Health information technology (IT), such as computerized physician order entry and electronic health records, has potential to improve the quality of health care. But the returns from widespread adoption of such technologies remain uncertain. We measured changes in the quality of care following adoption of electronic health records among a national sample of U.S. hospitals from 2004 to 2007. The use of computerized physician order entry and electronic health records resulted in significant improvements in two quality measures, with larger effects in academic than nonacademic hospitals. We conclude that achieving substantive benefits from national implementation of health IT may be a lengthy process. Policies to improve health IT's efficacy in nonacademic hospitals might be more beneficial than adoption subsidies.

In rural US counties not adjacent to urban areas, loss of hospital-based obstetric services, compared with counties with continual services, was associated with increases in out-of-hospital and preterm births and births in hospitals without obstetric units in the following year; the latter also occurred in urban-adjacent counties. These findings may inform planning and policy regarding rural obstetric services.

BackgroundGrowing concerns about the value and effectiveness of short-term volunteer trips intending to improve health in underserved Global South communities has driven the development of guidelines by multiple organizations and individuals. These are intended to mitigate potential harms and maximize benefits associated with such efforts.MethodThis paper analyzes 27 guidelines derived from a scoping review of the literature available in early 2017, describing their authorship, intended audiences, the aspects of short term medical missions (STMMs) they address, and their attention to guideline implementation. It further considers how these guidelines relate to the desires of host communities, as seen in studies of host country staff who work with volunteers.ResultsExisting guidelines are almost entirely written by and addressed to educators and practitioners in the Global North. There is broad consensus on key principles for responsible, effective, and ethical programs--need for host partners, proper preparation and supervision of visitors, needs assessment and evaluation, sustainability, and adherence to pertinent legal and ethical standards. Host country staff studies suggest agreement with the main elements of this guideline consensus, but they add the importance of mutual learning and respect for hosts.ConclusionsGuidelines must be informed by research and policy directives from host countries that is now mostly absent. Also, a comprehensive strategy to support adherence to best practice guidelines is needed, given limited regulation and enforcement capacity in host country contexts and strong incentives for involved stakeholders to undertake or host STMMs that do not respect key principles.Electronic supplementary materialThe online version of this article (10.1186/s12992-018-0330-4) contains supplementary material, which is available to authorized users.

Purpose The goal of this study was to assess perspectives of racially/ethnically diverse, low-income pregnant women on how doula services (nonmedical maternal support) may influence the outcomes of pregnancy and childbirth. Methods We conducted four in-depth focus group discussions with low-income pregnant women. We used a selective coding scheme based on five themes (agency, personal security, connectedness, respect, and knowledge) identified in the Good Birth framework, and analyzed salient themes in the context of the Gelberg-Anderson behavioral model and the social determinants of birth outcomes. Results Participants identified the role doulas played in mitigating the effects of social determinants. The five themes of a Good Birth characterized the means through which nonmedical support from doulas influenced the pathways between social determinants of health and birth outcomes. By addressing health literacy and social support needs, pregnant women noted that doulas affect access to and quality of health care services. Conclusions Access to doula services for pregnant women who are at risk of poor birth outcomes may help disrupt the pervasive influence of social determinants as predisposing factors for health during pregnancy and childbirth.

(JAMA. 2018;319(12):1239–1247) Between 2004 and 2014, hospital-based obstetric services have decreased from 55% to 46% in rural counties in the United States. Prior studies have shown that women and children in remote rural areas have delayed prenatal care initiation and higher rates of pregnancy hospitalizations, low birth weight, preterm births, and infant mortality. This retrospective cohort study examined whether the loss of rural obstetric services was associated with changes in location of childbirth or outcomes of care.

Purpose The purpose of this study was to describe the types and combinations of clinicians who are delivering babies in rural hospitals, their employment status, the relationship between hospital birth volume and staffing models, and the staffing challenges faced by rural hospitals. Methods We conducted a telephone survey of 306 rural hospitals in 9 states: Colorado, Iowa, Kentucky, New York, North Carolina, Oregon, Vermont, Washington, and Wisconsin, from November 2013-March 2014 to assess their obstetric workforce. Bivariate associations between hospitals’ annual birth volume and obstetric workforce characteristics were examined, as well as qualitative analysis of workforce changes and staffing challenges. Findings Hospitals with lower birth volume (< 240 births per year) are more likely to have family physicians and general surgeons attending deliveries, while those with a higher birth volume more frequently have obstetricians and midwives attending deliveries. Reported staffing challenges include scheduling, training, census fluctuation, recruitment and retention, and intra-hospital relationships. Conclusions Individual hospitals working in isolation may struggle to address staffing challenges. Federal and state policy makers, regional collaboratives, and health care delivery systems can facilitate solutions through programs such as telehealth, simulation training, and interprofessional education.

Background and Objectives: Implicit bias often affects patient care in insidious ways, and has the potential for significant damage. Several educational interventions regarding implicit bias have been developed for health care professionals, many of which foster reflection on individual biases and encourage personal awareness. In an attempt to address racism and other implicit biases at a more systemic level in our family medicine residency training program, our objectives were to offer and evaluate parallel trainings for residents and faculty by a national expert. Methods: The trainings addressed how both personal biases and institutional inequities contribute to structural racism, and taught skills for managing instances of implicit biases in one’s professional interactions. The training was deliberately designed to increase institutional capacity to engage in crucial conversations regarding implicit bias. Six months after the trainings, an external evaluator conducted two separate 1-hour focus groups, one with residents (n=18) and one with program faculty and leadership (n=13). Results: Four themes emerged in the focus groups: increased awareness of and commitment to addressing racial bias; appreciation of a safe forum for sharing concerns; new ways of addressing and managing bias; and institutional capacity building for continued vigilance and training regarding implicit bias. Conclusions: Both residents and faculty found this training to be important and empowering. All participants desired an ongoing programmatic commitment to the topic.

BACKGROUND A recent American College of Obstetricians and Gynecologists and Society for Maternal Fetal Medicine consensus statement on levels of maternity care lays out designations that correspond to specific capacities available in facilities that provide obstetric care. Pregnant women in rural and remote areas receive particular attention in discussions of regionalization and levels of care, owing to the challenges in assuring local access to high-acuity services when necessary. Currently, approximately half a million rural women give birth each year in US hospitals, and whether and which of these women give birth locally is crucial for successfully operationalizing maternal levels of care. OBJECTIVES To characterize rural women who give birth in non-local hospitals and measure local hospital characteristics and maternal diagnoses present at childbirth that are associated with non-local childbirth. STUDY DESIGN This was a repeat cross-sectional analysis of administrative hospital discharge data for all births to rural women in nine states in 2010 and 2012. Multivariate logistic regression models were used to predict the odds of childbirth in a non-local hospital (at least 30 road miles from the patient's residence). We examined patient age, race/ethnicity, payer, rurality, clinical diagnoses (diabetes, hypertension, hemorrhage during pregnancy, placental abnormalities, malpresentation, multiple gestation, preterm delivery, prior cesarean delivery, and a composite of diagnoses that may require maternal-fetal medicine consultation), as well as local hospital characteristics (birth volume, neonatal care level, ownership, accreditation, and system affiliation). RESULTS The rate of non-local childbirth among 216,076 rural women was 25.4%. It varied significantly by primary payer (Adjusted Odds Ratio [95% Confidence Interval]=0.76 [0.68,0.86]) for Medicaid vs. private insurance) and by clinical conditions including multiple gestation (1.82 [1.58,2.1]), preterm deliveries (2.41 [2.17,2.67]), and conditions which may require maternal fetal medicine services or consultation (1.28 [1.22,1.35]). Rural women whose local hospital did not have a neonatal intensive or intermediate care unit had nearly double the odds of giving birth at a non-local hospital (1.94 [1.64,2.31]). CONCLUSION Approximately 75% of rural women gave birth at local hospitals; rural women with preterm births and clinical complications, as well as those without local access to higher-acuity neonatal care, were more likely to give birth in non-local hospitals. However, after controlling for clinical complications, rural Medicaid beneficiaries were less likely to give birth at non-local hospitals, implying a potential access challenge for this population.