Racial/Ethnic Disparities in Peripartum Pain Assessment and Management.

OBJECTIVE: This study was conducted to determine if there were racial/ethnic disparities in pain assessment and management from labor throughout the postpartum period. METHODS: This was a retrospective cohort study of all births from January 2019 to December 2021 in a single urban, quaternary care hospital, excluding patients with hysterectomy, ICU stay, transfusion of more than 3 units of packed red blood cells, general anesthesia, or evidence of a substance abuse disorder. We characterized and compared patterns of antepartum and postpartum pain assessments, epidural use, pain scores, and postpartum pain management by racial/ethnic group with bivariable analyses. Multivariable regression was performed to test for an association between race/ethnicity and amount of opioid pain medication in milligram equivalent units, stratified by delivery mode. RESULTS: There were 18,085 births between 2019 and 2021 with available race/ethnicity data. Of these, 58.3% were white, 15.0% were Hispanic, 11.9% were Asian, 7.4% were Black, and the remaining 7.4% were classified as Other/Declined. There were no significant differences by race/ethnicity in the number of antepartum or postpartum pain assessments or the proportion of patients who received epidural analgesia. Black and Hispanic patients reported the highest maximum postpartum pain scores after vaginal and cesarean birth compared to white and Asian patients. However, Black and Hispanic patients received lower daily doses of opioid medications than white patients, regardless of delivery mode. After adjusting for patient factors and non-opioid medication dosages, all other racial/ethnic groups received less opioid medication than white patients. CONCLUSION: Inequities were found in postpartum pain treatment, including among patients reporting the highest pain levels.

Patient-Provider Discussions About Alcohol Use by Cancer History.

INTRODUCTION: The U.S. Preventive Services Task Force recommends that all adults be screened for alcohol use and those with hazardous use be provided a brief discussion. However, it is unclear to what extent healthcare providers screen for and discuss alcohol use with cancer survivors. METHODS: Frequency and content of alcohol prescreening and provider discussion about alcohol use was examined comparing cancer survivors and non-cancer controls in the 2015-2019 National Survey on Drug Use and Health. Multivariable Poisson regression with robust variance and complex survey procedures were used to estimate prevalence ratios (PR) adjusted for demographic characteristics. Data were analyzed in 2022. RESULTS: The prevalence of alcohol prescreening in a healthcare setting (78.4% vs 74.3%; PR: 1.05 [95% CI: 1.03-1.08]) and self-report of an in-person discussion about alcohol use with a healthcare provider (58.7% vs 55.0%; PR: 1.07 [95% CI: 1.03-1.10]) was higher among cancer survivors compared with non-cancer controls. Among those who had a discussion, the prevalence of being asked about drinking quantity was higher among cancer survivors compared with non-cancer controls (PR: 1.05 [95% CI: 1.02-1.08]). Among cancer survivors who reported usually consuming 3+ drinks per day in the past 30 days, only 15% (95% CI: 10.8-20.5) reported that a healthcare provider advised them to cut down on their drinking. CONCLUSIONS: Cancer survivors are being screened for alcohol use, but heavier users are infrequently advised by healthcare providers to reduce their consumption.

Association between acceptance of routine pregnancy vaccinations and COVID-19 vaccine uptake in pregnant patients.

OBJECTIVE: COVID-19 vaccination is a key approach to reduce morbidity and mortality in pregnant patients and their newborns. Anti-vaccine sentiment has recently increased with unclear impact on pregnant patients. We examined the association between acceptance of tetanus-diphtheria-acellular pertussis (Tdap) and influenza vaccines, considered to be routine pregnancy vaccines, and COVID-19 vaccine acceptance. Secondarily, we identified other predictors of COVID-19 vaccine uptake and described pregnancy outcomes in patients who were and were not vaccinated during pregnancy. METHODS: A retrospective cohort study of all patients who delivered at a single site from December 2020 - March 2022. Demographic, pregnancy, neonatal, and vaccination data were abstracted from the electronic medical record, which imports vaccine history from the California Immunization Registry. The relationship between influenza and Tdap vaccine acceptance, other baseline characteristics, and COVID-19 vaccine uptake was assessed using univariable and multivariable regression analysis. RESULTS: Of the 7857 patients who delivered during the study period, 4410 (56.1%) accepted the COVID-19 vaccine. Of those who received the COVID-19 vaccine, 3363 (97.6%) and 3049 (88.5%) received influenza and Tdap vaccines, respectively. Patients were more likely to receive the COVID-19 vaccine if they had advanced maternal age, obesity, Asian race, and private insurance. After adjustment for baseline differences, COVID vaccine acceptance was associated with receipt of Tdap (aOR 2.10, 95% CI 1.90-2.33) and influenza vaccines (aOR 2.83, 95% CI 2.55-3.14). There were no differences in preterm birth, low birthweight, and NICU admission between patients who received and did not receive the COVID-19 vaccine. CONCLUSION: Patients were more likely to accept COVID-19 vaccination if they received Tdap or influenza vaccinations. Older age, obesity, Asian race, and private insurance were independent predictors of vaccine uptake. Disparities in COVID-19 vaccination uptake bear further exploration to guide efforts in equitable and widespread vaccine distribution.

Engaging Black sexual minority women in breast cancer research: Lessons in community partnerships.

BACKGROUND: Black sexual minority women (BSMW) face significant breast cancer health inequities and are underrepresented in health research because of historical and present-day exclusion. However, there exists no peer-reviewed literature on best practices for the inclusion of BSMW in cancer research. "Our Breast Health: The Access Project" was a national primary data collection study in June 2018 through October 2019 that aimed to identify facilitators and barriers to breast cancer care among BSMW, and that successfully recruited the highest number of BSMW for any national breast cancer screening study at the time of its publication. METHODS: The present analysis highlights best practices for reaching BSMW by examining by how effective various recruitment sources were at recruiting BSMW. Recruitment partners were grouped into several categories: (1) cancer focused, (2) Black women or sexual minority women focused, (3) BSMW focused, (4) social media, and (5) other. Then logistic regression was used to estimate the odds that a particular recruitment source category could recruit BSMW compared with other categories. RESULTS: Partnerships with community-based organizations led by and intended for BSMW were the most successful at recruiting BSMW, demonstrating the importance of an intersectional approach to recruitment. Community-based organizations focused on BSMW specifically were 26 times more successful in recruiting BSMW to the study compared with recruiting Black women who were not sexual minorities (odds ratio, 26.43 [95% CI, 7.50-93.10]). CONCLUSIONS: Successful recruitment enables breast cancer research grounded in the perspectives of BSMW, which can generate key findings that have the potential to remedy longstanding health inequities for this population.

Capacity-Building for Collecting Patient-Reported Outcomes and Experiences (PRO) Data Across Hospitals.

PURPOSE: Patient-reported outcomes and experiences (PRO) data are an integral component of health care quality measurement and PROs are now being collected by many healthcare systems. However, hospital organizational capacity-building for the collection and sharing of PROs is a complex process. We sought to identify the factors that facilitated capacity-building for PRO data collection in a nascent quality improvement learning collaborative of 16 hospitals that has the goal of improving the childbirth experience. DESCRIPTION: We used standard qualitative case study methodologies based on a conceptual framework that hypothesizes that adequate organizational incentives and capacities allow successful achievement of project milestones in a collaborative setting. The 4 project milestones considered in this study were: (1) Agreements; (2) System Design; (3) System Development and Operations; and (4) Implementation. To evaluate the success of reaching each milestone, critical incidents were logged and tracked to determine the capacities and incentives needed to resolve them. ASSESSMENT: The pace of the implementation of PRO data collection through the 4 milestones was uneven across hospitals and largely dependent on limited hospital capacities in the following 8 dimensions: (1) Incentives; (2) Leadership; (3) Policies; (4) Operating systems; (5) Information technology; (6) Legal aspects; (7) Cross-hospital collaboration; and (8) Patient engagement. From this case study, a trajectory for capacity-building in each dimension is discussed. CONCLUSION: The implementation of PRO data collection in a quality improvement learning collaborative was dependent on multiple organizational capacities for the achievement of project milestones.

Exploring correlates of support for restricting breast cancer awareness marketing on alcohol containers among women.

BACKGROUND: Although alcohol consumption increases breast cancer risk, some alcohol products include breast cancer awareness marketing (i.e., pink ribbons) on alcohol containers, which poses a contradiction. Some researchers and advocacy groups have called for restrictions on use of the pink ribbon and other breast cancer awareness marketing on alcohol products. This exploratory study aimed to describe individual and behavioral correlates (age, knowledge, attitudes, purchase intention) of reported support for potential policy restrictions of pink ribbon labeling on alcohol containers. METHODS: The study sample was drawn from the Prolific crowd-sourced research platform in September 2020. Eligible participants included U.S. women aged 21+ years. The primary outcome was policy position for restrictions on pink ribbon labeling on alcohol containers, coded as support, neutral, or oppose. The association between pink ribbon labeling attitudes and support or opposition (vs neutral) was examined using multinomial logistic regression. Covariates were 1) knowledge of the alcohol-cancer link; 2) likelihood of buying an alcohol product with pink ribbon labeling; and 3) age. Models were used to calculate adjusted predicted probabilities for support, oppose, and neutral. RESULTS: The analytic sample included 511 women. Overall, 46% of women opposed, 34% were neutral, and 20% supported restricting pink ribbon labeling on alcohol containers. Controlling for all covariates, women who reported that wine increases cancer risk had the highest probability of opposing restrictions on pink ribbon labeling (56.4% [95%CI: 48.1%-64.8%]). Women who reported wine had no effect on cancer risk had the highest probability of being neutral about restrictions on pink ribbon labeling (45.5% [95% CI: 35.7%-55.3%]). Across levels of knowledge about the alcohol-cancer risk association, as favorable attitudes toward pink ribbon labeling increased, the probability of policy opposition increased and the probability of being policy neutral decreased. CONCLUSION: Findings from this study suggest women's favorable attitudes toward pink ribbon labeling on alcohol containers are a stronger predictor of support or opposition for restrictions on pink ribbon labeling than knowledge of the alcohol-cancer link. Future research could examine whether pink ribbon labeling may interact with potential or current health warnings on alcohol containers.

Using Potentially Preventable Severe Maternal Morbidity to Monitor Hospital Performance.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) measure of severe maternal morbidity (SMM) quantifies the burden of SMM but is not restricted to potentially preventable SMM. The authors adapted the CDC SMM measure for this purpose and evaluated it for use as a hospital performance measure. METHODS: Guidelines for defining performance SMM (pSMM) were (1) exclusion of preexisting conditions from outcome; (2) exclusion of inconsistently documented outcomes; and (3) risk adjustment for conditions that preceded hospitalization. California maternal hospital discharge data from 2016 to 2017 were used for model development, and 2018 data were used for model testing and evaluation of hospital performance. Separate models were developed for hospital types (Community, Teaching, Integrated Delivery System [IDS], and IDS Teaching), generating model-based expected pSMM values. Observed-to-expected (O/E) ratios were calculated for hospitals and used to categorize them as overperforming, average performing, or underperforming using 95% confidence intervals. Performance categories were compared for pSMM vs. CDC SMM (excluding blood transfusion). RESULTS: The overall 2016-2018 pSMM rate was 0.44%. All hospital types had over- and underperformers, and the proportions of Community, Teaching, IDS, and IDS Teaching hospitals whose performance differed from their performance on the CDC SMM measure were 12.1%, 25.0%, 38.9%, and 66.7%, respectively. CONCLUSION: The rate of potentially preventable SMM as defined by pSMM (0.44%) was less than half the previously published rate of CDC SMM (1.03%). pSMM identified differences in performance across hospitals, and pSMM and CDC SMM classified hospitals' performances differently. pSMM may be suitable for hospital comparisons because it identifies potentially preventable, hospital-acquired SMM that should be responsive to quality improvement activities.

Lack of Association Between Race and Ethnicity and Timely Treatment of Severe Peripartum Hypertension.

BACKGROUND: Hypertensive disorders of pregnancy are a leading cause of severe maternal morbidity and mortality. National guidelines recommend treatment within 30 to 60 minutes of confirmed severe hypertension to reduce the risk of maternal stroke. The objectives of this study were to quantify the number of patients who did not receive timely treatment of severe hypertension, identify barriers to timely treatment, and evaluate if race/ethnicity was associated with timeliness of treatment. METHODS: The researchers created an automated report to identify women who experienced severe hypertension during the delivery admission. The record for each case was reviewed to determine if treatment was timely (within 30 minutes). The study team compared rates of severe peripartum hypertension and rates of timely vs. not timely treatment by race/ethnicity. RESULTS: There were 12,069 deliveries from April 1, 2019, to March 31, 2021-with 684 (5.7%) women with at least one episode of severe hypertension, of whom 241 (35.2%) did not require treatment, leaving 443 (64.8%) women requiring treatment. A total of 441 women received treatment, with 417 (94.6%) treated in a timely manner. Black, Asian, and Hispanic women were all more likely to experience severe hypertension requiring treatment than white women (10.0%, 8.8%, 7.3% vs. 4.0%, respectively, p < 0.001). However, there was no difference in the in the rates of timely treatment between groups (92.6%, 93.0%, 93.9% vs. 96.3%, respectively, p = 0.59). CONCLUSION: Among patients with severe hypertension, 94.6% were treated in a timely manner, and race/ethnicity was not associated with timeliness of treatment. Provider education at all levels at our institution seems to be effective for timely treatment of severe hypertension and suggests that this process could be beneficial at other institutions.

Association of Primary Cesarean Delivery Rate With Dissemination of Nurse-Specific Cesarean Delivery Rates.

Strategies to safely reduce the rate of nulliparous, term, singleton, vertex (NTSV) cesarean deliveries have thus far largely ignored the contribution that labor and delivery nurses make to the delivery mode. We used a recently developed method to calculate nurse-specific cesarean delivery rates and provide these to labor and delivery nursing leadership, who shared the rates with labor and delivery nurses beginning in September 2020. We performed a 3-year interrupted time series analysis comparing our NTSV cesarean delivery rates before and after nurse-specific rates were released. On release of nurse-specific rates, our labor and delivery unit's NTSV cesarean delivery rate declined from 25.7% to 22.0%. Further work to find strategies to sustain nurse engagement is warranted.

Race/ethnicity differences in response to acute antihypertensive treatment of peripartum severe hypertension.

BACKGROUND: Hypertensive disorders of pregnancy increase maternal morbidity, mortality, and long-term risk for cardiovascular disease. The rising incidence of chronic hypertension and preeclampsia disproportionately affects people of color. There is a paucity of published data examining differences in the effectiveness of acute antihypertensive agents between pregnant patients of different races/ethnicities. We aimed to determine if the effectiveness of acute antihypertensive agents for peripartum severe hypertension differs by race/ethnicity. METHODS: A retrospective cohort study of patients with severe peripartum hypertension (systolic blood pressure ≥ 160 mmHg and/or diastolic blood pressure ≥ 110 mm Hg confirmed within 15 min) to determine whether the effectiveness of blood pressure control using nationally recommended medications (hydralazine, labetalol, nifedipine) differed by race/ethnicity. The primary outcome was reduction and maintenance of blood pressure to target ranges (140-150/90-100 mm Hg or below) for ≥4 h in each race/ethnicity group. Statistical tests included χ2, Fisher's exact, analysis of variance, and multivariable logistic regression. RESULTS: Of 729 patients receiving treatment for severe peripartum hypertension, all medications were effective (overall 86.4% efficacy) at controlling blood pressure. Labetalol was the most effective medication in White patients (93.0 vs. 74.7% for nifedipine and 86.5% for hydralazine, p < .001). No overall differences in medication effectiveness were found in Black, Asian, or LatinX patients. Black and Asian patients were more likely to experience >1 hypertensive episode [51.0 and 49.0%, respectively vs. 35.4% (White) and 40.0% (LatinX), p = .008]. CONCLUSION: Currently recommended therapies for severe peripartum hypertension are effective in controlling blood pressure for ≥4 h in patients of all race/ethnic groups. Labetalol was the most effective medication in White patients with no overall differences in medication effectiveness in Black, Asian, or LatinX patients.

The Impact of Race and Ethnicity on Use of Minimally Invasive Surgery for Myomas.

STUDY OBJECTIVE: To determine whether minimally invasive surgery (MIS) for uterine myomas is used differentially based on race and ethnicity. DESIGN: Retrospective cohort study. SETTING: Quaternary care academic hospital in the United States. PATIENTS: Patients undergoing hysterectomy or myomectomy for uterine myomas between March 15, 2015, and March 14, 2020 (N = 1311). Cases involving correction of pelvic organ prolapse, malignancy, peripartum hysterectomy, or combined procedures with nongynecologic specialties were excluded. Racial/ethnic composition of the study population was 40.0% non-Hispanic white (white), 27.9% non-Hispanic black (black), 14.0% Hispanic, 13.7% non-Hispanic Asian (Asian), and 4.3% non-Hispanic American Indian/Alaska Native/Pacific Islander/Other. INTERVENTIONS: Hysterectomy, myomectomy. MEASUREMENTS AND MAIN RESULTS: Of the 1311 cases, 35.9% were minimally invasive hysterectomy, 16.4% abdominal hysterectomy, 35.6% minimally invasive myomectomy, and 12.1% abdominal myomectomy. MIS rates were 94.7% among fellowship-trained minimally invasive gynecologic surgery subspecialists, 44.2% among obstetrics and gynecology specialists, and 46.8% among gynecologic oncologists. There were disparities in surgeon type based on race/ethnicity, with 59.8% of white patients having undergone surgery with a minimally invasive gynecologic surgery subspecialist vs 44.0% of black patients and 45.7% of Hispanic patients. Black and Hispanic patients were less likely to undergo MIS overall vs white patients (adjusted odds ratio [aOR] 0.33, 95% confidence interval [CI] 0.22-0.48 and aOR 0.44, 95% CI 0.28-0.72, respectively). Black and Hispanic patients undergoing hysterectomy were less likely than white patients to undergo MIS (aOR 0.33, 95% CI 0.21-0.51 and aOR 0.35, 95% CI 0.20-0.60, respectively). There were no significant differences in rates of MIS based on race/ethnicity for myomectomies nor differences in major or minor complications by race/ethnicity overall. CONCLUSION: At a quaternary care institution, black and Hispanic patients were significantly less likely than white patients to undergo MIS for uterine myomas, particularly for hysterectomy.

Elevated blood pressures during epidural placement are associated with increased risk of hypertensive disorders of pregnancy.

BACKGROUND: Many providers ignore hypertensive blood pressures (BPs) during epidural placement, attributing them to patient pain or malposition. We aimed to determine if an elevated BP during epidural placement was associated with increased risk for developing a hypertensive disorder of pregnancy (HDP). METHODS: Cohort study of previously normotensive nulliparous, singleton, term patients who received neuraxial analgesia and delivered at our institution in 2016. Primary exposure was BP during epidural window (one hour before and after epidural procedure start time). Primary outcome was HDP (gestational hypertension, preeclampsia, eclampsia, or HELLP syndrome) prior to discharge. Statistics included χ2, t-test, and multivariable logistic regression; α = 0.05. RESULTS: One thousand and eight hundred patients met study criteria. Patients with elevated BP during epidural window (n = 566, 31.4%) were more likely to develop HDP than patients who remained normotensive during epidural window (20.1% vs. 6.4%, adjusted OR 3.57 [95% CI 2.61-4.89]). The incidence of HDP increased in association with BP severity during epidural window: 7.3% for maximum systolic blood pressure (SBP) <140 mmHg; 18.4% for maximum SBP 140-159 mmHg (OR 2.9, 95% CI 2.0-4.0); and 29.9% for maximum SBP ≥160 mmHg (OR 5.4, 95% CI 2.9-9.8). The trend was similar for maximum diastolic BP. The magnitude of increased odds for HDP was highest for Black patients with elevated BP during epidural window (40.9% vs. 10.1%, OR 6.1, 95% CI 2.4-16). CONCLUSIONS: Previously normotensive patients with an elevated BP during labor epidural placement are significantly more likely to develop HDP than patients who remain normotensive. Elevated BP during epidural placement should not be disregarded to ensure timely diagnosis and treatment.

Comparing Methods of Identifying Outlying Nurses in Audits of Low-Risk Cesarean Delivery Rates.

BACKGROUND: The low-risk cesarean delivery (CD) rate is an established performance indicator for providers in maternity care for quality improvement purposes. PURPOSE: Our objectives were to assess nurse performance using adjusted nurse-level CD rates and to compare methods of identifying nurse outliers. METHODS: We conducted a retrospective, cohort study of 6970 births attended by 181 registered nurses in one hospital's maternity unit. Adjusted and unadjusted nurse-level CD rates were compared and agreement between 3 definitions (statistical, top decile, over a benchmark) of outliers calculated. RESULTS: Adjusted nurse-level CD rates varied from 5.5% to 53.2%, and the unadjusted rates varied from 5% to 50%. Risk adjustment had little impact on the ranking of nurses, and outliers were consistently identified by 3 definitions. CONCLUSIONS: Trade-offs between statistical certainty and feasibility need to be considered when classifying nurse outliers. Findings can help target interventions to improve nurse performance.

Routine Multidisciplinary Review of Severe Maternal Morbidity Is Associated with a Reduction in Preventable Cases of Severe Maternal Morbidity.

OBJECTIVE: Severe maternal morbidity (SMM) has increased by 45% in the United States and is estimated to affect up to 1.5% of all deliveries. Research has not yet been conducted that demonstrates a benefit to multidisciplinary review of SMM. The aim of our study was to determine if standardized, routine review of the cases of SMM by a multidisciplinary committee results in a reduction of potentially preventable cases of SMM. STUDY DESIGN: A retrospective cohort study of all women admitted for delivery at Cedars-Sinai Medical Center from March 1, 2012 to September 30, 2016. Our cohort was separated into two groups: a preintervention group composed of women admitted for delivery prior to the implementation of the obstetric Quality and Peer Review Committee (OBQPRC), and a postintervention group where the committee had been well established. Cases of confirmed SMM were presented to a multidisciplinary research committee, and the committee determined whether opportunities for improvement in care existed. The groups were compared with determine if there was a decreased incidence of preventable SMM following the implementation of the OBQPRC standardized review process. RESULTS: There were 30,319 deliveries during the study period; 13,120 deliveries in the preintervention group; and 13,350 deliveries in the postintervention group (2,649 deliveries during the transition period). There was no difference in the rate of SMM between the preintervention (125; 0.95%) and postintervention (129; 0.97%) groups, (p = 0.91). There was a significantly lower rate of opportunity for the improvement in care in the postintervention group (29.5%) compared with the preintervention group (46%; p = 0.005). CONCLUSION: We demonstrated a significant reduction in the rate of potentially preventable SMM following the implementation of routine review of all SMM suggesting that this process plays an important role in improving maternal care and outcomes. KEY POINTS: · Benefit to routine review of SMM has not been demonstrated.. · Routine review of SMM is associated with 36% reduction in potentially preventable SMM.. · This is the first study to demonstrate the benefit of routine review of SMM..

Pregnancy outcomes in very advanced maternal age women.

BACKGROUND: Advanced maternal age is associated with adverse pregnancy and delivery outcomes. Few studies have directly compared outcomes between women of advanced maternal age (35-44 years old) and women of very advanced maternal age (≥45 years old). OBJECTIVE: We aimed to determine the differences in outcomes between women of advanced maternal age and women of very advanced maternal age. STUDY DESIGN: This was a retrospective cohort study conducted at a large urban US medical center. Demographic and obstetrical data were collected in all patients who delivered within the study window (2012-2018). Characteristics and outcomes were compared between women of advanced maternal age and women of very advanced maternal age. Chi-square analyses were used to compare categorical variables. The Student t test or Wilcoxon tests were used, depending on the distribution, to compare continuous variables. RESULTS: A total of 45,435 women had delivery data for analysis. Of these women, 26,700 (59%) were not of advanced maternal age, 18,286 (40%) were of advanced maternal age, and 449 (1%) were of very advanced maternal age. Race and ethnicity varied significantly by age group. Nulliparity and postpartum hemorrhage were statistically higher in the very advanced maternal age group. Of note, cesarean delivery rates were 69.5% in the very advanced maternal age group and 39.5% in the advanced maternal age group (P<.001). Chronic hypertension, gestational hypertension, preeclampsia with and without severe features, superimposed preeclampsia, and eclampsia were all statistically significantly higher (at least 2-fold) in the very advanced maternal age group than the advanced maternal age group (P<.001). There was no significant difference in the rates of hemolysis, elevated liver enzymes, and low platelet count between the 2 groups. Rates of neonatal intensive care unit admission, Apgar score of <7 at 5 minutes, and neonatal length of stay of >5 days after cesarean delivery were higher in neonates from mothers of very advanced maternal age. Birthweights of neonates were significantly lower in mothers of very advanced maternal age. CONCLUSION: There were several important significant differences in the outcomes between women of very advanced maternal age women and women of advanced maternal age, especially concerning hypertensive disorders and cesarean delivery rates. These findings may influence patient counseling and strategies for antepartum surveillance.

Severe Maternal Morbidity in California Hospitals: Performance Based on a Validated Multivariable Prediction Model.

BACKGROUND: Severe maternal morbidity (SMM) is under development as a quality indicator for maternal health care. The aim of this study is to evaluate California hospital performance based on a standardized SMM measure. METHODS: California maternal hospital delivery discharge data from 2016 to 2017 were used to develop logistic regression models for SMM, adjusted for clinical risk factors at admission. Data from 2018 were used to test the models and evaluate hospital performance. SMM was defined per the Centers for Disease Control and Prevention, including (excluding) blood transfusion. Independent models were developed for each hospital type: community, teaching, integrated delivery system (IDS), and IDS teaching. Within each type, model-based expected SMM values and observed-to-expected (O/E) ratios were calculated for each hospital. For each hospital type, hospitals were ranked by O/E ratio, and over- and underperforming hospitals were identified using 95% confidence intervals. RESULTS: Rates of SMM including (excluding) transfusion by hospital type were 1.7% (0.9%) for community, 2.7% (1.5%) for teaching, 2.3% (1.2%) for IDS, and 3.0% (1.6%) for IDS teaching hospitals. In higher-volume community hospitals (≥ 500 births/year), the proportion of underperformers including (excluding) transfusion was 20.7% (11.0%). Summing over all hospital types, 25.3% (14.9%) of hospitals were identified as underperformers in that they experienced significantly more SMM events than expected including (excluding) transfusion. CONCLUSION: California hospital discharge data demonstrated significant hospital variation in standardized childbirth SMM. These data suggest that a standardized SMM measure may help guide and monitor statewide quality improvement efforts.

Delays in breast cancer care by race and sexual orientation: Results from a national survey with diverse women in the United States.

BACKGROUND: Despite known differences in breast cancer by both race and sexual orientation, data on the intersectional experiences of Black sexual minority women (BSMW) along the care continuum are scant. This study sought to understand delays in breast cancer care by examining the intersection of race and sexual orientation. METHODS: This online, cross-sectional survey enrolled racially and sexually diverse women aged ≥ 35 years who had been diagnosed with breast cancer within the prior 10 years or had an abnormal screening in the prior 24 months. The authors calculated summary statistics by race/sexual orientation categories, and they conducted univariate and multivariable modeling by using multiple imputation for missing data. RESULTS: BSMW (n = 101) had the highest prevalence of care delays with 5.17-fold increased odds of a care delay in comparison with White heterosexual women (n = 298) in multivariable models. BSMW reported higher intersectional stigma and lower social support than all other groups. In models adjusted for race, sexual orientation, and income, intersectional stigma was associated with a 2.43-fold increase in care delays, and social support was associated with a 32% decrease in the odds of a care delay. CONCLUSIONS: Intersectional stigma may be an important driver of breast cancer inequities for BSMW. Reducing stigma and ensuring access to appropriate social support that addresses known barriers can be an important approach to reducing inequities in the breast cancer care continuum.

Method to Calculate Nurse-Specific Cesarean Rates for the First and Second Stages of Labor.

To date, efforts to safely lower the cesarean birth rate for women with low-risk pregnancies have largely ignored the influence of labor and delivery nurses on mode of birth. This is mainly because of the complexity involved in attributing outcomes to specific nurses whose care had the greatest effect on mode of birth. An additional level of complexity arises from the type of care given to the woman during different stages of labor. In this article, we describe a strategy to designate nurses to births using an electronic medical record flowsheet, and we describe a method to calculate nurse-specific cesarean birth rates for the first and second stages of labor. Similar to physician-specific rates, we found wide variation in nurse-specific cesarean birth rates in both stages of labor, which suggests an opportunity to learn from best practices.

Exploring the relationship between the alcohol policy environment and nondiscrimination laws: Implications for binge drinking disparities among LGB adults in the United States.

BACKGROUND: Alcohol policies reduce population-level binge drinking; however, they may not reduce binge drinking disparities between different populations. We examined the association between the alcohol policy environment and binge drinking among Lesbian, Gay and Bisexual (LGB) and heterosexual adults in the presence and absence of state laws protecting LGB people from discrimination. METHODS: The 2015-2018 Behavioral Risk Factor Surveillance System (BRFSS) provided information about individual-level binge drinking, sexual identity, and individual-level covariates. The Alcohol Policy Scale (APS) score measures the strength of the alcohol policy environment. Presence of state-level nondiscrimination protections based on sexual orientation came from the Movement Advancement Project. Logistic regression models were used to test whether nondiscrimination statutes modified the association between the alcohol policy environment and binge drinking and whether this interaction differed for LGB and heterosexual adults. RESULTS: Among women, a 10 percentage-point increase in APS score was significantly associated with 7% lower odds of binge drinking in states with inclusive nondiscrimination laws (aOR: 0.93 [95% CI: 0.89-0.97; p = 0.0003]) but was not associated with binge drinking in states without inclusive laws (aOR: 0.98 [95% CI: 0.93-1.03] p = 0.4781). Moreover, binge drinking disparities comparing lesbian/bisexual women with heterosexual women were narrower in states with inclusive nondiscrimination laws. No significant association was found among men. CONCLUSIONS: Binge drinking disparities between lesbian and heterosexual women are negligible in states with inclusive laws and strong alcohol policy environments. Inclusive nondiscrimination laws are an indicator of less structural stigma directed at lesbian and bisexual women.

Alcohol testing and alcohol involvement among violent deaths by state, 2014-2016.

Blood alcohol concentration (BAC) testing rates vary across states, potentially biasing estimates of alcohol involvement in violent deaths. The National Violent Death Reporting System (NVDRS) collects information on violent deaths, including decedents' BACs. This study assessed characteristics of violent deaths by BAC testing status, and the proportion of decedents with a positive BAC or BAC ≥ 0.08 g/dL. NVDRS data from 2014 to 2016 (2014: 18 states; 2015: 27 states; 2016: 32 states) were analyzed to assess BAC testing (tested, not tested, unknown/missing) by state, decedent characteristics, and death investigation system (e.g., state medical examiner, coroners), in 2019. The proportion of violent deaths with a BAC > 0.0 or ≥ 0.08 g/dL was also assessed. Among 95,390 violent death decedents, 57.1% had a BAC test (range: 9.5% in Georgia to 95.8% in Utah), 2.3% were not tested, and 40.6% had an unknown/missing BAC testing status (range: 1.3% in Alaska to 78.0% in Georgia). Decedents who were 21-44 years, American Indian/Alaska Native or Hispanic, died by poisoning, died by undetermined intent, or were investigated by a state medical examiner were most likely to receive BAC testing. Among the violent deaths with a reported BAC, 41.1% had a positive BAC and 27.7% had a BAC ≥ 0.08 g/dL. About 2 in 5 violent deaths were missing data on alcohol testing. Increased testing and reporting of alcohol among violent deaths could inform the development and use of evidence-based prevention strategies (e.g., increasing alcohol taxes, regulating alcohol outlet density) for reducing violent deaths.