Redesigning ambulatory care management for uncontrolled type 2 diabetes: a prospective cohort study of the impact of a Boot Camp model on outcomes.

Objective: Type 2 diabetes care management (DCM) is challenging. Few studies report meaningful improvements in clinical care settings, warranting DCM redesign. We developed a Boot Camp to provide timely, patient-centered, technology-enabled DCM. Impact on hemoglobin A1c (HbA1c), emergency department (ED) visits and hospitalizations among adults with uncontrolled type 2 diabetes were examined. Research design and methods: The intervention was designed using the Practical Robust Implementation and Sustainability Model to embed elements of the chronic care model. Adults with HbA1c>9% (75 mmol/mol) enrolled between November 2014 and November 2017 received diabetes education and medication management by diabetes educators and nurse practitioners via initial clinic and subsequent weekly virtual visits, facilitated by near-real-time blood glucose transmission for 90 days. HbA1c and risk for ED visits and hospitalizations at 90 days, and potential savings from reducing avoidable medical utilizations were examined. Boot Camp completers were compared with concurrent, propensity-matched chart controls receiving usual DCM in primary care practices. Results: A cohort of 366 Boot Camp participants plus 366 controls was analyzed. Participants were 79% African-American, 63% female and 59% Medicare-insured or Medicaid-insured and mean age 56 years. Baseline mean HbA1c for cases and controls was 11.2% (99 mmol/mol) and 11.3% (100 mmol/mol), respectively. At 90 days, HbA1c was 8.1% (65 mmol/mol) and 9.9% (85 mmol/mol), p<0.001, respectively. Risk for 90-day all-cause hospitalizations decreased 77% for participants and increased 58% for controls, p=0.036. Mean potential for monetization of US$3086 annually per participant for averted hospitalizations were calculated. Conclusions: Redesigning diabetes care management using a pragmatic technology-enabled approach supported translation of evidence-based best practices across a mixed-payer regional healthcare system. Diabetes educators successfully participated in medication initiation and titration. Improvement in glycemic control, reduction in hospitalizations and potential for monetization was demonstrated in a high-risk cohort of adults with uncontrolled type 2 diabetes. Trial registration number: NCT02925312.

Integrated 'academic health system' offers new lessons for improving care delivery.

Academic medicine generates the knowledge every physician uses today when practicing contemporary, evidence-based medicine. To meet current challenges in healthcare, however, academic medicine must broaden its focus to include the science of how we improve the delivery of care.

The Prevalence and Impact of Substance Use Disorder and Treatment on Maternal Obstetric Experiences and Birth Outcomes Among Singleton Deliveries in Massachusetts.

Objectives Despite widely-known negative effects of substance use disorders (SUD) on women, children, and society, knowledge about population-based prevalence and impact of SUD and SUD treatment during the perinatal period is limited. Methods Population-based data from 375,851 singleton deliveries in Massachusetts 2003-2007 were drawn from a maternal-infant longitudinally-linked statewide dataset of vital statistics, hospital discharges (including emergency department (ED) visits), and SUD treatment records. Maternal SUD and SUD treatment were identified from 1-year pre-conception through delivery. We determined (1) the prevalence of SUD and SUD treatment; (2) the association of SUD with women's perinatal health service utilization, obstetric experiences, and birth outcomes; and (3) the association of SUD treatment with birth outcomes, using both bivariate and adjusted analyses. Results 5.5% of Massachusetts's deliveries between 2003 and 2007 occurred in mothers with SUD, but only 66% of them received SUD treatment pre-delivery. Women with SUD were poorer, less educated and had more health problems; utilized less prenatal care but more antenatal ED visits and hospitalizations, and had worse obstetric and birth outcomes. In adjusted analyses, SUD was associated with higher risk of prematurity (AOR 1.35, 95% CI 1.28-1.41) and low birth weight (LBW) (AOR 1.73, 95% CI 1.64-1.82). Women receiving SUD treatment had lower odds of prematurity (AOR 0.61, 95% CI 0.55-0.68) and LBW (AOR 0.54, 95% CI 0.49-0.61). Conclusions for Practice SUD treatment may improve perinatal outcomes among pregnant women with SUD, but many who need treatment don't receive it. Longitudinally-linked existing public health and programmatic records provide opportunities for states to monitor SUD identification and treatment.

Quality of Life and Burnout Rates Across Surgical Specialties: A Systematic Review.

Importance: Establishing strategies to minimize the burden of burnout and poor quality of life (QOL) on surgeons relies on a thorough understanding of QOL and burnout among the various surgical specialties. Objectives: To systematically review the literature across multiple surgical specialties and provide a comprehensive understanding of QOL and burnout among all surgeons, to delineate variation in rates of burnout and poor QOL, and to elucidate factors that are commonly implicated in these outcomes. Evidence Review: An OVID electronic search encompassing MEDLINE, PsycInfo, and EMBASE was completed using the following MeSH search terms: quality of life, burnout, surgeon, surgical specialty, and United States. Full articles published in English from January 1, 1980, to June 10, 2015, that evaluated US surgical specialists and included more than 1 question related to QOL were included. Review articles and evaluations that included medical students or nonsurgical health care professionals were excluded. Of 1420 titles, 41 articles met these criteria. The standardized methodologic principles of PRISMA for reporting systematic reviews guided analysis. Primary end points were QOL scores and burnout rates that compared sex, age, level of training (resident vs attending), surgical specialty, and the type of assessment tool. Secondary outcomes included proposed work hours and income as factors contributing to burnout. Owing to the heterogeneity of data reporting among articles, qualitative analysis was also reported. Findings: Of the 16 specialties included, pediatric (86% to 96%) and endocrine (96%) surgeons demonstrated the highest career satisfaction, whereas a portion of plastic surgeons (33%) and vascular surgeons (64%) were least satisfied. The effect of sex was variable. Residents demonstrated a significantly higher risk for burnout than attending surgeons across multiple specialties, including obstetrics and gynecology, otolaryngology, and orthopedic surgery. One-third of the studies found hours worked per week to be a statistically significant predictor of burnout, decreased career satisfaction, and poorer QOL. Conclusions and Relevance: Burnout and QOL vary across all surgical specialties. Whether sex affects burnout rates remains unclear. Residents are at an increased risk for burnout and more likely to report a poor QOL than attending surgeons.

Practice Patterns and Outcomes of Treatments for Atrial Fibrillation During Sepsis: A Propensity-Matched Cohort Study.

BACKGROUND: Atrial fibrillation (AF) during sepsis is associated with increased morbidity and mortality, but practice patterns and outcomes associated with rate- and rhythm-targeted treatments for AF during sepsis are unclear. METHODS: This was a retrospective cohort study using enhanced billing data from approximately 20% of United States hospitals. We identified factors associated with IV AF treatments (?-blockers [BBs], calcium channel blockers [CCBs], digoxin, or amiodarone) during sepsis. We used propensity score matching and instrumental variable approaches to compare mortality between AF treatments. RESULTS: Among 39,693 patients with AF during sepsis, mean age was 77 ± 11 years, 49% were women, and 76% were white. CCBs were the most commonly selected initial AF treatment during sepsis (14,202 patients [36%]), followed by BBs (11,290 [28%]), digoxin (7,937 [20%]), and amiodarone (6,264 [16%]). Initial AF treatment selection differed according to geographic location, hospital teaching status, and physician specialty. In propensity-matched analyses, BBs were associated with lower hospital mortality when compared with CCBs (n = 18,720; relative risk [RR], 0.92; 95% CI, 0.86-0.97), digoxin (n = 13,994; RR, 0.79; 95% CI, 0.75-0.85), and amiodarone (n = 5,378; RR, 0.64; 95% CI, 0.61-0.69). Instrumental variable analysis showed similar results (adjusted RR fifth quintile vs first quintile of hospital BB use rate, 0.67; 95% CI, 0.58-0.79). Results were similar among subgroups with new-onset or preexisting AF, heart failure, vasopressor-dependent shock, or hypertension. CONCLUSIONS: Although CCBs were the most frequently used IV medications for AF during sepsis, BBs were associated with superior clinical outcomes in all subgroups analyzed. Our findings provide rationale for clinical trials comparing the effectiveness of AF rate- and rhythm-targeted treatments during sepsis.

Practice Patterns and Outcomes Associated With Choice of Initial Vasopressor Therapy for Septic Shock.

OBJECTIVES: Clinical guidelines recommend norepinephrine as initial vasopressor of choice for septic shock, with dopamine suggested as an alternative vasopressor in selected patients with low risk of tachyarrhythmias and absolute or relative bradycardia. We sought to determine practice patterns and outcomes associated with vasopressor selection in a large, population-based cohort of patients with septic shock that allows for assessment of outcomes in clinically important subgroups. DESIGN: We performed a retrospective cohort study to determine factors associated with choice of dopamine as compared with norepinephrine as initial vasopressor for patients with septic shock. We used propensity score matching to compare risk of hospital mortality based on initial vasopressor. We performed multiple sensitivity analyses using alternative methods to address confounding and hospital-level clustering. We investigated interaction between vasopressor selection and mortality in clinical subgroups based on arrhythmia and cardiovascular risk. SETTING: Enhanced administrative data (Premier, Charlotte, NC) from 502 U.S. hospitals during the years 2010-2013. SUBJECTS: A total of 61,122 patients admitted with septic shock who received dopamine or norepinephrine as initial vasopressor during the first 2 days of hospitalization. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Norepinephrine (77.6%) was the most frequently used initial vasopressor during septic shock. Dopamine was preferentially selected by cardiologists, in the Southern United States, at nonteaching hospitals, for older patients with more cardiovascular comorbidities and was used less frequently over time. Patients receiving dopamine experienced greater hospital mortality (propensity-matched cohort: n = 38,788; 25% vs 23.7%; odds ratio, 1.08; 95% CI, 1.02-1.14). Sensitivity analyses showed similar results. Subgroup analyses showed no evidence for effect modification based on arrhythmia risk or underlying cardiovascular disease. CONCLUSIONS: In a large population-based sample of patients with septic shock in the United States, use of dopamine as initial vasopressor was associated with increased mortality among multiple clinical subgroups. Areas where use of dopamine as initial vasopressor is more common represent potential targets for quality improvement intervention.

Refining Measurement of Substance Use Disorders Among Women of Child-Bearing Age Using Hospital Records: The Development of the Explicit-Mention Substance Abuse Need for Treatment in Women (EMSANT-W) Algorithm.

Substance use disorder (SUD) in women of reproductive age is associated with adverse health consequences for both women and their offspring. US states need a feasible population-based, case-identification tool to generate better approximations of SUD prevalence, treatment use, and treatment outcomes among women. This article presents the development of the Explicit Mention Substance Abuse Need for Treatment in Women (EMSANT-W), a gender-tailored tool based upon existing International Classification of Diseases, 9th Edition, Clinical Modification diagnostic code-based groupers that can be applied to hospital administrative data. Gender-tailoring entailed the addition of codes related to infants, pregnancy, and prescription drug abuse, as well as the creation of inclusion/exclusion rules based on other conditions present in the diagnostic record. Among 1,728,027 women and associated infants who accessed hospital care from January 1, 2002 to December 31, 2008 in Massachusetts, EMSANT-W identified 103,059 women with probable SUD. EMSANT-W identified 4,116 women who were not identified by the widely used Clinical Classifications Software for Mental Health and Substance Abuse (CCS-MHSA) and did not capture 853 women identified by CCS-MHSA. Content and approach innovations in EMSANT-W address potential limitations of the Clinical Classifications Software, and create a methodologically sound, gender-tailored and feasible population-based tool for identifying women of reproductive age in need of further evaluation for SUD treatment. Rapid changes in health care service infrastructure, delivery systems and policies require tools such as the EMSANT-W that provide more precise identification methods for sub-populations and can serve as the foundation for analyses of treatment use and outcomes.

Putting residents in the office: an effective method to teach the systems-based practice competency.

OBJECTIVES: Systems-based practice (SBP) was 1 of 6 core competencies established by the Accreditation Council for Graduate Medical Education and has proven to be one of the most difficult to effectively implement. This pilot study presents an immersion workshop as an effective tool to teach the SBP competency in a way that could easily be integrated into a residency curriculum. DESIGN: In 2006, 16 surgical residents rotated through 3 stations for 30 minutes each: coding and billing, scheduling operations and return appointments, and patient check-in. Participants were administered a pretest and posttest questionnaire evaluating their knowledge of SBP, and were asked to evaluate the workshop. SETTING: Outpatient clinic at MedStar Georgetown University Hospital, Washington, DC. PARTICIPANTS: Residents in the general surgery residency training program at MedStar Georgetown University Hospital. RESULTS: Most residents (62.5%) improved their score after the workshop, whereas 31.25% showed no change and 6.25% demonstrated a decrease in score. Overall within their training levels, all groups demonstrated an increase in mean test score. Postgraduate year-2 residents demonstrated the greatest change in mean score (20%), whereas postgraduate year-4 residents demonstrated the smallest change in mean score (3.3%). CONCLUSIONS: An immersion workshop where general surgery residents gained direct exposure to SBP concepts in situ was an effective and practical method of integrating this core competency into the residency curriculum. Such a workshop could complement more formal didactic teaching and be easily incorporated into the curriculum. For example, this workshop could be integrated into the ambulatory care requirement that each resident must fulfill as part of their clinical training.

Treatment outcomes for substance use disorder among women of reproductive age in Massachusetts: a population-based approach.

INTRODUCTION: Longitudinal patterns of treatment utilization and relapse among women of reproductive age with substance use disorder (SUD) are not well known. In this statewide report spanning seven years we describe SUD prevalence, SUD treatment utilization, and differences in subsequent emergency department (ED) use and post-treatment relapse rates by type of treatment: none, 'acute only' (detoxification/stabilization), or 'ongoing' services. METHODS: We linked a statewide dataset of hospital discharge, observation stay and ED records with SUD treatment admission records from hospitals and freestanding facilities, and birth/fetal death certificates, in Massachusetts, 2002-2008. We aggregated episodes into individual woman records, identified evidence of SUD and treatment, and tested post-treatment outcomes. RESULTS: Nearly 150,000 (8.5%) of 1.7 million Massachusetts women aged 15-49 were identified as SUD-positive. Nearly half of SUD-positive women (71,533 or 48.3%) had evidence of hospital or facility-based SUD treatment; among these, 12% received acute care/detoxification only while 88% obtained 'ongoing' treatment. Treatment varied by substance type; women with dual diagnosis and those with opiate use were least likely to receive 'ongoing' treatment. Treated women were older and less likely to have a psychiatric history or chronic illness. Women who received 'acute only' services were more likely to relapse (12.4% vs. 9.6%) and had a 10% higher rate of ED visits post-treatment than women receiving 'ongoing' treatment. CONCLUSIONS: Many Massachusetts women of reproductive age need but do not receive adequate SUD treatment. 'Ongoing' services beyond detoxification/stabilization may reduce the likelihood of post-treatment relapse and/or reliance on the ED for subsequent medical care.

The association of injury with substance use disorder among women of reproductive age: an opportunity to address a major contributor to recurrent preventable emergency department visits?

OBJECTIVES: Substance use disorder (SUD) among women of reproductive age is a complex public health problem affecting a diverse spectrum of women and their families, with potential consequences across generations. The goals of this study were 1) to describe and compare the prevalence of patterns of injury requiring emergency department (ED) visits among SUD-positive and SUD-negative women and 2) among SUD-positive women, to investigate the association of specific categories of injury with type of substance used. METHODS: This study was a secondary analysis of a large, multisource health care utilization data set developed to analyze SUD prevalence, and health and substance abuse treatment outcomes, for women of reproductive age in Massachusetts, 2002 through 2008. Sources for this linked data set included diagnostic codes for ED, inpatient, and outpatient stay discharges; SUD facility treatment records; and vital records for women and for their neonates. RESULTS: Injury data (ICD-9-CM E-codes) were available for 127,227 SUD-positive women. Almost two-thirds of SUD-positive women had any type of injury, compared to 44.8% of SUD-negative women. The mean (±SD) number of events also differed (2.27 ± 4.1 for SUD-positive women vs. 0.73 ± 1.3 for SUD-negative women, p < 0.0001). For four specific injury types, the proportion injured was almost double for SUD-positive women (49.3% vs 23.4%), and the mean (±SD) number of events was more than double (0.72 ± 0.9 vs. 0.26 ± 0.5, p < 0.0001). The numbers and proportions of motor vehicle incidents and falls were significantly higher in SUD-positive women (22.5% vs. 12.5% and 26.6% vs. 11.0%, respectively), but the greatest differences were in self-inflicted injury (11.5% vs. 0.8%; mean ± SD events = 0.19 ± 0.9 vs. 0.009 ± 0.2, p < 0.0001) and purposefully inflicted injury (11.5% vs 1.9%, mean ± SD events = 0.18 ± 0.1 vs. 0.02 ± 0.2, p < 0.0001). In each of the injury categories that we examined, injury rates among SUD-positive women were lowest for alcohol disorders only and highest for alcohol and drug disorders combined. Among 33,600 women identified as using opioids, 2,132 (6.3%) presented to the ED with overdose. Multiple overdose visits were common (mean ± SD = 3.67 ± 6.70 visits). After adjustment for sociodemographic characteristics, psychiatric history, and complex/chronic illness, SUD remained a significant risk factor for all types of injury, but for the suicide/self-inflicted injury category, psychiatric history was by far the stronger predictor. CONCLUSIONS: The presence of SUD increases the likelihood that women in the 15- to 49-year age group will present to the ED with injury. Conversely, women with injury may be more likely to be involved in alcohol abuse or other substance use. The high rates of injury that we identified among women with SUD suggest the utility of including a brief, validated screen for substance use as part of an ED injury treatment protocol and referring injured women for assessment and/or treatment when scores indicate the likelihood of SUD.

The influence of neighborhood socioeconomic status and walkability on TV viewing time.

BACKGROUND: Influences on TV viewing time, which is associated with adverse health outcomes such as obesity and diabetes, need clarification. We assessed the relation of neighborhood socioeconomic status (SES) and walkability with TV viewing time in the Black Women's Health Study, a prospective study of African American women. METHODS: We created neighborhood SES and walkability scores using data from the U.S. census and other sources. We estimated odds ratios for TV viewing 5+ hours/day compared with 0-1 hours/day for quintiles of neighborhood SES and walkability scores. RESULTS: Neighborhood SES was inversely associated with TV viewing time. The odds ratio for watching 5+ hours/day in the highest compared with the lowest quintile of neighborhood SES was 0.66 (95% CI 0.54-0.81). Neighborhood walkability was not associated with TV viewing time. CONCLUSIONS: Neighborhood SES should be considered in devising strategies to combat the high levels of sedentariness prevalent in African American women.

Longitudinal assessment of urban form and weight gain in African-American women.

BACKGROUND: Numerous cross-sectional studies have found higher levels of obesity among residents of auto-oriented, sprawling areas compared to residents of more urban areas. PURPOSE: The association between neighborhood urban form and 6-year weight change was prospectively analyzed in the Black Women's Health Study, a cohort study of U.S. black women who enrolled in 1995 and are followed biennially with mailed questionnaires. METHODS: The analysis included 17,968 women who lived in New York City, Chicago, or Los Angeles and were followed from 1995 to 2001. Factor analysis was used to combine variables describing the urban form of participants' residential neighborhoods into an "urbanicity" score. Mixed linear regression models were used to calculate least-squares means for weight change across quintiles of the urbanicity score. Incidence rate ratios (IRRs) and 95% CIs for incident obesity in relation to the urbanicity score among women who were not obese at baseline were derived from Cox regression models. All results were adjusted for age, region, lifestyle factors, and neighborhood SES. Analyses were conducted in 2008-2010. RESULTS: In multivariate analysis, mean weight gain for women in the highest quintile of urbanicity score (most urban) was 0.79 kg less than for those in the lowest quintile, with a significant trend (p=0.003). The IRR for incident obesity in the highest quintile relative to the lowest was 0.83 (95% CI=0.71, 0.97), with a significant trend (p=0.042). CONCLUSIONS: Policies that encourage dense, urban residential development may have a positive role to play in addressing obesity in black women.

Epigenetic silencing of beta-spectrin, a TGF-beta signaling/scaffolding protein in a human cancer stem cell disorder: Beckwith-Wiedemann syndrome.

Hereditary cancer syndromes provide powerful insights into dysfunctional signaling pathways that lead to sporadic cancers. Beckwith-Wiedemann syndrome (BWS) is a hereditary human cancer stem cell syndrome currently linked to deregulated imprinting at chromosome 11p15 and uniparental disomy. However, causal molecular defects and genetic models have remained elusive to date in the majority of cases. The non-pleckstrin homology domain ß-spectrin (ß2SP) (the official name for human is Spectrin, beta, nonerythrocytic 1 (SPTBN1), isoform 2; the official name for mouse is Spectrin beta 2 (Spnb2), isoform 2), a scaffolding protein, functions as a potent TGF-ß signaling member adaptor in tumor suppression and development. Yet, the role of the ß2SP in human tumor syndromes remains unclear. Here, we report that ß2SP(+/-) mice are born with many phenotypic characteristics observed in BWS patients, suggesting that ß2SP mutant mice phenocopy BWS, and ß2SP loss could be one of the mechanisms associated with BWS. Our results also suggest that epigenetic silencing of ß2SP is a new potential causal factor in human BWS patients. Furthermore, ß2SP(+/-) mice provide an important animal model for BWS, as well as sporadic cancers associated with it, including lethal gastrointestinal and pancreatic cancer. Thus, these studies could lead to further insight into defects generated by dysfunctional stem cells and identification of new treatment strategies and functional markers for the early detection of these lethal cancers that otherwise cannot be detected at an early stage.

Has the surge in media attention increased public awareness about colorectal cancer and screening?

The Centers for Disease Control and Prevention's Screen for Life campaign in March 1999 followed by the creation of National Colorectal Cancer Awareness Month in March 2000 heralded a surge in media attention to promote awareness about CRC and stimulate interest in screening. Our objective was to assess whether these campaigns have achieved their goal of educating the public about CRC and screening. The study sample was comprised of mostly unscreened, average-risk, English-speaking patients aged 50-75 years seen in an urban primary care setting. Knowledge was assessed using a 12-item true/false questionnaire based primarily on the content of key messages endorsed by the National Colorectal Cancer Roundtable (Cancer 95:1618-1628, 2002) and adopted in many of the media campaigns. Multiple linear regression was performed to identify demographic correlates of knowledge. A total of 356 subjects (83% or=67%) were aware of who gets CRC, age to initiate screening, the goals of screening and potential benefits. Fewer were aware that removing polyps can prevent CRC and that both polyps and CRC may be asymptomatic. Knowledge scores were lower among Blacks and those with a high school degree or less. Race and education were independent correlates of knowledge. These data suggest that recent media campaigns have been effective in increasing public awareness about CRC risk and screening but important gaps in knowledge remain.

Dorsal motor nucleus of the vagus: a site for evoking simultaneous changes in crural diaphragm activity, lower esophageal sphincter pressure, and fundus tone.

The sphincter mechanism at the esophagogastric junction includes smooth muscle of the lower esophagus and skeletal muscle of the crural diaphragm (CD). Smooth muscle is known to be under the control of the dorsal motor nucleus of the vagus (DMV), while central nervous system (CNS) control of the CD is unknown. The main purposes of our study were to determine the CNS site that controls the CD and whether simultaneous changes in lower esophageal sphincter (LES) pressure and CD activity occur when this site is activated. Experiments were performed on anesthetized male ferrets whose LES pressure, CD activity, and fundus tone were monitored. To activate DMV neurons, L-glutamate was microinjected unilaterally into the DMV at three areas: intermediate, rostral, and caudal. Stimulation of the intermediate DMV decreased CD activity (-4.8 +/- 0.1 bursts/min and -0.3 +/- 0.01 mV) and LES pressure (-13.2 +/- 2.0 mmHg; n = 9). Stimulation of this brain site also produced an increase in fundus tone. Stimulation of the rostral DMV elicited increases in the activity of all three target organs (n = 5). Stimulation of the caudal DMV had no effect on the CD but did decrease both LES pressure and fundus tone (n = 5). All changes in LES pressure, fundus tone, and some DMV-induced changes in CD activity (i.e., bursts/min) were prevented by ipsilateral vagotomy. Our data indicate that simultaneous changes in activity of esophagogastric sphincters and fundus tone occur from rostral and intermediate areas of the DMV and that these changes are largely mediated by efferent vagus nerves.

Maternal outcomes associated with planned primary cesarean births compared with planned vaginal births.

OBJECTIVE: To compare the outcomes and costs associated with primary cesarean births with no labor (planned cesareans) to vaginal and cesarean births with labor (planned vaginal). METHODS: Analysis was based on a Massachusetts data system linking 470,857 birth certificates, fetal death records, and birth-related hospital discharge records from 1998 and 2003. We examined a subset of 244,088 mothers with no prior cesarean and no documented prenatal risk. We then divided mothers into two groups: those with no labor and a primary cesarean (planned primary cesarean deliveries-3,334 women) and those with labor and either a vaginal birth or a cesarean delivery (planned vaginal-240,754 women). We compared maternal rehospitalization rates and analyzed costs and length of stay. RESULTS: Rehospitalizations in the first 30 days after giving birth were more likely in planned cesarean (19.2 in 1,000) when compared with planned vaginal births (7.5 in 1,000). After controlling for age, parity, and race or ethnicity, mothers with a planned primary cesarean were 2.3 (95% confidence interval [CI] 1.74-2.9) times more likely to require a rehospitalization in the first 30 days postpartum. The leading causes of rehospitalization after a planned cesarean were wound complications (6.6 in 1,000) (P<.001) and infection (3.3 in 1,000). The average initial hospital cost of a planned primary cesarean of US dollars 4,372 (95% C.I. US dollars 4,293-4,451) was 76% higher than the average for planned vaginal births of US dollars 2,487 (95% C.I. US dollars 2,481-2,493), and length of stay was 77% longer (4.3 days to 2.4 days). CONCLUSION: Clinicians should be aware of the increased risk for maternal rehospitalization after cesarean deliveries to low-risk mothers when counseling women about their choices. LEVEL OF EVIDENCE: II.

Psychologic well-being of surgery residents after inception of the 80-hour workweek: a multi-institutional study.

BACKGROUND: The 80-hour workweek was adopted by US residency programs on July 1, 2003. Our published data from the preceding year indicated significant impairment in psychologic well-being among surgery residents. The purpose of this study was to determine whether psychologic well-being and academic performance of surgery residents improved after inception of the 80-hour workweek. METHODS: A single-blinded survey of general surgery residents (n=130) across 4 US training programs was conducted after July 1, 2003, with the use of validated psychometric surveys (Symptom Checklist-90-R and Perceived Stress Scale) and the American Board of Surgery In-Training Examination; comparison was done with preceding year and societal data. Primary outcomes were "psychologic distress" and "perceived stress." Secondary outcomes were "somatization," "depression," "anxiety," "interpersonal sensitivity," "hostility," "obsessive-compulsive behavior," "phobic anxiety," "paranoid ideation," "psychoticism." and "academic performance." The impact of demographic variables was assessed. RESULTS: Mean psychologic distress improved from the preceding year (P < .01) but remained elevated, compared with societal norms (P < .001). The proportion of residents meeting the criteria for clinical psychologic distress (>or=90th percentile) decreased from 38% before, to 24% after, July 2003. Mean perceived stress remained elevated, compared with norms (P < .0001) without improvement from the preceding year. Overall academic performance was unchanged. Previously elevated secondary psychologic outcomes improved after July 2003 (P < .05), although obsessive-compulsive behavior, depression, interpersonal sensitivity, hostility, and anxiety failed to normalize. Male gender and single status were independent risk factors for psychologic distress. CONCLUSIONS: Inception of the 80-hour workweek is associated with reduced psychologic distress among surgery residents. The perception of stress and academic performance remains unchanged.