Active surveillance pharmacovigilance for Clostridioides difficile infection and gastrointestinal bleeding: an analytic framework based on case-control studies

BACKGROUND

Active surveillance pharmacovigilance is an emerging approach to identify medications with unanticipated effects. We previously developed a framework called pharmacopeia-wide association studies (PharmWAS) that limits false positive medication associations through high-dimensional confounding adjustment and set enrichment. We aimed to assess the transportability and generalizability of the PharmWAS framework by using medical claims data to reproduce known medication associations with Clostridioides difficile infection (CDI) or gastrointestinal bleeding (GIB).

METHODS

We conducted case-control studies using Optum's de-identified Clinformatics Data Mart Database of individuals enrolled in large commercial and Medicare Advantage health plans in the United States. Individuals with CDI (from 2010 to 2015) or GIB (from 2010 to 2021) were matched to controls by age and sex. We identified all medications utilized prior to diagnosis and analysed the association of each with CDI or GIB using conditional logistic regression adjusted for risk factors for the outcome and a high-dimensional propensity score.

FINDINGS

For the CDI study, we identified 55,137 cases, 220,543 controls, and 290 medications to analyse. Antibiotics with Gram-negative spectrum, including ciprofloxacin (aOR 2.83), ceftriaxone (aOR 2.65), and levofloxacin (aOR 1.60), were strongly associated. For the GIB study, we identified 450,315 cases, 1,801,260 controls, and 354 medications to analyse. Antiplatelets, anticoagulants, and non-steroidal anti-inflammatory drugs, including ticagrelor (aOR 2.81), naproxen (aOR 1.87), and rivaroxaban (aOR 1.31), were strongly associated.

INTERPRETATION

These studies demonstrate the generalizability and transportability of the PharmWAS pharmacovigilance framework. With additional validation, PharmWAS could complement traditional passive surveillance systems to identify medications that unexpectedly provoke or prevent high-impact conditions.

FUNDING

U.S. National Institute of Diabetes and Digestive and Kidney Diseases.

Drug Shortages Prior to and During the COVID-19 Pandemic

Importance

Drug shortages are a chronic and worsening issue that compromises patient safety. Despite the destabilizing impact of the COVID-19 pandemic on pharmaceutical production, it remains unclear whether issues affecting the drug supply chain were more likely to result in meaningful shortages during the pandemic.

Objective

To estimate the proportion of supply chain issue reports associated with drug shortages overall and with the COVID-19 pandemic.

Design, Setting, and Participants

This longitudinal cross-sectional study used data from the IQVIA Multinational Integrated Data Analysis database, comprising more than 85% of drug purchases by US pharmacies from wholesalers and manufacturers, from 2017 to 2021. Data were analyzed from January to May 2023.

Exposure

Presence of a supply chain issue report to the US Food and Drug Administration or the American Society of Health-Systems Pharmacists (ASHP).

Main Outcomes and Measures

The main outcome was drug shortage, defined as at least 33% decrease in units purchased within 6 months of a supply chain issue report. Random-effects logistic regression models compared the marginal odds of shortages for drugs with vs without reports. Interaction terms assessed heterogeneity prior to vs during the COVID-19 pandemic and by drug characteristics (formulation, age, essential medicine status, clinician- vs self-administered, sales volume, and number of manufacturers).

Results

A total of 571 drugs exposed to 731 supply chain issue reports were matched to 7296 comparison medications with no reports. After adjusting for drug characteristics, 13.7% (95% CI, 10.4%-17.8%) of supply chain issue reports were associated with subsequent drug shortages vs 4.1% (95% CI, 3.6%-4.8%) of comparators (marginal odds ratio [mOR], 3.7 [95% CI, 2.6-5.1]). Shortages increased among both drugs with and without reports in February to April 2020 (34.2% of drugs with supply chain issue reports and 9.5% of comparison drugs; mOR, 4.9 [95% CI, 2.1-11.6]), and then decreased after May 2020 (9.8% of drugs with reports and 3.6% of comparison drugs; mOR, 2.9 [95% CI, 1.6-5.3]). Significant associations were identified by formulation (parenteral mOR, 1.9 [95% CI, 1.1-3.2] vs oral mOR, 5.4 [95% CI, 3.3-8.8]; P for interaction = .008), WHO essential medicine status (essential mOR, 2.2 [95% CI, 1.3-5.2] vs nonessential mOR, 4.6 [95% CI, 3.2-6.7]; P = .02), and for brand-name vs generic status (brand-name mOR, 8.1 [95% CI, 4.0-16.0] vs generic mOR, 2.4 [95% CI, 1.7-3.6]; P = .002).

Conclusions and Relevance

In this national cross-sectional study, supply chain issues associated with drug shortages increased at the beginning of the COVID-19 pandemic. Ongoing policy work is needed to protect US drug supplies from future shocks and to prioritize clinically valuable drugs at greatest shortage risk.

Effects of the valsartan recall on heart failure patients: A nationwide analysis

BACKGROUND

Valsartan is commonly used for cardiac conditions. In 2018, the Food and Drug Administration recalled generic valsartan due to the detection of impurities. Our objective was to determine if heart failure patients receiving valsartan at the recall date had a greater likelihood of unfavorable outcomes than patients using comparable antihypertensives.

METHODS

We conducted a cohort study of Optum's de-identified Clinformatics® Datamart (July 2017-January 2019). Heart failure patients with commercial or Medicare Advantage insurance who received valsartan were compared to persons who received non-recalled angiotensin receptor blockers (ARBs) and angiotensin converting enzyme-inhibitors (ACE-Is) for 1 year prior and including the recall date. Outcomes included a composite for all-cause hospitalization, emergency department (ED), and urgent care (UC) use and a measure of cardiac events which included hospitalizations for acute myocardial infarction and hospitalizations/ED/UC visits for stroke/transient ischemic attack, heart failure or hypertension at 6-months post-recall. Cox proportional hazard models with propensity score weighting compared the risk of outcomes between groups.

RESULTS

Of the 87 130 adherent patients, 15% were valsartan users and 85% were users of non-recalled ARBs/ACE-Is. Valsartan use was not associated with an increased risk of all-cause hospitalization/ED/UC use six-months post-recall (HR 1.00; 95% CI 0.96-1.03), compared with individuals taking non-recalled ARBs/ACE-Is. Similarly, cardiac events 6-months post-recall did not differ between individuals on valsartan and non-recalled ARBs/ACE-Is (HR 1.04; 95% CI 0.97-1.12).

CONCLUSIONS

The valsartan recall did not affect short-term outcomes of heart failure patients. However, the recall potentially disrupted the medication regimens of patients, possibly straining the healthcare system.

Characteristics differentiating problem representation synthesis between novices and experts

BACKGROUND

Formulating a thoughtful problem representation (PR) is fundamental to sound clinical reasoning and an essential component of medical education. Aside from basic structural recommendations, little consensus exists on what characterizes high-quality PRs.

OBJECTIVES

To elucidate characteristics that distinguish PRs created by experts and novices.

METHODS

Early internal medicine residents (novices) and inpatient teaching faculty (experts) from two academic medical centers were given two written clinical vignettes and were instructed to write a PR and three-item differential diagnosis for each. Deductive content analysis described the characteristics comprising PRs. An initial codebook of characteristics was refined iteratively. The primary outcome was differences in characteristic frequencies between groups. The secondary outcome was characteristics correlating with diagnostic accuracy. Mixed-effects regression with random effects modeling compared case-level outcomes by group.

RESULTS

Overall, 167 PRs were analyzed from 30 novices and 54 experts. Experts included 0.8 fewer comorbidities (p < .01) and 0.6 more examination findings (p = .01) than novices on average. Experts were less likely to include irrelevant comorbidities (odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.2-0.8) or a diagnosis (OR = 0.3, 95% CI = 0.1-0.8) compared with novices. Experts encapsulated clinical data into higher-order terms (e.g., sepsis) than novices (p < .01) while including similar numbers of semantic qualifiers (SQs). Regardless of expertise level, PRs following a three-part structure (e.g., demographics, temporal course, and clinical syndrome) and including temporal SQs were associated with diagnostic accuracy (p < .01).

CONCLUSIONS

Compared with novices, expert PRs include less irrelevant data and synthesize information into higher-order concepts. Future studies should determine whether targeted educational interventions for PRs improve diagnostic accuracy.

Singing In The Mask: Effects Of A Variably Occluded Face Mask On Singing

OBJECTIVE

A limitation of traditional semi-occluded vocal tract exercises (SOVTE) is the single sustained vowel task that precludes co-articulated singing. This study investigated immediate effects of a variably occluded face mask (VOFM) on vocal effort, acoustic, and aerodynamic measures in sung low and high pitches of healthy singers.

DESIGN

Single-group, pre-post intervention study.

METHODS

The outlet ports of disposable anesthesia facemasks were fitted with plastic caps with two drilled openings sizes (9.6 mm, 6.4 mm). Twenty-three singers with no voice complaints provided baseline vocal effort, acoustic, and aerodynamic measures in high and low pitches. Participants trained in four conditions: two VOFM sizes (9.6 mm, 6.4 mm) in combination with the 20th and 80th percentile of the singer's pitch range. Participants were trained on three phonatory tasks: repeated consonant/vowel syllables, sung sentence, and sustained vowel. Vocal effort before and after training was compared using a visual-analog scale, while standardized mean differences captured acoustic and aerodynamic changes before and after training.

RESULTS

Participants reported decreased vocal effort after VOFM training at all occlusion and pitch combinations. On average, consistent beneficial effect sizes were found in cepstral peak prominence (CPP) and cepstral spectral index of dysphonia (CSID) for all 4 occlusion-pitch combinations, and vocal intensity and mean estimated subglottal pressure increased for all 4 occlusion-pitch training combinations. Changes in mean phonatory airflow and resistance were less consistent.

DISCUSSION

There was an immediate effect of decreased vocal effort in singing after VOFM training. Acoustic and aerodynamic effects were variable and modest. Future studies should explore changes in these outcomes after VOFM in singing voice therapy.

Internal Medicine Residents' Perceptions of Their Continuity Clinic Training

OBJECTIVES

Internal Medicine (IM) residents have reported dissatisfaction with continuity clinic (CC) training, which may contribute to the increasing shortage of primary care physicians. Studies show balancing inpatient and outpatient duties as a driver of dissatisfaction, but few studies have compared CC with inpatient (IP) training, following transition to an X + Y model, or assessed the impact of show rates, continuity, and telemedicine use on resident perceptions. The aim of this study was to adapt a validated survey to compare residents' perceptions of their CC with their inpatient medicine training and examine the impact of objective clinic measures on training.

METHODS

This quantitative cross-sectional study included a survey that was sent to 152 residents at an academic IM program in May-June 2021. Clinic measures such as show versus no-show rates, continuity with the residents' own patients, and visit modality were obtained through the electronic health records at Veterans Affairs and non-Veterans Affairs CCs.

RESULTS

The survey response rate was 78% (118/152). Residents were more satisfied with inpatient general medicine rotations than their CC experience (4.5 vs 3.3 on a 5-point scale, P < 0.001). Residents were more likely to pursue a profession in inpatient IM than in primary care (3.7 vs 2.3, P < 0.001). No correlation was found between higher show rates, continuity with patients, or proportion of visits conducted through telemedicine and resident satisfaction with CC.

CONCLUSIONS

This study aligns with previous findings of IM resident dissatisfaction with CC training while adding a side-by-side comparison to inpatient training and including objective CC data. We identified new areas for improvement of CC training, including residents' medical knowledge through review of quality metrics, making CC representative of real-world practice, and mentorship from faculty.

Team Functioning and Performance in Child Advocacy Center Multidisciplinary Teams

The quality of teamwork in Child Advocacy Center (CAC) multidisciplinary teams is likely to affect the extent to which the CAC model improves outcomes for children and families. This study examines associations between team functioning and performance in a statewide sample of CAC teams. Multidisciplinary team members (N = 433) from 21 CACs completed measures of affective, behavioral, and cognitive team functioning. Team performance was assessed with three measures: team member ratings of overall performance, ratings of mental health screening/referral frequency, and caregiver satisfaction surveys. Linear mixed models and regression analyses tested associations between team functioning and performance. Affective team functioning (i.e., liking, trust, and respect; psychological safety) and cognitive team functioning (i.e., clear direction) were significantly associated with team members' ratings of overall performance. Behavioral team functioning (i.e., coordination) and cognitive team functioning were significantly associated with mental health screening/referral frequency. Team functioning was not associated with caregiver satisfaction with CAC services. Aspects of team functioning were associated with team members' perceptions of overall performance and mental health screening/referral frequency, but not caregiver satisfaction. Understanding associations between team functioning and performance in multidisciplinary teams can inform efforts to improve service quality in CACs and other team-based service settings.

A Retrospective Cohort Study of the 2018 Angiotensin Receptor Blocker Recalls and Subsequent Drug Shortages in Patients With Hypertension

BACKGROUND

Valsartan was recalled by the US Food and Drug Administration in July 2018 for carcinogenic impurities, resulting in a drug shortage and management challenges for valsartan users. The influence of the valsartan recall on clinical outcomes is unknown. We compared the risk of adverse events between hypertensive patients using valsartan and a propensity score-matched group using nonrecalled angiotensin receptor blockers and angiotensin-converting enzyme inhibitors.

METHODS AND RESULTS

We used Optum's deidentified Clinformatics Datamart (July 2017-January 2019). Hypertensive patients who received valsartan or nonrecalled angiotensin receptor blockers/angiotensin-converting enzyme inhibitors for 1 year before and on the recall date were compared. Primary outcomes were measured in the 6 months following the recall and included: (1) a composite measure of all-cause hospitalization, all-cause emergency department visit, and all-cause urgent care visit, and (2) a composite cardiac event measure of hospitalizations for acute myocardial infarction and hospitalizations/emergency department visits/urgent care visits for stroke/transient ischemic attack, heart failure, or hypertension. We compared the risk of outcomes between treatment groups using Cox proportional hazard models. Of the hypertensive patients, 76 934 received valsartan, and 509 472 received a nonrecalled angiotensin receptor blocker/angiotensin-converting enzyme inhibitor. Valsartan use at the time of recall was associated with a higher risk of all-cause hospitalization, emergency department use, or urgent care use (hazard ratio [HR], 1.02 [95% CI, 1.00-1.04]) and the composite of cardiac events (HR, 1.22 [95% CI, 1.15-1.29]) within 6 months after the recall.

CONCLUSIONS

The valsartan recall and shortage affected hypertensive patients. Local- and national-level systems need to be enhanced to protect patients from drug shortages by providing safe and reliable medication alternatives.

Patterns of Telemedicine Use and Glycemic Outcomes of Endocrinology Care for Patients With Type 2 Diabetes

Importance

Telemedicine can increase access to endocrinology care for people with type 2 diabetes (T2D), but patterns of use and outcomes of telemedicine specialty care for adults with T2D beyond initial uptake in 2020 are not known.

Objective

To evaluate patterns of telemedicine use and their association with glycemic control among adults with varying clinical complexity receiving endocrinology care for T2D.

Design, Setting, and Participants

Retrospective cohort study in a single large integrated US health system. Participants were adults who had a telemedicine endocrinology visit for T2D from May to October 2020. Data were analyzed from June 2022 to October 2023.

Exposure

Patients were followed up through May 2022 and assigned to telemedicine-only, in-person, or mixed care (both telemedicine and in-person) cohorts according to visit modality.

Main Outcomes and Measures

Multivariable regression models were used to estimate hemoglobin A1c (HbA1c) change at 12 months within each cohort and the association of factors indicating clinical complexity (insulin regimen and cardiovascular and psychological comorbidities) with HbA1c change across cohorts. Subgroup analysis was performed for patients with baseline HbA1c of 8% or higher.

Results

Of 11 498 potentially eligible patients, 3778 were included in the final cohort (81 Asian participants [2%], 300 Black participants [8%], and 3332 White participants [88%]); 1182 used telemedicine only (mean [SD] age 57.4 [12.9] years; 743 female participants [63%]), 1049 used in-person care (mean [SD] age 63.0 [12.2] years; 577 female participants [55%]), and 1547 used mixed care (mean [SD] age 60.7 [12.5] years; 881 female participants [57%]). Among telemedicine-only patients, there was no significant change in adjusted HbA1c at 12 months (-0.06%; 95% CI, -0.26% to 0.14%; P = .55) while in-person and mixed cohorts had improvements of 0.37% (95% CI, 0.15% to 0.59%; P < .001) and 0.22% (95% CI, 0.07% to 0.38%; P = .004), respectively. Patients with a baseline HbA1c of 8% or higher had a similar pattern of glycemic outcomes. For patients prescribed multiple daily injections vs no insulin, the 12-month estimated change in HbA1c was 0.25% higher (95% CI, 0.02% to 0.47%; P = .03) for telemedicine vs in-person care. Comorbidities were not associated with HbA1c change in any cohort.

Conclusions and Relevance

In this cohort study of adults with T2D receiving endocrinology care, patients using telemedicine alone had inferior glycemic outcomes compared with patients who used in-person or mixed care. Additional strategies may be needed to support adults with T2D who rely on telemedicine alone to access endocrinology care, especially for those with complex treatment or elevated HbA1c.

Sex, military occupation and rank are associated with risk of anterior cruciate ligament injury in tactical-athletes

INTRODUCTION

Anterior cruciate ligament (ACL) injury is common within the US military and represents a significant loss to readiness. Since recent changes to operational tempo, there has not been an analysis of ACL injury risk. The aim of this retrospective cohort study was to evaluate military occupation, sex, rank and branch of service on ACL injury risk in the US military from 2006 to 2018.

METHODS

The Defense Medical Epidemiology Database was queried for the number of US tactical athletes with International Classification of Diseases diagnosis codes 717.83 (old disruption of ACL), 844.2 (sprain of knee cruciate ligament), M23.61 (other spontaneous disruption of ACL) and S83.51 (sprain of ACL of knee) on their initial encounter. Relative risk and χ2 statistics were calculated to assess sex and military occupation effects on ACL injury. A multivariable negative binomial regression model evaluated changes in ACL injury incidence with respect to sex, branch of service and rank.

RESULTS

The study period displayed a significant decrease in the ACL injury rate at 0.18 cases per 1000 person-years or relative decrease of 4.08% each year (p<0.001) after averaging over the main and interactive effects of sex, rank and branch of service. The interaction effect of time with sex indicated a steeper decline in the incidence in men as compared with women. The risk of ACL injury by sex was modified by rank. The incidence among military personnel varied by occupation.

CONCLUSION

Despite the decline among tactical athletes over time, rates of ACL injury remain much higher than the general US population. Sex, rank, branch of service and military occupation were found to be risk factors for ACL injury. It is critical for policy makers to understand the salient risk factors for ACL injury to guide proactive measures to prevent injury.

Predictors of 1-year enteral autonomy in children with intestinal failure: A descriptive retrospective cohort study

INTRODUCTION

The International Intestinal Failure Registry (IIFR) is an international consortium to study intestinal failure (IF) outcomes in a large contemporary pediatric cohort. We aimed to identify predictors of early (1-year) enteral autonomy.

METHODS

We included IIFR pilot phase patients. IF was defined by a parenteral nutrition need for at least 60 days due to a primary gastrointestinal etiology. The primary outcome was time to enteral autonomy achievement. We built a mixed-effects Weibull accelerated failure time model with random effects by center to analyze variables associated with enteral autonomy achievement with a primary outcome of time ratio (TR).

RESULTS

We included 189 patients (82% with short bowel syndrome) representing 11 international centers. Cumulative incidence of early enteral autonomy was 51.6%, and death was 6.5%. In multivariable analysis, ostomy presence (TR, 2.63; 95% CI, 1.41-4.90) was associated with increased time to enteral autonomy achievement, and Asian/Indian (TR, 0.28; 95% CI, 0.10-0.81) and Pacific Islander race (TR, 0.34; 95% CI, 0.13-0.90) were associated with decreased time to enteral autonomy achievement. In a second model in the subset with measured percentage of bowel length remaining, ostomy presence (TR, 4.21; 95% CI, 1.90-9.33) was associated with increased time to enteral autonomy achievement, whereas greater percentage of bowel remaining (TR, 0.96; 95% CI, 0.94-0.98) was associated with decreased time to enteral autonomy achievement.

CONCLUSIONS

Minimizing bowel resection at initial surgery and establishing bowel continuity by ostomy reversal can effectively decrease the time to early enteral autonomy achievement in children with IF.

Recombinant von Willebrand factor and tranexamic acid for heavy menstrual bleeding in patients with mild and moderate von Willebrand disease in the USA (VWDMin): a phase 3, open-label, randomised, crossover trial

BACKGROUND

Heavy menstrual bleeding occurs in 80% of women with von Willebrand disease and is associated with iron deficiency and poor response to current therapies. International guidelines indicate low certainty regarding effectiveness of hormonal therapy and tranexamic acid. Although von Willebrand factor (VWF) concentrate is approved for bleeds, no prospective trials guide its use in heavy menstrual bleeding. We aimed to compare recombinant VWF with tranexamic acid for reducing heavy menstrual bleeding in patients with von Willebrand disease.

METHODS

VWDMin, a phase 3, open-label, randomised crossover trial, was done in 13 haemophilia treatment centres in the USA. Female patients aged 13-45 years with mild or moderate von Willebrand disease, defined as VWF ristocetin cofactor less than 0·50 IU/mL, and heavy menstrual bleeding, defined as a pictorial blood assessment chart (PBAC) score more than 100 in one of the past two cycles were eligible for enrolment. Participants were randomly assigned (1:1) to two consecutive cycles each of intravenous recombinant VWF, 40 IU/kg over 5-10 min on day 1, and oral tranexamic acid 1300 mg three times daily on days 1-5, the order determined by randomisation. The primary outcome was a 40-point reduction in PBAC score by day 5 after two cycles of treatment. Efficacy and safety were analysed in all patients with any post-baseline PBAC scores. The trial was stopped early due to slow recruitment on Feb 15, 2022, by a data safety monitoring board request, and was registered at ClinicalTrials.gov, NCT02606045.

FINDINGS

Between Feb 12, 2019, and Nov 16, 2021, 39 patients were enrolled, 36 of whom completed the trial (17 received recombinant VWF then tranexamic acid and 19 received tranexamic acid then recombinant VWF). At the time of this unplanned interim analysis (data cutoff Jan 27, 2022), median follow-up was 23·97 weeks (IQR 21·81-28·14). The primary endpoint was not met, neither treatment corrected PBAC score to the normal range. Median PBAC score was significantly lower after two cycles with tranexamic acid than with recombinant VWF (146 [95% CI 117-199] vs 213 [152-298]; adjusted mean treatment difference 46 [95% CI 2-90]; p=0·039). There were no serious adverse events or treatment-related deaths and no grade 3-4 adverse events. The most common grade 1-2 adverse events were mucosal bleeding (four [6%] patients during tranexamic acid treatment vs zero during recombinant VWF treatment) and other bleeding (four [6%] vs two [3%]).

INTERPRETATION

These interim data suggest that recombinant VWF is not superior to tranexamic acid in reducing heavy menstrual bleeding in patients with mild or moderate von Willebrand disease. These findings support discussion of treatment options for heavy menstrual bleeding with patients based on their preferences and lived experience.

FUNDING

National Heart Lung Blood Institute (National Institutes of Health).

Enrollee characteristics and receipt of colorectal cancer testing in Pennsylvania after adoption of the Affordable Care Act Medicaid expansion

BACKGROUND

Colorectal cancer (CRC) is the fourth most common cancer and the second leading cause of cancer-related death in the U.S. Despite increased CRC screening rates, they remain low among low-income non-older adults, including Medicaid enrollees who are more likely to be diagnosed at advanced stages.

OBJECTIVES

Given limited evidence regarding CRC screening service use among Medicaid enrollees, we examined multilevel factors associated with CRC testing among Medicaid enrollees in Pennsylvania after Medicaid expansion in 2015.

RESEARCH DESIGN

Using the 2014-2019 Medicaid administrative data, we performed multivariable logistic regression models to assess factors associated with CRC testing, adjusting for enrollment length and primary care services use.

SUBJECTS

We identified 15,439 adults aged 50-64 years newly enrolled through Medicaid expansion.

MEASURES

Outcome measures include receiving any CRC testing and by modality.

RESULTS

About 32% of our study population received any CRC testing. Significant predictors for any CRC testing include being male, being Hispanic, having any chronic conditions, using primary care services ≤4 times annually, and having a higher county-level median household income. Being 60-64 years at enrollment, using primary care services >4 times annually, and having higher county-level unemployment rates were significantly associated with a decreased likelihood of receiving any CRC tests.

CONCLUSIONS

CRC testing rates were low among adults newly enrolled in Medicaid under the Medicaid expansion in Pennsylvania relative to adults with high income. We observed different sets of significant factors associated with CRC testing by modality. Our findings underscore the urgency to tailor strategies by patients' racial, geographic, and clinical conditions for CRC screening.

Sex-related differences in the prevalence of substance use disorders, treatment, and overdose among parents with young children

Introduction

Risk factors and treatment rates for substance use disorders (SUDs) differ by sex. Females often have greater childcare and household responsibilities than males, which may inhibit SUD treatment. We examined how SUD, medication for opioid use disorder (MOUD) receipt, and overdose rates differ by sex among parents with young children (<5 years).

Methods

Using deidentified national administrative healthcare data from Optum's Clinformatics® Data Mart Database version 8.1 (2007-2021), we identified parents aged 26-64 continuously enrolled in commercial insurance for ≥ 30 days and linked to ≥ 1 dependent child < 5 years from January 1, 2016-February 29, 2020. We used generalized estimating equations to estimate the average predicted prevalence of SUD diagnosis, MOUD receipt after opioid use disorder (OUD) diagnosis, and overdose by parent sex in any month, adjusting for age, race/ethnicity, state of residence, enrollment month, and mental health conditions.

Results

From 2016 to 2020, there were 2,241,795 parents with a dependent child < 5 years, including 1,155,252 (51.5%) females and 1,086,543 (48.5%) males. Male parents had a higher average predicted prevalence of an SUD diagnosis (11.1% [11, 11.16]) than female parents (5.5% [5.48, 5.58]). Among parents with OUD, the average predicted prevalence of receiving MOUD was 27.4% [26.1, 28.63] among male and 19.7% [18.34, 21.04] among female parents, with no difference in overdose rates by sex.

Conclusion

Female parents are less likely to be diagnosed with an SUD or receive MOUD than male parents. Removing policies that criminalize parental SUD and addressing childcare-related barriers may improve SUD identification and treatment.

Team-focused implementation strategies to improve implementation of mental health screening and referral in rural Children's Advocacy Centers: study protocol for a pilot cluster randomized hybrid type 2 trial

BACKGROUND

Children's Advocacy Centers (CACs) use multidisciplinary teams to investigate and respond to maltreatment allegations. CACs play a critical role in connecting children with mental health needs to evidence-based mental health treatment, especially in low-resourced rural areas. Standardized mental health screening and referral protocols can improve CACs' capacity to identify children with mental health needs and encourage treatment engagement. In the team-based context of CACs, teamwork quality is likely to influence implementation processes and outcomes. Implementation strategies that target teams and apply the science of team effectiveness may enhance implementation outcomes in team-based settings.

METHODS

We will use Implementation Mapping to develop team-focused implementation strategies to support the implementation of the Care Process Model for Pediatric Traumatic Stress (CPM-PTS), a standardized screening and referral protocol. Team-focused strategies will integrate activities from effective team development interventions. We will pilot team-focused implementation in a cluster-randomized hybrid type 2 effectiveness-implementation trial. Four rural CACs will implement the CPM-PTS after being randomized to either team-focused implementation (n = 2 CACs) or standard implementation (n = 2 CACs). We will assess the feasibility of team-focused implementation and explore between-group differences in hypothesized team-level mechanisms of change and implementation outcomes (implementation aim). We will use a within-group pre-post design to test the effectiveness of the CPM-PTS in increasing caregivers' understanding of their child's mental health needs and caregivers' intentions to initiate mental health services (effectiveness aim).

CONCLUSIONS

Targeting multidisciplinary teams is an innovative approach to improving implementation outcomes. This study will be one of the first to test team-focused implementation strategies that integrate effective team development interventions. Results will inform efforts to implement evidence-based practices in team-based service settings.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT05679154 . Registered on January 10, 2023.

Research Review: A systematic review and meta-analysis of infant and toddler temperament as predictors of childhood attention-deficit/hyperactivity disorder

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder with onset as early as preschool and impairment across the lifespan. Temperament factors, specifically those that theoretically map onto ADHD symptoms, may be early markers of risk for developing later childhood ADHD that could be identifiable in infancy or toddlerhood. This meta-analysis examined the associations between these early temperamental factors and later symptoms and diagnosis of ADHD and mapped early temperament constructs onto the three ADHD symptom dimensions.

METHODS

A systemic review of the literature was conducted to identify prospective longitudinal studies that included theoretically relevant temperament constructs (sustained attention, activity level, inhibition, and negative emotionality) examined from birth to 36 months old and ADHD (symptoms or diagnosis) in preschool or childhood. The association between each temperament construct and ADHD outcomes was examined using pooled standardized estimates in meta-analyses.

RESULTS

Forty-eight articles (n = 112,716 infants/toddlers) prospectively examined temperament and the relation to childhood ADHD symptoms or diagnosis. Activity level (k = 18) in infancy and toddlerhood was moderately associated with childhood ADHD (r = .39, CI = 0.27, 0.51, p < .001). Moderate effect sizes were also observed for sustained attention (k = 9; r = -.28, CI = -0.42, -0.12, p < .001) and negative emotionality (k = 33; r = .25, CI = 0.16, 0.34, p < .001) with ADHD. The specificity of each temperament construct for later ADHD symptom dimensions was such that activity level and negative emotionality were predictive of all three symptom dimensions (i.e., inattention, hyperactivity/impulsivity, and combined), whereas sustained attention was only associated with combined symptoms.

CONCLUSIONS

Infant and toddler temperament is an early risk factor for the development of childhood ADHD that could be utilized for early intervention identification. Yet, this systematic review found that relatively few prospective longitudinal studies have examined sustained attention (k = 9) and inhibition (k = 15) in infancy and toddlerhood in relation to later ADHD highlighting the need for further research.

Cost of pediatric intestinal transplant in the United States: an analysis of the Pediatric Health Information Systems database

BACKGROUND

We aimed to evaluate costs from transplant to discharge in children who had undergone intestine transplant.

METHODS

We performed a cross-sectional observational study of pediatric intestine transplant recipients from 2004 through 2020 utilizing the Pediatric Health Information System® database. Standardized costs were applied to all charges and converted to 2021 US Dollars. We analyzed the association of cost from transplant to discharge with age, sex, race/ethnicity, length of stay, insurance type, transplant year, short bowel syndrome diagnosis, liver-containing graft, hospitalization status, and immunosuppressive regimen. Predictors with a p-value <0.20 in univariable analysis were included in a multivariable model, which was reduced to final model using backwards selection with a p-value of 0.05.

RESULTS

We identified 376 intestinal transplant recipients across 9 centers (median age 2 years, 44% female). Most patients had short bowel syndrome (294, 78%). The liver was included in 218 transplants (58%). Median post-transplant cost was $263,724 [IQR: $179,564-$384,147] and length-of-stay was 51.5 days [IQR 34-77]. In the final multivariable model, increased cost from transplant to hospital discharge was associated with liver-containing graft (+$31,805, p=0.028), T-cell depleting antibody use (+$77,004, p<0.001), and mycophenolate mofetil use (+$50,514, p=0.012) while controlling for insurance type and length of stay. A 60-day post-transplant hospital stay would cost an estimated $272,533.

CONCLUSIONS

Intestine transplant has high immediate cost and a nearly 2-month length of stay that varies by center, graft type, and immunosuppression regimen. Future work will examine the cost-effectiveness of various management strategies both pre- and post-transplant. This article is protected by copyright. All rights reserved.

Assessing Candidacy for Conversation Training Therapy: The Role of Patient Perception

OBJECTIVE

Voice therapy is the primary treatment modality for voice rehabilitation. Specific patient-ability factors beyond patient-characteristic factors (eg, disorder diagnosis, age, etc.), that influence individual patient responses to voice treatment remain largely unknown. The goal of the current study was to determine the relationship between patient-perceived improvements in both the sound and feel of voice during stimulability assessment and voice therapy outcomes.

STUDY DESIGN

Prospective Cohort study.

METHODS

This study was a single-arm, single-center, prospective study. Fifty patients with primary muscle tension dysphonia and benign vocal fold lesions were enrolled. Patients read the first four sentences of the Rainbow Passage and were asked if they experienced a change in the feel or sound of their voice following the stimulability prompt. Patients then completed four sessions of conversation training therapy (CTT) voice therapy and followed up one-week and three-months after their last therapy session, for a total of six time-points. Demographic data were collected at baseline, and voice handicap index 10 (VHI-10) scores were collected at each follow-up time-point. The primary exposure variables were CTT intervention and patient perception of voice change to stimulability probes. The primary outcome was change in VHI-10 score.

RESULTS

On average, VHI-10 scores improved for all participants following CTT treatment. All participants heard a change in the sound of voice with stimulability prompts. Descriptively, patients who reported a positive change in the feel of their voice after stimulability testing recovered faster (ie, experienced a sharper decline in VHI-10) compared to those who did not note a change in feel of voice during stimulability testing. However, the rate of change over time was not significantly different between groups.

CONCLUSION

Patient self-perception of a change in the sound and feel of voice in response to stimulability probes during initial evaluation is an important factor in treatment outcomes. Patients who perceive an improved feel of their voice production after stimulability probes may respond to voice therapy more quickly.

Associations between teamwork and implementation outcomes in multidisciplinary cross-sector teams implementing a mental health screening and referral protocol

PURPOSE

Teams play a central role in the implementation of new practices in settings providing team-based care. However, the implementation science literature has paid little attention to potentially important team-level constructs. Aspects of teamwork, including team interdependence, team functioning, and team performance, may affect implementation processes and outcomes. This cross-sectional study tests associations between teamwork and implementation antecedents and outcomes in a statewide initiative to implement a standardized mental health screening/referral protocol in Child Advocacy Centers (CACs).

METHODS

Multidisciplinary team members (N = 433) from 21 CACs completed measures of team interdependence; affective, behavioral, and cognitive team functioning; and team performance. Team members also rated the acceptability, appropriateness, and feasibility of the screening/referral protocol and implementation climate. The implementation outcomes of days to adoption and reach were independently assessed with administrative data. Associations between team constructs and implementation antecedents and outcomes were tested with linear mixed models and regression analyses.

RESULTS

Team task interdependence was positively associated with implementation climate and reach, and outcome interdependence was negatively correlated with days to adoption. Task and outcome interdependence were not associated with acceptability, appropriateness, or feasibility of the screening/referral protocol. Affective team functioning (i.e., greater liking, trust, and respect) was associated with greater acceptability, appropriateness, and feasibility. Behavioral and cognitive team functioning were not associated with any implementation outcomes in multivariable models. Team performance was positively associated with acceptability, appropriateness, feasibility, and implementation climate; performance was not associated with days to adoption or reach.

CONCLUSIONS

We found associations of team interdependence, functioning, and performance with both individual- and center-level implementation outcomes. Implementation strategies targeting teamwork, especially task interdependence, affective functioning, and performance, may contribute to improving implementation outcomes in team-based service settings.

Air Quality Index and Childhood Asthma: A Pilot Randomized Clinical Trial Intervention

INTRODUCTION

To reduce air pollution exposure, the U.S. asthma guidelines recommend that children check the Air Quality Index before outdoor activity. Whether adding the Air Quality Index and recommendations to asthma action plans reduces exacerbations and improves control and quality of life in children with asthma is unknown.

METHODS

A pilot, unblinded, randomized clinical trial of 40 children with persistent asthma, stratified by age and randomized 1:1, recruited from the University of Pittsburgh Medical Center Children's Hospital of Pittsburgh (Pittsburgh, PA) was conducted. All participants received asthma action plans and Air Quality Index education. The intervention group received printed Air Quality Index information and showed the ability to use AirNow. Asthma exacerbations were assessed through a questionnaire, asthma control was assessed with the Asthma Control Test and Childhood Asthma Control Test, and quality of life was assessed with the Pediatric Asthma Quality of Life Questionnaire. After randomization (July-October 2020), participants were followed monthly for 6 months (exit January-March 2021). Outcome differences between groups were evaluated at the exit visit and over time (analysis was in 2021).

RESULTS

At randomization, there were no significant differences in age, sex, race, or asthma severity. At exit, more intervention participants checked the Air Quality Index (63% vs 15%) with no differences in the proportion of asthma exacerbations or mean Childhood Asthma Control Test or Pediatric Asthma Quality of Life Questionnaire scores. The mean change in Asthma Control Test score was higher in the intervention group (change in Asthma Control Test=2.00 vs 0.15 for the control), which was modified by time (β=1.85, CI=0.09, 3.61). Physical activity was decreased overall and showed modification by treatment and time.

CONCLUSIONS

Addition of the Air Quality Index to asthma action plans led to improved asthma control by Asthma Control Test scores but may decrease outdoor activity.

Evaluation of an Internal Medicine Transition to Residency Course

OBJECTIVES

We sought to evaluate the effectiveness of a novel Internal Medicine (IM) transition to residency (TTR) curriculum.

METHODS

We performed a paired pre-/postsurvey evaluation of graduating fourth-year medical students' perceived preparedness and medical knowledge after participating in a recently developed IM TTR course.

RESULTS

The response rate was 51% (24 of 47). There was a significant improvement in 15 of 17 perceived preparedness items and significant improvement in the medical students' performance on the 8-question medical knowledge test.

CONCLUSIONS

The IM TTR curriculum improved medical students' medical knowledge and perceived preparedness for internship on a variety of high-yield clinical topics. The curriculum may be appealing to other institutions that are developing or revamping TTR courses.

Increasing access to immediate postpartum contraceptive implants: a prospective clinical trial among patients with opioid use disorder

OBJECTIVE

To evaluate the effects of increased access to immediate postpartum contraceptive implants (IPI) on repeat pregnancy and contraceptive use rates among patients with opioid use disorder (OUD).

MATERIALS AND METHODS

Between 2016 and 2018, 194 postpartum patients with OUD were offered the option of IPI placement at an institution with limited immediate postpartum long-acting reversible contraception availability and followed for one-year postpartum. Differences in pregnancy rates between participants who did and did not choose IPI were examined using logistic regression with inverse probability of treatment weighting from propensity scores accounting for differences between the two groups.

RESULTS

Among 194 participants, 96 (49.5%) chose an IPI and 98 (50.5%) chose an alternative method or no contraception (non-IPI). Among IPI participants, 76 (80.9%) continued to use their implant at one-year postpartum. Overall, 19 participants had a repeat pregnancy and 11 (57.9%) were unintended. In multivariable analyses, repeat pregnancy was more likely among those who did not choose IPI (OR 9.90; 95% CI 3.58-27.03) than those who did. Participants with OUD and who used alcohol (11.66; 1.38, 98.20) or cocaine (2.72; 1.23, 5.99) during pregnancy were more likely to choose IPI. Participants who were married (0.28; 0.09, 0.89), engaged in OUD treatment prior to pregnancy (0.48; 0.25, 0.93), and happier when they found out about their pregnancy (0.87; 0.77, 0.98) were less likely to choose IPI.

CONCLUSION

Offering patients with OUD the option of IPI is associated with high utilisation and continuation rates, and low rates of repeat pregnancy within one-year postpartum.

Assessment of BMI and Venous Thromboembolism Rates in Patients on Standard Chemoprophylaxis Regimens After Undergoing Free Tissue Transfer to the Head and Neck

Importance

Venous thromboembolism (VTE) is a severe complication after free tissue transfer to the head and neck (H&N). Enoxaparin 30 mg twice daily (BID) is a common regimen for chemoprophylaxis. However, differences in enoxaparin metabolism based on body weight may influence its efficacy and safety profile.

Objective

To assess the association between BMI and postoperative VTE and hematoma rates in patients treated with prophylactic enoxaparin 30 mg BID.

Design, Setting, and Participants

This was a retrospective review of a prospectively collected cohort from 2012 to 2022. Postoperative VTE, hematoma, and free flap pedicle thrombosis were recorded within 30 days of index surgery. The setting was a tertiary academic referral center. Participants included patients undergoing H&N reconstruction with free flaps that received fixed-dose subcutaneous enoxaparin 30 mg BID postoperatively. Statistical analysis was conducted from April to May 2022.

Main Outcomes and Measures

Outcomes include incidence of VTE, hematoma, and flap pedicle thrombosis events within 30 days of the surgery. Univariate and multivariable regression models were used to evaluate associations between BMI and other patient factors with these outcomes.

Results

Among the 765 patients included, 262 (34.24%) were female; mean (SD) age was 60.85 (12.64) years; and mean (SD) BMI was 26.36 (6.29). The rates of VTE and hematoma in the cohort were 3.92% (30 patients) and 5.09% (39 patients), respectively. After adjusting for patient factors, BMI was the only factor associated with VTE (OR, 1.07; 95% CI, 1.015-1.129). Obesity (BMI >30) was associated with increased odds of VTE (OR, 2.782; 95% CI, 1.197-6.564). Hematoma was not associated with BMI (OR, 0.988; 95% CI, 0.937-1.041). Caprini score of at least 9 was not associated with VTE (OR, 1.259; 95% CI, 0.428-3.701).

Conclusions and Relevance

This cohort study found that obesity was associated with an increased risk of VTE in patients after microvascular H&N reconstruction and while on standard postoperative chemoprophylaxis regimens. This association may suggest insufficient VTE prophylaxis in this group and a potential indication for weight-based dosing.

The Effect of Geographic Cohorting of Inpatient Teaching Services on Patient Outcomes and Resident Experience

BACKGROUND

Geographic cohorting is a hospital admission structure in which every patient on a given physician team is admitted to a dedicated hospital unit. Little is known about the long-term impact of this admission structure on patient outcomes and resident satisfaction.

OBJECTIVE

To evaluate the effect of geographic cohorting on patient outcomes and resident satisfaction among inpatient internal medicine teaching services within an academic hospital.

DESIGN AND INTERVENTION

We conducted an interrupted time series analysis examining patient outcomes before and after the transition to geographic cohorting of our 3 inpatient teaching services within a 520-bed academic hospital in November 2017. The study observation period spanned from January 2017 to October 2018, allowing for a 2-month run-in period (November-December 2017).

PARTICIPANTS

We included patients discharged from the inpatient teaching teams during the study period. We excluded patients admitted to the ICU and observation admissions.

MAIN MEASURES

Primary outcome was 6-month mortality adjusted for patient age, sex, race, insurance status, and Charlson Comorbidity Index (CCI) analyzed using a linear mixed effects model. Secondary outcomes included hospital length of stay (LOS), 7-day and 30-day readmission rate, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, and resident evaluations of the rotation.

KEY RESULTS

During the observation period, 1720 patients (mean age 64, 53% female, 56% white, 62% Medicare-insured, mean CCI 1.57) were eligible for inclusion in the final adjusted model. We did not detect a significant change in 6-month mortality, LOS, and 7-day or 30-day readmission rates. HCAHPS scores remained unchanged (77 to 80% top box, P = 0.19), while resident evaluations of the rotation significantly improved (mean overall score 3.7 to 4.0, P = 0.03).

CONCLUSIONS

Geographic cohorting was associated with increased resident satisfaction while achieving comparable patient outcomes to those of traditional hospital admitting models.

Prognostic implications of a one-item health literacy screen on health status outcomes among heart failure patients with depression

Background

Health literacy (HL) is the degree to which individuals can obtain, process, and understand basic health information and services. Although low HL portends greater risk for clinical events, its association with heart failure (HF)-specific health status- patients' symptoms, function and quality of life- is poorly understood. We thus explored the association of low HL with health status outcomes in depressed patients with HF, for whom treatment regimens can be complex.

Methods

Participants with HF with reduced ejection fraction and depression, from the Hopeful Heart trial, were categorized as having low or adequate HL at baseline using a validated, 1-item HL screen. HF-specific health status was measured at baseline, 3, 6, and 12 months using the 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ-12). Using serial risk-adjusted linear regression models, we assessed the association of HL with baseline, 12-month and 12-month change in the KCCQ Overall Summary (OS) scores (range 0-100; lower scores = worse health status).

Results

Among 629 participants, 35 % had low HL. Those with low HL had lower health status at all time points, including at 12 months after discharge (-9.8 points, 95%CI [-14.3, -5.3], p < 0.001), with poorer improvements in KCCQ-OS scores after accounting for baseline health status (-6.4 points, 95%CI [-10.5, -2.3], p = 0.002).

Conclusions

In those with HF and depression, low HL was common and associated with worse HF-specific health status and poorer improvement over time. A brief HL screen can identify patients at risk for poorer health status outcomes and for whom additional interventions may be warranted.

Time from diagnosis to treatment is associated with survival in patients with acute myeloid leukaemia: An analysis of 55 985 patients from the National Cancer Database

Acute myeloid leukaemia (AML) is conventionally thought of as a medical emergency. However, several studies on the association of time from diagnosis to treatment with survival did not have concordant results. Here we analyse 55 985 AML patients from the National Cancer Database, and we show that in patients less than 60 years old a five-day delay in chemotherapy initiation leads to worse long-term survival. The difference is small [hazard ratio (HR) 1.05, 95% confidence interval (CI) 1.01-1.09 in multivariate analysis] but statistically significant. This study raises the issue of power to detect small differences in retrospective studies.

High Mortality After Total Knee Arthroplasty Periprosthetic Joint Infection is Related to Preoperative Morbidity and the Disease Process but Not Treatment

BACKGROUND

Periprosthetic joint infection (PJI) mortality rate is approximately 20%. The etiology for high mortality remains unknown. The objective of this study was to determine whether mortality was associated with preoperative morbidity (frailty), sequalae of treatment, or the PJI disease process itself.

METHODS

A multicenter observational study was completed comparing 184 patients treated with septic revision total knee arthroplasty (TKA) to a control group of 38 patients treated with aseptic revision TKA. Primary outcomes included time and the cause of death. Secondary outcomes included preoperative comorbidities and Charlson Comorbidity Index (CCMI) measured preoperatively and at various postoperative timepoints.

RESULTS

The septic revision TKA cohort experienced earlier mortality compared to the aseptic cohort, with a higher mortality rate at 90 days, 1, 2, and 3 years after index revision surgery (P = .01). There was no significant difference for any single cause of death (P > .05 for each). The mean preoperative CCMI was higher (P = .005) in the septic revision TKA cohort. Both septic and aseptic cohorts experienced a significant increase in CCMI from the preoperative to 3 years postoperative (P < .0001 and P = .002) and time of death (P < .0001 both) timepoints. The septic revision TKA cohort had a higher CCMI 3 years postoperatively (P = .001) and at time of death (P = .046), but not one year postoperatively (P = .119).

CONCLUSION

Compared to mortality from aseptic revision surgery, septic revision TKA is associated with earlier mortality, but there is no single specific etiology. As quantified by changes in CCMI, PJI mortality was associated with both frailty and the PJI disease process, but not treatment.

Medical Student Attitudes on Explicit Informed Consent for Pelvic Exams Under Anesthesia

OBJECTIVE

To obtain an overview of medical student attitudes on the need for explicit consent for pelvic exams under anesthesia performed for educational purposes DESIGN: From February to October 2020, 201 medical students at a single medical school in the United States participated in a cross-sectional survey after completion of the obstetrics and gynecology clerkship. Outcome measures included endorsement of need for explicit informed consent for educational pelvic exams under anesthesia, and knowledge of informed consent processes for such exams.

SETTING

University of Pittsburgh School of Medicine PARTICIPANTS: Third- and fourth-year medical students RESULTS: Overall, 75% of medical students endorsed a need for explicit informed consent for educational pelvic exams under anesthesia, which extended to prostate, rectal, and breast exams under anesthesia. Additionally, 45% and 77% of these participants indicated that consent for educational pelvic exams under anesthesia should take the form of a separate signature line on the surgical consent form and/or a verbal form, respectively. Only 40% of students correctly identified institutional policy for obtaining informed consent for educational pelvic exams under anesthesia. Rotation with the oncologic surgical service (p = 0.02) and correct identification of institutional informed consent policies (p = 0.002) were associated with decreased perceptions of the importance of explicit informed consent for educational pelvic exams under anesthesia.

CONCLUSIONS

Medical students at the institution studied largely support explicit informed consent for educational pelvic and other sensitive exams under anesthesia, but a knowledge gap on institutional informed consent policy exists. Medical students support increased transparency and bodily autonomy. Due to the agreement of patients and medical students and the ethical rationale for this position, it may be appropriate for physicians and institutions to consider new processes of obtaining explicit informed consent for pelvic exams under anesthesia by medical students.

Association of Duration of Methadone or Buprenorphine Use During Pregnancy With Risk of Nonfatal Drug Overdose Among Pregnant Persons With Opioid Use Disorder in the US

This cohort study evaluates the association of the duration of methadone or buprenorphine use during pregnancy and the risk of nonfatal drug overdose among pregnant persons with opioid use disorder in the US.

A Video- and Case-Based Curriculum on the Management of Alcohol Use Disorder for Internal Medicine Residents

INTRODUCTION

Alcohol use disorder (AUD) is commonly undertreated. Physicians cite discomfort with AUD medication as a barrier to treatment. While several curricula teach and assess screening and brief interventions, few teach and assess learner knowledge of treatment options.

METHODS

We created a video- and case-based curriculum for internal medicine residents delivered by 16 internal medicine faculty in three 30-minute sessions at four clinic sites. Learner knowledge, attitudes, and confidence were assessed before and after the curriculum. We used qualitative methods to evaluate learner reflections. We also assessed faculty satisfaction with the curriculum.

RESULTS

Of 153 residents receiving the curriculum, 35 (23%) completed both pre- and postsurveys. Median percent correct on knowledge questions improved from 67% pre- to 80% postcurriculum (p < .001). Confidence increased for all three items assessing it, with a notable increase in confidence with pharmacotherapy (2.9 pre- vs. 4.5 postcurriculum on a 7-point Likert scale with high scores indicating greater confidence, p < .001). Positive attitudes toward people with AUD increased from 3.4 pre- to 3.9 postcurriculum (p < .001) on a 7-point Likert scale. Learners continued to express concerns about prescribing logistics, the role of primary care, and management of ongoing use. Thirteen of 16 faculty (83%) completed the postcurricular survey; all said they would be happy to facilitate again.

DISCUSSION

Implementation of this curriculum for the management of AUD improved resident knowledge, attitudes, and confidence in AUD treatment. The curriculum was acceptable to faculty and is ideal for programs looking to expand teaching about AUD.

The use of podcasts as a tool to teach clinical reasoning: a pseudorandomized and controlled study

OBJECTIVES

Podcasts have emerged as an efficient method for widespread delivery of educational clinical reasoning (CR) content. However, the impact of such podcasts on CR skills has not been established. We set out to determine whether exposure to expert reasoning in a podcast format leads to enhanced CR skills.

METHODS

This is a pseudo-randomized study of third-year medical students (MS3) to either a control group (n=22) of pre-established online CR modules, or intervention group (n=26) with both the online modules and novel CR podcasts. The podcasts were developed from four "clinical unknown" cases presented to expert clinician educators. After completing these assignments in weeks 1-2, weekly history and physical (H&P) notes were collected and graded according to the validated IDEA rubric between weeks 3-7. A longitudinal regression model was used to compare the H&P IDEA scores over time. Usage and perception of the podcasts was also assessed via survey data.

RESULTS

Ninety control and 128 intervention H&Ps were scored. There was no statistical difference in the change of average IDEA scores between intervention (0.92, p=0.35) and control groups (-0.33, p=0.83). Intervention participants positively received the podcasts and noted increased discussion of CR principles from both their ward (3.1 vs. 2.4, p=0.08) and teaching (3.2 vs. 2.5, p=0.05) attendings.

CONCLUSIONS

This is the first objective, pseudo-randomized assessment of CR podcasts in undergraduate medical education. While we did not demonstrate significant improvement in IDEA scores, our data show that podcasts are a well-received tool that can prime learners to recognize CR principles.

Operationalizing and analyzing 2-step gender identity questions: Methodological and ethical considerations

OBJECTIVE

Two-step questions to assess gender identity are recommended for optimizing care delivery for gender-diverse individuals. As gender identity fields are increasingly integrated into electronic health records, guidance is needed on how to analyze these data. The goal of this study was to assess potential approaches for analyzing 2-step gender identity questions and the impact of each on suicidal ideation.

MATERIALS AND METHODS

A regional Youth Risk Behavior Survey in one Northeastern school district used a 2-step question to assess gender identity. Three gender measurement strategies (GMSs) were used to operationalize gender identity, (1) combining all gender-diverse youth (GDY) into one category, (2) grouping GDY based on sex assigned at birth, and (3) categorizing GDY based on binary and nonbinary identities. Mixed-effects logistic regression was used to compare odds of suicidal ideation between gender identity categories for each GMS.

RESULTS

Of the 3010 participants, 8.3% were GDY. Subcategories of GDY had significantly higher odds (odds ratio range, 1.6-2.9) of suicidal ideation than cisgender girls regardless of GMS, while every category of GDY had significantly higher odds (odds ratio range, 2.1-5.0) of suicidal ideation than cisgender boys.

CONCLUSIONS

The field of clinical informatics has an opportunity to incorporate inclusive items like the 2-step gender identity question into electronic health records to optimize care and strengthen clinical research. Analysis of the 2-step gender identity question impacts study results and interpretation. Attention to how data about GDY are captured will support for more nuanced, tailored analyses that better reflect unique experiences within this population.

Outcomes associated with the use of medications for opioid use disorder during pregnancy

AIM

To test the effect of the duration of medication for opioid use disorder (MOUD) use during pregnancy on maternal, perinatal and neonatal outcomes.

DESIGN

Retrospective cohort analysis of claims, encounter and pharmacy data.

SETTING

Pennsylvania, USA.

PARTICIPANTS

We analyzed 13 320 pregnancies among 10 741 women with opioid use disorder aged 15-44 years enrolled in Pennsylvania Medicaid between 2009 and 2017.

MEASUREMENTS

We examined five outcomes during pregnancy and for 12 weeks postpartum: (1) overdose, (2) postpartum MOUD continuation, (3) preterm birth (< 37 weeks gestation), (4) term low birth weight (< 2500 g at ≥ 37 weeks) and (5) neonatal abstinence syndrome (NAS). Our primary exposure was the duration (count of weeks) of any MOUD use, including methadone or buprenorphine, during pregnancy.

FINDINGS

Among 13 320 pregnancies, 306 (2.3%) were complicated by an overdose, 1753 (13.2%) resulted in a preterm birth and 6787 (50.9%) continued MOUD postpartum. Among infants, 874 (7.6%) were low birth weight at term and 7706 (57.9%) were diagnosed with NAS. As the duration of MOUD use increased, we found a statistically significant decrease in the rate of overdose and preterm birth, a statistically significant increase in the rate of postpartum MOUD continuation and NAS and a decline in term low birth weight. Specifically, for each additional week of MOUD, the adjusted odds of overdose decreased by 2% [adjusted odds ratio (aOR) = 0.98; 95% confidence interval (CI) = 0.97, 0.99], preterm birth decreased by 1% (aOR = 0.99; 95% CI = 0.99, 1.00), postpartum MOUD continuation increased by 95% (aOR = 1.95; 95% CI = 1.87, 2.04) and NAS increased by 41% (aOR = 1.41; 95% CI = 1.35, 1.47). The odds of term low birth weight did not change (aOR = 1.00; 95% CI = 0.99, 1.00), although the rate declined with a longer duration of MOUD use during pregnancy.

CONCLUSIONS

Longer duration of medication for opioid use disorder use during pregnancy appears to be associated with improved maternal and perinatal outcomes.

Establishing Competencies for Leadership Development for Postgraduate Internal Medicine Residents

BACKGROUND

Although graduate medical education accrediting bodies recognize the importance of leadership for residents and encourage curricular development, it remains unclear which competencies are most important for early career physicians to possess.

OBJECTIVE

To generate a prioritized list of essential postgraduate leadership competencies to inform best practices for future curricular development.

METHODS

In 2019, we used a Delphi approach, which allows for generation of consensus, to survey internal medicine (IM) physicians in leadership roles with expertise in medical education and/or leadership programming within national professional societies. Panelists ranked a comprehensive list of established leadership competencies for health care professionals, across 3 established domains (character, emotional intelligence, and cognitive skills), on importance for categorical IM residents to perform by the end of residency. Respondents also identified number of content hours and pedagogical format best suited to teach each skill.

RESULTS

Sixteen and 14 panelists participated in Delphi rounds 1 and 2, respectively (88% response rate). Most were female (71%) and senior (64% in practice > 15 years, 57% full professor). All practiced in academic environments and all US regions were represented. The final consensus list included 12 "essential" and 9 "very important" leadership skills across all 3 leadership domains. Emotional intelligence and character domains were equally represented in the consensus list despite being disproportionately underweighted initially. Panelists most frequently recommended content delivery via mentorship/coaching, work-based reflection, and interactive discussion.

CONCLUSIONS

This study's results suggest that postgraduate curricular interventions should emphasize emotional intelligence and character domains of leadership and prioritize coaching, discussion, and reflection for delivery.

Efficacy of Blended Collaborative Care for Patients With Heart Failure and Comorbid Depression: A Randomized Clinical Trial

IMPORTANCE

Depression is often comorbid in patients with heart failure (HF) and is associated with worse clinical outcomes. However, depression generally goes unrecognized and untreated in this population.

OBJECTIVE

To determine whether a blended collaborative care program for treating both HF and depression can improve clinical outcomes more than collaborative care for HF only and physicians' usual care (UC).

DESIGN, SETTING, AND PARTICIPANTS

This 3-arm, single-blind, randomized effectiveness trial recruited 756 participants with HF with reduced left ventricular ejection fraction (<45%) from 8 university-based and community hospitals in southwestern Pennsylvania between March 2014 and October 2017 and observed them until November 2018. Participants included 629 who screened positive for depression during hospitalization and 2 weeks postdischarge and 127 randomly sampled participants without depression to facilitate further comparisons. Key analyses were performed November 2018 to March 2019.

INTERVENTIONS

Separate physician-supervised nurse teams provided either 12 months of collaborative care for HF and depression ("blended" care) or collaborative care for HF only (enhanced UC [eUC]).

MAIN OUTCOMES AND MEASURES

The primary outcome was mental health-related quality of life (mHRQOL) as measured by the Mental Component Summary of the 12-item Short Form Health Survey (MCS-12). Secondary outcomes included mood, physical function, HF pharmacotherapy use, rehospitalizations, and mortality.

RESULTS

Of the 756 participants (mean [SD] age, 64.0 [13.0] years; 425 [56%] male), those with depression reported worse mHRQOL, mood, and physical function but were otherwise similar to those without depression (eg, mean left ventricular ejection fraction, 28%). At 12 months, blended care participants reported a 4.47-point improvement on the MCS-12 vs UC (95% CI, 1.65 to 7.28; P = .002), but similar scores as the eUC arm (1.12; 95% CI, -1.15 to 3.40; P = .33). Blended care participants also reported better mood than UC participants (Patient-Reported Outcomes Measurement Information System-Depression effect size, 0.47; 95% CI, 0.28 to 0.67) and eUC participants (0.24; 95% CI, 0.07 to 0.41), but physical function, HF pharmacotherapy use, rehospitalizations, and mortality were similar by both baseline depression and randomization status.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial of patients with HF and depression, telephone-delivered blended collaborative care produced modest improvements in mHRQOL, the primary outcome, on the MCS-12 vs UC but not eUC. Although blended care did not differentially affect rehospitalization and mortality, it improved mood better than eUC and UC and thus may enable organized health care systems to provide effective first-line depression care to medically complex patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02044211.

An equivalence analysis of provider education in youth mental health care

OBJECTIVE

To test for equivalence between providers with and without advanced degrees in multiple domains related to delivery of evidence-based treatment.

DATA SOURCE

Provider and client data from an effectiveness trial of Alternatives for Families: A Cognitive Behavioral Therapy (AF-CBT) in a major metropolitan area in the United States.

STUDY DESIGN

We tested for equivalence between providers (N = 182) with and without advanced degrees in treatment-related knowledge, practices, and attitudes; job demands and stress; and training engagement and trainer-rated competence in AF-CBT. We also conducted exploratory analyses to test for equivalence in family clinical outcomes.

DATA COLLECTION

Providers completed measures prior to randomization and at 6-month follow-up, after completion of training and consultation in AF-CBT. Children and caregivers completed assessments at 0, 6, 12, and 18 months.

PRINCIPAL FINDINGS

Providers without advanced degrees were largely non-inferior to those with advanced degrees in treatment-related knowledge, practices, and attitudes, while findings for job demands and stress were mixed. Providers without advanced degrees were non-inferior to providers with advanced degrees in consultation attendance (B = -1.42; confidence interval (CI) = -3.01-0.16; margin of equivalence (Δ) = 2), number of case presentations (B = 0.64; CI = -0.49-1.76; Δ = 2), total training hours (B = -4.57; CI = -10.52-1.37; Δ = 3), and trainer-rated competence in AF-CBT (B = -0.04; CI = -3.04-2.96; Δ = 4), and they were significantly more likely to complete training (odds ratio = 0.66; CI = 0.10-0.96; Δ = 30%). Results for clinical outcomes were largely inconclusive.

CONCLUSIONS

Provider-level outcomes for those with and without advanced degrees were generally comparable. Additional research is needed to examine equivalence in clinical outcomes. Expanding evidence-based treatment training to individuals without advanced degrees may help to reduce workforce shortages and improve reach of evidence-based treatments.

Patient Recruitment Into a Multicenter Clinical Cohort Linking Electronic Health Records From 5 Health Systems: Cross-sectional Analysis

Background

There is growing interest in identifying and recruiting research participants from health systems using electronic health records (EHRs). However, few studies have described the practical aspects of the recruitment process or compared electronic recruitment methods to in-person recruitment, particularly across health systems.

Objective

The objective of this study was to describe the steps and efficiency of the recruitment process and participant characteristics by recruitment strategy.

Methods

EHR-based eligibility criteria included being an adult patient engaged in outpatient primary or bariatric surgery care at one of 5 health systems in the PaTH Clinical Research Network and having ≥2 weight measurements and 1 height measurement recorded in their EHR within the last 5 years. Recruitment strategies varied by site and included one or more of the following methods: (1) in-person recruitment by study staff from clinical sites, (2) US postal mail recruitment letters, (3) secure email, and (4) direct EHR recruitment through secure patient web portals. We used descriptive statistics to evaluate participant characteristics and proportion of patients recruited (ie, efficiency) by modality.

Results

The total number of eligible patients from the 5 health systems was 5,051,187. Of these, 40,048 (0.8%) were invited to enter an EHR-based cohort study and 1085 were enrolled. Recruitment efficiency was highest for in-person recruitment (33.5%), followed by electronic messaging (2.9%), including email (2.9%) and EHR patient portal messages (2.9%). Overall, 779 (65.7%) patients were enrolled through electronic messaging, which also showed greater rates of recruitment of Black patients compared with the other strategies.

Conclusions

We recruited a total of 1085 patients from primary care and bariatric surgery settings using 4 recruitment strategies. The recruitment efficiency was 2.9% for email and EHR patient portals, with the majority of participants recruited electronically. This study can inform the design of future research studies using EHR-based recruitment.

Grit Does Not Predict Burnout among First-Year Internal Medicine Residents

OBJECTIVES

Grit, defined as passion and perseverance for long-term goals, has been associated with the avoidance of burnout among residents in a number of specialties. We aimed to evaluate the relationship between grit and burnout among first-year Internal Medicine residents.

METHODS

During the 2018-2019 academic year, the authors recruited 75 first-year Internal Medicine residents within a large academic program to complete the Short Grit Scale (Grit-S) and the Maslach Burnout Inventory General Survey (MBI-GS) at baseline and after 6 and 12 months. The primary outcome was the association between baseline Grit-S and MBI-GS scores within the domains of emotional exhaustion (EE) or cynicism (CYN) over time using linear mixed models. Secondary outcomes included the association between grit and high burnout at 6 or 12 months, grit and persistently high burnout, and the association of baseline high burnout with later high scores at 6 and 12 months using logistic regression models and trends in grit over time using repeated-measures analysis of variance.

RESULTS

A total of 53 of 75 (71%) first-year residents completed the Grit-S and MBI-GS at baseline and at least one other time point. There was no association between grit and EE (P = 0.44) or CYN (P = 0.61) burnout domain scores. High baseline EE and high baseline CYN significantly increased the odds of later high burnout scores within each domain (EE odds ratio 9.66, 95% confidence interval 1.16-80.83; CYN odds ratio 13.37, 95% confidence interval 1.52-117.75). Grit scores and professional efficacy scores remained stable throughout the year (P = 0.15 and 0.46, respectively), while EE and CYN significantly increased (both P < 0.01).

CONCLUSIONS

In this single-center study, grit was not associated with burnout among first-year Internal Medicine residents; however, our findings highlight the value of baseline burnout scores in helping to identify first-year residents who may be at higher risk of later burnout.

A Multifaceted Intimate Partner Violence Communication Skills Curriculum Increases Screening Among Internal Medicine Residents

Background: Intimate partner violence (IPV) is common, yet physicians do not routinely screen patients for IPV. There are no clear recommendations for best educational practices for physician trainees that improve screening rates. Materials and Methods: We implemented an IPV curriculum combining didactics and communication skills training for internal medicine residents. Didactics included definitions, risk factors, screening recommendations, and documentation; communication skills training included developing unique screening and response phrases; and two simulated patient exercises. The primary outcome was screening documentation rates as measured through pre- and postcurriculum chart review. Secondary outcomes included knowledge, comfort, and attitudes measured through pre- and postcurriculum administration of an adapted Physician Readiness to Manage Intimate partner violence Survey (PREMIS). Postcurriculum semistructured interviews provided further details regarding behaviors and attitudes. Results: Forty residents completed the curriculum. 29/40 (73%) completed both pre- and postsurveys. Fifteen participated in semistructured interviews. Residents demonstrated increased screening documentation postcurriculum (p < 0.05). Residents showed improvement in 80% of objective knowledge questions, and in all perceived knowledge and comfort-based questions (p < 0.01). Statistically significant improvement was noted in many attitudinal domains, including reported screening rates (p < 0.05). In the semistructured interviews, participants reported experiencing both practice-based improvements and ongoing screening barriers. Practice-based improvements included increased screening comfort and frequency, and strengthening of the doctor-patient relationship. Ongoing screening barriers included time, resistance to practice change, competing medical needs, and personal discomfort. Conclusions: A multifaceted IPV curriculum for residents significantly improved documentation rates, knowledge, comfort, and attitudes. Residents reported increased comfort with screening and strengthened patient relationships but acknowledged ongoing barriers to screening.

Phonation Resistance Training Exercises (PhoRTE) With and Without Expiratory Muscle Strength Training (EMST) For Patients With Presbyphonia: A Noninferiority Randomized Clinical Trial

OBJECTIVES

Presbyphonia negatively impacts quality of life in patients with age-related voice changes. A proof-of-concept study showed promise for high vocal intensity exercise to treat presbyphonia, which became the basis for a novel intervention for age-related voice changes known as Phonation Resistance Training Exercises (PhoRTE). Expiratory Muscle Strength Training (EMST) has also been proposed as an additional intervention to target and strengthen the aging respiratory system; however, EMST has undergone limited evaluation as an adjunct treatment for elderly patients undergoing voice therapy for presbyphonia. This study determined if the addition of EMST to PhoRTE voice therapy (PhoRTE + EMST) is at least as effective at voice improvement as PhoRTE alone.

STUDY DESIGN

Prospective, randomized, controlled, single-blinded, non-inferiority.

MATERIALS AND METHODS

Participants aged 55 years or older with a diagnosis of vocal fold atrophy were randomized to complete PhoRTE therapy or PhoRTE + EMST. The primary outcome was change in Voice Handicap Index-10 (VHI-10). Secondary outcomes included the Aging Voice Index, maximum expiratory pressure, and acoustic and aerodynamic measures of voice. Repeated measures linear mixed models were constructed to analyze outcomes at a significance level of α = 0.10.

RESULTS

Twenty-six participants were recruited for the study, and 24 participants were randomized to either treatment arm. Sixteen participants completed the entire study. Both treatment arms showed statistically significant and clinically meaningful improvements in VHI-10 (PhoRTE mean [M] = -8.20, P < 0.001; PhoRTE + EMST M = -9.58, P < 0.001), and PhoRTE + EMST was noninferior to PhoRTE alone (P = 0.069). Both groups experienced a statistically significant pre-post treatment decrease (improvement) in AVI scores (PhoRTE M = -18.40, P = 0.004; PhoRTE + EMST M = -16.28, P = 0.005). PhoRTE+EMST had statistically significantly greater changes in maximum expiratory pressure compared to PhoRTE alone (PhoRTE M = 8.24 cm H₂O, PhoRTE + EMST M = 32.63 cm H₂O; P= 0.015). Some secondary acoustic and aerodynamic outcomes displayed trends toward improvement.

CONCLUSION

This study demonstrates that voice therapy targeting high vocal intensity exercise (eg, PhoRTE) and EMST can play a role in improving voice outcomes for patients with presbyphonia.

Implementation of a cluster randomized controlled trial: Identifying student peer leaders to lead E-cigarette interventions

E-cigarette use has been increasing among middle school students. Intervention programs to prevent e-cigarette initiation administered by authority figures are met with more resistance from youth compared to peer-led programs. Therefore, this study aimed to assess the feasibility, acceptability, and implementation process of using social network analysis (SNA) to identify student peer leaders in schools and train them to deliver e-cigarette prevention programming to their peers. Nine schools were recruited to participate in the study during the 2019-2020 school year. Schools were assigned to one of three conditions: (1) expert; (2) peer-random (selected peer-leaders would teach to random students); and (3) peer-fixed (selected peer-leaders would teach to assigned students based on nominations). Study participation varied by day due to school attendance, with 686 participants at baseline and 608 at posttest. Almost all students who did not complete the study resulted from the interruption of schools being closed due to COVID-19. Implementation issues fell into three categories: (1) scheduling, (2) day-of logistics, and (3) student group dynamics. Overall, the results showed positive satisfaction among teachers, who unanimously found the program appropriate for the grade-level and that peer-leaders worked well within their groups. Peer-led students-both random and assigned-reported having more fun and willing to tell friends to try the program compared to expert-led students. This study demonstrated the feasibility of implementing a peer-led e-cigarette prevention program for 6th grade students, using SNA to provide intervention rigidity and validity.

Benefits and Adverse Events Associated With Extended Antibiotic Use in Total Knee Arthroplasty Periprosthetic Joint Infection

BACKGROUND

Total knee arthroplasty (TKA) periprosthetic joint infection (PJI) can be managed with debridement, antibiotic therapy, and implant retention (DAIR). Oral antibiotics can be used after DAIR for an extended time period to improve outcomes. The objective of this study was to compare DAIR failure rates and adverse events between an initial course of intravenous antibiotic therapy and the addition of extended treatment with oral antibiotics.

METHODS

A multicenter observational study of patients diagnosed with a TKA PJI who underwent DAIR was performed. The primary outcome of interest was the failure rate derived from the survival time between the DAIR procedure and future treatment failure.

RESULTS

One hundred eight patients met inclusion criteria; 47% (n = 51) received an extended course of oral antibiotics. These patients had a statistically significant lower failure rate compared to those who received only intravenous antibiotics (hazard ratio, 2.47; P = .009). Multivariable analysis demonstrated that extended antibiotics independently predicted treatment success, controlling for other variables. There was no significant difference in failure rates between an extended course of oral antibiotics less or more than 12 months (P = .23). No significant difference in the rates of adverse events was observed between patients who received an initial course of antibiotics alone and those who received a combination of initial and extended antibiotic therapy (P = .59).

CONCLUSIONS

Extending therapy with oral antibiotics had superior infection-free survival for TKA PJI managed with DAIR. There was no increase in adverse events, demonstrating safety. After 1 year, there appears to be no significant benefit associated with continued antibiotic therapy.

Is there a 24-hour rhythm in alcohol craving and does it vary by sleep/circadian timing?

Increasing evidence implicates sleep/circadian factors in alcohol use; however, the role of such factors in alcohol craving has received scant attention. Prior research suggests a 24-hour rhythm in related processes (e.g., reward motivation), but more research directly investigating a rhythm in craving is needed. Moreover, prior evidence is ambiguous whether such a rhythm in alcohol craving may vary by sleep/circadian timing. To examine these possibilities, 36 late adolescents (18-22 years of age; 61% female) with regular alcohol use but without a current alcohol use disorder were recruited to complete smartphone reports of alcohol craving intensity six times a day for two weeks. During these two weeks, participants wore wrist actigraphs and completed two in-lab assessments (on Thursday and Sunday) of dim light melatonin onset (DLMO). Average actigraphically derived midpoint of sleep on weekends and average DLMO were used as indicators of sleep and circadian timing, respectively. Multilevel cosinor analysis revealed a 24-hour rhythm in alcohol craving. Findings across the sleep and circadian timing variables converged to suggest that sleep/circadian timing moderated the 24-hour rhythm in alcohol craving. Specifically, people with later sleep/circadian timing had later timing of peak alcohol craving. These findings add to the growing evidence of potential circadian influences on reward-related phenomena and suggest that greater consideration of sleep and circadian influences on alcohol craving may be useful for understanding alcohol use patterns and advancing related interventions.

Substance use disorders and risk of severe maternal morbidity in the United States

BACKGROUND

The contribution of substance use disorders to the burden of severe maternal morbidity in the United States is poorly understood. The objective was to estimate the independent association between substance use disorders during pregnancy and risk of severe maternal morbidity.

METHODS

Retrospective analysis of a weighted 53.4 million delivery hospitalizations from 2003 to 2016 among females aged>18 in the National Inpatient Sample. We constructed measures of substance use disorders using diagnostic codes for cannabis, opioids, and stimulants (amphetamines or cocaine) abuse or dependence during pregnancy. The outcome was the presence of any of the 21 CDC indicators of severe maternal morbidity. Using weighted multivariable logistic regression, we estimated the association between substance use disorders and adjusted risk of severe maternal morbidity. Because older age at delivery is predictive of severe maternal morbidity, we tested for effect modification between substance use and maternal age by age group (18-34 y vs >34 y).

RESULTS

Pregnant women with an opioid use disorder had an increased risk of severe maternal morbidity compared with women without an opioid use disorder (18-34 years: aOR: 1.51; 95 % CI: 1.41,1.61, >34 years: aOR: 1.17; 95 % CI: 1.00,1.38). Compared with their counterparts without stimulant use disorders, pregnant women with a simulant use disorder (amphetamines, cocaine) had an increased risk of severe maternal morbidity (18-34 years: aOR: 1.92; 95 % CI: 1.80,2.0, >34 years: aOR: 1.85; 95 % CI: 1.66,2.06). Cannabis use disorders were not associated with an increased risk of severe maternal morbidity.

CONCLUSION

Substance use disorders during pregnancy, particularly opioids, amphetamines, and cocaine use disorders, may contribute to severe maternal morbidity in the United States.

Provider Advice and Patient Perceptions on Weight Across Five Health Systems

INTRODUCTION

To improve the management of overweight and obesity in the primary care setting, an analysis of patient perceptions of weight status and predictors of weight loss attempts for those with overweight and obesity is needed.

METHODS

Primary care patients (n=949) across 5 health systems in the Mid-Atlantic region of the U.S. were surveyed in 2015; data analysis was performed in 2018. Survey data was combined with data via the electronic health record to understand patients' perceptions of weight, factors associated with weight loss efforts, and provider counseling practices.

RESULTS

Most participants with overweight or obesity perceived themselves as weighing too much and reported trying to lose weight. Furthermore, most participants with obesity reported receiving advice to lose weight by a provider in the past 12 months. However, less than half of patients with overweight reported receiving advice to lose weight, maintain weight, or develop healthy eating and physical activity patterns from a health professional in the past 12 months. Among participants with overweight and obesity, multivariable logistic regression analysis demonstrated that the perception of being overweight and receiving healthcare advice to lose weight had the highest odds of reporting attempted weight loss (OR=5.5, 95% CI=2.7, 11.2 and OR=3.9, 95% CI=1.9, 7.9, respectively).

CONCLUSIONS

The findings emphasize the importance of provider attention to weight management counseling and identifies patients with overweight as needing increased attention by providers.