Do women with a previous unintended birth subsequently experience missed opportunities for postpartum family planning counseling? A multilevel mixed effects analysis.

Client-provider communication about family planning (FP) remains an important strategy for preventing unintended pregnancy. Yet, the literature lacks empirical studies examining whether and how women's intendedness of a recent pregnancy may impact subsequent receipt of FP counseling. We investigated whether the intendedness of a recent pregnancy is associated with subsequent missed opportunities (MOs) for FP counseling, taking into account compositional and contextual factors. We performed a secondary analysis using pooled data from the 2016, 2017 and 2018 Performance Monitoring and Accountability 2020 cross-sectional surveys conducted in Nigeria, adjusting for complex design effects. Weighted multilevel logistic regression modeling was used to examine the relationships between pregnancy intention and MOs, overall and at the health facility, using two-level random intercept models. In the analytic sample of women within 24 months postpartum (N = 6479), nearly 60% experienced MOs for FP counseling overall and even 45% of those who visited a health facility visit in the past 12 months (N = 4194) experienced MOs. In the multivariable models adjusted for individual-/household- and community-level factors, women whose recent birth was either mistimed or unwanted were just as likely to have MOs for FP counseling as their counterparts whose pregnancy was intended (p > 0.05). Factors independently associated with a MOs include individual/household level factors such as level of education, exposure to FP media, household wealth index and contextual-level variables (geographic region). While evidence that pregnancy intendedness is associated with MOs for FP counseling remains inconclusive, efforts to mitigate these MOs requires prioritizing women's prior pregnancy intentions as well as equipping healthcare providers with the capacity need to provide high-quality client-centered FP counseling, particularly for women whose recent birth was unintended.

Identification of Clinician Training Techniques as an Implementation Strategy to Improve Maternal Health: A Scoping Review.

Training is a key implementation strategy used in healthcare settings. This study aimed to identify a range of clinician training techniques that facilitate guideline implementation, promote clinician behavior change, optimize clinical outcomes, and address implicit biases to promote high-quality maternal and child health (MCH) care. A scoping review was conducted within PubMed, CINAHL, PsycInfo, and Cochrane databases using iterative searches related to (provider OR clinician) AND (education OR training). A total of 152 articles met the inclusion/exclusion criteria. The training involved multiple clinician types (e.g., physicians, nurses) and was predominantly implemented in hospitals (63%). Topics focused on maternal/fetal morbidity/mortality (26%), teamwork and communication (14%), and screening, assessment, and testing (12%). Common techniques included didactic (65%), simulation (39%), hands-on (e.g., scenario, role play) (28%), and discussion (27%). Under half (42%) of the reported training was based on guidelines or evidence-based practices. A minority of articles reported evaluating change in clinician knowledge (39%), confidence (37%), or clinical outcomes (31%). A secondary review identified 22 articles related to implicit bias training, which used other reflective approaches (e.g., implicit bias tests, role play, and patient observations). Although many training techniques were identified, future research is needed to ascertain the most effective training techniques, ultimately improving patient-centered care and outcomes.

Assessing hospital differences in low-risk cesarean delivery metrics in Florida.

BACKGROUND: Unnecessary cesarean deliveries lead to increased maternal and neonatal morbidities and mortalities. In 2020, Florida had a cesarean delivery rate of 35.9%, the third highest in the nation. An effective quality improvement strategy to reduce overall cesarean delivery rates is to decrease primary cesarean deliveries in low-risk births (nulliparous, term, singleton, vertex). Of note, 3 nationally accepted hospital measures of low-risk cesarean delivery rates include the nulliparous, term, singleton, vertex; Joint Commission; and Society for Maternal-Fetal Medicine metrics. Comparing metrics is necessary because accurate and timely measurement is essential to support multihospital quality improvement efforts to reduce low-risk cesarean delivery rates and improve the quality of maternal care. OBJECTIVE: This study aimed to assess differences in hospital low-risk cesarean delivery rates in Florida using 5 different metrics of low-risk cesarean delivery rate based on (1) risk methodology, nulliparous, term, singleton, vertex; Joint Commission; and Society for Maternal-Fetal Medicine metrics, and (2) data source, linked birth certificate and hospital discharge records and hospital discharge records only. STUDY DESIGN: This was a population-based study of live Florida births from 2016 to 2019 to compare 5 approaches to calculating low-risk cesarean delivery rates. Analyses were performed using linked birth certificate data and inpatient hospital discharge data. The 5 low-risk cesarean delivery measures were defined as follows: nulliparous, term, singleton, vertex birth certificate; Joint Commission-linked used Joint Commission exclusions; Society for Maternal-Fetal Medicine-linked used Society for Maternal-Fetal Medicine exclusions; Joint Commission hospital discharge with Joint Commission exclusions; and Society for Maternal-Fetal Medicine hospital discharge with Society for Maternal-Fetal Medicine exclusions. Nulliparous, term, singleton, vertex birth certificate was based on data from birth certificates and not using linked hospital discharge data. Designated as nulliparous, term, singleton, vertex, it does not exclude other high-risk conditions. The second and third measures (Joint Commission-linked used Joint Commission exclusions and Society for Maternal-Fetal Medicine-linked used Society for Maternal-Fetal Medicine exclusions) use data elements from the full-linked dataset to designate nulliparous, term, singleton, vertex and excluded several high-risk conditions. The last 2 measures (Joint Commission hospital discharge with Joint Commission exclusions; and Society for Maternal-Fetal Medicine hospital discharge with Society for Maternal-Fetal Medicine exclusions) were based on data from hospital discharge data only and not using linked birth certificate data. These measures generally reflect term, singleton, and vertex because parity could not be assessed adequately on hospital discharge data. Hospital differences between these 5 measures were calculated overall and by neonatal intensive care unit level. RESULTS: Overall, the median of hospital low-risk cesarean rates decreased across the measures, from NTSV-BC 30.7%, to Joint Commission linked 29.1%, and Society for Maternal Fetal Medicine hospital discharge 29.2% with a large decrease to Joint Commission hospital discharge 19.4% and Society for Maternal Fetal Medicine hospital discharge 18.1%. A similar trend was seen by neonatal intensive care unit level. For each of the measures, level II had the highest median low-risk cesarean rates (nulliparous. term, singleton, vertex birth certificate) 32.7%, Joint Commission linked (31.4%), Society for Maternal Fetal Medicine linked: 31.1%, Society for Maternal Fetal Medicine hospital discharge 19.3%), except for level III Joint Commission hospital discharge (20.0%). A comparison of the median number of low-risk births overall and by neonatal intensive care unit level showed a decreasing number across the linked and hospital discharge measures. Again, a wide gap in low-risk cesarean delivery rates was identified between linked measures and hospital discharge measures. However, this gap narrowed as hospital rates increased. CONCLUSION: Quality monitoring of low-risk cesarean delivery rates measured by the nulliparous, term, singleton, vertex metric using the birth certificate was fairly accurate and provided timely assessment for use by Florida hospitals. The nulliparous, term, singleton, vertex birth certificate rates were comparable with low-risk metrics using the linked data source. Overall, metrics used within the same data source had similar rates, with the Society for Maternal-Fetal Medicine metric having the lowest rates. Across data sources, metrics using hospital discharge data only resulted in substantially underestimated rates because of the inclusion of multiparous women and should be interpreted with caution.

Evaluation of Administrative Data for Identifying Maternal Opioid Use at Delivery in Florida.

OBJECTIVES: Studies have shown significant increases in the prevalence of maternal opioid use. Most prevalence estimates are based on unverified ICD-10-CM diagnoses. This study determined the accuracy of ICD-10-CM opioid-related diagnosis codes documented during delivery and examined potential associations between maternal/hospital characteristics and diagnosis with an opioid-related code. METHODS: To identify people with prenatal opioid use, we identified a sample of infants born during 2017-2018 in Florida with a NAS related diagnosis code (P96.1) and confirmatory NAS characteristics (N = 460). Delivery records were scanned for opioid-related diagnoses and prenatal opioid use was confirmed through record review. The accuracy of each opioid-related code was measured using positive predictive value (PPV) and sensitivity. Modified Poisson regression was used to calculate adjusted relative risks (aRR) and 95% confidence intervals (CI). RESULTS: We found the PPV was nearly 100% for all ICD-10-CM opioid-related codes (98.5-100%) and the sensitivity was 65.9%. Non-Hispanic Black mothers were 1.8 times more likely than non-Hispanic white mothers to have a missed opioid-related diagnosis at delivery (aRR:1.80, CI 1.14-2.84). Mothers who delivered at a teaching status hospital were less likely to have a missed opioid-related diagnosis (p < 0.05). CONCLUSIONS FOR PRACTICE: We observed high accuracy of maternal opioid-related diagnosis codes at delivery. However, our findings suggest that over 30% of mothers with opioid use may not be diagnosed with an opioid-related code at delivery, although their infant had a confirmed NAS diagnosis. This study provides information on the utility and accuracy of ICD-10-CM opioid-related codes at delivery among mothers of infants with NAS.

From 2010 to 2017, maternal opioid-related diagnoses at delivery increased by 100% in the US. Most prevalence estimates are based on unverified ICD-10-CM diagnosis codes. Evaluations of maternal opioid-related diagnoses at delivery are extremely limited but essential for utilizing prevalence estimates generated from administrative data.

Race and Ethnicity Misclassification in Hospital Discharge Data and the Impact on Differences in Severe Maternal Morbidity Rates in Florida.

Hospital discharge (HD) records contain important information that is used in public health and health care sectors. It is becoming increasingly common to rely mostly or exclusively on HD data to assess and monitor severe maternal morbidity (SMM) overall and by sociodemographic characteristics, including race and ethnicity. Limited studies have validated race and ethnicity in HD or provided estimates on the impact of assessing health differences in maternity populations. This study aims to determine the differences in race and ethnicity reporting between HD and birth certificate (BC) data for maternity hospitals in Florida and to estimate the impact of race and ethnicity misclassification on state- and hospital-specific SMM rates. We conducted a population-based retrospective study of live births using linked BC and HD records from 2016 to 2019 (n = 783,753). BC data were used as the gold standard. Race and ethnicity were categorized as non-Hispanic (NH)-White, NH-Black, Hispanic, NH-Asian Pacific Islander (API), and NH-American Indian or Alaskan Native (AIAN). Overall, race and ethnicity misclassification and its impact on SMM at the state- and hospital levels were estimated. At the state level, NH-AIAN women were the most misclassified (sensitivity: 28.2%; positive predictive value (PPV): 25.2%) and were commonly classified as NH-API (30.3%) in HD records. NH-API women were the next most misclassified (sensitivity: 57.3%; PPV: 85.4%) and were commonly classified as NH-White (5.8%) or NH-other (5.5%). At the hospital level, wide variation in sensitivity and PPV with negative skewing was identified, particularly for NH-White, Hispanic, and NH-API women. Misclassification did not result in large differences in SMM rates at the state level for all race and ethnicity categories except for NH-AIAN women (% difference 78.7). However, at the hospital level, Hispanic women had wide variability of a percent difference in SMM rates and were more likely to have underestimated SMM rates. Reducing race and ethnicity misclassification on HD records is key in assessing and addressing SMM differences and better informing surveillance, research, and quality improvement efforts.

Treatment access for opioid use disorder among women with medicaid in Florida.

INTRODUCTION: Opioid use disorder (OUD) remains prevalent. Medications for OUD (MOUD) are standard care for pregnant and non-pregnant women. Previous research has identified barriers to MOUD for women with Medicaid but did not account for the type of MOUD (methadone vs. buprenorphine) or pregnancy status. We examined access to MOUD by treatment type for pregnant and non-pregnant women with Medicaid in Florida. METHODS: A secondary analysis of Florida "secret-shopper" data was conducted. Calls were made to clinicians from the 2018 Substance Abuse and Mental Health Services Administration provider list by women posing as either a pregnant or non-pregnant woman with OUD and Medicaid. We examined 546 calls to buprenorphine-waivered providers (BWP) and 139 to opioid treatment programs (OTP). Counts and percentages were used to describe caller success by type of treatment and pregnancy status. Chi-square tests were used to identify statistical differences. RESULTS: Only 42 % of calls reached a treatment provider in Florida. Pregnant and non-pregnant women were less likely to obtain an appointment with Medicaid coverage by a BWP than an OTP (p < 0.01). Nearly 40 % of OTPs offered appointments to callers with Medicaid compared to only 17 % of BWPs. Both types of providers denied appointments more often for pregnant women. Thirty-eight percent of BWP's and 12 % of OTP's denied appointments to pregnant women using cash or Medicaid payment. CONCLUSIONS: Our study demonstrates logistical and financial barriers to treatment for OUD among pregnant and non-pregnant women with Medicaid in Florida and highlights the need for improved systems of care.

MCH Leadership Training Program: An Innovative Application of an Implementation Science Framework.

INTRODUCTION: MCH training programs in schools of public health provide specialized training to develop culturally competent and skilled MCH leaders who will play key roles in public health infrastructure. Previous literature has reported on the effectiveness of MCH training programs (e.g., number of trainees, improvement in knowledge/skills); less attention has been devoted to understanding factors influencing program implementation during times of rapid change, while considering internal and external contexts (e.g., global pandemic, social unrest, uncertainty of funding, mental health issues, and other crises). PURPOSE: This article describes a graduate-level MCH leadership training program and illustrates how an implementation science framework can inform the identification of determinants and lessons learned during one year of implementation of a multi-year program. ASSESSMENT: Findings reveal how CFIR can be applicable to a MCH training program and highlight how constructs across domains can interact and represent determinants that serve as both a barrier and facilitator. Key lessons learned included the value of accountability, flexibility, learner-centeredness, and partnerships. CONCLUSION: Findings may apply to other programs and settings and could advance innovative training efforts that necessitate attention to the multi-level stakeholder needs (e.g., student, program, institution, community, and local/regional/national levels). Applying CFIR could be useful when interpreting process and outcome evaluation data and transferring findings and lessons learned to other organizations and settings. Integrating implementation science specifically into MCH training programs could contribute to the rigor, adaptability, and dissemination efforts that are critical when learning and sharing best practices to expand leadership capacity efforts that aim to eliminate MCH disparities across systems.

Refreshing the Perinatal Periods of Risk: A New Reference Group and Nationwide Large-County-Level Analyses.

INTRODUCTION: The Perinatal Periods of Risk approach (PPOR) is designed for use by communities to assess and address the causes of high fetal-infant mortality rates using vital records data. The approach is widely used by local health departments and their community and academic partners to inform and motivate systems changes. PPOR was developed and tested in communities based on data years from 1995 to 2002. Unfortunately, a national reference group has not been published since then, primarily due to fetal death data quality limitations. METHODS: This paper assesses data quality and creates a set of unbiased national reference groups using 2014-2016 national vital records data. Phase 1 and Phase 2 analytic methods were used to divide excess mortality into six components and create percentile plots to summarize the distribution of 100 large US counties for each component. RESULTS: Eight states with poor fetal death data quality were omitted from the reference groups to reduce bias due to missing maternal demographic information. There are large Black-White disparities among reference groups with the same age and education restrictions, and these vary by component. PPOR results vary by region, maternal demographics, and county. The magnitude of excess mortality components varies widely across US counties. DISCUSSION: New national reference groups will allow more communities to do PPOR. Percentile plots of 100 large US counties provide an additional benchmark for new communities using PPOR and help emphasize problem areas and potential solutions.

An Initiative "that you do for one person": Identifying Barriers and Facilitators to Implementing an Immediate Postpartum LARC Initiative in Florida Hospitals.

INTRODUCTION: In the United States (U.S.), perinatal quality improvement collaboratives have pursued implementing immediate postpartum long-acting reversible contraception (LARC) initiatives to increase people's access to contraception and support their fertility desires. This process evaluation aimed to identify barriers and facilitators to implementing an immediate postpartum LARC initiative in Florida. METHODS: Data collection included in-depth qualitative assessments (i.e., interviews, small focus group discussions) with hospitals in pre- and early stages of the implementation process. Snowball sampling was used to recruit participants. Interviews were conducted in-person or via Zoom or phone and were audio-recorded and transcribed verbatim. Four of the five domains within the Consolidated Framework for Implementation Research (e.g., process, intervention characteristics, inner and outer settings) informed the study design and data collection/analysis. RESULTS: Fourteen staff of diverse job roles from five hospitals participated. Factors that facilitated implementation were the strength of the evidence, relative advantage, internal and external networks, and engaging staff. Barriers to implementation included billing and reimbursement and needing significant support from external networks to progress through implementation phases. DISCUSSION: Findings suggest that depending on the task or phase, multiple factors work in tandem to serve as implementation barriers and facilitators. Additionally, evaluating hospitals' progress at the pre- and early implementation phases was critical for quickly finding solutions and benefited other hospitals in different stages. As this initiative requires substantial support, health systems should create and sustain a culture of excellence and efficiency to facilitate implementing initiatives that improve care quality.

Variations in Low-Risk Cesarean Delivery Rates in the United States Using the Society for Maternal-Fetal Medicine Definition.

OBJECTIVE: To assess variations in low-risk cesarean delivery rates in the United States using the Society for Maternal-Fetal Medicine (SMFM) definition of low-risk for cesarean delivery and to identify factors associated with low-risk cesarean deliveries. METHODS: From hospital discharge data in the 2018 National Inpatient Sample and State Inpatient Databases, we identified deliveries that were low-risk for cesarean delivery using the SMFM definition based on the International Classification of Diseases, Tenth Revision, Clinical Modification codes. We estimated national low-risk cesarean delivery rates overall and by patient characteristics, clinically relevant conditions not included in the SMFM definition, and hospital characteristics based on the nationally representative sample of hospital discharges in the National Inpatient Sample. Multivariate logistic regressions were estimated for the national sample to identify factors associated with low-risk cesarean delivery. We reported low-risk cesarean delivery rates for 27 states and the District of Columbia based on the annual state data that represented the universe of hospital discharges from participating states in the State Inpatient Databases. RESULTS: Of an estimated 3,634,724 deliveries in the 2018 National Inpatient Sample, 2,484,874 low-risk deliveries met inclusion criteria. The national low-risk cesarean delivery rate in 2018 was 14.6% (95% CI 14.4-14.8%). The rates varied widely by state (range 8.9-18.6%). Nationally, maternal age older than 40 years, non-Hispanic Black or Asian race, private insurance as primary payer, admission on weekday, obesity, diabetes, or hypertension, large metropolitan residence, and hospitals of the South census region were associated with low-risk cesarean delivery. CONCLUSION: Approximately one in seven low-risk deliveries was by cesarean in 2018 in the United States using the SMFM definition and the low-risk cesarean delivery rates varied widely by state.

Multilevel factors associated with length of stay for neonatal abstinence syndrome in Florida's NICUs: 2010-2015.

OBJECTIVE: To investigate potential factors influencing initial length of hospital stay (LOS) for infants with neonatal abstinence syndrome (NAS) in Florida. METHODS: The study population included 2984 term, singleton live births in 33 Florida hospitals. We used hierarchical linear modeling to evaluate the association of community, hospital, and individual factors with LOS. RESULTS: The average LOS of infants diagnosed with NAS varied significantly across hospitals. Individual-level factors associated with increased LOS for NAS included event year (P < 0.001), gestational age at birth (P < 0.001), maternal age (P = 0.002), maternal race and ethnicity (P < 0.001), maternal education (P = 0.032), and prenatal care adequacy (P < 0.001). Average annual hospital NAS volume (P = 0.022) was a significant hospital factor. CONCLUSION: NAS varies widely across hospitals in Florida. In addition to focusing on treatment regimens, to reduce LOS, public health and quality improvement initiatives should identify and adopt strategies that can minimize the prevalence and impact of these contributing factors.

Diagnosis Codes and Case Definitions for Neonatal Abstinence Syndrome.

BACKGROUND AND OBJECTIVES: The increase in neonatal abstinence syndrome (NAS) has underscored the need for NAS surveillance programs, but many rely on passive surveillance using unverified diagnosis codes. Few studies have evaluated the validity of these codes, and no study has assessed the recently proposed Council of State and Territorial Epidemiologists (CSTE) case definition. The Florida Birth Defects Registry investigated the accuracy of International Classification of Diseases, 10th Revision, Clinical Modification codes related to NAS (P96.1 and P04.49) and assessed the sensitivity of the CSTE case definition. METHODS: We identified a sample of infants born during 2016 coded with P96.1 and/or P04.49. Record review was completed for 128 cases coded with P96.1, 68 with P04.49, and 7 with both codes. Lacking consensus regarding a gold standard definition of NAS, we used clinical data to classify each case using the Florida and CSTE definitions. The code-specific accuracy was measured by using the positive predictive value (PPV). The clinical characteristics indicative of NAS were compared for case classification based on both definitions. RESULTS: By using the Florida definition, the overall PPV was 68% but varied by code: 95.3% for P96.1 and 13.2% for P04.49. The overall (47.8%) and code-specific PPVs were lower by using the CSTE definition. Comparison of clinical characteristics demonstrated that 60.7% of cases classified as no NAS by using the CSTE definition had robust clinical signs of NAS. In our sample, the CSTE case definition underestimated NAS prevalence. CONCLUSIONS: Only the P96.1 International Classification of Diseases, 10th Revision, Clinical Modification code displayed high accuracy. Discordance in NAS case definitions and surveillance methodologies may result in erroneous comparisons and conclusions that negatively impact NAS-related surveillance and research.

Sleep duration patterns from adolescence to young adulthood and the risk of asthma.

PURPOSE: This study examined the association between sleep duration trajectories from adolescence to young adulthood and the risk of asthma into young adulthood. METHODS: Using data from 10,362 participants in the National Longitudinal Study of Adolescent to Adult Health (Add Health) free of asthma at baseline, we constructed trajectories of sleep duration from adolescence (age 13-18 years) to young adulthood (age 24-32 years) and used them to examine the association between sleep duration patterns and the risk of new-onset asthma using a log-binomial regression model after adjusting for potential confounders. RESULTS: The results revealed that 14.4% of nonasthmatic participants had persistent short sleep duration, whereas 80.0% had adequate sleep duration from adolescence through young adulthood. Consistently short-sleepers had 1.52 times the risk of new-onset asthma by age 32 years (95% CI 1.11, 2.10) compared with consistently adequate sleepers. The association was stronger in those with a family history of asthma (aRR = 2.43, 95% CI 1.15, 5.13) than in those without such history (aRR = 1.43, 95% CI 1.05, 1.95). CONCLUSIONS: We conclude that persistent short sleep duration is associated with an increased risk of new-onset asthma in young adults. This association may be more pronounced among those at high risk of asthma because of family history.

Patients and providers' knowledge, attitudes, and beliefs regarding immediate postpartum long-acting reversible contraception: a systematic review.

The American College of Obstetricians and Gynecologists recommends long-acting reversible contraception (LARC) immediately postpartum for preventing unintended pregnancy. This systematic review identified patients' and providers' knowledge, attitudes, and beliefs regarding immediate postpartum LARC use. Web of Science, Embase, PubMed, PsychInfo, and CINHAL databases (from inception to December 2018) were searched using LARC and immediate postpartum as search terms. The inclusion criteria were observational US studies, peer-reviewed, and English language, and the exclusion criterion was published abstracts only. The search yielded 4140 articles, and 18 articles were included in the final sample. Articles focused on women (n = 6) emphasizing patient preferences about the use of postpartum intrauterine devices (IUDs) and comprised samples of postpartum women. Among articles focused on providers (n = 12), knowledge regarding immediate postpartum LARCs varied. Providers reported lack of training and lack of comfort with regard to counseling and insertion as barriers to providing postpartum IUDs. This review identified literature regarding patient and provider perspectives on immediate postpartum LARC. Future work should ascertain patients' and providers' needs and preferences for integrating LARC counseling as a viable contraception option during the immediate postpartum period, ultimately promoting optimal inter-pregnancy intervals and overall health for women and future offspring.

Assessing the Burden of Neonatal Abstinence Syndrome: Validation of ICD-9-CM Data, Florida, 2010-2011.

CONTEXT: On October 1, 2015, the United States transitioned from using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) to ICD-10-CM. Continuing to monitor the burden of neonatal abstinence syndrome (NAS) after the transition presently requires use of data dependent on ICD-9-CM coding to enable trend analyses. Little has been published on the validation of using ICD-9-CM codes to identify NAS cases. OBJECTIVE: To assess the validity of hospital discharge data (HDD) from selected Florida hospitals for passive NAS surveillance, based on ICD-9-CM codes, which are used to quantify baseline prevalence of NAS. DESIGN: We reviewed infant and maternal data for all births at 3 Florida hospitals from 2010 to 2011. Potential NAS cases included infants with ICD-9-CM discharge codes 779.5 and/or 760.72 in linked administrative data (ie, HDD linked to vital records) or in unlinked HDD and infants identified through review of neonatal intensive care unit admission logs or inpatient pharmacy records. Confirmed infant cases met 3 clinician-proposed criteria. Sensitivity and positive predictive value were calculated to assess validity for the 2 ICD-9-CM codes, individually and combined. RESULTS: Of 157 confirmed cases, 134 with 779.5 and/or 760.72 codes were captured in linked HDD (sensitivity = 85.4%) and 151 in unlinked HDD (sensitivity = 96.2%). Positive predictive value was 74.9% for linked HDD and 75.5% for unlinked HDD. For either HDD types, the single 779.5 code had the highest positive predictive value (86%), lowest number of false positives, and good to excellent sensitivity. CONCLUSIONS: Passive surveillance using ICD-9-CM code 779.5 in either linked or unlinked HDD identified NAS cases with reasonable validity. Our work supports the use of ICD-9-CM code 779.5 to assess the baseline prevalence of NAS through 2015.

Gestational Weight Loss: Comparison Between the Birth Certificate and the Medical Record, Florida, 2012.

Objective Examine agreement with the medical record (MR) when gestational weight loss (GWL) on the Florida birth certificate (BC) is ≥ 0 pounds (lbs). Methods In 2012, 3923 Florida-resident women had a live, singleton birth where BC indicated GWL ≥ 0 lbs. Of these, we selected a stratified random sample of 2141 and abstracted from the MR prepregnancy and delivery weight data used to compute four estimates of GWL (delivery minus prepregnancy weight) from different sources found within the MR (first prenatal visit record, nursing admission record, labor/delivery records, BC worksheet). We assessed agreement between the BC and MR estimates for GWL categorized as 0, 1-10, 11-19, and ≥ 20 lbs. Results Prepregnancy or delivery weight was missing or source not in the MR for 23-81% of records. Overall agreement on GWL between the BC and the four MR estimates ranged from 39.1 to 57.2%. Agreement by GWL category ranged from 10.6 to 38.0% for 0 lbs, 47.6 to 64.3% for 1-10 lbs, 49.5 to 60.0% for 11-19 lbs, and 47.8 to 67.7% for ≥ 20 lbs. Conclusions Prepregnancy and delivery weight were frequently missing from the MR or inconsistently documented across the different sources. When the BC indicated GWL ≥ 0 lbs, agreement with different sources of the MR was moderate to poor revealing the need to reduce missing data and better understand the quality of weight data in the MR.

Florida Populations Most at Risk of Not Being Up to Date With Colorectal Cancer Screening.

INTRODUCTION: The purpose of this study was to examine the characteristics of populations at risk of not being up to date on colorectal cancer screening in Florida. METHODS: We used Exhaustive Chi-squared Automatic Interaction Detection, a classification tree analysis, to identify subgroups not up to date with colorectal cancer screening using the 2013 Florida Behavioral Risk Factor Surveillance System. The data set was restricted to adults aged 50 to 75 years (n = 14,756). RESULTS: Only 65.5% of the sample was up to date on colorectal cancer screening. Having no insurance and having a primary care provider were the most significant predictors of not being up to date on screening. The highest risk subgroups were 1) respondents with no insurance and no primary care provider, regardless of their employment status (screening rate, 12.1%-23.7%); 2) respondents with no insurance but had a primary care provider and were employed (screening rate, 32.3%); and 3) respondents with insurance, who were younger than 55 years, and who were current smokers (screening rate, 42.0%). CONCLUSION: Some populations in Florida are at high risk for not being up to date on colorectal cancer screening. To achieve Healthy People 2020 goals, interventions may need to be further tailored to target these subgroups.

The Collaborative Improvement and Innovation Network (CoIIN) to Reduce Infant Mortality: An Outcome Evaluation From the US South, 2011 to 2014.

OBJECTIVES: To evaluate the impact of the Southern Public Health Regions' (Regions IV and IV) Collaborative Improvement and Innovation Network (CoIIN) to Reduce Infant Mortality, supported by the US Health Resources and Services Administration. METHODS: We examined pre-post change (2011-2014) for CoIIN strategies with available outcome data from vital records (early elective delivery, smoking) and the Pregnancy Risk Assessment Monitoring System (safe sleep) as well as preterm birth and infant mortality for Regions IV and VI relative to all other regions. RESULTS: For most outcomes, CoIIN improvements were greater in Regions IV and VI than in other regions. For example, early elective delivery decreased by 22% versus 14% in other regions, smoking cessation during pregnancy increased by 7% versus 2%, and back sleep position increased by 5% versus 2%. Preterm birth decreased by 4%, twice that observed in other regions, but infant mortality reductions did not differ significantly. CONCLUSIONS: The CoIIN approach to public health improvement shows promise in accelerating progress in intermediate outcomes and preterm birth. Impact on infant mortality may require additional strategies and sustained efforts.

Human papillomavirus vaccine information, motivation, and behavioral skills among young adult US women.

This study elicited the information needs, motivations, and behavioral skills related to human papillomavirus vaccine decision-making among young adult women. Interviews were conducted with college women, aged 18-26 years, and stratified by recently vaccinated ( N = 25) and unvaccinated ( N = 25). Comparative thematic analysis using the Information, Motivation, and Behavioral Skills Model was conducted. Healthcare providers were identified as the most trusted sources for information. While unvaccinated women did not have experience receiving the vaccine, they reported the same procedural knowledge for vaccination. These findings suggest that young adult women have the information and procedural knowledge for human papillomavirus vaccination, but motivations may influence their decision-making.