3/3/2017 Society of OBGYN Hospitalists - Administration https://soh.memberclicks.net/administrator/index.php?option=com_content§ionid=-1&task=edit&cid[]=103&fpRedirect=0 1/10 SOGH February 2017 Newsletter SOGH is dedicated to enhancing the safety and quality of OB/GYN Hospital Medicine by promoting excellence through education, coordination of hospital teams, and collaboration with healthcare delivery systems. This Newsletter Sponsored by Cervidil Comments or Questions about the Newsletter? Contact us! PRESIDENT'S MESSAGE The start of 2017 brings momentous change to SOGH. Our organization has transitioned from outsourced administrative services; provided by the Society of Hospital Medicine (thank you again SHM), to our own independent executive director, Toni Capra. The process of transition to a completely self sufficient society is following the critical path of tasks to be accomplished. Concurrently, the usual functions of the SOGH Board continue generally on pace. We are excited about our growth and an expansion in our ability to serve. We recognize that much work remains in our field. We hope to have you, our members, play an active role in our evolutionary transformation. SOGH still affords the opportunity for volunteers to help us toward meaningful progress in many aspects of women’s inpatient care. My email address is under the signature below; please feel free to use it. Moving forward with the thought of membership participation, I’d like to invite you to join SOGH at the special interest group session at ACOG’s Annual Clinical and Scientific Meeting on Saturday, May 6th from 1:004:00 p.m. in the San Diego Convention Center. We will offer networking and connection opportunities for all with an interest in our field. I’d like to end this message with some clinically useful information offered to us courtesy of The American Association of Neurosurgeons: “13 common EMTALA Violations” Even though this is a short list, it is a starting point in understanding the EMTALA statute. Knowledge of the law, its interpretive guidelines and case precedent decision is necessary for compliance. Best regards, Meredith Meredith V. Morgan, M.D.
Transcript
3/3/2017 Society of OBGYN Hospitalists - Administration
SOGH is dedicated to enhancing the safety and quality of OB/GYN Hospital Medicine by promoting excellence through education, coordination of hospital teams, and collaboration with healthcare
delivery systems.
This Newsletter Sponsored by Cervidil
Comments or Questions about the Newsletter? Contact us!
PRESIDENT'S MESSAGE
The start of 2017 brings momentous change to SOGH. Our organization has transitioned from outsourced administrative services; provided by the Society of Hospital Medicine (thank you again SHM), to our own independent executive director, Toni Capra. The process of transition to a completely selfsufficient society is following the critical path of tasks to be accomplished. Concurrently, the usual functions of the SOGH Board continue generally on pace.
We are excited about our growth and an expansion in our ability to serve. We recognize that much work remains in our field. We hope to have you, our members, play an active role in our evolutionary transformation. SOGH still affords the opportunity for volunteers to help us toward meaningful progress in many aspects of women’s inpatient care. My email address is under the signature below; please feel free to use it.
Moving forward with the thought of membership participation, I’d like to invite you to join SOGH at the special interest group session at ACOG’s Annual Clinical and Scientific Meeting on Saturday, May 6th from 1:004:00 p.m. in the San Diego Convention Center. We will offer networking and connection opportunities for all with an interest in our field.
I’d like to end this message with some clinically useful information offered to us courtesy of The American Association of Neurosurgeons: “13 common EMTALA Violations”
Even though this is a short list, it is a starting point in understanding the EMTALA statute. Knowledge of the law, its interpretive guidelines and case precedent decision is necessary for compliance.
Best regards,
MeredithMeredith V. Morgan, M.D.
3/3/2017 Society of OBGYN Hospitalists - Administration
We strive to keep our members abreast of news in the media that impacts or references our field. Here is some news worthy of sharing. Please note: The publication of third party articles should in no way be construed as an endorsement of their content by SOGH.
The Doctor as Patient: 'I Was Not Trying to Die'Physician turns neardeath experience into hospital empathy program
It is often described as a physician’s worst nightmare a pregnant patient in shock. Learn how this physician, who became such a patient, now shares this experience with others and fuels her passion to transform healthcare delivery.
Physician burnout: Detailing the impact, exploring solutions
Physician burnout and fatigue are on the radar of many ob/gyn hospitalists. Here is a compilation of strategies, courtesy of AMA Wire, you can use to promote your own wellness and avoid this common professional pitfall.
U.S. states mull contraception coverage as Obamacare repeal looms
The election and change in administration have thrust a spotlight on women’s health and reproductive rights. State legislators are taking action to increase access for contraception.
Marijuana Use in Pregnancy
These two articles describe the trends and examine the impact of marijuana use in pregnancy:
The Risks of Marijuana Use During PregnancyTrends in Marijuana Use Among Pregnant and Nonpregnant ReproductiveAged Women, 20022014
Ob/Gyn Hospitalist Physician in the National Spotlight
Congratulations to one of our own. Dr. Jane Van Dis, an OB/GYN hospitalist, SOGH's 2017 Annual Clinical Meeting CoChair, is being recognized for her commitment to the OB/GYN hospitalist field and her tireless efforts in improving the delivery of hospital based women’s healthcare. Thank you, Dr. van Dis for your dedication.
3/3/2017 Society of OBGYN Hospitalists - Administration
September 24 27, 2017The Roosevelt Hotel, New Orleans
The Society of Ob/Gyn Hospitalists is pleased to announce exciting learning and training opportunities at this year’s annual clinical meeting. The conference is designed to provide general obstetricians and gynecologists, OB/GYN hospitalists, certified nurse midwives, and OB/GYN residents with stateoftheart experiences and information on a wide variety of topics. Planned sessions include hands on courses covering various OB/GYN emergencies and training through simulation (SIM courses). Didactics covering many topics including team building and leadership skills will also be offered. Our goal is to increase your knowledge base, improve your competence, and provide familiarity with emergency simulations in OB/GYN hospitalist medicine. Emphasis will be placed on evidence based practice from some of our specialty’s leading physicians and faculty. Planned topics for this year include:
OB/GYN Hospitalists Core CompetenciesCommon Triage PresentationsMedicoLegal QuandariesSelfCare for the Health ProfessionalEvidenced Based Vaginal DeliveryCollaboration with Midwives
This year’s format will include didactic sessions, interactive audience sessions, highfidelity simulation training at a dedicated simulation training facility, case studies, breakout sessions, informational mealtime conferences and conversations. There will also be valuable opportunities to network with key leading industry representatives, colleagues, and potential employers. Our outstanding faculty are each chosen for their expertise in the topic of their presentation or skills training. We are certain that you will come away from this conference with tools, tips, training and new friendships from around the country. All in the setting of America's best city for hospitality. Registration information will be posted soon. Please check the Annual Conference page on the SOGH website for updates! Laissez les bons temps rouler! 2017 SOGH ACM CoChairs
Jane Van Dis, MD, FACOGTrina Pagano, MD, FACOG
3/3/2017 Society of OBGYN Hospitalists - Administration
Having such varied programs and structures, we recognize that the challenges faced by OB/GYN hospitalists are diverse. The 2016 ACM committee tackled this issue by creating lunchtime network opportunities for ACM attendees to discuss these topics and share their experience and solutions in small group settings. Here we present summaries of these discussions. More will follow in future SOGH newsletters.
How do OB/GYN hospitalists lead and direct programs?There is a need for a program administrator within each department. These duties are valuable and as such the administrative personnel should be compensated. Medical directors, because of their administrative duties usually take on fewer clinical shifts.
Interdepartmental political hurdles may be a challenge in directing a program.
As the role of the OB/GYN hospitalists evolve within a department, the duties can shift. Some programs have removed the responsibility of gyn coverage from the duties of the OB/GYN hospitalist due to the increasing demand of their labor units. There has also been a noticeable shift in the role of the OB/GYN hospitalist from department overseer and safety net provider to primary coverage of the Ob triage and ED. This shift has led to higher turnover of staff in some programs.
Some hospitalists are paid bonuses based on patient surveys. However, there is a push towards evaluating the value of a program based on quality metrics*. The credentialing process is something that our field needs to address.
Establishment of a backup system for the OB/GYN hospitalist is a vital part of the system.
How do OB/GYN hospitalists function as MFM Extenders?
Most OB/GYN hospitalists who participated in this discussion work at programs with 25003000 deliveries per year. Most commonly, MFMs provide consultation by phone only. This is especially true for the community hospitals. Some MFMs provide inpatient rounds within 1224 hours. One program presented has an MFM clinic in building. Most patients go there, but the MFMs do not come to the floor to see patients. Most MFMs do some sort of face to face or phone sign out rounds at least once every 24 hours. MFM programs that were short staffed provided services in the form of performing and interpretation of ultrasounds. In these cases, there was less interest in providing a face to face contact with the patient. Billing did not seem to be a big concern or motivation for the MFMs. Similarly, liability concerns did not seem to influence MFM involvement or noninvolvement. Participants stated that most had interdisciplinary support from specialties such as surgery, neuro, GI, etc. and in some cases patients were admitted to these services.
*Some suggested quality metrics were previously referenced in SOGH Oct. 2016 newsletter.
“CODE THIS!” (Case of the Month)
Substance Abuse Complicating Pregnancy in the Third Trimester by LoriLynne A. Webb, CPC and Renee Allen, MD, FACOG
3/3/2017 Society of OBGYN Hospitalists - Administration
22 year old G6P3023 at 33W2D gestation with a history of 3 prior cesarean sections was brought into Obstetrical Emergency Department (OBED) by EMS and police officers, under arrest, combative and delirious. Police officers report that the patient has a known history of drug usage. The patient was arrested for disorderly conduct in a public place and she was found to have on her person a large amount of methamphetamine and syringe needles. Despite the patient being combative and incoherent during initial evaluation, the ob/gyn hospitalist could ascertain that the patient also has a history of abusing bath salts. She has had only one prenatal visit with a local ob/gyn during this current pregnancy.
The patient was given Ativan in the OBED to manage her agitation. The ob/gyn hospitalist obtained the sparse prenatal records, which were reviewed thoroughly and provided the patient’s pertinent medical history. The patient’s past medical history was significant for attention deficit hyperactivity disorder (ADHD) bipolar disorder with depression, migraines and oppositional defiant disorder (ODD). The patient’s surgical history was significant for three prior cesarean sections and a cholecystectomy. The patient’s social history was significant for cigarette smoking and drug use with bath salts and methamphetamines. The patient’s medical record documented that she takes the following medications: Depakote, Bupropion and Ibuprofen. The patient has allergies to Amoxicillin, which causes her to have hives, Benadryl (no reaction documented) and latex. A detailed and comprehensive physical examination was performed:
Physical Examination
Vital Signs: T 36.6 HR: 101 RR: 22 BP: 118/73 O2 Sat 97% on RAGeneral: Somnolent, was combative now hard to arouse. Heart: Regular Rhythm and RateLungs: Clear auscultation Abdomen nontender, soft, nondistended, no rebound or guardingBack: No CVA tendernessObstetric Exam: NST: Fetal Heart Tones: baseline 130bpm EFM, variability moderate, positive accelerations, negative decelerations. Fetal Heart Rate Interpretation: Category 1. Tocometry: No Uterine contractionsCervix: closed/Thick/2 Legs: Pedal edema 0 +
Labs:
Urinalysis: negative for bacteria, proteinuria, glycosuria or hematuria,CBC: Hct 39%, Platelets 237CMP: K+ 3.0Serum level for Depakote was within normal limits
The patient was monitored closely over 4 hours and became less agitated and combative. Her vitals remained stable. Hydration with IV fluids containing KCL corrected her hypokalemia while she was in the ER. The patient was discharged to police with instructions to return for follow up prenatal care within 7 days. Since she needed to remain in police custody, the ob/gyn hospitalist was informed that she would be able to receive
3/3/2017 Society of OBGYN Hospitalists - Administration
and pose an immediate significant threat to life or physiologic function.
It is appropriate to append modifier 25 to ED codes 99281–99285 when these services lead to a decision to
perform diagnostic or therapeutic procedures. To append modifier 25 appropriately to an E/M code, the service
provided must meet the definition of a “significant, separately identifiable E/M service” as defined by CPT. According to CPT4, modifier 25 indicates that the service must meet the definition of a “significant, separately
identifiable E/M service” on the same day of a procedure or other service, when these services lead to a
decision to perform diagnostic or therapeutic procedures. In other words, modifier –25 does not apply when no
diagnostic medical/surgical and/or therapeutic medical/surgical procedure(s) is performed. Medicare requires
modifier 25 “always be appended to the emergency department E/M codes when provided”. It is not necessary
that the procedure and the E/M service be provided by the same physician/practitioner for the modifier –25 to
apply in the facility setting. It is appropriate to append modifier –25 to the qualifying E/M service code whether
the E/M and procedure were provided by the same professional. The diagnosis associated with the E/M service
may be the same as the diagnosis used for the medical/surgical procedure(s) used.. It does not matter if the
procedure was diagnostic or therapeutic.
LoriLynne A. Webb, CPC, CCSP, CCP, CHDA, COBGC and ICD10 CM/PCS Ambassador/Trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. LoriLynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via email at or you can also find current coding information on her blog site.
Dr. Renée Allen served coauthor of this column. She is the SOGH Liaison to the ACOG Committee on Health Economics and Coding. She currently works as an OB/GYN Hospitalist with Mednax/Obstetrix at Eastside Medical Center in Snellville, Georgia.
Questions regarding this case? Contact us!
SIM CORNER
Unplanned Vaginal Breech DeliveryPresented by Vanessa Torbenson, MD
Case summary: Patient presents in active labor with spontaneous rupture of membranes and begins to deliver a fetus in frank breech presentation.
Length: 1015 minutes
Target group: Obstetricians, Midwives, Nurses
Possible Team members for the Scenario:
Obstetrician Midwife Anesthesia Primary RN
Secondary RN Patient Family Member
3/3/2017 Society of OBGYN Hospitalists - Administration
1. Communicate effectively with patient /family.2. Communicate effectively with team using crisis resource management skills.
Scenario specific Goals:
1. Identify & declare vaginal breech delivery.2. Obtain staff and tools needed to optimize outcome for breech delivery.3. Prepare patient and staff for imminent breech delivery.4. Implement TeamSTEPPS principles, focusing on leadership, SBAR, situation monitoring and shared mental model.
5. Inform patient of delivery and plan.
Debriefing overview:
1. Review sequence of events.2. Review learning objectives.3. Review communication and team work skills.4. What went well?5. What would you do differently next time?6. Share key assessments and learning points with those present and not present.
Patient Case Summary:
Ms Bethany Bergossi is a 32 yo G4P3003 being evaluated in triage at 34 weeks gestation for preterm contractions. On arrival, vital signs are stable. FHT’s are initially category 1. Patient is very uncomfortable and has SROM while awaiting evaluation. Patient reports she has a strong desire to push and starts to bear down.
Baby begins to deliver and is found to be in frank breech position. FHT’s become category 2 with recurrent variable decelerations. As baby delivers fetal head becomes entrapped.
Set up: Patient in labor bed with legs off the side with half pelvis in between legs. Infant doll placed through the introitus in frank breech presentation. Have actress push infant to delivery of trunk and hold on to fetal head.
Category 2 tracing placed on monitor after category 1 tracing removed. Alternatively, a metronome app (for music) on your mobile device with fetal heart rate changing from 130’s bpm to mild bradycardia of 100’s bpm.
Equipment:
Hemipelvis capable of deliveryBaby mannequinPiper ForcepsDelivery trayFHR tracing or Metronome app to mimic FHR
View Sequence of Events Diagram
Sequence of Events:
1. Responder #1 (RN)—Calls out for help; remains with patient2. Responder #2 (OB)— Recognize breech, announces emergency to RN and asks for a second provider, open OR and Piper forceps
3. Responder #3 (RN)— retrieval of piper forceps; calls for second provider; peds; anesthesia
4. Responder #3 (2nd Ob provider) Asks for SBAR; enters in to help with delivery.5. Responder #4 (Peds)— Prepare for resuscitation of baby.
Responders # 5(Anesthesia)Available to give Nitroglycerin or need for emergent delivery.
Teaching Points:
1. Once a breech vaginal delivery is imminent ask for piper forceps and a second provider.2. Bed should be broken down.3. Maintain communication with patient and family.4. Maneuvers (Pinard, Bracht, MauriceauSmellieVeit)5. Piper forceps use; pelvic application6. Operating room should be opened.7. Possible need for Dührssen incision.
Debrief:
What went well?What could we have done better?Was SBAR used appropriately?Did everyone in the room have a shared mental model?Was the patient kept informed? What would you do differently next time?
3/3/2017 Society of OBGYN Hospitalists - Administration
Many institutions have a policy of routine Csection for breech deliveries. Competence in maneuvers for breech delivery should be maintained as occasionally a precipitous delivery may occur. Once delivery of fetus begins, birth should ideally be completed within 10 minutes. Traction on the fetus should be avoided as this may cause deflexion of the fetal head and increase the difficulty of delivery of the head. Piper forceps may be applied for delivery of the head. This is a pelvic application. If head entrapment occurs, a uterine relaxant such as terbutaline .25 mg subcutaneously or nitroglycerin 50200 mcg IV may be given. Ultimately a Zavanelli maneuver with cesarean delivery may be attempted.
References: Hofmeyr, G. Delivery of the fetus in breech presentation. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on January 12, 2017.)
Resources: Agency for Healthcare Research and Quality, AHRQ (TeamSTEPPS)
Vanessa Torbenson, M.D. is a consultant and instructor in the Division of Obstetrics at Mayo Clinic School of Medicine, Rochester Campus. She also serves as an Associate Program Director of OB/GYN.
3/10/2017 AANS - 13 Common EMTALA Violations
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Bulletin: Issue 10(4),2001
13 Common EMTALA Violations
Contact(s):Stephen A Frew
The EMTALA law renders many common practicesamong physicians and hospitals illegal, even thoughphysicians may think that what they are doing isprudent or simply good business. Physicians may viewtheir actions as harmless, but substantial fines mayresult. Here are 13 common errors by physicians oncall to emergency departments (ED) and the situationspertinent to each.
When asked to come in to see an ED patient:1. Debating with the ED physician over the necessityof coming in. Once the request is made to comein, the duty attaches. In addition, EMTALA placesthe decision power with the physician with "eyeson" the patient.
2. Refusing to come in and suggesting that thepatient be seen by another specialist. The oncallphysician must respond to all ED requests. Aneurosurgeon's refusal to come in based on abona fide belief that another specialist would bebetter suited to the patient's needs still will becited.
3. Refusing to come in and ordering the patienttransferred to another facility because of severityor scope of condition. EMTALA requires the
AANS/JNSPG Publications
3/10/2017 AANS - 13 Common EMTALA Violations
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transferred to another facility because of severityor scope of condition. EMTALA requires therequested physician to respond. Phone evaluationis not sufficient if the ED physician asks thespecialist to come in to see the patient. If thepatient is too serious after specialty evaluation,the duty of making the transfer belongs to thespecialist. If the ED physician asks only for aphone consultation, then merely giving a phoneconsult is not a violation, but should bedocumented by the ED physician as a phoneconsultation.
4. Instructing the ED physician to admit or to runvarious testing and delaying coming in to see thepatient until a later time. EMTALA requires promptresponse within a "reasonable" time. These timesare not extended by necessary or prudent testingor by admission. Delays in seeing admittedpatients often lead to violations for failure topromptly stabilize the patient.
5. Declining the patient based on the patient'sapparent needs exceeding the physician's scopeof practice. EMTALA requires physicians to rendercare within their privileges, not their scope ofusual practice. The physician specialist must comein and justify in writing any transfers and effectthe transfer.
6. Declining the patient because of the payer planstatus or selfpay status. EMTALA requiresservices to be rendered regardless of means orability to pay. Where evaluation or stabilizingcare, including surgery, is not complete, EMTALAprohibits seeking advance approval frominsurance companies or plans. (EMTALA does not,however, require the payer to make payment forthe services.)
7. Declining the patient because he or she waspreviously discharged from the physician'spractice for prior litigation or noncompliance.While the patient has the right to decline the oncall physician, the oncall physician does not havethe right under EMTALA to decline the patient.
8. Declining the patient on the basis that thespecialist physician is "not interested" in a case ofthat type. The oncall specialist is required torespond to all patients presenting.
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When contacted by another hospital seekingtransfer of a neurosurgery patient:9. Declining the patient because the neurosurgeonat the first hospital is not available or turneddown the patient improperly. As noted above,there is a duty to accept. Where it appears thefirst hospital's neurosurgeon may have violatedEMTALA by not being available when required forcall or refused to take the patient, the receivinghospital is required by EMTALA to report theincident to federal authorities within 72 hours.
10. Declining the transfer because the destinationhospital is not the closest, or the designatedcenter, or is not within the hospital's indigent carezone under local law. EMTALA requires thatpatients be accepted from anywhere within theboundaries of the United States, including Guamand Puerto Rico.
When asked to come in to see an ED patient oran inhouse patient on an emergency consult torule out an emergency medical condition orprovide stabilizing care:11. Declining because the patient is aligned with
another neurosurgeon or physician who isunavailable or declined to come in. Oncallobligations are not limited to unaligned patients.The U.S. Supreme Court, the statute itself andthe leading cases under the Supreme Court'sdecisions indicate that the EMTALA requirementsregarding stabilization, oncall, transfer, andacceptance are housewide obligations and notlimited solely to the ED.
When covering more than one hospital on call:12. Asking that a patient be sent to the hospital
where the oncall physician is currently seeingpatients instead of going to the patient's location.EMTALA requires all care to be rendered in thehospital where the patient presents. The onlycircumstances where the request to transferwould be valid would be if the needs of thepatient could not be met in timely fashion wherethe patient presented, the requested transferwould allow more timely intervention for patientsafety and response of the oncall physician wasnot possible (i.e., currently involved in surgery).Thorough documentation would be important.
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Thorough documentation would be important.
When contacted by another hospital that iswithout neurosurgery capability regardingtransfer of a hospitalized patient andneurosurgical evaluation or definitive care maybe necessary to stabilize the patient:13. Declining the requested transfer when a bed could
be made available at the destination hospitalwhere the neurosurgeon is oncall. EMTALArequires any hospital with specialized capabilitiesthat are greater than those of the sendinghospital to accept all such patients in transfer,regardless of their means or ability to pay. Theoncall physician is deemed to be within thecapabilities of the hospital and must accept unlessthere literally is not one more space to put thepatient, or some other circumstance, such as nonfunctional equipment, makes it impossible todeliver the needed service.
Stephen A. Frew, JD, practices law in Rockford, Ill.,www.medlaw.com.
Article ID: 9997
2/28/2017 The Doctor as Patient: 'I Was Not Trying to Die' | Medpage Today
U.S. states mull contraceptioncoverage as Obamacare repeallooms
FILE PHOTO - Supporters of contraception rally before Zubik v. Burwell, an appeal brought by Christian groupsdemanding full exemption from the requirement to provide insurance covering contraception under the AffordableCare Act, is heard by the U.S. Supreme Court in... REUTERS/Joshua Roberts/File Photo
By Jilian Mincer
Growing numbers of U.S. states are seeking to ensure that women have continuedaccess to free birth control in case the insurance benefit is dropped as part of President-elect Donald Trump's vow to repeal and replace the Affordable Care Act.
The 2010 law, popularly called Obamacare, requires most health insurance plans toprovide coverage for birth control without a patient co-payment, which can be as muchas $50 per month for birth control pills or $1,000 for long-acting contraceptives such asintrauterine devices.
California, Maryland, Vermont and Illinois since 2014 have enacted statutes codifyingthe Affordable Care Act's contraception mandate in state law and expanding on thefederal law's requirements. Democratic lawmakers in New York, Minnesota, Coloradoand Massachusetts said they are pursuing similar measures this year, with Obamacareunder mortal threat in Washington.
New York's Democratic attorney general, Eric Schneiderman, on Wednesday introducedsuch a measure in his state's legislature that would expand on the Obamacare
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such a measure in his state's legislature that would expand on the Obamacarecontraception mandate.
"Women across New York are very concerned that Republican efforts to repeal the ACAwill mean the loss of the contraception on which they rely," Schneiderman said.
"I won't hesitate to act to protect New Yorkers' rights - including the right to choose,and the right to birth control - no matter what a Trump administration does,"Schneiderman added, referring to abortion rights.
Trump, who succeeds Democratic President Barack Obama on Jan. 20, and his fellowRepublicans in Congress have made dismantling Obamacare their "first order ofbusiness," as Vice President-elect Mike Pence put it on Jan. 4. [nL1N1EU0RW]
Republicans in Congress have not presented a detailed proposal for repealing andreplacing the law but many Republicans and religious conservatives have opposed theObamacare contraception mandate. [nL1N1EU0RW]
Twenty-eight of the 50 states currently have laws requiring private insurers to providecoverage for birth control. But not all the laws affect all insurance plans, and only a fewmandate cost-free birth control.
OUT-OF-POCKET EXPENSES
The Obamacare contraception mandate has appliedsince 2012 to most new insurance plans includingemployer-provided coverage.
In 2013, for example, the mandate saved U.S. womenmore than $1.4 billion in out-of-pocket expenses forbirth control pills, according to a report by Universityof Pennsylvania researchers. Almost 6.9 millionprivately insured U.S. women used the pill that year.
The legislative move by some states, most of them Democratic governed, is designed toclear up uncertainty for some of the 55 million women who now have access to freecontraceptives and related treatments under the Affordable Care Act.
Conservatives also have chipped away at the Obamacare mandate in court. The U.S.Supreme Court ruled in 2014 that forcing family-owned businesses to pay for employeeinsurance coverage for birth control ran afoul of another federal law safeguardingreligious freedom.
The Supreme Court last May sent another legal challenge by nonprofit Christianemployers back to lower courts to reconsider the matter after tossing out their rulingsfavoring the Obama administration. [nL2N18D0PL]
"I think it is even more important now," said Colorado state Representative SusanLontine, who last year co-sponsored a contraception coverage bill in her state'slegislature that did not get passed but she expects to be resurrected in 2017. "We don'tknow what will happen on the federal level."
California in 2014 became the first state to pass a contraception mandate that wentfurther than the Obamacare language. Maryland, Vermont and Illinois last year passedlaws that also eliminated co-pays for vasectomies and allowed women to fill a birthcontrol prescription for at least six months rather than one to three.
The New York legislation would allow women to fill multiple months of a birth controlprescription, prohibit private insurers from "medical management" reviews that couldlimit or delay contraception coverage, and provide coverage for vasectomies without aco-pay.
Within a matter of months, the Trump administration even without congressionalaction could drop contraception from Obamacare's list of preventive services that
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3/10/2017 U.S. states mull contraception coverage as Obamacare repeal looms | Reuters
Did You Know?To teach him discipline, Donald Trump’s
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later graduated in 1964.
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action could drop contraception from Obamacare's list of preventive services thathealth insurance plans must cover without out-of-pocket costs, said Laurie Sobel,senior policy analyst at the nonprofit Kaiser Family Foundation.
If repealed, some employers might choose to maintain the coverage without a co-paybecause it is a relatively inexpensive benefit popular with employees.
The proportion of privately insured women who paid nothing out of pocket for birthcontrol pills increased from 15 percent in the fall of 2012 to 67 percent in the spring of2014 during the time when the coverage went into wide effect, according to theGuttmacher Institute research organization.
The no-cost contraceptives coverage also spurred women to switch to long-actingmethods such as the IUD, which is offered in the United States by Bayer, Teva, Allerganand Medicines360, studies have found.
More than 77 percent of women and 64 percent of men support the no-costcontraceptives coverage, according to a 2015 Washington Post/Kaiser FamilyFoundation survey.
(Reporting by Jilian Mincer; Editing by Caroline Humer, Edward Tobin and WillDunham)
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RESEARCH LETTER
Trends in Marijuana Use Among Pregnantand Nonpregnant Reproductive-Aged Women,2002-2014Between 2001 and 2013, marijuana use among US adults morethan doubled, many states legalized marijuana use, and atti-tudes toward marijuana became more permissive.1 In aggre-gated 2007-2012 data, 3.9% of pregnant women and 7.6% of
nonpregnant reproductive-aged women reported past-month marijuana use.2 Al-though the evidence is mixed,human and animal studiessuggest that prenatal mari-
juana exposure may be associated with poor offspring out-comes (eg, low birth weight, impaired neurodevelopment).3
The American College of Obstetricians and Gynecologists rec-ommends that pregnant women and women contemplatingpregnancy be screened for and discouraged from using mari-juana and other substances.4 Whether marijuana use haschanged over time among pregnant and nonpregnant repro-ductive-aged women is unknown.
Methods | The Columbia University Medical Center institu-tional review board waived review of this study. Informedoral consent was obtained from each participant. Data fromwomen aged 18 through 44 years from the annual NationalSurvey on Drug Use and Health (NSDUH) from 2002 through2014 were analyzed. The surveys used in-person audio
computer-assisted self-interviews (ACASI) about substanceuse and other behaviors in nationally representative samplesof the noninstitutionalized US population; average responserates since 2002 were 75%.5 Among participants reportinglifetime use of marijuana or hashish, recency of use wasassessed with the question: “How long has it been since youlast used marijuana or hashish?” Responses included “withinthe past 30 days,” “more than 30 days ago but within the past12 months,” and “more than 12 months ago.”5 Among preg-nant and nonpregnant women, log-Poisson regression(SUDAAN [RTI International], version 11.0.1) was used to esti-mate and test trends in the adjusted prevalences of past-month and past-year marijuana use over time, controlling forcomplex survey design, age, race/ethnicity, family income,and education. Differences in trends over time were exam-ined by pregnancy status and age (18-25 years and 26-44years). Results were considered statistically significant at a Pvalue of less than .05 (2-sided).
Results | Of the 200 510 women analyzed, 29.5% were aged 18through 25 years and 70.5% were aged 26 through 44 years;61.0% were white, 13.7% black, 17.2% Hispanic, and 8.1% otherrace/ethnicity; 59.2% had some college education; 55.9% hadannual family incomes less than $50 000; and 5.3% (n = 10 587)were pregnant.
Among all pregnant women, the adjusted prevalence ofpast-month marijuana use increased from 2.37% (95% CI,1.85%-3.04%) in 2002 to 3.85% (95% CI, 2.87%-5.18%) in2014 (prevalence ratio [PR], 1.62 [95% CI, 1.09-2.43]) (Table).The adjusted prevalence of past-month marijuana use was
Table. Trends in Prevalence of Marijuana Use in Pregnant and Nonpregnant Women, 2002-2014a
Nonpregnant 2809 (12.37) [12.05-12.70] 2824 (15.93) [15.48-16.40] 1.29 (1.23-1.35)a Data were from the US National Survey on Drug Use and Health (NSDUH).b Adjusted prevalence estimates are from the linear predicted prevalence model
described in footnote a of the Figure.c Sample sizes in 2002: pregnant women, n = 797; nonpregnant women,
n = 14 487.d Sample sizes in 2014: pregnant women, n = 735: nonpregnant women,
n = 14 583.e Prevalence ratios were the ratio of the adjusted prevalence estimates from
2014 divided by the adjusted prevalence estimates from 2002; ratios and 95%CIs were from log-Poisson regressions. CIs for prevalence ratios that did notinclude 1.00 within the lower and upper levels indicated statistically significantincreasing trends in marijuana use.
f The test for difference in prevalence ratios was the P value of thepregnancy × year interaction in the log-Poisson regression. This test indicatedwhether the ratio of the prevalence ratios for pregnant vs nonpregnantwomen differed significantly from 1.00. Nonsignificant P values (P ! .05)indicated insufficient evidence to conclude that the prevalence ratios differ.
g Past-month marijuana use was defined as responding “within the past 30days” to the question, “How long has it been since you last used marijuana orhashish?” Past-year marijuana use was defined as responses of “within the past30 days” or “more than 30 days ago but within the past 12 months” to theaforementioned question. Preprocessing of missing variables by predictivemean neighborhood imputation and recoding was done prior to public releaseof the NSDUH data sets.5 Because the analyses used the imputed variables ofNSDUH, there were no missing data.
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highest among those aged 18 to 25 years, reaching 7.47%(95% CI, 4.67%-11.93%) in 2014 (Figure), significantly higher(P = .02) than among those aged 26 to 44 years (2.12% [95%CI, 0.74%-6.09%]). However, increases over time did not dif-fer by age (P = .76). Past-year use was higher overall, reaching11.63% (95% CI, 9.78%-13.82%) in 2014, with similar trendsover time.
In nonpregnant women, prevalences of past-month use(2014: 9.27% [95% CI, 8.90%-9.65%]) and past-year use (2014:15.93% [95% CI, 15.48%-16.40%]) were higher overall, withsimilar trends over time. Increases over time in past-monthmarijuana use did not differ by pregnancy status (P = .64).
Discussion | Among pregnant women, the prevalence of past-month marijuana use increased 62% from 2002 through2014. Prevalence was highest among women aged 18 to 25years, indicating that young women are at greater risk forprenatal marijuana use. Study limitations are noted. Self-reported marijuana use may lead to underreporting due tosocial desirability and recall biases. However, use of ACASIhelps reduce such biases,5 and the increases over timeobserved in this study are consistent with increases over timein marijuana-related outcomes shown in other studies thatdid not rely on self-reports, supporting the validity of thefindings.6 Additionally, future studies should address dose,frequency of use, and clinical outcomes.
These results offer an important step toward understand-ing trends in marijuana use among women of reproductive age.Although the prevalence of past-month use among pregnant
women (3.85%) is not high, the increases over time and po-tential adverse consequences of prenatal marijuana exposure3
suggest further monitoring and research are warranted. To en-sure optimal maternal and child health, practitioners shouldscreen and counsel pregnant women and women contemplat-ing pregnancy about prenatal marijuana use.
Qiana L. Brown, PhD, MPH, LCSWAaron L. Sarvet, MPHDvora Shmulewitz, PhDSilvia S. Martins, MD, PhDMelanie M. Wall, PhDDeborah S. Hasin, PhD
Author Affiliations: Columbia University, New York, New York.
Corresponding Author: Deborah S. Hasin, PhD, Department of Psychiatry,Columbia University Medical Center, 1051 Riverside Dr, No. 123, New York, NY10032 ([email protected]).
Published Online: December 19, 2016. doi:10.1001/jama.2016.17383
Author Contributions: Dr Brown had full access to all of the data in the studyand takes responsibility for the integrity of the data and the accuracy of the dataanalysis.Concept and design: All authors.Acquisition, analysis, or interpretation of data: Brown, Shmulewitz, Wall,Sarvet, Hasin.Drafting of the manuscript: Brown, Martins, Hasin.Critical revision of the manuscript for important intellectual content: All authors.Statistical analysis: Brown, Shmulewitz, Wall, Sarvet, Hasin.Administrative, technical, or material support: Brown, Hasin.
Conflict of Interest Disclosures: All authors have completed and submitted theICMJE Form for Disclosure of Potential Conflicts of Interest and none werereported.
Figure. Year-to-Year Prevalencea of Past-Month Marijuana Useb Among Pregnant and Nonpregnant Women, Overall and by Age, 2002-2014c
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Linear predicted–adjusted prevalenceYear-to-year–adjusted prevalence
Year
Nonpregnant womenB
2002 2004 2006 2008 2010 2012 2014
Overall
Age18-25 y
Age26-44 y
a Year-to-year–adjusted and linear predicted–adjusted prevalence estimateswere from log-Poisson regressions. Models controlled for race/ethnicity(non-Hispanic white, non-Hispanic black, Hispanic, and other non-Hispanicminorities), family income ($0-$19 999, $20 000-$49 999,$50 000-$74 999, !$75 000), age (18-25 years, 26-34 years, 35-44 years),education (<high school, high school, some college), year (year was categoricalin the year-to-year model, and continuous in the linear predicted model),pregnancy status, pregnancy × year interaction, covariate × pregnancyinteractions, and complex survey design. Error bars indicate 95% CIs and areonly shown for overall year-to-year–adjusted prevalence estimates.Percentage of variability in dichotomous marijuana use explained by the
model with year as a continuous variable was 6% (McFadden pseudo-R2);the ratio of the pseudo-R2 statistics for the models with year as a continuousvs categorical variable was 0.98, indicating strong evidence for a linear trend.
b Past-month marijuana use was defined as responding “within the past 30days” to the question, “How long has it been since you last used marijuanaor hashish?”
c Data were from the US National Survey on Drug Use and Health. Sample sizeacross all years combined: pregnant women (n = 10 587), nonpregnantwomen (n = 189 923).
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Funding/Support: This work was supported by grants T32DA031099(Drs Brown and Hasin [program director]), R01DA037866 (Dr Martins), andR01DA034244 (Dr Hasin) from the National Institute on Drug Abuse and theNew York State Psychiatric Institute (Hasin, Wall).
Role of the Funder/Sponsor: The funding organizations and sponsoringagencies had no further role in the design and conduct of the study; collection,management, analysis, and interpretation of the data; preparation, review,or approval of the manuscript; and decision to submit the manuscript forpublication. The Substance Abuse and Mental Health Data Archive provided thepublic use data files for the US National Survey on Drug Use and Health, whichwas sponsored by the Office of Applied Studies of the Substance Abuse andMental Health Services Administration.
1. Hasin DS, Saha TD, Kerridge BT, et al. Prevalence of marijuana use disorders inthe United States between 2001-2002 and 2012-2013. JAMA Psychiatry. 2015;72(12):1235-1242.
2. Ko JY, Farr SL, Tong VT, Creanga AA, Callaghan WM. Prevalence and patternsof marijuana use among pregnant and nonpregnant women of reproductiveage. Am J Obstet Gynecol. 2015;213(2):201.e1-201.e10.
4. American College of Obstetricians and Gynecologists Committee onObstetric Practice. Committee opinion no. 637: marijuana use during pregnancyand lactation. Obstet Gynecol. 2015;126(1):234-238.
5. Center for Behavioral Health Statistics and Quality. 2014 National Survey onDrug Use and Health: Methodological Summary and Definitions. Rockville, MD:Substance Abuse and Mental Health Services Administration; 2015.
6. Hasin DS, Grant B. NESARC findings on increased prevalence of marijuanause disorders-consistent with other sources of information. JAMA Psychiatry.2016;73(5):532.
Use of Marijuana for Medical PurposesAmong Adults in the United StatesBy 2014, 23 states and the District of Columbia had legalizedmedical marijuana use, suggesting a need for informationabout national rates of marijuana use for medical purposes.1
Although 17% of past-yearmarijuana users reporteduse for medical purposes instates with medical mari-juana legalization,2 physi-c ians might recommend
medical marijuana use to patients regardless of their residingstates.3 Therefore, we examined differences between medi-cal and nonmedical marijuana users across all US states.
Methods | Data were from adults 18 years and older who par-ticipated in the 2013-2014 National Survey on Drug Use andHealth (NSDUH), providing representative data on marijuanaand other substance use among the US civilian, noninstitu-tionalized population.4 NSDUH data collection was approvedby the institutional review board at RTI International. Verbalinformed consent was received from each study participant.Data were collected by interviewers in personal visits, usingaudio computer-assisted self-administered interviews. The an-nual mean response rate for the 2013-2014 NSDUH was 59.3%.
In addition to sociodemographic and mental and physicalhealth characteristics, NSDUH collected data on substance useand use disorders, age of onset for each specific substance used,perceived risk of harm from marijuana use, perceived legaliza-tion of medical marijuana use in residing state, and perceivedmarijuana availability. To classify medical marijuana use, those
reporting past-year marijuana use were asked if any marijuanause was recommended by health care professionals and, if yes,whether all marijuana use was recommended.
We estimated the 12-month prevalence of medical mari-juana use only, nonmedical marijuana use only, and com-bined medical and nonmedical use (combined use; 2-sidedt test with a significance level of .05). We used multinomial lo-gistic regressions to examine characteristics distinguishing the3 groups. Our analyses used SUDAAN software (RTI Interna-tional), version 11.0.1, to account for the complex sample de-sign and sampling weights of NSDUH data.
Results | Based on 96 100 respondents, 12.9% (95% CI, 12.6%-13.2%) of US adults had past-year marijuana use (nonmedicaluse only, 11.6% [95% CI, 11.3%-11.8%], medical use only, 0.8%[95% CI, 0.7%-0.9%], combined use, 0.5% [95% CI, 0.4%-0.5%]). Among past-year adult marijuana users, 90.2% (95%CI, 89.5%-91.0%) used nonmedically only, 6.2% (95% CI, 5.6%-6.9%) used medically only, and 3.6% (95% CI, 3.1%-4.0%) usedmedically and nonmedically. Of medical marijuana users,78.8% (95% CI, 75.7%-81.9%) resided in states where medicalmarijuana was legal, and 21.2% (95% CI, 18.1%-24.3%) re-sided in other states.
Prevalence patterns among adults were similar acrossmedical use only, nonmedical use only, and combined usergroups with few exceptions (eTable in Supplement): com-pared with the West region, medical use only and combineduse was less common in other regions, and nonmedical useonly was more common in the Northeast. Medical use only wasmore common among those reporting fair or poor health thanbetter health and among those with stroke; the opposite wasfound for nonmedical use only. Compared with full-time em-ployed adults, nonmedical use only was less common andmedical use only was more common among disabled adults.
Compared with nonmedical use only, medical use only wasdirectly associated with older age, older marijuana initiationage, disability, Medicaid status, stroke diagnosis, poor self-rated health, anxiety disorder, daily or near daily marijuanause, residing in a medical marijuana legalization state, and per-ceived state legalization of medical marijuana, but was in-versely associated with heavy alcohol use and nonmedical useof prescription stimulants and analgesics (Table).
Discussion | Using nationally representative data, 9.8% of adultmarijuana users in the United States reported use for medicalpurposes. Although the prevalence of medical use was higherin states that had legalized medical marijuana, 21.2% of medi-cal marijuana users resided in states that had not, suggestingphysicians might recommend medical marijuana use regard-less of legalization.3
Similarities in correlates of medical and nonmedical us-ers, especially co-occurrence with psychiatric conditions andother substance use, suggest that some marijuana users mayaccess medical marijuana without medical need.5 However,medical-only marijuana users differed from nonmedical-only users in ways that are consistent with use to address medi-cal problems.6 Limitations of this study include lower re-sponse rates compared with prior years, which increases the
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potential for nonresponse bias, and limited questions aboutmedical marijuana use.
Wilson M. Compton, MD, MPEBeth Han, MD, PhD, MPHArthur Hughes, MSChristopher M. Jones, PharmD, MPHCarlos Blanco, MD, PhD
Author Affiliations: National Institute on Drug Abuse, Bethesda, Maryland(Compton, Blanco); Substance Abuse and Mental Health ServicesAdministration, Rockville, Maryland (Han, Hughes); Office of the AssistantSecretary for Planning and Evaluation, US Department of Health and HumanServices, Washington, DC (Jones).
Corresponding Author: Wilson M. Compton, MD, MPE, National Institute onDrug Abuse, 6001 Executive Blvd, MSC 9589, Bethesda, MD 20892-9589([email protected]).
Published Online: December 19, 2016. doi:10.1001/jama.2016.18900
Author Contributions: Dr Han had full access to all of the data in the study and takesresponsibility for the integrity of the data and the accuracy of the data analysis.
Table. Comparison of Characteristics of Adults With 12-Month MedicalMarijuana Use Only vs Those With Nonmedical Marijuana Use Onlyand vs Those With Medical and Nonmedical Marijuana Usea
Characteristics
Medical Use Onlyvs NonmedicalUse Only, AOR(95% CI)b
Medical Use Onlyvs Medical andNonmedical Use, AOR(95% CI)b
Age, y
18-29 0.6 (0.41-0.92)c 0.6 (0.36-1.15)
30-49 1.2 (0.80-1.70) 0.9 (0.50-1.55)
≥50 1 [Reference] 1 [Reference]
Employment status
Full-time 1 [Reference] 1 [Reference]
Part-time 1.2 (0.81-1.64) 1.3 (0.81-2.09)
Disabled for work 3.1 (1.96-4.81)c 2.5 (1.31-4.88)c
Unemployed 0.9 (0.61-1.35) 1.1 (0.65-1.94)
Health insurance
Private only 1 [Reference] 1 [Reference]
No insurancecoverage
1.4 (1.02-1.99)c 1.0 (0.66-1.60)
Medicaid 1.5 (1.05-2.19)c 1.1 (0.66-1.80)
Other 1.5 (0.98-2.41) 1.0 (0.56-1.79)
Metropolitanstatistical area
Large 1.5 (1.04-2.16)c 1.6 (1.00-2.61)
Small 1.4 (0.98-2.13) 1.5 (0.94-2.51)
Nonmetropolitan 1 [Reference] 1 [Reference]
Region
Northeast 0.2 (0.14-0.29)c 0.4 (0.25-0.73)c
Midwest 0.4 (0.27-0.52)c 0.7 (0.46-1.15)
South 0.3 (0.14-0.42)c 0.4 (0.20-0.76)c
West 1 [Reference] 1 [Reference]
Self-rated health
Excellent 0.5 (0.32-0.74)c 1.3 (0.72-2.46)
Very good 0.3 (0.23-0.50)c 0.9 (0.53-1.50)
Good 0.6 (0.44-0.90)c 1.0 (0.63-1.68)
Fair or poor 1 [Reference] 1 [Reference]
Stroke 2.8 (1.16-6.94)c 0.6 (0.19-2.00)
Diagnosed anxietydisorder
2.1 (1.50-3.01)c 1.1 (0.66-1.71)
Heavy alcohol use 0.6 (0.40-0.78)c 0.7 (0.44-1.03)
Nonmedical useof prescriptionpain relievers
0.7 (0.46-0.98)c 0.8 (0.47-1.36)
Nonmedical useof prescriptionstimulants
0.5 (0.23-0.85)c 0.8 (0.36-1.54)
Daily/near dailymarijuana use
3.5 (2.75-4.52)c 1.8 (1.27-2.47)
Age of firstmarijuana use
<18 1.1 (0.81-1.46) 1.0 (0.64-1.43)
18-29 1 [Reference] 1 [Reference]
≥30 2.5 (1.15-5.55)c 3.0 (0.96-9.38)
(continued)
Table. Comparison of Characteristics of Adults With 12-Month MedicalMarijuana Use Only vs Those With Nonmedical Marijuana Use Onlyand vs Those With Medical and Nonmedical Marijuana Usea (continued)
Characteristics
Medical Use Onlyvs NonmedicalUse Only, AOR(95% CI)b
Medical Use Onlyvs Medical andNonmedical Use, AOR(95% CI)b
Residing in a statethat legalizedmedical marijuana
1.8 (1.21-2.80)c 1.1 (0.63-2.03)
Perceived statelegalization ofmedical marijuana use
Yes 3.0 (2.08-4.36)c 2.1 (1.27-3.43)c
Not sure/unknown 1.0 (0.42-2.60) 1.7 (0.54-5.45)
No 1 [Reference] 1 [Reference]
Perceived riskof smoking marijuana1-2 times/wk
Slight 0.6 (0.45-0.76)c 0.9 (0.61-1.27)
Moderate 0.4 (0.21-0.58)c 0.8 (0.39-1.53)
Great 0.7 (0.26-1.95) 1.4 (0.32-5.88)
No 1 [Reference] 1 [Reference]
Abbreviation: AOR, adjusted odds ratio.a Data were obtained from the 2013-2014 National Survey on Drug Use and
Health (NSDUH). This analysis used SUDAAN software to account for thecomplex sample design and sampling weights of NSDUH data. The SubstanceAbuse and Mental Health Services Administration requires that anydescription of overall sample sizes based on the restricted-use data files has tobe rounded to the nearest 100 to minimize potential disclosure risk. Inaddition to the variables shown, the multivariable model also controlled forsurvey year, sex, race/ethnicity, education, number of past-year emergencydepartment visit, heart disease, hypertension, diabetes, asthma, hepatitis,HIV/AIDS, past-year major depressive episode, suicidal ideation, tobacco use,cocaine use, hallucinogen use, heroin use, inhalant use, nonmedical use ofprescription sedatives, marijuana use disorders, nonmarijuana illicit drug usedisorders, and perceived marijuana availability, which did not significantlydistinguish the 3 examined groups. Multicollinearity (using variance inflationfactors) and potential interaction effects between examined factors wereassessed and were not identified in the final multivariable model.
b The sample size for medical use only vs nonmedical use only was 18 200.The sample size for medical use only vs medical and nonmedical use was 1300.
c Value was a significant difference (P < .05) from the corresponding reference group.
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Concept and design: Compton, Han, Hughes, Jones.Acquisition, analysis, or interpretation of data: All authors.Drafting of the manuscript: Compton, Han.Critical revision of the manuscript for important intellectual content: All authors.Statistical analysis: Han, Hughes, Jones.Administrative, technical, or material support: Han.Supervision: Han.
Conflict of Interest Disclosures: All authors have completed and submitted theICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Comptonreports ownership of stock in General Electric, 3M, and Pfizer. No otherdisclosures were reported.
Funding/Support: The National Survey on Drug Use and Health was supportedby contracts from the Substance Abuse and Mental Health ServicesAdministration. This study was jointly sponsored by the National Institute on DrugAbuse of the National Institutes of Health, the Substance Abuse and MentalHealth Services Administration, and the Office of the Assistant Secretary forPlanning and Evaluation of the US Department of Health and Human Services.
Role of the Funder/Sponsors: The sponsors supported the authors who wereresponsible for preparation, review, and approval of the manuscript and thedecision to submit the manuscript for publication. The sponsors had no role inthe design and conduct of the study; analysis and interpretation of the data;preparation and review of the manuscript; or decision to submit the manuscriptfor publication. The sponsors reviewed and approved the manuscript.
Disclaimer: The findings and conclusions of this study are those of the authorsand do not necessarily reflect the views of the National Institute on Drug Abuseof the National Institutes of Health, the Substance Abuse and Mental HealthServices Administration, or the US Department of Health and Human Services.
1. ProCon.org. 28 Legal Medical Marijuana States and DC. http://medicalmarijuana.procon.org/view.resource.php?resourceID=000881. Accessed July 12, 2016.
2. Lin LA, Ilgen MA, Jannausch M, Bohnert KM. Comparing adults who usecannabis medically with those who use recreationally. Addict Behav. 2016;61:99-103.
4. Center for Behavioral Health Statistics and Quality. 2014 National Surveyon Drug Use and Health. http://www.samhsa.gov/data/sites/default/files/NSDUHmrbStatInference2014.pdf. Accessed September 18, 2016.
5. Roy-Byrne P, Maynard C, Bumgardner K, et al. Are medical marijuana usersdifferent from recreational users? Am J Addict. 2015;24(7):599-606.
6. Schauer GL, King BA, Bunnell RE, Promoff G, McAfee TA. Toking, vaping,and eating for health or fun. Am J Prev Med. 2016;50(1):1-8.
COMMENT & RESPONSE
Alternatives in the Evaluation of SuspectedCoronary Heart DiseaseTo the Editor The study by Dr Greenwood and colleagues1 sup-ports cardiovascular magnetic resonance (CMR) as an alter-native for the investigation of suspected stable coronary heartdisease (CHD), concluding that CMR led to a lower probabil-ity of unnecessary invasive angiography compared with theNational Institute for Health and Care Excellence (NICE) guide-lines, with no effect on major adverse cardiovascular events(MACE).
However, the lower rate of unnecessary invasive angiog-raphy was driven by the inadequate pretest probability scoreused in the NICE guidelines. Both the Duke and Diamond-Forester scores used in the NICE guidelines are known to over-estimate the prevalence of obstructive CHD.2 The effect ofnewer, better-calibrated scores such as the Coronary Artery Dis-ease Consortium scores3 may lead to an increase in the pro-portion of individuals with a low pretest probability that wouldnot require further testing. Moreover, the proportion of indi-viduals with a greater than 70% pretest probability would be
reduced, leading to a reduction in the rate of invasive angiog-raphy. Therefore, an estimate of the pretest probability of pa-tients in the trial according to the Coronary Artery Disease Con-sortium scores and the reduction in angiography would be ofparticular interest.
Regarding the conclusion of no significant difference in therates of MACE across groups, the authors did not specify thepower required to detect differences in the secondary out-comes. The adjusted hazard ratio for MACE was 1.37 (95% CI,0.52-3.57; P = .52) in the CMR group vs the NICE guidelinegroup, which, although not statistically significant, would beof clinical significance if corroborated by adequately pow-ered studies. This 30% relative difference in event rates be-tween groups is comparable with the difference between pla-cebo and statins in primary prevention trials, for example.4 Bypresenting those results as not statistically significant, the au-thors failed to acknowledge that this result may be caused bya type I error, with insufficient power to detect a clinicallymeaningful difference in events.
Marcio Sommer Bittencourt, MD, MPH, PhDJuliano Lara Fernandes, MD, PhD
Author Affiliations: Center for Clinical and Epidemiological Research,University of São Paulo, São Paulo, Brazil (Bittencourt); Jose Michel KalafResearch Institute, Radiologia Clinica de Campinas, Campinas, São Paulo, Brazil(Fernandes).
Corresponding Author: Marcio Sommer Bittencourt, MD, MPH, PhD,Center for Clinical and Epidemiological Research, University of São Paulo,Av Lineu Prestes, 2565—São Paulo, Brazil 05508-000 ([email protected]).
Conflict of Interest Disclosures: Both authors have completed and submittedthe ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Fernandesreported receiving nonfinancial support from Siemens AG and personal feesfrom Novartis AG and sanofi-aventis. No other disclosures were reported.
1. Greenwood JP, Ripley DP, Berry C, et al; CE-MARC 2 Investigators. Effect ofcare guided by cardiovascular magnetic resonance, myocardial perfusionscintigraphy, or NICE guidelines on subsequent unnecessary angiography rates:the CE-MARC 2 randomized clinical trial. JAMA. 2016;316(10):1051-1060.
2. Genders TS, Steyerberg EW, Hunink MG, et al. Prediction model to estimatepresence of coronary artery disease: retrospective pooled analysis of existingcohorts. BMJ. 2012;344:e3485.
3. Bittencourt MS, Hulten E, Polonsky TS, et al. European Society ofCardiology-recommended Coronary Artery Disease Consortium pretestprobability scores more accurately predict obstructive coronary disease andcardiovascular events than the Diamond and Forrester score: the PartnersRegistry. Circulation. 2016;134(3):201-211.
4. Randomised trial of cholesterol lowering in 4444 patients with coronaryheart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet. 1994;344(8934):1383-1389.
To the Editor In the Clinical Evaluation of Magnetic ResonanceImaging in Coronary Heart Disease 2 (CE-MARC 2) trial,Dr Greenwood and colleagues1 addressed the question ofwhether CMR can reduce the number of unnecessary inva-sive coronary angiographies in patients with suspected CHDcompared with a myocardial perfusion scintigraphy (MPS)–guided approach and with the NICE guidelines, which also in-tegrate cardiac computed tomography in the evaluation oflower-risk patients. However, I was concerned that per proto-col, inconclusive and negative noninvasive imaging test results(which should not be followed by invasive angiography) could
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The Risks of Marijuana Use During Pregnancy
Currently, 29 states and Washington, DC, have passedlaws to legalize medical marijuana. Although evidencefor the effectiveness of marijuana or its extracts formost medical indications is limited and in many casescompletely lacking, there are a handful of exceptions.For example, there is increasing evidence for the effi-cacy of marijuana in treating some forms of pain andspasticity, and 2 cannabinoid medications (dronabinoland nabilone) are approved by the US Food and DrugAdministration for alleviating nausea induced by cancerchemotherapy. A systematic review and meta-analysisby Whiting et al1 found evidence, although of low qual-ity, for the effectiveness of cannabinoid drugs in the lat-ter indication. The antinausea effects of tetrahydrocan-nabinol (THC), the main psychoactive ingredient inmarijuana, are mediated by the interactions of THCwith type 1 cannabinoid (CB1) receptors in the dorsalvagal complex. Cannabidiol, another cannabinoid inmarijuana, exerts antiemetic properties through othermechanisms. Nausea is a medically approved indicationfor marijuana in all states where medical use of thisdrug has been legalized.
However, some sources on the internet are tout-ing marijuana as a solution for the nausea that com-monly accompanies pregnancy, including the severe con-dition hyperemesis gravidarum. Although research onthe prevalence of marijuana use by pregnant women is
limited, some data suggest that this population is turn-ing to marijuana for its antiemetic properties, particu-larly during the first trimester of pregnancy, which is theperiod of greatest risk for the deleterious effects of drugexposure to the fetus. Marijuana is the most widely usedillicit drug during pregnancy, and its use is increasing.Using data from the National Survey of Drug Use andHealth, Brown et al2 report in this issue of JAMA that3.85% of pregnant women between the ages of 18 and44 years reported past-month marijuana use in 2014,compared with 2.37% in 2002. In addition, an analysisof pregnancy data from Hawaii reported that womenwith severe nausea during pregnancy, compared withother pregnant women, were significantly more likely touse marijuana (3.7% vs 2.3%, respectively).3
Although the evidence for the effects of marijuanaon human prenatal development is limited at this point,research does suggest that there is cause for concern.A recent review and meta-analysis found that infants of
women who used marijuana during pregnancy weremore likely to be anemic, have lower birth weight, andrequire placement in neonatal intensive care than in-fants of mothers who did not use marijuana.4 Studieshave also shown links between prenatal marijuana ex-posure and impaired higher-order executive functionssuch as impulse control, visual memory, and attentionduring the school years.5
The potential for marijuana to interfere with neu-rodevelopment has substantial theoretical justification.The endocannabinoid system is present from thebeginning of central nervous system development,around day 16 of human gestation, and is increasinglythought to play a significant role in the proper forma-tion of neural circuitry early in brain development,including the genesis and migration of neurons, theoutgrowth of their axons and dendrites, and axonalpathfinding. Substances that interfere with this systemcould affect fetal brain growth and structural and func-tional neurodevelopment. An ongoing prospectivestudy, for example, found an association between pre-natal cannabis exposure and fetal growth restrictionduring pregnancy and increased frontal cortical thick-ness among school-aged children.6
Some synthetic cannabinoids, such as thosefound in “K2/Spice” products, interact with cannabi-noid receptors even more strongly than THC and have
been shown to be teratogenic in ani-mals. A recent study in mice foundbrain abnormalities, eye deformations,and facial disfigurement (cleft palate)in mouse fetuses exposed at day 8 ofgestation to a potent full cannabinoidagonist, CP-55,940.7 The percentageof mouse fetuses with birth defectsincreased in a linear fashion with dose.
(The eighth day of mouse gestation is roughly equiva-lent to the third or fourth week of embryonic develop-ment in humans, which is before many mothers knowthey are pregnant.) It is unknown whether these kindsof effects translate to humans; thus far, use of syn-thetic cannabinoids has not been linked to humanbirth defects, although use of these substances is stillrelatively new.
THC is only a partial agonist at the CB1 receptor,but the marijuana being used both medicinally and rec-reationally today has much higher THC content than inprevious generations (12% in 2014 vs 4% in 1995),when many of the existing studies of the teratogenicityof marijuana were performed. Marijuana is also beingused in new ways that have the potential to expose theuser to much higher THC concentrations—such as thepractice of using concentrated extracts (eg, hash oil).
More research is needed to clarify the neurodevel-opmental effects of prenatal exposure to marijuana,
Pregnant women and those consideringbecoming pregnant should be advisedto avoid using marijuana or othercannabinoids either recreationallyor to treat their nausea.
VIEWPOINT
Nora D. Volkow, MDNational Institute onDrug Abuse, NationalInstitutes of Health,Bethesda, Maryland.
Wilson M. Compton,MD, MPENational Institute onDrug Abuse, NationalInstitutes of Health,Bethesda, Maryland.
Eric M. Wargo, PhDNational Institute onDrug Abuse, NationalInstitutes of Health,Bethesda, Maryland.
Related articlepage 207
CorrespondingAuthor: Eric M. Wargo,PhD, Science PolicyBranch, Office ofScience Policy andCommunications,National Institute onDrug Abuse, 6001Executive Blvd, Room5235, Bethesda, MD20892-9591 ([email protected]).
Opinion
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especially high-potency formulations, and synthetic cannabinoids.One challenge is separating these effects from those of alcohol,tobacco, and other drugs, because many users of marijuana orK2/Spice also use other substances. In women who use drugs dur-ing pregnancy, there are often other confounding variables relatedto nutrition, prenatal care, and failure to disclose substance usebecause of concerns about adverse legal consequences.
Even with the current level of uncertainty about the influenceof marijuana on human neurodevelopment, physicians and otherhealth care providers in a position to recommend medical marijuanamust be mindful of the possible risks and err on the side of cautionby not recommending this drug for patients who are pregnant. Al-though no states specifically list pregnancy-related conditions among
the allowed recommendations for medical marijuana, neither do anystates currently prohibit or include warnings about the possibleharms of marijuana to the fetus when the drug is used duringpregnancy.8 (Only 1 state, Connecticut, currently includes an excep-tion to the medical marijuana exemption in cases in which medicalmarijuana use could harm another individual, although potentialharm to a fetus is not specifically listed.)
In 2015, the American College of Obstetricians and Gynecolo-gists issued a committee opinion discouraging physicians from sug-gesting use of marijuana during preconception, pregnancy, andlactation.9 Pregnant women and those considering becoming preg-nant should be advised to avoid using marijuana or other cannabi-noids either recreationally or to treat their nausea.
ARTICLE INFORMATION
Published Online: December 19, 2016.doi:10.1001/jama.2016.18612
Conflict of Interest Disclosures: All authors havecompleted and submitted the ICMJE Form forDisclosure of Potential Conflicts of Interest.Dr Compton reported long-term stock holdings inGeneral Electric Co, 3M Companies, and Pfizer Inc.No other authors reported disclosures.
REFERENCES
1. Whiting PF, Wolff RF, Deshpande S, et al.Cannabinoids for medical use: a systematic reviewand meta-analysis. JAMA. 2015;313(24):2456-2473.
2. Brown QL, Shmulewitz D, Martins SS, Wall MM,Sarvet AL, Hasin DS. Trends in marijuana use amongpregnant and non-pregnant reproductive-agedwomen, 2002-2014. JAMA. doi:10.1001/jama.2016.17383
3. Roberson EK, Patrick WK, Hurwitz EL. Marijuanause and maternal experiences of severe nauseaduring pregnancy in Hawai’i. Hawaii J Med PublicHealth. 2014;73(9):283-287.
4. Gunn JKL, Rosales CB, Center KE, et al. Prenatalexposure to cannabis and maternal and child healthoutcomes: a systematic review and meta-analysis.BMJ Open. 2016;6(4):e009986.
5. Wu C-S, Jew CP, Lu H-C. Lasting impactsof prenatal cannabis exposure and the role ofendogenous cannabinoids in the developing brain.Future Neurol. 2011;6(4):459-480.
6. El Marroun H, Tiemeier H, Franken IHA, et al.Prenatal cannabis and tobacco exposure in relationto brain morphology: a prospective neuroimagingstudy in young children. Biol Psychiatry. 2016;79(12):971-979.
teratogenicity of the synthetic cannabinoidCP-55,940 in mice. [published online December 18,2015]. Neurotoxicol Teratol. doi:10.1016/j.ntt.2015.12.004
8. Pacula R. Medical marijuana laws for patients.Prescription Drug Abuse Policy System website.http://www.pdaps.org/dataset/overview/medical-marijuana-patient-related-laws/57bee7d8d42e07216bfecce8. AccessedNovember 17, 2016.
9. American College of Obstetricians andGynecologists (ACOG). Committee Opinion 637:marijuana use during pregnancy and lactation.ACOG website. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Marijuana-Use-During-Pregnancy-and-Lactation. July 2015.Accessed November 17, 2016.
Opinion Viewpoint
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3/10/2017 OBHG Physician in the National Spotlight
GREENVILLE, S.C., Jan. 16, 2017 /PRNewswire-iReach/ -- Jane van Dis, MD, FACOG — ObHospitalist Group Medical Director for BusinessDevelopment — recently received multipleprofessional accolades for her medical expertise andleadership, as well as her compassionate approach topatient care. In mid-2016, the American College ofObstetricians and Gynecologists (ACOG) elected heras its District IX, Section III Vice Chair. Later the sameyear, Dr. van Dis also was named OB/GYN Chair atBakersfield Memorial Hospital in Bakersfield, CA.
Dr. van Dis also serves as Co-Chair for the AnnualClinical Meeting of the Society of OB/GYNHospitalists (SOGH) and is responsible for the designand development of a three-day course of didacticsand high-fidelity simulation training for OBhospitalists. In addition, Dr. van Dis has been selectedto represent District IX at ACOG's annualCongressional Leadership Training Conference, whichwill take place in Washington D.C. March 12-14, 2017.
Most recently, Dr. van Dis was selected to participatein the Dignity Health Physician LeadershipDevelopment Program (PLDP), which is designed toengender visionary physician leaders to help navigateevolving delivery models. Only 1% of Dignity HealthSystem physicians are selected to serve in thiscapacity.
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3/10/2017 OBHG Physician in the National Spotlight
"Dr. van Dis is deeply passionate about OB/GYNpractice, and her sincere commitment shows ineverything she does," said Dr. Mark Simon, OBHGVice President for Medical Affairs. "Her patients adoreher, and her colleagues respect her. OBHG is proudthat she is part of its national network of more than500 clinicians serving 100 hospitals in 27 states."
A national, award-winning essay Dr. van Dis wrote forACOG during her residency in 2005 expresses wellher unique perspective: "The story of ourreproductive lives is one that touches the core of whatit means for us to be human, and the obstetrician-gynecologist, in his or her proximity, becomes awitness to that humanity."
Dr. van Dis graduated from the University of SouthDakota Sanford School of Medicine and completedher residency at the University of California at LosAngeles (UCLA). She previously served as anassistant professor at the University of MinnesotaDepartment of OB/GYN, as Director of the MedicalStudent OB/GYN Clerkship, and as an associatephysician with Kaiser Permanente. She also served asAdjunct Assistant Clinical Professor of Obstetrics andGynecology, Keck School of Medicine - DepartmentObstetrics & Gynecology.
About Ob Hospitalist Group
For 10 years, Ob Hospitalist Group has led the nationin elevating the quality and safety of women'shealthcare by providing 24/7 Board Certifiedphysicians who deliver real-time triage and hospital-based obstetric coverage to ensure consistent, timelycare for patients as well as affordable, non-competitive support for local OB/GYN physicians.Headquartered in Greenville, SC, OBHG's nationalnetwork includes over 500 dedicated OB hospitalistsin 100 partner hospitals across 27 states. Learn moreat www.OBHG.com
Media Contact: Guy Kohn, Ob Hospitalist Group,8649083524, [email protected]
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