Empirical evidence on COVID-19 vaccination and lactation-related outcomes remains limited. We used electronic health record data from 4 US healthcare systems to assess the association between COVID-19 vaccination and milk feeding outcomes. We included pregnant persons with a live birth between December 2020 and September 2022 with infant linkage. We assessed 2 COVID-19 vaccination exposure windows-during pregnancy (≥20 weeks gestation vs no vaccination during pregnancy) or postpartum (<7 months after delivery vs none). We estimated adjusted prevalence ratios (aPR) for COVID-19 vaccination during pregnancy and human milk feeding non-initiation and discontinuation, and we estimated adjusted hazard ratios (aHR) for postpartum COVID-19 vaccination and human milk feeding discontinuation. In the study population used to assess pregnancy exposure (N = 10 757), 4.2% of birthing parents did not initiate human milk feeding. Non-initiation did not differ by vaccination during pregnancy (aPR = 0.99; 95% CI, 0.98-1.01). Antenatal vaccination was not associated with human milk feeding discontinuation at 2 and 6 months after delivery. In the study population used to assess postpartum exposure (N = 17 161), human milk feeding discontinuation did not differ by postpartum vaccination (aHR = 1.03; 95% CI, 0.95-1.11). COVID-19 vaccination in pregnancy and postpartum were not associated with human milk feeding discontinuation.

BACKGROUND:Serious illness conversation (SIC) is a structured conversation framework designed to improve shared decision making and promote goal-concordant care with patients anticipating end-of-life care decisions. OBJECTIVE:Examine reach, timeliness, and quality of SIC implementation across a health system after implementation of a SIC Program (SICP). Examine factors associated with SIC completion for eligible patients. DESIGN:Retrospective observational cohort study of decedents eligible for SIC from 2022 to 2024 in a large health system in the United States. MEASUREMENTS:Proportion of eligible patients with a documented SIC, demographic and clinical characteristics, timing of SIC relative to eligibility and death, number, and quality of SIC sessions. RESULTS:About 7424 patients met the inclusion criteria, and half (49.5%) of those had SIC documentation. Of those, mean number of SICs was 3.6 (SD 5.56). First documented SIC included defined quality components 31.1% of the time. Factors associated with SIC included palliative care visits (OR 2.26, 95% CI 1.84, 2.78), a primary care provider in the system (OR 1.77, 95% CI 1.59, 1.96), and an inpatient admission with discharge to home care (OR 2.36, 95% CI 2.07, 2.70). Patients with dementia (OR 0.58, 95% CI 0.51, 0.66) were less likely to have SIC. CONCLUSION:Systemwide implementation of an SICP engaged half of eligible patients; many of those had multiple documented conversations prior to death. More work is needed to engage eligible patients, especially those with dementia, and to improve conversation quality.

BACKGROUND:No published study to date has reported on the association between preferred language and COVID-19 vaccine uptake during pregnancy, and even less is known about COVID-19 vaccine disparities during lactation. OBJECTIVES:To assess COVID-19 vaccine uptake during pregnancy and lactation by language, English proficiency, and race/ethnicity. STUDY DESIGN:We conducted a retrospective cohort study using electronic health records (EHR) from four US healthcare systems. The study included patients receiving prenatal care who had a live birth between December 2020 September 2022 and no COVID-19 vaccinations before pregnancy (pregnancy analysis) or delivery (lactation analysis). Self-identified (i) preferred language, (ii) limited English proficiency, based on patient request for an interpreter, and (iii) race and ethnicity were identified from EHR. The primary outcome was receipt of the first dose of the COVID-19 vaccine during pregnancy for the pregnancy analysis, and between delivery and human milk feeding discontinuation, up to 180 days after delivery, for the lactation analysis. Adjusted rate ratios (aRR) and 95% confidence intervals (CI) for receipt of first COVID-19 vaccine dose during pregnancy or lactation were estimated separately. RESULTS:Among 10,332 individuals eligible for initial COVID-19 vaccine during pregnancy, groups with lower uptake during pregnancy included Ethiopian languages (aRR 0.60, 95% CI 0.43-0.83) and Somali (aRR 0.39, 95% CI 0.28-0.54) versus English language, limited versus no limited English proficiency (aRR 0.66, 95% CI 0.58-0.76), and non-Hispanic Black versus White (aRR 0.56, 95% CI 0.51-0.62). Among 9271 individuals, groups with lower uptake during lactation included Ethiopian languages (aRR 0.48, 95% CI 0.30-0.77) and Somali (aRR 0.60, 95% CI 0.46-0.80) versus English language, and non-Hispanic Black versus White (aRR 0.77, 95% CI 0.70-0.86). Temporal trends showed lower vaccine uptake for non-English preferred language and non-Hispanic Black groups during pregnancy and lactation, especially during the earlier months of vaccine roll-out. CONCLUSIONS:There were language and racial/ethnic disparities in initial perinatal COVID-19 vaccination. The findings highlight the need to address language-related and other barriers during the rollout of new vaccines.

OBJECTIVE:Patients with Limited English Proficiency (LEP) experience delays in the initiation of their emergency department (ED) care due to barriers in obtaining a medical interpreter. This delay may negatively affect their experience and lead to downstream health inequities. This study aimed to analyze whether LEP patients wait longer to be seen once they are moved into an ED room. METHODS:This is a retrospective analysis of data from two affiliated EDs with similar ED triage processes. The primary aim was defined as the time to physician self-assignment (TTPS). The TTPS was compared between those who required an interpreter and those who did not. These differences were analyzed using appropriate descriptive and inferential statistical methods. RESULTS:47,038 encounters were included for analysis, with 3259 (6.9%) of these for patients who had a documented need for an interpreter. Weighted median TTPS for patients who required an interpreter was 7.4 [6.7, 8.2] minutes while those who did not require an interpreter was 5.8 [5.7, 5.9] minutes. This difference represented a 27% increase in TTPS relative to patients without interpreter need. When TTPS was stratified by race, this remained statistically significant for White (4.5 min) and Black patients (2.1 min). CONCLUSIONS:In this patient population, patients who required an interpreter waited longer to be evaluated by an emergency provider. The reasons for this difference and the downstream implications of this result remain unclear.

BACKGROUND AND OBJECTIVES Some Minnesota clinicians perceive that the incidence of prophylactic vitamin K refusal is increasing, yet the actual incidence and which populations are most likely to refuse is unknown. Our objective is to identify the incidence of vitamin K refusal and to characterize the maternal-newborn dyads with increased refusal rates. METHODS This retrospective multi-institution study analyzed vitamin K refusal in newborns born from 2015 to 2019. Maternal-newborn dyad delivery and community characteristics (language, religion, population size) were collected and analyzed by univariable and multivariable logistic regression. RESULTS Among 102 451 term infants, 1.3% did not receive intramuscular vitamin K. Refusal increased from 0.9% in 2015 to 1.6% by 2019 (P < .0001). In multivariable analysis, factors associated with increased likelihood of refusal included female sex (odds ratio [OR] 1.22, 95% CI 1.09–1.36), exclusive human milk feeding at hospital discharge (OR 3.46, 95% CI 2.87–4.17), parity greater than 0 (OR ranging from 1.32 [95% CI 1.13–1.54] for parity of 1, to 3.70 [95% CI 2.80–4.90] for parity of 4), having a midwife at delivery (OR 1.70, 95% CI 1.45–2.01), public insurance (OR 1.84, 95% CI 1.60–2.12), and Russian language (OR 4.92, 95% CI 2.90–8.35). Some religious identities had higher refusal rates (ie, Pentecostal 7.0%, Baptist 3.3%). CONCLUSION In a cohort of Minnesota hospital-born infants, the incidence of vitamin K refusal increased between 2015 and 2019. We identified large populations (eg, public insurance, exclusive human milk feeding) and smaller discrete communities (eg, Russian, Pentecostal) with opportunities for increasing prophylactic vitamin K acceptance through targeted community conversations.

BACKGROUND:In the United States, birthing parent-infant dyads may receive care from multiple healthcare systems. Linkage of an individual's electronic health records (EHR) across healthcare systems, in addition to birthing parent-infant linkage, may be necessary to obtain appropriate clinical data for perinatal health research. OBJECTIVES:To develop a privacy-preserving process to link the health records of patients shared by two health systems for a perinatal health study, and to assess data enhancements associated with the linkage. METHODS:We included pregnant patients who received care from at least one of two healthcare systems based in Minnesota, USA and their infants born between December 2020 and September 2022 who had at least one well visit. We identified infants from one health system with birthing parents who potentially received care in the second health system based on the infant's delivery hospital. We implemented a one-way matching process using an algorithm to generate unique hash values for each record at each health system. Specifically, we used four hash ID rules based on six identifiers available in the EHR at both sites plus a consistent salt. RESULTS:One health system identified 3524 infants with birthing parents who potentially received care in the second system. The second system identified 39,321 infants delivered at the hospitals of interest during the study period. The algorithm matched 3406 (96.7%) infant records. After applying the study eligibility criteria, the birthing-parent records gained through hash matching increased the study population by 7.2% from 8100 to 8686. Overall, 13.6% of the study population had data from the second health system. Some demographic and pregnancy characteristics differed from those with data from the first system only. CONCLUSIONS:The hash matching approach can increase study size, patient diversity, and data completeness in a privacy-preserving manner for perinatal health studies among patients that use multiple healthcare systems.

This cohort study evaluates the performance of dried blood spot polymerase chain reaction (PCR) testing for the identification of congenital cytomegalovirus among infants in Minnesota.

Background: Preeclampsia is a leading cause of maternal mortality, puerperal ICU admission, and iatrogenic preterm delivery. Some small studies suggest that acupuncture and acupressure may improve blood pressure, but few studies have examined the impact of these treatments on outcomes in patients with preterm preeclampsia with severe features.Objective: This retrospective chart review study assessed if acupuncture/acupressure (AQ/AP) in conjunction with routine care is associated with longer time from admission to delivery or gestational age at delivery in hospitalized patients with preterm preeclampsia compared to routine care alone. Secondary outcomes included breakthrough antihypertensive use, mean arterial pressure (MAP), postpartum length of stay, ICU admission, measures of hepatic and renal function, platelet counts, birthweights, and 5-min Apgar scores.Study Design: This was a retrospective matched cohort study (2010-2020) of patients with preterm preeclampsia with severe features admitted for expectant management. Patients receiving AQ/AP were matched with controls who received only routine care.Results: The final sample of 100 matched pairs found the mean latency period from admission to delivery was 2.5 days longer in the AQ/AP group (95% CI: 0.81-4.26, p = 0.004). Breakthrough antihypertensive medication use, changes in MAP, and other biomarkers did not differ significantly.Conclusion: Among patients hospitalized for preeclampsia with severe features, those who received acupuncture and/or acupressure treatment had a longer time to delivery than matched controls, but AQ/AP treatment was not significantly associated with MAP or use of breakthrough antihypertensive medication.

This study aimed to assess clinical efficiency and maternal and neonatal outcomes for patients who underwent outpatient cervical ripening using mechanical methods (osmotic dilators and Foley balloon) compared with patients who underwent inpatient ripening.A retrospective cohort study from March 2020 to March 2022 compared patients with low-risk, term, singleton pregnancies who underwent outpatient cervical ripening to clinically similar patients who had inpatient ripening. Inverse probability of treatment weighting for analysis of outcomes to account for differences in groups and comparisons of outcomes are reported as mean differences with 95% confidence intervals (CIs).The cohort included 391 patients (116 outpatient, 275 inpatient). Among the outpatient group, half used only mechanical devices, and all others received additional pharmacological methods after admission for labor induction. Among the inpatient group, the most common cervical ripening method was pharmacological only (66.2%), followed by both pharmacological and mechanical (25.8%), and 8% used only mechanical. After outpatient cervical ripening, patients had significantly higher cervical dilation (mean difference 1.9 cm, 95% CI: 1.6, 2.3) and simplified bishop scores (mean difference 1.6, 95% CI: 1.2, 2.1) on admission compared with the inpatient group. The average time from admission to delivery was 5.8 hours shorter (95% CI: -8.6, -2.9) for the outpatient group compared with the inpatient group, and the average total length of stay was 7.1 hours shorter (95% CI: -12.1, -2.1) for the outpatients among patients with vaginal deliveries. Both groups had similar hours of oxytocin use, and mode of delivery, and did not differ for maternal complications or neonatal outcomes.Outpatient cervical ripening using multiple mechanical methods was associated with significantly higher cervical dilation, shorter average time from patient admission to delivery, and shorter total length of stay for vaginal deliveries. Outpatient cervical ripening may be an important option for easing resource utilization for induced labor. · Outpatient cervical ripening resulted in superior cervical dilation and Bishop scores.. · Hospital length of stay was shorter for those receiving outpatient cervical ripening.. · Maternal complications and neonatal outcomes did not differ by setting..

OBJECTIVES: Systemic thrombolysis improves outcomes in patients with pulmonary embolism (PE) but is associated with the risk of hemorrhage. The data on efficacy and safety of reduced-dose alteplase are limited. The study objective was to compare the characteristics, outcomes, and complications of patients with PE treated with full- or reduced-dose alteplase regimens. DESIGN: Multicenter retrospective observational study. SETTING: Tertiary care hospital and 15 community and academic centers of a large healthcare system. PATIENTS: Hospitalized patients with PE treated with systemic alteplase. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Pre- and post-alteplase hemodynamic and respiratory variables, patient outcomes, and complications were compared. Propensity score (PS) weighting was used to adjust for imbalances of baseline characteristics between reduced- and full-dose patients. Separate analyses were performed using the unweighted and weighted cohorts. Ninety-eight patients were treated with full-dose (100 mg) and 186 with reduced-dose (50 mg) regimens. Following alteplase, significant improvements in shock index, blood pressure, heart rate, respiratory rate, and supplemental oxygen requirements were observed in both groups. Hemorrhagic complications were lower with the reduced-dose compared with the full-dose regimen (13% vs. 24.5%, p = 0.014), and most were minor. Major extracranial hemorrhage occurred in 1.1% versus 6.1%, respectively (p = 0.022). Complications were associated with supratherapeutic levels of heparin anticoagulation in 37.5% of cases and invasive procedures in 31.3% of cases. The differences in complications persisted after PS weighting (15.4% vs. 24.7%, p = 0.12 and 1.3% vs. 7.1%, p = 0.067), but did not reach statistical significance. There were no significant differences in mortality, discharge destination, ICU or hospital length of stay, or readmission after PS weighting. CONCLUSIONS: In a retrospective, PS-weighted observational study, when compared with the full-dose, reduced-dose alteplase results in similar outcomes but fewer hemorrhagic complications. Avoidance of excessive levels of anticoagulation or invasive procedures should be considered to further reduce complications.

The objective of this study is to evaluate if racial and other demographic disparities exist between patients who enrolled or declined participation in a congenital cytomegalovirus (cCMV) newborn universal screening research study. We examined characteristics for patients approached over a 2-year period to participate in a cCMV newborn screening study. Maternal characteristics included age, race, ethnicity, preferred language, interpreter need, insurance type, and number of living children. Recruitment period was also examined (pre-pandemic January 1 to December 31, 2019, and during COVID-19 July 1, 2021 to June 30, 2022). Characteristics were compared for patients who enrolled in the study and those who declined participation using descriptive statistics and logistic regression. Of the study sample (n = 4156), 3148 (75.7

BACKGROUND:Elevated care at home (ECH) is a novel in-home care model supporting early hospital discharge and providing an alternative to institutional postacute care. OBJECTIVES:This study compares patient characteristics, mortality, and readmission outcomes of hospitalized patients who transitioned to ECH to patients who transitioned to skilled nursing facilities (SNF) and skilled home health services (SHH). METHODS:A retrospective study of patients between May 2020 and January 2022 transitioned from the hospital to ECH, SNF, or SHH. The analysis compared patient characteristics, 30-day mortality, and readmission stratified by COVID-19 infection status. Outcomes were assessed using logistic regression after propensity score matching. RESULTS:Of 32,132 eligible patients, 6.3% were transitioned to ECH, 39.7% to SNF, and 54.0% to SHH. After matching, all baseline characteristics except for age were balanced between groups. Postmatch and adjusting for age differences, ECH patients experienced lower risk of death compared to SNF (adjusted odds ratio [AOR] 0.61, 95% confidence interval [CI] 0.40, 0.92) and similar risk of hospital readmission compared to SNF patients (AOR 1.08, 95% CI 0.89, 1.31) and SHH patients (AOR 0.96, 95% CI 0.80, 1.16). COVID-19-negative ECH patients compared to matched SNF patients were more likely to readmit (AOR 1.30, 95% CI 1.02, 1.65) with no significant difference in risk of mortality (AOR 0.72, 95% CI 0.44, 1.18). CONCLUSIONS:ECH had similar or improved outcomes relative to SNF and SHH. COVID-19-negative ECH patients experienced higher readmissions relative to SNF. ECH supported patients to return home from the hospital and provided an alternative to an institutional postacute setting.

ObjectiveLanguage used by providers in medical documentation may reveal evidence of race-related implicit bias. We aimed to use natural language processing (NLP) to examine if prevalence of stigmatizing language in emergency medicine (EM) encounter notes differs across patient race/ethnicity.MethodsIn a retrospective cohort of EM encounters, NLP techniques identified stigmatizing and positive themes. Logistic regression models analyzed the association of race/ethnicity and themes within notes. Outcomes were the presence (or absence) of 7 different themes: 5 stigmatizing (difficult, non-compliant, skepticism, substance abuse/seeking, and financial difficulty) and 2 positive (compliment and compliant).ResultsThe sample included notes from 26,363 unique patients. NH Black patient notes were less likely to contain difficult (odds ratio (OR) 0.80, 95% confidence interval (CI), 0.73-0.88), skepticism (OR 0.87, 95% CI, 0.79-0.96), and substance abuse/seeking (OR 0.62, 95% CI, 0.56-0.70) compared to NH White patient notes but more likely to contain non-compliant (OR 1.26, 95% CI, 1.17-1.36) and financial difficulty (OR 1.14, 95% CI, 1.04-1.25). Hispanic patient notes were less likely to contain difficult (OR 0.68, 95% CI, 0.58-0.80) and substance abuse/seeking (OR 0.78, 95% CI, 0.66-0.93). NH NA/AI patient notes had twice the odds as NH White patient notes to contain a stigmatizing theme (OR 2.02, 95% CI, 1.64-2.49).ConclusionsUsing an NLP model to analyze themes in EM notes across racial groups, we identified several inequities in the usage of positive and stigmatizing language. Interventions to minimize race-related implicit bias should be undertaken.

This study aimed to describe patient characteristics, satisfaction, and outcome measures for patients undergoing outpatient cervical ripening.A retrospective cohort study using electronic health record data from March 2020 to March 2022 from a large health system. The sample included patients with a low-risk singleton pregnancy undergoing outpatient cervical ripening with either an osmotic dilator or Foley balloon catheter. A subset of patients completed satisfaction surveys. Frequencies and means were used to describe the population and conduct comparisons by device type. Inverse probability of treatment weighted estimates were generated to address baseline differences between patients in the two device groups.Outpatient cervical ripening was completed by 120 patients (80 osmotic dilators and 40 Foley balloon catheters). The mean time from insertion to inpatient admission was 16.2 ± 4.8 hours. The mean change in simplified Bishop score (SBS) was 1.8 ± 1.4 and the mean change in dilation was 1.8 ± 1.1 cm. There were no differences in the amount of cervical change by device type. Patients returned earlier than planned 16.7% of the time, primarily for contractions or rupture of membranes. Following outpatient cervical ripening, the time from admission to delivery was 19.9 ± 10.3 hours, with no difference by device type. Vaginal delivery occurred for 74.8% of patients. Patients reported overall satisfaction with the outpatient cervical ripening experience, with the highest satisfaction among those with osmotic dilators. Patients with both device types stated they would recommend outpatient cervical ripening to others, and experienced low levels of stress and discomfort at home prior to hospital admission.Patients participating in outpatient cervical ripening with osmotic dilators or Foley balloon catheters experienced clinically meaningful changes in dilation and SBSs while at home and reported general satisfaction with the outpatient program experience. · Outpatient use of osmotic dilators or Foley balloon catheters improved Bishop scores.. · Patient and device complications were comparable to other research findings.. · Patients reported overall satisfaction with outpatient cervical ripening..