1
|
Shao SJ, Cassidy AG, Alanizi A, Agarwal A, Sobhani NC. Contraceptive counseling and choices in pregnancies with maternal cardiac disease. J Matern Fetal Neonatal Med 2023; 36:2217318. [PMID: 37263627 DOI: 10.1080/14767058.2023.2217318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/12/2023] [Accepted: 05/18/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVE Unplanned pregnancies in women with maternal cardiac disease (MCD) are associated with increased morbidity and mortality, but the majority of these individuals do not use highly reliable contraception on postpartum hospital discharge. Contraceptive counseling in this population outside of pregnancy is incomplete and counseling during pregnancy remains poorly characterized. Our objective was to evaluate the provision and quality of contraceptive counseling for individuals with MCD during pregnancy. METHODS All individuals with MCD who delivered between 2008 and 2021 at a tertiary care institution with a multidisciplinary cardio-obstetrics team were sent a 27-question survey. A subset of questions were derived from the validated Interpersonal Quality in Family Planning (IQFP) survey, which emphasizes interpersonal connection, adequate information, and decision support for the individual. Each participant received a $15 gift card for survey completion. We performed chart review for clinical and demographic details, including cardiac risk score. RESULTS Of 522 individuals to whom the survey was sent, 133 responded and met inclusion criteria. Overall, 67% discussed contraception with their general obstetrician, 36% with their maternal-fetal medicine (MFM) specialist, and 24% with their cardiologist. Compared to individuals with low cardiac risk scores, those with high cardiac risk scores had a nonsignificant trend toward being more likely to discuss contraception with a MFM provider (52% vs 33%, p = .08). 65% reported that their provider was 'excellent' or 'good' in all IQFP domains. Respondents valued providers who respected their autonomy and offered thorough counseling. Respondents disliked feeling pressured or uninformed about the safety of contraceptive options. CONCLUSION Most individuals with MCD reported excellent contraceptive counseling during pregnancy. Additional work is needed to understand barriers to and enablers for effective, patient-centered contraceptive counseling and use in this population.
Collapse
Affiliation(s)
- Shirley J Shao
- School of Medicine, University of California San Francisco, CA, USA
| | - Arianna G Cassidy
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Maternal-Fetal Medicine, University of California, San Francisco, CA, USA
| | - Aryn Alanizi
- School of Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Anushree Agarwal
- Department of Medicine, Division of Cardiology, University of California, San Francisco, CA, USA
| | - Nasim C Sobhani
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Maternal-Fetal Medicine, University of California, San Francisco, CA, USA
| |
Collapse
|
2
|
Yellin S, Wiener S, Kankaria R, Vorawandthanachai T, Hsu D, Haberer K, Bortnick AE, Diana WS. Characteristics and outcomes of socioeconomically disadvantaged pregnant individuals with adult congenital heart disease presenting to a Cardio-Obstetrics Program. Am J Obstet Gynecol MFM 2023; 5:101146. [PMID: 37659603 PMCID: PMC11157696 DOI: 10.1016/j.ajogmf.2023.101146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/20/2023] [Accepted: 08/26/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND Outcomes of individuals with adult congenital heart disease who are socioeconomically disadvantaged and cared for in cardio-obstetrical programs, are lacking. OBJECTIVE This study aimed to describe the clinical characteristics, maternal pregnancy outcomes, and contraceptive uptake in individuals with adult congenital heart disease in an urban cardio-obstetrical program. STUDY DESIGN Retrospective data were collected for individuals with adult congenital heart disease seen in the Maternal Fetal Medicine-Cardiology Joint Program at Montefiore Health System between 2015 and 2021 and compared using modified World Health Organization class I, II vs the modified World Health Organization class ≥II/III. RESULTS Over 90% of individuals with adult congenital heart disease were pregnant at the time of referral. Modified World Health Organization class I, II (n=77, 62.4% Black or Hispanic/Latina) had a total of 94 pregnancies and modified World Health Organization class ≥II/III (n=49, 49.0% Black or Hispanic/Latina) had a total of 56 pregnancies. Over 25% of individuals in each group had a body mass index ≥30 (P=.78), and very low summary socioeconomic scores. Modified World Health Organization class ≥II/III were more likely to be anticoagulated in the first trimester than modified World Health Organization class I, II (10.7% vs 0.0%, P=.002) and throughout pregnancy (14.3% vs 3.2% P=.02). Modified World Health Organization class ≥II/III were more likely to require arterial monitoring during delivery than modified World Health Organization class I, II (14.3% vs 0.0%, P=.001) or delivery under general anesthesia (8.9% vs 1.1%, P=.03) but had a comparable frequency of cesarean delivery (35.8% vs 41.3%, P=.68). There were no in-hospital maternal deaths. There was no difference in the type of contraception recommended by modified World Health Organization class, however, modified World Health Organization class ≥II/III were more likely to receive long-acting types or permanent sterilization (35.6% vs 54.6%, P=.045). CONCLUSION In a socioeconomically disadvantaged cohort with adult congenital heart disease from a historically marginalized community, those with modified World Health Organization class ≥II/III had more complex antepartum and intrapartum needs but similar maternal and obstetrical outcomes as modified World Health Organization class I, II. The multidisciplinary approach offered by a cardio-obstetrics program may contribute to successful outcomes in this high-risk cohort, and these data are hypothesis-generating.
Collapse
Affiliation(s)
- Shira Yellin
- Albert Einstein College of Medicine, Bronx, NY (Dr. Yellin, Dr. Wiener, Dr. Kankaria, Dr. Vorawandthanachai, Dr. Hsu, Dr. Haberer, Dr. Bortnick, and Dr. Diana)
| | - Sara Wiener
- Albert Einstein College of Medicine, Bronx, NY (Dr. Yellin, Dr. Wiener, Dr. Kankaria, Dr. Vorawandthanachai, Dr. Hsu, Dr. Haberer, Dr. Bortnick, and Dr. Diana)
| | - Rohan Kankaria
- Albert Einstein College of Medicine, Bronx, NY (Dr. Yellin, Dr. Wiener, Dr. Kankaria, Dr. Vorawandthanachai, Dr. Hsu, Dr. Haberer, Dr. Bortnick, and Dr. Diana)
| | - Thammatat Vorawandthanachai
- Albert Einstein College of Medicine, Bronx, NY (Dr. Yellin, Dr. Wiener, Dr. Kankaria, Dr. Vorawandthanachai, Dr. Hsu, Dr. Haberer, Dr. Bortnick, and Dr. Diana)
| | - Daphne Hsu
- Albert Einstein College of Medicine, Bronx, NY (Dr. Yellin, Dr. Wiener, Dr. Kankaria, Dr. Vorawandthanachai, Dr. Hsu, Dr. Haberer, Dr. Bortnick, and Dr. Diana); Division of Pediatric Cardiology and Adult Congenital Heart Program, Department of Pediatrics, Children's Hospital at Montefiore Medical Center, Bronx, NY (Dr. Hsu and Dr. Haberer)
| | - Kim Haberer
- Albert Einstein College of Medicine, Bronx, NY (Dr. Yellin, Dr. Wiener, Dr. Kankaria, Dr. Vorawandthanachai, Dr. Hsu, Dr. Haberer, Dr. Bortnick, and Dr. Diana); Division of Pediatric Cardiology and Adult Congenital Heart Program, Department of Pediatrics, Children's Hospital at Montefiore Medical Center, Bronx, NY (Dr. Hsu and Dr. Haberer)
| | - Anna E Bortnick
- Albert Einstein College of Medicine, Bronx, NY (Dr. Yellin, Dr. Wiener, Dr. Kankaria, Dr. Vorawandthanachai, Dr. Hsu, Dr. Haberer, Dr. Bortnick, and Dr. Diana); Division of Cardiology, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (Dr. Bortnick and Dr. Diana); Maternal Fetal Medicine-Cardiology Joint Program, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (Dr. Bortnick and Dr. Diana); Department of Women's Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (Dr. Bortnick and Dr. Diana)
| | - Wolfe S Diana
- Albert Einstein College of Medicine, Bronx, NY (Dr. Yellin, Dr. Wiener, Dr. Kankaria, Dr. Vorawandthanachai, Dr. Hsu, Dr. Haberer, Dr. Bortnick, and Dr. Diana); Division of Cardiology, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (Dr. Bortnick and Dr. Diana); Maternal Fetal Medicine-Cardiology Joint Program, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (Dr. Bortnick and Dr. Diana); Department of Women's Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (Dr. Bortnick and Dr. Diana).
| |
Collapse
|
3
|
Russo M, Boehler-Tatman M, Albright C, David C, Kennedy L, Roberts AW, Shalhub S, Afifi R. Aortic dissection in pregnancy and the postpartum period. Semin Vasc Surg 2022; 35:60-68. [PMID: 35501042 DOI: 10.1053/j.semvascsurg.2022.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/16/2022] [Accepted: 02/16/2022] [Indexed: 01/18/2023]
Abstract
Pregnancy-associated aortic dissection (AD) is a rare event, with an incidence of 0.0004% per pregnancy. The work of the Aortic Dissection Collaborative identified pregnancy-associated AD as a high-priority topic, despite its rarity. The Pregnancy Working Group, which included physicians and patient stakeholders, performed a systematic literature review of pregnancy-associated AD from 1960 to 2021 and identified 6,333 articles through PubMed, OVID MEDLINE, Cochrane, Embase, CINAHL and Web of Science. The inclusion criterion was AD in pregnant populations and exclusion criteria were case reports, conference abstracts, and languages other than English. Assessment of full-text articles for eligibility after removal of duplicates from all databases yielded 68 articles to be included in the final review. Topics included were timing of AD in pregnancy, type of AD, and management considerations of pregnancy-associated AD. The Pregnancy Working Group identified gaps in knowledge and future areas of research for pregnancy-associated AD, including clinical management, mental health outcomes post AD, reproductive and genetic counseling, and contraception after AD. Future collaborative projects could be a multicenter, international registry for all pregnancy-associated AD to refine the risk factors, best practice and management of AD in pregnancy. In addition, future mixed methodology studies may be useful to explore social, mental, and emotional factors related to pregnancy-associated AD and to determine support groups' effect on anxiety and depression related to these events in the pregnancy and postpartum period.
Collapse
Affiliation(s)
- Melissa Russo
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Women and Infants Hospital, Providence, Warren Alpert Medical School of Brown University, Providence, RI
| | | | - Catherine Albright
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Washington Medical Center, Seattle, WA
| | - Carmen David
- Aortic Dissection Collaborative Patient Stakeholder Group, Bedford, TX
| | | | - Aaron W Roberts
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center, Houston, TX
| | - Sherene Shalhub
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA
| | - Rana Afifi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), 6400 Fannin Street, Suite #2850, Houston, TX 77030.
| | | |
Collapse
|
4
|
Nekuei N, Kohan S, Movahedi M, Sadeghi M. Identifying and responding to the sexual reproductive health needs of women with heart disease: A qualitative study. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2022; 27:221-228. [PMID: 36237959 PMCID: PMC9552580 DOI: 10.4103/ijnmr.ijnmr_230_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/06/2021] [Accepted: 11/29/2021] [Indexed: 11/06/2022]
Abstract
Background: Recognizing the needs of women with heart disease in the field of reproductive health and meeting them can reduce the related complications. The aim of this study was to identify the sexual and reproductive health needs of these women. Materials and Methods: The present study was conducted with qualitative approach (Content analysis). Ten married women of reproductive age with heart disease and 20 providers and managers in, Isfahan, Iran, were selected by using purposive and snowball methods (in 2020). The research setting included heart disease clinics, offices of health team, comprehensive health centers, and the Isfahan Maternal Health Department. Data were collected by semi-structured individual face-to-face interviews in the clinic or other appropriate locations. Some interviews were conducted virtually. Analysis was performed by Qualitative contentment analysis / Conventional content analysis. Results: Sexual and reproductive health needs of women with heart disease were emerged in five main categories, “planned childbearing,” “ssociocultural support,” “Early reproductive health care of girls,” “health team attention to sexual health,” and “health system revision.” Conclusions: Providing comprehensive reproductive health services before and during pregnancy, family planning, and sexual health for women with heart disease is necessary. It seems that using a multidisciplinary team approach could improve their reproductive health.
Collapse
|
5
|
Yu B, Li M, Han SP, Yu Z, Zhu J. Circular RNA hsa_circ_105039 promotes cardiomyocyte differentiation by sponging miR‑17 to regulate cyclinD2 expression. Mol Med Rep 2021; 24:861. [PMID: 34664684 PMCID: PMC8548937 DOI: 10.3892/mmr.2021.12501] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 09/10/2021] [Indexed: 11/06/2022] Open
Abstract
Previously it was found that hsa_circ_105039 was underexpressed in the heart tissue of patients with congenital heart disease (CHD). However, the function and mechanism of hsa_circ_105039 in CHD are unclear. In the present study, induced pluripotent stem (iPS) cells were differentiated into cardiomyocytes using 1% dimethyl sulfoxide (DMSO). Cell differentiation, viability, migration and apoptosis were measured before and following hsa_circ_105039 knockdown or overexpression. The results indicated that hsa_circ_105039 overexpression promoted cell differentiation, viability and migration; whereas apoptosis was simultaneously repressed. A luciferase reporter assay verified that hsa_circ_105039 acted as a sponge for microRNA (miR)‑17 and that cyclinD2 was a direct target of miR‑17. Furthermore, differentiation‑related genes and proteins were analyzed by reverse transcription‑quantitative PCR and western blotting, respectively. The results showed that hsa_circ_105039 could also upregulate the expression of differentiation‑related genes and proteins, including natriuretic peptide A, cardiac troponin I, GATA‑binding protein 4 and homobox transcription factor, in iPS cells. The results suggested that hsa_circ_105039 exerted a protective effect by promoting miR‑17/cyclinD2 in DMSO‑induced iPS cardiomyocytes, which indicated that hsa_circ_105039 is a potential key molecule for the diagnosis of CHD.
Collapse
Affiliation(s)
- Boshi Yu
- Department of Pediatrics, Women's Hospital of Nanjing Medical University Nanjing Maternity and Child Health Care Hospital, Nanjing, Jiangsu 210004, P.R. China
| | - Mengmeng Li
- Department of Pediatrics, Women's Hospital of Nanjing Medical University Nanjing Maternity and Child Health Care Hospital, Nanjing, Jiangsu 210004, P.R. China
| | - Shu Ping Han
- Department of Pediatrics, Women's Hospital of Nanjing Medical University Nanjing Maternity and Child Health Care Hospital, Nanjing, Jiangsu 210004, P.R. China
| | - Zhangbin Yu
- Department of Pediatrics, Women's Hospital of Nanjing Medical University Nanjing Maternity and Child Health Care Hospital, Nanjing, Jiangsu 210004, P.R. China
| | - Jingai Zhu
- Department of Pediatrics, Women's Hospital of Nanjing Medical University Nanjing Maternity and Child Health Care Hospital, Nanjing, Jiangsu 210004, P.R. China
| |
Collapse
|
6
|
Sharma G, Ying W, Silversides CK. The Importance of Cardiovascular Risk Assessment and Pregnancy Heart Team in the Management of Cardiovascular Disease in Pregnancy. Cardiol Clin 2021; 39:7-19. [PMID: 33222816 DOI: 10.1016/j.ccl.2020.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Pregnancy-related maternal morbidity and mortality is increasing because of complications from cardiovascular disease. Pregnancy results in physiologic changes that can adversely impact the cardiovascular system and lead to adverse pregnancy outcomes. A multidisciplinary pregnancy heart team is essential to safely navigate women with heart disease through pregnancy. This role of the pregnancy heart team is to offer preconception counseling, determine pregnancy risks and educate women about those risks, develop a comprehensive antenatal and delivery plan, and ensure appropriate postpartum follow-up. These steps are important to improve cardiovascular outcomes in pregnancy.
Collapse
Affiliation(s)
- Garima Sharma
- Division of Cardiology, Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine and Hospital, 1800 Orleans Street, Zayed 7125s, Baltimore, MD 21287, USA.
| | - Wendy Ying
- Division of Cardiology, Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine and Hospital, 1800 Orleans Street, Zayed 7125s, Baltimore, MD 21287, USA. https://twitter.com/WendyYingMD
| | - Candice K Silversides
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Research Program, Mount Sinai and Toronto General Hospitals, 700 University Avenue, Room 3-913, Toronto, Ontario M5G 1Z5, Canada. https://twitter.com/CandiceSilvers1
| |
Collapse
|
7
|
Yamasaki K, Sawatari H, Konagai N, Kamiya CA, Yoshimatsu J, Muneuchi J, Watanabe M, Fukuda T, Mizuno A, Sakamoto I, Yamamura K, Ohkusa T, Tsutsui H, Niwa K, Chishaki A. Peripartum Management of Pregnant Women With Congenital Heart Disease. Circ J 2019; 83:2257-2264. [PMID: 31462608 DOI: 10.1253/circj.cj-19-0369] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The average maternal age at delivery, and thus the associated maternal risk are increasing including in women with congenital heart disease (CHD). A comprehensive management approach is therefore required for pregnant women with CHD. The present study aimed to investigate the factors determining peripartum safety in women with CHD.Methods and Results:We retrospectively collected multicenter data for 217 pregnant women with CHD (age at delivery: 31.4±5.6 years; NYHA classifications I and II: 88.9% and 7.4%, respectively). CHD severity was classified according to the American College of Cardiology/American Heart Association guidelines as simple (n=116), moderate complexity (n=69), or great complexity (n=32). Cardiovascular (CV) events (heart failure: n=24, arrhythmia: n=9) occurred in 30 women during the peripartum period. Moderate or great complexity CHD was associated with more CV events during gestation than simple CHD. CV events occurred earlier in women with moderate or great complexity compared with simple CHD. Number of deliveries (multiparity), NYHA functional class, and severity of CHD were predictors of CV events. CONCLUSIONS This study identified not only the severity of CHD according to the ACC/AHA and NYHA classifications, but also the number of deliveries, as important predictive factors of CV events in women with CHD. This information should be made available to women with CHD and medical personnel to promote safe deliveries.
Collapse
Affiliation(s)
- Keiko Yamasaki
- Faculty of Health Sciences, Department of Nursing, Ube Frontier University
| | - Hiroyuki Sawatari
- Department of Health Care for Adults, Graduate School of Biomedical and Health Sciences, Hiroshima University
| | - Nao Konagai
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center
| | - Chizuko A Kamiya
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center
| | - Jun Yoshimatsu
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center
| | - Jun Muneuchi
- Department of Pediatrics, Community Healthcare Organization Kyushu Hospital
| | - Mamie Watanabe
- Department of Pediatrics, Community Healthcare Organization Kyushu Hospital
| | - Terunobu Fukuda
- Department of Cardiology, Cardiovascular Center, St. Luke's International University Hospital
| | - Atsushi Mizuno
- Department of Cardiology, Cardiovascular Center, St. Luke's International University Hospital
| | - Ichiro Sakamoto
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | - Kenichiro Yamamura
- Department of Pediatrics, Kyushu University Graduate School of Medical Sciences
| | - Tomoko Ohkusa
- Faculty of Health Sciences, Department of Nursing, Ube Frontier University
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | - Koichiro Niwa
- Department of Cardiology, Cardiovascular Center, St. Luke's International University Hospital
| | - Akiko Chishaki
- Department of Health Sciences, Kyushu University Graduate School of Medical Sciences
| |
Collapse
|
8
|
Real-world healthcare utilization in adult congenital heart disease: a systematic review of trends and ratios. Cardiol Young 2019; 29:553-563. [PMID: 31046858 DOI: 10.1017/s1047951119000441] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND As a result of medical advances, the adult congenital heart disease population is rapidly expanding. Nonetheless, most patients remain prone to increased morbidity and mortality. Therefore, long-term medical resource use is required. This systematic review aims to present the trends over the past decades of medical resource utilization in adult congenital heart disease as well as its current status, with a focus on hospitalizations, emergency department visits, outpatient cardiology visits, and visits to other healthcare professionals. METHODS MEDLINE (Pubmed), Embase, and Web of Science were searched for retrospective database research publications. The ISPOR checklist for retrospective database research was used for quality appraisal. Trends over time are explored. RESULTS Twenty-one articles met the inclusion criteria. All but one of the studies was conducted in Western Europe and North America. The absolute number of hospitalizations has been increasing over the last several decades. This increase is highest in patients with mild lesions, although these numbers are largely driven by hospitalizations of patients with an atrial septal defect or a patent foramen ovale. Meanwhile, outpatient cardiology visits are increasing at an even higher pace, and occur most often in geriatric patients and patients with severe lesions. Conversely, the number of hospitalizations per 100 patients is decreasing over time. Literature is scarce on other types of healthcare use. CONCLUSION A strong rise in healthcare utilization is noticed, despite the mitigating effect of improved efficiency levels. As the population continues to grow, innovative medical management strategies will be required to accommodate its increasing healthcare utilization.
Collapse
|