Contraceptive counseling practices and patient experience: Results from a cluster randomized controlled trial at Planned Parenthood.

OBJECTIVES: Systematic reviews of contraceptive counseling interventions have shown inconsistent impact on patient outcomes. The current study assessed the effects of an evidence-informed contraceptive counseling staff training intervention on patient experience, contraceptive selection, and behavior over three months of follow-up. STUDY DESIGN: We randomly assigned 10 Planned Parenthood health centers in the Southeastern US to intervention (staff received contraceptive counseling training) and control (usual counseling) groups. From December 2016-June 2017, patients completed surveys immediately post visit (n = 756) and one and three months after. We compared differences in patients' counseling experience (e.g., number of evidence-informed practices experienced, satisfaction with counseling), contraceptive selection, and behavior (e.g., method discontinuation, accurate pill use, condom use) between study groups using mixed effect models with health center specified as a random effect. RESULTS: Seven hundred and fifty-six participants completed the baseline survey; 579 (77%) completed one or both follow-up surveys. The intervention group was more likely to report experiencing all evidence-informed counseling practices (adj. Prevalence Ratio [aPR] = 2.27, 95% CI 1.27, 4.04) with less variation in the number of practices and higher satisfaction with their counseling than the control group (p < 0.01). We found no sustained differences in contraceptive behaviors at both one- and three-month follow-up. CONCLUSIONS: We found immediate positive effects of the intervention on patients' perceptions of their counseling experience and no differences in changes in contraceptive behavior over time between the study groups. IMPLICATIONS: Evidence-based strategies to improve the quality of contraceptive care and subsequent outcomes, while centering patients' needs and preferences, are needed. The contraceptive counseling intervention offers a tool for increasing consistency in contraceptive counseling practices across health centers and improving patient satisfaction.

Preemptive Oral Acetaminophen for Women Undergoing Total Laparoscopic Hysterectomy.

OBJECTIVE: To decrease hospital expenses by administering oral acetaminophen rather than intravenous (IV) acetaminophen to women who undergo laparoscopic hysterectomy. DESIGN: A quality improvement project using a between-groups, pre-/postimplementation design for women undergoing total laparoscopic hysterectomy. Retrospective chart review was used to compare data of women who received intraoperative IV acetaminophen before implementation versus women who received oral acetaminophen after implementation. Pain scores and opioid consumption in morphine equivalents were recorded at four time points. SETTING/LOCAL PROBLEM: A 369-bed hospital in the southeastern United States, where, in 2016, nearly $260,000 was spent on perioperative IV acetaminophen for all operating room cases. PARTICIPANTS: Women between the ages of 18 and 55 years scheduled to have total laparoscopic hysterectomy were included. Excluded were women with a history of chronic pain, opioid use, or liver pathology; women with a contraindication to nonsteroidal anti-inflammatory drugs; and women whose procedures were converted from laparoscopic to open. INTERVENTION/MEASUREMENTS: Women were instructed to take oral acetaminophen the day before surgery in divided doses, with 1 g every 6 hours, for a total dose of 3 g. On the day of surgery, women received the final 1-g dose of oral acetaminophen. RESULTS: There were no significant differences between groups for pain scores or total opioids received before implementation (mean = 3.28, standard deviation = 2.05) compared with after implementation (mean = 3.65, standard deviation = 1.63; t [18] = -.043, p = .674). The preimplementation cost per individual was $30.03 for 1 g of IV acetaminophen, and the postimplementation cost was $0.36 for 2 500-mg oral acetaminophen tablets, a 98.8% relative cost decrease per woman. CONCLUSION: Replacing IV acetaminophen with preemptive oral acetaminophen has the potential to save money without compromising care.

Move to improve: progressive mobility in the intensive care unit.

Bed rest has detrimental consequences, and therefore in the ICU, progressive early mobility should be the goal for every patient expected to survive. This article examines the consequences of immobility, barriers experienced when attempting to increase patients' mobility, and ways in which dedicated mobility teams can overcome these barriers.

Which imaging modality is superior for prediction of response to neoadjuvant chemotherapy in patients with triple negative breast cancer?

Background and Objectives. Triple negative breast cancer (TNBC) has been shown to be generally chemosensitive. We sought to investigate the utility of mammography (MMG), ultrasonography (US), and breast magnetic resonance imaging (MRI) in predicting residual disease following neoadjuvant chemotherapy for TNBC. Methods. We identified 148 patients with 151 Stage I-III TNBC treated with neoadjuvant chemotherapy. Residual tumor size was estimated by MMG, US, and/or MRI prior to surgical intervention and compared to the subsequent pathologic residual tumor size. Data were compared using chi-squared test. Results. Of 151 tumors, 44 (29%) did not have imaging performed prior to surgical treatment. Thirty-eight (25%) tumors underwent a pathologic complete response (pCR), while 113 (75%) had residual invasive disease. The imaging modality was accurate to within 1 cm of the final pathologic residual disease in 74 (69%) cases and within 2 cm in 94 (88%) cases. Groups were similar with regards to patient age, race, tumor size and grade, and clinical stage (P > 0.05). Accuracy to within 1 cm was the highest for US (83%) and the lowest for MMG (56%) (P < 0.05). Conclusions. Breast US and MRI were more accurate than MMG in predicting residual tumor size following neoadjuvant chemotherapy in patients with TNBC. None of the imaging modalities were predictive of a pCR.

Reconstruction patterns in a single institution cohort of women undergoing mastectomy for breast cancer.

OBJECTIVES: The purpose of the current study was to conduct a patient-centered investigation of reconstruction practices following mastectomy at our institution. METHODS: A questionnaire was administered to patients who underwent unilateral or bilateral mastectomy for breast cancer from 2006 to 2010. The survey queried on demographics, surgical choices, and rationale for those choices. Data were summarized by contingency tables and compared by chi-square test or Fisher's exact test, as appropriate. RESULTS: Of 321 patients queried, 185 (58 %) underwent unilateral mastectomy and 136 (42 %) underwent bilateral mastectomy (mean age 56 ± 12 years). Overall, 189 (59 %) women underwent breast reconstruction, and 132 (41 %) did not. Immediate breast reconstruction was performed in 125 of 189 (69 %) women, whereas 67 of 189 (31 %) underwent delayed reconstruction. The method of definitive reconstruction included 143 of 189 (75 %) prostheses, 32 of 189 (17 %) abdominal tissue flap, 12 of 189 (6 %) latissimus flap (±implant), and 5 of 189 (2 %) with a combination of prostheses and tissue flaps. Of the 114 patients who did not undergo reconstruction, 68 (60 %) reported lack of desire for reconstruction as their motive, and the remaining 46 (40 %) reported medical contraindications for reconstruction or did not report a specific reason. CONCLUSIONS: A significant percentage of women undergoing unilateral or bilateral mastectomy for breast cancer at our institution elect to undergo reconstruction. Prosthetic reconstruction was the most common method utilized. The impetus for referral to the reconstructive surgeon was nearly always initiated by the surgical oncologist.

Fear of recurrence and perceived survival benefit are primary motivators for choosing mastectomy over breast-conservation therapy regardless of age.

INTRODUCTION: Recent studies have reported increases in the rate of mastectomy and contralateral prophylactic mastectomy (CPM). We hypothesized that there would be different reasons for choosing mastectomy for women aged <50 compared with those aged ≥50 years. METHODS: A questionnaire was administered to 332 patients who underwent unilateral or bilateral mastectomy for breast cancer from 2006 to 2010. The survey queried on demographics, surgical choices, and rationale for those choices. A retrospective chart review was performed to determine tumor characteristics. Responses and clinical characteristics were described by contingency tables and compared using Fisher exact test or χ(2) test, as appropriate. RESULTS: Of 332 patients surveyed, 310 were evaluable. Median age was 55 years, including 88 patients <50 (28 %) and 222 patients ≥50 (72 %) at time of diagnosis. Forty-four percent of women <50 and 41 % of women ≥50 were given the option of breast conservation and chose mastectomy (p > 0.63). The two groups did not differ in their reason for choosing mastectomy, with lower recurrence risk and improved survival cited as the two most common reasons. Younger patients were more likely to undergo reconstruction and CPM (p < 0.0001) as well as have estrogen receptor-negative tumors, undergo neoadjuvant chemotherapy, and have higher magnetic resonance imaging utilization (p < 0.05). CONCLUSIONS: Choosing mastectomy and the reasons for doing so were the same for women aged <50 and ≥50 years. Prospective studies are needed to determine whether patient education regarding perceived versus actual recurrence risk and survival would alter this decision-making process.

Positive margin rates following breast-conserving surgery for stage I-III breast cancer: palpable versus nonpalpable tumors.

BACKGROUND: Margin status is a significant risk factor for local recurrence. We sought to examine whether the method of tumor localization predicted the margin status and the need for re-excision for both nonpalpable and palpable breast cancer. METHODS: We identified 358 consecutive breast cancer patients who were treated with breast-conserving therapy (BCT) from 1999 to 2006. Data included patient and tumor characteristics, method of localization (needle versus palpation), and pathologic outcomes. Descriptive statistics were used for data summary and data were compared using χ(2). RESULTS: Of 358 patients undergoing BCT, 234 (65%) underwent needle localization for a nonpalpable tumor and 124 (35%) underwent a palpation-guided procedure. Patients undergoing palpation-guided procedures were younger and had larger tumors at a more advanced pathologic stage of disease than those undergoing needle localization procedures (P < 0.05 for each). Patient race, tumor grade, presence of lymphovascular invasion, biomarker profile, and nodal status were not significantly different between the two groups (P > 0.05). Overall, 137 patients (38%) had one or more positive margins: 90 of 234 (38%) who had a needle localization procedure and 47 of 124 (38%) who had a palpation-guided procedure (P > 0.05). The number of margins affected did not differ significantly between the two groups. CONCLUSION: Although patients with palpable breast cancer had larger tumors than those with nonpalpable breast cancer, the incidence and number of positive margins was similar to those who had needle localization for nonpalpable tumors. Improved methods of localization are needed to reduce the rate of positive margins and the need for re-excision.