BackgroundThe objective of this study is to develop predictive models for persistent opioid use following lower extremity joint arthroplasty and determine if ensemble learning and an oversampling technique may improve model performance.MethodsWe compared various predictive models to identify at-risk patients for persistent postoperative opioid use using various preoperative, intraoperative, and postoperative data, including surgical procedure, patient demographics/characteristics, past surgical history, opioid use history, comorbidities, lifestyle habits, anesthesia details, and postoperative hospital course. Six classification models were evaluated: logistic regression, random forest classifier, simple-feedforward neural network, balanced random forest classifier, balanced bagging classifier, and support vector classifier. Performance with Synthetic Minority Oversampling Technique (SMOTE) was also evaluated. Repeated stratified k-fold cross-validation was implemented to calculate F1-scores and area under the receiver operating characteristics curve (AUC).ResultsThere were 1042 patients undergoing elective knee or hip arthroplasty in which 242 (23.2%) reported persistent opioid use. Without SMOTE, the logistic regression model has an F1 score of 0.47 and an AUC of 0.79. All ensemble methods performed better, with the balanced bagging classifier having an F1 score of 0.80 and an AUC of 0.94. SMOTE improved performance of all models based on F1 score. Specifically, performance of the balanced bagging classifier improved to an F1 score of 0.84 and an AUC of 0.96. The features with the highest importance in the balanced bagging model were postoperative day 1 opioid use, body mass index, age, preoperative opioid use, prescribed opioids at discharge, and hospital length of stay.ConclusionsEnsemble learning can dramatically improve predictive models for persistent opioid use. Accurate and early identification of high-risk patients can play a role in clinical decision making and early optimization with personalized interventions.

PURPOSE Women family physicians experience challenges in maintaining worklife balance while practicing in rural communities. We sought to better understand the personal and professional strategies that enable women in rural family medicine to balance work and personal demands and achieve long-term career satisfaction.METHODS Women family physicians practicing in rural communities in the United States were interviewed using a semistructured format. Interviews were recorded, professionally transcribed, and analyzed using an immersion and crystallization approach, followed by detailed coding of emergent themes. RESULTSThe 25 participants described a set of strategies that facilitated successful work-life balance. First, they used reduced or flexible work hours to help achieve balance with personal roles. Second, many had supportive relationships with spouses and partners, parents, or other members of the community, which facilitated their ability to be readily available to their patients. Third, participants maintained clear boundaries around their work lives, which helped them to have adequate time for parenting, recreation, and rest.CONCLUSIONS Women family physicians can build successful careers in rural communities, but supportive employers, relationships, and patient approaches provide a foundation for this success. Educators, employers, communities, and policymakers can adapt their practices to help women family physicians thrive in rural communities. 2016;14:244-251. doi: 10.1370/afm.1931. Ann Fam Med INTRODUCTIONT he United States faces a chronic, severe shortage of rural physicians, which has a negative impact on population health.1-4 Rural America is economically, socially, and environmentally diverse, yet residents of rural communities share common difficulties accessing health care, including longer distances to care, and a disproportionate shortage of women and minority physicians.5-8 A lack of women rural physicians especially limits access to care for women patients, who often prefer women clinicians and appear to complete more screening tests when seen by women. 9 Rural female physicians are also more likely to attend births than male peers, 10,11 an important practice characteristic as many rural areas have a shortage of obstetrics professionals. 12,13 Promoting the success of women family physicians in rural communities is therefore important for community health.Acknowledging that women are an essential component of the rural physician workforce, 6 several studies have explored what factors attract women to rural practice and enable their success. Many rural physicians have had rural life experience.14,15 Previous studies have described common joys associated with rural practice, including multidimensional patient relationships, [16][17][18] the variety and professional challenges associated with a broad scope of practice, 10,18 the opportunity to serve one's community, [17][18][19][20] clinical autonomy, 17 and the attractions of small town life. 17,18,20 Women physicians also report no...

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Midwifery is rooted in public health, and most of its history has been community oriented. In India, midwifery evolved during the British rule; but over the years with changes in political and program priorities, the role and the capacity of midwives has changed substantially. The verticalization of national health programs has obscured the midwives’ community focus and inhibited its contribution to the wider public health. There is a global acceptance and recognition of the midwifery model of care and skilled delivery for ensuring effective maternal health outcomes. The approaches are in line with local needs and have proved its effectiveness in resource-constrained settings. It is important to recognize the substantial contribution they make to public health, working to promote the long-term well-being of women, their babies and families, by offering information and advice on nutrition, supplementation, breastfeeding, and immunization. There is considerable scope for developing the midwifery model through enhancing the extent of their involvement in assessing health needs of local populations, designing, managing and evaluating maternal and health services, making timely and effective referrals and developing family-centered care.