Browsing by Author "McKenzie, Fatima"
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Item Comparing neonatal morbidity and mortality estimates across specialty in periviable counseling(Taylor & Francis, 2015-12) Edmonds, Brownsyne Tucker; McKenzie, Fatima; Panoch, Janet; Frankel, Richard M.; Department of Obstetrics and Gynecology, IU School of MedicineObjective To describe and compare estimates of neonatal morbidity and mortality communicated by neonatologists and obstetricians in simulated periviable counseling encounters. Methods A simulation-based study of 16 obstetricians (OBs) and 15 neonatologists counseling standardized patients portraying pregnant women with ruptured membranes at 23 weeks gestation. Two investigators tabulated all instances of numerically-described risk estimates across individuals and by specialty. Results Overall, 12/15 (80%) neonatologists utilized numeric estimates of survival; 6/16 (38%) OBs did. OBs frequently deferred the discussion of “exact numbers” to neonatologists. The twelve neonatologists provided 13 unique numeric estimates, ranging from 3% to 50% survival. Half of those neonatologists provided 2-3 different estimates in a single encounter. By comparison, six OBs provided 4 unique survival estimates (“50%”, “30-40%”, “1/3-1/2”, “<10%”). Only 2/15 (13%) neonatologists provided numeric estimates of survival without impairment. None of the neonatologists used the term ‘intact’ survival, while 5 OBs did. Three neonatologists gave numeric estimates of long-term disability and one OB did. Conclusion We found substantial variation in estimates and noteworthy omissions of discussions related to long-term morbidity. Across specialties, we noted inconsistencies in the use and meaning of terms like ‘intact survival.’ More tools and training are needed to improve the quality and consistency of periviable risk-communication.Item "Doctor, what would you do?": physicians' responses to patient inquiries about periviable delivery(Elsevier, 2015-01) Tucker Edmonds, Brownsyne; McKenzie, Fatima; Panoch, Janet E.; Wocial, Lucia D.; Barnato, Amber E.; Frankel, Richard M.; Department of Obstetrics and Gynecology, IU School of MedicineOBJECTIVE: To qualitatively assess obstetricians' and neonatologists' responses to standardized patients (SPs) asking "What would you do?" during periviable counseling encounters. METHODS: An exploratory single-center simulation study. SPs, portraying a pregnant woman presenting with ruptured membranes at 23 weeks, were instructed to ask, "What would you do?" if presented options regarding delivery management or resuscitation. Responses were independently reviewed and classified. RESULTS: We identified five response patterns: 'Disclose' (9/28), 'Don't Know' (11/28), 'Deflect' (23/28), 'Decline' (2/28), and 'Ignore' (2/28). Most physicians utilized more than one response pattern (22/28). Physicians 'deflected' the question by: restating or offering additional medical information; answering with a question; evoking a hypothetical patient; or redirecting the SP to other sources of support. When compared with neonatologists, obstetricians (40% vs. 15%) made personal or professional disclosures more often. Though both specialties readily acknowledged the importance of values in making a decision, only one physician attempted to elicit the patient's values. CONCLUSION: "What would you do?" represented a missed opportunity for values elicitation. Interventions are needed to facilitate values elicitation and shared decision-making in periviable care. PRACTICE IMPLICATIONS: If physicians fail to address patients' values and goals, they lack the information needed to develop patient-centered plans of care.Item Evaluating Shared Decision Making in Trial of Labor After Cesarean Counseling Using Objective Structured Clinical Examinations(Association of American Medical Colleges, 2020) Tucker Edmonds, Brownsyne; Hoffman, Shelley M.; Laitano, Tatiana; McKenzie, Fatima; Panoch, Janet; Litwiller, Abigail; Di Corcia, Mark J.; Obstetrics and Gynecology, School of MedicineIntroduction Although shared decision making (SDM) is optimal for trial of labor after cesarean (TOLAC) counseling, resources to assess residents' clinical competency and communication skills are lacking. We addressed this gap by developing and testing an objective structured clinical examination (OSCE) to evaluate whether learners were able to use SDM in TOLAC counseling. Methods We created three simulation scenarios with increasing complexity to assess the skills of residents in their first, second, or third postgraduate year in using SDM in TOLAC counseling. All cases involved a standardized patient requesting a TOLAC consultation. Residents were provided with a medical history and instructed to counsel and develop a care plan. A 10-item scoring rubric was used, and each item was rated 0 (absent), 1 (partial), or 2 (complete). Three coders independently rated the encounters; discrepancies were resolved by consensus. Results Over 3 years, 39 residents participated in 60 OSCE encounters. The majority provided complete discussions of the clinical issue (93%), chances of success (72%), and maternal and fetal risks (100% and 85%, respectively) but obtained partial assessments of understanding (78%). Discussions of benefits were typically absent, with the exception of the maternal benefits (47%). More than 40% of residents did not discuss the patient's goals, 53% lacked discussion of uncertainties related to TOLAC, and half failed to explore the patient's preference, with most deferring a decision to a future encounter. Discussion Residents consistently discussed diagnosis, prognosis, and maternal risks yet infrequently addressed goals and preferences—two critical elements of SDM.Item Evaluating Shared Decision-Making in Postpartum Contraceptive Counseling Using Objective Structured Clinical Examinations(Mary Ann Liebert, 2022-12-26) Tucker Edmonds, Brownsyne; Hoffman, Shelley M.; Laitano, Tatiana; McKenzie, Fatima; Panoch, Janet; Litwiller, Abigail; DiCorcia, Mark J.; Obstetrics and Gynecology, School of MedicineBackground: Shared decision-making (SDM) may support widespread uptake of progestin-containing long-acting reversible contraceptives in the immediate postpartum period. We piloted an Objective Structured Clinical Examination (OSCE) to evaluate first-year obstetrics and gynecology resident physicians' use of SDM in postpartum contraception counseling. Methods: As part of their 2015 and 2016 OSCEs, first-year OB/GYN residents were instructed to provide contraceptive counseling to a Standardized Patient (SP) portraying a 29-year-old postpartum patient seen during rounds on the morning following her delivery. Three investigators independently scored each resident encounter using a 10-item rubric adapted from a 9-item SDM measure and assigned scores of 0 (absent), 1 (partial), or 2 (complete). Each encounter was video and audio recorded, then transcribed for qualitative analysis. Descriptive statistics was produced using SPSS version 24. Results: Eighteen residents participated. The majority (78%) discussed contraceptive options and timing of initiation. Nearly 33% elicited factors most important to the SP in influencing her preference. Only 6% discussed the benefits of exclusive breastfeeding, and few addressed the uncertainty of progesterone on milk supply and production. Conclusion: Although residents conveyed ample clinical information, the vast majority did not discuss elements of SDM, such as her preferences, values, and goals for future fertility and breastfeeding. Our work revealed that critical elements of SDM are often not explored and deliberated by resident physicians. Trainings (e.g., OSCEs) are needed to equip residents with effective communication skills to facilitate more SDM in postpartum contraceptive care.Item The influence of resuscitation preferences on obstetrical management of periviable deliveries(Nature Publishing Group, 2015-03) Edmonds, Brownsyne Tucker; McKenzie, Fatima; Hendrix, Kristin S.; Perkins, Susan M.; Zimet, Gregory D.; Department of Obstetrics & Gynecology, IU School of MedicineObjective Determine the relative influence of patient's resuscitation preferences on periviable delivery management. Methods Surveyed 295 obstetrician-gynecologists about managing periviable preterm premature rupture of membranes. Across 10 vignettes, we systematically varied gestational age; occupation; method of conception; and resuscitation preference. Physicians rated their likelihood (0-10) of proceeding with induction, steroids, and cesarean. Data were analyzed via conjoint analysis. Results 205 physician responses were included. Median ratings for management decisions were: induction 1.89; steroids 5.00; cesarean for labor 3.89; cesarean for distress 4.11. Gestational age had the greatest influence on physician ratings across all decisions (importance values ranging from 72.6-86.6), followed by patient's resuscitation preference (range= 9.3-21.4). Conclusion Gestational age is weighted more heavily than patients’ resuscitation preferences in obstetricians’ decision-making for periviable delivery management. Misalignment of antenatal management with parental resuscitation preferences may adversely affect periviable outcomes. Interventions are needed to facilitate more patient-centered decision-making in periviable care.Item Maternal-Fetal Medicine physicians' practice patterns for 22-week delivery management(Taylor & Francis, 2016) Edmonds, Brownsyne Tucker; McKenzie, Fatima; Robinson, Barret K.; Department of Obstetrics and Gynecology, IU School of MedicineOBJECTIVE: To describe Maternal-Fetal Medicine (MFM) physicians' practice patterns for 22-week delivery management. MEHODS: Surveyed 750 randomly-sampled members of the Society of Maternal-Fetal Medicine, querying MFMs' practices and policies guiding 22-week delivery management. RESULTS: Three hundred and twenty-five (43%) MFMs responded. Nearly all (87%) would offer induction. Twenty-eight percent would order steroids, and 12% would perform cesarean for a patient desiring resuscitation. Offering induction differed significantly based on the provider's practice setting, region, religious service attendance and political affiliation. In multivariable analyses, political affiliation remained a significant predictor of offering induction (p = 0.03). CONCLUSIONS: Most MFMs offer induction for PPROM at 22 weeks. A noteworthy proportion is willing to order steroids and perform cesarean. Personal beliefs and practice characteristics may contribute to these decisions. While little is known about the efficacy of these interventions at 22 weeks, some MFMs will offer obstetrical intervention if resuscitation is intended.Item Maternal-Fetal Medicine physicians’ practice patterns for 22-week delivery management(Taylor and Francis, 2015) Edmonds, Brownsyne Tucker; McKenzie, Fatima; Robinson, Barrett K.; Department of Obstetrics and Gynecology, IU School of MedicineObjective: To describe Maternal-Fetal Medicine (MFM) physicians’ practice patterns for 22-week delivery management. Mehods: Surveyed 750 randomly-sampled members of the Society of Maternal-Fetal Medicine, querying MFMs’ practices and policies guiding 22-week delivery management. Results: Three hundred and twenty-five (43%) MFMs responded. Nearly all (87%) would offer induction. Twenty-eight percent would order steroids, and 12% would perform cesarean for a patient desiring resuscitation. Offering induction differed significantly based on the provider’s practice setting, region, religious service attendance and political affiliation. In multivariable analyses, political affiliation remained a significant predictor of offering induction (p = 0.03). Conclusions: Most MFMs offer induction for PPROM at 22 weeks. A noteworthy proportion is willing to order steroids and perform cesarean. Personal beliefs and practice characteristics may contribute to these decisions. While little is known about the efficacy of these interventions at 22 weeks, some MFMs will offer obstetrical intervention if resuscitation is intended.Item Morbidity and mortality associated with mode of delivery for breech periviable deliveries(Elsevier, 2015-07) Tucker Edmonds, Brownsyne; McKenzie, Fatima; Macheras, Michelle; Srinivas, Sindhu K.; Lorch, Scott A.; Department of Obstetrics and Gynecology, IU School of MedicineOBJECTIVE: The purpose of this study was to estimate the odds of morbidity and death that are associated with cesarean delivery, compared with vaginal delivery, for breech fetuses who are delivered from 23-24 6/7 weeks' gestational age. STUDY DESIGN: We conducted a retrospective cohort study of state-level maternal and infant hospital discharge data that were linked to vital statistics for breech deliveries that occurred from 23-24 6/7 weeks' gestation in California, Missouri, and Pennsylvania from 2000-2009 (N = 1854). Analyses were stratified by gestational age (23-23 6/7 vs 24-24 6/7 weeks' gestation). RESULTS: Cesarean delivery was performed for 46% (335 fetuses) and 77% (856 fetuses) of 23- and 24-week breech fetuses. In multivariable analyses, overall survival was greater for cesarean-born neonates (adjusted odds ratio [AOR], 3.98; 95% confidence interval [CI], 2.24-7.06; AOR, 2.91; 95% CI, 1.76-4.81, respectively). When delivered for nonemergent indications, cesarean-born survivors were more than twice as likely to experience major morbidity (intraventricular hemorrhage, bronchopulmonary dysplasia, necrotizing enterocolitis, asphyxia composite; AOR, 2.83; 95% CI, 1.37-5.84; AOR, 2.07; 95% CI, 1.11-3.86 at 23 and 24 weeks' gestation, respectively). Among intubated neonates, despite a short-term survival advantage, there was no difference in survival to >6-month corrected age (AOR, 1.77; 95% CI, 0.83-3.74; AOR, 1.50; 95% CI, 0.81-2.76, respectively). There was no difference in survival for intubated 23-week neonates who were delivered by cesarean for nonemergent indications or cesarean-born neonates who weighed <500 g. CONCLUSION: Cesarean delivery increased overall survival and major morbidity for breech periviable neonates. However, among intubated neonates, despite a short-term survival advantage, there was no difference in 6-month survival. Also, cesarean delivery did not increase survival for neonates who weighed <500 g. Patients and providers should discuss explicitly the trade-offs related to neonatal death and morbidity, maternal morbidity, and implications for future pregnancies.Item Obstetrical Providers’ Management of Chronic Pain in Pregnancy: A Vignette Study(Oxford University Press, 2017) Tucker Edmonds, Brownsyne; McKenzie, Fatima; Austgen, MacKenzie B.; Ashburn-Nardo, Leslie; Matthias, Marianne S.; Hirsh, Adam T.; Obstetrics and Gynecology, School of MedicineObjective: Describe obstetrical providers' management of a hypothetical case on chronic pain in pregnancy and determine whether practices differ based on patient race. Design and setting: This was a self-administered survey at a clinical conference. Subjects: Seventy-six obstetrician-gynecologists and one nurse practitioner were surveyed. Methods: A case-vignette described a pregnant patient presenting with worsening chronic lower back pain, requesting an opioid refill and increased dosage. We varied patient race (black/white) across two randomly assigned identical vignettes. Providers indicated their likelihood of prescribing opioids, drug testing, and referring on a 0 (definitely would not) to 10 (definitely would) scale; rated their suspicions/concerns about the patient on a 0-10 VAS scale; and ranked those concerns in order of importance. We calculated correlation coefficients, stratifying analyses by patient race. Results: Providers were not inclined to refill the opioid prescription (median = 3.0) or increase the dose (median = 1.0). They were more likely to conduct urine drug tests on white than black patients ( P = 0.008) and more likely to suspect that white patients would divert the medication ( P =0.021). For white patients, providers' highest-ranked concern was the patient's risk of abuse/addiction, whereas, for black patients, it was harm to the fetus. Suspicion about symptom exaggeration was more closely related to decisions about refilling the opioid prescriptions and increasing the dose for black patients (r = -0.357, -0.439, respectively), whereas these decisions were more closely correlated with concerns about overdose for white patients (r = -0.406, -0.494, respectively). Conclusions: Provider suspicion and concerns may differ by patient race, which may relate to differences in pain treatment and testing. Further study is warranted to better understand how chronic pain is managed in pregnancy.Item Offering Induction of Labor for 22-Week Premature Rupture of Membranes: A Survey of Obstetricians.(NPG, 2015-08) McKenzie, Fatima; Tucker Edmonds, Brownsyne; Department of Obstetrics & Gynecology, IU School of MedicineObjective: To describe obstetricians’ induction counseling practices for 22-week preterm premature rupture of membranes (PPROM) and identify provider characteristics associated with offering induction. Methods: Surveyed 295 obstetricians on their likelihood (0–10) of offering induction for periviable PPROM across 10 vignettes. 22-week vignettes were analyzed, stratified by parental resuscitation preference. Bivariate analyses identified physician characteristics associated with reported likelihood ratings. Results: Obstetricians (N=205) were not likely to offer induction. Median ratings by preference were: resuscitation 1.0, uncertain 1.0, and comfort care 3.0. Only 41% of obstetricians were likely to offer induction to patients desiring comfort care. Additionally, several provider-level factors, including practice region, parenting status, and years in practice, were significantly associated with offering induction. Conclusions: Obstetricians do not readily offer induction when counseling patients with 22-week ruptured membranes, even when patients prefer palliation. This may place women at risk for infectious complications without accruing a neonatal benefit from prolonged latency.