Iowa Health Research Articles

Factors Impacting Fertility Preservation in Adolescents and Young Adults with Cancer: A Retrospective Study.

Purpose: Fertility preservation before therapy is underutilized for those diagnosed with cancer as an adolescent or young adult (AYA). The purpose of this study was to describe factors impacting utilization of fertility preservation consultations and procedures among AYAs at the University of Iowa Health Care (UIHC). Methods: Patients were identified by the oncology registry at UIHC. Disease site, histology, date of diagnosis, sex, race, ethnicity, insurance, and zip code data were gathered by the registrars. UIHC's electronic medical record was queried for fertility preservation consultation. The Reproductive Endocrinology and Infertility clinical database captured information about patients who underwent fertility preservation. Rural-urban commuting area codes measured rurality. Descriptive statistics and multivariate linear probability models were used to predict the probability of fertility preservation consultation and procedure. Results: From 2008 to 2017, 2932 AYAs were treated for an invasive malignancy at UIHC. Of the 440 (15%) who received a fertility preservation consultation, 156 (5%) underwent a fertility preservation procedure. Multivariate analyses showed that AYAs with public insurance coverage, those diagnosed with central nervous system (CNS) disease or melanoma, and those >30 years old at diagnosis had a significant decrease in the percentage point probability of having a consultation. The percentage point probability of undergoing a procedure was decreased for female patients, those with melanoma or carcinoma, those seen by a pediatric-based provider, and those diagnosed after 25 years of age. Conclusion: This study has important implications for practice and policy, particularly regarding insurance coverage and patient and provider characteristics leading to fertility preservation consultations and procedures for AYAs with cancer.

162 Development of a New Bowel Preparation Prediction Model Based on Patient's Questionnaire: To Proceed or Not to Proceed With Colonoscopy? A Study From Veterans Affairs Hospital to Stratify High Risk Population

INTRODUCTION: Bowel preparation (BP) is one of the intra-procedural quality indicators. The percentage of poor BP leading to repeat colonoscopy in = or < 1 year should not exceed more than 15%. The challenge remains that before doing the colonoscopy, we cannot reliably predict, whether a BP will be adequate for a good quality examination? The aim of our study is to propose a model based on patient's questionnaire that can identify patients with poor BP in pre-operative (pre-op) area prior to their colonoscopy. METHODS: From November 2018 to May 2019, 461 consecutive patients of 18 years of age or older who presented to Veterans Affairs (VA) Nebraska-Western Iowa Health Care System for colonoscopy each completed a voluntary questionnaire in the pre-op prior to their colonoscopies. This study was approved by VA institutional review board (IRB#00163). Information was collected regarding gender, age, ethnicity, education level, first colonoscopy, days of BP, BP instructions, amount of BP completed, last solid meal, timing of last bowel movement (BM), travel time to VA, nausea/vomiting and abdominal pain/bloating while taking BP, Bristol stool scale and last BM stool character (A-clear liquid stool, B-turbid, C-soft stools). Information regarding the Boston bowel preparation scale (BBPS) was calculated during the colonoscopy. Accuracy of the model was measured by the area under ROC curve. Statistical analysis was performed using STATA version 14.2. RESULTS: 461 patients were included (94% males, 92% Caucasians). BBPS score of 5 or greater was noted in 95% of the patients. We used a multivariable logistic regression model using most of the variables depicted in Table 1 to predict the outcome of a patient having a BBPS score of 5 or greater. Area under the ROC curve was 0.7675 (Figure 1). With a cut point for the predicted probability of having a Boston Prep Score of 5 or greater of ≥0.8935, we achieved a sensitivity of 87.4% and a specificity of 50%. The coefficients included in the predicted model are depicted in Table 2. CONCLUSION: Our new bowel preparation prediction model to predict probability of having a BBPS of 5 or greater in pre-op area achieved sensitivity of 87.4% and specificity of 50% with area under ROC = 0.7675. Only 5% of our patient population had BBPS < 5 which could explain the low specificity of our predicted model. Multi-center studies are needed to further validate our model.

Recalibration and External Validation of the Risk Analysis Index: A Surgical Frailty Assessment Tool.

The Risk Analysis Index (RAI) predicts 30-, 180-, and 365-day mortality based on variables constitutive of frailty. Initially validated, in a single-center Veteran hospital, we sought to improve model performance by recalibrating the RAI in a large, veteran surgical registry, and to externally validate it in both a national surgical registry and a cohort of surgical patients for whom RAI was measured prospectively before surgery. The RAI was recalibrated among development and confirmation samples within the Veterans Affairs Surgical Quality Improvement Program (VASQIP; 2010-2014; N = 480,731) including major, elective noncardiac surgery patients to create the revised RAI (RAI-rev), comparing discrimination and calibration. The model was tested externally in the American College of Surgeons National Surgical Quality Improvement Program dataset (NSQIP; 2005-2014; N = 1,391,785), and in a prospectively collected cohort from the Nebraska Western Iowa Health Care System VA (NWIHCS; N = 6,856). Recalibrating the RAI significantly improved discrimination for 30-day [c = 0.84-0.86], 180-day [c = 0.81-0.84], and 365-day mortality [c = 0.78-0.82] (P < 0.001 for all) in VASQIP. The RAI-rev also had markedly better calibration (median absolute difference between observed and predicted 180-day mortality: decreased from 8.45% to 1.23%). RAI-rev was highly predictive of 30-day mortality (c = 0.87) in external validation with excellent calibration (median absolute difference between observed and predicted 30-day mortality: 0.6%). The discrimination was highly robust in men (c = 0.85) and women (c = 0.89). Discrimination also improved in the prospectively measured cohort from NWIHCS for 180-day mortality [c = 0.77 to 0.80] (P < 0.001). The RAI-rev has improved discrimination and calibration as a frailty-screening tool in surgical patients. It has robust external validity in men and women across a wide range of surgical settings and available for immediate implementation for risk assessment and counseling in preoperative patients.

Telepharmacy service brings HIV preventive to rural Iowans.

An innovative telepharmacy service in Iowa offers convenience and discretion while delivering the benefits of preexposure prophylaxis (PrEP) to people in rural parts of the state who are at risk for HIV infection. Angela Hoth, clinical pharmacist for University of Iowa (UI) Health Care and project manager for TelePrEP, described the program as “a public health-partnered, virtual pharmacist telemedicine model to provide HIV prevention within Iowa.” “What that means,” she explained, “is that we partner with public health to identify people who may benefit from PrEP.” The Iowa Department of Public Health’s 2017 HIV surveillance report stated that 125 Iowans were newly diagnosed with HIV infection that year and 2,790 were living with HIV. Federal guidelines recommend PrEP—in most cases, a daily oral fixed-dose combination regimen consisting of 200 mg of emtricitabine and 300 mg of tenofovir disoproxil fumarate—for patients at substantial risk for HIV infection. A PrEP indication was approved in 2012 for Truvada, Gilead Sciences Inc.’s emtricitabine–tenofovir disoproxil fumarate combination product.

Pituitary Evaluation in Patients with Low Prostate-Specific Antigen

To evaluate pituitary function in men with a low screening prostate-specific antigen (PSA) of ≤0.1 ng/mL and test the hypothesis that low PSA is associated with hypogonadism alone or other hormone deficiency. This was a case-control study evaluating the rates of hypogonadism and low insulin-like growth factor (IGF)-1 in a cohort of men with low or normal screening PSA level. Sixty-four men >40 years old without known prostate disease were divided into a low-PSA group (PSA ≤0.1 ng/mL) and normal-PSA group (PSA 1 to 4 ng/mL). Hormonal evaluation included total testosterone, prolactin, luteinizing hormone, follicle-stimulating hormone, IGF-1, growth hormone, thyroid-stimulating hormone, free thyroxine, morning cortisol, and adrenocorticotropic hormone. The difference between each patient's observed IGF-1 and the IGF-1 age-specific lower limit was calculated. The odds ratios (ORs) for having hypogonadism and associated 95% confidence intervals (CIs) were calculated using the Cochran-Mantel-Haenszel test. The rate of hypogonadism was significantly higher in the low-PSA group (n = 44) compared with the normal-PSA control group (n = 20) (45.5% vs. 15.0%; OR, 4.7; 95% CI, 1.2 to 18.4; P = .027). The total testosterone in the low-PSA group was significantly lower compared with the control group (181.7 ng/dL vs. 263.7 ng/dL; P = .008). IGF-1 values were below their lower bound in 18.6% of subjects in the low-PSA group, compared with 0% in the control group. Men with low PSA have significantly higher rates of hypogonadism and low IGF-1 compared with those with normal PSA. In such men, we recommend hormonal evaluation to exclude associated pituitary dysfunction. BMI = body mass index; GH = growth hormone; IGF-1 = insulin-like growth factor 1; MRI = magnetic resonance imaging; PSA = prostate-specific antigen; T2DM = type 2 diabetes mellitus; VA-NWIHCS = VA-Nebraska Western Iowa Health Care System.

The workforce trends of physician assistants in Iowa (1995-2015).

BackgroundPhysician assistants are expected to have an important role in providing both primary and specialty care. Iowa has a large rural (and aging) population and faces challenges to provide equitable access to care. This study examined changes in the Iowa physician assistant workforce (1995–2015) focusing on practice setting (primary v. subspecialty care) and geographic location (rural/urban, Health Professional Shortage Area). Documenting their current locations and service in HPSAs for primary care will help health planners track future changes.MethodsData from 1995–2015 from the Iowa Health Professions Inventory (Office of Statewide Clinical Education Programs, Carver College of Medicine, University of Iowa) were combined with US census data on rural location and HPSA status. SPSS was used to compare Iowa and national data. Growth trends were analyzed using joinpoint regression.ResultsThe overall Iowa physician assistant workforce increased 161% between 1995 and 2015. In 2015, more than two-thirds (71%) were female and more than 30% practiced in rural counties. The average annual growth rate of primary care PAs (per 100,000 population) was significantly higher in the periods from 1995–1997 and 1997–2001 (22.4% and 7.4% respectively) than in period from 2001–2015 (3.8%). By 2015, 56% of Iowa’s physician assistants practiced in primary care (versus 29.6% nationally). Of these, 44% of primary care physician assistants in Iowa practiced in counties, geographic locations or worksites designated as Health Professional Shortage Areas for primary care.ConclusionsA high proportion of Iowa’s physician assistant workforce practiced in primary care and many served patients in Health Professional Shortage Areas. The number of physician assistants in Iowa will continue to grow and serve an important role in providing access to health care, particularly to rural Iowans.

Abstract WP59: A Clot Burden Score Predicts Functional Outcome and Neurological Complications After Cerebral Venous Sinus Thrombosis

Background and purpose: Involvement of deep venous structures is associated with worse outcomes in patients with cerebral venous sinus thrombosis (CVST); however, the impact of clot burden has not been studied. The aim of this study was to assess the value of a novel quantitative clot burden score as an independent predictor of clinical outcomes. Methods: We retrospectively reviewed all patients admitted to University of Iowa Health Care with CVST between 2004-2014. All patients received standard of care medical management per AHA/ASA recommendations. The degree of the thrombosis was categorized in admission MR venograms as (partial=1 vs. complete occlusion=2). Clot burden scores were computed as the sum of the thrombosis degree in the following vessels: cerebral veins (cortical veins, internal cerebral, vein of Rosenthal, vein of Galen) and cerebral sinuses (superior sagittal, inferior sagittal, straight, torcula, transverse/sigmoid). The primary outcome was modified Rankin Scale (mRS) at discharge. Secondary outcomes included hemorrhage, infarction, and cerebral edema. Multiple regressions were conducted to examine effects of clot burden scores on each of the four outcomes. Results: 115 patients met inclusion criteria, 76 women, and mean age 42. Thrombosis in cerebral veins area was noted in 58(50%), clot burden score Median=4, IQR=2; while 108(96%) had thrombosis in the cerebral sinuses area, Median=4, IQR=5. Clot burden in cerebral veins (p=.005) but not in cerebral sinuses, was associated with worse discharge mRS, r= .22. This effect remained significant when adjusting for age and gender (p=.002), but not when adjusting for complications including ICH, infarct, edema. Importantly, higher clot burden score in the cerebral veins predicted ICH (OR=1.73, p&lt;.001), infarct size (OR=1.66, p&lt;.001), and edema (OR=1.71, p&lt;.001). Conclusion: Quantitative clot burden measurement of the cerebral veins conveys additional prediction on outcomes of CVST. Our findings suggest that the worse clinical outcomes associated with clot burden in the cerebral veins may be mediated by ICH, infarct size, and/or edema. The structural differences between the cerebral veins and sinuses may play a role in the variability in clinical outcomes among patients with CVST.

Abstract WP63: Global Cerebral Edema is Associated With Worse Outcomes in Patients With Cerebral Venous Sinus Thrombosis

Background and Purpose: Obstruction of venous drainage may lead to venous hypertension, edema, infarction or intracerebral hemorrhage (ICH) in patients with cerebral venous thrombosis (CVST). While the presence of ICH and infarction are associated with worse outcomes, the independent effect of edema remains unknown. We aimed to evaluate the impact of the characteristics of brain edema on functional outcomes as measured by the modified Rankin Scale (mRS) at discharge. Methods: We retrospectively reviewed all patients who presented to the University of Iowa Health Care with CVST between 2004-2014. All patients received standard of care management per available AHA/ASA recommendations. Edema was categorized as focal vasogenic, focal cytotoxic or global cerebral edema (GCE). Vasogenic edema was described as hyperintensity on FLAIR MRI sequences around the location of venous clot while cytotoxic edema was noted when hyperintensities were visualized around the location of ICH/ venous infarction on FLAIR or DWI respectively. GCE was scored when bilateral finger-like extensions into gray white junction and effacement of gyri/sulci were seen on CT scans as described by Claassen et al. Edema scorer was blinded to outcome measures. Multiple regressions were conducted on mRS outcome to test hypotheses of interest. A p value ≤ 0.05 was set as statistically significant. Results: 115 patients met inclusion criteria, 76 women, mean age 42. A total of 30(26%) had venous infarction, 34(30%)ICH , 57(50%) had cerebral edema(20% vasogenic, 35% cytotoxic and 32% GCE). The three edema types together explained 22% variance in discharge mRS (p&lt;.001). The effect of GCE remained significant (p=.001) when adjusting for age, presence/absence of ICH and infarct. The 95%CIs for discharge mRS among those with GCE [2.89-4.17] compared to those without GCE [1.44-2.12]. Vasogenic and cytotoxic edema did not contribute significantly to prediction in multivariate analyses. Conclusions: Characterization of early cerebral edema might contribute to a better prognostication of high risk patients after CVTS. GCE in particular forecast an unfavorable outcome. Further understanding of its pathogenesis may represent a new therapeutic window for refractory patients to standard therapies.

Abstract WP47: Quantitative Analysis of Hemorrhage and Infarct Volume for Predicting Outcome in Cerebral Venous Sinus Thrombosis

Background and purpose: Intracerebral hemorrhage (ICH) and venous infarction are known complications that independently predict poor outcome in patients with cerebral venous sinus thrombosis (CVST). We aimed to study the utility of precise quantification of volumes of venous infarction and ICH using digitalized images in refining our prediction of discharge outcome. Methods: We retrospectively reviewed all patients with CVST admitted to University of Iowa Health Care between 2004-2014. All patients received standard of care management per available AHA/ASA recommendations. Scans were analyzed using Carestream Vue PACS software. Gradient Echo (GRE) MRI sequence was used to calculate ICH volume. When MRI was not available CT was used. Diffusion Weighted Imaging (DWI) MRI sequence was used to calculate infarction volume. Volume scorer was blinded to the clinical outcomes. Univariate and multivariate analyses were conducted. A p value ≤ 0.05 was set as statistically significant. Results: 115 patients met inclusion criteria, 76 women, mean age 42. A total of 30 (26%) had venous infarction, 34 (30%) had ICH. The median volumes were 8 cc (SD=27) for ICH and 14 cc (SD= 35) for infarction. Both ICH and infarction volumes were significantly higher among those with a poor functional outcome (mRS=3-6) [Mdn=16 cc, SD=32 for ICH; Mdn=33 cc, SD=46 for infarction] than those with good outcome [Mdn=5 cc, SD=7 for ICH; Mdn=7 cc, SD=162 for infarction], p= .029 and p=.027 respectively. The correlation between ICH volume and mRS was r=.43, p=.012 and the corresponding correlation for infarction volume was r=.62, p=.002. Regressions testing the effects of ICH and infarction volumes on discharge mRS showed that both significantly contributed (p&lt;.001 &amp; p=.004 respectively). These effects remained significant when controlling for the effects of age, gender, presence of deep infarct, and altered mental status at presentation (p=.001 and p=.013 respectively). Conclusion: Quantitative measurement of Infarction and ICH volumes on admission leads to a more accurate prediction of outcome at discharge in CVST patients. Its combination with clinical variables might signify an additional prognostication tool for identification of high risk patients refractory to standard therapy.

Emergency Nursing Review Questions: May 2016

The review questions that are featured in each of issue of JEN are based on the Emergency Nursing Core Curriculum and other pertinent resources to emergency nursing practice, pediatric and adult. These questions offer emergency nurses an opportunity to test their knowledge about their practice. Tracy Shaw is Trauma Coordinator, Iowa Health–Des Moines, Des Moines, IA, and owner of Working Noodle Enterprises, a nursing educational consulting company.

Iowa Wavering on Medicaid: From Expansion to Modernization.

Iowa is one of six states to expand Medicaid through section 1115 waivers. Iowa's alternative approach to Medicaid expansion, known as the Iowa Health and Wellness Plan, was the result of a bipartisan compromise, motivated by the pending expiration of a preexisting section 1115 waiver that served sixty-five thousand Iowans. The Iowa Health and Wellness Plan emphasizes personal responsibility and private involvement. Key features include beneficiary premiums, incentives for healthy behaviors, and premium assistance for some beneficiaries to purchase insurance in the health insurance marketplace. However, Iowa has struggled to implement its expansion as initially envisioned, due largely to the lack of private insurers willing and able to insure new Medicaid enrollees in the marketplace. In 2016 Iowa will dramatically increase the role of managed care in Medicaid, with the vast majority of beneficiaries receiving almost all Medicaid services through a capitated managed care organization. This article highlights the local factors driving expansion, the interplay of the state and federal political landscape, the challenges of providing consumer choice within Iowa's marketplace, and the future of Iowa's Medicaid program under managed care.

Emergency Nursing Review Questions: January 2016

The review questions that are featured in each of issue of JEN are based on the Emergency Nursing Core Curriculum and other pertinent resources to emergency nursing practice, pediatric and adult. These questions offer emergency nurses an opportunity to test their knowledge about their practice. The review questions that are featured in each of issue of JEN are based on the Emergency Nursing Core Curriculum and other pertinent resources to emergency nursing practice, pediatric and adult. These questions offer emergency nurses an opportunity to test their knowledge about their practice. Tracy Shaw is Trauma Coordinator, Iowa Health–Des Moines, Des Moines, IA, and owner of Working Noodle Enterprises, a nursing educational consulting company.

Registered Dietitian Takes the Wheel at Center for Nutrition Policy and Promotion

This month marks the 20th anniversary of the establishment of the US Department of Agriculture (USDA) Center for Nutrition Policy and Promotion (CNPP). As a multidisciplinary organization, staff is comprised of economists, food scientists, nutrition educators, policy specialists, and, of course, registered dietitians (RDs). While RDs have always been an integral part of CNPP, one has not filled the top leadership position since CNPP’s first executive director, Eileen Kennedy, DSc, RD—until now. As we celebrate this significant milestone, we are proud to welcome and introduce to you our new executive director, Angie Tagtow, MS, RD, LD. To have an RD at the top of our leadership once again is a testament to the strength of the profession, and for this special edition of the MyPlate Message Chronicles, our newest executive director will share with you her vision for 2015 and beyond. Since CNPP’s inauguration on December 1, 1994, this small but mighty agency within the USDA has been at the core of our nation’s food and nutrition policies and programs. In the federal space, CNPP is often viewed as the trusted source for nutrition information, linking scientific research with the nutritional needs of Americans. The creation of CNPP came at a time when Americans were beginning to realize the link between nutrition and health, but struggled to make informed choices due to the prevalence of conflicting nutrition messages. CNPP has the unique role of conducting robust evidence-based analyses, as well as developing and promoting dietary guidance, ensuring that nutrition messages to consumers are actionable and based on sound evidence. Behind the scenes, over 20 RDs, making up nearly 60% of CNPP staff, lead and support far-reaching projects such as ChooseMyPlate.gov, Dietary Guidelines for Americans, SuperTracker, What’s Cooking? USDA Mixing Bowl, and the Nutrition Evidence Library (NEL.gov). At this pivotal time in nutrition and health there is much at stake, but I feel confident in the knowledge and talent of CNPP staff to help move our nation in the right direction. To be appointed executive director of CNPP is truly an honor and an RD’s dream. Previous roles I’ve held include founder and managing editor of the Journal of Hunger and Environmental Nutrition, founder and convener of the Iowa Food Access & Health Work Group, cofounder of the Iowa Food Systems Council, nutrition and food systems consultant with the Iowa Department of Public Health, endowed chair at the University of Minnesota, and founder of Environmental Nutrition Solutions, LLC. As a member of the Academy of Nutrition and Dietetics, I have served on the House of Delegates, on the Sustainable Food System Task Force, and as chair of the Hunger and Environmental Nutrition dietetic practice group. With over 25 years of experience in the field of nutrition, I am excited to have a front row seat to new and exciting opportunities that will ultimately improve the nutrition and wellbeing of Americans. With the release of the 2015 Dietary Guidelines fast approaching, I look forward to supporting the last phases of the process and its final launch. It will be a whirlwind when the time comes, but it is a challenge I wholeheartedly embrace. I find it thrilling as a nutrition and dietetics practitioner to be connected with dietary guidance that will ultimately inform many important programs and provide access to healthy food for our nation. Looking forward, I have many hopes and aspirations for the future of CNPP. I plan to advance the agency’s existing programs and initiatives to maximize their reach, ensuring that even more Americans are receiving messages based on the Dietary Guidelines for Americans. I also look forward to building upon CNPP’s partnership networks to enhance collaboration across the private and public sectors, engage policymakers, and establish stronger international connections. After only 6 months at CNPP, I am truly amazed at what our small staff is capable of and I am proud to lead this agency into the future.Center for Nutrition Policy and Promotion Online ResourcesTo stay up-to-date on the latest projects and resources from CNPP and MyPlate, visit the following websites:•CNPP.usda.gov•ChooseMyPlate.gov•SuperTracker.usda.gov•Facebook.com/MyPlate•Twitter.com/MyPlate

Online Emergency Nursing Review Questions: May 2014

These online review questions, featured each issue in JEN, offer emergency nurses an opportunity to test their knowledge about their practice. Tracy Shaw is Trauma Coordinator, Iowa Health–Des Moines, Des Moines, IA, and owner of Working Noodle Enterprises, a nursing educational consulting company.

Profile of vismodegib and its potential in the treatment of advanced basal cell carcinoma

Basal cell carcinoma (BCC) is the most common human malignancy. Recent advances in our understanding of the critical biologic pathways implicated in the development and progression of BCC have led to the development of the first molecular targeted therapy for this disease. The hedgehog pathway is mutated in virtually all patients with BCC and recent trials with vismodegib, an inhibitor of this pathway, have shown significant responses. This review will discuss the importance of the hedgehog pathway in the pathogenesis of BCC and describe in detail the pharmacology of vismodegib in relation to its activity in advanced BCC.

Cervical surgery for cervical intraepithelial neoplasia and prolonged time to conception of a live birth: a case–control study

To determine whether women with a history of surgery for cervical intraepithelial neoplasia (CIN) are at an increased risk of subfertility, measured as a time to pregnancy of more than 12 months. Case-control study. Iowa Health in Pregnancy Study (IHIPS), a population-based case-control study of preterm and small-for-gestational-age (SGA) live birth outcomes (from May 2002 through June 2005) in the USA. Women with an intended pregnancy and a history of either one prior cervical surgery (n = 152), colposcopy only (n = 151), or no prior cervical surgery or colposcopy (n = 1021). Cervical treatment history, pregnancy intention, time to pregnancy, and other variables were self-reported by computer-assisted telephone interviews. Odds ratios were calculated using logistic regression to estimate the risk of prolonged time to pregnancy among women with a history of cervical surgery or colposcopy alone, compared with untreated women (control group). Prolonged time to pregnancy (i.e. >1 year). Prolonged time to pregnancy was most prevalent among treated women (16.4%), compared with untreated women (8.4%) and women with colposcopy only (8.6%) (P = 0.039). After adjusting for covariates, women with prior cervical surgery had a more than two-fold higher risk of prolonged time to pregnancy compared with untreated women (aOR 2.09, 95% CI 1.26-3.46). In contrast, women with a history of colposcopy only had a risk equivalent to that found among untreated women (aOR 1.02, 95% CI 0.56-1.89). Women with a history of cervical treatment for CIN are at increased risk of subfertility, measured as a time to pregnancy of more than 12 months.

The Promise of the Brand: How Health System Leaders Are Guiding the Transition to Health Services Integration

Many regional (and national) not-for-profit community health systems in United States were formed from asset mergers. By merging, community hospitals exchanged independence and certain rights of decision making for enhanced access to future investment capital, better payer contracting leverage, centralized corporate support services, and enhanced security in uncertain markets ahead. These hospitals often retained a governing board; a CEO who reported to that board; and a few areas of purview typically relating to designs and methods for affiliating and integrating with physicians, clinical services and programs offered, credential ing and privileging of members of independent medical staff, and - to a certain extent - definitions of quality and efficiency of care provided.SHIFTING TO INTEGRATED HEALTHSome community hospitals expected to join a system and still be able to run their own show. This approach worked reasonably well for many health systems through 1980s and 1990s. Today, however, executives of health systems overseeing such models are rethinking approach in favor of a transformation to level of regionalized, integrated, and coordinated community healthcare. They have realized that, to deliver on a brand promise of patient-centered, evidence-based, costeffective healthcare delivery, this next phase of transformative change becomes clear: They need to deliver standardized care models, methods, and practices.This change in thinking by a growing number of health system leaders stems largely from emerging demands for community healthcare provision that is predictable, reliable, and uniform in clinical approach, outcomes, and total costs of care. So, perhaps conventional precepts of healthcare is local and the community standard of care is how we do it here no longer hold sway in U.S. marketplace of future.Factors contributing to this shift in thinking include following trends:* Hospitals within same health system have taken very different paths to their affiliation with and integration of physicians, causing clinical care patterns and operational and financial performance results to vary.* Rapid and extensive consolidation of third-party health insurance carriers has led to standardization of definitions and expectations regarding evidence-based clinical best practices, high-quality clinical outcomes, and acceptable total costs of care.* Wide variations are occurring in adoptions and adaptations of information and clinical technologies.* Variations in approach to clinical service line design and delivery are being seen.FOUR LEADERS' EXPERIENCES WITH INTEGRATIONThese new directions and related changes may present substantial challenges. Peter Person, MD, CEO of Essentia Health, based in Duluth, Minnesota, leads a health system with assets and staff in four states. Essentia is several years into its standardization of cancer care services across sites and geographic regions. What drove strategy? According to Dr. Person, We can't reasonably call ourselves an integrated system of care when our clinical approach to same cancer diagnosis differs markedly across sites carrying our brand.Alan Kaplan, MD, FACHE, senior vice president and chief clinical officer of Iowa Health System in Des Moines, has been working for last three years with employed physician leaders, affiliated hospital presidents, and corporate executives to transform health system's physician integration strategy from a collection of locally designed and operated physician affiliation models to a unified, systemwide, and fully integrated multispecialty medical group. Eventually, this group is expected to exceed 1,000 physicians, all operating from a singular mission, strategy, clinical services blueprint, and operating platform. According to Dr. Kaplan, The most important thing we can and should do is to deliver to our patients elevated levels of clinical quality and consistency across sites of care. …

Volume to Value

Traditional fee-for-service medicine has put physicians on an unsustainable treadmill of volume that escalates healthcare costs regardless of the quality of care they provide. This article shares the experience of UnityPoint Health (formerly Iowa Health System) in designing and implementing patient-centered, physician-led, coordinated care as a building block for transforming the delivery system. Keys to the effort's success include aligning physicians, hospitals, and home care delivery in terms of organizational goals and having the ability to gather, analyze, and share data to manage population health. On April 16, 2013, Iowa Health System became UnityPoint Health, dedicated to transforming the delivery of care through a coordinated system that offers regional, organized systems of care in most of our markets in Iowa and Illinois. These capabilities allowed the system to enter into value-based accountable care organization contracts that cover more than 220,000 lives. The transition ultimately will lead to population health-driven approaches in which compensation will be based on the management of specific populations or chronic diseases over a specified period. As increased value from care coordination becomes clear, the external environment will demand this better system, and patients will expect it.

Erratum to “Management of squamous cell carcinoma of the head and neck in the elderly: Review and recommendations” [J. Geriatr. Oncol. 3 (2012) 265–272

Alva Weir⁎, Apar Kishor Ganti , Mollie deShazo, Sandeep Samant, Arti Hurria Department of Medicine, University of Tennessee Health Science Center, Veterans Affairs Medical Center, Memphis, TN, USA Veterans Affairs Medical Center-Nebraska, Western Iowa Health Care System, Omaha, NE, USA Department of Medicine, University of Nebraska Medical Center, USA Department of Medicine, University of Alabama Birmingham, Birmingham, AL, USA Department of Otolaryngology/Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA Cancer and Aging Research Program, City of Hope Comprehensive Cancer Center, Duarte, CA, USA

Correction of Systematic Bias in Ultrasound Dating in Studies of Small-for-Gestational-Age Birth: An Example From the Iowa Health in Pregnancy Study

The authors examined whether early ultrasound dating (≤20 weeks) of gestational age (GA) in small-for-gestational-age (SGA) fetuses may underestimate gestational duration and therefore the incidence of SGA birth. Within a population-based case-control study (May 2002-June 2005) of Iowa SGA births and preterm deliveries identified from birth records (n = 2,709), the authors illustrate a novel methodological approach with which to assess and correct for systematic underestimation of GA by early ultrasound in women with suspected SGA fetuses. After restricting the analysis to subjects with first-trimester prenatal care, a nonmissing date of the last menstrual period (LMP), and early ultrasound (n = 1,135), SGA subjects' ultrasound GA was 5.5 days less than their LMP GA, on average. Multivariable linear regression was conducted to determine the extent to which ultrasound GA predicted LMP dating and to correct for systematic misclassification that results after applying standard guidelines to adjudicate differences in these measures. In the unadjusted model, SGA subjects required a correction of +1.5 weeks to the ultrasound estimate. With adjustment for maternal age, smoking, and first-trimester vaginal bleeding, standard guidelines for adjudicating differences in ultrasound and LMP dating underestimated SGA birth by 12.9% and overestimated preterm delivery by 8.7%. This methodological approach can be applied by researchers using different study populations in similar research contexts.