Implementation of a Multidisciplinary Medication Refill Protocol.

Introduction: Primary care clinicians spend significant time managing nonvisit activities, including processing of requests for prescription renewal. Delays in processing refills may lead to patient dissatisfaction and impact provider productivity. Having nonclinicians process refills can be more efficient and time-saving. We aimed to evaluate the use of a multidisciplinary medication refill protocol to decrease the time to complete refill requests. Methods: We implemented nursing-driven management of refill requests within two family medicine residency clinics in Milwaukee, Wisconsin (Phase 1: single clinic implementation [March 2017-June 2019]; Phase 2: added second clinic prepandemic [June 2019-March 2020] and postpandemic [April 2020-December 2020]). The multidisciplinary refill protocol was created by faculty, residents, pharmacy, and nursing. Data were collected using electronic health record time stamps to determine when refill requests were initiated and filled by faculty, residents, and nurses. We used Mood's median test to compare the median time for medication refill completion. We used Levene's test to test for equal variance surrounding the median of each caregiver group. We used Fisher's exact test or χ2 test with Yates' correction for 2×2 contingency tables. Results: In both phases, we identified a significant reduction in median time to refill completion ( P<.001) and variability of time to refill completion ( P<.001). Notably, in Phase 1, reduction in median refill time was most apparent among residents (383 vs 79 min postimplementation); and in Phase 2, the percentage of refills completed within 48 hours significantly increased between the pre-COVID-19 and COVID-19 pandemic among faculty and nursing in Clinic 1 and residents and faculty in Clinic 2 (all P's<.001). Conclusions: Implementation of a multidisciplinary refill protocol significantly improved time and predictability of refill completion in both phases.

Using Prophylactic Antihemorrhagic Medications in Second-Trimester Surgical Abortions.

We aimed to estimate the association of prophylactic antihemorrhagic medication use during dilation and evacuation (D&E) with operative hemorrhage and estimated blood loss (EBL). Records for all pregnant patients between 14 and less than 22 weeks of gestation who had a D&E procedure from January 2012 to December 2019 were retrospectively reviewed. Prophylactic antihemorrhagic medication use was defined as receiving vasoconstrictors, uterotonics, or both before identification of hemorrhage during a D&E procedure. Overall, 147 D&E procedures were completed at a mean of 16.4 (±2.2) weeks of gestation. Prophylactic medications were used in 72.1% (n=106) of D&E procedures. Prophylactic medication use was associated with lower operative hemorrhage (21.7% vs 51.2%, P <.01) and lower EBL (336.9 mL vs 551.3 mL, P <.01).

Impact of Geodemographic Factors on Antibiotic Prescribing for Acute, Uncomplicated Bronchitis or Upper Respiratory Tract Infection.

OBJECTIVE: To assess the impact of geodemographic factors on antibiotic prescribing for adult acute, uncomplicated bronchitis or upper respiratory tract infection. METHODS: A retrospective, observational study of 63,051 single health-system, outpatient discharges with a primary diagnosis of bronchitis or upper respiratory tract infection in 2019. Univariate analyses of prescribing predictors and multivariable stepwise logistic modeling were performed. RESULTS: Patients who were older (aOR 1.02; 95% CI 1.02, 1.02), male (1.10; 1.06, 1.14), black (1.29; 1.22, 1.38), smoked (1.18; 1.14, 1.23), seen in urgent care (1.26; 1.22, 1.31) and living in an area with more owner-occupied housing (1.41; 1.30, 1.53) were more likely to receive antibiotics. Patients who were Asian (0.88; 0.77, 0.99), had Medicare (0.83; 0.78, 0.87), Medicaid (0.84; 0.79, 0.87) or Exchange insurance (0.90; 0.82, 0.98), or seen in the emergency department (0.43; 0.40, 0.46) were less likely to receive antibiotics. Distance from a patient's address and their encounter location did not predict antibiotic prescribing. CONCLUSIONS: Antibiotic prescribing interventions for adult acute bronchitis and upper respiratory tract infections could target patients living in an area with higher socioeconomic status.

Association of Natural Waterways and Legionella pneumophila Infection in Eastern Wisconsin: A Case-Control Study.

Preliminary research has suggested possible associations between natural waterways and Legionella infection, and we previously explored these associations in eastern Wisconsin using positive L. pneumophila serogroup 1 urine antigen tests (LUAT) as diagnostic. This case-control study was a secondary analysis of home address data from patients who underwent LUAT at a single eastern Wisconsin health system from 2013 to 2017. Only zip codes within the health system's catchment area that registered ≥3 positive cases and ≥50 completed tests, as well as geographically adjacent zip codes with ≥2 positive cases and ≥50 tests, were included. A 1:3 ratio of cases to randomly selected controls was used. Home addresses were geocoded and mapped using ArcGIS software (Esri); nearest waterway and distance to home was identified. Distance to nearest waterway according to ArcGIS was verified/corrected using Google Maps incognito. Distances were analyzed using chi-squared and 2-sample t-tests. Overall, mean distance to nearest waterway did not differ between cases (2958 ± 2049 ft) and controls (2856 ± 2018 ft; P=0.701). However, in a subset of nonurban zip codes, cases were closer to nearest waterway than controls (1165 ± 905 ft vs 2113 ± 1710 ft; P=0.019). No association was found between cases and type of waterway. Further research is needed to investigate associations and differences between natural and built environmental water sources in relation to legionellosis.

Seroprevalence of COVID-19 IgG Antibody in Resident and Fellow Physicians in Milwaukee, Wisconsin: Analysis of a Cross-Sectional Survey.

PURPOSE: Medical trainees are likely at differential risk of exposure to COVID-19 per respective clinical activity. We sought to determine the seroprevalence of COVID-19 antibody (Ab) among resident and fellow physicians with varying degrees of exposure to COVID-19. METHODS: A cross-sectional study of Milwaukee-based resident and fellow physicians, encompassing December 2019-June 2020, was conducted. Relevant variables of interest were ascertained by survey and payroll data, and Abbott ARCHITECT Ab test (index cut-off of ≥1.4) was performed. Descriptive statistics were generated, with 95% CI calculated for the study's primary outcome of seroprevalence. RESULTS: Among survey respondents (92 of 148, 62%), 61% were male, 44% were non-White, mean age was 31 years, 94% had no underlying conditions, and 52% were either family or internal medicine residents. During the study period, ≥32% reported cough, headache, or sore throat and 62% traveled outside of Wisconsin. Overall, 83% thought they had a COVID-19 exposure at work and 33% outside of work; 100% expressed any exposure. Of those exposed at work, 56% received COVID-19 pay, variously receiving 69 mean hours (range: 0-452). Ultimately, 82% (75 of 92) had an Ab test completed; 1 individual (1.3%; 95% CI: 0.0-3.9) tested seropositive, was not previously diagnosed, and had received COVID-19 pay. CONCLUSIONS: The low Ab seroprevalence found in resident and fellow physicians was similar to the concurrently reported 3.7% Ab-positive rate among 2456 Milwaukee-based staff in the same integrated health system. Ultimately, COVID-19 seroconversion may be nominal in properly protected resident and fellow physicians despite known potential exposures.

Factors Associated With Breast Cancer Surgery Delay Within a Coordinated Multihospital Community Health System: When Does Surgical Delay Impact Outcome?

BACKGROUND: Multiple factors influence the time elapsed between diagnosis of breast cancer and surgical extirpation of the primary tumor. The disease-free interval between resection of primary breast cancer and first evidence of recurrence is predictive of mortality. We aimed to determine patient, disease, and treatment factors associated with a delay in time to surgery (TTS) and identify the point when prolonged TTS negatively impacts disease-free survival. PATIENTS AND METHODS: Cancer registry and electronic medical record data for patients with breast cancer who underwent surgery as first course of treatment during 2006-2016 were retrospectively reviewed. Patients undergoing surgery in ≤30 vs. 31-60 vs. >60 days of initial diagnosis were compared. Kaplan-Meier survival analyses with Cox proportional hazards were performed to evaluate impact of time from breast cancer diagnosis to definitive therapeutic surgery on breast cancer recurrence or death (all-cause). RESULTS: Overall, 4462 patients were analyzed, 43.4% of whom underwent surgery beyond 30 days. The following factors were associated with TTS >30 days: age <50, non-Hispanic White race/ethnicity, commercial or health exchange/Medicaid insurance, diagnosis of noninvasive disease (i.e., ductal carcinoma in situ), had breast magnetic resonance imaging before definitive surgery, underwent total mastectomy (especially if immediate reconstruction, particularly if autologous, was performed), and did not receive adjuvant therapies (P < .001 for all). After adjusting for relevant variables, significant predictors of recurrence/death included a TTS >60 days, increased patient age, higher breast cancer stage, and triple-negative biomarker expression. CONCLUSION: Risk of recurrence or death is not compromised until TTS exceeds 60 days after initial breast cancer diagnosis.

Family-centered cesarean delivery: a randomized controlled trial.

BACKGROUND: Women who undergo cesarean delivery report that they are less satisfied with their child birthing experience and have a later skin-to-skin contact. Because cesarean deliveries account for nearly one-fifth of all births globally, improving the child birthing experience is imperative. One delivery technique that may improve the child birthing experience, termed the family-centered cesarean, allows the mother to view the birth of her baby and to have the baby immediately placed on her chest following delivery. OBJECTIVE: Our primary outcome was to compare satisfaction with birthing experiences between women who underwent either a family-centered or traditional cesarean delivery. Our secondary outcomes compared timing of skin-to-skin contact, and maternal and neonatal outcomes between the 2 methods of cesarean delivery. STUDY DESIGN: Pregnant women aged ≥18 years who had been admitted to Labor and Delivery with a planned cesarean delivery at 1 of 2 delivery units were prospectively enrolled. Women were randomized 1:1, but not blinded, to either the family-centered cesarean (Method 1; N=68) or traditional cesarean (Method 2; N=61). Time to skin-to-skin interactions and newborn vitals were recorded by a nurse at time of delivery. A self-administered questionnaire was provided to participants in the hospital on postpartum to obtain satisfaction with the birthing experience using a modified Likert scale, ranging from 1 (lowest) to 5 (highest). Baseline characteristics and all other variables of interest were abstracted from the electronic medical record. Baseline characteristics, maternal satisfaction, and maternal or neonatal outcomes between methods of delivery were compared using t tests and Pearson chi-squared (or Fisher exact), as appropriate. RESULTS: Between June 2016 and July 2018, women who were randomized to either Method 1 or Method 2 did not significantly differ by baseline characteristics. This study was unable to detect a difference in satisfaction (4.6 Method 1 vs 4.4 Method 2; P=.27). However, mean time to skin-to-skin contact was significantly different. Patients in Method 1 established skin-to-skin contact on average 11.2 minutes earlier than those in Method 2 (5.1 vs 16.3; P<.01). No other differences in maternal and neonatal outcomes were identified. CONCLUSION: Although our study did not find statistical differences in maternal or newborn outcomes, including maternal satisfaction, the family-centered cesarean was significantly associated with earlier skin-to-skin contact. Given the known benefits of earlier skin-to-skin contact without associated harm, women should be allowed to choose either method of cesarean delivery based on their personal preference.

Breast cancer recurrence risk after hormonal contraceptive use in survivors of reproductive age.

OBJECTIVE: To assess the risk of recurrence with hormonal contraceptive use in breast cancer survivors of reproductive age. STUDY DESIGN: In this retrospective study, women ages 18-51 years who were diagnosed with primary stage 0-3 breast cancer between 2006-2016 and subsequently entered remission were included. Patients with missing information within the cancer registry or electronic medical record and those with a history of hysterectomy and/or sterilization procedure prior to diagnosis were excluded. Hormonal contraception use was defined as being prescribed an oral contraceptive pill (OCP), patch, vaginal ring, medroxyprogesterone injection, etonogestrel implant, or levonorgestrel-releasing intrauterine device (IUD). Women were separated into two groups, hormonal contraceptive users and non-users. Basic descriptive and inferential statistics were used to compare groups as appropriate. The primary outcome reviewed was local or distant breast cancer recurrence. Secondary outcomes included all-cause mortality and pregnancy. RESULTS: Following exclusions, 1370 women remained in the cohort. Ninety-seven women (7.08 %) received a prescription for a form of hormonal contraception. When comparing groups, hormonal contraceptive users were more likely to be between 18-40 years of age (46.39 % vs. 17.99 % non-users;P < 0.01) and never smokers (68.04 % vs. 38.57 % non-users; P < 0.01). Patients did not differ between groups based on any other demographic or cancer-related characteristic, including tumor hormone receptor expression. Overall, 92 patients (6.72 %) experienced local or distant recurrence during the study period. Recurrence did not differ between groups (6.19 % users vs. 6.76 % non-users; P = 0.83). All-cause mortality and pregnancy rates also did not differ between hormonal contraceptive users and non-users. CONCLUSION: The study shows no increased risk of recurrence associated with hormonal contraceptive use after breast cancer diagnosis and remission.

Dancing During Labor: Are Women Down to Boogie?

Recent social media trends have demonstrated increased interest in dancing during the final weeks of pregnancy and labor. However, there is limited evidence about dancing during labor and its impact on labor pain and duration as well as patient satisfaction. Before conducting a prospective study, given that enrollment is often challenging, our feasibility study aimed to assess the willingness of pregnant women to participate in a future study evaluating low-impact dance during labor. We anonymously surveyed a convenience sample of English-speaking/reading pregnant women who presented for prenatal care at 1 of 3 clinics from June 2019 to July 2019. Questions related to women's interest in dancing during labor and limited demographic information were collected and analyzed. Overall, 88.6% of pregnant women who completed the survey expressed interest in participating in a future study on low-impact dance during labor, with Caucasian patients and those ≥35 years of age being less interested in future participation (P<0.05 for both). Interest in participating was not influenced by any other demographic characteristic, pregnancy history, or current activity level. Given sufficient interest among pregnant women in participating in a study aimed at evaluating the potential benefits of low-impact dance during labor, enrollment numbers may be easier to achieve than previously expected.

Retrospective review of cesarean hysterectomy outcomes utilizing uterine intravascular interventions in a large, community-based healthcare setting.

OBJECTIVE: To explore outcomes of women with planned cesarean hysterectomies, with or without use of internal iliac intravascular occlusive balloon catheter or uterine artery embolization (UAE). STUDY DESIGN: We retrospectively reviewed adult women who underwent a planned cesarean hysterectomy, 2004-2019. All planned cases were included, regardless of indication. Planned surgeries were divided into three groups: balloon placement, UAE, or no intervention. Patients with balloon placement were further subdivided into: balloons placed but not deployed or balloons placed and deployed intraoperatively. Hemorrhage was defined as estimated blood loss (EBL) ≥1,500 mL. An adverse outcome was defined as one or more of the following: intensive care unit admission, thromboembolism, ureteral stent placement, amputation, or reoperation. Basic descriptive and inferential statistics were used to explore differences among groups and adverse outcomes. RESULTS: A total of 34 patients underwent planned cesarean hysterectomy. Ten patients (29.4%) had balloons placed, nine (26.5%) had UAE, and 15 (44.1%) had no intervention. Risk of hemorrhage was clinically higher among those with balloon placement (80% vs. 33% UAE vs. 60% no intervention; P = 0.14), with mean EBL (3,605.0 mL vs. 1,488.9 mL vs. 2,289.3 mL; P = 0.05) and mean transfusion requirements (9.3 units vs. 2.8 vs. 4.4; P = 0.01) being significantly higher. Adverse outcomes were also significantly higher among those with balloon placement (80.0% vs. 66.7% UAE vs. 20.0% no intervention; P ≤ 0.01). Of the ten patients with balloons placed, four were deployed. Among those with balloons placed and deployed, mean EBL (5,250.0 mL vs. 2,508.3 mL balloons placed but not deployed vs. 2,289.3 mL no intervention; P=0.04) and mean transfusion requirements (11 units vs. 7.5 units balloons placed but not deployed vs. 4.4 units no intervention; P = 0.05) were significantly higher. Adverse outcomes were also significantly higher among those who had balloons placed and deployed (100.0% vs. 66.7% balloons placed but not deployed vs. 20.0% no intervention; P ≤ 0.01). CONCLUSIONS: Balloon placement, regardless of deployment, may not be beneficial to women undergoing a planned cesarean hysterectomy. Although UAE was also associated with adverse outcomes, it may be a better option for reducing intraoperative blood loss among patients with a planned cesarean hysterectomy.

A Quality Brief of an Oncological Multisite Massage and Acupuncture Therapy Program to Improve Cancer-Related Outcomes.

Objectives: Cancer treatment can present its own physical and mental challenges resulting in symptoms such as fatigue, stress, pain, nausea, and vomiting. Aurora Health Care is a large health system with 19 cancer centers. Integrative therapies such as acupuncture and massage have demonstrated success in reducing cancer-related symptoms and side effects to conventional cancer treatment and improving patient outcomes. In 2018, 15 of the 19 Aurora Cancer Clinics embedded a replicable Integrative Cancer Care closed model to provide adjuvant therapies for the best patient outcomes. This quality improvement study aimed to explore if the replicable integrative care model could demonstrate consistent outcomes for massage and acupuncture therapies aimed at symptom reduction across multiple oncology clinics. Design: Aurora Cancer Care and Aurora Integrative Medicine designed a reproducible integrative therapy service model to be embedded into the Aurora Cancer Centers. Integrative therapies within the cancer centers allow patients easy access to care before, during, or after their cancer treatment. In 2018, 15 of the 19 cancer clinics had integrative therapies available to patients with cancer. This model required unified operations, onboarding, training, competency, and clinical oversight to achieve consistent processes for consistent outcomes. Furthermore, these innovative models prioritized the following: patient access (easy and affordable); service delivery (consistent and operationalized); clinical outcomes (effective and meaningful); and caliber of clinician (competent and confident). Aurora Health Care employs massage therapists (Mts) and acupuncturists (Ats). This employment model allows for standards and program model adherence. To achieve competent and confident clinician's, MT or AT must complete a cancer treatment-focused competency training program relative to their respective profession and adherence to practice standards outlined. The training program is built on evidence-based practice, observation, direct demonstration, return demonstration, mentorship, and ongoing quality review by clinical leaders. Aurora's Integrative Cancer Care closed model of care is accessible to patients through philanthropic funds secured to underwrite the free service of MT provided during infusion treatments. Funds also provided three free AT sessions. Ongoing acupuncture therapies were provided at a low-cost group acupuncture fee at $25.00 per treatment. Acupuncture is available in group format and provided either before or after chemotherapy treatment. The free services were intended to introduce the concept of integrative therapies as a viable adjuvant option with conventional cancer care. As this model incorporates a mix of philanthropic funding and low-cost fees to offset the cost of the therapy provider, it is referred to as a "closed model" or accessible only to those patients under the care of an Aurora Cancer specialist. In 2018, 15 Aurora Cancer Clinics offered massage and 11 Aurora Cancer Clinics offered acupuncture. Patients who self-selected integrative therapies via system-employed Mts and Ats were surveyed pre/post acupuncture and MT treatments using a visual analog scale about their perceived levels of pain, stress, nausea, and neuropathy. The staff integrative clinicians collected data from patients, and post-treatment data were compiled by the Department of Integrative Medicine. Settings/Location: Aurora Cancer Centers are embedded within Aurora hospitals or free-standing clinics located throughout Wisconsin. In 2018, 15 cancer clinic locations embedded Mts, and 11 cancer clinic locations embedded Ats. Subjects: Oncology patients. Interventions: Clinical competencies were developed and applied to address indications, contraindications, and oncology-specific procedures to ensure that consistent quality of therapies was provided across sites. In 2018, Ats delivered 4367 Ats across 11 locations and Mts delivered 4197 Mts across 15 locations. During this study, the number of treatments provided was tracked versus episodic care. Outcome Measures: Pre/post AT and MT pain, stress, nausea, and neuropathy scores were recorded (0 [least] to 10 [worst]) and compared using paired t-tests. Results: Pre/post AT scores for pain, neuropathy, stress, and nausea were all significantly different (p < 0.001). For AT, there was a reported decrease in pain, stress, and neuropathy of 61.7%, 68.8%, and 47.9%, respectively. Pre/post MT scores for pain, neuropathy, nausea, and stress were also significantly different (p < 0.001). MT was greater at reducing stress and pain, 42.5% and 34.4%, respectively. Conclusions: Across 15 cancer clinics, both AT and MT treatments consistently and significantly reduced cancer-related side effects. These findings highlight the value of conducting a larger randomized-controlled trial to further assess the impact of Oncological Multisite Massage and Acupuncture Therapy on cancer-related symptoms across multiple oncologic clinics.

Attempted Isolation of Cryptococcus Species and Incidental Isolation of Exophiala dermatitidis from Human Oral Cavities.

Recent molecular studies suggest that Cryptococcus may inhabit the normal human mouth. We attempted to isolate Cryptococcus from 21 adult non-acutely ill patients and 40 volunteer medical and non-medical staff in Southeastern Wisconsin, USA. An upper lip sulcus culture and an oral rinse specimen were inoculated separately onto Staib (birdseed) agar containing chloramphenicol and incubated in gas impermeable zip lock bags at 35 °C. No cryptococci were grown from any of the 122 samples from the 61 subjects. Both specimens from a woman with no risk factors for fungal disease yielded a black yeast at 4 days on Staib agar. This isolate was shown to be Exophiala dermatitidis by colony and microscopic morphology, analysis by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry, and sequencing through the internal transcribed spacer ribosomal RNA gene. This appears to be a novel isolation of E. dermatitidis from the oral cavity of a generally healthy human.

Epidemiologic Survey of Legionella Urine Antigen Testing Within a Large Wisconsin-Based Health Care System.

PURPOSE: Legionella pneumophila pneumonia is a life-threatening, environmentally acquired infection identifiable via Legionella urine antigen tests (LUAT). We aimed to identify cumulative incidence, demographic distribution, and undetected disease outbreaks of Legionella pneumonia via positive LUAT in a single eastern Wisconsin health system, with a focus on urban Milwaukee County. METHODS: A multilevel descriptive ecologic study was conducted utilizing electronic medical record data from a large integrated health care system of patients who underwent LUAT from 2013 to 2017. A random sample inclusive of all positive tests was reviewed to investigate geodemographic differences among patients testing positive versus negative. Statistical comparisons used chi-squared or 2-sample t-tests; stepwise regression followed by binary logistic regression was used for multivariable analysis. Positive cases identified by LUAT were mapped to locate hotspots; positive cases versus total tests performed also were mapped by zip code. RESULTS: Of all LUAT performed (n=21,599), 0.68% were positive. Among those in the random sample (n=11,652), positive cases by LUAT were more prevalent in the June-November time period (86.2%) and younger patients (59.4 vs 67.7 years) and were disproportionately male (70.3% vs 29.7%) (P<0.0001 for each). Cumulative incidence was higher among nonwhite race/ethnicity (1.91% vs 1.01%, P<0.0001) but did not remain significant on multivariable analysis. Overall, 5507 tests were performed in Milwaukee County zip codes, yielding 82 positive cases by LUAT (60.7% of all positive cases in the random sample). A potential small 2016 outbreak was identified. CONCLUSIONS: Cumulative incidence of a positive LUAT was less than 1%. LUAT testing, if done in real time by cooperative health systems, may complement public health detection of Legionella pneumonia outbreaks.

Can Magnetic Resonance Imaging Predict Pathologic Findings for Endometrioid Endometrial Cancer?

This pilot study aimed to assess the feasibility of precisely measuring tumor diameter and myometrial invasion in patients with endometrioid endometrial cancer (EEC) using preoperative contrast-enhanced magnetic resonance imaging (MRI). Adult patients with confirmed diagnosis of complex hyperplasia with atypia or EEC were included. Three radiologists separately measured tumor diameter and myometrial invasion. Basic descriptive statistics were used to describe patient characteristics and to compare radiology- and pathology-measured tumor diameter and myometrial invasion. Using the pathology results for tumor diameter as the gold standard for comparison, at least 1 radiologist was able to predict largest tumor diameter within 5 mm for 41.7% of patients. Similarly, based on pathology results for myometrial invasion, at least 1 radiologist was able to predict myometrial invasion within 5% for 50% of patients. All radiologists were able to predict superficial (<50%) or deep (≥50%) myometrial invasion for 75% of patients, with greater sensitivity, specificity, and accuracy for deep myometrial invasion. Given variation among radiologic measurements, it is difficult to recommend preoperative MRI as a basis for measuring tumor diameter and myometrial invasion. Even so, the ability to predict superficial versus deep myometrial invasion may benefit patients with EEC for whom surgery is not a viable option or for those seeking fertility-sparing treatment options.

Dancing During Labor: Social Media Trend or Future Practice?

Over the past 30 years, medical interventions in pregnancy and childbirth have increased. Some pregnant women seek less invasive and nonpharmacological options to manage discomforts during labor. While exercise during pregnancy is recommended, less is known about exercise, specifically dancing, during labor. While anecdotal evidence is supportive, little is known about the implications of exercise and dance during the first stage of labor for pain reduction and labor progression. Some movements common in dance, such as expanding hip circles that loosen and relax muscles of the pelvic floor, may be beneficial to women during labor. Available evidence suggests that dancing during the first stage of labor may decrease duration and intensity of pain and increase patient satisfaction, but further study is warranted. Ultimately, before assessing the implications of dance during labor, a feasibility study should be conducted to determine pregnant women's willingness to participate in a prospective or randomized controlled trial.

Enhancing Immunization Rates in Two Urban Academic Primary Care Clinics: A Before and After Assessment.

PURPOSE: Immunization rates in many cities in the United States remain suboptimal compared to Healthy People 2020 Goals and are lower than national averages. This study aimed to determine whether a lecture-based educational intervention targeted at nurses and medical assistants would improve vaccination rates. METHODS: We conducted a quality improvement study in two urban academic family medicine clinics serving a predominantly Medicaid patient population as well as a sizable proportion of refugees. The intervention consisted of 3 lectures that were delivered to clinic nurses and medical assistants. Vaccinations in 1689 patients - 872 in the 3-month preintervention period, 817 in the 3-month postintervention period - were analyzed. RESULTS: Following the educational intervention, a statistically significant increase was seen only in human papillomavirus vaccine immunization rates for 13-18-year-olds (from 90.7% [n=54] to 100% [n=45]; P=0.036). When the results were stratified by clinic, only 1 site showed statistically significant increases in: pneumococcal polysaccharide vaccine (23-valent) for high-risk 19-to-64-year-olds (from 36.4% [n=154] to 47.8% [n=136]; P=0.049); Haemophilus influenzae type B vaccine for 2-month-to-5-year-olds (from 91.1% [n=112] to 97.3% [n=111]; P=0.048); and meningococcal conjugate vaccine (quadrivalent) for 13-18-year olds (from 85.2% [n=27] to 100% [n=26]; P=0.042). No increases were seen for our study's refugee patient population (n=171), and a significant decrease of the second-dose measles, mumps, and rubella vaccine (P=0.036) occurred in this subcohort. CONCLUSIONS: Ultimately, this quality improvement study demonstrated that educational interventions alone have a limited impact on increasing immunization rates.

Utilization of Acupuncture Services in the Emergency Department Setting: A Quality Improvement Study.

PURPOSE: Patients often present to the emergency department (ED) for pain. As opioid fatalities rise, alternative treatments are warranted for pain management. Acupuncture, a nonpharmacological treatment involving the insertion of needles into skin or tissue at specific points within the body, may help to decrease acute pain. Our study aimed to assess the utilization and impact of acupuncture in the ED for acute pain management. METHODS: We conducted a retrospective analysis of purposefully collected quality improvement data. Patients who were ≥18 years old and who presented to the ED at an urban medical center in Wisconsin during 2017 were offered acupuncture services based on their emergency severity index (ESI; range: highest severity [1] - lowest severity [5]), reason for visit, and physician approval. Paired t-tests were used to examine mean differences between pre- and post-acupuncture pain, stress, anxiety, and nausea scores (range: none [0] - worst [10]). Multivariable regression models also were constructed. RESULTS: A total of 379 patients received acupuncture. Patients presented predominately with an ESI score of 3 (68.9%) or 4 (24.8%); 46.4% received opioids in the ED. Mean pre- and post-acupuncture pain scores significantly differed (6.5 vs 3.4; P<0.001); receiving opioids during the ED visit was not associated with improved pain scores (P=0.948). Stress (5.7 vs 1.9), anxiety (4.8 vs 1.6), and nausea (1.6 vs 0.6) scores also improved (P<0.001) following acupuncture. CONCLUSIONS: Emergency department acupuncture significantly decreased pain, stress, anxiety, and nausea. Our findings support a larger randomized controlled trial to further assesses the impact of acupuncture for acute pain in other ED settings.

Incorporating Home Visits in a Primary Care Residency Clinic: The Patient and Physician Experience.

PURPOSE: Home visits, once a popular but now uncommon form of health care delivery, are on the rise. Few studies have focused on the value the experience brings to resident physicians and their patients. METHODS: A 6-month pilot was conducted with 11 residents who participated in 32 home visits with 11 patients. Patient and resident experiences were captured through a survey following the home visits. RESULTS: In all, 100% of patients and a majority of residents were very interested in being a part of and incorporating future home visits, respectively. Every patient in the survey said that the visits resulted in increased trust of their doctor. The top reasons residents regarded home visits as important included: 1) good for patient care, 2) strengthened relationships with patients, and 3) improved understanding of environmental and social factors affecting patients. CONCLUSIONS: Our pilot found that home visits were beneficial to both patients and residents and may be a significant part of the future direction of health care. Ultimately, our hope is to better meet patients' needs by incorporating home visits in residency training and making them a more common practice.