Sangini S. Sheth

Wide Variation Found In Hospital Facility Costs For Maternity Stays Involving Low-Risk Childbirth

Childbirth is the leading cause of hospital admission in the United States, yet there has been little research on variation in hospital costs associated with childbirth. Using data from the 2011 Nationwide Inpatient Sample, we characterized the variation in estimated facility costs of hospitalizations for low-risk childbirth across US hospitals. We found that the average estimated facility cost per maternity stay ranged from

Surgical site infections in gynecology.

1,189 to

Missed opportunities for HPV immunization among young adult women

11,986 (median:

Variation in Hospital Intrapartum Practices and Association With Cesarean Rate

4,215), with a 2.2-fold difference between the 10th and 90th percentiles. Estimated facility costs were higher at hospitals with higher rates of cesarean delivery or serious maternal morbidity. Hospitals having government or nonprofit ownership; being a rural hospital; and having relatively low volumes of childbirths, low proportions of childbirths covered by Medicaid, and long stays also had significantly higher costs. The large variation in estimated facility cost for low-risk childbirths among hospitals suggests that hospital practices might be an important contributor to variation in cost and that there may be opportunities for cost reduction. The safe reduction of cesarean deliveries, increasing the coordination of care, and emphasizing value of care through new payment and delivery systems reforms may help reduce hospital costs and cost variation associated with childbirth in the United States.

Missed Opportunities and Barriers to Human Papillomavirus Vaccination Among Young Adult Women [220].

Importance Surgical site infections (SSIs) are preventable, yet nearly 2% of all surgical cases are complicated by an SSI. Each SSI increases the cost of a postoperative hospital stay by more than

Patient and provider perspectives on Bedsider.org, an online contraceptive information tool, in a low income, racially diverse clinic population.

10,000. Thus, SSI prevention has become the focus of health care systems and hospitals because it is a reducible health care cost. Objective The objective of this review was to better understand the guidelines and recommendations related to the prevention, diagnosis, and management of SSIs. Evidence Acquisition This study is a thorough review of the most up-to-date peer-reviewed articles and review articles as well as guidelines and recommendations of various professional organizations including the US Centers for Disease Control and Prevention and the American College of Obstetrics and Gynecology. Results A review of the literature has identified several evidence-based recommendations that physicians should adhere to in an effort to decrease the incidence of SSIs. Conclusions and Relevance By adhering to clinical recommendations and evidence, we can correctly prevent, diagnose, and treat SSIs. In turn, this will improve health outcomes and decrease health care–related costs, thus increasing the value of health care that we provide to patients. Furthermore, we can gain improvements in the quality measures used by hospitals and insurers. Target Audience Obstetricians and gynecologists, family physicians Learning Objectives After completing this CME activity, physicians should be better able to apply evidenced-based guidelines in the prevention of SSIs, including the appropriate use of preoperative prophylactic antibiotics; evaluate a patient’s risks for SSIs based on known risk factors.

Impact of a clinical interventions bundle on uptake of HPV vaccine at an OB/GYN clinic

BACKGROUND: Despite the availability of a safe and efficacious vaccine against human papillomavirus, uptake of the vaccine in the United States is low. Missed clinical opportunities to recommend and to administer human papillomavirus vaccine are considered one of the most important reasons for its low uptake in adolescents; however, little is known about the frequency or characteristics of missed opportunities in the young adult (18–26 years of age) population. OBJECTIVE: The objective of the study was to assess both the rates of and the factors associated with missed opportunities for human papillomavirus immunization among young adult women who attended an urban obstetrics and gynecology clinic. STUDY DESIGN: In this cross‐sectional study, medical records were reviewed for all women 18–26 years of age who were underimmunized (<3 doses) and who sought care from Feb. 1, 2013, to January 31, 2014, at an urban, hospital‐based obstetrics and gynecology clinic. A missed opportunity for human papillomavirus immunization was defined as a clinic visit at which the patient was eligible to receive the vaccine and a dose was due but not administered. Multivariable logistic regression was used to test associations between sociodemographic variables and missed opportunities. RESULTS: There were 1670 vaccine‐eligible visits by 1241 underimmunized women, with a mean of 1.3 missed opportunities/person. During the study period, 833 of the vaccine eligible women (67.1%) had at least 1 missed opportunity. Overall, the most common types of visits during which a missed opportunity occurred were postpartum visits (17%) or visits for either sexually transmitted disease screening (21%) or contraception (33%). Of the patients with a missed opportunity, 26.5% had a visit at which an injectable medication or a different vaccine was administered. Women who identified their race as black had higher adjusted odds of having a missed opportunity compared with white women (adjusted odds ratio, 1.61 [95% confidence interval, 1.08–2.41], P < .02). Women who reported a non‐English‐ or non‐Spanish‐preferred language had lower adjusted odds of having a missed opportunity (adjusted odds ratio, 0.25 [95% confidence interval, 0.07–0.87], P = .03). No other patient characteristics assessed in this study were significantly associated with having a missed opportunity. CONCLUSION: A majority of young‐adult women in this study had missed opportunities for human papillomavirus immunization, and significant racial disparity was observed. The greatest frequency of missed opportunities occurred with visits for either contraception or for sexually transmitted disease screening.

Risk of Spontaneous Abortion After Inadvertent Human Papillomavirus Vaccination in Pregnancy.

Objective To examine hospital variation in intrapartum care and its relationship with cesarean rates. Design Cross‐sectional survey. Setting Connecticut and Massachusetts hospitals providing obstetric services. Participants Nurse managers or other clinical staff knowledgeable about intrapartum care. Methods We assessed labor and delivery unit capacity and staffing, fetal monitoring, labor management, intrapartum interventions, newborn care, quality assurance, and performance review practices. Association of hospital characteristics and intrapartum practices with cesarean rate was evaluated using Wilcoxon exact rank sum test and Kendalls tau‐b correlation coefficient. Results Among 60 eligible hospitals, respondents from 39 hospitals (65%) completed the survey. Cesarean rates varied from 21% to 42% (median = 30%). Regular review of cesarean rates and indications (85%), regular provision of feedback on cesarean rates and indications to physicians (80%), and regular review of vaginal birth after cesarean rates (94%) were commonly performed at responding hospitals. These practices, however, were not associated with hospital cesarean rate. Hospitals that offered cesarean at the request of the woman (p < .01) and had more liberal indications for labor induction (p < .01) and cesarean birth (p < .01) had significantly greater cesarean rates than institutions without these practices. Routinely placing an intravenous line (p < .01) and drawing blood for complete blood count/type and antibody screen (p < .01) in low‐risk women were associated with greater cesarean rates; having a certified nurse‐midwife in house at all times (p = .01) and permitting women to eat during labor (p = .02) were associated with lower cesarean rates. Conclusion Intrapartum practices of hospitals varied markedly. These different patterns of care may suggest differing levels of intrapartum intervention.

Critical Incident Debriefing: Impact of a Teaching Module for OB/GYN Residents

INTRODUCTION: Significant gaps exist in utilization of the human papillomavirus (HPV) vaccine. The purpose of this study is to assess rates of and missed opportunities for HPV vaccination among young adult women. METHODS: We reviewed medical records of women ages 18–26 years seeking care at an urban, hospital-based obstetrics and gynecology clinic from February 2013 to January 2014. Demographic and clinical data were abstracted to determine rates of HPV vaccine initiation and completion and frequency of missed vaccination opportunities. &khgr;2 tests and logistic regression were used to identify independent risk factors for poor vaccine coverage. RESULTS: Among 1,184 young adult women seeking care during the study period, 30% were ages 17–20 years, 49% ages 21–24 years, and 21% ages 25–26 years. Forty-three percent of women were non-Hispanic blacks, 9% non-Hispanic whites, 37% reported Hispanic ethnicity with other or unreported race. Most reported English as their preferred language (88%) and had Medicaid insurance (78%). Human papillomavirus vaccination rates were low (14% completed, 11% incomplete). Vaccine completion and initiation rates were higher among English-preferring (P<.001), insured (P=.008 and <.001, respectively), and black female patients (P<.001). The frequency of missed vaccination opportunities among non-initiators included: 47 women with at least one visit for a well-woman examination, 120 for contraception management, 194 for postpartum visits, and 105 for urgent gynecologic visits. A total of 112 women received medroxyprogesterone acetate, and 257 women were administered vaccinations or other medications. CONCLUSION: Young adult women receiving care at a hospital-based obstetrics and gynecology clinic have low rates of HPV vaccination. Targeted interventions addressing missed opportunities could significantly improve HPV vaccine coverage.