Validating Parallel-Forms Tests for Assessing Anesthesia Resident Knowledge.

We created a serious game to teach first year anesthesiology (CA-1) residents to perform general anesthesia for cesarean delivery. We aimed to investigate resident knowledge gains after playing the game and having received one of 2 modalities of debriefing. We report on the development and validation of scores from parallel test forms for criterion-referenced interpretations of resident knowledge. The test forms were intended for use as pre- and posttests for the experiment. Validation of instruments measuring the study's primary outcome was considered essential for adding rigor to the planned experiment, to be able to trust the study's results. Parallel, multiple-choice test forms development steps included: (1) assessment purpose and population specification; (2) content domain specification and writing/selection of items; (3) content validation by experts of paired items by topic and cognitive level; and (4) empirical validation of scores from the parallel test forms using Classical Test Theory (CTT) techniques. Field testing involved online administration of 52 shuffled items from both test forms to 24 CA-1's, 21 second-year anesthesiology (CA-2) residents, 2 fellows, 1 attending anesthesiologist, and 1 of unknown rank at 3 US institutions. Items from each form yielded near-normal score distributions, with similar medians, ranges, and standard deviations. Evaluations of CTT item difficulty (item p values) and discrimination (D) indices indicated that most items met assumptions of criterion-referenced test design, separating experienced from novice residents. Experienced residents performed better on overall domain scores than novices (P < .05). Kuder-Richardson Formula 20 (KR-20) reliability estimates of both test forms were above the acceptability cut of .70, and parallel forms reliability estimate was high at .86, indicating results were consistent with theoretical expectations. Total scores of parallel test forms demonstrated item-level validity, strong internal consistency and parallel forms reliability, suggesting sufficient robustness for knowledge outcomes assessments of CA-1 residents.

Structural Racism and Use of Labor Neuraxial Analgesia Among Non-Hispanic Black Birthing People.

OBJECTIVE: To assess the association between structural racism and labor neuraxial analgesia use. METHODS: This cross-sectional study analyzed 2017 U.S. natality data for non-Hispanic Black and White birthing people. The exposure was a multidimensional structural racism index measured in the county of the delivery hospital. It was calculated as the mean of three Black-White inequity ratios (ratios for lower education, unemployment, and incarceration in jails) and categorized into terciles, with the third tercile corresponding to high structural racism. The outcome was the labor neuraxial analgesia rate. Adjusted odds ratios and 95% CIs of neuraxial analgesia associated with terciles of the index were estimated with multivariate logistic regression models. Black and White people were compared with the use of an interaction term between race and ethnicity and the racism index. RESULTS: Of the 1,740,716 birth certificates analyzed, 396,303 (22.8%) were for Black people. The labor neuraxial analgesia rate was 77.2% for Black people in the first tercile of the racism index, 74.7% in the second tercile, and 72.4% in the third tercile. For White people, the rates were 80.4%, 78.2%, and 78.2%, respectively. For Black people, compared with the first tercile of the racism index, the second tercile was associated with 18.4% (95% CI, 16.9-19.9%) decreased adjusted odds of receiving neuraxial analgesia and the third tercile with 28.3% (95% CI, 26.9-29.6%) decreased adjusted odds. For White people, the decreases were 13.4% (95% CI, 12.5-14.4%) in the second tercile and 15.6% (95% CI, 14.7-16.5%) in the third tercile. A significant difference in the odds of neuraxial analgesia was observed between Black and White people for the second and third terciles. CONCLUSION: A multidimensional index of structural racism is associated with significantly reduced odds of receiving labor neuraxial analgesia among Black people and, to a lesser extent, White people.

State-Level Indicators of Structural Racism and Severe Adverse Maternal Outcomes During Childbirth.

OBJECTIVES: Structural racism (SR) is viewed as a root cause of racial and ethnic disparities in maternal health outcomes. However, evidence linking SR to increased odds of severe adverse maternal outcomes (SAMO) is scant. This study assessed the association between state-level indicators of SR and SAMO during childbirth. METHODS: Data for non-Hispanic Black and non-Hispanic white women came from the US Natality file, 2017-2018. The exposures were state-level Black-to-white inequity ratios for lower education level, unemployment, and prison incarceration. The outcome was patient-level SAMO, including eclampsia, blood transfusion, hysterectomy, or intensive care unit admission. Adjusted odds ratios (aORs) of SAMO associated with each ratio were estimated using multilevel models adjusting for patient, hospital, and state characteristics. RESULTS: A total of 4,804,488 birth certificates were analyzed, with 22.5% for Black women. SAMO incidence was 106.4 per 10,000 (95% CI 104.5, 108.4) for Black women, and 72.7 per 10,000 (95% CI 71.8, 73.6) for white women. Odds of SAMO increased 35% per 1-unit increase in the unemployment ratio for Black women (aOR 1.35; 95% CI 1.04, 1.73), and 16% for white women (aOR 1.16; 95% CI 1.01, 1.33). Odds of SAMO increased 6% per 1-unit increase in the incarceration ratio for Black women (aOR 1.06; 95% CI 1.03, 1.10), and 4% for white women (aOR 1.04; 95% CI 1.02, 1.06). No significant association was observed between SAMO and the lower education level ratio. CONCLUSIONS FOR PRACTICE: State-level Black-to-white inequity ratios for unemployment and incarceration are associated with significantly increased odds of SAMO.

Pain during cesarean delivery: A patient-related prospective observational study assessing the incidence and risk factors for intraoperative pain and intravenous medication administration.

INTRODUCTION: The incidence of pain during cesarean delivery (PDCD) remains unclear. Most studies evaluated PDCD using interventions suggesting inadequate analgesia: neuraxial replacement, unplanned intravenous medication (IVM), or conversion to general anesthesia. Few assess self-reported pain. This study evaluates the incidence of and risk factors for self-reported PDCD and IVM administration. METHODS: Between May and September 2022, English-speaking women undergoing cesarean delivery under neuraxial anesthesia were approached within the first 48 h. Participants answered a 16-question survey about intraoperative anesthesia care. Clinical characteristics were extracted from electronic medical records. The primary outcome was PDCD. Secondary outcomes were analgesic IVM (opioids alone or in combination with ketamine, midazolam, or dexmedetomidine) and conversion to general anesthesia. Risk factors for PDCD and analgesic IVM were identified using multivariable logistic regression models. RESULTS: Pain was reported by 46/399 (11.5%; 95% CI: 8.6, 15.1) participants. Analgesic IVM was administered to 16 (34.8%) women with PDCD and 45 (12.6%) without. Conversion to general anesthesia occurred in 3 (6.5%) women with and 4 (1.1%) without PDCD. Risk factors associated with PDCD were substance use disorder and intrapartum epidural extension. Risk factors associated with analgesic IVM were PDCD, intrapartum epidural extension when ≥2 epidural top-ups were given for labor analgesia, and longer surgical duration. DISCUSSION: In our cohort of scheduled and unplanned cesarean deliveries, the incidence of PDCD was 11.5%. A significant proportion of women (15.1%) received analgesic IVM, of which some but not all reported pain, which requires further evaluation to identify triggers for IVM administration and strategies optimizing shared decision-making.

Acquired Hemophilia A: A Rare, Acquired Coagulopathy in the Postpartum Setting.

Postpartum hemorrhage (PPH) remains a leading cause of maternal morbidity. Pregnancy-associated acquired hemophilia A (AHA) caused by autoantibodies against factor VIII can present with recurrent episodes of postpartum bleeding. Case 1 A 50-year-old G2P0112 presented with vaginal bleeding 22 days postcaesarean. She underwent dilation and curettage, hysterectomy, and interventional radiology (IR) embolization before AHA diagnosis. She was hospitalized for 32 days and received 23 units of blood product. She remains without relapse of AHA after 5 years. Case 2 A 48-year-old G3P1021 presented with vaginal bleeding 8 days postcaesarean. She underwent three surgeries and IR embolization before AHA diagnosis. She was hospitalized for 18 days and received 39 units of blood product. Prednisone and cyclophosphamide were continued after discharge. AHA is a rare cause of PPH. An isolated prolonged activated partial thromboplastin time (aPTT) should prompt further workup in postpartum patients with refractory bleeding. Rapid recognition of AHA can prevent significant morbidity related to hemorrhage, massive transfusion, and multiple surgeries.

Association of Labor Neuraxial Analgesia with Maternal Blood Transfusion.

BACKGROUND: Labor neuraxial analgesia may reduce the odds of postpartum hemorrhage, the leading indication for maternal blood transfusion during childbirth. This study tested the hypothesis that labor neuraxial analgesia is associated with reduced odds of maternal blood transfusion overall. METHODS: U.S. birth certificate data in the Natality File of the National Vital Statistics System for all 50 states from 2015 to 2018 for vaginal and intrapartum cesarean deliveries were analyzed. The exposure was labor neuraxial analgesia. The primary outcome was maternal blood transfusion, recorded on the birth certificate, which has low sensitivity for this outcome. Adjusted odds ratios and 95% CIs of blood transfusion associated with neuraxial analgesia were estimated using propensity score matching. The adjusted odds ratios were estimated overall and according to delivery mode, and treatment effect was compared between vaginal and intrapartum cesarean deliveries using an interaction term. Sensitivity analyses were performed using inverse propensity score weighting and quantitative bias analysis for outcome misclassification. RESULTS: Of the 12,503,042 deliveries analyzed, 9,479,291 (75.82%) were with neuraxial analgesia, and 42,485 (0.34%) involved maternal blood transfusion. After propensity score matching, the incidence of blood transfusion was 0.30% in women without neuraxial analgesia (7,907 of 2,589,493) and 0.20% in women with neuraxial analgesia (5,225 of 2,589,493), yielding an adjusted odds ratio of 0.87 (95% CI, 0.82 to 0.91) overall. For intrapartum cesarean deliveries, the adjusted odds ratio was 0.55 (95% CI, 0.48 to 0.64), and for vaginal deliveries it was 0.93 (95% CI,. 0.88 to 0.98; P value for the interaction term < 0.001). The results were consistent in the sensitivity analyses, although the quantitative bias analysis demonstrated wide variation in potential effect size point estimates. CONCLUSIONS: Labor neuraxial analgesia may be associated with reduced odds of maternal blood transfusion in intrapartum cesarean deliveries and, to a lesser extent, vaginal deliveries. The specific effect size varies widely by delivery mode and is unclear given the poor sensitivity of the data set for the maternal transfusion primary outcome.

Medicaid expansion and risk of eclampsia.

BACKGROUND: Eclampsia is an indicator of severe maternal morbidity and can be prevented through increased prenatal care access and early prenatal care utilization. The 2014 Medicaid expansion under the Patient Protection and Affordable Care Act allowed states to expand Medicaid coverage to nonelderly adults with incomes up to 138% of the federal poverty level. Its implementation has led to a significant increase in prenatal care access and utilization. OBJECTIVE: This study aimed to assess the association of Medicaid expansion under the Affordable Care Act with eclampsia incidence. STUDY DESIGN: This natural experiment study was based on US birth certificate data from January 2010 to December 2018 in 16 states that expanded Medicaid in January 2014 and in 13 states that did not expand Medicaid during the study period. The outcome was eclampsia incidence, the intervention was the implementation of the Medicaid expansion, and the exposure was state expansion status. Using the interrupted time series method, we compared temporal trends in the incidence of eclampsia before and after the intervention in expansion vs non-expansion states with adjustments for patient and hospital county characteristics. RESULTS: Of the 21,570,021 birth certificates analyzed, 11,433,862 (53.0%) were in expansion states and 12,035,159 (55.8%) were in the postintervention period. The diagnosis of eclampsia was recorded in 42,677 birth certificates or 19.8 per 10,000 (95% confidence interval, 19.6-20.0). The incidence of eclampsia was higher for Black people (29.1 per 10,000) than for White (20.7 per 10,000), Hispanic (15.3 per 10,000), and birthing people of other race and ethnicity (15.4 per 10,000). In the expansion states, the incidence of eclampsia increased during the preintervention period and decreased during the postintervention period; in the nonexpansion states, a reverse pattern was observed. A statistically significant difference was observed between expansion and nonexpansion states in temporal trends between the pre- and postintervention periods, with an overall 1.6% decrease (95% confidence interval, 1.3-1.9) in the incidence of eclampsia in expansion states compared with nonexpansion states. The results were consistent in subgroup analyses according to maternal race and ethnicity, education level (less than high school or high school and higher), parity (nulliparous or parous), delivery mode (vaginal or cesarean delivery), and poverty in the residence county (high or low). CONCLUSION: Implementation of the Affordable Care Act Medicaid expansion was associated with a small statistically significant reduction in the incidence of eclampsia. Its clinical significance and cost-effectiveness remain to be determined.

Association of the United States Affordable Care Act Dependent Coverage Provision with Labor Neuraxial Analgesia Use.

BACKGROUND: Providing continuous health insurance coverage during the perinatal period may increase access to and utilization of labor neuraxial analgesia. This study tested the hypothesis that implementation of the 2010 Dependent Coverage Provision of the Patient Protection and Affordable Care Act, requiring private health insurers to allow young adults to remain on their parent's plan until age 26 yr, was associated with increased labor neuraxial analgesia use. METHODS: This study used a natural experiment design and birth certificate data for spontaneous vaginal deliveries in 28 U.S. states between 2009 and 2013. The intervention was the Dependent Coverage Provision, categorized into pre- and postintervention periods (January 2009 to August 2010 and September 2010 to December 2013, respectively). The exposure was women's age, categorized as exposed (21 to 25 yr) and unexposed (27 to 31 yr). The outcome was the labor neuraxial analgesia utilization rate. RESULTS: Of the 4,515,667 birth certificates analyzed, 3,033,129 (67.2%) indicated labor neuraxial analgesia use. For women aged 21 to 25 yr, labor neuraxial analgesia utilization rates were 64.9% during the preintervention period and 68.9% during the postintervention period (difference, 4.0%; 95% CI, 3.9 to 4.2). For women aged 27 to 31 yr, labor neuraxial analgesia utilization rates were 64.9% during the preintervention period and 67.7% during the postintervention period (difference, 2.8%; 95% CI, 2.7 to 2.9). After adjustment, implementation of the Dependent Coverage Provision was associated with a 1.0% (95% CI, 0.8 to 1.2) absolute increase in labor neuraxial analgesia utilization rate among women aged 21 to 25 yr compared with women aged 27 to 31 yr. The increase was statistically significant for White and Hispanic women but not for Black and Other race and ethnicity women. CONCLUSIONS: Implementation of the Dependent Coverage Provision was associated with a statistically significant increase in labor neuraxial analgesia use, but the small effect size is unlikely of clinical significance.

A Case Report of Spinal Anesthesia for Cerclage Placement in the Setting of Severe Hypertrophic Obstructive Cardiomyopathy.

Neuraxial anesthesia is preferred over general anesthesia in obstetric patients to avoid airway manipulation, aspiration, and maternal-fetal transfer of medications; however, a sudden sympathetic block is generally avoided in patients with hypertrophic obstructive cardiomyopathy (HOCM). The case of a 31-year-old G2P0010 with HOCM with severe resting left ventricular outflow tract (LVOT) obstruction and systolic anterior motion of the mitral valve undergoing a cerclage under choroprocaine spinal anesthesia is presented. Risks and benefits of general versus neuraxial anesthesia, and epidural versus spinal anesthesia, in this specific setting are reviewed.

Development and design of a mobile application for prescription opioid clinical decision-making: a feasibility study in New York City, USA.

OBJECTIVES: Excessive opioid prescribing is a contributing factor to the opioid epidemic in the USA. We aimed to develop, implement and evaluate the usability of a clinical decision-making mobile application (app) for opioid prescription after surgery. METHODS: We developed two clinical decision trees, one for opioid prescription after adult laparoscopic cholecystectomy and one for posterior spinal fusion surgery in adolescents. We developed a mobile app incorporating the two algorithms with embedded clinical decision-making, which was tested by opioid prescribers. A survey collected prescription intention prior to app use and participants' evaluation. Participants included opioid prescribers for patients undergoing (1) laparoscopic cholecystectomy in adults or (2) posterior spinal fusion in adolescents with idiopathic scoliosis. RESULTS: Eighteen healthcare providers were included in this study (General Surgery: 8, Paediatrics: 10). Intended opioid prescription before app use varied between departments (General Surgery: 0-10 pills (mean=5.9); Paediatrics: 6-30 pills (mean=20.8)). Intention to continue using the app after using the app multiple times varied between departments (General Surgery: N=3/8; Paediatrics: N=7/10). The most reported reason for not using the app is lack of time. CONCLUSIONS: In this project evaluating the development and implementation of an app for opioid prescription after two common surgeries with different prescription patterns, the surgical procedure with higher intended and variable opioid prescription (adolescent posterior spinal fusion surgery) was associated with participants more willing to use the app. Future iterations of this opioid prescribing intervention should target surgical procedures with high variability in both patients' opioid use and providers' prescription patterns.

External Validation of a Multivariable Prediction Model for Placenta Accreta Spectrum.

BACKGROUND: Placenta accreta spectrum (PAS) is a disorder of abnormal placentation associated with severe postpartum hemorrhage, maternal morbidity, and mortality. Predelivery prediction of this condition is important to determine appropriate delivery location and multidisciplinary planning for operative management. This study aimed to validate a prediction model for PAS developed by Weiniger et al in 2 cohorts who delivered at 2 different United States tertiary centers. METHODS: Cohort A (Brigham and Women's Hospital; N = 253) included patients with risk factors (prior cesarean delivery and placenta previa) and/or ultrasound features of PAS presenting to a tertiary-care hospital. Cohort B (Columbia University Irving Medical Center; N = 99) consisted of patients referred to a tertiary-care hospital specifically because of ultrasound features of PAS. Using the outcome variable of surgical and/or pathological diagnosis of PAS, discrimination (via c-statistic), calibration (via intercept, slope, and flexible calibration curve), and clinical usefulness (via decision curve analysis) were determined. RESULTS: The model c-statistics in cohorts A and B were 0.728 (95% confidence interval [CI], 0.662-0.794) and 0.866 (95% CI, 0.754-0.977) signifying acceptable and excellent discrimination, respectively. The calibration intercept (0.537 [95% CI, 0.154-0.980] for cohort A and 3.001 [95% CI, 1.899- 4.335] for B), slopes (0.342 [95% CI, 0.170-0.532] for cohort A and 0.604 [95% CI, -0.166 to 1.221] for B), and flexible calibration curves in each cohort indicated that the model underestimated true PAS risks on average and that there was evidence of overfitting in both validation cohorts. The use of the model compared to a treat-all strategy by decision curve analysis showed a greater net benefit of the model at a threshold probability of >0.25 in cohort A. However, no net benefit of the model over the treat-all strategy was seen in cohort B at any threshold probability. CONCLUSIONS: The performance of the Weiniger model is variable based on the case-mix of the population with regard to PAS clinical risk factors and ultrasound features, highlighting the importance of spectrum bias when applying this PAS prediction model to distinct populations. The model showed benefit for predicting PAS in populations with substantial case-mix heterogeneity at threshold probability of >25%.

A Systematic Scoping Review of Peridelivery Pain Management for Pregnant People With Opioid Use Disorder: From the Society for Obstetric Anesthesia and Perinatology and Society for Maternal Fetal Medicine.

The prevalence of pregnant people with opioid use disorder (OUD), including those receiving medications for opioid use disorder (MOUD), is increasing. Challenges associated with pain management in people with OUD include tolerance, opioid-induced hyperalgesia, and risk for return to use. Yet, there are few evidence-based recommendations for pain management in the setting of pregnancy and the postpartum period, and many peripartum pain management studies exclude people with OUD. This scoping review summarized the available literature on peridelivery pain management in people with OUD, methodologies used, and identified specific areas of knowledge gaps. PubMed and Embase were comprehensively searched for publications in all languages on peripartum pain management among people with OUD, both treated with MOUD and untreated. Potential articles were screened by title, abstract, and full text. Data abstracted were descriptively analyzed to map available evidence and identify areas of limited or no evidence. A total of 994 publications were imported for screening on title, abstracts, and full text, yielding 84 publications identified for full review: 32 (38.1%) review articles, 14 (16.7%) retrospective studies, and 8 (9.5%) case reports. There were 5 randomized controlled trials. Most studies (64%) were published in perinatology (32; 38.1%) journals or anesthesiology (22; 26.2%) journals. Specific areas lacking trial or systematic review evidence include: (1) methods to optimize psychological and psychosocial comorbidities relevant to acute pain management around delivery; (2) alternative nonopioid and nonpharmacologic analgesia methods; (3) whether or not to use opioids for severe breakthrough pain and how best to prescribe and monitor its use after discharge; (4) monitoring for respiratory depression and sedation with coadministration of other analgesics; (5) optimal neuraxial analgesia dosing and adjuncts; and (6) benefits of abdominal wall blocks after cesarean delivery. No publications discussed naloxone coprescribing in the labor and delivery setting. We observed an increasing number of publications on peripartum pain management in pregnant people with OUD. However, existing published works are low on the pyramid of evidence (reviews, opinions, and retrospective studies), with a paucity of original research articles (<6%). Opinions are conflicting on the utility and disutility of various analgesic interventions. Studies generating high-quality evidence on this topic are needed to inform care for pregnant people with OUD. Specific research areas are identified, including utility and disutility of short-term opioid use for postpartum pain management, role of continuous wound infiltration and truncal nerve blocks, nonpharmacologic analgesia options, and the best methods to support psychosocial aspects of pain management.

Nurse workforce diversity and reduced risk of severe adverse maternal outcomes.

BACKGROUND: Racial and ethnic diversification of the physician and nurse workforce is recommended as a leverage point to address the impact of structural racism in maternal care, but empirical evidence supporting this recommendation is currently lacking. OBJECTIVE: This study aimed to assess the association between state-level registered nurse workforce racial and ethnic diversity and severe adverse maternal outcomes during childbirth. STUDY DESIGN: This population-based cross-sectional study analyzed 2017 US birth certificate data. Severe adverse maternal outcomes included eclampsia, blood transfusion, hysterectomy, or intensive care unit admission. Proportions of minoritized racial and ethnic registered nurses in each state were abstracted from the American Community Survey (5-year estimate, 2013-2017). This proportion was categorized into 3 terciles, with the first tercile corresponding to the lowest proportion and the third tercile corresponding to the highest proportion. Crude and adjusted odds ratios and 95% confidence intervals of severe adverse maternal outcomes associated with terciles of the state proportion of minoritized racial and ethnic nurses were estimated using logistic regression models. RESULTS: Of the 3,668,813 birth certificates studied, 29,174 recorded severe adverse maternal outcomes (79.5 per 10,000; 95% confidence interval, 78.6-80.4). The mean state proportion of minoritized racial and ethnic nurses was 22.1%, ranging from 3.3% in Maine to 68.2% in Hawaii. For White mothers, the incidence of severe adverse outcomes was 85.3 per 10,000 for those who gave births in states in the first tercile of the proportion of minoritized racial and ethnic nurses and 53.9 per 10,000 for those who gave birth in states in the third tercile (risk difference, -31.4 per 10,000; 95% confidence interval, -34.4 to -28.5). It corresponds to a 37% decreased risk of severe adverse maternal outcomes associated with giving birth in a state in the third tercile (crude odds ratio, 0.63; 95% confidence interval, 0.60-0.66). A decreased risk of severe adverse maternal outcomes was observed for Black mothers (crude odds ratio, 0.65; 95% confidence interval, 0.61-0.70), Hispanic mothers (crude odds ratio, 0.51; 95% confidence interval, 0.48-0.54), and Asian and Pacific Islander mothers (crude odds ratio, 0.65; 95% confidence interval, 0.58-0.72) but not for Native American mothers (crude odds ratio, 0.89; 95% confidence interval, 0.72-1.09) or mothers with >1 race (crude odds ratio, 1.44; 95% confidence interval, 0.72-1.09). After adjustment for patients and hospital characteristics, giving birth in states in the third tercile was associated with a reduced risk of severe adverse outcomes as follows: 32% for White mothers (adjusted odds ratio, 0.68; 95% confidence interval, 0.59-0.77), 20% for Black mothers (adjusted odds ratio, 0.80; 95% confidence interval, 0.65-0.99), 31% for Hispanic mothers (adjusted odds ratio, 0.69; 95% confidence interval, 0.58-0.82), and 50% for Asian and Pacific Islander mothers (adjusted odds ratio, 0.50; 95% confidence interval, 0.38-0.65). The associations of the proportion of minoritized racial and ethnic nurses with the risk of severe adverse maternal outcomes were not statistically significant for Native American mothers and more than 1 race mothers. Results were similar when blood transfusion was excluded from the outcome measure. CONCLUSION: A diverse state registered nurse workforce was associated with a reduced risk of severe adverse maternal outcomes during childbirth.