Definitions Of Severe Maternal Morbidity Research Articles

Racial/ethnic disparities in costs, length of stay, and severity of severe maternal morbidity

In contrast to other high-resource countries, the United States has experienced increases in the rates of severe maternal morbidity. In addition, the United States has pronounced racial and ethnic disparities in severe maternal morbidity, especially for non-Hispanic Black people, who have twice the rate as non-Hispanic White people. This study aimed to examine whether the racial and ethnic disparities in severe maternal morbidity extended beyond the rates of these complications to include disparities in maternal costs and lengths of stay, which could indicate differences in the case severity. This study used California's linkage of birth certificates to inpatient maternal and infant discharge data for 2009 to 2011. Of the 1.5 million linked records, 250,000 were excluded because of incomplete data, for a final sample of 1,262,862. Cost-to-charge ratios were used to estimate costs from charges (including readmissions) after adjusting for inflation to December 2017. Mean diagnosis-related group-specific reimbursement was used to estimate physician payments. We used the Centers for Disease Control and Prevention definition of severe maternal morbidity, including readmissions up to 42 days after delivery. Adjusted Poisson regression models estimated the differential risk of severe maternal morbidity for each racial or ethnic group, compared with the non-Hispanic White group. Generalized linear models estimated the associations of race and ethnicity with costs and length of stay. Asian or Pacific Islander, Non-Hispanic Black, Hispanic, and other race or ethnicity patients all had higher rates of severe maternal morbidity than non-Hispanic White patients. The largest disparity was between non-Hispanic White and non-Hispanic Black patients, with unadjusted overall rates of severe maternal morbidity of 1.34% and 2.62%, respectively (adjusted risk ratio, 1.61; P<.001). Among patients with severe maternal morbidity, the adjusted regression estimates showed that non-Hispanic Black patients had 23% (P<.001) higher costs (marginal effect of $5023) and 24% (P<.001) longer hospital stays (marginal effect of 1.4 days) than non-Hispanic White patients. These effects changed when cases, such as cases where a blood transfusion was the only indication of severe maternal morbidity, were excluded, with 29% higher costs (P<.001) and 15% longer length of stay (P<.001). For other racial and ethnic groups, the increases in costs and length of stay were smaller than those observed for non-Hispanic Black patients, and many were not significantly different from non-Hispanic White patients. Hispanic patients had higher rates of severe maternal morbidity than non-Hispanic White patients; however, Hispanic patients had significantly lower costs and length of stay than non-Hispanic White patients. There were racial and ethnic differences in the costs and length of stay among patients with severe maternal morbidity across the groupings that we examined. The differences were especially large for non-Hispanic Black patients compared with non-Hispanic White patients. Non-Hispanic Black patients experienced twice the rate of severe maternal morbidity; in addition, the higher relative costs and longer lengths of stay for non-Hispanic Black patients with severe maternal morbidity support greater case severity in that population. These findings suggest that efforts to address racial and ethnic inequities in maternal health need to consider differences in case severity in addition to the differences in the rates of severe maternal morbidity and that these differences in case severity merit additional investigation.

What we talk about when we talk about severe maternal morbidity: a call to action to critically review severe maternal morbidity as an outcome measure

Severe maternal morbidity has historically functioned as an umbrella term to define major, potentially life-threatening obstetrical, medical, and surgical complications of pregnancy. There is no overarching or consensus definition of the constellation of conditions that have been used variably to define severe maternal morbidity, although it is clear that having a well-honed definition of severe maternal morbidity is important for research, quality improvement, and health policy purposes. Although severe maternal morbidity may ultimately elude a single unifying definition because different features may be relevant depending on context and modality of data acquisition, it is valuable to explore the intellectual frameworks and various applications of severe maternal morbidity in current practice, and to consider the potential benefit of more consolidated terminology for maternal morbidity.

100 Maternal and neonatal hospitalization costs associated with severe maternal morbidity

Severe maternal morbidity (SMM) is defined by the CDC as a collection of pregnancy outcomes that have short- and long-term impacts. Of importance are the costs associated with SMM, which have not been well explored in the literature. Therefore, we sought to assess the hospitalization costs associated with SMM compared to no SMM, and which specific diagnoses were associated with the highest costs. This was a retrospective cohort study of all singleton, non-anomalous live births between 23-42 weeks’ gestation in California state between 2007-2011. Women were excluded if they had incomplete data for costs, length of stay, severe maternal morbidity or were outliers in costs. We considered hospitalization costs and length of stay separately for women and neonates. All costs were adjusted to 2020 US dollars. Analyses were conducted using Kruskal-Wallis equality-of-populations rank test with a significance level of 0.05. There were 18,569 births with diagnoses of SMM. The overall median hospitalization costs were $25,647 among women with SMM and $4,342 for their neonates. Excluding women who received blood transfusions, 3,700 women had diagnoses of SMM with costs of $32,697 and $5,431 for their neonates. Both definitions of SMM were associated with higher hospitalization costs and length of stay for both women and their neonates compared to those without SMM. When examined by diagnosis, the highest maternal median hospitalization costs were among those with temporary tracheostomy ($320,912), acute myocardial infarction ($94,688), ventricular fibrillation ($85,221), acute respiratory distress syndrome ($84,082) and amniotic fluid embolism ($82,285). SMM was associated with significantly higher hospitalization costs when compared to no SMM for both women and their neonates. The costs of specific SMM diagnoses are highly variable.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Measurement of hemorrhage-related severe maternal morbidity with billing versus electronic medical record data

Objective Measurement of obstetric hemorrhage-related morbidity is important for quality assurance purposes but presents logistical challenges in large populations. Billing codes are typically used to track severe maternal morbidity but may be of suboptimal validity. The objective of this study was to evaluate the validity of billing code diagnoses for hemorrhage-related morbidity compared to data obtained from the electronic medical record. Study design Deliveries occurring between July 2014 and July 2017 from three hospitals within a single system were analyzed. Three outcomes related to obstetric hemorrhage that are part of the Centers for Disease Control and Prevention definition of severe maternal morbidity (SMM) were evaluated: (i) transfusion, (ii) disseminated intravascular coagulation (DIC), and (iii) acute renal failure (ARF). ICD-9-CM and ICD-10-CM for these conditions were ascertained and compared to blood bank records and laboratory values. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) with 95% confidence intervals (CI) were calculated. Ancillary analyses were performed comparing codes and outcomes between hospitals and comparing ICD-9-CM to ICD-10-CM codes. Comparisons of categorical variables were performed with the chi-squared test. T-tests were used to compare continuous outcomes. Results 35,518 deliveries were analyzed. 786 women underwent transfusion, 168 had serum creatinine ≥1.2 mg/dL, and 99, 40, and 16 had fibrinogen ≤200, ≤150, and ≤100 mg/dL, respectively. Transfusion codes were 65% sensitive (95% CI 62–69%) with a 91% PPV (89–94%) for blood bank records of transfusion. DIC codes were 22% sensitive (95% CI 15–32%) for a fibrinogen cutoff of ≤200 mg/dL with 15% PPV (95% CI 10–22%). Sensitivity for ARF was 33% (95% CI 26–41%) for a creatinine of 1.2 mg/dL with a PPV of 63% (95% CI 52–73%). Sensitivity of ICD-9-CM for transfusion was significantly higher than ICD-10-CM (81%, 95% CI 76–86% versus 56%, 95% CI 51–60%, p < .01). Evaluating sensitivity of codes by individual hospitals, sensitivity of diagnosis codes for transfusion varied significantly (Hospital A 47%, 95% CI 36–58% versus Hospital B 63%, 95% CI 58–67% versus Hospital C 80%, 95% CI 74–86%, p < .01). Conclusion Use of administrative billing codes for postpartum hemorrhage complications may be appropriate for measuring trends related to disease burden and resource utilization, particularly in the case of transfusion, but may be suboptimal for measuring clinical outcomes within and between hospitals.

Validation of criteria to identify severe maternal morbidity.

Epidemiologic research on severe maternal morbidity often relies on a screening definition of the outcome because a gold standard approach requires medical record review. To determine the validity of screening or identification criteria to classify cases of severe maternal morbidity using the definition of severe maternal morbidity proposed by the American College of Obstetricians and Gynecologists (ACOG). From all singleton deliveries at Magee-Womens Hospital in Pittsburgh, Pennsylvania (2010-2011; n=19307), we selected all deliveries that had at least one screening or identification criteria for severe maternal morbidity (n=349) and a random sample of deliveries with no case identification criteria (n=349). Screen-positive deliveries were a delivery with any of the following: Centers for Disease Control and Prevention International Classification of Diseases 9th Revision diagnosis and procedure codes for the identification of severe maternal morbidity; prolonged post-partum length of stay; or maternal intensive care unit admission. We identified true cases through detailed chart review using the suggested diagnoses in the 2016 ACOG and SMFM Obstetric Care Consensus on severe maternal morbidity. We calculated the positive and negative predictive values of the screening criteria. Approximately 1.8% of deliveries screened positive for severe maternal morbidity. After medical record review, 166 screen-positive deliveries were true cases (48% positive predictive value), and 347 screen-negative cases were true negatives (99% negative predictive value). Two screen-negative cases were false negatives. If we applied the negative predictive value to the population, 109 true cases would be missed with these criteria. The criteria we used to identify potential cases of severe acute maternal morbidity had poor performance in our cohort. In the absence of resources to apply the gold standard outcome definition to a large population, validation data and analytic strategies that incorporate measurement error are essential to estimate the direction and magnitude of the resulting bias.

Learning to Identify Severe Maternal Morbidity from Electronic Health Records.

Severe maternal morbidity (SMM) is broadly defined as significant complications in pregnancy that have an adverse effect on women’s health. Identifying women who experience SMM and reviewing their obstetric care can assist healthcare organizations in recognizing risk factors and best practices for management. Various definitions of SMM have been posited, but there is no consensus. Existing definitions are further limited in that they 1) are often rooted in existing clinical knowledge (which is problematic as many risk factors remain unknown), leading to poor positive predictive performance (PPV), and 2) have limited scalability as they often require substantial chart review. Thus, in this paper, a machine learning framework was introduced to automatically identify SMM and relevant risk factors from electronic health records (EHRs). We evaluated this framework with EHR data from 45,858 deliveries at a large academic medical center. The framework outperformed a state-of-the-art model from the U.S. Centers for Disease Control and Prevention (AUC of 0.94 vs. 0.80). Specially, it improved upon PPV by 59% (CDC: 0.22 vs. our model: 0.35). In the process, we revealed several novel SMM indicators, including disorders of fluid or electrolytes, systemic inflammatory response syndrome, and acidosis.

Severe maternal morbidity from direct obstetric causes in West Africa: incidence and case fatality rates.

Data on maternal morbidity make it possible to assess how many women are likely to need essential obstetric care, and permit the organization, monitoring and evaluation of safe motherhood programmes. In the present paper we propose operational definitions of severe maternal morbidity and report the frequency of such morbidity as revealed in a population-based survey of a cohort of 20,326 pregnant women in six West African countries. The methodology and questionnaires were the same in all areas. Each pregnant woman had four contacts with the obstetric survey team: at inclusion, between 32 and 36 weeks of amenorrhoea, during delivery and 60 days postpartum. Direct obstetric causes of severe morbidity were observed in 1215 women (6.17 cases per 100 live births). This ratio varied significantly between areas, from 3.01% in Bamako to 9.05% in Saint-Louis. The main direct causes of severe maternal morbidity were: haemorrhage (3.05 per 100 live births); obstructed labour (2.05 per 100), 23 cases of which involved uterine rupture (0.12 per 100); hypertensive disorders of pregnancy (0.64 per 100), 38 cases of which involved eclampsia (0.19 per 100); and sepsis (0.09 per 100). Other direct obstetric causes accounted for 12.2% of cases. Case fatality rates were very high for sepsis (33.3%), uterine rupture (30.4%) and eclampsia (18.4%); those for haemorrhage varied from 1.9% for antepartum or peripartum haemorrhage to 3.7% for abruptio placentae. Thus at least 3-9% of pregnant women required essential obstetric care. The high case fatality rates of several complications reflected a poor quality of obstetric care.