Longitudinal Evaluation of a Deprescribing Protocol in Skilled Nursing Facilities.

Objective: To determine whether a deprescribing effort reduced several key classes of medications, and the overall number of medication classes per patient, among long-term residents of skilled nursing facilities (SNFs). Design: Retrospective, longitudinal pre/post evaluation. Data from before and during the implementation of the deprescribing effort (2017 through 2019) were compared with data from the post-intervention year (2020). Setting and Patients: Long-term resident data reported through annual comprehensive reviews conducted at two SNFs located in central New York State between 2017 and 2020 (N = 12,144). Interventions: Multifaceted, interdisciplinary deprescribing effort to reduce medications in SNF residence including clinician education, guideline development, and individual chart reviews began in 2019. Results: The mean number of medications prescribed per resident was lower at both facilities after the intervention (mean = 1.74 at both facilities) versus preintervention (1.90 at Facility 1, 1.86 at Facility 2). Significant decreases were observed in the usage rates for diuretics (-4.2%; P = 0.001), opioids (-3.8%; P = 0.001), and antipsychotics (-2.4%; P = 0.010). The raw antidepressant usage rate increased by 1.5% after the intervention but the change was not significant. Effects were robust to covariate adjustment. Conclusion: A combined, comprehensive approach to deprescribing was associated with a reduction in the overall number of medication classes per resident and in several key classes of medications. Additional research with more data and covariate control is in progress for verification of these findings.

Use of open-text responses to recode categorical survey data on postpartum contraception use among women in the United States: A mixed-methods inquiry of Pregnancy Risk Assessment Monitoring System data.

BACKGROUND: Postpartum contraception prevents unintended pregnancies and short interpregnancy intervals. The Pregnancy Risk Assessment Monitoring System (PRAMS) collects population-based data on postpartum contraception nonuse and reasons for not using postpartum contraception. In addition to quantitative questions, PRAMS collects open-text responses that are typically left unused by secondary quantitative analyses. However, abundant preexisting open-text data can serve as a resource for improving quantitative measurement accuracy and qualitatively uncovering unexpected responses. We used PRAMS survey questions to explore unprompted reasons for not using postpartum contraception and offer insight into the validity of categorical responses. METHODS AND FINDINGS: We used 31,208 categorical 2012 PRAMS survey responses from postpartum women in the US to calculate original prevalences of postpartum contraception use and nonuse and reasons for contraception nonuse. A content analysis of open-text responses systematically recoded data to mitigate survey bias and ensure consistency, resulting in adjusted prevalence calculations and identification of other nonuse themes. Recoded contraception nonuse slightly differed from original reports (21.5% versus 19.4%). Both calculations showed that many respondents reporting nonuse may be at a low risk for pregnancy due to factors like tubal ligation or abstinence. Most frequent nonuse reasons were not wanting to use birth control (27.1%) and side effect concerns (25.0%). Other open-text responses showed common themes of infertility, and breastfeeding as contraception. Comparing quantitative and qualitative responses revealed contradicting information, suggesting respondent misinterpretation and confusion surrounding the term "pregnancy prevention." Though this analysis may be limited by manual coding error and researcher biases, we avoided coding exhaustion via 1-hour coding periods and validated reliability through intercoder kappa scores. CONCLUSIONS: In this study, we observed that respondents reporting contraception nonuse often described other methods of pregnancy prevention and contraception barriers that were not included in categorical response options. Open-text responses shed light on a more comprehensive list of pregnancy prevention methods and nonuse options. Our findings contribute to survey questions that can lead to more accurate depiction of postpartum contraceptive behavior. Additionally, future use of these qualitative methods may be used to improve other health behavior survey development and resulting data.

Effect of gestational disorders on preterm birth, low birthweight, and NICU admission.

OBJECTIVE: Many modifiable maternal behaviors and experiences before and during pregnancy are associated with adverse health outcomes. The relationship between a number of maternal and gestational disorders and perinatal outcomes (preterm birth, low birth weight and neonatal intensive care unit (NICU)) admission in the Central New York population is determined using the Statewide Perinatal Data System, in a retrospective population-based cohort study. METHODS: Singleton births excluding newborns with congenital anomalies among 165,739 women between 2004 and 2012 are included in this study. Multivariable logistic regression analysis is used to estimate odds ratios (OR) and 95% confidence intervals (CI) adjusted for maternal age, race, education, employment, parity, body mass index, smoking, drug use, depression, abortions, gender of child, prenatal care, and hospital level. RESULTS: Previous preterm birth and vaginal bleeding are independent high-risk factors for all three perinatal outcomes, pre-pregnancy diabetes (OR 4.95, 95% CI 4.34, 5.64) for preterm birth and (OR 7.45, 95% CI 6.58, 8.44) for NICU admission; and gestational hypertension (OR 4.35, 95% CI 4.03, 4.70) for low birth weight. Among infections, bacterial vaginosis is retained in the multivariable model as a risk factor for preterm and low birth weight while hepatitis C is a risk factor for NICU admission. CONCLUSIONS: Our findings suggest the continued importance of addressing the need to provide preconception and inter conception care for women since many modifiable risk factors are correlated and need to be addressed well before the woman becomes pregnant.

National survey of attitudes towards pregnancy termination procedures among anaesthesiology residents in the US.

Anaesthesiologists are vital to abortion access in the US. An online survey of 215 anaesthesiology residents assessed attitudes towards abortion. Among the surveyed residents, first-trimester abortion was more acceptable than second-trimester abortion (P<0.001). Few respondents objected to abortion in cases of fetal anomalies or maternal health indications. Further, 77.3% of surveyed residents reported past participation in abortion procedures, including 77.8% of residents with objections to abortion in some circumstances. Anaesthesiology residents who are female, childless and non-religious were more likely to find first-trimester abortion acceptable.

Utilization of palliative care and acute care services in older adults with advanced cancer.

OBJECTIVES: There is a gap in knowledge regarding the rates of utilization of palliative care services (PCS) and acute care services (ACS) among older patients with advanced cancer close to end of life. We analyzed the utilization of these services among older adults (65 years and older) and compared them to those in younger adults (40-64 years) with advanced cancer. MATERIALS AND METHODS: A retrospective chart review of 567 veterans who died with advanced cancer between 2002 and 2009 and utilized PCS and ACS prior to death was conducted after IRB approval. To assess PCS utilization, we studied the mean duration between day of hospice referral and time of death (DOR) and the mean length of stay with hospice (LoS). The frequency of emergency room visits (ERVLM), hospital admissions (HALM), and ICU admissions (ICULM) in the last month of life was used as a measure for ACS. The differences among older and younger patients were compared using two sample t-tests. RESULTS: Older adults had earlier referral to PCS [mean DOR: 47.3 versus 34.5 days, p=0.015], longer stay with hospice [mean LoS: 32.5 versus 20.2 days, p=0.007], fewer hospital [HALM: 0.7 versus 0.9, p=0.043], and ICU admissions [ICULM: 0.1 versus 0.2, p=0.030] per patient. The proportion of patients utilizing ER visits [53.5 % versus 59.5%, p=0.173] and hospital admissions [58.6% versus 65.1%, p=0.13] in the last month of life was similar in both age groups with fewer older adults utilizing ICU care [13.2% versus 19.5%, p=0.047]. CONCLUSION: Older patients with cancer are likely to be referred to PCS earlier than younger patients and spend a longer duration with PCS prior to death. However, there continues to be significant utilization of ACS in all patients with advanced cancer. Better understanding of the goals of care in older adults with cancer and education of oncology providers regarding the need to utilize and integrate palliative care services earlier in the course of disease is imperative.

Aromatase inhibitor (anastrozole) affects growth of endometrioma cells in culture.

OBJECTIVE: To study the effects of aromatase inhibitor (anastrozole) on the growth and estradiol secretion of endometrioma cells in culture. DESIGN: Endometrioma cells are grown in vitro until maximum growth before used in this study. This was done in the research laboratory for tissue culture, in an academic hospital. INTERVENTIONS: Testosterone at a concentration of 10 µg/mL was added as a substrate for the intracellular aromatase. In addition, aromatase inhibitor was added at a concentration of 200 and 300 µg/mL. The effect on cell growth and estradiol secretion is evaluated using Student's t-test. RESULTS: The use of testosterone increased estradiol secretion by endometrioma cells in culture. The use of aromatase inhibitor significantly inhibited the growth of endometrioma cells, and estradiol secretion. CONCLUSION: Aromatase inhibitor (anastrozole) may be an effective treatment for endometriosis due to inhibition of cellular aromatase.

It takes at least two: male partner factors, racial/ethnic disparity, and Chlamydia trachomatis among pregnant women.

Chlamydia trachomatis (CT), the most prevalent sexually transmitted infection in the United States, disproportionately infects women and people of color. This study aimed to identify risk factors for racial and ethnic disparities for CT infection, re-infection, and persistent infection among pregnant women. We present a secondary analysis of births from a retrospective cohort study in Syracuse, NY from January 2000 through March 2002. African American women [OR 3.35 CI (2.29, 4.92)], Latin American women [OR 4.35 CI (2.52, 7.48)], unmarried women [OR 7.57 CI (4.38, 13.10)], and teen mothers [OR 3.87 CI (2.91, 5.16)] demonstrated statistically significant increased risk for infection. In multivariate analyses that included male partner variables, father's race/ethnicity but not the mother's race/ethnicity remained statistically associated with CT. Despite near universal rates of screening pregnant women, challenges to CT control remain and reflect barriers to testing and treatment of male partners.

The paternal component of the "healthy migrant" effect: fathers' natality and infants' low birth weight.

This study examines the predictors of birth outcomes among women of European and African ancestry and considers the birthplace of the babies' fathers (foreign born vs. native born) as a protective factor. This is a secondary data analysis of 146,431 singleton births among women of European and African ancestry, both native-born and foreign-born, in a 21 birth hospital region of Central New York State from 1996 to 2003. Foreign born fathers were found to have 15% fewer low birth weight infants than US-born fathers, after controlling for the race and birthplace of the mother, tobacco use and Medicaid. Although this secondary data analysis does not allow us to determine the social determinants of the better birth outcomes among infants of foreign born fathers, it does demonstrate that fathers matter and that foreign born fathers are associated with reduced low birth weight in their infants.

Effects of intimate partner violence on pregnancy trauma and placental abruption.

AIMS: Intimate partner violence (IPV) during pregnancy increases women's risk of pregnancy complications and adverse birth outcomes. The goal of this study was to examine the association between IPV and prenatal trauma and placental abruption during pregnancy. METHODS: Prenatal and hospital obstetrical charts were reviewed for 2873 women who gave birth between January 2000 and March 2002 in a Northeastern city. We examined associations among sociodemographic characteristics, health-related variables, IPV, and pregnancy trauma and placental abruption using univariate and multivariate logistic regression. RESULTS: Of the 2873 women in the analyses, 105 (3.7%) reported IPV during prenatal care. After controlling for sociodemographic variables; tobacco, alcohol, and drug use; preeclampsia; and gestational diabetes during pregnancy, women who reported IPV also had higher odds of pregnancy trauma and placental abruption (adjusted odds ratio [OR] 32.08, 95% confidence interval [CI] 14.33-71.80, p < 0.01, and OR 5.17, 95% CI 1.37-19.51, p < 0.05, respectively). CONCLUSIONS: This study found that IPV is a significant and independent risk factor for pregnancy trauma and placental abruption after controlling for factors typically associated with these outcomes. This study has implications for partner violence screening and intervention policies among pregnant women and highlights the importance of making distinctions about the type of IPV that women experience.

Structural violence, urban retail food markets, and low birth weight.

This paper investigates urban retail food markets and health in Syracuse, New York. A structured observational analysis found that a majority of corner markets do not sell fresh produce or low fat dairy products, but conduct a lively business selling lottery tickets, cigarettes, and liquor. A comparison of census tracts with and without access to supermarkets that sell fresh produce and other healthy food found that pregnant women living in proximity to a supermarket had significantly fewer low birth weight births than other pregnant women regardless of income level.

Environmental injustice: childhood lead poisoning, teen pregnancy, and tobacco.

PURPOSE: This study investigates the persistent relationships between childhood lead exposure, repeat teen pregnancy, and tobacco use in a sample of teenage females in Syracuse, NY. METHODS: We analyzed the association of childhood lead poisoning with repeat pregnancy and tobacco use among 536 teens (aged 15-19 years) in Syracuse, NY, who received services at Syracuse Healthy Start between 1998 and 2002. RESULTS: The mothers' childhood lead exposure, controlling for race, age, and Medicaid status, was associated with repeat teen pregnancy and tobacco use. CONCLUSION: Long-term negative health outcomes associated with childhood lead exposure should not be underestimated. This study helps to shore up prior research that found lead poisoning to have a long-lasting impact on children's functioning and healthy development. Policy efforts focused on neighborhood development and health education continue to be sorely needed.

Implementing evidence-based practice: evaluation of an opinion leader strategy to improve breast-feeding rates.

OBJECTIVE: The objective was to evaluate the effectiveness of opinion leaders in raising breast-feeding rates. STUDY DESIGN: A randomized controlled trial of an opinion leader strategy in 18 hospitals in Central New York State compared mothers' intention to breast-feed during baseline and study years. Multivariate logistic regression with a mixed model analyzed the effects on breast-feeding exclusively and on breast- and formula-feeding combined. RESULTS: Obstetric clinicians had a high degree of knowledge about breast-feeding benefits and of perceived responsibility to recommend breast-feeding. Obstetricians, family practitioners, and midwives agreed on the person identified as the opinion leader, in each case an obstetrician who was chief of obstetrics or obstetrics-gynecology. Breast-feeding rates in hospitals with the opinion leader intervention did not differ significantly from those in control-group hospitals during the study year. CONCLUSION: The opinion leader strategy in this case did not improve breast-feeding rates during the study year. Opinion leader strategies may make assumptions about clinician control that are not justified in situations such as breast-feeding.

Bicycle helmet effectiveness in preventing injury and death.

This case--bicycle helmet effectiveness--is one of a series of teaching cases in the Case-Based Series in Population-Oriented Prevention (C-POP). It has been developed for use in medical school and residency prevention curricula. The complete set of cases is presented in this supplement to the American Journal of Preventive Medicine. This case examines the cost-effectiveness of three interventions to increase utilization of bicycle helmets to avert head injuries in individuals aged 18 years and under in Onondaga Count NY. Students are initially presented with data on head injuries, hospitalization, and death related to bicycle use. They then appraise a published study on the effectiveness of bicycle helmets in averting head injury. Finally, students work in groups to determine the cost-effectiveness of each intervention by calculating implementation costs and the specific number of head injuries averted associated with intervention. The three interventions are legislative, school, and community-based campaigns to increase helmet use. Students are provided with budget estimates and assumptions needed to complete the exercise. Cost-effectiveness analysis, cost-benefit analysis, and related concepts are discussed, including provider versus societal perspectives and importance of sensitivity analysis.

Women's willingness to share information and participation in prenatal care systems.

With the expanded use of computerized databases to gather information, a concomitant interest in using databases for public health purposes has developed. The authors investigated correlates of consenting to participate in such databases. The Regional Perinatal Data System combines electronic birth certificate information with questions asked of all women delivering a livebirth. Each woman is asked to consent to share information with 1) her obstetric provider, 2) her infant's pediatric provider, and 3) an immunization registry. From 1996 to 1999, women who responded to the consent question and whose livebirth did not result in death or adoption were included. Odds ratios with 95% confidence intervals denoted the magnitude of association for refusing consent. Women who were "self-pay" (odds ratio = 2.0, 95% confidence interval: 1.7, 2.4), foreign born (odds ratio = 1.9, 95% confidence interval: 1.7, 2.1), and aged 40 or more years (odds ratio = 2.0, 95% confidence interval: 1.6, 2.3) were more likely to refuse to share data. Women eligible for but not participating in the Special Supplemental Nutrition Program for Women, Infants, and Children were significantly more likely to not share their information with others (odds ratio = 1.5, 95% confidence interval: 1.3, 1.6), after controlling for confounders. Refusing to share information with other sources is not random, and women refusing consent often do not participate in publicly available programs.

Named reporting and mandatory partner notification in New York State: the effect on consent for perinatal HIV testing.

The impact of the implementation of named reporting and mandatory partner notification on the percentage of patients not accepting prenatal human immunodeficiency virus (HIV) testing or deferring prenatal care has been examined in only a preliminary fashion. This retrospective, population-based cohort study of 5,007 patients admitted to a tertiary care labor-and-delivery unit in Central New York State between December 15, 1999, and March 14, 2001, is the first study to address the impact of named reporting and mandatory partner notification on prenatal HIV testing and prenatal care seeking. The percentage of patients who did not undergo prenatal HIV testing was significantly increased after the institution of named reporting and mandatory partner notification: 118/4,030 preimplementation, 59/966 postimplementation, with relative risk (RR) = 2.09 (1.54 < RR < 2.83). This remained significant after logistic regression controlled for confounding variables, with odds ratio (OR) = 1.5 (1.07 < OR < 2.10). The percentage of patients who did not receive prenatal care was significantly increased after the institution of named reporting and mandatory partner notification: 14/4,030 preimplementation, 18/966 postimplementation, with RR = 5.36 (2.68 < RR < 10.75). This remained significant after logistic regression controlled for confounding variables. OR = 3.77 (1.84 < OR < 7.72). There is a strong indication that the institution of named reporting and mandatory partner notification has significantly impacted the willingness of pregnant women to undergo HIV testing and prenatal care. Further analysis of the impact in perinatal populations is needed before the continued implementation of this controversial public policy initiative.