UCLA Clinical Translational Science Institute

项目总结

Project Summary Maternal risk appropriate care has been proposed by the American College of Obstetricians & Gynecologists (ACOG), Society of Maternal Fetal Medicine (SMFM), the Centers for Disease Control (CDC) and other stakeholders as a national system-wide recommendation to improve safety in childbirth and to decrease the rising rate of maternal morbidity and mortality. ACOG, SMFM, and various other stakeholders have advocated for certifying hospitals based on hospital resources with a system ranked from I-IV where Level I has essential resources and provides care for low risk women, Level II and III takes care of intermediate risk women, and Level IV is a regional center with 24/7 access to onsite multidisciplinary consultants and critical care resources. In response to the NIH IMPROVE initiative, this supplement proposal focuses on hemorrhage--the 4th leading cause of maternal mortality. Reports suggest that upwards of 66-93% may be avoidable making it the leading cause of preventable maternal death. Abnormal placentation (placenta accreta spectrum (PAS) disorders and placenta previa) is a leading cause of hemorrhage. Rates are increasing due to increasing rates of cesarean delivery, and risk of cesarean varies by race/ethnicity. Many researchers, clinicians, and patient advocacy groups support regionalizing care for women with PAS with care coordinated by centers of excellence or "accreta centers” with designated teams and standardized protocols. However, to date, there has not been a systematic evaluation of outcomes by hospitals based on risk appropriate care at the hospital level, and even the specialized “accreta centers” have not provided data demonstrating improvement in health disparities. In response to the NIH IMPROVE initiative, the current proposal uses California discharge data (2013-2016), to address the following study aims: (1) describe maternal outcomes in women with abnormal placentation (PAS or placenta previa) by level of maternal care and race/ethnicity; (2) evaluate the interactions of levels of maternal care and race/ethnicity on severe maternal morbidity (SMM) for women with PAS; and (3) evaluate the interaction of levels of maternal care and race/ethnicity on SMM for women with placenta previa—an alternate condition that likely could be influenced by maternal risk appropriate care. This study will be the first to evaluate if outcomes are better for women with PAS or placenta previa based on risk appropriate care and if level of care mitigates observed disparities in SMM for these high-risk conditions. Further, this study provides a framework to study different clinical conditions where referral to risk appropriate care can be evaluated.