Integrating long-acting reversible contraceptives into primary care internal medicine practices: A clinical innovation to reduce wait time.

BACKGROUND: Long-acting reversible contraception (LARC) has long been regarded as highly effective and safe. However, access is limited and lengthy when specialty referrals are required. OBJECTIVES: To integrate LARC services into an urban internal medicine primary care practice to decrease wait time for LARC procedures. DESIGN/METHODS: This pre-post with control group study took place at two large urban academic primary care practices (Practices A and B) and included patients ages 18 to 45 years assigned female sex at birth. Pre-implementation baseline data were collected retrospectively from 2019 to 2020 by identifying subjects who requested LARC insertion or removal via their primary care practice and were referred to Obstetrics and Gynecology (Ob/Gyn) for the procedure. Wait time was noted from time of initial request in the medical record to time of procedure. Practice A developed an integrated primary care LARC program in which one of their LARC-trained providers began offering these procedures within their own practice. All other providers within the practice were educated on how to counsel patients about the devices and procedures. Practice B did not have an in-house LARC provider and continued referring patients to Ob/Gyn. Post-implementation data were collected prospectively 2021-2022. RESULTS: Ninety-one patients in Practice A experienced a significant decrease in wait time (87 vs 21 days, p < 0.001) over the observation period, with a majority undergoing procedures on their first visit with the in-house LARC provider. Wait time for the 54 patients in Practice B remained unchanged (57 vs 47 days, p = .59), often requiring multiple specialty visits. CONCLUSION: Integrating LARC services into a primary care internal medicine practice can significantly reduce wait times for these procedures with the potential to contribute to increased reproductive and menstrual autonomy.

Racial Inequities in Adolescent Contraceptive Care Delivery: A Reproductive Justice Issue.

STUDY OBJECTIVE: The objective of this study was to examine racial/ethnic disparities in contraceptive delivery for adolescent patients within an adolescent medicine subspecialty clinical system before and during the COVID-19 pandemic. Secondarily, we aimed to assess the relationship between race and contraceptive delivery by telehealth. DESIGN: Retrospective cohort study using electronic health record data SETTING: Three adolescent medicine subspecialty clinics in a large academic hospital system, including an urban location and 2 suburban locations PARTICIPANTS: Patients assigned female sex at birth prescribed hormonal contraception between January 1st, 2018, and May 31st, 2021. MAIN OUTCOME MEASURES: Method and type of contraceptive prescribed (short-acting, medium-acting, long-acting reversible contraception [LARC]) RESULTS: There were 2453 patients in the study; 47.5% were White, 36.0% were Black, and 8.1% identified as Hispanic. After controlling for insurance and age, Black patients, compared with non-Black patients, had twofold higher odds of receiving LARC compared with a short-acting method across the study period (aOR = 2.0; 95% CI, 1.52-2.62). We identified effect modification with significant interaction between Black race and the pandemic period, with evidence of a higher marginal probability of Black patients receiving LARCs during the pandemic. Additionally, during the pandemic, patients receiving new contraceptive prescriptions via telehealth were less likely to be Black (aOR = 0.63; 95% CI, 0.41-0.94) or publicly insured (aOR = 0.56; 95% CI, 0.38-0.81). CONCLUSION: Our data show significantly higher prescribing of LARCs to Black adolescents by clinicians, which could suggest differences in physician contraceptive counseling with a bias toward preferentially counseling Black patients toward LARCs. Our data also show that Black and publicly insured patients had decreased utilization of contraceptive care by telehealth during the pandemic.

A 12-Year-Old Girl with Weight Loss.

A 12-Year-Old Girl with Weight LossThis report examines a case of chronic weight loss, anxiety, abdominal pain, and nausea in an adolescent girl. With directed questioning, physical examination, and testing, an illness script for the presentation emerges; the differential is refined until a final diagnosis is made.

Burnout and Perceptions of Stigma and Help-Seeking Behavior Among Pediatric Fellows.

BACKGROUND AND OBJECTIVES: Although burnout has been studied extensively among students and residents, in few studies have researchers examined burnout among fellowship trainees. We measured burnout among fellows in our freestanding children's hospital and evaluated fellows' perceptions of stigma around (and willingness to seek treatment for) psychological distress. The objectives are as follows: to (1) measure burnout among pediatric fellows, (2) assess fellows' perceptions of stigma around help seeking for mental illness, and (3) examine the relationship between burnout and willingness to seek behavioral health counseling. METHODS: We distributed a 48-item inventory to all 288 fellows in our pediatric center. Items included the Maslach Burnout Inventory and Likert-type matrices to assess attitudes toward behavioral health treatment and associated stigma. We used 2-sampled t-tests to associate burnout with willingness to seek mental health treatment. RESULTS: A total of 152 fellows (52%) responded, of whom 53% met the threshold for burnout. Most reported believing that their program directors (78%), attending physicians (72%), and patients (82%) hold negative attitudes about mental illness and its treatment; 68% believed that employers would reject their application if they knew they sought counseling. Fellows with burnout were more likely to believe that others in the clinical learning environment hold negative views of help seeking for behavioral health (odds ratio 1.2-1.9). CONCLUSIONS: Just over one-half of the pediatric fellows in our center meet the threshold for burnout. They also experience significant workplace-based stigma around help seeking for psychological distress. Fellows with burnout are more likely than their peers to perceive significant stigma around help seeking for their distress, making them a particularly at-risk learner population.

The role of resilience in healthcare transitions among adolescent kidney transplant recipients.

PURPOSE: AYAs with KTs experience high rates of premature allograft loss during the HCT. There is a critical need to identify protective factors associated with stable HCT. Resilience-the ability to adapt and thrive in the setting of adversity-has known positive impact on health outcomes. This study explored the novel role of resilience constructs as protective factors in securing stable HCT among AYA with KT. METHODS: We conducted semi-structured interviews of adolescents and young adults who transitioned from a single pediatric transplant center to multiple adult nephrology centers between 2010 and 2017. Interviews explored the role of key resilience constructs in participants' lives around the time of HCT. Participants were stratified into stable or unstable HCT groups based on biological markers of allograft function and clinical data from chart review. Content analyses of interview transcripts were reviewed and compared among HCT groups. RESULTS: Thirty-two participants enrolled (17 stable; 15 unstable). Key resilience constructs more salient in the stable versus unstable HCT group were confidence in and connection to one's healthcare team. Reports of healthcare self-management competencies were similar across both HCT groups. CONCLUSIONS: Confidence in and connection to one's healthcare team appear to be linked with a stable HCT among AYA with KT. This suggests that interdependence, the ability to foster connections with and elicit support from healthcare providers, as opposed to complete independence or autonomy, which is often advised in the HCT process, is a critical component of resilience linked to stable HCT.

Developing a Hospital-Wide Transition Program for Young Adults With Medical Complexity.

PURPOSE: Transitional age adults (18-24 years) are the fastest growing cohort of patients in children's hospitals across the nation. The purpose of the study was to standardize pediatric to adult healthcare transfers of complex adult patients through a tiered and multimodal population-based intervention. METHODS: The Multidisciplinary Intervention Navigation Team (MINT) was developed to decrease variations in pediatric to adult medical transitions. System-level goals were to (1) increase provider and leadership engagement, (2) increase transition tools, (3) increase use of electronic medical record-based clinical decision supports, (4) improve transition practices through development of transition policies and clinical pathways; (5) increase transition education for patients and caregivers; (6) increase the adult provider referral network; and (7) implement an adult transition consult service for complex patients (MINT Consult). RESULTS: Between July 2015 and March 2017, MINT identified 11 transition champions, increased the number of divisions with drafted transition policies from 0 to 7, increased utilization of electronic medical record-based transition support tools from 0 to 7 divisions, held seven psychoeducational events, and developed a clinical pathway. MINT has received more than 70 patient referrals. Of patients referred, median age is 21 years (range, 17-43); 70% (n = 42) have an intellectual disability. Referring pediatric providers (n = 25) reported that MINT helped identify adult providers and coordinate care with other Children's Hospital of Philadelphia specialists (78%); and that MINT saved greater than 2 hours of time (48%). CONCLUSIONS: MINT improved the availability, knowledge, and use of transition-related resources; saved significant time among care team members; and increased provider comfort around transition-related conversations.

A Multidisciplinary Transition Consult Service: Patient Referral Characteristics.

PURPOSE: Children's hospitals must provide developmentally appropriate care to increasing numbers of young adults with complex healthcare needs as they transition to adult-oriented care. This article describes the patients, service, and short-term outcomes of an interprofessional healthcare transition (HCT) consult team comprised of nurses, social workers, a community health worker, and physicians. DESIGN AND METHODS: The Adult Consult Team's tiered population framework stratifies patients by medical complexity. The team coordinates HCT services for patients with the highest complexity. Patients at least 18 years old are eligible if they have at least two specialists or an intellectual or developmental disability (IDD). Through a comprehensive medical and psychosocial assessment, the team prepares patients/families for adult-oriented healthcare. RESULTS: The Adult Consult Team received 197 referrals from July 2017 to June 2018. Patients had at least two specialists (73%), IDD (71%), technology dependence (e.g., gastrostomy tube, 37%) and Medicaid insurance (57%). The team assisted patients seen in its outpatient clinic with navigating mental health services (39%), insurance issues (13%), IDD services (15%), and the guardianship process (37%) and creating comprehensive care plans. CONCLUSIONS: The Adult Consult Team transferred 30 patients with medical complexity to adult primary and specialty care, significantly improving pediatric inpatient and outpatient capacity for pediatric-aged patients. A broad range of young adult medical, psychosocial, legal, educational, and vocational needs were addressed. PRACTICE IMPLICATIONS: An interprofessional team approach can help large pediatric healthcare systems address the multi-faceted needs of patients who are medically and psychosocially complex as they enter adulthood.

Validation of overactive bladder questionnaire (1-week recall version) in medically complex elderly patients with overactive bladder.

INTRODUCTION: The 33-item Overactive Bladder questionnaire (OAB-q; 1-week recall version) has been psychometrically validated in middle-aged, generally healthy patients with overactive bladder. The present analysis was conducted to determine the psychometric validity of the OAB-q in medically complex elderly patients. METHODS: OAB-q structure was evaluated using a second-order confirmatory factor analysis (CFA) model with five domains and one aggregated domain, using pooled data from two clinical trials (786 observations) for urgency urinary incontinence (UUI). Psychometric validity was evaluated with CFA, Cronbach coefficient α (CCA) for reliability, Spearman correlations for convergent validity, differences in OAB-q scores in relation to UUI severity and Patient Perception of Bladder Condition (PPBC) scores for known-groups validity, and effect size (ES) of differences in mean scores of OAB-q domains over time for treatment responsiveness. RESULTS: Participants were predominantly female (82.2%) and white (85.9%); mean age was 75.0 years. The second-order CFA was confirmed with a Bentler's comparative fit index of 0.90, t values for path coefficients of >1.96, and standardized path coefficients of >0.40. OAB-q domains demonstrated good internal consistency (CCA >0.7). Convergent validity was supported by moderate correlations (0.4-0.7) between OAB-q domain and PPBC scores. Significant differences in OAB-q domain scores between groups with different symptom severity established known-groups validity. Significant changes in mean OAB-q scores from baseline to week 12 with moderate-to-large ES (0.50-0.80) demonstrated treatment responsiveness. CONCLUSIONS: The OAB-q demonstrates reliability, concurrent and discriminant validity, and responsiveness to treatment. The evidence shows that the OAB-q is psychometrically sound for use in medically complex elderly patients with overactive bladder.

Disordered Eating Behaviors in Emerging Adults With Type 1 Diabetes: A Common Problem for Both Men and Women.

INTRODUCTION: Emerging adults (EA) with disordered eating behaviors (DEBs) and Type 1 diabetes (T1D) are at increased risk for severe complications of T1D, and these behaviors have been reported in EA women with T1D. Few studies, though, have included men. This study assessed the prevalence of DEB in both EA men and women with T1D. METHODS: DEB was measured with the diabetes-specific Diabetes Eating Problem Survey-Revised (DEPS-R); scores of 20 or greater indicate need for further evaluation for DEB. RESULTS: A total of 27 women and 33 men (age range = 21 ± 2.5 years) completed the DEPS-R; 27% of women and 18% of men had scores of 20 or greater (p = .23). Hemoglobin A1c level was significantly higher in subjects with elevated DEPS-R scores (10.4 ± 2.1% vs. 7.8 ± 1.3%; p < .001), and DEPS-R scores correlated with increased body mass index values (r = 0.27, p < .05). DISCUSSION: Clinicians should assess for DEB in both male and female emerging adults with T1D, especially overweight patients with poor glycemic control.

Development of a predictive model for urgency urinary incontinence.

The ability to set realistic expectations of treatment response in patients with overactive bladder (OAB) can have an impact on patient engagement and adherence to study medication. In order to help set treatment expectations for OAB, a Physician Predictive Tool has been developed based on predictive modelling. Models have been developed utilizing data from eight Phase 3 and 4 fesoterodine clinical trials and these models enable the prediction of individual treatment response in subjects with OAB, based on various baseline characteristics. The data utilized and covariates that were hypothesized to influence treatment response are described. The model selection and development process are also outlined, and the final model and some example results utilizing this model are presented. Finally, we discuss the potential benefits and limitations of such a predictive tool.

UTILITY OF PSYCHOLOGICAL SCREENING OF YOUNG ADULTS WITH TYPE 1 DIABETES TRANSITIONING TO ADULT PROVIDERS.

OBJECTIVE: Screening for depression, diabetes distress, and disordered eating in youth with type 1 diabetes (T1D) is recommended, as these comorbidities contribute to poor glycemic control. No consensus exists on which measures are optimal, and most previous studies have used nondisease-specific measures. We examined the utility of screening for these disorders using two disease-specific and one general measure at the time of transition from pediatric to adult care. METHODS: Forty-three young adults from a T1D transition clinic completed the Patient Health Questionnaire, the Diabetes Distress Scale, and the Diabetes Eating Problem Survey-Revised. Chart review determined if clinicians noted similar symptoms during the year prior to transition. Metabolic data were also recorded. RESULTS: Chart review identified 5 patients with depressive symptoms and 8 patients with diabetes distress. Screening identified 2 additional patients with depressive symptoms and 1 additional patient with diabetes distress. Of those noted to have symptomatic depression or diabetes distress on chart review, several subsequently screened negative on transition. Disordered eating was not detected by chart review, but 23.5% screened positive on transition. While depression, diabetes distress, and disordered eating positively correlated with glycated hemoglobin (HbA1c) (r = 0.31, P = .05; r = 0.40, P = .009; r = 0.63, P<.001, respectively), disordered eating accounted for the majority of observed variance (df = 1; F = 18.6; P<.001). Even though HbA1c was higher in patients with versus without disordered eating (P<.001), body mass index did not differ between the 2 groups (P = .51). CONCLUSION: In young adults with T1D, formal screening provides an opportunity to detect psychological problems, which, when treated, may help optimize metabolic control during the transition process. ABBREVIATIONS: T1D = type 1 diabetes HbA1C = hemoglobin A1c YCDP = Yale Children's Diabetes Program PHQ-8 = Patient Health Questionnaire-8 DDS = Diabetes Distress Scale DEPS-R = Diabetes Eating Problem Survey-Revised.

Menstrual management and reproductive concerns in adolescent and young adult women with underlying hematologic or oncologic disease.

PURPOSE OF REVIEW: Heavy menstrual bleeding is common among adolescent and young adult women, and can affect health-related quality of life. The cause of heavy menstrual bleeding is not uncommonly because of an underlying hematologic or oncologic disease process, which substantially influences the way patients are counseled and treated. RECENT FINDINGS: Options for menstrual management are more numerous today than ever before and range from minimizing monthly blood loss to suppressing the cycle altogether. However, an underlying bleeding disorder or malignancy can introduce many nuances and limits in individual patient care, which this review highlights. Additionally, because survival rates for adolescent and young adult cancers are improving, more of these patients are planning for lives after their disease, which may include starting or adding to a family. Options for fertility preservation during cancer therapy regimens are solidifying and both primary practitioners and subspecialists should be aware of the possibilities. SUMMARY: Patients with underlying hematologic or oncologic disease require management of menstrual bleeding, but also deserve a comprehensive evaluation and counseling regarding their individualized contraceptive needs and fertility preservation options during their reproductive years. This review employs the latest evidence from current literature to help guide clinicians caring for this unique demographic.

Acute nonarteritic anterior ischemic optic neuropathy and exposure to phosphodiesterase type 5 inhibitors.

INTRODUCTION: Nonarteritic anterior ischemic optic neuropathy (NAION), a rare visual disorder, has been reported in men using phosphodiesterase type 5 inhibitors (PDE5i) for erectile dysfunction. AIM: We examined whether intermittent use of PDE5i is associated with acute NAION onset within approximately five half-lives following drug ingestion. METHODS: One hundred two ophthalmology centers in the United States and Europe identified potential cases of NAION. An expert adjudication committee conducted a blind review of the records of those with recent PDE5i use to classify cases as Definite, Possible, or not NAION. Subjects provided information on PDEi use via telephone interview. Each NAION case's PDE5i exposure immediately prior to onset was compared against his recent patterns of use in an observational case-crossover design. A sample size of 40 cases with intermittent PDE5i exposure in the 30 days prior to NAION onset was needed to detect an odds ratio (OR) of 3.0 with 80% power. MAIN OUTCOME MEASURES: The daily relative risk for acute NAION on days within five half-lives of PDE5i use vs. other days was estimated via an OR obtained from conditional logistic regression. RESULTS: Among 43 Definite NAION cases with PDE5i exposure in the prior 30 days, the OR was 2.15 (95% confidence interval [CI]: 1.06, 4.34). When 21 Possible NAION cases were included (n = 64), the OR was 2.36 (95% CI: 1.33, 4.19). CONCLUSIONS: We found an approximately twofold increased risk of acute NAION within five half-lives of PDE5i use compared with use in a more prior time period. Bias from inaccurate recall of exposure was unlikely to have substantially affected the results. Based on our results, we estimate that weekly use of PDE5i adds three NAION cases per 100,000 men 50 years and older annually.