Aubry Parker NY UNMC by mikeholy

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									     Revealing Disparities in
    Pregnancy Outcomes Using
       PPOR and FIMMRR
Richard H. Aubry, MD, MPH, Martha Wojtowycz, PhD, Michelle Bode, MD,
       MPH, Pamela Parker, BA, Kristen Luke-Houseman, RN, BA

                    Center for Maternal and Child Health
          State University of New York Upstate Medical University
                 Department of Obstetrics and Gynecology

    Supported by a grant from the Community Health Foundation of Western and Central New York.
        The Community Health Foundation is a non-profit private foundation with a mission to
         improve the health and health care of the people of Western and Central New York.




                              February 2010
            Objective

To examine the relationship of
poor socioeconomic condition, as
reflected by Medicaid status, to
poor outcomes of pregnancy.
The Central New York Region consists of a 13 county area spanning
   from St. Lawrence County in the North to Broome and Tioga
       counties in the South and includes 21 birth hospitals.
Statewide Perinatal Data System (SPDS)
  Population-based birth registry that captures
  information on all live births in New York State. It
  consists of the New York State Electronic Birth
  Certificate (EBC) and additional voluntary questions,
  e.g., such as the content of prenatal care, intentions of
  pregnancy, and perinatal depression, that are expected
  to be used for quality improvement purposes. The
  SPDS contains data on: maternal demographics;
  obstetrical history; prenatal care; labor and delivery
  information; and birth outcomes.
               SPDS: Pay Source Coding



  Medicaid – select this choice if the mother’s care was paid for by Medicaid, PCAP,
   MOMS, Child Health Plus A, Medicaid Managed Care, or Family Health Plus (39.8%)
  Private Insurance – select this item if the mother’s care was paid for by private
  insurance including indemnity insurance and/or managed care insurance (51.2%)
  Self-pay – select this item if the mother had no health insurance (1.1%)
  Indian Health Service (0.1%)
  CHAMPUS/TRICARE (Military and dependents) (5.0%)
  Other government (e.g. Child Health Plus B, Veteran’s Administration) (1.0%)
  Other (1.8%)
  Unknown (0.1%)

Medicaid group also applies to Medicaid as secondary payor. (5.5%)
    Fetal-Infant Mortality/Morbidity
     Review/Registry (FIMMRR)
Clinically oriented, community based registry to capture
detailed data on mortalities/ morbidities for the 21 birth
hospitals in the Central New York Region.

By evaluating data from chart reviews of all fetal and
infant mortalities (≥ 300 grams) as well as major
morbidities, patterns have been identified which have
informed recommendations for improvements (both
social and medical).
             FIMMRR: Maternal Risk Factors
____ Major pre-pregnancy medical problems: ________________
____ Poor OB History:                                             ____ Adolescent pregnancy (≤ 16 y.o.)
     ____ History of infertility                                  ____ Advanced maternal age (≥ 35 y.o.)
     ____ 2 Prior losses before 20 weeks                          ____ Housing problems
     ____ Prior loss after 20 weeks                               ____ Mental illness (past or present)
     ____ History of preterm delivery        (<37 Wks)            ____ Maternal stress:
     ____ History of previous SGA/IUGR birth                      ____ Emotional stress (at work or home)
____ Poor nutrition, BMI______                                          ____ Physical stress (at work or home)
     (circle) Obese, underweight                                        ____ Loss of partner (circle)
____ Poor Care Seeker (circle)                                    Divorce, Separation, Death, Military Deployment, Other
     Second Trimester, Third Trimester, No Prenatal Care                ____ Death of family member
____ Poor compliance with prenatal visits (missed >2)                   ____ Pt or partner incarcerated/Legal problems
____ Substance abuse (circle)                                           ____ Other
         Tobacco, alcohol, marijuana, prescription drugs, other   ____ Family violence
____ Poor social setting (in present pregnancy):                  ____ Cultural problems:
____ < 12th Grade education completed and no GED                        ____ Recent immigrant (Non-Western origin)
____ Partner uninvolved                                                 ____ Language barrier (written or verbal)
____ History of parenting problems                                      ____ Cultural/Religious belief system limits or
     ____ Other                                                                prohibits medical interventions
____ Transportation problems                                            ____ Other
____ Occupational problems                                        ____ Less than 6 months since last birth
____ Family planning problems                                     ____ Current pregnancy result of Assisted
____ Economic issues:                                                          Reproductive Technology
     ____ Unemployed/ partner unemployed                          ____ Other
____ Medicaid Insurance
     ____ Needs public assistance (housing, healthcare, etc.)
     ____ WIC referral
     ____ Other
       FIMMRR: Causes of Fetal Death /
          Prenatal/Intrapartal Factors
         Contributing to Infant Death

_____ Abruptio Placenta/Placental Infarct     _____ Perinatal TORCH Infection __________
_____ Antiphospholipid/SLE Syndrome           _____ Intrapartal asphyxia
_____ Blood Factor Sensitization              _____ Intrauterine Growth Restriction
_____ Chorioamnionitis (bacterial)            _____ Maternal Trauma – Type ____________
_____ Chronic hypertension/Pre-eclampsia      _____ Non-Immune Hydrops
_____ Cocaine Abuse                           _____ Termination of Pregnancy,
_____ Diabetes: Class ___, Type ___           Indication__________________
_____ Fetal Anomaly/Chromosomal Abnormality   _____ Twin-Twin Transfusion Syndrome
_____ Feto-Maternal Hemorrhage                _____ Other ________________
    FIMMRR: Causes of Infant Death
Circle single dominant cause, check all others noted:

_____Congenital Anomaly/Chromosomal Abnormality         If SIDS, check-off appropriate items:
_____Metabolic Disorder                                 _____Co-sleeping
_____Sepsis – Bacterial                                   _____ Smoking Household
_____Perinatal Viral Infection                            _____ Substance Abuse in Household
_____Perinatal asphyxia                                 _____ Use of Any Impairing Substance
_____Hyaline Membrane Disease                             _____ Unsafe Sleep Environment
_____Blood Factor Sensitization                           _____ Exclusive Breastfeeding
_____CNS hemorrhage                                       _____ Any Breastfeeding
_____SIDS                                               _____Unsafe Sleep Environment
_____Trauma – accident                                  _____Smoking Household
_____Termination of Pregnancy, Indication               _____Substance Abuse in Household
_____Overwhelming Immaturity                            _____Prone Sleeping
_____Unexplained                                        _____Other _______________
_____Physical Abuse/Neglect
_____Other _____________________
FIMMRR: Causes of Death-ICD10

 _____Congenital malformations, deformations and chromosomal abnormalities
 _____Disorders related to short gestation, low birth weight, not elsewhere classified
 _____Sudden infant death syndrome
 _____Newborn affected by maternal complications of pregnancy
 _____Newborn affected by complications of placenta, cord and membranes
 _____Accidents (unintentional injuries)
 _____Respiratory distress of newborn
 _____Bacterial sepsis of newborn
 _____Neonatal hemorrhage
 _____Intrauterine hypoxia and birth asphyxia
 _____All other causes
                         Data Notes

Statewide Perinatal Data System (SPDS)
   primary source for population characteristics
   secondary source for identification of neonatal
    and post neonatal deaths

Fetal Infant Morbidity/Mortality Review/Registry
(FIMMRR)
   only source for detailed data on fetal deaths
   primary source for detailed data on neonatal and post
    neonatal deaths
          Population Characteristics
     Central New York Region 2006-2007
                                       Non-Medicaid   Medicaid
≥ 300 grams                    Total                             p value
                                         Insured      Insured
Live Births + Fetal Deaths     38962      21277        17685
Live Births                    38739      21166        17573

Maternal Age (<17 y)           1.2%       0.3%         2.2%      < .001
Maternal Race (non-white)      14.7%      9.4%         21.0%     < .001
Maternal Education (< 12 y)    16.0%      4.3%         30.2%     < .001
Marital Status (not married)   42.5%      17.8%        72.2%     <.001
      Population Characteristics
 Central New York Region 2006-2007
                                      Non-Medicaid Medicaid
≥ 300 grams                   Total                         p value
                                        Insured    Insured
Live Births + Fetal Deaths    38962      21277      17685
Live Births                   38739      21166      17573

Early Prenatal Care           75.3%      84.4%      64.3%    < .001
Adequate Prenatal Care        82.5%      88.4%      75.4%    < .001
Smoking During
                              21.8%      10.3%      35.6%    < .001
  Pregnancy
Illegal Drug Use              2.1%       0.5%        4.1%    < .001
Obese (prepregnancy BMI>30)   27.1%      25.8%       28.7%   < .001
Breastfeeding                 67.6%      76.8%       56.6%   < .001
          Birth Outcomes

Despite increased risk factors for the
Medicaid insured women, most birth
outcomes in the Central New York
Region are not significantly different
between Medicaid and Non-Medicaid
insured women.
             Gestational Age
   Central New York Region 2006-2007
                                     Non-Medicaid Medicaid
≥ 300 grams                  Total                           p value
                                       Insured    Insured
Live Births + Fetal Deaths   38962      21277      17685
Live Births                  38739      21166      17573

Preterm                      9.7%       9.8%        9.5%       NS
 <24 weeks                   0.2%       0.2%        0.2%       NS
 24-27 weeks                 0.5%       0.4%        0.5%       NS
 28-31 weeks                 1.0%       1.0%        0.9%       NS
 32-36 weeks                 8.0%       8.1%        7.9%       NS
 37+ weeks                   90.3%      90.2%      90.4%       NS
      Birthweight/Intrauterine Growth
    Central New York Region 2006-2007
                                     Non-Medicaid   Medicaid
≥ 300 grams                  Total                             p value
                                       Insured      Insured
Live Births + Fetal Deaths   38962      21277        17685
Live Births                  38739      21166        17573

LBW (<2500 grams)            7.7%       7.3%          8.2%     < .001
VLBW (<1500 grams)           1.4%       1.5%          1.4%       NS
ELBW (< 1000 grams)          0.6%        0.7%        0.7%        NS

Small for Gestational Age    10.6%      7.0%         13.4%     < .001
Large for Gestational Age    9.1%       10.8%        8.2%      < .001
              Morbidity

Rates of LBW and especially Small for
Gestational Age are significantly higher
in Medicaid Insured births.
                  Mortality

Using the Fetal-Infant Morbidity/Mortality
Review/Registry (FIMMRR), we also explored
the Fetal/Infant death rates among Medicaid and
Non-Medicaid insured women.
   Standard Calculation of Death Rates
                       (all ≥ 300 grams)

Overall
  number of total deaths/total live births + fetal deaths
Fetal
  number of intrauterine deaths/total live births + fetal deaths
Neonatal
  number of deaths ≤ 28 days of life/total live births
Post-Neonatal
  number of deaths 29 -365 days of life/total live births
Infant
  Neonatal + Post-Neonatal
             Central New York Region 2006-2007
            Total Live Births + Fetal Deaths = 38962
                       *
            14                                            Total
            12                                            Non-Medicaid Insured
                                                          Medicaid Insured
rate/1000




            10

             8                                                                    *

             6

             4
                                                              *
             2

             0
                 Overall      Fetal       Neonatal      Post-            Infant
                                                       Neonatal
                    * p< .001 Non-Medicaid Insured vs Medicaid Insured
    Central New York Region 2006-2007
   Total Live Births + Fetal Deaths = 38962


                                             Post
≥ 300 grams    Overall   Fetal   Neonatal              Infant
                                            Neonatal
Total           11.4     5.7       4.3        1.4       5.7
Non-Medicaid     9.4     5.2       3.7        0.5       4.2
Medicaid        13.7     6.3       5.0        2.5       7.5
                       Findings
The significant difference in mortality is concentrated
within the Infant Deaths, most strikingly the Post-
Neonatal Deaths.

The lack of a significant difference in mortality for both
Fetal and Neonatal Deaths, suggests a potential
protective effect by Medicaid.

Further analysis, using the Perinatal Periods of Risk
approach, provided a different prospective.
                                       Total
                 Central New York Region 2006-2007
                             Live Births + Fetal Deaths = 38962
Overall Fetal-Infant Mortality Rate 11.3 per 1, 000 Live Births & Fetal Deaths

                                        Age at Death
                             Fetal Death      Neonatal   Post- neonatal
  Birthweight




                                       Maternal Health/
                300-1499 g
                                       Prematurity 6.9


                              Maternal       Newborn         Infant
                  1500+ g
                               Care           Care           Health
                                 1.9            1.4               1.1
                     Non-Medicaid Insured
                 Central New York Region 2006-2007
                             Live Births + Fetal Deaths = 21277
Overall Fetal-Infant Mortality Rate 9.4 per 1, 000 Live Births & Fetal Deaths

                                        Age at Death
                              Fetal Death     Neonatal    Post- neonatal
  Birthweight




                                        Maternal Health/
                300-1499 g
                                        Prematurity 6.1


                              Maternal       Newborn          Infant
                  1500+ g
                               Care           Care            Health
                                  2.0            0.9              0.4
                         Medicaid Insured
                 Central New York Region 2006-2007
                             Live Births + Fetal Deaths = 17685
Overall Fetal-Infant Mortality Rate 13.7 per 1, 000 Live Births & Fetal Deaths

                                        Age at Death
                              Fetal Death     Neonatal    Post- neonatal
  Birthweight




                                        Maternal Health/
                300-1499 g
                                        Prematurity 8.0


                               Maternal      Newborn          Infant
                  1500+ g
                                Care          Care            Health
                                  1.8            1.9              2.0
        Perinatal Periods of Risk (PPOR)
              Central New York Region 2006-2007

                                              Non-Medicaid Medicaid
≥ 300 grams                           Total                           sig
                                                Insured    Insured
Live Births + Fetal Deaths            38962      21277      17685
Live Births                           38739      21166      17573

Overall Fetal-Infant Mortality Rate   11.3        9.4        13.7     S
  Maternal Health/Prematurity          6.9        6.1         8.0     S
  Maternal Care                        1.9        2.0         1.8     NS
  Newborn Care                         1.4        0.9         1.9     NS
  Infant Health                        1.1        0.4         2.0     S
      Perinatal Periods of Risk (PPOR)
          Central New York Region 2006-2007

                                              Reference Non-Reference
≥ 300 grams                           Total                           sig
                                                 Group     Group
Live Births + Fetal Deaths            38962    26806        12156
Live Births                           38739    26667        12072

Overall Fetal-Infant Mortality Rate   11.3       9.6         15.2      S
  Maternal Health/Prematurity          6.9       5.9         9.3       S
  Maternal Care                        1.9       1.8         2.1      NS
  Newborn Care                         1.4       1.2         1.7      NS
  Infant Health                        1.1       0.7         2.2       S
         Perinatal Periods of Risk (PPOR)
              Central New York Region 2006-2007

                                              Non-Medicaid Medicaid Reference
≥ 300 grams                           Total
                                                Insured    Insured   Group
Live Births + Fetal Deaths            38962      21277      17685     26806
Live Births                           38739      21166      17573     26667

Overall Fetal-Infant Mortality Rate   11.3        9.4        13.7      9.6
  Maternal Health/Prematurity          6.9        6.1         8.0      5.9
  Maternal Care                        1.9        2.0         1.8      1.8
  Newborn Care                         1.4        0.9         1.9      1.2
  Infant Health                        1.1        0.4         2.0      0.7
      Perinatal Periods of Risk (PPOR)
          Central New York Region 2006-2007

                    Excess Mortality Rates
              in comparison with Reference Group
                                              Non-Medicaid   Medicaid
≥ 300 grams                           Total
                                                Insured      Insured
Overall Fetal-Infant Mortality Rate   1.70        -0.20        4.1
  Maternal Health/Prematurity         1.00        0.20         2.10
  Maternal Care                       0.10        0.20         0.00
  Newborn Care                        0.20        -0.30        0.70
  Infant Health                       0.40        -0.30        1.30
      Perinatal Periods of Risk (PPOR)
          Central New York Region 2006-2007

                   Excess Mortality Numbers
              in comparison with Reference Group
                                              Non-Medicaid   Medicaid
≥ 300 grams                           Total
                                                Insured      Insured
Overall Fetal-Infant Mortality Rate    66          -4           73
  Maternal Health/Prematurity          39          4            37
  Maternal Care                        4           4            0
  Newborn Care                         8           -6           12
  Infant Health                        16          -6           23
  Perinatal Periods of Risk (PPOR)
     Central New York Region 2006-2007

Comparison to Reference Group supports our
previous Findings.

It is also useful to examine the distribution of
various causes of death in each PPOR category.
        Fetal-Infant Morbidity/Mortality Review & Registry
         Central New York Region 2006-2007
     Dominant Cause of Death: rate/1000 live births + fetal deaths
≥ 300 grams                   Maternal Health/Prematurity          Maternal Care

                             Non-Medicaid     Medicaid      Non-Medicaid      Medicaid
                                 6.1            8.0             2.0             1.8
Abruptio/Placental Infarct       0.66          1.41             0.23           0.45
Other Placental Problems         0.47          0.56             0.33           0.39
Cord Accident/Prolapse           0.29          0.45             0.38           0.11
Congenital Anomaly/              1.34          1.02             0.33           0.06
Chromosomal Abnormality
Prematurity                      0.52            0.96            0                 0.17
Overwhelming Immaturity          2.05            2.25            0                   0
Other                            0.15            0.34           0.14               0.11
Sepsis                           0.19            0.34            0                 0.06
SIDS/SUID                         0              0.11            0                   0
Trauma                            0              0.06            0                   0
Unexplained                      0.43            0.50           0.57               0.45
      Fetal-Infant Morbidity/Mortality Review & Registry
       Central New York Region 2006-2007
   Dominant Cause of Death: rate/1000 live births + fetal deaths
≥ 300 grams                         Newborn Care                  Infant Health

                             Non-Medicaid   Medicaid   Non-Medicaid          Medicaid
                                 0.9          1.9          0.4                 2.0
Abruptio/Placental Infarct        0            0            0                   0
Other Placental Problems         0.22        0.06           0                   0
Cord Accident/Prolapse            0          0.06           0                   0
Congenital Anomaly/              0.54        1.34          0.13               0.46
Chromosomal Abnormality
Prematurity                       0              0          0                       0
Overwhelming Immaturity           0              0          0                       0
Other                            0.09          0.06         0                     0.29
Sepsis                           0.05          0.17        0.04                   0.11
SIDS/SUID                         0            0.11        0.18                   0.74
Trauma                            0            0.11        0.04                    0.4
Unexplained                       0              0          0                       0
 Cause of Death Conclusions
These findings support our earlier Findings that
pre-pregnancy and early pregnancy factors, along
with post neonatal factors play the largest role in
the disparity between death rates among Medicaid
and Non-Medicaid insured women.

A protective effect of Medicaid Status is
suggested regarding Fetal and Neonatal deaths.
              Sharing the Results
CNY Regional Perinatal Forum

CNY Regional Perinatal Program/Affiliate Hospitals

Onondaga County Health Department/Syracuse Healthy Start

SUNY Upstate Medical University
  Departmental Grand Rounds (OB-GYN/Pediatrics)
  Masters in Public Health courses
    Resultant Targeted Interventions
 Improve preconceptional/interconceptional care
 Facilitate access to early/quality prenatal care
 Implement stronger smoking cessation programs
 Improve maternal post partum supports and
  counseling about importance of Safe Sleep
  Environment
               Contact Information:
        Center for Maternal & Child Health
            www.upstate.edu/cmatch/
                   315-464-5706
   Richard H. Aubry, MD, MPH           aubryr@upstate.edu
   Pamela Parker, BA                   parkerp@upstate.edu
   Kristen Luke-Houseman, RN, BA       lukehouk@upstate.edu



        Preliminary Data. Not for release without permission.

								
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