Prenatal and Postpartum Care Disparities in a Large Medicaid Program

Objectives Pennsylvania’s maternal mortality, infant mortality, and preterm birth rates rank 24th, 35th, and 25th in the country, and are higher among racial and ethnic minorities. Provision of prenatal and postpartum care represents one way to improve these outcomes. We assessed the extent of disparities in the provision and timeliness of prenatal and postpartum care for women enrolled in Pennsylvania Medicaid. Methods We performed a cross-sectional evaluation of representative samples of women who delivered live births from November 2011 to 2015. Our outcomes were three binary effectiveness-of-care measures: prenatal care timeliness, frequency of prenatal care, and postpartum care timeliness. Pennsylvania’s Managed Care Organizations (MCOs) were required to submit these outcomes to the state after reviewing administrative and medical records through a standardized, validated sampling process. We assessed for differences in outcomes by race, ethnicity, region, year, and MCO using logistic regression. Results We analyzed data for 12,228 women who were 49% White, 31% Black/African American, 4% Asian, and 15% Hispanic/Latina. Compared to Black/African American women, white and Asian women had higher odds of prenatal and postpartum care. Hispanic/Latina women had higher frequency of prenatal care than non-Hispanic women. Pennsylvania’s Southeast had lower prenatal care and Northwest had lower postpartum care than other regions. Prenatal care significantly decreased in 2014 and increased in 2015. We observed differences between MCOs, and as MCO performance diminished, racial disparities within each plan widened. We explored hypotheses for observed disparities in secondary analyses. Conclusions for Practice Our data demonstrate that interventions should address disparities by race, region, and MCO in equity-promoting measures.     

Improving Postpartum Care: Identifying Opportunities to Reduce Postpartum Emergency Room Visits Among Publicly-Insured Women of Color

Maternal and Child Health Journal - The purpose of this study was to explore the postpartum experiences of publicly-insured women of color, and identify how postpartum care can be improved to...     

Racial Segregation and Disparities in Health Care Delivery: Conceptual Model and Empirical Assessment

Objective. This study examines two dimensions of racial segregation across hospitals, using a disease for which substantial disparities have been documented.
Data Sources. Black ( n =32,289) and white ( n =244,042) patients 67 years and older admitted for acute myocardial infarction during 2004–2005 in 105 hospital markets were identified from Medicare data. Two measures of segregation were calculated: Dissimilarity (i.e., dissimilar distribution by race across hospitals), and Isolation (i.e., racial isolation within hospitals). For each measure, markets were categorized as having low, medium, or high segregation.
Study Design. The relationship of hospital segregation to residential segregation and other market characteristics was evaluated. Cox proportional hazards regression was used to evaluate disparities in the use of revascularization within 90 days by segregation level.
Results. Agreement of segregation category based on Dissimilarity and Isolation was poor ( κ =0.12), and the relationship of disparities in revascularization to segregation differed by measure. The hazard of revascularization for black relative to white patients was lowest (i.e., greatest disparity) in markets with low Dissimilarity, but it was unrelated to Isolation.
Conclusions. Significant racial segregation across hospitals exists in many U.S. markets, although the magnitude and relationship to disparities depends on definition. Dissimilar distribution of race across hospitals may reflect divergent cultural preferences, social norms, and patient assessments of provider cultural competence, which ultimately impact utilization.     

Developing an Integrated Strategy to Reduce Ethnic and Racial Disparities in the Delivery of Clinical Preventive Services for Older Americans

Objectives. To determine the optimum strategy for increasing up-to-date (UTD) levels in older Americans, while reducing disparities between White, Black, and Hispanic adults, aged 65 years and older.Methods. Data were analyzed from the 2008 Behavioral Risk Factor Surveillance System, quantifying the proportion of older Americans UTD with influenza and pneumococcal vaccinations, mammograms, Papanicolaou tests, and colorectal cancer screening. A comparison of projected changes in UTD levels and disparities was ascertained by numerically accounting for UTD adults lacking 1 or more clinical preventive services (CPS). Analyses were performed by gender and race/ethnicity.Results. Expanded provision of specific vaccinations and screenings each increased UTD levels. When those needing only vaccinations were immunized, there was a projected decrease in racial/ethnic disparities in UTD levels (2.3%–12.2%). When those needing only colorectal cancer screening, mammography, or Papanicolaou test were screened, there was an increase in UTD disparities (1.6%–4.5%).Conclusions. A primary care and public health focus on adult immunizations, in addition to other CPS, offers an effective strategy to reduce disparities while improving UTD levels.Clinical preventive services (CPS), such as screening tests and vaccinations, are important interventions for identifying, forestalling, and preventing disease across the life span. They are typically delivered in primary care practices and, increasingly, in community settings.1 The Advisory Committee on Immunization Practices (ACIP)2 and the US Preventive Services Task Force (USPSTF)3 have established guidelines for the delivery of these services for adults aged 65 years and older. Recommendations for persons aged 65 years and older include the following core CPS: influenza and pneumococcal vaccinations (PPV), cardiovascular screenings, and colorectal cancer screening. Additional recommendations for women in this age range include mammography and, in certain circumstances, Papanicolaou (Pap) tests.These core CPS are distinct in that they are ranked highly by the ACIP or USPSTF (grades A or B), and recommended based on demographic characteristics (age and gender) rather than on health condition, making them appropriate interventions for both primary care and public health. In 2010, a Healthy People 2020 objective was established to increase by 10% the proportion of older adults “up-to-date” (UTD) with core preventive services, from a 2008 baseline of 46.3% in men and 47.9% in women.4 Several studies confirmed that racial and ethnic minorities were less likely to receive each of these measures compared with their non-Hispanic White peers.5–7 Given a growing and increasingly diverse older US population,8 expanding access to and delivery of core CPS, while reducing racial and ethnic disparities in the receipt of these measures, is a priority.4 Developing an approach that integrates the work of the clinical and public health communities to accomplish this objective is likely to be the most effective strategy for achieving this goal. This integrated approach is supported by the recommendations of The Community Guide to Preventive Services9 and the Guide to Clinical Preventive Services,3 which together provide evidence-based recommendations across the prevention spectrum.10With the goal of enhancing the linkages between community and primary care to facilitate the uptake of preventive services, we examine the question of which preventive service(s) are needed to maximally improve UTD levels while decreasing racial/ethnic disparities in UTD levels among adults aged 65 years and older. Health disparities refer to “differences in health outcomes between groups that reflect social inequalities,” and their elimination requires an enhanced understanding of which groups are most vulnerable, how the disparities can be corrected through available interventions, and monitoring over time.11 As part of this assessment, projected changes in UTD levels and disparities were calculated, based on comparing the impact of providing different core preventive services to persons in each racial/ethnic group who were missing a single service, using 2008 data as a baseline. Projected UTD changes for Blacks and Hispanics were compared with those for Whites. Because we analyzed an all-or-none measure, it was only when projecting increases in the delivery of preventive services for persons missing a single service that levels of being UTD and associated racial and ethnic disparities would change. From a programmatic standpoint, every person should receive every CPS recommended for him or her.     

Disparities Rank High in Prioritized Research,Systems and Service Delivery Needs in Missouri

Objectives: An essential function of public health is to conduct research and in Missouri, a research agenda was initiated to promote the health and well being of women and children. In 2005, a survey was emailed to 180 maternal and child health (MCH) researchers throughout the state, with 130 responding for a 72.2% response rate. These individuals were asked to select research priorities out of a list of 130 research agenda items, identify personal areas of expertise, and to recommend new research topics. Results: Results focused on identifying research priorities and research experts. The first, of the five leading research priorities, was researching disparities in terms of age, race, ethnicity, and gender, regarding sexually transmitted diseases, chronic disease, birth outcomes, prenatal care, access to care, childhood exposure to lead, immunizations and vaccinations, mental health, substance abuse, and oral health. The four remaining, of the top five specific research priorities, in order of priority, included (2) reducing barriers to health care access, (3) constructing research ecologically, (4) increasing access to oral health care for children, and (5) reducing the prevalence of children who are at-risk for being overweight. Of the 130 respondents, 83.1% reported at least one area of expertise, with a mean of 7.4 areas of expertise per respondent (range 0–41). Forty percent of the respondents reported health care access as an area of expertise, followed by school health, community development, family support, and pre/post natal care (38.5%, 36.2%, 30.0%, 28.5%, and 26.9%) respectively. Interestingly, only 17.7% of the respondents reported disparities as their area of expertise. Conclusions: The goal of moving innovations towards changes in practice can only happen when resources are available to assess innovations and communities are ready to implement those innovations. The prioritization of this MCH research agenda, prioritized by a community of MCH researchers with expertise in conducting MCH related research, is the first step towards changes in practice, ultimately leading to improvements in the health of women and children in Missouri.     

产后出血高危因素分析

目的：探讨产后出血的高危因素,为今后围产保健工作提供有效的防治措施。方法：采用回顾性分析,对2005～2007年间我院收治的74例产后出血病例的资料进行分析。结果：产后出血的前三位病因依次为宫缩乏力、胎盘因素、软产道损伤。引起产后出血的高危因素为：多次孕产史、羊水过多、巨大儿、双胎妊娠、产程延长等。结论：加强健康宣教,减少人工流产,加强围产保健管理．重视孕期、产时、产后的高危因素,可以有效降低产后出血的发生率。     

Disparities in Geographic Access to Pediatric Subspecialty Care

Purpose: To identify correlates of geographic access to pediatric medical subspecialists in the United States and identify characteristics of populations at risk for poor geographic access. Methods: Geographic access was operationalized as distance to care. Using data from the American Board of Pediatrics and the Claritas’ Pop-Facts Database, the straight-line distance between each zip code in the United States and the nearest subspecialist was calculated for each pediatric subspecialty using zip code centroids. Using 16 specialty-specific, random-effects multiple regression models, zip code characteristics associated with being farther from a subspecialty provider were identified. Results: Under-18 population, metropolitan status, and presence of a nearby teaching facility were associated with shorter distances to care across pediatric subspecialties. The proportion of the population below the federal poverty level was positively associated with greater distances to care. Zip codes in the Mountain and West North Central regions, likewise, were significantly farther from pediatric subspecialists, even when statistically controlling for other factors. Conclusions: Pediatric populations at risk for poor geographic access to pediatric subspecialty care include those who reside in zip codes with high concentrations of poverty, in rural and small metropolitan areas, and in the Mountain and West North Central regions. The extent to which these distances create barriers to receipt of care is not established.

Effectiveness of Hip Protectors to Reduce Risk for Hip Fracture from Falls in Long-Term Care

ObjectiveTo generate evidence of the effectiveness of hip protectors to minimize risk of hip fracture at the time of falling among residents of long-term care (LTC) by contrasting rates of hip fractures between falls with and without hip protectors.DesignA 12-month, retrospective cohort study. We retrospectively reviewed fall incident reports recorded during the 12 months prior to baseline in participating homes.Setting and participantsA population-based sample comprising all residents from 14 LTC homes owned and operated by a single regional health authority, who experienced at least 1 recorded fall during the 12-month study.ResultsAt baseline, the pooled mean (standard deviation) age of residents in participating homes was 82.7 (11.3) years and 68% were female. Hip protectors were worn in 2108 of 3520 (60%) recorded falls. Propensity to wear hip protectors was associated with male sex, cognitive impairment, wandering behavior, cardiac dysrhythmia, use of a cane or walker, use of anti-anxiety medication, and presence of urinary and bowel incontinence. The incidence of hip fracture was 0.33 per 100 falls in falls with hip protectors compared with 0.92 per 100 falls in falls without hip protectors, representing an unadjusted relative risk (RR) of hip fracture of 0.36 (95% confidence interval 0.14–0.90, P = .029) between protected and unprotected falls. After adjusting for propensity to wear hip protectors, the RR of hip fracture was 0.38 (95% confidence interval 0.14–0.99, P = .048) during protected vs unprotected falls.Conclusions and implicationsHip protectors were worn in 60% of falls, and the risk of hip fracture was reduced by nearly 3-fold by wearing a hip protector at the time of falling. Given that most clinical trials have failed to attain a similar level of adherence, our findings support the need for future research on the benefits of dissemination and implementation strategies to maximize adherence with hip protectors in LTC.     

The National Health Plan Collaborative to Reduce Disparities and Improve Quality

BACKGROUND: Despite numerous reports and initiatives, progress in reducing racial/ethnic disparities in health care has been slow. The National Health Plan Collaborative (NHPC), a novel public-private partnership between nine health plans covering approximately 95 million lives, leading learning and research organizations, the Agency for Healthcare Research and Quality, and the Robert Wood Johnson Foundation, was established in December 2004 to address these disparities. PROGRESS TO DATE: The health plans were able to overcame initial challenges in obtaining information on race/ethnicity of their enrollees and examined their diabetes performance measure to assess disparities in care. By February 2006, the initial nine plans that had joined the NHPC progressed from focusing solely on data collection and management issues and were engaged in outreach activities to members, providers, or community or had completed capacity development for disparities work. Five plans had implemented one or more pilot interventions. Plans also addressed unanticipated challenges, such as sorting through large amounts of data to target disparities. CHALLENGES AND LESSONS LEARNED: Because many of the plans are complex national entities with varying regional and departmental structures, simply achieving coordination of disparities activities across the organization has been a major challenge and, in many cases, a major breakthrough. CONCLUSIONS: The NHPC represents a model of shared learning and innovation through which health plans are tackling racial/ethnic disparities. Now that most of the plans have some data on their enrollees with diabetes and have begun targeting disparities, they want to capitalize on their collective industry strength to influence policy on issues related to disparities.     

Practical Steps to Improve Air Flow in Long-Term Care Resident Rooms to Reduce COVID-19 Infection Risk

The potential for spread of COVID-19 infections in skilled nursing facilities and other long-term care sites poses new challenges for nursing home administrators to protect patients and staff. It is anticipated that as acute care hospitals reach capacity, nursing homes may retain COVID-19 infected residents longer prior to transferring to an acute care hospital. This article outlines 5 pragmatic steps that long-term care facilities can take to manage airflow within resident rooms to reduce the potential for spread of infectious airborne droplets into surrounding areas, including hallways and adjacent rooms, using strategies adapted from negative-pressure isolation rooms in acute care facilities.