Postpartum Readmission and Uninsurance at Readmission for Medicaid versus Privately Insured Births

The 2023 Gerard W. Ostheimer Lecture. A Contemporary Narrative Review of Maternal Mortality and Morbidity: Opportunities to Improve Peripartum Outcomes

The Gerard W. Ostheimer lecture is given annually to members of the Society for Obstetric Anesthesia and Perinatology. This lecture summarizes new and emerging literature that informs the clinical practice of obstetric anesthesiology. This is a narrative review of 2022 literature pertinent to maternal morbidity and mortality in all income settings globally. Themes associated with worse maternal mortality rate (MMR), challenges health care workers face, public health priority areas, and initiatives to help countries achieve the United Nations Sustainable Development Goal targets for MMR are discussed. MMRs are higher in low- and middle-income countries (LMICs) compared to high-income countries (HICs). Cesarean delivery rates are rising most rapidly in LMICs, warranting urgent maternal health care workforce planning efforts in these settings. Globally racial, ethnic, and geographical disparities in maternal mortality continue to be evident in global health care settings. In the United States, the MMR is rising. The evolving changes in abortion legislation in the United States may further negatively impact maternal morbidity and mortality. The need to implement American Society of Anesthesiologists-recommended obstetric anesthesia quality metrics to facilitate benchmarking and to improve patient experience and outcomes is discussed as well as the need for professional society guidance on minimum staffing levels in American labor and delivery units.

Socioeconomic, Demographic, and Clinical Factors Associated with Postpartum Readmission

Purpose: To determine if socioeconomic, demographic, and clinical characteristics are associated with postpartum readmission. Methods: A retrospective cohort study evaluating all pregnant patients that delivered at seven hospitals within a large academic health system in New York between January 1, 2018 and March 1, 2020. Demographic information, medical comorbidities, and characteristics of antepartum, intrapartum, and postpartum care were compared between patients who were readmitted within 6 weeks postpartum and those who were not. Postpartum patients who presented to the emergency department but remained less than 23 hours were excluded. Patient ZIP codes were linked to data from the United States Census Bureau's American Community Survey and used as a proxy for neighborhood socioeconomic status. Mixed effects logistic regression was used to evaluate factors associated with an increased risk of postpartum readmission while adjusting for potential confounders. Results: A total of 57,507 delivery hospitalizations were evaluated, and 1,481 (2.5%) patients were readmitted. Black race (aOR: 1.56, 95% CI: 1.30-1.86, p < 0.001) and public health insurance (aOR: 1.19, 95% CI: 1.05-1.35, p = 0.007) were associated with an increased likelihood of postpartum readmission. Chronic hypertension (aOR: 2.83, 95% CI: 2.33-3.44, p < 0.001), body mass index >25 kg/m2 (aOR: 1.22, 95% CI: 1.05-1.42, p = 0.01), gestational weight gain >40 lb (aOR: 1.19, 95% CI: 1.01-1.40, p = 0.04), and administration of blood products (aOR: 2.18, 95% CI: 1.68-2.82, p < 0.001) were associated with an increased odd of readmission. Neighborhood characteristics were not associated with postpartum readmission. Conclusion: Efforts to reduce postpartum readmissions should focus on high-risk populations. Specific sociodemographic and clinical characteristics are associated with this complication.

Redesigning Care for the Management of Postpartum Hypertension: How Can Ob-Gyns and Primary Care Physicians Partner in Caring for Patients after a Hypertensive Pregnancy?

The standard care model in the postpartum period is ripe for disruption and attention. Hypertensive disorders of pregnancy (HDPs) can continue to be a challenge for the postpartum person in the immediate postpartum period and is a harbinger of future health risks. The current care approach is inadequate to address the needs of these women. We propose a model for a multidisciplinary clinic and collaboration between internal medicine specialists and obstetric specialists to shepherd patients through this high-risk time and provide a bridge for lifelong care to mitigate the risks of a HDP. KEY POINTS: · HDPs are increasing in prevalence.. · The postpartum period can be more complex for women with HDPs.. · A multidisciplinary clinic could fill the postpartum care gap for women with HDP..

Postpartum readmission in Maryland by race and ethnicity, 2016-2019

BACKGROUND

The majority of maternal deaths occur in the postpartum period. We sought to compare postpartum readmission by race and ethnicity to better understand whether there are disparities in maternal health in the postpartum period as indicated by readmission to the hospital.

OBJECTIVE

This study aimed to use state-wide Maryland data to identify postpartum readmission rates by race and ethnicity, as well as the major risk factors, indications, and timing of readmission.

STUDY DESIGN

In this retrospective study (2016-2019), childbirth hospitalizations for patients of childbearing age were identified from the Maryland State Inpatient Database, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Indication for readmission was described. Multivariable logistic regression models were employed to determine racial and ethnic differences in postpartum readmissions, adjusting for maternal and obstetrical characteristics.

RESULTS

Among total deliveries (n=260,778), 3914 patients (1.5%) were readmitted within 60 days of delivery. The most common primary diagnoses at readmission were hypertension and infection. The prevalence of readmission was 1.2% (1306/111,325) for White patients, 2.3% (1786/79,412) for Black patients, 1.2% (485/40,862) for Hispanic patients and 1.2% (337/29,179) for patients of Other race or ethnicity (P<.0001). Black patients had the highest rates of readmission for hypertensive disorders as compared with all other races (37%, P<.0001). In adjusted models, Black patients were more likely to be readmitted than White patients (odds ratio, 1.64; confidence interval, 1.52-1.77). The majority of all readmissions occurred in the first week after delivery with Black patients having higher rates of readmission in the second week relative to all other groups (P<.0001).

CONCLUSION

Hypertension is a leading cause of postpartum readmission in Maryland. Black patients were more likely to be readmitted for hypertensive disorders of pregnancy and to have delayed readmission relative to other race or ethnic groups. Maryland public health officials should address disparities with interventions targeting racial and ethnic minorities, patients at risk for hypertensive disorders, and barriers to timely care.

Standardized Clinical Assessment and Management Plan to Reduce Readmissions for Postpartum Hypertension

OBJECTIVE

To evaluate the effect of a postpartum hypertension standardized clinical assessment and management plan on postpartum readmissions and emergency department (ED) visits.

METHODS

We conducted a prospective cohort study of patients with postpartum hypertension (either chronic hypertension or hypertensive disorders of pregnancy) who delivered at a single tertiary care center for 6 months after enacting an institution-wide standardized clinical assessment and management plan (postintervention group). Patients in the postintervention group were compared with patients in a historical control group. The standardized clinical assessment and management plan included 1) initiation or uptitration of medication for any blood pressure (BP) higher than 150/100 mm Hg or any two BPs higher than 140/90 mm Hg within a 24-hour period, with the goal of achieving normotension (BP lower than 140/90 mm Hg) in the 12 hours before discharge; and 2) enrollment in a remote BP monitoring system on discharge. The primary outcome was postpartum readmission or ED visit for hypertension. Multivariable logistic regression was used to evaluate the association between standardized clinical assessment and management plan and the selected outcomes. A sensitivity analysis was performed with propensity score weighting. A planned subanalysis in the postintervention cohort identified risk factors associated with requiring antihypertensive uptitration after discharge. For all analyses, the level of statistical significance was set at P<.05.

RESULTS

Overall, 390 patients in the postintervention cohort were compared with 390 patients in a historical control group. Baseline demographics were similar between groups with the exception of lower prevalence of chronic hypertension in the postintervention cohort (23.1% vs 32.1%, P=.005). The primary outcome occurred in 2.8% of patients in the postintervention group and in 11.0% of patients in the historical control group (adjusted odds ratio [aOR] 0.24, 95% CI 0.12-0.49, P<.001). A matched propensity score analysis controlling for chronic hypertension similarly demonstrated a significant reduction in the incidence of the primary outcome. Of the 255 patients (65.4%) who were compliant with outpatient remote BP monitoring, 53 (20.8%) had medication adjustments made per protocol at a median of 6 days (interquartile range 5-8 days) from delivery. Non-Hispanic Black race (aOR 3.42, 95% CI 1.68-6.97), chronic hypertension (aOR 2.09, 95% CI 1.13-3.89), having private insurance (aOR 3.04, 95% CI 1.06-8.72), and discharge on antihypertensive medications (aOR 2.39, 95% CI 1.33-4.30) were associated with requiring outpatient adjustments.

CONCLUSION

A standardized clinical assessment and management plan significantly reduced postpartum readmissions and ED visits for patients with hypertension. Close outpatient follow-up to ensure appropriate medication titration after discharge may be especially important in groups at high risk for readmission.