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Midgette Y, Halvorson E, Chandler A, Aguilar A, Strahley AE, Gomez Y, Lassiter R, Akinola M, Hanson S, Montez K. Caregiver and Provider Perceptions of Health Disparities in the NICU: A Qualitative Study. Acad Pediatr 2024:S1876-2859(24)00284-5. [PMID: 39069230 DOI: 10.1016/j.acap.2024.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 07/08/2024] [Accepted: 07/21/2024] [Indexed: 07/30/2024]
Abstract
OBJECTIVES To describe the experience of caregivers and their perceptions of disparate care in the NICU, and (2) explore inter-professional NICU provider perspectives on potential biases and perceptions of disparate care. METHODS This qualitative study was conducted in one southeastern level IV NICU. Semi-structured interviews assessed caregiver and provider perspectives on NICU care. Purposive sampling ensured ≥50% of caregivers self-identified as racial and/or ethnic minorities. Interviews were recorded, transcribed verbatim, and audio verified. A coding scheme was developed, raw data were systematically coded, and emerging themes were identified using thematic analyses. RESULTS 23 caregivers and 14 providers were interviewed, including 5 neonatologists, 6 nurses, and 3 residents. Caregivers were predominantly English-speaking (85%); 96% were mothers with a mean age of 32 years. Neonates were predominantly racial and ethnic minorities (62%). Providers were predominantly White (71%) and female (71%). Five themes emerged: (1) ineffective, biased communication between caregivers, providers, and healthcare team may contribute to disparities (2) language barriers and lack of interpreter access play a significant role in perceived negative care; (3) lack of caregiver involvement and role in decision-making may negatively influence NICU outcomes, especially for those not able to be present at the bedside; and (4) multiple biases may affect neonatal health disparities. CONCLUSION Our study highlights the importance of considering both provider and racial and/or ethnic minority caregiver perceptions disparities in NICU care delivery. It adds to the literature as one of the few qualitative studies comparing perceptions of disparate NICU care among both caregivers and providers.
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Affiliation(s)
- Yasmeen Midgette
- Department of Pediatrics, Wake Forest University School of Medicine, One Medical Center Blvd, Winston-Salem, NC 27157.
| | - Elizabeth Halvorson
- Department of Pediatrics, Wake Forest University School of Medicine, One Medical Center Blvd, Winston-Salem, NC 27157.
| | - Allison Chandler
- Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, 525 Vine St, Winston-Salem, NC 27101.
| | - Aylin Aguilar
- Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, 525 Vine St, Winston-Salem, NC 27101.
| | - Ashley E Strahley
- Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, 525 Vine St, Winston-Salem, NC 27101.
| | - Yorjannys Gomez
- Department of Pediatrics, Wake Forest University School of Medicine, One Medical Center Blvd, Winston-Salem, NC 27157.
| | - Rebekah Lassiter
- Department of Pediatrics, Wake Forest University School of Medicine, One Medical Center Blvd, Winston-Salem, NC 27157.
| | - Modupeola Akinola
- Department of Pediatrics, Wake Forest University School of Medicine, One Medical Center Blvd, Winston-Salem, NC 27157.
| | - Shannon Hanson
- Department of Pediatrics, Wake Forest University School of Medicine, One Medical Center Blvd, Winston-Salem, NC 27157.
| | - Kimberly Montez
- Departments of Pediatrics and Social Sciences & Health Policy, Wake Forest University School of Medicine, One Medical Center Blvd, Winston-Salem, NC 27157.
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Reddy KP, Ludomirsky AB, Jones AL, Shustak RJ, Faerber JA, Naim MY, Lopez KN, Mercer-Rosa LM. Racial, ethnic, and socio-economic disparities in neonatal ICU admissions among neonates born with cyanotic CHD in the United States, 2009-2018. Cardiol Young 2024:1-8. [PMID: 38653722 DOI: 10.1017/s1047951124024971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
INTRODUCTION Disparities in CHD outcomes exist across the lifespan. However, less is known about disparities for patients with CHD admitted to neonatal ICU. We sought to identify sociodemographic disparities in neonatal ICU admissions among neonates born with cyanotic CHD. MATERIALS & METHODS Annual natality files from the US National Center for Health Statistics for years 2009-2018 were obtained. For each neonate, we identified sex, birthweight, pre-term birth, presence of cyanotic CHD, and neonatal ICU admission at time of birth, as well as maternal age, race, ethnicity, comorbidities/risk factors, trimester at start of prenatal care, educational attainment, and two measures of socio-economic status (Special Supplemental Nutrition Program for Women, Infants, and Children [WIC] status and insurance type). Multivariable logistic regression models were fit to determine the association of maternal socio-economic status with neonatal ICU admission. A covariate for race/ethnicity was then added to each model to determine if race/ethnicity attenuate the relationship between socio-economic status and neonatal ICU admission. RESULTS Of 22,373 neonates born with cyanotic CHD, 77.2% had a neonatal ICU admission. Receipt of WIC benefits was associated with higher odds of neonatal ICU admission (adjusted odds ratio [aOR] 1.20, 95% CI 1.1-1.29, p < 0.01). Neonates born to non-Hispanic Black mothers had increased odds of neonatal ICU admission (aOR 1.20, 95% CI 1.07-1.35, p < 0.01), whereas neonates born to Hispanic mothers were at lower odds of neonatal ICU admission (aOR 0.84, 95% CI 0.76-0.93, p < 0.01). CONCLUSION Maternal Black race and low socio-economic status are associated with increased risk of neonatal ICU admission for neonates born with cyanotic CHD. Further work is needed to identify the underlying causes of these disparities.
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Affiliation(s)
- Kriyana P Reddy
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Avital B Ludomirsky
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Andrea L Jones
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rachel J Shustak
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer A Faerber
- Data Science and Biostatistics Unit, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Maryam Y Naim
- Division of Cardiac Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine and Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Keila N Lopez
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Laura M Mercer-Rosa
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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LaManna S, Hatfield B, McCann E. Considering the Influence of Social Determinants of Health on Parent Feeding Practices: A Case Example. Adv Neonatal Care 2024; 24:110-118. [PMID: 38241685 DOI: 10.1097/anc.0000000000001138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
Abstract
BACKGROUND Social determinants of health (SDOH) are the nonmedical factors that influence health outcomes. SDOH can be grouped into 5 domains: economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, and social and community context. SDOH impact people's health and quality of life but may also contribute to disparities in access to food, education, and healthcare. SDOH uniquely influence parent feeding practices in the neonatal intensive care unit (NICU) in a variety of ways, ranging from logistical considerations for parent visitation to cultural beliefs such as family perception of human milk feeding. EVIDENCE ACQUISITION A hypothetical case example of a preterm infant with a feeding disorder in the NICU is used to connect SDOH that influence prenatal health, parental lived experience, and postnatal medical care to maternal and infant outcomes with implications for feeding practices. Barriers and facilitators to successful feeding practices in the NICU and at discharge are considered for each SDOH domain. RESULTS This case example increases awareness of SDOH and how they influence parent feeding practices in the NICU, focusing on the intersection of SDOH, parent stress, and oral feeding outcomes. Examples were provided for how to support applying findings into practice. IMPLICATIONS FOR PRACTICE AND RESEARCH By being creating a culture of SDOH awareness, NICU staff can assist families in overcoming barriers by putting supports in place to increase equitable participation in developmentally supportive feeding practices during the NICU stay.
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Affiliation(s)
- Stefanie LaManna
- Author Affiliation: American Speech-Language-Hearing Association, Rockville, Maryland (Mss LaManna and Hatfield); and Independent Researcher, Voorhees, New Jersey (Ms McCann)
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Mays EJ, Diggs S, Vesoulis ZA, Warner B. The Effects of Health Disparities on Neonatal Outcomes. Crit Care Nurs Clin North Am 2024; 36:11-22. [PMID: 38296368 DOI: 10.1016/j.cnc.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
The history of racism in the United States was established with slavery, and the carry-over effect continues to impact health care through structural and institutional racism. Racial segregation and redlining have impacted access to quality health care, thereby impacting prematurity and infant mortality rates. Health disparities also impact neonatal morbidities such as intraventricular hemorrhage and necrotizing enterocolitis and the family care experience including the establishment of breastfeeding and health care provider interactions.
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Affiliation(s)
- Erin J Mays
- St. Louis Children's Hospital NICU, 1 Childrens Place, St Louis, MO 63110, USA.
| | - Stephanie Diggs
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, 1 Childrens Place, #8116-NWT 8, St Louis, MO 63110, USA
| | - Zachary A Vesoulis
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, 1 Childrens Place, #8116-NWT 8, St Louis, MO 63110, USA
| | - Barbara Warner
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, 1 Childrens Place, #8116-NWT 8, St Louis, MO 63110, USA
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van de Kamp E, Ma J, Monangi N, Tsui FR, Jani SG, Kim JH, Kahn RS, Wang CJ. Addressing Health-Related Social Needs and Mental Health Needs in the Neonatal Intensive Care Unit: Exploring Challenges and the Potential of Technology. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:7161. [PMID: 38131713 PMCID: PMC10742453 DOI: 10.3390/ijerph20247161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/21/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023]
Abstract
Unaddressed health-related social needs (HRSNs) and parental mental health needs in an infant's environment can negatively affect their health outcomes. This study examines the challenges and potential technological solutions for addressing these needs in the neonatal intensive care unit (NICU) setting and beyond. In all, 22 semistructured interviews were conducted with members of the NICU care team and other relevant stakeholders, based on an interpretive description approach. The participants were selected from three safety net hospitals in the U.S. with level IV NICUs. The challenges identified include navigating the multitude of burdens families in the NICU experience, resource constraints within and beyond the health system, a lack of streamlined or consistent processes, no closed-loop referrals to track status and outcomes, and gaps in support postdischarge. Opportunities for leveraging technology to facilitate screening and referral include automating screening, initiating risk-based referrals, using remote check-ins, facilitating resource navigation, tracking referrals, and providing language support. However, technological implementations should avoid perpetuating disparities and consider potential privacy or data-sharing concerns. Although advances in technological health tools alone cannot address all the challenges, they have the potential to offer dynamic tools to support the healthcare setting in identifying and addressing the unique needs and circumstances of each family in the NICU.
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Affiliation(s)
- Eline van de Kamp
- Athena Institute, Faculty of Science, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands;
| | - Jasmin Ma
- Center for Policy, Outcomes, and Prevention, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA; (J.M.); (S.G.J.)
| | - Nagendra Monangi
- Division of Neonatology, Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA; (N.M.); (J.H.K.)
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA;
| | - Fuchiang Rich Tsui
- Tsui Laboratory, Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, PA 19146, USA;
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Shilpa G. Jani
- Center for Policy, Outcomes, and Prevention, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA; (J.M.); (S.G.J.)
| | - Jae H. Kim
- Division of Neonatology, Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA; (N.M.); (J.H.K.)
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA;
| | - Robert S. Kahn
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA;
- Michael Fisher Child Health Equity Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
| | - C. Jason Wang
- Center for Policy, Outcomes, and Prevention, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA; (J.M.); (S.G.J.)
- Department of Pediatrics and Department of Health Policy, Stanford University School of Medicine, Stanford, CA 94305, USA
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Woo JL, Laternser C, Anderson BR, Grobman WA, Monge MC, Davis MM. Association Between Prenatal Diagnosis and Age at Surgery for Noncritical and Critical Congenital Heart Defects. Circ Cardiovasc Qual Outcomes 2023; 16:e009638. [PMID: 37539540 PMCID: PMC10524984 DOI: 10.1161/circoutcomes.122.009638] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 05/30/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND The relationship between the prenatal diagnosis of congenital heart defects (CHDs) and age at CHD surgery is poorly understood, despite the known relationships between age at surgery and long-term outcomes. The objective of this study was to determine the associations between prenatal diagnosis of CHD and age at surgery, and whether these associations differ for critical and noncritical CHDs. METHODS This is a cohort analysis of patients aged 0 to 9 years who received their initial cardiac surgery at Ann & Robert H. Lurie Children's Hospital of Chicago between 2015 and 2021 with prenatal diagnosis as the exposure variable. All data were obtained from the locally maintained Society of Thoracic Surgeons Congenital Heart Surgery Database at Lurie Children's Hospital. We used multivariable fixed effects regression models to estimate the strength of the association of prenatal diagnosis with age at surgery among patients with critical (surgery ≤60 days) and noncritical (surgery >60 days) CHDs. RESULTS Of 1131 individuals who met inclusion criteria, 532 (47%) had a prenatal diagnosis, 428 (38%) had critical CHDs, 533 (47%) were female, and the median age at surgery was 119 days (interquartile range, 11-309 days). After controlling for demographics, comorbidities, and surgical complexity, the mean age at surgery was significantly younger in those with prenatally versus postnatally diagnosed critical CHD (7.1 days sooner, P<0.001) and noncritical CHDs (atrial septal defects [12.4 months sooner, P=0.037], ventricular septal defects [6.0 months sooner, P<0.003], and noncritical coarctation of the aorta [1.8 months sooner, P=0.010]). CONCLUSIONS Younger age at CHD surgery, which is associated with postsurgical neurodevelopmental and physical outcomes, is significantly associated with prenatal CHD diagnosis. This relationship was identified for both critical and noncritical CHDs.
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Affiliation(s)
- Joyce L Woo
- Division of Cardiology, Department of Pediatrics (J.L.W., C.L.), Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
- Department of Medical Social Sciences (J.L.W., M.M.D.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Christina Laternser
- Division of Cardiology, Department of Pediatrics (J.L.W., C.L.), Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Brett R Anderson
- Division of Cardiology, Department of Pediatrics, Columbia University Irving Medical Center, NewYork-Presbyterian Morgan Stanley Children's Hospital (B.R.A.)
| | - William A Grobman
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus (W.G.)
| | - Michael C Monge
- Division of Cardiac Surgery, Department of Surgery (M.M.), Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Matthew M Davis
- Division of Advanced General Pediatrics and Primary Care, Department of Pediatrics (M.M.D.), Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Stanley Manne Children's Health Institute (M.M.D.), Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
- Department of Medical Social Sciences (J.L.W., M.M.D.), Northwestern University Feinberg School of Medicine, Chicago, IL
- Department of Medicine (M.M.D.), Northwestern University Feinberg School of Medicine, Chicago, IL
- Department of Preventive Medicine (M.M.D.), Northwestern University Feinberg School of Medicine, Chicago, IL
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Qattea I, Burdjalov M, Quatei A, Agha KT, Kteish R, Aly H. Disparities in Neonatal Mortalities in the United States. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1386. [PMID: 37628385 PMCID: PMC10453382 DOI: 10.3390/children10081386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/06/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023]
Abstract
OBJECTIVE We aimed to look for the mortality of Black and White Neonates and compare the Black and White neonates' mortalities after stratifying the population by many significant epidemiologic and hospital factors. DESIGN/METHOD We utilized the National Inpatient Sample (NIS) dataset over seven years from 2012 through 2018 for all neonates ≤ 28 days of age in all hospitals in the USA. Neonatal characteristics used in the analysis included ethnicity, sex, household income, and type of healthcare insurance. Hospital characteristics were urban teaching, urban non-teaching, and rural. Hospital location was classified according to the nine U.S. Census Division regions. RESULTS Neonatal mortality continues to be higher in Black populations: 21,975 (0.63%) than in White populations: 35,495 (0.28%). Government-supported health insurance was significantly more among Black populations when compared to White (68.8% vs. 35.3% p < 0.001). Household income differed significantly; almost half (49.8%) of the Black population has income ≤ 25th percentile vs. 22.1% in White. There was a significant variation in mortality in different U.S. LOCATIONS In the Black population, the highest mortality was in the West North Central division (0.72%), and the lower mortality was in the New England division (0.51%), whereas in the White population, the highest mortality was in the East South-Central division (0.36%), and the lowest mortality was in the New England division (0.21%). Trend analysis showed a significant decrease in mortality in Black and White populations over the years, but when stratifying the population by sex, type of insurance, household income, and type of hospital, the mortality was consistently higher in Black groups throughout the study years. CONCLUSIONS Disparities in neonatal mortality continue to be higher in Black populations; there was a significant variation in mortality in different U.S. LOCATIONS In the Black population, the highest mortality was in the West North Central division, and the lower mortality was in the New England division, whereas in the White population, the highest mortality was in the East South Central division, and the lowest mortality was in the New England division. There has been a significant decrease in mortality in Black and White populations over the years, but when stratifying the population by many significant epidemiologic and hospital factors, the mortality was consistently higher in Black groups throughout the study years.
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Affiliation(s)
- Ibrahim Qattea
- Department of Neonatalogy, Cleveland Clinic Children’s, 9500 Euclid Avenue #M31-37, Cleveland, OH 44195, USA; (A.Q.); (H.A.)
- Department of Pediatrics, Nassau University Medical Center, New York, NY 11554, USA;
| | - Maria Burdjalov
- College of Arts and Sciences, The Ohio State University, Columbus, OH 43210, USA;
| | - Amani Quatei
- Department of Neonatalogy, Cleveland Clinic Children’s, 9500 Euclid Avenue #M31-37, Cleveland, OH 44195, USA; (A.Q.); (H.A.)
| | - Khalil Tamr Agha
- Department of Pediatrics, Upstate Golisano Children Hospital, Syracuse, NY 13210, USA;
| | - Rayan Kteish
- Department of Pediatrics, Nassau University Medical Center, New York, NY 11554, USA;
| | - Hany Aly
- Department of Neonatalogy, Cleveland Clinic Children’s, 9500 Euclid Avenue #M31-37, Cleveland, OH 44195, USA; (A.Q.); (H.A.)
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Joseph RA. Understanding Facilitators and Barriers to Providing Equity-Oriented Care in the NICU. Neonatal Netw 2023; 42:202-209. [PMID: 37491038 DOI: 10.1891/nn-2022-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2023] [Indexed: 07/27/2023]
Abstract
The current study examined the use of immersive technology as a way to improve access to high-quality interpersonal breastfeeding interactions in an undergraduate clinical lactation course. In particular, we investigated the impact of immersive consultation videos and related activities on student self-efficacy, motivational beliefs, and perceived skill level. Results indicate that usability was high, with participants rating videos, interactives, and activities positively. Although no significant improvements in their level of interest or perceived skill were found, students did report a significant increase in self-efficacy and their perceived ability to meet the course learning objectives. Our results demonstrate that high-quality immersive videos can be an important learning tool for teaching clinical skills when access to direct patient care is limited or absent.
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Holman C, Glover A, Fertaly K, Nelson M. Operationalizing risk-appropriate perinatal care in a rural US State: directions for policy and practice. BMC Health Serv Res 2023; 23:601. [PMID: 37291539 DOI: 10.1186/s12913-023-09552-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 05/15/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Risk-appropriate care improves outcomes by ensuring birthing people and infants receive care at a facility prepared to meet their needs. Perinatal regionalization has particular importance in rural areas where pregnant people might not live in a community with a birthing facility or specialty care. Limited research focuses on operationalizing risk-appropriate care in rural and remote settings. Through the implementation of the Centers for Disease Control and Prevention (CDC) Levels of Care Assessment Tool (LOCATe), this study assessed the system of risk-appropriate perinatal care in Montana. METHODS Primary data was collected from Montana birthing facilities that participated in the CDC LOCATe version 9.2 (collected July 2021 - October 2021). Secondary data included 2021 Montana birth records. All birthing facilities in Montana received an invitation to complete LOCATe. LOCATe collects information on facility staffing, service delivery, drills, and facility-level statistics. We added additional questions on transport. RESULTS Nearly all (96%) birthing facilities in Montana completed LOCATe (N = 25). The CDC applied its LOCATe algorithm to assign each facility with a level of care that aligns directly with guidelines published by the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG), and Society for Maternal-Fetal Medicine (SMFM). LOCATe-assessed levels for neonatal care ranged from Level I to Level III. Most (68%) facilities LOCATe-assessed at Level I or lower for maternal care. Close to half (40%) self-reported a higher-level of maternal care than their LOCATe-assessed level, indicating that many facilities believe they have greater capacity than outlined in their LOCATe-assessed level. The most common ACOG/SMFM requirements contributing to the maternal care discrepancies were the lack of obstetric ultrasound services and a physician anesthesiologist. CONCLUSIONS The Montana LOCATe results can drive broader conversations on the staffing and service requirements necessary to provide high-quality obstetric care in low-volume rural hospitals. Montana hospitals often rely on Certified Registered Nurse Anesthetists (CRNA) for anesthesia services and telemedicine to access specialty providers. Integrating a rural health perspective into the national guidelines could enhance the utility of LOCATe to support state strategies to improve the provision of risk-appropriate care.
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Affiliation(s)
- Carly Holman
- Rural Institute for Inclusive Communities, University of Montana, Missoula, MT, USA.
| | - Annie Glover
- Rural Institute for Inclusive Communities, University of Montana, Missoula, MT, USA
- School of Public and Community Health Sciences, University of Montana, Missoula, MT, USA
| | - Kaitlin Fertaly
- Rural Institute for Inclusive Communities, University of Montana, Missoula, MT, USA
| | - Megan Nelson
- Rural Institute for Inclusive Communities, University of Montana, Missoula, MT, USA
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Kozhimannil KB, Leonard SA, Handley SC, Passarella M, Main EK, Lorch SA, Phibbs CS. Obstetric Volume and Severe Maternal Morbidity Among Low-Risk and Higher-Risk Patients Giving Birth at Rural and Urban US Hospitals. JAMA HEALTH FORUM 2023; 4:e232110. [PMID: 37354537 DOI: 10.1001/jamahealthforum.2023.2110] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2023] Open
Abstract
Importance Identifying hospital factors associated with severe maternal morbidity (SMM) is essential to clinical and policy efforts. Objective To assess associations between obstetric volume and SMM in rural and urban hospitals and examine whether these associations differ for low-risk and higher-risk patients. Design, Setting, and Participants This retrospective cross-sectional study of linked vital statistics and patient discharge data was conducted from 2022 to 2023. Live births and stillbirths (≥20 weeks' gestation) at hospitals in California (2004-2018), Michigan (2004-2020), Pennsylvania (2004-2014), and South Carolina (2004-2020) were included. Data were analyzed from December 2022 to May 2023. Exposures Annual birth volume categories (low, medium, medium-high, and high) for hospitals in urban (10-500, 501-1000, 1001-2000, and >2000) and rural (10-110, 111-240, 241-460, and >460) counties. Main Outcome and Measures The main outcome was SMM (excluding blood transfusion); covariates included age, payer status, educational attainment, race and ethnicity, and obstetric comorbidities. Analyses were stratified for low-risk and higher-risk obstetric patients based on presence of at least 1 clinical comorbidity. Results Among more than 11 million urban births and 519 953 rural births, rates of SMM ranged from 0.73% to 0.50% across urban hospital volume categories (high to low) and from 0.47% to 0.70% across rural hospital volume categories (high to low). Risk of SMM was elevated for patients who gave birth at rural hospitals with annual birth volume of 10 to 110 (adjusted risk ratio [ARR], 1.65; 95% CI, 1.14-2.39), 111 to 240 (ARR, 1.37; 95% CI, 1.10-1.70), and 241 to 460 (ARR, 1.26; 95% CI, 1.05-1.51), compared with rural hospitals with greater than 460 births. Increased risk of SMM occurred for low-risk and higher-risk obstetric patients who delivered at rural hospitals with lower birth volumes, with low-risk rural patients having notable discrepancies in SMM risk between low (ARR, 2.32; 95% CI, 1.32-4.07), medium (ARR, 1.66; 95% CI, 1.20-2.28), and medium-high (ARR, 1.68; 95% CI, 1.29-2.18) volume hospitals compared with high volume (>460 births) rural hospitals. Among hospitals in urban counties, there was no significant association between birth volume and SMM for low-risk or higher-risk obstetric patients. Conclusions and Relevance In this cross-sectional study of births in US rural and urban counties, risk of SMM was elevated for low-risk and higher-risk obstetric patients who gave birth in lower-volume hospitals in rural counties, compared with similar patients who gave birth at rural hospitals with greater than 460 annual births. These findings imply a need for tailored quality improvement strategies for lower volume hospitals in rural communities.
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Affiliation(s)
- Katy Backes Kozhimannil
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Stephanie A Leonard
- Department of Obstetrics & Gynecology, Stanford University School of Medicine, Stanford, California
- California Maternal Quality Care Collaborative, Stanford
| | - Sara C Handley
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania, Philadelphia
| | - Molly Passarella
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elliott K Main
- Department of Obstetrics & Gynecology, Stanford University School of Medicine, Stanford, California
- California Maternal Quality Care Collaborative, Stanford
| | - Scott A Lorch
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania, Philadelphia
| | - Ciaran S Phibbs
- Health Economics Resource Center, Veterans Affairs Palo Alto Healthcare System, Menlo Park, California
- Departments of Pediatrics and Health Policy, Stanford University School of Medicine, Stanford, California
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11
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Pineda R, Kati Knudsen, Breault CC, Rogers EE, Mack WJ, Fernandez-Fernandez A. NICUs in the US: levels of acuity, number of beds, and relationships to population factors. J Perinatol 2023; 43:796-805. [PMID: 37208426 PMCID: PMC10197033 DOI: 10.1038/s41372-023-01693-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 04/13/2023] [Accepted: 04/28/2023] [Indexed: 05/21/2023]
Abstract
OBJECTIVE To 1) define the number and characteristics of NICUs in the United States (US) and 2) identify hospital and population characteristics related to US NICUs. STUDY DESIGN Cohort study of US NICUs. RESULTS There were 1424 NICUs identified in the US. Higher number of NICU beds was positively associated with higher NICU level (p < 0.0001). Higher acuity level and number of NICU beds related to being in a children's hospital (p < 0.0001;p < 0.0001), part of an academic center (p = 0.006;p = 0.001), and in a state with Certificate of Need legislation (p = 0.023;p = 0.046). Higher acuity level related to higher population density (p < 0.0001), and higher number of beds related to increasing proportions of minorities in the population up until 50% minorities. There was also significant variation in NICU level by region. CONCLUSIONS This study contributes new knowledge by describing an updated registry of NICUs in the US in 2021 that can be used for comparisons and benchmarking.
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Affiliation(s)
- Roberta Pineda
- Chan Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, CA, USA.
- Keck School of Medicine, Department of Pediatrics, Los Angeles, CA, USA.
- Gehr Family Center for Health Systems Science and Innovation, University of Southern California, Los Angeles, CA, USA.
- Program in Occupational Therapy, Washington University, St. Louis, MO, USA.
| | - Kati Knudsen
- Neonatal Intensive Care Unit, Providence St. Vincent Medical Center, Portland, OR, USA
| | - Courtney C Breault
- California Perinatal Quality Care Collaborative (CPQCC), Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Elizabeth E Rogers
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Wendy J Mack
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA
| | - Alicia Fernandez-Fernandez
- Physical Therapy Department, Dr. Pallavi Patel College of Health Care Sciences, Nova Southeastern University, Fort Lauderdale, FL, USA
- Neonatal Intensive Care Unit, South Miami Hospital, Miami, FL, USA
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12
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Thorsen ML, Harris S, Palacios JF, McGarvey RG, Thorsen A. American Indians travel great distances for obstetrical care: Examining rural and racial disparities. Soc Sci Med 2023; 325:115897. [PMID: 37084704 PMCID: PMC10164064 DOI: 10.1016/j.socscimed.2023.115897] [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: 09/28/2022] [Revised: 01/20/2023] [Accepted: 04/06/2023] [Indexed: 04/23/2023]
Abstract
Rural, American Indian/Alaska Native (AI/AN) people, a population at elevated risk for complex pregnancies, have limited access to risk-appropriate obstetric care. Obstetrical bypassing, seeking care at a non-local obstetric unit, is an important feature of perinatal regionalization that can alleviate some challenges faced by this rural population, at the cost of increased travel to give birth. Data from five years (2014-2018) of birth certificates from Montana, along with the 2018 annual survey of the American Hospital Association (AHA) were used in logistic regression models to identify predictors of bypassing, with ordinary least squares regression models used to predict factors associated with the distance (in miles) birthing people drove beyond their local obstetric unit to give birth. Logit analyses focused on hospital-based births to Montana residents delivered during this time period (n = 54,146 births). Distance analyses focused on births to individuals who bypassed their local obstetric unit to deliver (n = 5,991 births). Individual-level predictors included maternal sociodemographic characteristics, location, perinatal health characteristics, and health care utilization. Facility-related measures included level of obstetric care of the closest and delivery hospitals, and distance to the closest hospital-based obstetric unit. Findings suggest that birthing people living in rural areas and on American Indian reservations were more likely to bypass to give birth, with bypassing likelihood depending on health risk, insurance, and rurality. AI/AN and reservation-dwelling birthing people traveled significantly farther when bypassing. Findings highlight that distance traveled was even farther for AI/AN people facing pregnancy health risks (23.8 miles farther than White people with pregnancy risks) or when delivering at facilities offering complex care (14-44 miles farther than White people). While bypassing may connect rural birthing people to more risk-appropriate care, rural and racial inequities in access persist, with rural, reservation-dwelling AI/AN birthing people experiencing greater likelihood of bypassing and traveling greater distances when bypassing.
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Affiliation(s)
- Maggie L Thorsen
- Department of Sociology and Anthropology, Montana State University, USA.
| | - Sean Harris
- Jake Jabs College of Business and Entrepreneurship, Montana State University, USA
| | - Janelle F Palacios
- Department of Obstetrics and Gynecology, Kaiser Permanente Northern California, Oakland, California, 94611, USA
| | - Ronald G McGarvey
- IESEG School of Management, Univ. Lille, CNRS, UMR 9221 - LEM - Lille Economie Management, F-59000, Lille, France
| | - Andreas Thorsen
- Jake Jabs College of Business and Entrepreneurship, Montana State University, USA
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13
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Abstract
Rural communities are a vital segment of the US population; however, these communities are shrinking, and their population is aging. Rural women experience health disparities including increased risk of maternal morbidity and mortality. In this article, we will explore these trends and their determinants both within and external to the health care system. Health care providers, public health professionals, and policymakers should be aware of these social and structural factors that influence health outcomes and take action to reduce generational cycles of health disparity. Opportunities to improve the health and pregnancy outcomes for rural women and rural populations are highlighted.
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14
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Ondusko DS, Liu J, Hatch B, Profit J, Carter EH. Associations between maternal residential rurality and maternal health, access to care, and very low birthweight infant outcomes. J Perinatol 2022; 42:1592-1599. [PMID: 35821103 DOI: 10.1038/s41372-022-01456-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 06/17/2022] [Accepted: 06/30/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Infant mortality is increased in isolated rural areas. This study compares prenatal factors, access to care, and health outcomes for very-low birthweight (VLBW) infants by degree of maternal residential rurality. METHODS This descriptive population-based retrospective cohort study used the California Perinatal Quality Care Collaborative registry to study VLBW infants. Rurality was assigned as urban, large rural, and small rural/isolated using the Rural Urban Commuting Area codes. We used hierarchical random effect models to test the association of rurality with survival without major morbidity. RESULTS The study included 38 614 dyads. VLBW survival without major morbidity decreased with increasing rurality and the relationship remained significant for small rural/isolated areas (OR 0.79, p = 0.03) after adjustment. Birth weight, gestational age, and infant sex were similar across geographic groups. CONCLUSION A rural urban disparity exists for VLBW survival without major morbidity. Our findings generate hypotheses about factors that may be driving these disparities.
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Affiliation(s)
- Devlynne S Ondusko
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, OR, USA.
| | - Jessica Liu
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA, USA.,California Perinatal Quality Care Collaborative, Palo Alto, CA, USA
| | - Brigit Hatch
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Jochen Profit
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA, USA.,California Perinatal Quality Care Collaborative, Palo Alto, CA, USA
| | - Emily Hawkins Carter
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, OR, USA
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15
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Brachio SS, Reichman V. Scoring Quality, Scoring Equity: The Promise and Power of Scorecards to Facilitate Bidirectional, Real-Time Communication. J Pediatr 2022; 247:14-16. [PMID: 35577117 DOI: 10.1016/j.jpeds.2022.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 05/11/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Sandhya S Brachio
- Division of Neonatology, Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian, New York, New York.
| | - Vicky Reichman
- Department of Pediatrics, Lenox Hill Hospital, New York, New York
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16
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Abstract
Advances in neonatal intensive care have improved outcomes for preterm newborns, but significant racial/ethnic disparities persist. Neonatal disparities have their origin in a complex set of factors that include systemic racism and structural disadvantages endured by minority families, but differential quality of care in the neonatal intensive care unit (NICU) remains an important and modifiable source of disparity. NICU care has been shown to be segregated and unequal: Black and Hispanic infants are more likely to be cared for in lower quality NICUs and may receive worse care within a NICU. To eliminate disparities in care and outcomes, it is important to identify and address the mechanisms that lead to lower quality care for minority preterm infants. In this review, we identify improvements in both technical (clinical) and relational (engaging and supporting families) processes of care as critical to better outcomes for minority infants and families.
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Affiliation(s)
- Dhurjati Ravi
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA; California Perinatal Quality Care Collaborative, Palo Alto, CA, USA.
| | - Alexandra Iacob
- Division of Neonatal and Perinatal Medicine, Department of Pediatrics, School of Medicine, University of California Irvine, Irvine, CA, USA
| | - Jochen Profit
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA; California Perinatal Quality Care Collaborative, Palo Alto, CA, USA
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