Long-term outcomes after elective sterilization procedures — a comparative retrospective cohort study of Medicaid patients

Objectives: The objectives were to compare the long-termoutcomes, including hysterectomy, chronic pelvic pain (CPP) and abnormal uterine bleeding (AUB), in women post hysteroscopic sterilization (HS) and laparoscopic tubal ligation (TL) in the Medicaid population. Study design: This was a retrospective observational cohort analysis using data from the US Medicaid Analytic Extracts Encounters database.Women aged 18 to 49 years with at least one claimfor HS (n=3929) or TL (n=10,875) between July 1, 2009, through December 31, 2010, were included. Main outcome measures were hysterectomy, CPP or AUB in the 24 months poststerilization. Propensity score matching was used to control for patient demographics and baseline characteristics. Logistic regression analysis investigated the variables associated with a 24-month rate of each outcome in the HS versus laparoscopic TL cohorts. Results: Postmatching analyses were performed at 6, 12 and 24 months post index procedure. At 24 months, hysterectomy was more common in the laparoscopic TL than the HS group (3.5% vs. 2.1%; p=.0023), as was diagnosis of CPP (26.8% vs. 23.5%; p=.0050). No significant differences in AUB diagnoseswere observed. Logistic regression identified HS as being associated with lower risk of hysterectomy ( odds ratio [OR] 0.77 [95% confidence interval {CI} 0.60–0.97]; p=.0274) and lower risk of CPP diagnosis (OR 0.91 [95% CI 0.83–0.99]; p= .0336) at 24 months poststerilization. Conclusion: In Medicaid patients,HS is associated with a significantly lower risk of hysterectomyor CPP diagnosis 24 months poststerilization versus laparoscopic TL. Incidence of AUB poststerilization is not significantly different.While some differences in outcomes were statistically significant, the effect sizes were small, and the conclusion is one of equivalence and not clinical superiority. Implications statement: This propensity score matching analysis confirms that pelvic pain andAUBarecommon in women before and after sterilization regardless of whether the procedure is performed hysteroscopically or laparoscopically. Moreover, HS is associated with a significantly lower risk of hysterectomy or a CPP diagnosis in the 24 months poststerilization when compared to TL

Reactions to uncertainty and the accuracy of diagnostic mammography.

BackgroundReactions to uncertainty in clinical medicine can affect decision making.ObjectiveTo assess the extent to which radiologists' reactions to uncertainty influence diagnostic mammography interpretation.DesignCross-sectional responses to a mailed survey assessed reactions to uncertainty using a well-validated instrument. Responses were linked to radiologists' diagnostic mammography interpretive performance obtained from three regional mammography registries.ParticipantsOne hundred thirty-two radiologists from New Hampshire, Colorado, and Washington.MeasurementMean scores and either standard errors or confidence intervals were used to assess physicians' reactions to uncertainty. Multivariable logistic regression models were fit via generalized estimating equations to assess the impact of uncertainty on diagnostic mammography interpretive performance while adjusting for potential confounders.ResultsWhen examining radiologists' interpretation of additional diagnostic mammograms (those after screening mammograms that detected abnormalities), a 5-point increase in the reactions to uncertainty score was associated with a 17% higher odds of having a positive mammogram given cancer was diagnosed during follow-up (sensitivity), a 6% lower odds of a negative mammogram given no cancer (specificity), a 4% lower odds (not significant) of a cancer diagnosis given a positive mammogram (positive predictive value [PPV]), and a 5% higher odds of having a positive mammogram (abnormal interpretation).ConclusionMammograms interpreted by radiologists who have more discomfort with uncertainty have higher likelihood of being recalled

How partnerships for community-based health professions training were affected by national changes in funding

Background: Area Health Education Centers (AHEC) have contributed to U.S. healthcare workforce training since 1971. National funders recently refocused efforts from K-12 students to matriculated health profession students, which reduced annual funding by $75,000 (25%) per year per Center. Objectives: To describe how community partnership changed due to funding reductions. Methods: Key informant interviews were conducted with all four regional center directors with community partnerships. Lessons learned: Hosted regional centers navigated partnerships in ways that did not significantly change programs because the host institutions supported continuing the partnerships. Independent centers experienced significant changes in partnerships by ending well-established programs and starting new programs with new partners. Both hosted and independent centers took salary cuts, downsized staff, and applied for grants and contracts to fill the funding gap. Improved communication with the Oregon AHEC program office was reported as needed. Conclusions: Navigating partnerships differed according to host status

Development of a Diagnostic Test Set to Assess Agreement in Breast Pathology: Practical Application of the Guidelines for Reporting Reliability and Agreement Studies (GRRAS)

Diagnostic test sets are a valuable research tool that contributes importantly to the validity and reliability of studies that assess agreement in breast pathology. In order to fully understand the strengths and weaknesses of any agreement and reliability study, however, the methods should be fully reported. In this paper we provide a step-by-step description of the methods used to create four complex test sets for a study of diagnostic agreement among pathologists interpreting breast biopsy specimens. We use the newly developed Guidelines for Reporting Reliability and Agreement Studies (GRRAS) as a basis to report these methods

Marine Conservation Begins at Home : How a Local Community and Protection of a Small Bay Sent Waves of Change Around the UK and Beyond

The Firth of Clyde, on the west coast of Scotland, was once one of the most productive fishing grounds in Europe. However, successive decades of poor management and overfishing led to a dramatic loss of biodiversity and the collapse of finfish fisheries. In response, concerned local residents on the Isle of Arran, which lies in the middle of the Clyde, formed the Community of Arran Seabed Trust (COAST) in 1995. After 13 years of campaigning, a small (2.67 km2) area in Lamlash Bay became Scotland’s first no-take zone (NTZ) in 2008, and only the second in the UK. Since protection, biodiversity has increased substantially, along with the size, age and density of commercially important species such as the king scallop, Pecten maximus, and the European lobster, Homarus gammarus. Arguably more important, however, is the influence the Lamlash Bay NTZ and COAST have had on UK marine protection in general. Most notably, detailed research has created a case study that clearly demonstrates the benefits of protection in an area where little such evidence is available. This case has been used repeatedly to support efforts for increased protection of UK waters to help rebuild marine ecosystems and enhance their resilience in an uncertain future. In Scotland specifically, lobbying by COAST led to the designation of a much larger marine protected area (MPA, >250 km2) around the south of Arran, one of 30 new MPAs in the country. Evidence from Lamlash Bay has supported development of strong protection for these MPAs, seeing off lobbyist efforts to weaken management. Arran’s conservation success has been recognized internationally and is inspiring greater involvement of local communities around the UK, and further afield, to take the destiny of their coastal waters into their own hands. Successful marine conservation begins at home

Economic models for sustainable interprofessional education

Limited information exists on funding models for interprofessional education (IPE) course delivery, even though potential savings from IPE could be gained in healthcare delivery efficiencies and patient safety. Unanticipated economic barriers to implementing an IPE curriculum across programs and schools in University settings can stymie or even end movement toward collaboration and sustainable culture change. Clarity among stakeholders, including institutional leadership, faculty, and students, is necessary to avoid confusion about IPE tuition costs and funds flow, given that IPE involves multiple schools and programs sharing space, time, faculty, and tuition dollars. In this paper, we consider three funding models for IPE: (a) Centralized (b) Blended, and (c) Decentralized. The strengths and challenges associated with each of these models are discussed. Beginning such a discussion will move us toward understanding the return on investment of IPE

Characteristics associated with requests by pathologists for second opinions on breast biopsies.

AIMS: Second opinions in pathology improve patient safety by reducing diagnostic errors, leading to more appropriate clinical treatment decisions. Little objective data are available regarding the factors triggering a request for second opinion despite second opinion consultations being part of the diagnostic system of pathology. Therefore we sought to assess breast biopsy cases and interpreting pathologists characteristics associated with second opinion requests. METHODS: Collected pathologist surveys and their interpretations of 60 test set cases were used to explore the relationships between case characteristics, pathologist characteristics and case perceptions, and requests for second opinions. Data were evaluated by logistic regression and generalised estimating equations. RESULTS: 115 pathologists provided 6900 assessments; pathologists requested second opinions on 70% (4827/6900) of their assessments 36% (1731/4827) of these would not have been required by policy. All associations between case characteristics and requesting second opinions were statistically significant, including diagnostic category, breast density, biopsy type, and number of diagnoses noted per case. Exclusive of institutional policies, pathologists wanted second opinions most frequently for atypia (66%) and least frequently for invasive cancer (20%). Second opinion rates were higher when the pathologist had lower assessment confidence, in cases with higher perceived difficulty, and cases with borderline diagnoses. CONCLUSIONS: Pathologists request second opinions for challenging cases, particularly those with atypia, high breast density, core needle biopsies, or many co-existing diagnoses. Further studies should evaluate whether the case characteristics identified in this study could be used as clinical criteria to prompt system-level strategies for mandating second opinions

The influence of tumor regression, solar elastosis, and patient age on pathologists\u27 interpretation of melanocytic skin lesions.

It is not known whether patient age or tumor characteristics such as tumor regression or solar elastosis influence pathologists\u27 interpretation of melanocytic skin lesions (MSLs). We undertook a study to determine the influence of these factors, and to explore pathologist\u27s characteristics associated with the direction of diagnosis. To meet our objective, we designed a cross-sectional survey study of pathologists\u27 clinical practices and perceptions. Pathologists were recruited from diverse practices in 10 states in the United States. We enrolled 207 pathologist participants whose practice included the interpretation of MSLs. Our findings indicated that the majority of pathologists (54.6%) were influenced toward a less severe diagnosis when patients were70 years of age, or by the presence of tumor regression or solar elastosis (58.5%, 71.0%, and 57.0%, respectively). Generally, pathologists with dermatopathology board certification and/or a high caseload of MSLs were more likely to be influenced, whereas those with more years\u27 experience interpreting MSL were less likely to be influenced. Our findings indicate that the interpretation of MSLs is influenced by patient age, tumor regression, and solar elastosis; such influence is associated with dermatopathology training and higher caseload, consistent with expertise and an appreciation of lesion complexity

Tools to Assess Behavioral and Social Science Competencies in Medical Education: A Systematic Review

Behavioral and social science (BSS) competencies are needed to provide quality health care, but psychometrically validated measures to assess these competencies are difficult to find. Moreover, they have not been mapped to existing frameworks, like those from the Liaison Committee on Medical Education (LCME) and Accreditation Council for Graduate Medical Education (ACGME). This systematic review aimed to identify and evaluate the quality of assessment tools used to measure BSS competencies