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Background
Breast cancer is a leading cause of death in the United States. Continuing medical education programs such as the American Board of Internal Medicine's Maintenance of Certification (MOC) program can increase early detection of cancers by educating physicians about the benefits of screening. Did the imposition of American Board of Internal Medicine's MOC requirement affect guideline-compliant mammography screening?Method
To address this question, we took advantage of a natural experiment that occurred when one group of general internists was required to complete MOC by 2001 because they initially certified in 1991 (MOC required) and another group was grandfathered out of this requirement because they initially certified in 1989 (MOC grandfathers). To measure associations with the MOC requirement, we compared mammography screening in the 2 years before and the 3 years after the 2001 MOC requirement among beneficiaries treated by the MOC-required physicians and compared this difference with the same difference in mammography screening among a control group of beneficiaries treated by the MOC-grandfathered physicians.Results
We found that the MOC requirement was associated with a regression adjusted 2.8% increase (p < .001) in annual screening and 1.7% increase (p < .001) in biennial screening. When we limited the sample to beneficiaries with no screening at baseline (1999 and 2000), these figures increased to 8.5% (p = .02) and 6.4% (p = .01), respectively.Conclusions
The MOC requirement was associated with an improvement in guideline-compliant mammography screening with the most pronounced improvements among women who were the least adherent at baseline and therefore might have benefited the most from screening. 相似文献5.
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Kristina M. Cordasco Anita H. Yuan Marjorie J. Danz Melissa M. Farmer LaShawnta Jackson Ellen F. Yee Donna L. Washington 《Women's health issues》2019,29(2):144-152
Background
Abnormal uterine bleeding (AUB) is common among primary care patients. We assessed the extent to which Veterans Health Administration (VA) primary care patients with AUB are receiving guideline-adherent primary care.Methods
We identified women with AUB presenting to primary care providers across four VA health care systems from June 2013 to September 2015. We performed a structured abstraction of electronic medical record data for 15 indicators of guideline-adherent AUB care. We determined whether documented care was guideline-adherent and compared adherence of care by primary care providers by VA Designated Women's Health Provider status and by volume of clinical encounters with women veterans.Results
Across 305 episodes of AUB, 53% of the care was guideline adherent. There was high adherence with documenting menopausal status (98%), ordering diagnostic studies and referrals for postmenopausal women (92%), and documenting bleeding patterns (87%). There was lower adherence with documenting whether there was active bleeding (55%), performing thyroid testing (47%), performing a pelvic examination (42%), ordering diagnostic studies and referrals in younger women with increased endometrial cancer risk (40%), assessing for pregnancy (32%), assessing for cervical motion, uterine, or adnexal tenderness in patients with intrauterine devices (30%), and assessing for elevated endometrial cancer risk (6%). There were no significant differences in overall guideline adherence between primary care providers who were, versus were not, VA Designated Women's Health Providers, or by provider volume of encounters with women veterans.Conclusions
VA primary care has high guideline adherence when caring for postmenopausal women with AUB. Quality improvement and educational initiatives are needed to improve primary care for AUB in younger women veterans. 相似文献7.
Objectives
Postpartum depression affects a substantial proportion of new mothers in the United States. Although most employed women return to paid work after birth, the association between duration of maternity leave and postpartum depression is unclear. We therefore aimed to explore this relationship among mothers in the United States.Methods
Data included 177 mothers from a national survey who had returned to work full time after having a baby. Multivariable logistic regression was used to explore the independent association between duration of maternity leave and experiencing of postpartum depressive symptoms in the 2 weeks preceding the postpartum survey completion.Results
Overall, duration of maternity leave was not significantly associated with experiencing postpartum depression symptoms (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.80–1.01). This effect, however, varied by duration of maternity leave. Among women who took maternity leaves of 12 weeks or less, every additional week of leave was associated with a lesser odds of experiencing postpartum depressive symptoms (OR, 0.58; 95% CI, 0.40–0.84). Among women who took maternity leaves longer than 12 weeks, leave duration was not associated with postpartum depression symptoms (OR, 0.97; 95% CI, 0.73–1.29).Conclusions
Maternity leaves equaling 12 weeks or less may contribute additional risk for postpartum depressive symptoms, possibly because mothers are juggling employment alongside of important physical and emotional changes during this period. This association underscores the importance of ensuring that mothers have at least 12 weeks of leave from full-time employment after the birth of a baby. 相似文献8.
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Objectives
In 2013, the majority of women lived in states considered hostile to abortion rights, or states with numerous abortion restrictions. By comparison, 31% lived in supportive states. This study examined differences in abortion service delivery according to the policy climate in which clinics must operate.Methods
Data come from the 2014 Abortion Provider Census, which contains information about all known abortion-providing facilities in the United States. In addition to number and type of facility, we examine several aspects of abortion care: provision of only early medication abortion (EMA-only), whether an advanced practice clinician provided abortions, gestational parameters, and average charge for procedure. All indicators were examined nationally and according to whether the clinic was in a state that was hostile, middle ground, or supportive of abortion rights.Results
In 2014, hostile and supportive states accounted for the same proportion of all U.S. abortions—44% (each)—although 57% of women age 15 to 44 lived in hostile states. Hostile states had one-half as many abortion-providing facilities as supportive ones. EMA-only facilities accounted for 37% of clinics in supportive states compared with 8% in hostile states. Sixty-five percent of clinics in supportive states reported that advanced practice clinicians provided abortion care, compared with 3% in hostile states. After cost of living adjustments, a first-trimester surgical abortion was most expensive in middle-ground states ($470) and least expensive in supportive states ($402).Conclusions
The distribution of abortion services, the type of facility in which they are provided, and the amount a facility charges all vary according to the abortion policy climate. 相似文献12.
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Brian T. Nguyen Jennifer L. Elia Cathrine Y. Ha Bliss E. Kaneshiro 《Women's health issues》2018,28(1):51-58
Objective
Conflicting research findings on the association of obesity and pregnancy intention may be due to their collective definition of obesity at a body mass index of 30 kg/m2 or greater. However, obese women with a BMI of 40 kg/m2 or greater may be both behaviorally and clinically different from obese women with a lower BMI. This study reexamines this relationship, stratifying by class of obesity; the study also explores variations in contraceptive use by class of obesity given their potential contribution to the incidence of unintended or unwanted pregnancy.Methods
This study combined data from the 2006 through 2010 and 2011 through 2013 US National Survey of Family Growth. Pregnancy intention (intended, mistimed, unwanted) and current contraceptive use (no method, barrier, pill/patch/ring/injection, long-acting reversible contraceptive, sterilization) were compared across body mass index categories: normal (18.5–24.9 kg/m kg/m2), overweight (25.0–29.9), obese class 1 (30.0–34.9 kg/m2), class 2 (35.0–39.9 kg/m2), and class 3 (≥40 kg/m2, severe obesity). Weighted multinomial logistic regressions were refined to determine independent associations of body mass index class and pregnancy intention, as well as contraceptive method, controlling for demographic, socioeconomic, and reproductive factors.Results
Body mass index data were available for 9,848 nonpregnant, sexually active women who reported not wanting to become pregnant. Women with class 3 obesity had significantly greater odds of mistimed (adjusted odd ratio [aOR], 1.67; 95% confidence interval [CI], 1.02–2.75) or unwanted (aOR, 1.96; 95% CI, 1.15–3.32) pregnancy compared with normal weight women. Women with class 2 or 3 obesity were more likely to not be using contraception (aOR, 1.53–1.62; 95% CI, 1.04–2.29). Although women with class 2 obesity were more likely to be using long-acting reversible contraceptive methods and sterilization over short-acting hormonal methods (aOR, 1.67; 95% CI, 1.08–2.57; aOR, 2.05; 95% CI,1.44–2.91), this association was not observed among women with class 3 obesity.Conclusions
Women with class 3 obesity are at greater risk of unintended pregnancy and are less likely to be using contraception than normal weight women. Whether these findings are related to patient and/or provider barriers that are not as visible among women with class 1 and class 2 obesity warrants further investigation. 相似文献15.
Ian Waldman Stephen Wagner Audrey S. Kulaylat Timothy A. Deimling 《Women's health issues》2018,28(5):456-461
Objectives
We sought to determine if there is an association between preoperative risk factors as defined by the American Society of Anesthesiologists (ASA) physical status score and the route of hysterectomy for benign indications.Methods
In this retrospective cohort study, the American College of Surgeons National Surgical Quality Improvement Project database was used to determine the route of hysterectomy, using Current Procedural Terminology codes, and associated ASA class. The analysis included abdominal, vaginal, total laparoscopic, and laparoscopic assisted vaginal routes of hysterectomy. Routes of hysterectomy were also grouped as either abdominal or minimally invasive for analysis. Multinomial logistic regression was used to model route of hysterectomy as a function of patient covariates, including ASA class, age, race and ethnicity, and body mass index.Results
The analysis included 117,919 patients from the National Surgical Quality Improvement Project database. Patients with ASA classification of III or IV to V had significantly decreased odds of undergoing a minimally invasive approach for hysterectomy (odds ratio [OR], 0.81 [95% confidence interval (CI)], 0.77–0.85; and OR, 0.42 [95% CI, 0.37–0.48], respectively). Secondary outcome analysis revealed that a body mass index of more than 30 kg/m2 was associated with significantly lower odds of undergoing a minimally invasive hysterectomy (OR, 0.87; 95% CI, 0.85–0.89). With respect to race/ethnicity, all non-White groups had decreased odds of undergoing a hysterectomy via a minimally invasive approach. Age 75 years or older was correlated with an increased likelihood of minimally invasive hysterectomy (OR, 1.18; 95% CI, 1.10–1.26).Conclusions
Patients with increased preoperative risk as defined by a high ASA classification are less likely to undergo a hysterectomy using a minimally invasive route for benign indications. 相似文献16.
Kathryn P. Derose Bing Han Stephanie Williamson Deborah A. Cohen 《Women's health issues》2018,28(1):6-13
Introduction
Physical inactivity is more prevalent among women than men and is related to poor health outcomes. Neighborhood parks constitute an important resource for physical activity (PA), however, previous studies of park users have found fewer women being physically active.Methods
We conducted a hierarchical mixed-effect regression analysis of the independent associations between gender and park use and PA among a population-based sample in high-poverty neighborhoods in Los Angeles. Data sources included 1) structured interviews with adults (≥18 years of age) in randomly selected households within 1 mile of study parks (n = 2,973), 2) systematic observations of study parks (n = 48), and 3) neighborhood characteristics from the 2010 U.S. Census.Results
After controlling for race/ethnicity, education, body mass index of 30 kg/m2 or greater, health status, proximity to park, having children under the age of 18, perceived park safety, estimated screen time, and park- and neighborhood-level variables, statistically significant differences were found between women and men on all outcomes. Compared with men, women reported fewer park visits in the past week (?0.28 times/week; p < .001) and shorter durations of a typical park visit (?11.11 min/visit; p < .001). Women were also less likely than men to report levels of PA that meet national guidelines (≥150 minutes of moderate to vigorous PA per week; risk difference = ?0.06; p < .01) or to exercise in the park (risk difference = ?0.13; p < .001) or elsewhere (risk difference = ?0.13; p < .001).Conclusions
Women living in high-poverty neighborhoods use parks less for PA than men. Improved park-level design, programming, and other policy interventions may be needed to mitigate disparities in park use and PA for all. 相似文献17.
Aims
Researchers at the U.S. Centers for Disease Control and Prevention (CDC) recently estimated the number of women at risk for alcohol-exposed pregnancies (AEPs) as 3.3 million per month. The number of women at risk was widely interpreted as the actual number of AEPs. The actual number of AEPs may be easier to interpret and may be more a more relevant public health metric for evaluating efforts to reduce AEPs. We estimated the expected actual number of AEPs among U.S. women 15–44 years of age and the expected actual number of alcohol-exposed births (AEBs).Methods
Like the CDC researchers, we used data about women aged 15–44 years who were neither pregnant nor sterile from the 2011–2013 National Survey of Family Growth. We identified women who had had sex without contraception in the last 4 weeks and reported binge drinking or drinking on more than 7 of the last 30 days. We then estimated the expected actual number of AEPs and AEBs, accounting for the chances of becoming pregnant and for pregnancy outcomes (birth, miscarriage, and abortion). We also conducted sensitivity analyses with varying assumptions.Results
Estimated prevalences of AEPs and AEBs were 1.2% (95% confidence interval, 0.9–1.7) and 0.8% (95% confidence interval, 0.5–1.2), respectively. During a 1-month period, we estimate 731,000 U.S. women had AEPs and 481,000 resulted in AEBs. Sensitivity analyses indicate expected actual AEP estimates ranging from 104,000 to 1,242,000 and AEBs from 79,000 to 816,000.Conclusions
Under our assumptions, the estimated expected actual number of AEPs is 2.5 million less than the CDC estimate of the number at risk of an AEP. By using evidence-informed assumptions for the chances of becoming pregnant and common pregnancy outcomes, our estimate of the expected actual number of AEPs is only 22% as large as the CDC's estimate of number at risk, and our estimate of expected actual number of AEBs only 15% as large. The evidence-informed assumptions used here should inform future efforts to estimate expected actual numbers of AEPs and AEBs. 相似文献18.
Introduction
Given the recent reforms in the United States health care system, including the passage and implementation of the Affordable Care Act, as well as anticipated upcoming changes to health care coverage, it is critical that publicly funded health care providers understand how to effectively work with their states' Medicaid programs and the private health insurance plans in their service areas to provide high-quality contraceptive care to the millions of women relying on services at these sites annually.Methods
We collected survey data from a nationally representative sample of 535 clinics providing family planning services that received Title X funding and conducted semistructured interviews with 23 administrators at a subsample of surveyed clinics to explore provider-reported experiences working with health plans and to identify barriers to, and practices that lead to, adequate reimbursement for services provided.Results
Providers report that knowledgeable staff are crucial to securing contracts with both public and private insurance plan issuers, and that the contracts they secure often include coverage restrictions on methods or services clinics offer their clients. Good staff relationships with issuers are key to obtaining adequate and consistent reimbursement for all covered services.Conclusions
Providers are trying to understand how insurance programs in their area knit together. Regardless of how U.S. health policies and delivery systems may change in the coming years, it is imperative that publicly funded family planning centers continue to work with health plans and maximize their third-party revenue to provide services to those in need. 相似文献19.
Emily M. Johnston Andrea E. Strahan Peter Joski Anne L. Dunlop E. Kathleen Adams 《Women's health issues》2018,28(2):122-129
Introduction
We use data from the Behavioral Risk Factor Surveillance System (BRFSS) from 2012 to 2015 to estimate the effects of the Affordable Care Act's (ACA) Medicaid expansions on insurance coverage and access to care for low-income women of reproductive age (19–44).Methods
We use two-way fixed effects difference-in-differences models to estimate the effects of Medicaid expansions on low-income (<100% of the Federal Poverty Level) women of reproductive age. Additional models are stratified to estimate effects based on women's parental status, pre-ACA state Medicaid eligibility levels, and the presence of a state Medicaid family planning waiver.Results
ACA Medicaid expansions decreased uninsurance among low-income women of reproductive age by 13.2 percentage points. This decrease was driven by a decrease of 27.4 percentage points for women without dependent children, who also experienced a decrease in the likelihood of not having a personal doctor (13.3 percentage points). We find a 3.8-percentage point reduction in the likelihood of experiencing a cost barrier to care among all women, but no significant effects for other access measures or subgroups. When stratified by state policies, decreases in uninsurance were greater in states expanding from pre-ACA eligibility levels of less than 50% of Federal Poverty Level (19.4 percentage points) and in states without a Medicaid family planning waiver (17.6 percentage points).Conclusions
The ACA Medicaid expansion increased insurance coverage for low-income women of reproductive age, with the greatest effects for women without dependent children and women residing in states with relatively lower pre-ACA Medicaid eligibility levels or with no family planning waiver before the ACA. 相似文献20.
Elena G. Gibson Julia C. Gage Philip E. Castle Isabel C. Scarinci 《Women's health issues》2019,29(1):38-47