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Introduction Nonurgent clinically significant test results (CSTRs) are a common cause of missed and delayed diagnoses. However, little is known about the impact of electronic health record (EHR) transitions on CSTR follow-up. This study examines follow-up rates for three CSTRs (incidental pulmonary nodules [IPNs]), prostate-specific antigen [PSA], and Pap smears) before and after EHR transition. Methods This is a retrospective cohort study at an urban tertiary medical center using an interrupted time series (ITS) design to assess monthly changes in CSTR follow-up—defined as completion of computed tomography chest imaging 5 to 13 months after first mention of an IPN in a radiology report; completion of a follow-up PSA test, urology visit, or prostate biopsy within 6 months of the first reported PSA > 4; or completion of a colposcopy or gynecology visit within 6 months of a first reported abnormal Pap smear. Patients were included with first-onset abnormal CSTRs for IPN, PSAs > 4, or abnormal Pap smears occurring in the 24 months before and after the EHR transition. Results There were no significant differences in follow-up in the IPN or the Pap smear ITS models. In the PSA ITS model, follow-up was significantly decreasing (p = 0.0133) in the preintervention period, and there was a significant change in trend from intervention to postintervention (p = 0.0279). Conclusion EHR transition reversed a decreasing trend over time for PSA test follow-up, while IPN and Pap smear follow-up trends did not change significantly. Effects of EHR transition may differ by test studied.

The Challenge Effective teamwork and communication skills are essential for safe and reliable health care. These skills require training and practice. Experiential learning is optimal for training adults, and the industry has recognized simulation training as an exemplar of this approach. Yet despite decades of investment, this training is inaccessible and underutilized for most of the more than 12 million health care professionals in the United States. Designing a Solution This report describes the design process of an adapted simulation training created to overcome the key barriers to scaling simulation-based teamwork training: access to technology, time away from clinical work, and availability of trained simulation educators. The prototype training is designed for delivery in one-hour segments and relies on observation of video simulation scenarios and within-group debriefing, which are promising variations on traditional simulation training. To our knowledge, these two simulation approaches have not been previously combined. The resulting prototype minimizes the need for an on-site trained simulation educator. This report details the development of a training model, its subsequent modification based on pilot testing, and the evaluation of the resulting redesigned prototype. Preliminary Evaluation Participant evaluations of the redesigned prototype were highly positive, with 92% reporting that they would like to participate in additional, similar training sessions. Positive results were also found in assessment of feasibility, acceptability, psychological safety, and behavioral intention (reported intention to alter behavior).

Since the 1990s, following similar reforms to its general politico-administrative systems, Uganda has decentralized its public healthcare system by shifting decision-making power away from its central Ministry of Health and towards more distal administrative levels. Previous research has used decision space—the decision-making autonomy demonstrated by entities in an administrative hierarchy—to measure overall health system decentralization. This study aimed to determine how the decision-making autonomy reported by managers of Ugandan healthcare facilities (de facto decision space) differs from that which they are allocated by official policies (de jure decision space). Additionally, it sought to determine associations between decision space and indicators of managerial performance. Using quantitative primary healthcare data from Ugandan healthcare facilities, our study determined the decision space expressed by facility managers and the performance of their facilities on measures of essential drug availability, quality improvement and performance management. We found managers reported greater facility-level autonomy than expected in disciplining staff compared with recruitment and promotion, suggesting that managerial functions that require less financial or logistical investment (i.e. discipline) may be more susceptible to differences in de jure and de facto decision space than those that necessitate greater investment (i.e. recruitment and promotion). Additionally, we found larger public health facilities expressed significantly greater facility-level autonomy in drug ordering compared with smaller facilities, which indicates ongoing changes in the Ugandan medical supply chain to a hybrid ‘push-pull’ system. Finally, we found increased decision space was significantly positively associated with some managerial performance indicators, such as essential drug availability, but not others, such as our performance management and quality improvement measures. We conclude that increasing managerial autonomy alone is not sufficient for improving overall health facility performance and that many factors, specific to individual managerial functions, mediate relationships between decision space and performance.

Objective The aim of this study is to model the association between gestational age at birth and early child development through 3 years of age. Study Design Development of 5,868 children in Upstate KIDS (New York State; 2008–2014) was assessed at 7 time points using the Ages and Stages Questionnaire (ASQ). The ASQ was implemented using gestational age corrected dates of birth at 4, 8, 12, 18, 24, 30, and 36 months. Whether children were eligible for developmental services from the Early Intervention Program was determined through linkage. Gestational age was based on vital records. Statistical models adjusted for covariates including sociodemographic factors, maternal smoking, and plurality. Results Compared with gestational age of 39 weeks, adjusted odds ratios (aOR) and 95% confidence intervals of failing the ASQ for children delivered at Conclusion Gestational age was inversely associated with developmental delays for all gestational ages. Evidence from our study is potentially informative for low-risk deliveries at 39 weeks, but it is notable that deliveries at 40 weeks exhibited further lower risk.

BACKGROUND: Prenatal exposure to persistent organic pollutants (POPs) may be associated with obesogenic effects in offspring. Our study is the first to investigate associations between concentrations of POPs from newborn dried blood spots (DBS) and birth characteristics. METHODS: Concentrations of 10 polychlorinated biphenyl congeners (PCBs), polybrominated diphenyl ether-47 (PBDE-47), and p,p´-dichlorodiphenyldichloroethylene (p,p´-DDE) were measured from DBSs collected at birth from 2065 singleton infants. DBS samples were pooled in groups of five and assayed together in order to reach limits of detection. Differences in risk of large for gestational age (LGA, defined as >90(th) percentile of birthweight for sex and gestational age), small for gestational age (SGA

Background Person-centeredness is a foundation of high-quality health systems but is poorly measured in low- and middle-income countries (LMICs). We piloted an online survey of four LMICs to identify the prevalence and correlates of excellent patient-reported quality of care (QOC). Objective The aims of this study were to investigate the examine people’s overall ratings of care quality in relation to their experiences seeking care in their respective health systems as well as individual-, provider- and facility-level predictors. Methods We administered a cross-sectional online survey using Random Domain Intercept Technology to collect a sample of random internet users across India, Kenya, Mexico and Nigeria in November 2016. The primary outcome was patient-reported QOC. Covariates included age, gender, level of education, urban/rural residence, person for whom care was sought, type of provider seen, public or private sector status of the health facility and type of facility. The exposure was an index of health system responsiveness based on a framework from the World Health Organization. We used descriptive statistics to determine the prevalence of excellent patient-reported QOC and multivariable Poisson regression to calculate adjusted prevalence ratios (aPRs) for predictors of excellent patient-reported quality. Results Fourteen thousand and eight people completed the survey (22.6% completion rate). Survey respondents tended to be young, male, well-educated and urban-dwelling, reflective of the demographic of the internet-using population. Four thousand one and ninety-one (29.9%) respondents sought care in the prior 6 months. Of those, 21.8% rated their QOC as excellent. The highest proportion of respondents gave the top rating for wait time (44.6%), while the lowest proportion gave the top rating for facility cleanliness (21.7%). In an adjusted analysis, people who experienced the highest level of health system responsiveness were significantly more likely to report excellent QOC compared to those who did not (aPR 8.61, 95% confidence interval [95% CI]: 7.50, 9.89). In the adjusted model, urban-dwelling individuals were less likely to report excellent quality compared to rural-dwelling individuals (aPR 0.88, 95% CI: 0.78, 0.99). People who saw community health workers (aPR 1.37, 95% CI: 1.12, 1.67) and specialists (aPR 1.30, 95% CI: 1.12, 1.50) were more likely to report excellent quality than those who saw primary care providers. High perceived respect from the provider or staff was most highly associated with excellent ratings of quality, while ratings of wait time corresponded the least. Conclusion Patient-reported QOC is low in four LMICs, even among a well-educated, young population of internet users. Better health system responsiveness may be associated with better ratings of care quality. Improving person-centered care will be an important component of building high-quality health systems in these LMICs.

Worldwide, many newborns die in the first month of life, with most deaths happening in low/middle-income countries (LMICs). Families’ use of evidence-based newborn care practices in the home and timely care-seeking for illness can save newborn lives. Postnatal education is an important investment to improve families’ use of evidence-based newborn care practices, yet there are gaps in the literature on postnatal education programees that have been evaluated to date. Recent findings from a 13 000+ person survey in 3 states in India show opportunities for improvement in postnatal education for mothers and families and their use of newborn care practices in the home. Our survey data and the literature suggest the need to incorporate the following strategies into future postnatal education programming: implement structured predischarge education with postdischarge reinforcement, using a multipronged teaching approach to reach whole families with education on multiple newborn care practices. Researchers need to conduct robust evaluation on postnatal education models incorporating these programee elements in the LMIC context, as well as explore whether this type of education model can work for other health areas that are critical for families to survive and thrive.

Concerns remain about the health of children conceived by infertility treatment. Studies to date have predominantly not identified substantial long-term health effects after accounting for plurality, which is reassuring given the increasing numbers of children conceived by infertility treatment worldwide. However, as technological advances in treatment arise, ongoing studies remain critical for monitoring health effects. To study whether the techniques used in infertility treatment cause health differences, however, remains challenging due to identification of an appropriate comparison group, heterogeneous treatment, and confounding by the underlying causes of infertility. In fact, the factors that are associated with underlying infertility, including parental obesity and other specific male and female factors, may be important independent factors to consider. This review will summarize key methodological considerations in studying children conceived by infertility treatment including the evidence of associations between underlying infertility factors and child health.

Normal maternal thyroid function during pregnancy is essential for fetal development and depends upon an adequate supply of iodine. Little is known about how iodine status is associated with preterm birth and small for gestational age (SGA) in mildly iodine insufficient populations. Our objective was to evaluate associations of early pregnancy serum iodine, thyroglobulin (Tg), and thyroid-stimulating hormone (TSH) with odds of preterm birth and SGA in a prospective, population-based, nested case-control study from all births in Finland (2012&ndash, 2013). Cases of preterm birth (n = 208) and SGA (n = 209) were randomly chosen from among all singleton births. Controls were randomly chosen from among singleton births that were not preterm (n = 242) or SGA (n = 241) infants during the same time period. Women provided blood samples at 10&ndash, 14 weeks&rsquo, gestation for serum iodide, Tg and TSH measurement. We used logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for preterm birth and SGA. Each log-unit increase in serum iodide was associated with higher odds of preterm birth (adjusted OR = 1.19, 95% CI = 1.02&ndash, 1.40), but was not associated with SGA (adjusted OR = 1.01, 95% CI = 0.86&ndash, 1.18). Tg was not associated with preterm birth (OR per 1 log-unit increase = 0.87, 95% CI = 0.73&ndash, 1.05), but was inversely associated with SGA (OR per log-unit increase = 0.78, 95% CI = 0.65&ndash, 0.94). Neither high nor low TSH (versus normal) were associated with either outcome. These findings suggest that among Finnish women, iodine status is not related to SGA, but higher serum iodide may be positively associated with preterm birth.

Key Points Question How frequently do women in Ghana bypass the health care facility nearest their homes in favor of more distant facilities perceived to offer better care, and what factors are associated with this choice? Findings In this survey study including 1946 reproductive-aged (ie, 16-49 years) women in Ghana in 2017, 32% of women reported bypassing their nearest health care facility. Women who bypassed sought care at hospitals and private facilities more frequently and paid nearly 2-fold in out-of-pocket costs for care compared with women who did not bypass. Meaning These findings suggest that the services offered at many primary care facilities in Ghana may not be meeting the needs of women., This survey study examines the prevalence, individual characteristics and experiences, and costs associated with bypassing the nearest health care facility among women in Ghana., Importance Recent reports have highlighted that expanding access to health care is ineffective at meeting the goal of universal health coverage if the care offered does not meet a minimum level of quality. Health care facilities nearest to patient’s homes that are perceived to offer inadequate or inappropriate care are frequently bypassed in favor of more distant private or tertiary-level hospital facilities that are perceived to offer higher-quality care. Objective To estimate the frequency with which women in Ghana bypass the nearest primary health care facility and describe patient experiences, costs, and other factors associated with this choice. Design, Setting, and Participants This nationally representative survey study was conducted in 2017 and included 4203 households to identify women in Ghana aged 15 to 49 years (ie, reproductive age) who sought primary care within the last 6 months. Women who sought care within the past 6 months were included in the study. Data were analyzed from 2018 to 2019. Exposures Bypass was defined as a woman’s report that she sought care at a health facility other than the nearest facility. Main Outcomes and Measures Sociodemographic characteristics, reasons why women sought care, reasons why women bypassed their nearest facility, ratings for responsiveness of care, patient experience, and out-of-pocket costs. All numbers and percentages were survey-weighted to account for survey design. Results A total of 4289 women met initial eligibility criteria, and 4207 women (98.1%) completed the interview. A total of 1993 women reported having sough health care in the past 6 months, and after excluding those who were ineligible and survey weighting, the total sample included 1946 women. Among these, 629 women (32.3%) reported bypassing their nearest facilities for primary care. Women who bypassed their nearest facilities, compared with women who did not, were more likely to visit a private facility (152 women [24.5%] vs 202 women [15.6%]) and borrow money to pay for their care (151 women [24.0%] vs 234 women [17.8%]). After adjusting for covariates, women who bypassed reported paying a mean of 107.2 (95% CI, 79.1-135.4) Ghanaian Cedis (US $18.50 [95% CI, $13.65-$23.36]) for their care, compared with a mean of 58.6 (95% CI, 28.1-89.2) Ghanaian Cedis (US $10.11 [95% CI, $4.85-15.35]) for women who did not bypass (P = .006). Women who bypassed cited clinician competence (136 women [34.3%]) and availability of supplies (93 women [23.4%]) as the most important factors in choosing a health facility. Conclusions and Relevance The findings of this survey study suggest that bypassing the nearest health care facility was common among women in Ghana and that available services at lower levels of primary care are not meeting the needs of a large proportion of women. Among the benefits women perceived from bypassing were clinician competence and availability of supplies. These data provide insights to policy makers regarding potential gaps in service delivery and may help to guide primary health care improvement efforts.

IntroductionPerson-centredness, including patient experience and satisfaction, is a foundational element of quality of care. Evidence indicates that poor experience and satisfaction are drivers of underutilisation of healthcare services, which in turn is a major driver of avoidable mortality. However, there is limited information about patient experience of care at the population level, particularly in low-income and middle-income countries.MethodsA multistage cluster sample design was used to obtain a nationally representative sample of women of reproductive age in Ghana. Women were interviewed in their homes regarding their demographic characteristics, recent care-seeking characteristics, satisfaction with care, patient-reported outcomes, and—using questions from the World Health Survey Responsiveness Module—the seven domains of responsiveness of outpatient care to assess patient experience. Using Poisson regression with log link, we assessed the relationship between responsiveness and satisfaction, as well as patient-reported outcomes.ResultsWomen who reported more responsive care were more likely to be more educated, have good access to care and have received care at a private facility. Controlling for respondent and visit characteristics, women who reported the highest responsiveness levels were significantly more likely to report that care was excellent at meeting their needs (prevalence ratio (PR)=13.0), excellent quality of care (PR=20.8), being very likely to recommend the facility to others (PR=1.4), excellent self-rated health (PR=4.0) and excellent self-rated mental health (PR=5.1) as women who reported the lowest responsiveness levels.DiscussionThese findings support the emerging global consensus that responsiveness and patient experience of care are not luxuries but essential components of high-performing health systems, and highlight the need for more nuanced and systematic measurement of these areas to inform priority setting and improvement efforts.

BACKGROUND: Residential proximity to major roadways, and prenatal exposures to particulate matter 1000m away from a major roadway, those resided 50–100m [RR: 2.12 (1.00–4.52)] and 100–500m [RR: 2.07 (1.02–4.22)] away had twice the risk of failing the communication domain. Prenatal exposures to both PM(2.5) and ozone during various pregnancy windows had weak but significant associations with failing any developmental domain with effects ranging from 1.6%-2.7% for a 10 μg/m(3) increase in PM(2.5) and 0.7%-1.7% for a 10ppb increase in ozone. Average daily postnatal ozone exposure was positively associated with failing the overall screening by 8 months [3.3% (1.1%-5.5%)], 24 months [17.7% (10.4%-25.5%)], and 30 months [7.6%, (1.3%-14.3%)]. Findings were mixed for postnatal PM(2.5) exposures. CONCLUSIONS: In this prospective cohort study, proximity to major roadway and prenatal/early-life exposures to PM(2.5) and O(3) were associated with developmental delays. While awaiting larger studies with personal air pollution assessment, efforts to minimize air pollution exposures during critical developmental windows may be warranted.

BackgroundPolycystic ovarian syndrome (PCOS) is the most common cause of female infertility and is associated with higher levels of circulating androgens. Exposure to higher levels of androgens in utero may be a risk factor for obesity among children of women with PCOS.MethodsWe examined whether maternal PCOS was associated with differences in offspring growth and obesity in the Upstate KIDS study, a prospective cohort study of infants born in New York State (excluding New York City) oversampled for fertility treatments and multiple births. Measurements of offspring length/height and weight were recorded at doctor’s visits through 3 years of age. PCOS diagnosis was self-reported by mothers at baseline. We used linear mixed models with robust SEs to estimate differences in growth by maternal PCOS exposure. We used logistic regression to examine whether infants experienced rapid weight gain at 4, 9 and 12 months. Growth measures were reported by 4098 mothers for 4949 children (1745 twins). Of these, 435 mothers (10.6%) had a diagnosis of PCOS.ResultsCompared with children born to mothers without PCOS, children of mothers with PCOS did not have significant differences in weight (4.81 g, 95% CI −95.1 to 104.7), length/height (0.18 cm, 95% CI −0.16 to 0.52) and body mass index (−0.14 kg/m2, 95% CI −0.30 to 0.01) through 3 years of age. We also observed no association between maternal PCOS and offspring rapid weight gain.ConclusionsOverall, we found little evidence to suggest that maternal PCOS influences early childhood growth in this large, prospective cohort study.

INTRODUCTION Iodine is essential for thyroid function, and iodine deficiency during pregnancy is common in Europe and the USA. However, no published studies have examined the role of iodine deficiency in the relation between thyroid function and gestational diabetes mellitus (GDM). MATERIAL AND METHODS We conducted a population-based, nested case-control study within the Finnish Maternity Cohort using pregnancy and perinatal outcome data from the Finnish Maternal Birth Register. We randomly selected 224 GDM cases with singleton pregnancies and 224 controls without GDM from all singleton births occurring in Finland during 2012-2013. Blood was drawn at 10-14 weeks' gestation and analyzed for serum iodide, thyroglobulin, and thyroid-stimulating hormone (TSH) concentrations. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CI) of GDM. RESULTS Very high thyroglobulin concentration (>95% percentile; >83 μg/L) was not associated with significantly altered odds of GDM compared to those with normal levels (OR 0.41; 95% CI: 0.12, 1.38). High concentrations of TSH were also not associated with increased odds of GDM compared to normal levels of TSH (OR 0.45; 95% CI: 0.06, 3.18). Women in the lowest 5th percentile (

Objective— The relationship between air pollution and cardiovascular disease may be explained by changes in high-density lipoprotein (HDL). Approach and Results— We examined the cross-sectional relationship between air pollution and both HDL cholesterol and HDL particle number in the MESA Air study (Multi-Ethnic Study of Atherosclerosis Air Pollution). Study participants were 6654 white, black, Hispanic, and Chinese men and women aged 45 to 84 years. We estimated individual residential ambient fine particulate pollution exposure (PM 2.5 ) and black carbon concentrations using a fine-scale likelihood-based spatiotemporal model and cohort-specific monitoring. Exposure periods were averaged to 12 months, 3 months, and 2 weeks prior to examination. HDL cholesterol and HDL particle number were measured in the year 2000 using the cholesterol oxidase method and nuclear magnetic resonance spectroscopy, respectively. We used multivariable linear regression to examine the relationship between air pollution exposure and HDL measures. A 0.7×10 − 6 m − 1 higher exposure to black carbon (a marker of traffic-related pollution) averaged over a 1-year period was significantly associated with a lower HDL cholesterol (−1.68 mg/dL; 95% confidence interval, −2.86 to −0.50) and approached significance with HDL particle number (−0.55 mg/dL; 95% confidence interval, −1.13 to 0.03). In the 3-month averaging time period, a 5 μg/m 3 higher PM 2.5 was associated with lower HDL particle number (−0.64 μmol/L; 95% confidence interval, −1.01 to −0.26), but not HDL cholesterol (−0.05 mg/dL; 95% confidence interval, −0.82 to 0.71). Conclusions— These data are consistent with the hypothesis that exposure to air pollution is adversely associated with measures of HDL.

Background Recent studies have failed to establish a causal relationship between high‐density lipoprotein cholesterol levels ( HDL ‐C) and cardiovascular disease ( CVD ), shifting focus to other HDL measures. We previously reported that smaller/denser HDL levels are protective against cerebrovascular disease. This study sought to determine which of small+medium HDL particle concentration ( HDL ‐P) or large HDL ‐P was more strongly associated with carotid intima‐media thickening ( cIMT ) in an ethnically diverse cohort. Methods and Results In cross‐sectional analyses of participants from the Multi Ethnic Study of Atherosclerosis ( MESA ), we evaluated the associations of nuclear magnetic resonance spectroscopy–measured small+medium versus large HDL ‐P with cIMT measured in the common and internal carotid arteries, through linear regression. After adjustment for CVD confounders, low‐density lipoprotein cholesterol ( LDL ‐C), HDL ‐C, and small+medium HDL ‐P remained significantly and inversely associated with common (coefficient=−1.46 μm; P =0.00037; n=6512) and internal cIMT (coefficient=−3.82 μm; P =0.0051; n=6418) after Bonferroni correction for 4 independent tests (threshold for significance=0.0125; α=0.05/4). Large HDL ‐P was significantly and inversely associated with both cIMT outcomes before HDL ‐C adjustment; however, after adjustment for HDL ‐C, the association of large HDL ‐P with both common (coefficient=1.55 μm; P =0.30; n=6512) and internal cIMT (coefficient=4.84 μm; P =0.33; n=6418) was attenuated. In a separate sample of 126 men, small/medium HDL ‐P was more strongly correlated with paraoxonase 1 activity ( r p =0.32; P =0.00023) as compared to both total HDL ‐P ( r p =0.27; P =0.0024) and large HDL ‐P ( r p =0.02; P =0.41) measures. Conclusions Small+medium HDL ‐P is significantly and inversely correlated with cIMT measurements. Correlation of small+medium HDL ‐P with cardioprotective paraoxonase 1 activity may reflect a functional aspect of HDL responsible for this finding.

Glucosamine and chondroitin are products commonly used by older adults in the US and Europe. There is limited evidence that they have anti-inflammatory properties, which could provide risk reduction of several diseases. However, data on their long-term health effects is lacking. To evaluate whether use of glucosamine and chondroitin are associated with cause-specific and total mortality. Participants (n = 77,510) were members of a cohort study of Washington State (US) residents aged 50–76 years who entered the cohort in 2000–2002 by completing a baseline questionnaire that included questions on glucosamine and chondroitin use. Participants were followed for mortality through 2008 (n = 5,362 deaths). Hazard ratios (HR) for death adjusted for multiple covariates were estimated using Cox models. Current (baseline) glucosamine and chondroitin use were associated with a decreased risk of total mortality compared to never use. The adjusted HR associated with current use of glucosamine (with or without chondroitin) was 0.82 (95 % CI 0.75–0.90) and 0.86 (95 % CI 0.78–0.96) for chondroitin (included in two-thirds of glucosamine supplements). Current use of glucosamine was associated with a significant decreased risk of death from cancer (HR 0.87 95 % CI 0.76–0.98) and with a large risk reduction for death from respiratory diseases (HR 0.59 95 % CI 0.41–0.83). Use of glucosamine with or without chondroitin was associated with reduced total mortality and with reductions of several broad causes of death. Although bias cannot be ruled out, these results suggest that glucosamine may provide some mortality benefit.