Patient Sociodemographics and Comorbidities and Birth Hospital Characteristics Associated With Postpartum Emergency Department Care.
Patient Sociodemographics and Comorbidities and Birth Hospital Characteristics Associated With Postpartum Emergency Department Care.
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DOI：
10.1001/jamanetworkopen.2023.3927
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发表时间：
2023-03-01
影响因子：
13.8
通讯作者：
Lin, Michelle P.
中科院分区：
文献类型：
--
作者：
Zarrin, Haley;Vargas-Torres, Carmen;Janevic, Teresa;Stern, Toni;Lin, Michelle P.
本队列研究调查了2014年1月1日至2016年11月15日期间纽约州产后急诊就诊的患者和医院特征。哪些患者和医院特征与产后急诊科就诊有关？这项包括608559例产科出院患者的回顾性队列研究发现，年龄较小、种族和少数民族、公共保险和有更多合并症的患者产后急诊科就诊的几率更高。产后到少数族裔医院、安全网医院和产科出院率较低的医院就诊的可能性更大。这些发现表明，在所有类型的医院中，黑人和西班牙裔患者的产后急诊科就诊率更高，特别是在安全网医院和那些服务于种族和少数民族群体的医院，这表明需要进行结构性改革以减少孕产妇健康差距。产后急诊科（ED）访问可能表明难以获得护理和产妇发病率的风险。确定与产后急诊科就诊率相关的患者和医院特征。这项回顾性队列研究使用了2014年至2016年纽约州住院患者数据库和州急诊科数据库的数据。纳入了2014年1月1日至2016年11月15日期间纽约州急症医院的所有产科出院病例。住院患者数据库中的产科出院与ED数据库中同一患者随后的ED访问相关联。数据分析时间为2020年2月至2022年8月。评估的患者特征包括年龄、种族、保险、家庭邮政编码收入四分位数、Charlson合并症指数评分和产科风险因素。评估的医院特征包括安全网络状况、教学状况以及作为一家不成比例地为种族和少数民族人口服务的医院的状况。主要结果是产科出院后42天内的任何急诊科就诊。采用具有2水平嵌套混合效应的多水平逻辑回归来解释患者和医院特征以及医院水平聚类。在608559例产科出院中，有35299例（5.8%）在42天内就诊。产院产后ED就诊率中位数（IQR）为6.3%（4.6%-8.7%）。平均（SD）年龄为28.4（9.1）岁，其中亚洲患者53006人（8.7%），黑人患者90675人（14.9%），西班牙裔患者101 812人（16.7%），白人患者275 860人（45.3%）；292991人（48%）参加了医疗补助，290526人（47.7%）参加了私人保险。亚裔患者产后ED就诊率最低（53006名亚裔患者产后ED就诊2118次[3.99%]），黑人患者产后ED就诊率最高（90675名黑人患者产后ED就诊8306次[9.15%]）。黑人患者产后急诊科就诊的几率更大(比值比[OR]， 1.31; 95% CI, 1.26-1.35; P <。001)和西班牙裔患者（OR, 1.19; 95% CI, 1.15-1.24; P < 0.001）。001)相对于白人患者；有医疗保险的患者(OR, 1.55; 95% CI, 1.39-1.72; P <。001),医疗补助(优势比,1.37;95%置信区间,1.34 - -1.41;P <。001)或自付保险（or, 1.50; 95% CI, 1.41-1.59; P < 0.001）。001)相对于商业保险；在安全网医院出生的新生儿(OR, 1.43; 95% CI, 1.37-1.51; P <。001)和医院不成比例地服务于种族和少数民族人群（OR, 1.14; 95% CI, 1.08-1.20; P < .001）；在每年少于500名新生儿的医院分娩(OR, 1.25; 95% CI, 1.14-1.39; P <。001)相对于年出生人数超过2000的人。在教学医院分娩后产后急诊科就诊的调整后几率较低(OR, 0.82; 95% CI, 0.74-0.91; P <。001)和大都市医院（OR, 0.74; 95% CI, 0.65-0.85; P < .001）。该队列研究发现，在所有类型的医院中，黑人和西班牙裔患者产后急诊科就诊的调整后几率更高，特别是在安全网医院和那些不成比例地为种族和少数民族人群服务的医院。这些发现支持迫切需要减轻造成产妇保健差异的结构性种族主义。
This cohort study examines patient and hospital characteristics associated with postpartum emergency department visits in New York State from January 1, 2014, to November 15, 2016. Which patient and hospital characteristics are associated with postpartum ED visits? This retrospective cohort study including 608 559 obstetric discharges found higher odds of postpartum ED visits among patients who were younger, from racial and ethnic minority groups, publicly insured, and had more comorbid medical conditions. Postpartum ED visits were more likely after giving birth at hospitals serving racial and ethnic minority groups, safety net hospitals, and hospitals with fewer obstetric discharges. These findings suggest that Black and Hispanic patients experienced higher rates of postpartum ED visit rates across all hospital types, particularly at safety net hospitals and those serving racial and ethnic minority groups, suggesting structural changes are needed to reduce maternal health disparities. Postpartum emergency department (ED) visits may indicate poor access to care and risk for maternal morbidity. To identify patient and hospital characteristics associated with postpartum ED visit rates. This retrospective cohort study used data from the 2014 to 2016 New York State Inpatient Database and State Emergency Department Database. All obstetric discharges from acute care hospitals in New York State from January 1, 2014, through November 15, 2016, were included. Obstetric discharges in the inpatient database were linked to subsequent ED visits by the same patient in the ED database. Data were analyzed from February 2020 to August 2022. Patient characteristics assessed included age, race, insurance, home zip code income quartile, Charlson Comorbidity Index score, and obstetric risk factors. Hospital characteristics assessed included safety net status, teaching status, and status as a hospital disproportionally serving racial and ethnic minority populations. The primary outcome was any ED visit within 42 days of obstetric discharge. Multilevel logistic regression with 2-level nested mixed effects was used to account for patient and hospital characteristics and hospital-level clustering. Of 608 559 obstetric discharges, 35 299 (5.8%) were associated with an ED visit within 42 days. The median (IQR) birth hospital postpartum ED visit rate was 6.3% (4.6%-8.7%). The mean (SD) age was 28.4 (9.1) years, 53 006 (8.7%) were Asian patients, 90 675 (14.9%) were Black patients, 101 812 (16.7%) were Hispanic patients, and 275 860 (45.3%) were White patients; 292 991 (48%) were insured by Medicaid, and 290 526 (47.7%) had private insurance. Asian patients had the lowest postpartum ED visit rates (2118 ED visits after 53 006 births by Asian patients [3.99%]), and Black patients had the highest postpartum ED visit rates (8306 ED visits after 90 675 births by Black patients [9.15%]). Odds of postpartum ED visits were greater for Black patients (odds ratio [OR], 1.31; 95% CI, 1.26-1.35; P < .001) and Hispanic patients (OR, 1.19; 95% CI, 1.15-1.24; P < .001) relative to White patients; those with Medicare (OR, 1.55; 95% CI, 1.39-1.72; P < .001), Medicaid (OR, 1.37; 95% CI, 1.34-1.41; P < .001), or self-pay insurance (OR, 1.50; 95% CI, 1.41-1.59; P < .001) relative to commercial insurance; births that occurred at safety net hospitals (OR, 1.43; 95% CI, 1.37-1.51; P < .001) and hospitals disproportionately serving racial and ethnic minority populations (OR, 1.14; 95% CI, 1.08-1.20; P < .001); and births that occurred at hospitals with fewer than 500 births per year (OR, 1.25; 95% CI, 1.14-1.39; P < .001) relative to those with more than 2000 annual births. Adjusted odds of postpartum ED visits were lower after birth at teaching hospitals (OR, 0.82; 95% CI, 0.74-0.91; P < .001) and metropolitan hospitals (OR, 0.74; 95% CI, 0.65-0.85; P < .001). This cohort study found that Black and Hispanic patients experienced higher adjusted odds of postpartum ED visits across all hospital types, particularly at safety net hospitals and those disproportionately serving racial and ethnic minority populations . These findings support the urgent need to mitigate structural racism underlying maternal health disparities.
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