• Initial Generalist Versus Subspecialist Provider for Fertility Treatment, Use of In Vitro Fertiliation, and Time to Pregnancy

      Boltz, Mandy; The University of Arizona College of Medicine - Phoenix; Stanford, Joseph B. (The University of Arizona., 2016-03-23)
      Background and Significance: Infertility is a common problem in the United States. Infertility is recognized as a disease by the World Health Organization (WHO) and is identified as an emerging public health priority by the Centers for Disease Control (CDC). It is also associated with numerous effects on women’s physical and emotional health, and involves treatment methods that are medically invasive and associated with health implications for the resulting children. A better understanding of the role of generalist providers in the management of infertility may lead to opportunities to promote a balanced approach to infertility. Research Questions: 1) With what types of providers do most women initiate infertility care? 2) How do women who enter care with a generalist provider differ from those who enter care with a fertility subspecialist? 3) Are different outcomes associated with presenting first to a generalist provider versus a fertility subspecialist? Methods: We analyzed mixed-mode questionnaire data from 279 Utah women with primary infertility enrolled through population-based sampling. We compared women presenting first to generalist providers with women presenting first to fertility subspecialists, with the main outcomes of receiving in vitro fertilization (IVF), time to pregnancy, and live birth. Results: The first point of contact for most women (84%) with infertility was a generalist provider. Only 5% of women sought care initially from a fertility subspecialist, and these women were more likely to have higher incomes, be older, and have been trying to conceive for longer periods of time before seeking care. Women who presented first to a generalist provider were less likely to receive IVF (aOR 0.17; 95% CI: 0.05, 0.57), were equally likely to achieve a pregnancy, and had similar times to pregnancy (aHR 0.80; 95% CI: 0.38, 1.69) as women who presented first to a subspecialist, after controlling for age, time attempting to conceive before seeking care, and income. Conclusion: In this population-based sample of women with primary infertility, presenting first to a generalist was associated with a decreased likelihood of receiving IVF and a similar time to pregnancy. Generalist providers are frequently the first point of care for women with difficulty conceiving and are uniquely positioned to promote a balanced management of infertility.
    • Management of Rhinosinusitis During Pregnancy: Systematic Review and Expert Panel Recommendations

      Jategaonkar, Ameya; The University of Arizona College of Medicine - Phoenix; Lal, Devyani (The University of Arizona., 2016-04)
      Background: Rhinosinusitis, both acute and chronic, represents a common disease. Approximately 29.6 million adults in the United States suffer from sinusitis with 11 million suffering from CRS1. The multicenter GA2LEN study showed that amongst lifetime nonsmokers, women were at a greater risk of being affected by chronic rhinosinusitis than men2. Various other rhinologic manifestations of pregnancy have also been described. Nevertheless, management of rhinosinusitis during pregnancy is poorly described in the literature. Objectives: 1. Conduct a systematic review of the literature for the management of acute and chronic rhinosinusitis (CRS) during pregnancy. 2. Make evidence based recommendations on the management of acute and chronic rhinosinusitis during pregnancy. Methods: A systematic review of the literature was conducted using MEDLINE and EMBASE databases. Search terms included “rhinitis” OR “sinusitis” OR “rhinosinusitis” AND “pregnant” OR “women” OR “gender”. Title, abstract, and full manuscript review was conducted. Full manuscripts including citations and references were reviewed if the abstract noted any gender specific outcomes. A multispecialty panel of experts in the fields of rhinology, allergyimmunology, and obstetrics‐gynecology was invited to review the systematic review. Recommendations were sought on the use of the following for the management of CRS during pregnancy: oral corticosteroids, antibiotics, leukotriene antagonists, topical corticosteroid sprays/irrigations/drops, aspirin desensitization, elective surgery for CRS, and vaginal birth vs. planned cesarean delivery for patients with history of skull base erosions or CSF rhinorrhea. Results: 3052 abstracts were screened, and 88 manuscripts were reviewed. No relevant level 1, 2 or 3 studies were found. Expert panel recommendations were synthesized. Conclusions: Several recommendations were made. These include continuing all modern topical corticosteroids for CRS maintenance, using pregnancy safe antibiotics for acute rhinosinusitis and CRS exacerbations, and discontinuing aspiring therapy for desensitization in patients with aspirin exacerbated respiratory disease.
    • Perception of Access to Prenatal Care of Women Presenting to the Emergency Department During the First Trimester of Pregnancy

      Deason, Brandon; The University of Arizona College of Medicine - Phoenix; Bayless, Patricia (The University of Arizona., 2016-03-23)
      Background: Despite the large amount of research regarding prenatal care (PNC) in physicians’ offices, hospital outpatient clinics, and community health centers, there is a great paucity of information regarding the role the Emergency Department plays in PNC. Objective: To understand the factors associated with pregnant women’s choice to seek prenatal care in the Emergency Department. Methods: This study is an investigative examination of the attitudes towards and perceived barriers to PNC of women in the first trimester of pregnancy presenting to the Emergency Department at an urban level 1 trauma center. Survey questions examined demographic information and patient factors, such as how they found out about the pregnancy, if they had seen a doctor for this pregnancy, use of PNC in prior pregnancies, and whether they would utilize first trimester PNC in the future. Additionally, the survey contained a series of statements about the importance of PNC and factors affecting their utilization as rated on a 5 point Likert scale. All data was abstracted and coded into Excel. Descriptive statistics and 95% confidence intervals were calculated. Logistic regression was used to predict future PNC use. Results: A total of 74 patients who met the inclusion criteria were surveyed. Ninety‐three percent (CI 84‐97%) knew they were pregnant prior to presenting to the ED. Thirty‐seven percent (CI 27‐50%) had a prenatal visit prior to the index ED visit. Twelve percent (CI 6‐22%) reported they were at the ED for PNC, 70% (CI 59‐80%) for another OB/GYN issue, and 18% (CI 10‐28%) for a reason unrelated to pregnancy. However, 22% strongly agreed and 8% agreed that if they had PNC they would not have come to the ED that day. Predictors of future PNC use included knowledge of pregnancy prior to ED visit, number of pregnancies, belief that PNC is important for the mother’s health, knowledge of where to receive PNC, and belief that taking prenatal vitamins during pregnancy can help the baby. Conclusions: For the population of pregnant females presenting to an urban level 1 trauma emergency department during the first trimester of pregnancy, a large proportion (30%) reported they would not have come to the ED if they received PNC. This would represent a significant reduction in ED visits per year if these women received appropriate services. Future research would need to further delineate the perceived barriers to PNC in this population.