Adherence to hysterosalpingogram appointments following hysteroscopic sterilization among low-income women

Background

The few studies on post-Essure hysterosalpingogram (HSG) adherence rates show inconsistent results. This study examined associations between sociodemographic variables not examined in prior studies and HSG adherence among low-income women.

Study Design

Medical records of 286 women who underwent sterilization between August 31, 2005, and September 30, 2011, were reviewed. chi-Square and Mann–Whitney U tests were used to determine variable associations with HSG adherence.

Results

The adherence rate for the first HSG was 85.0% (243/286). Variables associated with adherence were lower education level (p=.01), not working outside the home (p=.04), being married (p<.0001), lower gravidity (p=.03), fewer lifetime number of sexual partners (p<.0001), no sexually transmitted infection history (p<.01), Hispanic ethnicity (p<.0001), Spanish as a primary language (p<.0001) and living farther from the clinic (p<.01).

Conclusions

This study demonstrates that achieving high rates of adherence with the recommended HSG following Essure placement is feasible among low income populations. Furthermore, not speaking English or having to commute a far distance to the clinic do not appear to be barriers. This is encouraging considering the importance of this test to confirm tubal occlusion.     

What are the Factors Predictive of Hysterosalpingogram Compliance After Female Sterilization by the Essure Procedure in a Publicly Insured Population?

To determine what factors are predictive of post-Essure hysterosalpingogram (HSG) compliance. We conducted a retrospective chart review of all patients who underwent the Essure procedure at the two campuses of the Truman Medical Center, Kansas City, Missouri, from January 1, 2005 through December 31, 2010. Our study population consisted primarily of women who were publicly insured (89.0 %) and unmarried (76.7 %). Of 132 patients referred for HSG, 70 (53.0 %) complied. In adjusted analyses women 35 years and older had an almost fourfold higher odds of HSG compliance (OR = 3.72, 95 % CI 1.35–10.23) and women with 3 or more living children had a 64 % lower odds of HSG compliance (OR = 0.36, 95 % CI 0.16?0.82). Women younger than 35 who had 3 or more children had the lowest compliance rate (36.4 %) suggesting an interaction between age and parity. Women undergoing the Essure procedure at the campus with a dedicated protocol to ensure compliance had an almost fourfold higher odds of HSG compliance (OR = 3.67, 95 % CI 1.01–13.40). In a population consisting largely of publicly insured, unmarried women, several factors are predictive of post-Essure HSG compliance. These include age, parity and the presence or absence of an institutional protocol to keep track of patients after their Essure procedure.     

Postpartum contraceptive preferences of HIV-infected women in the era of highly active antiretroviral therapy (HAART) and scheduled cesarean deliveries

Background

We sought to determine if postpartum tubal ligation among HIV-infected women changed with the introduction of highly active antiretroviral therapy (HAART) and scheduled cesarean delivery.

Methods

Retrospective cohort study of HIV-infected women delivered before (Pre-HAART) and after (Post-HAART) the introduction of HAART and scheduled cesarean delivery. Rates of the primary outcome, postpartum tubal ligation (PPTL), were compared by univariable and multivariable analyses.

Results

We found that 34.5% (60/174) of women in the Post-HAART period chose PPTL, compared to 22.0% (18/82) in the Pre-HAART period [unadjusted OR=1.87 (95% CI 1.02–3.44), p=.04]. When stratified by mode of delivery, rates of PPTL were not significantly different between the two periods. Similarly, in multivariable analysis controlling for confounders, rates of PPTL were not different between the two periods [adjusted OR=1.40 (95% CI=0.66–2.99), p=.39].

Conclusions

HIV-infected women on HAART are overall more likely to have PPTL, but cesarean delivery appears to be the facilitator of this choice.     

Immediate placement of intrauterine devices after first and second trimester pregnancy termination

Background

We reviewed our experience with intrauterine device (IUD) placement after surgical abortion up to 20 weeks' gestation.

Study Design

Women presenting for elective abortion between January 2004 and March 2009 who requested an IUD were included in this retrospective review.

Results

Of 308 women requesting postabortion IUD placement, 221 (72%) planned insertion at the time of abortion (immediate group) and 87 (28%) planned insertion at their postoperative visit (interval group). IUDs were placed in 96% of the immediate group and in 23% of the interval group (212/221 vs. 20/87; p<.0001). Failure to return for placement was the most common reason for noninsertion in the interval group (60/87=69%). Follow-up information was obtained for 56% of patients and was documented a median of 137 days postabortion (range 3–1594 days). There was no difference in complication rates between groups. Expulsion rates were 3% and 0% in the immediate and interval groups, respectively (6/212 vs. 0/20; p=.4). Considering only those with documented follow-up after immediate insertion (119), there was a nonsignificant trend towards increased expulsion with placement after second vs. first trimester abortion (4/54=7% vs. 2/65=2%; p=.3). When analyzing the 172 subjects with documented follow-up, those planning immediate insertion were more likely to have an IUD in situ at the last contact than those planning later insertion (84/124=68% vs. 20/48=42%; p=.002).

Conclusion

Immediate postabortion IUD insertion is safe and effective. Given the low rate of return for interval insertion, immediate placement may be preferable.     

Outcomes of Elective Outpatient Hysteroscopic Sterilization in Undocumented Women: A Retrospective Analysis

ObjectiveTo determine the feasibility of hysteroscopic sterilization in low-income and unauthorized immigrant women when financial barriers to care are removed.MethodsOutpatient hysteroscopic sterilization for low-income women at an urban clinic was made possible by grant funding. All procedures were performed by obstetrician/gynecologist attending physicians or supervised trainees. Electronic records were reviewed for cases performed from June 2010 to December 11, 2013. Outcome incidences and complications were determined. Subgroup analyses using demographic and clinical factors were performed.ResultsHysteroscopic sterilization was attempted in 197 patients. Most were Hispanic (93%) and undocumented immigrants (83%). Bilateral placement was achieved on first attempt in 92% (181/197). Successful placement was ultimately achieved in 96% (190/197), and 88% (168/190) returned for hysterosalpingogram (HSG). Appropriate tubal occlusion was documented on 96% (161/168) of HSGs with mean time of 3.5 ± 1.3 months. Repeat HSG at 6 months showed 100% occlusion (7/7). Of the initial cohort, 85% (168/197) could ultimately rely on Essure for contraception. One pregnancy was self-reported 9 months after the procedure; the patient had not followed up for HSG. There were no pregnancies among those who completed follow-up. There were no cases of procedural complications. Successful Essure placement was not associated with age, parity, immigration status, or clinical characteristics (analgesics administered, history of cesarean section, vaginal delivery, cervical surgery, ectopic, fibroids, or pelvic inflammatory disease). The only factor positively associated with HSG follow-up was age 35 years or younger (53% vs. 47%; p = .03).ConclusionsSuccessful hysteroscopic sterilization can be achieved in an undocumented, low-income population. Rates of confirmatory HSG follow-up were found to be higher than in the general population. Public funding of programs could decrease unintended pregnancies and pregnancy-related costs.     

The oncology nurse coordinator: role perceptions of staff members and nurse coordinators

Background

There is extensive evidence that the role of nurse coordinators is beneficial for patients. Nurse coordinators are more available to patients compared to general registered nurses, know better to control symptoms and work as team players with multiple care providers. Despite its significance, there is a dearth of literature on the subject in Israel and a lack of clarity regarding the definitions of the role in terms of responsibilities and authorities. The aim of the study is to: To examine how the role of nurse oncology coordinator is implemented in various fields of oncology and to describe the actual performance of different kinds of oncology nurse coordinators and staff perceptions regarding this role in one tertiary hospital in Jerusalem.

Methods

A phenomenological approach was used to explore the participants’ experiences and views of nurse coordinators’ performance. We conducted a qualitative study using in-depth semi-structured interviews. Interviewees included 30 employees from different levels of the hospitals, and leading figures associated with oncology medicine outside of the hospital: Nurses and physicians of the Sharett Oncology Institute of Hadassah Ein Kerem Hospital in Jerusalem, the administrative staff of Hadassah Ein Kerem Hospital, head nurses of the Israel Cancer Association, the chairperson of the Non-Profit Organization of Oncology Nurses, nurse directors at the Ministry of Health Nursing Division, and seven nurse coordinators at Hadassah Ein Kerem Hospital in diverse fields of oncology.

Results

The nurse coordinator is perceived as an important staff member providing care to cancer patients. Several key elements were found to be common features in the work of all nurse coordinators: emotional support, guidance to patients, and coordination of patients’ care.

Conclusions

The nurse coordinator plays a noteworthy role in the health care system. In view of the variety of roles that the nurse coordinator assumes in different units, performance standards must be adapted to the performance areas for each unit, as well as nurses’ professional development requirements. Changes in a service organization and careful attention to the continuum of care highlight the need to develop and to strengthen the role of a nurse who coordinates treatment over the entire continuum of care, both in the hospital and in the community.

     

Postpartum insertion of levonorgestrel--intrauterine system at three time periods: a prospective randomized pilot study

Background

The study was conducted to determine the feasibility of levonorgestrel–intrauterine system (LNG-IUS) insertion at three different times postpartum.

Study Design

From August 2009 to January 2010, all women desiring LNG-IUS for postpartum contraception were offered enrollment into our study and randomized to three insertion times: immediate (within 10 min of placenta delivery), early (10 min to 48 h postpartum) or interval (≥6 weeks postpartum).

Results

Forty-six women met inclusion criteria and were analyzed. There was no difference in utilization rates at 3 and 6 months between groups (p=.931). Expulsion rates were significantly higher and pain during insertion was significantly lower in the immediate and early groups (p<.001) when compared to the interval group.

Conclusion

Insertion of LNG-IUS ≤48 h postpartum is feasible in our institution and may be associated with similar utilization at 6 months, increased expulsion rates and decreased pain at insertion when compared to placement after 6 weeks.     

Effects of prophylactic misoprostol administration prior to intrauterine device insertion in nulliparous women

Background

This study was conducted to examine the effects of prophylactic misoprostol prior to intrauterine device (IUD) placement in nulliparous women.

Study Design

Nulliparous, reproductive-aged women desiring an IUD for contraception were randomized to receive 400 mcg of buccal misoprostol or placebo 90 min prior to IUD insertion. Subjects completed a series of 100-mm visual analogue scales (VAS, anchors: 0=none, 100 mm=worst imaginable) to measure their perceived pain at several times points (anticipated pain, leg positioning, speculum placement, tenaculum placement, IUD insertion, equipment removal and 5 min postinsertion). Secondary outcomes included provider “ease of placement” (100-mm VAS, anchors: 0=easy, 100 mm=extremely difficult), side effects and retention of the IUD after 1 month (self-report or clinic visit). The study had 80% power (α=0.05, one-sided) to detect a reduction with treatment of 20 mm in VAS scores with a combined sample size of 34.

Results

A total of 40 subjects were randomized to receive either misoprostol or placebo, and 35 completed the study. Five subjects withdrew (four prior to receiving study medication and one declined IUD). Baseline characteristics were similar between groups. There were no significant differences in patient-reported pain with IUD placement [misoprostol 65 mm (SD 21), placebo 55 mm (SD 21), p=.83] or at any other time point. Moreover, the misoprostol group reported significantly more preinsertion nausea (29% vs. 5%, p=.05) and cramping (47% vs. 16%, p=.04) than the placebo group. While provider-reported ease of insertion was not significantly different between groups, three placebo patients required additional dilation vs. none in the misoprostol group. All 35 subjects underwent follow-up at least 1 month postinsertion, and no expulsions were reported.

Conclusion

Prophylactic misoprostol prior to IUD placement in nulliparous women did not reduce patient perceived pain, but it did appear to increase preinsertion side effects.     

Intrauterine device insertion after medical abortion

Background

Studies comparing immediate intrauterine device (IUD) insertion after first-trimester surgical abortion with interval insertion show similar efficacy and expulsion rates. However, women randomized to interval insertion of an IUD are less likely to return for device placement. An ideal time to insert intrauterine contraception may be the day a woman presents for verification of a completed medical abortion. We examined immediate insertion of IUDs after completed first-trimester medical abortion.

Study Design

This is a prospective, observational clinical study to determine expulsion rates of intrauterine contraception placed immediately after confirmed, completed first-trimester medical abortion.

Results

Of 118 subjects, 78 women had levonorgestrel IUDs placed, whereas 41 women received copper IUDs. Of 97 subjects who completed the study, there were 4 clinical expulsions (4.1%) during 3 months of follow-up. There were no diagnosed pelvic infections, pregnancies, or uterine perforations. The continuation rate at 3 months was 80%.

Conclusion

Intrauterine devices inserted at the time of completed, confirmed first-trimester medical abortion have low rates of expulsion.     

Drug persistence and compliance affect patient-reported outcomes in overactive bladder syndrome

Purpose

To evaluate persistence and compliance for patients receiving antimuscarinics for overactive bladder (OAB), and to assess patient-reported outcomes (PROs) according to persistence and compliance.

Methods

This was a 24-week, multicenter, prospective, observational study that included 952 OAB patients who had newly started antimuscarinics. Patients aged ≥18 years with a total OAB Symptom Score (OABSS) ≥3 and an urgency score of OABSS ≥2 were eligible for the study. Drug persistence and compliance were evaluated at 4, 12, and 24 weeks. Changes in scores on PROs were compared between groups (persistence vs. non-persistence and compliance vs. non-compliance) after 24 weeks. Factors contributing to persistence were examined using multivariate logistic regression.

Results

After 24 weeks, 56.8 % of patients remained on treatment. The persistence rates were 85.6 and 71.4 % after 4 and 12 weeks, respectively. The compliance rates were 75.6, 53.8, and 34.3 % after 4, 12, and 24 weeks, respectively. Patients who were persistent in taking antimuscarinics resulted in significant improvements in OABSS and OAB questionnaire short form score compared with those who were non-persistent (all p < 0.05). Changes from baseline in OABSS (p = 0.735) and the EuroQoL five-dimensions score (p = 0.384) were not significantly different between compliant and non-compliant groups. Predictors of high persistence included older age (OR 1.017, p = 0.007) and dry OAB (OR 1.422, p = 0.013).

Conclusions

Patients who were persistent with antimuscarinics showed significant improvements in PROs compared to those who were non-persistent.

     

Blockade of tubal patency following transcervical administration of polidocanol foam: initial studies in rhesus macaques

Objective

To demonstrate the feasibility of polidocanol foam (PF) as a nonsurgical method of female permanent contraception using a nonhuman primate model.

Study Design

Four groups of adult female rhesus macaques underwent either transcervical treatment with 5% PF directly into the uterine cavity, treatment with inert (methylcellulose, MF) foam or no treatment followed by removal of the reproductive tract for histologic evaluation. Untreated animals were included in Group 1 (n= 3). Group 2 animals (n= 4) were treated once with MF. Group 3 (n= 7) received a single, and Group 4 (n= 5) received multiple monthly treatments with PF; in these 2 groups, baseline tubal patency was assessed either laparoscopically by chromopertubation (CP) or by hysterosalpingography.

Results

Group 1 (untreated) and Group 2 (MF) animals had normal tubal histology. In contrast, Group 3 and 4 females treated with PF showed evidence of tubal damage. In Group 4, bilateral tubal blockade was noted on CP after two (n= 2) or three (n= 3) treatments. Histologic analysis confirmed complete tubal occlusion (loss of epithelium, fibrosis) in three of these animals, and one showed significant tubal damage localized to the intramural segment. Nontarget (cervix, vagina, endometrium, ovary) reproductive tissues were unaffected. While similar tubal changes were observed after a single treatment (Group 3), endometrial hemorrhage was also noted as an acute change.

Conclusion

PF is a promising candidate agent for nonsurgical permanent female contraception. The histologic features of PF occlusion are confined to the intramural portion of the tube.

Implications

This study in rhesus macaques supports further development of transcervical administration of PF as a nonsurgical approach to permanent contraception. A nonsurgical method could reduce risks and costs associated with surgical female sterilization and increase access to permanent contraception.     

Nursing Home Staffing Requirements and Input Substitution: Effects on Housekeeping,Food Service,and Activities Staff

Objective

To study the effect of minimum nurse staffing requirements on the subsequent employment of nursing home support staff.

Data Sources

Nursing home data from the Online Survey Certification and Reporting (OSCAR) System merged with state nurse staffing requirements.

Study Design

Facility-level housekeeping, food service, and activities staff levels are regressed on nurse staffing requirements and other controls using fixed effect panel regression.

Data Extraction Method

OSCAR surveys from 1999 to 2004.

Principal Findings

Increases in state direct care and licensed nurse staffing requirements are associated with decreases in the staffing levels of all types of support staff.

Conclusions

Increased nursing home nurse staffing requirements lead to input substitution in the form of reduced support staffing levels.     

International nurse recruitment and NHS vacancies: a cross-sectional analysis

Background

Foreign-trained nurse recruits exceeded the number of new British-trained recruits on the UK nurse register for the first time in 2001. As the nursing shortage continues, health care service providers rely increasingly on overseas nurses to fill the void. Which areas benefit the most? And where would the NHS be without them?

Methods

Using cross-sectional data from the 2004 Nursing and Midwifery Council register, nurse resident postcodes are mapped to Strategic Health Authorities to see where foreign recruits locate and how they affect nurse shortages throughout the UK.

Results

Areas with the highest vacancy rates also have the highest representation of foreign recruits, with 24% of foreign-trained nurses in the UK residing in the London area and another 16% in the SouthEast (comparable numbers for British-trained nurses are 11% and 13%, respectively). Without foreign recruitment, vacancy rates could be up to five times higher (three times higher if only Filipino recruits remained).

Conclusion

The UK heavily relies on foreign recruitment to fill vacancies, without which the staffing crisis would be far worse, particularly in high vacancy areas.

     

Duration of use of a levonorgestrel IUS amongst nulliparous and adolescent women

Background

Intrauterine devices are cost-effective if used for 2 or more years. Early discontinuation may lead to reduced cost-effectiveness of this method and unintended pregnancy if other contraceptives are not used. This study sought to examine rates and reasons for discontinuation of IUS use in adolescents versus older women and nulliparous versus parous women, as these groups may be more likely to discontinue use.

Study Design

Retrospective cohort study of women receiving a levonorgestrel IUS between June 2005 and April 2008 was conducted. Medical records were reviewed for all visits following placement of the IUS; rates and reasons for IUS discontinuation were calculated and categorized. Data were examined under two scenarios: (1) assuming that all women not seen for follow-up continued IUS use and (2) only including women with follow-up visits. Cox regression was used to control for age, parity, race and marital status in comparing rates of IUS discontinuation and expulsion in nulliparous versus parous women and adolescents versus older women.

Results

Of the 828 women included in this analysis, 104 (12.6%) were nulliparous, and 131 (15.8%) were ≤20 years of age. Nulliparous women were not more likely than parous women to have expelled their IUS [hazard ratio (95% confidence interval), 1.40 (0.57, 3.43)]. Adolescent women were more likely to experience expulsion than older women, although this did not reach statistical significance [hazard ratio, 1.49 (0.76, 2.92)]. When we looked at reasons for IUS removal, we found that nulliparous women were not more likely than parous women to have their IUS removed because of dissatisfaction with the contraceptive method (6.7% vs. 11.5%, p=.15) or desire to become pregnant (1.9% vs. 2.6%, p=.50). Similarly, adolescents were not more likely than older women to have their IUS removed because of dissatisfaction with the contraceptive method (10.7% vs. 10.9%, p=.94) or desire to become pregnant (3.1% vs. 2.4%, p=.43).

Conclusions

Adolescents and nulliparous women are not more likely to prematurely discontinue use of their IUS than adult or parous women.     

Immediate vs. delayed post-abortal copper T 380A IUD insertion in cases over 12 weeks of gestation

Background

The intrauterine device (IUD) is a safe, effective, well-tolerated form of contraception. Immediate placement after second-trimester abortion could increase high-tier contraception use in women who are at high risk for unintended pregnancy.

Study Design

This randomized controlled trial compared immediate vs. delayed placement of Copper T380A IUD insertion 2–4 weeks after second trimester abortion. The primary outcome analyzed was the percentage of women using a copper T380A IUD 6 months after surgery. Secondary outcomes were percentage of subjects using other high or middle tier contraception, expulsion, infection and repeat pregnancy rates as well as IUD satisfaction. In expectation of a high loss to follow-up at 6 months, 215 subjects were enrolled for a desired sample size of 158 subjects.

Results

Contraceptive and pregnancy status at 6 months was known for 159 of 215 subjects. Women randomized to immediate insertion were significantly more likely to have an IUD at 6 months compared to delayed (81.7% vs. 28.4%, p=.003). Relative risk was 11.2 (95% CI 5–26). There were 8 (5.1%) of 159 repeat unintended pregnancies. No women had a repeat pregnancy that had an IUD placed in the operating room. In the as-treated analysis, 64 women in the immediate group received the IUD and 0% had a repeat pregnancy. Of the remaining 95 women, 8 (8.4%) had a repeat pregnancy. This is a statistically significant difference (p=.022).

Conclusion

Placing the IUD immediately after the procedure significantly increases the likelihood of use of effective contraception following a second-trimester procedure. Women who have an IUD placed immediately after their procedure may also be less likely to have a subsequent unplanned pregnancy.     

Routine counseling about intrauterine contraception for women seeking emergency contraception

Objective

To compare contraceptive knowledge and use among women seeking emergency contraception (EC) before and after an inner-city clinic began providing structured counseling and offering same-day intrauterine device (IUD) or implant placement to all women seeking EC.

Study design

For 8 months before and 21 months after this change in clinic policy, women aged 15–45 who wanted to avoid pregnancy for at least 6 months were asked to complete surveys immediately, 3 and 12 months after their clinic visit. In addition, we abstracted electronic medical record (EMR) data on all women who sought EC (n= 328) during this period. We used chi-squared tests to assess pre/post differences in survey and EMR data.

Results

Surveys were completed by 186 women. After the clinic began offering structured counseling, more women had accurate knowledge of the effectiveness of IUDs, immediately and 3 months after their clinic visit. In addition, more women initiated IUD or implant use (survey: 40% vs. 17% preintervention, p=0.04; EMR: 22% vs. 10% preintervention, p=0.01), and fewer had no contraceptive use (survey: 3% vs. 17% preintervention, p<0.01; EMR: 32% vs. 68%, p<0.01) in the 3 months after seeking EC. EMR data indicate that when same-day placement was offered, 11.0% of women received a same-day IUD. Of those who received a same-day IUD, 88% (23/26) reported IUD use at 3-months and 80% (12/15) at 12 months.

Conclusions

Routine provision of structured counseling with the offer of same-day IUD placement increases knowledge and use of IUDs 3 months after women seek EC.

Implications

Women seeking EC from family planning clinics should be offered counseling about highly effective reversible contraceptives with the option of same-day contraceptive placement.     

Tubal risk markers for failure to place transcervical sterilization coils

BackgroundThere is a growing body of literature on placement rates of the Essure® procedure, yet prior studies have not attempted to identify tubal-associated risk factors for placement failures. The current study examines risk markers associated with the inability to deploy the Essure® coils into the tubal lumen using the new ESS305 design.Study DesignWe used electronic medical record data to assess risk markers associated with the inability to place the Essure coils in the tubal lumen using the new ESS305 design. A total of 310 attempted procedures between June 14, 2007, and April 29, 2011, were analyzed.ResultsThere were 18 tubal failures (5.8%) out of the 310 attempted procedures. A history of a prior sexually transmitted infection (STI) was associated with tubal failure (odds ratio 2.64, 95% confidence interval 1.01–6.90, p=.048).ConclusionsWe speculate that the observed association between a prior STI and an inability to place the coil was due to a past history of pelvic inflammatory disease.     

Impact of Contextual Factors on Interventions to Reduce Acute Care Transfers II Implementation and Hospital Readmission Rates

Objectives

Identify contextual and implementation factors impacting the effectiveness of an organizational-level intervention to reduce preventable hospital readmissions from affiliated skilled nursing facilities (SNFs).