2016 Publications

Research Department Publications 2016

Anderson, B., Peters, E., Fialkow, M., Taouk, L. (2016, Epub Ahead of Print). Obstetrician-gynecologists’ opinions about the Affordable Care Act and their expectations about how it will affect their practice. Preventive Medicine.

As the primary healthcare providers for women, obstetrician-gynecologists' (OB/GYNs) experiences with and opinions about the Affordable Care Act (ACA) are important to understand. An online survey was sent to 1000 randomly selected OB/GYNs who are members of the American College of Obstetricians and Gynecologists (ACOG) in 2014. Of those, 523 opened the email and 163 responded (31% participation rate). Data were collected August 2014-October 2014 and analyzed in 2015–2016. Support for the ACA was widely distributed, with the largest subset of the sample (about 21%) in the “very supportive” category. Opinions of the ACA were more supportive than they were in a previous study conducted in 2011. When given a list of possible positive and negative impacts of the ACA on their practice, roughly 1 in 5 reported that the ACA increased work-related stress (28%), decreased total profits (22%), and lowered career satisfaction (22%), whereas 8.6% reported that the ACA increased quality of care. Around half of the providers thought that their newly insured patients would have the same level of education (42%) and numeric ability (55%) as their current patients. Almost all respondents (87%) indicated that it is at least slightly important for patients to understand their numeric likelihood of risk (such as numeric risk information from medications, treatments, and other procedures you might prescribe) —31% think it is extremely important and 44% think it is moderately important.

Dhesi, A., Murtough, K., Lim, J., Schulkin, J., McGovern, P., Power, M., Morelli, S. (2016). Metabolic screening in patients with polycystic ovary syndrome is largely underutilized among obstetrician-gynecologists. American Journal of Obstetrics & Gynecology. 215(5): 579.e1-579.e5

BACKGROUND:  Women with polycystic ovary syndrome have substantially higher rates of insulin resistance, impaired glucose tolerance, type 2 diabetes, dyslipidemia, and metabolic syndrome when compared with women without the disease. Given the high prevalence of these comorbidities, guidelines issued by the American College of Obstetricians and Gynecologists and the Endocrine Society recommend that all women with polycystic ovary syndrome undergo screening for impaired glucose tolerance and dyslipidemia with a 2 hour 75 g oral glucose tolerance test and fasting lipid profile upon diagnosis and also undergo repeat screening every 2-5 years and every 2 years, respectively. Although a hemoglobin A1C and/or fasting glucose are widely used screening tests for diabetes, both the American College of Obstetricians and Gynecologists and the Endocrine Society preferentially recommend the 2 hour oral glucose tolerance test in women with polycystic ovary syndrome as a superior indicator of impaired glucose tolerance/diabetes mellitus.

METHODS:  An online survey study targeting American College of Obstetricians and Gynecologists fellows and junior fellows.

RESULTS:  However, we found that gynecologists underutilize current recommendations for metabolic screening in women with polycystic ovarian syndrome. Of the respondents, 22.3% would not order any screening test at the initial visit for at least 50% of their patients with polycystic ovary syndrome. The most common tests used to screen for impaired glucose tolerance in women with polycystic ovary syndrome were hemoglobin A1C (51.0%) and fasting glucose (42.7%). Whereas 54.1% would order a fasting lipid profile in at least 50% of their polycystic ovary syndrome patients, only 7% of respondents order a 2 hour oral glucose tolerance test.

CONCLUSION:  We call for increased efforts to encourage obstetrician-gynecologists to address metabolic abnormalities in their patients with polycystic ovary syndrome. Such efforts should include education of physicians early in their careers, at the medical student and resident level. Efforts should also include implementation of continuing medical education activities, both locally and at the national level, to improve understanding of the metabolic implications of polycystic ovary syndrome. Electronic medical record systems should be utilized to generate prompts for appropriate screening tests in patients with a diagnosis of polycystic ovary syndrome. Because obstetrician-gynecologists may be the only physicians seen by many polycystic ovary syndrome patients, particularly those in their young reproductive years, such interventions could effectively promote optimal preventative health care and early diagnosis of metabolic comorbidities in these at-risk women.

Fay, E., Hoppe, K., Eckert, L., Schulkin, J. (2016). Survey of Obstetrics and Gynecology Residents Regarding Pneumococcal Vaccination in Pregnancy: Education, Knowledge, and Barriers to Vaccination. Infectious Diseases in Obstetrics and Gynecology. 2016: 1752379

OBJECTIVE: The 23-valent pneumococcal vaccine is recommended for adults over 65 years of age and younger adults with certain medical conditions. The Centers for Disease Control and Prevention (CDC) state insufficient evidence to recommend routine pneumococcal vaccination during pregnancy, but the vaccine is indicated for pregnant women with certain medical conditions. We designed this project to gauge obstetrics and gynecology (OB/GYN) resident knowledge of maternal pneumococcal vaccination.

METHODS: We administered a 22-question survey to OB/GYN residents about maternal pneumococcal vaccination. We performed descriptive analysis for each question.

RESULTS: 238 OB/GYN residents responded. Overall, 69.3% of residents reported receiving vaccination education and 86.0% reported having ready access to vaccine guidelines and safety data. Most residents knew that asplenia (78.2%), pulmonary disease (77.3%), and HIV/AIDS (69.4%) are indications for vaccination but less knew that cardiovascular disease (45.0%), diabetes (35.8%), asthma (42.8%), nephrotic syndrome (19.7%), and renal failure (33.6%) are also indications for vaccination.

CONCLUSION: OB/GYN residents are taught about vaccines and have ready access to vaccine guidelines and safety data. However, knowledge of indications for pneumococcal vaccination in pregnancy is lacking. Likely, the opportunity to vaccinate at-risk pregnant patients is being missed.

Jones, K., Carroll, S., Hawks, D., McElwain, C., Schulkin, J. (2016). Efforts to improve immunization coverage during pregnancy among ob-gyns. Infectious Diseases in Obstetrics and Gynecology. 2016: 6120701

BACKGROUND: Influenza and Tdap vaccines are vital factors for improving maternal and neonatal health outcomes.

METHODS: A prospective, longitudinal study was conducted to determine whether the American College of Obstetricians and Gynecologists’ (ACOG) efforts to increase ob-gyn use of their immunization toolkits and vaccination administration were successful. A pre- and post-intervention questionnaire was mailed to a random sample of 1,500 ACOG members between August 2012 and July 2015.
RESULTS: Significantly more post-intervention survey ob-gyns reported that they received the immunization toolkits than pre-intervention survey ob-gyns (84.5% versus 67.0%, p < .001). The large majority of ob-gyns from both surveys (76.9% vs. 78.9%) reported that they offered or planned to offer influenza vaccinations to their patients for the 2012-2013 and 2014-2015 flu seasons. Post-intervention survey respondents were significantly more likely than pre-intervention survey participants to report that they routinely offer Tdap vaccinations to all patients during pregnancy (76.8% versus 59.3%, p < .001).

CONCLUSION: ACOG’s efforts to improve ob-gyn use of immunization toolkits and vaccine administration appear to have been successful in several ways. ACOG’s toolkits are an example of an effective intervention to overcome barriers to offering vaccines and help improve influenza and Tdap immunization coverage for pregnant women.

Jones, N., Schulkin, J., Urban, R., Wright, J., Burke, W., Hou, J., McElwain, C., Tergas, A. (2016, Epub ahead of print). Physician practice patterns of risk-reducing salpingectomy for prevention of ovarian cancer.  Cancer Investigation.

BACKGROUND: Opportunistic bilateral salpingectomy (OBS) has been proposed as an ovarian cancer risk-reducing strategy.

METHODS: A survey was emailed to 300 members of the American College of Obstetricians and Gynecologists.

RESULTS: 125 (42%) surveys were returned: 60% female, 88% generalists, 67% private practice. Only 36% correctly identified the lifetime risk of ovarian cancer, only 23% understood the risk-reducing benefit of bilateral salpingo-oophorectomy. 75% perform salpingectomy during hysterectomy, 26-53% use for sterilization depending on approach. Concerns were increased operative time and complications. For BRCA mutations, 64% recommend BSO, 12% recommend a two-step risk-reducing strategy, and 14% refer to gynecologic oncology.

CONCLUSIONS: We identified broad support and factors limiting willingness to perform OBS.

Lum, D., Sokol, E., Berek, J., Schulkin, J., Chen, L., McElwain, C., Wright, J. (2016). Impact of the 2014 FDA Warnings Against Power Morcellation. Journal of Minimally Invasive Gynecology. 23(4):548-56.

OBJECTIVE: To determine whether members of the AAGL Advancing Minimally Invasive Gynecologic Surgery Worldwide (AAGL) and members of the American College of Obstetricians and Gynecologists Collaborative Ambulatory Research Network (ACOG CARN) have changed their clinical practice based on the 2014 FDA warnings against power morcellation.

DESIGN: Survey study.

SETTING: Participants were invited to complete this online survey


INTERVENTIONS: An online anonymous survey with 24 questions regarding demographics and changes to clinical practice during minimally invasive myomectomies and hysterectomies based on the 2014 FDA warnings against power morcellation.  

MEASUREMENTS AND RESULTS: A total of 615 AAGL members and 54 ACOG CARN members responded (response rates of 8.2% and 60%, respectively). Before the FDA warnings, 85.8% and 86.9%, respectively, were using power morcellation during myomectomies and hysterectomies. After the FDA warnings, 71.1% and 75.8% of respondents reported stopping use of power morcellation during myomectomies and hysterectomies. The most common reasons cited for discontinuing the use of power morcellation or using it less often were hospital mandate (45.6%), the concern for legal consequences (16.1%), and the April 2014 FDA warning (13.9%). Nearly half of respondents (45.6%) reported an increase in their rate of laparotomy. Most (80.3%) believed that the 2014 FDA warnings have not led to an improvement in patient outcomes and have led to harming patients (55.1%). 

CONCLUSION: AAGL and ACOG CARN respondents reported decreased use of power morcellation during minimally invasive gynecologic surgery after the 2014 FDA warnings, the most common reason cited being hospital mandate. Rates of laparotomy have increased. Most members surveyed believe that the FDA warnings have not improved patient outcomes.

Lyell, D., Power, M., Murtough, K., Ness, A., Anderson, B., Erickson, K., Schulkin, J. (2016). Surgical Techniques at Cesarean Delivery: U.S. Survey.  The Surgery Journal. 02(04): e119-e125.

Objective To assess the frequency of surgical techniques at cesarean delivery (CD) among U.S. obstetricians.

Methods Members of the American College of Obstetrician Gynecologists were randomly selected and e-mailed an online survey that assessed surgical closure techniques, demographics, and reasons. Data were analyzed using SPSS (IBM Corp., Armonk, New York, United States), descriptive statistics, and analysis of variance.

Results Our response rate was 53%, and 247 surveys were analyzed. A similar number of respondents either “always or usually” versus “rarely or never” reapproximate the rectus muscles (38.4% versus 43.3%, p = 0.39), and close parietal peritoneum (42.5% versus 46.9%, p = 0.46). The most frequently used techniques were double-layer hysterotomy closure among women planning future children (73.3%) and suturing versus stapling skin (67.6%); the least frequent technique was closure of visceral peritoneum (12.2%). Surgeons who perform double-layer hysterotomy closure had fewer years in practice (15.0 versus 18.7 years, p = 0.021); surgeons who close visceral peritoneum were older (55.5 versus 46.4 years old, p < 0.001) and had more years in practice (23.8 versus 13.8 years practice; p < 0.001).

Conclusion Similar numbers of obstetricians either reapproximate or leave open the rectus muscles and parietal peritoneum at CD, suggesting that wide variation in practice exists. Surgeon demographics and safety concerns play a role in some techniques.

Mohamed, S., Al-Hendy, A., Schulkin, J., Power, M. (2016). Opinions and practice of US- based obstetrician- gynecologists regarding vitamin D screening and supplementation of pregnant women. Journal of Pregnancy. 2016:1454707

Abstract: Background: Vitamin D deficiency/insufficiency is prevalent among pregnant women in the US. Recommendations for adequate levels of maternal circulating 25-hydroxyvitamin D and appropriate vitamin D supplementation for pregnant women differ between the Institute of Medicine and the Endocrine Society. Practicing obstetrician-gynecologists must make clinical decisions in this environment of uncertain guidance.

Methods: An online questionnaire with questions on physician and patient population demographics, physician opinion regarding concerns associated with vitamin D deficiency/insufficiency, and practice patterns regarding screening and supplementing pregnant women was administered to 225 randomly selected practicing obstetrician-gynecologists.

Results: Of the 225 potential participants, 101 (45%) completed the questionnaire. A majority indicated that vitamin D insufficiency was a problem in their patient population (68.4%) and that most of their pregnant patients would benefit from taking a vitamin D supplement (66.3%). Most considered vitamin D supplementation during pregnancy (82.1%) safe. Half (52.5%) would recommend vitamin D supplementation during pregnancy to some patients, but only 16.8% to all. Opinion was split between the competing recommendations for supplementation and screening for circulating levels of vitamin D. Only one of four (25.8%) routinely screen their pregnant patients for vitamin D status. Physicians who indicated vitamin D status was a problem in their patient population were more likely to screen routinely (32.8% versus 9.7%, P = 0.002) and believe their patients would benefit from supplementation (91.2% versus 16.1%, P = 0.001).

Conclusions: Despite widespread concern over vitamin D status in their populations few physicians screen. Practice was split between the two competing recommendations.

Raglan G., Cain J., Schulkin J. (2016) Brief Report on Obstetricians'/Gynecologists' Distribution of Scarce Resources. Journal for Healthcare Quality. 38(5): 322-5.

On a day-to-day basis, doctors must decide which treatments are most beneficial for their patients, and which make the most sense in terms of costs. In medical decision making, factors such as efficiency and cost-effectiveness can be particularly challenging to navigate because many of the most expensive procedures encountered in medical practice are also high-stake treatments for patients. One-hundred-six obstetricians-gynecologists (Obs/Gyns) completed a survey asking them to allocate the following resources in scenarios in which they are scarce: human papilloma virus (HPV) vaccinations, mammograms, and in vitro fertilization (IVF) treatments. Additional questions focused on how fairness and cost-effectiveness factored into the allocation decisions of each group. Results indicated that Obs/Gyns were more efficient in their distribution of HPV vaccinations and mammograms than in their distribution of IVF treatments. More efficient responding was associated with placing less emphasis on fairness in decision making. This study demonstrates the differences that exist in the emphasis that physicians place on medical evidence, cost, outcomes, and perceptions of fair (equal) allocation when faced with different costs and health impacts.

Smid, M., Smiley, S.G., Schulkin J., Stamilio, D.M, Edwards, R.K., & Stuebe, A.M. (2016) The Problem of the Pannus: Physician Preference Survey and a Review of the Literature on Cesarean Skin Incision in Morbidly Obese Women. American Journal of Perinatology. 33(5):463-72

OBJECTIVE: This study aims to determine preferences of a nationally representative sample of obstetrician/gynecologists (OB/GYNs) regarding cesarean delivery (CD) incision practices for women with morbid obesity (body mass index _ 40 kg/m2). 

STUDY DESIGN: We conducted an online survey using the American College of Obstetricians and Gynecologists database. We compared physician demographics, practice characteristics, and CD incision type preference. 

RESULTS: After exclusion of ineligible participants, 247 OB/GYNs completed the survey (42% response rate). In nonemergency CD of morbidly obese women, 84% of physicians preferred a Pfannenstiel skin incision (67% preferring taping the pannus; 17% without taping the pannus). In emergency CD, 66% preferred a Pfannenstiel incision (46% without taping the pannus; 20% with taping the pannus) and 20% a vertical incision. For both emergency and nonemergency CD, there was no difference in incision type preferences by provider years in practice, practice scope, or number of CD performed each year. 

CONCLUSION: Given the preference of a Pfannenstiel incision with taping the pannus during CD of morbidly obese women, further investigation is needed to assess the risks and benefits of this incision and the practice of elevating the pannus.

Stark, L., Power, M., Turrentine, M., Samelson, R., Siddiqui, M., Paglia, M., Strassberg, E., Kelly, E.,   Murtough, K., Schulkin, J. (2016) Influenza Vaccination among Pregnant Women: Patient Beliefs and Medical Provider Practices. Infectious Diseases in Obstetrics and Gynecology. 2016:3281975.

OBJECTIVE:  The purpose of this study was to understand the attitudes and practices of patients and medical providers regarding the influenza vaccination, as well as identifying potential barriers that exist in vaccine acceptance among pregnant women.

STUDY DESIGN:  We recruited four medical centers to participate in a study on the attitudes and practices of medical providers and pregnant patients regarding influenza vaccination. Medical providers and patients were given voluntary surveys and medical record data was collected over two flu seasons, from 2013 to 2015.

RESULTS:  Discrepancies between self-reports of medical providers and patients and medical records were observed. Nearly 80% of patients self-reported accepting the influenza vaccine, but medical record data only reported 36% of patients accepting the vaccine. Similarly, all medical providers reported giving recommendations for the vaccine, but only 85% of patients reported receiving a recommendation. Age, education, a medical provider’s recommendation, and educational materials were found to positively influence patient beliefs about the influenza vaccine. Accepting the vaccine was influenced by a patient’s previous actions, beliefs, and a medical provider’s recommendation. Patients who reported previously not accepting the vaccine and had negative feelings towards the vaccine but accepted it while pregnant reported concern for the health and safety of their baby.

CONCLUSION:  Future research should focus on groups that may be less likely to accept the vaccine and ways to dispel negative myths. Medical provider should continue to strongly recommend the vaccine and provide educational materials.

Taouk, L., Schulkin, J. (2016). Transgenerational transmission of pregestational and prenatal experience: maternal adversity, enrichment, and underlying epigenetic and environmental mechanisms. Journal of Developmental Origins of Health and Disease. 7(6):588-601.

Transgenerational transmission refers to positive and negative adaptations in brain function and behavior that affect following generations. In this paper, empirical findings regarding the transgenerational transmission of maternal adversity during three critical periods – childhood, pregestational adulthood and pregnancy – will be reviewed in terms of pregnancy outcomes, maternal care, offspring behavior and development, and physiological functioning. Research on the transgenerational transmission of enrichment and the implications for interventions to ameliorate the consequences of adversity will also be presented. In the final section, underlying epigenetic and environmental mechanisms that have been proposed to explain how experience is transferred across generations through transgenerational transmission will be reviewed. Directions for future research are suggested throughout.

Urban, R., Swensen, R., Schulkin, J., Schiff, M. (2016). Implementing the flipped classroom on a gynecologic oncology service. Journal of Reproductive Medicine. 61(5):405-410.

OBJECTIVE: To determine the impact of a new curriculum based on the “flipped classroom” model on the gynecologic oncology (gyn onc) section of the annual in-service examination for residents in obstetrics and gynecology.

STUDY DESIGN: We introduced a curriculum focused on a weekly topic for teaching the residents on the gyn onc service in January of 2009. We compared the overall mean gyn onc–specific percent-correct scores on the in-service examination before (1999–2009) and after (2010–2011) the implementation of the curriculum using linear regression to estimate the mean percentage point change and 95% confidence interval, adjusting for clustering by residents.

RESULTS: Our analysis included 90 residents (73 females and 17 males), which yielded 295 scores for analysis. We found a significant increase of 6.5 percentage points (95% CI 3.5–9.6) in the gyn onc mean percent correct for all postgraduate year levels combined after initiation of our curriculum. During that same period the overall in-service examination percent-correct scores did not significantly change.

CONCLUSION: Our curriculum, focusing on a weekly topic, resulted in improvement in in-service examination scores. This type of curriculum could be applied to other areas of resident education within obstetrics and gynecology.


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