Adolescent Long-Acting Reversible Contraceptive Use, Same-Day Insertions, and Pregnancies Following a Quality Initiative.

OBJECTIVE: To compare long-acting reversible contraceptive (LARC) use, pregnancy rate, and same-day LARC insertion among adolescents before and after a Kaiser Permanente Northern California quality initiative. METHODS: A 2016 Kaiser Permanente Northern California initiative aimed to increase adolescent LARC access. Interventions included patient education resources, electronic protocols, and insertion training for pediatric, family medicine, and gynecology providers. This study examined a retrospective cohort of adolescents aged 15-18 years who used contraception before (2014-2015, n = 30,094) and after (2017-2018, n = 28,710) implementation. Contraceptive types included LARC (intrauterine device or implant), injectable, and contraceptive pill, patch, or ring. We reviewed a random sample of LARC users (n = 726) to identify same-day insertions. Multivariable analysis examined the effects of year of provision, age, race, ethnicity, LARC type, and counseling clinic. RESULTS: Preintervention, 12.1% of adolescents used LARC, 13.6% used injectable, and 74.3% used pill, patch, or ring. Postintervention, the proportions were 23.0%, 11.6%, and 65.4%, respectively, with the odds of LARC provision of 2.57 (95% confidence interval (CI) 2.44-2.72). The pregnancy rate decreased from 2.2% to 1.4% (p < .0001). Higher rates of pregnancy were observed with injectable contraception and in Black and Hispanic adolescents. Same-day LARC insertion rate was 25.1% without significant variation post intervention (OR 1.44, 95% confidence interval 0.93-2.23). Contraceptive counseling in gynecology clinics increased the odds of same-day provision, while non-Hispanic Black race lowered odds. DISCUSSION: A multifaceted quality intervention was associated with a 90% increase in LARC use and a 36% decrease in teenage pregnancy rate. Future directions may include promoting same-day insertions, targeting interventions in pediatric clinics, and focusing on racial equity.

Study of the Use of Lipid Panels as a Marker of Insulin Resistance to Determine Cardiovascular Risk.

CONTEXT: When assessing the lipid panel, practical physicians tend to focus on the low-density lipoprotein cholesterol (LDL-c). However, an elevated triglyceride/high-density lipoprotein cholesterol (HDL-c) ratio, suggesting insulin resistance, also effectively predicts cardiovascular outcomes but requires different treatments than an elevated LDL-c. We tested whether high triglyceride/HDL-c ratios are associated with more risk than high LDL-c concentrations or other lipid markers of atherogenicity. METHODS: We followed 103,646 members aged 50 to 75 years without cardiovascular disease or diabetes in a community health plan. Subjects were categorized as insulin sensitive or insulin resistant on the basis of triglyceride and HDL-c in the index year. The primary outcome was ischemic heart disease. The percentage of subjects with a primary outcome after 8 years was stratified by insulin category, lipid measures, and blood pressure. Hazard ratios (HR) for insulin resistance, LDL-c, age, sex, and the presence of hypertension were determined in a multivariate analysis. RESULTS: Subjects with insulin resistance but lipid measures healthier than the median had worse outcomes than those who were insulin sensitive but had unhealthier lipid measures such as non-HDL-c and the ratios of total cholesterol/HDL-c and LDL-c/HDL-c. The HR for a 60 mg/dL increase in LDL-c was 1.14 (95% confidence interval [CI], 1.10-1.18); the HR for an LDL-c greater than 160 mg/dL was 1.19 (95% CI, 1.12-1.28). In contrast, the hazard ratio for having an insulin-resistant triglyceride/HDL-c ratio was 1.68 (95% CI, 1.57-1.80), compared with an insulin-sensitive ratio. There was no difference in outcomes between insulin-resistant but normotensive patients and insulin-sensitive but hypertensive patients. CONCLUSION: Insulin resistance, as manifested by a high triglyceride/HDL-c ratio, was associated with adverse cardiovascular outcomes more than other lipid metrics, including LDL-c, which had little concordance. Physicians and patients should not overlook the triglyceride/HDL-c ratio.

Interdisciplinary treatment for vestibular dysfunction: the effectiveness of mindfulness, cognitive-behavioral techniques, and vestibular rehabilitation.

OBJECTIVE: To investigate whether an interdisciplinary program for vestibular patients improved health outcomes and health care utilization. STUDY DESIGN: Case series with chart review. SETTING: Outpatient neurotology clinic. SUBJECTS AND METHODS: Patients (N = 167) with dizziness attended an interdisciplinary neurotology clinic; 129 were offered group treatment. After an introductory session, group treatment included 5 sessions incorporating mindfulness, cognitive-behavioral techniques, and vestibular rehabilitation. Physical and emotional functioning, depression,anxiety, dizziness, impairment, coping, skill use, and patient satisfaction were measured with rating scales pre- and post-group treatment. Data from 51 patients (male/female = 14/37; age range, 25-82 years) were analyzed with paired t tests or nonparametric tests. Logistic regression analyzed predictors of outcome and utilization for 116 patients (male/female = 81/35; age range, 11-86 years) attending the interdisciplinary clinic, introductory session, and/or group. RESULTS: After group treatment, patients reported better mood (P = .0482); better physical (P = .0006) and mental (P = .0183) health; better functionality, coping, and skill use (Ps< .0001); less impairment (P < .0001); and fewer limitations from dizziness (P < .0001). Higher pretreatment levels of depression (P = .0216), poorer initial mental (P = .0164) or physical (P = .0059) health, and peripheral diagnosis (P = .0220) predicted better outcome. Group treatment decreased utilization more than the interdisciplinary clinic with (P = .0183) or without (P = .0196) the introductory session; 78% of patients with any level of participation showed less utilization. Clinic patients had fewer radiology procedures than group patients (P = .0365). Patients were highly satisfied with the program and found it more effective than previous treatment. CONCLUSION: Interdisciplinary treatment improves patient coping, functionality, and satisfaction and decreases overall health care utilization in vestibular patients.