Papers

Submitted
Submitted.
2020
and National Academies of Sciences, Engineering M. Birth Settings in America: Outcomes, Quality, Access, and Choice. (Scrimshaw SC, Backes EP). Washington, DC: The National Academies Press; 2020 pp. 368. Publisher's VersionAbstract
The delivery of high quality and equitable care for both mothers and newborns is complex and requires efforts across many sectors. The United States spends more on childbirth than any other country in the world, yet outcomes are worse than other high-resource countries, and even worse for Black and Native American women. There are a variety of factors that influence childbirth, including social determinants such as income, educational levels, access to care, financing, transportation, structural racism and geographic variability in birth settings. It is important to reevaluate the United States' approach to maternal and newborn care through the lens of these factors across multiple disciplines.Birth Settings in America: Outcomes, Quality, Access, and Choice reviews and evaluates maternal and newborn care in the United States, the epidemiology of social and clinical risks in pregnancy and childbirth, birth settings research, and access to and choice of birth settings.
Chee M, Lenti G, Farnan J, Cook M, Weissman A, Wallingford S, Moriates C, Shah N, Lynch S, Stebbins M, et al. Development and testing of a module to promote generic oral contraceptive prescribing among nurse practitioners. J Am Assoc Nurse Pract. 2020;32 (1) :24-34.Abstract
Although generic oral contraceptives (OCPs) can improve adherence and reduce health care expenditures, use of generic OCPs remains low, and the factors that affect generic prescribing are not well understood. We aimed to understand the barriers and facilitators of generic OCP prescribing and potential solutions to increase generic OCP prescribing, as well as pilot an educational module to address clinician misconceptions about generic OCPs. We developed focus group scripts using the 4D model of appreciative inquiry. A total of four focus groups occurred, two at the American Association of Nurse Practitioners (AANP) national conference and two at the American College of Physicians (ACP) Internal Medicine meeting. Focus group transcripts were analyzed using a constant comparative method with no a priori hypothesis to generate emerging and reoccurring themes. Findings from these focus groups were used to develop an educational module promoting generic OCP prescribing. Participants were recruited from the AANP Network for Research and the ACP Research Panel. This study demonstrates that health system factors, workflow factors, clinician factors, and patient factors were the main barriers to and facilitators of generic OCP prescribing. Nurse practitioners were responsive to an educational module and reported increased willingness to discuss and prescribe generic OCPs after completing the module. Interventions to increase generic OCP prescribing must address clinician and patient factors within the context of workflow and larger health system factors.
Rudin RS, Friedberg MW, Shekelle P, Shah N, Bates DW. Getting Value From Electronic Health Records: Research Needed to Improve Practice. Ann Intern Med. 2020;172 (11_Supplement) :S130-S136.Abstract
Electronic health records (EHRs) are now widely adopted in the United States, but health systems have barely begun using them to deliver high-value care. More directed and rigorous research is needed to fulfill the promise of EHRs to not only store information but also support the delivery of better care. This article describes 4 potential benefits of EHR-based research: improving clinical decisions, supporting triage decisions, enabling collaboration among the care team (including patients), and increasing productivity via automation of tasks. Six recommendations are made for conducting and reporting research to catalyze value creation: develop interventions systematically by using user-centered design and a building-block approach; assess value in terms of cost, quality, outcomes, and work required of providers and patients; consider the time horizon for the intervention; test best practices for implementation in a range of real-world contexts; assess subtleties of behavior change tools used to improve high-value behaviors; and report the intervention in enough detail that it can be replicated, including context. Just as research played a critical role in developing early EHR prototypes and demonstrating their value to justify dissemination, research will continue to be essential in the next phase: expanding EHR-based interventions and maximizing their role in creating value.
Peahl AF, Gourevitch RA, Luo EM, Fryer KE, Moniz MH, Dalton VK, Fendrick MA, Shah N. Right-Sizing Prenatal Care to Meet Patients' Needs and Improve Maternity Care Value. Obstet Gynecol. 2020;135 (5) :1027-1037.Abstract
Prenatal care is one of the most widely used preventive care services in the United States, yet prenatal care delivery recommendations have remained largely unchanged since just before World War II. The current prenatal care model can be improved to better serve modern patients and the health care providers who care for them in three key ways: 1) focusing more on promotion of health and wellness as opposed to primarily focusing on medical complications, 2) flexibly incorporating patient preferences, and 3) individualizing care. As key policymakers and stakeholders grapple with higher maternity care costs and poorer outcomes, including lagging access, equity, and maternal and infant morbidity and mortality in the United States compared with other high-income countries, the opportunity to improve prenatal care has been given insufficient attention. In this manuscript, we present a new conceptual model for prenatal care that incorporates both patients' medical and social needs into four phenotypes, and use human-centered design methods to describe how better matching patient needs with prenatal services can increase the use of high-value services and decrease the use of low-value services. Finally, we address some of the key challenges to implementing right-sized prenatal care, including capturing outcomes through research and payment.
2019
Lenti G, Norenberg A, Farnan JM, Weissman A, Cook M, Shah N, Moriates C, Wallingford S, Lynch S, Stebbins M, et al. Development and testing of a web module to IMPROVE generic prescribing of oral contraceptives among primary care physicians. J Clin Pharm Ther. 2019;44 (4) :579-587.Abstract
WHAT IS KNOWN AND OBJECTIVE: The use of generic oral contraceptives (OCPs) can improve adherence and reduce healthcare costs, yet scepticism of generic drugs remains a barrier to generic OCP discussion and prescription. An educational web module was developed to reduce generic scepticism related to OCPs, improve knowledge of generic drugs and increase physician willingness to discuss and prescribe generic OCPs. METHODS: A needs assessment was completed using in-person focus groups at American College of Physicians (ACP) Annual Meeting and a survey targeting baseline generic scepticism. Insights gained were used to build an educational web module detailing barriers and benefits of generic OCP prescription. The module was disseminated via email to an ACP research panel who completed our baseline survey. Post-module evaluation measured learner reaction, knowledge and intention to change behaviour along with generic scepticism. RESULTS AND DISCUSSION: The module had a response rate of 56% (n = 208/369). Individuals defined as generic sceptics at baseline were significantly less likely to complete our module compared to non-sceptics (responders 9.6% vs non-responders 16.8%, P = 0.04). The majority (85%, n = 17/20) of baseline sceptics were converted to non-sceptics (P < 0.01) following completion of the module. Compared to non-sceptics, post-module generic sceptics reported less willingness to discuss (sceptic 33.3% vs non-sceptic 71.5%, P < 0.01), but not less willingness to prescribe generic OCPs (sceptic 53.3% vs non-sceptic 67.9%, P = 0.25). Non-white physicians and international medical graduates (IMG) were more likely to be generic sceptics at baseline (non-white 86.9% vs white 69.9%, P = 0.01, IMG 13.0% vs USMG 5.0% vs unknown 18.2%, P = 0.03) but were also more likely to report intention to prescribe generic OCPs as a result of the module (non-white 78.7% vs white 57.3%, P < 0.01, IMG 76.1% vs USMG 50.3% vs unknown 77.3%, P = 0.03). WHAT IS NEW AND CONCLUSION: A brief educational web module can be used to promote prescribing of generic OCPs and reduce generic scepticism.
Gourevitch RA, Mehrotra A, Galvin G, Plough AC, Shah NT. Does comparing cesarean delivery rates influence women's choice of obstetric hospital?. Am J Manag Care. 2019;25 (2) :e33-e38.Abstract
OBJECTIVES: Despite public reporting of wide variation in hospital cesarean delivery rates, few women access this information when deciding where to deliver. We hypothesized that making cesarean delivery rate data more easily accessible and understandable would increase the likelihood of women selecting a hospital with a low cesarean delivery rate. STUDY DESIGN: We conducted a randomized controlled trial of 18,293 users of the Ovia Health mobile apps in 2016-2017. All enrollees were given an explanation of cesarean delivery rate data, and those randomized to the intervention group were also given an interactive tool that presented those data for the 10 closest hospitals with obstetric services. Our outcome measures were enrollees' self-reported delivery hospital and views on cesarean delivery rates. METHODS: Intent-to-treat analysis using 2-sided Pearson's χ2 tests. RESULTS: There was no significant difference across the experimental groups in the proportion of women who selected hospitals with low cesarean delivery rates (7.0% control vs 6.8% intervention; P = .54). Women in the intervention group were more likely to believe that hospitals in their community had differing cesarean delivery rates (66.9% vs 55.9%; P <.001) and to report that they looked at cesarean delivery rates when choosing their hospital (44.5% vs 33.9%; P <.001). CONCLUSIONS: Providing women with an interactive tool to compare cesarean delivery rates across hospitals in their community improved women's familiarity with variation in cesarean delivery rates but did not increase their likelihood of selecting hospitals with lower rates.
Plough A, Polzin-Rosenberg D, Galvin G, Shao A, Sullivan B, Henrich N, Shah NT. An Exploratory Study of the Relationship between Facility Design and the Provision of Childbirth Care. J Midwifery Womens Health. 2019;64 (1) :12-17.Abstract
INTRODUCTION: Across health care, facility design has been shown to significantly affect quality of care; however, in maternity care, the mechanisms of how facility design affects provision of care are understudied. We aim to identify and illustrate key mechanisms that may explain how facility design helps or hinders clinicians in providing childbirth care. METHODS: We reviewed the literature to select design elements for inclusion. Using a modified Delphi consensus process, we engaged an interdisciplinary advisory board to prioritize these elements with regard to potential effect on care provision. The advisory board proposed mechanisms that may explain how the prioritized facility design elements help or hinder care, which the study team organized into themes. We then explored these themes using semistructured interviews with managers at 12 diverse birth centers and hospital-based labor and delivery units from across the United States. RESULTS: The design of childbirth facilities may help or hinder the provision of care through at least 3 distinct mechanisms: 1) flexibility and adaptability of spaces to changes in volume or acuity; 2) physical and cognitive anchoring that can create default workflows or mental models of care; and 3) facilitation of sharing knowledge and workload across clinicians. DISCUSSION: Facility designs may intentionally or unintentionally influence the workflows, expectations, and cultures of childbirth care.
Sudhof L, Shah NT. In Pursuit of Value-Based Maternity Care. Obstet Gynecol. 2019;133 (3) :541-551.Abstract
Value-based care has become the new paradigm for clinical practice, with significant implications for maternity services, where there is a large opportunity to provide better care at lower cost. Childbirth is the most common reason for hospitalization in the United States and represents the single largest category of hospital-based expenditures. At the same time, the United States ranks low among developed countries on measures of maternal and neonatal health, suggesting that we are not using resources optimally. Improving the value of maternity services will require public policies that measure and pay for quality rather than quantity of care. Equally important, clinicians will need to employ new strategies to deliver value, including considering prices, individualizing the use of new technologies, prioritizing team-based approaches to care, bridging pregnancy and contraception counseling, and engaging expecting families in new ways.
Shah NT, Sudhoff L. In Reply. Obstet Gynecol. 2019;134 (1) :180-181.
Uribe-Leitz T, Barrero-Castillero A, Cervantes-Trejo A, Santos JM, de la Rosa-Rabago A, Lipsitz SR, Basavilvazo-Rodriguez MA, Shah N, Molina RL. Trends of caesarean delivery from 2008 to 2017, Mexico. Bull World Health Organ. 2019;97 (7) :502-512.Abstract
Caesarean delivery rates in Mexico are among the highest in the world. Given heightened public and professional awareness of this problem and the updated 2014 national guidelines to reduce the frequency of caesarean delivery, we analysed trends in caesarean delivery by type of facility in Mexico from 2008 to 2017. We obtained birth-certificate data from the Mexican General Directorate for Health Information and grouped the total number of vaginal and caesarean deliveries into five categories of facility: health-ministry hospitals; private hospitals; government employment-based insurance hospitals; military hospitals; and other facilities. Delivery rates were calculated for each category nationally and for each state. On average, 2 114 630 (95% confidence interval, CI: 2 061 487-2 167 773) live births occurred nationally each year between 2008 and 2017. Of these births, 53.5% (1 130 570; 95% CI: 1 108 068-1 153 072) were vaginal deliveries, and 45.3% (957 105; 95% CI: 922 936-991 274) were caesarean deliveries, with little variation over time. During the study period, the number of live births increased by 4.4% (from 1 978 380 to 2 064 507). The vaginal delivery rate decreased from 54.8% (1 083 331/1 978 380) to 52.9% (1 091 958/2 064 507), giving a relative percentage decrease in the rate of 3.5%. The caesarean delivery rate increased from 43.9% (869 018/1 978 380) to 45.5% (940 206/2 064 507), giving a relative percentage increase in the rate of 3.7%. The biggest change in delivery rates was in private-sector hospitals. Since 2014, rates of caesarean delivery have fallen slightly in all sectors, but they remain high at 45.5%. Policies with appropriate interventions are needed to reduce the caesarean delivery rate in Mexico, particularly in private-sector hospitals.
2018
Molina RL, Gombolay M, Jonas J, Modest AM, Shah J, Golen TH, Shah NT. Association Between Labor and Delivery Unit Census and Delays in Patient Management: Findings From a Computer Simulation Module. Obstetrics & Gynecology. 2018;131 (3) :545-552.
Avery MD, Bell AD, Bingham D, Corry MP, Delbanco SF, Gullo SL, Ivory CH, Jennings JC, Kennedy HP, Kozhimannil KB. Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing. The Journal of Perinatal Education. 2018;27 (3) :130-134.
Nijagal MA, Shah NT, Levin-Scherz J. Both patients and maternity care providers can benefit from payment reform: four steps to prepare. American journal of obstetrics and gynecology. 2018;218 (4) :411. e1-411. e6.
Kozhimannil KB, Graves AJ, Ecklund AM, Shah N, Aggarwal R, Snowden JM. Cesarean Delivery Rates and Costs of Childbirth in a State Medicaid Program After Implementation of a Blended Payment Policy. Medical care. 2018;56 (8) :658-664.
Plough A, Henrich N, Galvin G, Shah NT. Common challenges managing bed and staff availability on labor and delivery units in the United States: A qualitative analysis. Birth. 2018.
Edmonds JK, Miley K, Angelini KJ, Shah NT. Decision Making about Hospital Arrival among Low‐Risk Nulliparous Women after Spontaneous Labor Onset at Home. Journal of midwifery & women's health. 2018.
Gourevitch R, Mehrotra A, Galvin G, Plough A, Shah NT. Does Comparison of Local Cesarean Rates Influence Where Women Deliver? A Randomized Controlled Trial [21k]. Obstetrics & Gynecology. 2018;131 :124S.
Shah NT. Eroding Access and Quality of Childbirth Care in Rural US Counties. Jama. 2018;319 (12) :1203-1204.
Chee M, Zhang JX, Ngooi S, Moriates C, Shah N, Arora VM. Generic Substitution Rates of Oral Contraceptives and Associated Out-of-Pocket Cost Savings Between January 2010 and December 2014. JAMA internal medicine. 2018;178 (4) :561-563.

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