Induction of labor in twin compared with singleton pregnancies.

OBJECTIVE: To estimate the likelihood of cesarean delivery and length of labor in twin pregnancies undergoing induction of labor as compared with singleton pregnancies. METHODS: This was a retrospective cohort study of 100 patients with twin pregnancy in one maternal-fetal medicine practice undergoing induction of labor from 2005 to 2012. The control group was 100 randomly selected patients in the same practice with a singleton pregnancy undergoing induction of labor over the same time period. The primary outcome was mode of delivery (vaginal or cesarean). RESULTS: The likelihood of cesarean delivery did not differ between the groups (19% in twins compared with 21% in singletons, P=.724) nor did the time from induction to vaginal delivery (median and interquartile time 9.7 [5.5-12.5] hours in twins compared with 10.4 [6.6, 14.1] hours in singletons, P=.255). Results were not different when we looked at nulliparous patients only or multiparous patients only. On adjusted analysis of risk factors for cesarean delivery in patients undergoing induction, twin pregnancy was not independently associated with cesarean delivery. CONCLUSION: Patients with twin pregnancies undergoing induction of labor have a similar risk of cesarean delivery and a similar length of labor as patients with singleton pregnancies undergoing induction of labor. LEVEL OF EVIDENCE: II.

An evidence integration triangle for aligning science with policy and practice.

Over-reliance on decontextualized, standardized implementation of efficacy evidence has contributed to slow integration of evidence-based interventions into health policy and practice. This article describes an "evidence integration triangle" (EIT) to guide translation, implementation, prevention efforts, comparative effectiveness research, funding, and policymaking. The EIT emphasizes interactions among three related components needed for effective evidence implementation: (1) practical evidence-based interventions; (2) pragmatic, longitudinal measures of progress; and (3) participatory implementation processes. At the center of the EIT is active engagement of key stakeholders and scientific evidence and attention to the context in which a program is implemented. The EIT model is a straightforward framework to guide practice, research, and policy toward greater effectiveness and is designed to be applicable across multiple levels-from individual-focused and patient-provider interventions, to health systems and policy-level change initiatives.

Harmonized patient-reported data elements in the electronic health record: supporting meaningful use by primary care action on health behaviors and key psychosocial factors.

BACKGROUND: Electronic health records (EHR) have the potential to improve patient care through efficient access to complete patient health information. This potential may not be reached because many of the most important determinants of health outcome are rarely included. Successful health promotion and disease prevention requires patient-reported data reflecting health behaviors and psychosocial issues. Furthermore, there is a need to harmonize this information across different EHR systems. METHODS: To fill this gap a three-phased process was used to conceptualize, identify and recommend patient-reported data elements on health behaviors and psychosocial factors for the EHR. Expert panels (n=13) identified candidate measures (phase 1) that were reviewed and rated by a wide range of health professionals (n=93) using the grid-enabled measures wiki social media platform (phase 2). Recommendations were finalized through a town hall meeting with key stakeholders including patients, providers, researchers, policy makers, and representatives from healthcare settings (phase 3). RESULTS: Nine key elements from three areas emerged as the initial critical patient-reported elements to incorporate systematically into EHR--health behaviors (eg, exercise), psychosocial issues (eg, distress), and patient-centered factors (eg, demographics). Recommendations were also made regarding the frequency of collection ranging from a single assessment (eg, demographic characteristics), to annual assessment (eg, health behaviors), or more frequent (eg, patient goals). CONCLUSIONS: There was strong stakeholder support for this initiative reflecting the perceived value of incorporating patient-reported elements into EHR. The next steps will include testing the feasibility of incorporating these elements into the EHR across diverse primary care settings.

Prolonged gonadotropin stimulation is associated with decreased ART success.

PURPOSE: to evaluate whether the duration of gonadotropin stimulation predicts the likelihood of live birth after ART. METHODS: all IVF or ICSI cycles using fresh autologous oocytes at our institution between January 2004 and December 2007 were analyzed. RESULTS: out of 699 cycles resulting in oocyte retrieval, 193 produced a live birth (27.6%). Women who achieved a live birth had a significantly shorter stimulation phase (11.1 vs. 11.5 days, respectively). Multivariable analysis suggested that 13 days or longer of stimulation decreased the likelihood of a live birth by 53% as compared to cycles that were 10-12 days long (odds ratio [OR] 0.47; 95% confidence interval [CI]: 0.30-0.75) after adjustment for female age, maximum historical FSH, total dose of gonadotropin received, oocytes retrieved, embryos transferred, antagonist suppression and PCOS diagnosis. CONCLUSIONS: prolonged duration of gonadotropin stimulation is an independent negative predictor of ART success in our cohort.

Maintenance of long-term behavior change.

OBJECTIVES: To describe the formation and work of the Health Maintenance Consortium (HMC), a collaborative of researchers funded by the National Institutes of Health to study long-term behavior change across a variety of diseases and conditions. METHODS: The historical development of the program, especially the focus on behavior change maintenance, is briefly described. Previous work on behavior change that paved the way for the HMC is also discussed. RESULTS: Aiming to accelerate the pace of discovery and application, NIH funding to create the HMC has created a strong research base for making progress toward filling key knowledge and intervention gaps in long-term behavior change. CONCLUSIONS: Investments in behavior change and maintenance have yielded important information that can be used to guide the development of future programs to improve health.

Computer-administered screening of reproductive-aged women for diabetes risk in primary care settings, feasibility and acceptability of such screening, and validity of risk assessments based on self-reported weight.

INTRODUCTION: Obesity, a major public health problem, is the key modifiable component of diabetes risk. Addressing obesity and diabetes risk during primary care visits is recommended but, because of time constraints, is often difficult for health care providers to do. The purpose of this study was to determine whether technology can streamline risk assessment and leave more time to educate patients. We also tested the validity of self-reported weight in assessing diabetes risk. METHODS: We recruited English-speaking women aged 18 to 44 years who came to a clinic for medical appointments from July through October 2003. Study participants completed a self-administered computer questionnaire that collected the following data: weight, height, family history of diabetes, level of exercise, amount of television time, and daily servings of fruits and vegetables. Self-reported and scale-measured weights were compared to determine the effect of self-reported weight on results of the American Diabetes Association's Diabetes Risk Test (DRT). In determining the sensitivity and specificity of self-reported weight, we used scale measurements as the standard. RESULTS: Complete data were collected on 231 women, including 214 women without a history of a diabetes diagnosis. Compared with DRT results (determined by scale-measured weight), questionnaire results (determined by self-reported weight) had sensitivities of 93.9% (95% confidence interval [CI], 85.2%-97.6%) for high risk for diabetes and 90.4% (95% CI, 83.3%-94.7%) for moderate risk. The specificity of the self-administered DRT for any diabetes risk was 97.8% (95% CI, 88.4%-99.6%). About half the women reported discussing nutrition and exercise with their health care providers CONCLUSION: Health care professionals can provide personalized diabetes education and counseling on the basis of information collected by self-administered computerized questionnaires. In general, patients provided a self-reported weight that did not substantially bias estimates of diabetes risk.

Summary of the 2000 Surgeon General's listening session: toward a national action plan on overweight and obesity.

OBJECTIVE: To provide insight into discussions at the Surgeon General's Listening Session, "Toward a National Action Plan on Overweight and Obesity," and to complement The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity. RESEARCH METHODS AND PROCEDURES: On December 7 and 8, 2000, representatives from federal, state, academic, and private sectors attended the Surgeon General's Listening Session and were given an opportunity to recommend what to include in a national plan to address overweight and obesity. The public was invited to comment during a corresponding public comment period. The Surgeon General's Listening Session was also broadcast on the Internet, allowing others to view the deliberations live or access the archived files. Significant discussion points from the Listening Session have been reviewed by representatives of the federal agencies and are the basis of this complementary document. RESULTS: Examples of issues, strategies, and barriers to change are discussed within five thematic areas: schools, health care, family and community, worksite, and media. Suggested cooperative or collaborative actions for preventing and decreasing overweight and obesity are described. An annotated list of some programmatic partnerships is included. DISCUSSION: The Surgeon General's Listening Session provided an opportunity for representatives from family and community groups, schools, the media, the health-care environment, and worksites to become partners and to unite around the common goal of preventing and decreasing overweight and obesity. The combination of approaches from these perspectives offers a rich resource of opportunity to combat the public health epidemic of overweight and obesity.