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Risk Factors for Loss to Follow-Up in the Lower Extremity Limb Salvage Population. Plast Reconstr Surg 2021; 148:883-893. [PMID: 34415857 DOI: 10.1097/prs.0000000000008356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Limb salvage for chronic lower extremity wounds requires long-term care best delivered by specialized multidisciplinary centers. This optimizes function, reduces amputation rates, and improves mortality. These centers may be limited to urban/academic settings, making access and appropriate follow-up challenging. Therefore, the authors hypothesize that both system- and patient-related factors put this population at exceedingly high risk for loss to follow-up. METHODS Records were reviewed retrospectively for 200 new patients seen at the Georgetown Center for Wound Healing in 2013. The primary outcome was loss to follow-up, defined as three consecutive missed appointments despite explicit documentation indicating the need for return visits. Demographic, clinical, and geographic data were compared. Multivariate logistic regression analysis for loss to follow-up status controlled for variables found significant in the bivariate analysis. Spatial dependency was evaluated using variograms. RESULTS Over a 6.5-year-period, 49.5 percent of patients followed were lost to follow-up. Male sex and increased driving distance to the limb salvage center were risk factors for loss to follow-up. Wound-specific characteristics including ankle and knee/thigh location were also associated with higher rates of loss to follow-up. There was no spatial dependency or discrete clustering of at-risk patients. CONCLUSIONS This study is the first of its kind to investigate the demographic and clinical characteristics that predispose chronic lower extremity wound patients to loss to follow-up. These findings inform stakeholders of the high rates of loss to follow-up and support decentralized specialty care, in the form of telemedicine, satellite facilities, and/or dedicated case managers. Future work will focus on targeting vulnerable populations through focused interventions to reduce patient and system burden. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Hunter C, Jensen J, Imeah B, McCarron M, Clark M. A Retrospective Cost-Effectiveness Analysis of Mifepristone-Misoprostol Medical Abortions in the First Year at the Regina General Hospital. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 43:211-218. [PMID: 33153943 PMCID: PMC7445185 DOI: 10.1016/j.jogc.2020.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/30/2020] [Accepted: 08/04/2020] [Indexed: 12/05/2022]
Abstract
Objective In July 2017, mifepristone–misoprostol (mife/miso) became available for medical abortion at the Regina General Hospital's Women's Health Centre (RGH WHC). We investigated whether the proportion of abortions performed medically changed as a result of the introduction of mife/miso, whether using mife/miso instead of the surgical alternative would result in cost savings to the health care system, and whether abortion type differed between patients residing in and outside of Regina. Methods We conducted a retrospective chart review of all 306 medical abortions from the RGH WHC between July 1, 2017 and June 30, 2018. We obtained medical and surgical abortion information from that year and the preceding one from an administrative database. Statistical methods were used to calculate the costs of mife/miso, methotrexate-misoprostol (MTX/miso) and surgical abortion, as well as cost-effectiveness ratios. Results The proportion of medical abortions increased from 15.4% in 2016/2017 to 28.7% in 2017/2018 (χ21 = 54.629; P < 0.001). Calculated costs for mife/miso, with and without complications were CAD $1173.70 and CAD $1708.90, respectively, versus CAD $871.10 and CAD $1204.10, respectively, for MTX/miso, and CAD $1445.95 and CAD $2261.95, respectively, for hospital-based vacuum aspiration. At a willingness-to-pay threshold of CAD $318 (the cost of mife/miso), statistical modelling showed a 61.3% chance that mife/miso was more cost-effective than surgical abortion and a 90.8% chance that it was more cost-effective than MTX/miso. Patients from Regina were significantly more likely (χ21 = 29.406; P < 0.001) to receive a medical abortion (34.9% of abortions) than those living outside of Regina (19.6% of abortions). Conclusion The proportion of abortions completed medically increased significantly over the period studied. Patients from Regina were more likely to receive medical abortion during both time periods. Mife/miso had a >50% probability of cost-effectiveness over both surgical and MTX/miso options.
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Affiliation(s)
- Caitlin Hunter
- Department of Family Medicine, University of Saskatchewan, Saskatoon, SK
| | - Joshua Jensen
- Department of Family Medicine, University of Saskatchewan, Saskatoon, SK
| | - Biaka Imeah
- Research Department, Saskatchewan Health Authority, Regina, SK
| | | | - Megan Clark
- Department of Family Medicine, University of Saskatchewan, Saskatoon, SK; Women's Health Centre, Regina General Hospital, Saskatchewan Health Authority, Regina, SK.
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Wiebe ER, Campbell M, Ramasamy H, Kelly M. Comparing telemedicine to in-clinic medication abortions induced with mifepristone and misoprostol. Contracept X 2020; 2:100023. [PMID: 32550538 PMCID: PMC7286176 DOI: 10.1016/j.conx.2020.100023] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 03/17/2020] [Accepted: 03/31/2020] [Indexed: 11/26/2022] Open
Abstract
Objective The objective was to compare the practical aspects of providing medication abortions through telemedicine and in-person clinic visits so that clinics can use this information when planning to add this service. Study design We conducted a comparative retrospective chart review comparing telemedicine medication abortions to a control group matched for date seen. We extracted and compared demographics, use of dating ultrasound, outcomes and unscheduled visits or communications with staff and physicians. Results During the study period, we provided 4340 medication abortions, of which 182 (4.2%) were provided through by telemedicine; 199 patients met the criteria to be in the control group. The mean age was 28.7 years for telemedicine patients and 28.1 years for in-person patients (p = .38). The mean gestational ages were also similar, 48.2 days for telemedicine patients and 46.5 days for in-person patients (p = .03). Only 33 (18.1%) of telemedicine patients had dating ultrasounds compared to 199 (100%) of in-clinic patients (p < .001). The proportions of documented completed abortions (164/182, 90.1% and 179/199, 89.9%, p = .76) were similar, as were the proportions of aspirations for completion (6/182, 3.3% and 9/199, 4.5%, p = .54) and the proportions lost to follow-up (5.5% and 6.6%, p = .66). There were 10 complications in each group (5.5% of telemedicine patients and 5.0% of in-clinic patients) (p > 0.5). Unscheduled communications with office assistants were greater in the telemedicine patients than the in-person patients (84/182, 46.2% vs. 43/199, 21.6% in-person, p < .001). Conclusion We found that telemedicine patients required more unscheduled communications and received ultrasounds far less often compared to in-clinic patients. Implications We could provide telemedicine without the need for ultrasound to most women. Larger studies without routine ultrasound use are needed to validate our findings. Unscheduled communication with clinic staff was more frequent with telemedicine medication abortion patients. This information may help clinics when planning to add this service.
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Warden S, Genkin I, Hum S, Dunn S. Outcomes During Early Implementation of Mifepristone-Buccal Misoprostol Abortions up to 63 Days of Gestation in a Canadian Clinical Setting. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 41:647-652. [PMID: 31007171 DOI: 10.1016/j.jogc.2018.05.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 05/16/2018] [Accepted: 05/17/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE In January 2017, mifepristone became available in Canada. The goal of this study was to determine the effectiveness and safety of mifepristone-misoprostol abortion during its early implementation in a Canadian setting. METHODS This retrospective chart review included the first 477 patients who had a mifepristone-misoprostol abortion from March 13 to October 31, 2017, in an urban sexual health clinic. Women with pregnancies up to 63days of gestation had an initial dating ultrasound and β-human chorionic gonadotropin determination. They were provided mifepristone 200 mg orally in clinic, followed 24-48hours later with misoprostol 800 µg buccally at home. Follow-up, 7-14days later, in clinic or by telephone, used symptom review and follow-up β-human chorionic gonadotropin or ultrasound. The primary outcome was successful abortion, defined as expulsion of pregnancy without uterine aspiration. RESULTS Of 477 consecutive mifepristone abortions, 422 women (88.5%) had documented follow-up, with 408 (96.7%) successful abortions, including eight in women who had a repeat dose of misoprostol. Fourteen (3.3%) unsuccessful abortions required uterine aspiration, two (0.5%) for ongoing pregnancy and 12 (2.8%) for incomplete abortion or persistent bleeding. Seventeen women (4.0%) had emergency department visits, one (0.2%) of whom was hospitalized and three (0.7%) of whom received blood transfusion. Four women (1.0%) were treated for infection. CONCLUSION Mifepristone-misoprostol medical abortion was safe and effective during early implementation in Canada, comparable to previously published outcomes.
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Affiliation(s)
- Sarah Warden
- Department of Family and Community Medicine, University of Toronto, Toronto, ON; Women's College Hospital Family Practice Health Centre, Toronto, ON
| | - Inna Genkin
- Department of Family and Community Medicine, University of Toronto, Toronto, ON; Women's College Hospital Family Practice Health Centre, Toronto, ON.
| | - Susan Hum
- Women's College Hospital Family Practice Health Centre, Toronto, ON
| | - Sheila Dunn
- Department of Family and Community Medicine, University of Toronto, Toronto, ON; Women's College Hospital Family Practice Health Centre, Toronto, ON
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Jones HE, O’Connell White K, Norman WV, Guilbert E, Lichtenberg ES, Paul M. First trimester medication abortion practice in the United States and Canada. PLoS One 2017; 12:e0186487. [PMID: 29023594 PMCID: PMC5638562 DOI: 10.1371/journal.pone.0186487] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 09/29/2017] [Indexed: 11/23/2022] Open
Abstract
We conducted a cross-sectional survey of abortion facilities from professional networks in the United States (US, n = 703) and Canada (n = 94) to estimate the prevalence of medication abortion practices in these settings and to look at regional differences. Administrators responded to questions on gestational limits, while up to five clinicians per facility reported on 2012 medication abortion practice. At the time of fielding, mifepristone was not approved in Canada. 383 (54.5%) US and 78 (83.0%) Canadian facilities participated. In the US, 95.3% offered first trimester medication abortion compared to 25.6% in Canada. While 100% of providers were physicians in Canada, just under half (49.4%) were advanced practice clinicians in the US, which was more common in Eastern and Western states. All Canadian providers used misoprostol; 85.3% with methotrexate. 91.4% of US providers used 200 mg of mifepristone and 800 mcg of misoprostol, with 96.7% reporting home misoprostol administration. More than three-quarters of providers in both countries required an in-person follow-up visit, generally with ultrasound. 87.7% of US providers routinely prescribed antibiotics compared to 26.2% in Canada. Nonsteroidal anti-inflammatory drugs were the most commonly reported analgesic, with regional variation in opioid narcotic prescription. In conclusion, medication abortion practice follows evidence-based guidelines in the US and Canada. Efforts to update practice based on the latest evidence for reducing in-person visits and increasing provision by advanced practice clinicians could strengthen these services and reduce barriers to access. Research is needed on optimal antibiotic and analgesic use.
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Affiliation(s)
- Heidi E. Jones
- Dept. of Epidemiology & Biostatistics, CUNY School of Public Health, New York, New York, United States of America
- * E-mail:
| | - Katharine O’Connell White
- Dept. of Obstetrics & Gynecology, Baystate Medical Center, Springfield, Massachusetts, United States of America
- Dept. of Obstetrics & Gynecology, Boston University/Boston Medical Center, Boston, Massachusetts, United States of America
| | - Wendy V. Norman
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Edith Guilbert
- Institut National de Santé Publique du Québec, Québec, Canada
| | - E. Steve Lichtenberg
- Family Planning Medical Associates Medical Group, Chicago, Illinois, United States of America
| | - Maureen Paul
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
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Ortiz-Prado E, Simbaña K, Gómez L, Stewart-Ibarra AM, Scott L, Cevallos-Sierra G. Abortion, an increasing public health concern in Ecuador, a 10-year population-based analysis. Pragmat Obs Res 2017; 8:129-135. [PMID: 28761387 PMCID: PMC5516879 DOI: 10.2147/por.s129464] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVES To describe the epidemiology of abortion in Ecuador from 2004 to 2014 and compare the prevalence between the public and the private health care systems. METHODS This is a cross-sectional analysis of the overall mortality and morbidity rate due to abortion in Ecuador, based on public health records and other government databases. RESULTS From 2004 to 2014, a total of 431,614 spontaneous abortions, miscarriage and other types of abortions were registered in Ecuador. The average annual rate of abortion was 115 per 1,000 live births. The maternal mortality rate was found to be 43 per 100,000 live births. CONCLUSIONS Abortion is a significant and wide-ranging problem in Ecuador. The study supports the perception that in spite of legal restrictions to abortion in Ecuador, women are still terminating pregnancies when they feel they need to do so. The public health system reported >84% of the national overall prevalence.
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Affiliation(s)
- Esteban Ortiz-Prado
- OneHealth Research Group, Faculty of Medicine, Universidad De Las Americas, Quito, Ecuador.,Department of Cellular Biology, Physiology and Immunology, Institute of Biomedicine, Universitat de Barcelona, Spain.,Department of Physiology, Faculty of Medicine "Eugenio Espejo", Universidad Tecnologica Equinoccial, Quito, Ecuador.,Department of Medicine, College of Medicine
| | - Katherine Simbaña
- Center for Global Health and Translational Science, Upstate Medical University, State University of New York, Syracuse, NY, USA.,Faculty of Medical Science, School of Medicine, Universidad Central del Ecuador
| | - Lenin Gómez
- Center for Global Health and Translational Science, Upstate Medical University, State University of New York, Syracuse, NY, USA.,Faculty of Medical Science, School of Medicine, Universidad Central del Ecuador
| | - Anna M Stewart-Ibarra
- Department of Medicine, College of Medicine.,Prometeo Program, SENESCYT, Quito, Ecuador
| | - Lisa Scott
- Graduate College of Biomedical Sciences, Western University of Health Sciences, Lebanon, OR, USA
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Abstract
OBJECTIVE This guideline reviews the evidence relating to the provision of first-trimester medical induced abortion, including patient eligibility, counselling, and consent; evidence-based regimens; and special considerations for clinicians providing medical abortion care. INTENDED USERS Gynaecologists, family physicians, registered nurses, midwives, residents, and other healthcare providers who currently or intend to provide pregnancy options counselling, medical abortion care, or family planning services. TARGET POPULATION Women with an unintended first trimester pregnancy. EVIDENCE Published literature was retrieved through searches of PubMed, MEDLINE, and Cochrane Library between July 2015 and November 2015 using appropriately controlled vocabulary (MeSH search terms: Induced Abortion, Medical Abortion, Mifepristone, Misoprostol, Methotrexate). Results were restricted to systematic reviews, randomized controlled trials, clinical trials, and observational studies published from June 1986 to November 2015 in English. Additionally, existing guidelines from other countries were consulted for review. A grey literature search was not required. VALUES The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force for Preventive Medicine rating scale (Table 1). BENEFITS, HARMS AND/OR COSTS Medical abortion is safe and effective. Complications from medical abortion are rare. Access and costs will be dependent on provincial and territorial funding for combination mifepristone/misoprostol and provider availability. SUMMARY STATEMENTS Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care RECOMMENDATIONS Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care.
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