Integrating long-acting reversible contraceptives into primary care internal medicine practices: A clinical innovation to reduce wait time.

BACKGROUND: Long-acting reversible contraception (LARC) has long been regarded as highly effective and safe. However, access is limited and lengthy when specialty referrals are required. OBJECTIVES: To integrate LARC services into an urban internal medicine primary care practice to decrease wait time for LARC procedures. DESIGN/METHODS: This pre-post with control group study took place at two large urban academic primary care practices (Practices A and B) and included patients ages 18 to 45 years assigned female sex at birth. Pre-implementation baseline data were collected retrospectively from 2019 to 2020 by identifying subjects who requested LARC insertion or removal via their primary care practice and were referred to Obstetrics and Gynecology (Ob/Gyn) for the procedure. Wait time was noted from time of initial request in the medical record to time of procedure. Practice A developed an integrated primary care LARC program in which one of their LARC-trained providers began offering these procedures within their own practice. All other providers within the practice were educated on how to counsel patients about the devices and procedures. Practice B did not have an in-house LARC provider and continued referring patients to Ob/Gyn. Post-implementation data were collected prospectively 2021-2022. RESULTS: Ninety-one patients in Practice A experienced a significant decrease in wait time (87 vs 21 days, p < 0.001) over the observation period, with a majority undergoing procedures on their first visit with the in-house LARC provider. Wait time for the 54 patients in Practice B remained unchanged (57 vs 47 days, p = .59), often requiring multiple specialty visits. CONCLUSION: Integrating LARC services into a primary care internal medicine practice can significantly reduce wait times for these procedures with the potential to contribute to increased reproductive and menstrual autonomy.

Burnout and Perceptions of Stigma and Help-Seeking Behavior Among Pediatric Fellows.

BACKGROUND AND OBJECTIVES: Although burnout has been studied extensively among students and residents, in few studies have researchers examined burnout among fellowship trainees. We measured burnout among fellows in our freestanding children's hospital and evaluated fellows' perceptions of stigma around (and willingness to seek treatment for) psychological distress. The objectives are as follows: to (1) measure burnout among pediatric fellows, (2) assess fellows' perceptions of stigma around help seeking for mental illness, and (3) examine the relationship between burnout and willingness to seek behavioral health counseling. METHODS: We distributed a 48-item inventory to all 288 fellows in our pediatric center. Items included the Maslach Burnout Inventory and Likert-type matrices to assess attitudes toward behavioral health treatment and associated stigma. We used 2-sampled t-tests to associate burnout with willingness to seek mental health treatment. RESULTS: A total of 152 fellows (52%) responded, of whom 53% met the threshold for burnout. Most reported believing that their program directors (78%), attending physicians (72%), and patients (82%) hold negative attitudes about mental illness and its treatment; 68% believed that employers would reject their application if they knew they sought counseling. Fellows with burnout were more likely to believe that others in the clinical learning environment hold negative views of help seeking for behavioral health (odds ratio 1.2-1.9). CONCLUSIONS: Just over one-half of the pediatric fellows in our center meet the threshold for burnout. They also experience significant workplace-based stigma around help seeking for psychological distress. Fellows with burnout are more likely than their peers to perceive significant stigma around help seeking for their distress, making them a particularly at-risk learner population.

The role of resilience in healthcare transitions among adolescent kidney transplant recipients.

PURPOSE: AYAs with KTs experience high rates of premature allograft loss during the HCT. There is a critical need to identify protective factors associated with stable HCT. Resilience-the ability to adapt and thrive in the setting of adversity-has known positive impact on health outcomes. This study explored the novel role of resilience constructs as protective factors in securing stable HCT among AYA with KT. METHODS: We conducted semi-structured interviews of adolescents and young adults who transitioned from a single pediatric transplant center to multiple adult nephrology centers between 2010 and 2017. Interviews explored the role of key resilience constructs in participants' lives around the time of HCT. Participants were stratified into stable or unstable HCT groups based on biological markers of allograft function and clinical data from chart review. Content analyses of interview transcripts were reviewed and compared among HCT groups. RESULTS: Thirty-two participants enrolled (17 stable; 15 unstable). Key resilience constructs more salient in the stable versus unstable HCT group were confidence in and connection to one's healthcare team. Reports of healthcare self-management competencies were similar across both HCT groups. CONCLUSIONS: Confidence in and connection to one's healthcare team appear to be linked with a stable HCT among AYA with KT. This suggests that interdependence, the ability to foster connections with and elicit support from healthcare providers, as opposed to complete independence or autonomy, which is often advised in the HCT process, is a critical component of resilience linked to stable HCT.

Disordered Eating Behaviors in Emerging Adults With Type 1 Diabetes: A Common Problem for Both Men and Women.

INTRODUCTION: Emerging adults (EA) with disordered eating behaviors (DEBs) and Type 1 diabetes (T1D) are at increased risk for severe complications of T1D, and these behaviors have been reported in EA women with T1D. Few studies, though, have included men. This study assessed the prevalence of DEB in both EA men and women with T1D. METHODS: DEB was measured with the diabetes-specific Diabetes Eating Problem Survey-Revised (DEPS-R); scores of 20 or greater indicate need for further evaluation for DEB. RESULTS: A total of 27 women and 33 men (age range = 21 ± 2.5 years) completed the DEPS-R; 27% of women and 18% of men had scores of 20 or greater (p = .23). Hemoglobin A1c level was significantly higher in subjects with elevated DEPS-R scores (10.4 ± 2.1% vs. 7.8 ± 1.3%; p < .001), and DEPS-R scores correlated with increased body mass index values (r = 0.27, p < .05). DISCUSSION: Clinicians should assess for DEB in both male and female emerging adults with T1D, especially overweight patients with poor glycemic control.

UTILITY OF PSYCHOLOGICAL SCREENING OF YOUNG ADULTS WITH TYPE 1 DIABETES TRANSITIONING TO ADULT PROVIDERS.

OBJECTIVE: Screening for depression, diabetes distress, and disordered eating in youth with type 1 diabetes (T1D) is recommended, as these comorbidities contribute to poor glycemic control. No consensus exists on which measures are optimal, and most previous studies have used nondisease-specific measures. We examined the utility of screening for these disorders using two disease-specific and one general measure at the time of transition from pediatric to adult care. METHODS: Forty-three young adults from a T1D transition clinic completed the Patient Health Questionnaire, the Diabetes Distress Scale, and the Diabetes Eating Problem Survey-Revised. Chart review determined if clinicians noted similar symptoms during the year prior to transition. Metabolic data were also recorded. RESULTS: Chart review identified 5 patients with depressive symptoms and 8 patients with diabetes distress. Screening identified 2 additional patients with depressive symptoms and 1 additional patient with diabetes distress. Of those noted to have symptomatic depression or diabetes distress on chart review, several subsequently screened negative on transition. Disordered eating was not detected by chart review, but 23.5% screened positive on transition. While depression, diabetes distress, and disordered eating positively correlated with glycated hemoglobin (HbA1c) (r = 0.31, P = .05; r = 0.40, P = .009; r = 0.63, P<.001, respectively), disordered eating accounted for the majority of observed variance (df = 1; F = 18.6; P<.001). Even though HbA1c was higher in patients with versus without disordered eating (P<.001), body mass index did not differ between the 2 groups (P = .51). CONCLUSION: In young adults with T1D, formal screening provides an opportunity to detect psychological problems, which, when treated, may help optimize metabolic control during the transition process. ABBREVIATIONS: T1D = type 1 diabetes HbA1C = hemoglobin A1c YCDP = Yale Children's Diabetes Program PHQ-8 = Patient Health Questionnaire-8 DDS = Diabetes Distress Scale DEPS-R = Diabetes Eating Problem Survey-Revised.

Menstrual management and reproductive concerns in adolescent and young adult women with underlying hematologic or oncologic disease.

PURPOSE OF REVIEW: Heavy menstrual bleeding is common among adolescent and young adult women, and can affect health-related quality of life. The cause of heavy menstrual bleeding is not uncommonly because of an underlying hematologic or oncologic disease process, which substantially influences the way patients are counseled and treated. RECENT FINDINGS: Options for menstrual management are more numerous today than ever before and range from minimizing monthly blood loss to suppressing the cycle altogether. However, an underlying bleeding disorder or malignancy can introduce many nuances and limits in individual patient care, which this review highlights. Additionally, because survival rates for adolescent and young adult cancers are improving, more of these patients are planning for lives after their disease, which may include starting or adding to a family. Options for fertility preservation during cancer therapy regimens are solidifying and both primary practitioners and subspecialists should be aware of the possibilities. SUMMARY: Patients with underlying hematologic or oncologic disease require management of menstrual bleeding, but also deserve a comprehensive evaluation and counseling regarding their individualized contraceptive needs and fertility preservation options during their reproductive years. This review employs the latest evidence from current literature to help guide clinicians caring for this unique demographic.