Differences in outpatient, emergency, and inpatient use among pregnant women with a substance-related diagnosis

Emergency care utilization in persons with substance related diagnoses

Background

Substance use is a significant contributor to emergency department (ED) visits. Little is known about ED utilization patterns of individuals with substance related diagnosis (SRD). We used electronic health records (EHR) from a large healthcare system in California to examine ED healthcare utilization and socio-demographic characteristics of individuals with SRDs.

Methods

We used EHR data on all adult patients in our health system from April 2012 through September 2019 to conduct adjusted logistic regression models to determine socio-demographic correlates of SRDs (e.g., use, misuse, dependence) and associations between having an SRD and receiving emergency care.

Results

Among the sample (n = 342,651), the majority were female (55.08 %), Non-Hispanic White (58.10 %), with mean age of 48.26 (SD = 18.10), and there were 18,015 (5.26 %) individuals with an SRD. Patients with an alcohol-related diagnosis had the highest odds of visiting the ED (aOR = 3.75), followed by those with opioid (aOR = 3.57) and stimulant-related diagnoses (aOR = 3.48). Individuals with an SRD were more likely to identify as male, Black/African American, Hispanic/Latinx, have no health insurance, and have a serious mental illness. In the adjusted model, those with an SRD were significantly more likely to have ever received emergency care (aOR 3.72 [95 % CI 3.62-3.84]) than those without an SRD.

Discussion

Our study found an association between having an SRD and utilizing emergency health services. Demographic characteristics suggest disparities exist for those with SRDs around gender, race/ethnicity, insurance status, and mental health. These data can help with screening and targeted responses to prevent or provide emergency care.

Antepartum Emergency Department Use and Associations with Maternal and Neonatal Outcomes in a Large Hospital System

Objectives

Prenatal care in the United States has remained unchanged for decades, with pregnant patients often experiencing high rates of hospital emergency department (ED) visits. It is unknown how many of these ED visits are potentially preventable with better access to timely and effective outpatient or home prenatal care. This multihospital health system quality improvement study was undertaken to analyze patient risk factors for acute antepartum hospital use as well as associations with adverse maternal and neonatal birth outcomes.

Methods

The retrospective cohort study analyzed electronic health record and administrative data on ED visits in the 270 days before a delivery admission for alive, singleton births at nine system hospitals over 52 months. We use logistic regression to estimate the likelihood of hospital use by patient demographic and clinical characteristics and present the association of acute antepartum hospital use with maternal and neonatal birth outcomes.

Results

Overall, 17.5% of 68,200 patients had antepartum ED visits, including 248 inpatient admissions, with significant variation between hospitals. As compared to non-Hispanic white patients, Hispanic and especially non-Hispanic Black and Medicaid patients had significantly higher odds of acute antepartum hospital use as did patients with preexisting conditions. Birth outcomes were significantly (p < 0.01) worse among individuals with antepartum hospital utilization.

Conclusion

Acute antepartum hospital use was concentrated among lower income, minority patients, and those with chronic conditions with significant variation across system hospitals. There is a need for research into innovations in prenatal care that are best at reaching our most vulnerable patients, reducing preventable hospital utilization, and improving birth outcomes.

Early Insights into Implementation of Universal Screening, Brief Intervention, and Referral to Treatment for Perinatal Substance Use

OBJECTIVES

Perinatal substance use is a growing concern across the United States. Universal screening, brief intervention, and referral to treatment (SBIRT) is one systems-level approach to addressing perinatal substance use. The objective of this study is to assess early efforts to implement SBIRT in an outpatient obstetric clinic.

METHODS

The research team implemented universal screening with the 5 P's screening tool. Providers then engaged patients in a brief intervention and referred to a care manager who then worked with patients via tele-health to connect patients with needed services. Feasibility was measured through the collection of aggregate data describing frequency of universal screening and referral to treatment. The implementation team met bi-weekly to reflect on implementation barriers and facilitators.

RESULTS

In the first year of implementation, 48.5% of patients receiving care in the clinic completed the 5 P's screener at least once during the perinatal period. Screening occurred in a little over a quarter (26.5%) of eligible visits. Of the 463 patients that completed the 5 P's at least once during the perinatal period, 195 (42%) unique patients screened positive (answered yes to at least one question).

CONCLUSIONS FOR PRACTICE

Early implementation efforts suggest this approach is feasible in this obstetric setting. Similar implementation studies should consider implementing universal screening for substance use and perinatal mood and anxiety disorders simultaneously; guide efforts using an implementation framework; invest resources in more intensive training and ongoing coaching for providers; and adopt strategies to track frequency and fidelity of brief intervention.

Disparities in Perinatal and Emergency Care Receipt Among Women With Perinatal Opioid Use Disorder in Medicaid, 2007 to 2012

OBJECTIVES

This study aimed to better understand receipt of perinatal and emergency care among women with perinatal opioid use disorder (OUD) and explore variation by race/ethnicity.

METHODS

We used 2007-2012 Medicaid Analytic eXtract (MAX) data from all 50 states and the District of Columbia to examine 6,823,471 deliveries for women 18 to 44 years old. Logistic regressions modeled the association between (1) OUD status and receipt of perinatal and emergency care, and (2) receipt of perinatal and emergency care and race/ethnicity, conditional on OUD diagnosis and controlling for patient and county characteristics. We used robust SEs, clustered at the individual level, and included state and year fixed effects.

RESULTS

Women with perinatal OUD were less likely to receive adequate prenatal care (adjusted odds ratio [aOR], 0.45; 95% confidence interval [CI], 0.44-0.46) and attend the postpartum visit (aOR, 0.46; 95% CI, 0.45-0.47) and more likely to seek emergency care (aOR, 1.48; 95% CI, 1.45-1.51) than women without perinatal OUD. Among women with perinatal OUD, Black, Hispanic, and American Indian and Alaskan Native (AI/AN) women were less likely to receive adequate prenatal care (aOR, 0.68 [95% CI, 0.64-0.72]; aOR, 0.86 [95% CI, 0.80-0.92]; aOR, 0.71 [95% CI, 0.64-0.79]) and attend the postpartum visit (aOR, 0.85 [95% CI, 0.80-0.91]; aOR, 0.86 [95% CI, 0.80-0.93]; aOR, 0.83 [95% CI, 0.73-0.94]) relative to non-Hispanic White women. Black and AI/AN women were also more likely to receive emergency care (aOR, 1.13 [95% CI, 1.05-1.20]; aOR, 1.12 [95% CI, 1.00-1.26]).

CONCLUSIONS

Our findings suggest that women with perinatal OUD, in particular Black, Hispanic, and AI/AN women, may be missing opportunities for preventive care and comprehensive management of their physical and behavioral health during pregnancy.