Patient experience and decision-making process for laser photocoagulation for monochorionic twin pregnancy: A qualitative exploration

INTRODUCTION

To explore patients' perspectives on diagnosis and treatment options for complicated monochorionic multiple gestations, and experiences with fetoscopic laser photocoagulation.

METHODS

This is a prospective cohort study of patients undergoing laser photocoagulation. Participants were interviewed during pregnancy and the postpartum period. Qualitative analysis was performed.

RESULT

27 patients who were candidates for laser photocoagulation were included. All elected to have laser photocoagulation. Patients chose surgery with goals of improving survival, decreasing the risk of preterm delivery, and improving the long-term health of their fetuses. They demonstrated accurate knowledge of the risks and benefits of treatment. Most (74%) felt that laser photocoagulation represented their only viable clinical option. Few seriously considered pregnancy termination or selective reduction (7% and 11% respectively). Postpartum, patients expressed no regrets about their decisions for surgery, but many felt unprepared for the challenges of preterm delivery.

CONCLUSION

Participants weighed treatment options similarly to fetal specialists. They acknowledged but did not seriously consider treatments other than fetoscopic laser photocoagulation, and were highly motivated to do whatever they could to improve outcomes for their fetuses.

Prenatal and postpartum depression diagnosis in a large health system: prevalence and disparities

BACKGROUND/OBJECTIVES/INTRODUCTION

Depression during pregnancy or postpartum carries the same risks as general depression as well as additional risks specific to pregnancy, infant health and maternal well-being. The purpose of this study is to document the prevalence of depression symptoms and diagnosis during pregnancy and in the first 3 months postpartum among a cohort of women receiving prenatal care in a large health system. Secondarily, we examine variability in screening results and diagnosis by race, ethnicity, language, economic status and other maternal characteristics during pregnancy and postpartum.

PATIENTS/MATERIALS AND METHODS

A retrospective study with two cohorts of patients screened for depression during pregnancy and postpartum. Out of 7807 patients with at least three prenatal care visits and a delivery in 2016, 6725 were screened for depression (87%) at least once during pregnancy or postpartum. Another 259 were excluded because of missing race data. The final sample consisted of 6523 prenatal care patients who were screened for depression; 4914 were screened for depression in pregnancy, 4619 were screened postpartum (0-3 months). There were 3010 screened during both periods who are present in both the pregnancy and postpartum cohorts. Depression screening results are from the Patient Health Questionnaire (PHQ-9) and diagnosis of depression was measured using ICD codes. For patients screened more than once during either time period, the highest score is used for analysis.

RESULTS

Approximately, 11% of women had a positive depression screen as indicated by an elevated PHQ-9 score (>10) during pregnancy (11.3%) or postpartum (10.7%). Prevalence of depression diagnosis was similar in the two periods: 12.6% during pregnancy and 13.0% postpartum. A diagnosis of depression during pregnancy was most prevalent among women who were age 24 and younger (19.7%), single (20.5%), publicly insured (17.8%), multiracial (24.1%) or Native American (23.8%), and among women with a history of depression in the past year (58.9%). Among women with a positive depression screen, Black women were less than half as likely as White women to receive a diagnosis in adjusted models (AOR 0.40, CI: 0.23-0.71, p = .002). This difference was not present postpartum.

CONCLUSIONS

Depression symptoms and diagnoses differ by maternal characteristics during pregnancy with some groups at substantially higher risk. Efforts to examine disparities in screening and diagnosis are needed to identify reasons for variability in prenatal depression diagnosis between Black and White women.Key messagesWomen who were young, single, have public insurance, and women who identify as multiracial or non-Hispanic (NH) Native American were most likely to have a positive depression screen or a diagnosis for depression.After adjustment for confounders, NH Black women with a positive depression screen were about half as likely to have a diagnosis of depression during pregnancy as NH White women.Awareness of the differing prevalence of depression risk screening results, diagnoses and potential for variation in diagnosis may identify opportunities to improve equity in the delivery of essential mental health care to all patients.

The Use of Saliva Samples to Test for Congenital Cytomegalovirus Infection in Newborns: Examination of False-Positive Samples Associated with Donor Milk Use

A universal screening research study was conducted in six hospitals to identify the clinical sensitivity of polymerase chain reaction (PCR) testing on newborn dried blood spots (DBSs) versus saliva specimens for the diagnosis of congenital cytomegalovirus (cCMV). CMV DNA positive results from DBSs or saliva were confirmed with urine testing. Findings of several false-positive (FP) saliva PCR results prompted an examination of a possible association with donor milk. Documentation of the frequency of positive saliva results, including both true-positive (TP) and FP status from clinical confirmation, occurred. The frequency of donor milk use was compared for TP and FP cases. Of 22,079 participants tested between 2016 and 2022, 96 had positive saliva results, 15 were determined to be FP, 79 TP, and 2 were excluded for incomplete clinical evaluation. Newborn donor milk use was identified for 18 (19.14%) of all the positive saliva screens. Among the 15 FPs, 11 (73.33%) consumed donor milk compared to 7 of the 79 TPs (8.8%) (OR 28.29, 95% CI 7.10-112.73, p < 0.001). While milk bank Holder pasteurization inactivates CMV infectivity, CMV DNA may still be detectable. Due to this possible association, screening programs that undertake testing saliva for CMV DNA may benefit from documenting donor milk use as a potential increased risk for FP results.

Implementation and Outcomes of a Model of Care for Placenta Accreta Spectrum in a Community-Based Private Practice

OBJECTIVE

 The aim of the study is to describe a model of care and outcomes for placenta accreta spectrum (PAS) implemented in the context of a community based non-academic health system.

STUDY DESIGN

 The program for management of PAS includes a multidisciplinary team approach with protocols for ultrasound assessment, diagnosis, and surgery. The program was implemented in the two largest private hospitals in the Twin Cities, Minnesota, United States. Maternal and fetal outcomes as well as cost were compared for histopathologic confirmed PAS cases before (2007-2014, n = 41) and after (2015-2017, n = 26) implementation of the PAS program.

RESULTS

 Implementation of the PAS program was associated with ICU admission reductions from 53.7 to 19.2%, p = 0.005; a decrease of 1,682 mL in mean estimated blood loss (EBL) (p = 0.061); a decrease in transfusion from 85.4 to 53.9% (p = 0.005). The PAS program also resulted in a (non-significant) decrease in both surgical complications from 48.8 to 38.5% (p = 0.408) and postoperative complications from 61.0 to 42.3% (p = 0.135). The total cost of care for PAS cases in the 3 years after implementation of the program decreased by 33%.

CONCLUSION

 The implementation of a model of care for PAS led by a perinatology practice at a large regional non-academic referral center resulted in reductions of ICU admissions, operating time, transfusion, selected surgical complications, overall postoperative complications, and cost.

KEY POINTS

· Implementation of a PAS care model resulted in reduced ICU admissions from 53.7% to 19.2%.. · Patient safety increased by reducing blood loss, transfusions and postoperative complications.. · This model decreased operating time, as well as total cost of care by 33%..

The impact of a population-based prevention program on cardiovascular events: Findings from the heart of new Ulm project

BACKGROUND

Cardiovascular disease (CVD) and its associated risk factors are the principal drivers of mortality and healthcare costs in the United States with rural residents experiencing higher CVD death rates than their urban counterparts.

METHODS

The purpose of this study was to examine incidence of major CVD events over 9 years of implementation of the Heart of New Ulm (HONU) Project, a rural population-based CVD prevention initiative. HONU interventions were delivered at individual, organizational, and community levels addressing clinical risk factors, lifestyle behaviors and environmental changes. The sample included 4,056 residents of New Ulm matched with 4,056 residents from a different community served by the same health system. The primary outcome was a composite of major CVD events (myocardial infarction, ischemic stroke, percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), and CVD-related death). Secondary outcomes were the individual CVD events and procedures.

RESULTS

The proportion of residents in New Ulm with a major CVD event (7.79%) was not significantly different than the comparison community (8.43%, P = .290). However, the total number of events did differ by community with fewer events in New Ulm than the comparison community (447 vs 530, P = .005), with 48 fewer strokes (84 vs 132, P = .001) and 42 fewer PCI procedures (147 vs 189, P = 0.019) in New Ulm. Incidence of ischemic stroke was lower in the New Ulm community (1.85 vs 2.61, P = .020) than in the comparison community. Other specific CVD events did not have significantly different incidence or frequencies between the 2 communities.

CONCLUSION

In HONU, the proportion of residents experiencing a CVD event was not significantly lower than a match comparison community. However, there was a significant reduction in the total number of CVD events in New Ulm, driven primarily by lower stroke, PCI, and CABG events in the intervention community.

Universal childhood obesity prevention in a rural community: Study design, methods and baseline participant characteristics of the NU-HOME randomized controlled trial

Childhood obesity is a major health concern in the United States (US) and those living in rural communities are at higher risk than their urban counterparts. Few prevention trials have engaged whole families of school-age children in community settings, and none to date have promoted family meals, family activity and healthful home environments in rural settings through a rigorous, randomized controlled trial (RCT). The New Ulm at HOME (NU-HOME) study recruited 114 parent/child dyads in a two-arm (intervention versus wait-list control) RCT to test the efficacy of a family meals-focused program aimed to prevent excess weight gain among 7-10 year-old children in rural Minnesota. The NU-HOME program was adapted from a previously tested program for urban families through a unique community collaboration. The program included 7 monthly in-person sessions for all family members. Parents also participated in 4 motivational goal-setting phone calls. The primary outcome measures were age- and sex-adjusted child body mass index (BMI) z-score, percent body fat, and incidence of overweight and obesity post-intervention. Secondary outcomes included quality of food and beverage availability in the home; family meals and snacks; children's dietary intake quality (e.g., Healthy Eating Index (HEI)-2015, fruits and vegetables, sugar-sweetened beverages, snacks); and children's screen time and weekly minutes of moderate-to-vigorous physical activity, total physical activity, and sedentary behavior. The NU-HOME RCT was a collaborative effort of academic and health system researchers, interventionists and community leaders that aimed to prevent childhood obesity in rural communities through engagement of the whole family in an interactive intervention.

Trends in prevalence of guideline-based use of lipid-lowering therapy in a large health system

BACKGROUND

The 2013 ACC/AHA (American College of Cardiology/American Heart Association) cholesterol guidelines provided an evidence-based rationale for the allocation of lipid-lowering therapy based on risk for atherosclerotic cardiovascular disease (ASCVD). Adoption of these guidelines was initially suboptimal but whether this has improved over time remains unclear.

HYPOTHESIS

Prevalence of guideline-based statin therapy will increase over time.

METHODS

Electronic health record data were used to create two cross-sectional data sets of patients (age 40-75) served in 2013 and 2017 by a large health system. Data sets included demographics, clinical risk factors, lipid values, diagnostic codes, and active medication orders during each period. Prevalence of indications for statin therapy according to the ACC/AHA guidelines and statin prescriptions were compared between each time period.

RESULTS

In 2013, of the 219 376 adults, 57.7% of patients met statin eligibility criteria, of which 61.3% were prescribed any statin and 19.0% a high intensity statin. Among those eligible, statin use was highest in those with established ASCVD (83.9%) and lowest in those with elevated ASCVD risk >7.5% (39.3%). In 2017, of the 256 074 adults, 62.3% were statin eligible, of which 62.3% were prescribed a statin and 24.3% a high intensity statin. In 2017, 66.4% of statin eligible men were prescribed a statin compared to 57.4% of statin eligible women (P < 0.001). The use of ezetimibe (3.6% in 2013, 2.4% in 2017) and protein convertase subtilisin/kexin type 9 inhibitors (<0.1% and 0.1%) was infrequent.

CONCLUSION

In a large health system, guideline-based statin use has remained suboptimal. Improved strategies are needed to increase statin utilization in appropriate patients.

Population-Level Reach of Cardiovascular Disease Prevention Interventions in a Rural Community: Findings from the Heart of New Ulm Project

This study examines participation by residents of a rural community in programs implemented as part of The Heart of New Ulm (HONU) Project, a population-based cardiovascular disease (CVD) prevention initiative. The study compares participation rates for the various interventions to assess which were the most engaging in the priority community and identifies factors that differentiate participants vs. nonparticipants. Participation data were merged with electronic health record (EHR) data representing the larger community population to enable an analysis of participation in the context of the entire community. HONU individual-level interventions engaged 44% of adult residents in the community. Participation ranked as follows: (1) heart health screenings (37% of adult residents), (2) a year-long community weight loss intervention (12% of adult residents), (3) community health challenges (10% of adult residents), and (4) a phone coaching program for invited high CVD-risk residents (enrolled 6% of adult residents). Interventions that yielded the highest engagement were those that had significant staffing and recruited participants over several months, often with many opportunities to participate or register. Compared to nonparticipants, HONU participants were significantly older and a higher proportion were female, married, overweight or obese, and had high cholesterol. Participants also had a lower prevalence of smoking and diabetes than nonparticipants. Findings indicate community-based CVD prevention initiatives can be successful in engaging a high proportion of adult community members. Partnering with local health care systems can allow for use of EHR data to identify eligible participants and evaluate reach and engagement of the priority population.

Who Gives Birth in the Water? A Retrospective Cohort Study of Intended versus Completed Waterbirths

INTRODUCTION

Most waterbirth studies have been conducted outside the United States with a primary focus on birth outcomes. Studies to date provide limited information about how often women choosing waterbirth end water immersion before the birth and about the reasons for tub exit. This study examines a cohort of women intending a hospital-based waterbirth and documents the timing and reasons for tub exit. Demographic, clinical, and intrapartum care provider characteristics among women completing waterbirth were compared with those who exited the water prior to birth.

METHODS

This is a collaborative, multisite study from 2 health systems (8 hospitals) using retrospective electronic health records from August 2014 through December 2017.

RESULTS

Of 576 women who entered the waterbirth tub, 48% exited prior to the birth. The primary reasons for exit were maternal choice (50%), medical indication (32%), and provider decision (13%). Women exiting in the first stage did so primarily by choice (57%), whereas medical indication (42%) was the most common reason among women exiting in the second stage. Women who completed waterbirth did not differ from those who exited prior to birth with regard to age, race, ethnicity, country of origin, language, marital status, or intrapartum care provider specialty. Women completing waterbirth were more likely to have previously given birth (72% vs 47%) and to have a provider with more water immersion births during the study period (65% vs 55%).

DISCUSSION

Giving birth in the tub was associated with parity and intrapartum care provider experience. Half of the women intending waterbirth in this study exited the tub, with variation in exit reason by stage and provider type. It is important for women to understand that they or their provider may change the birth plan based on labor progress and maternal experience.

Population-level changes in lifestyle risk factors for cardiovascular disease in the Heart of New Ulm Project

Lifestyle significantly influences development of cardiovascular disease (CVD), but limited data exists demonstrating lifestyle improvements in community-based interventions. This study aims to document how lifestyle risk factors changed at the population level in the context of Heart of New Ulm (HONU), a community-based CVD prevention initiative in Minnesota.

HONU intervened across worksites, healthcare and the community/environment to reduce CVD risk factors. HONU collected behavioral measures including smoking, physical activity, fruit/vegetable consumption, alcohol use and stress at heart health screenings from 2009 to 2014. All screenings were documented in the electronic health record (EHR). Changes at the community level for the target population (age 40–79) were estimated using weights created from EHR data and modeled using generalized estimating equation models.

Screening participants were similar to the larger patient population with regard to age, race, and marital status, but were slightly healthier in regards to BMI, LDL cholesterol, blood pressure, and less likely to smoke. Community-level improvements were significant for physical activity (62.8% to 70.5%, p < 0.001) and 5+ daily fruit/vegetable servings (16.9% to 28.1%, p < 0.001), with no significant change in smoking, stress, alcohol or BMI.

By leveraging local EHR data and integrating it with patient-reported outcomes, improvements in nutrition and physical activity were identified in the HONU population, but limited changes were noted for smoking, alcohol consumption and stress. Systematically documenting behaviors in the EHR will help healthcare systems impact the health of the communities they serve, both at the individual and population level.

Assessing the impact of the heart of New Ulm Project on cardiovascular disease risk factors: A population-based program to reduce cardiovascular disease

The Heart of New Ulm Project (HONU), is a population-based project designed to reduce modifiable cardiovascular disease (CVD) risk factors in the rural community of New Ulm, MN. HONU interventions address multiple levels of the social-ecological model. The community is served by one health system, enabling the use of electronic health record (EHR) data for surveillance. The purpose of this study was to assess if trends in CVD risk factors and healthcare utilization differed between a cohort of New Ulm residents age 40-79 and matched controls selected from a similar community, using EHR data from baseline (2008-2009) through three follow up time periods (2010-2011, 2012-2013, 2014-2015). Matching, using covariate balance sparse technique, yielded a sample of 4077 New Ulm residents and 4077 controls. We used mixed effects longitudinal models to examine trends over time between the two groups. Blood pressure, total cholesterol, low-density lipoprotein-cholesterol, and triglycerides showed better management in New Ulm over time compared to the controls. The proportion of residents in New Ulm with controlled blood pressure increased by 6.2 percentage points compared to an increase of 2 points in controls (p < 0.0001). As the cohort aged, 10-year ASCVD risk scores increased less in New Ulm (5.1) than the comparison community (5.9). The intervention and control community did not differ with regard to inpatient stays, smoking, or glucose. Findings suggest efficacy for the HONU project interventions for some outcomes.

Prenatal care: associations with prenatal depressive symptoms and social support in low-income urban women

We examined associations of depressive symptoms and social support with late and inadequate prenatal care in a low-income urban population. The sample was prenatal care patients at five community health centers. Measures of depressive symptoms, social support, and covariates were collected at prenatal care entry. Prenatal care entry and adequacy came from birth certificates. We examined outcomes of late prenatal care and less than adequate care in multivariable models. Among 2341 study participants, 16% had elevated depressive symptoms, 70% had moderate/poor social support, 21% had no/low partner support, 37% had late prenatal care, and 29% had less than adequate prenatal care. Women with both no/low partner support and elevated depressive symptoms were at highest risk of late care (AOR 1.85, CI 1.31, 2.60, p < 0.001) compared to women with both good partner support and low depressive symptoms. Those with good partner support and elevated depressive symptoms were less likely to have late care (AOR 0.74, CI 0.54, 1.10, p = 0.051). Women with moderate/high depressive symptoms were less likely to experience less than adequate care compared to women with low symptoms (AOR 0.73, CI 0.56, 0.96, p = 0.022). Social support and partner support were negatively associated with indices of prenatal care use. Partner support was identified as protective for women with depressive symptoms with regard to late care. Study findings support public health initiatives focused on promoting models of care that address preconception and reproductive life planning. Practice-based implications include possible screening for social support and depression in preconception contexts.

Lifestyle changes and prevention of metabolic syndrome in the Heart of New Ulm Project

Prior research has shown that unhealthy lifestyles increase the risk for developing a number of chronic diseases, but there are few studies examining how lifestyle changes impact metabolic syndrome. This study analyzed the association between two-year changes in key lifestyle risk metrics and incident metabolic syndrome in adults. A retrospective cohort study was conducted using data from metabolic syndrome free adults in the Heart of New Ulm Project (New Ulm, MN). The outcome was incident metabolic syndrome observed two years after baseline in 2009. The primary predictor was change in optimal lifestyle score based on four behavioral risk factors, including smoking, alcohol use, fruit/vegetable consumption, and physical activity. In the analytical sample of 1059 adults, 12% developed metabolic syndrome by 2011. Multivariable regression models (adjusted for baseline lifestyle score, age, sex, education, cardiovascular disease, and diabetes) revealed that a two-year decrease in optimal lifestyle score was associated with significantly greater odds of incident metabolic syndrome (OR = 2.92; 95% CI: 1.69, 5.04; p < 0.001). This association was primarily driven by changes in obesity, fruit/vegetable consumption, and alcohol intake. As compared to improving poor lifestyle habits, maintaining a healthy lifestyle seemed to be most helpful in avoiding metabolic syndrome over the two-year study timeframe.

A Description of Inpatient Palliative Care Actions for Patients With Acute Heart Failure

In a recent randomized trial, inpatient palliative care (PC) visits were associated with improved quality of life and symptom burden for patients with heart failure. To better understand what actions by PC providers may have led to those outcomes, we conducted chart reviews of 101 patients in the intervention group (who received PC). Palliative care actions are described for all patients and for those with higher symptoms. Orders were written for 24% of patients, most frequently for pain. Recommendations to change current care were made for 40% of patients. At least 1 element of future care planning was documented for 99% of patients. Palliative care for inpatients with HF led to additive actions beyond standard care, especially for pain, and promoted HF-specific goals of care discussions.

Two-year impact of lifestyle changes on workplace productivity loss in the Heart of New Ulm Project

OBJECTIVE

Unhealthy lifestyles have been associated with lower workplace productivity and are the main targets of worksite wellness programmes. The degree to which workplace productivity increases over time in response to changes in lifestyle habits, however, remains unclear. The purpose of this study was to examine the association between 2-year changes in key lifestyle risk factors and workplace productivity loss.

METHOD

A retrospective cohort of 1273 employed adults in 2009 and 2011 was studied from the Heart of New Ulm Project. The outcome was overall workplace productivity loss in 2011. Predictors included 2-year changes in smoking, alcohol use, fruit/vegetable consumption and physical activity, as well as an optimal lifestyle score based on a composite of these four factors.

RESULTS

The adjusted model indicated that participants who continued to smoke over 2 years had significantly greater overall workplace productivity loss compared to those who remained non-smokers during the same timeframe (9.8% vs 2.5% productivity loss, p=0.031). Lifestyle improvements, however, were not associated with a reduction in workplace productivity loss.

CONCLUSIONS

Employed adults in this cohort who quit smoking, moderated alcohol use, increased fruit/vegetable consumption, or increased physical activity over 2 years did not have less productivity loss compared to those whose lifestyle factors remained stable. In workforces where productivity is already high and/or lifestyle factors are generally healthy, further lifestyle improvements may have limited impact on employee productivity. Larger experimental studies in more diverse regions are needed to help guide employers' investments in lifestyle-oriented worksite wellness programmes.

Inpatient palliative care for patients with acute heart failure: outcomes from a randomized trial

BACKGROUND

Heart failure (HF) is associated with a high symptom burden and reduced quality of life (QOL). Models integrating palliative care (PC) into HF care have been proposed, but limited research is available on the outcomes of such models.

OBJECTIVE

Our aim was to assess if inpatient PC for HF patients is associated with improvements in symptom burden, depressive symptoms, QOL, or differential use of services.

METHODS

Patients hospitalized with acute HF were randomized to receive a PC consult with follow-up as determined by provider or standard care. Two hundred thirty-two patients (116 intervention/116 control) from a large tertiary-care urban hospital were recruited over a 10-month period. Primary outcomes were symptom burden, depressive symptoms, and QOL measured at baseline, 1, and 3 months. Secondary outcomes included advance care planning (ACP), inpatient 30-day readmission, hospice use, and death.

RESULTS

Improvements were greater at both 1 and 3 months in the intervention group for primary outcome summary measures after adjusting for age, gender, and marital status differences between study groups. QOL scores increased by 12.92 points in the intervention and 8 points in the control group at 1 month (difference+4.92, p<0.001). Improvement in symptom burden was 8.39 in the intervention group and 4.7 in the control group at 1 month (+3.69, p<0.001). ACP was the only secondary outcome associated with the intervention (hazard ratio [HR] 2.87, p=0.033).

CONCLUSION

An inpatient PC model for patients with acute HF is associated with short-term improvement in symptom burden, QOL, and depressive symptoms.

Exploring electronic health records as a population health surveillance tool of cardiovascular disease risk factors

The objective of this study was to examine the utility of using electronic health record (EHR) data for periodic community health surveillance of cardiovascular disease (CVD) risk factors through 2 research questions. First, how many years of EHR data are needed to produce reliable estimates of key population-level CVD health indicators for a community? Second, how comparable are the EHR estimates relative to those from community screenings? The study takes place in the context of the Heart of New Ulm Project, a 10-year population health initiative designed to reduce myocardial infarctions and CVD risk factor burden in a rural community. The community is served by 1 medical center that includes a clinic and hospital. The project screened adult residents of New Ulm for CVD risk factors in 2009. EHR data for 3 years prior to the heart health screenings were extracted for patients from the community. Single- and multiple-year EHR prevalence estimates were compared for individuals ages 40-79 years (N=5918). EHR estimates also were compared to screening estimates (N=3123). Single-year compared with multiyear EHR data prevalence estimates were sufficiently precise for this rural community. EHR and screening prevalence estimates differed significantly-systolic blood pressure (BP) (124.0 vs. 128.9), diastolic BP (73.3 vs. 79.2), total cholesterol (186.0 vs. 201.0), body mass index (30.2 vs. 29.5), and smoking (16.6% vs. 8.2%)-suggesting some selection bias depending on the method used. Despite differences between data sources, EHR data may be a useful source of population health surveillance to inform and evaluate local population health initiatives.

Program participation and blood pressure improvement in the Heart of New Ulm Project, Minnesota, 2009-2011

Introduction

The Heart of New Ulm (HONU) Project is a community-based heart disease prevention intervention that delivers various component programs through health care, work sites, and the community. We examined the association between HONU program participation and blood pressure (BP) control over the first 2 years of the project.

Methods

The sample included residents aged 40 to 79 years from the target zip code who attended a heart health screening at baseline (2009) and again at follow-up (2011). BP control was defined as achieving or maintaining a BP less than 140/90 mm Hg in 2011.

Results

BP improvements were observed in the sample: 81.7% of those who had controlled BP in 2009 maintained controlled BP 2 years later, and 52.4% of those with uncontrolled BP at baseline had controlled BP 2 years later (mean [SD] change in systolic BP, −10.6 mm Hg [20.8]). In the final adjusted model, participation in any 2 component programs of the HONU Project was associated with significantly higher odds of BP control among those with uncontrolled BP at baseline (n = 374). Participation in any component of the HONU Project among those with uncontrolled BP was associated with significant BP improvement compared with no participation.

Conclusions

The clinical, work site, and community education and behavioral programs (eg, healthful diet or physical activity) delivered as part of a population-level heart disease prevention intervention were associated with meaningful BP improvements over 2 years among those with uncontrolled BP at baseline.

Assessing the food environment of a rural community: baseline findings from the heart of New Ulm project, Minnesota, 2010-2011

Introduction

Changes in the food environment in the United States during the past few decades have contributed to increased rates of obesity, diabetes, and heart disease. Improving the food environment may be an effective primary prevention strategy to address these rising disease rates. The purpose of this study was to assess the consumer food environment of a rural community with high rates of obesity and low levels of fruit and vegetable consumption. Findings were used to identify food environment intervention strategies to be implemented as part of a larger community-based heart disease prevention program.

Methods

We used the Nutrition Environment Measures Survey for Restaurants (NEMS-R) and Stores (NEMS-S) to assess 34 restaurants, 3 grocery stores, and 5 convenience stores in New Ulm, Minnesota.

Results

At least half of the restaurants offered nonfried vegetables and 100% fruit juice. Only 32% had at least 1 entrée or 1 main dish salad that met standards for “healthy.” Fewer than half (41%) had fruit available and under one-third offered reduced-size portions (29%) or whole-grain bread (26%). Grocery stores had more healthful items available, but findings were mixed on whether these items were made available at a lower price than less healthful items. Convenience stores were less likely to have fruits and vegetables and less likely to carry more healthful products (except milk) than grocery stores.

Conclusion

Baseline findings indicated opportunities to improve availability, quality, and price of foods to support more healthful eating. A community-wide food environment assessment can be used to strategically plan targeted interventions.

Prevalence of the American Heart Association's "ideal cardiovascular health" metrics in a rural, cross-sectional, community-based study: the Heart of New Ulm Project

Background

The American Heart Association (AHA) recently created the construct of “ideal cardiovascular health” based on 7 cardiovascular health metrics to measure progress toward their 2020 Impact Goal. The present study applied this construct to assess the baseline cardiovascular health of a rural population targeted with a community‐based cardiovascular disease prevention program.

Methods and Results

The sample consists of 4754 New Ulm, Minn, adult residents who participated in either the 2009 or 2011 community heart health screenings offered by the Hearts Beat Back: The Heart of New Ulm (HONU) Project (mean age 52.1 years, 58.3% women). Data collected at the screenings were analyzed to replicate the AHA's ideal cardiovascular health measure and the 7 metrics that comprise the construct. Screening participants met, on average (±SD), 3.4 (±1.4) ideal cardiovascular health metrics. Only 1.0% of participants met the AHA's definition of ideal health in all metrics and 7.1% met ≤1 ideal health metric. Higher proportions of women met the ideal category in all metrics except physical activity. Women over the age of 60 were less likely to meet the ideal category for cholesterol and hypertension than were men in the same age range.

Conclusion

Prevalence of ideal cardiovascular health is extremely low in this rural population. To make progress toward the 2020 Impact Goal, targeted community‐based interventions must be implemented based on the most prevalent cardiovascular risk factors.

Validation of the alcohol use module from a multidimensional prenatal psychosocial risk screening instrument

The purpose of the study was to validate the Prenatal Risk Overview (PRO) Alcohol use domain against a structured diagnostic interview. The PRO was developed to screen for 13 psychosocial risk factors associated with poor birth outcomes. After clinic staff administered the PRO to prenatal patients, they asked for consent to administration of selected modules of the structured clinical interview for DSM-IV (SCID) by a research assistant. To assess the criterion validity of the PRO, low and moderate/high risk classifications from the alcohol use domain were cross-tabulated with SCID Alcohol Use Disorder variables. The study sample included 744 women. Based on PRO responses, 48.7% reported alcohol use during the 12 months before they learned they were pregnant; 5.4% reported use post pregnancy awareness. The typical quantity consumed pre-pregnancy was four or more drinks per occasion. Based on the SCID, 7.4% met DSM-IV criteria for either Alcohol Abuse or Dependence. Sensitivity and specificity of the PRO for Alcohol Use Disorders were 83.6 and 80.3%, respectively. Negative predictive value was 98.4% and positive predictive value was 25.3%. The results indicate the PRO effectively identified pregnant women with Alcohol Use Disorders. However, prenatal screening must also detect consumption patterns that do not meet diagnostic thresholds but may endanger fetal development. The PRO also identified women who continued to drink after they knew they were pregnant, as well as those whose previous drinking habits put them at risk for resumption of hazardous use.

Validation of the Patient Health Questionnaire (PHQ)-9 for prenatal depression screening

The study was designed to validate the Patient Health Questionnaire (PHQ-9) for depression risk identification among pregnant women. Pregnant women were routinely administered the Prenatal Risk Overview, a comprehensive psychosocial screening interview, which included the PHQ-9, at their prenatal intake appointment at three community clinics. Study participants completed the Structured Clinical Interview for DSM-IV (SCID) at a later appointment. PHQ-9 risk classifications were cross-tabulated with SCID diagnostic categories to examine concordance, sensitivity, specificity, and positive and negative predictive values. The study sample included 745 women. Prevalence of a current major depressive episode was 3.6 %; an additional 7.0 % were classified as meeting subdiagnostic criteria of three or more depressive symptoms. A PHQ-9 score cutoff of 10 yielded sensitivity and specificity rates of 85 and 84 %, respectively, for a depression diagnosis and 75 and 88 % for a subdiagnosis, respectively. Positive predictive value was higher for the expanded group (43 %) than that of the diagnosis-only group (17 %). The PHQ-9, embedded within a multidimensional risk screening interview, effectively identified pregnant women who met criteria for current depression. The moderate risk score cutoff also identified women with subdiagnostic symptom levels who may benefit from interventions to alleviate their distress and improve pregnancy outcomes.

Systematic prenatal screening for psychosocial risks

The Prenatal Risk Overview (PRO) was designed to screen for 13 psychosocial risk factors associated with poor birth outcomes. This study describes the development and implementation of the PRO in 4 community health centers. The study also examines the prevalence, co-occurrence, and inter-correlations of psychosocial risks in their prenatal populations. The study sample included 1,386 prenatal patients screened between November 2005 and April 2007; 95% were women of color; 77% were not married. The PRO classified 48% at moderate or high risk for housing instability; 32% for food insecurity; 75% for lack of social support; 7% for intimate partner violence; 9% for other physical/sexual abuse; 18% for depression; 23% for cigarette use, 23% for alcohol use, and 25% for drug use. Systematically assessing and quantifying psychosocial risks are essential activities for evaluating the extent to which appropriate and timely responses to identified risks reduce infant mortality, preterm births, and low birth weights.

Alcohol and drug use before and during pregnancy: an examination of use patterns and predictors of cessation

OBJECTIVES

This study examines alcohol and nonmedical drug use before and during pregnancy and identifies the predictors of use cessation before the first prenatal visit.

METHODS

Data analyses were based on the Prenatal Risk Overview (PRO), a structured interview that screens for psychosocial risk factors associated with poor birth outcomes. The study sample includes 1,492 consecutive prenatal care patients from four urban clinics between November 2005 and June 2007.

RESULTS

Reported alcohol and drug use pre-pregnancy was much higher among U.S.-born women than immigrants, and among unmarried women than married women. American Indians had the highest rates among racial/ethnic groups. Since learning of their pregnancy, 5.6% of patients reported alcohol use and 10.7% reported drug use, reflecting cessation rates of 87.0% for alcohol and 55.6% for drugs. In logistic regression analyses, older age, current smoking, and lack of transportation predicted both alcohol and drug use continuation. Alcohol use continuation was also predicted by pre-pregnancy alcohol use frequency, depression, and physical/sexual abuse by someone other than an intimate partner. Drug use continuation was also predicted by race (higher for American Indians and African Americans), and pre-pregnancy drug use frequency.

CONCLUSIONS

Women who continued to use alcohol or drugs after learning they were pregnant were more frequent users than spontaneous quitters, more likely to smoke cigarettes, and had more psychosocial stressors. Achieving higher rates of cessation may require approaches that simultaneously address substance use and impediments to quitting. Higher continuation rates among some cultural groups require further investigation.

Pregnancy-related changes in body fat

OBJECTIVE

To determine patterns of subcutaneous body fat change from preconception through 6 weeks postpartum, and factors that modify them.

STUDY DESIGN

A prospective study of 557 healthy women enrolled prior to pregnancy.

MAIN OUTCOME MEASURE

Body weight and skinfold thickness at the thigh, triceps, and subscapula, preconception, in each trimester, and 6 weeks postpartum, along with other variables.

RESULTS

Subcutaneous body fat stores remained stable (P>0.13) during the first 6 weeks after conception, and increased from 6 to 35 weeks by 1.5 mm at the triceps, 4.2 mm at the subscapular, and 7.3 mm (P<0.01) at the thigh areas. Body fat changes correlated poorly with weight changes, reflecting differences in the time course for the changes. They differed by preconceptional body mass index (BMI), parity, and infant gender (P<0.05). Women with the highest BMIs tended to gain less subcutaneous fat early, primiparous women gained more at thigh (P=0.01) and subscapular (P=0.027), and women carrying males had higher gains at the thigh (P=0.032) and subscapular sites (P=0.058) than other women. Breastfeeding status did not affect postpartum body fat changes, but women who breastfed exclusively had significantly lower skinfold thicknesses than non-exclusive breastfeeders from preconception through 6 weeks postpartum (P=0.041).

CONCLUSION

Subcutaneous body fat is stored and utilized at different sites at specific times during and after pregnancy. The pattern and amount of change varies depending on characteristics of women and their pregnancies.