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Maternal hypertension may be an underrecognized but important risk factor for perinatal death in low resource settings. We investigated the association of maternal hypertension and perinatal mortality in rural Bangladesh. This nested, matched case-control study used data from a 2019 cross-sectional survey and demographic surveillance database in Baliakandi, Bangladesh. We randomly matched each pregnancy ending in perinatal death with five pregnancies in which the neonate survived beyond seven days based on maternal age, education, and wealth quintile. We estimated associations of antenatal care-seeking and self-reported hypertension with perinatal mortality using conditional logistic regression and used median and interquartile ranges to assess the mediation of antenatal care by timing or frequency. Among 191 cases and 934 matched controls, hypertension prevalence was 14.1% among cases and 7.7% among controls. Compared with no diagnosis, the probability of perinatal death was significantly higher among women with a pre-gestational hypertension diagnosis (OR 2.90, 95% CI 1.29, 6.57), but not among women with diagnosis during pregnancy (OR 1.68, 95% CI 0.98, 2.98). We found no association between the number of antenatal care contacts and perinatal death (p = 0.66). Among women with pre-gestational hypertension who experienced a perinatal death, 78% had their first antenatal contact in the sixth or seventh month of gestation. Hypertension was more common among rural women who experience a perinatal death. Greater effort to prevent hypertension prior to conception and provide early maternity care to women with hypertension could improve perinatal outcomes in rural Bangladesh.

Background Patient and family engagement (PFE) has been defined as a partnership between patients, families, and health care providers to achieve positive health care outcomes. There is evidence that PFE is critical to improving outcomes. We sought to systematically identify and map the evidence on PFE strategies for adults with chronic conditions and identify areas needing more research. Methods We searched PubMed, CINAHL, EMBASE, and Cochrane, January 2015 to September 2021 for systematic reviews on strategies for engaging patients with chronic conditions and their caregivers. From each review, we abstracted search dates, number and type of studies, populations, interventions, and outcomes. PFE strategies were categorized into direct patient care, health system, and community-policy level strategies. We found few systematic reviews on strategies at the health system, and none at the community-policy level. In view of this, we also searched for original studies that focused on PFE strategies at those two levels and reviewed the PFE strategies used and study findings. Results We found 131 reviews of direct patient care strategies, 5 reviews of health system strategies, and no reviews of community-policy strategies. Four original studies addressed PFE at the health system or community-policy levels. Most direct patient care reviews focused on self-management support (SMS) ( n = 85) and shared decision-making (SDM) ( n = 43). Forty-nine reviews reported positive effects, 35 reported potential benefits, 37 reported unclear benefits, and 4 reported no benefits. Health system level strategies mainly involved patients and caregivers serving on advisory councils. PFE strategies with the strongest evidence focused on SMS particularly for patients with diabetes. Many SDM reviews reported potential benefits especially for patients with cancer. Discussion Much more evidence exists on the effects of direct patient care strategies on PFE than on the effects of health system or community-policy strategies. Most reviews indicated that direct patient care strategies had positive effects or potential benefits. A limitation of this evidence map is that due to its focus on reviews, which were plentiful, it did not capture details of individual interventions. Nevertheless, this evidence map should help to focus attention on gaps that require more research in efforts to improve PFE.

To address the obesity epidemic, there is a need for novel paradigms, including those that address the timing of eating and sleep in relation to circadian rhythms. Electronic health records (EHRs) are an efficient way to identify potentially eligible participants for health research studies. Mobile health (mHealth) apps offer available and convenient data collection of health behaviors, such as timing of eating and sleep. The aim of this descriptive analysis was to report on recruitment, retention, and app use from a 6-month cohort study using a mobile app called Daily24. Using an EHR query, adult patients from three health care systems in the PaTH clinical research network were identified as potentially eligible, invited electronically to participate, and instructed to download and use the Daily24 mobile app, which focuses on eating and sleep timing. Online surveys were completed at baseline and 4 months. We described app use and identified predictors of app use, defined as 1 or more days of use, versus nonuse and usage categories (ie, immediate, consistent, and sustained) using multivariate regression analyses. Of 70,661 patients who were sent research invitations, 1021 (1.44%) completed electronic consent forms and online baseline surveys; 4 withdrew, leaving a total of 1017 participants in the analytic sample. A total of 53.79% (n=547) of the participants were app users and, of those, 75.3% (n=412), 50.1% (n=274), and 25.4% (n=139) were immediate, consistent, and sustained users, respectively. Median app use was 28 (IQR 7-75) days over 6 months. Younger age, White race, higher educational level, higher income, having no children younger than 18 years, and having used 1 to 5 health apps significantly predicted app use (vs nonuse) in adjusted models. Older age and lower BMI predicted early, consistent, and sustained use. About half (532/1017, 52.31%) of the participants completed the 4-month online surveys. A total of 33.5% (183/547), 29.3% (157/536), and 27.1% (143/527) of app users were still using the app for at least 2 days per month during months 4, 5, and 6 of the study, respectively. EHR recruitment offers an efficient (ie, high reach, low touch, and minimal participant burden) approach to recruiting participants from health care settings into mHealth research. Efforts to recruit and retain less engaged subgroups are needed to collect more generalizable data. Additionally, future app iterations should include more evidence-based features to increase participant use.

Purpose of Review The “fourth trimester” concept, defined as the first 12 weeks after delivery (and beyond), is a critical window of time for clinicians to intervene to optimize women’s cardiovascular health after pregnancy. A timely and comprehensive postpartum cardiovascular assessment should be performed in all women following delivery in order to (1) follow up medical conditions present prior to conception, (2) evaluate symptoms and signs of common postpartum complications, and (3) identify risk factors and prevent future adverse cardiovascular outcomes. In this review, we aim to discuss major maternal cardiovascular risk factors such as hypertensive disorders of pregnancy, gestational diabetes mellitus, postpartum weight retention, and postpartum depression, as well as lactation as a potential protective risk modifying factor. Additionally, we will review effectiveness of outpatient interventions to enhance transitions in cardiovascular care during the fourth trimester. Recent Findings A seamless hand-off from obstetric to primary care, and potentially cardiology, is needed for early detection and management of hypertension, weight, glycemic control, stress and mood, and long-term cardiovascular risk. Additionally, the use of telemedicine, blood pressure self-monitoring, remote activity monitoring, and behavioral health coaches are potentially feasible modalities to augment clinic-based care for cardiovascular risk factors and weight management, but additional studies are needed to study their long-term effectiveness. Summary Development of a comprehensive postpartum care plan with careful consideration of each patient’s risk profile and access to resources is critical to improve maternal morbidity and mortality, reduce health disparities, and achieve long-term cardiovascular health for women. Supporting postpartum well-being of women during this transition period requires a multidisciplinary approach, especially primary care engagement, and planning should start before delivery.

Background Pregnancy provides an opportunity to promote healthy lifestyle behaviors. This study’s aim was to explore the perspectives of pregnant and postpartum women and obstetric providers around behavioral lifestyle changes in pregnancy and postpartum. Methods We conducted a qualitative study with pregnant and postpartum patients recruited from 2 prenatal care clinics at an urban, academic hospital in the United States. In-depth interviews with 23 pregnant or postpartum women and 11 obstetric providers were completed between October 2015–April 2016. Interviews were audio-recorded and transcribed verbatim. We coded transcripts for thematic content and applied the PRECEDE-PROCEED framework for results to directly inform program development. Results Six themes highlighted the predisposing, enabling and reinforcing factors that enable and sustain health behavior changes in pregnancy and postpartum: 1) “Motivation to have a healthy baby” during pregnancy and to “have my body back” after delivery, 2) Pre-pregnancy knowledge and experiences about pregnancy and the postpartum period, 3) Prioritizing wellness during pregnancy and postpartum, 4) The power of social support, 5) Accountability, 6) Integration with technology to reinforce behavior change. Conclusions In this qualitative study, pregnant and postpartum women and obstetric providers described themes that are aimed at encouraging lifestyle changes to promote healthy weight gain in pregnancy and can directly inform the development of a behavioral weight management intervention for pregnant and postpartum women that is patient-centered and tailored to their needs.

Introduction While social capital can prevent diabetes, these benefits can be heterogeneous with respect to socioeconomic status. We investigated the association between social capital and gestational diabetes mellitus (GDM) while examining effect modification by household income. Materials and Methods We conducted a secondary data analysis using the Tohoku Medical Megabank Project Birth and Three‐Generation Cohort Study carried out between July 2013 and March 2017. Social capital (mutual aid, social trust, informal social control, collective action) and covariates were self‐reported, while GDM diagnosis and other medical and physiological information were obtained from medical records. To assess the association between social capital and GDM, we conducted logistic regression models. We further tested for interactions between social capital and household income as well as stratified the models by income. Results Among 20,339 study participants, 700 (3.4%) were diagnosed with GDM. Multivariable logistic regression models found that social trust and collective action were associated with lower GDM prevalence, even after adjustment of covariates. When stratifying household income, however, social capital was significantly associated with the reduced risks of GDM only among participants with higher household income (OR: 0.90, 95% CI: 0.85–0.97). No significant association was observed among those with lower household income. Conclusions The health benefit of social capital on GDM prevalence was heterogeneous, and the protective effect of social capital on GDM was found only among women with higher household income. The differential impact of social capital on GDM highlights the need for targeted interventions addressing structural health inequities.

Objective To describe physician perspectives on the causes of and solutions to obesity care and identify differences in these perspectives by number of years since completion of medical school. Design National cross-sectional online survey from 9 February to 1 March 2011. Setting USA. Participants 500 primary care physicians. Main Measures We evaluated physician perspectives on: (1) causes of obesity, (2) competence in treating obese patients, (3) perspectives on the health professional most qualified to help obese patients lose or maintain weight and (4) solutions for improving obesity care. Results Primary care physicians overwhelmingly supported additional training (such as nutrition counselling) and practice-based changes (such as having scales report body mass index) to help them improve their obesity care. They also identified nutritionists/dietitians as the most qualified providers to care for obese patients. Physicians with fewer than 20 years since completion of medical school were more likely to identify lack of information about good eating habits and lack of access to healthy food as important causes of obesity. They also reported feeling relatively more successful helping obese patients lose weight. The response rate for the survey was 25.6%. Conclusions Our results indicate a perceived need for improved medical education related to obesity care.

Background Clinical decision support systems (CDSS) are electronic health record tools that support practitioners' decision‐making at the point‐of‐care. CDSS may aid clinical care but are not often centered on patients or practitioners. Aims To develop and preliminarily test a CDSS designed to support evidence‐based obesity treatment, promote a patient‐centered experience, and integrate with clinical workflows. Materials & Methods The CDSS allowed patients to complete a pre‐visit questionnaire via the patient portal, which activated multiple elements for the primary care practitioner (PCP). A 3‐month proof‐of‐concept study was conducted among 10 PCPs at 5 clinics to determine usefulness, usability, and acceptability through validated surveys (mean score ≥ 2.5 signified positive outcome; max 5). Using t‐tests, pre‐post differences in PCPs' frequency of self‐reported clinical practices (1‐never; 5‐always) were examined. Results Most PCPs were physicians with mean experience of 10.8 years (SD 7.5). Overall, mean scores for usefulness, usability, and acceptability were 3.2 (SD 0.8), 3.5 (SD 0.9), and 3.6 (SD 0.9), respectively. PCPs reported significant increases in three key clinical practices—counseling on behavioral interventions (3.1 vs. 3.9 [p < 0.01]), referring to weight‐loss programs (2.8 vs. 3.5 [p < 0.01]), and discussing anti‐obesity medications (3.3 vs. 3.8 [p = 0.02]). Conclusion This weight management CDSS was useful and usable for PCPs and improved obesity‐related practice habits. Future studies need to evaluate its impact on patient outcomes.

Background Older people with hypertension and multiple chronic conditions (MCC) receive complex treatments and face challenging trade-offs. Patients’ preferences for different health outcomes can impact multiple treatment decisions. Since evidence about outcome preferences is especially scarce among people with MCC our aim was to elicit preferences of people with MCC for outcomes related to hypertension, and to determine how these outcomes should be weighed when benefits and harms are assessed for patient-centered clinical practice guidelines and health economic assessments. Methods We sent a best-worst scaling preference survey to a random sample identified from a primary care network of Kaiser Permanente (Colorado, USA). The sample included individuals age 60 or greater with hypertension and at least two other chronic conditions. We assessed average ranking of patient-important outcomes using conditional logit regression (stroke, heart attack, heart failure, dialysis, cognitive impairment, chronic kidney disease, acute kidney injury, fainting, injurious falls, low blood pressure with dizziness, treatment burden) and studied variation across individuals. Results Of 450 invited participants, 217 (48%) completed the survey, and we excluded 10 respondents who had more than two missing choices, resulting in a final sample of 207 respondents. Participants ranked stroke as the most worrisome outcome and treatment burden as the least worrisome outcome (conditional logit parameters: 3.19 (standard error 0.09) for stroke, 0 for treatment burden). None of the outcomes were always chosen as the most or least worrisome by more than 25% of respondents, indicating that all outcomes were somewhat worrisome to respondents. Predefined subgroup analyses according to age, self-reported life-expectancy, degree of comorbidity, number of medications and antihypertensive treatment did not reveal meaningful differences. Conclusions Although some outcomes were more worrisome to patients than others, our results indicate that none of the outcomes should be disregarded for clinical practice guidelines and health economic assessments.

IntroductionGestational diabetes mellitus (GDM) is a common complication of pregnancy with implications for cardiovascular health. Among reproductive-aged women, less is known about nativity-related disparities in cardiometabolic risk profiles and GDM history. We examined how cardiometabolic risk profiles and GDM history differed by nativity and explored associations between acculturation, cardiometabolic risk profiles and GDM history.Research design and methodsWe analyzed cross-sectional data from the 2016–2017 National Health Interview Survey among reproductive-aged women (18–49 years) who both reported ever being pregnant and answered the question on GDM history. Using multivariable logistic regression, we examined the percentage with GDM history and compared cardiometabolic profiles by nativity status and acculturation (duration of US residence).ResultsOf 9525 women, 22.5% were foreign-born. Also, 11.7% of foreign-born women had a GDM history vs 9.6% of US-born women. Foreign-born women with ≥10 years US residence had the highest age-standardized percentage with GDM history (11.0%) compared with US-born women (9.2%) and foreign-born women with <10 years US residence (6.7%). US-born women had a higher prevalence of hypertension, current smoking, and alcohol use than foreign-born women. Among foreign-born women, those with ≥10 years US residence had a higher prevalence of hypertension, current smoking, and alcohol use than those with <10 years US residence. In the fully adjusted model, foreign-born women with ≥10 years US residence had higher odds of GDM history than US-born women (OR 1.43; 95% CI 1.17 to 1.76) while foreign-born women with <10 years US residence and US-born women has similar odds of GDM history.ConclusionsGreater duration of US residence may be associated with nativity-related disparities in GDM. Acculturation, including changing health-related behaviors may explain the disparities among foreign-born women and should be further investigated to appropriately target interventions to prevent GDM and future cardiometabolic diseases.