Evaluating feedback from an implementation advisory board to assess the rollout of a postpartum patient navigation program.

BACKGROUND: Patient navigation is an individualized intervention to facilitate comprehensive care which has not yet been fully implemented in obstetric or postpartum care. METHODS: We aimed to develop and evaluate a mechanism to incorporate feedback regarding implementation of postpartum patient navigation for low-income birthing individuals at an urban academic medical center. This study analyzed the role of an Implementation Advisory Board (IAB) in supporting an ongoing randomized trial of postpartum navigation. Over the first 24 months of the trial, the IAB included 11 rotating obstetricians, one clinic resource coordinator, one administrative leader, two obstetric nurses, one primary care physician, one social worker, and one medical assistant. Members completed serial surveys regarding program implementation, effects on patient care, and areas for improvement. Quarterly IAB meetings offered opportunities for additional feedback. Survey responses and meeting notes were analyzed using the constant comparative method and further interpreted within the Exploration, Preparation, Implementation, Sustainment (EPIS) Framework. RESULTS: Members of the IAB returned 37 surveys and participated in five meetings over 24 months. Survey analysis revealed four themes among the inner context: reduced clinician burden, connection of care teams, communication strategies, and clinic workflow. Bridging factors included improved patient access to care, improved follow-up, and adding social context to care. Innovation factors included availability of navigators, importance of consistent communication, and adaptation over time. Meeting notes highlighted the importance of bidirectional feedback regarding implementation, and members expressed positive opinions regarding navigators' effects on patient care, integration into clinic workflow, and responsiveness to feedback. IAB members initially suggested changes to improve implementation; later survey responses demonstrated successful program adaptations. CONCLUSIONS: Members of an implementation advisory board provided key insights into the implementation of postpartum patient navigation that may be useful to promote dissemination of navigation and establish avenues for the engagement of implementing partners in other innovations. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03922334 . Registered April 19, 2019. The results here do not present the results of the primary trial, which is ongoing.

An Enhanced Postpartum Transition Program to Primary Care.

Background: Gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP) are risk factors for future cardiovascular disease, yet few individuals receive postpartum care with primary care clinicians (PCP). To facilitate transitions of care to PCPs and improve cardiovascular health monitoring within the first 13 months postpartum, we developed and piloted an enhanced postpartum referral pathway for patients with GDM or HDP. Methods: Eligible patients included those who received perinatal care at a large, urban, academic medical center, experienced GDM or HDP during their most recent pregnancy, and lacked an existing PCP. Resident, faculty, and advanced practitioners referred patients during antenatal, delivery-related, or postpartum visits. A dedicated scheduler contacted patients to schedule an appointment with a women's health-focused resident or faculty PCP. The percent of patients who attended a postpartum PCP visit, who had an HbA1c and cholesterol panel checked within the first 13 months postpartum, were compared between patients referred and not referred to the program using adjusted odds ratios (aOR). Results: Of 129 individuals referred, 48.1% attended a PCP visit, 31.8% completed cholesterol screening, and 41.9% completed HbA1c screening within 13 months postpartum. After adjusting for age, parity, insurance, and referral indication, referred individuals had greater odds for each outcome (PCP visit: aOR = 6.0, 95% CI 4.0-9.0; cholesterol: aOR = 2.4, 95% 1.6-3.9; HbA1c: aOR = 2.5, 95% CI 1.7-3.7) compared with nonreferred individuals in the same time period. Discussion: A enhanced postpartum PCP referral pathway pilot for birthing individuals was associated with improved follow-up in the first year postpartum.

Trends in Cardiovascular Health Counseling Among Postpartum Individuals.

Importance: Poor prepregnancy cardiovascular health (CVH) and adverse pregnancy outcomes (APOs) are key risk factors for subsequent cardiovascular disease (CVD) in birthing adults. The postpartum visit offers an opportunity to promote CVH among at-risk individuals. Objective: To determine prevalence, predictors, and trends in self-reported CVH counseling during the postpartum visit. Design, Setting, and Participants: Serial, cross-sectional analysis of data from 2016-2020 from the Pregnancy Risk Assessment Monitoring System (PRAMS), a nationally representative, population-based survey. The primary analysis included individuals who attended a postpartum visit 4 to 6 weeks after delivery with available data on receipt of CVH counseling, self-reported prepregnancy CVD risk factors (obesity, diabetes, and hypertension), and APOs (gestational diabetes, hypertensive disorders of pregnancy, and preterm birth) (N = 167 705 [weighted N = 8 714 459]). Exposures: Total number of CVD risk factors (0, 1, or ≥2 prepregnancy risk factors or APOs). Main Outcomes and Measures: Annual, age-adjusted prevalence of self-reported postpartum CVH counseling per 100 individuals, defined as receipt of counseling for healthy eating, exercise, and losing weight gained during pregnancy, was calculated overall and by number of CVD risk factors. Average annual percent change (APC) assessed trends in CVH counseling from 2016 through 2020. Data were pooled to calculate rate ratios (RRs) for counseling that compared individuals with and without CVD risk factors after adjustment for age, education, postpartum insurance, and delivery year. Results: From 2016 through 2020, prevalence of self-reported postpartum CVH counseling declined from 56.2 to 52.8 per 100 individuals among those with no CVD risk factors (APC, -1.4% [95% CI, -1.8% to -1.0%/y]), from 58.5 to 57.3 per 100 individuals among those with 1 risk factor (APC, -0.7% [95% CI, -1.3% to -0.1%/y]), and from 61.9 to 59.8 per 100 individuals among those with 2 or more risk factors (APC, -0.8% [95% CI, -1.3% to -0.3%/y]). Reporting receipt of counseling was modestly higher among individuals with 1 risk factor (RR, 1.05 [95% CI, 1.04 to 1.07]) and with 2 or more risk factors (RR, 1.11 [95% CI, 1.09 to 1.13]) compared with those who had no risk factors. Conclusions and Relevance: Approximately 60% of individuals with CVD risk factors or APOs reported receiving CVH counseling at their postpartum visit. Prevalence of reporting CVH counseling decreased modestly over 5 years.

Utilizing Natural Language Processing of Narrative Feedback to Develop a Predictive Model of Pre-Clerkship Performance: Lessons Learned.

Background: Natural language processing is a promising technique that can be used to create efficiencies in the review of narrative feedback to learners. The Feinberg School of Medicine has implemented formal review of pre-clerkship narrative feedback since 2014 through its portfolio assessment system but this process requires considerable time and effort. This article describes how natural language processing was used to build a predictive model of pre-clerkship student performance that can be utilized to assist competency committee reviews. Approach: The authors took an iterative and inductive approach to the analysis, which allowed them to identify characteristics of narrative feedback that are both predictive of performance and useful to faculty reviewers. Words and phrases were manually grouped into topics that represented concepts illustrating student performance. Topics were reviewed by experienced reviewers, tested for consistency across time, and checked to ensure they did not demonstrate bias. Outcomes: Sixteen topic groups of words and phrases were found to be predictive of performance. The best-fitting model used a combination of topic groups, word counts, and categorical ratings. The model had an AUC value of 0.92 on the training data and 0.88 on the test data. Reflection: A thoughtful, careful approach to using natural language processing was essential. Given the idiosyncrasies of narrative feedback in medical education, standard natural language processing packages were not adequate for predicting student outcomes. Rather, employing qualitative techniques including repeated member checking and iterative revision resulted in a useful and salient predictive model.

Improving Postpartum and Long-Term Health After an Adverse Pregnancy Outcome: Examining Interventions From a Health Equity Perspective.

Gestational diabetes mellitus and hypertensive disorders in pregnancy are adverse pregnancy outcomes (APOs) that affect 15% of pregnancies in the United States. These APOs have long-term health implications, with greater risks of future cardiovascular and chronic disease later in life. In this manuscript, we review the importance of timely postpartum follow-up and transition to primary care after APOs for future disease prevention. We also discuss interventions to improve postpartum follow-up and long-term health after an APO. In recognizing racial and ethnic disparities in APOs and chronic disease, we review important considerations of these interventions through a health equity lens.

Women's health update: A literature review impacting primary care.

The authors review studies on key issues in women's health with potential impact on internal medicine practice. The reviewed articles discuss cardiovascular disease risks, bone health, breast cancer genetics, cervical cancer prevention, depression in the peripartum period, pelvic pain, and emergency contraception.

Primary Care Clinician Perspectives on Patient Navigation to Improve Postpartum Care for Patients with Low Income.

Background: Birthing individuals experience significant physical and psychosocial transitions during the postpartum period. Despite amplified health needs, many individuals do not successfully transition from obstetric to primary care. Patient navigation provides a patient-centered solution that has been applied to other health care specialties resulting in improved care coordination and patient engagement for populations in greatest need. Our objective was to understand primary care clinician perspectives regarding the role of navigators in improving postpartum care for individuals with low income. Methods: In this qualitative investigation, we conducted focus groups with primary care clinicians from family and internal medicine specialties. Semistructured interview guides addressed clinician perceptions of navigator roles during the postpartum period and recommendations for navigator training. Focus group discussions were digitally recorded, transcribed, and analyzed via a constant comparative method. Results: Twenty-eight primary care clinicians, including 26 physicians and 2 advanced practice registered nurses, participated in 8 focus groups. Participants reported favorable attitudes toward implementation of a postpartum patient navigation program. Themes regarding useful navigation services included streamlining obstetric to primary care transition, enhancing visit effectiveness, creating personalized postpartum care, and providing patient- and clinician-focused education. Recommendations for navigator training included education on basic medical concerns that are common in the postpartum period, health information privacy and electronic health record use, health care systems, and community resources.Clinical Trial Registration number: NCT03922334. Conclusions: Primary care clinicians were highly receptive to the concept of patient navigation as a process to improve health in the postpartum period through enhanced care coordination and improved patient knowledge, engagement, and self-efficacy.

Establishing Trust When Assessing Learners: Barriers and Opportunities.

Trust plays a critical role in the assessment of learners in the clinical setting. In an ideal system, learners can be vulnerable and share their limitations and areas for improvement, while faculty possess the time and skill to provide specific feedback that enables learners to achieve competency in clinical skills. For medical students, a number of threats to the establishment of trust in the learning environment exist, including the interplay between feedback and grades, the existence of bias, and competing demands for faculty time. However, several strategies can help institutions to overcome these threats and foster a culture of trust related to assessment and assessment systems: Provide ungraded environments where learners are able to be vulnerable, cocreate assessments and assessment systems with faculty and learners, acknowledge and address bias, and provide faculty with adequate time and resources to employ best practices in assessment. By intentionally employing these strategies, our institutions can support trust in assessment systems and further learner growth and achievement.

A Qualitative Analysis of Narrative Preclerkship Assessment Data to Evaluate Teamwork Skills.

Construct: Students entering the health professions require competency in teamwork. Background: Although many teamwork curricula and assessments exist, studies have not demonstrated robust longitudinal assessment of preclerkship students' teamwork skills and attitudes. Assessment portfolios may serve to fill this gap, but it is unknown how narrative comments within portfolios describe student teamwork behaviors. Approach: We performed a qualitative analysis of narrative data in 15 assessment portfolios. Student portfolios were randomly selected from 3 groups stratified by quantitative ratings of teamwork performance gathered from small-group and clinical preceptor assessment forms. Narrative data included peer and faculty feedback from these same forms. Data were coded for teamwork-related behaviors using a constant comparative approach combined with an identification of the valence of the coded statements as either "positive observation" or "suggestion for improvement." Results: Eight codes related to teamwork emerged: attitude and demeanor, information facilitation, leadership, preparation and dependability, professionalism, team orientation, values team member contributions, and nonspecific teamwork comments. The frequency of codes and valence varied across the 3 performance groups, with students in the low-performing group receiving more suggestions for improvement across all teamwork codes. Conclusions: Narrative data from assessment portfolios included specific descriptions of teamwork behavior, with important contributions provided by both faculty and peers. A variety of teamwork domains were represented. Such feedback as collected in an assessment portfolio can be used for longitudinal assessment of preclerkship student teamwork skills and attitudes.

The Impact of Women's Health Residency Tracks on Career Outcomes.

BACKGROUND: Women's health residency tracks within several internal medicine residencies provide gender-specific education to residents. The impact of these programs has not been evaluated. The objective of this study was to determine the impact that women's health residency tracks have on career outcomes. MATERIALS AND METHODS: The participants in the study were women's health track (WHT) graduates from three different programs. To account for the impact of gender, we also surveyed female graduates who did not participate in WHT from the same programs, paired by year of graduation (non-WHT). Participants completed an online survey and provided a copy of their updated curriculum vitae (CV). Survey responses and CV data were analyzed separately. RESULTS: Of the 218 eligible graduates, 133 completed the survey and 86 provided a CV for a response rate of 63.8%. Regarding clinical care, 31.8% of WHT graduates focused on women's health in practice compared with only 16.1% of non-WHT graduates (Cohen's h 0.43). WHT graduates were more likely to have presented nationally on women's health topics (53.3% vs. 16.7%, p-value 0.030) and teach women's health topics (51.4% vs. 26.7%%, Cohen's h 0.51). WHT graduates were more likely to have assumed a women's health leadership role (34.5% vs. 0.0%, p-value 0.018). CONCLUSION: Graduates of women's health residency tracks remain involved in women's health in clinical practice, scholarship, teaching, and leadership. While all internal medicine residents should receive comprehensive women's health education, WHTs are an effective way of promoting women's healthcare and scholarship.

A Randomized Educational Intervention Trial to Determine the Effect of Online Education on the Quality of Resident-Delivered Care.

BACKGROUND: There is limited research on whether online formative self-assessment and learning can change the behavior of medical professionals. OBJECTIVE: We sought to determine if an adaptive longitudinal online curriculum in bone health would improve resident physicians' knowledge, and change their behavior regarding prevention of fragility fractures in women. METHODS: We used a randomized control trial design in which 50 internal medicine resident physicians at a large academic practice were randomized to either receive a standard curriculum in bone health care alone, or to receive it augmented with an adaptive, longitudinal, online formative self-assessment curriculum delivered via multiple-choice questions. Outcomes were assessed 10 months after the start of the intervention. Knowledge outcomes were measured by a multiple-choice question examination. Clinical outcomes were measured by chart review, including bone density screening rate, calculation of the fracture risk assessment tool (FRAX) score, and rate of appropriate bisphosphonate prescription. RESULTS: Compared to the control group, residents participating in the intervention had higher scores on the knowledge test at the end of the study. Bone density screening rates and appropriate use of bisphosphonates were significantly higher in the intervention group compared with the control group. FRAX score reporting did not differ between the groups. CONCLUSIONS: Residents participating in a novel adaptive online curriculum outperformed peers in knowledge of fragility fracture prevention and care practices to prevent fracture. Online adaptive education can change behavior to improve patient care.

Functional analysis of subunit e of the F1Fo-ATP synthase of the yeast Saccharomyces cerevisiae: importance of the N-terminal membrane anchor region.

Mitochondrial F1Fo-ATP synthase complexes do not exist as physically independent entities but rather form dimeric and possibly oligomeric complexes in the inner mitochondrial membrane. Stable dimerization of two F1Fo-monomeric complexes involves the physical association of two membrane-embedded Fo-sectors. Previously, formation of the ATP synthase dimeric-oligomeric network was demonstrated to play a critical role in modulating the morphology of the mitochondrial inner membrane. In Saccharomyces cerevisiae, subunit e (Su e) of the Fo-sector plays a central role in supporting ATP synthase dimerization. The Su e protein is anchored to the inner membrane via a hydrophobic region located at its N-terminal end. The hydrophilic C-terminal region of Su e resides in the intermembrane space and contains a conserved coiled-coil motif. In the present study, we focused on characterizing the importance of these regions for the function of Su e. We created a number of C-terminal-truncated derivatives of the Su e protein and expressed them in the Su e null yeast mutant. Mitochondria were isolated from the resulting transformant strains, and a number of functions of Su e were analyzed. Our results indicate that the N-terminal hydrophobic region plays important roles in the Su e-dependent processes of mitochondrial DNA maintenance, modulation of mitochondrial morphology, and stabilization of the dimer-specific Fo subunits, subunits g and k. Furthermore, we show that the C-terminal coiled-coil region of Su e functions to stabilize the dimeric form of detergent-solubilized ATP synthase complexes. Finally, we propose a model to explain how Su e supports the assembly of the ATP synthase dimers-oligomers in the mitochondrial membrane.