Clinical Decision Support to Promote Safe Prescribing to Women of Reproductive Age: A Cluster-Randomized Trial

BACKGROUND

Potentially teratogenic medications are frequently prescribed without provision of contraceptive counseling.

OBJECTIVE

To evaluate whether computerized clinical decision support (CDS) can increase primary care providers?? (PCPs??) provision of family planning services when prescribing potentially teratogenic medications.

DESIGN

Cluster-randomized trial conducted in one academic and one community-based practice between October of 2008 and April of 2010.

PARTICIPANTS/INTERVENTIONS

Forty-one PCPs were randomized to receive one of two types of CDS which alerted them to risks of medication-induced birth defects when ordering potentially teratogenic medications for women who may become pregnant. The ??simple?? CDS provided a cautionary alert; the ??multifaceted?? CDS provided tailored information and links to a structured order set designed to facilitate safe prescribing. Both CDS systems alerted PCPs about medication risk only once per encounter.

MAIN MEASURES

We assessed change in documented provision of family planning services using data from 35,110 encounters and mixed-effects models. PCPs completed surveys before and after the CDS systems were implemented, allowing assessment of change in PCP-reported counseling about the risks of medication-induced birth defects and contraception.

KEY RESULTS

Both CDS systems were associated with slight increases in provision of family planning services when potential teratogens were prescribed, without a significant difference in improvement by CDS complexity (p?=?0.87). Because CDS was not repeated, 13% of the times that PCPs received CDS they substituted another potential teratogen. PCPs reported significant improvements in several counseling and prescribing practices. The multifaceted group reported a greater increase in the number of times per month they discussed the risks of medication use during pregnancy (multifaceted: +4.9?±?7.0 vs. simple: +0.8?±?3.2, p?=?0.03). The simple CDS system was associated with greater clinician satisfaction.

CONCLUSIONS

CDS systems hold promise for increasing provision of family planning services when fertile women are prescribed potentially teratogenic medications, but further refinement of these systems is needed.     

The Composition of Intern Work While on Call

BACKGROUND

The work of house staff is being increasingly scrutinized as duty hours continue to be restricted.

OBJECTIVE

To describe the distribution of work performed by internal medicine interns while on call.

DESIGN

Prospective time motion study on general internal medicine wards at a VA hospital affiliated with a tertiary care medical center and internal medicine residency program.

PARTICIPANTS

Internal medicine interns.

MAIN MEASURES

Trained observers followed interns during a ??call?? day. The observers continuously recorded the tasks performed by interns, using customized task analysis software. We measured the amount of time spent on each task. We calculated means and standard deviations for the amount of time spent on six categories of tasks: clinical computer work (e.g., writing orders and notes), non-patient communication, direct patient care (work done at the bedside), downtime, transit and teaching/learning. We also calculated means and standard deviations for time spent on specific tasks within each category. We compared the amount of time spent on the top three categories using analysis of variance.

KEY RESULTS

The largest proportion of intern time was spent in clinical computer work (40?%). Thirty percent of time was spent on non-patient communication. Only 12?% of intern time was spent at the bedside. Downtime activities, transit and teaching/learning accounted for 11?%, 5?% and 2?% of intern time, respectively.

CONCLUSION

Our results suggest that during on call periods, relatively small amounts of time are spent on direct patient care and teaching/learning activities. As intern duty hours continue to decrease, attention should be directed towards preserving time with patients and increasing time in education.     

Effects of post-abortion family planning services on preventing unintended pregnancy and repeat abortion (INPAC): a cluster randomised controlled trial in 30 Chinese provinces

Background

Around 10 million induced abortions are conducted annually in China; a third of the women having had those abortions have undergone repeat abortions. Most abortions are performed in hospital settings in which post-abortion family planning (PAFP) services are often lacking. This study aims to evaluate the effects of integrating PAFP services into abortion services on the reduction of unintended pregnancy and repeat abortion in China.

Concurrent Validity of Single-Item Measures of Emotional Exhaustion and Depersonalization in Burnout Assessment

BACKGROUND

Burnout is a common problem among physicians and physicians-in-training. The Maslach Burnout Inventory (MBI) is the gold standard for burnout assessment, but the length of this well-validated 22-item instrument can limit its feasibility for survey research.

OBJECTIVE

To evaluate the concurrent validity of two questions relative to the full MBI for measuring the association of burnout with published outcomes.

DESIGN, PARTICIPANTS, AND MAIN MEASURES

The single questions ??I feel burned out from my work?? and ??I have become more callous toward people since I took this job,?? representing the emotional exhaustion and depersonalization domains of burnout, respectively, were evaluated in published studies of medical students, internal medicine residents, and practicing surgeons. We compared predictive models for the association of each question, versus the full MBI, using longitudinal data on burnout and suicidality from 2006 and 2007 for 858 medical students at five United States medical schools, cross-sectional data on burnout and serious thoughts of dropping out of medical school from 2007 for 2222 medical students at seven United States medical schools, and cross-sectional data on burnout and unprofessional attitudes and behaviors from 2009 for 2566 medical students at seven United States medical schools. We also assessed results for longitudinal data on burnout and perceived major medical errors from 2003 to 2009 for 321 Mayo Clinic Rochester internal medicine residents and cross-sectional data on burnout and both perceived major medical errors and suicidality from 2008 for 7,905 respondents to a national survey of members of the American College of Surgeons.

KEY RESULTS

Point estimates of effect for models based on the single-item measures were uniformly consistent with those reported for models based on the full MBI. The single-item measures of emotional exhaustion and depersonalization exhibited strong associations with each published outcome (all p???0.008). No conclusion regarding the relationship between burnout and any outcome variable was altered by the use of the single-item measures rather than the full MBI.

CONCLUSIONS

Relative to the full MBI, single-item measures of emotional exhaustion and depersonalization exhibit strong and consistent associations with key outcomes in medical students, internal medicine residents, and practicing surgeons.     

Exposure to candesartan during the first trimester of pregnancy in type 1 diabetes: experience from the placebo-controlled diabetic retinopathy candesartan trials

Aims/hypothesis

The teratogenic consequences of angiotensin-converting enzyme inhibitors angiotensin receptor blockers (ARBs) during the second and third trimesters of pregnancy are well described. However, the consequences of exposure during the first trimester are unclear, especially in diabetes. We report the experience from DIRECT (DIabetic REtinopathy and Candesartan Trials), three placebo-controlled studies designed to examine the effects of an ARB, candesartan, on diabetic retinopathy.

Methods

Over 4?years or longer, 178 normotensive women with type 1 diabetes (86 randomised to candesartan, 32?mg once daily, and 92 assigned to placebo) became pregnant (total of 208 pregnancies).

Results

More than half of patients were exposed to candesartan or placebo prior to or in early pregnancy, but all discontinued it at an estimated 8?weeks from the last menstrual period. Full-term pregnancies (51 vs 50), premature deliveries (21 vs 27), spontaneous miscarriages (12 vs 15), elective terminations (15 vs 14) and other outcomes (1 vs 2) were similar in the candesartan and placebo groups. There were two stillbirths and two ??sick babies?? in the candesartan group, and one stillbirth, eight ??sick babies?? and one cardiac malformation in the placebo group.

Conclusions/interpretation

The risk for fetal consequences of ARBs in type 1 diabetes may not be high if exposure is clearly limited to the first trimester. Long-term studies in fertile women can be conducted with ARBs during pregnancy, provided investigators diligently stop their administration upon planning or detection of pregnancy.

Trial registration

ClinicalTrials.gov DIRECT-Prevent 1 NCT00252733; DIRECT-Protect 1 NCT00252720; DIRECT-Protect 2 NCT00252694.

Funding

The study was funded jointly by AstraZeneca and Takeda.     

Clinician Stress and Patient–Clinician Communication in HIV Care

BACKGROUND

Clinician stress is common, but few studies have examined its relationship with communication behaviors.

OBJECTIVE

To investigate associations between clinician stress and patient?Cclinician communication in primary HIV care.

DESIGN

Observational study.

PARTICIPANTS

Thirty-three primary HIV clinicians and 350 HIV-infected adult, English-speaking patients at three U.S. HIV specialty clinic sites.

MAIN MEASURES

Clinicians completed the Perceived Stress Scale, and we categorized scores in tertiles. Audio-recordings of patient??clinician encounters were coded using the Roter Interaction Analysis System. Patients rated the quality of their clinician??s communication and overall quality of medical care. We used regression with generalized estimating equations to examine associations between clinician stress and communication outcomes, controlling for clinician gender, clinic site, and visit length.

KEY RESULTS

Among the 33 clinicians, 70?% were physicians, 64?% were women, 67?% were non-Hispanic white, and the mean stress score was 3.9 (SD 2.4, range 0?C8). Among the 350 patients, 34?% were women, 55?% were African American, 23?% were non-Hispanic white, 16?% were Hispanic, and 30?% had been with their clinicians >5?years. Verbal dominance was higher for moderate-stress clinicians (ratio?=?1.93, p?<?0.01) and high-stress clinicians (ratio?=?1.76, p?=?0.01), compared with low-stress clinicians (ratio 1.45). More medical information was offered by moderate-stress clinicians (145.5 statements, p <0.01) and high-stress clinicians (125.9 statements, p?=?0.02), compared with low-stress clinicians (97.8 statements). High-stress clinicians offered less psychosocial information (17.1 vs. 19.3, p?=?0.02), and patients of high-stress clinicians rated their quality of care as excellent less frequently than patients of low-stress clinicians (49.5?% vs. 66.9?%, p?<?0.01). However, moderate-stress clinicians offered more partnering statements (27.7 vs. 18.2, p?=?0.04) and positive affect (3.88 vs. 3.78 score, p?=?0.02) than low-stress clinicians, and their patients?? ratings did not differ.

CONCLUSIONS

Although higher stress was associated with verbal dominance and lower patient ratings, moderate stress was associated with some positive communication behaviors. Prospective mixed methods studies should examine the complex relationships across the continuum of clinician well-being and health communication.     

Hospitalist Career Decisions Among Internal Medicine Residents

BACKGROUND

Hospital medicine is a rapidly growing field of internal medicine. However, little is known about internal medicine residents’ decisions to pursue careers in hospital medicine (HM).

OBJECTIVE

To identify which internal medicine residents choose a career in HM, and describe changes in this career choice over the course of their residency education.

DESIGN

Observational cohort using data collected from the annual Internal Medicine In-Training Examination (IM-ITE) survey.

PARTICIPANTS

16,781 postgraduate year 3 (PGY-3) North American internal medicine residents who completed the annual IM-ITE survey in 2009–2011, 9,501 of whom completed the survey in all 3 years of residency.

MAIN MEASSURES

Self-reported career plans for individual residents during their postgraduate year 1 (PGY-1), postgraduate year 2 (PGY-2) and PGY-3.

KEY RESULTS

Of the 16,781 graduating PGY-3 residents, 1,552 (9.3 %) reported HM as their ultimate career choice. Of the 951 PGY-3 residents planning a HM career among the 9,501 residents responding in all 3 years, 128 (13.5 %) originally made this decision in PGY-1, 192 (20.2 %) in PGY-2, and 631 (66.4 %) in PGY-3. Only 87 (9.1 %) of these 951 residents maintained a career decision of HM during all three years of residency education.

CONCLUSIONS

Hospital medicine is a reported career choice for an important proportion of graduating internal medicine residents. However, the majority of residents do not finalize this decision until their final year.     

Impact of 4 + 1 Block Scheduling on Patient Care Continuity in Resident Clinic

BACKGROUND

Leaders in medical education have called for redesign of internal medicine training to improve ambulatory care training. 4?+?1 block scheduling is one innovative approach to enhance ambulatory education.

AIM

To determine the impact of 4?+?1 scheduling on resident clinic continuity.

SETTING

Resident continuity clinic in traditional scheduling in which clinics are scheduled intermittently one-half day per week, compared to 4?+?1 in which residents alternate 1 week of clinic with 4 weeks of an inpatient rotation or elective.

PARTICIPANTS

First-year internal medicine residents.

PROGRAM DESCRIPTION

We measured patient–provider visit continuity, phone triage encounter continuity, and lab follow-up continuity.

PROGRAM EVALUATION

In traditional scheduling as opposed to 4?+?1 scheduling, patients saw their primary resident provider a greater percentage; 71.7 % vs. 63.0 % (p?=?0.008). In the 4?+?1 model, residents saw their own patients a greater percentage; 52.1 % vs. 37.1 % (p?=?0.0001). Residents addressed their own labs more often in 4?+?1 model; 90.7 % vs. 75.6 % (p?=?0.001). There was no significant difference in handling of triage encounters; 42.3 % vs. 35.8 % (p?=?0.12).

DISCUSSION

4?+?1 schedule improves visit continuity from a resident perspective, and may compromise visit continuity from the patient perspective, but allows for improved laboratory follow-up, which we pose should be part of an emerging modern definition of continuity.     

Effect of Patient- and Medication-Related Factors on Inpatient Medication Reconciliation Errors

Background

Little research has examined the incidence, clinical relevance, and predictors of medication reconciliation errors at hospital admission and discharge.

Objective

To identify patient- and medication-related factors that contribute to pre-admission medication list (PAML) errors and admission order errors, and to test whether such errors persist in the discharge medication list.

Design, Participants

We conducted a cross-sectional analysis of 423 adults with acute coronary syndromes or acute decompensated heart failure admitted to two academic hospitals who received pharmacist-assisted medication reconciliation during the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL?CCVD) Study.

Main Measures

Pharmacists assessed the number of total and clinically relevant errors in the PAML and admission and discharge medication orders. We used negative binomial regression and report incidence rate ratios (IRR) of predictors of reconciliation errors.

Key Results

On admission, 174 of 413 patients (42%) had ??1 PAML error, and 73 (18%) had ??1 clinically relevant PAML error. At discharge, 158 of 405 patients (39%) had ??1 discharge medication error, and 126 (31%) had ??1 clinically relevant discharge medication error. Clinically relevant PAML errors were associated with older age (IRR?=?1.46; 95% CI, 1.00?C 2.12) and number of pre-admission medications (IRR?=?1.17; 95% CI, 1.10?C1.25), and were less likely when a recent medication list was present in the electronic medical record (EMR) (IRR?=?0.54; 95% CI, 0.30?C0.96). Clinically relevant admission order errors were also associated with older age and number of pre-admission medications. Clinically relevant discharge medication errors were more likely for every PAML error (IRR?=?1.31; 95% CI, 1.19?C1.45) and number of medications changed prior to discharge (IRR?=?1.06; 95% CI, 1.01?C1.11).

Conclusions

Medication reconciliation errors are common at hospital admission and discharge. Errors in preadmission medication histories are associated with older age and number of medications and lead to more discharge reconciliation errors. A recent medication list in the EMR is protective against medication reconciliation errors.     

Increasing the use of advance directives in medical outpatients

Objective

We studied whether a simple educational intervention would increase patient completion of advance directives and discussions on end-of-life issues.

Design

Randomized, controlled trial.

Setting

Outpatient clinic of a teaching hospital.

Subjects

One hundred eighty-seven outpatients of a primary care internal medicine clinic.

Intervention

Study subjects attended a 1-hour interactive seminar and received an informational pamphlet and advance directive forms. Control subjects received by mail the pamphlet and forms only.

Measurements and main results

Completion of the advance directive was the main measurement. There were no significant differences in baseline characteristics of either group. Follow-up at 1 month revealed advance directive completion in 38% of study versus 24% of control subjects (p=.04), and discussions on advance planning in 73% of study versus 57% of control subjects (p=.02). Patients most likely to complete the documents were white, married, or attendees at the educational seminar.

Conclusions

Interactive group seminars for medical outpatients increased discussions and use of written advance directives.     

Neglect of attention to reproductive health in women with HIV infection: contraceptive use and unintended pregnancies in the Swiss HIV Cohort Study

Objectives

Women with HIV infection are mainly of reproductive age and need safe, effective and affordable contraception to avoid unintended pregnancies. The aim of this study was to evaluate contraceptive use and unintended pregnancies in this population in Switzerland.

Methods

A self‐report anonymous questionnaire on contraceptive methods, adherence to them, and unintended pregnancies was completed by women included in the Swiss HIV Cohort Study (SHCS) between November 2013 and June 2014. Sociodemographic characteristics and information related to combined antiretroviral therapy and HIV disease status were obtained from the SHCS database.

Results

Of 462 women included, 164 (35.5%) reported not using any contraception. Among these, 65 (39.6%) reported being sexually active, although 29 (44.6%) were not planning a pregnancy. Of 298 women using contraception, the following methods were reported: condoms, 219 (73.5%); oral hormonal contraception, 32 (10.7%); and intrauterine devices, 28 (9.4%). Among all women on contraception, 32 (10.7%) reported using more than one contraceptive method and 48 (16%) had an unintended pregnancy while on contraception (18, condoms; 16, oral contraception; four, other methods). Of these, 68.1% terminated the pregnancy and almost half (43.7%) continued using the same contraceptive method after the event.

Conclusions

Family planning needs in HIV‐positive women are not fully addressed because male condoms remained the predominant reported contraceptive method, with a high rate of unintended pregnancies. It is of utmost importance to provide effective contraception such as long‐acting reversible contraceptives for women living with HIV.

     

An Evaluation of Internal Medicine Residency Continuity Clinic Redesign to a 50/50 Outpatient–Inpatient Model

BACKGROUND

There have been recent calls for improved internal medicine outpatient training, yet assessment of clinical and educational variables within existing models is lacking.

OBJECTIVE

To assess the impact of clinic redesign from a traditional weekly clinic model to a 50/50 outpatient–inpatient model on clinical and educational outcomes.

DESIGN

Pre-intervention and post-intervention study intervals, comparing the 2009–2010 and 2010–2011 academic years.

PARTICIPANTS

Ninety-six residents in a Primary Care Internal Medicine site of a large academic internal medicine residency program who provide care for > 13,000 patients.

INTERVENTION

Continuity clinic redesign from a traditional weekly clinic model to a 50/50 model characterized by 50 % outpatient and 50 % inpatient experiences scheduled in alternating 1 month blocks, with twice weekly continuity clinic during outpatient months and no clinic during inpatient months.

MAIN MEASURES

1) Clinical outcomes (panel size, patient visits, adherence with chronic disease and preventive service guidelines, continuity of care, patient satisfaction, and perceived safety/teamwork in clinic); 2) Educational outcomes (attendance at teaching conference, resident and faculty satisfaction, faculty assessment of resident clinic performance, and residents’ perceived preparedness for outpatient management).

RESULTS

Redesign was associated with increased mean panel size (120 vs. 137.6; p?≤ 0.001), decreased continuity of care (63 % vs. 48 % from provider perspective; 61 % vs. 51 % from patient perspective; p ≤ ?0.001 for both; team continuity was preserved), decreased missed appointments (12.5 % vs. 10.9 %; p ≤ ?0.01), improved perceived safety and teamwork (3.6 vs. 4.1 on 5-point scale; p ≤ ?0.001), improved mean teaching conference attendance (57.1 vs. 64.4; p ≤ ?0.001), improved resident clinic performance (3.6 vs. 3.9 on 5-point scale; p ≤ ?0.001), and little change in other outcomes.

CONCLUSION

Although this model requires further study in other settings, these results suggest that a 50/50 model may allow residents to manage more patients while enhancing the climate of teamwork and safety in the continuity clinic, compared to traditional models. Future work should explore ways to preserve continuity of care within this model.     

A simple clinical scoring system using ferritin, fasting insulin, and type IV collagen 7S for predicting steatohepatitis in nonalcoholic fatty liver disease

Background

Liver histology is the gold standard for the diagnosis of nonalcoholic steatohepatitis (NASH). Noninvasive, simple, reproducible, and reliable biomarkers are greatly needed to differentiate NASH from nonalcoholic fatty liver disease (NAFLD).

Methods

To construct a scoring system for predicting NASH, 177 Japanese patients with biopsy-proven NAFLD were enrolled. To validate the scoring system, 442 biopsy-proven NAFLD patients from eight hepatology centers in Japan were also enrolled.

Results

In the estimation group, 98 (55%) patients had NASH. Serum ferritin [??200?ng/ml (female) or ??300?ng/ml (male)], fasting insulin (??10???U/ml), and type IV collagen 7S (??5.0?ng/ml) were selected as independent variables associated with NASH, by multilogistic regression analysis. These three variables were combined in a weighted sum [serum ferritin ??200?ng/ml (female) or ??300?ng/ml (male)?=?1 point, fasting insulin ??10???U/ml?=?1 point, and type IV collagen 7S ??5.0?ng/ml?=?2 points] to form an easily calculated composite score for predicting NASH, called the NAFIC score. The area under the receiver operating characteristic (AUROC) curve for predicting NASH was 0.851 in the estimation group and 0.782 in the validation group. The NAFIC AUROC was the greatest among several previously established scoring systems for detecting NASH, but also for predicting severe fibrosis.

Conclusions

NAFIC score can predict NASH in Japanese NAFLD patients with sufficient accuracy and simplicity to be considered for clinical use.     

Reducing Peg-IFN doses causes later virologic response or no response in HCV genotype 1 patients treated with Peg-IFN alfa-2b plus ribavirin

Background

The timing to the first undetectable hepatitis C virus (HCV) RNA level is strongly associated with sustained virologic response in pegylated interferon (Peg-IFN) plus ribavirin combination therapy for patients with chronic hepatitis C (CH-C) with genotype 1. This study was conducted to clarify the impact of drug exposure to Peg-IFN on the timing of HCV RNA negativity in Peg-IFN plus ribavirin combination therapy for CH-C patients with genotype 1.

Methods

A total of 1409 patients treated with Peg-IFN alfa-2b plus ribavirin were enrolled and classified into four categories according to the Peg-IFN dosage. Furthermore, 100 patients were extracted from each Peg-IFN dosage category to adjust for characteristic factors, using the propensity score method.

Results

Peg-IFN exposure was dose-dependently associated with the timing of HCV RNA negativity (p????0.001). The HCV RNA negative rate at week 4 decreased from 12% with a Peg-IFN dose of >1.5???g/kg/week to 1?C3% with a dose of <1.5???g/kg/week (p????0.001), and at week 12 the rate had decreased from 44% with a dose of ??1.2???g/kg/week to 18% with a dose of <1.2???g/kg/week (p?=?0.001). Treatment failure (patients without a 1-log decrease of HCV RNA at week 4 or a 2-log decrease of HCV RNA at week 12, or positive at week 24) was found in 54?C66% of patients given <1.2???g/kg/week (p????0.001), and these patients accounted for 64% of the non-responders.

Conclusions

The timing of HCV RNA negativity depends significantly on the Peg-IFN dose. Reducing the Peg-IFN dose can induce a later virologic response or non-response in HCV genotype 1 patients treated with Peg-IFN plus ribavirin.     

Appendicite aiguë et grossesse, une situation délicate : à propos de huit cas

Background

Abdominal pain in a pregnant woman suggests a diagnosis of appendicitis. However, many other pathologies also occur during pregnancy that could cause abdominal pain, and require suitable treatment. The aim of this work is to discuss the diagnostic, therapeutic and prognostic aspects of appendicitis during pregnancy.

Patients and methods

Eight patients were admitted for appendicitis during pregnancy and were prospectively studied over a 24-month period. Seven patients presented an appendical syndrome. The eighth patient presented a threat of premature childbirth with fever. The gestational age ranged from 12 to 30 weeks.

Results

All our patients were operated. Surgical exploration showed generalised purulent peritonitis in one patient. There were no complications for six of our patients. We reported a foetal death in one case and an abortion in another case. The histological examination showed appendicitis without specificity or malignancy in all eight cases.

Conclusion

The diagnosis of appendicitis in pregnant women is often difficult, and serious forms are frequent. This leads us to search immediately for appendicitis in pregnant women with abdominal pain and fever.     

Utilization of Primary and Obstetric Care After Medically Complicated Pregnancies: An Analysis of Medical Claims Data

BACKGROUND

Because pregnancy complications, including gestational diabetes mellitus (GDM) and hypertensive disorders in pregnancy, are risk factors for diabetes and cardiovascular disease, post-delivery follow-up is recommended.

OBJECTIVE

To determine predictors of post-delivery primary and obstetric care utilization in women with and without medical complications.

RESEARCH DESIGN

Five-year retrospective cohort study using commercial and Medicaid insurance claims in Maryland.

SUBJECTS

7,741 women with a complicated pregnancy (GDM, hypertensive disorders and pregestational diabetes mellitus [DM]) and 23,599 women with a comparison pregnancy.

MEASURES

We compared primary and postpartum obstetric care utilization rates in the 12 months after delivery between the complicated and comparison pregnancy groups. We conducted multivariate logistic regression to assess the association between pregnancy complications, sociodemographic predictor variables and utilization of care, stratified by insurance type.

RESULTS

Women with a complicated pregnancy were older at delivery (p?<?0.001), with higher rates of cesarean delivery (p?<?0.0001) and preterm labor or delivery (p?<?0.0001). Among women with Medicaid, 56.6 % in the complicated group and 51.7 % in the comparison group attended a primary care visit. Statistically significant predictors of receiving a primary care visit included non-Black race, older age, preeclampsia or DM, and depression. Among women with commercial health insurance, 60.0 % in the complicated group and 49.5 % in the comparison group attended a primary care visit. Pregnancy complication did not predict a primary care visit among women with commercial insurance.

CONCLUSIONS

Women with pregnancy complications were more likely to attend primary care visits post-delivery compared to the comparison group, but overall visit rates were low. Although Medicaid expansion has potential to increase coverage, innovative models for preventive health services after delivery are needed to target women at higher risk for chronic disease development.     

Medical Students’ Attention to Multiple Risk Behaviors: A Standardized Patient Examination

BACKGROUND

Risk behaviors tend to cluster, particularly among smokers, with negative health effects. To optimize patients?? health and wellbeing, health care providers ideally would assess and intervene upon the multiple risks with which patients may present.

OBJECTIVE

This study examined medical students?? skills in assessing and treating multiple risk behaviors.

DESIGN

Using a randomized experimental design, medical students?? counseling interactions were evaluated with a standardized patient presenting with sexual health concerns and current tobacco use with varied problematic drinking status (alcohol-positive or alcohol-negative).

PARTICIPANTS

One hundred and fifty-six third-year medical students.

MAIN MEASURES

Student and standardized patient completed measures evaluated student knowledge, attitudes, and clinical performance.

KEY RESULTS

Overall, most students assessed tobacco use (85%); fewer assessed alcohol use (54%). Relative to the alcohol-negative case, students seeing the alcohol-positive case were less likely to assess sexually transmitted disease history (80% vs. 91%, p?=?0.042), or patients?? readiness to quit smoking (41% vs. 60%, p?=?0.025), and endorsed greater attitudinal barriers to tobacco treatment (p?=?0.030). Patient satisfaction was significantly lower for the alcohol-positive than the alcohol-negative case; clinical performance ratings moderated this relationship.

CONCLUSIONS

When presented with a case of multiple risks, medical students performed less effectively and received lower patient satisfaction ratings. Findings were moderated by students?? overall clinical performance. Paradigm shifts are needed in medical education that emphasize assessment of multiple risks, new models of conceptualizing behavior change as a generalized process, and treatment of the whole patient for optimizing health outcomes.