Objective This study aimed to compare attendance of nutritional counseling, dietary composition, exercise patterns, and socioeconomic factors among obese women with inappropriate gestational weight gain (iGWG) versus appropriate GWG (aGWG). Study Design Medicaid-eligible women receiving prenatal care at a tertiary care center from January 2013 to December 2015 were offered individualized nutritional counseling by a registered dietitian encouraging well-balanced meals and 150 min/wk of exercise. We conducted a prospective case–control study of obese women (body mass index or BMI ≥30) with a singleton gestation with iGWG (<11 or >20 pounds) versus aGWG (11–20 pounds). Dietary intake, activity level, and socioeconomic factors were compared with Chi-square, Fisher's exact, Student's t-test, and Wilcoxon Rank Sum tests as indicated, and odds ratios with 95% confidence intervals were calculated. Multivariate regression analysis for significant variables was performed. A subgroup analysis of women with BMI ≥40 was planned. Results A total of 401 women were analyzed: 78% (n = 313) with iGWG and 22% (n = 88) with aGWG. Demographics were similar between groups. Women with iGWG less frequently reported physician reinforcement of counseling and reported more physical inactivity and unemployment; there were no differences in caloric intake or macronutrient profile between groups. Multivariate regression identified physician reinforcement and employment as independent predictors of aGWG. Among women with BMI ≥40 (n = 133), those with iGWG (78%) were less likely to attend counseling, report physician reinforcement of counseling, and have adequate caloric and protein intake when compared with those with aGWG (22%). Activity level and socioeconomic factors were not different between groups. Conclusion Physician reinforcement of nutritional counseling, greater activity level, and employment are associated with aGWG in women with BMI ≥30, while individualized professional nutritional counseling and dietary modifications were further associated with aGWG in women with BMI ≥40. Thus, greater focus should be placed on enhancing exposure to counseling and altering nutritional and exercise choices to optimize aGWG. Key Points

Objective:Accurate vital statistics data are critical for monitoring population health and strategizing public health interventions. Previous analyses of statewide birth data have identified several factors that may reduce birth certificate accuracy including systematic errors and limited data review by clinicians. The aim of this initiative was to increase the proportion of hospitals in Alabama reporting accurate birth certificate data from 67% to 87% within 1 year. Methods:The Alabama Perinatal Quality Collaborative led this statewide collaborative effort. Process measures included monthly monitoring of 11 variables across 5-10 patient birth certificates per month per hospital. Accuracy determination, defined as ≥95% accuracy of the variables analyzed, was performed by health care specialists at each hospital by comparing birth certificate variables from vital statistics with data obtained from original hospital source materials. Three months of retrospective, baseline accuracy data were collected before project initiation from which actionable drivers and change ideas were identified at individual hospitals. Data were analyzed using statistical process control measures. Results:Thirty-one hospitals entered data throughout the course of the initiative, accounting for 850 chart analyses and 9350 variable assessments. The least accurately reported variables included birth weight, maternal hypertension, and antenatal corticosteroid exposure. At baseline, 67% of hospitals reported birth certificate accuracy rates ≥ 95%, which increased to 90% of hospitals within 2 months and was sustained for the remainder of the initiative. Conclusion:Statewide, multidisciplinary quality improvement efforts increased birth certificate accuracy vital to public health surveillance.

Objective Enhanced recovery protocols are now established as the standard of care leading to improved perioperative outcomes and associated cost-benefits. The objective of this study was to evaluate the impact of an enhanced recovery program on complication rates in high-risk gynecologic oncology patients undergoing surgery. Methods This retrospective cohort study included gynecologic oncology patients with pathology-proven malignancy undergoing non-emergent laparotomy from October 2016 to December 2018 managed on an enhanced recovery protocol, and a control group from October 2015 through September 2016 prior to enhanced recovery protocol implementation. The primary outcome was complication rates in a high-risk population pre- and post-enhanced recovery protocol. High-risk patients were defined as those with obesity (body mass index >30 kg/m2) and/or age ≥65 years. Analysis was performed using Statistical Package for Social Sciences (SPSS) v.24. Results A total of 363 patients met the inclusion criteria: 104 in the control group and 259 in the enhanced recovery protocol group. Patient demographics, including age, body mass index, diagnosis, and performance status, were similar. Overall complication rates were less in the enhanced recovery protocol group (29% vs 53.8%; p<0.0001). The enhanced recovery protocol group had a shorter length-of-stay compared with control (3.3 vs 4.2 days; p<0.0001). The 30-day readmission rates were similar between the groups (9.6% vs 13.5%; p=0.19). In the enhanced recovery protocol group compared with control, complication rates were less in obese patients (29.4% vs 57.8%; p<0.0001), morbidly obese patients (20.9% vs 76.2%; p<0.0001), and age ≥65 (36.1% vs 57.1%; p<0.0001). The most common complications in the enhanced recovery protocol group were ileus (9.7%), pulmonary complications (2.7%), and blood transfusions (10.8%). Conclusions Implementation of an enhanced recovery protocol decreases complication rates and length-of-stay in morbidly obese and geriatric patients with gynecologic malignancy without an increase in readmission rates.

Sociodemographic (SD) factors and obesity (BMI>30) are correlated, and both are associated with poor perinatal outcomes including preeclampsia, preterm birth, low birthweight, and perinatal death. Which specific SD factors are associated with poor outcomes in these women is understudied. We evaluated SD factors independently associated with poor maternal and neonatal outcomes in obese women. This was a retrospective cohort study of Medicaid funded women offered enhanced social and nutritional services through the Strong Start Program (1/2013-12/2015). We included women with singletons and BMI≥30 at first prenatal visit. Primary outcomes were composite maternal and neonatal morbidity (Figure). We evaluated 24 maternal and partner sociodemographic and other characteristics for association with maternal and neonatal morbidity (Table). Chi-square, Fisher's exact, Student's t-test, and Wilcoxon rank sum tests were used to compare outcomes across exposures. We used multivariable logistic regression models with backward selection to determine most significant SD factors associated with maternal and neonatal morbidity. 411 women were included for analysis: 243 (59%) with maternal morbidity, 195 (47%) with neonatal morbidity. Multiple sociodemographic factors were significantly associated with maternal and neonatal morbidity (see table for bolded exposures), all with p<0.01. After multivariable analyses, high school education, and paternal unemployment as well as multiparity chronic hypertension, and pre-gestational diabetes, were factors most associated with maternal outcomes (Figure). Family financial support and paternal full time employment as well as the medical co-morbidities were associated with neonatal outcomes (Figure). In low-income women with BMI≥30, specific maternal and partner social factors and preexisting medical conditions are independently associated with adverse outcomes. This suggests poor outcomes in these women may arise from a complex interplay of lack of financial/social support and medical comorbidities.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Objective. The objective of this study was to evaluate the impact of a post-surgical restrictive opioid prescribing algorithm (ROPA) in gynecologic oncology patients. Methods. This cohort study included gynecologic oncology patients undergoing any surgical procedure from 08/2018-7/2019 after implementation of a ROPA. Patients were compared to historical controls managed without a ROPA from 10/2016-9/2017. Patients were educated preoperatively about pain management goals, the ROPA, and opioid disposal. A 4-tiered system was developed to standardize prescriptions at discharge based on surgical complexity and inpatient opioid requirements. Patients were surveyed at their postoperative visit to assess home opioid use and satisfaction. Statistical analysis was performed using SPSS Statistics v.24. Results. 2549 patients met inclusion criteria; 1321 in the historical control group and 1228 in the ROPA group. Demographics, including age, BMI, and performance status were similar. Compared with the control group, the average number of opioid pills prescribed was significantly lower in the ROPA group (30.5 vs 11.3; p < 0.001) along with the morphine milligram equivalents (MME) (152.5 MME vs. 83.3 MME; p < 0.001). The percentage of patients requiring opioid refill within 30 days was similar (13.0% vs. 12.6%; p = 0.71). 95.7% of patients surveyed were satisfied with their pain regimen. The total number of pills prescribed annually decreased from 34,130 in the control group to 13,888 in the ROPA group. Conclusions. A restrictive prescribing practice allows for a significantly lower number of opioids to be prescribed to postoperative patients while maintaining patient satisfaction. There was no increase in opioid refill requests using a ROPA in patients undergoing surgery. (C) 2020 Elsevier Inc. All rights reserved.

Inappropriate gestational weight gain (iGWG) is linked to poor perinatal outcomes. However, achieving appropriate GWG (aGWG) may be limited by socioeconomic status (SES) which can restrict food options, physical activity, and patient support systems. We aimed to compare dietary and exercise patterns as well as SES factors among obese women (BMI≥30) with aGWG versus iGWG. Low SES women receiving prenatal care at a single tertiary care center from 1/2013-12/2015 were offered individualized nutritional counseling (NC) by a registered dietitian encouraging well-balanced meals using the Department of Agriculture MyPlate guide and 150 minutes/week of exercise. We conducted a retrospective case control study of obese women with singleton gestations with aGWG (11-20 pounds) versus iGWG (< 11 or >20 pounds). Dietary makeup, activity level, and SES factors were compared with chi-square, Fisher's exact, student's t-test, and Wilcoxon Rank Sum tests as appropriate, and odds ratios (95% CIs) were calculated (Tables). A subgroup analysis of class III obesity (BMI≥40) was planned. 411 women were analyzed: 22% (n=89) had aGWG and 78% (n=322) had iGWG. Demographics were similar between groups. Women with iGWG were less likely to report physician reinforcement of NC and more inactivity; there were no differences in food diary compliance, or self-reported caloric intake or dietary composition between groups. Those with iGWG were also less likely to be employed (Table 1). When limited to BMI≥40 (n=136), those with iGWG (78%) versus aGWG (22%) were less likely to attend NC, report physician reinforcement of NC, and have adequate caloric and protein intake, and were more likely to be inactive; there were no differences in SES factors (Table 2). Physician reinforcement of NC, greater activity, and employment are associated with aGWG in obese women, with NC and dietary modifications further associated with aGWG in women with BMI≥40. Given the limited impact of SES factors, enhancing exposure to NC and altering nutritional and exercise choices should be utilized to optimize GWG.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Boitano, Teresa KL. MD; Smith, Haller J. MD; Harmon, Duncan MD; Xhaja, Anisa MHA, MSHQS; Leal, Laura MSN; Todd, Allison MSN, RN; Straughn, J Michael MD Author Information

Honors programs within schools of nursing have the potential to enhance young nurses' interest in developing programs of research early in their careers and can thus contribute to the successful development of nursing knowledge. Such programs also provide opportunities to enhance knowledge and skill in leadership and teamwork at a critical time during the development of their professional nurse identity. This article presents the successful approach one organization took when revising its honors program to meet the current needs of students, society, and the profession.

OBJECTIVE:We sought to evaluate the frequency of, and factors associated with, the use of 3 evidence-based interventions: antenatal corticosteroids for fetal lung maturity, progesterone for prevention of recurrent preterm birth, and magnesium sulfate for fetal neuroprotection.STUDY DESIGN:A self-administered survey was conducted from January through May 2011 among obstetricians from 21 hospitals that included 30 questions regarding their knowledge, attitudes, and practice of the 3 evidence-based interventions and the 14-item short version of the Team Climate for Innovation survey. Frequency of use of each intervention was ascertained from an obstetrical cohort of women between January 2010 and February 2011.RESULTS:A total of 329 obstetricians (74% response rate) who managed 16,946 deliveries within the obstetrical cohort participated in the survey. More than 90% of obstetricians reported that they incorporated each intervention into routine practice. Actual frequency of administration in women eligible for the treatments was 93% for corticosteroids, 39% for progesterone, and 71% for magnesium sulfate. Provider satisfaction with quality of treatment evidence was 97% for corticosteroids, 82% for progesterone, and 57% for magnesium sulfate. Obstetricians perceived that barriers to treatment were most frequent for progesterone (76%), 30% for magnesium sulfate, and 17% for corticosteroids. Progesterone use was more frequent among patients whose provider reported the quality of the evidence was above average to excellent compared with poor to average (42% vs 25%, respectively; P < .001), and they were satisfied with their knowledge of the intervention (41% vs 28%; P = .02), and was less common among patients whose provider reported barriers to hospital or pharmacy drug delivery (31% vs 42%; P = .01). Corticosteroid administration was more common among patients who delivered at hospitals with 24 hours a day-7 days a week maternal-fetal medicine specialist coverage (93% vs 84%; P = .046), CONCLUSION: Obstetricians in Maternal-Fetal Medicine Units Network hospitals frequently use these evidence-based interventions; however, progesterone use was found to be related to their assessment of evidence quality. Neither progesterone nor the other interventions were associated with overall climate of innovation within a hospital as measured by the Team Climate for Innovation. National Institutes of Health Consensus Conference Statements may also have an impact on use; there is such a statement for antenatal corticosteroids but not for progesterone for preterm prevention or magnesium sulfate for fetal neuroprotection.