Geographic Differences in Preconception Health Indicators Among Ohio Women Who Delivered Live Births, 2019-2021.

To determine whether geographic differences in preconception health indicators exist among Ohio women with live births, we analyzed 9 indicators from the 2019-2021 Ohio Pregnancy Assessment Survey (N = 14,377) by county type. Appalachian women reported lower rates of folic acid intake and higher rates of depression than women in other counties. Appalachian and rural non-Appalachian women most often reported cigarette use. Suburban women reported lower rates of diabetes, hypertension, and unwanted pregnancy than women in other counties. Preconception health differences by residence location suggest a need to customize prevention efforts by region to improve health outcomes, particularly in regions with persistent health disparities.

Prevalence and correlates of very rapid repeat pregnancy: Pregnancy Risk Assessment Monitoring System, United States, 2009-2020.

BACKGROUND: Most rapid repeat pregnancies, defined as those occurring within 18 months of a previous birth, are unintended. These pregnancies are associated with later initiation of prenatal care and are more common among people with lower socio-economic status and among racially and ethnically minoritised populations. OBJECTIVES: To assess prevalence and correlate pregnancies occurring in the immediate period after a live birth in the United States, using the Pregnancy Risk Assessment Monitoring System (PRAMS). METHODS: We assessed data from the 2009-2020 PRAMS, a population-based survey of perinatal maternal characteristics of mothers of liveborn infants in US locations. We assessed pregnancies reported during the immediate postpartum period (approximately 2-6 months post-delivery), and term this 'very rapid repeat pregnancy' (VRRP). We assessed the adjusted prevalence of VRRP from 2009 to 2020. From 2016 to 2020, we calculated adjusted prevalence ratios (aPR) with 95% confidence intervals (CI) for maternal characteristics. RESULTS: The adjusted prevalence of VRRP ranged from 0.38% (95% CI: 0.29, 0.48) in 2009 to 0.76% (95% CI: 0.61, 0.91) in 2020. Demographic characteristics associated with VRRP included younger age, lower educational attainment, and being unmarried. Black mothers had a higher prevalence of VRRP compared to white mothers. Mothers who attended a healthcare visit in the 12 months preconception had a lower prevalence of VRRP as did mothers who attended a postpartum check-up, compared to their counterparts without these visits. Among those receiving prenatal care, mothers whose prenatal healthcare provider asked about postpartum contraception birth had a lower prevalence of VRRP, compared to those not asked about postpartum contraception. CONCLUSIONS: VRRP appeared to increase over time in 2009-2020. Mothers who are younger, Black, have lower educational attainment, or who did not attend healthcare visits before or after pregnancy had a higher prevalence of VRRP and may comprise a population who would benefit from additional family planning resources.

Applying the Urgent Maternal Warning Signs Initiative in a Novel Setting.

ABSTRACT: Symptoms of urgent maternal warning signs (UMWS) may occur during pregnancy or after delivery and may have lasting effects or indicate a life-threatening situation if left untreated. The state department of health sponsored a quality improvement project (QIP) to broaden the reach of UMWS education beyond traditional clinical settings, to public health settings where prenatal and postpartum women are seen. Specifically, the QIP implemented process changes to provide education (written and verbal) and resources to individuals receiving services from Women, Infants, and Children clinics during pregnancy and up to 12 weeks postpartum. Clinics submitted participant-level data although the Research Electronic Data Capture secure data portal. The key results indicated an increase in both written and verbal education. In addition, the project monitored referrals made specific to conditions identified through project-specific data collection and the provision of UMWS education.

A Medicaid Statewide Hypertension Quality Improvement Project: Initial Results.

Background Hypertension control is critical to reducing cardiovascular disease, challenging to achieve, and exacerbated by socioeconomic inequities. Few states have established statewide quality improvement (QI) infrastructures to improve blood pressure (BP) control across economically disadvantaged populations. In this study, we aimed to improve BP control by 15% for all Medicaid recipients and by 20% for non-Hispanic Black participants. Methodology This QI study used repeated cross-sections of electronic health record data and, for Medicaid enrollees, linked Medicaid claims data for 17,672 adults with hypertension seen at one of eight high-volume Medicaid primary care practices in Ohio from 2017 to 2019. Evidence-based strategies included (1) accurate BP measurement; (2) timely follow-up; (3) outreach; (4) a standardized treatment algorithm; and (5) effective communication. Payers focused on a 90-day supply (vs. 30-day) of BP medications, home BP monitor access, and outreach. Implementation efforts included an in-person kick-off followed by monthly QI coaching and monthly webinars. Weighted generalized estimating equations were used to estimate the baseline, one-year, and two-year implementation change in the proportion of visits with BP control (<140/90 mm Hg) stratified by race/ethnicity. Results For all practices, the percentage of participants with controlled BP increased from 52% in 2017 to 60% in 2019. Among non-Hispanic Whites, the odds of achieving BP control in year one and year two were 1.24 times (95% confidence interval: 1.14, 1.34) and 1.50 times (1.38, 1.63) higher relative to baseline, respectively. Among non-Hispanic Blacks, the odds for years one and two were 1.18 times (1.10, 1.27) and 1.34 times (1.24, 1.45) higher relative to baseline, respectively. Conclusions A hypertension QI project as part of establishing a statewide QI infrastructure improved BP control in practices with a high volume of disadvantaged patients. Future efforts should investigate ways to reduce inequities in BP control and further explore factors associated with greater BP improvements and sustainability.

The Ohio Maternal Safety Quality Improvement Project: initial results of a statewide perinatal hypertension quality improvement initiative implemented during the COVID-19 pandemic.

BACKGROUND: Hypertensive disorders of pregnancy are a leading cause of severe maternal morbidity and mortality, and studies have shown that more than 60% of cases are preventable. As part of a statewide quality Maternal Safety Quality Improvement Project, we adapted the Alliance for Innovation on Maternal Health Severe Hypertension in Pregnancy bundle in a consortium of maternity hospitals in Ohio to improve care processes and outcomes for patients with a severe hypertensive event during pregnancy or the postpartum period. OBJECTIVE: This study aimed to report the first year of data from this Maternal Safety Quality Improvement Project, including an assessment of the process measures by hospital level of maternal care designation, and provide perspective on the unique challenges of implementing a large-scale Maternal Safety Quality Improvement Project during a global pandemic. STUDY DESIGN: This Maternal Safety Quality Improvement Project engaged Ohio level 1 to 4 maternity hospitals and provided multimodal quality improvement support. Participating hospitals submitted monthly patient-level data, which included all cases of new-onset sustained severe hypertension. The primary process measure was the proportion of birthing people in Ohio with sustained severe hypertension who received treatment with appropriate acute antihypertensive therapy within 60 minutes. The secondary process measures included receipt of a follow-up appointment after hospital discharge within 72 hours (if discharged on medication) or 10 days (if discharged without medication), a blood pressure cuff on hospital discharge, and education about urgent maternal warning signs. Data for primary and secondary process measures were plotted on a biweekly basis, and statistical process control methods were used to identify special cause variation over time. Data were stratified by various demographic variables, including race or ethnicity, insurance status, and maternal level of care. To assess the effect of the COVID-19 pandemic on this Maternal Safety Quality Improvement Project, process measure data were compared with COVID-19 case volume in Ohio across the study epoch. RESULTS: A total of 29 hospitals participated in the project from July 2020 to September 2021. Data were collected on 4948 hypertensive events representing 4678 unique patients. In aggregate, the primary process measure (timely and appropriate treatment) demonstrated a 19.3% increase (from a baseline of 56.5% to 67.4%; P<.001). The secondary process measures demonstrated significant increases ranging from 26.1% to 166.8% (all P<.001). Both non-Hispanic Black and White pregnant or postpartum people demonstrated shifts and sustained improvements in the treatment of severe hypertension, which did not differ by race across the study period. Process measure improvements were achieved and sustained across peaks in the COVID-19 pandemic. CONCLUSION: This Ohio Maternal Safety Quality Improvement Project demonstrated meaningful changes in project process measures in the identification and treatment of severe hypertension in pregnancy and the postpartum period. Process measures improvements were achieved across all hospital levels of maternal care, and differences were not observed by race or ethnicity. Our findings suggest that a robust and comprehensive quality improvement initiative with appropriate support and resources can achieve meaningful gains in the setting of a global pandemic.

Delivery at Catholic hospitals and postpartum contraception use, five US states, 2015-2018.

OBJECTIVES: To evaluate whether the prevalence of postpartum contraceptive use was lower among people who delivered at a Catholic hospital compared to a non-Catholic hospital. METHODS: We linked 2015-2018 Pregnancy Risk Assessment Monitoring System (PRAMS) survey data from five states to hospital information from the corresponding birth certificate file. People with a live birth self-reported their use of contraception methods on the PRAMS survey at 2-6 months postpartum, which we coded into two dichotomous (yes vs. no) outcomes for use of female sterilization and highly-effective contraception (female/male sterilization, intrauterine device, implant, injectable, oral contraception, patch, or ring). We conducted multilevel log-binomial regression to examine the relationship between birth hospital type and postpartum contraception use adjusting for confounders. RESULTS: Prevalence of female sterilization for people who delivered at a Catholic hospital was 51% lower than that of their counterparts delivering at a non-Catholic hospital (adjusted prevalence ratio: 0.49; 95% confidence interval: 0.37-0.65). CONCLUSION: We found lower use of postpartum female sterilization, but no difference in highly effective contraception overall, for people who delivered at a Catholic hospital compared to a non-Catholic hospital.

A statewide quality improvement (QI) initiative for better health outcomes and family stability among pregnant women with opioid use disorder (OUD) and their infants.

A collaborative led by state health and human service agencies, academic leaders, and stakeholders tested interventions to expand use of medication assisted treatment (MAT) through a maternal medical home (MMH) model that coordinated behavioral health and prenatal care with social supports for pregnant women with opioid use disorder (OUD) enrolled in Medicaid. The program was anchored in four clinical organizations with distinct models of care: community behavioral health, residential behavioral health, hospital-based obstetrical practice, and co-located obstetrical and behavioral health. A modified version of the Institute for Healthcare Improvement Breakthrough Series Model for Improvement was implemented using monthly performance data feedback to conduct small tests of change and improve care. Administrative data from the state's Medicaid, vital statistics, and child welfare systems were linked to evaluate the impact of MOMS on 252 mother-infant dyads compared to a sample of 846 Medicaid beneficiaries with OUD in the third trimester of pregnancy. MOMS participation was associated with increased likelihood of MAT in trimesters one, two and three (AOR = 2.30, 4.40, 2.75, respectively), behavioral health counseling during trimesters two and three (AOR = 3.75 and 2.07, respectively), retention in MAT during postpartum months one through three and four through six (AOR = 2.86, 2.40, respectively), and marginally lower out-of-home placement of infants born to mothers with OUD (AOR = 0.66). Within the MOMS program, greater participation in behavioral health treatment and MAT (χ2(3) ≥ 12.09) was observed in the co-located behavioral health/obstetrical care practice site compared to behavioral health-led and obstetrical provider-led sites.

Local Income Inequality, Individual Socioeconomic Status, and Unmet Healthcare Needs in Ohio, USA.

Purpose: Income inequality has been implicated as a potential risk to population health due to lower provision of healthcare services in deeply unequal countries or communities. We tested whether county economic inequality was associated with individual self-report of unmet healthcare needs using a state health survey data set. Methods: Adults residents of Ohio responding to the 2015 Ohio Medicaid Assessment Survey were included in the analysis. Ohio's 88 counties were classified into quartiles according to the Gini coefficient of income inequality. The primary outcome was a composite of self-reported unmet dental care, vision care, mental healthcare, prescription medication, or other healthcare needs within the past year. Unmet healthcare needs were compared according to county inequality quartile using weighted logistic regression. Results: The analytic sample included 37,140 adults. The weighted proportion of adults with unmet healthcare needs was 28%. In multivariable logistic regression, residents of counties in the highest (odds ratio [OR]=1.13, 95% confidence interval [CI]: 1.01-1.26; p=0.030) and second-highest (OR=1.16, 95% CI: 1.04-1.30; p=0.010) quartiles of income inequality experienced more unmet healthcare needs than residents of the most equal counties. Conclusion: Higher county-level income inequality was associated with individual unmet healthcare needs in a large state survey. This finding represents novel evidence for an individual-level association that may explain aggregate-level associations between community economic inequality and population health outcomes.

Cost effectiveness of bronchial thermoplasty in patients with severe uncontrolled asthma.

RATIONALE: Based on its clinical effectiveness, bronchial thermoplasty (BT) was approved by the Food and Drug Administration in 2010 for the treatment of severe persistent asthma in patients 18 years and older whose asthma is not well-controlled with inhaled corticosteroids and long-acting beta-agonist medicines. OBJECTIVE: Assess the 10 year cost-effectiveness of BT for individuals with severe uncontrolled asthma. METHODS: Using a Markov decision analytic model, the cost-effectiveness of BT was estimated. The patient population involved a hypothetical cohort of 41-year-old patients comparing BT to usual care over a 10-year time frame. The main outcome measure was cost in 2013 dollars per additional quality adjusted life year (QALY). RESULTS: Treatment with BT resulted in 6.40 QALYs and $7512 in cost compared to 6.21 QALYs and $2054 for usual care. The incremental cost-effectiveness ratio for BT at 10 years was $29,821/QALY. At a willingness to pay per QALY of $50,000, BT continues to be cost effective unless the probability of severe asthma exacerbation drops below 0.63 exacerbation per year or the cost of BT rises above $10,384 total for all three bronchoscopic procedures needed to perform thermoplasty and to cover the entire bronchial tree (baseline = $6690). CONCLUSIONS: BT is a cost-effective treatment for asthmatics at high risk of exacerbations. Continuing to follow asthmatics treated with BT beyond 5 years will help inform longer efficacy and support its cost-effectiveness.

Effectiveness and safety of patient activation interventions for adults with type 2 diabetes: systematic review, meta-analysis, and meta-regression.

BACKGROUND: Patient activation interventions (PAIs) engage patients in care by promoting increased knowledge, confidence, and/or skills for disease self-management. However, little is known about the impact of these interventions on a wide range of outcomes for adults with type 2 diabetes (DM2), or which of these interventions, if any, have the greatest impact on glycemic control. METHODS: Electronic databases were searched from inception through November 2011. Of 16,290 citations, two independent reviewers identified 138 randomized trials comparing PAIs to usual care/control groups in adults with DM2 that reported intermediate or long-term outcomes or harms. For meta-analyses of continuous outcomes, we used a random-effects model to derive pooled weighted mean differences (WMD). For all-cause mortality, we calculated the pooled odds ratio (OR) using Peto's method. We assessed statistical heterogeneity using the I (2) statistic and conducted meta-regression using a random-effects model when I (2) > 50 %. A priori meta-regression primary variables included: intervention strategies, intervention leader, baseline outcome value, quality, and study duration. RESULTS: PAIs modestly reduced intermediate outcomes [A1c: WMD 0.37 %, CI 0.28-0.45 %, I (2) 83 %; SBP: WMD 2.2 mmHg, CI 1.0-3.5 mmHg, I (2) 72 %; body weight: WMD 2.3 lbs, CI 1.3-3.2 lbs, I (2) 64 %; and LDL-c: WMD 4.2 mg/dL, CI 1.5-6.9 mg/dL, I (2) 64 %]. The evidence was moderate for A1c, low/very low for other intermediate outcomes, low for long-term mortality and very low for complications. Interventions had no effect on hypoglycemia (evidence: low) or short-term mortality (evidence: moderate). Higher baseline A1c, pharmacist-led interventions, and longer follow-up were associated with larger A1c improvements. No intervention strategy outperformed any other in adjusted meta-regression. CONCLUSIONS: PAIs modestly improve A1c in adults with DM2 without increasing short-term mortality. These results support integration of these interventions into primary care for adults with uncontrolled glycemia, and provide evidence to insurers who do not yet cover these programs.

Proteomic analysis of climatic keratopathy droplets.

PURPOSE: To identify the proteins in the corneal droplets of climatic droplet keratopathy (CDK), a disease that results in the formation of droplets on the cornea. Progressive accumulation of droplets in CDK leads to visual loss. METHODS: Proteomic mass spectrometry of the CDK specimens was performed after fractionation of proteins in 4% to 20% SDS-polyacrylamide gels. Droplets were derived from two human donors. Immunohistochemistry with antibodies was performed to confirm the presence of identified proteins on donor tissues from patients with CDK and control subjects. RESULTS: Proteomic analyses revealed identification of 105 proteins in CDK specimens. Immunohistochemical analyses confirmed localization of annexin A2 and glyceraldehyde 3-dehydrogenase (GAPDH), proteins identified by proteomic analyses in CDK specimens. The proteins were subjected to analyses with the Kyoto Encyclopedia of Genes and Genomes (KEGG) Database which showed that a few biochemical pathways were more frequent for the identified proteins. CONCLUSIONS: Approximately 105 proteins were identified in CDK specimens, and a subset of them was confirmed by immunohistochemistry. Several of these may play a role in fibril or deposit formation.