Hospital quality, Medicaid expansion, and racial/ethnic disparities in maternal mortality and morbidity

摘要：产妇不良后果的种族和民族差异仍然是一个重要的公共卫生问题。 有问题。在纽约市(NYC)医院进行的研究表明，少数民族女性更有可能 在低质量的医院分娩，而且他们在医院内患严重孕产妇疾病的风险也更高 发病率(SMM)高于白人女性，即使在占保险种类之后。尽管这些研究 代表了我们理解SMM差异的重要指针，但仍有许多悬而未决的问题 关于分娩质量如何使少数族裔的不良结局发生率更高 女人。首先，尚不清楚种族/民族在分娩医院质量方面的差异(之间和内部) 存在于纽约市以外的城市或地区，特别是在农村地区。其次，关于中国的信息很少。 不同种族/民族地位的妇女分娩地点不同的原因。三、先行先试 审查医疗保健提供方面的种族差异主要集中在个人层面的因素上，而忽视了 可能起作用的更广泛的宏观社会和结构性条件(例如结构性种族主义)。最后，它 目前尚不清楚扩大医疗补助等重要政策对产科医院质量的影响， 尤其是为少数民族和农村服务的医院。调查更高水平因素的研究 迫切需要超越个人层面的因素来解释孕产妇结局中的种族/民族差异 设计有效的干预措施。因此，拟议的研究将涉及以下问题：1)确定 分娩医院质量对产妇死亡率和SMM的种族/民族差异的贡献；2)检查 医院内经风险调整的孕产妇死亡率和严重发病率方面的种族/民族差异，并确定 这些差距是否与医疗保险的类型以及更广泛的社会和结构有关 条件；3)确定与使用和绕行有关的社会和个人层面的母体因素 高质量的医院；4)确定扩大医疗补助收入资格对收入最高达 138%的联邦贫困水平：(目标4a)医院质量(特别是安全网和农村服务医院)；以及 (目标4b)产妇死亡率和SMM发生率，总体或按种族/族裔和社会经济情况分列 状态。我们将使用与医院出院数据相关联的出生证明数据，并辅之以其他数据集 从2000年到2019年从美国八个州获得的数据，以开发经风险调整的孕产妇死亡率和SMM综合数据 结果将使我们能够对医院进行排名。我们随后将使用医院排名来审查 医院质量对种族/民族差异的贡献。扩大医疗补助计划的目标将利用 自然的实验框架和差异分析导致将每种状态与其自身进行比较， 在医疗补助扩大之前和之后。在研究结束时，我们将更好地了解 8个州所有母亲在医疗保健系统中的种族/民族差异，并将确定潜在的 可以对缩小差距产生深远影响的需要改进的领域。

Abstract: Racial and ethnic disparities in maternal adverse outcomes remain a significant public health problem. Studies conducted in New York City (NYC) hospitals have shown that minority women are more likely to deliver in low-quality hospitals and that they are also at a higher within-hospital risk of severe maternal morbidity (SMM) than white women, even after accounting for type of insurance. Although these studies represent important pointers in our understanding of SMM disparities, there are still many open questions about how quality of delivery hospitals drives the higher rates in adverse outcomes observed for minority women. First, it is unknown whether racial/ethnic differences in delivery hospital quality (between and within) exist in cities or regions other than NYC, especially in rural areas. Second, there is little information on the reasons for differences in where women of different racial/ethnic status deliver. Third, previous efforts examining racial disparities in healthcare delivery have mainly focused on individual-level factors overlooking the broader macro-level societal and structural conditions (e.g., structural racism) that may be at play. Finally, it is unknown how important policies such as Medicaid expansion have impacted obstetric hospital quality, especially minority- and rural-serving hospitals. Research studies investigating higher level factors that transcend individual-level factors to explain racial/ethnic disparities in maternal outcomes are urgently needed to design effective interventions. Thus, the proposed study will address the following: 1) Determine the contribution of delivery hospital quality to racial/ethnic disparities in maternal mortality and SMM; 2) Examine within-hospital racial/ethnic disparities in risk-adjusted maternal mortality and severe morbidity and identify whether these disparities are associated with types of medical insurance and broader societal and structural conditions; 3) Determine societal- and individual-level maternal factors associated with using versus bypassing high-quality hospitals; 4) Identify the impact of expanded Medicaid income eligibility to adults earning up to 138% federal poverty level on: (Aim 4a) hospital quality (especially safety-net and rural-serving hospitals); and (Aim 4b) the incidence of maternal mortality and SMM, either overall or by race/ethnicity and socioeconomic status. We will use birth certificate data linked to hospital discharge data and supplemented by other datasets from eight U.S. states from 2000-2019 to develop a risk-adjusted maternal mortality and SMM composite outcome which will allow us to rank hospitals. We will subsequently use hospital ranking to examine the contribution of hospital quality to racial/ethnic disparities. The aim on Medicaid expansion will make use of a natural experiment framework and difference-in-difference analysis resulting in comparing each state to itself, before and after Medicaid expansion. At the end of the study, we will have a better understanding of racial/ethnic disparities in the health care system among all mothers in eight states and will identify potential areas for improvement that can have profound implications on reducing disparities.