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Salazar EG, Passarella M, Formanowski B, Phibbs CS, Lorch SA, Handley SC. The impact of volume and neonatal level of care on outcomes of moderate and late preterm infants. J Perinatol 2024; 44:1409-1415. [PMID: 38413758 PMCID: PMC11347722 DOI: 10.1038/s41372-024-01901-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 01/18/2024] [Accepted: 01/29/2024] [Indexed: 02/29/2024]
Abstract
OBJECTIVE Evaluate the relationship of neonatal unit level of care (LOC) and volume with mortality or morbidity in moderate-late preterm (MLP) (32-36 weeks' gestation) infants. DESIGN Retrospective cohort study of 650,865 inborn MLP infants in 4976 hospitals-years using 2003-2015 linked administrative data from 4 states. Exposure was combined neonatal LOC and MLP annual volume. The primary outcome was death or morbidity (respiratory distress syndrome, severe intraventricular hemorrhage, necrotizing enterocolitis, sepsis, infection, pneumothorax, extreme length of stay) with components as secondary outcomes. Poisson regression models adjusted for patient characteristics with a random effect for unit were used. RESULTS In adjusted models, high-volume level 2 units had a lower risk of the primary outcome compared to low-volume level 3 units (aIRR 0.90 [95% CI 0.83-0.98] vs. aIRR 1.13 [95% CI 1.03-1.24], p < 0.001) CONCLUSION: MLP infants had improved outcomes in high-volume level 2 units compared to low-volume level 3 units in adjusted analysis.
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MESH Headings
- Humans
- Infant, Newborn
- Retrospective Studies
- Female
- Infant, Premature
- Male
- Hospitals, High-Volume
- Infant, Premature, Diseases/therapy
- Infant, Premature, Diseases/mortality
- Intensive Care Units, Neonatal
- Hospitals, Low-Volume/statistics & numerical data
- Gestational Age
- Length of Stay/statistics & numerical data
- United States
- Infant Mortality
- Infant
- Respiratory Distress Syndrome, Newborn/therapy
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Affiliation(s)
- Elizabeth G Salazar
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Molly Passarella
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Brielle Formanowski
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ciaran S Phibbs
- Stanford University School of Medicine, Stanford, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Scott A Lorch
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sara C Handley
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Rebouças P, Paixão ES, Ramos D, Pescarini J, Pinto-Junior EP, Falcão IR, Ichihara MY, Sena S, Veiga R, Ribeiro R, Rodrigues LC, Barreto ML, Goes EF. Ethno-racial inequalities on adverse birth and neonatal outcomes: a nationwide, retrospective cohort study of 21 million Brazilian newborns. LANCET REGIONAL HEALTH. AMERICAS 2024; 37:100833. [PMID: 39070074 PMCID: PMC11269955 DOI: 10.1016/j.lana.2024.100833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 04/30/2024] [Accepted: 06/18/2024] [Indexed: 07/30/2024]
Abstract
Background Ethno-racial inequalities are critical determinants of health outcomes. We quantified ethnic-racial inequalities on adverse birth outcomes and early neonatal mortality in Brazil. Methods We conducted a cohort study in Brazil using administrative linked data between 2012 and 2019. Estimated the attributable fractions for the entire population (PAF) and specific groups (AF), as the proportion of each adverse outcome that would have been avoided if all women had the same baseline conditions as White women, both unadjusted and adjusted for socioeconomics and maternal risk factors. AF was also calculated by comparing women from each maternal race/skin colour group in different groups of mothers' schooling, with White women with 8 or more years of education as the reference group and by year. Findings 21,261,936 newborns were studied. If all women experienced the same rate as White women, 1.7% of preterm births, 7.2% of low birth weight (LBW), 10.8% of small for gestational age (SGA) and 11.8% of early neonatal deaths would have been prevented. Percentages preventable were higher among Indigenous (22.2% of preterm births, 17.9% of LBW, 20.5% of SGA and 19.6% of early neonatal deaths) and Black women (6% of preterm births, 21.4% of LBW, 22.8% of SGA births and 20.1% of early neonatal deaths). AF was higher in groups with fewer years of education among Indigenous, Black and Parda for all outcomes. AF increased over time, especially among Indigenous populations. Interpretation A considerable portion of adverse birth outcomes and neonatal deaths could be avoided if ethnic-racial inequalities were non-existent in Brazil. Acting on the causes of these inequalities must be central in maternal and child health policies. Funding Bill & Melinda Gates Foundation and Wellcome Trust.
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Affiliation(s)
- Poliana Rebouças
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Bahia, Brazil
| | - Enny S. Paixão
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Bahia, Brazil
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Dandara Ramos
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Bahia, Brazil
- Instituto de Saúde Coletiva, Federal University of Bahia, Salvador, Bahia, Brazil
| | - Julia Pescarini
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Bahia, Brazil
| | - Elzo Pereira Pinto-Junior
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Bahia, Brazil
| | - Ila R. Falcão
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Bahia, Brazil
| | - Maria Yury Ichihara
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Bahia, Brazil
| | - Samila Sena
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Bahia, Brazil
| | - Rafael Veiga
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Bahia, Brazil
| | - Rita Ribeiro
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Bahia, Brazil
- Faculdade de Nutrição, Federal University of Bahia, Salvador, Bahia, Brazil
| | - Laura C. Rodrigues
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Maurício L. Barreto
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Bahia, Brazil
- Instituto de Saúde Coletiva, Federal University of Bahia, Salvador, Bahia, Brazil
| | - Emanuelle F. Goes
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Bahia, Brazil
- Instituto de Saúde Coletiva, Federal University of Bahia, Salvador, Bahia, Brazil
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Dyess NF, Carr CB, Mavis SC, Caruso CG, Izatt S, French H, Dadiz R, Bonachea EM, Gray MM. Implicit Bias and Health Disparities Education in the Neonatal Intensive Care Unit. Am J Perinatol 2024; 41:1634-1644. [PMID: 38190976 DOI: 10.1055/a-2240-1979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
OBJECTIVE This study aimed to characterize implicit bias (IB) and health disparities (HD) education in neonatal-perinatal medicine (NPM), including current educational opportunities, resources, and barriers. STUDY DESIGN A national web-based survey was sent to NPM fellows, neonatologists, and frontline providers after iterative review by education experts from the National Neonatology Curriculum Committee. Quantitative data were analyzed with chi-square and Fisher's exact tests. Qualitative data were evaluated using thematic analysis. RESULTS Of the 452 NPM survey respondents, most desired additional IB (76%) and HD (83%) education. A greater proportion of neonatologists than fellows received IB (83 vs. 57%) and HD (87 vs. 74%) education. Only 41% of neonatologists reported that their institution requires IB training. A greater proportion of fellows than neonatologists expressed dissatisfaction with the current approaches for IB (51 vs. 25%, p < 0.001) and HD (43 vs. 25%, p = 0.015) education. The leading drivers of dissatisfaction included insufficient time spent on the topics, lack of specificity to NPM, inadequate curricular scope or depth, and lack of local educator expertise. A minority of faculty who were tasked to educate others have received specific educator training on IB (21%) and HD (16%). Thematic analysis of survey free-text responses identified three main themes on the facilitators and barriers to successful IB and HD education: individual, environmental, and curricular design variables. CONCLUSION NPM trainees and neonatologists desire tailored, active, and expert-guided IB and HD education. Identified barriers are important to address in developing an effective IB/HD curriculum for the NPM community. KEY POINTS · There is a gap between the current delivery of IB/HD education and the needs of the NPM community.. · NPM trainees and neonatologists desire tailored, active, and expert-guided IB and HD education.. · A successful curriculum should be widely accessible, NPM-specific, and include facilitator training..
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Affiliation(s)
| | - Cara Beth Carr
- Division of Neonatology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Stephanie C Mavis
- Division of Neonatal Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Catherine G Caruso
- Division of Neonatology, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Susan Izatt
- Division of Neonatology, Department of Pediatrics, Duke University, Durham, North Carolina
| | - Heather French
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rita Dadiz
- Division of Neonatology, Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Elizabeth M Bonachea
- Division of Neonatology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Megan M Gray
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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Salazar EG, Passarella M, Formanowski B, Rogowski J, Edwards E, Phibbs C, Lorch SA. The Association of NICU Strain with Neonatal Mortality and Morbidity. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.07.07.24310050. [PMID: 39040203 PMCID: PMC11261945 DOI: 10.1101/2024.07.07.24310050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Abstract
Objective To examine the association of admission NICU strain with neonatal mortality and morbidity. Study Design 2008-2021 South Carolina cohort using linked vital statistics and discharge data of 22-44 weeks GA infants, born at hospitals with ≥ level 2 unit and ≥5 births of infants <34 weeks GA/year. The exposure was tertiles of admission NICU strain, defined as the sum of infants <44 weeks GA with a congenital anomaly plus all infants born <33 weeks GA at midnight on the day of birth. We used Poisson generalized linear mixed models to examine the association of exposure to strain with the primary outcome of a composite of mortality and term and preterm morbidities adjusting for patient and hospital characteristics. Results We studied 64,647 infants from 30 hospitals. High strain was associated with increased risk of mortality and morbidity adjusting for patient/hospital factors (aIRR 1.07, 95% CI 1.01 - 1.12). Conclusion NICU strain is associated with increased adverse outcomes.
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Parikh K, Hall M, Tieder JS, Dixon G, Ward MC, Hinds PS, Goyal MK, Rangel SJ, Flores G, Kaiser SV. Disparities in Racial, Ethnic, and Payer Groups for Pediatric Safety Events in US Hospitals. Pediatrics 2024; 153:e2023063714. [PMID: 38343330 DOI: 10.1542/peds.2023-063714] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2023] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Health care disparities are pervasive, but little is known about disparities in pediatric safety. We analyzed a national sample of hospitalizations to identify disparities in safety events. METHODS In this population-based, retrospective cohort study of the 2019 Kids' Inpatient Database, independent variables were race, ethnicity, and payer. Outcomes were Agency for Healthcare Research and Quality pediatric safety indicators (PDIs). Risk-adjusted odds ratios were calculated using white and private payer reference groups. Differences by payer were evaluated by stratifying race and ethnicity. RESULTS Race and ethnicity of the 5 243 750 discharged patients were white, 46%; Hispanic, 19%; Black, 15%; missing, 8%; other race/multiracial, 7%, Asian American/Pacific Islander, 5%; and Native American, 1%. PDI rates (per 10 000 discharges) were 331.4 for neonatal blood stream infection, 267.5 for postoperative respiratory failure, 114.9 for postoperative sepsis, 29.5 for postoperative hemorrhage/hematoma, 5.6 for central-line blood stream infection, 3.5 for accidental puncture/laceration, and 0.7 for iatrogenic pneumothorax. Compared with white patients, Black and Hispanic patients had significantly greater odds in 5 of 7 PDIs; the largest disparities occurred in postoperative sepsis (adjusted odds ratio, 1.55 [1.38-1.73]) for Black patients and postoperative respiratory failure (adjusted odds ratio, 1.34 [1.21-1.49]) for Hispanic patients. Compared with privately insured patients, Medicaid-covered patients had significantly greater odds in 4 of 7 PDIs; the largest disparity occurred in postoperative sepsis (adjusted odds ratios, 1.45 [1.33-1.59]). Stratified analyses demonstrated persistent disparities by race and ethnicity, even among privately insured children. CONCLUSIONS Disparities in safety events were identified for Black and Hispanic children, indicating a need for targeted interventions to improve patient safety in the hospital.
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Affiliation(s)
- Kavita Parikh
- Children's National Hospital, Washington, District of Columbia
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | | | - Gabrina Dixon
- Children's National Hospital, Washington, District of Columbia
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Maranda C Ward
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Pamela S Hinds
- Children's National Hospital, Washington, District of Columbia
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Monika K Goyal
- Children's National Hospital, Washington, District of Columbia
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | | | - Glenn Flores
- Department of Pediatrics, University of Miami Miller School of Medicine, and Holtz Children's Hospital, Jackson Health System, Miami, Florida
| | - Sunitha V Kaiser
- University of California, San Francisco, California
- Philip R. Lee Institute for Health Policy Studies, San Francisco, California
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Nicole Teal E, Baer RJ, Jelliffe-Pawlowski L, Mengesha B. Racial Disparities in Cesarean Delivery Rates: Do Hospital-Level Factors Matter? Am J Perinatol 2024; 41:375-382. [PMID: 37913783 DOI: 10.1055/s-0043-1776346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
OBJECTIVE This study aimed to assess whether racial disparities in nulliparous, term, singleton, vertex cesarean delivery rates vary among hospitals of different type (academic vs. nonacademic), setting (urban vs. rural), delivery volume, and patient population. STUDY DESIGN This is a retrospective cohort study including singleton term vertex live births in nulliparous Black and non-Hispanic White birthing people in California between 2011 and 2017. Cesarean delivery rates were obtained using birth certificate data and International Classification of Diseases, 9th/10th Revision codes. Risk of cesarean delivery was compared among Black versus White birthing people by hospital type (academic, nonacademic), setting (rural, suburban, urban), volume (< 1,200, 1,200-2,300, 2,400-3,599, ≥3,600 deliveries annually), and patient population (proportion Black-serving). Federal Information Processing codes were used to designate hospital setting. Risks were calculated using univariable and multivariable logistic regression and adjusted for birthing person age, body mass index, medical comorbidities, gestational age, labor type (spontaneous vs. induction), and infant birthweight. RESULTS The sample included 59,441 Black (cesarean delivery rate: 30.2%) and 363,624 White birthing people (cesarean delivery rate: 26.1%). Black birthing people were significantly more likely than White birthing people to have a cesarean delivery across nearly all hospital-level factors considered with adjusted relative risks ranging from 1.1 to 1.3. The only exception was rural settings in which the adjusted relative risk was 1.3 but did not reach statistical significance. CONCLUSION Black-White disparities in nulliparous, term, singleton, vertex cesarean delivery rates were persistent across all hospital-level factors we considered: academic status, rurality, delivery volume, and patient population. Furthermore, disparities existed at roughly the same magnitude regardless of hospital characteristics. These global increased risks likely reflect structural inequities in care, which contribute to disparities in pregnancy-related morbidity and mortality. These data should encourage providers, hospital systems, and quality collaboratives to further investigate racial disparities in cesarean delivery rates and develop strategies for eliminating them. KEY POINTS · Nulliparous Black birthing people are more likely than White to undergo cesarean delivery.. · This persists across hospitals of all academic status, rurality, delivery volume, and patient population.. · These findings likely reflect structural rather than institutional inequities in obstetric care..
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Affiliation(s)
- E Nicole Teal
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Diego, San Diego, California
| | - Rebecca J Baer
- California Preterm Birth Initiative, University of California, San Francisco, San Francisco, California
| | - Laura Jelliffe-Pawlowski
- California Preterm Birth Initiative, University of California, San Francisco, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Biftu Mengesha
- California Preterm Birth Initiative, University of California, San Francisco, San Francisco, California
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Tsai JW, Janke A, Krumholz HM, Khidir H, Venkatesh AK. Race and Ethnicity and Emergency Department Discharge Against Medical Advice. JAMA Netw Open 2023; 6:e2345437. [PMID: 38015503 PMCID: PMC10685883 DOI: 10.1001/jamanetworkopen.2023.45437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/18/2023] [Indexed: 11/29/2023] Open
Abstract
Importance Although discharges against medical advice (DAMA) are associated with greater morbidity and mortality, little is known about current racial and ethnic disparities in DAMA from the emergency department (ED) nationally. Objective To characterize current patterns of racial and ethnic disparities in rates of ED DAMA. Design, Setting, and Participants This cross-sectional study used data from the Nationwide Emergency Department Sample on all hospital ED visits made between January to December 2019 in the US. Main Outcomes and Measures The main outcome was odds of ED DAMA for Black and Hispanic patients compared with White patients nationally and in analysis adjusted for sociodemographic factors. Secondary analysis examined hospital-level variation in DAMA rates for Black, Hispanic, and White patients. Results The study sample included 33 147 251 visits to 989 hospitals, representing the estimated 143 million ED visits in 2019. The median age of patients was 40 years (IQR, 22-61 years). Overall, 1.6% of ED visits resulted in DAMA. DAMA rates were higher for Black patients (2.1%) compared with Hispanic (1.6%) and White (1.4%) patients, males (1.7%) compared with females (1.5%), those with no insurance (2.8%), those with lower income (<$27 999; 1.9%), and those aged 35 to 49 years (2.2%). DAMA visits were highest at metropolitan teaching hospitals (1.8%) and hospitals that served greater proportions of racial and ethnic minoritized patients (serving ≥57.9%; 2.1%). Odds of DAMA were greater for Black patients (odds ratio [OR], 1.45; 95% CI, 1.31-1.57) and Hispanic patients (OR, 1.16; 95% CI, 1.04-1.29) compared with White patients. After adjusting for sociodemographic characteristics (age, sex, income, and insurance status), the adjusted OR (AOR) for DAMA was lower for Black patients compared with the unadjusted OR (AOR, 1.18; 95% CI, 1.09-1.28) and there was no difference in odds for Hispanic patients (AOR, 1.03; 95% CI, 0.92-1.15) compared with White patients. After additional adjustment for hospital random intercepts, DAMA disparities reversed, with Black and Hispanic patients having lower odds of DAMA compared with White patients (Black patients: AOR, 0.94 [95% CI, 0.90-0.98]; Hispanic patients: AOR, 0.68 [95% CI, 0.63-0.72]). The intraclass correlation in this secondary analysis model was 0.118 (95% CI, 0.104-0.133). Conclusions and Relevance This national cross-sectional study found that Black and Hispanic patients had greater odds of ED DAMA than White patients in unadjusted analysis. Disparities were reversed after patient-level and hospital-level risk adjustment, and greater between-hospital than within-hospital variation in DAMA was observed, suggesting that Black and Hispanic patients are more likely to receive care in hospitals with higher DAMA rates. Structural racism may contribute to ED DAMA disparities via unequal allocation of health care resources in hospitals that disproportionately treat racial and ethnic minoritized groups. Monitoring variation in DAMA by race and ethnicity and hospital suggests an opportunity to improve equitable access to health care.
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Affiliation(s)
- Jennifer W. Tsai
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Alexander Janke
- VA Ann Arbor Healthcare System/University of Michigan Institute for Healthcare Policy and Innovation, National Clinician Scholars Program, Ann Arbor
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Hazar Khidir
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
- National Clinician Scholars Program, Yale University, New Haven, Connecticut
| | - Arjun K. Venkatesh
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- National Clinician Scholars Program, Yale University, New Haven, Connecticut
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Lee EK, Donley G, Ciesielski TH, Freedman DA, Cole MB. Spatial availability of federally qualified health centers and disparities in health services utilization in medically underserved areas. Soc Sci Med 2023; 328:116009. [PMID: 37301106 DOI: 10.1016/j.socscimed.2023.116009] [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: 10/26/2022] [Revised: 05/11/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023]
Abstract
Federally qualified health centers (FQHCs) improve access to care for important health services (e.g., preventive care), particularly among marginalized and underserved communities. However, whether spatial availability of FQHCs influences care-seeking behavior for medically underserved residents is unclear. The objective of this study was to examine the relationships of present-day zip-code level availability of FQHCs, historic redlining, and health services utilization (i.e., at FQHCs and any health clinic/facility) in six large states. We further examined these associations by states, FQHC availability (i.e., 1, 2-4 and ≥5 FQHC sites per zip code) and geographic areas (i.e., urbanized vs. rural, redlined vs. non-redlined sections of urban areas). Using Poisson and multivariate regression models, we found that in medically underserved areas, having at least one FQHC site was associated with greater likelihood of patients seeking health services at FQHCs [rate ratio (RR) = 3.27, 95%CI: 2.27-4.70] than areas with no FQHCs available, varying across states (RRs = 1.12 to 6.33). Relationships were stronger in zip codes with ≥5 FQHC sites, small towns, metropolitan areas, and redlined sections of urban areas (HOLC D-grade vs. C-grade: RR = 1.24, 95%CI: 1.21-1.27). However, these relationships did not remain true for routine care visits at any health clinic or facility (β = -0.122; p = 0.008) or with worsening HOLC grades (β = -0.082; p = 0.750), potentially due to the contextual factors associated with FQHC locations. Findings suggest that efforts to expand FQHCs may be most impactful for medically underserved residents living in small towns, metropolitan areas and redlined sections of urban areas. Because FQHCs can provide high quality, culturally competent, cost-effective access to important primary care, behavioral health, and enabling services that uniquely benefit low-income and marginalized patient populations, particularly those who have been historically denied access to health care, improving availability of FQHCs may be an important mechanism for improving health care access and reducing subsequent inequities for these underserved groups.
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Affiliation(s)
- Eun Kyung Lee
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA.
| | - Gwendolyn Donley
- Institute for Research on Poverty, University of Wisconsin-Madison, Madison, WI, USA.
| | - Timothy H Ciesielski
- Mary Ann Swetland Center for Environmental Health, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Darcy A Freedman
- Mary Ann Swetland Center for Environmental Health, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Megan B Cole
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
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Menda N, Edwards E. Measuring Equity for Quality Improvement. Clin Perinatol 2023; 50:531-543. [PMID: 37201995 DOI: 10.1016/j.clp.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Applying an equity lens to quality improvement (QI) by collecting, reviewing, and using data that measure health disparities helps identify whether QI interventions improve outcomes evenly and equally across the population or have a greater impact in an advantaged or disadvantaged group. Methodological issues inherent in measuring disparities include appropriately selecting data sources; ensuring reliability and validity of equity data; choosing a suitable comparison group; and understanding between-group variation. The integration and utilization of QI techniques to promote equity is dependent on meaningful measurement to develop targeted interventions and provide a means of ongoing real-time assessment.
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Affiliation(s)
- Nina Menda
- Department of Pediatrics, University of Wisconsin, 202 South Park Street, McConnell Hall, 4th Floor, Madison, WI 53715, USA.
| | - Erika Edwards
- Vermont Oxford Network, Burlington, VT 05401, USA; Department of Pediatrics, Robert Larner, MD, College of Medicine, University of Vermont, Burlington, VT 05405, USA; Department of Mathematics and Statistics, College of Engineering and Mathematical Sciences, University of Vermont, Burlington, VT 05405, USA
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Salazar EG, Montoya-Williams D, Passarella M, McGann C, Paul K, Murosko D, Peña MM, Ortiz R, Burris HH, Lorch SA, Handley SC. County-Level Maternal Vulnerability and Preterm Birth in the US. JAMA Netw Open 2023; 6:e2315306. [PMID: 37227724 PMCID: PMC10214038 DOI: 10.1001/jamanetworkopen.2023.15306] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/11/2023] [Indexed: 05/26/2023] Open
Abstract
Importance Appreciation for the effects of neighborhood conditions and community factors on perinatal health is increasing. However, community-level indices specific to maternal health and associations with preterm birth (PTB) have not been assessed. Objective To examine the association of the Maternal Vulnerability Index (MVI), a novel county-level index designed to quantify maternal vulnerability to adverse health outcomes, with PTB. Design, Setting, and Participants This retrospective cohort study used US Vital Statistics data from January 1 to December 31, 2018. Participants included 3 659 099 singleton births at 22 plus 0/7 to 44 plus 6/7 weeks of gestation born in the US. Analyses were conducted from December 1, 2021, through March 31, 2023. Exposure The MVI, a composite measure of 43 area-level indicators, categorized into 6 themes reflecting physical, social, and health care landscapes. Overall MVI and theme were stratified by quintile (very low to very high) by maternal county of residence. Main Outcomes and Measures The primary outcome was PTB (gestational age <37 weeks). Secondary outcomes were PTB categories: extreme (gestational age ≤28 weeks), very (gestational age 29-31 weeks), moderate (gestational age 32-33 weeks), and late (gestational age 34-36 weeks). Multivariable logistic regression quantified associations of MVI, overall and by theme, with PTB, overall and by PTB category. Results Among 3 659 099 births, 298 847 (8.2%) were preterm (male, 51.1%; female, 48.9%). Maternal race and ethnicity included 0.8% American Indian or Alaska Native, 6.8% Asian or Pacific Islander, 23.6% Hispanic, 14.5% non-Hispanic Black, 52.1% non-Hispanic White, and 2.2% with more than 1 race. Compared with full-term births, MVI was higher for PTBs across all themes. Very high MVI was associated with increased PTB in unadjusted (odds ratio [OR], 1.50 [95% CI, 1.45-1.56]) and adjusted (OR, 1.07 [95% CI, 1.01-1.13]) analyses. In adjusted analyses of PTB categories, MVI had the largest association with extreme PTB (adjusted OR, 1.18 [95% CI, 1.07-1.29]). Higher MVI in the themes of physical health, mental health and substance abuse, and general health care remained associated with PTB overall in adjusted models. While the physical health and socioeconomic determinant themes were associated with extreme PTB, physical health, mental health and substance abuse, and general health care themes were associated with late PTB. Conclusions and Relevance The findings of this cohort study suggest that MVI was associated with PTB even after adjustment for individual-level confounders. The MVI is a useful measure for county-level PTB risk that may have policy implications for counties working to lower preterm rates and improve perinatal outcomes.
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Affiliation(s)
- Elizabeth G. Salazar
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Diana Montoya-Williams
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Molly Passarella
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Carolyn McGann
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kathryn Paul
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Daria Murosko
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michelle-Marie Peña
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
- Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Robin Ortiz
- Department of Pediatrics, Institute for Excellence in Health Equity, NYU Grossman School of Medicine, New York, New York
- Department of Population Health, Institute for Excellence in Health Equity, NYU Grossman School of Medicine, New York, New York
| | - Heather H. Burris
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott A. Lorch
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sara C. Handley
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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11
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Abstract
Long-standing health disparities in maternal reproductive health, infant morbidity and mortality, and long-term developmental outcomes are rooted in a foundation of structural racism. Social determinants of health profoundly affect reproductive health outcomes of Black and Hispanic women disproportionately; they have higher rates of death during pregnancy and preterm birth. Their infants are also more likely to be cared for in poorer quality neonatal intensive care units (NICUs), receive poorer quality of NICU care, and are less likely to be referred to an appropriate high-risk NICU follow-up program. Interventions that mitigate the impact of racism will help to eliminate health disparities.
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Affiliation(s)
- Yvette R Johnson
- Texas Christian University, Burnett School of Medicine, Cook Children's Medical Center, N.E.S.T. Developmental Follow-up Clinic, 1500 Cooper Street, Fort Worth, TX 76104, USA.
| | - Charleta Guillory
- Baylor College of Medicine, Texas Children's Hospital, Section of Neonatology, 6621 Fannin, Houston, TX 77030, USA
| | - Sonia Imaizumi
- Newtown Square, MultiPlan.com, 18 Campus Boulevard, Suite 200, Newtown Square, PA 19073, USA
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12
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Nicolas CT, Carter SR, Martin CA. Impact of maternal factors, environmental factors, and race on necrotizing enterocolitis. Semin Perinatol 2023; 47:151688. [PMID: 36572622 DOI: 10.1016/j.semperi.2022.151688] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Necrotizing enterocolitis (NEC) is a complex disease with a multifactorial etiology. As the leading cause of intestinal morbidity and mortality among premature infants, many resources are being dedicated to neonatal care and molecular targets in the newborn intestine. However, NEC is heavily influenced by maternal and perinatal factors as well. Given its nature, preventive approaches to NEC are more likely to improve outcomes than new treatment strategies. Therefore, this review focuses on maternal, environmental, and racial factors associated with the development of NEC, with an emphasis on those that may be modifiable to decrease the incidence of the disease.
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Affiliation(s)
- Clara T Nicolas
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Stewart R Carter
- Department of Surgery, Division of Pediatric Surgery, University of Louisville School of Medicine, Louisville, KY, United States
| | - Colin A Martin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States; Department of General and Thoracic Surgery, Children's of Alabama, Birmingham, AL, United States.
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13
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Schmitz K, Kleinman LC. Quality of care in the delivery hospital contributes to racial disparities in outcomes for low-risk newborns. Evid Based Nurs 2022; 25:89. [PMID: 35301228 DOI: 10.1136/ebnurs-2021-103483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 06/14/2023]
Affiliation(s)
- Kristine Schmitz
- Pediatrics, Rutgers Robert Wood Johnson Medical School Department of Pediatrics, New Brunswick, New Jersey, USA
| | - Lawrence Charles Kleinman
- Pediatrics, Rutgers Robert Wood Johnson Medical School Department of Pediatrics, New Brunswick, New Jersey, USA
- Urban-Global Public Health, Rutgers School of Public Health, Piscataway, NJ, USA
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14
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The Prenatal Neighborhood Environment and Geographic Hotspots of Infants with At-risk Birthweights in New York City. J Urban Health 2022; 99:482-491. [PMID: 35641714 PMCID: PMC9187826 DOI: 10.1007/s11524-022-00662-2] [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] [Accepted: 04/27/2022] [Indexed: 10/18/2022]
Abstract
Infants born with low or high ("at-risk") birthweights are at greater risk of adverse health outcomes across the life course. Our objective was to examine whether geographic hotspots of low and high birthweight prevalence in New York City had different patterns of neighborhood risk factors. We performed census tract-level geospatial clustering analyses using (1) birthweight prevalence and maternal residential address from an all-payer claims database and (2) domains of neighborhood risk factors (socioeconomic and food environment) from national and local datasets. We then used logistic regression analysis to identify specific neighborhood risk factors associated with low and high birthweight hotspots. This study examined 2088 census tracts representing 419,025 infants. We found almost no overlap (1.5%) between low and high birthweight hotspots. The majority of low birthweight hotspots (87.2%) overlapped with a socioeconomic risk factor and 95.7% overlapped with a food environment risk factor. Half of high birthweight hotspots (50.0%) overlapped with a socioeconomic risk factor and 48.8% overlapped with a food environment risk factor. Low birthweight hotspots were associated with high prevalence of excessive housing cost, unemployment, and poor food environment. High birthweight hotspots were associated with high prevalence of uninsured persons and convenience stores. Programs and policies that aim to prevent disparities in infant birthweight should examine the broader context by which hotspots of at-risk birthweight overlap with neighborhood risk factors. Multi-level strategies that include the neighborhood context are needed to address prenatal pathways leading to low and high birthweight outcomes.
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15
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Liu J, Pang EM, Iacob A, Simonian A, Phibbs CS, Profit J. Evaluating Care in Safety Net Hospitals: Clinical Outcomes and Neonatal Intensive Care Unit Quality of Care in California. J Pediatr 2022; 243:99-106.e3. [PMID: 34890584 PMCID: PMC8960349 DOI: 10.1016/j.jpeds.2021.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/22/2021] [Accepted: 12/02/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To examine the characteristics of safety net (sn) and non-sn neonatal intensive care units (NICUs) in California and evaluate whether the site of care is associated with clinical outcomes. STUDY DESIGN This population-based retrospective cohort study of 34 snNICUs and 104 non-snNICUs included 22 081 infants born between 2014 and 2018 with a birth weight of 401-1500 g or gestational age of 22-29 weeks. Quality of care as measured by the Baby-MONITOR score and rates of survival without major morbidity were compared between snNICUs and non-snNICUs. RESULTS Black and Hispanic infants were cared for disproportionately in snNICUs, where care and outcomes varied widely. We found no significant differences in Baby-Measure Of Neonatal InTensive care Outcomes Research (MONITOR) scores (z-score [SD]: snNICUs, -0.31 [1.3]; non-snNICUs, 0.03 [1.1]; P = .1). Among individual components, infants in snNICUs exhibited lower rates of human milk nutrition at discharge (-0.64 [1.0] vs 0.27 [0.9]), lower rates of no health care-associated infection (-0.27 [1.1] vs 0.14 [0.9]), and higher rates of no hypothermia on admission (0.39 [0.7] vs -0.25 [1.1]). We found small but significant differences in survival without major morbidity (adjusted rate, 65.9% [95% CI, 63.9%-67.9%] for snNICUs vs 68.3% [95% CI, 67.0%-69.6%] for non-snNICUs; P = .02) and in some of its components; snNICUs had higher rates of necrotizing enterocolitis (3.8% [3.4%-4.3%] vs 3.1% [95% CI, 2.8%-3.4%]) and mortality (95% CI, 7.1% [6.5%-7.7%] vs 6.6% [6.2%-7.0%]). CONCLUSIONS snNICUs achieved similar performance as non-snNICUs in quality of care except for small but significant differences in any human milk at discharge, infection, hypothermia, necrotizing enterocolitis, and mortality.
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Affiliation(s)
- Jessica Liu
- Division of Neonatology, Department of Pediatrics, Perinatal Epidemiology and Health Outcomes Research Unit, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA; California Perinatal Quality Care Collaborative, Palo Alto, CA
| | - Emily M Pang
- Division of Neonatology, Department of Pediatrics, Perinatal Epidemiology and Health Outcomes Research Unit, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA
| | - Alexandra Iacob
- California Perinatal Quality Care Collaborative, Palo Alto, CA; Division of Neonatal/Perinatal Medicine, Department of Pediatrics, School of Medicine, University of California Irvine, Orange, CA
| | - Aida Simonian
- California Perinatal Quality Care Collaborative, Palo Alto, CA
| | - Ciaran S Phibbs
- Division of Neonatology, Department of Pediatrics, Perinatal Epidemiology and Health Outcomes Research Unit, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA; Health Economics Resource Center and Center for Implementation to Innovation, Veterans Affairs Palo Alto Healthcare System, Menlo Park, CA
| | - Jochen Profit
- Division of Neonatology, Department of Pediatrics, Perinatal Epidemiology and Health Outcomes Research Unit, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA; California Perinatal Quality Care Collaborative, Palo Alto, CA.
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16
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Reconceptualizing Measures of Black–White Disparity in Infant Mortality in U.S. Counties. POPULATION RESEARCH AND POLICY REVIEW 2022. [DOI: 10.1007/s11113-022-09711-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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17
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Boghossian NS, Geraci M, Edwards EM, Horbar JD. Changes in hospital quality at hospitals serving black and hispanic newborns below 30 weeks' gestation. J Perinatol 2022; 42:187-194. [PMID: 34601491 PMCID: PMC8825745 DOI: 10.1038/s41372-021-01222-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 09/07/2021] [Accepted: 09/22/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Examine whether the quality of Black and Hispanic serving (BHS) compared with not BHS (NBHS) NICUs has changed differentially over time. STUDY DESIGN Infants 24-29 weeks' gestation born at U.S. Vermont Oxford Network centers (2006-2018) were studied. We calculated adjusted hospital quality scores as the predicted probabilities of composite in-hospital mortality and morbidities from a logistic model. We regressed hospital quality scores on birth year to estimate the linear temporal slope by BHS-serving status for hospitals within each Census division. RESULTS Hospital quality improved similarly over time for BHS and NBHS hospitals across all divisions except West South Central where a mean change in the composite score was -18.8 (95% CI: -24.1, -13.5) for NBHS and -9.3 (95% CI: -14.1, -4.6) for BHS hospitals (p-value = 0.009). CONCLUSION Hospital quality improved similarly for BHS and NBHS hospitals across most divisions. Variation within and between divisions should be a focus for quality improvement.
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Affiliation(s)
- Nansi S. Boghossian
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Marco Geraci
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina,MEMOTEF Department, Sapienza – University of Rome
| | - Erika M. Edwards
- Vermont Oxford Network, Burlington, Vermont,Department of Mathematics and Statistics, University of Vermont, Burlington, Vermont,Department of Pediatrics, University of Vermont College of Medicine, Burlington, Vermont
| | - Jeffrey D. Horbar
- Vermont Oxford Network, Burlington, Vermont,Department of Pediatrics, University of Vermont College of Medicine, Burlington, Vermont
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18
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Sosnaud B. Cross-State Differences in the Processes Generating Black-White Disparities in Neonatal Mortality. Demography 2021; 58:2089-2115. [PMID: 34568897 DOI: 10.1215/00703370-9510578] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The U.S. Black neonatal mortality rate is more than twice the White rate. This dramatic disparity can be decomposed into two components: (1) disparities due to differences in the distribution of birth weights, and (2) disparities due to differences in birth weight-specific mortality. I utilize this distinction to explore how the social context into which infants are born contributes to gaps in mortality between Black and White neonates. I analyze variation in Black-White differences in neonatal mortality across 33 states using 1995-2010 data. For each state, I calculate the contribution of differences in birth weight distribution versus differences in birth weight-specific mortality to the total disparity in mortality between White and Black neonates. Disparities are largely a product of different birth weight distributions between Black and White newborns (mirroring the pattern for the United States as a whole). However, in at least nine states, differences in birth weight-specific mortality make a notable contribution. This pattern is observed even among those from advantaged sociodemographic backgrounds and is driven by differences in mortality among very low birth weight neonates. This calls attention to inequality in medical care at birth as an importantcontributor to racial disparities in neonatal mortality.
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Affiliation(s)
- Benjamin Sosnaud
- Department of Sociology and Anthropology, Trinity University, San Antonio, TX, USA
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19
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Glazer KB, Zeitlin J, Egorova NN, Janevic T, Balbierz A, Hebert PL, Howell EA. Hospital Quality of Care and Racial and Ethnic Disparities in Unexpected Newborn Complications. Pediatrics 2021; 148:peds.2020-024091. [PMID: 34429339 PMCID: PMC9708325 DOI: 10.1542/peds.2020-024091] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To investigate racial and ethnic differences in unexpected, term newborn morbidity and the influence of hospital quality on disparities. METHODS We used 2010-2014 birth certificate and discharge abstract data from 40 New York City hospitals in a retrospective cohort study of 483 834 low-risk (term, singleton, birth weight ≥2500 g, without preexisting fetal conditions) neonates. We classified morbidity according to The Joint Commission's unexpected newborn complications metric and used multivariable logistic regression to compare morbidity risk among racial and ethnic groups. We generated risk-standardized complication rates for each hospital using mixed-effects logistic regression to evaluate quality, ranked hospitals on this measure, and assessed differences in the racial and ethnic distribution of births across facilities. RESULTS The unexpected complications rate was 48.0 per 1000 births. Adjusted for patient characteristics, morbidity risk was higher among Black and Hispanic infants compared with white infants (odds ratio: 1.5 [95% confidence interval 1.3-1.9]; odds ratio: 1.2 [95% confidence interval 1.1-1.4], respectively). Among the 40 hospitals, risk-standardized complications ranged from 25.3 to 162.8 per 1000 births. One-third of Black and Hispanic women gave birth in hospitals ranking in the highest-morbidity tertile, compared with 10% of white and Asian American women (P < .001). CONCLUSIONS Black and Hispanic women were more likely to deliver in hospitals with high complication rates than were white or Asian American women. Findings implicate hospital quality in contributing to preventable newborn health disparities among low-risk, term births. Quality improvement targeting routine obstetric and neonatal care is critical for equity in perinatal outcomes.
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Affiliation(s)
- Kimberly B. Glazer
- Departments of Population Health Science and Policy, and Obstetrics, Gynecology and Reproductive Science, and Blavatnik Family Women’s Health Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jennifer Zeitlin
- Departments of Population Health Science and Policy, and Obstetrics, Gynecology and Reproductive Science, and Blavatnik Family Women’s Health Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York;,Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center of Research in Epidemiology and Statistics Sorbonne Paris Cité, Université de Paris and Institut National de la Santé et de la Recherche Médicale, Institut National de la Recherche Agronomique, Paris, France
| | - Natalia N. Egorova
- Departments of Population Health Science and Policy, and Obstetrics, Gynecology and Reproductive Science, and Blavatnik Family Women’s Health Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Teresa Janevic
- Departments of Population Health Science and Policy, and Obstetrics, Gynecology and Reproductive Science, and Blavatnik Family Women’s Health Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Amy Balbierz
- Departments of Population Health Science and Policy, and Obstetrics, Gynecology and Reproductive Science, and Blavatnik Family Women’s Health Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York;,Grossman School of Medicine, New York University, New York, New York
| | - Paul L. Hebert
- School of Public Health, University of Washington, Seattle, Washington
| | - Elizabeth A. Howell
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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20
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Dhurjati R, Main E, Profit J. Institutional Racism: A Key Contributor to Perinatal Health Inequity. Pediatrics 2021; 148:peds.2021-050768. [PMID: 34429337 DOI: 10.1542/peds.2021-050768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
| | - Elliott Main
- Maternal-Fetal Medicine and Obstetrics, School of Medicine, Stanford University, Stanford, California
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21
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Janevic T, Zeitlin J, Egorova NN, Hebert P, Balbierz A, Stroustrup AM, Howell EA. Racial and Economic Neighborhood Segregation, Site of Delivery, and Morbidity and Mortality in Neonates Born Very Preterm. J Pediatr 2021; 235:116-123. [PMID: 33794221 PMCID: PMC9582630 DOI: 10.1016/j.jpeds.2021.03.049] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/22/2021] [Accepted: 03/25/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To assess the influence of racial and economic residential segregation of home or hospital neighborhood on very preterm birth morbidity and mortality in neonates born very preterm. STUDY DESIGN We constructed a retrospective cohort of n = 6461 infants born <32 weeks using 2010-2014 New York City vital statistics-hospital data. We calculated racial and economic Index of Concentration at the Extremes for home and hospital neighborhoods. Neonatal mortality and morbidity was defined as death and/or severe neonatal morbidity. We estimated relative risks for Index of Concentration at the Extremes measures and neonatal mortality and morbidity using log binomial regression and the risk-adjusted contribution of delivery hospital using Fairlie decomposition. RESULTS Infants whose mothers live in neighborhoods with the greatest relative concentration of Black residents had a 1.6 times greater risk of neonatal mortality and morbidity than those with the greatest relative concentration of White residents (95% CI 1.2-2.1). Delivery hospital explained more than one-half of neighborhood differences. Infants with both home and hospital in high-concentration Black neighborhoods had a 38% adjusted risk of neonatal mortality and morbidity compared with 25% of those with both home and hospital high-concentration White neighborhoods (P = .045). CONCLUSIONS Structural racism influences very preterm birth neonatal mortality and morbidity through both the home and hospital neighborhood. Quality improvement interventions should incorporate a framework that includes neighborhood context.
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Affiliation(s)
- Teresa Janevic
- Blavatnik Family Women's Health Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Jennifer Zeitlin
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY,Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Biostatistics Sorbonne Paris Cité, DHU Risks in pregnancy, Paris Descartes University
| | - Natalia N. Egorova
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Paul Hebert
- University of Washington School of Public Health, Seattle, WA
| | - Amy Balbierz
- Blavatnik Family Women’s Health Research Institute,Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Anne Marie Stroustrup
- Department of Pediatrics, Division of Neonatology, Cohen Children's Medical Center at Northwell Health, New Hyde Park, NY
| | - Elizabeth A. Howell
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennslyvania
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22
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Edwards EM, Greenberg LT, Profit J, Draper D, Helkey D, Horbar JD. Quality of Care in US NICUs by Race and Ethnicity. Pediatrics 2021; 148:e2020037622. [PMID: 34301773 PMCID: PMC8344358 DOI: 10.1542/peds.2020-037622] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/04/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Summary measures are used to quantify a hospital's quality of care by combining multiple metrics into a single score. We used Baby-MONITOR, a summary quality measure for NICUs, to evaluate quality by race and ethnicity across and within NICUs in the United States. METHODS Vermont Oxford Network members contributed data from 2015 to 2019 on infants from 25 to 29 weeks' gestation or of 401 to 1500 g birth weight who were inborn or transferred to the reporting hospital within 28 days of birth. Nine Baby-MONITOR measures were individually risk adjusted, standardized, equally weighted, and averaged to derive scores for African American, Hispanic, Asian American, and American Indian infants, compared with white infants. RESULTS This prospective cohort included 169 400 infants at 737 hospitals. Across NICUs, Hispanic and Asian American infants had higher Baby-MONITOR summary scores, compared with those of white infants. African American and American Indian infants scored lower on process measures, and all 4 minority groups scored higher on outcome measures. Within NICUs, the mean summary scores for African American, Hispanic, and Asian American NICU subsets were higher, compared with those of white infants in the same NICU. American Indian summary NICU scores were not different, on average. CONCLUSIONS With Baby-MONITOR, we identified differences in NICU quality by race and ethnicity. However, the summary score masked within-measure quality gaps that raise unanswered questions about the relationships between race and ethnicity and processes and outcomes of care.
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Affiliation(s)
- Erika M Edwards
- Vermont Oxford Network, Burlington, Vermont
- Department of Pediatrics, Robert Larner, MD College of Medicine
- Department of Mathematics and Statistics, College of Engineering and Mathematical Sciences, The University of Vermont, Burlington, Vermont
| | | | - Jochen Profit
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University and Lucile Packard Children's Hospital, Palo Alto, California
- California Perinatal Quality Care Collaborative, Palo Alto, California
| | - David Draper
- Department of Statistics, Jack Baskin School of Engineering, University of California, Santa Cruz, Santa Cruz, California
| | - Daniel Helkey
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University and Lucile Packard Children's Hospital, Palo Alto, California
| | - Jeffrey D Horbar
- Vermont Oxford Network, Burlington, Vermont
- Department of Pediatrics, Robert Larner, MD College of Medicine
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Lorch SA, Rogowski J, Profit J, Phibbs CS. Access to risk-appropriate hospital care and disparities in neonatal outcomes in racial/ethnic groups and rural-urban populations. Semin Perinatol 2021; 45:151409. [PMID: 33931237 PMCID: PMC8184635 DOI: 10.1016/j.semperi.2021.151409] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Variations in infant and neonatal mortality continue to persist in the United States and in other countries based on both socio-demographic characteristics, such as race and ethnicity, and geographic location. One potential driver of these differences is variations in access to risk-appropriate delivery care. The purpose of this article is to present the importance of delivery hospitals on neonatal outcomes, discuss variation in access to these hospitals for high-risk infants and their mothers, and to provide insight into drivers for differences in access to high-quality perinatal care using the available literature. This review also illustrates the lack of information on a number of topics that are crucial to the development of evidence-based interventions to improve access to appropriate delivery hospital services and thus optimize the outcomes of high-risk mothers and their newborns.
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Affiliation(s)
- Scott A. Lorch
- Children's Hospital of Philadelphia, Division of Neonatology,Perelman School of Medicine, University of Pennsylvania
| | | | - Jochen Profit
- Stanford University School of Medicine, Department of Pediatrics, Division of Neonatal Medicine
| | - Ciaran S. Phibbs
- Stanford University School of Medicine, Department of Pediatrics, Division of Neonatal Medicine,Veterans Affairs Palo Alto Health Care System
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Arnolds M, Laventhal N. Perinatal Counseling at the Margin of Gestational Viability: Where We've Been, Where We're Going, and How to Navigate a Path Forward. J Pediatr 2021; 233:255-262. [PMID: 33567323 DOI: 10.1016/j.jpeds.2021.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 02/01/2021] [Accepted: 02/03/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Marin Arnolds
- Division of Neonatology, Department of Pediatrics, Evanston Hospital, NorthShore University HealthSystem, Evanston, IL; Pritzker School of Medicine, University of Chicago, Chicago, IL.
| | - Naomi Laventhal
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, MI
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Glazer KB, Zeitlin J, Howell EA. Intertwined disparities: Applying the maternal-infant dyad lens to advance perinatal health equity. Semin Perinatol 2021; 45:151410. [PMID: 33865629 PMCID: PMC8184592 DOI: 10.1016/j.semperi.2021.151410] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Differences in the quality of delivery hospital care contribute to persistent, intertwined racial and ethnic disparities in both maternal and infant health. Despite the shared causal pathways and overlapping burden of maternal and infant health disparities, little research on perinatal quality of care has addressed obstetric and neonatal care jointly to improve outcomes and reduce health inequities for the maternal-infant dyad. In this paper, we review the role of hospital quality in shaping perinatal health outcomes, and investigate how a framework that considers the mother-infant dyad can enhance our understanding of the full burden of obstetric and neonatal disparities on health and society. We conclude with a discussion of how integrating a maternal-infant dyad lens into research and clinical intervention to improve quality of care can move the needle on disparity reduction for both women and infants around the time of birth and throughout the life course.
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Affiliation(s)
- Kimberly B Glazer
- Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Blavatnik Family Women's Health Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States.
| | - Jennifer Zeitlin
- Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Université de Paris, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, F-75004 Paris, France
| | - Elizabeth A Howell
- Department of Obstetrics & Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
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Berry OO, Londoño Tobón A, Njoroge WFM. Social Determinants of Health: the Impact of Racism on Early Childhood Mental Health. Curr Psychiatry Rep 2021; 23:23. [PMID: 33712922 DOI: 10.1007/s11920-021-01240-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Despite increased literature on the impact of racism in the past decades, relatively few studies have focused on the effects of racism on younger children. This article reviews research from the past 5 years focusing on the impact of racism on infant and early childhood mental health and socioemotional development. RECENT FINDINGS Longitudinal studies provide evidence that very young children are highly influenced by exposure to multiple and interconnecting levels of racism and discrimination. These forms of exposure (structural and personally mediated, which can be further divided into direct and indirect exposure) are particularly nefarious to young children's socioemotional development and have implications for adolescent and adult mental health with lasting sequelae. Furthermore, the effects of racism on parenting practices and maternal/caregiver mental health appear to indicate mechanisms through which racism affects young children. Although more studies are needed in this area, recent literature indicates that racism is a social determinant of health that adversely impacts infant and early childhood socioemotional, and behavioral development. Future studies should focus on understanding the mechanisms through which racism impacts early childhood development and health, and interventions to prevent and mitigate the effects of racism.
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Affiliation(s)
- Obianuju O Berry
- Department of Child Psychiatry, New York University, New York, NY, USA. .,Office of Behavioral Health, New York Health + Hospital, New York, NY, USA.
| | - Amalia Londoño Tobón
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Wanjikũ F M Njoroge
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Abstract
BACKGROUND There are pervasive and documented disparities in maternal and infant outcomes related to race and ethnicity. Critical awareness is growing in our current cultural environment about strategies to improve health equity, the need to challenge implicit bias, and dismantle racism in healthcare to decrease racial health inequities. METHODS In this article, we provide a summary of health inequities that exist within the perinatal/neonatal population and offer strategies for initiating conversations and improving health equity by challenging bias and increasing diversity. RESULTS Transformative leaders must understand the evidence related to health disparities, understand social drivers of inequity issues, and identify solutions to influence change. IMPLICATIONS FOR PRACTICE With heightened awareness and examination of implicit bias, we can improve care for all infants and their families. IMPLICATIONS FOR RESEARCH We need to continue research and quality improvement efforts to improve health equity. Furthermore, research is needed that focus on social determinants of health as drivers of preterm delivery and birth complications, rather than biological (eg, racialized) factors.Video Abstract available at:https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=42.
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Mujahid MS, Kan P, Leonard SA, Hailu EM, Wall-Wieler E, Abrams B, Main E, Profit J, Carmichael SL. Birth hospital and racial and ethnic differences in severe maternal morbidity in the state of California. Am J Obstet Gynecol 2021; 224:219.e1-219.e15. [PMID: 32798461 DOI: 10.1016/j.ajog.2020.08.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 07/10/2020] [Accepted: 08/10/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Birth hospital has recently emerged as a potential key contributor to disparities in severe maternal morbidity, but investigations on its contribution to racial and ethnic differences remain limited. OBJECTIVE We leveraged statewide data from California to examine whether birth hospital explained racial and ethnic differences in severe maternal morbidity. STUDY DESIGN This cohort study used data on all births at ≥20 weeks gestation in California (2007-2012). Severe maternal morbidity during birth hospitalization was measured using the Centers for Disease Control and Prevention index of having at least 1 of the 21 diagnoses and procedures (eg, eclampsia, blood transfusion, hysterectomy). Mixed-effects logistic regression models (ie, women nested within hospitals) were used to compare racial and ethnic differences in severe maternal morbidity before and after adjustment for maternal sociodemographic and pregnancy-related factors, comorbidities, and hospital characteristics. We also estimated the risk-standardized severe maternal morbidity rates for each hospital (N=245) and the percentage reduction in severe maternal morbidity if each group of racially and ethnically minoritized women gave birth at the same distribution of hospitals as non-Hispanic white women. RESULTS Of the 3,020,525 women who gave birth, 39,192 (1.3%) had severe maternal morbidity (2.1% Black; 1.3% US-born Hispanic; 1.3% foreign-born Hispanic; 1.3% Asian and Pacific Islander; 1.1% white; 1.6% American Indian and Alaska Native, and Mixed-race referred to as Other). Risk-standardized rates of severe maternal morbidity ranged from 0.3 to 4.0 per 100 births across hospitals. After adjusting for covariates, the odds of severe maternal morbidity were greater among nonwhite women than white women in a given hospital (Black: odds ratio, 1.25; 95% confidence interval, 1.19-1.31); US-born Hispanic: odds ratio, 1.25; 95% confidence interval, 1.20-1.29; foreign-born Hispanic: odds ratio, 1.17; 95% confidence interval, 1.11-1.24; Asian and Pacific Islander: odds ratio, 1.26; 95% confidence interval, 1.21-1.32; Other: odds ratio, 1.31; 95% confidence interval, 1.15-1.50). Among the studied hospital factors, only teaching status was associated with severe maternal morbidity in fully adjusted models. Although 33% of white women delivered in hospitals with the highest tertile of severe maternal morbidity rates compared with 53% of Black women, birth hospital only accounted for 7.8% of the differences in severe maternal morbidity comparing Black and white women and accounted for 16.1% to 24.2% of the differences for all other racial and ethnic groups. CONCLUSION In California, excess odds of severe maternal morbidity among racially and ethnically minoritized women were not fully explained by birth hospital. Structural causes of racial and ethnic disparities in severe maternal morbidity may vary by region, which warrants further examination to inform effective policies.
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Affiliation(s)
- Mahasin S Mujahid
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA.
| | - Peiyi Kan
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Stephanie A Leonard
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
| | - Elleni M Hailu
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA
| | - Elizabeth Wall-Wieler
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Barbara Abrams
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA
| | - Elliott Main
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
| | - Jochen Profit
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Suzan L Carmichael
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
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Using rising tides to lift all boats: Equity-focused quality improvement as a tool to reduce neonatal health disparities. Semin Fetal Neonatal Med 2021; 26:101198. [PMID: 33558160 PMCID: PMC8809476 DOI: 10.1016/j.siny.2021.101198] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Evidence of health disparities affecting newborns abounds. Although quality improvement (QI) methodology is often suggested as a tool to advance health equity, the impact of QI initiatives on disparities is variable. QI work may mitigate, worsen, or perpetuate existing disparities. QI projects designed without an intentional focus on equity promotion may foster intervention-generated inequalities that further disadvantage vulnerable groups. This article reviews disparities in perinatal and neonatal care, the impact of QI on health disparities, and the concept of "Equity-Focused Quality Improvement" (EF-QI). EF-QI differs from QI with an equity lens in that it is action-oriented and centered around equity. EF-QI initiatives purposely integrate equity throughout the fabric of the project and are inclusive, collaborative efforts that foreground and address the needs of disadvantaged populations. EF-QI principles are applicable at every stage of project conception, execution, analysis, and dissemination, and may provide opportunities for reducing disparities in neonatal care.
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Cuna A, Sampath V, Khashu M. Racial Disparities in Necrotizing Enterocolitis. Front Pediatr 2021; 9:633088. [PMID: 33681105 PMCID: PMC7930220 DOI: 10.3389/fped.2021.633088] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/28/2021] [Indexed: 12/20/2022] Open
Abstract
Necrotizing enterocolitis (NEC) is a serious disease of the intestinal tract affecting 5-10% of pre-term infants with up to 50% mortality in those that require surgery. There is wide variation in the rates and outcomes of NEC by race and ethnicity, and the reasons for this disparity are poorly understood. In this article, we review the epidemiology and discuss possible explanations for racial and ethnic differences in NEC. Most of the current evidence investigating the role of race in NEC comes from North America and suggests that Hispanic ethnicity and non-Hispanic Black race are associated with higher risk of NEC compared to non-Hispanic White populations. Differences in pre-term births, breastfeeding rates, and various sociodemographic factors does not fully account for the observed disparities in NEC incidence and outcomes. While genetic studies are beginning to identify candidate genes that may increase or decrease risk for NEC among racial populations, current data remain limited by small sample sizes and lack of validation. Complex interactions between social and biological determinants likely underly the differences in NEC outcomes among racial groups. Larger datasets with detailed social, phenotypic, and genotypic information, coupled with advanced bioinformatics techniques are needed to comprehensively understand racial disparities in NEC.
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Affiliation(s)
- Alain Cuna
- School of Medicine, University of Missouri Kansas City, Kansas City, MO, United States.,Division of Neonatology, Children's Mercy Kansas City, Kansas City, MO, United States
| | - Venkatesh Sampath
- School of Medicine, University of Missouri Kansas City, Kansas City, MO, United States.,Division of Neonatology, Children's Mercy Kansas City, Kansas City, MO, United States
| | - Minesh Khashu
- Neonatal Service, University Hospitals Dorset, Poole, United Kingdom.,Bournemouth University, Dorset, United Kingdom
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Oribhabor GI, Nelson ML, Buchanan-Peart KAR, Cancarevic I. A Mother's Cry: A Race to Eliminate the Influence of Racial Disparities on Maternal Morbidity and Mortality Rates Among Black Women in America. Cureus 2020; 12:e9207. [PMID: 32685330 PMCID: PMC7366037 DOI: 10.7759/cureus.9207] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 07/15/2020] [Indexed: 11/06/2022] Open
Abstract
Racial/ethnic disparities in maternal care exist, even as medicine continues to progress on several aspects, medical care continues to fail countless women each year, particularly minority women and women of color. Black and American Indian/Alaska Native women experienced exponentially more pregnancy-related deaths. Recognizing factors that underlie disparities in pregnancy-related deaths and implementing preventive approaches to resolve them may mitigate racial/ethnic disparities in pregnancy-related mortality. Future research on these disparities should focus on strategies for reducing racial/ethnic inequalities in pregnancy-related deaths, including improving access to high-quality preconception, maternity, and postpartum care for minority women, multi-ethnic education for physicians and healthcare providers in a bid to eliminate implicit biases, adequate funding, and improvement of healthcare facilities in minority areas, education of healthcare providers on variation in the incidence of some certain conditions in different ethnic groups so that care is patient-centered and culturally appropriate. All of these can be enforced through the community, healthcare facility, patient, family, physician, and system-level collaboration.
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Affiliation(s)
- Geraldine I Oribhabor
- Obstetrics and Gynecology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Maxine L Nelson
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | | | - Ivan Cancarevic
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Howell EA, Janevic T, Blum J, Zeitlin J, Egorova NN, Balbierz A, Hebert PL. Double Disadvantage in Delivery Hospital for Black and Hispanic Women and High-Risk Infants. Matern Child Health J 2020; 24:687-693. [PMID: 32303940 PMCID: PMC7265984 DOI: 10.1007/s10995-020-02911-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To determine whether delivery hospitals that perform poorly for women also perform poorly for high-risk infants and to what extent Black and Hispanic women receive care at hospitals that perform poorly for both women and infants. METHODS We examined the correlation between hospital rankings for severe maternal morbidity and very preterm morbidity and mortality in New York City Hospitals using linked birth certificate and state discharge data for 2010-2014. We used mixed-effects logistic regression with a random hospital-specific intercept to generate risk standardized severe maternal morbidity rates and very preterm birth neonatal morbidity and mortality rates for each hospital. We ranked hospitals separately by these risk-standardized rates. We used k-means cluster analysis to categorize hospitals based on their performance on both metrics and risk-adjusted multinomial logistic regression to estimate adjusted probabilities of delivering in each hospital-quality cluster by race/ethnicity. RESULTS Hospital rankings for severe maternal morbidity and very preterm neonatal morbidity-mortality were moderately correlated (r = .32; p = .05). A 5-cluster solution best fit the data and yielded the categories for hospital performance for women and infants: excellent, good, fair, fair to poor, poor. Black and Hispanic versus White women were less likely to deliver in an excellent quality cluster (adjusted percent of 11%, 18% vs 28%, respectively, p < .001) and more likely to deliver in a poor quality cluster (adjusted percent of 28%, 20%, vs. 4%, respectively, p < .001). CONCLUSIONS FOR PRACTISE Hospital performance for maternal and high-risk infant outcomes is only moderately correlated but Black and Hispanic women deliver at hospitals with worse outcomes for both women and very preterm infants.
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Affiliation(s)
- Elizabeth A Howell
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1070, New York, NY, 10029, USA.
- Blavatnik Family Women's Health Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA.
- Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, 10029, USA.
| | - Teresa Janevic
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1070, New York, NY, 10029, USA
- Blavatnik Family Women's Health Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, 10029, USA
| | - James Blum
- Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, 10029, USA
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1002, New York, NY, 10029, USA
| | - Jennifer Zeitlin
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Biostatistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| | - Natalia N Egorova
- Blavatnik Family Women's Health Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, 10029, USA
| | - Amy Balbierz
- Blavatnik Family Women's Health Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, 10029, USA
| | - Paul L Hebert
- University of Washington School of Public Health, Seattle, WA, USA
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Perez NP, Stapleton SM, Tabrizi MB, Watkins MT, Lillemoe KD, Kelleher CM, Chang DC. The impact of race on choice of location for elective surgical care in New York city. Am J Surg 2020; 219:557-562. [PMID: 32007235 DOI: 10.1016/j.amjsurg.2020.01.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 11/07/2019] [Accepted: 01/19/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND The "white-flight" phenomenon of the mid-20th century contributed to the perpetuation of residential segregation in American society. In light of recent reports of racial segregation in our healthcare system, could a contemporary "white-flight" phenomenon also exist? METHODS The New York Statewide Planning and Research Cooperative System was used to identify all Manhattan and Bronx residents of New York city who underwent elective cardiothoracic, colorectal, general, and vascular surgeries from 2010 to 2016. Primary outcome was borough of surgical care in relation to patient's home borough. Multivariable analyses were performed. RESULTS White patients who reside in the Bronx are significantly more likely than racial minorities to travel into Manhattan for elective surgical care, and these differences persist across different insurance types, including Medicare. CONCLUSIONS Marked race-based differences in choice of location for elective surgical care exist in New York city. If left unchecked, these differences can contribute to furthering racial segregation within our healthcare system.
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Affiliation(s)
- Numa P Perez
- Massachusetts General Hospital, Department of Surgery, 55 Fruit St, Boston, MA, 02114, USA; Massachusetts General Hospital, Codman Center for Clinical Effectiveness in Surgery, Charles River Plaza, Suite 403, 165 Cambridge Street, Boston, MA, 02114, USA.
| | - Sahael M Stapleton
- Massachusetts General Hospital, Department of Surgery, 55 Fruit St, Boston, MA, 02114, USA; Massachusetts General Hospital, Codman Center for Clinical Effectiveness in Surgery, Charles River Plaza, Suite 403, 165 Cambridge Street, Boston, MA, 02114, USA
| | - Maryam B Tabrizi
- Massachusetts General Hospital, Department of Surgery, 55 Fruit St, Boston, MA, 02114, USA
| | - Michael T Watkins
- Massachusetts General Hospital, Department of Surgery, 55 Fruit St, Boston, MA, 02114, USA
| | - Keith D Lillemoe
- Massachusetts General Hospital, Department of Surgery, 55 Fruit St, Boston, MA, 02114, USA
| | - Cassandra M Kelleher
- Massachusetts General Hospital, Department of Surgery, 55 Fruit St, Boston, MA, 02114, USA; Massachusetts General Hospital, Codman Center for Clinical Effectiveness in Surgery, Charles River Plaza, Suite 403, 165 Cambridge Street, Boston, MA, 02114, USA
| | - David C Chang
- Massachusetts General Hospital, Department of Surgery, 55 Fruit St, Boston, MA, 02114, USA; Massachusetts General Hospital, Codman Center for Clinical Effectiveness in Surgery, Charles River Plaza, Suite 403, 165 Cambridge Street, Boston, MA, 02114, USA
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Howell EA, Egorova NN, Janevic T, Brodman M, Balbierz A, Zeitlin J, Hebert PL. Race and Ethnicity, Medical Insurance, and Within-Hospital Severe Maternal Morbidity Disparities. Obstet Gynecol 2020; 135:285-293. [PMID: 31923076 PMCID: PMC7117864 DOI: 10.1097/aog.0000000000003667] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To examine within-hospital racial and ethnic disparities in severe maternal morbidity rates and determine whether they are associated with differences in types of medical insurance. METHODS We conducted a population-based, cross-sectional study using linked 2010-2014 New York City discharge and birth certificate data sets (N=591,455 deliveries) to examine within-hospital black-white, Latina-white, and Medicaid-commercially insured differences in severe maternal morbidity. We used logistic regression to produce risk-adjusted rates of severe maternal morbidity for patients with commercial and Medicaid insurance and for black, Latina, and white patients within each hospital. We compared these within-hospital adjusted rates using paired t-tests and conditional logit models. RESULTS Severe maternal morbidity was higher among black and Latina women than white women (4.2% and 2.9% vs 1.5%, respectively, P<.001) and among women insured by Medicaid than those commercially insured (2.8% vs 2.0%, P<.001). Women insured by Medicaid compared with those with commercial insurance had similar risk for severe maternal morbidity within the same hospital (P=.54). In contrast, black women compared with white women had significantly higher risk for severe maternal morbidity within the same hospital (P<.001), as did Latina women (P<.001). Conditional logit analyses confirmed these findings, with black and Latina women compared with white women having higher risk for severe maternal morbidity (adjusted odds ratio [aOR] 1.52; 95% CI 1.46-1.62 and aOR 1.44; 95% CI 1.36-1.53, respectively) and women insured by Medicaid compared with those commercially insured having similar risk. CONCLUSION Within hospitals in New York City, black and Latina women are at higher risk of severe maternal morbidity than white women; this is not associated with differences in types of insurance.
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Affiliation(s)
- Elizabeth A Howell
- Departments of Population Health Science & Policy and Obstetrics, Gynecology, and Reproductive Science and the Blavatnik Family Women's Health Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Biostatistics Sorbonne Paris Cité, DHU Risks in pregnancy, Paris Descartes University, Paris, France; and the University of Washington School of Public Health, Seattle, Washington
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Abstract
OBJECTIVES This study aimed to examine multilevel risk factors for health care-associated infection (HAI) among very low birth weight (VLBW) infants with a focus on race/ethnicity and its association with variation in infection across hospitals. STUDY DESIGN This is a population-based cohort study of 20,692 VLBW infants born between 2011 and 2015 in the California Perinatal Quality Care Collaborative. RESULTS Risk-adjusted infection rates varied widely across neonatal intensive care units (NICUs), ranging from 0 to 24.6% across 5 years. Although Hispanic infants had higher odds of HAI overall, race/ethnicity did not affect the variation in infection rates. Non-Hispanic black mothers were more likely to receive care in NICUs within the top tertile of infection risk. Yet, among NICUs in this tertile, infants across all races and ethnicities suffered similar high rates of infection. CONCLUSION Hispanic infants had higher odds of infection. We found significant variation in infection across NICUs, even after accounting for factors usually associated with infection.
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Affiliation(s)
- Jessica Liu
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Lucile Packard Children’s Hospital, Stanford University School of Medicine, Palo Alto, California
- California Perinatal Quality Care Collaborative, Palo Alto, California
| | - Charlotte Sakarovitch
- Division of Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California
- Medical Data Lab, Université Côte d’Azur, Nice, France
| | - Krista Sigurdson
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Lucile Packard Children’s Hospital, Stanford University School of Medicine, Palo Alto, California
- California Perinatal Quality Care Collaborative, Palo Alto, California
| | - Henry C. Lee
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Lucile Packard Children’s Hospital, Stanford University School of Medicine, Palo Alto, California
- California Perinatal Quality Care Collaborative, Palo Alto, California
| | - Jochen Profit
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Lucile Packard Children’s Hospital, Stanford University School of Medicine, Palo Alto, California
- California Perinatal Quality Care Collaborative, Palo Alto, California
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Beck AF, Edwards EM, Horbar JD, Howell EA, McCormick MC, Pursley DM. The color of health: how racism, segregation, and inequality affect the health and well-being of preterm infants and their families. Pediatr Res 2020; 87:227-234. [PMID: 31357209 PMCID: PMC6960093 DOI: 10.1038/s41390-019-0513-6] [Citation(s) in RCA: 131] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/04/2019] [Indexed: 02/06/2023]
Abstract
Racism, segregation, and inequality contribute to health outcomes and drive health disparities across the life course, including for newborn infants and their families. In this review, we address their effects on the health and well-being of newborn infants and their families with a focus on preterm birth. We discuss three causal pathways: increased risk; lower-quality care; and socioeconomic disadvantages that persist into infancy, childhood, and beyond. For each pathway, we propose specific interventions and research priorities that may remedy the adverse effects of racism, segregation, and inequality. Infants and their families will not realize the full benefit of advances in perinatal and neonatal care until we, collectively, accept our responsibility for addressing the range of determinants that shape long-term outcomes.
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Affiliation(s)
- Andrew F Beck
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of General & Community Pediatrics and Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Erika M Edwards
- Vermont Oxford Network, Burlington, VT, USA.
- Department of Pediatrics, Robert Larner, MD, College of Medicine, University of Vermont, Burlington, VT, USA.
- Department of Mathematics and Statistics, College of Engineering and Mathematical Sciences, University of Vermont, Burlington, VT, USA.
| | - Jeffrey D Horbar
- Vermont Oxford Network, Burlington, VT, USA
- Department of Pediatrics, Robert Larner, MD, College of Medicine, University of Vermont, Burlington, VT, USA
| | - Elizabeth A Howell
- Blavatnik Family Women's Health Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marie C McCormick
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - DeWayne M Pursley
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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Parker MG, Greenberg LT, Edwards EM, Ehret D, Belfort MB, Horbar JD. National Trends in the Provision of Human Milk at Hospital Discharge Among Very Low-Birth-Weight Infants. JAMA Pediatr 2019; 173:961-968. [PMID: 31479097 PMCID: PMC6724150 DOI: 10.1001/jamapediatrics.2019.2645] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 05/23/2019] [Indexed: 01/30/2023]
Abstract
IMPORTANCE Human milk confers important health benefits to very low-birth-weight (VLBW) infants (≤1500 g). The extent to which the use of human milk has changed over time and the factors associated with human milk use nationally in this population are poorly understood. OBJECTIVES To describe US trends in the provision of human milk at hospital discharge for VLBW infants during the past decade according to census region and maternal race/ethnicity, quantify associations of census region and maternal race/ethnicity with the provision of human milk at hospital discharge, and examine regional and state variations in any provision of human milk at hospital discharge among racial/ethnic groups. DESIGN, SETTING, AND PARTICIPANTS A cohort study was conducted of 346 248 infants, born at 23 to 29 weeks' gestation or with a birth weight of 401 to 1500 g, who were cared for at 802 US hospitals in the Vermont Oxford Network from January 1, 2008, to December 31, 2017. The US census region was categorized as West, Midwest, Northeast, and South (reference). Maternal race/ethnicity was categorized as non-Hispanic white (reference), non-Hispanic black, Hispanic, Asian and Pacific Islanders, and Native American. MAIN OUTCOMES AND MEASURES Any provision of human milk at hospital discharge, defined as the use of human milk as the only enteral feeding or the use of human milk in combination with fortifier or formula. RESULTS Of the 346 248 infants in the study (172 538 boys and 173 710 girls), 46.2% were non-Hispanic white, 30.1% were non-Hispanic black, 18.3% were Hispanic of any race, 4.7% were Asian and Pacific Islanders, and 0.8% were Native American. Any provision of human milk at hospital discharge increased steadily among all infants, from 44% in 2008 to 52% in 2017. There were increases across all US census regions and racial/ethnic groups. Any provision of human milk at hospital discharge was higher in the West (among singleton births: adjusted prevalence ratio, 1.32; 95% CI, 1.25-1.39; among multiple births: adjusted prevalence ratio, 1.28; 95% CI, 1.21-1.35) and Northeast (among singleton births: adjusted prevalence ratio, 1.11; 95% CI, 1.04-1.19; among multiple births: adjusted prevalence ratio, 1.11; 95% CI, 1.04-1.19), compared with the South, and was higher among Asian mothers (among singleton births: adjusted prevalence ratio, 1.21; 95% CI, 1.18-1.25; among multiple births: adjusted prevalence ratio, 1.12; 95% CI, 1.09-1.15) and lower among Hispanic (among singleton births: adjusted prevalence ratio, 0.98; 95% CI, 0.96-1.01; among multiple births: adjusted prevalence ratio, 0.88; 95% CI, 0.86-0.91), Native American (among singleton births: adjusted prevalence ratio, 0.64; 95% CI, 0.59-0.70; among multiple births: adjusted prevalence ratio, 0.59; 95% CI, 0.50-0.69), and non-Hispanic black mothers (among singleton births: adjusted prevalence ratio, 0.67; 95% CI, 0.65-0.70; among multiple births: adjusted prevalence ratio, 0.57; 95% CI, 0.54-0.60), compared with non-Hispanic white mothers. These results were robust to adjustment for birth year and infant characteristics. Wide regional and state variations were found in any provision of human milk at hospital discharge. CONCLUSIONS AND RELEVANCE Overall prevalence of any provision of human milk at hospital discharge among VLBW infants has steadily increased during the past decade. Disparities by US region and race/ethnicity in the provision of human milk exist and have not diminished over time.
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Affiliation(s)
- Margaret G. Parker
- Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | | | - Erika M. Edwards
- Vermont Oxford Network, Burlington, Vermont
- Department of Pediatrics, Robert Larner College of Medicine, University of Vermont, Burlington
- Department of Mathematics and Statistics, College of Engineering and Mathematical Sciences, University of Vermont, Burlington
| | - Danielle Ehret
- Vermont Oxford Network, Burlington, Vermont
- Department of Pediatrics, Robert Larner College of Medicine, University of Vermont, Burlington
| | - Mandy B. Belfort
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey D. Horbar
- Vermont Oxford Network, Burlington, Vermont
- Department of Pediatrics, Robert Larner College of Medicine, University of Vermont, Burlington
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Howell EA, Ahmed ZN, Sofaer S, Zeitlin J. Positive Deviance to Address Health Equity in Quality and Safety in Obstetrics. Clin Obstet Gynecol 2019; 62:560-571. [PMID: 31206366 PMCID: PMC6988184 DOI: 10.1097/grf.0000000000000472] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Racial/ethnic disparities persist in obstetrical outcomes. In this paper, we ask how research in obstetrical quality can go beyond a purely quantitative approach to tackle the challenge of health inequity in quality and safety. This overview debriefs the use of positive deviance and mixed methods in others areas of medicine, describes the shortcomings of quantitative methods in obstetrics and presents qualitative studies carried out in obstetrics as well as the insights provided by this method. The article concludes by proposing positive deviance as a mixed methods approach to generate new knowledge for addressing racial and ethnic disparities in maternal outcomes.
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Affiliation(s)
- Elizabeth A Howell
- Blavatnik Family Women's Health Research Institute
- Departments of Population Health Science & Policy
- Obstetrics, Gynecology, and Reproductive Science
| | - Zainab N Ahmed
- Departments of Population Health Science & Policy
- Obstetrics, Gynecology, and Reproductive Science
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Shoshanna Sofaer
- American Institutes for Research, Washington, District of Columbia
| | - Jennifer Zeitlin
- Departments of Population Health Science & Policy
- Icahn School of Medicine at Mount Sinai, New York, New York
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Biostatistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
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Ravi D, Sigurdson K, Profit J. Improving Quality of Care Can Mitigate Persistent Disparities. Pediatrics 2019; 144:e20192002. [PMID: 31405886 PMCID: PMC6855819 DOI: 10.1542/peds.2019-2002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2019] [Indexed: 11/24/2022] Open
Affiliation(s)
- Dhurjati Ravi
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and
- California Perinatal Quality Care Collaborative, Stanford, California
| | - Krista Sigurdson
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and
- California Perinatal Quality Care Collaborative, Stanford, California
| | - Jochen Profit
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and
- California Perinatal Quality Care Collaborative, Stanford, California
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Racial and Ethnic Differences in Pediatric Pulmonary Hypertension: An Analysis of the Pediatric Pulmonary Hypertension Network Registry. J Pediatr 2019; 211:63-71.e6. [PMID: 31176455 PMCID: PMC6776463 DOI: 10.1016/j.jpeds.2019.04.046] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 03/26/2019] [Accepted: 04/23/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To investigate racial and ethnic differences in pulmonary hypertension subtypes and survival differences in a pediatric population. STUDY DESIGN This was a retrospective analysis of a cohort of patients with pulmonary hypertension (aged ≤18 years) enrolled in the Pediatric Pulmonary Hypertension Network registry between 2014 and 2018, comprising patients at eight Pediatric Centers throughout North America (n = 1417). RESULTS Among children diagnosed after the neonatal period, pulmonary arterial hypertension was more prevalent among Asians (OR, 1.83; 95% CI, 1.21-2.79; P = .0045), lung disease-associated pulmonary hypertension among blacks (OR, 2.09; 95% CI, 1.48-2.95; P < .0001), idiopathic pulmonary arterial hypertension among whites (OR, 1.58; 95% CI, 1.06-2.41; P = .0289), and pulmonary veno-occlusive disease among Hispanics (OR, 6.11; 95% CI, 1.34-31.3; P = .0184). Among neonates, persistent pulmonary hypertension of the newborn (OR, 4.07; 95% CI, 1.54-10.0; P = .0029) and bronchopulmonary dysplasia (OR, 8.11; 95% CI, 3.28-19.8; P < .0001) were more prevalent among blacks, and congenital diaphragmatic hernia was more prevalent among whites (OR, 2.29; 95% CI, 1.25-4.18; P = .0070). An increased mortality risk was observed among blacks (HR, 1.99; 95% CI, 1.03-3.84; P = .0396), driven primarily by the heightened mortality risk among those with lung disease-associated pulmonary hypertension (HR, 2.84; 95% CI, 1.15-7.04; P = .0241). CONCLUSIONS We found significant racial variability in the prevalence of pulmonary hypertension subtypes and survival outcomes among children with pulmonary hypertension. Given the substantial burden of this disease, further studies to validate phenotypic differences and to understand the underlying causes of survival disparities between racial and ethnic groups are warranted.
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Sigurdson K, Mitchell B, Liu J, Morton C, Gould JB, Lee HC, Capdarest-Arest N, Profit J. Racial/Ethnic Disparities in Neonatal Intensive Care: A Systematic Review. Pediatrics 2019; 144:peds.2018-3114. [PMID: 31358664 PMCID: PMC6784834 DOI: 10.1542/peds.2018-3114] [Citation(s) in RCA: 148] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2019] [Indexed: 12/15/2022] Open
Abstract
CONTEXT Racial and ethnic disparities in health outcomes of newborns requiring care in the NICU setting have been reported. The contribution of NICU care to disparities in outcomes is unclear. OBJECTIVE To conduct a systematic review of the literature documenting racial/ethnic disparities in quality of care for infants in the NICU setting. DATA SOURCES Medline/PubMed, Scopus, Cumulative Index of Nursing and Allied Health, and Web of Science were searched until March 6, 2018, by using search queries organized around the following key concepts: "neonatal intensive care units," "racial or ethnic disparities," and "quality of care." STUDY SELECTION English language articles up to March 6, 2018, that were focused on racial and/or ethnic differences in the quality of NICU care were selected. DATA EXTRACTION Two authors independently assessed eligibility, extracted data, and cross-checked results, with disagreements resolved by consensus. Information extracted focused on racial and/or ethnic disparities in quality of care and potential mechanism(s) for disparities. RESULTS Initial search yielded 566 records, 470 of which were unique citations. Title and abstract review resulted in 382 records. Appraisal of the full text of the remaining 88 records, along with the addition of 5 citations from expert consult or review of bibliographies, resulted in 41 articles being included. LIMITATIONS Quantitative meta-analysis was not possible because of study heterogeneity. CONCLUSIONS Overall, this systematic review revealed complex racial and/or ethnic disparities in structure, process, and outcome measures, most often disadvantaging infants of color, especially African American infants. There are some exceptions to this pattern and each area merits its own analysis and discussion.
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Affiliation(s)
- Krista Sigurdson
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University and Lucile Packard Children's Hospital, Palo Alto, California; .,Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, San Francisco, California.,California Perinatal Quality Care Collaborative, Palo Alto, California
| | - Briana Mitchell
- Perinatal Epidemiology and Health Outcomes Research
Unit, Division of Neonatology, Department of Pediatrics, School of Medicine,
Stanford University and Lucile Packard Children’s Hospital, Palo Alto,
California;,California Perinatal Quality Care Collaborative, Palo
Alto, California
| | - Jessica Liu
- Perinatal Epidemiology and Health Outcomes Research
Unit, Division of Neonatology, Department of Pediatrics, School of Medicine,
Stanford University and Lucile Packard Children’s Hospital, Palo Alto,
California;,California Perinatal Quality Care Collaborative, Palo
Alto, California
| | - Christine Morton
- California Maternal Quality Care Collaborative, Palo
Alto, California; and
| | - Jeffrey B. Gould
- Perinatal Epidemiology and Health Outcomes Research
Unit, Division of Neonatology, Department of Pediatrics, School of Medicine,
Stanford University and Lucile Packard Children’s Hospital, Palo Alto,
California;,California Perinatal Quality Care Collaborative, Palo
Alto, California
| | - Henry C. Lee
- Perinatal Epidemiology and Health Outcomes Research
Unit, Division of Neonatology, Department of Pediatrics, School of Medicine,
Stanford University and Lucile Packard Children’s Hospital, Palo Alto,
California;,California Perinatal Quality Care Collaborative, Palo
Alto, California
| | | | - Jochen Profit
- Perinatal Epidemiology and Health Outcomes Research
Unit, Division of Neonatology, Department of Pediatrics, School of Medicine,
Stanford University and Lucile Packard Children’s Hospital, Palo Alto,
California;,California Perinatal Quality Care Collaborative, Palo
Alto, California
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Howell EA, Hebert PL, Zeitlin J. Racial Segregation and Inequality of Care in Neonatal Intensive Care Units Is Unacceptable. JAMA Pediatr 2019; 173:420-421. [PMID: 30907946 DOI: 10.1001/jamapediatrics.2019.0240] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Elizabeth A Howell
- Blavatnik Family Women's Health Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Paul L Hebert
- University of Washington School of Public Health, Seattle
| | - Jennifer Zeitlin
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.,Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Center for Epidemiology and Biostatistics Sorbonne Paris Cité, Universitary Hospital Departement Risks in Pregnancy, Paris Descartes University, Paris, France
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Abstract
Significant racial and ethnic disparities in maternal morbidity and mortality exist in the United States. Black women are 3 to 4 times more likely to die a pregnancy-related death as compared with white women. Growing research indicates that quality of health care, from preconception through postpartum care, may be a critical lever for improving outcomes for racial and ethnic minority women. This article reviews racial and ethnic disparities in severe maternal morbidities and mortality, underlying drivers of these disparities, and potential levers to reduce their occurrence.
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Racial and Ethnic Disparities in the Use of Mother's Milk Feeding for Very Low Birth Weight Infants in Massachusetts. J Pediatr 2019; 204:134-141.e1. [PMID: 30274926 DOI: 10.1016/j.jpeds.2018.08.036] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 08/01/2018] [Accepted: 08/16/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To examine the extent to which maternal race/ethnicity is associated with mother's milk use among hospitalized very low birth weight (VLBW) infants and maternal receipt of hospital breastfeeding support practices (human milk prenatal education, first milk expression <6 hours after delivery, lactation consultation <24 hours, any skin-to-skin care <1 month). STUDY DESIGN We studied 1318 mother-VLBW infant pairs in 9 Massachusetts level 3 neonatal intensive care units (NICUs) between January 2015 and November 2017. We estimated associations of maternal race/ethnicity with any and exclusive mother's milk on day 7, on day 28, and at discharge/transfer and hospital practices. We estimated HRs comparing the probability of continued milk use over the hospitalization by race/ethnicity and tested mediation by hospital practices, adjusting for birth weight and gestational age and including hospital and plurality as random effects. RESULTS Mothers were 48% non-Hispanic white, 21% non-Hispanic black, and 20% Hispanic. Initiation of mother's milk was similar across groups, but infants of Hispanic mothers (hazard ratio [HR], 2.71; 95% CI, 2.05-3.59) and non-Hispanic black mothers (HR, 1.55; 95% CI, 1.17-2.07) stopped receiving milk earlier in the hospitalization compared with infants of non-Hispanic white mothers. Hispanic mothers had lower odds of providing skin-to-skin care at <1 month (OR, 0.61; 95% CI, 0.43-0.87) compared with non-Hispanic whites. CONCLUSIONS Hispanic and non-Hispanic black mothers were less likely than non-Hispanic white mothers to continue providing milk for their VLBW infants throughout the NICU stay.
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Parker MG, Lopera AM, Kalluri NS, Kistin CJ. "I Felt Like I Was a Part of Trying to Keep My Baby Alive": Perspectives of Hispanic and Non-Hispanic Black Mothers in Providing Milk for Their Very Preterm Infants. Breastfeed Med 2018; 13:657-665. [PMID: 30299981 DOI: 10.1089/bfm.2018.0104] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background: Compared with non-Hispanic white, Hispanic and non-Hispanic black mothers of very preterm infants are less likely to provide mother's milk at the point of hospital discharge; the perspectives of these mothers are poorly understood. Objectives: To examine the perceived barriers and facilitators of providing milk for very preterm infants during the hospitalization among Hispanic and non-Hispanic black mothers. Materials and Methods: We conducted 23 in-depth, semistructured interviews of English and Spanish-speaking Hispanic and non-Hispanic black mothers that initiated milk production for their very preterm infants, ≤1,750 g at birth. Following thematic saturation, results were validated through expert triangulation and member checking. Results: Twelve mothers were Hispanic, where three were English speaking and nine were Spanish speaking. Eleven mothers were non-Hispanic black and English speaking. We found themes pertaining to general experiences: (1) Breastfeeding intent impacts mothers' success in providing milk throughout the hospitalization; (2) Pumping milk for a hospitalized infant is repetitive, exhausting, and does not elicit the same emotional connection as breastfeeding; (3) Hospital providers are an important source of support, when sufficient time is spent to address ongoing issues; (4) Providing milk creates a unique sense of purpose when mothers otherwise feel a lack of control; and we found themes pertaining to the experiences of Hispanic and non-Hispanic black mothers: (1) Breastfeeding as a cultural norm influences mothers' intent to initiate and continue breastfeeding; (2) Hospital staff are viewed as more supportive when interactions and treatment are perceived as racially/ethnically unbiased and (3) when communication occurs in the primary language; and (4) Mother-infant separation creates logistical challenges that negatively impact ongoing milk production. Conclusions: While providing milk for a hospitalized very preterm infant is exhausting, and logistically challenging, Hispanic and non-Hispanic black mothers are inspired to do so because of their intent to breastfeed, support from hospital providers, and feelings of purpose.
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Affiliation(s)
- Margaret G Parker
- Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Adriana M Lopera
- Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Nikita S Kalluri
- Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Caroline J Kistin
- Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
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Sall L, Hayward RD, Fessler MM, Edhayan E. Between-hospital and between-neighbourhood variance in trauma outcomes: cross-sectional observational evidence from the Detroit metropolitan area. BMJ Open 2018; 8:e022090. [PMID: 30478107 PMCID: PMC6254416 DOI: 10.1136/bmjopen-2018-022090] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Disparities in treatment outcomes for traumatic injury are an important concern for care providers and policy makers. Factors that may influence these disparities include differences in risk exposure based on neighbourhood of residence and differences in quality of care between hospitals in different areas. This study examines geographical disparities within a single region: the Detroit metropolitan area. DESIGN Data on all trauma admissions between 2006 and 2014 were obtained from the Michigan State Inpatient Database. Admissions were grouped by patient neighbourhood of residence and admitting hospital. Generalised linear mixed modelling procedures were used to determine the extent of shared variance based on these two levels of categorisation on three outcomes. Patients with trauma due to common mechanisms (falls, firearms and motor vehicle traffic) were examined as additional subgroups. SETTING 66 hospitals admitting patients for traumatic injury in the Detroit metropolitan area during the period from 2006 to 2014. PARTICIPANTS 404 675 adult patients admitted for treatment of traumatic injury. OUTCOME MEASURES In-hospital mortality, length of stay and hospital charges. RESULTS Intraclass correlation coefficients indicated that there was substantial shared variance in outcomes based on hospital, but not based on neighbourhood of residence. Among all injury types, hospital-level differences accounted for 12.5% of variance in mortality risk, 28.5% of variance in length of stay and 32.2% of variance in hospital charges. Adjusting the results for patient age, injury severity, mechanism and comorbidities did not result in significant reduction in the estimated variance at the hospital level. CONCLUSIONS Based on these data, geographical disparities in trauma treatment outcomes were more strongly attributable to differences in access to quality hospital care than to risk factors in the neighbourhood environment. Transfer of high-risk cases to hospitals with greater institutional experience in the relevant area may help address mortality disparities in particular.
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Affiliation(s)
- Lauren Sall
- Department of Surgery, St John Hospital and Medical Center, Detroit, Michigan, USA
| | - R David Hayward
- Department of Surgery, St John Hospital and Medical Center, Detroit, Michigan, USA
| | - Mary M Fessler
- Department of Surgery, St John Hospital and Medical Center, Detroit, Michigan, USA
| | - Elango Edhayan
- Department of Surgery, St John Hospital and Medical Center, Detroit, Michigan, USA
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Aboudi D, Shah SI, La Gamma EF, Brumberg HL. Impact of neonatologist availability on preterm survival without morbidities. J Perinatol 2018; 38:1009-1016. [PMID: 29743659 DOI: 10.1038/s41372-018-0103-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 02/09/2018] [Accepted: 02/21/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVES We assessed birth hospital level and neonatal outcomes within a model of regionalization featuring neonatologists at all levels of care, including well-baby nurseries without an accompanying neonatal intensive care unit. METHODS Data were analyzed by NY State adaptation of American Academy of Pediatrics defined levels of care; n = 998, 23-30 weeks gestational age, 400-1250 g birth weight, and admitted to the regional center (2006-2015). Primary outcomes were survival, neurologic survival, and intact survival. RESULTS Level III hospitals transferred 82% of neonates ≥24 h of life compared to ≤2% at Level I or II hospitals (p < 0.05). Primary outcomes were equivalent for Levels I vs. II born neonates with similar postnatal age at transfer and similar to inborn rates (Levels I and II vs. IV). CONCLUSIONS When transferred within 24 h, Levels I or II born infants had equivalent outcomes to inborn Level IV infants in a model of neonatologist availability at all deliveries.
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Affiliation(s)
- David Aboudi
- Department of Pediatrics, Division of Newborn Medicine, Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, NY, 10595, USA
| | - Shetal I Shah
- Department of Pediatrics, Division of Newborn Medicine, Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, NY, 10595, USA
| | - Edmund F La Gamma
- Department of Pediatrics, Division of Newborn Medicine, Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, NY, 10595, USA
| | - Heather L Brumberg
- Department of Pediatrics, Division of Newborn Medicine, Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, NY, 10595, USA.
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48
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Where You Are Born Really Does Matter: Why Birth Hospital and Quality of Care Contribute to Racial/Ethnic Disparities. Adv Neonatal Care 2018; 18:81-82. [PMID: 29595545 DOI: 10.1097/anc.0000000000000480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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49
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Measuring and improving comprehensive pediatric cardiac care: Learning from continuous quality improvement methods and tools. PROGRESS IN PEDIATRIC CARDIOLOGY 2018. [DOI: 10.1016/j.ppedcard.2018.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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50
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Howell EA, Janevic T, Hebert PL, Egorova NN, Balbierz A, Zeitlin J. Differences in Morbidity and Mortality Rates in Black, White, and Hispanic Very Preterm Infants Among New York City Hospitals. JAMA Pediatr 2018; 172:269-277. [PMID: 29297054 PMCID: PMC5796743 DOI: 10.1001/jamapediatrics.2017.4402] [Citation(s) in RCA: 137] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Substantial quality improvements in neonatal care have occurred over the past decade yet racial and ethnic disparities in morbidity and mortality remain. It is uncertain whether disparate patterns of care by race and ethnicity contribute to disparities in neonatal outcomes. OBJECTIVES To examine differences in neonatal morbidity and mortality rates among non-Hispanic black (black), Hispanic, and non-Hispanic white (white) very preterm infants and to determine whether these differences are explained by site of delivery. DESIGN, SETTING, AND PARTICIPANTS Population-based retrospective cohort study of 7177 nonanomalous infants born between 24 and 31 completed gestational weeks in 39 New York City hospitals using linked 2010 to 2014 New York City discharge abstract and birth certificate data sets. Mixed-effects logistic regression with a random hospital-specific intercept was used to generate risk-adjusted neonatal morbidity and mortality rates for very preterm infants in each hospital. Hospitals were ranked using this measure, and differences in the distribution of black, Hispanic, and white very preterm births were assessed among these hospitals. The statistical analysis was performed in 2016-2017. EXPOSURE Race/ethnicity. MAIN OUTCOMES AND MEASURES Composite of mortality (neonatal or in-hospital up to 1 year) or severe neonatal morbidity (bronchopulmonary dysplasia, severe necrotizing enterocolitis, retinopathy of prematurity stage 3 or greater, or intraventricular hemorrhage grade 3 or greater). RESULTS Among 7177 very preterm births (VPTBs), morbidity and mortality occurred in 2011 (28%) and was higher among black (893 [32.2%]) and Hispanic (610 [28.1%]) than white (319 [22.5%]) VPTBs (2-tailed P < .001). The risk-standardized morbidity and mortality rate was twice as great for VPTB infants born in hospitals in the highest morbidity and mortality tertile (0.40; 95% CI, 0.38-0.41) as for those born in the lowest morbidity and mortality tertile (0.16; 95% CI, 0.14-0.18). Black (1204 of 2775 [43.4%]) and Hispanic (746 of 2168 [34.4%]) VPTB infants were more likely than white (325 of 1418 [22.9%]) VPTB infants to be born in hospitals in the highest morbidity and mortality tertile (2-tailed P < .001; black-white difference, 20%; 95% CI, 18%-23% and Hispanic-white difference, 11%; 95% CI, 9%-14%). The largest proportion of the explained disparities can be attributed to differences in infant health risks among black, Hispanic, and white VPTB infants. However, 40% (95% CI, 30%-50%) of the black-white disparity and 30% (95% CI, 10%-49%) of the Hispanic-white disparity was explained by birth hospital. CONCLUSIONS AND RELEVANCE Black and Hispanic VPTB infants are more likely to be born at hospitals with higher risk-adjusted neonatal morbidity and mortality rates, and these differences contribute to excess morbidity and mortality among black and Hispanic infants.
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Affiliation(s)
- Elizabeth A. Howell
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York,Women’s Health Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York,Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Teresa Janevic
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York,Women’s Health Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Paul L. Hebert
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington
| | - Natalia N. Egorova
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York,Women’s Health Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Amy Balbierz
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York,Women’s Health Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jennifer Zeitlin
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York,INSERM Joint Research Unit 1153, Obstetrical, Perinatal, and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Biostatistics Sorbonne Paris Cité, University Hospital Department Risks in Pregnancy, Paris Descartes University, Paris, France
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