Angela Nannini

Underreporting of pregnancy-related mortality in the United States and Europe.

OBJECTIVE: Available maternal mortality statistics do not allow valid international comparisons. Our objective was to uniformly measure underreporting of mortality from pregnancy in official statistics from selected regions within the U.S. and Europe, and to provide comparable revised profiles of pregnancy-related mortality. METHODS: We developed a standardized enhanced method to uniformly identify and classify pregnancy-associated deaths from 2 U.S. states, Massachusetts and North Carolina, and 2 European countries, Finland and France, for the years 1999–2000. Identification method included the use of all data available from the death certificate as well as computerized linkage of births and deaths registers. All cases were reviewed and classified by an international panel of experts. RESULTS: Four-hundred-and-four pregnancy-associated deaths were identified and reviewed. Underestimation of mortality causally related to pregnancy based on International Classification of Diseases cause-of-death codes alone varied from 22% in France to 93% in Massachusetts. Underreporting was greater in the regions with lower initial maternal mortality ratios. The distribution of causes of pregnancy-related mortality was specific to each region. The leading causes of death were cardiovascular conditions in Massachusetts; hemorrhage, pregnancy-induced hypertension, and peripartum cardiomyopathy in North Carolina; noncardiovascular medical conditions in Finland; and hemorrhage in France. CONCLUSION: This study shows the limitations of maternal mortality statistics based on International Classification of Diseases cause-of-death codes alone. Linkage of births and deaths registers should routinely be used in the ascertainment of pregnancy-related deaths. In addition, extension of the definition of a maternal death should be considered. Beyond pregnancy-related mortality ratios, considering the specific distribution of causes-of-death is important to define prevention strategies. LEVEL OF EVIDENCE: II-2

Perinatal outcomes of twin births conceived using assisted reproduction technology: a population-based study†

BACKGROUND Approximately 18% of multiple births in the USA result from assisted reproduction technology (ART). Although many studies comparing ART and naturally conceived twins report no difference in risks for perinatal outcomes, others report slight to moderate positive or protective associations. METHODS We selected twin deliveries with and without indication of ART from Massachusetts live birth-infant death records from 1997 to 2000 linked to the US ART surveillance system. The sample was restricted to deliveries by mothers with increased socioeconomic status, private health insurance and intermediate/plus prenatal care use. Our final sample included 1446 and 2729 ART and non-ART twin deliveries, respectively. Odds ratios (OR) for associations between ART and perinatal outcomes were adjusted for maternal demographic factors, smoking, prenatal care and hospital care level. RESULTS ART twin deliveries were less likely than non-ART to be very preterm (adjusted OR 0.75; 95% confidence interval 0.58-0.97) or include a very low birthweight (<1500 g) infant (0.75; 0.58-0.95) or infant death (0.55; 0.35-0.88). In stratified analyses, these findings were observed among primiparous deliveries, but there were no risk differences among multiparous ART and non-ART twin deliveries. CONCLUSIONS ART treatment was not a risk factor for adverse perinatal outcome, and risks for several outcomes were somewhat lower among ART twin deliveries. Nonetheless, ART is strongly associated with twinning and twins remain a high-risk group, relative to singletons. Promoting singleton gestation in assisted conception is an important strategy for reducing adverse outcomes.

Accuracy of assisted reproductive technology information on the Massachusetts birth certificate, 1997–2000

OBJECTIVE To evaluate the accuracy of assisted reproductive technology (ART) reporting on the Massachusetts birth certificate and to explore the individual and hospital-level characteristics associated with ART reporting. DESIGN Validity analysis of population-based data. SETTING Live-birth deliveries by Massachusetts-resident mothers during 1997-2000. PATIENT(S) Live births and delivery mothers. INTERVENTION(S) The ART data maintained by the Centers for Disease Control and Prevention were linked with the live birth-infant death records in Massachusetts. Successfully linked records were used as the gold standard for ART-related deliveries in evaluating the validity of the ART information reported on the Massachusetts birth certificate. MAIN OUTCOME MEASURE(S) Sensitivity and specificity. RESULT(S) The sensitivity of ART reporting on the birth certificate was 27% and the specificity >99%. Sensitivity of ART reporting was higher among women with multiple deliveries (twins: 32%; triplets+: 43%) and preterm deliveries (36%). CONCLUSION(S) During the period evaluated, reporting of ART information on the birth certificate was incomplete, and ART births identified through the birth certificate were a biased sample of the population of ART births. Using delivery hospital data as the sole source of ART information for the standard birth certificate may yield inaccurate information.

Winning Policy Change to Promote Community Health Workers: Lessons From Massachusetts in The Health Reform Era

There is a national movement among community health workers (CHWs) to improve compensation, working conditions, and recognition for the workforce through organizing for policy change. As some of the key advocates involved, we describe the development in Massachusetts of an authentic collaboration between strong CHW leaders of a growing statewide CHW association and their public health allies. Collaborators worked toward CHW workforce and public health objectives through alliance building and organizing, legislative advocacy, and education in the context of opportunities afforded by health care reform. This narrative of the path to policy achievements can inform other collaborative efforts attempting to promote a policy agenda for the CHW workforce across the nation.

Nurse Practitioner Organizational Climate in Primary Care Settings: Implications for Professional Practice

The expansion of the nurse practitioner (NP) workforce in primary care is key to meeting the increased demand for care. Organizational climates in primary care settings affect NP professional practice and the quality of care. This study investigated organizational climate and its domains affecting NP professional practice in primary care settings. A qualitative descriptive design, with purposive sampling, was used to recruit 16 NPs practicing in primary care settings in Massachusetts. An interview guide was developed and pretested with two NPs and in 1 group interview with 7 NPs. Data collection took place in spring of 2011. Individual interviews lasted from 30-70 minutes, were audio recorded, and transcribed. Data were analyzed using Atlas.ti 6.0 software by 3 researchers. Content analysis was applied. Three previously identified themes, NP-physician relations, independent practice and autonomy, and professional visibility, as well as two new themes, organizational support and resources and NP-administration relations emerged from the analyses. NPs reported collegial relations with physicians, challenges in establishing independent practice, suboptimal relationships with administration, and lack of support. NP contributions to patient care were invisible. Favorable organizational climates should be promoted to support the expanding of NP workforce in primary care and to optimize recruitment and retention efforts.

Probabilistic Linkage of Assisted Reproductive Technology Information with Vital Records, Massachusetts 1997-2000

To assess the validity of probabilistic linkage (PL) in combining national surveillance data on assisted reproductive technology (ART) with Massachusetts birth and infant death data, for the purpose of monitoring maternal and child health outcomes of ART. A study conducted in 2006 utilized direct identifiers to match Massachusetts birth records with records on ART procedures performed to Massachusetts residents in fertility clinics located in Massachusetts and Rhode Island, achieving a linkage rate of 87.5%. The present study employed PL using the program Link Plus, without access to direct identifiers. The primary linking variables were maternal and infant dates of birth, and plurality. Ancillary variables such as maternal ZIP code and gravidity helped resolve duplicate matches and capture additional matches. PL linked 5,390 (87.8%) of 6,139 deliveries, correctly identifying 96.4% of the matches previously obtained using deterministic linkage methods. PL yielded a high linkage rate with satisfactory validity; this method may be applied in other states to help monitor the maternal and child health outcomes of ART.

Revisiting Scope of Practice Facilitators and Barriers for Primary Care Nurse Practitioners: A Qualitative Investigation

Revisiting scope of practice (SOP) policies for nurse practitioners (NPs) is necessary in the evolving primary care environment with goals to provide timely access, improve quality, and contain cost. This study utilized qualitative descriptive design to investigate NP roles and responsibilities as primary care providers (PCPs) in Massachusetts and their perceptions about barriers and facilitators to their SOP. Through purposive sampling, 23 NPs were recruited and they participated in group and individual interviews in spring 2011.The interviews were audio recorded and transcribed. Data were analyzed using Atlas.ti 6.0 software, and content analysis was applied. In addition to NP roles and responsibilities, three themes affecting NP SOP were: regulatory environment; comprehension of NP role; and work environment. NPs take on similar responsibilities as physicians to deliver primary care services; however, the regulatory environment and billing practices, lack of comprehension of the NP role, and challenging work environments limit successful NP practice.

Patient comprehension of discharge instructions from the emergency department: A literature review

Purpose To examine research published from 1995 to 2010, evaluating patient comprehension of discharge instructions from emergency department (ED) or urgent care (UC) settings. Specifically, we examined: (a) the interventions utilized to provide discharge instructions, (b) the methods used to assess patient comprehension, and (c) the most effective strategies for assuring patient comprehension of ED discharge instructions. Data sources A comprehensive literature review was conducted utilizing the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Reference Center Academic, Medline, Cochrane, and Ovid. English language peer‐reviewed articles published between 1995 and 2010 were reviewed. Search terms included patient, comprehension, understanding, discharge instructions, health education, and emergency medicine. Conclusions Increases in patient comprehension of ED discharge instructions are identified with alternative teaching interventions (multimedia) in comparison to traditional standardized written discharge instructions (usual care). Literature suggests clinicians seldom clarify patient comprehension in practice, though effective methods are noted in research. Future research is needed to explore innovative teaching interventions and their impact upon patient comprehension and patient outcomes. Implications for practice To ensure patient comprehension of discharge instructions, the simplification of discharge material is paramount. Nurse practitioners working in ED or UC settings can improve upon “usual care” by exploring more innovative teaching interventions.

Development and psychometric testing of the Nurse Practitioner Primary Care Organizational Climate Questionnaire.

Background:Policy makers and healthcare organizations are calling for expansion of the nurse practitioner (NP) workforce in primary care settings to assure timely access and high-quality care for the American public. However, many barriers, including those at the organizational level, exist that may undermine NP workforce expansion and their optimal utilization in primary care. Objectives:This study developed a new NP-specific survey instrument, Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ), to measure organizational climate in primary care settings and conducted its psychometric testing. Methods:Using instrument development design, the organizational climate domain pertinent for primary care NPs was identified. Items were generated from the evidence and qualitative data. Face and content validity were established through two expert meetings. Content validity index was computed. The 86-item pool was reduced to 55 items, which was pilot tested with 81 NPs using mailed surveys and then field-tested with 278 NPs in New York State. SPSS 18 and Mplus software were used for item analysis, reliability testing, and maximum likelihood exploratory factor analysis. Results:Nurse Practitioner Primary Care Organizational Climate Questionnaire had face and content validity. The content validity index was .90. Twenty-nine items loaded on four subscale factors: professional visibility, NP–administration relations, NP–physician relations, and independent practice and support. The subscales had high internal consistency reliability. Cronbach’s alphas ranged from.87 to .95. Discussion:Having a strong instrument is important to promote future research. Also, administrators can use it to assess organizational climate in their clinics and propose interventions to improve it, thus promoting NP practice and the expansion of NP workforce.

Neonatal Outcomes and Mental Illness, Substance Abuse, and Intentional Injury During Pregnancy

Mental illness (MI), substance abuse (SA), and intentional injury (II) are known individual risk factors for adverse pregnancy outcomes. Their combined association with preterm birth (PTB) and low birth weight (LBW) remains relatively unexplored. We examined hospital utilization for the co-occurrence of II and MI or SA in pregnant women in Massachusetts and assessed their interactive association with PTB and LBW. This retrospective cohort study used ICD-9 and E-codes reported on linked birth and hospital utilization data to identify MI, SA, and II diagnoses during pregnancy for 176,845 Massachusetts resident women who delivered during 2002–2004. Adjusted odds ratios (OR) for the independent and joint associations of MI, SA, and II on PTB and LBW were calculated. Two thousand two hundred and eight women (1.6%) had a prenatal MI visit, 834 (0.5%) a prenatal SA visit, and 847 (0.5%) a prenatal II visit. Among them 163 women had MI and II visits and 69 had SA and II visits. SA, MI, and II were all significant predictors of LBW and PTB. Women with both SA and II had higher odds of PTB (OR 2.7 95% CI 1.3–5.7) and LBW (OR 5.3 95% CI 3.9–7.3) than women with neither diagnosis. Prenatal MI, SA, and II are risk factors for LBW and PTB. Women with SA and II co-diagnoses have greater risk of LBW and PTB than women with neither diagnosis. Screening, timely diagnosis, and treatment of women with co-occurring morbidities, particularly II and SA, should be incorporated into reproductive and perinatal health programs.