and unmet health care needs during the pandemic, this paper synthesizes existing knowledge on transportation patterns and barriers across five types of health care needs. While the literature is limited by the absence of detailed data for trips to health care, key themes emerged across populations and settings. We find that some patients, many of whom already experience transportation disadvantage, likely need extra support during the pandemic to overcome new travel barriers related to changes in public transit or the inability to rely on others for rides. Telemedicine is working as a partial substitute for some visits but cannot fulfill all health care needs, especially for vulnerable groups. Structural inequality during the pandemic has likely compounded health care access barriers for low-income individuals and people of color, who face not only disproportionate health risks, but also greater difficulty in transportation access and heightened economic hardship due to COVID-19. Partnerships between health and transportation systems hold promise for jointly addressing disparities in health- and transportation-related challenges but are largely limited to Medicaid-enrolled patients. Our findings suggest that transportation and health care providers should look for additional strategies to ensure that transportation access is not a reason for delayed medical care during and after the COVID-19 pandemic.

Method to Calculate Nurse-Specific Cesarean Rates for the First and Second Stages of Labor.

To date, efforts to safely lower the cesarean birth rate for women with low-risk pregnancies have largely ignored the influence of labor and delivery nurses on mode of birth. This is mainly because of the complexity involved in attributing outcomes to specific nurses whose care had the greatest effect on mode of birth. An additional level of complexity arises from the type of care given to the woman during different stages of labor. In this article, we describe a strategy to designate nurses to births using an electronic medical record flowsheet, and we describe a method to calculate nurse-specific cesarean birth rates for the first and second stages of labor. Similar to physician-specific rates, we found wide variation in nurse-specific cesarean birth rates in both stages of labor, which suggests an opportunity to learn from best practices.

A scoping review of severe maternal morbidity: describing risk factors and methodological approaches to inform population-based surveillance.

BACKGROUND: Current interest in using severe maternal morbidity (SMM) as a quality indicator for maternal healthcare will require the development of a standardized method for estimating hospital or regional SMM rates that includes adjustment and/or stratification for risk factors. OBJECTIVE: To perform a scoping review to identify methodological considerations and potential covariates for risk adjustment for delivery-associated SMM. SEARCH METHODS: Following the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews, systematic searches were conducted with the entire PubMed and EMBASE electronic databases to identify publications using the key term "severe maternal morbidity." SELECTION CRITERIA: Included studies required population-based cohort data and testing or adjustment of risk factors for SMM occurring during the delivery admission. Descriptive studies and those using surveillance-based data collection methods were excluded. DATA COLLECTION AND ANALYSIS: Information was extracted into a pre-defined database. Study design and eligibility, overall quality and results, SMM definitions, and patient-, hospital-, and community-level risk factors and their definitions were assessed. MAIN RESULTS: Eligibility criteria were met by 81 studies. Methodological approaches were heterogeneous and study results could not be combined quantitatively because of wide variability in data sources, study designs, eligibility criteria, definitions of SMM, and risk-factor selection and definitions. Of the 180 potential risk factors identified, 41 were categorized as pre-existing conditions (e.g., chronic hypertension), 22 as obstetrical conditions (e.g., multiple gestation), 22 as intrapartum conditions (e.g., delivery route), 15 as non-clinical variables (e.g., insurance type), 58 as hospital-level variables (e.g., delivery volume), and 22 as community-level variables (e.g., neighborhood poverty). CONCLUSIONS: The development of a risk adjustment strategy that will allow for SMM comparisons across hospitals or regions will require harmonization regarding: a) the standardization of the SMM definition; b) the data sources and population used; and c) the selection and definition of risk factors of interest.

Virtual Reality Reduces Pain in Laboring Women: A Randomized Controlled Trial.

OBJECTIVE: Virtual reality (VR) represents a potential method for easing labor pain and in nonpregnant patients has been shown to achieve similar or greater analgesia than hydromorphone. Few studies of VR have been performed in pregnant women. The aim of this randomized controlled trial (RCT) is to evaluate whether VR is effective in reducing pain in laboring women. STUDY DESIGN: An open-label, RCT of nulliparous, term women in labor in a tertiary care hospital. We included women with a pain score level of 4 to 7 having regular contractions at least every 5 minutes. We excluded women who had received any pharmacologic pain relief including neuraxial analgesia and those with contraindications to VR. Participants were randomized to up to 30 minutes of either VR or the control arm (no additional intervention). Our primary outcome was the difference in differences from pre- to postintervention pain score. Prespecified secondary outcomes included postintervention pain scores, duration of intervention use, pharmacologic analgesia use, maternal vitals, and obstetric outcomes. RESULTS: From March 2018 to February 2019, 40 subjects were enrolled, randomized, and completed the study; 19 were randomized to control and 21 to the VR arm. Most baseline characteristics were similar between groups. For the primary outcome, those assigned to the control arm had a statistically significant increase in pain of +0.58, while the VR arm had a significant reduction in pain of -0.52 (p = 0.03). There was also a difference in the proportion who had a minimum clinically important difference in pain (0% control and 23.8% VR; p = 0.049). Postintervention maternal heart rate was higher in the control arm (86.8 vs. 76.3, p = 0.01). Most other secondary outcomes did not differ. CONCLUSION: In our study, we found that VR was effective for reducing pain in women in labor as compared with those receiving no intervention. KEY POINTS: · Virtual reality (VR) represents a nonpharmacologic option for pain relief.. · VR has been little studied in pregnant or laboring women.. · VR was associated with a reduction in pain in nulliparous women in labor..

Pituitary apoplexy associated with acute COVID-19 infection and pregnancy.

PURPOSE: We report a case of a pregnant female presenting with pituitary apoplexy and simultaneous SARS-CoV-2 infection with a focus on management decisions. CLINICAL HISTORY: A 28-year-old G5P1 38w1d female presented with 4 days of blurry vision, left dilated pupil, and headache. She tested positive for SARS-CoV-2 on routine nasal swab testing but denied cough or fever. Endocrine testing demonstrated an elevated serum prolactin level, and central hypothyroidism. MRI showed a cystic-solid lesion with a fluid level in the pituitary fossa and expansion of the sella consistent with pituitary apoplexy. Her visual symptoms improved with corticosteroid administration and surgery was delayed to two weeks after her initial COVID-19 infection and to allow for safe delivery of the child. A vaginal delivery under epidural anesthetic occurred at 39 weeks. Two days later, transsphenoidal resection of the mass was performed under strict COVID-19 precautions including use of Powered Air Purifying Respirators (PAPRs) and limited OR personnel given high risk of infection during endonasal procedures. Pathology demonstrated a liquefied hemorrhagic mass suggestive of pituitary apoplexy. She made a full recovery and was discharged home two days after surgery. CONCLUSION: Here we demonstrate the first known case of successful elective induction of vaginal delivery and transsphenoidal intervention in a near full term gravid patient presenting with pituitary apoplexy and acute SARS-CoV-2 infection. Further reports may help determine if there is a causal relationship or if these events are unrelated. Close adherence to guidelines for caregivers can greatly reduce risk of infection.

Screening for Anxiety in Adolescent and Adult Women: A Recommendation From the Women's Preventive Services Initiative.

DESCRIPTION: The Women's Preventive Services Initiative (WPSI), a national coalition of women's health professional organizations and patient representatives, developed a recommendation on screening for anxiety in adolescent and adult women to improve detection; achieve earlier diagnosis and treatment; and improve health, function, and well-being. The WPSI's recommendations are intended to guide clinical practice and coverage of services for the Health Resources and Services Administration and other stakeholders. The target audience for this recommendation includes all clinicians providing preventive health care to women, particularly in primary care settings. This recommendation applies to women and adolescent girls aged 13 years or older who are not currently diagnosed with anxiety disorders, including pregnant and postpartum women. METHODS: The WPSI developed this recommendation after evaluating results of a systematic review of the effectiveness of screening, accuracy of screening instruments, and benefits and harms of treatments in adolescent girls and adult women. No studies directly evaluated the overall effectiveness or harms of screening for anxiety. Twenty-seven screening instruments and their variations were moderately to highly accurate in identifying anxiety (33 individual studies and 2 systematic reviews; 171 studies total). Symptoms improved and relapse rates decreased with psychological therapies (246 randomized controlled trials [RCTs] in 5 systematic reviews) and with selective serotonin reuptake inhibitors or selective serotonin and norepinephrine reuptake inhibitors (126 RCTs in 3 systematic reviews). The WPSI also considered the effect of screening on symptom progression and identification of associated and underlying conditions, as well as implementation factors. RECOMMENDATION: The WPSI recommends screening for anxiety in women and adolescent girls aged 13 years or older who are not currently diagnosed with anxiety disorders, including pregnant and postpartum women. Optimal screening intervals are unknown, and clinical judgment should be used to determine frequency. When screening suggests the presence of anxiety, further evaluation is necessary to establish the diagnosis and determine appropriate treatment and follow-up.