E. Kathleen Adams

Effects of smoking during pregnancy: Five meta-analyses

BACKGROUND The purpose of this study was to estimate, using meta-analysis, pooled odds ratios for the effects of smoking on five pregnancy complications: placenta previa, abruptio placenta, ectopic pregnancy, preterm premature rupture of the membrane (PPROM), and pre-eclampsia. METHODS Published articles were identified through computer search and literature review. Five criteria were applied to those studies initially identified to determine those eligible for the meta-analysis. A random effects model was applied to derive pooled odds ratios for the eligible studies for each pregnancy complication. Meta-analyses were repeated on subsets of the studies to confirm the overall results. RESULTS Smoking was found to be strongly associated with an elevated risk or placenta previa, abruptio placenta, ectopic pregnancy, and PPROM, and a decreased risk of pre-eclampsia. All pooled odds ratios were statistically significant. The pooled ratios ranged from 1.58 for placenta previa to 1.77 for ectopic pregnancy. The pooled odds ratio for pre-eclampsia was 0.51 and all subset analyses confirmed this seemingly protective effect. CONCLUSIONS Smoking during pregnancy is a significant and preventable factor affecting ectopic pregnancy, placental abruption, placenta previa, and PPROM. The findings of smokings apparently protective effect on pre-eclampsia should be balanced with these harmful effects. In addition, the biological linkage between smoking and pre-eclampsia is not yet well understood. Pregnant women should be advised to stop smoking in order to reduce the overall risk of pregnancy complications as well as any risk of adverse impact on the unborn child.

Impact of the National Breast and Cervical Cancer Early Detection Program on mammography and pap test utilization among white, Hispanic, and African American women: 1996–2000†

Prevention, including routine cancer screening, is key to meeting national goals for the elimination of death and suffering due to cancer. Since 1991, the U.S. government has invested in programs such as the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) to detect breast and cervical cancer early among uninsured low‐income women. A concomitant goal is reducing racial disparities in screening and early detection, and the NBCCEDP program targets low‐income women who are more often racial and ethnic minorities. This paper analyzes data to test for effects of the NBCCEDP and other determinants of screening across racial/ethnic groups. We used data from the Behavioral Risk Factor Surveillance System (BRFSS) for 1996 through 2000. These data indicate that gaps in testing for breast and cervical cancers between African American and non‐Hispanic white women aged 40–64 years have closed but remain for Hispanics. Multivariate findings indicate that the longevity of free screening sites through the NBCCEDP significantly increased both tests for non‐Hispanic white women. The data do not confirm this effect for other racial and ethnic groups. Analysis did indicate that public insurance, or Medicaid, was equal to private insurance in promoting increased testing for African Americans and Hispanics, but not for non‐Hispanic whites. Assuring that Medicaid remains available for women in this nonelderly group and increasing access to free screening sites can lead us closer to national screening goals, yet policies still need to address racial/ethnic disparities in insurance and service delivery. Cancer 2007.

Patient Satisfaction With Primary Care: Does Type of Practitioner Matter?

Objective:The objective of this study was to evaluate the association of patient satisfaction with type of practitioner attending visits in the primary care practice of a managed care organization (MCO). Study Design:We conducted a retrospective observational study of 41,209 patient satisfaction surveys randomly sampled from visits provided by the pediatrics and adult medicine departments from 1997 to 2000. Logistic regression, with practitioner and practice fixed effects, of patient satisfaction versus dissatisfaction was estimated for each of 3 scales: practitioner interaction, care access, and overall experience. Models were estimated separately by department. Independent variables were type of practitioner attending the visit and other patient and visit characteristics. Results:Adjusted for patient and visit characteristics, patients were significantly more likely to be satisfied with practitioner interaction on visits attended by physician assistant/nurse practitioners (PA/NPs) than visits attended by MDs in both the adult medicine and pediatrics practices. Patient satisfaction with care access or overall experience did not significantly differ by practitioner type. In adult medicine, patients were more satisfied on diabetes visits provided by MDs than by PA/NPs. Otherwise, patient satisfaction for the combined effects of practitioner type and specific presenting condition did not differ. Conclusions:Averaged over many primary care visits provided by many physicians and midlevel practitioners, patients in this MCO were as satisfied with care provided by PA/NPs as with care provided by MDs.

Hospital Choice Models: A Review and Assessment of their Utility for Policy Impact Analysis

The changing competitive hospital environment and recent greater availability of patient origin data have stimulated an increased research interest in factors influencing the reason patients are admitted to one hospital over another. Hospital marketers and managed care planners seek information for attracting patients and for negotiating hospital provider networks, respectively. Hospital choice models can help regulators make better informed assessments of the welfare implications of proposed mergers or closures. The literature shows the development of increasingly sophisticated models and techniques for analysis of hospital choice. Recent studies have also related the findings to health policy issues. This review summarizes the historical developments and the cumulative knowledge gained about hospital choice to date, identifies some key issues in need of greater attention, and assesses the potential strengths and limitations of contemporary choice models for making policy impact assessments.

California Safety-Net Hospitals Likely To Be Penalized By ACA Value, Readmission, And Meaningful-Use Programs

The Affordable Care Act includes provisions to increase the value obtained from health care spending. A growing concern among health policy experts is that new Medicare policies designed to improve the quality and efficiency of hospital care, such as value-based purchasing (VBP), the Hospital Readmissions Reduction Program (HRRP), and electronic health record (EHR) meaningful-use criteria, will disproportionately affect safety-net hospitals, which are already facing reduced disproportionate-share hospital (DSH) payments under both Medicare and Medicaid. We examined hospitals in California to determine whether safety-net institutions were more likely than others to incur penalties under these programs. To assess quality, we also examined whether mortality outcomes were different at these hospitals. Our study found that compared to non-safety-net hospitals, safety-net institutions had lower thirty-day risk-adjusted mortality rates in the period 2009-11 for acute myocardial infarction, heart failure, and pneumonia and marginally lower adjusted Medicare costs. Nonetheless, safety-net hospitals were more likely than others to be penalized under the VBP program and the HRRP and more likely not to meet EHR meaningful-use criteria. The combined effects of Medicare value-based payment policies on the financial viability of safety-net hospitals need to be considered along with DSH payment cuts as national policy makers further incorporate performance measures into the overall payment system.

Reducing Prenatal Smoking: The Role of State Policies

BACKGROUND Maternal smoking causes adverse health outcomes for both mothers and infants and leads to excess healthcare costs at delivery and beyond. Even with substantial declines over the past decade, around 23% of women enter pregnancy as a smoker and though almost half quit during pregnancy, half or more quitters resume smoking soon after delivery. PURPOSE To examine the independent effects of higher cigarette taxes and prices, smokefree policies, and tobacco control spending on maternal smoking prior to, during, and after a pregnancy during a period in which states have made changes in such policies. METHODS Data from pooled cross-sections of women with live births during 2000-2005 in 29 states plus New York City (n=225,445) were merged with cigarette price data inclusive of federal, state, and local excise taxes, full or partial bans on smoking in public places, and tobacco control spending. Probit regression models using a mixed panel, state fixed effects, and time indicators were used to assess effect of policies on smoking (during 3 months before pregnancy); quitting by last 3 months of pregnancy; and having sustained quitting at the time of completing the postpartum survey. RESULTS Multivariate analysis indicated that a

Determining the clinical efficacy and cost savings of successful external cephalic version.

1.00 increase in taxes and prices increases third-trimester quits by between 4 and 5 percentage points after controlling for the other policies and covariates. Implementing a full private worksite smoking ban increases quits by the third trimester by an estimated 5 percentage points. Cumulative spending on tobacco control had no effect on pregnancy smoking rates overall. Association of tobacco control policies with maternal smoking varied by age. CONCLUSIONS States can use multiple tobacco control policies to reduce maternal smoking. Combining higher taxes with smokefree policies particularly can be effective.

Prenatal care initiation among very low-income women in the aftermath of welfare reform: does pre-pregnancy Medicaid coverage make a difference?

OBJECTIVE The aim of this study was to determine predictors of successful external cephalic version and to calculate the associated cost savings achieved with success. STUDY DESIGN A retrospective study of 203 women with singleton gestations who underwent external cephalic version was performed. Descriptive, univariate, and multivariate analyses were performed on patient-specific risk data to predict successful version. National claims data were used for the cost simulation. RESULTS Higher parity (p = 0.02), transverse-oblique presentation (p = 0.001), posterior placenta (p = 0.001), and a longer duration of pregnancy (p = 0.001) significantly increased the likelihood of a successful version. Heavier maternal weight was negatively associated with successful version (p = 0.05). The cost simulation revealed an average savings of

Sociodemographic, insurance, and risk profiles of maternal smokers post the 1990s: how can we reach them?

2462 for each successful version. CONCLUSION This study identifies clinical variables associated with an increased external cephalic version success rate. If, in fact, successful external cephalic version reduces both maternal and fetal morbidity associated with cesarean delivery and, as demonstrated in this analysis, the costs associated with the delivery, then greater effort should be made to maximize the success rate of external cephalic version.

Costs of smoking : A focus on maternal, childhood, and other short-run costs

Objectives: To examine pre-pregnancy Medicaid coverage and initiation of prenatal care among women likely eligible for Medicaid coverage regardless of pregnancy. Methods: The Pregnancy Risk Assessment Monitoring System (PRAMS) was used to identify very low-income women with Medicaid payment for delivery. We then compared prenatal care initiation among women with (Non-GAP) and without (Medicaid GAP) pre-pregnancy Medicaid coverage. Results: Rates of first trimester prenatal care were 47.3% for women in the Medicaid GAP, 70.0% for women who were not. The adjusted odds ratio for being in the Medicaid GAP and delayed prenatal care was 2.7 (95% CI 1.2, 6.2), although this varied by race/ethnicity and education. The relationship was strongest among White and Hispanic women with less than a high school education: OR=13.8, (95% CI 3.0, 62.7) and OR=19.0 (95% CI 2.4, 149.2), respectively. Conclusions: Pre-pregnancy Medicaid coverage appears to be associated with early initiation of prenatal care. Almost a decade after welfare reform, it is essential to preserve the Medicaid expansions for pregnant women, foster Medicaid family planning waivers, and promote access to primary care and early prenatal care, particularly for very low-income women.