This month's cover story examines iron-deficiency anemia in pregnancy and the role of intravenous iron.

Vol 66 No 07: July 2021

Contraceptive services, financial incentives may help those with OUD prevent unintended pregnancy

An event from SMFM: 2021 First-Year Fellows Retreat

Articles

Here's what to expect this week on Contemporary OB/GYN®.

This week on Contemporary OB/GYN: July 26 to July 30

“Ten years ago, we published a study that found that 86% of a large sample of pregnant women using opioids reported that their pregnancies were unintended. That rate is nearly double that of the general population,” said principal investigator Sarah Heil, PhD, a professor of psychiatry and psychological science at the University of Vermont Larner College of Medicine in Burlington. “This suggested a substantial unmet contraceptive need among women with OUD, but there was very little in the scientific literature about how to address the gap between women’s reproductive intentions and their contraceptive behavior.”

The current study consisted of 138 women, aged 20 to 44, who were receiving medication for OUD and at high risk for an unintended pregnancy at trial enrollment between May 2015 and September 2018.

The women were randomly assigned to receive 1 of 3 conditions: usual care like information about contraceptive methods and community healthcare facilities (the control group, n = 48); onsite contraceptive services adapted from the World Health Organization (WHO), including 6 months of follow-up visits to assess method satisfaction and delivered in a facility colocated with the Chittenden Clinic, an opioid treatment program in Burlington (n = 48); and the same onsite contraceptive services, plus financial incentives for attending the follow-up visits (n = 42).

“The incentives were gift cards, not cash, that progressively increased in value from a low of $15 to a high of $47.50,” Heil told 

. “Each participant could choose gift cards for retailers that she preferred. But the women were never required to use a method, and incentives were not linked in any way to contraceptive use.”

Follow-up visits occurred once a week for 2 months, followed by every other week for 2 months, then monthly for the last 2 months, “because data shows prescription contraceptive discontinuation is highest right after initiation and then progressively decreases over time,” Heil said.

The percentage of participants with verified prescription contraceptive use at the 6-month end-of-treatment assessment was 10.4% for usual care; 29.2% for contraceptive services without incentives; and 54.8% for contraceptive services with incentives (

Those effects also were sustained at the 12-month final assessment: 6.3%, 25.0%, and 42.9%, respectively (

The percentage of participants with an unintended pregnancy during the 12-month trial was 22.2%, 16.7%, and 4.9%, respectively (

Each dollar invested also yielded an estimated $5.59 in societal cost-benefits for contraceptive services vs. usual care; $6.14 for contraceptive services plus incentives vs. usual care; and $6.96 for combining incentives with contraceptive services vs. contraceptive services alone.

“We were surprised that about 50% of the participants randomized to each study condition said they wanted a long-acting reversible contraceptive (LARC), such as an intrauterine device (IUD) or implant,” Heil said. “Despite this, none of the participants in the usual care condition were using a LARC method at either of the 2 trial assessments. This underscores the need for interventions like the 2 we tested, which resulted in approximately 20% and 40% of participants being given a LARC method.”

Clinicians should be aware that many women with OUD at risk for unintended pregnancy are interested in more effective contraceptive methods, including LARCs, but rarely are able to secure them in the current health care system, according to Heil. “Colocating contraceptive services with an opioid treatment program, with or without the addition of incentives, helps decrease unmet contraceptive need, so we encourage contraceptive service providers to look for opportunities to work with opioid treatment programs in their community,” she said.

Heil reports no relevant financial disclosures.

Heil SH, Melbostad HS, Matusiewicz AK, et al. Efficacy and cost-benefit of onsite contraceptive services with and without incentives among women with opioid use disorder at high risk for unintended pregnancy: a randomized clinical trial. 

Published online July 14, 2021. doi:10.1001/jamapsychiatry.2021.1715

Among women with opioid use disorder (OUD) at high risk for unintended pregnancy, onsite contraceptive services coupled with financial incentives to attend follow-up visits to assess contraceptive satisfaction was a significantly more efficacious and cost-beneficial intervention than without incentives or with usual care, according to a prospective randomized clinical trial in JAMA Psychiatry.

Despite the inadvisability of performing early amniocentesis (EA) before 15 gestational weeks due to a high rate of miscarriage, a retrospective cohort study has found no significant difference in the procedure-related risk of miscarriage between EA, at around 14 weeks gestation, and mid-trimester amniocentesis (MA).

NIPT may not be as effective for twin pregnancies

Clinicians should carefully consider using noninvasive prenatal testing (NIPT) for the screening of chromosomal abnormalities in twin pregnancies because the combined positive predictive value (PPV) is limited and the screening efficiency is not stable, according to a prospective study.

Use of women's preventive health services during COVID-19

All categories of women’s preventive health services that required an in-person visit plummeted during the spring of 2020 due to the COVID-19 pandemic, in comparison to 2019, but then rebounded to near 2019 levels by July 2020.

Risk factors determine need for fetal echocardiogram in IVF pregnancies

In vitro fertilization (IVF) pregnancies only need fetal echocardiogram monitoring if other risk factors are present, according to a recent study.

Neurodevelopment outcomes of extremely preterm births

As more extremely preterm infants survive delivery, a study examines whether the advances that allowed for that survival also improve neurodevelopmental outcomes.

It's been a busy week for the Contemporary OB/GYN® team. 

In case you missed it: July 19 to July 23

 reports that IVF pregnancies do not require routine fetal echocardiogram monitoring unless there are other risk factors

as data shows the incidence of congenital heart defects (CHD) does not differ between IVF and baseline population rates. The study was conducted by Kurt R Bjorkman, MD, and colleagues. Bjorkman is from the department of pediatrics at the Yale School of Medicine in New Haven, Connecticut, and the section of pediatric cardiology at the department of pediatrics at the University of Iowa Hospitals and Clinics in Iowa City, Iowa.

Researchers performed a cohort study where they compared a prospectively maintained database from 2012 to 2018 of all fetal echocardiograms and collected data from both Connecticut’s statewide hospital registry and from the Connecticut Birth Defects Registry.1 The study’s setting was a large tertiary care center. Researchers examined 181,749 live births and 9,252 fetal echocardiograms. They excluded fetal echocardiograms from the final analysis of pregnancies that were complicated by monochorionic twins, cardiac, or other abnormality noted on previous ultrasound; an anomaly in previous pregnancy, diabetes, patients with a previous child with a CHD, a family history of CHD and medication exposure.

Researchers reported 2,230 IVF pregnancies had fetal echocardiography performed. Of these, 2,040 had no known risk factors for CHD. Researchers reported a mean gestational age at the time of the screening of 22.2 ± 1.4 weeks. “The odds ratio for CHD in the IVF group compared with statewide population rates was 1.4 (95% CI 0.9-2.1),” study authors reported.1

In the more than 2,000 fetuses scanned, 26 fetuses had a CHD diagnosis, with 21 being clinically insignificant ventricular septal defects, researchers said.1 One fetal echocardiogram showed pulmonary stenosis, which was not present at birth, and researchers reported only 4 of these were clinically significant defects.

Bjorkman and colleagues said the results of the study showed that rates of CHD among IVF pregnancies that have no other risk factors are not different than the baseline population. In addition, most CHD diagnoses in this group were found to be clinically insignificant. “Routine screening with fetal echocardiography in all IVF pregnancies provides limited utility beyond routine prenatal care,” and “that in otherwise low-risk pregnancies, IVF conception alone may not be a strong enough indication for fetal echocardiogram,” researchers concluded.1

®, Bjorkman said the study’s findings are significant, because “currently, the American Heart Association, the American Institute of Ultrasound in Medicine, and the American Society of Echocardiography recommend consideration of fetal echo in all IVF-conceived pregnancies. The most significant finding of this study was that in following these guidelines, the incidence of CHD present at birth--as detected by fetal echo in pregnancies without other risk factors for CHD--was 0.9%, which has an odds ratio of 0.97 (95% CI 0.6 – 1.5) when compared to the control and is not different than other published rates of CHD in the general population.”

He added that most of the CHD detected in IVF pregnancies was not clinically significant, as “most were ventricular septal defects that either resolved spontaneously prior to birth or shortly after and required no further follow-up. By following current guidelines, the rate of clinically significant congenital heart defects detected by fetal echo in pregnancies without other risk factors was only 0.2%. This equates to 510 fetuses scanned to detect 1 clinically significant congenital heart defect,” he said.

For steps to take beyond the study, Bjorkman said this study gives reason to re-evaluate current recommendations for screening with fetal echo in all pregnancies conceived by IVF. “Given the high number of scans needed to be completed to detect one significant CHD, the recommendation for screening all pregnancies conceived by IVF carries with it a significant financial and time-consuming burden to the medical system, and likely significant additional stress to many pregnant patients for each diagnosis. With this, it may be prudent to be more selective in choosing to only screen IVF pregnancies that have additional risk factors for CHD,” Bjorkman noted.

Bjorkman KR, Bjorkman SH, Ferdman DJ, Sfakianaki AK, Copel JA, Bahtiyar MO. Utility of routine screening fetal echocardiogram in pregnancies conceived by in vitro fertilization. Published online ahead of print, 2021 Jun 28. 

. 2021;S0015-0282(21)00418-0. doi:10.1016/j.fertnstert.2021.04.035

Ms. Hester is Content Specialist with Contemporary OB/GYN and Contemporary Pediatrics.

Medical advancements in perinatal and neonatal care have led to greater survival for extremely preterm infants. A 

 examined whether these advances had also led improvements in the neurodevelopmental outcomes in children who were born <28 weeks’ gestation.1

The investigators used 4 prospective longitudinal cohort studies that included all live extremely preterm births 22 to 27 weeks’ gestation in the state of Victoria, Australia in 1991-1992, 1997, 2005, and 2016-2017. The main outcomes looked at were survival, blindness, cerebral palsy, developmental delay, deafness, and neurodevelopmental disability at 2 years’ corrected age. Delays in development included a developmental quotient that was less than -1 SD relative to the control group averages on the Bayley Scales. A major neurodevelopmental disability involved moderate to severe cerebral palsy, blindness, deafness, or a developmental quotient less than −2 SDs.

Data were available for 1152 children across the 4 studies. The investigators found that survival to 2 years of age was highest in the 2016-2017 cohort (73% [215 of 293]) in comparison with the other cohorts: 1991-1992: 53% (225 of 428); 1997: 70% (151 of 217); 2005: 63% (170 of 270). Additionally, cerebral palsy was not as common in 2016-2017 (6%) than the other 3 time periods (1991-1992: 11%; 1997: 12%; 2005: 10%). No notable changes in the rates of developmental quotient less than -2 SDs (1991-1992: 18%; 1997: 22%; 2005: 7%; 2016-2017: 15%) or rates of major neurodevelopmental disability (1991-1992: 20%; 1997: 26%; 2005: 15%; 2016-2017: 15%) were found across the eras. Across all 4 cohorts, both blindness and deafness were not common. Furthermore, the rate of survival that was also free from major neurodevelopmental disability went up steadily over time 42% (1991-1992), 51% (1997), 53% (2005), and 62% (2016-2017) (odds ratio, 1.30; 95% CI, 1.15-1.48 per decade; 

The investigators concluded that children who are born extremely preterm are increasingly surviving to age 2 years without a major disability. Furthermore, this increased rate of survival was not linked to an increase in neurodevelopmental disability.

1. Cheong J, Olsen J, Lee K, et al. Temporal trends in neurodevelopmental outcomes to 2 years after extremely preterm birth. 

. July 19, 2021. Epub ahead of print. doi:10.1001/jamapediatrics.2021.2052

This article was originally published on Contemporary Pediatrics®. 

Specifically, vitamin C and vitamin E supplements effectively reduced dysmenorrhea severity and improved dyspareunia and severity of pelvic pain.

The triple-blind, placebo-controlled clinical trial enrolled 60 reproductive-aged women between the ages of 15 and 45 with pelvic pain and stages 1 to 3 of laparoscopic-verified endometriosis who were referred to Sarem Hospital in Tehran, Iran, from June to November 2017.

Participants were randomized to 1 of 2 groups. Group A (n = 30) was given a combination of vitamin C (1000 mg/day, 2 tablets of 500 mg each) and vitamin E (800 IU/day, 2 tablets of 400 IU each) for 8 weeks, whereas group B (n = 30) was given placebo pills daily for the same duration.

A visual analogue scale (VAS) estimated the pain intensity score before and every 2 weeks after treatment initiation.

Blood samples were drawn by venipuncture and an enzyme-linked immunosorbent assay (ELISA) measured malondialdehyde (MDA), reactive oxygen spices (ROS) and total antioxidant capacity (TAC).

After 8 weeks, the combination vitamin group showed a significant reduction in MDA and ROS compared to the placebo group.

But there was no significant decline in TAC after treatment.

 < .001) significantly decreased in the treatment group after 8 weeks of vitamin supplementation.

“Vitamin C and vitamin E can have interactive effects to reduce cellular damage induced by ROS,” wrote the authors. “It seems vitamin C and vitamin E can be used to neutralize the oxidative damage in endometriosis. These vitamins can scrub free radicals and oxidative stress.”

Vitamin C is a water-soluble vitamin that acts as a physiological antioxidant and can protect cells against disease caused by oxidative stress such as endometriosis, according to the authors.

Conversely, vitamin E is a lipid-soluble antioxidant that can also delay or prevent oxidative stress-induced diseases.

“These vitamins may be considered as neutralizing agents against free radicals and ROS generated by endometriotic cells,” wrote the authors.

Study results are consistent with previous studies, according to the authors, noting that some studies have concluded that vitamin C reduces endometriotic cyst volume and weight.

Moreover, vitamin C has a significant dose-dependent effect in natural killer cells and endometriotic tissue implantation.

Both vitamins appear to prevent the peroxidative process spread by their chain-breaking property and help tissue to balance oxidant-antioxidant levels.

ROS reduction is key in endometriosis treatment, according to the authors, and that the antioxidant action of vitamins might reduce the clinical symptoms of endometriosis.

It also has been proposed that the decreased inflammation with the combination vitamin treatment protocol can suppress pain-generating molecules.

The finds of the current and other studies support the use of vitamin C as a safe, widely available and inexpensive therapeutic agent for endometriosis, at least for symptomatic relief.

The authors advocate large-scale studies with long follow-up to confirm the role of antioxidant supplementation in improving oxidative stress state, chronic pelvic pain, dysmenorrhea, and dyspareunia in endometriosis.

Amini L, Chekini R, Nateghi MR, et al. The effect of combined vitamin C and vitamin E supplementation on oxidative stress markers in women with endometriosis: a randomized, triple-blind placebo-controlled clinical trial. 

A randomized controlled study in Pain Research & Management validates the potential role of antioxidants in managing endometriosis. 

Combined vitamin supplementation improves some symptoms in endometriosis patients, study shows

This is the major finding of an analysis of data from the prospective cohort study TRacking Adolescents' Individual Lives Survey (TRAILS) in women aged 13 to 25.

Journal of Child Psychology and Psychiatry

 underscores one of the potential side effects of oral contraceptives, which will help women and their health care providers make informed choices among possible methods of birth control.

“Oral contraceptives are used by many women and are generally considered safe; however, several studies have suggested that their use may increase risk for depression, especially when oral contraceptives are used during adolescence,” said Albertine Oldehinkel, PhD, a professor of lifecourse epidemiology of common mental disorders at the University Medical Center Groningen in Groningen, The Netherlands.

Oldehinkel, who serves as principal investigator of the TRAILS study, said the evidence is mixed on oral contraceptives causing depression and that little is known about long-term effects of the birth control method after discontinuing use.

“In TRAILS, we followed women from early adolescence until young adulthood and collected information about both oral contraceptive use and depressive symptoms and disorders, so we had an excellent opportunity to shed more light on this issue,” Oldehinkel told 

The research team analyzed a variety of different models, 818 in total, among 534 adolescent oral contraceptive users and 191 nonusers.

The results indicated that adolescent oral contraceptive users were, across all models, on average 1.41 times (minimum estimation 1.08, maximum 2.18) more likely to have an episode of MMD in early adulthood than adolescents who did not use oral contraceptives (

This association was mainly driven by adolescents with no history of MDD, who were on average 1.72 more likely to have an episode of MMD in early adulthood after oral contraceptive use.

“Associations between oral contraceptive use and depression had been reported before, and our results strengthen the evidence for this association,” Oldehinkel said. “In addition, it was interesting to notice that this connection was strongest for women who had not been depressed before.”

Because the TRAILS study was observational, “it is too early to jump to causal conclusions,” Oldehinkel said. “We therefore do not yet advocate that oral contraceptive use be limited to prevent depression risk, because many women benefit from oral contraceptive use. But it is important for clinicians to be aware that oral contraceptive use among adolescents might produce an increased risk of depression.”

Depression is an extremely heterogeneous disorder with various expressions and risk factors, according to Oldehinkel, and the etiology of depressive disorders is highly multifactorial. “Depressive episodes are almost always caused by a combination of personal vulnerabilities and external triggers, but the exact nature of these factors can vary widely,” she said. “Oral contraceptive use might be one of those triggers.”

To reduce the incidence of MDD in the study population, Oldehinkel recommends teaching children from an early age onward how to cope with stressful experiences effectively to increase their resilience.

“Still, it appears to be very hard to reduce the prevalence of depression, despite a wealth of evidence-based prevention and intervention strategies,” she said. “It is definitely not an easy job.”

Oldehinkel reports no relevant financial disclosures.

Anderl C, de Wit AE, Giltay E, et al. Association between adolescent oral contraceptive use and future major depressive disorder: a prospective cohort study. 

. Published online July 12, 2021. doi:10.1111/jcpp.13476

Adolescent oral contraceptive use is associated with a small yet meaningful increased risk of experiencing an episode of major depressive disorder (MDD) in early adulthood, especially among women with no history of MDD in adolescence. 

Oral contraceptive use during adolescence has small but meaningful link to future depression

Big picture, what sort of mindset is helpful for a practicing ob-gyn to have when wanting to get more involved in coverage by health plans for ob-gyn services?

McDonald is president and founder of Aledo Consulting in Indianapolis, Indiana.

Loken is a founding member of Diana Consulting, a women’s health medical and clinical affairs agency. She is a practicing ob-gyn in Indianapolis, Indiana.

Over the last year and a half, physicians around the world have been focused on managing patients, their teams, and themselves through the COVID pandemic. This has not been an easy time for physicians. Right now, many feel like firefighters returning to the firehouse after putting out a big fire, exhausted. For our ob-gyn colleagues, in particular, there may be an overhang of postponed surgeries and office visits to attend to. For many, it’s simply not an easy time to find the energy and focus. Some practicing physicians we know are energized by spending time regularly advocating for coverage policy changes. It’s energizing to them because advocating for these changes is an important way for them to exhibit beneficence for their patients.

An important first step before getting involved in such an endeavor is to think about how it will align with the way you are wired. Here are some questions to answer for yourself before you get started to make sure this is an activity that is likely to align with what brings you energy:

Do you feel that there are coverage issues that are having a negative impact on the quality of care that you can deliver to your patients?

Would you like to be a part of the process that brings about changes to this situation?

Are you comfortable with a certain amount of conflict?

Do you mind that these efforts, typically, play out over the long-term rather than the short-term?

Enjoying the process and seeing it as grounded in your professional role of exhibiting beneficence towards your patients are both important aspects to feel positive in the long run about your involvement in the activity and being able to stick to it over the long run yourself.

The old saying goes, “A journey begins with a single step.” Changing coverage policies is an iterative process. It very rarely occurs with the first letter, the first phone call, or the first appeal of a claim. The ultimate reward is that when the change comes, you can look at the effort you spent to change the coverage policy and improve the care of your patients, and you can say, “I am a part of that.” For many physicians, such an experience can be quite energizing.

How can a practicing ob-gyn meaningfully influence the coverage of ob-gyn services for their patients?

There are 4 important steps to take to have a meaningful influence on the coverage of ob-gyn services for your patients.First, know the payment rules that are a concern to you. Yes, payment rules are complicated, but if you are going to advocate for their change, you must know what they are currently because it helps you to “talk the talk.” Second, when you think a policy is not appropriate, write a letter explaining why it is not appropriate and how it can be made right. Third, if you have the opportunity, call up the accountable health plan Medical Director and tell them the same thing that you would put in a letter. Fourth, and finally, if claims for services are being denied because of a policy that you disagree with, appeal the denial of payment.

In discussions we’ve had over the years with medical directors about their policies, there is 1 common answer that they enjoy giving, “I’m not hearing any complaints about that.” That answer means that there is no reason to change the current policy. The real purpose of all the letters and calls and appeals is so that medical directors cannot fall back on that comment. It’s important to appreciate that 1 letter, 1 phone call, or 1 appeal ordinarily does not cause a change to a coverage policy. It typically takes dozens to hundreds of interactions at each health plan, depending on the size of the health plan. The most common answer you will receive is a polite and non-committal, “Thank you for your communication, we will take it under consideration in our future deliberations on this topic.”But your efforts have put a stake in the ground and established that the physicians are to some degree in conflict with the existing policy.

Also, if you are writing about a specific coverage policy, know the next review date. That’s commonly printed right on the policy. You can send in another updated letter about 100 days prior to the next review date. Let them know that you remain passionate about this issue.Persistence has an important role in how these policies are changed. So, whether you write 1 letter about a policy that concerns you or dozens of letters, you were part of that change. And when the policy is changed, you have changed the type of care that your patients can receive routinely. And that should be an uplifting chain of events for you.

Sometimes we hear the phrase, “You should appeal every claim even if you do not win.”What do you think about that?

Appealing claims is an important way to let health plans know that you are a clinician who believes that a certain policy should be changed. Hockey legend Wayne Gretzky once said, “You miss 100% of the shots that you don’t take.” If you have a denied claim, and you don’t take any action to appeal the denial, that’s pretty much the end of it and there is essentially a 100% chance that you won’t get paid for the service. When you file an appeal, your communication should be about the appealed claim and about the policy that the denial was based upon. You need to have measured expectations of the result of any appeal.In hockey, not every shot on goal scores, and in the appeals game, not every appeal results in payment for the service.

When you appeal denials, it is important to know that there are multiple levels of appeal.There are: 1) first-level appeals, 2) reconsideration appeals, and 3) at the highest level, outside appeals when appeals are sent to an independent clinician reviewer outside of the health plan. First-level appeals, for the most part, confirm that the denial followed the existing policy appropriately. Doing a lot of first-level appeals is not going to create pressure for changing a policy. Second-level appeals tend to be where the individual patient factors are taken into consideration. Highest-level, outside appeals, are when claims are sent to a panel of outside reviewers, and they may be as open to look at the coverage policy as well as the actual service provided.Also, outside reviewers are often specialty-matched, so the person or people reviewing your issues is likely to be an ob-gyn, just like you. If they agree with your position, it can put pressure on the health plan to change its coverage policy.

If you were to take 5 claims and submit 5 first-level appeals, that amount of effort is likely to have a much smaller impact than if you took one claim and appealed it multiple times until it went to external review. The focus isn’t really on the policy itself until you have an external appeal. If you appeal a claim, be prepared to receive a “No,” and then be prepared to take your appeal to the next level.

What role does our specialty society, the American College of Obstetricians and Gynecologists (ACOG), have in advocating for changes in insurance coverage?

The role of ACOG in advocating for coverage changes cannot be overstated. As a practicing ob-gyn, you should think about whether to focus your policy change advocacy efforts on working on your own, on working as part of the ACOG process at the state level, on working as part of the ACOG process at the national level, or on working simultaneously in more than 1 of these manners.

Here’s a recent example of the importance of ACOG in changing health plan coverage decisions. On September 23, 2020, ACOG expanded its recommendation for noninvasive prenatal testing (NIPT) from just high-risk pregnancies to all pregnancies.1 One month following this announcement, Centene became the first large national health plan to update its NIPT policy to cover average risk pregnancies.2 Centene was simply the first domino to fall, and, essentially, all the other health plans followed rapidly.A major factor in all these policy changes was that ACOG gave a full-throated endorsement of NIPT as the new standard of care in the management of pregnancies. Getting payer coverage of services can require an endorsement of the type that leaves no question that any health plan that chooses not to cover the technology is not supporting the professionally recognized standard of care.

How might steps differ for an ob-gyn who is part of an integrated system versus in private practice?

If you are an ob-gyn practicing within an integrated system, your system is a stakeholder in your advocacy efforts, whether you want them to be or not. Sometimes that can be an advantage.Take, for instance, when the integrated delivery system contains a health plan subsidiary. Think of the example of Geisinger Health System and Geisinger Health Plan. The health plan may be just across the parking lot from where you practice; the decision-making staff at the health plan may be people whom you know due to a shared experience at the health system; and your health system and the health plan may report to a common senior management team. In such a situation, your advocacy efforts might be amplified, and you could be more effective than, say, if you are in independent practice.

In conclusion, advocating for changes in health plan coverage policies is an important way that ob-gyns can exhibit beneficence toward your patients beyond the typical care-giving roles.Changing these coverage policies requires broad collaborative efforts between physicians and their specialty societies.Each discrete action, no matter how modest its scale -- 1 appealed claim, 1 letter to the health plan about the situation, or 1 phone call to a medical director -- contributes to the overall effort and makes you, ultimately, part of the eventual success.

New ACOG guidelines recommend cfDNA-based NIPT for all pregnancies, not just risky ones. American Society for Clinical Pathology. Accessed July 20, 2021. 

https://www.ascp.org/content/news-archive/news-detail/2020/09/24/new-acog-guidelines-recommend-cfdna-based-nipt-for-all-pregnancies-not-just-risky-ones

ACOG win! Major player updates coverage guidelines to align with NIPT recommendation. The American College of Obstetricians and Gynecologists. Accessed July 20, 2021. 

https://www.acog.org/news/news-articles/2020/10/acog-win-major-payer-updates-coverage-guidelines-to-align-with-acog-nipt-recommendation

Over the last year and a half, physicians around the world have been focused on managing patients, their teams, and themselves through the COVID pandemic. This has not been an easy time for physicians. 

Practical guidance for navigating complex world of insurance coverage, payer issues

Ob-gyns are well positioned to assist in opening a dialogue with female patients about their sexual health. In a recent review article by Winkley et al, it was determined that even though sexual dysfunction causes substantial distress and negatively impacts quality of life, there is significant under-reporting of its incidence in woman with diabetes, with a disparity seen between spontaneous reports of sexual dysfunction compared with screen-detected sexual dysfunction in research trials.

Sexual dysfunction is an amalgamation of physical and psychological issues, including inadequate communication between sexual partners, poor body image, job loss, and medical considerations. Updates to the Diagnostic and Statistical Manual of Mental Disorders V (DSM-V) reduced the number of diagnostic categories of sexual dysfunction from 4 to 3, along with introducing a 6-month minimum duration of symptoms for a formal diagnosis since some sexual disorders may be temporary or stress-induced. In order to determine if a sexual disorder is temporary, a deeper exploration of what is happening needs to take place. The challenge is that this assessment can be a sensitive topic for women and clinicians to raise and discuss during clinical consultation.

The American Diabetes Association notes that the lack of conversations surrounding this issue is 2-fold. Only 19% of women with diabetes have spoken with their doctor about sexual problems, and doctors aren’t comfortable delving into their patient’s sexual performance and health.

 According to 1 study, only 40% of ob-gyns routinely ask their patients about sexual problems.

With limited physician/patient dialogue, all members of the diabetes interprofessional team need to increase their awareness that sexual health, albeit an uncomfortable subject, needs to be discussed more frequently with patients.

“Diabetes specialists are not used to asking women about sexual functioning as they normally are focused on pregnancy and contraception,” said Kirsty Winkley, PhD, a diabetes specialist nurse and health psychologist at King's College London & Florence Nightingale Faculty of Nursing & Midwifery and co-author of the recent review article. “They may be worried they could offend a woman, especially if women with diabetes are unaware that some of their problems with sex are related to diabetes.”

The recent review article notes that there are several screening questionnaires that can be leveraged as tools to open the lines of communication when determining if sexual dysfunction is present among women with diabetes. These include the Female Sexual Function Index (FSFI), the Brief Sexual Symptom Checklist for Women (BSSC-W) and the Changes in Sexual Functioning Questionnaire 14 (CSFQ-14). However, use of these tools is not widespread in the clinical setting.

“In the U.K. at least, these are not routinely used,” Winkley said. “They have been used in a research context. However, it might be easier for diabetes specialists to raise the issue if women complete the scales or perhaps are provided with some information on the association between sexual dysfunction and diabetes.”

There are several indicators that demonstrate that women with diabetes are at greater risk for sexual dysfunction. Glucose levels can impact sexual intercourse by altering vaginal lubrication, causing pain during sex and affecting the ability to orgasm. Depression, which is noted with increased prevalence in all patients with diabetes, can be linked to diminished sexual drive. General fatigue or having sex without concerns of hypoglycemia, as well as a negative body image due to the use of medical devices to manage the disease (insulin pumps, injection site scarring), can be additional troubling matters for patients.

Several treatment options have demonstrated the ability to reduce levels of sexual dysfunction in women with diabetes, including pharmacological interventions (phosphodiesterase 5 [PDE 5] inhibitors, hormone replacement or anti-depressant therapy), non-pharmacologic interventions (weight loss, psychological interventions) and sexual health information guides utilized as part of clinical consultations. Once sexual dysfunction is identified in a patient with diabetes, shared decision-making efforts can be put into place to reduce or ease the negative aspects of sexual dysfunction that are impacting these women and their quality of life.

Part of that mindset needs to include the consideration of the patient as a whole entity. The Diabetes Care for You (DCFY) service, which was developed in accordance with National Health Service care guidelines in the United Kingdom, combines diabetes and psychotherapy services. The DCFY service incorporates the use of patient health questionnaires with improvements in diabetes self-management to address overall well-being as part of disease management. Validating the value of this model, the recognition of sexual dysfunction in women with diabetes within this service was particularly commended when DCFY won the 2019 UK Quality in Care (QiC Diabetes) award under the Mind and Body Healthy Together category.1

Continued improvements in the care of women with diabetes enduring sexual dysfunction warrants emphasis. Winkley offered that continuing the educational efforts is an ongoing necessity. “By raising awareness of the issue, I hope that this may lead to more research and better treatment and support for women with diabetes,” Winkley said. “Women's health issues in general need to be given more attention.”

Winkley K, Kristensen C, Fosbury J. Sexual health and function in women with diabetes. 

Lindau ST, Tang H, Gomero A, et al. Sexuality among middle-aged and older adults with diagnosed and undiagnosed diabetes: a national, population-based study. 

. 2010;33(10):2202-10. doi: 10.2337/dc10-0524

Sobecki JN, Curlin FA, Rasinski KA, Lindau ST. What we don't talk about when we don't talk about sex: results of a national survey of U.S. obstetrician/gynecologists. 

. 2012;9(5):1285-94. doi: 10.1111/j.1743-6109.2012.02702.x

The management of diabetes is multifaceted, often requiring the collaboration of a multidisciplinary team of providers. While sexual side effects of diabetes are not commonly discussed during patient visits, there is a correlation between the presence of diabetes and frequent sexual dysfunction in women.

Lower risk of peripheral arterial disease linked to certain dietary eating patterns

“Recent research on how the impacts of the Medicare program differ by race/ethnicity or geography are sorely lacking,” said lead author Jacob Wallace, PhD, an assistant professor of public health at the Yale School of Public Health and Institute for Social and Policy Studies in New Haven, Connecticut. “This is an understudied aspect of the Medicare program — that it equalizes access to health insurance across localities and populations — and it is important to consider during a period in which Congress is actively debating whether to expand Medicare.”

The investigators analyzed a total of 2,434,320 respondents in the Behavioral Risk Factor Surveillance System (BRFSS) and mortality data from the U.S. Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research Data from January 2008 to December 2018.

Immediately after age 65 years, insurance coverage increased from 86.3% to 95.8% for Black Americans, from 77.4% to 91.3% for Hispanic Americans, and from 92.0% to 98.5% for White Americans.

This finding translates into a 53% reduction in the disparity between White Americans and Black Americans and a 51% reduction between White Americans and Hispanic Americans versus before age 65.

Medicare eligibility also was associated with narrowed disparities between White Americans and Hispanic Americans in access to a usual source of care from 10.5% to 7.5% (

 =.05), cost-related barriers to care from 11.4% to 6.9% (

 <.001) and influenza vaccination rates from 8.1% to 3.3% (

However, disparities between White Americans and Black Americans for these 3 metrics before and after age 65 were not significantly different.

But the share of people in poor self-reported health decreased by 3.8 percentage points among Hispanic Americans and 2.6 percentage points among Black Americans, compared to only 0.2 percentage points for White Americans.

Mortality-related disparities at age 65 years were unchanged.

“We were surprised that eligibility for Medicare was associated with reductions in racial and ethnic disparities in a set of economically, politically and geographically diverse states, rather than being concentrated in the regions of the country where uninsured rates are highest, like in the South,” Wallace told 

. “The states with the largest reductions in disparities were located all across the country, including Minnesota and Illinois in the Midwest, New York and New Jersey in the Northeast, and Texas and Oklahoma in the South.”

While the authors did not find a reduction in racial and ethnic disparities in death at age 65, “a growing body of evidence concludes that health insurance reduces mortality,” Wallace said.

The design of the current study, known as regression discontinuity, estimates the short-term impacts of Medicare. “If Medicare reduces long-term mortality by improving care management, our study is not well-suited to capturing those effects,” Wallace said.

Nonetheless, because the study demonstrates that Medicare leads to substantial reductions in disparities, “policies that expand Medicare, such as the proposal in Congress to reduce the Medicare eligibility age to 60, offer a viable path to addressing disparities and advancing health equity,” Wallace said.

More research is desperately needed to identify other policies that reduce racial and ethnic disparities, according to Wallace. “We must go beyond merely documenting racial and ethnic disparities and focus on identifying and crafting policies that eliminate them,” Wallace said.

Wallace reports no relevant financial disclosures.

Wallace J, Jiang K, Goldsmith-Pinkham P, and Song, Z. Changes in racial and ethnic disparities in access to care and health among US adults at age 65 years. 

. Published online July 26, 2021. doi:10.1001/jamainternmed.2021.3922

A cross-sectional study in JAMA Internal Medicine has found that entry to Medicare increases coverage rates, access to care, and self-reported health, and it also closes gaps in access and health between racial and ethnic groups.