Missouri's Abortion law: Access to care for Patients with Lethal Fetal Anomalies at a Midwest Tertiary care Center.

OBJECTIVES: Missouri passed an 8-week gestational age abortion in August 2019. The objective of this study was to compare distance and time from referral to evaluation between patients who continued their pregnancy and those who terminated in patients with severe and lethal fetal anomalies and estimate the impact of the Missouri gestational age abortion ban on distance to abortion care in this patient population. METHODS: This is a retrospective cohort study of patients seen at the Washington University in St. Louis (WUSTL) Fetal Care Center (FCC) with a severe or lethal fetal anomaly between July 2018 and June 2019. Patient characteristics including gestational age at referral and distance traveled to the FCC were compared between patients who underwent abortion and who continued their pregnancies. RESULTS: From July 2018 to June 2019, 463 patients were seen in the Fetal Care Center and 13% (60/463) were diagnosed with severe or lethal fetal anomalies comprising the study population for this analysis. Of these, 21 (35%) patients underwent an abortion, and 39 (65%) patients continued their pregnancy. Patients who underwent abortion were referred at a significantly earlier gestational age (median 19 weeks [IQR 17, 20 weeks] v. 20 weeks [IQR 18, 24 weeks]), p = 0.04. There was a statistically significant difference between the median latency time between patients who underwent an abortion and who continued their pregnancy (median 8 days [IQR 4,13 days] v. 14 days [IQR 9, 22 days], p < 0.01). CONCLUSION: Patients with severe or lethal fetal anomalies are often evaluated at later gestational ages, which may preclude their access to abortion services.

Impact of the COVID-19 pandemic on referral to and delivery of gynecologic oncology care.

OBJECTIVE: To evaluate the impact of the COVID-19 pandemic on referral to and delivery of gynecologic oncology care at a National Cancer Institute-designated Comprehensive Cancer Center. METHODS: We conducted a retrospective cohort study of patients referred for evaluation by a gynecologic oncologist at Washington University in St. Louis from October 2019 - February 2020 (pre-COVID-19), and April - August 2020 (COVID-19). The primary outcome, time from referral to evaluation by a gynecologic oncologist, was compared between the two time periods. Secondary outcomes included time from initial evaluation to treatment and delays/interruptions in care due to the pandemic. Sub-group analyses were performed on patients with a cancer diagnosis to evaluate the impact of COVID-19 on treatment decision making. RESULTS: 884 patients were referred during the study period. Total referrals fell by 32% (526 to 358 patients, p < 0.001) and referrals for cancer fell by 18% (228 to 188 patients, p = 0.049). The pandemic did not impact time from referral to initial gynecologic oncology appointment overall (pre-COVID-19: 19.1 vs. COVID-19: 17.4 days, p = 0.315) or among patients with cancer (14.4 vs. 13.9 days, p = 0.662). Time from initial appointment to cancer treatment decreased by 9 days (34 days to 25 days, p = 0.001). CONCLUSION: Referrals to gynecologic oncology decreased significantly during the early months of COVID-19. Though time from referral to evaluation was not impacted by the pandemic, time to treatment initiation decreased despite institutional changes related to COVID-19.

Offering onsite COVID-19 vaccination to high-risk obstetrical patients: initial findings.

OBJECTIVE: The COVID-19 pandemic has had a disproportionate effect on pregnant women, with higher rates of viral infection and disease severity.1 The development of highly effective vaccines has significantly reduced SARS-CoV-2 transmission and clinical disease.2 However, vaccine uptake has been low in the pregnant population.3 The Centers for Disease Control and Prevention guidance suggests that limited vaccine access, not vaccine hesitancy, has driven the lower uptake rates in at-risk populations.4 We describe our experience with vaccination uptake rates among high-risk obstetrical patients before and after onsite BNT162b2 messenger RNA vaccination availability in outpatient clinics as part of a pilot program to improve vaccine access among pregnant patients. STUDY DESIGN: This was a quality improvement project at a single academic medical center. Onsite vaccination was available once a week at 2 high-risk obstetrical clinics staffed by obstetrical residents, maternal-fetal medicine (MFM) fellows, and MFM attendings were selected for our vaccine pilot program. Onsite vaccinations were immediately available for use in the clinic starting May 11, 2021. Data were collected over a 4-week period (April 27, 2021, to May 20, 2021), which included 4 clinic days before onsite vaccine availability (April 27, 2021 to May 10, 2021) and 4 days with onsite vaccine availability (May 11, 2021, to May 20, 2021). Patients were considered exposed to onsite vaccination if they had any clinic visits during the latter 2 weeks of the study period. All patients were counseled by providers at each visit using our institution's standardized COVID-19 vaccination discussion tool designed for pregnant and breastfeeding patients.5 Counseling was documented in each patient's chart per the American College of Obstetricians and Gynecologists. Before and throughout the study period, pregnancy was listed as a qualifying condition for priority vaccination in Missouri and Illinois. At this time, vaccinations were readily available in the local area surrounding our clinical space. Data on vaccine administration were collected via the Missouri and Illinois state databases over a period of 1 month after the pilot program was closed, allowing for the collection of data on patients who pursued vaccination offsite for scheduling or personal reasons. This project was deemed exempt by the Office for Human Research Protections. RESULTS: We reviewed data from 124 clinic visits, where a total of 93 individual patients were seen in the 4-week period; 6 had previously been vaccinated at external sites and the remaining 87 were eligible (Figure). The majority of our patient population was non-Hispanic Black women with public or no insurance (Table). Of the 32 eligible patients seen and counseled before onsite vaccination availability, 1 (3%) proceeded to receive the vaccination offsite. Of the 55 eligible patients seen and counseled after onsite vaccination availability, 2 (3%) proceeded with onsite vaccination and an additional 4 (7%) proceeded with vaccination offsite. Onsite vaccination availability did not significantly increase the vaccination rates (3% vs 11%; P=.22). Of the 55 eligible patients counseled during onsite vaccination availability, 25 were seen and counseled exclusively during the onsite vaccination pilot period and none of these patients accepted onsite vaccination or pursued vaccination offsite. CONCLUSION: Because only 3% of eligible, high-risk obstetrical patients proceeded with onsite vaccination, our experience suggests that vaccine hesitancy, not availability, is a critical driver of the low vaccination rates in this population. Although a larger sample size may have demonstrated statistical difference, the overall low vaccination uptake rate forced the closure of our pilot program over concerns for wasted vaccination doses. In a population at high risk for progression to severe COVID-19, only 14% of our study population was vaccinated, whereas Missouri reported a 41% vaccination rate during this time.6 These findings suggest that increased access alone may not improve vaccination rates in obstetrical patients even after counseling by expert clinicians. These findings are limited by the pre/post nature of the comparison, exposing the sample to bias as vaccination recommendations and population sentiment was rapidly evolving during this time period. However, the consistency of counseling and patient population provided by a single clinical setting limited other sources of bias during the study period. Vaccine hesitancy is multifactorial and complex and urgently requires more evaluation in this high-risk population. Vaccine hesitancy in pregnancy is well documented, but early reports suggest that the COVID-19 vaccination uptake rate is markedly lower than that of other vaccines during pregnancy. Our finding that none of the women who were seen exclusively during the onsite vaccination period accepted vaccination may suggest that repeat clinic visits and the associated establishment of rapport and trust is a vital part of vaccine decision making. Earlier intervention, before patient views on novel therapeutics such as vaccinations can be formulated and fixed, may aid in uptake. Further qualitative work and inclusion of pregnant women in vaccine trials is an initial step.

Group Prenatal Care as a Strategy to Address Diabesity.

Group prenatal care is a health care delivery model that utilizes shared medical appointments to place greater focus on patient education, mutual support, and increased time with the clinician to promote a healthy pregnancy. Several studies suggest that medically low-risk women participating in group prenatal care have improved pregnancy outcomes, but the same tenants can likely be used to help women with diabetes and obesity achieve healthy outcomes during pregnancy and throughout their life course. This chapter will review the background, care model, and evidence regarding group medical visits for pregnant women with diabetes and obesity.

Patient and counselor satisfaction with structured contraceptive counseling by health center staff in federally qualified health centers.

OBJECTIVES: To characterize patient and counselor satisfaction with structured, tier-based contraceptive counseling provided by a nonclinician. STUDY DESIGN: We conducted a planned secondary analysis of patient and counselor surveys from a study that enrolled women in 2 contraceptive care programs. All participants received structured contraceptive counseling from trained staff members. Women and counselors completed a confidential post-visit survey regarding satisfaction with counseling and medical mistrust. We used univariate and multivariable regressions to examine differences in high satisfaction with counseling (top score), perceived counselor influence, and perceived counselor judgment by participant characteristics. RESULTS: Nine hundred forty-two participants completed surveys; most reported they felt respected (100.0%), trusted the counseling information (99.5%), and that counseling helped them choose a contraceptive method (83.8%). Black race, high school education, public insurance, an income below the federal poverty level, and enrollment site were associated with high medical mistrust. Participants with high medical mistrust were less likely to be highly satisfied with counseling (adjusted relative risk (RR) 0.72; 95% confidence interval [CI] 0.63-0.82), more likely to perceive influence (RR 1.77; 95% CI 1.37-2.28), and more likely to perceive judgment (adjusted odds ratio 8.91; 95% CI 3.61-22.01). Mostly, counselors felt they were able to answer participant questions (98.8%), establish good rapport (95.9%), and that participants understood the information presented (98.0%). CONCLUSIONS: Overall, participants were satisfied with tier-based contraceptive counseling delivered by nonclinician staff members. Those with high levels of medical mistrust were less likely to be satisfied. The majority of women found the information beneficial in contraceptive decision making. IMPLICATIONS: Overall, women reported high satisfaction with tier-based contraceptive counseling delivered by a nonclinician in 3 federally qualified health centers. However, women with high medical mistrust were less likely to report high levels of satisfaction and more likely to report perceived influence or judgment from the counselor.

Arterial, but Not Venous, Reconstruction Increases 30-Day Morbidity and Mortality in Pancreaticoduodenectomy.

BACKGROUND: Vascular reconstruction during pancreaticoduodenectomy is increasingly utilized to improve pancreatic cancer resectability. However, few multi-institutional studies have evaluated the morbidity and mortality of arterial and venous reconstruction during this procedure. METHODS: A retrospective analysis was performed utilizing the targeted pancreas module of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) for pancreaticoduodenectomy from 2014 to 2015. Demographics, comorbidities, and 30-day outcomes for patients who underwent venous or arterial reconstruction and both were compared to no reconstruction. RESULTS: A total of 3002 patients were included in our study: 384 with venous reconstruction, 52 with arterial, 81 with both, and 2566 without. Compared to patients without reconstruction, those who underwent venous reconstruction had more congestive heart failure (1.8% vs 0.2%, P < 0.01), those with arterial reconstruction had higher rates of pulmonary disease (11.5% vs. 4.5%, P = 0.02), and neoadjuvant chemotherapy was more common in both venous (34% vs 12%, P < 0.01) and arterial reconstruction (21% vs 12%, P = 0.04). In multivariable analysis, there was no increase in morbidity or mortality following venous reconstruction. However, arterial reconstruction was associated with increased 30-day mortality with an odds ratio (OR): 6.7, 95%; confidence interval (CI): 1.8-25. Morbidity was increased as represented with return to the operating room (OR: 4.5, 95%; CI: 1.5-15), pancreatic fistula (OR: 4.4, 95%; CI: 1.7-11), and reintubation (OR: 3.9, 95%; CI: 1.1-14). CONCLUSIONS: Venous reconstruction during pancreaticoduodenectomy does not increase perioperative morbidity or mortality and should be considered for patients previously considered to be unresectable or those where R0 resection would otherwise not be possible due to venous involvement. Careful consideration should be made prior to arterial reconstruction given the significant increase in perioperative complications and death within 30 days.

Familiarity and acceptability of long-acting reversible contraception and contraceptive choice.

BACKGROUND: Contraceptive choice is a preference-sensitive decision that is affected by contraceptive attributes, patient experience, and reproductive history. Familiarity with and acceptability of specific contraceptive methods may influence patient decisions. OBJECTIVE: The purpose of this study was to describe the acceptability of and previsit familiarity with long-acting reversible contraception (intrauterine devices and contraceptive implants) compared with depo-medroxyprogesterone acetate and oral contraceptive pills in women seeking contraceptive care and to investigate the relationship between acceptability and contraceptive choice. STUDY DESIGN: This was a secondary analysis of a study that was designed to compare 2 contraceptive care programs conducted at 3 Midwest federally qualified health centers. After contraceptive counseling, participants completed a baseline interviewer-administered survey before the healthcare provider visit. We asked participants questions about previsit familiarity with and acceptability of the intrauterine device, implant, depo-medroxyprogesterone acetate, and oral contraceptive pills. We assessed familiarity using 2 questions: (1) Before today have you ever heard of the [method]? (2) Do you know any woman who has/has used the [method]? Acceptability was assessed for each method on a 0-10 scale, with 0 being "strongly dislike" and 10 being "strongly like." We dichotomized the scores into high acceptability (7-10) and low/moderate acceptability (0-6) for analysis. We examined differences in demographic and reproductive characteristics between women with high and low long-acting reversible contraception acceptability using the chi-square test. We used univariate and multivariable Poisson regressions to examine the relationship among participants' characteristics, method acceptability, and method choice. We adjusted for any covariate that changed the effect size of acceptability by >10%. RESULTS: There were 1007 women included in the analysis: 900 women (89%) reported that they had heard of the intrauterine device, and 592 women (59%) knew someone who had used the intrauterine device. Eight hundred sixty-five (86%) women had heard of the implant, and 636 women (63%) knew someone who had used it. Knowledge of depo-medroxyprogesterone acetate and oral contraceptive pills was high (>98% for both). Five hundred seventy-six women (57%) found 1 or both long-acting reversible contraception methods highly acceptable. Women with high long-acting reversible contraception acceptability were more likely to be adolescents or aged 30-45 years, white, Hispanic, married/cohabitating, and uninsured and were less likely to desire a child in the next 1-3 years. They were more likely to desire a hormonal intrauterine device (90.5% vs 9.5%), copper intrauterine device (81.1% vs 18.9%), or implant (89.8% vs 10.2%) compared with women with low acceptability (P<.001). In adjusted analyses, women with high acceptability of an intrauterine device were more likely to desire an intrauterine device (adjusted relative risk, 9.62; 95% confidence interval, 6.42-14.42). Women with high acceptability of an implant were also more likely to desire one (adjusted relative risk, 8.74; 95% confidence interval, 6.17-12.38). Women were more likely to desire an intrauterine device or an implant if they knew someone who used the method. Previous use of the method and demographic factors were not associated with method choice. CONCLUSION: Previsit familiarity with intrauterine devices and implants was high in our federally qualified health centers population, although not as high as depo-medroxyprogesterone acetate and oral contraceptive pills. In adjusted analyses, women who found an intrauterine device or implant highly acceptable and who knew someone who had used the method were more likely to choose those respective methods at the end of their visit.

Video observation to map hand contact and bacterial transmission in operating rooms.

BACKGROUND: Hand hygiene (HH) is considered a primary intervention to avoid transmission of bacteria in health care settings and to prevent health care-associated infections. Despite efforts to decrease the incidence of health care-associated infections by improving HH, HH compliance rates vary widely depending on the hospital environment. METHODS: We used intraoperative video observation to map temporal patterns of anesthesia provider hand contact with anesthesia work environment (AWE) surfaces and to assess HH compliance. Serial bacterial cultures of high contact objects were subsequently used to characterize bacterial transmission over time. RESULTS: Using World Health Organization criteria, we found a large number of HH opportunities and a low rate of HH compliance by anesthesia providers (mean, 2.9%). We observed an inverse correlation between provider hand hygiene compliance during induction and emergence from anesthesia (3.2% and 4.1%, respectively) and the magnitude of AWE surface contamination (103 and 147 CFU, respectively) at these time points. We found no correlation between frequency of hand contact with the AWE and bacterial contamination. CONCLUSIONS: Compliance with current HH recommendations by anesthesia providers is not feasible. However, there does appear to be a correlation between HH compliance rates and bacterial contamination of the AWE, an observation that should stimulate further work to design new methods for control of bacterial transmission in operating rooms.

Prevention of intravenous bacterial injection from health care provider hands: the importance of catheter design and handling.

BACKGROUND: Device-related bloodstream infections are associated with a significant increase in patient morbidity and mortality in multiple health care settings. Recently, intraoperative bacterial contamination of conventional open-lumen 3-way stopcock sets has been shown to be associated with increased patient mortality. Intraoperative use of disinfectable, needleless closed catheter devices (DNCCs) may reduce the risk of bacterial injection as compared to conventional open-lumen devices due to an intrinsic barrier to bacterial entry associated with valve design and/or the capacity for surface disinfection. However, the relative benefit of DNCC valve design (intrinsic barrier capacity) as compared to surface disinfection in attenuation of bacterial injection in the clinical environment is untested and entirely unknown. The primary aim of the current study was to investigate the relative efficacy of a novel disinfectable stopcock, the Ultraport zero, with and without disinfection in attenuating intraoperative injection of potential bacterial pathogens as compared to a conventional open-lumen stopcock intravascular device. The secondary aims were to identify risk factors for bacterial injection and to estimate the quantity of bacterial organisms injected during catheter handling. METHODS: Four hundred sixty-eight operating room environments were randomized by a computer generated list to 1 of 3 device-injection schemes: (1) injection of the Ultraport zero stopcock with hub disinfection before injection, (2) injection of the Ultraport zero stopcock without prior hub disinfection, and (3) injection of the conventional open-lumen stopcock closed with sterile caps according to usual practice. After induction of general anesthesia, the primary anesthesia provider caring for patients in each operating room environment was asked to perform a series of 5 injections of sterile saline through the assigned device into an ex vivo catheter system. The primary outcome was the incidence of bacterial contamination of the injected fluid column (effluent). Risk factors for effluent contamination were identified in univariate analysis, and a controlled laboratory experiment was used to generate an estimate of the bacterial load injected for contaminated effluent samples. RESULTS: The incidence of effluent bacterial contamination was 0% (0/152) for the Ultraport zero stopcock with hub disinfection before injection, 4% (7/162) for the Ultraport zero stopcock without hub disinfection before injection, and 3.2% (5/154) for the conventional open-lumen stopcock. The Ultraport zero stopcock with hub disinfection before injection was associated with a significant reduction in the risk of bacterial injection as compared to the conventional open-lumen stopcock (RR = 8.15 × 10(-8), 95% CI, 3.39 × 10(-8) to 1.96 × 10(-7), P = <0.001), with an absolute risk reduction of 3.2% (95% CI, 0.5% to 7.4%). Provider glove use was a risk factor for effluent contamination (RR = 10.48, 95% CI, 3.16 to 34.80, P < 0.001). The estimated quantity of bacteria injected reached a clinically significant threshold of 50,000 colony-forming units per each injection series. CONCLUSIONS: The Ultraport zero stopcock with hub disinfection before injection was associated with a significant reduction in the risk of inadvertent bacterial injection as compared to the conventional open-lumen stopcock. Future studies should examine strategies designed to facilitate health care provider DNCC hub disinfection and proper device handling.

Multiple reservoirs contribute to intraoperative bacterial transmission.

BACKGROUND: Intraoperative stopcock contamination is a frequent event associated with increased patient mortality. In the current study we examined the relative contributions of anesthesia provider hands, the patient, and the patient environment to stopcock contamination. Our secondary aims were to identify risk factors for stopcock contamination and to examine the prior association of stopcock contamination with 30-day postoperative infection and mortality. Additional microbiological analyses were completed to determine the prevalence of bacterial pathogens within intraoperative bacterial reservoirs. Pulsed-field gel electrophoresis was used to assess the contribution of reservoir bacterial pathogens to 30-day postoperative infections. METHODS: In a multicenter study, stopcock transmission events were observed in 274 operating rooms, with the first and second cases of the day in each operating room studied in series to identify within- and between-case transmission events. Reservoir bacterial cultures were obtained and compared with stopcock set isolates to determine the origin of stopcock contamination. Between-case transmission was defined by the isolation of 1 or more bacterial isolates from the stopcock set of a subsequent case (case 2) that were identical to reservoir isolates from the preceding case (case 1). Within-case transmission was defined by the isolation of 1 or more bacterial isolates from a stopcock set that were identical to bacterial reservoirs from the same case. Bacterial pathogens within these reservoirs were identified, and their potential contribution to postoperative infections was evaluated. All patients were followed for 30 days postoperatively for the development of infection and all-cause mortality. RESULTS: Stopcock contamination was detected in 23% (126 out of 548) of cases with 14 between-case and 30 within-case transmission events confirmed. All 3 reservoirs contributed to between-case (64% environment, 14% patient, and 21% provider) and within-case (47% environment, 23% patient, and 30% provider) stopcock transmission. The environment was a more likely source of stopcock contamination than provider hands (relative risk [RR] 1.91, confidence interval [CI] 1.09 to 3.35, P = 0.029) or patients (RR 2.56, CI 1.34 to 4.89, P = 0.002). Hospital site (odds ratio [OR] 5.09, CI 2.02 to 12.86, P = 0.001) and case 2 (OR 6.82, CI 4.03 to 11.5, P < 0.001) were significant predictors of stopcock contamination. Stopcock contamination was associated with increased mortality (OR 58.5, CI 2.32 to 1477, P = 0.014). Intraoperative bacterial contamination of patients and provider hands was linked to 30-day postoperative infections. CONCLUSIONS: Bacterial contamination of patients, provider hands, and the environment contributes to stopcock transmission events, but the surrounding patient environment is the most likely source. Stopcock contamination is associated with increased patient mortality. Patient and provider bacterial reservoirs contribute to 30-day postoperative infections. Multimodal programs designed to target each of these reservoirs in parallel should be studied intensely as a comprehensive approach to reducing intraoperative bacterial transmission.