Video

BOSTON – From the earliest days of using catheter ablation to treat atrial fibrillation (AF), in the 1990s, clinicians have defined ablation success based on whether patients had recurrence of their arrhythmia following treatment. New findings suggest that this standard was off, and that a much better measure of ablation’s success is the extent to which it cuts atrial fibrillation burden, the overall percentage of time a patient spends in the arrhythmic state.

The new study used data collected in the CASTLE-AF (Catheter Ablation vs. Standard Conventional Treatment in Patients With LV Dysfunction and AF) multicenter trial, which compared the efficacy of AF ablation with antiarrhythmic drug treatment in patients with heart failure for improving survival and freedom from hospitalization for heart failure. The trial’s primary finding showed that, in 363 randomized patients, AF ablation cut the primary adverse event rate by 38% relative to antiarrhythmic drug therapy (New Engl J Med. 2018 Feb 1;378[5]:417-27)

Mitchel L. Zoler/MDedge News

Mitchel L. Zoler/MDedge News

Ablation was significantly more effective than drug therapy for cutting atrial fibrillation burden, which started at an average of about 50% in all patients at baseline. AF burden fell to an average of about 10%-15% among the ablated patients when measured at several time points during follow-up, whereas AF burden remained at an average of about 50% or higher among the drug-treated patients.

Mitchel L. Zoler/MDedge News

One further observation in the new analysis was that a drop in AF burden was linked with improved outcomes regardless of whether or not a “blanking period” was imposed on the data. Researchers applied a 90-day blanking period after ablation when assessing the treatment’s efficacy to censor from the analysis recurrences that occurred soon after ablation. The need for a blanking period during the first 90 days “was put to rest” by this new analysis, Dr. Brachmann said.

CASTLE-AF was sponsored by Biotronik. Dr. Brachmann has been a consultant to and has received research funding from Biotronik and several other companies. Dr. Krahn has been a consultant to Medtronic and has received research support from Medtronic and Boston Scientific. Dr. Link had no disclosures.

[email protected]

SOURCE: Brachmann J et al. Heart Rhythm 2018, Abstract B-LBCT02-04.
 

BOSTON – From the earliest days of using catheter ablation to treat atrial fibrillation (AF), in the 1990s, clinicians have defined ablation success based on whether patients had recurrence of their arrhythmia following treatment. New findings suggest that this standard was off, and that a much better measure of ablation’s success is the extent to which it cuts atrial fibrillation burden, the overall percentage of time a patient spends in the arrhythmic state.

The new study used data collected in the CASTLE-AF (Catheter Ablation vs. Standard Conventional Treatment in Patients With LV Dysfunction and AF) multicenter trial, which compared the efficacy of AF ablation with antiarrhythmic drug treatment in patients with heart failure for improving survival and freedom from hospitalization for heart failure. The trial’s primary finding showed that, in 363 randomized patients, AF ablation cut the primary adverse event rate by 38% relative to antiarrhythmic drug therapy (New Engl J Med. 2018 Feb 1;378[5]:417-27)

Mitchel L. Zoler/MDedge News

Mitchel L. Zoler/MDedge News

Ablation was significantly more effective than drug therapy for cutting atrial fibrillation burden, which started at an average of about 50% in all patients at baseline. AF burden fell to an average of about 10%-15% among the ablated patients when measured at several time points during follow-up, whereas AF burden remained at an average of about 50% or higher among the drug-treated patients.

Mitchel L. Zoler/MDedge News

One further observation in the new analysis was that a drop in AF burden was linked with improved outcomes regardless of whether or not a “blanking period” was imposed on the data. Researchers applied a 90-day blanking period after ablation when assessing the treatment’s efficacy to censor from the analysis recurrences that occurred soon after ablation. The need for a blanking period during the first 90 days “was put to rest” by this new analysis, Dr. Brachmann said.

CASTLE-AF was sponsored by Biotronik. Dr. Brachmann has been a consultant to and has received research funding from Biotronik and several other companies. Dr. Krahn has been a consultant to Medtronic and has received research support from Medtronic and Boston Scientific. Dr. Link had no disclosures.

[email protected]

SOURCE: Brachmann J et al. Heart Rhythm 2018, Abstract B-LBCT02-04.
 

BOSTON – From the earliest days of using catheter ablation to treat atrial fibrillation (AF), in the 1990s, clinicians have defined ablation success based on whether patients had recurrence of their arrhythmia following treatment. New findings suggest that this standard was off, and that a much better measure of ablation’s success is the extent to which it cuts atrial fibrillation burden, the overall percentage of time a patient spends in the arrhythmic state.

The new study used data collected in the CASTLE-AF (Catheter Ablation vs. Standard Conventional Treatment in Patients With LV Dysfunction and AF) multicenter trial, which compared the efficacy of AF ablation with antiarrhythmic drug treatment in patients with heart failure for improving survival and freedom from hospitalization for heart failure. The trial’s primary finding showed that, in 363 randomized patients, AF ablation cut the primary adverse event rate by 38% relative to antiarrhythmic drug therapy (New Engl J Med. 2018 Feb 1;378[5]:417-27)

Mitchel L. Zoler/MDedge News

Mitchel L. Zoler/MDedge News

Ablation was significantly more effective than drug therapy for cutting atrial fibrillation burden, which started at an average of about 50% in all patients at baseline. AF burden fell to an average of about 10%-15% among the ablated patients when measured at several time points during follow-up, whereas AF burden remained at an average of about 50% or higher among the drug-treated patients.

Mitchel L. Zoler/MDedge News

One further observation in the new analysis was that a drop in AF burden was linked with improved outcomes regardless of whether or not a “blanking period” was imposed on the data. Researchers applied a 90-day blanking period after ablation when assessing the treatment’s efficacy to censor from the analysis recurrences that occurred soon after ablation. The need for a blanking period during the first 90 days “was put to rest” by this new analysis, Dr. Brachmann said.

CASTLE-AF was sponsored by Biotronik. Dr. Brachmann has been a consultant to and has received research funding from Biotronik and several other companies. Dr. Krahn has been a consultant to Medtronic and has received research support from Medtronic and Boston Scientific. Dr. Link had no disclosures.

[email protected]

SOURCE: Brachmann J et al. Heart Rhythm 2018, Abstract B-LBCT02-04.
 

AUSTIN, TEX. – In a randomized survey, the Food and Drug Administration’s previous letter-category labeling of drugs for pregnant women made prescribers more likely to prescribe appropriate medication than the new labeling standards without the letters.

The FDA removed the letter categories A, B, C, D, and X in 2014 in the belief “that a narrative structure for pregnancy labeling is best able to capture and convey the potential risks of drug exposure based on animal or human data, or both,” as stated in the FDA ruling.

“The [old] FDA categories are actually based upon the evidence related to clinical trials or animal trials and known risks to the fetus or the mother. The categorizations really reflect the evidence that we have or the absence of evidence as to whether medications can be safely used during pregnancy,” Dr. Robinson explained in a video interview. But letters can be perceived as overall “grades,” even though they aren’t.

The researchers sought to evaluate the effect of the letters’ removal by surveying doctors at two centers in New York City and two annual specialty meetings from October 2015 to May 2016.

The survey “included demographic information, followed by four clinical vignettes. Each vignette described a pregnant woman and presented an indication for prescribing a particular drug which was FDA approved. Each vignette was followed by detailed drug information as found in the FDA-approved package insert with the new [Pregnancy and Lactation Labeling Rule] content and formatting,” Dr. Robinson said at the meeting.

The 162 survey respondents estimated their likelihood of prescribing given the information in the vignette. The respondents were randomized to see the letter category or not. Category X (positive evidence of risk that clearly outweighs potential benefits) was not included. For all four remaining categories, the respondents who were shown the letter category were more likely to prescribe. Category B was significantly affected in a mixed linear model, and both categories B and C were significantly affected in a multivariate model.

“The new system of revised labeling may be more ambiguous and present new challenges for clinical decision making that could result in decreased access to medications for pregnant women,” Dr. Robinson said.

Dr. Robinson and her coauthors reported no relevant disclosures.

[email protected]

SOURCE: Robinson A et al. ACOG 2018. Abstract OP5.

AUSTIN, TEX. – In a randomized survey, the Food and Drug Administration’s previous letter-category labeling of drugs for pregnant women made prescribers more likely to prescribe appropriate medication than the new labeling standards without the letters.

The FDA removed the letter categories A, B, C, D, and X in 2014 in the belief “that a narrative structure for pregnancy labeling is best able to capture and convey the potential risks of drug exposure based on animal or human data, or both,” as stated in the FDA ruling.

“The [old] FDA categories are actually based upon the evidence related to clinical trials or animal trials and known risks to the fetus or the mother. The categorizations really reflect the evidence that we have or the absence of evidence as to whether medications can be safely used during pregnancy,” Dr. Robinson explained in a video interview. But letters can be perceived as overall “grades,” even though they aren’t.

The researchers sought to evaluate the effect of the letters’ removal by surveying doctors at two centers in New York City and two annual specialty meetings from October 2015 to May 2016.

The survey “included demographic information, followed by four clinical vignettes. Each vignette described a pregnant woman and presented an indication for prescribing a particular drug which was FDA approved. Each vignette was followed by detailed drug information as found in the FDA-approved package insert with the new [Pregnancy and Lactation Labeling Rule] content and formatting,” Dr. Robinson said at the meeting.

The 162 survey respondents estimated their likelihood of prescribing given the information in the vignette. The respondents were randomized to see the letter category or not. Category X (positive evidence of risk that clearly outweighs potential benefits) was not included. For all four remaining categories, the respondents who were shown the letter category were more likely to prescribe. Category B was significantly affected in a mixed linear model, and both categories B and C were significantly affected in a multivariate model.

“The new system of revised labeling may be more ambiguous and present new challenges for clinical decision making that could result in decreased access to medications for pregnant women,” Dr. Robinson said.

Dr. Robinson and her coauthors reported no relevant disclosures.

[email protected]

SOURCE: Robinson A et al. ACOG 2018. Abstract OP5.

AUSTIN, TEX. – In a randomized survey, the Food and Drug Administration’s previous letter-category labeling of drugs for pregnant women made prescribers more likely to prescribe appropriate medication than the new labeling standards without the letters.

The FDA removed the letter categories A, B, C, D, and X in 2014 in the belief “that a narrative structure for pregnancy labeling is best able to capture and convey the potential risks of drug exposure based on animal or human data, or both,” as stated in the FDA ruling.

“The [old] FDA categories are actually based upon the evidence related to clinical trials or animal trials and known risks to the fetus or the mother. The categorizations really reflect the evidence that we have or the absence of evidence as to whether medications can be safely used during pregnancy,” Dr. Robinson explained in a video interview. But letters can be perceived as overall “grades,” even though they aren’t.

The researchers sought to evaluate the effect of the letters’ removal by surveying doctors at two centers in New York City and two annual specialty meetings from October 2015 to May 2016.

The survey “included demographic information, followed by four clinical vignettes. Each vignette described a pregnant woman and presented an indication for prescribing a particular drug which was FDA approved. Each vignette was followed by detailed drug information as found in the FDA-approved package insert with the new [Pregnancy and Lactation Labeling Rule] content and formatting,” Dr. Robinson said at the meeting.

The 162 survey respondents estimated their likelihood of prescribing given the information in the vignette. The respondents were randomized to see the letter category or not. Category X (positive evidence of risk that clearly outweighs potential benefits) was not included. For all four remaining categories, the respondents who were shown the letter category were more likely to prescribe. Category B was significantly affected in a mixed linear model, and both categories B and C were significantly affected in a multivariate model.

“The new system of revised labeling may be more ambiguous and present new challenges for clinical decision making that could result in decreased access to medications for pregnant women,” Dr. Robinson said.

Dr. Robinson and her coauthors reported no relevant disclosures.

[email protected]

SOURCE: Robinson A et al. ACOG 2018. Abstract OP5.

AUSTIN, TEX. – Encouraging an upright position and allowing mobility during labor is a cost-effective intervention that could save hundreds of millions of dollars while preventing cesarean deliveries, uterine rupture, and maternal deaths, according to a recent cost-effectiveness study.

Alyssa Hersh, a medical student at Oregon Health & Sciences University, Portland, developed the analysis using an innovative model that examines the costs associated not just with the first delivery, but also the probable next delivery.

“Our model was dependent on the ability to reduce cesareans and also reduce labor times,” said Ms. Hersh in a video interview. “So this reduction in cesareans allowed women to avoid having an increased risk of uterine rupture, of emergent hysterectomy, and other downstream consequences.”

The “two-delivery model” takes into account the average number of births per woman in the United States, “such that the risks, benefits, and costs are framed within the public health perspective of the average U.S. childrearing woman’s entire reproductive course,” she and her coauthors wrote in the poster accompanying the presentation at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

This model captures the downstream effects of a first cesarean delivery on the next delivery, for example, providing a more realistic picture of the true costs of cesarean delivery for a nulliparous female.

Some of the known benefits of being upright and mobile during labor, Ms. Hersh said, include shortened labor and reduced risk for cesarean delivery. Cost-effectiveness of this approach for low-risk women, she said, had not been fully explored.

For the analysis, Ms. Hersh and her colleagues used a theoretical cohort of 1.8 million women, approximating the number of nulliparous term deliveries in the United States each year. They used rates of cesarean delivery for women laboring in upright and recumbent positions that were drawn from the literature, but lower than national averages: 7.8% of recumbent women and 5.4% of upright women went on to cesarean delivery in the model used by the investigators.

The outcomes tracked in the analysis included cesarean delivery, uterine rupture, hysterectomy attributed to uterine rupture, costs, and quality-adjusted life years (QALYs). All of the outcomes were tracked for the index pregnancy and the second pregnancy.

Ms. Hersh and her coinvestigators found that in the theoretical cohort, “laboring upright led to 64,890 fewer cesarean deliveries, 15 fewer maternal deaths, 113 fewer uterine ruptures, and 30 fewer hysterectomies.”

These reductions were associated with a savings for this cohort of $785 million, and an increase in QALYs of 2,142.

Using Monte Carlo simulation techniques to ascertain the effect of varying cesarean rates and other components of the model, Ms. Hersh and her colleagues found that the model remained cost-effective even with variation in all of the inputs.

“Laboring upright is a no-cost intervention that leads to improved outcomes, decreased costs, and increased QALYs during a woman’s first and second deliveries,” wrote Ms. Hersh and her associates. “This model argues for increasing systems factors that support women to be upright and mobile during labor, and in doing so, promoting improved health for our patients.”

Said Ms. Hersh, “This is an easy way for hospitals to adopt policies that can enable women to have improved outcomes.”

Ms. Hersh and her colleagues had no relevant financial disclosures.

[email protected]

SOURCE: Hersh A et al. ACOG 2018. Abstract 34C.

AUSTIN, TEX. – Encouraging an upright position and allowing mobility during labor is a cost-effective intervention that could save hundreds of millions of dollars while preventing cesarean deliveries, uterine rupture, and maternal deaths, according to a recent cost-effectiveness study.

Alyssa Hersh, a medical student at Oregon Health & Sciences University, Portland, developed the analysis using an innovative model that examines the costs associated not just with the first delivery, but also the probable next delivery.

“Our model was dependent on the ability to reduce cesareans and also reduce labor times,” said Ms. Hersh in a video interview. “So this reduction in cesareans allowed women to avoid having an increased risk of uterine rupture, of emergent hysterectomy, and other downstream consequences.”

The “two-delivery model” takes into account the average number of births per woman in the United States, “such that the risks, benefits, and costs are framed within the public health perspective of the average U.S. childrearing woman’s entire reproductive course,” she and her coauthors wrote in the poster accompanying the presentation at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

This model captures the downstream effects of a first cesarean delivery on the next delivery, for example, providing a more realistic picture of the true costs of cesarean delivery for a nulliparous female.

Some of the known benefits of being upright and mobile during labor, Ms. Hersh said, include shortened labor and reduced risk for cesarean delivery. Cost-effectiveness of this approach for low-risk women, she said, had not been fully explored.

For the analysis, Ms. Hersh and her colleagues used a theoretical cohort of 1.8 million women, approximating the number of nulliparous term deliveries in the United States each year. They used rates of cesarean delivery for women laboring in upright and recumbent positions that were drawn from the literature, but lower than national averages: 7.8% of recumbent women and 5.4% of upright women went on to cesarean delivery in the model used by the investigators.

The outcomes tracked in the analysis included cesarean delivery, uterine rupture, hysterectomy attributed to uterine rupture, costs, and quality-adjusted life years (QALYs). All of the outcomes were tracked for the index pregnancy and the second pregnancy.

Ms. Hersh and her coinvestigators found that in the theoretical cohort, “laboring upright led to 64,890 fewer cesarean deliveries, 15 fewer maternal deaths, 113 fewer uterine ruptures, and 30 fewer hysterectomies.”

These reductions were associated with a savings for this cohort of $785 million, and an increase in QALYs of 2,142.

Using Monte Carlo simulation techniques to ascertain the effect of varying cesarean rates and other components of the model, Ms. Hersh and her colleagues found that the model remained cost-effective even with variation in all of the inputs.

“Laboring upright is a no-cost intervention that leads to improved outcomes, decreased costs, and increased QALYs during a woman’s first and second deliveries,” wrote Ms. Hersh and her associates. “This model argues for increasing systems factors that support women to be upright and mobile during labor, and in doing so, promoting improved health for our patients.”

Said Ms. Hersh, “This is an easy way for hospitals to adopt policies that can enable women to have improved outcomes.”

Ms. Hersh and her colleagues had no relevant financial disclosures.

[email protected]

SOURCE: Hersh A et al. ACOG 2018. Abstract 34C.

AUSTIN, TEX. – Encouraging an upright position and allowing mobility during labor is a cost-effective intervention that could save hundreds of millions of dollars while preventing cesarean deliveries, uterine rupture, and maternal deaths, according to a recent cost-effectiveness study.

Alyssa Hersh, a medical student at Oregon Health & Sciences University, Portland, developed the analysis using an innovative model that examines the costs associated not just with the first delivery, but also the probable next delivery.

“Our model was dependent on the ability to reduce cesareans and also reduce labor times,” said Ms. Hersh in a video interview. “So this reduction in cesareans allowed women to avoid having an increased risk of uterine rupture, of emergent hysterectomy, and other downstream consequences.”

The “two-delivery model” takes into account the average number of births per woman in the United States, “such that the risks, benefits, and costs are framed within the public health perspective of the average U.S. childrearing woman’s entire reproductive course,” she and her coauthors wrote in the poster accompanying the presentation at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

This model captures the downstream effects of a first cesarean delivery on the next delivery, for example, providing a more realistic picture of the true costs of cesarean delivery for a nulliparous female.

Some of the known benefits of being upright and mobile during labor, Ms. Hersh said, include shortened labor and reduced risk for cesarean delivery. Cost-effectiveness of this approach for low-risk women, she said, had not been fully explored.

For the analysis, Ms. Hersh and her colleagues used a theoretical cohort of 1.8 million women, approximating the number of nulliparous term deliveries in the United States each year. They used rates of cesarean delivery for women laboring in upright and recumbent positions that were drawn from the literature, but lower than national averages: 7.8% of recumbent women and 5.4% of upright women went on to cesarean delivery in the model used by the investigators.

The outcomes tracked in the analysis included cesarean delivery, uterine rupture, hysterectomy attributed to uterine rupture, costs, and quality-adjusted life years (QALYs). All of the outcomes were tracked for the index pregnancy and the second pregnancy.

Ms. Hersh and her coinvestigators found that in the theoretical cohort, “laboring upright led to 64,890 fewer cesarean deliveries, 15 fewer maternal deaths, 113 fewer uterine ruptures, and 30 fewer hysterectomies.”

These reductions were associated with a savings for this cohort of $785 million, and an increase in QALYs of 2,142.

Using Monte Carlo simulation techniques to ascertain the effect of varying cesarean rates and other components of the model, Ms. Hersh and her colleagues found that the model remained cost-effective even with variation in all of the inputs.

“Laboring upright is a no-cost intervention that leads to improved outcomes, decreased costs, and increased QALYs during a woman’s first and second deliveries,” wrote Ms. Hersh and her associates. “This model argues for increasing systems factors that support women to be upright and mobile during labor, and in doing so, promoting improved health for our patients.”

Said Ms. Hersh, “This is an easy way for hospitals to adopt policies that can enable women to have improved outcomes.”

Ms. Hersh and her colleagues had no relevant financial disclosures.

[email protected]

SOURCE: Hersh A et al. ACOG 2018. Abstract 34C.

AUSTIN, TEX. – This interview was conducted at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. It has been edited for length and clarity.

OB.GYN. NEWS: Here at ACOG, there were two studies from your research group at Oregon Health & Sciences University, Portland, that examined the cost-effectiveness of pregnancy interventions using a “two-delivery” model. Could you explain a little more about what that is, and how you arrived at this model?

DR. CAUGHEY: We’ve been working on decision analytics and cost-effectiveness studies of a number of ways to approach pregnancy, whether it be complicated pregnancies or uncomplicated normal pregnancies.

One of the things that we think is really important to think about is the impact of management and outcomes in the current pregnancy, and how it might affect future pregnancies.

So, for example, if you have a vaginal delivery this time, that makes you multiparous with a prior vaginal delivery next time; that is kind of the goal in pregnancy. It just makes all future labor and delivery experiences so much easier. Whereas, if you have a prior C-section, we all know that now you’re high risk. Everybody gets nervous about you. Are you going to get a trial of labor? Can you find a hospital that will do a trial of labor? And there are all these downstream implications of the delivery in the first pregnancy.

If you think about it, there are a number of ways that we can manage the first pregnancy. There are a number of risk factors for increasing risk for cesarean delivery. And we can include those in models that are considered in downstream pregnancies. And so we’ve been doing that increasingly.

When we think about our vaginal birth after cesarean models, we had two presentations that considered that. One was how we manage the maternal position in labor, and the other was how we use doulas in labor. You think, well gosh, we’re spending money on this doula in this pregnancy – that’s a certain expenditure. Is it worth it?

Part of “Is it worth it?” is not just the current pregnancy, but the downstream pregnancy as well.

OB.GYN. NEWS: What has sparked your interest in looking at obstetric care delivery in this way?

DR. CAUGHEY: I did my PhD in health economics. I began it as a 3rd-year maternal fetal medicine fellow and during my early career as an assistant professor at the University of California, San Francisco.

A lot of people think that economics in general is kind of about finance. Actually, microeconomics in particular is about the allocation of scarce resources to optimize utility – utility as general wellbeing or happiness.

So people will say that this thing, or that intervention, is cost effective, and often what they think they mean is, “It saves money.” But most things don’t save money. Most things in health care cost money. There are a few things in health care that do save money – vaccinations, contraception. Contraception actually saves money – but most things cost money. We have to spend money to get something right.

And the way we do that in health economics is that we think we’re going to get some happiness, some utility, some better outcomes from the money we’re putting in. One of the things that we don’t do very well as a species is think about these downstream outcomes.

In our models, when we think about morbidity and mortality we’re incorporating two and three pregnancy models. Think about what happens in the future, and then think about if we do something – if we spend money on an induction of labor or having a doula or something like that, is it worth it for what we get?

Antenatal testing, for example. Or, is it worth it for you to be testing people with diabetes once a week? Twice a week? More? Less? Part of it is figuring out what you’ll get for it. The measurement of what you get for it is called quality-adjusted life years, and that’s the measure of happiness multiplied times life expectancy.

We incorporate that in standard ways to build these models, to help us make decisions around best practices. Now, the economics piece of it probably matters. We’re the richest country that’s probably ever going to be – not just ever has been but probably ever going to be – the way we’re using up scarce resources to beat the band.

Yet, we still have an issue of allocation. We have people that have less; we have enormous disparities, whether it be racial and ethnic disparities, or socioeconomic disparities. And so we need to figure out ways to be more efficient and allocate those scarce resources properly to the outcomes that will be the best.

I think that’s what we’re working on: creating models to think about how to allocate those scarce resources.

OB.GYN. NEWS: How can a busy obstetrician think about the work you’re doing and incorporate it into her practice on a day-to-day basis?

DR. CAUGHEY: As an economist, I want to step back from time to time and think about public health and allocation of scarce resources.

But as a busy practicing clinician, I don’t necessarily want you consciously to think about cost. There are people who will push back on this and say, “Oh no, we should always be cost conscious.” Actually, what I really want you to do is incorporate best practices into the care of the patient at that moment, and do the thing that improves her outcomes best at that moment.

What we want to do, instead, is design systems that will properly incentivize. Incentivize doesn’t mean you think, “Oh gosh, if I do this thing I’m going to get an extra dollar.” It means subconsciously that those incentives are there, and those incentives don’t have to just be about dollars. Often in our field, they’re about time – what takes less time and more time to do something. So if we provide little extra roadblocks, then you’re more likely to go the other way and do something else.

For example: the hard stop. We did all this research in the 2000s to show that you probably shouldn’t deliver babies just for fun before 39 weeks’ gestational age. There should be an indication. If we don’t allow any hard stop, if we don’t block the pathway, then patients are pushing us, they’re uncomfortable, they’re like, “Just deliver me.” So we said, “No, no, no, we’re going to block this. In fact, we’re actually going to provide a hard stop reimbursement-wise. And medical directors of hospitals are going to have to preapprove.” And so that provides a blockade, and makes it easier just not to do it.

So I think that’s what we want: At the bedside and in your office, we want clinicians to still just be really good doctors. But then, to get involved and help design systems to incentivize us to do the right things.

Aaron B. Caughey, MD, PhD, is professor and chair of the department of obstetrics and gynecology and associate dean for Women’s Health Research and Policy at Oregon Health & Science University, Portland, and is a member of the U.S. Preventive Services Task Force. He reported that he had no relevant financial disclosures.

[email protected]

AUSTIN, TEX. – This interview was conducted at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. It has been edited for length and clarity.

OB.GYN. NEWS: Here at ACOG, there were two studies from your research group at Oregon Health & Sciences University, Portland, that examined the cost-effectiveness of pregnancy interventions using a “two-delivery” model. Could you explain a little more about what that is, and how you arrived at this model?

DR. CAUGHEY: We’ve been working on decision analytics and cost-effectiveness studies of a number of ways to approach pregnancy, whether it be complicated pregnancies or uncomplicated normal pregnancies.

One of the things that we think is really important to think about is the impact of management and outcomes in the current pregnancy, and how it might affect future pregnancies.

So, for example, if you have a vaginal delivery this time, that makes you multiparous with a prior vaginal delivery next time; that is kind of the goal in pregnancy. It just makes all future labor and delivery experiences so much easier. Whereas, if you have a prior C-section, we all know that now you’re high risk. Everybody gets nervous about you. Are you going to get a trial of labor? Can you find a hospital that will do a trial of labor? And there are all these downstream implications of the delivery in the first pregnancy.

If you think about it, there are a number of ways that we can manage the first pregnancy. There are a number of risk factors for increasing risk for cesarean delivery. And we can include those in models that are considered in downstream pregnancies. And so we’ve been doing that increasingly.

When we think about our vaginal birth after cesarean models, we had two presentations that considered that. One was how we manage the maternal position in labor, and the other was how we use doulas in labor. You think, well gosh, we’re spending money on this doula in this pregnancy – that’s a certain expenditure. Is it worth it?

Part of “Is it worth it?” is not just the current pregnancy, but the downstream pregnancy as well.

OB.GYN. NEWS: What has sparked your interest in looking at obstetric care delivery in this way?

DR. CAUGHEY: I did my PhD in health economics. I began it as a 3rd-year maternal fetal medicine fellow and during my early career as an assistant professor at the University of California, San Francisco.

A lot of people think that economics in general is kind of about finance. Actually, microeconomics in particular is about the allocation of scarce resources to optimize utility – utility as general wellbeing or happiness.

So people will say that this thing, or that intervention, is cost effective, and often what they think they mean is, “It saves money.” But most things don’t save money. Most things in health care cost money. There are a few things in health care that do save money – vaccinations, contraception. Contraception actually saves money – but most things cost money. We have to spend money to get something right.

And the way we do that in health economics is that we think we’re going to get some happiness, some utility, some better outcomes from the money we’re putting in. One of the things that we don’t do very well as a species is think about these downstream outcomes.

In our models, when we think about morbidity and mortality we’re incorporating two and three pregnancy models. Think about what happens in the future, and then think about if we do something – if we spend money on an induction of labor or having a doula or something like that, is it worth it for what we get?

Antenatal testing, for example. Or, is it worth it for you to be testing people with diabetes once a week? Twice a week? More? Less? Part of it is figuring out what you’ll get for it. The measurement of what you get for it is called quality-adjusted life years, and that’s the measure of happiness multiplied times life expectancy.

We incorporate that in standard ways to build these models, to help us make decisions around best practices. Now, the economics piece of it probably matters. We’re the richest country that’s probably ever going to be – not just ever has been but probably ever going to be – the way we’re using up scarce resources to beat the band.

Yet, we still have an issue of allocation. We have people that have less; we have enormous disparities, whether it be racial and ethnic disparities, or socioeconomic disparities. And so we need to figure out ways to be more efficient and allocate those scarce resources properly to the outcomes that will be the best.

I think that’s what we’re working on: creating models to think about how to allocate those scarce resources.

OB.GYN. NEWS: How can a busy obstetrician think about the work you’re doing and incorporate it into her practice on a day-to-day basis?

DR. CAUGHEY: As an economist, I want to step back from time to time and think about public health and allocation of scarce resources.

But as a busy practicing clinician, I don’t necessarily want you consciously to think about cost. There are people who will push back on this and say, “Oh no, we should always be cost conscious.” Actually, what I really want you to do is incorporate best practices into the care of the patient at that moment, and do the thing that improves her outcomes best at that moment.

What we want to do, instead, is design systems that will properly incentivize. Incentivize doesn’t mean you think, “Oh gosh, if I do this thing I’m going to get an extra dollar.” It means subconsciously that those incentives are there, and those incentives don’t have to just be about dollars. Often in our field, they’re about time – what takes less time and more time to do something. So if we provide little extra roadblocks, then you’re more likely to go the other way and do something else.

For example: the hard stop. We did all this research in the 2000s to show that you probably shouldn’t deliver babies just for fun before 39 weeks’ gestational age. There should be an indication. If we don’t allow any hard stop, if we don’t block the pathway, then patients are pushing us, they’re uncomfortable, they’re like, “Just deliver me.” So we said, “No, no, no, we’re going to block this. In fact, we’re actually going to provide a hard stop reimbursement-wise. And medical directors of hospitals are going to have to preapprove.” And so that provides a blockade, and makes it easier just not to do it.

So I think that’s what we want: At the bedside and in your office, we want clinicians to still just be really good doctors. But then, to get involved and help design systems to incentivize us to do the right things.

Aaron B. Caughey, MD, PhD, is professor and chair of the department of obstetrics and gynecology and associate dean for Women’s Health Research and Policy at Oregon Health & Science University, Portland, and is a member of the U.S. Preventive Services Task Force. He reported that he had no relevant financial disclosures.

[email protected]

AUSTIN, TEX. – This interview was conducted at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. It has been edited for length and clarity.

OB.GYN. NEWS: Here at ACOG, there were two studies from your research group at Oregon Health & Sciences University, Portland, that examined the cost-effectiveness of pregnancy interventions using a “two-delivery” model. Could you explain a little more about what that is, and how you arrived at this model?

DR. CAUGHEY: We’ve been working on decision analytics and cost-effectiveness studies of a number of ways to approach pregnancy, whether it be complicated pregnancies or uncomplicated normal pregnancies.

One of the things that we think is really important to think about is the impact of management and outcomes in the current pregnancy, and how it might affect future pregnancies.

So, for example, if you have a vaginal delivery this time, that makes you multiparous with a prior vaginal delivery next time; that is kind of the goal in pregnancy. It just makes all future labor and delivery experiences so much easier. Whereas, if you have a prior C-section, we all know that now you’re high risk. Everybody gets nervous about you. Are you going to get a trial of labor? Can you find a hospital that will do a trial of labor? And there are all these downstream implications of the delivery in the first pregnancy.

If you think about it, there are a number of ways that we can manage the first pregnancy. There are a number of risk factors for increasing risk for cesarean delivery. And we can include those in models that are considered in downstream pregnancies. And so we’ve been doing that increasingly.

When we think about our vaginal birth after cesarean models, we had two presentations that considered that. One was how we manage the maternal position in labor, and the other was how we use doulas in labor. You think, well gosh, we’re spending money on this doula in this pregnancy – that’s a certain expenditure. Is it worth it?

Part of “Is it worth it?” is not just the current pregnancy, but the downstream pregnancy as well.

OB.GYN. NEWS: What has sparked your interest in looking at obstetric care delivery in this way?

DR. CAUGHEY: I did my PhD in health economics. I began it as a 3rd-year maternal fetal medicine fellow and during my early career as an assistant professor at the University of California, San Francisco.

A lot of people think that economics in general is kind of about finance. Actually, microeconomics in particular is about the allocation of scarce resources to optimize utility – utility as general wellbeing or happiness.

So people will say that this thing, or that intervention, is cost effective, and often what they think they mean is, “It saves money.” But most things don’t save money. Most things in health care cost money. There are a few things in health care that do save money – vaccinations, contraception. Contraception actually saves money – but most things cost money. We have to spend money to get something right.

And the way we do that in health economics is that we think we’re going to get some happiness, some utility, some better outcomes from the money we’re putting in. One of the things that we don’t do very well as a species is think about these downstream outcomes.

In our models, when we think about morbidity and mortality we’re incorporating two and three pregnancy models. Think about what happens in the future, and then think about if we do something – if we spend money on an induction of labor or having a doula or something like that, is it worth it for what we get?

Antenatal testing, for example. Or, is it worth it for you to be testing people with diabetes once a week? Twice a week? More? Less? Part of it is figuring out what you’ll get for it. The measurement of what you get for it is called quality-adjusted life years, and that’s the measure of happiness multiplied times life expectancy.

We incorporate that in standard ways to build these models, to help us make decisions around best practices. Now, the economics piece of it probably matters. We’re the richest country that’s probably ever going to be – not just ever has been but probably ever going to be – the way we’re using up scarce resources to beat the band.

Yet, we still have an issue of allocation. We have people that have less; we have enormous disparities, whether it be racial and ethnic disparities, or socioeconomic disparities. And so we need to figure out ways to be more efficient and allocate those scarce resources properly to the outcomes that will be the best.

I think that’s what we’re working on: creating models to think about how to allocate those scarce resources.

OB.GYN. NEWS: How can a busy obstetrician think about the work you’re doing and incorporate it into her practice on a day-to-day basis?

DR. CAUGHEY: As an economist, I want to step back from time to time and think about public health and allocation of scarce resources.

But as a busy practicing clinician, I don’t necessarily want you consciously to think about cost. There are people who will push back on this and say, “Oh no, we should always be cost conscious.” Actually, what I really want you to do is incorporate best practices into the care of the patient at that moment, and do the thing that improves her outcomes best at that moment.

What we want to do, instead, is design systems that will properly incentivize. Incentivize doesn’t mean you think, “Oh gosh, if I do this thing I’m going to get an extra dollar.” It means subconsciously that those incentives are there, and those incentives don’t have to just be about dollars. Often in our field, they’re about time – what takes less time and more time to do something. So if we provide little extra roadblocks, then you’re more likely to go the other way and do something else.

For example: the hard stop. We did all this research in the 2000s to show that you probably shouldn’t deliver babies just for fun before 39 weeks’ gestational age. There should be an indication. If we don’t allow any hard stop, if we don’t block the pathway, then patients are pushing us, they’re uncomfortable, they’re like, “Just deliver me.” So we said, “No, no, no, we’re going to block this. In fact, we’re actually going to provide a hard stop reimbursement-wise. And medical directors of hospitals are going to have to preapprove.” And so that provides a blockade, and makes it easier just not to do it.

So I think that’s what we want: At the bedside and in your office, we want clinicians to still just be really good doctors. But then, to get involved and help design systems to incentivize us to do the right things.

Aaron B. Caughey, MD, PhD, is professor and chair of the department of obstetrics and gynecology and associate dean for Women’s Health Research and Policy at Oregon Health & Science University, Portland, and is a member of the U.S. Preventive Services Task Force. He reported that he had no relevant financial disclosures.

[email protected]

NEW YORK – Psychiatrists are uniquely equipped to take the lead in providing cost-effective, evidence-based addiction treatment services, according to Lama Bazzi, MD, and Elie Aoun, MD.

As cochairs of a session titled, “Psychiatrists at the Helm of the Opioid Epidemic” at the annual meeting of the American Psychiatric Association, Dr. Bazzi and Dr. Aoun addressed how psychiatrists can take the lead as part of multidisciplinary teams, as well as roles they can play in policy and the criminal justice system to “shift the paradigm in terms of how the general public thinks about addiction.”

They also discussed existing models and some new models they have been working on to address the problem.

“We want to empower psychiatrists to feel that they already have the knowledge base to do what needs to be done, and to just ... put out there different ways that we can brainstorm together to do that,” Dr. Bazzi of Maimonides Medical Center, Brooklyn, N.Y., said in a video interview at the meeting.

She and Dr. Aoun also discussed an ongoing project that involves input from law enforcement and support from the APA; an online training module is being developed to address different mental disorders – including substance use disorders – and other issues that officers face, such as racial biases and disparities.

“The curriculum that we’re working on is going to be symptom based,” said Dr. Aoun, of Columbia University, New York, explaining that this approach is more practical for helping law enforcement officers in dealing with issues involving individuals with mental disorders.

Another project focuses on keeping people with mental disorders out of the criminal justice system, he said.

“Every step [of the criminal justice process] is an opportunity to intercept people with mental illness and provide them with intervention,” he said, noting that an adaptation of the model for patients with addictions is also in the works.

He and Dr. Bazzi also focused on where psychiatrists, as experts in both mental health and addiction, can fit into the process.

Dr. Bazzi and Dr. Aoun reported having no disclosures.

[email protected]

NEW YORK – Psychiatrists are uniquely equipped to take the lead in providing cost-effective, evidence-based addiction treatment services, according to Lama Bazzi, MD, and Elie Aoun, MD.

As cochairs of a session titled, “Psychiatrists at the Helm of the Opioid Epidemic” at the annual meeting of the American Psychiatric Association, Dr. Bazzi and Dr. Aoun addressed how psychiatrists can take the lead as part of multidisciplinary teams, as well as roles they can play in policy and the criminal justice system to “shift the paradigm in terms of how the general public thinks about addiction.”

They also discussed existing models and some new models they have been working on to address the problem.

“We want to empower psychiatrists to feel that they already have the knowledge base to do what needs to be done, and to just ... put out there different ways that we can brainstorm together to do that,” Dr. Bazzi of Maimonides Medical Center, Brooklyn, N.Y., said in a video interview at the meeting.

She and Dr. Aoun also discussed an ongoing project that involves input from law enforcement and support from the APA; an online training module is being developed to address different mental disorders – including substance use disorders – and other issues that officers face, such as racial biases and disparities.

“The curriculum that we’re working on is going to be symptom based,” said Dr. Aoun, of Columbia University, New York, explaining that this approach is more practical for helping law enforcement officers in dealing with issues involving individuals with mental disorders.

Another project focuses on keeping people with mental disorders out of the criminal justice system, he said.

“Every step [of the criminal justice process] is an opportunity to intercept people with mental illness and provide them with intervention,” he said, noting that an adaptation of the model for patients with addictions is also in the works.

He and Dr. Bazzi also focused on where psychiatrists, as experts in both mental health and addiction, can fit into the process.

Dr. Bazzi and Dr. Aoun reported having no disclosures.

[email protected]

NEW YORK – Psychiatrists are uniquely equipped to take the lead in providing cost-effective, evidence-based addiction treatment services, according to Lama Bazzi, MD, and Elie Aoun, MD.

As cochairs of a session titled, “Psychiatrists at the Helm of the Opioid Epidemic” at the annual meeting of the American Psychiatric Association, Dr. Bazzi and Dr. Aoun addressed how psychiatrists can take the lead as part of multidisciplinary teams, as well as roles they can play in policy and the criminal justice system to “shift the paradigm in terms of how the general public thinks about addiction.”

They also discussed existing models and some new models they have been working on to address the problem.

“We want to empower psychiatrists to feel that they already have the knowledge base to do what needs to be done, and to just ... put out there different ways that we can brainstorm together to do that,” Dr. Bazzi of Maimonides Medical Center, Brooklyn, N.Y., said in a video interview at the meeting.

She and Dr. Aoun also discussed an ongoing project that involves input from law enforcement and support from the APA; an online training module is being developed to address different mental disorders – including substance use disorders – and other issues that officers face, such as racial biases and disparities.

“The curriculum that we’re working on is going to be symptom based,” said Dr. Aoun, of Columbia University, New York, explaining that this approach is more practical for helping law enforcement officers in dealing with issues involving individuals with mental disorders.

Another project focuses on keeping people with mental disorders out of the criminal justice system, he said.

“Every step [of the criminal justice process] is an opportunity to intercept people with mental illness and provide them with intervention,” he said, noting that an adaptation of the model for patients with addictions is also in the works.

He and Dr. Bazzi also focused on where psychiatrists, as experts in both mental health and addiction, can fit into the process.

Dr. Bazzi and Dr. Aoun reported having no disclosures.

[email protected]

AUSTIN, TEX. – The risk of depression was more than doubled in women who were anemic during pregnancy, according to a recent retrospective cohort study of nearly 1,000 women. Among patients who had anemia at any point, the relative risk of screening positive for postpartum depression was 2.25 (95% confidence interval, 1.22-4.16).

“This was an unexpected finding,” said Shannon Sutherland, MD, of the University of Connecticut, Farmington, in an interview after she presented the findings at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

“Maternal suicide exceeds hemorrhage and hypertensive disease as a cause of U.S. maternal mortality,” wrote Dr. Sutherland and her collaborators in the poster accompanying the presentation. And anemia is common: “Anemia in pregnancy can be as high as 27.4% in low-income minority pregnant women in the third trimester,” they wrote.

“If we can find something like this that affects depression, and screen for it and correct for it, we can make a real big difference in patients’ lives,” said Dr. Sutherland in a video interview. “Screening for anemia ... is such a simple thing for us to do, and I also think it’s very easy for us to correct, and very cheap for us to correct.”

The 922 study participants were at least 16 years old and receiving postpartum care at an outpatient women’s health clinic. Patients who had diseases that disrupted iron metabolism or were tobacco users, and those on antidepressants, anxiolytics, or antipsychotics were excluded from the study. Other exclusion criteria included anemia that required transfusion, and intrauterine fetal demise or neonatal mortality.

To assess depression, Dr. Sutherland and her colleagues administered the Edinburgh Postnatal Depression Scale at routine postpartum visits. Dr. Sutherland and her coinvestigators calculated the numbers of respondents who fell above and below the cutoff for potential depression on the 10-item self-report scale. They then looked at the proportion of women who scored positive for depression among those who were, and those who were not, anemic.

Possible depression was indicated by depression scale scores of 9.2% of participants, while three quarters (75.2%) were anemic either during pregnancy or in the immediate postpartum period. Among anemic patients, 10.8% screened positive for depression, while 4.8% of those without anemia met positive screening criteria for postpartum depression (P = .007).

Dr. Sutherland and her collaborators noted that fewer women in their cohort had postpartum depression than the national average of 19%. They may have missed some patients who would later develop depression since the screening occurred at the first postpartum visit; also, “it is possible that women deeply affected by [postpartum depression] may have been lost to follow-up,” they wrote.

Participants had a mean age of about 26 years, and body mass index was slightly higher for those with anemia than without (mean, 32.2 vs 31.2 kg/m²; P = .025).

Postpartum depression was not associated with marital status, substance use, ethnicity, parity, or the occurrence of postpartum hemorrhage, in the investigators’ analysis.

Dr. Sutherland said that, in their analysis, she and her coinvestigators did not find an association between degree of anemia and the likelihood, or severity, of postpartum depression. However, they did find that anemia of any degree in the immediate peripartum period was most strongly associated with postpartum depression.

Though the exact mechanism of the anemia-depression link isn’t known, the fatigue associated with anemia may help predispose women to postpartum depression, said Dr. Sutherland. Also, she said, “iron can make a difference in synthesizing neurotransmitters” such as serotonin, “so it may follow that you might have some depressive symptoms.”

“The next step after this study, which was a launching point, is to see if we correct the degree of anemia and bring them to normal levels, if that can help decrease the risk of postpartum depression,” said Dr. Sutherland.

Dr. Sutherland and her coinvestigators reported that they had no relevant financial disclosures.

[email protected]

SOURCE: Sutherland S et al. ACOG 2018. Abstract 35C.

AUSTIN, TEX. – The risk of depression was more than doubled in women who were anemic during pregnancy, according to a recent retrospective cohort study of nearly 1,000 women. Among patients who had anemia at any point, the relative risk of screening positive for postpartum depression was 2.25 (95% confidence interval, 1.22-4.16).

“This was an unexpected finding,” said Shannon Sutherland, MD, of the University of Connecticut, Farmington, in an interview after she presented the findings at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

“Maternal suicide exceeds hemorrhage and hypertensive disease as a cause of U.S. maternal mortality,” wrote Dr. Sutherland and her collaborators in the poster accompanying the presentation. And anemia is common: “Anemia in pregnancy can be as high as 27.4% in low-income minority pregnant women in the third trimester,” they wrote.

“If we can find something like this that affects depression, and screen for it and correct for it, we can make a real big difference in patients’ lives,” said Dr. Sutherland in a video interview. “Screening for anemia ... is such a simple thing for us to do, and I also think it’s very easy for us to correct, and very cheap for us to correct.”

The 922 study participants were at least 16 years old and receiving postpartum care at an outpatient women’s health clinic. Patients who had diseases that disrupted iron metabolism or were tobacco users, and those on antidepressants, anxiolytics, or antipsychotics were excluded from the study. Other exclusion criteria included anemia that required transfusion, and intrauterine fetal demise or neonatal mortality.

To assess depression, Dr. Sutherland and her colleagues administered the Edinburgh Postnatal Depression Scale at routine postpartum visits. Dr. Sutherland and her coinvestigators calculated the numbers of respondents who fell above and below the cutoff for potential depression on the 10-item self-report scale. They then looked at the proportion of women who scored positive for depression among those who were, and those who were not, anemic.

Possible depression was indicated by depression scale scores of 9.2% of participants, while three quarters (75.2%) were anemic either during pregnancy or in the immediate postpartum period. Among anemic patients, 10.8% screened positive for depression, while 4.8% of those without anemia met positive screening criteria for postpartum depression (P = .007).

Dr. Sutherland and her collaborators noted that fewer women in their cohort had postpartum depression than the national average of 19%. They may have missed some patients who would later develop depression since the screening occurred at the first postpartum visit; also, “it is possible that women deeply affected by [postpartum depression] may have been lost to follow-up,” they wrote.

Participants had a mean age of about 26 years, and body mass index was slightly higher for those with anemia than without (mean, 32.2 vs 31.2 kg/m²; P = .025).

Postpartum depression was not associated with marital status, substance use, ethnicity, parity, or the occurrence of postpartum hemorrhage, in the investigators’ analysis.

Dr. Sutherland said that, in their analysis, she and her coinvestigators did not find an association between degree of anemia and the likelihood, or severity, of postpartum depression. However, they did find that anemia of any degree in the immediate peripartum period was most strongly associated with postpartum depression.

Though the exact mechanism of the anemia-depression link isn’t known, the fatigue associated with anemia may help predispose women to postpartum depression, said Dr. Sutherland. Also, she said, “iron can make a difference in synthesizing neurotransmitters” such as serotonin, “so it may follow that you might have some depressive symptoms.”

“The next step after this study, which was a launching point, is to see if we correct the degree of anemia and bring them to normal levels, if that can help decrease the risk of postpartum depression,” said Dr. Sutherland.

Dr. Sutherland and her coinvestigators reported that they had no relevant financial disclosures.

[email protected]

SOURCE: Sutherland S et al. ACOG 2018. Abstract 35C.

AUSTIN, TEX. – The risk of depression was more than doubled in women who were anemic during pregnancy, according to a recent retrospective cohort study of nearly 1,000 women. Among patients who had anemia at any point, the relative risk of screening positive for postpartum depression was 2.25 (95% confidence interval, 1.22-4.16).

“This was an unexpected finding,” said Shannon Sutherland, MD, of the University of Connecticut, Farmington, in an interview after she presented the findings at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

“Maternal suicide exceeds hemorrhage and hypertensive disease as a cause of U.S. maternal mortality,” wrote Dr. Sutherland and her collaborators in the poster accompanying the presentation. And anemia is common: “Anemia in pregnancy can be as high as 27.4% in low-income minority pregnant women in the third trimester,” they wrote.

“If we can find something like this that affects depression, and screen for it and correct for it, we can make a real big difference in patients’ lives,” said Dr. Sutherland in a video interview. “Screening for anemia ... is such a simple thing for us to do, and I also think it’s very easy for us to correct, and very cheap for us to correct.”

The 922 study participants were at least 16 years old and receiving postpartum care at an outpatient women’s health clinic. Patients who had diseases that disrupted iron metabolism or were tobacco users, and those on antidepressants, anxiolytics, or antipsychotics were excluded from the study. Other exclusion criteria included anemia that required transfusion, and intrauterine fetal demise or neonatal mortality.

To assess depression, Dr. Sutherland and her colleagues administered the Edinburgh Postnatal Depression Scale at routine postpartum visits. Dr. Sutherland and her coinvestigators calculated the numbers of respondents who fell above and below the cutoff for potential depression on the 10-item self-report scale. They then looked at the proportion of women who scored positive for depression among those who were, and those who were not, anemic.

Possible depression was indicated by depression scale scores of 9.2% of participants, while three quarters (75.2%) were anemic either during pregnancy or in the immediate postpartum period. Among anemic patients, 10.8% screened positive for depression, while 4.8% of those without anemia met positive screening criteria for postpartum depression (P = .007).

Dr. Sutherland and her collaborators noted that fewer women in their cohort had postpartum depression than the national average of 19%. They may have missed some patients who would later develop depression since the screening occurred at the first postpartum visit; also, “it is possible that women deeply affected by [postpartum depression] may have been lost to follow-up,” they wrote.

Participants had a mean age of about 26 years, and body mass index was slightly higher for those with anemia than without (mean, 32.2 vs 31.2 kg/m²; P = .025).

Postpartum depression was not associated with marital status, substance use, ethnicity, parity, or the occurrence of postpartum hemorrhage, in the investigators’ analysis.

Dr. Sutherland said that, in their analysis, she and her coinvestigators did not find an association between degree of anemia and the likelihood, or severity, of postpartum depression. However, they did find that anemia of any degree in the immediate peripartum period was most strongly associated with postpartum depression.

Though the exact mechanism of the anemia-depression link isn’t known, the fatigue associated with anemia may help predispose women to postpartum depression, said Dr. Sutherland. Also, she said, “iron can make a difference in synthesizing neurotransmitters” such as serotonin, “so it may follow that you might have some depressive symptoms.”

“The next step after this study, which was a launching point, is to see if we correct the degree of anemia and bring them to normal levels, if that can help decrease the risk of postpartum depression,” said Dr. Sutherland.

Dr. Sutherland and her coinvestigators reported that they had no relevant financial disclosures.

[email protected]

SOURCE: Sutherland S et al. ACOG 2018. Abstract 35C.

NEW YORK – Sustained peacekeeping operations are associated with unique psychological stressors, and understanding of these stressors on the part of both community and military psychiatrists can help make a difference at each stage of a deployment cycle, according to Elspeth Cameron Ritchie, MD.

During a workshop at the annual meeting of the American Psychiatric Association entitled “War and Peace: Understanding the Psychological Stressors Associated with Sustained Peacekeeping Operations (PKOs),” chaired by Dr. Ritchie of the Uniformed Services University of the Health Sciences, Bethesda, Md., various dimensions of salient psychological stress were discussed, as were approaches for minimizing any resultant impact on the psychological health of peacekeepers.

In this video interview, Dr. Ritchie discussed the differences and similarities between peacekeeping operations and military operations with respect to stressors and their effects, and the risk of posttraumatic stress disorder among peacekeepers.

Although treatment for PTSD is “pretty much the same,” it is important to “tailor the treatment for the situation,” she said.

“Lay out the different options, explain them to the patient, and partner with the patient in terms of what is the best option for them,” she said.

Dr. Ritchie reported having no relevant disclosures.

[email protected]

SOURCE: Ritchie EC et al. APA Workshop

NEW YORK – Sustained peacekeeping operations are associated with unique psychological stressors, and understanding of these stressors on the part of both community and military psychiatrists can help make a difference at each stage of a deployment cycle, according to Elspeth Cameron Ritchie, MD.

During a workshop at the annual meeting of the American Psychiatric Association entitled “War and Peace: Understanding the Psychological Stressors Associated with Sustained Peacekeeping Operations (PKOs),” chaired by Dr. Ritchie of the Uniformed Services University of the Health Sciences, Bethesda, Md., various dimensions of salient psychological stress were discussed, as were approaches for minimizing any resultant impact on the psychological health of peacekeepers.

In this video interview, Dr. Ritchie discussed the differences and similarities between peacekeeping operations and military operations with respect to stressors and their effects, and the risk of posttraumatic stress disorder among peacekeepers.

Although treatment for PTSD is “pretty much the same,” it is important to “tailor the treatment for the situation,” she said.

“Lay out the different options, explain them to the patient, and partner with the patient in terms of what is the best option for them,” she said.

Dr. Ritchie reported having no relevant disclosures.

[email protected]

SOURCE: Ritchie EC et al. APA Workshop

NEW YORK – Sustained peacekeeping operations are associated with unique psychological stressors, and understanding of these stressors on the part of both community and military psychiatrists can help make a difference at each stage of a deployment cycle, according to Elspeth Cameron Ritchie, MD.

During a workshop at the annual meeting of the American Psychiatric Association entitled “War and Peace: Understanding the Psychological Stressors Associated with Sustained Peacekeeping Operations (PKOs),” chaired by Dr. Ritchie of the Uniformed Services University of the Health Sciences, Bethesda, Md., various dimensions of salient psychological stress were discussed, as were approaches for minimizing any resultant impact on the psychological health of peacekeepers.

In this video interview, Dr. Ritchie discussed the differences and similarities between peacekeeping operations and military operations with respect to stressors and their effects, and the risk of posttraumatic stress disorder among peacekeepers.

Although treatment for PTSD is “pretty much the same,” it is important to “tailor the treatment for the situation,” she said.

“Lay out the different options, explain them to the patient, and partner with the patient in terms of what is the best option for them,” she said.

Dr. Ritchie reported having no relevant disclosures.

[email protected]

SOURCE: Ritchie EC et al. APA Workshop

NEW YORK – Legislation enacted in some states in the wake of mass shootings seeks to limit access to firearms for people with mental illness, but research presented at the annual meeting of the American Psychiatric Association raises questions about the value of that approach.

During a workshop entitled “The ‘Crazed Gunman’ Myth: Examining Mental Illness and Firearm Violence,” researchers from the Yale University in New Haven, Conn., presented new findings that support existing data calling into question whether laws considered to be “common-sense approaches” to stopping gun violence really can reduce the likelihood of mass shootings.

The research shows that, while such legislation might help reduce suicides and domestic violence, it is unlikely to prevent mass shootings. It appears, based on the frequency and context of firearm use in more than 400 crimes that resulted in an insanity acquittal in Connecticut, for example, that individuals with mental illness are less likely than others to misuse firearms.

In this video, workshop chair Reena Kapoor, MD, also of Yale University, discusses the findings and notes that she and her colleagues seek to move past politics and ideology to focus on science that can guide policy and legislative efforts in a potentially more effective direction.

“We’ve also found that in spite of the media narrative, there has also been a slight decrease in how often [mentally ill offenders] use guns, over the years in the study,” she said. “Although the data are preliminary, it doesn’t support this idea that mentally ill people are more dangerous than ever, that they’re using guns more often in their violence; it actually says quite the opposite.”

Dr. Kapoor reported having no disclosures.

[email protected]

SOURCE: Kapoor R et al. APA 2018 Workshop.

NEW YORK – Legislation enacted in some states in the wake of mass shootings seeks to limit access to firearms for people with mental illness, but research presented at the annual meeting of the American Psychiatric Association raises questions about the value of that approach.

During a workshop entitled “The ‘Crazed Gunman’ Myth: Examining Mental Illness and Firearm Violence,” researchers from the Yale University in New Haven, Conn., presented new findings that support existing data calling into question whether laws considered to be “common-sense approaches” to stopping gun violence really can reduce the likelihood of mass shootings.

The research shows that, while such legislation might help reduce suicides and domestic violence, it is unlikely to prevent mass shootings. It appears, based on the frequency and context of firearm use in more than 400 crimes that resulted in an insanity acquittal in Connecticut, for example, that individuals with mental illness are less likely than others to misuse firearms.

In this video, workshop chair Reena Kapoor, MD, also of Yale University, discusses the findings and notes that she and her colleagues seek to move past politics and ideology to focus on science that can guide policy and legislative efforts in a potentially more effective direction.

“We’ve also found that in spite of the media narrative, there has also been a slight decrease in how often [mentally ill offenders] use guns, over the years in the study,” she said. “Although the data are preliminary, it doesn’t support this idea that mentally ill people are more dangerous than ever, that they’re using guns more often in their violence; it actually says quite the opposite.”

Dr. Kapoor reported having no disclosures.

[email protected]

SOURCE: Kapoor R et al. APA 2018 Workshop.

NEW YORK – Legislation enacted in some states in the wake of mass shootings seeks to limit access to firearms for people with mental illness, but research presented at the annual meeting of the American Psychiatric Association raises questions about the value of that approach.

During a workshop entitled “The ‘Crazed Gunman’ Myth: Examining Mental Illness and Firearm Violence,” researchers from the Yale University in New Haven, Conn., presented new findings that support existing data calling into question whether laws considered to be “common-sense approaches” to stopping gun violence really can reduce the likelihood of mass shootings.

The research shows that, while such legislation might help reduce suicides and domestic violence, it is unlikely to prevent mass shootings. It appears, based on the frequency and context of firearm use in more than 400 crimes that resulted in an insanity acquittal in Connecticut, for example, that individuals with mental illness are less likely than others to misuse firearms.

In this video, workshop chair Reena Kapoor, MD, also of Yale University, discusses the findings and notes that she and her colleagues seek to move past politics and ideology to focus on science that can guide policy and legislative efforts in a potentially more effective direction.

“We’ve also found that in spite of the media narrative, there has also been a slight decrease in how often [mentally ill offenders] use guns, over the years in the study,” she said. “Although the data are preliminary, it doesn’t support this idea that mentally ill people are more dangerous than ever, that they’re using guns more often in their violence; it actually says quite the opposite.”

Dr. Kapoor reported having no disclosures.

[email protected]

SOURCE: Kapoor R et al. APA 2018 Workshop.

AUSTIN, TEX. – Transgender patients face many barriers to care, including a lack of necessary expertise among providers, but a large majority of those surveyed in a study in which they were asked whether they would want to go to a transgender-only clinic said they would not.

Lauren Abern, MD, of Atrius Health, Cambridge, Mass., discussed the aims and results of her survey at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

The anonymous online survey consisted of 120 individuals, aged 18-64 years: 100 transgender men and 20 transgender women. Of these, 83 reported experiencing barriers to care. The most common problem cited was cost (68, 82%), and other barriers were access to care (47, 57%), stigma (33, 40%), and discrimination (23, 26%). Cost was a factor even though a large majority of the respondents had health insurance; a majority of respondents had an income of less than $24,000 per year.

The most common way respondents found transgender-competent health care was through word of mouth (79, 77%).

When asked whether they would want to go to a transgender-only clinic, a majority of both transgender women and transgender men respondents either answered, “no,” or that they were unsure (86, 77%). Some respondents cited a desire not to out themselves as transgender, and others considered the separate clinic medically unnecessary. One wrote: “You wouldn’t need a broken foot–only clinic.”

“Basic preventative services can be provided without specific expertise in transgender health. If providers are uncomfortable, they should refer [transgender patients] elsewhere.” said Dr. Abern.

The survey project was conducted in collaboration with the University of Miami and the YES Institute in Miami.

Dr. Abern also spoke about wider transgender health considerations for the ob.gyn. in a separate presentation at the meeting and in a video interview.

For example, transgender men on testosterone may have persistent bleeding and may be uncomfortable with pelvic exams.

Making more inclusive intake forms and fostering a respectful office environment (for example, having a nondiscrimination policy displayed in the waiting area) are measures beneficial to all patients, she said.

“My dream or goal would be that transgender people can be seen and accepted at any office and feel comfortable and not avoid seeking health care.”

[email protected]

AUSTIN, TEX. – Transgender patients face many barriers to care, including a lack of necessary expertise among providers, but a large majority of those surveyed in a study in which they were asked whether they would want to go to a transgender-only clinic said they would not.

Lauren Abern, MD, of Atrius Health, Cambridge, Mass., discussed the aims and results of her survey at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

The anonymous online survey consisted of 120 individuals, aged 18-64 years: 100 transgender men and 20 transgender women. Of these, 83 reported experiencing barriers to care. The most common problem cited was cost (68, 82%), and other barriers were access to care (47, 57%), stigma (33, 40%), and discrimination (23, 26%). Cost was a factor even though a large majority of the respondents had health insurance; a majority of respondents had an income of less than $24,000 per year.

The most common way respondents found transgender-competent health care was through word of mouth (79, 77%).

When asked whether they would want to go to a transgender-only clinic, a majority of both transgender women and transgender men respondents either answered, “no,” or that they were unsure (86, 77%). Some respondents cited a desire not to out themselves as transgender, and others considered the separate clinic medically unnecessary. One wrote: “You wouldn’t need a broken foot–only clinic.”

“Basic preventative services can be provided without specific expertise in transgender health. If providers are uncomfortable, they should refer [transgender patients] elsewhere.” said Dr. Abern.

The survey project was conducted in collaboration with the University of Miami and the YES Institute in Miami.

Dr. Abern also spoke about wider transgender health considerations for the ob.gyn. in a separate presentation at the meeting and in a video interview.

For example, transgender men on testosterone may have persistent bleeding and may be uncomfortable with pelvic exams.

Making more inclusive intake forms and fostering a respectful office environment (for example, having a nondiscrimination policy displayed in the waiting area) are measures beneficial to all patients, she said.

“My dream or goal would be that transgender people can be seen and accepted at any office and feel comfortable and not avoid seeking health care.”

[email protected]

AUSTIN, TEX. – Transgender patients face many barriers to care, including a lack of necessary expertise among providers, but a large majority of those surveyed in a study in which they were asked whether they would want to go to a transgender-only clinic said they would not.

Lauren Abern, MD, of Atrius Health, Cambridge, Mass., discussed the aims and results of her survey at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

The anonymous online survey consisted of 120 individuals, aged 18-64 years: 100 transgender men and 20 transgender women. Of these, 83 reported experiencing barriers to care. The most common problem cited was cost (68, 82%), and other barriers were access to care (47, 57%), stigma (33, 40%), and discrimination (23, 26%). Cost was a factor even though a large majority of the respondents had health insurance; a majority of respondents had an income of less than $24,000 per year.

The most common way respondents found transgender-competent health care was through word of mouth (79, 77%).

When asked whether they would want to go to a transgender-only clinic, a majority of both transgender women and transgender men respondents either answered, “no,” or that they were unsure (86, 77%). Some respondents cited a desire not to out themselves as transgender, and others considered the separate clinic medically unnecessary. One wrote: “You wouldn’t need a broken foot–only clinic.”

“Basic preventative services can be provided without specific expertise in transgender health. If providers are uncomfortable, they should refer [transgender patients] elsewhere.” said Dr. Abern.

The survey project was conducted in collaboration with the University of Miami and the YES Institute in Miami.

Dr. Abern also spoke about wider transgender health considerations for the ob.gyn. in a separate presentation at the meeting and in a video interview.

For example, transgender men on testosterone may have persistent bleeding and may be uncomfortable with pelvic exams.

Making more inclusive intake forms and fostering a respectful office environment (for example, having a nondiscrimination policy displayed in the waiting area) are measures beneficial to all patients, she said.

“My dream or goal would be that transgender people can be seen and accepted at any office and feel comfortable and not avoid seeking health care.”

[email protected]

AUSTIN, TEX. – Women with the highest levels of obesity were at higher odds of experiencing a composite serious maternal morbidity outcome, while women at all levels of obesity experienced elevated risks of some serious complications of pregnancy, compared with women with a body mass index (BMI) in the normal range, according to a recent study.

Looking at individual indicators of severe maternal morbidity, Marissa Platner, MD, and her study coauthors saw that women who fell into the higher levels of obesity had significantly elevated odds of some complications.

“Those risks are really impressive, with odds ratios of two and three times that of a normal-weight patient,” said Dr. Platner in a video interview.

The adjusted odds ratio of acute renal failure for women with superobesity (BMI of 50 kg/m² or more) was 3.62 (95% confidence interval, 1.75-7.52); odds ratios for renal failure were not significantly elevated for less-obese women.

Women with all levels of obesity had elevated risks of experiencing heart failure during a procedure or surgery, with adjusted odds ratios ranging from 1.68 (^{95% CI, 1.48-1.93}) for women with class I obesity (BMI, 30-34.9 kg/m²⁾ to 2.23 for women with superobesity (95% CI, 1.15-4.33).

Results from the retrospective cohort study were presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

Dr. Platner and her colleagues examined 4 years of New York City delivery data that were linked to birth certificates, identifying those singleton live births for whom maternal prepregnancy BMI data were available.

[email protected]

SOURCE: Platner M et al. ACOG 2018, Abstract 39I.

AUSTIN, TEX. – Women with the highest levels of obesity were at higher odds of experiencing a composite serious maternal morbidity outcome, while women at all levels of obesity experienced elevated risks of some serious complications of pregnancy, compared with women with a body mass index (BMI) in the normal range, according to a recent study.

Looking at individual indicators of severe maternal morbidity, Marissa Platner, MD, and her study coauthors saw that women who fell into the higher levels of obesity had significantly elevated odds of some complications.

“Those risks are really impressive, with odds ratios of two and three times that of a normal-weight patient,” said Dr. Platner in a video interview.

The adjusted odds ratio of acute renal failure for women with superobesity (BMI of 50 kg/m² or more) was 3.62 (95% confidence interval, 1.75-7.52); odds ratios for renal failure were not significantly elevated for less-obese women.

Women with all levels of obesity had elevated risks of experiencing heart failure during a procedure or surgery, with adjusted odds ratios ranging from 1.68 (^{95% CI, 1.48-1.93}) for women with class I obesity (BMI, 30-34.9 kg/m²⁾ to 2.23 for women with superobesity (95% CI, 1.15-4.33).

Results from the retrospective cohort study were presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

Dr. Platner and her colleagues examined 4 years of New York City delivery data that were linked to birth certificates, identifying those singleton live births for whom maternal prepregnancy BMI data were available.

[email protected]

SOURCE: Platner M et al. ACOG 2018, Abstract 39I.

AUSTIN, TEX. – Women with the highest levels of obesity were at higher odds of experiencing a composite serious maternal morbidity outcome, while women at all levels of obesity experienced elevated risks of some serious complications of pregnancy, compared with women with a body mass index (BMI) in the normal range, according to a recent study.

Looking at individual indicators of severe maternal morbidity, Marissa Platner, MD, and her study coauthors saw that women who fell into the higher levels of obesity had significantly elevated odds of some complications.

“Those risks are really impressive, with odds ratios of two and three times that of a normal-weight patient,” said Dr. Platner in a video interview.

The adjusted odds ratio of acute renal failure for women with superobesity (BMI of 50 kg/m² or more) was 3.62 (95% confidence interval, 1.75-7.52); odds ratios for renal failure were not significantly elevated for less-obese women.

Women with all levels of obesity had elevated risks of experiencing heart failure during a procedure or surgery, with adjusted odds ratios ranging from 1.68 (^{95% CI, 1.48-1.93}) for women with class I obesity (BMI, 30-34.9 kg/m²⁾ to 2.23 for women with superobesity (95% CI, 1.15-4.33).

Results from the retrospective cohort study were presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

Dr. Platner and her colleagues examined 4 years of New York City delivery data that were linked to birth certificates, identifying those singleton live births for whom maternal prepregnancy BMI data were available.

[email protected]

SOURCE: Platner M et al. ACOG 2018, Abstract 39I.