Jonathan Shaw

All Publications

• Breaking Down the Barriers Between Health and Social Care Services: Implementing a Social Determinants of Health Network NEJM Catalyst Rosenbaum, E., Shaw, J. G., Wagner, T. H., Vilendrer, S., Winget, M., Killikelly, C., Olney, L., Coletti, E., Horan, M., Kelly, M., Asch, S. M. 2023; 4 (6)

  View details for DOI 10.1056/CAT.22.0286

• Pandemic Through the Lens of Black Barbershops: COVID-19's Impact and Barbers' Potential Role as Public Health Extenders. Journal of immigrant and minority health Taylor, N. K., Faulks, M., Brown-Johnson, C. G., Rosas, L. G., Shaw, J. G., Saliba-Gustafsson, E. A., Asch, S. M. 2022

  Abstract

  We examined the impact of COVID-19 on Black barbershops and their potential role as public health extenders. A 30-item survey was distributed to predominantly Black barbershop owners and barbers across 40 different states/territories in the US between June and October 2020. The survey addressed the impact of COVID-19 on Black barbershops, and barbers' interest in engaging in health outreach programs. The majority reported that stay-at-home orders had significant to severe impact on their business; few were prepared for the financial impact and less than half thought they qualified for government assistance. The majority were already providing health education and outreach to the Black community and showed interest in continuing to provide such services, like information on COVID-19. Barbers in Black-serving barbershops, a well-documented effective place for public health outreach to the Black community, show promise as public health extenders in the response to the COVID-19 pandemic.

  View details for DOI 10.1007/s10903-022-01420-x

  View details for PubMedID 36417031

• Evaluating clinician-led quality improvement initiatives: A system-wide embedded research partnership at Stanford Medicine. Learning health systems Vilendrer, S., Saliba-Gustafsson, E. A., Asch, S. M., Brown-Johnson, C. G., Kling, S. M., Shaw, J. G., Winget, M., Larson, D. B. 2022; 6 (4): e10335

  Abstract

  Many healthcare delivery systems have developed clinician-led quality improvement (QI) initiatives but fewer have also developed in-house evaluation units. Engagement between the two entities creates unique opportunities. Stanford Medicine funded a collaboration between their Improvement Capability Development Program (ICDP), which coordinates and incentivizes clinician-led QI efforts, and the Evaluation Sciences Unit (ESU), a multidisciplinary group of embedded researchers with expertise in implementation and evaluation sciences.To describe the ICDP-ESU partnership and report key learnings from the first 2 y of operation September 2019 to August 2021.Department-level physician and operational QI leaders were offered an ESU consultation to workshop design, methods, and overall scope of their annual QI projects. A steering committee of high-level stakeholders from operational, clinical, and research perspectives subsequently selected three projects for in-depth partnered evaluation with the ESU based on evaluability, importance to the health system, and broader relevance. Selected project teams met regularly with the ESU to develop mixed methods evaluations informed by relevant implementation science frameworks, while aligning the evaluation approach with the clinical teams' QI goals.Sixty and 62 ICDP projects were initiated during the 2 cycles, respectively, across 18 departments, of which ESU consulted with 15 (83%). Within each annual cycle, evaluators made actionable, summative findings rapidly available to partners to inform ongoing improvement. Other reported benefits of the partnership included rapid adaptation to COVID-19 needs, expanded clinician evaluation skills, external knowledge dissemination through scholarship, and health system-wide knowledge exchange. Ongoing considerations for improving the collaboration included the need for multi-year support to enable nimble response to dynamic health system needs and timely data access.Presence of embedded evaluation partners in the enterprise-wide QI program supported identification of analogous endeavors (eg, telemedicine adoption) and cross-cutting lessons across QI efforts, clinician capacity building, and knowledge dissemination through scholarship.

  View details for DOI 10.1002/lrh2.10335

  View details for PubMedID 36263267

  View details for PubMedCentralID PMC9576232

• Nonmedical Transdisciplinary Perspectives of Black and Racially and Ethnically Diverse Individuals About Antiracism Practices: A Qualitative Study. JAMA network open Shankar, M., Cox, J., Baratta, J., De Leon, G., Shaw, J. G., Israni, S. T., Zulman, D. M., Brown-Johnson, C. G. 2022; 5 (2): e2147835

  Abstract

  Importance: Overwhelming evidence that anti-Black racism is associated with health inequities is driving clinician demand for antiracism practices that promote health equity.Objective: To investigate how nonmedical professionals address personally mediated, institutional, and internalized racism and to adapt these practices for the clinical setting.Design, Setting, and Participants: Using an approach from human-centered design for this qualitative study, virtual qualitative interviews were conducted among 40 professionals from nonmedical fields to investigate antiracism practices used outside of medicine. Inductive thematic analysis was conducted to identify latent themes and practices that may be adaptable to health care, subsequently using an established theoretical framework describing levels of racism to interpret and organize themes. Convenience and purposive sampling was used to recruit participants via email, social media, and electronic flyers.Main Outcomes and Measures: Antiracism practices adapted to medicine.Results: Among 40 professionals from nonmedical fields, most were younger than age 40 years (23 individuals [57.5%]) and there were 20 (50.0%) women; there were 25 Black or African American individuals (62.5%); 4 East Asian, Southeast Asian, or South Asian individuals (10.0%); 3 individuals with Hispanic, Latinx, or Spanish origin (7.5%); and 3 White individuals. Participants described personally mediated, institutional, and internalized antiracism practices that may be adaptable to promote health equity for Black patients. Personally mediated antiracism practices included dialogue and humble inquiry, building trust, and allyship and shared humanity; clinicians may be able to adopt these practices by focusing on patient successes, avoiding stigmatizing language in the electronic health record, and using specific phrases to address racism in the moment. Institutional antiracism practices included education, representation, and mentorship; in the health care setting, clinics may be able to develop staff affiliate groups, focus on improving racial health equity outcomes, and conduct antiracism trainings. Internalized antiracism practices centered on authenticity; clinicians may be able to write positionality statements reflecting their identity and the expertise they bring to clinical encounters.Conclusions and Relevance: This study's findings suggest that antiracism practices from outside the health care sector may offer innovative strategies to promote health equity by addressing personally mediated, institutional, and internalized racism in clinical care.

  View details for DOI 10.1001/jamanetworkopen.2021.47835

  View details for PubMedID 35138395

• Primary Care 2.0: A Prospective Evaluation of a Novel Model of Advanced Team Care With Expanded Medical Assistant Support. Annals of family medicine Shaw, J. G., Winget, M., Brown-Johnson, C., Seay-Morrison, T., Garvert, D. W., Levine, M., Safaeinili, N., Mahoney, M. R. 2021; 19 (5): 411-418

  Abstract

  PURPOSE: Assess effectiveness of Primary Care 2.0: a team-based model that incorporates increased medical assistant (MA) to primary care physician (PCP) ratio, integration of advanced practice clinicians, expanded MA roles, and extended the interprofessional team.METHODS: Prospective, quasi-experimental evaluation of staff/clinician team development and wellness survey data, comparing Primary Care 2.0 to conventional clinics within our academic health care system. We surveyed before the model launch and every 6-9 months up to 24 months post implementation. Secondary outcomes (cost, quality metrics, patient satisfaction) were assessed via routinely collected operational data.RESULTS: Team development significantly increased in the Primary Care 2.0 clinic, sustained across all 3 post implementation time points (+12.2, +8.5, + 10.1 respectively, vs baseline, on the 100-point Team Development Measure) relative to the comparison clinics. Among wellness domains, only "control of work" approached significant gains (+0.5 on a 5-point Likert scale, P = .05), but was not sustained. Burnout did not have statistically significant relative changes; the Primary Care 2.0 site showed a temporal trend of improvement at 9 and 15 months. Reversal of this trend at 2 years corresponded to contextual changes, specifically, reduced MA to PCP staffing ratio. Adjusted models confirmed an inverse relationship between team development and burnout (P <.0001). Secondary outcomes generally remained stable between intervention and comparison clinics with suggestion of labor cost savings.CONCLUSIONS: The Primary Care 2.0 model of enhanced team-based primary care demonstrates team development is a plausible key to protect against burnout, but is not sufficient alone. The results reinforce that transformation to team-based care cannot be a 1-time effort and institutional commitment is integral.

  View details for DOI 10.1370/afm.2714

  View details for PubMedID 34546947

• Building Bridges Between Community Health Centers and Academic Medical Centers in a COVID-19 Pandemic. Journal of the American Board of Family Medicine : JABFM Taylor, N. K., Aboelata, N., Mahoney, M., Seay-Morrison, T., Singh, B., Chang, S., Asch, S. M., Shaw, J. G. 2021; 34 (Supplement): S229–S232

  Abstract

  The threat to the public health of the United States from the COVID-19 pandemic is causing rapid, unprecedented shifts in the health care landscape. Community health centers serve the patient populations most vulnerable to the disease yet often have inadequate resources to combat it. Academic medical centers do not always have the community connections needed for the most effective population health approaches. We describe how a bridge between a community health center partner (Roots Community Health Center) and a large academic medical center (Stanford Medicine) brought complementary strengths together to address the regional public health crisis. The 2 institutions began the crisis with an overlapping clinical and research faculty member (NKT). Building on that foundation, we worked in 3 areas. First, we partnered to reach underserved populations with the academic center's newly developed COVID test. Second, we developed and distributed evidence-based resources to these same communities via a large community health navigator team. Third, as telemedicine became the norm for medical consultation, the 2 institutions began to research how reducing the digital divide could help improve access to care. We continue to think about how best to create enduring partnerships forged through ongoing deeper relationships beyond the pandemic.

  View details for DOI 10.3122/jabfm.2021.S1.200182

  View details for PubMedID 33622844

• Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter. JAMA Zulman, D. M., Haverfield, M. C., Shaw, J. G., Brown-Johnson, C. G., Schwartz, R. n., Tierney, A. A., Zionts, D. L., Safaeinili, N. n., Fischer, M. n., Thadaney Israni, S. n., Asch, S. M., Verghese, A. n. 2020; 323 (1): 70–81

  Abstract

  Time constraints, technology, and administrative demands of modern medicine often impede the human connection that is central to clinical care, contributing to physician and patient dissatisfaction.To identify evidence and narrative-based practices that promote clinician presence, a state of awareness, focus, and attention with the intent to understand patients.Preliminary practices were derived through a systematic literature review (from January 1997 to August 2017, with a subsequent bridge search to September 2019) of effective interpersonal interventions; observations of primary care encounters in 3 diverse clinics (n = 27 encounters); and qualitative interviews with physicians (n = 10), patients (n = 27), and nonmedical professionals whose occupations involve intense interpersonal interactions (eg, firefighter, chaplain, social worker; n = 30). After evidence synthesis, promising practices were reviewed in a 3-round modified Delphi process by a panel of 14 researchers, clinicians, patients, caregivers, and health system leaders. Panelists rated each practice using 9-point Likert scales (-4 to +4) that reflected the potential effect on patient and clinician experience and feasibility of implementation; after the third round, panelists selected their "top 5" practices from among those with median ratings of at least +2 for all 3 criteria. Final recommendations incorporate elements from all highly rated practices and emphasize the practices with the greatest number of panelist votes.The systematic literature review (n = 73 studies) and qualitative research activities yielded 31 preliminary practices. Following evidence synthesis, 13 distinct practices were reviewed by the Delphi panel, 8 of which met criteria for inclusion and were combined into a final set of 5 recommendations: (1) prepare with intention (take a moment to prepare and focus before greeting a patient); (2) listen intently and completely (sit down, lean forward, avoid interruptions); (3) agree on what matters most (find out what the patient cares about and incorporate these priorities into the visit agenda); (4) connect with the patient's story (consider life circumstances that influence the patient's health; acknowledge positive efforts; celebrate successes); and (5) explore emotional cues (notice, name, and validate the patient's emotions).This mixed-methods study identified 5 practices that have the potential to enhance physician presence and meaningful connection with patients in the clinical encounter. Evaluation and validation of the outcomes associated with implementing the 5 practices is needed, along with system-level interventions to create a supportive environment for implementation.

  View details for DOI 10.1001/jama.2019.19003

  View details for PubMedID 31910284

• Effect of an Intensive Outpatient Program to Augment Primary Care for High-Need Veterans Affairs Patients: A Randomized Clinical Trial. JAMA internal medicine Zulman, D. M., Pal Chee, C., Ezeji-Okoye, S. C., Shaw, J. G., Holmes, T. H., Kahn, J. S., Asch, S. M. 2017; 177 (2): 166-175

  Abstract

  Many organizations are adopting intensive outpatient care programs for high-need patients, yet little is known about their effectiveness in integrated systems with established patient-centered medical homes.To evaluate how augmenting the Veterans Affairs (VA) medical home (Patient Aligned Care Teams [PACT]) with an Intensive Management program (ImPACT) influences high-need patients' costs, health care utilization, and experience.Randomized clinical trial at a single VA facility. Among 583 eligible high-need outpatients whose health care costs or hospitalization risk were in the top 5% for the facility, 150 were randomly selected for ImPACT; the remaining 433 received standard PACT care.The ImPACT multidisciplinary team addressed health care needs and quality of life through comprehensive patient assessments, intensive case management, care coordination, and social and recreational services.Primary difference-in-difference analyses examined changes in health care costs and acute and extended care utilization over a 16-month baseline and 17-month follow-up period. Secondary analyses estimated the intervention's effect on ImPACT participants (using randomization as an instrument) and for patients with key sociodemographic and clinical characteristics. ImPACT participants' satisfaction and activation levels were assessed using responses to quality improvement surveys administered at baseline and 6 months.Of 140 patients assigned to ImPACT, 96 (69%) engaged in the program (mean [SD] age, 68.3 [14.2] years; 89 [93%] male; mean [SD] number of chronic conditions, 10 [4]; 62 [65%] had a mental health diagnosis; 21 [22%] had a history of homelessness). After accounting for program costs, adjusted person-level monthly health care expenditures decreased similarly for ImPACT and PACT patients (difference-in-difference [SE] -$101 [$623]), as did acute and extended care utilization rates. Among respondents to the ImPACT follow-up survey (n = 54 [56% response rate]), 52 (96%) reported that they would recommend the program to others, and pre-post analyses revealed modest increases in satisfaction with VA care (mean [SD] increased from 2.90 [0.72] to 3.16 [0.60]; P = .04) and communication (mean [SD] increased from 2.99 [0.74] to 3.18 [0.60]; P = .03).Intensive outpatient care for high-need patients did not reduce acute care utilization or costs compared with standard VA care, although there were positive effects on experience among patients who participated. Implementing intensive outpatient care programs in integrated settings with well-established medical homes may not prevent hospitalizations or achieve substantial cost savings.clinicaltrials.gov Identifier: NCT02932228.

  View details for DOI 10.1001/jamainternmed.2016.8021

  View details for PubMedID 28027338

• Social Isolation and Medicare Spending: Among Older Adults, Objective Isolation Increases Expenditures While Loneliness Does Not Journal of Aging and Health Shaw, J. G., Farid, M., Noel-Miller, C., Joseph, N., Houser, A., Asch, S. M., Bhattacharya, J., Flowers, L. 2017; 29 (7): 1119-1143

  Abstract

  Evaluate objective isolation and loneliness' impact on Medicare spending and outcomes.We linked Health and Retirement Study data to Medicare claims to analyze objective isolation (scaled composite of social contacts and network) and loneliness (positive response to 3-item loneliness scale) as predictors of subsequent Medicare spending. In multivariable regression adjusting for health and demographics, we determined marginal differences in Medicare expenditures. Secondary outcomes included spending by setting, and mortality.Objective isolation predicts greater spending, $1,644(p<0.001) per beneficiary annually, whereas loneliness predicts reduced spending, -$768(p<0.001). Increased spending concentrated in inpatient and nursing-home (SNF) care; despite more healthcare, objectively isolated beneficiaries had 31%(p<0.001) greater risk of death. Loneliness did not predict SNF use nor mortality, but predicted slightly less inpatient and outpatient care.Objectively isolated seniors have higher Medicare spending, driven by increased hospitalization and institutionalization, and face greater mortality. Policies supporting social connectedness could reap significant savings.

  View details for DOI 10.1177/0898264317703559

  View details for PubMedCentralID PMC5847278

• Posttraumatic Stress Disorder and Risk of Spontaneous Preterm Birth OBSTETRICS AND GYNECOLOGY Shaw, J. G., Asch, S. M., Kimerling, R., Frayne, S. M., Shaw, K. A., Phibbs, C. S. 2014; 124 (6): 1111-1119

  Abstract

  To evaluate the association between antenatal posttraumatic stress disorder (PTSD) and spontaneous preterm delivery.We identified antenatal PTSD status and spontaneous preterm delivery in a retrospective cohort of 16,334 deliveries covered by the Veterans Health Administration from 2000 to 2012. We divided mothers with PTSD into those with diagnoses present the year before delivery (active PTSD) and those only with earlier diagnoses (historical PTSD). We identified spontaneous preterm birth and potential confounders including age, race, military deployment, twins, hypertension, substance use, depression, and results of military sexual trauma screening and then performed multivariate regression to estimate adjusted odds ratio (OR) of spontaneous preterm delivery as a function of PTSD status.Of 16,334 births, 3,049 (19%) were to mothers with PTSD diagnoses, of whom 1,921 (12%) had active PTSD. Spontaneous preterm delivery was higher in those with active PTSD (9.2%, n=176) than those with historical (8.0%, n=90) or no PTSD (7.4%, n=982) before adjustment (P=.02). The association between PTSD and preterm birth persisted, when adjusting for covariates, only in those with active PTSD (adjusted OR 1.35, 95% confidence interval [CI] 1.14-1.61). Analyses adjusting for comorbid psychiatric and medical diagnoses revealed the association with active PTSD to be robust.In this cohort, containing an unprecedented number of PTSD-affected pregnancies, mothers with active PTSD were significantly more likely to suffer spontaneous preterm birth with an attributable two excess preterm births per 100 deliveries (95% CI 1-4). Posttraumatic stress disorder's health effects may extend, through birth outcomes, into the next generation.

  View details for DOI 10.1097/AOG.0000000000000542

  View details for Web of Science ID 000345341100008

• Evaluation of video visit appropriateness for common symptoms seen in primary care: A retrospective cohort study. Journal of telemedicine and telecare Chen, D., Gonzales, E., Winget, M., Shaw, J., Artandi, M., Tsai, S. A., Nelligan, I. 2024: 1357633X231224094

  Abstract

  INTRODUCTION: Little is known about which conditions seen in primary care are appropriate for video visits. This study evaluated video visits compared to office visits for six conditions: abdominal pain, joint pain, back pain, headache, chest pain, and dizziness.METHODS: Six hundred charts of adult patients from our institution's same-day outpatient clinic were reviewed in this study. Charts for video visits evaluating the aforementioned chief complaints that occurred between August and October 2020 were reviewed and compared with charts for office visits that occurred from August to September 2019. Frequencies of 3-week follow-up visits, Emergency Room visits, imaging, and referrals for office and video visits were measured. Reasons for in-person evaluation for patients seen by video were determined by review of clinician notes.RESULTS: Three-week in-person follow-up was more frequent for patients presenting with chest pain (52% vs 18%, p=0.0007) and joint pain (24% vs 8%, p=0.05) after video evaluation, relative to an office evaluation. Three-week in-person follow-up was also more frequent for patients presenting with dizziness (38% vs 28%) and low back pain (24% vs 14%); however, this difference was not statistically significant. Patients presenting with headache and abdominal pain did not have a higher rate of follow-up.DISCUSSION: Based on the frequency of in-person follow-up, this study suggests that video visits are generally adequate for evaluating headache and abdominal pain. Patients with dizziness and chest pain have the highest frequency of in-person and Emergency Room follow-up within 3 weeks when first seen by video compared to other conditions evaluated and may be less suitable for an initial video visit. Institutions can consider these findings when scheduling and providing guidance to patients on what type of visit is most appropriate for their symptoms.

  View details for DOI 10.1177/1357633X231224094

  View details for PubMedID 38254267

• Medicine plus mindset: A mixed-methods evaluation of a novel mindset-focused training for primary care teams. Patient education and counseling Leibowitz, K. A., Howe, L. C., Winget, M., Brown-Johnson, C., Safaeinili, N., Shaw, J. G., Thakor, D., Kwan, L., Mahoney, M., Crum, A. J. 2024; 122: 108130

  Abstract

  Patient mindsets influence health outcomes; yet trainings focused on care teams' understanding, recognizing, and shaping patient mindsets do not exist. This paper aims to describe and evaluate initial reception of the "Medicine Plus Mindset" training program.Clinicians and staff at five primary care clinics (N = 186) in the San Francisco Bay Area received the Medicine Plus Mindset Training. The Medicine Plus Mindset training consists of a two-hour training program plus a one-hour follow-up session including: (a) evidence to help care teams understand patients' mindsets' influence on treatment; (b) a framework to support care teams in identifying specific patient mindsets; and (c) strategies to shape patient mindsets.We used a common model (Kirkpatrick) to evaluate the training based on participants' reaction, learnings, and behavior. Reaction: Participants rated the training as highly useful and enjoyable. Learnings: The training increased the perceived importance of mindsets in healthcare and improved self-reported efficacy of using mindsets in practice. Behavior: The training increased reported frequency of shaping patient mindsets.Development of this training and the study's results introduce a promising and feasible approach for integrating mindset into clinical practice. Practice Implications Mindset training can add a valuable dimension to clinical care and should be integrated into training and clinical practice.

  View details for DOI 10.1016/j.pec.2023.108130

  View details for PubMedID 38242012

• An exploratory analysis of factors associated with spontaneous preterm birth among pregnant veterans with post-traumatic stress disorder. Women's health issues : official publication of the Jacobs Institute of Women's Health Panelli, D. M., Chan, C. S., Shaw, J. G., Shankar, M., Kimerling, R., Frayne, S. M., Herrero, T. C., Lyell, D. J., Phibbs, C. S. 2023; 33 (2): 191-198

  Abstract

  Pregnant veterans with post-traumatic stress disorder (PTSD) are at increased risk for spontaneous preterm birth, yet the underlying reasons are unclear. We examined factors associated with spontaneous preterm birth among pregnant veterans with active PTSD.This was an observational study of births from administrative databases reimbursed by the Veterans Health Association (VA) between 2005 and 2015. Singleton livebirths among veterans with active PTSD within 12 months prior to childbirth were included. The primary outcome was spontaneous preterm birth. Maternal demographics, psychiatric history, and pregnancy complications were evaluated as exposures. Covariates significant on bivariate analysis, as well as age and race/ethnicity as a social construct, were included in multivariable logistic regression to identify factors associated with spontaneous preterm birth. Additional analyses stratified significant covariates by the presence of active concurrent depression and explored interactions between antidepressant use and preeclampsia.Of 3,242 eligible births to veterans with active PTSD, 249 (7.7%) were spontaneous preterm births. The majority of veterans with active PTSD (79.1%) received some type of mental health treatment, and active concurrent depression was prevalent (61.4%). Preeclampsia/eclampsia (adjusted odds ratio [aOR] 3.30, 95% confidence interval [CI] 1.67-6.54) and ≥6 antidepressant medication dispensations within 12 months prior to childbirth (aOR 1.89, 95% CI 1.29-2.77) were associated with spontaneous preterm birth. No evidence of interaction was seen between antidepressant use and preeclampsia on spontaneous preterm birth (p=0.39). Findings were similar when stratified by active concurrent depression.Among veterans with active PTSD, preeclampsia/eclampsia and ≥6 antidepressant dispensations were associated with spontaneous preterm birth. While the results do not imply that people should discontinue needed antidepressants during pregnancy in veterans with PTSD, research into these factors might inform preterm birth prevention strategies for this high-risk population.

  View details for DOI 10.1016/j.whi.2022.09.005

  View details for PubMedID 37576490

  View details for PubMedCentralID PMC10421070

• Postpartum long-acting reversible contraceptive use among active-duty, female U.S. Army soldiers. American journal of obstetrics and gynecology Eastin, E. F., Nelson, D. A., Shaw, J. G., Shaw, K. A., Kurina, L. M. 2023

  Abstract

  BACKGROUND: Postpartum utilization of long-acting reversible contraception (LARC) has been found to be effective at increasing inter-pregnancy intervals, reducing unintended pregnancies, and optimizing health outcomes for mothers and babies. Among female active-duty military members, reproductive planning may be particularly important, yet little is known about postpartum long-acting reversible contraceptive use among active-duty soldiers.OBJECTIVES: (1) To quantify postpartum uptake of long-acting reversible contraception among U.S. Army active-duty female soldiers, and (2) to identify demographic and military-specific characteristics associated with utilization.STUDY DESIGN: This retrospective cohort study used longitudinal data on all digitally recorded health encounters for active-duty U.S. Army soldiers from 2014-2017. The servicewomen included in our analysis were aged 18-44 years with at least one delivery and a minimum of four months of total observed time post-delivery within the study period. We defined postpartum long-acting reversible contraception utilization as initiation in the delivery month or in the three calendar months following delivery, and identified likely immediate postpartum initiation via the proxy of placement recorded during the same month as delivery. We then evaluated predictors of postpartum long-acting reversible contraception utilization using multivariable logistic regression.RESULTS: Inclusion criteria were met by 15,843 soldiers. Of those, 3,162 (19.96%) received a method of long-acting reversible contraception in the month of, or within the three months following, delivery. Fewer than 5% of these women utilized immediate postpartum long-acting reversible contraception. Among women receiving a postpartum long-acting reversible contraceptive method, 1,803 (57.0%) received an IUD, 1,328 (42.0%) received an etonogestrel implant and 31 received both (0.98%). Soldiers of younger age, self-reported White race, and those married or previously married were more likely to initiate long-acting reversible contraception in the postpartum period. Race-stratified analyses showed that self-reported White women had the highest utilization rates overall. Compared to these women, the adjusted odds of postpartum utilization among self-reported Black and Asian/Pacific Islander women were 18% and 30% lower, respectively (both p<0.001). There was also a trend of decreasing postpartum utilization with increasing age within each race group. Differences observed between age groups and race identities could partially be attributed to differential utilization of permanent contraception (sterilization), which was found to be significantly more prevalent among both women aged 30 years or older, as well as among Black-identifying women.CONCLUSION: Among active-duty U.S. Army servicewomen, one in five utilized postpartum long-acting reversible contraception, with fewer than 5 percent of these women utilizing an immediate postpartum method. Within this population with universal healthcare coverage, we observed relatively low rates of utilization and significant differences in uptake of effective postpartum long-acting contraceptive methods across self-reported race categories.

  View details for DOI 10.1016/j.ajog.2023.07.023

  View details for PubMedID 37460035

• Variations in Provision of Long-Acting Reversible Contraception Across Veterans Health Administration Facilities. Journal of general internal medicine Mahorter, S., Vinekar, K., Shaw, J. G., Mor, M. K., Pleasure, Z. H., Gawron, L. M., Callegari, L. S. 2023

  View details for DOI 10.1007/s11606-023-08123-5

  View details for PubMedID 37340270

• The Stanford Lightning Report: A pragmatic methodological approach for rapid qualitative synthesis Brown-Johnson, C., Safaeinili, N., Zionts, D., Holdsworth, L. M., Shaw, J. G., Asch, S. M., Mahoney, M., Winget, M. BMC. 2023

  View details for Web of Science ID 001057952600050

• Evolution of a Project to Improve Inpatient-to-Outpatient Dermatology Care Transitions: Mixed Methods Evaluation. JMIR dermatology Kling, S. M., Aleshin, M. A., Saliba-Gustafsson, E. A., Garvert, D. W., Brown-Johnson, C. G., Amano, A., Kwong, B. Y., Calugar, A., Shaw, J. G., Ko, J. M., Winget, M. 2023; 6: e43389

  Abstract

  BACKGROUND: In-hospital dermatological care has shifted from dedicated dermatology wards to consultation services, and some consulted patients may require postdischarge follow-up in outpatient dermatology. Safe and timely care transitions from inpatient-to-outpatient specialty care are critical for patient health, but communication around these transitions can be disjointed, and workflows can be complex.OBJECTIVE: In this 3-phase quality improvement effort, we developed and evaluated an intervention that leveraged an electronic health record (EHR) feature, known as SmartPhrase, to enable a new workflow to improve transitions from inpatient care to outpatient dermatology.METHODS: Phase 1 (February-March 2021) included interviews with patients and process mapping with key stakeholders to identify gaps and inform an intervention: a SmartPhrase table and associated workflow to promote collection of patient information needed for scheduling follow-up and closed-loop communication between dermatology and scheduling teams. In phase 2 (April-May 2021), semistructured interviews-with dermatologists (n=5), dermatology residents (n=5), and schedulers (n=6)-identified pain points and refinements. In phase 3, the intervention was evaluated by triangulating data from these interviews with measured changes in scheduling efficiency, visit completion, and messaging volume preimplementation (January-February 2021) and postimplementation (April-May 2021).RESULTS: Preintervention pain points included unclear workflow for care transitions, limited patient input in follow-up planning, multiple messaging channels (eg, EHR based, email, and phone messages), and time-inefficient patient tracking. The intervention addressed most pain points; interviewees reported the intervention was easy to adopt and improved scheduling efficiency, workload, and patient involvement. More visits were completed within the desired timeframe of 14 days after discharge during the postimplementation period (21/47, 45%) than the preimplementation period (28/41, 68%; P=.03). The messaging workload also decreased from 88 scheduling-related messages sent for 25 patients before implementation to 30 messages for 8 patients after implementation.CONCLUSIONS: Inpatient-to-outpatient specialty care transitions are complex and involve multiple stakeholders, thus requiring multifaceted solutions. With deliberate evaluation, broad stakeholder input, and iteration, we designed and implemented a successful solution using a standard EHR feature, SmartPhrase, integrated into a standardized workflow to improve the timeliness of posthospital specialty care and reduce workload.

  View details for DOI 10.2196/43389

  View details for PubMedID 37632927

• Postpartum long-acting reversible contraception among privately insured: national analysis 2007-2016, by term and preterm birth. Contraception Shaw, J. G., Goldthwaite, L. M., Marić, I., Shaw, K. A., Stevenson, D. K., Shaw, G. M. 2023: 110065

  Abstract

  To investigate postpartum long-acting reversible contraception (LARC) use among privately insured women, with specific consideration of use after preterm delivery.We used the national IBM® MarketScan® Commercial Database to identify singleton deliveries from 2007-2016, spontaneous preterm birth, and follow up ≤12 weeks postpartum. We assessed ≤12 week postpartum LARC placement overall and after spontaneous preterm deliveries, across study years. We examined timing of placement, rates of postpartum follow-up, and state-level variation in postpartum LARC.Among 3,132,107 singleton deliveries, 6.6% were spontaneous preterm. Over the time period, total postpartum LARC use increased: 4.8% to 11.7% for intrauterine devices (IUDs), 0.2% to 2.4% for implants. In 2016, those who experienced a spontaneous preterm birth were less likely to initiate postpartum IUDs compared to their peers (10.2% vs 11.8%, p<0.001), minimally more likely to initiate implants (2.7% vs 2.4%, p=0.04) and more likely to present for postpartum care (61.7% vs 55.9%, p<0.001). LARC placement prior to hospital discharge was rare (preterm: 8 per 10,000 deliveries vs all others: 6.3 per 10,000 deliveries, p=0.002). State level analysis showed wide variation in postpartum LARC (range 6%-32%).While postpartum LARC use increased among the privately insured 2007 to 2016, few received LARC prior to hospital discharge. Those experiencing preterm birth were no more likely to receive inpatient LARC. Postpartum follow-up remained low and regional variation of LARC was high, highlighting the need for efforts to remove barriers to inpatient postpartum LARC for all who desire it-public and privately insured alike.Among the half of U.S. births that are privately insured, postpartum LARC is increasing after both term and preterm births, yet exceedingly few (<0.1%) received LARC prior to hospital discharge.

  View details for DOI 10.1016/j.contraception.2023.110065

  View details for PubMedID 37210023

• Physical Fitness in Relationship to Depression and Post-Traumatic Stress Disorder During Pregnancy Among U.S. Army Soldiers. Journal of women's health (2002) Panelli, D. M., Nelson, D. A., Wagner, S., Shaw, J. G., Phibbs, C. S., Kurina, L. M. 2023

  Abstract

  Background: Depression and post-traumatic stress disorder (PTSD) are prevalent in pregnancy, especially among military members. These conditions can lead to adverse birth outcomes, yet, there's a paucity of evidence for prevention strategies. Optimizing physical fitness is one understudied potential intervention. We explored associations between prepregnancy physical fitness and antenatal depression and PTSD in soldiers. Materials and Methods: This was a retrospective cohort study of active-duty U.S. Army soldiers with live births between 2011 and 2014, identified with diagnosis codes from inpatient and outpatient care. The exposure was each individual's mean Army physical fitness score from 10 to 24 months before childbirth. The primary outcome was a composite of active depression or PTSD during pregnancy, defined using the presence of a code within 10 months before childbirth. Demographic variables were compared across four quartiles of fitness scores. Multivariable logistic regression models were conducted adjusting for potential confounders selected a priori. A stratified analysis was conducted for depression and PTSD separately. Results: Among 4,583 eligible live births, 352 (7.7%) had active depression or PTSD during pregnancy. Soldiers with the highest fitness scores (Quartile 4) were less likely to have active depression or PTSD in pregnancy (Quartile 4 vs. Quartile 1 adjusted odds ratio 0.55, 95% confidence interval 0.39-0.79). Findings were similar in stratified analyses. Conclusion: In this cohort, the odds of active depression or PTSD during pregnancy were significantly reduced among soldiers with higher prepregnancy fitness scores. Optimizing physical fitness may be a useful tool to reduce mental health burden on pregnancy.

  View details for DOI 10.1089/jwh.2022.0538

  View details for PubMedID 37196157

• Assessing Racial Disparities in Access, Use, and Outcomes for Pregnant and Postpartum Veterans and Their Infants in Veterans Health Administration. Journal of women's health (2002) Katon, J. G., Bossick, A. S., Tartaglione, E. V., Enquobahrie, D. A., Haeger, K. O., Johnson, A. M., Ma, E. W., Savitz, D., Shaw, J. G., Todd-Stenberg, J., Yano, E. M., Washington, D. L., Christy, A. Y. 2023

  Abstract

  Objective: Limited population-based data examines racial disparities among pregnant and postpartum veterans. Our objective was to determine whether Black/white racial disparities in health care access, use, and veteran and infant outcomes are present among pregnant and postpartum veterans and their infants using Veterans Health Administration (VA) care. Methods: The VA National Veteran Pregnancy and Maternity Care Survey included all veterans with a VA paid live birth between June 2018 and December 2019. Participants could complete the survey online or by telephone. The independent variable was self-reported race. Outcomes included timely initiation of prenatal care, perceived access to timely prenatal care, attendance at a postpartum check-up, receipt of needed mental health care, cesarean section, postpartum rehospitalization, low birthweight, preterm birth, admission to a neonatal intensive care unit, and breastfeeding. Nonresponse weighted general linear models with a log-link were used to examine associations of race with outcomes. Cox regression was used to examine the association of race with duration of breastfeeding. Models adjusted for age, ethnicity, urban versus rural residence, and parity. Results: The analytic sample consisted of 1,220 veterans (Black n = 916; white n = 304) representing 3,439 weighted responses (Black n = 1,027; white n = 2,412). No racial disparities were detected for health care access or use. Black veterans were more likely than white veterans to have a postpartum rehospitalization (RR 1.67, 95% CI: 1.04-2.68) and a low-birthweight infant (RR 1.67, 95% CI: 1.20-2.33). Conclusion: While no racial disparities were detected for health care access and use, we identified disparities in postpartum rehospitalization and low birthweight, underscoring that access is not sufficient for ensuring health equity.

  View details for DOI 10.1089/jwh.2022.0507

  View details for PubMedID 37186805

• An Exploratory Analysis of Factors Associated With Spontaneous Preterm Birth Among Pregnant Veterans With Post-Traumatic Stress Disorder WOMENS HEALTH ISSUES Panelli, D. M., Chan, C. S., Shaw, J. G., Shankar, M., Kimerling, R., Frayne, S. M., Herrero, T. C., Lyell, D. J., Phibbs, C. S. 2023; 33 (2): 191-198

  View details for DOI 10.1016/j.whi.2022.09.005

  View details for Web of Science ID 000990469400001

• Associations between physical fitness, depression, and PTSD during pregnancy among US Army soldiers Panelli, D. M., Wagner, S., Phibbs, C. S., Shaw, J. G., Nelson, D., Kurina, L. MOSBY-ELSEVIER. 2023: S121

  View details for Web of Science ID 000909337400167

• Impact of psychiatric conditions on the risk of severe maternal morbidity in veterans Panelli, D. M., Esmaeili, A., Joyce, V., Chan, C., Gujral, K., Schmitt, S., Murphy, N., Kimerling, R., Leonard, S. A., Shaw, J. G., Phibbs, C. S. MOSBY-ELSEVIER. 2023: S457-S458

  View details for Web of Science ID 000909337401261

• Veteran Postpartum Health: VA Care Team Perspectives on Care Coordination, Health Equity, and Trauma-Informed Care. Military medicine Gopisetty, D. D., Shaw, J. G., Gray, C., Frayne, S., Phibbs, C., Shankar, M. 2022

  Abstract

  INTRODUCTION: A growing number of veterans are having children, and pregnancy is an opportunity to engage with health care. Within the Veterans Health Administration (VA), the VA maternity care coordination program supports veterans before, during, and after pregnancy, which are periods that inherently involve transitions between clinicians and risk care fragmentation. Postpartum transitions in care are known to be especially tenuous, with low rates of primary care reengagement. The objective of this study is to better understand this transition from the perspectives of the VA care teams.MATERIALS AND METHODS: Eight semi-structured qualitative interviews with VA team members who work in maternity care were conducted at a single VA center's regional network. Interviews explored the transition from maternity care to primary care to understand the care team's perspective at three levels: patient, clinician, and systems. Rapid qualitative analysis was used to identify emergent themes.RESULTS: Participants identified facilitators and opportunities for improvement in the postpartum transition of care. Patient-clinician trust is a key facilitator in the transition from maternity to primary care for veterans, and the breadth of VA services emerged as a key system-level facilitator to success. Interviewees also highlighted opportunities for improvement, including more trauma-informed practices for nonbinary veterans, increased care coordination between VA and community staff, and the need for training in postpartum health with an emphasis on health equity for primary care clinicians.CONCLUSIONS: The Department of Veterans Affairs Healthcare System care team perspectives may inform practice changes to support the transition from maternity to primary care for veterans. To move toward health equity, a system-level approach to policy and programming is necessary to reduce barriers to primary care reengagement. This study was limited in terms of sample size, and future research should explore veteran perspectives on VA postpartum care transitions.

  View details for DOI 10.1093/milmed/usac275

  View details for PubMedID 36151892

• Gynecologist Supply Deserts Across the VA and in the Community. Journal of general internal medicine Friedman, S., Shaw, J. G., Hamilton, A. B., Vinekar, K., Washington, D. L., Mattocks, K., Yano, E. M., Phibbs, C. S., Johnson, A. M., Saechao, F., Berg, E., Frayne, S. M. 2022

  Abstract

  The Veterans Health Administration (VA) refers patients to community providers for specialty services not available on-site. However, community-level specialist shortages may impede access to care.Compare gynecologist supply in veterans' county of residence versus at their VA site.We identified women veteran VA patients from fiscal year (FY) 2017 administrative data and assessed availability of a VA gynecologist within 50 miles (hereafter called "local") of veterans' VA homesites (per national VA organizational survey data). For the same cohort, we then assessed community-level gynecologist availability; counties with < 2 gynecologists/10,000 women (per the Area Health Resource File) were "inadequate-supply" counties. We examined the proportion of women veterans with local VA gynecologist availability in counties with inadequate versus adequate gynecologist supply, stratified by individual and VA homesite characteristics. Chi-square tests assessed statistical differences.All women veteran FY2017 VA primary care users nationally.Availability of a VA gynecologist within 50 miles of a veteran's VA homesite; county-level "inadequate-supply" of gynecologists.Among 407,482 women, 9% were in gynecologist supply deserts (i.e., lacking local VA gynecologist and living in an inadequate-supply county). The sub-populations with the highest proportions in gynecologist supply deserts were rural residents (24%), those who got their primary care at non-VAMC satellite clinics (13%), those who got their care at a site without a women's clinic (13%), and those with American Indian or Alaska Native (12%), or white (12%) race. Among those in inadequate-supply counties, 59.9% had gynecologists at their local VA; however, 40.1% lacked a local VA gynecologist.Most veterans living in inadequate-supply counties had local VA gynecology care, reflecting VA's critical role as a safety net provider. However, for those in gynecologist supply deserts, expanded transportation options, modified staffing models, or tele-gynecology hubs may offer solutions to extend VA gynecology capacity.

  View details for DOI 10.1007/s11606-022-07591-5

  View details for PubMedID 36042097

• Evaluating clinician-led quality improvement initiatives: A system-wide embedded research partnership at Stanford Medicine LEARNING HEALTH SYSTEMS Vilendrer, S., Saliba-Gustafsson, E. A., Asch, S. M., Brown-Johnson, C. G., Kling, S. R., Shaw, J. G., Winget, M., Larson, D. B. 2022

  View details for DOI 10.1002/lrh2.10335

  View details for Web of Science ID 000843397900001

• Lactogenesis and breastfeeding after immediate versus delayed birth-hospitalization insertion of etonogestrel contraceptive implant: A non-inferiority trial. American journal of obstetrics and gynecology Henkel, A., Lerma, K., Reyes, G., Gutow, H., Shaw, J. G., Shaw, K. A. 2022

  Abstract

  BACKGROUND: Initiating a progestin-based contraceptive prior to the drop in progesterone required to start lactogenesis stage II (LII) could theoretically impact lactation. Previous studies have shown that initiating progestin-based contraception in the postnatal period prior to birth-hospitalization discharge has no detriment on breastfeeding initiation or continuation compared to interval initiation as an outpatient; however, there is currently no breastfeeding data on the impact of initiating the etonogestrel contraceptive implant (ETG-implant) in the early postnatal period immediately in the delivery room.OBJECTIVE: This study examined the effect of delivery room vs delayed birth-hospitalization contraceptive ETG-implant insertion on breastfeeding outcomes.STUDY DESIGN: This is a non-inferiority randomized controlled trial to determine if time to LII (initiation of copious milk secretion) differs by timing of ETG-implant insertion during the birth-hospitalization. We randomly assigned pregnant people to insertion at 0-2 hours (delivery room) versus 24-48 hours (delayed) post-delivery. Participants intended to breastfeed, desired a contraceptive implant for postpartum contraception, were fluent in English or Spanish, and without an allergy or contraindication to the ETG-implant. We collected demographic information and breastfeeding intentions at enrollment. Onset of LII was assessed daily using a validated tool. The non-inferiority margin for the mean difference in time to LII was defined as 12 hours in a per-protocol analysis. Additional electronic surveys collected data on breastfeeding and contraceptive continuation at 2 and 4 weeks, 3, 6, and 12 months.RESULTS: We enrolled and randomized 95 participants; 77 participants were included in the modified intention-to-treat analysis (n=38 in the delivery room group and n=39 in the delayed group) after excluding eighteen due to withdrawing consent, changing contraceptive or breastfeeding plans, or failing to provide primary outcome data. 69 participants are included in the as-treated analysis (n=35 delivery room, n=34 delayed); 8 participants who received the ETG-implant outside the protocol windows were excluded and 2 participants from the delivery room group received the ETG-implant at 24-48 hours and were analyzed with the delayed group. Participants were similar between groups in age, gestational age, prior breastfeeding experience. Delivery room insertion was non-inferior to delayed birth-hospitalization insertion in time to LII (delivery room: [mean+standard deviation] 65+25 hours; delayed: 73+61 hours, mean difference -9 hours, 95% confidence interval [CI] -27, 10). Onset of LII by postpartum day 3 was not significantly different between groups. Lactation failure occurred in 5.5% (n=2) participants in the delayed group. Ongoing breastfeeding rates did not differ between groups with decreasing rates of any/exclusive breastfeeding over the first postpartum year. Most people continued to use the implant at 12 months, which did not differ by group.CONCLUSION: Delivery room insertion of the contraceptive ETG-implant does not delay onset of lactogenesis when compared to initiation later in the birth-hospitalization and therefore should be offered routinely as part of person-centered postpartum contraceptive counseling regardless of breastfeeding intentions.

  View details for DOI 10.1016/j.ajog.2022.08.012

  View details for PubMedID 35964661

• Teledermatology to Facilitate Patient Care Transitions From Inpatient to Outpatient Dermatology: Mixed Methods Evaluation. Journal of medical Internet research Kling, S. M., Saliba-Gustafsson, E. A., Winget, M., Aleshin, M. A., Garvert, D. W., Amano, A., Brown-Johnson, C. G., Kwong, B. Y., Calugar, A., El-Banna, G., Shaw, J. G., Asch, S. M., Ko, J. M. 2022; 24 (8): e38792

  Abstract

  BACKGROUND: Both clinicians and patients have increasingly turned to telemedicine to improve care access, even in physical examination-dependent specialties such as dermatology. However, little is known about whether teledermatology supports effective and timely transitions from inpatient to outpatient care, which is a common care coordination gap.OBJECTIVE: Using mixed methods, this study sought to retrospectively evaluate how teledermatology affected clinic capacity, scheduling efficiency, and timeliness of follow-up care for patients transitioning from inpatient to outpatient dermatology care.METHODS: Patient-level encounter scheduling data were used to compare the number and proportion of patients who were scheduled and received in-clinic or video dermatology follow-ups within 14 and 90 days after discharge across 3 phases: June to September 2019 (before teledermatology), June to September 2020 (early teledermatology), and February to May 2021 (sustained teledermatology). The time from discharge to scheduling and completion of patient follow-up visits for each care modality was also compared. Dermatology clinicians and schedulers were also interviewed between April and May 2021 to assess their perceptions of teledermatology for postdischarge patients.RESULTS: More patients completed follow-up within 90 days after discharge during early (n=101) and sustained (n=100) teledermatology use than at baseline (n=74). Thus, the clinic's capacity to provide follow-up to patients transitioning from inpatient increased from baseline by 36% in the early (101 from 74) and sustained (100 from 74) teledermatology periods. During early teledermatology use, 61.4% (62/101) of the follow-ups were conducted via video. This decreased significantly to 47% (47/100) in the following year, when COVID-19-related restrictions started to lift (P=.04), indicating more targeted but still substantial use. The proportion of patients who were followed up within the recommended 14 days after discharge did not differ significantly between video and in-clinic visits during the early (33/62, 53% vs 15/39, 38%; P=.15) or sustained (26/53, 60% vs 28/47, 49%; P=.29) teledermatology periods. Interviewees agreed that teledermatology would continue to be offered. Most considered postdischarge follow-up patients to be ideal candidates for teledermatology as they had undergone a recent in-person assessment and might have difficulty attending in-clinic visits because of competing health priorities. Some reported patients needing technological support. Ultimately, most agreed that the choice of follow-up care modality should be the patient's own.CONCLUSIONS: Teledermatology could be an important tool for maintaining accessible, flexible, and convenient care for recently discharged patients needing follow-up care. Teledermatology increased clinic capacity, even during the pandemic, although the timeliness of care transitions did not improve. Ultimately, the care modality should be determined through communication with patients to incorporate their and their caregivers' preferences.

  View details for DOI 10.2196/38792

  View details for PubMedID 35921146

• The Presence 5 for Racial Justice Framework for Anti-Racist Communication with Black Patients. Health services research Brown-Johnson, C., Cox, J., Shankar, M., Baratta, J., De Leon, G., Garcia, R., Hollis, T., Verano, M., Henderson, K., Upchurch, M., Safaeinili, N., Shaw, J. G., Fortuna, R. J., Beverly, C., Walsh, M., Somerville, C. S., Haverfield, M., Israni, S. T., Verghese, A., Zulman, D. M. 2022

  Abstract

  To identify communication practices that clinicians can use to address racism faced by Black patients, build trusting relationships, and empower Black individuals in clinical care.Qualitative data (N=112 participants, August 2020 to March 2021) collected in partnership with clinics primarily serving Black patients in Leeds, AL; Memphis, TN; Oakland, CA; and Rochester, NY.This multi-phased project was informed by human-centered design thinking and community-based participatory research principles. We mapped emergent communication and trust-building strategies to domains from the Presence 5 framework for fostering meaningful connection in clinical care.Interviews and focus group discussions explored anti-racist communication and patient-clinician trust (n=36 Black patients; n=40 non-medical professionals and n=24 clinicians of various races and ethnicities). The Presence 5 Virtual National Community Advisory Board guided analysis interpretation.The emergent Presence 5 for Racial Justice (P5RJ) practices include: 1) Prepare with intention by reflecting on identity, bias, and power dynamics; and creating structures to address bias and structural determinants of health; 2) Listen intently and completely without interruption and listen deeply for the potential impact of anti-Black racism on patient health and interactions with healthcare; 3) Agree on what matters most by having explicit conversations about patient goals, treatment comfort and consent, and referral planning; 4) Connect with the patient's story, acknowledging socioeconomic factors influencing patient health and focusing on positive efforts; 5) Explore emotional cues by noticing and naming patient emotions, and considering how experiences with racism might influence emotions.P5RJ provides a framework with actionable communication practices to address pervasive racism experienced by Black patients. Effective implementation necessitates clinician self-reflection, personal commitment, and institutional support that offers time and resources to elicit a patient's story and to address their needs.

  View details for DOI 10.1111/1475-6773.14015

  View details for PubMedID 35765147

• Diagnostic journeys: characterization of patients and diagnostic outcomes from an academic second opinion clinic. Diagnosis (Berlin, Germany) Chao, S., Lotfi, J., Lin, B., Shaw, J., Jhandi, S., Mahoney, M., Singh, B., Nguyen, L., Halawi, H., Geng, L. N. 2022

  Abstract

  Diagnostic programs and second opinion clinics have grown and evolved in the recent years to help patients with rare, puzzling, and complex conditions who often suffer prolonged diagnostic journeys, but there is a paucity of literature on the clinical characteristics of these patients and the efficacy of these diagnostic programs. This study aims to characterize the diagnostic journey, case features, and diagnostic outcomes of patients referred to a team-based second opinion clinic at Stanford.Retrospective chart review was performed for 237 patients evaluated for diagnostic second opinion in the Stanford Consultative Medicine Clinic over a 5 year period. Descriptive case features and diagnostic outcomes were assessed, and correlation between the two was analyzed.Sixty-three percent of our patients were women. 49% of patients had a potential precipitating event within about a month prior to the start of their illness, such as medication change, infection, or medical procedure. A single clear diagnosis was determined in 33% of cases, whereas the remaining cases were assessed to have multifactorial contributors/diagnoses (20%) or remained unclear despite extensive evaluation (47%). Shorter duration of illness, fewer prior specialties seen, and single chief symptom were associated with higher likelihood of achieving a single clear diagnosis.A single-site academic consultative service can offer additional diagnostic insights for about half of all patients evaluated for puzzling conditions. Better understanding of the clinical patterns and patient experiences gained from this study helps inform strategies to shorten their diagnostic odysseys.

  View details for DOI 10.1515/dx-2022-0029

  View details for PubMedID 35596123

• Timeliness and Adequacy of Prenatal Care Among Department of Veterans Affairs-Enrolled Veterans: The First Step May Be the Biggest Hurdle. Women's health issues : official publication of the Jacobs Institute of Women's Health Katon, J. G., Shaw, J. G., Joyce, V. R., Schmitt, S. K., Phibbs, C. S. 1800

  Abstract

  INTRODUCTION: Little is known about access to and use of prenatal care by veterans using U.S. Department of Veterans Affairs (VA) maternity benefits. We compared the timeliness and adequacy of prenatal care by veteran status and payor.STUDY DESIGN: We used VA clinical and admistrative data linked with California vital statistics patient discharge data to identify all births to VA-enrolled veterans and non-veterans between 2000 and 2012. Births were categorized based on veteran status and payor (non-veterans with Medicaid, non-veterans with private insurance, VA-enrolled veterans using VA maternity care benefits, and VA-enrolled veterans with other payor). Outcomes were timeliness of prenatal care (initiation before the end of the first trimester) and adequacy of prenatal care as measured by the Kotelchuck Index (inadequate, intermediate, adequate). Covariates included demographic, health, and pregnancy characteristics. We used generalized linear models and multinomial logistic regression to analyze the association of veteran status and payor with timeliness of prenatal care and adequacy of prenatal care, respectively.RESULTS: We identified 6,196,432 births among VA-enrolled veterans (n=17,495) and non-veterans (n=6,178,937). Non-veterans using Medicaid had the lowest percentage of timely prenatal care (78.1%; n=2,240,326), followed by VA-enrolled veterans using VA maternity care benefits (82.8%; n=1,248). VA-enrolled veterans using VA maternity care benefits were the most likely to receive adequate prenatal care (92.0%; n=1,365). Results remained consistent after adjustment.CONCLUSIONS: This study provides key baseline data regarding access to and use of prenatal care by veterans using VA maternity benefits. Longitudinal studies including more recent data are needed to understand the impact of changing VA policy.

  View details for DOI 10.1016/j.whi.2021.12.008

  View details for PubMedID 35074265

• Presence 5 for Racial Justice Workshop: Fostering Dialogue Across Medical Education to Disrupt Anti-Black Racism in Clinical Encounters. MedEdPORTAL : the journal of teaching and learning resources Shankar, M., Henderson, K., Garcia, R., Li, G., Titer, K., Acholonu, R. G., Essien, U. R., Brown-Johnson, C., Cox, J., Shaw, J. G., Haverfield, M. C., Taylor, K., Israni, S. T., Zulman, D. 2022; 18: 11227

  Abstract

  Introduction: Anti-Black racism has strong roots in American health care and medical education. While curricula on social determinants of health are increasingly common in medical training, curricula directly addressing anti-Black racism are limited. Existing frameworks like the Presence 5 framework for humanism in medicine can be adapted to develop a novel workshop that promotes anti-racism communication.Methods: We performed a literature review of anti-racism collections and categorized anti-racism communication practices using the Presence 5 framework to develop the Presence 5 for Racial Justice Workshop. Implementation included an introductory didactic, a small-group discussion, and a large-group debrief. Participants evaluated the workshop via an online survey, and we analyzed the resulting qualitative feedback.Results: A total of 17 participants took part in two workshops, with nine of the participants responding to the evaluation survey. Themes that emerged from survey responses included strengths of and improvements for the workshop structure (protected time for anti-racism discussion, dialogue between learners and faculty) and content (specific phrases and language, practicing self-reflection).Discussion: The workshop provides participants with a semistructured discussion around the five anti-racism communication practices. Barriers to implementation include incorporating the workshop into existing curricula and ensuring diverse learners. Barriers to evaluating the workshop include the low survey response rate. Recommendations to improve the workshop include using case-based discussion and varying the workshop structure according to institutional needs. Next steps include an implementation study to evaluate the acceptability, feasibility, and effectiveness of the workshop.

  View details for DOI 10.15766/mep_2374-8265.11227

  View details for PubMedID 35198729

• Patient and Clinician Perspectives of New and Return Ambulatory Teleneurology Visits. Neurology. Clinical practice Kling, S. M., Falco-Walter, J. J., Saliba-Gustafsson, E. A., Garvert, D. W., Brown-Johnson, C. G., Miller-Kuhlmann, R., Shaw, J. G., Asch, S. M., Yang, L., Gold, C. A., Winget, M. 1800; 11 (6): 472-483

  Abstract

  Background and Objectives: To evaluate the adoption and perceived utility of video visits for new and return patient encounters in ambulatory neurology subspecialties.Methods: Video visits were launched in an academic, multi-subspecialty, ambulatory neurology clinic in March 2020. Adoption of video visits for new and return patient visits was assessed using clinician-level scheduling data from March 22 to May 16, 2020. Perceived utility of video visits was explored via a clinician survey and semistructured interviews with clinicians and patients/caregivers. Findings were compared across 5 subspecialties and 2 visit types (new vs return).Results: Video visits were adopted rapidly; all clinicians (n = 65) integrated video visits into their workflow within the first 6 weeks, and 92% of visits were conducted via video, although this varied by subspecialty. Utility of video visits was higher for return than new patient visits, as indicated by surveyed (n = 48) and interviewed clinicians (n = 30), aligning with adoption patterns. Compared with in-person visits, clinicians believed that it was easier to achieve a similar physical examination, patient-clinician rapport, and perceived quality of care over video for return rather than new patient visits. Of the 25 patients/caregivers interviewed, most were satisfied with the care provided via video, regardless of visit type, with the main limitation being the physical examination.Discussion: Teleneurology was robustly adopted for both new and return ambulatory neurology patients during the COVID-19 pandemic. Return patient visits were preferred over new patient visits, but both were feasible. These results provide a foundation for developing targeted guidelines for sustaining teleneurology in ambulatory care.

  View details for DOI 10.1212/CPJ.0000000000001065

  View details for PubMedID 34992955

• Making the financial case for immediate postpartum intrauterine device: a budget impact analysis. American journal of obstetrics and gynecology Fitzgerald, A. C., Shaw, J. G., Shaw, K. A. 2021

  Abstract

  BACKGROUND: Clinical guidelines support inpatient postpartum intrauterine device insertion; however, inpatient placement remains infrequent, in part due to inconsistent private insurance reimbursement.OBJECTIVE: The purpose of this study was to explore how the payer's costs and number of unintended pregnancies associated with postpartum intrauterine device differed on the basis of placement timing.STUDY DESIGN: Using a decision tree model, following a hypothetical cohort of people who intend to use an intrauterine device after their delivery, we conducted a cost analysis comparing planned approach of inpatient versus outpatient postpartum insertion. Using a two-year time horizon, probability and cost estimates were derived from literature review. Our primary outcome was total accrued costs to the payer. Secondarily, we examined rates of early repeat pregnancy, and sensitivity to estimates of key inputs including expulsion rates and intrauterine device cost.RESULTS: While inpatient intrauterine device placement's up-front costs were higher, total cost of this approach was lower. Including costs of managing expulsions and complications, our model suggests that for every 1000 people desiring postpartum intrauterine device, intended inpatient intrauterine device placement resulted in a total cost savings of $211,100 and prevention of 37 additional pregnancies as compared to outpatient placement. Inpatient cost savings were superior to outpatient largely due to a known high proportion not returning for outpatient placement, and the resulting higher number of unintended pregnancies among patients desiring outpatient placement. In sensitivity analyses, we found that total cost to the payer was sensitive to the probability of expulsion after immediate postpartum intrauterine device placement.CONCLUSIONS: For beneficiaries desiring postpartum intrauterine device, payers are likely to save money by fully reimbursing inpatient intrauterine device placement rather than incentivizing placement at the frequently missed postpartum visit. These results support the financial case for private insurers to fully and separately reimburse (i.e. "unbundle" from the single payment for delivery) inpatient postpartum intrauterine device placement.

  View details for DOI 10.1016/j.ajog.2021.11.1348

  View details for PubMedID 34801445

• Postpartum Transition of Care: Racial/Ethnic Gaps in Veterans' Re-Engagement in VA Primary Care after Pregnancy. Women's health issues : official publication of the Jacobs Institute of Women's Health Shankar, M., Chan, C. S., Frayne, S. M., Panelli, D. M., Phibbs, C. S., Shaw, J. G. 2021

  Abstract

  INTRODUCTION: Pregnancy presents an opportunity to engage veterans in health care. Guidelines recommend primary care follow-up in the year postpartum, but loss to follow-up is common, poorly quantified, and especially important for those with gestational diabetes (GDM) and hypertension. Racial maternal inequities are well-documented and might be exacerbated by differential postpartum care. This study explores variation in postpartum re-engagement in U.S. Department of Veteran Affairs health care system (VA) primary care to identify potential racial/ethnic inequities in this care transition.METHODS: We conducted a complete case analysis of the 2005-2014 national VA birth cohort (n=18,414), and subcohorts of veterans with GDM (n=1,253), and hypertensive disorders of pregnancy (HDP; n=2,052) using VA-reimbursed discharge claims and outpatient data. Outcomes included incidence of any VA primary care visit in the postpartum year; in age-adjusted logistic regression, we explored race/ethnicity as a primary predictor.RESULTS: In the year after a VA-covered birth, the proportion of veterans with one or more primary care visit was 53.8% overall, and slightly higher in the GDM (56.0%) and HDP (57.4%) subcohorts. In adjusted models, the odds of VA primary care follow-up were significantly lower for Black/African American (odds ratio, 0.87; 95% confidence interval, 0.81-0.93), Asian (odds ratio, 0.76; 95% confidence interval, 0.61-0.95), and Hawaiian/other Pacific Islander (odds ratio, 0.73; 95% confidence interval, 0.55-0.96) veterans, compared with White veterans. Among the subcohorts with GDM or HDP, there were no significant associations between primary care and race/ethnicity.CONCLUSIONS: One-half of veterans re-engage in VA primary care after childbirth, with significant racial differences in this care transition. Re-engagement for those with the common pregnancy complications of HDP and GDM is only slightly higher, and less than 60%. The potential for innovations like VA maternity care coordinators to address such gaps merits attention.

  View details for DOI 10.1016/j.whi.2021.06.003

  View details for PubMedID 34229932

• Evaluation of Patient and Clinician Perspectives for New and Return Ambulatory Teleneurology Visits, with special attention to subspecialty differences Falco-Walter, J., Kling, S., Saliba-Gustafsson, E., Yang, L., Miller-Kuhlmann, R., Garvert, D., Brown-Johnson, C., Shaw, J., Asch, S., Winget, M., Gold, C. LIPPINCOTT WILLIAMS & WILKINS. 2021

  View details for Web of Science ID 000729283600146

• Clinical factors associated with spontaneous preterm birth in women with active post-traumatic stress disorder Panelli, D. M., Chan, C., Shaw, J. G., Shankar, M., Herrero, T., Lyell, D. J., Phibbs, C. S. MOSBY-ELSEVIER. 2021: S100

  View details for Web of Science ID 000621547400147

• COVID-19 Community Interventions Task Force: Building Bridges Between EM and Community Health Centers Rajeev, S., Wang, E., Shaw, J. G., Newberry, J. A. Society for Academic Emergency Medicine. 2021 ; SAEM Pulse (Jan-Feb 2021): 40–43

  Abstract

  Working together, the CCI Task Force created a venue for knowledge sharing and identifying community needs, which in turn increased access to testing, personal protective equipment (PPE), and evidence-based protocols, while improving connections with community resources.

• The prevalence of COVID-19 in healthcare personnel in an adult and pediatric academic medical center. American journal of infection control Shepard, J., Kling, S. M., Lee, G., Wong, F., Frederick, J., Skhiri, M., Holubar, M., Shaw, J. G., Stafford, D., Schilling, L., Kim, J., Ick Chang, S., Frush, K., Hadhazy, E. 2021; 49 (5): 542–46

  Abstract

  BACKGROUND: It is vital to know which healthcare personnel (HCP) have a higher chance of testing positive for severe acute respiratory syndrome coronavirus 2 (COVID-19).METHODS: A retrospective analysis was conducted at Stanford Children's Health (SCH) and Stanford Health Care (SHC) in Stanford, California. Analysis included all HCP, employed by SCH or SHC, who had a COVID-19 reverse transcriptase polymerase chain reaction (RT-PCR) test resulted by the SHC Laboratory, between March 1, 2020 and June 15, 2020. The primary outcome was the RT-PCR percent positivity and prevalence of COVID-19 for HCP and these were compared across roles.RESULTS: SCH and SHC had 24,081 active employees, of which 142 had at least 1 positive COVID-19 test. The overall HCP prevalence of COVID-19 was 0.59% and percent positivity was 1.84%. Patient facing HCPs had a significantly higher prevalence (0.66% vs 0.43%; P = .0331) and percent positivity (1.95% vs 1.43%; P = .0396) than nonpatient facing employees, respectively. Percent positivity was higher in food service workers (9.15%), and environmental services (5.96%) compared to clinicians (1.93%; P < .0001) and nurses (1.46%; P < .0001), respectively.DISCUSSION AND CONCLUSION: HCP in patient-facing roles and in support roles had a greater chance of being positive of COVID-19.

  View details for DOI 10.1016/j.ajic.2021.01.004

  View details for PubMedID 33896582

• Supporting First Responders and Essential Workers During a Pandemic: Needs Assessment and Mixed-Methods Implementation Evaluation of a COVID-19 App-Based Intervention. Journal of medical Internet research Vilendrer, S. n., Amano, A. n., Brown Johnson, C. G., Favet, M. n., Safaeinili, N. n., Villasenor, J. n., Shaw, J. G., Hertelendy, A. J., Asch, S. M., Mahoney, M. n. 2021

  Abstract

  The COVID-19 pandemic has created unprecedented challenges for first responders (e.g., police, fire, and emergency medical services) and non-medical essential workers (e.g., food, transportation and other industries). Health systems may be uniquely suited to support these workers given their medical expertise, and mobile applications ("apps") can reach local communities despite social distancing requirements. Formal evaluation of real-world mobile app-based interventions are lacking.We aimed to evaluate the adoption, acceptability and appropriateness of an academic medical center's app-based intervention (COVID-19 Guide App) designed to support first responders and essential workers' access to COVID-19 information and testing services. We also sought to better understand the COVID-19 related needs of these workers early in the pandemic.To understand overall community adoption, COVID-19 Guide App views and download data were described. To understand adoption, appropriateness and acceptability of the app and workers' unmet needs, semi-structured qualitative interviews were conducted by phone, video and in-person with first responder and essential workers in the San Francisco Bay Area, recruited through purposive, convenience, and snowball sampling. Interview transcripts and field notes were qualitatively analyzed and presented using an implementation outcomes framework.From April 2020 launch to September 2020, the app received 8,262 views from unique devices and 6,640 downloads (80.4% conversion rate, 0.61% adoption rate across the Bay Area). App acceptability was mixed amongst 17 first responders interviewed and high amongst 10 essential workers interviewed. Select themes included the need for personalized and accurate information, access to testing, and securing personal safety. First responders faced additional challenges related to inter-professional coordination and a culture of heroism that could both protect against and exacerbate health vulnerability.First responders and essential workers both report challenges related to obtaining accurate information, testing services, and other resources. A mobile app intervention has the potential to combat these challenges through the provision of disease-specific information and access to testing services but may be most effective if delivered as part of a larger ecosystem of support. Differentiated interventions that acknowledge and address the divergent needs between first responders and non-first responder essential workers may optimize acceptance and adoption.

  View details for DOI 10.2196/26573

  View details for PubMedID 33878023

• Relationship of socio-demographics, comorbidities, symptoms and healthcare access with early COVID-19 presentation and disease severity. BMC infectious diseases Vaughan, L. n., Veruttipong, D. n., Shaw, J. G., Levy, N. n., Edwards, L. n., Winget, M. n. 2021; 21 (1): 40

  Abstract

  COVID-19 studies are primarily from the inpatient setting, skewing towards severe disease. Race and comorbidities predict hospitalization, however, ambulatory presentation of milder COVID-19 disease and characteristics associated with progression to severe disease is not well-understood.We conducted a retrospective chart review including all COVID-19 positive cases from Stanford Health Care (SHC) in March 2020 to assess demographics, comorbidities and symptoms in relationship to: 1) their access point of testing (outpatient, inpatient, and emergency room (ER)) and 2) development of severe disease.Two hundred fifty-seven patients tested positive: 127 (49%), 96 (37%), and 34 (13%) at outpatient, ER and inpatient, respectively. Overall, 61% were age < 55; age > 75 was rarer in outpatient setting (11%) than ER (14%) or inpatient (24%). Most patients presented with cough (86%), fever/chills (76%), or fatigue (63%). 65% of inpatients reported shortness of breath compared to 30-32% of outpatients and ER patients. Ethnic/minority patients had a significantly higher risk of developing severe disease (Asian OR = 4.8 [1.6-14.2], Hispanic OR = 3.6 [1.1-11.9]). Medicare-insured patients were marginally more likely (OR = 4.0 [0.9-17.8]). Other factors associated with developing severe disease included kidney disease (OR = 6.1 [1.0-38.1]), cardiovascular disease (OR = 4.7 [1.0-22.1], shortness of breath (OR = 5.4 [2.3-12.6]) and GI symptoms (OR = 3.3 [1.4-7.7]; hypertension without concomitant CVD or kidney disease was marginally significant (OR = 2.3 [0.8-6.5]).Early widespread symptomatic testing for COVID-19 in Silicon Valley included many less severely ill patients. Thorough manual review of symptomatology reconfirms the heterogeneity of COVID-19 symptoms, and challenges in using clinical characteristics to predict decline. We re-demonstrate that socio-demographics are consistently associated with severity.

  View details for DOI 10.1186/s12879-021-05764-x

  View details for PubMedID 33421991

• Socioeconomic Differences Persist in Use of Permanent versus Long-Acting Reversible Contraception: An Analysis of the National Survey for Family Growth, 2006-2010 versus 2015-2017. Contraception Beshar, I., So, J., Chelvakumar, M., Cahill, E. P., Shaw, K. A., Shaw, J. G. 2020

  Abstract

  OBJECTIVE: Permanent contraception has historically been more prevalent among non-White women with lower education and income. Given increasing popularity of long-acting reversible contraception (LARC), we examine changing sociodemographic patterns of permanent contraception and LARC.STUDY DESIGN: We performed a descriptive analysis of the National Survey of Family Growth (NSFG) from 2006-2017, with multivariable analyses of the 2006-2010 and 2015-2017 cohorts. Using multinomial logistic regression, we investigate predictors of contraceptive category (permanent contraception versus LARC, lower-efficacy contraception versus LARC) in reproductive-aged women.RESULTS: 8,161 respondents were included in two distinct but analogous regression analyses: 1) the most recent survey cohort, 2015-2017, and 2) the cohort a decade prior, 2006-2010. Over this period, the prevalence of LARC increased nearly three-fold (6.2% to 16.7%), while permanent contraception use trended downwards (22% to 18.6%). Yet, in adjusted models, we observed little change in the sociodemographic predictors of permanent contraception: from the early to recent cohort, use of permanent contraception (versus LARC) remained less likely among college graduates (multinomial odds ratio (OR) 0.45[95% CI 0.21, 0.97]) and Hispanic women (OR 0.41[0.21, 0.82]). In addition, high income (>$74,999) and metropolitan residence came to predict less use (OR 0.33[0.13, 0.84] and 0.47[0.23, 0.97]). Multiparity, advanced age (over ≥35), and marital status remained strong predictors of permanent contraception.CONCLUSION: Although use of LARC nearly equals that of permanent contraception in the most recent NSFG survey, socioeconomic differences persist. Continued effort is needed to detect and address structural barriers to accessing the most effective forms of contraception for women.IMPLICATIONS: Comparing 2006-2010 to 2015-2017, reliance on female permanent contraception decreased while LARC use increased, making prevalence more similar. However, significant socioeconomic differences persist in who chooses permanent contraception, with urban, educated, higher-income women more likely to use LARC. Ongoing efforts are needed to understand and reduce economic barriers to LARC.

  View details for DOI 10.1016/j.contraception.2020.12.008

  View details for PubMedID 33359509

• Retaining VA Women's Health Primary Care Providers: Work Setting Matters. Journal of general internal medicine Schwartz, R., Frayne, S. M., Friedman, S., Romodan, Y., Berg, E., Haskell, S. G., Shaw, J. G. 2020

  Abstract

  BACKGROUND: When an experienced provider opts to leave a healthcare workforce (attrition), there are significant costs, both direct and indirect. Turnover of healthcare providers is underreported and understudied, despite evidence that it negatively impacts care delivery and negatively impacts working conditions for remaining providers. In the Veterans Affairs (VA) healthcare system, attrition of women's health primary care providers (WH-PCPs) threatens a specially trained workforce; it is unknown what factors contribute to, or protect against, their attrition.OBJECTIVE: Based on evidence that clinic environment, adequate support resources, and workload affect provider burnout and intent to leave, we explored if such clinic characteristics predict attrition of WH-PCPs in the VA, to identify protective factors.DESIGN: This analysis drew on two waves of existing national VA survey data to examine predictors of WH-PCP attrition, via logistic regression.PARTICIPANTS: All 2,259 providers from 140 facilities VA-wide who were WH-PCPs on September 30, 2016.MAIN MEASURES: The dependent variable was WH-PCP attrition in the following year. Candidate predictors were clinic environment (working in: a comprehensive women's health center, a limited women's health clinic, a general primary care clinic, or multiple clinic environments), availability of co-located specialty support resources (mental health, social work, clinical pharmacy), provider characteristics (gender, professional degree), and clinic workload (clinic sessions per week).KEY RESULTS: Working exclusively in a comprehensive women's health center uniquely predicted significantly lower risk of WH-PCP attrition (adjusted odds ratio 0.40; CI 0.19-0.86).CONCLUSIONS: A comprehensive women's health center clinical context may promote retention of this specially trained primary care workforce. Exploring potential mechanisms-e.g., shared mission, appropriate support to meet patients' needs, or a cohesive team environment-may inform broader efforts to retain front-line providers.

  View details for DOI 10.1007/s11606-020-06285-0

  View details for PubMedID 33063204

• CFIR simplified: Pragmatic application of and adaptations to the Consolidated Framework for Implementation Research (CFIR) for evaluation of a patient-centered care transformation within a learning health system. Learning health systems Safaeinili, N., Brown-Johnson, C., Shaw, J. G., Mahoney, M., Winget, M. 2020; 4 (1): e10201

  Abstract

  The Consolidated Framework for Implementation Research (CFIR) is a commonly used implementation science framework to facilitate design, evaluation, and implementation of evidence-based interventions. Its comprehensiveness is an asset for considering facilitators and barriers to implementation and also makes the framework cumbersome to use. We describe adaptations we made to CFIR to simplify its pragmatic application, for use in a learning health system context, in the evaluation of a complex patient-centered care transformation.We conducted a qualitative study and structured our evaluation questions, data collection methods, analysis, and reporting around CFIR. We collected qualitative data via semi-structured interviews and observations with key stakeholders throughout. We identified and documented adaptations to CFIR throughout the evaluation process.We analyzed semi-structured interviews with key stakeholders (n = 23) from clinical observations (n = 5). We made three key adaptations to CFIR: (a) promoted "patient needs and resources," a subconstruct of the outer setting, to its own domain within CFIR during data analysis; (b) divided the "inner setting" domain into three layers that account for the hierarchy of health care systems (i. pilot clinic, ii. peer clinics, and iii. overarching health care system); and (c) tailored several construct definitions to fit a patient-centered, primary care setting. Analysis yielded qualitative findings concentrated in the CFIR domains "intervention characteristics" and "outer setting," with a robust number of findings in the new domain "patient needs and resources."To make CFIR more accessible and relevant for wider use in the context of patient-centered care transformations within a learning health system, a few adaptations are key. Specifically, we found success by teasing apart interactions across the inner layers of a health system, tailoring construct definitions, and placing additional focus on patient needs.

  View details for DOI 10.1002/lrh2.10201

  View details for PubMedID 31989028

  View details for PubMedCentralID PMC6971122

• Accelerated launch of video visits in ambulatory neurology during COVID-19: Key lessons from the Stanford experience. Neurology Yang, L., Brown-Johnson, C. G., Miller-Kuhlmann, R., Kling, S. M., Saliba-Gustafsson, E. A., Shaw, J. G., Gold, C. A., Winget, M. 2020

  Abstract

  The COVID-19 pandemic has rapidly moved telemedicine from discretionary to necessary. Here we describe how the Stanford Neurology Department: 1) rapidly adapted to the COVID-19 pandemic, resulting in over 1000 video visits within four weeks and 2) accelerated an existing quality improvement plan of a tiered roll out of video visits for ambulatory neurology to a full-scale roll out. Key issues we encountered and addressed were related to: equipment/software, provider engagement, workflow/triage, and training. Upon reflection, the key drivers of our success were provider engagement and a supportive physician champion. The physician champion played a critical role understanding stakeholder needs, including staff and physicians' needs, and creating workflows to coordinate both stakeholder groups. Prior to COVID-19, physician interest in telemedicine was mixed. However, in response to county and state stay-at-home orders related to COVID-19, physician engagement changed completely; all providers wanted to convert a majority of visits to video visits as quickly as possible. Rapid deployment of neurology video visits across all its subspecialties is feasible. Our experience and lessons learned can facilitate broader utilization, acceptance, and normalization of video visits for neurology patients in the present as well as the much anticipated post-pandemic era.

  View details for DOI 10.1212/WNL.0000000000010015

  View details for PubMedID 32611634

• Effect of Delivery Room Postpartum Contraceptive Implant Insertion on Initiation of Breastfeeding Shaw, K. A., Lerma, K., Reyes, G., Gutow, H., Shaw, J. G. LIPPINCOTT WILLIAMS & WILKINS. 2020: 105S

  View details for Web of Science ID 000554572900366

• Sociodemographic Trends in Long Acting Reversible Contraception vs. Female Sterilization, 2006-2017 Beshar, I. B., Chelvakumar, M., So, J., Cahill, E. P., Shaw, K. A., Shaw, J. G. LIPPINCOTT WILLIAMS & WILKINS. 2020: 100S

  View details for Web of Science ID 000554572900348

• The Stanford Lightning Report Method: A comparison of rapid qualitative synthesis results across four implementation evaluations. Learning health systems Brown-Johnson, C., Safaeinili, N., Zionts, D., Holdsworth, L. M., Shaw, J. G., Asch, S. M., Mahoney, M., Winget, M. 2020; 4 (2): e10210

  Abstract

  Current evaluation methods are mismatched with the speed of health care innovation and needs of health care delivery partners. We introduce a qualitative approach called the lightning report method and its specific product-the "Lightning Report." We compare implementation evaluation results across four projects to explore report sensitivity and the potential depth and breadth of lightning report method findings.The lightning report method was refined over 2.5 years across four projects: team-based primary care, cancer center transformation, precision health in primary care, and a national life-sustaining decisions initiative. The novelty of the lightning report method is the application of Plus/Delta/Insight debriefing to dynamic implementation evaluation. This analytic structure captures Plus ("what works"), Delta ("what needs to be changed"), and Insights (participant or evaluator insights, ideas, and recommendations). We used structured coding based on implementation science barriers and facilitators outlined in the Consolidated Framework for Implementation Research (CFIR) applied to 17 Lightning Reports from four projects.Health care partners reported that Lighting Reports were valuable, easy to understand, and they implied reports supported "corrective action" for implementations. Comparative analysis revealed cross-project emphasis on the domains of Inner Setting and Intervention Characteristics, with themes of communication, resources/staffing, feedback/reflection, alignment with simultaneous interventions and traditional care, and team cohesion. In three of the four assessed projects, the largest proportion of coding was to the clinic-level domain of Inner Setting-ranging from 39% for the cancer center project to a high of 56% for the life-sustaining decisions project.The lightning report method can fill a gap in rapid qualitative approaches and is generalizable with consistent but flexible core methods. Comparative analysis suggests it is a sensitive tool, capable of uncovering differences and insights in implementation across projects. The Lightning Report facilitates partnered evaluation and communication with stakeholders by providing real-time, actionable insights in dynamic health care implementations.

  View details for DOI 10.1002/lrh2.10210

  View details for PubMedID 32313836

  View details for PubMedCentralID PMC7156867

• Trained and Ready, but Not Serving?-Family Physicians' Role in Reproductive Health Care. Journal of the American Board of Family Medicine : JABFM Chelvakumar, M., Shaw, J. G. 2020; 33 (2): 182–85

  View details for DOI 10.3122/jabfm.2020.02.200033

  View details for PubMedID 32179600

• Post-traumatic stress disorder in pregnancy: Does treatment impact the risk of preterm birth? Panelli, D. M., Chan, C., Shaw, J. G., Herrero, T., Lyell, D. J., Phibbs, C. S. MOSBY-ELSEVIER. 2020: S328

  View details for DOI 10.1016/j.ajog.2019.11.520

  View details for Web of Science ID 000504997300503

• "Racial Bias…I'm Not Sure if It Has Affected My Practice": a Qualitative Exploration of Racial Bias in Team-Based Primary Care. Journal of general internal medicine Brown-Johnson, C. n., Shankar, M. n., Taylor, N. K., Safaeinili, N. n., Shaw, J. G., Winget, M. n., Mahoney, M. n. 2020

  View details for DOI 10.1007/s11606-020-06219-w

  View details for PubMedID 32935312

• Rapid implementation of video visits in neurology during COVID-19: a mixed methods evaluation. Journal of medical Internet research Saliba-Gustafsson, E. A., Miller-Kuhlmann, R. n., Kling, S. M., Garvert, D. W., Brown-Johnson, C. G., Lestoquoy, A. S., Verano, M. R., Yang, L. n., Falco-Walter, J. n., Shaw, J. G., Asch, S. M., Gold, C. A., Winget, M. n. 2020

  Abstract

  Telemedicine has been used for decades; yet, despite its many advantages, its uptake and rigorous evaluation of feasibility across neurology's ambulatory subspecialties has been sparse. The SARS-CoV-2 (COVID-19) pandemic however, prompted healthcare systems worldwide to reconsider traditional healthcare delivery. To safeguard healthcare workers and patients many healthcare systems quickly transitioned to telemedicine, including across neurology subspecialties, providing a new opportunity to evaluate this modality of care.To evaluate the accelerated implementation of video visits in ambulatory neurology during the COVID-19 pandemic, we used mixed methods to assess the adoption, acceptability, appropriateness, and perceptions of potential sustainability.Video visits were launched rapidly in ambulatory neurology clinics of a large academic medical center. To assess adoption, we analyzed clinician-level scheduling data collected between March 22 and May 16, 2020. We assessed acceptability, appropriateness, and sustainability via a clinician survey (n=48) and semi-structured interviews with providers (n=30) completed between March and May 2020.Video visits were adopted rapidly; 65 (98%) clinicians integrated video visits into their workflow within the first 6 implementation weeks and 92% of all visits were conducted via video. Video visits were largely considered acceptable by clinicians, although various technological issues impacted satisfaction. Video visits were reported to be more convenient for patients, families, and/or caregivers than in-person visits; however, access to technology, the patient's technological capacity, and language difficulties were considered barriers. Many clinicians expressed optimism about future utilization of video visits in neurology. They believed that video visits promote continuity of care and can be incorporated into their practice long-term, although several insisted that they can never replace the in-person examination.Video visits are an important addition to clinical care in ambulatory neurology and are anticipated to remain a permanent supplement to in-person visits, promoting patient care continuity, and flexibility for patients and clinicians alike.

  View details for DOI 10.2196/24328

  View details for PubMedID 33245699

• INCIDENCE OF PELVIC FLOOR DISORDERS IN US ARMY FEMALE SOLDIERS. Urology Rogo-Gupta, L. J., Nelson, D. A., Young-Lin, N. n., Shaw, J. G., Kurina, L. M. 2020

  Abstract

  To determine the incidence of pelvic floor disorders (PFD) among active-duty US Army female soldiers.We studied 102,015 women for incident PFD using the Stanford Military Data Repository, which comprises medical, demographic and service-related information on all soldiers on active duty in the US Army during 2011-14. Cox proportional hazards estimated adjusted associations with PFD diagnoses. In the adjusted models, military-specific characteristics and fitness were evaluated alongside known PFD predictors.Among 102,015 subjects at risk there was a cumulative incidence of 6.4% over a mean of 27 months (median 29, range 1-42). In adjusted models, obese soldiers were more likely to have a PFD compared to those of normal weight (HR 1.23, CI 1.14-1.34, p<0.001) and those with recent weight gain were more likely to have a PFD compared to those without (HR 1.32, CI 1.24-1.40, p<0.05). Women with the lowest physical fitness scores were more likely to have a PFD (HR 1.14, CI 1.04-1.25) compared to those with the highest scores.Over a median follow-up time of 29 months, 1 in 15 women in this active-duty cohort was diagnosed with a PFD. Optimizing risk factors including BMI and physical fitness may benefit the pelvic health of female soldiers, independent of age, children, and years of service.

  View details for DOI 10.1016/j.urology.2020.05.085

  View details for PubMedID 32650018

• Can Patient-Provider Interpersonal Interventions Achieve the Quadruple Aim of Healthcare? A Systematic Review. Journal of general internal medicine Haverfield, M. C., Tierney, A. n., Schwartz, R. n., Bass, M. B., Brown-Johnson, C. n., Zionts, D. L., Safaeinili, N. n., Fischer, M. n., Shaw, J. G., Thadaney, S. n., Piccininni, G. n., Lorenz, K. A., Asch, S. M., Verghese, A. n., Zulman, D. M. 2020

  Abstract

  Human connection is at the heart of medical care, but questions remain as to the effectiveness of interpersonal interventions. The purpose of this review was to characterize the associations between patient-provider interpersonal interventions and the quadruple aim outcomes (population health, patient experience, cost, and provider experience).We sourced data from PubMed, EMBASE, and PsycInfo (January 1997-August 2017). Selected studies included randomized controlled trials and controlled observational studies that examined the association between patient-provider interpersonal interventions and at least one outcome measure of the quadruple aim. Two abstractors independently extracted information about study design, methods, and quality. We characterized evidence related to the objective of the intervention, type and duration of intervention training, target recipient (provider-only vs. provider-patient dyad), and quadruple aim outcomes.Seventy-three out of 21,835 studies met the design and outcome inclusion criteria. The methodological quality of research was moderate to high for most included studies; 67% of interventions targeted the provider. Most studies measured impact on patient experience; improvements in experience (e.g., satisfaction, patient-centeredness, reduced unmet needs) often corresponded with a positive impact on other patient health outcomes (e.g., quality of life, depression, adherence). Enhanced interpersonal interactions improved provider well-being, burnout, stress, and confidence in communicating with difficult patients. Roughly a quarter of studies evaluated cost, but the majority reported no significant differences between intervention and control groups. Among studies that measured time in the clinical encounter, intervention effects varied. Interventions with lower demands on provider time and effort were often as effective as those with higher demands.Simple, low-demand patient-provider interpersonal interventions may have the potential to improve patient health and patient and provider experience, but there is limited evidence that these interventions influence cost-related outcomes.

  View details for DOI 10.1007/s11606-019-05525-2

  View details for PubMedID 31919725

• "They are interrelated, one feeds off the other": A taxonomy of perceived disease interactions derived from patients with multiple chronic conditions. Patient education and counseling Zulman, D. M., Slightam, C. A., Brandt, K., Lewis, E. T., Asch, S. M., Shaw, J. G. 2019

  Abstract

  OBJECTIVE: To understand patients' experiences with condition interactions and develop a taxonomy to inform care for patients with multiple chronic conditions.METHODS: We conducted qualitative and quantitative analysis of free-text data from patient surveys in which respondents were asked to indicate their most bothersome chronic condition and describe how their other conditions affect their self-care for that condition. Using standard content analysis, we developed a taxonomy comprising how patients perceive interactions among their conditions, and examined cross-cutting themes that reflect qualities of these interactions.RESULTS: Among 383 eligible survey respondents, the mean (SD) number of chronic conditions was 4 (2); common conditions included hypertension (60%), chronic pain (49%), arthritis (41%), depression (32%), diabetes (29%), and post-traumatic stress disorder (26%). Patients' perceived condition interactions took four broad forms: 1) unidirectional interactions among conditions and/or treatments, 2) cyclical or multidimensional interactions, 3) uncertain or indistinct interactions, and 4) no perceived interaction. Cross-cutting themes included beliefs about causal relationships between conditions, identification of interactions as negative vs. positive, and interactions between physical and mental health.CONCLUSION: This study presents a novel taxonomy of condition interactions from the patient perspective.PRACTICE IMPLICATIONS: Understanding perceived condition interactions may support patient self-management and shared decision-making efforts.

  View details for DOI 10.1016/j.pec.2019.11.020

  View details for PubMedID 31787406

• What is clinician presence? A qualitative interview study comparing physician and non-physician insights about practices of human connection. BMJ open Brown-Johnson, C., Schwartz, R., Maitra, A., Haverfield, M. C., Tierney, A., Shaw, J. G., Zionts, D. L., Safaeinili, N., Thadaney Israni, S., Verghese, A., Zulman, D. M. 2019; 9 (11): e030831

  Abstract

  OBJECTIVE: We sought to investigate the concept and practices of 'clinician presence', exploring how physicians and professionals create connection, engage in interpersonal interaction, and build trust with individuals across different circumstances and contexts.DESIGN: In 2017-2018, we conducted qualitative semistructured interviews with 10 physicians and 30 non-medical professionals from the fields of protective services, business, management, education, art/design/entertainment, social services, and legal/personal services.SETTING: Physicians were recruited from primary care clinics in an academic medical centre, a Veterans Affairs clinic, and a federally qualified health centre.PARTICIPANTS: Participants were 55% men and 45% women; 40% were non-white.RESULTS: Qualitative analyses yielded a definition of presence as a purposeful practice of awareness, focus, and attention with the intent to understand and connect with individuals/patients. For both medical and non-medical professionals, creating presence requires managing and considering time and environmental factors; for physicians in particular, this includes managing and integrating technology. Listening was described as central to creating the state of being present. Within a clinic, presence might manifest as a physician listening without interrupting, focusing intentionally on the patient, taking brief re-centering breaks throughout a clinic day, and informing patients when attention must be redirected to administrative or technological demands.CONCLUSIONS: Clinician presence involves learning to step back, pause, and be prepared to receive a patient's story. Building on strategies from physicians and non-medical professionals, clinician presence is best enacted through purposeful intention to connect, conscious navigation of time, and proactive management of technology and the environment to focus attention on the patient. Everyday practice or ritual supporting these strategies could support physician self-care as well as physician-patient connection.

  View details for DOI 10.1136/bmjopen-2019-030831

  View details for PubMedID 31685506

• CFIR simplified: Pragmatic application of and adaptations to the Consolidated Framework for Implementation Research (CFIR) for evaluation of a patient-centered care transformation within a learning health system LEARNING HEALTH SYSTEMS Safaeinili, N., Brown-Johnson, C., Shaw, J. G., Mahoney, M., Winget, M. 2019

  View details for DOI 10.1002/lrh2.10201

  View details for Web of Science ID 000487784900001

• Role definition is key-Rapid qualitative ethnography findings from a team-based primary care transformation. Learning health systems Brown-Johnson, C., Shaw, J. G., Safaeinili, N., Chan, G. K., Mahoney, M., Asch, S., Winget, M. 2019; 3 (3): e10188

  Abstract

  Purpose: Implementing team-based care into existing primary care is challenging; understanding facilitators and barriers to implementation is critical. We assessed adoption and acceptability of new roles in the first 6months of launching a team-based care model focused on preventive care, population health, and psychosocial support.Methods: We conducted qualitative rapid ethnography at a community-based test clinic, including 74hours of observations and 28 semi-structured interviews. We identified implementation themes related to team-based care and specifically the integration of three roles purposively designed to enhance coordination for better patient outcomes, including preventive screening and mental health: (1) medical assistants as care coordinators; (2) extended care team specialists, including clinical pharmacist and behavioral health professional; and (3) advanced practice providers (APPs)-ie, nurse practitioners and physician assistants.Results: All stakeholders (ie, patients, providers, and staff) reported positive perceptions of care coordinators and extended care specialists; these roles were well defined and quickly implemented. Care coordinators effectively managed care between visits and established strong patient relationships. Specialist colocation facilitated patient access and well-supported diabetes services and mental health care. We also observed unanticipated value: Care coordinators relayed encounter-relevant chart information to providers while scribing; extended care specialists supported informal continuing medical education. In contrast, we observed uncertain definition and expectations of the APP role across stakeholders; accordingly, adoption and acceptability of the role varied.Conclusions: Practice redesign can redistribute responsibility and patient connection throughout a team but should emphasize well-defined roles. Ethnography, conducted early in implementation with multistakeholder perspectives, can provide rapid and actionable insights about where roles may need refinement or redefinition to support ultimate physical and mental health outcomes for patients.

  View details for DOI 10.1002/lrh2.10188

  View details for PubMedID 31317071

• High-Need Patients' Goals and Goal Progress in a Veterans Affairs Intensive Outpatient Care Program. Journal of general internal medicine Hsu, K. Y., Slightam, C., Shaw, J. G., Tierney, A., Hummel, D. L., Goldstein, M. K., Chang, E. T., Boothroyd, D., Zulman, D. M. 2019

  Abstract

  BACKGROUND: Healthcare systems nationwide are implementing intensive outpatient care programs to optimize care for high-need patients; however, little is known about these patients' personal goals and factors associated with goal progress.OBJECTIVE: To describe high-need patients' goals, and to identify factors associated with their goal progress DESIGN: Retrospective cohort study PARTICIPANTS: A total of 113 high-need patients participated in a single-site Veterans Affairs intensive outpatient care program.MAIN MEASURES: Two independent reviewers examined patients' goals recorded in the electronic health record, categorized each goal into one of three domains (medical, behavioral, or social), and determined whether patients attained goal progress during program participation. Logistic regression was used to determine factors associated with goal progress.RESULTS: The majority (n=72, 64%) of the 113 patients attained goal progress. Among the 100 (88%) patients with at least one identified goal, 58 set goal(s) in the medical domain; 60 in the behavioral domain; and 52 in the social domain. Within each respective domain, 41 (71%) attained medical goal progress; 34 (57%) attained behavioral goal progress; and 32 (62%) attained social goal progress. Patients with mental health condition(s) (aOR 0.3; 95% CI 0.1-0.9; p=0.03) and those living alone (aOR 0.4; 95% CI 0.1-1.0; p=0.05) were less likely to attain goal progress. Those with mental health condition(s) and those who were living alone were least likely to attain goal progress (interaction aOR 0.1 compared to those with neither characteristic; 95% CI 0.0-0.7; p=0.02).CONCLUSIONS: Among high-need patients participating in an intensive outpatient care program, patient goals were fairly evenly distributed across medical, behavioral, and social domains. Notably, individuals living alone with mental health conditions were least likely to attain progress. Future care coordination interventions might incorporate strategies to address this gap, e.g., broader integration of behavioral and social service components.

  View details for DOI 10.1007/s11606-019-05010-w

  View details for PubMedID 31140094

• Improving contraceptive choice for military servicewomen: better provision serves both women and deployment planning BMJ SEXUAL & REPRODUCTIVE HEALTH Shaw, J. G., Shaw, K. A. 2019; 45 (2): 86–87

  View details for DOI 10.1136/bmjsrh-2018-200238

  View details for Web of Science ID 000471856700002

• Transdisciplinary Strategies for Physician Wellness: Qualitative Insights from Diverse Fields Journal of General Internal Medicine Schwartz, R., Haverfield, M. C., Brown-Johnson, C., Maitra, A., Tierney, A., Bharadwaj, S., Shaw, J. G., Azimpour, F., Thadaney Israni, S., Verghese, A., Zulman, D. M. 2019

  Abstract

  While barriers to physician wellness have been well detailed, concrete solutions are lacking.We looked to professionals across diverse fields whose work requires engagement and interpersonal connection with clients. The goal was to identify effective strategies from non-medical fields that could be applied to preserve physician wellness.We conducted semi-structured interviews with 30 professionals outside the field of clinical medicine whose work involves fostering effective connections with individuals.Professionals from diverse professions, including the protective services (e.g., police officer, firefighter), business/finance (e.g., restaurateur, salesperson), management (e.g., CEO, school principal), education, art/design/entertainment (e.g., professional musician, documentary filmmaker), community/social services (e.g., social worker, chaplain), and personal care/services (e.g., massage therapist, yoga instructor).Interviews covered strategies that professionals use to initiate and maintain relationships, practices that cultivate professional fulfillment and preserve wellness, and techniques that facilitate emotional presence during interactions. Data were coded using an inductive thematic analysis approach.Professionals identified self-care strategies at both institutional and individual levels that support wellness. Institutional-level strategies include scheduling that allows for self-care, protected time to connect with colleagues, and leadership support for debriefing after traumatic events. Individual strategies include emotionally protective distancing techniques and engagement in a bidirectional exchange that is central to interpersonal connection and professional fulfillment.In this exploratory study, the purposive sampling technique and single representative per occupation could limit the generalizability of findings.Across diverse fields, professionals employ common institutional and personal wellness strategies that facilitate meaningful engagement, support collegiality, and encourage processing after intense events. The transdisciplinary nature of these wellness strategies highlights universal underpinnings that support wellbeing in those engaging in people-oriented professions.

  View details for DOI 10.1007/s11606-019-04913-y

• Misoprostol as an Adjunct to Overnight Osmotic Dilators Prior to Second Trimester Dilation and Evacuation: A Systematic Review and Meta-Analysis. Contraception Cahill, E. P., Henkel, A. n., Shaw, J. G., Shaw, K. A. 2019

  Abstract

  Misoprostol as an Adjunct to Overnight Osmotic Dilators Prior to Second Trimester Dilation and Evacuation: A Systematic Review and Meta-Analysis. Cahill EP, Henkel AG, Shaw JG, Shaw KA OBJECTIVE: To understand effect of adjunct misoprostol with overnight osmotic dilators for dilation and evacuation for cervical preparation after 16 weeks gestation on procedure time and dilation, complication rate, and side effects.We searched PubMed, ClinicalTrials.gov, POPLINE, and the Cochrane Controlled Trials Register using search terms for second trimester, abortion, misoprostol, dilators and reviewed reference lists of published reports. Randomized controlled trials of cervical preparation for second trimester D&E using overnight osmotic dilators comparing adjunct misoprostol to placebo were included. Weighted mean and standard deviation (SD) and pooled binary outcomes were compared with two sample t-test or chi-square respectively.Among 84 articles identified, three met inclusion criteria of randomized controlled trials comparing adjunct misoprostol to placebo with overnight osmotic dilators prior to second trimester abortion with 457 total subjects at 16-24 weeks gestation (misoprostol n=228; placebo n=229). In the meta-analysis, misoprostol as compared to placebo did not significantly decrease mean procedure times (8.5 + 4.6 vs 9.6 + 5.8 minutes, p=0.78) or need for manual dilation (18% vs 28%, p=0.23). There was no difference in total complications (p=0.61), major complications (hemorrhage, uterine perforation, hospitalization, p=0.44), or cervical lacerations (p=0.87).Current limited evidence suggests that use of adjunctive misoprostol with osmotic dilators after 16 weeks does not affect procedure time or need for manual dilation. Further research is needed to determine if adjunctive misoprostol affects major complications and blood loss.Adjunctive misoprostol does not affect procedure time or need for manual dilation in mid to late second trimester abortion. Further research is needed to determine the effect of adjunctive misoprostol on major complications and blood loss.

  View details for DOI 10.1016/j.contraception.2019.09.005

  View details for PubMedID 31811840

• Obstetric Outcomes in U.S. Veterans: Emerging Knowledge, Considerations, and Gaps. Seminars in reproductive medicine Hugin, M. n., Shaw, J. G. 2019

  Abstract

  In the post-9/11 era, the number of young women serving, and deploying, in the military grew rapidly; as they exit service, there is tremendous increase in reproductive-aged women Veterans. Here, we review the limited but growing research regarding Veterans' pregnancy and obstetric outcomes. U.S. women Veterans returning from deployment carry a high burden of physical and mental health conditions, and often trauma. As poor mental health is known to predict poorer maternal and infant sequelae, there are unique concerns around perinatal outcomes in Veterans. Accordingly, there is new attention to their reproductive risks and needs-evidenced by recent research and programmatic efforts within the VA. Emerging research suggests that the unique health profiles of pregnant Veterans, including prevalent posttraumatic stress disorder, predict increased risk of preterm birth, preeclampsia, and gestational diabetes. In the most contemporary large study, relying on California birth data, Veterans who relied on VA for their health care coverage were high risk, with increased rates of preeclampsia and Cesarean delivery. Additionally, Veterans' infants (compared with non-Veterans') were more likely to require NICU care. Additional research is needed to explore upstream factors leading to these poorer outcomes. Current effort to coordinate VA and non-VA care for Veteran mothers is warranted.

  View details for DOI 10.1055/s-0039-1692128

  View details for PubMedID 31185514

• Long-acting Reversible Contraception (LARC) Provision by Family Physicians: Low But on the Rise. Journal of the American Board of Family Medicine : JABFM Chelvakumar, M., Jabbarpour, Y., Coffman, M., Jetty, A., Glazer Shaw, J. 2019; 32 (1): 10–12

  Abstract

  Although the fraction of family physicians (FPs) providing Long Acting Reversible Contraceptive (LARC) services increased between 2014 and 2017, the most recent estimates show that less than a quarter of family physicians include provision of LARC in their practice. Increasing the number of FPs providing LARC will help increase patients' access to the most effective forms of birth control currently available.

  View details for DOI 10.3122/jabfm.2019.01.180215

  View details for PubMedID 30610136

• Primary Care 2.0: Design of a Transformational Team-Based Practice Model to Meet the Quadruple Aim. American journal of medical quality : the official journal of the American College of Medical Quality Brown-Johnson, C. G., Chan, G. K., Winget, M., Shaw, J. G., Patton, K., Hussain, R., Olayiwola, J. N., Chang, S., Mahoney, M. 2018: 1062860618802365

  Abstract

  A new transformational model of primary care is needed to address patient care complexity and provider burnout. An 18-month design effort (2015-2016) included the following: (1) Needs Finding, (2) Integrated Facility Design, (3) Design Process Assessment, and (4) Development of Evaluation. Initial outcome metrics were assessed. The design team successfully applied Integrated Facility Design to primary care transformation design; qualitative survey results suggest that design consensus was facilitated by team-building activities. Initial implementation of Quadruple Aim-related outcome metrics showed positive trends. Redesign processes may benefit from emphasis on team building to facilitate consensus and increased patient involvement to incorporate patient voices successfully.

  View details for PubMedID 30409021

• Selection of Higher Risk Pregnancies into Veterans Health Administration Programs: Discoveries from Linked Department of Veterans Affairs and California Birth Data. Health services research Shaw, J. G., Joyce, V. R., Schmitt, S. K., Frayne, S. M., Shaw, K. A., Danielsen, B., Kimerling, R., Asch, S. M., Phibbs, C. S. 2018

  Abstract

  OBJECTIVE: To describe variation in payer and outcomes in Veterans' births.DATA/SETTING: Secondary data analyses of deliveries in California, 2000-2012.STUDY DESIGN: We performed a retrospective, population-based study of all live births to Veterans (confirmed via U.S. Department of Veterans Affairs (VA) enrollment records), to identify payer and variations in outcomes among: (1) Veterans using VA coverage and (2) Veteran vs. all other births. We calculated odds ratios (aOR) adjusted for age, race, ethnicity, education, and obstetric demographics.METHODS: We anonymously linked VA administrative data for all female VA enrollees with California birth records.PRINCIPAL FINDINGS: From 2000 to 2012, we identified 17,495 births to Veterans. VA covered 8.6 percent (1,508), Medicaid 17.3 percent, and Private insurance 47.6 percent. Veterans who relied on VA health coverage had more preeclampsia (aOR 1.4, CI 1.0-1.8) and more cesarean births (aOR 1.2, CI 1.0-1.3), and, despite similar prematurity, trended toward more neonatal intensive care (NICU) admissions (aOR 1.2, CI 1.0-1.4) compared to Veterans using other (non-Medicaid) coverage. Overall, Veterans' birth outcomes (all-payer) mirrored California's birth outcomes, with the exception of excess NICU care (aOR 1.15, CI 1.1-1.2).CONCLUSIONS: VA covers a higher risk fraction of Veterans' births, justifying maternal care coordination and attention to the maternal-fetal impacts of Veterans' comorbidities.

  View details for PubMedID 30198185

• FOSTERING PATIENT-PROVIDER CONNECTION DURING CLINICAL ENCOUNTERS: INSIGHTS FROM NON-MEDICAL PROFESSIONALS Schwartz, R., Brown-Johnson, C., Haverfield, M. C., Tierney, A. A., Bharadwaj, S., Zionts, D. L., Romero, I., Piccininni, G., Shaw, J. G., Thadaney, S., Azimpour, F., Verghese, A., Zulman, D. M. SPRINGER. 2018: S200

  View details for Web of Science ID 000442641400264

• Deployment and Preterm Birth Among US Army Soldiers. American journal of epidemiology Shaw, J. G., Nelson, D. A., Shaw, K. A., Woolaway-Bickel, K., Phibbs, C. S., Kurina, L. M. 2018; 187 (4): 687-695

  Abstract

  With increasing integration of women into combat roles in the US military, it is critical to determine whether deployment, which entails unique stressors and exposures, is associated with adverse reproductive outcomes. Few studies have examined whether deployment increases the risk of preterm birth; no studies (to our knowledge) have examined a recent cohort of servicewomen. We therefore used linked medical and administrative data from the Stanford Military Data Repository for all US Army soldiers with deliveries between 2011 and 2014 to estimate the associations of prior deployment, recency of deployment, and posttraumatic stress disorder with spontaneous preterm birth (SPB), adjusting for sociodemographic, military-service, and health-related factors. Of 12,877 deliveries, 6.1% were SPBs. The prevalence was doubled (11.7%) among soldiers who delivered within 6 months of their return from deployment. Multivariable discrete-time logistic regression models indicated that delivering within 6 months of return from deployment was strongly associated with SPB (adjusted odds ratio = 2.1, 95% confidence interval: 1.5, 2.9). Neither multiple past deployments nor posttraumatic stress disorder was significantly associated with SPB. Within this cohort, timing of pregnancy in relation to deployment was identified as a novel risk factor for SPB. Increased focus on servicewomen's pregnancy timing and predeployment access to reproductive counseling and effective contraception is warranted.

  View details for DOI 10.1093/aje/kwy003

  View details for PubMedID 29370332

  View details for PubMedCentralID PMC5889029

• THE PREVALENCE OF PELVIC FLOOR DISORDERS IN ACTIVE DUTY FEMALE SOLDIERS: DATA FROM THE STANFORD MILITARY DATA REPOSITORY Rogo-Gupta, L., Nelson, D., Young-Lin, N., Shaw, J., Kurina, L. WILEY. 2018: S567–S568

  View details for Web of Science ID 000427016100082

• Reproductive Health of Women Veterans: A Systematic Review of the Literature from 2008 to 2017. Seminars in reproductive medicine Katon, J. G., Zephyrin, L. n., Meoli, A. n., Hulugalle, A. n., Bosch, J. n., Callegari, L. n., Galvan, I. V., Gray, K. E., Haeger, K. O., Hoffmire, C. n., Levis, S. n., Ma, E. W., Mccabe, J. E., Nillni, Y. I., Pineles, S. L., Reddy, S. M., Savitz, D. A., Shaw, J. G., Patton, E. W. 2018; 36 (6): 315–22

  Abstract

  The literature on the reproductive health and healthcare of women Veterans has increased dramatically, though there are important gaps. This article aims to synthesize recent literature on reproductive health and healthcare of women Veterans. We updated a literature search to identify manuscripts published between 2008 and July 1, 2017. We excluded studies that were not original research, only included active-duty women, or had few women Veterans in their sample. Manuscripts were reviewed using a standardized abstraction form. We identified 52 manuscripts. Nearly half (48%) of the new manuscripts addressed contraception and preconception care (n = 15) or pregnancy (n = 10). The pregnancy and family planning literature showed that (1) contraceptive use and unintended pregnancy among women Veterans using VA healthcare is similar to that of the general population; (2) demand for VA maternity care is increasing; and (3) women Veterans using VA maternity care are a high-risk population for adverse pregnancy outcomes. A recurrent finding across topics was that history of lifetime sexual assault and mental health conditions were highly prevalent among women Veterans and associated with a wide variety of adverse reproductive health outcomes across the life course. The literature on women Veterans' reproductive health is rapidly expanding, but remains largely observational. Knowledge gaps persist in the areas of sexually transmitted infections, infertility, and menopause.

  View details for PubMedID 31003246

• Sourcebook: Women Veterans in the Veterans Health Administration. Volume 4: Longitudinal Trends in Sociodemographics, Utilization, Health Profile, and Geographic Distribution. Frayne, S. M., Phibbs, C. S., Saechao, F., Friedman, S. A., Shaw, J. G., Romodan, Y., Berg, E., Lee, J., Ananth, L., Iqbal, S., Hayes, P., Haskell, S. Women’s Health Evaluation Initiative, Women’s Health Services, Veterans Health Administration, Department of Veterans Affairs. Washington DC. 2018

  Abstract

  https://www.womenshealth.va.gov/WOMENSHEALTH/docs/WHS_Sourcebook_Vol-IV_508c.pdf

• Contraception in US servicewomen: emerging knowledge, considerations, and needs CURRENT OPINION IN OBSTETRICS & GYNECOLOGY Harrington, L. A., Shaw, K. A., Shaw, J. G. 2017; 29 (6): 431–36

  Abstract

  We describe current literature regarding contraceptive use among women serving in the military. We explore the state of contraceptive use by female servicewomen, gaps in knowledge, special considerations, and evidence of unmet needs.Recent data on US servicewomen show that overall rates of contraceptive use remain low. Data highlight disparities and suggest barriers to contraceptive uptake persist, with contraceptive use being lower around the time of deployment. Methods that do not require daily use or prescription refills, such as long-acting reversible contraception (LARC) - intrauterine devices and contraceptive implants - may be distinctly well suited for service and deployment. Two contemporary studies document growing popularity of LARC methods among female members of the military, possibly driven by a surge in contraceptive implant use. Nonetheless, LARC appears to remain underutilized.Despite no-cost provision, the importance of preventing unplanned pregnancy, and the potential benefits of cycle control during service, emerging data about the US military suggest barriers to and underutilization of contraception, particularly LARC. Research is needed to explore preferences and tailor contraceptive counseling to servicewomen. Existing and future work can inform efforts to standardize military provider training and ensure all servicewomen are appropriately counseled and have timely access to any method they may choose.

  View details for PubMedID 28915159

• Long-Acting Reversible Contraceptive Placement Among Active-Duty U.S. Army Servicewomen. Obstetrics and gynecology Erickson, A. K., Nelson, D. A., Shaw, J. G., Loftus, P. D., Kurina, L. M., Shaw, K. A. 2017; 129 (5): 800-809

  Abstract

  To quantify uptake of long-acting reversible contraceptives (LARC)-intrauterine devices (IUDs) and hormonal implants-among U.S. Army active-duty female soldiers and identify characteristics associated with uptake.This retrospective cohort study used the Stanford Military Data Repository, which includes all digitally recorded health encounters for active-duty U.S. Army soldiers from 2011 to 2014. We analyzed data from women aged 18-44 years to assess rates of LARC initiation using medical billing codes. We then evaluated predictors of LARC initiation using multivariable regression.Among 114,661 servicewomen, 14.5% received a LARC method; among those, 60% received an IUD. Intrauterine device insertions decreased over the study period (38.7-35.9 insertions per 1,000 women per year, β=0.14, 95% confidence interval [CI] -0.23 to -0.05, P<.05), whereas LARC uptake increased, driven by an increase in implant insertions (20.3-35.4/1,000 women per year, β=0.41, CI 0.33-0.48, P<.001). Younger age was a positive predictor of LARC uptake: 32.4% of IUD users and 62.6% of implant users were in the youngest age category (18-22 years) compared with 9.6% and 2.0% in the oldest (36-44 years). The likelihood of uptake among the youngest women (compared with oldest) was most marked for implants (adjusted relative risk 7.12, CI 5.92-8.55; P<.001). A total of 26.2% of IUD users had one child compared with 13.2% among non-LARC users (adjusted relative risk 1.94, CI 1.85-2.04, P<.001). The majority (52.2%) of those initiating IUDs were married, which was predictive of uptake over never-married women (adjusted relative risk 1.52, CI 1.44-1.59, P<.001).Among servicewomen, we observed low but rising rates of LARC insertion, driven by increasing implant use. Unmarried and childless soldiers were less likely to initiate LARC. These findings are consistent with potential underutilization and a need for education about LARC safety and reversibility in a population facing unique consequences for unintended pregnancies.

  View details for DOI 10.1097/AOG.0000000000001971

  View details for PubMedID 28383371

• Post-traumatic Stress Disorder and Antepartum Complications: a Novel Risk Factor for Gestational Diabetes and Preeclampsia PAEDIATRIC AND PERINATAL EPIDEMIOLOGY Shaw, J. G., Asch, S. M., Katon, J. G., Shaw, K. A., Kimerling, R., Frayne, S. M., Phibbs, C. S. 2017; 31 (3): 185-194

  Abstract

  Prior work shows that Post-traumatic Stress Disorder (PTSD) predicts an increased risk of preterm birth, but the causal pathway(s) are uncertain. We evaluate the associations between PTSD and antepartum complications to explore how PTSD's pathophysiology impacts pregnancy.This retrospective cohort analysis of all Veterans Health Administration (VA)-covered deliveries from 2000-12 used the data of VA clinical and administration. Mothers with current PTSD were identified using the ICD-9 diagnostic codes (i.e. code present during the antepartum year), as were those with historical PTSD. Medical and administrative data were used to identify the relevant obstetric diagnoses, demographics and health, and military deployment history. We used Poisson regression with robust error variance to derive the adjusted relative risk estimates (RR) for the association of PTSD with five clinically relevant antepartum complications [gestational diabetes (GDM), preeclampsia, gestational hypertension, growth restriction, and abruption]. Secondary outcomes included proxies for obstetric complexity (repeat hospitalisation, prolonged delivery hospitalisation, and caesarean delivery).Of the 15 986 singleton deliveries, 2977 (19%) were in mothers with PTSD diagnoses (1880 (12%) current PTSD). Mothers with the complication GDM were 4.9% and those with preeclampsia were 4.6% of all births. After adjustment, a current PTSD diagnosis (reference = no PTSD) was associated with an increased risk of GDM (RR 1.4, 95% confidence interval (CI) 1.2, 1.7) and preeclampsia (RR 1.3, 95% CI 1.1, 1.6). PTSD also predicted prolonged (>4 day) delivery hospitalisation (RR 1.2, 95% CI 1.01, 1.4), and repeat hospitalisations (RR 1.4, 95% CI 1.2, 1.6), but not caesarean delivery.The observed association of PTSD with GDM and preeclampsia is consistent with our nascent understanding of PTSD as a disruptor of neuroendocrine and cardiovascular health.

  View details for DOI 10.1111/ppe.12349

  View details for Web of Science ID 000400170000004

  View details for PubMedID 28328031

• Medicare Spends More on Socially Isolated Older Adults Flowers, L., Houser, A., Noel-Miller, C., Shaw, J., Bhattacharya, J., Schoemaker, L., Farid, M. AARP Public Policy Institute. Washington, DC. 2017 ; Insight on the Issues (125): 1–15
• Interpretation of epidemiologic studies very often lacked adequate consideration of confounding. Journal of clinical epidemiology Hemkens, L. G., Ewald, H. n., Naudet, F. n., Ladanie, A. n., Shaw, J. G., Sajeev, G. n., Ioannidis, J. P. 2017

  Abstract

  Confounding bias is a most pervasive threat to validity of observational epidemiologic research. We assessed whether authors of observational epidemiologic studies consider confounding bias when interpreting the findings.We randomly selected 120 cohort or case-control studies published in 2011 and 2012 by the general medical, epidemiologic, and specialty journals with the highest impact factors. We used Web of Science to assess citation metrics through January 2017.Sixty-eight studies (56.7%, 95% confidence interval: 47.8-65.5%) mentioned "confounding" in the Abstract or Discussion sections, another 20 (16.7%; 10.0-23.3%) alluded to it, and there was no mention or allusion at all in 32 studies (26.7%; 18.8-34.6%). Authors often acknowledged that for specific confounders, there was no adjustment (34 studies; 28.3%) or deem it possible or likely that confounding affected their main findings (29 studies; 24.2%). However, only two studies (1.7%; 0-4.0%) specifically used the words "caution" or "cautious" for the interpretation because of confounding-related reasons and eventually only four studies (3.3%; 0.1-6.5%) had limitations related to confounding or any other bias in their Conclusions. Studies mentioning that the findings were possibly or likely affected by confounding were more frequently cited than studies with a statement that findings were unlikely affected (median 6.3 vs. 4.0 citations per year, P = 0.04).Many observational studies lack satisfactory discussion of confounding bias. Even when confounding bias is mentioned, authors are typically confident that it is rather irrelevant to their findings and they rarely call for cautious interpretation. More careful acknowledgment of possible impact of confounding is not associated with lower citation impact.

  View details for PubMedID 28943377

• Adjunct mifepristone for cervical preparation prior to dilation and evacuation: a randomized trial CONTRACEPTION Shaw, K. A., Shaw, J. G., Hugin, M., Velasquez, G., Hopkins, F. W., Blumenthal, P. D. 2015; 91 (4): 313-319

  Abstract

  The objective was to investigate mifepristone as a potential adjunct to cervical preparation for surgical abortion after 19weeks of gestation, with the aim of improving procedure access, convenience and comfort.This is a site-stratified, block-randomized, noninferiority trial of 50 women undergoing surgical abortion between 19 and 23 6/7weeks of gestation randomized to receive either one set of osmotic dilators plus mifepristone the day prior to procedure (mifepristone group) or two sets of osmotic dilators (placed 18-24 h apart) in the 2 days prior to procedure (control group). All subjects received preprocedure misoprostol. Primary outcome was procedure time. Secondary outcomes included preoperative cervical dilation, ease of procedure, and side effects and pain experienced by subjects.Mean gestational age was similar between groups (20weeks); more nulliparous subjects were randomized to the mifepristone group (46% vs. 12%, p=.009). Mean procedure times were similar: mifepristone group 11:52 (SD 5:29) vs. control group 10:56 (SD 5:08); difference in means -56s, with confidence interval (95% CI -4:09 to +2:16) not exceeding the 5-min difference we a priori defined as clinically significant. Preprocedure cervical dilation did not differ and was >3cm for the majority of subjects in both groups. There was no difference (p=.6) in ease of procedure reported by providers. Preoperative (postmisoprostol) pain and postoperative pain levels were greater with mifepristone (p = 0.02 and p= 0.04 respectively). Overall subject experience was not different (p=0.80), with most reporting a "better than expected" experience.Mifepristone with one set of osmotic dilators and misoprostol did not result in longer procedure times or less cervical dilation than serial (two sets) of osmotic dilators and misoprostol, and has the potential to improve access to second trimester abortion without compromising safety.Use of mifepristone for cervical preparation before surgical abortion after 19weeks allows for fewer visits and fewer osmotic dilators without compromising cervical dilation or increasing procedure time.

  View details for DOI 10.1016/j.contraception.2014.11.014

  View details for Web of Science ID 000351190700009

  View details for PubMedID 25499589

• Partnered Research in Healthcare Delivery Redesign for High-Need, High-Cost Patients: Development and Feasibility of an Intensive Management Patient-Aligned Care Team (ImPACT) JOURNAL OF GENERAL INTERNAL MEDICINE Zulman, D. M., Ezeji-Okoye, S. C., Shaw, J. G., Hummel, D. L., Holloway, K. S., Smither, S. F., Breland, J. Y., Chardos, J. F., Kirsh, S., Kahn, J. S., Asch, S. M. 2014; 29: S861-S869

  Abstract

  We employed a partnered research healthcare delivery redesign process to improve care for high-need, high-cost (HNHC) patients within the Veterans Affairs (VA) healthcare system.Health services researchers partnered with VA national and Palo Alto facility leadership and clinicians to: 1) analyze characteristics and utilization patterns of HNHC patients, 2) synthesize evidence about intensive management programs for HNHC patients, 3) conduct needs-assessment interviews with HNHC patients (n = 17) across medical, access, social, and mental health domains, 4) survey providers (n = 8) about care challenges for HNHC patients, and 5) design, implement, and evaluate a pilot Intensive Management Patient-Aligned Care Team (ImPACT) for a random sample of 150 patients.HNHC patients accounted for over half (52 %) of VA facility patient costs. Most (94 %) had three or more chronic conditions, and 60 % had a mental health diagnosis. Formative data analyses and qualitative assessments revealed a need for intensive case management, care coordination, transitions navigation, and social support and services. The ImPACT multidisciplinary team developed care processes to meet these needs, including direct access to team members (including after-hours), chronic disease management protocols, case management, and rapid interventions in response to health changes or acute service use. Two-thirds of invited patients (n = 101) enrolled in ImPACT, 87 % of whom remained actively engaged at 9 months. ImPACT is now serving as a model for a national VA intensive management demonstration project.Partnered research that incorporated population data analysis, evidence synthesis, and stakeholder needs assessments led to the successful redesign and implementation of services for HNHC patients. The rigorous design process and evaluation facilitated dissemination of the intervention within the VA healthcare system.Employing partnered research to redesign care for high-need, high-cost patients may expedite development and dissemination of high-value, cost-saving interventions.

  View details for DOI 10.1007/s11606-014-3022-7

  View details for Web of Science ID 000345410200010

  View details for PubMedCentralID PMC4239286

• Gestational Diabetes and Hypertensive Disorders of Pregnancy Among Women Veterans Deployed in Service of Operations in Afghanistan and Iraq JOURNAL OF WOMENS HEALTH Katon, J., Mattocks, K., Zephyrin, L., Reiber, G., Yano, E. M., Callegari, L., Schwarz, E. B., Goulet, J., Shaw, J., Brandt, C., Haskell, S. 2014; 23 (10): 792-800

  View details for DOI 10.1089/jwh.2013.4681

  View details for Web of Science ID 000343237900005

• To sling or not to sling at time of abdominal sacrocolpopexy: a cost-effectiveness analysis. journal of urology Richardson, M. L., Elliott, C. S., Shaw, J. G., Comiter, C. V., Chen, B., Sokol, E. R. 2013; 190 (4): 1306-1312

  Abstract

  OBJECTIVES: To compare the cost-effectiveness of three strategies for use of a mid-urethral sling (MUS) to prevent occult stress urinary incontinence (SUI) in those undergoing abdominal sacrocolpopexy (ASC). METHODS: Using decision-analysis modeling, we compared cost-effectiveness over a 1 year post-operative time period of three treatment approaches: 1) ASC alone with deferred option for MUS; 2) ASC with universal concomitant MUS; and 3) preoperative urodynamic study (UDS) for selective MUS. Using published data, we modeled probabilities of SUI after ASC with or without MUS, the predictive value of UDS to detect occult SUI, and the likelihood of complications after MUS. Costs were derived from Medicare 2010 reimbursement rates. The main outcome modeled was incremental cost effectiveness ratio (ICER) per quality-adjusted life years (QALY) gained. In addition to base-case analysis, one-way sensitivity analyses were performed. RESULTS: In our model, universally performing MUS at the time of ASC was the most cost-effective approach, with an incremental cost per QALY gained of $2867 when compared to performing ASC alone. Preoperative UDS was more costly and less effective than universally performing intraoperative MUS. The cost-effectiveness of ASC + MUS was robust to sensitivity analysis, with a cost-effectiveness ratio consistently below $20,000 per QALY. CONCLUSIONS: Universal concomitant MUS is the most cost-effective prophylaxis strategy for occult SUI in women undergoing ASC. The use of pre-operative UDS to guide MUS placement at the time of ASC is not cost-effective.

  View details for DOI 10.1016/j.juro.2013.03.046

  View details for PubMedID 23524201

• Mifepristone-misoprostol dosing interval and effect on induction abortion times: a systematic review. Obstetrics and gynecology Shaw, K. A., Topp, N. J., Shaw, J. G., Blumenthal, P. D. 2013; 121 (6): 1335-1347

  Abstract

  To examine the effect of the interval between mifepristone and misoprostol administration on induction time (first misoprostol dose to abortion), total procedure time (mifepristone administration to abortion), and safety and efficacy in second-trimester induction abortion (13-24 weeks).We searched MEDLINE (1966-2012), ClinicalTrials.gov, POPLINE, and the Cochrane Controlled Trials Register using search terms for second trimester, abortion, misoprostol, and mifepristone and reviewed reference lists of published reports.Our search revealed 138 articles of which 29 met inclusion criteria: 20 randomized controlled trials and nine observational studies. Studies were included if, in any study arm, mifepristone and misoprostol were used for medical abortion in the second trimester.Two authors independently reviewed the articles and abstracted the data using standardized data abstraction templates to summarize data. Discrepancies were resolved by consensus. Three studies directly compared a 1-day to 2-day mifepristone-misoprostol interval; they showed small differences in median induction times (weighted average 7.3 hours, range 7-8.5 for a 1-day interval; weighted average 6.8 hours, range 6.3-7.2 for a 2-day interval) and no significant difference in percent expelled by 12 hours or 24 hours. When all randomized studies using mifepristone and misoprostol were pooled by comparable mifepristone-misoprostol interval and misoprostol dose, induction times (first misoprostol dose to expulsion) were only 1-2 hours longer for a 12- to 24-hour interval compared with a 36-48-hour interval, whereas total abortion times (mifepristone to expulsion) were at least 18 hours longer in the 36- to 48-hour group. Induction times varied by misoprostol dosing, with 400-microgram misoprostol protocols resulting in shorter induction times than 200-microgram protocols.Shortening the mifepristone-misoprostol interval, thereby reducing total abortion time, does not compromise the safety or efficacy of second-trimester medication abortion and may be used to accommodate patient or health care provider preference.

  View details for DOI 10.1097/AOG.0b013e3182932f37

  View details for PubMedID 23812471

• Attitudes of preclinical and clinical medical students toward interactions with the pharmaceutical industry ACADEMIC MEDICINE Hyman, P. L., Hochman, M. E., Shaw, J. G., Steinman, M. A. 2007; 82 (1): 94-99

  Abstract

  Medical school is a critical time for physicians in training to learn the professional norms of interacting with the pharmaceutical industry, yet little is known about how students' attitudes vary during the course of training. This study sought to determine students' opinions about pharmaceutical industry interactions with medical students and whether these opinions differ between preclinical and clinical students.The authors surveyed medical students at Harvard Medical School (HMS) from November 2003 through January 2004 using a six-question survey. The authors then analyzed how responses differed among the classes.Out of 723 questionnaires, 418 were returned--an overall response rate of 58%. A total of 107 (26%) students believed that it is appropriate for medical students to accept gifts from pharmaceutical companies, and 76 (18%) agreed that the medical school curriculum should include events sponsored by the pharmaceutical industry. Many students--253 (61%)--reported that they do not feel adequately educated about pharmaceutical industry-medical professionals' interactions. Preclinical and clinical students had similar opinions for the majority of their responses. Finally, students who reported feeling better educated about pharmaceutical industry interactions tended to be less skeptical of the industry and more likely to view interactions with the industry as appropriate.Students' opinions about interactions with the pharmaceutical industry were similar between preclinical and clinical students, suggesting that the current medical school experience may have limited impact on students' views about interactions with the pharmaceutical industry.

  View details for Web of Science ID 000243237200013

  View details for PubMedID 17198299