Susan Hughes

Vaginal Birth After Cesarean in California: Before and After a Change in Guidelines

PURPOSE In 1999 the American College of Obstetricians and Gynecologists (ACOG) adopted more-restrictive guidelines for vaginal birth after cesarean delivery (VBAC). This study assesses trends in VBAC in California and compares neonatal and maternal mortality rates among women attempting VBAC delivery or undergoing repeat cesarean delivery before and after this guideline revision. METHODS The 1996 through 2002 California Birth Statistical Master Files were used to identify 386,232 California residents who previously gave birth by cesarean delivery and had a singleton birth planned in a California hospital. RESULTS Attempted VBAC deliveries decreased significantly from 24% before to 13.5% after guideline revision (P <.001). Neonatal mortality rates per 1,000 live births for attempted VBAC deliveries were not different from repeat cesarean delivery rates among neonates weighing ≥1,500 g in either the study periods 1996 to 1999 or 2000 to 2002. Neonatal mortality rates for attempted VBAC deliveries were higher for repeat cesarean deliveries among neonates weighing <1,500 g in the same periods (attempted VBAC: 1996–1999, 253.2; 95% Poisson confidence interval [CI], 197.7–308.6; 2000–2002, 336.8; CI, 254.3–419.4; repeat cesarean delivery: 1996–1999, 59.1; CI, 48.3–69.9; 2000–2002, 60.5, CI, 48.4–72.5). Maternal death rates per 100,000 live births for attempted VBAC deliveries were similar for both periods (1996–1999, 2.0; CI, 0.1–11.0; 2000–2002, 8.5; CI, 1.0–30.6). CONCLUSIONS Neonatal and maternal mortality rates did not improve despite increasing rates of repeat cesarean delivery during the years after the ACOG 1999 VBAC guideline revision. Women with infants weighing ≥1,500 g encountered similar neonatal and maternal mortality rates with VBAC or repeat cesarean delivery.

Effects of echinacea on the frequency of upper respiratory tract symptoms: a randomized, double-blind, placebo-controlled trial

Background Upper respiratory tract infection symptoms are a common cause of morbidity. Herbal preparations of the plant Echinacea purpurea have immune-enhancing properties. Objective To compare the frequency of upper respiratory tract symptoms in individuals receiving E purpurea capsules and those receiving placebo to evaluate the preventive efficacy of echinacea. Methods In a randomized, double-blind clinical trial, 90 volunteers recruited from hospital personnel were randomly assigned to receive 3 capsules twice daily of either placebo (parsley) or E purpurea for 8 weeks during the winter months. Upper respiratory tract symptoms were reported weekly during this period. Results Fifty-eight individuals were included in the final data analysis: 28 in the echinacea group and 30 in the placebo group. Individuals in the echinacea group reported 9 sick days per person during the 8-week period, whereas the placebo group reported 14 sick days (z = −0.42; P = .67). Mild adverse effects were noted by 8% of the echinacea group and 7% of the placebo group (P = .24). Conclusion Prophylactic treatment with commercially available E purpurea capsules did not significantly alter the frequency of upper respiratory tract symptoms compared with placebo use.

Controlling for race/ethnicity: a comparison of California commercial health plans CAHPS scores to NCBD benchmarks

BackgroundBecause California has higher managed care penetration and the race/ethnicity of Californians differs from the rest of the United States, we tested the hypothesis that Californias lower health plan Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey results are attributable to the states racial/ethnic composition.MethodsCalifornia CAHPS survey responses for commercial health plans were compared to national responses for five selected measures: three global ratings of doctor, health plan and health care, and two composite scores regarding doctor communication and staff courtesy, respect, and helpfulness. We used the 2005 National CAHPS 3.0 Benchmarking Database to assess patient experiences of care. Multiple stepwise logistic regression was used to see if patient experience ratings based on CAHPS responses in California commercial health plans differed from all other states combined.ResultsCAHPS patient experience responses in California were not significantly different than the rest of the nation after adjusting for age, general health rating, individual health plan, education, time in health plan, race/ethnicity, and gender. Both California and national patient experience scores varied by race/ethnicity. In both California and the rest of the nation Blacks tended to be more satisfied, while Asians were less satisfied.ConclusionsCalifornia commercial health plan enrollees rate their experiences of care similarly to enrollees in the rest of the nation when seven different variables including race/ethnicity are considered. These findings support accounting for more than just age, gender and general health rating before comparing health plans from one state to another. Reporting on race/ethnicity disparities in member experiences of care could raise awareness and increase accountability for reducing these racial and ethnic disparities.

Trends in Rural and Urban Deliveries and Vaginal Births: California 1998‐2002

CONTEXT Pregnant women in rural areas may give birth in either rural or urban hospitals. Differences in outcomes between rural and urban hospitals may influence patient decision making. PURPOSE Trends in rural and urban obstetric deliveries and neonatal and maternal mortality in California were compared to inform policy development and patient and provider decision making in rural health care settings. METHODS Deliveries in California hospitals identified by the California Department of Health Services, Birth Statistical Master Files for years 1998 through 2002 were analyzed. Three groups of interest were created: rural hospital births to all mothers, urban hospital births to rural mothers, and urban hospital births to urban mothers. FINDINGS Of 2,620,096 births analyzed, less than 4% were at rural hospitals. Neonatal death rates were significantly higher in babies born to rural mothers with no pregnancy complications who delivered a normal weight baby vaginally at an urban hospital compared to urban mothers delivering at an urban hospital (0.2 [CI 0.2-0.4] deaths per 1,000 births versus 0.1 [CI 0.1-0.1]). Logistic regression analysis showed that delivery in a rural hospital was a protective factor compared to urban mothers delivering in an urban hospital, with an odds ratio of 0.8 (CI 0.6-0.9). Maternal death rates were not different. CONCLUSIONS Rural obstetric services in this period showed favorable neonatal and maternal safety profiles. This information should reassure patients considering a rural hospital delivery, and aid policy makers and health care providers striving to ensure access to obstetric services for rural populations.

The Significance of Harm Reduction as a Social and Health Care Intervention for Injecting Drug Users: An Exploratory Study of a Needle Exchange Program in Fresno, California

Infectious disease remains a significant social and health concern in the United States. Preventing more people from contracting HIV/AIDS or Hepatitis C (HCV), requires a complex understanding of the interconnection between the biomedical and social dimensions of infectious disease. Opiate addiction in the US has skyrocketed in recent years. Preventing more cases of HIV/AIDS and HCV will require dealing with the social determinants of health. Needle exchange programs (NEPs) are based on a harm reduction approach that seeks to minimize the risk of infection and damage to the user and community. This article presents an exploratory small-scale quantitative study of the injection drug using habits of a group of injection drug users (IDUs) at a needle exchange program in Fresno, California. Respondents reported significant decreases in high risk IDU behaviors, including sharing of needles and to a lesser extent re-using of needles. They also reported frequent use of clean paraphernalia. Greater collaboration between social and health outreach professionals at NEPs could provide important frontline assistance to people excluded from mainstream office-based services and enhance efforts to reduce HIV/AIDS or HCV infection.

Lightning Safety Awareness of Visitors in Three California National Parks

OBJECTIVE To assess the level of lightning safety awareness among visitors at 3 national parks in the Sierra Nevada Mountains of California. METHODS A 12-question, short answer convenience sample survey was administered to participants 18 years of age and over concerning popular trails and points of interest with known lightning activity. There were 6 identifying questions and 5 knowledge-based questions pertaining to lightning that were scored on a binary value of 0 or 1 for a total of 10 points for the survey instrument. Volunteers in Fresno, California, were used as a control group. Participants were categorized as Sequoia and Kings Canyon National Park (SEKI), frontcountry (FC), or backcountry (BC); Yosemite National Park (YNP) FC or BC; and Fresno. Analysis of variance (ANOVA) was used to test for differences between groups. RESULTS 467 surveys were included for analysis: 77 in Fresno, 192 in SEKI, and 198 in YNP. National park participants demonstrated greater familiarity with lightning safety than individuals from the metropolitan community (YNP 5.84 and SEKI 5.65 vs Fresno 5.14, P = .0032). There were also differences noted between the BC and FC subgroups (YNP FC 6.07 vs YNP BC 5.62, P = .02; YNP FC 6.07 vs SEKI FC 5.58, P = .02). Overall results showed that participants had certain basic lightning knowledge but lacked familiarity with other key lightning safety recommendations. CONCLUSIONS While there are statistically significant differences in lightning safety awareness between national parks and metropolitan participants, the clinical impact of these findings are debatable. This study provides a starting point for providing educational outreach to visitors in these national parks.

Parental satisfaction without antibiotics.

iral infections do not respond to antibiotic therapy, and overuse of antibiotics for viral conditions contributes to the emergence of antibiotic-resistant bacteria. 1 Many patients, however, expect to receive antibiotics for acute infections, 2 and studies have shown that clini-cians are more likely to prescribe antibiotics if they believe patients are expecting them. 3 Patients who do not receive antibiotics may become frustrated and dissatisfi ed with their healthcare. Although parental teaching interventions can improve satisfaction when a child with a viral infection does not receive antibiotics, studies have shown little benefi t. Efforts are underway to reduce the use of antibiotics for viral infections. 5,6 The National Committee for Quality Assurance (NCQA) and Healthcare Effectiveness Data and Information Set (HEDIS) includes three measures that assess appropriate use of antibiotics: not using antibiotics for children with upper respiratory infections; not prescribing antibiotics for adults diagnosed with bronchitis and children with bronchiolitis; and verifying children with pharyngitis after a rapid strep assay or a throat culture before using antibiotics. 7 If providers were confi dent that parents could be sat-isfi ed with appropriate antibiotic-free care for children with a viral infection, they might be less likely to prescribe antibiotics. This investigation describes parental satisfaction with care provided by an NP in a rural health clinic that cares for a predominantly Hispanic population when a child is diagnosed with a viral infection and receives supportive care that does not include antibiotics.

The Relationship Between a Statewide Preceptorship Program and Family Medicine Residency Selection

Objective: The purpose of this study was to investigate the extent to which participation in the California Academy of Family Physicians Foundation Family Medicine (FM) Preceptorship Program, as well as medical school, degree earned, gender, and match year predicted FM residency match. Methods: Allopathic and osteopathic students who applied to the preceptorship program from 1996 to 2002 were followed until residency match. Chi-square (χ2) analysis was used to compare preceptorship participants, nonparticipants (students who applied but did not complete the preceptorship), and nonapplicants (students who did not apply to the preceptorship) for FM match rates and to compare participants to nonparticipants for primary care match rates. FM match data for California schools from 1999 to 2005 were used to perform a logistic regression predicting FM match. Results: Twenty-four percent of participants matched into FM residency programs whereas only 13% of nonparticipants and 13% of nonapplicants selected FM (χ2 = 24.97; P < .001). There was not a statistically significant difference between the proportion of participants and nonparticipants who matched into primary care (χ2 = 0.12; P = .73). Odds ratio results of logistic regression for participants compared with nonapplicants matching into FM was 2.7 (95% CI, 2.0–3.6; P < .001). Conclusion: Preceptorship program participants were more likely than both nonparticipants and nonapplicants to select a FM residency.

Difficult Interpersonal Encounters with Medical Students and Residents: Two Objective Standardized Teaching Encounters

Introduction Objective standardized teaching exercises (OSTEs) are widely used to develop professional competencies, especially in the health care professions. An OSTE involves exposing different providers to the same, time-limited scenario that is concurrently observed and/or recorded for either formative or summative evaluation. As there are limited resources available for creating a resident-specific OSTE, especially those applicable to family and community medicine residents, we created and evaluated a resident OSTE (R-OSTE) for second- and third-year family and community medicine residents. Methods This R-OSTE involved two cases. The first featured Taylor, a third-year medical student resistant to feedback. The second featured Kris, a first-year resident nervous about approaching the attending on duty. Our R-OSTE had residents teaching interpersonal skills to trained actors in a standardized learner role. Results Residents in the teaching role were formatively evaluated by peer observers (fellow residents) and standardized learners on interpersonal domains such as communication and professionalism. Learners gave residents an average performance rating of 4.9 on a 1 to 6 scale with 1 = Very Poor and 6 = Excellent. Residents also evaluated the OSTE itself, rating their experience on multiple teaching-related statements. Eighty-six percent of residents agreed this exercise was an appropriate development activity for family medicine residents. Overall, our R-OSTE was rated highly for relevance to teaching by the residents. Discussion The residents were rated highly by both peer observers and standardized learners. However, there was little variability in peer observer scores, indicating the need for an alternative method of measurement.

Stress Ulcer Prophylaxis in Hospitalized Patients, Subsequent Use in Primary Care, and Physicians' Opinions About Acid-Suppressive Therapy.

Objectives Stress ulcer prophylaxis (SUP) is not indicated in most hospitalized patients. This study determined the prevalence of the use of proton pump inhibitors (PPI) and histamine receptor 2 blockers (H2B) in hospitalized patients, continued PPI/H2B use after discharge, and physicians’ opinions about SUP. Methods A retrospective electronic chart review, as well as a national survey of residents and faculty in primary care residency programs to determine the appropriateness of SUP. Results Of 753 charts reviewed, 332 hospitalized patients with outpatient follow-up were included; 303 of them had either PPI or H2B ordered during hospitalization, but only 120 patients had an indication for SUP. Stepwise logistic regression results showed patients with a history of PPI/H2B use were 16.6 times more likely to receive SUP (odds ratio 16.6; 95% confidence interval 2.2–124.7). In addition, a PPI/H2B indication also significantly predicted SUP use (odds ratio 5.1; 95% confidence interval 1.2–22.2). A total of 171 completed surveys were received: 73% residents and 27% faculty. Only 24% reported being aware of SUP guidelines; 17% reported using electronic health record order set suggestions for SUP. Conclusions More than 90% of hospitalized patients received SUP; less than half of them had an indication for needing SUP. A large number of patients discharged on PPI/H2B continued to receive it in the outpatient setting at 6 months follow-up. Only 24% of physicians reported using SUP based on guidelines. Physician education and evidence-based validation of electronic health record order sets are potential areas for improvement.