Background: Research to date has focused on strategies and resources used by effective champions of healthcare change efforts, rather than personal characteristics that contribute to their success. We sought to identify and describe champion attributes influencing outcomes of healthcare change efforts. To examine attributes of champions, we used postpartum contraceptive care as a case study, because recommended services are largely unavailable, and implementation requires significant effort. Methods: We conducted a comparative case study of the implementation of inpatient postpartum contraceptive care at 11 U.S. maternity hospitals in 2017–18. We conducted site visits that included semi-structured key informant interviews informed by the Consolidated Framework for Implementation Research (CFIR). Phase one analysis (qualitative content analysis using a priori CFIR codes and cross-case synthesis) showed that implementation leaders (“champions”) strongly influenced outcomes across sites. To understand champion effects, phase two inductive analysis included (1) identifying and elaborating key attributes of champions; (2) rating the presence or absence of each attribute in champions; and 3) cross-case synthesis to identify patterns among attributes, context, and implementation outcomes. Results: We completed semi-structured interviews with 78 clinicians, nurses, residents, pharmacy and revenue cycle staff, and hospital administrators. All identified champions were obstetrician-gynecologists. Six key attributes of champions emerged: influence, ownership, physical presence at the point of change, persuasiveness, grit, and participative leadership style. These attributes promoted success by enabling champions to overcome institutional siloing, build and leverage professional networks, create tension for change, cultivate a positive learning climate, optimize compatibility with existing workflow, and engage key stakeholders. Not all champion attributes were required for success, and having all attributes did not guarantee success. Conclusions: Effective champions appear to leverage six key attributes to facilitate healthcare change efforts. Prospective evaluations of the interactions among champion attributes, context, and outcomes may further elucidate how champions exert their effects.

There has been little progress in adolescent health outcomes in recent decades. Researchers and youth-serving organizations struggle to accurately elicit youth voice and translate youth perspectives into health care policy. Our aim is to describe the protocol of the MyVoice Project, a longitudinal mixed methods study designed to engage youth, particularly those not typically included in research. Text messaging surveys are collected, analyzed, and disseminated in real time to leverage youth perspectives to impact policy. Youth aged 14 to 24 years are recruited to receive weekly text message surveys on a variety of policy and health topics. The research team, including academic researchers, methodologists, and youth, develop questions through an iterative writing and piloting process. Question topics are elicited from community organizations, researchers, and policy makers to inform salient policies. A youth-centered interactive platform has been developed that automatically sends confidential weekly surveys and incentives to participants. Parental consent is not required because the survey is of minimal risk to participants. Recruitment occurs online (eg, Facebook, Instagram, university health research website) and in person at community events. Weekly surveys collect both quantitative and qualitative data. Quantitative data are analyzed using descriptive statistics. Qualitative data are quickly analyzed using natural language processing and traditional qualitative methods. Mixed methods integration and analysis supports a more in-depth understanding of the research questions. We are currently recruiting and enrolling participants through in-person and online strategies. Question development, weekly data collection, data analysis, and dissemination are in progress. MyVoice quickly ascertains the thoughts and opinions of youth in real time using a widespread, readily available technology-text messaging. Results are disseminated to researchers, policy makers, and youth-serving organizations through a variety of methods. Policy makers and organizations also share their priority areas with the research team to develop additional question sets to inform important policy decisions. Youth-serving organizations can use results to make decisions to promote youth well-being.

In contrast to peer nations, the United States is experiencing rapid increases in maternal mortality. Trends in individual and population-level demographic factors and health trends may play a role in this change. We analyzed state-level maternal mortality for the years 1997–2012 using multilevel mixed-effects regression grouped by state, using publicly available data including whether a state had adopted the 2003 U.S. Standard Certificate of Death, designed to simplify identification of pregnant and recently pregnant decedents. We calculated the proportion of the increase in maternal mortality attributable to specific factors during the study period. Maternal mortality was associated with higher population prevalence of obesity and high school non-completion among women of childbearing age; these factors explained 31.0% and 5.3% of the attributable increase in maternal mortality during the study period, respectively. Among delivering mothers, prevalence of diabetes (17.0%), attending fewer than 10 prenatal visits (4.9%), and African American race (2.0%) were also associated with higher maternal mortality, as was time-varying state adoption of the 2003 death certificate (31.1%). Our findings indicate that, in addition to better case ascertainment of maternal deaths, adverse changes in chronic diseases, insufficient healthcare access, and social determinants of health represent identifiable risks for maternal mortality that merit prompt attention in population-directed interventions and health policies.

OBJECTIVE: To measure rates of long-acting reversible contraception (LARC), including intrauterine devices and contraceptive implants, and tubal sterilization during delivery hospitalizations and correlates of their use. METHODS: This retrospective cohort study used the 2008–2013 National Inpatient Sample, a publicly available all-payer database. We identified delivery hospitalizations with the International Classification of Diseases, 9th Revision, Clinical Modification codes for intrauterine device insertion, contraceptive implant insertion, and tubal sterilization. We used weighted multivariable logistic regression to examine associations between predictors (age, delivery mode, medical comorbidity, payer, hospital type, geographic region, and year) and likelihood of LARC and sterilization and to compare characteristics of LARC and sterilization users. RESULTS: Our sample included 4,691,683 discharges, representing 22,667,204 delivery hospitalizations. Long-acting reversible contraception insertion increased from 1.86 per 10,000 deliveries (2008–2009) to 13.5 per 10,000 deliveries (2012–2013; P<.001); tubal sterilization remained stable (711–683 per 10,000 deliveries; P=.24). In multivariable analysis adjusting for all predictors, compared with neither LARC nor sterilization, LARC use was highest among women with medical comorbidities (count per 10,000 deliveries: 15.04, standard error 2.11, adjusted odds ratio [OR] 1.92, 95% confidence interval [CI] 1.72–2.13), nonprivate payer (13.50, standard error 2.14, adjusted OR 5.23, 95% CI 3.82–7.16), and at urban teaching hospitals (14.92, standard error 2.25, adjusted OR 20.85, 95% CI 12.73–34.15). Sterilization was least likely among women aged 24 years or younger (251.04, standard error 4.88, adjusted OR 0.12 95% CI 0.12–0.13, compared with 35 years or older) and most likely with cesarean delivery (1,568.74, standard error 20.81, adjusted OR 6.25, 95% CI 5.88–6.63). Comparing only LARC and sterilization users, LARC users tended to have nonprivate insurance (84.95% compared with 57.17%, adjusted OR 1.90, 95% CI 1.38–2.63) and deliver at urban teaching hospitals (94.65% compared with 45.47%, adjusted OR 38.39, 23.52–62.64) in later study years (2012–2013; 55.72% compared with 32.18%, adjusted OR 8.26, 95% CI 4.42–15.44, compared with 2008–2009). CONCLUSION: Long-acting reversible contraception insertion increased from 1.86 to 13.5 per 10,000 deliveries but remained less than 2% of the sterilization rate. Inpatient postpartum LARC insertion is more likely among sicker, poorer women delivering at urban teaching hospitals.