Limitations of Noninvasive Tests-Based Population-Level Risk Stratification Strategy for Nonalcoholic Fatty Liver Disease.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are highly prevalent but underdiagnosed. AIMS: We used an electronic health record data network to test a population-level risk stratification strategy using noninvasive tests (NITs) of liver fibrosis. METHODS: Data were obtained from PCORnet® sites in the East, Midwest, Southwest, and Southeast United States from patients aged [Formula: see text] 18 with or without ICD-10-CM diagnosis codes for NAFLD, NASH, and NASH-cirrhosis between 9/1/2017 and 8/31/2020. Average and standard deviations (SD) for Fibrosis-4 index (FIB-4), NAFLD fibrosis score (NFS), and Hepatic Steatosis Index (HSI) were estimated by site for each patient cohort. Sample-wide estimates were calculated as weighted averages across study sites. RESULTS: Of 11,875,959 patients, 0.8% and 0.1% were coded with NAFLD and NASH, respectively. NAFLD diagnosis rates in White, Black, and Hispanic patients were 0.93%, 0.50%, and 1.25%, respectively, and for NASH 0.19%, 0.04%, and 0.16%, respectively. Among undiagnosed patients, insufficient EHR data for estimating NITs ranged from 68% (FIB-4) to 76% (NFS). Predicted prevalence of NAFLD by HSI was 60%, with estimated prevalence of advanced fibrosis of 13% by NFS and 7% by FIB-4. Approximately, 15% and 23% of patients were classified in the intermediate range by FIB-4 and NFS, respectively. Among NAFLD-cirrhosis patients, a third had FIB-4 scores in the low or intermediate range. CONCLUSIONS: We identified several potential barriers to a population-level NIT-based screening strategy. HSI-based NAFLD screening appears unrealistic. Further research is needed to define merits of NFS- versus FIB-4-based strategies, which may identify different high-risk groups.

Contraceptive Procedures in Internal Medicine Clinics and Resident Education: a Qualitative Study of Implementation Methods, Barriers, and Facilitators.

BACKGROUND: Long-acting reversible contraceptives (LARCs) such as intrauterine devices (IUDs) and implants are highly effective and increasingly popular. Internal Medicine (IM) clinics and residency curricula do not routinely include LARCs, which can limit patient access to these methods. In response, internists are integrating LARCs into IM practices and residency training. OBJECTIVE: This study examines the approaches, facilitators, and barriers reported by IM faculty to incorporating LARCs into IM clinics and resident education. DESIGN: We interviewed faculty who were prior or current LARC providers and/or teachers in 15 IM departments nationally. Each had implemented or attempted to implement LARC training for residents in their IM practice. Semi-structured interviews were used. PARTICIPANTS: Eligible participants were a convenience sample of clinicians identified as key informants at each institution. APPROACH: We used inductive thematic coding analysis to identify themes in the transcribed interviews. KEY RESULTS: Fourteen respondents currently offered LARCs in their clinic and 12 were teaching these procedures to residents. LARC integration into IM clinics occurred in 3 models: (1) a dedicated procedure or women's health clinic, (2) integration into existing IM clinical sessions, or (3) an interdisciplinary IM and family medicine or gynecology clinic. Balancing clinical and educational priorities was a common theme, with chosen LARC model(s) reflecting the desired priority balance at a given institution. Most programs incorporated a mix of educational modalities, with opportunities based upon resident interest and desired educational goals. Facilitators and barriers related to clinical (equipment, workflow), educational (curriculum, outcomes), or process considerations (procedural volume, credentialing). Participants reported that support from multiple stakeholders including patients, residents, leadership, and other departments was necessary for success. CONCLUSION: The model for integration of LARCs into IM clinics and resident education depends upon the clinical resources, patient needs, stakeholder support, and educational goals of the program.

Impact of the Early Phase of the COVID-19 Pandemic on US Healthcare Workers: Results from the HERO Registry.

BACKGROUND: The HERO registry was established to support research on the impact of the COVID-19 pandemic on US healthcare workers. OBJECTIVE: Describe the COVID-19 pandemic experiences of and effects on individuals participating in the HERO registry. DESIGN: Cross-sectional, self-administered registry enrollment survey conducted from April 10 to July 31, 2020. SETTING: Participants worked in hospitals (74.4%), outpatient clinics (7.4%), and other settings (18.2%) located throughout the nation. PARTICIPANTS: A total of 14,600 healthcare workers. MAIN MEASURES: COVID-19 exposure, viral and antibody testing, diagnosis of COVID-19, job burnout, and physical and emotional distress. KEY RESULTS: Mean age was 42.0 years, 76.4% were female, 78.9% were White, 33.2% were nurses, 18.4% were physicians, and 30.3% worked in settings at high risk for COVID-19 exposure (e.g., ICUs, EDs, COVID-19 units). Overall, 43.7% reported a COVID-19 exposure and 91.3% were exposed at work. Just 3.8% in both high- and low-risk settings experienced COVID-19 illness. In regression analyses controlling for demographics, professional role, and work setting, the risk of COVID-19 illness was higher for Black/African-Americans (aOR 2.32, 99% CI 1.45, 3.70, p < 0.01) and Hispanic/Latinos (aOR 2.19, 99% CI 1.55, 3.08, p < 0.01) compared with Whites. Overall, 41% responded that they were experiencing job burnout. Responding about the day before they completed the survey, 53% of participants reported feeling tired a lot of the day, 51% stress, 41% trouble sleeping, 38% worry, 21% sadness, 19% physical pain, and 15% anger. On average, healthcare workers reported experiencing 2.4 of these 7 distress feelings a lot of the day. CONCLUSIONS: Healthcare workers are at high risk for COVID-19 exposure, but rates of COVID-19 illness were low. The greater risk of COVID-19 infection among race/ethnicity minorities reported in the general population is also seen in healthcare workers. The HERO registry will continue to monitor changes in healthcare worker well-being during the pandemic. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT04342806.

General Internists as Change Agents: Opportunities and Barriers to Leadership in Health Systems and Medical Education Transformation.

Health systems are increasingly engaging in mission development around the quadruple aim of patient experience of care, population health, cost of care, and work-life balance of clinicians. This integrated approach is closely aligned with the education principles and competencies of health systems science (HSS), which includes population health, high-value care, leadership, teamwork, collaboration, and systems thinking. Influenced by health outcomes research, the systems-based practice competency, and the Clinical Learning Environment Review, many medical schools and residency programs are taking on the challenge of comprehensively incorporating these HSS competencies into the education agenda. General internal medicine physicians, inclusive of hospitalists, geriatricians, and palliative and primary care physicians, are at the frontlines of this transformation and uniquely positioned to contribute to and lead health system transformation, role model HSS competencies for trainees, and facilitate the education of a new workforce equipped with HSS skills to accelerate change in healthcare. Although GIM faculty are positioned to be early adopters and leaders in evolving systems of care and education, professional development and changes with academic health systems are required. This Perspective article explores the conceptualization and opportunities to effectively link GIM with healthcare and medical education transformation.

Combined hormonal contraception use in reproductive-age women with contraindications to estrogen use.

BACKGROUND: The Centers for Disease Control and Prevention's US Medical Eligibility Criteria for Contraceptive Use recommends that combined hormonal contraceptives (ie, birth control pills, contraceptive patch, vaginal ring) should be avoided in women with specific medical conditions because of the increased risk of cardiovascular events associated with estrogen use. Whether women with category 3 (theoretical or proven risk usually outweigh the advantages) or category 4 (unacceptable health risk) contraindications are appropriately avoiding estrogen-containing combined hormonal contraceptives is unknown. OBJECTIVE: We describe the prevalence of combined hormonal contraceptive use among a sample of reproductive-age women with medical contraindications to estrogen use. Our hypothesis was that women with categories 3 and 4 contraindications would use estrogen-containing contraception less often than women without medical contraindications. We also explored whether inappropriate estrogen-containing contraceptive use is related to contraceptive provider characteristics. STUDY DESIGN: Data are from the baseline survey of the MyNewOptions study, which included privately insured women residing in Pennsylvania aged 18-40 years, who were sexually active and not intending pregnancy in the next year. Women were surveyed about their medical conditions, contraceptive use, and characteristics of their contraceptive provider. Women were considered to have a contraindication to combined hormonal contraceptives if they reported a category 3 or category 4 contraindication: hypertension, smokers older than age 35 years, a history of venous thromboembolism, diabetes with complications, coronary artery disease, systemic lupus erythematosus with antiphospholipid antibodies, breast cancer, or migraine headaches with aura. χ(2) tests for general association were used to compare combined hormonal contraceptives use, contraceptive health provider characteristics, and sociodemographic data in women with and without contraindications to estrogen use. RESULTS: The MyNewOptions baseline study sample included 987 adult women who were mostly young (46% were 18-25 years), white (94%), employed (70%), and married or cohabiting (54%). Thirteen percent (n = 130) of the sample had a medical contraindication to estrogen-containing contraceptive use: migraine with aura (81%) was the most common contraindication, followed by smokers older than age 35 years (7%), hypertension (11%), history of venous thromboembolism (4%), and diabetes with complications (2%). High use of combined hormonal contraceptives was reported among the women with medical contraindications to estrogen at 39% (n = 51). This was not statistically different from women without a medical contraindication (47%, P = .1). Among the 130 women with a contraindication, whether they did or did not use an estrogen-containing contraceptive did not vary by education level, income, or weight category. With respect to their contraceptive prescribers, there were no differences in prescriber specialty, provider type, or clinic type comparing women using and not using an estrogen-containing contraceptive. CONCLUSION: Among this study sample of reproductive-age women, there was a high rate of combined hormonal contraceptive use in women with a medical contraindication to estrogen use. These women may be at an increased risk for cardiovascular events. Processes need to be improved to ensure that women with medical contraindications to estrogen-containing contraception are being offered the safest and most effective methods, including long-acting reversible contraceptives, such as intrauterine devices and the contraceptive implant.

Impact of an Overnight Internal Medicine Academic Hospitalist Program on Patient Outcomes.

BACKGROUND: Many academic hospitals have implemented overnight hospitalists to supervise house staff and improve outcomes, but few studies have described the impact of this role. OBJECTIVE: To investigate the effect of an overnight academic hospitalist program on patient-level outcomes. Secondary objectives were to describe the program's revenue generation and work tasks. DESIGN: Retrospective interrupted time-series analysis of patients admitted to the medicine service before and after implementation of the program. PARTICIPANTS: All patients aged 18 and older admitted to the acute or intermediate care units between 7:00 p.m. and 6:59 a.m. during the period before (April 2011-August 2012) and after (September 2012-April 2014) program implementation. INTERVENTION: An on-site attending-level physician directly supervising medicine house staff overnight, providing clinical care during high-volume periods, and ensuring safe handoffs to daytime providers. MAIN MEASURES: Primary outcomes included in-hospital mortality, 30-day hospital readmissions, length of stay, and upgrades in care on the night of admission and during hospitalization. Multivariable models estimated the effect on outcomes after adjusting for secular trends. Revenue generation and work tasks are reported descriptively. KEY RESULTS: During the study period, 6484 patients were admitted to the medicine service: 2722 (42 %) before and 3762 (58 %) after implementation. No differences were found in mortality (1.1 % vs. 0.9 %, p=0.38), 30-day readmissions (14.8 % vs. 15.6 %, p=0.39), mean length of stay (3.09 vs. 3.08 days, p=0.86), or upgrades to intensive care on the night of admission (0.4 % vs. 0.7 %, p=0.11) or during hospitalization (3.5 % vs. 4.2 %, p=0.20). During the first year, hospitalists billed 1209 patient encounters (3.3/shift) and 63 procedures (0.2/shift), and supervised 1939 patient admissions (6.12/shift) while supervising house staff 3-h/shifts. CONCLUSIONS: Implementation of an overnight academic hospitalist program showed no impact on several important clinical outcomes, and revenue generation was modest. As overnight hospitalist programs develop, investigations are needed to delineate the return on investment and focus on other outcomes that may be more sensitive to change, such as errors and provider/patient satisfaction.

Women's Awareness of Their Contraceptive Benefits Under the Patient Protection and Affordable Care Act.

The Patient Protection and Affordable Care Act mandates that there be no out-of-pocket cost for Food and Drug Administration-approved contraceptive methods. Among 987 privately insured reproductive aged Pennsylvania women, fewer than 5% were aware that their insurance covered tubal sterilization, and only 11% were aware that they had full coverage for an intrauterine device. For the Affordable Care Act contraceptive coverage mandate to affect effective contraception use and reduce unintended pregnancies, public awareness of the expanded benefits is essential.

Colorectal cancer screening in high-risk groups is increasing, although current smokers fall behind.

BACKGROUND: There is limited information about colorectal cancer (CRC) screening trends in high-risk groups, including the black, obese, diabetic, and smoking populations. For this study, the authors evaluated national CRC screening trends in these high-risk groups to provide insights into whether screening resources are being appropriately used. METHODS: This was a nationally representative, population-based study using the Behavioral Risk Factor Surveillance System from the Centers for Disease Control. Data analysis was performed using bivariate analyses with weighted logistic regression. RESULTS: In the general population, CRC screening increased significantly from 59% to 65% during the years 2006 to 2010. The screening prevalence in non-Hispanic blacks was 58% in 2006 and 65% in 2010. Among obese individuals, the prevalence of up-to-date CRC screening increased significantly from 59% in 2006 to 66% in 2010. Screening prevalence in individuals with diabetes was 63% in 2006 and 69% in 2010. The CRC screening prevalence in current smokers was 45% in 2006 and 50% in 2010. The odds of CRC screening in the non-Hispanic black population, the obese population, and the diabetic population were higher than in non-Hispanic whites, normal weight individuals, and the population without diabetes, respectively. Current smokers had significantly lower odds of CRC screening than never-smokers in the years studied (2006: odds ratio [OR], 0.71; 95% confidence interval [CI], 0.66-0.76; 2008: OR, 0.67; 95% CI, 0.63-0.71; 2010: OR, 0.69; 95% CI, 0.66-0.73). CONCLUSIONS: The prevalence of CRC screening in high-risk groups is trending upward. Despite this, current smokers have significantly lower odds of CRC screening compared with the general population.

Patient-centered interprofessional collaborative care: factors associated with bedside interprofessional rounds.

BACKGROUND: Medical care delivered in hospital-based medicine units requires interprofessional collaborative care (IPCC) to improve quality. However, models such as bedside interprofessional rounds, or encounters that include the team of physician and nurse providers discussing medical care at the patient's bedside, are not well studied. OBJECTIVE: To examine the incidence of and time spent in bedside interprofessional rounds on internal medicine teaching services in one academic medical center. DESIGN AND PARTICIPANTS: Observational descriptive study of internal medicine faculty serving as inpatient medicine attending physicians. Participants completed a daily electronic survey following team rounding sessions to assess rounding characteristics (November 2012-June 2013); variables such as resident level-of-training, attending physician years' of experience, house staff call day and clinic schedule were obtained from administrative data. Descriptive, Kruskal-Wallis, and multivariable logistic regression statistics were used to evaluate the study objectives. MAIN MEASURES: Primary outcomes were: (1) incidence of bedside interprofessional rounds, (2) time spent with patients during bedside interprofessional rounding encounters, and, (3) factors associated with increased occurrence of and time spent with patients during bedside interprofessional rounds. Covariates included resident level-of-training, attending physician years' of experience, census size, and call day. KEY RESULTS: Of 549 rounding sessions, 412 surveys were collected (75 % response) from 25 attending physicians. Bedside interprofessional rounds occurred with 64 % of patients (median 8.0 min/encounter), differing by unit (intermediate care 81 %, general medicine 63 %, non-medicine 57 %, p < 0.001). Factors independently associated with increased occurrence of bedside interprofessional rounds were senior resident (OR 2.67, CI 1.75-4.06, PGY-3/PGY-4 vs. PGY-2), weekdays (OR 1.74, CI 1.13-2.69), team census size ≤ 11 (OR 2.36, CI 1.37-4.06), and attending physicians with ≤ 4 years' experience (OR 2.15, CI 1.31-3.55). Factors independently associated with increased time spent during encounters were attending physicians with ≤ 4 years (OR 2.38, CI 1.44-3.95), 5-15 years of experience (OR 1.82, CI 1.10-3.02), and weekdays (OR 1.71, CI 1.10-2.65). CONCLUSIONS: These findings highlight factors associated with increasing or decreasing occurrence and time spent in bedside interprofessional collaborative care delivery. Systematic changes to census size caps, resident scheduling, and attending physician education and staffing may be required to increase the occurrence of interprofessional collaborative care.

Paging "Dr. Google": does technology fill the gap created by the prenatal care visit structure? Qualitative focus group study with pregnant women.

BACKGROUND: The prenatal care visit structure has changed little over the past century despite the rapid evolution of technology including Internet and mobile phones. Little is known about how pregnant women engage with technologies and the interface between these tools and medical care, especially for women of lower socioeconomic status. OBJECTIVE: We sought to understand how women use technology during pregnancy through a qualitative study with women enrolled in the Women, Infants, and Children (WIC) program. METHODS: We recruited pregnant women ages 18 and older who owned a smartphone, at a WIC clinic in central Pennsylvania. The focus group guide included questions about women's current pregnancy, their sources of information, and whether they used technology for pregnancy-related information. Sessions were audiotaped and transcribed. Three members of the research team independently analyzed each transcript, using a thematic analysis approach. Themes related to the topics discussed were identified, for which there was full agreement. RESULTS: Four focus groups were conducted with a total of 17 women. Three major themes emerged as follows. First, the prenatal visit structure is not patient-centered, with the first visit perceived as occurring too late and with too few visits early in pregnancy when women have the most questions for their prenatal care providers. Unfortunately, the educational materials women received during prenatal care were viewed as unhelpful. Second, women turn to technology (eg, Google, smartphone applications) to fill their knowledge gaps. Turning to technology was viewed to be a generational approach. Finally, women reported that technology, although frequently used, has limitations. CONCLUSIONS: The results of this qualitative research suggest that the current prenatal care visit structure is not patient-centered in that it does not allow women to seek advice when they want it most. A generational shift seems to have occurred, resulting in pregnant women in our study turning to the Internet and smartphones to fill this gap, which requires significant skills to navigate for useful information. Future steps may include developing interventions to help health care providers assist patients early in pregnancy to seek the information they want and to become better consumers of Internet-based pregnancy resources.

A strength training program for primary care patients, central Pennsylvania, 2012.

INTRODUCTION: Primary care providers can recommend strength training programs to use "Exercise as Medicine," yet few studies have examined the interest of primary care patients in these programs. METHODS: We conducted a cross-sectional survey of primary care patients in central Pennsylvania. Interest in participating in free group-based strength training and weight control programs was assessed, in addition to patient demographics, medical history, and quality of life. RESULTS: Among 414 patients, most (61.0%) were aged 54 or older, and 64.0% were female. More patients were interested in a strength training program (55.3%) than in a weight control program (45.4%). Nearly three-quarters (72.8%) of those reporting 10 or more days of poor physical health were interested in a strength training program compared with 49.5% of those reporting no days of poor physical health. After adjusting for potential confounders, those reporting poorer physical health had 2.7 greater odds (95% confidence interval, 1.4-5.1) of being interested in a strength training program compared with those reporting better physical health. Patients with hypertension, diabetes, or high cholesterol were not more interested in a strength training program than those without these conditions. CONCLUSION: Primary care practices may consider offering or referring patients to community-based strength training programs. This study observed high levels of interest in these widely available programs. Practices may also consider screening and referring those with poorer physical health, as they may be the most interested and have the most to gain from participating.

Impact of the Affordable Care Act on Prescription Contraceptive Use and Costs Among Privately Insured Women, 2006-2020.

BACKGROUND: In the years immediately following the Affordable Care Act (ACA)'s contraceptive coverage requirement, out-of-pocket costs fell for all Food and Drug Administration-approved contraceptive methods and use of long-acting reversible contraception (LARC) increased. This analysis examines whether these trends have continued through 2020 for privately insured women. METHODS: Using 2006-2020 MarketScan data, we examined trends in prescription contraceptive use and out-of-pocket costs among women 13 to 49 years old. Multivariable analyses model the likelihood of contraceptive use and paying $0 post-ACA requirement (vs. pre-ACA requirement) for contraception, controlling for age group, U.S. region, urban versus rural, and cohort year. RESULTS: The likelihood of LARC insertion increased post-ACA requirement (adjusted odds ratio [aOR] 1.127, 95% confidence interval [CI] 1.121-1.133), with insertion rates peaking at 3.73% for intrauterine devices (IUDs) and 1.08% for implants in 2019, before declining with the onset of the COVID-19 pandemic in 2020. Although the likelihood of paying $0 for LARC increased after the ACA requirement (IUD: aOR 5.495, 95% CI 5.278-5.716; implant: aOR 7.199, 95% CI 6.992-7.412), the proportion of individuals paying $0 declined to 69% for IUDs and 73% for implants in 2020, after having peaked at 88% in 2014 and 90% in 2016, respectively. For oral contraceptives, both use (aOR 1.028, 95% CI 1.026-1.030) and paying $0 (aOR 20.399, 95% CI 20.301-20.499) increased significantly after the ACA requirement. CONCLUSION: With the exception of oral contraceptives, the proportion of individuals paying $0 for all contraceptive methods declined after peaking in 2014 for IUDs, 2016 for the implant, and 2019 for non-LARC methods. Future monitoring is needed to understand the continuing impact of the ACA requirement on prescription contraceptive use and costs.

Pediatric Gastrointestinal Outcomes During the Post-Acute Phase of COVID-19.

Background: The impact of COVID-19 on gastrointestinal (GI) outcomes in children during the post-acute and chronic phases of the disease is not well understood. Methods: We conducted a retrospective cohort study across twenty-nine healthcare institutions from March 2020 to September 2023, including 413,455 pediatric patients with confirmed SARS-CoV-2 infection and 1,163,478 controls without infection. Infection was confirmed via polymerase chain reaction (PCR), serology, antigen tests, or clinical diagnosis of COVID-19 and related conditions. We examined the incidence of predefined GI symptoms and disorders during the post-acute (28 to 179 days post-infection) and chronic (180 to 729 days post-infection) phases. The adjusted risk ratios (aRRs) were calculated using stratified Poisson regression, with stratification based on propensity scores. Results: Our cohort comprised 1,576,933 patients, with females representing 48.0% of the sample. The analysis revealed that children with SARS-CoV-2 infection had an increased risk of developing at least one GI symptom or disorder in both the post-acute (8.64% vs. 6.85%; aRR 1.25, 95% CI 1.24-1.27) and chronic phases (12.60% vs. 9.47%; aRR 1.28, 95% CI 1.26-1.30) compared to uninfected peers. Specifically, the risk of abdominal pain was higher in COVID-19 positive patients during the post-acute phase (2.54% vs. 2.06%; aRR 1.14, 95% CI 1.11-1.17) and chronic phase (4.57% vs. 3.40%; aRR 1.24, 95% CI 1.22-1.27). Interpretation: Children with a history of SARS-CoV-2 infection are at an increased risk of GI symptoms and disorders during the post-acute and chronic phases of COVID-19. This highlights the need for ongoing monitoring and management of GI outcomes in this population.

A silent response to the obesity epidemic: decline in US physician weight counseling.

BACKGROUND: Guidelines recommend that physicians screen all adults for obesity and offer an intensive counseling and behavioral interventions for weight loss for obese adults. Current trends of weight-related counseling are unknown in the setting of the US obesity epidemic. OBJECTIVES: To describe primary care physician (PCP) weight-related counseling, comparing counseling rates in 1995-1996 and 2007-2008. RESEARCH DESIGN: Data analysis of outpatient PCP visits in 1995-1996 and 2007-2008, as reported in the National Ambulatory Medical Care Survey. SUBJECTS: A total of 32,519 adult primary care visits with PCPs. MEASURES: Rates of counseling for weight, diet, exercise, and a composite variable, weight-related counseling (defined as counseling for weight, diet, or exercise) between survey years. Adjusted analyses controlled for patient and visit characteristics. RESULTS: Weight counseling declined from 7.8% of visits in 1995-1996 to 6.2% of visits in 2007-2008 [adjusted odds ratios, 0.64; 95% confidence intervals, 0.53, 0.79]. Rates of receipt of diet, exercise, and weight-related counseling similarly declined. Greater declines in odds of weight-counseling receipt were observed among those with hypertension (47%), diabetes (59%), and obesity (41%), patients who stand the most to gain from losing weight. CONCLUSIONS: Rates of weight counseling in primary care have significantly declined despite increased rates of overweight and obesity in the United States. Further, these declines are even more marked in patients with obesity and weight-related comorbidities, despite expectations to provide such care by both patients and policymakers. These findings have implications for determining deliverable, novel ways to engage PCPs in addressing the obesity epidemic.

Mode of first delivery and women's intentions for subsequent childbearing: findings from the First Baby Study.

BACKGROUND: More than a dozen studies have reported a reduced rate of childbearing after caesarean delivery (CD). It has been hypothesised that this is because women who deliver by CD are less likely to intend to have subsequent children than women who deliver vaginally - either before childbirth or as a consequence of CD. Little research has addressed either of these hypotheses. METHODS: As part of an ongoing prospective study, we interviewed 3006 women in their third trimester and 1 month after first childbirth to assess subsequent childbearing intentions. RESULTS: Women who delivered by CD were similar to those who delivered vaginally in intent to have at least one additional child, both before childbirth (90.1% vaginal, 89.9% CD; P = 0.97) and after (87.8% vaginal, 87.1% CD; P = 0.87); however, women who had CD were less likely to intend two or more additional children, both before childbirth (34.7% vaginal, 29.2% CD; P = 0.03) and after (32.2% vaginal, 26.1% CD; P = 0.01). Among women who intended to have at least one additional child before childbirth, 5.0% reported intending to have no additional children 1 month after delivery (5.1% vaginal, 4.6% CD; P = 0.52). CONCLUSIONS: Women whose first delivery is by CD are less likely to intend a relatively large family of three or more children than those who deliver vaginally, but delivery by CD does not decrease women's intentions to have at least one more child any more than does vaginal delivery, at least in the short term.

Barriers to colorectal cancer screening among women in rural central Pennsylvania: primary care physicians' perspective.

INTRODUCTION: Colorectal cancer (CRC) is the third leading cause of death among women in the USA. Rural populations have lower rates of CRC screening than their urban counterparts, and rural women have lower screening rates compared with rural men. The purpose of this qualitative study was to identify (1) beliefs of primary care physicians (PCPs) about CRC screening in rural communities, (2) factors that may cause gender disparities in CRC screening in rural areas, and (3) solutions to overcome those barriers. METHODS: Semi-structured interviews were conducted with 17 PCPs practicing in rural central Pennsylvania. PCPs were asked about their CRC screening practices for women, availability of CRC screening services, reminder systems for CRC screening, and barriers to screening specific to their rural communities and to gender. Thematic analysis was used to identify major themes. RESULTS: All 17 PCPs endorsed the importance of CRC screening, but believed that there are barriers to CRC screening specific to women and to rural location. All PCPs identified colonoscopy as their screening method of choice, and generally reported that access to colonoscopy services in their rural areas was not a significant barrier. Barriers to CRC screening for women in rural communities were related to (1) PCPs' CRC screening practices, (2) gender-specific barriers to CRC screening, (3) patient-related barriers, (4) community-related barriers, and (5) physician practice-related barriers. Physicians overwhelmingly identified patient education as necessary for improving CRC screening in their rural communities, but believed that education would have to come from a source outside the rural primary care office due to lack of resources, personnel, and time. CONCLUSION: Overall, the PCPs in this study were motivated to identify ways to improve their ability to engage more eligible patients in CRC screening. These findings suggest several interventions to potentially improve CRC screening for women in rural areas, including encouraging use of other effective CRC screening modalities (eg fecal occult blood testing) when colonoscopy is not possible, systems-based reminders that leverage electronic resources and are not visit-dependent, and public health education campaigns aimed specifically at women in rural communities.

The impact of the 2015 ACOG screening guidelines on the diagnosis of postpartum depression among privately insured women.

BACKGROUND: Postpartum depression (PPD), is underdiagnosed and undertreated. In 2015, the American College of Obstetricians and Gynecologists (ACOG) recommended that women be screened for PPD at least once during the perinatal period. The effect of the recommendation on PPD diagnosis is unknown. METHODS: Using the MerativeTM MarketScan® database, PPD prevalence was identified in privately insured women ages 13-45 with a live birth between 2013 and 2016. Postpartum depression was defined as an ICD diagnosis code for PPD or other depression, or a new pharmacy claim for an antidepressant medication during the first 12 months following delivery. Multivariable logistic regression was used to estimate the likelihood of PPD both before and after the ACOG PPD Committee Opinion. RESULTS: The study included 244,624 women ages 13-45 who had a live birth in 2013 through 2016. PPD prevalence before and after the 2015 ACOG Committee Opinion was 15.1 % and 17.2 %, respectively. The likelihood of PPD was not statistically different following the 2015 Committee Opinion (adjusted OR, 1.00, 95 % CI, 0.97-1.03) when controlling for age, year, delivery complications, and geographic region. LIMITATIONS: Sociodemographic variables are not included in the MarketScan database and therefore could not be analyzed as covariates. Re-defining a PPD diagnosis as above interfered with the ability to measure a prior history of mood disorders as a covariate. CONCLUSION: Implementation of the ACOG recommendations was not associated with a significant increase in PPD diagnosis. This suggests that physician organization recommendations alone are not sufficient to increase detection of PPD.

Differing prevalence of microcephaly and macrocephaly in male and female fetuses.

Objective: To compare the proportion of female and male fetuses classified as microcephalic (head circumference [HC] < 3rd percentile) and macrocephalic (>97th percentile) by commonly used sex-neutral growth curves. Methods: For fetuses evaluated at a single center, we retrospectively determined the percentile of the first fetal HC measurement between 16 and 0/7 and 21-6/7 weeks using the Hadlock, Intergrowth-21st, and NICHD growth curves. The association between sex and the likelihood of being classified as microcephalic or macrocephalic was evaluated with logistic regression. Results: Female fetuses (n = 3,006) were more likely than male fetuses (n = 3,186) to be classified as microcephalic using the Hadlock (0.4% male, 1.4% female; odds ratio female vs. male 3.7, 95% CI [1.9, 7.0], p < 0.001), Intergrowth-21st (0.5% male, 1.6% female; odds ratio female vs. male 3.4, 95% CI [1.9, 6.1], p < 0.001), and NICHD (0.3% male, 1.6% female; odds ratio female vs. male 5.6, 95% CI [2.7, 11.5], p < 0.001) curves. Male fetuses were more likely than female fetuses to be classified as macrocephalic using the Intergrowth-21st (6.0% male, 1.5% female; odds ratio male vs. female 4.3, 95% CI [3.1, 6.0], p < 0.001) and NICHD (4.7% male, 1.0% female; odds ratio male vs. female 5.1, 95% CI [3.4, 7.6], p < 0.001) curves. Very low proportions of fetuses were classified as macrocephalic using the Hadlock curves (0.2% male, < 0.1% female; odds ratio male vs. female 6.6, 95% CI [0.8, 52.6]). Conclusion: Female fetuses were more likely to be classified as microcephalic, and male fetuses were more likely to be classified as macrocephalic. Sex-specific fetal head circumference growth curves could improve interpretation of fetal head circumference measurements, potentially decreasing over- and under-diagnosis of microcephaly and macrocephaly based on sex, therefore improving guidance for clinical decisions. Additionally, the overall prevalence of atypical head size varied using three growth curves, with the NICHD and Intergrowth-21st curves fitting our population better than the Hadlock curves. The choice of fetal head circumference growth curves may substantially impact clinical care.