Publications by authors named "Meredith J Alston"

14 Publications

  • Page 1 of 1

Evaluation of Early Pregnancy Concerns in an Early Pregnancy Unit Compared With an Emergency Department.

Obstet Gynecol 2020 11;136(5):995-1000

Department of Obstetrics & Gynecology, University of Colorado School of Medicine, Aurora, and Denver Health Medical Center, Denver, Colorado.

Objective: To assess total time for evaluation of women with first-trimester pregnancy concerns in an early pregnancy unit compared with an emergency department (ED) within a single safety net hospital system.

Methods: We performed a retrospective cohort study at Denver Health Medical Center from May 1, 2017, to April 30, 2018. All patients who presented to the early pregnancy unit and a random sample of patients who presented to the ED were identified, stratified by month. Patients were eligible if they were aged 12-55 years, hemodynamically stable, in the first trimester with a positive pregnancy test, and without a prior ultrasonogram. Evaluation time was calculated as difference between registration or check-in and the discharge time. We extracted patient demographics, reproductive histories, presenting symptoms, diagnosis, and management plans at time of discharge from the electronic medical record. Descriptive statistics and multivariate analyses were performed. Lastly, a preliminary analysis of total charges was conducted.

Results: Of 250 patients originally identified, 165 met inclusion criteria (79 from the early pregnancy unit and 86 from the ED). There was no statistical difference in race, ethnicity, or insurance type between groups. Median evaluation time was significantly reduced in the early pregnancy unit compared with the ED (45 minutes [interquartile range 31-61] vs 236 minutes [interquartile range 173-307], respectively, P<.001). After adjusting for patient characteristics and clinical presentation, the average total evaluation time among patients in the early pregnancy unit (36 minutes) was 80% lower compared with patients in the ED (180 minutes). Median evaluation charges were significantly less for patients in the early pregnancy unit compared with those in the ED ($586.22 [interquartile range 384.83-757.34] vs $1,350.97 [interquartile range 975.77-3,553.62], respectively, P<.001).

Conclusion: Time and charges for evaluation of women with first-trimester pregnancy concerns were significantly lower in an early pregnancy unit compared with an ED. Early pregnancy units should be considered as an alternative care model for patients in the first trimester of pregnancy in the United States.
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http://dx.doi.org/10.1097/AOG.0000000000004080DOI Listing
November 2020

Attitudes of Trainees in Obstetrics and Gynecology Regarding the Structure of Residency Training.

Obstet Gynecol 2019 10;134 Suppl 1:22S-28S

Department of Obstetrics and Gynecology, University of Colorado School of Medicine and Denver Health Medical Center, Denver, Colorado; the Department of Obstetrics and Gynecology, University of California, San Francisco School of Medicine, San Francisco, California; Loyola University School of Medicine, Maywood, Illinois; the Department of Obstetrics and Gynecology, Texas A&M School of Medicine, Bryan, Texas; the University of Utah School of Medicine, Salt Lake City, Utah; the Department of Obstetrics and Gynecology, Saint Joseph's Hospital, Denver, Colorado; and the Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, Washington.

Objective: To measure future and current resident perspectives on obstetrics and gynecology residency training structure and possible future models.

Methods: Medical students invited for obstetrics and gynecology residency interviews and residents (postgraduate year [PGY]-1-4) at the University of Colorado, the University of Washington, the University of California San Francisco, Loyola University, Saint Joseph's Hospital, and Texas A&M in 2017-2018 received a voluntary, electronic survey regarding possible models for restructuring residency training. Student and resident responses were compared using χ test for categorical and two-sample t-test for continuous items.

Results: Applicants (63%, 280/444) and residents (66%, 101/153) had similar response rates (overall response rate 64%). Applicants (24%) and residents (29%) reported having concerns about the current structure of residency training. The ideal residency duration was reported as 4 years by 72% of applicants and 85% of residents. Lack of gynecologic surgical volume was the most frequently reported concern among applicants (75%) and residents (72%). Fourth-year tracking (focusing on training aligned with postgraduation career path) was preferred by 90% of applicants and 77% of residents (P=.002) and 92% among respondents planning fellowship. Most applicants (68%) and residents (75%) preferred not starting fellowship training after the 3rd year of residency.

Discussion: The majority of learners surveyed support a 4-year training structure but likewise support individualizing training in PGY-4. It is imperative that obstetrics and gynecology leadership consider this and other feedback from learners when considering modifications to the current training paradigm.
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http://dx.doi.org/10.1097/AOG.0000000000003430DOI Listing
October 2019

Career Expectations of Obstetrics and Gynecology Residents and Future Residents.

Obstet Gynecol 2018 10;132 Suppl 1:1S-7S

Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, and Denver Health Medical Center, Denver, Colorado; the Department of Obstetrics and Gynecology, UCSF School of Medicine, San Francisco, California; Loyola University Stritch School of Medicine, Chicago, Illinois; the Department of Obstetrics and Gynecology, Texas A&M School of Medicine, Bryan Texas; Colorado School of Public Health, University of Colorado, Aurora, and Department of Obstetrics and Gynecology, St. Joseph's Hospital, Denver, Colorado; and the Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, Washington.

Objective: To understand contemporary fourth-year medical student and resident career expectations in obstetrics and gynecology.

Methods: Students invited for obstetrics and gynecology residency interviews and residents (postgraduate years 1-4) at the University of Colorado, University of Washington, University of California San Francisco, Loyola University, St. Joseph's Hospital, and Texas A&M in 2016-2017 received a voluntary, electronic survey regarding career expectations. Questions were compared between students and residents using a χ test for category responses and for age a two-sample t test.

Results: Response rates were similar between students (68% [277/409]) and residents (63% [97/153]). Residents compared with students were more frequently planning to enter private practice (43% vs 19%) and less frequently planning an academic career (19.4% vs 30.4%) or subspecialties (38% vs 51%) (P<.001). Although most respondents planned to work full-time (96% vs 94.9%), 83% (vs 94%) of residents planned to work greater than 40 hours per week (P<.001). Respondents reported greater than $150,000 in educational debt (65%) and anticipated starting salary greater than $200,000 (89%). More residents planned to retire by age 60 years (23% vs 7%) (P<.001). Thirty-eight percent of residents reported having changed career plans during residency, citing work-life balance as the most important factor (89%).

Discussion: Trainees' career expectations appear to evolve over time moving toward a higher likelihood to pursue private practice, work fewer hours, and retire earlier despite large educational debt. It is critical that the specialty understand these trends when planning to address national workforce needs.
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http://dx.doi.org/10.1097/AOG.0000000000002817DOI Listing
October 2018

Frequency of Adequate Endometrial Biopsy in Evaluation of Postmenopausal Women With Benign Endometrial Cells on Pap Test.

J Low Genit Tract Dis 2017 Oct;21(4):258-260

1Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO, 2Department of Obstetrics and Gynecology, Denver Health Medical Center, Denver, CO; and 3Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham AL.

Objective: The aim of the study was to determine the frequency that endometrial biopsies (EMBs) performed on postmenopausal (PMP) women with benign endometrial cells (BECs) on Pap test are adequate for assessing malignancy or hyperplasia.

Methods: This is a case series including all PMP women older than 55 years at a single academic institution between January 2008 and September 2015 with a Pap test result including BEC. Patients were identified via an internal cytology database. Patient data, the ability to obtain an EMB, and the result of the EMB were collected. An adequate EMB was defined as the presence of glands and stroma sufficient to assess for endometrial hyperplasia and/or malignancy. Descriptive statistics were performed, and then univariable and logistic regression analyses were used to evaluate associations of patient factors and adequacy of EMB.

Results: One hundred sixteen women met inclusion criteria. One hundred seven had an EMB scheduled (92%) and of those 91 EMBs were obtained (85%). Of the obtained biopsies, 63 were inadequate to rule out the diagnosis of hyperplasia and/or malignancy (69%). Of these, 19 patients underwent pelvic ultrasound (30%), 12 followed up with repeat Pap test (19%), and 4 underwent dilation and curettage (6%). Of the adequate biopsies, 5 had a diagnosis of hyperplasia (18%) and 5 with malignancy (18%).

Conclusions: In PMP women with BEC on Pap test, adequate EMB was only obtained in 31% of patients. Most patients without an adequate biopsy had no further workup of their abnormal Pap test.
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http://dx.doi.org/10.1097/LGT.0000000000000332DOI Listing
October 2017

Obstetricians and Gynecologists of the Future: A Survey of Medical Students Applying to Residency.

Obstet Gynecol 2017 10;130 Suppl 1:1S-7S

Department of Obstetrics and Gynecology, University of Colorado School of Medicine and Denver Health Medical Center, Denver, Colorado; the Department of Obstetrics and Gynecology, University of California, San Francisco School of Medicine, San Francisco, California; Loyola University School of Medicine, Chicago, Illinois; the Department of Obstetrics and Gynecology, New York University School of Medicine, New York, New York; the Colorado School of Public Health, University of Colorado Denver, Denver, Colorado; and the Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, Washington.

Objective: To understand the characteristics and career goals of medical students selecting a career in obstetrics and gynecology.

Methods: In 2015-2016, medical students invited for interviews for obstetrics and gynecology residency at the University of Colorado, University of Washington, University of California San Francisco, Loyola University, and New York University received a voluntary 20-item electronic survey regarding factors influencing their choice of medical specialty.

Results: Two hundred twenty-six of 356 students responded (63%). Mean age was 27 years, and 88% (n=199) were women. General surgery was the most common alternate specialty (36%, n=81). The most commonly cited drawback to obstetrics and gynecology was "long hours" (66%, n=148). After residency, 157 (70%) applicants planned to complete fellowship training, 127 (56%) pursue international work, 156 (69%) seek an academic position, and 207 (92%) practice in an urban setting. One hundred twenty-four applicants (55%) planned to work 51-60 hours per week and 111 (49%) planned to take 2-3 nights of call per month. Two thirds (n=150) predicted they will have greater than $100,000 educational debt on graduation.

Conclusion: Contemporary residency applicants have high educational debt and disproportionately plan to pursue fellowship, international work, careers in academic medicine, and work in urban centers. Based on the projected career plans among obstetrics and gynecology applicants, the workforce needs of the population may not be met.
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http://dx.doi.org/10.1097/AOG.0000000000002192DOI Listing
October 2017

Factors Influencing Residency Program Selection by Medical Students Pursuing Obstetrics and Gynecology.

J Grad Med Educ 2017 Feb;9(1):123-127

Background : Little is known about the factors that influence medical student selection of obstetrics and gynecology (ob-gyn) residency programs.

Objective : We assessed the factors influencing residency program selection by fourth-year medical students pursuing ob-gyn training.

Methods : A voluntary, anonymous, 19-question survey of residency selection factors was distributed to all fourth-year medical students interviewing at 1 of 5 academic ob-gyn departments for a residency position during the 2013-2014 interview season. Participants were surveyed about the relative importance (not important, somewhat important, important) of various residency selection factors, including operative experience, exposure to subspecialties, curricular experience, access to fellowships, and administrative aspects of residency, including adherence to duty hour restrictions.

Results : Of 322 potential respondents, 262 (81%) completed the survey. Surgical training and training in laparoscopic surgery were deemed "important" by nearly all respondents (98%, 258 of 262, and 97%, 253 of 262, respectively). Factors that were considered "not important" by a significant group of respondents included maternity/paternity leave policies (22%, 58 of 259); opportunity for international rotations/electives (20%, 51 of 259); exposure to quality and safety initiatives (13%, 34 of 259); and training in abortion (13%, 34 of 262).

Conclusions : Fourth-year medical students identified surgical training as the most important factor in selecting an ob-gyn residency, a finding that is particularly relevant as decreasing and changing surgical volumes affect residency training in this specialty.
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http://dx.doi.org/10.4300/JGME-D-16-00148.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5319611PMC
February 2017

Influence of Residency Training on Operative Vaginal Delivery in Independent Practice.

J Reprod Med 2016 Nov-Dec;61(11-12):562-8

Objective: To determine if residency training in the use of forceps and vacuums in vaginal deliveries is associated with their use in postgraduate practice.

Study Design: We surveyed all Ob/Gyn residency graduates of 4 academic programs from 2004-2012. The average number of vacuums and forceps performed per graduating resident was linked to respondents, who were then grouped by self-report as using forceps alone, vacuums alone, or both in practice. Multivariable logistic regression determined predictors of use of forceps and vacuums in practice

Results: The response rate was 61.2% (n=200). Those practicing obstetrics (n=171) were classified as forceps only (24%), vacuums only (22%), or both (54%). Use of forceps in practice was greater for those who graduated within the last 5 years (OR 7.55, 95% CI 2.37-24.07), felt inadequately trained in vacuums (OR 4.58, 95% CI 1.23-17.00), cared for a patient population <50% privately insured (OR 4.08, 95% CI 1.58-10.52), and performed more forceps in residency (OR 1.69, 95% CI 1.31-2.18 per 5 forceps performed on average). The only significant predictor of vacuum use was the number of vacuum deliveries performed in residency (OR 3.71, 95% CI 2.28-6.01 per 5 vacuums performed on average).

Conclusion: Independent practice pattern for operative vaginal delivery reflects residency training for both vacuums and forceps.
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October 2018

Advising and Interview Patterns of Medical Students Pursuing Obstetrics and Gynecology Residency.

Obstet Gynecol 2016 Oct;128 Suppl 1:17S-22S

Departments of Obstetrics and Gynecology, University of Colorado School of Medicine and Denver Health Medical Center, Denver, Colorado, University of California, San Francisco School of Medicine, San Francisco, California, and University of Washington School of Medicine, Seattle, Washington; and Loyola University School of Medicine, Chicago, Illinois.

Objective: To describe the advising practices at medical schools and interview patterns among medical students pursuing obstetrics and gynecology residency training.

Methods: A voluntary, anonymous survey was distributed to all applicants interviewing for obstetrics and gynecology residency during the 2014-2015 cycle at the University of Colorado, University of Washington, University of California, San Francisco, and Loyola University. Demographic data were obtained. The survey explored student advising in the residency application process including number of applications and interviews recommended by advisors. Data are reported as percentage for each survey item and compared by select demographics using an exact χ.

Results: Among 315 unique possible applicants, 73% (n=230) responded. Students were most commonly advised by the obstetrics and gynecology clerkship director (33%) with recommendations to apply to 21-30 programs (48%). Thirty-four percent of students applied to 21-30 programs, 32% to 31-40 programs, and 30% to greater than 40 programs. Students were advised (70%) and planned (55%) to interview at 10-14 programs. Concern over competitiveness of the applicant pool was the most important factor (31%) in determining the number of applications. The number of programs advised to or plan to interview at was greater for those in the couples match (P<.001).

Conclusion: Medical students pursuing obstetrics and gynecology are most likely to be advised by obstetrics and gynecology clerkship directors and concern over the competitiveness of the applicant pool results in students applying to large numbers of programs. This practice may adversely affect the obstetrics and gynecology match process for both programs and applicants through the requirements of managing additional applications and potentially needing to complete a greater number of interviews.
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http://dx.doi.org/10.1097/AOG.0000000000001573DOI Listing
October 2016

Lack of Agreement Between Endocervical Brush and Endocervical Curettage in Women Undergoing Repeat Endocervical Sampling.

J Low Genit Tract Dis 2016 Oct;20(4):296-9

1University of Colorado, Department of Obstetrics and Gynecology, Aurora, Colorado; and 2Denver Health Medical Center, Department of Obstetrics and Gynecology, Denver, Colorado.

Objective: To evaluate agreement between an abnormal endocervical brush (ECB) collected at the time of colposcopy and subsequent endocervical curettage (ECC).

Methods: All women evaluated for lower genital tract disease at a single academic institution were prospectively entered into a database. The database was queried for those who had a colposcopic exam with ECB between April 1, 2013, and June 15, 2015, and who subsequently returned for an ECC to further evaluate eligibility for expectant management or ablative therapy. ECB and ECC results were divided into 2 groups: "low-grade" included low-grade squamous intraepithelial lesions (LSIL) or atypical squamous cells of undetermined significance, and "high-grade" included high-grade squamous intraepithelial lesions (HSIL) or atypical squamous cells-cannot exclude high-grade. Women with atypical glandular cells and unsatisfactory ECB results were excluded. Percent agreement between ECB and ECC was calculated based on these categories.

Results: Seventy-nine women were included: 54 (68%) had a low-grade ECB, and 25 (32%) had a high-grade ECB. Of those who had a low-grade ECB, 4 had a low-grade ECC, 3 had a high-grade ECC, and 47 were negative, resulting in an agreement of 7.4% (4/54). Of those who had a high-grade ECB, 1 had a low-grade ECC, 4 had a high-grade ECC, and 20 were negative, resulting in 16% (4/25) agreement.

Conclusions: Our data suggest that there is poor agreement between ECC and ECB in our patient population.
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http://dx.doi.org/10.1097/LGT.0000000000000252DOI Listing
October 2016

Discontinuation of Tocolytics for Preterm Labor in an Academic Safety Net Hospital: Impact on the Duration of Betamethasone Exposure.

J Reprod Med 2016 Mar-Apr;61(3-4):109-13

Objective: To evaluate the impact of discontinuation of tocolytics on the completion of the corticosteroid course among preterm neonates in an academic safety net hospital.

Study Design: Retrospective cohort study of all singleton pregnancies with preterm labor resulting in delivery between 24 and 34 weeks' gestation at Denver Health Medical Center (DHMC) between 1/1/2004 and 5/31/2009. In January 2007 DHMC discontinued the use of tocolytic therapy for preterm labor. Study subjects were grouped based on whether their delivery occurred before or after the change in policy. Multivariable logistic regression was used to determine whether the use of tocolysis increased the odds of completion of the betamethasone while adjusting for cervical examination at admission.

Results: Of 169 infant/mother pairs who met inclusion criteria, 102 delivered prior to the discontinuation of tocolytics and 67 delivered after the discontinuation of tocolytics. Treatment with tocolysis increased the odds of completing the 48-hour betamethasone window (OR 2.59, 95% CI 1.16-5.79). Each centimeter increase in cervical dilation at the time of admission decreased the odds of completing the betamethasone window (OR 0.50, 95% CI 0.39-0.62).

Conclusion: The use of tocolytics increased the odds of completion of the betamethasone window in an academic safety net hospital among neonates born between 24 and 34 weeks' gestation.
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May 2016

Adherence to Management Recommendations in Patients Diagnosed With Cervical Intraepithelial Neoplasia 2 or 3.

J Low Genit Tract Dis 2016 Jan;20(1):44-6

Departments of Obstetrics and Gynecology, 1University of Colorado School of Medicine, Aurora, and 2Denver Health Medical Center, Denver, CO.

Objective: The aim of the study was to evaluate the rate of patient adherence to provider recommendations for biopsy proven cervical intraepithelial neoplasia (CIN) 2 or 3 in an academic safety-net hospital.

Materials And Methods: This is a case series of patients with biopsy-proven CIN 2 or 3 identified via pathology records between January 1, 2008 to December 31, 2012 at a single academic safety-net hospital. Patients with human immunodeficiency virus, lupus, or pregnancy were excluded. Patient demographics, recommended management, and patient adherence were extracted from the patient chart. Complete adherence was defined as completion of follow-up recommendations within 6 months of the recommended follow-up date. The primary outcome was rate of complete adherence to management recommendations. Descriptive statistics, univariate analysis, and multivariable logistic regression were performed.

Results: Six hundred eighty-four patients met inclusion and exclusion criteria. The complete adherence rate was 89% (n = 606). In multivariable analyses, those who completed follow-up were older (mean = 31 vs 29 years; p = .031), more likely to use a long-acting reversible contraceptive or sterilization for contraception (92% vs 87%; p = .036) and more likely to have been recommended excision (90% vs 83%; p = .009). In multivariable analysis, using a long-acting reversible contraceptive or sterilization (odds ratio = 1.75; CI = 1.02-3.0) and the recommendation of any kind of treatment as opposed to expectant management (odds ratio = 3.89; CI = 1.96-7.70) remained significantly associated with complete follow-up.

Conclusions: Patients were overall highly adherent to management recommendations when diagnosed with CIN 2 or 3. Those patients recommended to undergo treatment as opposed to observation were more likely to follow up.
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http://dx.doi.org/10.1097/LGT.0000000000000148DOI Listing
January 2016

Perinatal High-Grade Cervical Cytology: A Case Series From a Safety Net Institution.

J Low Genit Tract Dis 2015 Oct;19(4):329-32

1School of Medicine, University of Colorado, Aurora, CO, and 2Department of Obstetrics and Gynecology, Denver Health Medical Center, Denver, CO.

Objective: To describe the outcomes of women with high-grade cervical cytology in pregnancy and to identify factors that predict completion of appropriate postpartum follow-up.

Methods: We describe a case series of all patients with high-grade cervical cytology collected during pregnancy between 2007 and 2011 at a single institution. Patients were considered adherent with follow-up if they received any kind of postpartum evaluation or treatment for their cervical dysplasia at our institution within 9 months of delivery.

Results: Of 138 women with high-grade cervical cytology in pregnancy, 87 (63%) had high-grade squamous intraepithelial lesion, 47 (34%) had atypical squamous cells that cannot rule out high-grade (ASC-H), and 4 (3%) had atypical glandular cells (AGC). Most patients (81%) underwent colposcopy during pregnancy. A total of 48 patients (43%) had biopsies performed, 26 (54%) were CIN 2 or 3, and one (2%) was adenocarcinoma in situ (AIS). A total of 97 (70%) of 138 patients completed recommended postpartum follow-up, resulting in the detection of one additional case of AIS and one case of invasive adenocarcinoma. Hispanic ethnicity (odds ratio [OR], 3.6; confidence interval [CI], 1.4-9.1), being married (OR, 4.5; CI, 1.6-12.4), being employed (OR, 3.7; CI, 1.3-10.5), and CIN2 or 3 on antenatal biopsy (OR, 9.8; CI, 2.0-47.9) were all significantly associated with completion of postpartum follow-up.

Conclusion: Colposcopy during pregnancy resulted in the detection of one case of AIS. Postpartum evaluation and treatment detected an additional case of AIS as well as one case of invasive cervical adenocarcinoma. Whereas certain demographic characteristics were associated with completion of recommended follow-up, the strongest association is with a high-grade biopsy during pregnancy.
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http://dx.doi.org/10.1097/LGT.0000000000000135DOI Listing
October 2015

Does the number of forceps deliveries performed in residency predict use in practice?

Am J Obstet Gynecol 2015 Jul 17;213(1):93.e1-93.e4. Epub 2015 Mar 17.

Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Department of Obstetrics and Gynecology, Denver Health Medical Center, Denver, CO. Electronic address:

Objective: We aimed to determine whether a threshold number of forceps deliveries in residency predicts use of forceps in independent practice.

Study Design: We surveyed obstetrics and gynecology residency graduates of 2 academic programs from 2008 through 2012 regarding the use of operative vaginal delivery in practice. At these programs, residents are trained in both forceps and vacuums. Individual case log data were obtained with the number of forceps deliveries performed by each respondent during residency. Respondents were grouped as currently using any forceps or vacuums alone. A logistic regression model estimated the probability of forceps use, predicted by the number of residency forceps deliveries. From the resulting receiver-operating characteristic curve, we assessed sensitivity, specificity, positive predictive value, and area under the curve.

Results: The response rate was 85% (n = 58) and 90% (n = 52) practice obstetrics. Seventy-nine percent (n = 41) use forceps in practice. The mean number of forceps performed during residency was 22.3 ± 1.3 (mean ± SE) in the any-forceps group and 18.5 ± 2.1 in the vacuums-only group (P = .14). Although the model performed only moderately (area under the curve, 0.61, 95% confidence interval [CI], 0.42-0.81), more than 13 residency forceps deliveries corresponded to a 95% sensitivity (95% CI, 84-99) and a positive predictive value of 83% (95% CI, 69-92) for using forceps in practice. The specificity of this threshold is 27% (95% CI, 6-61).

Conclusion: Although exceeding 13 forceps deliveries made it highly likely that obstetricians would use them in practice, further study is necessary to set goals for a number of resident forceps deliveries that translate into use in practice.
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http://dx.doi.org/10.1016/j.ajog.2015.03.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4485574PMC
July 2015
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