Opioid utilization after orthopaedic trauma hospitalization among Medicaid-insured adults.

Opioids are vital to pain management and sedation after trauma-related hospitalization. However, there are many confounding clinical, social, and environmental factors that exacerbate pain, post-injury care needs, and receipt of opioid prescriptions following orthopaedic trauma. This retrospective study sought to characterize differences in opioid prescribing and dosing in a national Medicaid eligible sample from 2010-2018. The study population included adults, discharged after orthopaedic trauma hospitalization, and receiving an opioid prescription within 30 days of discharge. Patients were identified using the International Classification of Diseases (ICD-9; ICD-10) codes for inpatient diagnosis and procedure. Filled opioid prescriptions were identified from National Drug Codes and converted to morphine milligram equivalents (MME). Opioid receipt and dosage (e.g., morphine milligram equivalents [MME]) were examined as the main outcomes using regressions and analyzed by year, sex, race/ethnicity, residence rurality-urbanicity, and geographic region. The study population consisted of 86,091 injured Medicaid-enrolled adults; 35.3% received an opioid prescription within 30 days of discharge. Male patients (OR = 1.12, 95% CI: 1.07-1.18) and those between 31-50 years of age (OR = 1.15, 95% CI: 1.08-1.22) were found to have increased odds ratio of receiving an opioid within 30 days of discharge, compared to female and younger patients, respectively. Patients with disabilities (OR = 0.75, 95% CI: 0.71-0.80), prolonged hospitalizations, and both Black (OR = 0.87, 95% CI: 0.83-0.92) and Hispanic patients (OR = 0.72, 95% CI: 0.66-0.77), relative to white patients, had lower odds ratio of receiving an opioid prescription following trauma. Additionally, Black and Hispanic patients received lower prescription doses compared to white patients. Individuals hospitalized in the Southeastern United States and those between the ages of 51-65 age group were found to be prescribed lower average daily MME. There were significant variations in opioid prescribing practices by race, sex, and region. National guidelines for use of opioids and other pain management interventions in adults after trauma hospitalization may help limit practice variation and reduce implicit bias and potential harms in outpatient opioid usage.

Advancing Equity in U.S. Hospital Systems: Employee Understandings of Health Equity and Steps for Improvement.

GOALS: Equity in the U.S. healthcare system remains a vital goal for healthcare leaders. Although many hospitals and healthcare systems have adopted a social determinants of health approach to more equitable care, many challenges have limited the effectiveness of their efforts. In this study, we wanted to explore whether healthcare leaders and providers understand the concept of equity and can link the concepts to practical applications within healthcare systems. METHODS: We explored how hospital leadership and providers at a major public hospital in Atlanta, Georgia, understand equity topics both conceptually and at a practical implementation level. We conducted 28 focus groups for >4 months involving 233 staff members, during which participants were asked about their understanding of various equity-related terms and equity implementation within the hospital. PRINCIPAL FINDINGS: Our findings reveal that there is little consensus among staff regarding the conceptual meanings of various health equity-related terms, and only a small minority of staff can articulate a conceptual definition that reflects current research-based understandings of equity. Furthermore, there is little consensus regarding how staff believes that health equity is practically enacted through various hospital programs, even among interviewees who could correctly articulate equity topics. These findings have no association with a role in the organization or length of time employed at the hospital. PRACTICAL APPLICATIONS: These findings indicate a need for a more nuanced understanding of health equity and further clarification and education on how to implement health equity. Although understanding at the conceptual level is an important first step, conceptual knowledge alone is not enough to support health equity at either the individual staff level or the system level. Our recommendations cover strategic development; education specific to the hospital system and its unique needs; consideration of the specific roles of individuals in the organization; and the designation of diversity, equity, and inclusion staff and offices in a hospital organization.

Perception of weight and threat to health.

OBJECTIVES: To examine African American women's perception of their risk for obesity-related comorbid illnesses compared to their weight category. METHODS: Participants were recruited from urban health centers in Atlanta, Georgia. Anthropometric measurements and self-reported demographics, medical conditions, and health beliefs about obesity and its related comorbid diseases were recorded. RESULTS: More than 80% of the women (N=323) were either overweight or obese. Among overweight women, 44% reported being a normal weight. Seventy-two percent of the obese women reported being overweight, and 13.6% reported that they were obese. All women reported that each disease was "very serious;" however, overweight women reported having the same risk for each disease as normal weight women. Obese women reported having a higher risk of each disease (p < .05 for all diseases). CONCLUSION: Overweight and obese women underestimate their weight categories. Overweight, but not obese, women reported the same perceived susceptibility for obesity-related comorbid diseases as normal-weight women. An increase in the perceived threat to health may motivate women to increase prevention efforts in the early stage of overweight to prevent or delay morbidity or mortality.

Adolescent contraceptive care for the practicing pediatrician.

Improved use of contraception has been intrinsic in the decline of teenaged pregnancies in the United States. Recent advances in contraception, including the development of new progestins and longer-acting reversible methods, have greatly increased the options available for adolescents. By frankly discussing adverse effects, offering clear explanations of noncontraceptive benefits, and developing strategies for improving compliance, providers can play a key role in facilitating successful contraceptive use in young patients.

Serologic detection of herpes simplex virus type 2 antibodies among pregnant women using a point-of-care test from Focus Diagnostics.

BACKGROUND: Serologic assays that identify herpes simplex type 2 (HSV-2) type-specific antibodies have been commercially available for more than a decade. Greater acceptance of these tests is hindered by uncertainty regarding their performance in real-world clinical settings. OBJECTIVES: The primary objective was to compare the test characteristics of the Focus HerpeSelect Express Assay (EA) versus the Focus HerpeSelect enzyme linked immunoassay (ELISA) for detection of HSV-2 type-specific antibodies among pregnant women enrolled from 3 geographic sites with varying prevalences of HSV-2 infection. A second objective was to evaluate the performance of a HSV-2 testing strategy in which EA screens and ELISA confirms HSV-2 serodiagnosis. STUDY DESIGN: We enrolled 399 pregnant women from Atlanta, GA, Moorestown, NJ, and Pittsburgh, PA into this cross-sectional investigation. Capillary whole blood was obtained from study participants, and evaluated for the presence of type-specific HSV-2 antibodies using the EA. Serum samples were also obtained from all study participants for subsequent identification of HSV-2 type-specific antibodies using both ELISA and the Focus Immunoblot assays. RESULTS: We observed 96.2% agreement between results obtained with EA and ELISA. Overall, when compared to ELISA results, the sensitivity of EA for detection of HSV-2 type-specific antibodies was 94.2% and the specificity was 97.1%. Using Immunoblot results as our standard for performance calculations, the positive predictive value (PPV) of HSV-2 serodiagnosis increased from 91.7% to 98.2% when ELISA was used to confirm EA testing. CONCLUSIONS: EA provides similar results to ELISA for the identification of HSV-2 type-specific antibodies among pregnant women. As use of the point-of-care (POC) EA in conjunction with confirmatory ELISA testing improves the PPV of HSV-2 serodiagnosis compared to the use of EA or ELISA testing alone, validation of this diagnostic algorithm in other at-risk populations may be warranted.

Do African American mothers accurately estimate their daughters' weight category?

OBJECTIVES: We attempted to determine if mothers of overweight daughters accurately perceived the daughters' weight category and whether physician diagnosis of overweight was associated with accurate maternal perception of a daughter's weight. DESIGN: This was a cross-sectional study that used the Morehouse School of Medicine Obesity Health Belief Survey. Descriptive statistics were used with categorical variables; chi2 was used to identify associations between dichotomous and categorical data. SETTING: Participants were enrolled in the study at the West End Medical Centers Inc., a federally qualified health center in Atlanta, Georgia. RESULTS: Among overweight girls, 19% of mothers underestimated the girls' weight category, and 60% of the mothers underestimated the magnitude of their daughters' weight category (P < .001). Among the mothers of girls at risk for overweight, there was a statistically significant association between being told their daughter was overweight by a physician and an accurate perception of the daughter's weight category by the mother CONCLUSION: Despite this national epidemic, not all of mothers of overweight girls identify them as overweight. Physicians may play an important role in helping mothers recognize overweight in their daughter. Ultimately, accurately perceiving their daughters' weight category may influence maternal readiness to change to reduce overweight and reduce the health burden of overweight.

Estimating dissemination of Centers for Disease Control and Prevention Sexually Transmitted Disease Treatment Guidelines from a survey of physicians.

Periodically, the Centers for Disease Control and Prevention (CDC) produce guidelines for the treatment of sexually transmitted diseases (STDs) in the USA. To date, few evaluations of the dissemination of these guidelines exist. A paper and pencil survey was distributed via priority mail to a sample of Atlanta-area physicians, 416 (34%) of whom responded with complete data. Physicians were drawn from private practice, managed-care settings and public settings. In all, 85% of respondents treated STD, with a further 10% referring cases. Of those treating STD, 56% owned a copy of the 2002 CDC Treatment Guidelines, and 26% knew how to access them. The corresponding figures for physicians not treating STD were 25% and 30%. Of the physicians who did have copies, half had accessed the internet for their copies. Acquisition of, or the knowledge of how to acquire, the CDC STD Treatment Guidelines was widespread. The internet may be an effective and cost-saving means of disseminating the guidelines, although the continued need for print distribution should not be discounted.

Sexually transmitted disease prevention in adolescents and young adults.

OBJECTIVE: Sexuality is one of the most pervasive aspects of the human life cycle. It warrants attention in childhood, adolescence and adulthood, and is an integral part of each health maintenance visit. Given this, it is unfortunate that U.S. medical schools do not offer more training in soliciting sexual histories and initiating dialogue about sexually healthy lifestyles. METHODS: Fourth-year medical student completed an adolescent and young-adult sexually transmitted disease elective. RESULTS: This elective allows medical students to confront personal biases and discomfort levels yet remain objective. It is also an opportunity to explore how the provider's body language and facial expressions can discourage information disclosure. Although sexuality is very prevalent in our society today, patients may still be apprehensive about discussing details of their sexual practices. Therefore, it becomes incumbent upon the physician to create an environment free from personal prejudice in order to best serve the patient. CONCLUSIONS: In order to promote sexual health awareness in a society that can be conservative and judgmental in this subject matter, it is essential to train all healthcare providers to lead discussions, educate patients and provide treatment in hopes that sexual health promotion will become as important as other socially accepted healthcare concerns.

Sexual history-taking among primary care physicians.

BACKGROUND: Because many people seek sexual healthcare in settings where they seek primary healthcare, the extent to which primary care physicians take sexual histories is important. We surveyed Atlanta-area primary care physicians to estimate the extent to which they take sexual histories as well as the components of those histories and the circumstances under which they are taken. METHODS: Four-hundred-sixteen physicians in four specialties (obstetrics/gynecology, internal medicine, general/family practice, pediatrics) responded to a mail survey conducted during 2003-2004. Respondents answered whether they asked about sexual activity at all, including specific components of a comprehensive sexual history such as sexual as sexual orientation, numbers of partners and types of sexual activity, during routine exams, initial exams, complaint-based visits or never. Respondents also reported their opinions on whether they felt trained and comfortable taking sexual histories. RESULTS: Respondents (51% male, 58% white) saw an average of 94 patients per week. A majority (56%) felt adequately trained, while 79% felt comfortable taking sexual histories. Almost three in five (58%) asked about sexual activity at a routine visit, but much smaller proportions (12-34%) asked about the components of a sexual history. However, 76% of physicians reported asking about sexual history (61-75% for various components) if they felt it would be relevant to the chief complaint. CONCLUSIONS: Most physicians report feeling comfortable taking sexual histories and will do so if the patient's apparent complaint is related to sexual health. But sexual histories as part of routine and preventive healthcare are less common, and many physicians miss essential components of a comprehensive sexual history. Structural changes and suggestions for training to enhance sexual history-taking are discussed.

Reducing HIV/AIDS transmission among African-American females: is the female condom a solution?

Rates of HIV/AIDS have increased at an alarming rate among minority women, especially African-American women. Suggestions that have been presented to decrease HIV/AIDS transmission among African-American women include promoting abstinence and the use of the male condom. Little recognition and support have been given for promoting the female condom as a viable solution to combating the HIV/AIDS epidemic.

HIV testing rates among African Americans: why are they not increasing?

HIV/AIDS disproportionately affects the African-American community. It is imperative to increase the awareness of HIV/AIDS as well as the amount of people getting tested. Sometimes strategies to increase testing in the African-American community do not have to do with access but more so with other circumstances surrounding testing. These include fear of needles, being discriminated against if HIV-positive, perception of low risk, and long waiting periods for results. It is important to consider that all of these factors have an effect on peoples' decision to be tested for HIV/AIDS when offering testing.

Physicians' STD diagnosis and screening practices in the South.

OBJECTIVES: Sexually transmitted diseases (STDs) remain at high levels in the South compared with the rest of the nation. Physician diagnosis levels and screening behaviors fall among the elements about which more knowledge is needed to address these high levels. This article assesses Southern physicians' STD diagnosis histories and screening behaviors, focusing on curable STDs. METHODS: The sample included 1,306 physicians practicing in 13 Southern states and in the District of Columbia. These physicians formed part of a larger survey (n = 4,233) and answered questions concerning STD diagnosis history and screening behaviors. Analyses focus on chlamydial infection and gonorrhea individually, as well as composite statistics for gonorrhea, chlamydial infection, syphilis, pelvic inflammatory disease, trichomoniasis, and nongonococcal urethritis. RESULTS: Approximately 80% of physicians had diagnosed a curable STD, and 56% screened for any STD. The most common diagnosis techniques were culture and DNA probe. Several variables were individually associated with screening and diagnostic methods. Being female, African-American, or an obstetrician/gynecologist were associated with increased likelihood to screen for STDs in multivariate analyses. CONCLUSIONS: Southern physicians were less likely to screen for STDs than their counterparts in other areas of the United States, although they were more likely to have diagnosed STDs. Results suggest that some targeted and evaluated screening practices may be useful in this area of the country.

Adolescent beliefs about infertility.

PURPOSE: Explore adolescents' definition of fertility and range of beliefs regarding causes of infertility. METHODS: Qualitative study involving five focus groups that met between April 2001 and December 2001 at a hospital-based adolescent health center. All groups were led by one experienced moderator and observed by two investigators. Audiotapes of the group discussions were transcribed and reviewed independently by three investigators who met and reached consensus on underlying themes. RESULTS: Most adolescents generally understood fertility as the ability to become pregnant. Ten themes emerged as causes of infertility. Anatomic/gynecologic causes generated the most responses and most detailed discussion (e.g., "The coating on the egg is too hard and the sperm can't get in to fertilize the egg."). Other commonly mentioned causes were male factors (e.g., "He cannot produce sperm."), sexually transmitted infections (e.g., "like chlamydia caused scarring in the fallopian tubes"), genetics (e.g.,"a birth defect") and substance use (e.g., "if a man smoke weed all day, the egg may not develop because of problems with his sperm"). Less commonly mentioned themes were stress, contraception, environmental toxins, violence and injury. CONCLUSIONS: Most adolescents defined fertility as the ability to become pregnant and reported an extensive range of beliefs about the causes of infertility. Providers should consider eliciting adolescents' definitions of fertility and also exploring beliefs about causes of infertility with their patients when counseling about sexuality and contraception to determine if an adolescent has inaccurate beliefs about their fertility.

Attitudes and experiences with levonorgestrel 100 microg/ethinyl estradiol 20 microg among women during a 3-month trial.

To describe attitudes and experiences with a low-dose oral contraceptive pill (Alesse) over 3 months, women aged 18 years and older (n = 218) were enrolled from 16 locations to evaluate their experiences with Alesse. The questionnaire assessed demographic and personal characteristics, attitudes and experiences, and satisfaction. The participants had a mean age of 26.7 years and most were single, Caucasian, had completed high school, had a regular sexual partner, and had previously used OCs. Sixty percent of participants could discuss pill use easily with their mothers, 92% with friends, and 96% with partners; 45% of the women were unsure about their mother's previous OC use. Of the 11 side effects assessed, the most frequently anticipated side effect was weight gain. There was a significant relationship between anticipated and reported side effects for weight and mood changes; however, there remained a number of women for whom these differed. Most (90%) were satisfied with Alesse. Even when beginning on 20 microg pills, some women may still anticipate side effects such as weight gain typically associated with higher doses of estrogen. Healthcare providers should assess women's attitudes and anticipated experiences with OCs and counsel accordingly.