Understanding social needs in pregnancy: Prospective validation of a digital short-form screening tool and patient survey

BACKGROUND

Social determinants of health significantly affect health outcomes, yet are infrequently addressed in prenatal care.

OBJECTIVE

This study aimed to improve the efficiency and experience of addressing social needs in pregnancy through: (1) testing a digital short-form screening tool; and (2) characterizing pregnant people's preferences for social needs screening and management.

STUDY DESIGN

We developed a digital short-form social determinants of health screening tool from PRAPARE (Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences), and a survey to query patients' preferences for addressing social needs. Instruments were administered online to peripartum participants, with equal representation of patients with public and private insurance. We calculated the sensitivity and specificity of the short-form tool vs PRAPARE. Quantitative responses were characterized using descriptive statistics. Free-text responses were analyzed with matrix and thematic coding. Survey data were analyzed by subgroups of historically marginalized populations.

RESULTS

A total of 215 people completed the survey. Participants were predominantly White (167; 77.7%) and multiparous (145; 67.4%). Unmet social needs were prevalent with both the short-form tool (77.7%) and PRAPARE (96.7%). The sensitivity (79.3%) and specificity (71.4%) of the short-form screener were high for detecting any social need. Most participants believed that it was important for their pregnancy care team to know their social needs (material: 173, 80.5%; support: 200, 93.0%), and over half felt comfortable sharing their needs through in-person or digital modalities if assistance was or was not available (material: 117, 54.4%; support: 122, 56.7%). Free-text themes reflected considerations for integrating social needs in routine prenatal care. Acceptability of addressing social needs in pregnancy was high among all groups.

CONCLUSION

A digital short-form social determinants of health screening tool performs well when compared with the gold standard. Pregnant people accept social needs as a part of routine pregnancy care. Future work is needed to operationalize efficient, effective, patient-centered approaches to addressing social needs in pregnancy.

Improving communication and teamwork during labor: A feasibility, acceptability, and safety study

BACKGROUND

TeamBirth was designed to promote best practices in shared decision making (SDM) among care teams for people giving birth. Although leading health organizations recommend SDM to address gaps in quality of care, these recommendations are not consistently implemented in labor and delivery.

METHODS

We conducted a mixed-methods trial of TeamBirth among eligible laboring patients and all clinicians (nurses, midwives, and obstetricians) at four high-volume hospitals during April 2018 to September 2019. We used patient and clinician surveys, abstracted clinical data, and administrative claims to evaluate the feasibility, acceptability, and safety of TeamBirth.

RESULTS

A total of 2,669 patients (approximately 28% of eligible delivery volume) and 375 clinicians (78% response rate) responded to surveys on their experiences with TeamBirth. Among patients surveyed, 89% reported experiencing at least one structured full care team conversation ("huddle") during labor and 77% reported experiencing multiple huddles. There was a significant relationship between the number of reported huddles and patient acceptability (P < 0.001), suggestive of a dose response. Among clinicians surveyed, 90% would recommend TeamBirth for use in other labor and delivery units. There were no significant changes in maternal and newborn safety measures.

CONCLUSIONS

Implementing a care process that aims to improve communication and teamwork during labor with high fidelity is feasible. The process is acceptable to patients and clinicians and shows no negative effects on patient safety. Future work should evaluate the effectiveness of TeamBirth in improving care experience and health outcomes.

Impact of an educational program and decision tool on choice of maternity hospital: the delivery decisions randomized clinical trial

Background

Reducing cesarean rates is a public health priority. To help pregnant people select hospitals with lower cesarean rates, numerous organizations publish publically hospital cesarean rate data. Few pregnant people use these data when deciding where to deliver. We sought to determine whether making cesarean rate data more accessible and understandable increases the likelihood of pregnant people selecting low-cesarean rate hospitals.

Methods

We conducted a 1:1 randomized controlled trial in 2019–2021 among users of a fertility and pregnancy mobile application. Eligible participants were trying to conceive for fewer than five months or were 28–104 days into their pregnancies. Of 189,456 participants approached and enrolled, 120,621 participants met entry criteria and were included in analyses. The intervention group was offered an educational program explaining the importance of hospital cesarean rates and an interactive tool presenting hospital cesarean rates as 1-to-5-star ratings. Control group users were offered an educational program about hospital choice and a hospital choice tool without cesarean rate data. The primary outcome was the star rating of the hospital selected by each patient during pregnancy. Secondary outcomes were the importance of cesarean rates in choosing a hospital and delivery method (post-hoc secondary outcome).

Results

Of 120,621 participants (mean [SD] age, 27.8 [7.9]), 12,284 (10.2%) reported their choice of hospital during pregnancy, with similar reporting rates in the intervention and control groups. Intervention group participants selected hospitals with higher star ratings (2.52 vs 2.16; difference, 0.37 [95% CI, 0.32 to 0.43] p < 0.001) and were more likely to believe that the hospitals they chose would impact their chances of having cesarean deliveries (38.5% vs 33.1%, p < 0.001) but did not assign higher priority to cesarean delivery rates when choosing their hospitals (76.2% vs 74.3%, p = 0.05). There was no difference in self-reported cesarean rates between the intervention and control groups (31.4% vs 31.4%, p = 0.98).

Conclusion

People offered an educational program and interactive tool to compare hospital cesarean rates were more likely to use cesarean data in selecting a hospital and selected hospitals with lower cesarean rates but were not less likely to have a cesarean.

Clinical Trial Registration

Registered December 9, 2016 at clinicaltrials.gov, First enrollment November 2019. ID NCT02987803, https://clinicaltrials.gov/ct2/show/NCT02987803

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05087-y.

Implementation strategies within a complex environment: A qualitative study of a shared decision-making intervention during childbirth

BACKGROUND

Shared decision-making (SDM) may improve communication, teamwork, patient experience, respectful maternity care, and safety during childbirth. Despite these benefits, SDM is not widely implemented, and strategies for implementing SDM interventions are not well described. We assessed the acceptability and feasibility of TeamBirth, an SDM solution that centers the birthing person in decision-making through simple tools that structure communication among the care team. We identified and described implementation strategies that bridge the gap between knowledge and practice.

METHODS

We conducted a qualitative study among four hospitals in the United States to understand the acceptability and feasibility of TeamBirth. We interviewed 103 clinicians and conducted 16 focus group discussions with 52 implementers between June 2018 and October 2019. We drew on the Consolidated Framework for Implementation Research to understand acceptability and feasibility, and to identify and describe the underlying contextual factors that affected implementation.

RESULTS

We found that clinicians and implementers valued TeamBirth for promoting clarity about care plans among the direct care team and for centering the birthing person in decision-making. Contextual factors that affected implementation included strength of leadership, physician practice models, and quality improvement culture. Effective implementation strategies included regular data feedback and adapting "flexible" components of TeamBirth to the local context.

DISCUSSION

By identifying and describing TeamBirth's contextual factors and implementation strategies, our findings can help bridge the implementation gap of SDM interventions. Our in-depth analysis offers tangible lessons for other labor and delivery unit leaders as they seek to integrate SDM practices in their own settings.

The design of "TeamBirth": A care process to improve communication and teamwork during labor

BACKGROUND

Despite evidence that communication and teamwork are critical to patient safety, few care processes have been intentionally designed for this purpose in labor and delivery. The purpose of this project was to design an intrapartum care process that aims to improve communication and teamwork between clinicians and patients.

METHODS

We followed the "Double-Diamond" design method with four sequential steps: Discover, Define, Develop, and Deliver. In Discover, we searched professional guidelines and peer-reviewed literature to delineate the challenges to quality of intrapartum care and to uncover options for solutions. In Define, we convened an interdisciplinary group of experts to focus the problem scope and prioritize solution features. In Develop, we created initial prototype solutions. In Deliver, we engaged clinicians and patients in rapid cycle testing to iteratively produce a care process called "TeamBirth" that aims to improve team communication.

RESULTS

We designed TeamBirth, an intrapartum care process composed of brief team meetings ("huddles") between clinicians and patients. Huddles are navigated by a shared planning board placed in the labor and delivery room in view of the patient and their care team. The board promotes transparent and reliable communication and contains four areas to be acknowledged or discussed: (a) the names of the team members, starting with the patient; (b) the patient's preferences; (c) the care plan for the patient, baby, and labor progress; and (d) when the next team huddle is anticipated.

DISCUSSION

We identified an opportunity to improve the safety and dignity of childbirth care through an intrapartum care process that promotes reliable and structured communication and teamwork. Future work should evaluate the acceptability and feasibility of implementation and potential impact on safety and experience of care.

Assessing the Feasibility of Measuring Variation in Facility Design Among American Childbirth Facilities

OBJECTIVE

To assess the feasibility of quantifying variation in childbirth facility design and explore the implications for childbirth service delivery across the United States.

BACKGROUND

Design has been shown to impact quality of care in childbirth. However, most prior studies use qualitative data to examine associations between the design of patient rooms and patient experience. There has been limited exploration of measures of unit design and its impact on care provision.

METHOD

We recruited 12 childbirth facilities that were diverse with regard to facility type, location, delivery volume, cesarean delivery rate, and practice model. Each facility provided annotated floor plans and participated in a site visit or telephone interview to provide information on their design and clinical practices. These data were analyzed with self-reported primary cesarean delivery rates to assess associations between design and care delivery.

RESULTS

We observed wide variation in childbirth unit design. Deliveries per labor room per year ranged from 75 to 479. The ratio of operating rooms to labor rooms ranged from 1:1 to 1:9. The average distance between labor rooms and workstations ranged from 23 to 114 ft, and the maximum distance between labor rooms ranged from 9 to 242 ft. More deliveries per room, fewer labor rooms per operating room, and longer distances between spaces were all associated with higher primary cesarean delivery rates.

CONCLUSIONS

Clinically relevant differences in design can be feasibly measured across diverse childbirth facilities. The design of these facilities may not be optimally matched to service delivery needs.

Common challenges managing bed and staff availability on labor and delivery units in the United States: A qualitative analysis

BACKGROUND

Managers of labor and delivery units need to ensure that their limited supply of beds and nursing staff are adequately available, despite uncertainty with respect to patient needs. The ability to address this challenge has been associated with patient outcomes; however, best practices have not been defined.

METHODS

We conducted a secondary analysis of 96 interviews with nurse and physician managers from 48 labor and delivery units across the United States. Included units represented a diverse range of characteristics, but skewed toward higher volume teaching hospitals. The prior study scored management practice based on their proactiveness (ability to mitigate challenges before they occur). Based on emerging themes, we identified common challenges in managing bed and staff availability and performed an analysis of positive deviants to identify an additional criterion for effective management performance.

RESULTS

We identified four key challenges common to all labor and delivery units, (1) scheduling planned cases, (2) tracking patient flow, (3) monitoring bed and staff availability in the moment, and (4) adjusting bed and staff availability in the moment. We also identified "systematicness" (ability to address challenges in a consistent and reliable manner) as an emerging criterion for effective management. We observed that being proactive and systematic represented distinct characteristics, and units with both proactive and systematic practices appeared best positioned to effectively manage limited beds and staffing.

DISCUSSION

Labor and delivery unit managers should distinctly assess both the proactiveness and systematicness of their existing management practices and consider how their practices could be modified to improve care.

Association of Previous Cesarean Delivery With Surgical Complications After a Hysterectomy Later in Life

Importance

In recent decades, the global rates of cesarean delivery have rapidly increased. Nonetheless, the influence of cesarean deliveries on surgical complications later in life has been understudied.

Objective

To investigate whether previous cesarean delivery increases the risk of reoperation, perioperative and postoperative complications, and blood transfusion when undergoing a hysterectomy later in life.

Design, Setting, and Participants

This registry-based cohort study used data from Danish nationwide registers on all women who gave birth for the first time between January 1, 1993, and December 31, 2012, and underwent a benign, nongravid hysterectomy between January 1, 1996, and December 31, 2012. The dates of this analysis were February 1 to June 30, 2016.

Exposure

Cesarean delivery.

Main Outcomes and Measures

Reoperation, perioperative and postoperative complications, and blood transfusion within 30 days of a hysterectomy.

Results

Of the 7685 women (mean [SD] age, 40.0 [5.3] years) who met the inclusion criteria, 5267 (68.5%) had no previous cesarean delivery, 1694 (22.0%) had 1 cesarean delivery, and 724 (9.4%) had 2 or more cesarean deliveries. Among the 7685 included women, 3714 (48.3%) had an abdominal hysterectomy, 2513 (32.7%) had a vaginal hysterectomy, and 1458 (19.0%) had a laparoscopic hysterectomy. In total, 388 women (5.0%) had a reoperation within 30 days after a hysterectomy. Compared with women having vaginal deliveries, fully adjusted multivariable analysis showed that the adjusted odds ratio of reoperation for women having 1 previous cesarean delivery was 1.31 (95% CI, 1.03-1.68), and the adjusted odds ratio was 1.35 (95% CI, 0.96-1.91) for women having 2 or more cesarean deliveries. Perioperative and postoperative complications were reported in 934 women (12.2%) and were more frequent in women with previous cesarean deliveries, with adjusted odds ratios of 1.16 (95% CI, 0.98-1.37) for 1 cesarean delivery and 1.30 (95% CI, 1.02-1.65) for 2 or more cesarean deliveries. Blood transfusion was administered to 195 women (2.5%). Women having 2 or more cesarean deliveries had an adjusted odds ratio for receiving blood transfusion of 1.93 (95% CI, 1.21-3.07) compared with women having no previous cesarean delivery.

Conclusions and Relevance

Women with at least 1 previous cesarean delivery face an increased risk of complications when undergoing a hysterectomy later in life. The results support policies and clinical efforts to prevent cesarean deliveries that are not medically indicated.

How do pregnant women use quality measures when choosing their obstetric provider?

BACKGROUND

Given increased public reporting of the wide variation in hospital obstetric quality, we sought to understand how women incorporate quality measures into their selection of an obstetric hospital.

METHODS

We surveyed 6141 women through Ovia Pregnancy, an application used by women to track their pregnancy. We used t tests and chi-square tests to compare response patterns by age, parity, and risk status.

RESULTS

Most respondents (73.2%) emphasized their choice of obstetrician/midwife over their choice of hospital. Over half of respondents (55.1%) did not believe that their choice of hospital would affect their likelihood of having a cesarean delivery. While most respondents (74.9%) understood that quality of care varied across hospitals, few prioritized reported hospital quality metrics. Younger women and nulliparous women were more likely to be unfamiliar with quality metrics. When offered a choice, only 43.6% of respondents reported that they would be willing to travel 20 additional miles farther from their home to deliver at a hospital with a 20 percentage point lower cesarean delivery rate.

DISCUSSION

Women's lack of interest in available quality metrics is driven by differences in how women and clinicians/researchers conceptualize obstetric quality. Quality metrics are reported at the hospital level, but women care more about their choice of obstetrician and the quality of their outpatient prenatal care. Additionally, many women do not believe that a hospital's quality score influences the care they will receive. Presentations of hospital quality data should more clearly convey how hospital-level characteristics can affect women's experiences, including the fact that their chosen obstetrician/midwife may not deliver their baby.

The value of case management in the publicly funded substance abuse treatment system. The perspective of program directors, case managers and clients

The many purposes of this article is to understand the role and value of case management from the perspective of program directors, case managers and clients. A survey of program directors from publicly funded substance abuse treatment programs in Boston was administered, and in-depth interviews with a sample of program directors, case managers, and clients were conducted. Case management allowed programs to serve more complex clients and increased time available for counselors to focus on the clinical needs of clients. From the perspective of case managers and clients, much of the value of case management came from educating clients about steps they could take to meet their needs and then supporting them in their efforts as they took these steps. Successful steps taken to deal with these needs helped lay the foundation necessary to confront the challenges of treatment. Program directors, case managers, and clients considered case management a valuable enhancement to substance abuse treatment.

HIV testing in substance abusers

HIV testing among substance abusers in the United States is a significant public and individual health issue in need of further examination. We analyzed interview data gathered over 15 months in 1992 and 1993 from 2315 patients on presentation for addiction treatment to determine the frequency of and factors associated with previous HIV testing. Among this group of alcohol, heroin, and cocaine abusers, 53% (1231) reported previous HIV testing. Although in bivariate and multivariable analyses those with identifiable risk factors for HIV were more likely to have been tested, 27% of injection drug users, 38% with multiple sexual partners, and 39% of those with a history of a sexually transmitted disease (STD) had not been HIV tested. Other factors associated with previous HIV testing included having a primary care physician, the primary care physician's awareness of the patient's substance abuse problem, and having received prior addiction care. However, 38% of substance abusers who had previously received addiction treatment beyond detoxification had not been tested. Of those tested, 10% (n = 122) reported a positive test, and 7% (n = 81) had not received the test results. Of those with positive test results, 37% were not injection drug users. Promotion of HIV testing among alcohol and other drug abusers in both medical and substance abuse treatment settings should be a priority.

The functioning and well being of persons who seek treatment for drug and alcohol use

We assessed the reliability of the Medical Outcomes Study Short Form Health Survey (SF-20) in a heterogeneous group of persons seeking drug and alcohol treatment. Patients (n = 2688) seeking detoxification and treatment at four intake sites for Addiction Treatment in Boston, Massachusetts, received all components of the SF-20 including physical, role, and social functioning; mental health; health perception and bodily pain. The primary drugs used were alcohol 38%, cocaine 38%, heroin 24%. Reliability coefficients for the MOS scales ranged from 0.70 to 0.92. Users of these three drugs had similar profiles among the health components. Sociodemographic characteristics in combination explained 2-7% of score variance. Alcohol and other drug use had little effect on physical or role function scores. Health perception and pain subscale scores were low. We conclude the MOS survey is a reliable measure of function and well being in this population. Like other chronic diseases, alcohol and drug use have powerful effects on quality of life.

Improving publicly funded substance abuse treatment: the value of case management

OBJECTIVES

This study evaluated the impact of case management on client retention in treatment and short-term relapse for clients in the publicly funded substance abuse treatment system.

METHODS

A retrospective cohort design was used to study clients discharged from the following four modalities in 1993 and 1994: short-term residential (3112 clients), long-term residential (2888 clients), outpatient (7431 clients), and residential detox (7776 clients). Logistic regression models were used to analyze the impact of case management after controlling for baseline characteristics.

RESULTS

The odds that case-managed clients reached a length of stay previously identified as associated with more successful treatment were 1.6 (outpatient programs) to 3.6 (short-term residential programs) times higher than the odds for non-case-managed clients. With the exception of outpatient clients, the odds of case-managed clients' being admitted to detox within 90 days after discharge (suggesting relapse) were about two thirds those of non-case-managed clients. The odds of case-managed detox clients' transitioning to post-detox treatment (a good outcome) were 1.7 times higher than the odds for non-case-managed clients.

CONCLUSIONS

Case management is a low-cost enhancement that improves short-term outcomes of substance abuse treatment programs.

Physician unawareness of serious substance abuse

PURPOSE

To describe and assess the prevalence of perceived physician unawareness of serious substance abuse.

PATIENTS AND METHODS

We report an observational study with validation of multivariable results of data collected by interview from persons presenting for addictions treatment in the public system who reported having a physician.

RESULTS

Of 3,253 patients interviewed, 87% (2,843) responded to the question about having a physician. Of 1,440 patients who stated that they had physicians, 45% (651) reported that the physician who cared for them was unaware of their substance abuse. In multivariable logistic regressions adjusting for sociodemographics, health status, and substance abuse histories, the following patient characteristics were found to be independently associated with physician unawareness of substance abuse and were confirmed in a validation analysis (OR = Odds Ratio, CI = 95% Confidence Interval); no prior episodic medical illness (OR = 1.98, CI = 1.35-2.92), no health insurance (OR = 1.89, CI = 1.33-2.70), no prior mental health treatment (OR = 1.75, CI = 1.06-2.88), no chronic medical illness (OR = 1.69, CI = 1.18-2.40), no prior substance abuse treatment (OR 1.64, CI 1.17-2.31), and no prior detoxification (OR = 1.54, CI = 1.14-2.22).

CONCLUSIONS

Forty-five percent of patients with substance abuse serious enough to prompt a presentation for treatment stated that the physician who cared for them was unaware of their substance abuse. Patients without health insurance, a history of medical illness, or prior substance abuse or mental health treatment were more likely to have reported physician unawareness. Even among substance abusing patients requesting addiction treatment, many perceive that their physicians do not recognize their substance abuse.

Conference report: community-based health promotion--state of the art and recommendations for the future

The evaluators of the Henry J. Kaiser Family Foundation Community Health Promotion Grants Program in the West and the Foundation brought together 21 researchers, funders, and community organizers with a variety of perspectives on community-based health promotion to share what has been learned to date and how that knowledge should be applied in the future. The two-day conference was divided into three sessions, covering conceptual, implementation, and evaluation issues. Specific topics were selected by the organizers with input from participants. Two papers were presented in each session, followed by comments from discussants and a general discussion involving the entire group. The dominant theme of the conference was the relationship between communities and outside institutions, focusing on problems with the current state of relations and how they might be improved in the future. All viewed building partnerships between communities and institutions as a desirable goal; however, the challenges involved in building effective partnerships are considerable and require a substantial investment to make them work. Recommendations that emerged from the discussions included explicitly acknowledging the diverse interests of the parties in community-based programs at the earliest stages of program planning; making a concerted effort to bridge the cultural gaps that exist among the parties; structuring funding to allow enough lead time for partnerships to develop or using social reconnaissance to identify strong existing partnerships; and integrating the evaluation more closely into the process of program development.

The effect of anonymous vs. nonanonymous rating conditions on patient satisfaction and motivation ratings in a population of substance abuse patients

Patient self-report in evaluations involving alcohol and other drug abuse has generally been found to be reliable and valid. However, little is known about the variables associated with greater or lesser degrees of reliability and validity. This study was conducted to determine how motivation and satisfaction ratings obtained under anonymous conditions would compare with ratings obtained under nonanonymous conditions. Over the course of 12 months, 1397 subjects in the Boston Target Cities Project were assigned to either confidential or fully anonymous data collection procedures in an interrupted time-series design. Anonymity had either no effect on ratings or accounted for < 1% of the variance. Satisfaction and motivation ratings obtained under confidential conditions are probably as reliable and valid as ratings obtained under fully anonymous conditions.

Length of stay as an outcome in an era of managed care. An empirical study

Longer length of stay (LOS) in substance abuse treatment, a standard measure of treatment success, conflicts with pressures from managed care. To maintain LOS as an outcome, we identified, for four modalities, LOS categories such that program completion rates were relatively constant within category and differed among categories. We validated the cutoffs by showing that future utilization over a 2-year period by clients differed by category. Clients in the long-LOS category used the system in a way consistent with more successful treatment. Thus, rather than using increase in LOS as an outcome, one can use increase in the percentage of clients reaching the long-LOS category. Categories were developed and utilization analyzed for discharges from publicly funded Boston treatment programs between 1/92 and 12/94 from the following modalities: short-term residential (5,462 discharges), long-term residential (5,086 discharges), outpatient (13,656 discharges), and detox (19,965 discharges).

Implementing the Boston Healthy Start Initiative: a case study of community empowerment and public health

This article examines the efforts on the part of a city health department, in partnership with a broad-based coalition of community-based, government, and social service agencies, to plan and implement, using principles of empowerment and community participation, a federally funded infant mortality reduction program. It examines the social and institutional dynamics of sharing power in an environment highly charged politically. Infant mortality in Boston is much more than a public health problem. It is the focal point of complex racial, political, and institutional factors. This case study illustrates how empowerment moves from rhetoric to reality and the challenge to both traditional public health practice and traditional community mobilization. The article describes the federal Healthy Start Initiative and its community participation mandate, the background on infant mortality in Boston, a case study of the development of the Healthy Start program from the perspective of community empowerment, and finally, the lessons learned in the first 2 years of the program. It describes the controversies encountered, some of the mistakes made, and the ways found that government must be reinvented if empowerment is to be a real public health tool.

Access to primary health care: developing state and local strategies for high risk groups

Competition and a rapidly changing market place have dramatically altered the dynamics of primary health care delivery in urban areas across the US, focusing new attention on access to care for the indigent. Public and private sector policymakers in Boston, Massachusetts, addressed these issues by examining the health status, payer coverage and availability of providers of primary health care for individuals at risk. Strategies were targeted in the areas of health insurance, reimbursement, and provider organisations to improve access to services at the state and local level.