United States


Background:
Iron deficiency anemia (IDA) is an important contributor to the systemic disease process in heart failure (HF). Intravenous (IV) Iron repletion has been shown to be superior to oral iron repletion with respect to decreased side effect profile, improved quality of life, reduced mortality and rehospitalization in HF patients. No study has outlined a multidisciplinary hospital-based process in identifying and treating this specific cohort of patients with IV Iron repletion. 

Objectives: 
Our quality improvement (QI) initiative sought to identify patients with IDA and HF in real time and treat them with IV iron repletion instead of oral iron supplementation during their hospitalization using a multidisciplinary approach. 

Methods: 
Between May 2021 and February 2022, using a daily real time electronic medical record patient intake filter, we identified patients admitted for acute decompensated heart failure with a hemoglobin of less than or equal to 12g/dl. Patients were further analyzed for IDA via laboratory iron panel. In accordance with the European Society of Cardiology (ESC) guidelines, anemic patients with a ferritin &lt;100 µg/L or ferritin of 100-299 µg/L with a transferrin saturation &lt;20% qualified for IV Iron repletion. An IDA QI team was created consisting of internal medicine residents, advanced care practitioners, cardiology fellows, and pharmacists to educate providers, identify and treat qualified patients. Patients were treated with IV Iron Sucrose 300mg/day for three consecutive days.

Results:
54 patients were included in the study with three outliers removed, 16 patients were given oral iron sulfate therapy and 36 received IV iron sucrose therapy. Heart failure with reduced ejection fraction was the predominant HF phenotype with 38 patients. The average hemoglobin of our cohort was 8.6 with a mean corpuscular volume of 90.2, ferritin of 98, serum iron of 26, TIBC of 253, and transferrin of 200. A statistically significant decrease in average hospital length of stay was noted in the IV iron repletion arm of 5 days versus 10 days in the oral repletion group (p &lt;0.01). There was no statistically significant difference in length of stay among HF patients with varying levels of ferritin. 

Conclusion: 
Our quality improvement project successfully created a real time multidisciplinary approach to identifying and treating patients with IDA and HF. A statistically significant decrease in length of stay was associated with IV iron repletion. We increased the utilization of IV iron compared to oral repletion by more than 100% during the same time. As a result of this project, IV iron repletion is now a part of our armamentarium in holistically treating heart failure. 



2022 AMA Research Challenge

Iron Deficiency Anemia and Treatment in ​Heart Failure: A Novel Multidisciplinary Quality Improvement Project


IWSSIP is an international conference that brings together researchers and developers from both academia and industry reporting the latest scientific and theoretical advances to discuss and debate major issues and state-of-the-art aspects on systems, signals and image processing.

###### For the session discussion, each author will be seated at individual breakout tables.  Please find which table they will be at here:
###### [QA table assignments in Gather.town](https://drive.google.com/file/d/1hBHOD_KF7NSsaTcpYcHCZslXJvQVxJQe/view?usp=sharing)

IWSSIP 2021

Background:
Iron deficiency anemia (IDA) is an important contributor to the systemic disease process in heart failure (HF). Intravenous (IV) Iron repletion has been shown to be superior to oral iron repletion with respect to decreased side effect profile, improved quality of life, reduced mortality and rehospitalization in HF patients. No study has outlined a multidisciplinary hospital-based process in identifying and treating this specific cohort of patients with IV Iron repletion. 

Objectives: 
Our quality improvement (QI) initiative sought to identify patients with IDA and HF in real time and treat them with IV iron repletion instead of oral iron supplementation during their hospitalization using a multidisciplinary approach. 

Methods: 
Between May 2021 and February 2022, using a daily real time electronic medical record patient intake filter, we identified patients admitted for acute decompensated heart failure with a hemoglobin of less than or equal to 12g/dl. Patients were further analyzed for IDA via laboratory iron panel. In accordance with the European Society of Cardiology (ESC) guidelines, anemic patients with a ferritin <100 µg/L or ferritin of 100-299 µg/L with a transferrin saturation <20% qualified for IV Iron repletion. An IDA QI team was created consisting of internal medicine residents, advanced care practitioners, cardiology fellows, and pharmacists to educate providers, identify and treat qualified patients. Patients were treated with IV Iron Sucrose 300mg/day for three consecutive days.

Results:
54 patients were included in the study with three outliers removed, 16 patients were given oral iron sulfate therapy and 36 received IV iron sucrose therapy. Heart failure with reduced ejection fraction was the predominant HF phenotype with 38 patients. The average hemoglobin of our cohort was 8.6 with a mean corpuscular volume of 90.2, ferritin of 98, serum iron of 26, TIBC of 253, and transferrin of 200. A statistically significant decrease in average hospital length of stay was noted in the IV iron repletion arm of 5 days versus 10 days in the oral repletion group (p <0.01). There was no statistically significant difference in length of stay among HF patients with varying levels of ferritin. 

Conclusion: 
Our quality improvement project successfully created a real time multidisciplinary approach to identifying and treating patients with IDA and HF. A statistically significant decrease in length of stay was associated with IV iron repletion. We increased the utilization of IV iron compared to oral repletion by more than 100% during the same time. As a result of this project, IV iron repletion is now a part of our armamentarium in holistically treating heart failure.

poster

Welcome to the largest national, multi-specialty research event **featuring research from 750 medical students, residents and fellows, and international medical graduates.**


#### Event Details
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At the conclusion of this event, the AMA will announce the top five finalists who will advance to the AMA Research Challenge finals, present their research to an elite panel of judges and compete to win a $10,000 grand prize sponsored by Laurel Road.
 

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**Oct. 20, 6 — 7 p.m. Central**
 **How to plan a career in academic medicine** 
 Learn how to plan a career in academic medicine and get your questions answered. [Access Here](https://underline.io/events/363/lounge)
 
 **Speakers**
![](https://assets.underline.io/uploads/markdown_image/1/image/d5adb133dfc58eb0a6d469e9cedcd5d4.jpg)
Ricardo Correa, MD, EdD
![](https://assets.underline.io/uploads/markdown_image/1/image/5f9437ab87861538bf02b9ca7c0d926e.jpg)
Stuart M. Greenstein, MD
![](https://assets.underline.io/uploads/markdown_image/1/image/05b1b637c99286d558c371f8e8b185ce.jpg)
Stephanie Strohbeen, MD
 
 **Oct. 22, 11 a.m. — Noon Central**
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 **Speakers**
![](https://assets.underline.io/uploads/markdown_image/1/image/8ce6235e957d31cb5e6f9097cc6f6972.jpg)
Jessica Li, MD/PhD Candidate
![](https://assets.underline.io/uploads/markdown_image/1/image/9950ef2e0237f54cb3d8280334d42491.jpg)
Charles Lopresto, DO

### Sponsor
AMA would like to thank Laurel Road for sponsoring a $10,000 grand prize for the winner of the AMA Research Challenge. Laurel Road is not involved in the judging or scoring process to select the winner. The winner will be announced on Dec. 7 during the AMA Research Challenge finals. Payment of the grand prize will be directly from Laurel Road. See the AMA Research Challenge Official Rules for terms and conditions.

![](https://assets.underline.io/uploads/markdown_image/1/image/611e331d4a0eba0920f240cfc04b4d77.png)

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Register to explore research in a variety of topics. AMA members get exclusive access to score posters in the semifinals.

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Welcome to the largest national, multi-specialty research event featuring research from 750 medical students, residents and fellows, and international medical graduates.


Background: Atopic dermatitis (AD) is a common relapsing inflammatory skin condition associated with a high economic burden due to its chronicity and multitude of direct and indirect treatment costs. AD disproportionately impacts children and minority populations, and treatment choices are cost-prohibitive for many patients.

Objective: To describe the treatment and management of AD from a cost-conscious perspective.

Methods: A review of the literature was conducted with PubMed using the following key words: atopic dermatitis, cost, medications, treatment, management, efficacy, adherence, education, and prophylactic.

Results: The use of moisturizers prophylactically in high-risk infants who have yet to develop AD may reduce incidence of disease and associated costs. Increasing patient medication adherence and moisturizing between flares also reduces costs in AD. The use of corticosteroids as a first-line treatment is efficacious and cost-effective for mild cases of AD, however in severe cases of AD corticosteroids alone are not sufficient. Systemic biologics are necessary in some patients with severe cases of AD; however, they are associated with high costs. Phototherapy, through portable home units, tanning beds, and natural sunlight are cost-effective alternatives. Effective management of AD improves with education programs for both the patient and their family, reducing long-term costs in the management of this disease.

Conclusion: Reducing AD treatment costs requires consideration of prophylactic therapies, patient education, and should differ based on the severity of disease. A multifaceted approach to AD treatment reduces costs and healthcare barriers. This article is protected by copyright. All rights reserved.


Reducing Costs in Atopic Dermatitis

Abstract Title
Factors Associated With Mortality and Prolonged Hospital Stay Among Skull Fracture Patients

Background
Skull fractures pose a high demand on hospital resources. The implication of skull fracture on patient length of hospitalization and mortality has not been elucidated. Identifying predictors of differential mortality risk and prolonged hospital stay in skull fracture patients present opportunities to improve patient outcomes and management of hospital resources. 

Methods
The 2019 National Emergency Department Sample database was used to outline the demographics of patients with a primary skull fracture. Multivariate logistic regression was used to determine factors that contributed to a long inpatient stay and death. Charlson Comorbidity Index (CCI) was calculated to correct for comorbidities relevant to mortality and hospital stay.

Results
In 2019, 1,769,709 patients presented to the emergency department with primary skull fractures.
Level I trauma center inpatients were at greater odds of long hospital stay (OR:2.40; 95% CI [1.72-3.35], p<0.001). Relative to other income groups, the highest income quartile had the lowest likelihood of a prolonged stay (OR:2.40; 95% CI [1.72-3.35], p<0.001). Inpatients presenting with multiple comorbid conditions (CCI: 3+) reported distinctly high likelihood of long hospital stay (OR:3.20; 95% CI [2.45-4.18], p<0.001) and death (OR: 2.18, CI [1.24-3.83], p=0.007). Medicaid beneficiaries reported lower odds of death due to skull fracture than Medicare inpatients (OR:0.63; 95% CI [0.40-0.98], p=0.04). Skull fractures sustained by fall (OR: 0.37 95% CI [0.23-0.58], p<0.001) or physical assault (OR: 0.34 95% CI [0.18-0.63], p<0.001) observed significantly lower odds of death than other-cause fractures. Vault fracture type was associated with both longest hospital stay (OR:3.49; 95% CI [2.54-4.80], p<0.001) and highest mortality rate (OR: 4357; 95% CI [589-32172], p<0.001). 

Conclusion
Distinct odds of prolonged hospitalization and mortality were realized across a motley of covariate-adjusted inpatient and hospital factors. Mindfulness of the associations reported here may serve well to mitigate bed management inefficiencies and improve skull fracture outcomes.

Factors Associated With Mortality and Prolonged Hospital Stay Among Skull Fracture Patients

Introduction: Availability of inpatient pediatric services has declined across the United States between 2008-2018, with rural areas experiencing steepest declines. Despite the movement of pediatric care to children’s centers, most children are still cared for in community hospitals nationally. Assessing the availability and providers of inpatient pediatric care in Wisconsin is an important step in ensuring the health care needs of children in the state continue to be met. 
Methods: A cross-sectional survey was distributed to Wisconsin hospitals to determine pediatric services and physician workforce. Response rate was 130/138 (94%), including 56/58 (97%) of Critical Access Hospitals (CAHs). Results of specific inpatient pediatric subdivisions were analyzed by descriptive statistics. 
Results: Hospitals that provide inpatient newborn care are mostly staffed by pediatricians (P) and family physicians (FP), while CAHs are staffed by FP. Hospitals with neonatal intensive care units are staffed by neonatologists, with telemedicine utilized in CAHs. Hospitals with general pediatric admissions are staffed by P or FP, while CAHs are staffed by FP. Hospitals with pediatric intensive care units are staffed by pediatric intensivists. 
Conclusions: Despite workforce disparities and shortages, hospitals across Wisconsin, including many CAHs, continue to provide inpatient pediatric services. Family physicians play a major role in the pediatric healthcare delivery in Wisconsin hospitals. Robust inpatient pediatric training of family physicians may enable rural health authorities to continue addressing the gaps that persist in inpatient pediatric care accessibility.

Inpatient Pediatrics and Clinician Workforce in Wisconsin: The State of the State

Advanced liver diseases (ALDs) present with a gross burden to one’s health and quality of life – cirrhosis and liver cancer, for instance, account for approximately 3.5% of deaths across the world. By investigating the preponderance of research grants focused on ALDs within key patient-centered domains such as palliative care, geriatrics, and supportive care, we seek to identify future directions for funding areas of research that greatly benefit patients in critically ill condition. The primary aim of this study was to describe the number and total funding of research grants awarded on palliative care, geriatrics, and supportive care research focused on advanced liver disease. We referred to previous literature on these domains of research to develop and identify search terms to be used in NIH Reporter, a search tool that provides publicly available information on NIH-funded research grants. An abstract and title review of the studies was completed to determine which grants are relevant to the domains in question. After a title and abstract review showed 345 relevant studies on ALD, only 12 (3.5%) were in the domains of PC, geriatrics, and/or supportive care. Likewise, of approximately 146 billion dollars devoted to funding towards ALD research, around 6.6 million dollars (4.5%) were focused towards any of these domains. Our research indicates that there is a greater need for funding in the domains of palliative care, geriatrics, or supportive care research within advanced liver disease. Patient-centered research is important for ensuring improved clinical outcomes and patient quality of life. With the expected increase in our geriatric population over the next several decades, there will need to be greater emphasis on such research domains.

The State of Funding for Palliative Care, Supportive Care, and Geriatrics Research in Advanced Liver Disease

Background:
Survey of procedures performed across all surgical subspecialties at the Iowa City VAMC in FY2018 showed that the rate of 30-day period surgical site infections (SSI) was significantly higher than that of national average. Average cost saving from single deep or organ space SSI and single superficial SSI are approximately $34,407 and $1,000, respectively. SSI places significant financial burden to the healthcare systems and complicates the course of postoperative recovery. 

Methods:
Previously, all patients undergoing surgery at the Iowa City VAMC underwent Chlorohexidine Gluconate (CHG) bath prior to surgery. A new surgical site infection prevention protocol (SSIPP) involving 2% CHG cloths for skin, Povidone Iodine nasal swab, and 0.12% CHG mouth rinse was implemented in October of 2019 (Figure 1,2)). All eligible cases were reviewed since the implementation of the SSIPP. All recorded SSI were categorized into deep/organ space SSI or superficial SSI. This was compared with the rate of SSI recorded before the SSIPP implementation and cost savings were estimated accordingly.

Results:
From 10/01/2019 to 09/30/2020 a total of 885 eligible cases were reviewed, revealing a total of 3 deep/organ space SSI. This is significantly lower than 15 deep/organ space SSI recorded from 01/01/2018 to 12/31/2018 out of 1042 cases (p=0.016). However, rate of superficial SSI from 10/01/2019 to 03/30/2020 was significantly different from that of 2018 (p=0.80).

Compared to 2018, estimated total cost savings from reductions in deep/organ space SSI ($516,105 vs $258,052) and superficial SSI ($9,000 vs $6,000) approximates to $415,884.

Conclusion
SSI is a known surgical complication that places significant financial burden on healthcare systems and puts patients at greater risk of postoperative mortality and morbidity. Preoperative infection prevention protocol involving CHG cloths, Povidone Iodine swab, and CHG mouth rinse has significantly decreased the overall rate of SSI and those that involve deep/organ space SSI. This approximates to total cost savings of $415,884 at no cost to the patient.


Preoperative Infection Prevention Protocol to Reduce Rate of Surgical Site Infections

Introduction: Multimorbidity in surgery is common and associated with worse postoperative outcomes. However, the conventional multimorbidity definition (≥2 comorbidities) labels the vast majority of elderly patients as multimorbid, limiting its clinical benefit. We developed and validated a better surgical specialty-specific multimorbidity definition based on distinct comorbidity combinations called Qualifying Comorbidity Sets (QCSs).

Methods: We used Medicare claims data for patients aged 66-90 years hospitalized for general (GS), orthopedic (OS), or vascular surgery (VS). Using 2016-2017 data, we identified all comorbidity combinations associated with a double-or-greater risk of 30-day mortality compared to the overall population undergoing the same procedure; these were defined as QCSs. We applied these QCSs to 2018-2019 data (GS=462,904 patients, OS=1,493,999, VS=301,336) to obtain 30-day mortality estimates. For further validation, we tested whether multimorbid patients treated at better-resourced (based on nursing resources, surgical volume, teaching status) vs. other hospitals had differential outcomes using multivariate matching.

Results: Compared to the conventional multimorbidity definition, the QCS-based definition labeled fewer patients as multimorbid: GS=85.0% vs. 55.9% (p<0.0001); OS=66.6% vs. 40.2% (p<0.0001); VS=96.2% vs. 52.7% (p<0.0001) (Table 1). Thirty-day mortality was higher by the QCS-based definition: GS=3.96% [conventional] vs. 5.64% [QCS-based] (p<0.0001); OS=1.13% vs. 1.68% (p<0.0001); VS=4.43% vs. 7.00% (p<0.0001). Better-resourced hospitals offered larger mortality benefits for multimorbid vs. non-multimorbid GS and OS patients (GS absolute risk reduction difference-in-difference=-0.94% [95% CI -1.24%,-0.63%], p<0.0001; OS difference-in-difference=-0.20% [95% CI -0.29%,-0.10%], p<0.0001).

Conclusion: Our QCS-based multimorbidity definition identifies a more specific, higher risk pool of patients compared to the conventional definition, allowing for better clinical decision-making.

Redefining Multimorbidity in Older Surgical Patients

Social determinants of health (SDOH) studies have underscored the impact of the local environment on both cancer outcomes and cardiovascular health. Adolescent and young adult (AYA) lymphoma survivors are commonly treated with cardiotoxic treatments that increase risk of poor cardiovascular outcomes. Thus, investigations of neighborhood-level measures and cardiovascular burden in diverse AYA lymphoma populations may provide insight into mediators of disparities in AYA lymphoma survivors.

This study utilizes a multi-ethnic cohort of AYA lymphoma survivors (N=353), diagnosed between ages 15-39, seen at MD Anderson Cancer Center. Clinical data abstraction for demographics, treatment, and follow-up information was completed. Follow-up data includes cardiovascular-related variables, such as BMI at baseline and last follow-up, diagnoses of hypertension, hyperlipidemia, heart failure and other cardiovascular diseases, and treatment with cardiovascular medications. Zip codes obtained from the medical record were used to query the U.S. Census Bureau to gather zip-code tabulation areas (ZCTA). Each ZCTA was linked with their associated Area Deprivation Index (ADI) values from the Public Health Neighborhood Atlas (University of Wisconsin). Clinical data and ADI values were evaluated to identify differences in poor cardiovascular burden by ADI and by ethnic group. 

The cohort includes 275 (77.9%) non-Hispanic white, 29 (8.2%) non-Hispanic Black, and 49 (13.9%) Hispanic cancer survivors (2+ years from diagnosis). The mean ADI value was 46.4 for the non-Hispanic whites, 58.2 for the non-Hispanic Blacks, and 55.5 for the Hispanic population. In total, 276 (78.2%) of the population was diagnosed with Hodgkin lymphoma and 77 (21.8%) with non-Hodgkin lymphoma. Based on the survivors with available clinical data, 34 (64.2%) had a cardiovascular disease (CVD) diagnosis and 43 (71.7%) were taking cardiac medications at follow-up. 

Differences in ADI between AYA lymphoma survivors by self-identified race/ethnicity were observed that suggest non-White AYA survivors experience higher burdens of poor SDOH compared their White AYA counterparts. Patients with a diagnosis of CVD and patients taking cardiac medications had higher ADI levels than those without, significantly so regarding cardiac medications. Survival of the multi-ethnic cohort by ADI quartiles was not significantly different, but when analyzed by highest versus lowest quartile some disadvantage was evident. Further analysis is needed to elucidate this relationship and provide sufficient evidence for potential social interventions.

Investigating the Impact of Neighborhood Deprivation Level on Cardiovascular Burden in Adolescent and Young Adult Lymphoma Survivors

We present a case of cutaneous scalp metastasis of retroperitoneal leiomyosarcoma. The patient in this case has an initial complaint of left upper quadrant pain, unintentional weight loss, fatigue, and night sweats. On initial physical exam he was found to have two right sided scalp nodules. The patient underwent a series of tests which resulted in a diagnosis of leiomyosarcoma of the retroperitoneum with metastasis to the right sided cutaneous scalp. Leiomyosarcoma is a rare malignancy of smooth muscle cells. It most commonly arises from uterine tissue but other primary locations include other gynecologic tissue, gastrointestinal, somatic soft tissue, and in the case of this patient, retroperitoneal. As with other sarcomas, metastasis likely occurs via hematogenous route. The literature on scalp metastasis of leiomyosarcoma is limited to case reports. To the best of our knowledge, only 4 other reports have been documented of retroperitoneal leiomyosarcoma metastasis to the cutaneous scalp have been identified. In one of these cases, metastasis to many other sites were found as well including lungs, hip, and thigh. Interestingly, in the case we present, no other metastasis besides the cutaneous scalp has been found. Our case serves to highlight the importance of a high index of clinical suspicion when caring for these patients. A full head to toe physical exam should be performed regularly and cutaneous nodules should be biopsied in order to assess for metastasis.

Metastasis of retroperitoneal leiomyosarcoma to the cutaneous scalp

Background: Frailty is a spectrum describing a demographic more likely to experience adverse events such as falls, disability, and hospital admission. The Modified Frailty Index (mFI) is a method of quantifying frailty, predicting increased risk of 30-day readmission. Though assessing risk of 30-day readmission is important, 44.7% of posterior lumbar decompression surgery readmissions occurred beyond 30 days. Therefore, a predictive model accounting for readmission within 90 days post-operatively will be more useful for this procedure.
Methods: This is a retrospective study on patient mFI and 90-day readmission for lumbar interbody fusion procedures involving two or more vertebral levels. Patients filled out an 11-point questionnaire derived from mFI prior to XLIF, OLIF, PLIF, TLIF, or ALIF surgery. mFI score and readmission data will be collected between the dates of January 2019 and December 2021. Next, associations will be assessed using Spearman’s rank-order correlation and ROC curves to determine the range of scores associated with readmission within 90 days.
Results: The purpose of this project is to assess whether a patient questionnaire format of the 11-point mFI can be used to predict risk of 90-day readmission for elderly patients undergoing multi-level lumbar interbody fusions. We expect for there to be a positive correlation between mFI and 90-day readmission.
Conclusion: The frailty questionnaire will provide a more time efficient alternative to mFI-11. The ability to calculate risk for 90-day readmission will more accurately assess the patient procedural risk. This will improve pre-operative counseling and may be helpful in reducing hospital length of stay while keeping the emotional interests of patients in mind.

Questionnaire Format of the Modified Frailty Index as a Predictor of 90-Day Readmission in Multi-Level Lumbar Interbody Fusion Patients

Background: Sterilization is an effective form of contraception with approximately 18.6% of women aged 15-49 years relying on this method, however only 39-57% of women who request this procedure prenatally ultimately undergo postpartum sterilization. The implications for incomplete but desired postpartum sterilization procedures negatively impact the health of women. At Penn State Hershey Medical Center (PSHMC), immediate postpartum sterilization after vaginal delivery is not standard practice, so a root cause analysis was done to identify existing barriers to postpartum sterilization after vaginal delivery at PSHMC.
Methods: Voluntary one-on-one qualitative interviews were conducted with a multidisciplinary group of stakeholders involved in performing postpartum sterilization. Stakeholders consisted of women’s health attendings, family and community medicine attendings, ob-gyn residents, anesthesiologists, and nursing leadership with the goal of obtaining a comprehensive understanding of this issue.
Results: Participants were asked standardized questions that were selected according to participant role in the postpartum sterilization process. Barriers identified were found to be either logistic and/or cultural. A root-cause analysis in the form of a fishbone model was performed to identify barriers and create targeted solutions for the future.
Conclusion: Due to the high rates of short-interval pregnancy, dissatisfaction, and associated health consequences, interview participants agreed that postpartum sterilization was an important procedure that patients should be able to obtain. It was also identified that the current model at PSHMC does not adequately provide this service to women who desire it. A sample standard operating procedure was created to begin formulating a framework to help increase the rate of postpartum sterilization to 1 per month at PSHMC, with cyclic re-evaluation.

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Iron Deficiency Anemia and Treatment in ​Heart Failure: A Novel Multidisciplinary Quality Improvement Project

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Reducing Costs in Atopic Dermatitis

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Sudden Death Classification Using Electrocardiogram Signals and Structural Co-occurrence Matrix in Patients with Chagas Disease

Iron Deficiency Anemia and Treatment in Heart Failure: A Novel Multidisciplinary Quality Improvement Project