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Yu X, Johnson JE, Roman LA, Key K, McCoy White J, Bolder H, Raffo JE, Meng R, Nelson H, Meghea CI. Neighborhood Deprivation and Severe Maternal Morbidity in a Medicaid Population. Am J Prev Med 2024; 66:850-859. [PMID: 37995948 PMCID: PMC11034747 DOI: 10.1016/j.amepre.2023.11.016] [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: 09/05/2023] [Revised: 11/15/2023] [Accepted: 11/15/2023] [Indexed: 11/25/2023]
Abstract
INTRODUCTION Few studies have examined whether neighborhood deprivation is associated with severe maternal morbidity (SMM) in already socioeconomically disadvantaged populations. Little is known about to what extent neighborhood deprivation accounts for Black-White disparities in SMM. This study investigated these questions among a statewide Medicaid-insured population, a low-income population with heightened risk of SMM. METHODS Data were from Michigan statewide linked birth records and Medicaid claims between 01/01/2016 and 12/31/2019, and were analyzed between 2022 and 2023. Neighborhood deprivation was measured with the Area Deprivation Index at census block group and categorized as low, medium, or high deprivation. Multilevel logistic models were used to examine the association between neighborhood deprivation and SMM. Fairlie nonlinear decomposition was conducted to quantify the contribution of neighborhood deprivation to SMM racial disparity. RESULTS People in the most deprived neighborhoods had higher odds of SMM than those in the least deprived neighborhoods (aOR [95% CI]: 1.27 [1.15, 1.40]). Such association was observed in Black (aOR [95% CI]: 1.34 [1.07, 1.67]) and White (aOR [95% CI]: 1.26 [1.12, 1.42]) racial subgroups. Decomposition showed that of 57.5 (cases per 10,000) explained disparity in SMM, neighborhood deprivation accounted for 23.1 (cases per 10,000; 95% CI: 16.3, 30.0) or two-fifths (40.2%) of the Black-White disparity. Analysis on SMM excluding blood transfusion showed consistent but weaker results. CONCLUSIONS Neighborhood deprivation may be used as an effective tool to identify at-risk individuals within a low-income population. Community-engaged interventions aiming at improving neighborhood conditions may be helpful to reduce both SMM prevalence and racial inequity in SMM.
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Affiliation(s)
- Xiao Yu
- Department of Obstetrics, Gynecology and Reproductive Biology, Michigan State University College of Human Medicine, Grand Rapids and East Lansing, Michigan.
| | - Jennifer E Johnson
- Department of Obstetrics, Gynecology and Reproductive Biology, Michigan State University College of Human Medicine, Grand Rapids and East Lansing, Michigan; Charles Stewart Mott Department of Public Health, Michigan State University, Flint, Michigan; Department of Psychiatry and Behavioral Medicine, Michigan State University, Grand Rapids, Michigan
| | - Lee Anne Roman
- Department of Obstetrics, Gynecology and Reproductive Biology, Michigan State University College of Human Medicine, Grand Rapids and East Lansing, Michigan
| | - Kent Key
- Charles Stewart Mott Department of Public Health, Michigan State University, Flint, Michigan
| | - Jonne McCoy White
- Charles Stewart Mott Department of Public Health, Michigan State University, Flint, Michigan
| | - Hannah Bolder
- Department of Obstetrics, Gynecology and Reproductive Biology, Michigan State University College of Human Medicine, Grand Rapids and East Lansing, Michigan
| | - Jennifer E Raffo
- Department of Obstetrics, Gynecology and Reproductive Biology, Michigan State University College of Human Medicine, Grand Rapids and East Lansing, Michigan
| | - Ran Meng
- Department of Obstetrics, Gynecology and Reproductive Biology, Michigan State University College of Human Medicine, Grand Rapids and East Lansing, Michigan
| | - Hannah Nelson
- Department of Obstetrics, Gynecology and Reproductive Biology, Michigan State University College of Human Medicine, Grand Rapids and East Lansing, Michigan
| | - Cristian I Meghea
- Department of Obstetrics, Gynecology and Reproductive Biology, Michigan State University College of Human Medicine, Grand Rapids and East Lansing, Michigan
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Collins IC, Blanchard CT, Tipre M, Oben A, Robinson A, Kako T, Joly JM, Cribbs MG, Casey B, Tita A, Sinkey R. Breastfeeding Practices in Patients with Heart Disease Stratified by Area Deprivation Index. Breastfeed Med 2024; 19:256-261. [PMID: 38502815 DOI: 10.1089/bfm.2023.0295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
Objective: We sought to evaluate breastfeeding (BF) practices in patients with maternal cardiac disease (MCD) stratified by area deprivation index (ADI) to identity communities at risk. Study Design: Retrospective cohort of patients managed by the University of Alabama at Birmingham (UAB) Cardio-Obstetrics Program. Patients were included if they had ≥1 prenatal visit with the Cardio-Obstetrics team, delivered at UAB, and had a street address on file. The primary outcome was BF rate at hospital discharge. Secondary outcomes included BF intent on admission and BF at the postpartum (PP) visit. ADI reports socioeconomic disadvantage at the census tract level; 1 = least deprived and 100 = most deprived. Baseline characteristics and BF rates were compared by ADI categories: Low (ADI 1-33), medium (ADI 34-66), and high (ADI 67-100). Results: One hundred and forty-eight patients were included: 14 (10%) low, 42 (28%) medium, and 92 (62%) high ADI. Patients in the high ADI category were younger relative to those in the medium or low ADI (26 versus 28 versus 32 years; p < 0.01) and less likely to be married or living with a partner (30.4% versus 58.5% versus 71.4%; p < 0.01), There was no difference in BF intent between the lowest, medium, and highest ADI categories (85.7% versus 85.4% versus 81.6%; p = 0.38) or BF rates at hospital discharge (100% versus 92.7% versus 85.6%, p = 0.23). However, there was a significant difference in BF rates at the PP visit (90% versus 63.0% versus 38.6%; p < 0.01) even after controlling for differences in baseline characteristics (odds ratio = 0.11 (95% confidence interval [0.01-0.93]), p = 0.043). Conclusions: There was an association between living in a resource-poor community and early cessation of BF in our population of patients with MCD. Community-based interventions targeting mothers with heart disease living in high ADI communities may help these individuals achieve higher BF rates.
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Affiliation(s)
- Isabel C Collins
- University of Alabama at Birmingham Marnix E. Heersink School of Medicine, Birmingham, Alabama, USA
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Christina T Blanchard
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Center for Women's Reproductive Health, Birmingham, Alabama, USA
| | - Meghan Tipre
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ayamo Oben
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Center for Women's Reproductive Health, Birmingham, Alabama, USA
| | - Ashton Robinson
- University of Alabama at Birmingham Marnix E. Heersink School of Medicine, Birmingham, Alabama, USA
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Tavonna Kako
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Center for Women's Reproductive Health, Birmingham, Alabama, USA
| | - Joanna M Joly
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Alabama, USA
| | - Marc G Cribbs
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Alabama, USA
| | - Brian Casey
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Center for Women's Reproductive Health, Birmingham, Alabama, USA
| | - Alan Tita
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Center for Women's Reproductive Health, Birmingham, Alabama, USA
| | - Rachel Sinkey
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Center for Women's Reproductive Health, Birmingham, Alabama, USA
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Morenz AM, Liao JM, Au DH, Hayes SA. Area-Level Socioeconomic Disadvantage and Health Care Spending: A Systematic Review. JAMA Netw Open 2024; 7:e2356121. [PMID: 38358740 PMCID: PMC10870184 DOI: 10.1001/jamanetworkopen.2023.56121] [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: 10/19/2023] [Accepted: 12/21/2023] [Indexed: 02/16/2024] Open
Abstract
Importance Publicly available, US Census-based composite measures of socioeconomic disadvantage are increasingly being used in a wide range of clinical outcomes and health services research. Area Deprivation Index (ADI) and Social Vulnerability Index (SVI) are 2 of the most commonly used measures. There is also early interest in incorporating area-level measures to create more equitable alternative payment models. Objective To review the evidence on the association of ADI and SVI with health care spending, including claims-based spending and patient-reported barriers to care due to cost. Evidence Review A systematic search for English-language articles and abstracts was performed in the PubMed, Web of Science, Embase, and Cochrane databases (from inception to March 1, 2023). Peer-reviewed articles and abstracts using a cross-sectional, case-control, or cohort study design and based in the US were identified. Data analysis was performed in March 2023. Findings This review included 24 articles and abstracts that used a cross-sectional, case-control, or cohort study design. In 20 of 24 studies (83%), ADI and SVI were associated with increased health care spending. No association was observed in the 4 remaining studies, mostly with smaller sample sizes from single centers. In adjusted models, the increase in spending associated with higher ADI or SVI residence was $574 to $1811 for index surgical hospitalizations, $3003 to $24 075 for 30- and 90-day episodes of care, and $3519 for total annual spending for Medicare beneficiaries. In the studies that explored mechanisms, postoperative complications, readmission risk, and poor primary care access emerged as health care system-related drivers of increased spending. Conclusions and Relevance The findings of this systematic review suggest that both ADI and SVI can play important roles in efforts to understand drivers of health care spending and in the design of payment and care delivery programs that capture aspects of social risk. At the health care system level, higher health care spending and poor care access associated with ADI or SVI may represent opportunities to codesign interventions with patients from high ADI or SVI areas to improve access to high-value health care and health promotion more broadly.
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Affiliation(s)
- Anna M. Morenz
- Department of Medicine, University of Washington, Seattle
- Program on Policy Evaluation and Learning in the Pacific Northwest, Seattle, Washington
| | - Joshua M. Liao
- Department of Medicine, University of Washington, Seattle
- Program on Policy Evaluation and Learning in the Pacific Northwest, Seattle, Washington
- Now with Department of Medicine, University of Texas Southwestern Medical Center, Dallas
- Now with Program on Policy Evaluation and Learning, Dallas, Texas
| | - David H. Au
- Department of Medicine, University of Washington, Seattle
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Sophia A. Hayes
- Department of Medicine, University of Washington, Seattle
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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Kondracki AJ, Li W, Mokhtari M, Muchandi B, Ashby JA, Barkin JL. Pregnancy-related maternal mortality in the state of Georgia: Timing and causes of death. WOMEN'S HEALTH (LONDON, ENGLAND) 2024; 20:17455057241267103. [PMID: 39054728 PMCID: PMC11282520 DOI: 10.1177/17455057241267103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 06/13/2024] [Accepted: 06/20/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND The maternal mortality rate in the United States is high and disparities among non-Hispanic White and non-Hispanic Black women remain. In the State of Georgia, the pregnancy-related death rate is among the worst in the nation. OBJECTIVE To examine current pregnancy-related deaths in the State of Georgia using measures of timing and cause-specific mortality across maternal sociodemographic characteristics. DESIGN This cross-sectional study of pregnancy-related deaths in Georgia was based on 2016-2019 maternal mortality data obtained from the Georgia Department of Public Health. METHODS Our study analysis involved complete-case data of maternal deaths identified as pregnancy-related deaths (n = 129). Statistical analyses included two distinct population-level measures: (a) timing (i.e. during pregnancy, 0 to 60 days, 61 to 180 days, and 181 to 365 days postpartum) and (b) cause-specific deaths patterned by sociodemographic groups of women and by rural and urban county of residence. Categorical variables were compared using the Chi square or Fisher's exact test and presented as numbers and percentages. A post hoc power analysis was conducted to inform whether there was sufficient power to detect statistically significant effects given available sample sizes. RESULTS Among a total of 129 pregnancy-related deaths, 30 (23.3%) deaths occurred during pregnancy and 63 (48.8%) deaths occurred within the first 60 days postpartum. Pregnancy-related deaths were disproportionally common among non-Hispanic Black, 25 to 34 years old, and poorly educated women. Three leading underlying causes, cardiomyopathy (22.7%), hemorrhage (21.6%), and cardiovascular or coronary disease (20.4%), accounted for about 65% of all pregnancy-related deaths. Mental health conditions were common causes of death among non-Hispanic White women during pregnancy and in late postpartum. CONCLUSION Continued monitoring, collecting and analyzing reliable data will help identify root causes and find ways to eliminate the disproportionate burden of pregnancy-related deaths in the State of Georgia.
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Affiliation(s)
- Anthony J Kondracki
- Department of Community Medicine, Mercer University School of Medicine, Savannah, GA, USA
| | - Wei Li
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | | | - Bhuvaneshwari Muchandi
- Department of Community Medicine, Mercer University School of Medicine, Savannah, GA, USA
| | - John A Ashby
- Department of Community Medicine, Mercer University School of Medicine, Savannah, GA, USA
| | - Jennifer L Barkin
- Department of Community Medicine, Mercer University School of Medicine, Savannah, GA, USA
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Lee HH, Dziak JJ, Avenetti DM, Berbaum ML, Edomwande Y, Kliebhan M, Zhang T, Licona-Martinez K, Martin MA. Association between neighborhood disadvantage and children's oral health outcomes in urban families in the Chicago area. Front Public Health 2023; 11:1203523. [PMID: 37457261 PMCID: PMC10345837 DOI: 10.3389/fpubh.2023.1203523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 05/30/2023] [Indexed: 07/18/2023] Open
Abstract
Purpose The prevalence of childhood caries in urban Chicago, compared with national and state data, indicates that neighborhood context influences oral health. Our objective was to delineate the influence of a child's neighborhood on oral health outcomes that are predictive of caries (toothbrushing frequency and plaque levels). Methods Our study population represents urban, Medicaid-enrolled families in the metropolitan Chicago area. Data were obtained from a cohort of participants (child-parent dyads) who participated in the Coordinated Oral Health Promotion (CO-OP) trial at 12 months of study participation (N = 362). Oral health outcomes included toothbrushing frequency and plaque levels. Participants' neighborhood resource levels were measured by the Area Deprivation Index (ADI). Linear and logistic regression models were used to measure the influence of ADI on plaque scores and toothbrushing frequency, respectively. Results Data from 362 child-parent dyads were analyzed. The mean child age was 33.6 months (SD 6.8). The majority of children were reported to brush at least twice daily (n = 228, 63%), but the mean plaque score was 1.9 (SD 0.7), classified as "poor." In covariate-adjusted analyses, ADI was not associated with brushing frequency (0.94, 95% CI 0.84-1.06). ADI was associated with plaque scores (0.05, 95% CI 0.01-0.09, p value = 0.007). Conclusions Findings support the hypothesis that neighborhood-level factors influence children's plaque levels. Because excessive plaque places a child at high risk for cavities, we recommend the inclusion of neighborhood context in interventions and policies to reduce children's oral health disparities. Existing programs and clinics that serve disadvantaged communities are well-positioned to support caregivers of young children in maintaining recommended oral health behaviors.
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Affiliation(s)
- Helen H. Lee
- Department of Anesthesiology, College of Medicine, University of Illinois Chicago, Chicago, IL, United States
- Institute for Health Research and Policy, University of Illinois Chicago, Chicago, IL, United States
| | - John J. Dziak
- Institute for Health Research and Policy, University of Illinois Chicago, Chicago, IL, United States
| | - David M. Avenetti
- Institute for Health Research and Policy, University of Illinois Chicago, Chicago, IL, United States
- Department of Pediatric Dentistry, College of Dentistry, University of Illinois Chicago, Chicago, IL, United States
| | - Michael L. Berbaum
- Institute for Health Research and Policy, University of Illinois Chicago, Chicago, IL, United States
| | - Yuwa Edomwande
- Institute for Health Research and Policy, University of Illinois Chicago, Chicago, IL, United States
| | - Margaret Kliebhan
- Department of Pediatrics, College of Medicine, University of Illinois Chicago, Chicago, IL, United States
| | - Tong Zhang
- Institute for Health Research and Policy, University of Illinois Chicago, Chicago, IL, United States
| | - Karla Licona-Martinez
- Institute for Health Research and Policy, University of Illinois Chicago, Chicago, IL, United States
| | - Molly A. Martin
- Institute for Health Research and Policy, University of Illinois Chicago, Chicago, IL, United States
- Department of Pediatrics, College of Medicine, University of Illinois Chicago, Chicago, IL, United States
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Balk EM, Danilack VA, Bhuma MR, Cao W, Adam GP, Konnyu KJ, Peahl AF. Reduced Compared With Traditional Schedules for Routine Antenatal Visits: A Systematic Review. Obstet Gynecol 2023; Publish Ahead of Print:00006250-990000000-00794. [PMID: 37290105 DOI: 10.1097/aog.0000000000005193] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/23/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To assess differences in maternal and child outcomes in studies comparing reduced routine antenatal visit schedules with traditional schedules. DATA SOURCES A search was conducted of PubMed, Cochrane databases, EMBASE, CINAHL, and ClinicalTrials.gov through February 12, 2022, searching for antenatal (prenatal) care, pregnancy, obstetrics, telemedicine, remote care, smartphones, telemonitoring, and related terms, as well as primary study designs. The search was restricted to high-income countries. METHODS OF STUDY SELECTION Double independent screening was done in Abstrackr for studies comparing televisits and in-person routine antenatal care visits for maternal, child, health care utilization, and harm outcomes. Data were extracted into SRDRplus with review by a second researcher. TABULATION, INTEGRATION, AND RESULTS Five randomized controlled trials and five nonrandomized comparative studies compared reduced routine antenatal visit schedules with traditional schedules. Studies did not find differences between schedules in gestational age at birth, likelihood of being small for gestational age, likelihood of a low Apgar score, likelihood of neonatal intensive care unit admission, maternal anxiety, likelihood of preterm birth, and likelihood of low birth weight. There was insufficient evidence for numerous prioritized outcomes of interest, including completion of the American College of Obstetricians and Gynecologists-recommended services and patient experience measures. CONCLUSION The evidence base is limited and heterogeneous and allowed few specific conclusions. Reported outcomes included, for the most part, standard birth outcomes that do not have strong plausible biological connection to structural aspects of antenatal care. The evidence did not find negative effects of reduced routine antenatal visit schedules, which may support implementation of fewer routine antenatal visits. However, to enhance confidence in this conclusion, future research is needed, particularly research that includes outcomes of most importance and relevance to changing antenatal care visits. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42021272287.
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Affiliation(s)
- Ethan M Balk
- Center for Evidence Synthesis in Health and the Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island; the Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; the Department of Social Medicine and Health Education, School of Public Health, Peking University, Beijing, China; and the Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
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Balk EM, Danilack VA, Cao W, Bhuma MR, Adam GP, Konnyu KJ, Peahl AF. Televisits Compared With In-Person Visits for Routine Antenatal Care: A Systematic Review. Obstet Gynecol 2023; Publish Ahead of Print:00006250-990000000-00796. [PMID: 37290109 DOI: 10.1097/aog.0000000000005194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/23/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To compare benefits and harms of televisits and in-person visits in people receiving routine antenatal care. DATA SOURCES A search was conducted of PubMed, Cochrane databases, EMBASE, CINAHL, and ClinicalTrials.gov through February 12, 2022, for antenatal (prenatal) care, pregnancy, obstetrics, telemedicine, remote care, smartphones, telemonitoring, and related terms, as well as primary study designs. The search was restricted to high-income countries. METHODS OF STUDY SELECTION Double independent screening was done in Abstrackr for studies comparing televisits and in-person routine antenatal care visits for maternal, child, health care utilization, and harm outcomes. Data were extracted into SRDRplus with review by a second researcher. TABULATION, INTEGRATION, AND RESULTS Two randomized controlled trials, four nonrandomized comparative studies, and one survey compared visit types between 2004 and 2020, three of which were conducted during the coronavirus disease 2019 (COVID-19) pandemic. Number, timing, and mode of televisits and who provided care varied across studies. Low-strength evidence from studies comparing hybrid (televisits and in-person visits) and all in-person visits did not indicate differences in rates of neonatal intensive care unit admission of the newborn (summary odds ratio [OR] 1.02, 95% CI 0.82-1.28) or preterm births (summary OR 0.93, 95% CI 0.84-1.03). However, the studies with stronger, although still statistically nonsignificant, associations between use of hybrid visits and preterm birth compared the COVID-19 pandemic and prepandemic eras, confounding the association. There is low-strength evidence that satisfaction with overall antenatal care was greater in people who were pregnant and receiving hybrid visits. Other outcomes were sparsely reported. CONCLUSION People who are pregnant may prefer hybrid televisits and in-person visits. Although there is no evidence of differences in clinical outcomes between hybrid visits and in-person visits, the evidence is insufficient to evaluate most outcomes. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42021272287.
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Affiliation(s)
- Ethan M Balk
- Center for Evidence Synthesis in Health and the Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island; the Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; the Department of Social Medicine and Health Education, School of Public Health, Peking University, Beijing, China; and the Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
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