Catherine Battaglia

Birth outcomes in Colorado's undocumented immigrant population.

BackgroundThe birth outcomes of undocumented women have not been systematically studied on a large scale. The growing number of undocumented women giving birth in the United States has important implications for clinical care and public health policy. The objective of this study was to describe birth outcomes of undocumented immigrants in Colorado.MethodsRetrospective descriptive study of singleton births to 5961 undocumented women using birth certificate data for 1998–1999.ResultsUndocumented mothers were younger, less educated, and more likely to be single. They had higher rates of anemia, were less likely to gain enough weight, and less likely to receive early prenatal care. They were much less likely to use alcohol or tobacco. Undocumented women had a lower rate of low birth weight (5.3% v 6.5%, P < .001) or preterm infants (12.9% v 14.5%; p = .001). Undocumented women experienced higher rates of labor complications including excessive bleeding (2.3% v 0.8%, p < .001) and fetal distress (8.7% v 3.6%, p < .001).ConclusionUndocumented women have lower rates of preterm delivery and low birth weight infants, but higher rates of pregnancy related risk factors. Higher prevalence of some risk factors which are amenable to medical intervention reveals the need for improved prenatal care in this group.

Pilot study of intravenous magnesium sulfate in refractory cardiac arrest: safety data and recommendations for future studies

UNLABELLED Recent case reports have evidenced a temporal association between administration of i.v. magnesium sulfate (M) and resuscitation from prolonged cardiac arrest refractory to standard (S) ACLS attempts. However, speculation has arisen that M as a vasodilator, may decrease aortic diastolic and coronary perfusion pressure (CPP), aortic systolic and cerebral perfusion pressures (CePP), which may decrease resuscitation rates and neurologic recovery, as compared to standard ACLS alone (SA). OBJECTIVE To resolve positive beginning evidence vs. negative theory, we conducted a pilot study of M+S vs. SA in refractory cardiac arrest on resuscitation rates (% R, return of stable pulses > 30 min without CPR, first in-hospital cardiac arrest > 5-min duration) and neurologic recovery/survival to hospital discharge (SHD). METHODS All patients from 1 January 1990-31 December 1991 at Rose Hospital, in cardiac arrest refractory to S through the first epinephrine dose (including 3 defibrillation attempts with pulseless VT/VF) were included in the data analysis, except: (1) patients with trauma, known poisoning, < 18 years, pregnancy excluded; (2) Standard ACLS alone patients with cardiac arrest < 5-min duration were not included in the SA comparison group, because the shortest cardiac arrest time before i.v. MgSO4 administration in the M+S group was 5 min. M+S (N = 29) and SA (N = 33) groups were also comparable on mean age (72-73 years) in this open-label prospective case-matched control group study. RESULTS SHD rates were nearly equivalent between M+S (5.2%) and SA (4.5%). Complete or partial neurologic recovery, as best neurologic status post-R, occurred in 21% (6/29) M+S patients vs. 9% (3/33) SA (P = 0.17), even though cardiac arrest time on the study code call for resuscitated patients averaged shorter with SA (14.2 min) than M+S (19.8 min). M was frequently administered late in the resuscitation attempt--code call to M administration averaged 16.5 min (< 10 min in only 4/28 patients). A trend toward increased % R with M was evidenced: 21% (7/33) SA vs. 35% (10/29) M+S (P = 0.21). A temporal association between M administration and first return of spontaneous circulation (ROSC) was also documented in 4 of 10 M+S patients (pulseless electrical activity (3)/pulseless VT (1)), who had first ROSC/R occur within 0.5-2.25 min following first i.v. M bolus delivery, after 11-30 min (mean = 20 min) of continuous pulseless rhythm refractory to standard ACLS. All M+S resuscitations occurred within the dose range 2.5-5 g (i.v. push): 3/6 (50%) and 7/13 (54%) R occurred with 1-3 g and 4-5 g MgSO4, respectively (at least 11/13 patients had peripheral i.v. delivery with 4-5 g M). Analyzing post-ROSC hypotension proved important, as 50% of pts with first recorded systolic BP post-ROSC < 90 mmHg were resuscitated vs. 83% with > 90 mmHg (P = 0.10). A trend toward increased post-ROSC hypotension was evidenced with i.v. MgSO4: Recorded first or second systolic BP < 90 mmHg post-ROSC occurred in 66% of M+S vs. 42% of SA patients. All 3 M+S patients having a wide open i.v. levophed infusion as vasopressor support, started immediately post-ROSC/i.v. MgSO4 with systolic BP < 90 mmHg and continued at least 15 min (titrating to a systolic BP approximately 110 mmHg), had a temporal association between M delivery and R after 14-30 min of continuous pulselessness refractory to S. CONCLUSION Human research determining whether i.v. MgSO4 increases long-term survival from refractory cardiac arrest should be vigorously pursued, as it is safe to proceed given the above described considerations.

Interventional radiologic treatment of hepatocellular carcinoma-A cost analysis from the payer perspective

PURPOSE To determine whether there is a cost advantage for one of the three commonly performed interventional radiology (IR) procedures (chemoembolization, selective internal radiation therapy [SIRT], radiofrequency ablation [RFA]) in the treatment of hepatocellular carcinoma (HCC). MATERIALS AND METHODS A cost analysis from the payer perspective was performed. Primary data were collected from a university hospital, and sensitivity testing was done by comparing coding information obtained at two other tertiary care medical facilities. Medicare allowable reimbursements were used to estimate costs. Decision analytic models using decision tree analysis and Monte Carlo simulations were used to compare alternatives. Simulations were performed comparing all three procedures, followed by a two-way comparison of chemoembolization and SIRT. RESULTS Simple decision tree analyses showed that RFA was less expensive compared with chemoembolization and SIRT. Monte Carlo simulations showed average reimbursements for each of the three procedures that was largely dependent on the number of repeat procedures required (

Developing leadership and advocacy skills in medical students through service learning.

9,362 vs

Training primary care clinicians in motivational interviewing: A comparison of two models

30,107 vs

Interprofessional education in leadership and advocacy.

35,629 for RFA, chemoembolization, and SIRT; P < .001). When comparing only chemoembolization and SIRT, chemoembolization was the lower cost strategy in most scenarios, but SIRT was lower in cost in more than one-third of the simulations. CONCLUSIONS RFA was the least costly of the three IR strategies in nearly all scenarios studied in these models. Although chemoembolization was less expensive than SIRT in most instances, Monte Carlo simulation showed a preference for SIRT in more than one-third of all scenarios. Sensitivity analyses showed that the most important variables assessed were the need for repeat procedures.

Systematic, Multimethod Assessment of Adaptations Across Four Diverse Health Systems Interventions

INTRODUCTION Traditional medical training focuses on ameliorating disease states but not on the underlying socially determined causes. The LEADS (Leadership Education Advocacy Development Scholarship) program at the University of Colorado Denver School of Medicine was designed to train medical students to become effective advocates and to promote health at the community level. METHODS Participants in the LEADS Track complete courses in advocacy skills, perform a summer internship, and complete a mentored scholarly activity addressing population health. Students are paired with a faculty mentor and a community-based organization. RESULTS Students report empowerment, improved self-efficacy, and increased likelihood of future engagement in leadership and health advocacy. Community sponsors also rate the experience as highly valuable. CONCLUSIONS A curriculum in advocacy and leadership skills that includes an intensive, community-based service learning experience is effective at increasing student empowerment and disposition toward community service.

Implementing smoking cessation guidelines for hospitalized Veterans: Cessation results from the VA-BEST trial

OBJECTIVES To evaluate implementing two training models for motivational interviewing (MI) to address tobacco use with primary care clinicians. METHODS Clinicians were randomized to moderate or high intensity. Both training modalities included a single ½ day workshop facilitated by MI expert trainers. The high intensity (HI) training provided six booster sessions including telephone interactions with simulated patients and peer coaching by MI champions over 3 months. To assess performance of clinicians to deliver MI, an objective structured clinical evaluation (OSCE) was conducted before and 12 weeks after the workshop training. RESULTS Thirty-four clinicians were enrolled; 18 were randomly assigned to HI. Compared to the moderate intensity group, the HI group scored significantly higher during the OSCE for three of six global Motivational Interviewing Treatment Integrity scale scores. There was also significant improvement for three of the four measures of MI counseling knowledge, skills and confidence. CONCLUSIONS Using champions and telephone interactions with simulated patients as enhancement strategies for MI training programs is feasible in the primary care setting and results in greater gains in MI proficiency. PRACTICE IMPLICATIONS Results confirm and expand evidence for use of booster sessions to improve the proficiency of MI training programs for primary care clinicians.

Perspectives on a Home Telehealth Care Management Program for Veterans With Posttraumatic Stress Disorder Who Smoke

Time Directive (EWTD) and the hours of work being reduced to an average 48 hours a week. It is perceived by senior doctors that junior doctors, especially FY1s, are seeing fewer acute admissions when on-call, even during the day, compared to their preEWTD predecessors. Alas, EWTD is often blamed as to why FY1s maybe clerking fewer patients when on-call, however a study performed at a large London Teaching hospital found that the introduction of reduced hours was not the only reason why the opportunity to clerk ill patients had declined. The FY1s understand the importance of seeing acutely ill patients to help develop their clinical skills and they want to be on-call, but there seems to be few opportunities to be on-call and even when on-call FY1s seem to have few opportunities to clerk acute patients. Several factors combine to reduce the likelihood of the FY1 being first to assess an acutely ill patient, especially the increasing number of posts with no on-calls. The need to assess rapidly to avoid breaching A&E 4-hour targets, and an increasing focus on patient safety have led to more senior doctors being the first contact in acute patient care. More senior trainees may not trust an FY1 to see sicker patients, either because they do not work together regularly, or because with fewer previous opportunities to do so, the FY1s have less confidence or ability. It is important to emphasize that the FY1 year is a learning year, but concerning that the FY1s feel that they have ‘to ask permission’ to clerk cases, suggesting that FY1s see themselves more as a learner than part of the team – more akin to medical students. Finally, FY1s value being on-call as this leads to managing acutely ill patients and helps them to gain confidence. However, rota constraints, changing on-call team composition, a reduced sense of acute medicine as ‘‘their role’’, and the introduction of posts without acute components, combine to reduce FY1s’ opportunities to experience acute medicine.

The Veterans Health Administration's proposal for APRN full-practice authority.

Background Many health outcomes and implementation science studies have demonstrated the importance of tailoring evidence-based care interventions to local context to improve fit. By adapting to local culture, history, resources, characteristics, and priorities, interventions are more likely to lead to improved outcomes. However, it is unclear how best to adapt evidence-based programs and promising innovations. There are few guides or examples of how to best categorize or assess health-care adaptations, and even fewer that are brief and practical for use by non-researchers. Materials and methods This study describes the importance and potential of assessing adaptations before, during, and after the implementation of health systems interventions. We present a promising multilevel and multimethod approach developed and being applied across four different health systems interventions. Finally, we discuss implications and opportunities for future research. Results The four case studies are diverse in the conditions addressed, interventions, and implementation strategies. They include two nurse coordinator-based transition of care interventions, a data and training-driven multimodal pain management project, and a cardiovascular patient-reported outcomes project, all of which are using audit and feedback. We used the same modified adaptation framework to document changes made to the interventions and implementation strategies. To create the modified framework, we started with the adaptation and modification model developed by Stirman and colleagues and expanded it by adding concepts from the RE-AIM framework. Our assessments address the intuitive domains of Who, How, When, What, and Why to classify and organize adaptations. For each case study, we discuss how the modified framework was operationalized, the multiple methods used to collect data, results to date and approaches utilized for data analysis. These methods include a real-time tracking system and structured interviews at key times during the intervention. We provide descriptive data on the types and categories of adaptations made and discuss lessons learned. Conclusion The multimethod approaches demonstrate utility across diverse health systems interventions. The modified adaptations model adequately captures adaptations across the various projects and content areas. We recommend systematic documentation of adaptations in future clinical and public health research and have made our assessment materials publicly available.