Jessica A. Lavery

Gestational diabetes in the United States: temporal changes in prevalence rates between 1979 and 2010

To examine age–period–cohort effects on trends in gestational diabetes mellitus (GDM) prevalence in the US, and to evaluate how these trends have affected the rates of stillbirth and large for gestational age (LGA)/macrosomia.

The Prevalence of Potentially Modifiable Functional Deficits and the Subsequent Use of Occupational and Physical Therapy by Older Adults with Cancer

BACKGROUND Occupational and physical therapy (OT/PT) services seek to reduce morbidity, mortality, and improve the quality of life of individuals; however, little is known about the needs and use of OT/PT for older adults with cancer. The goal of this study was to describe the functional deficits and their associations with other factors, and to examine the use of OT/PT after a noted functional deficit. MATERIALS AND METHODS This study analyzed data from an institution-based registry that included geriatric assessments of older adults with cancer linked to billing claims data. Logistic regression was used to model predictors of functional deficits. Use of OT/PT was determined and validated with medical chart review. RESULTS 529 patients with cancer, a median age of 71, 78% were female, 87% Caucasian, 57% married, 53% post-secondary education, and 63% with breast cancer were included. In a multivariable model, the odds of having any functional deficits increased with age [5 year OR: 1.31, 95% CI: (1.10, 1.57)] were higher for those with a high school diploma versus those with advanced degrees [OR: 1.66, 95% CI: (1.00, 2.77)] and were higher for patients with comorbidities [OR: 1.15, 95% CI: (1.10, 1.21)]. Of patients with functional deficits only 9% (10/111) received OT/PT within 12 months of a noted deficit. DISCUSSION The odds of having any potentially modifiable functional deficit were higher in patients with increasing age, comorbid conditions, and with less than a college degree. Few were referred for OT/PT services suggesting major underutilization of these potentially beneficial services.

Severe placental abruption: clinical definition and associations with maternal complications.

BACKGROUND Placental abruption traditionally is defined as the premature separation of the implanted placenta before the delivery of the fetus. The existing clinical criteria of severity rely exclusively on fetal (fetal distress or fetal death) and maternal complications without consideration of neonatal or preterm delivery-related complications. However, two-thirds of abruption cases are accompanied by fetal or neonatal complications, including preterm delivery. A clinically meaningful classification for abruption therefore should include not only maternal complications but also adverse fetal and neonatal outcomes that include intrauterine growth restriction and preterm delivery. OBJECTIVES The purpose of this study was to define severe placental abruption and to compare serious maternal morbidity profiles of such cases with all other cases of abruption (ie, mild abruption) and nonabruption cases. STUDY DESIGN We performed a retrospective cohort analysis using the Premier database of hospitalizations that resulted in singleton births in the United States between 2006 and 2012 (n = 27,796,465). Severe abruption was defined as abruption accompanied by at least 1 of the following events: maternal (disseminated intravascular coagulation, hypovolemic shock, blood transfusion, hysterectomy, renal failure, or in-hospital death), fetal (nonreassuring fetal status, intrauterine growth restriction, or fetal death), or neonatal (neonatal death, preterm delivery or small for gestational age) complications. Abruption cases that did not qualify as being severe were classified as mild abruption cases. The morbidity profile included amniotic fluid embolism, pulmonary edema, acute respiratory or heart failure, acute myocardial infarction, cardiomyopathy, puerperal cerebrovascular disorders, or coma. Associations were expressed as rate ratios with 95% confidence intervals that were derived from fitting log-linear Poisson regression models. RESULTS The overall prevalence rate of abruption was 9.6 per 1000, of which two-thirds of cases were classified as being severe (6.5 per 1000). Serious maternal complications occurred in 15.4, 33.3, and 141.7 per 10,000 among nonabruption cases and mild and severe abruption cases, respectively. In comparison with no abruption, the rate ratio for serious maternal complications were 1.52 (95% confidence interval, 1.35-1.72) and 4.29 (95% confidence interval, 4.11-4.47) in women with mild and severe placental abruption, respectively. Rate ratios for the individual complications were 2- to 7-fold higher among severe abruption cases. Furthermore, the rate ratios for serious maternal complications among severe abruption cases compared with mild abruption cases was 3.47 (95% confidence interval, 3.05-3.95). This association was considerably stronger for virtually all maternal complications among cases with severe abruption compared with mild abruption. Annual rates of mild and severe abruption were fairly constant during the study period. Although the maternal complication rate among non-abruption births was stable from 2006-2012, the rate of complications among mild abruption cases dropped from 2006-2008 and then leveled off thereafter. In contrast, the rate of serious complications among severe abruption cases remained fairly stable from 2006-2010 and increased sharply thereafter. CONCLUSIONS Severe abruption was associated with a distinctively higher morbidity risk profile compared with the other 2 groups. The clinical characteristics and morbidity profile of mild abruption were more similar to those of women without an abruption. These findings suggest that the definition of severe placental abruption based on the proposed specific criteria is clinically relevant and may facilitate epidemiologic and genetic research.

Neurodevelopmental outcomes in children in relation to placental abruption

Placental abruption has a profound impact on perinatal mortality, but implications for neurodevelopment during childhood remain unknown. We examined the association between abruption and neurodevelopment at 8 months and 4 and 7 years and evaluated the extent to which these associations were mediated through preterm delivery.

Serious maternal complications in relation to severe pre‐eclampsia: a retrospective cohort study of the impact of hospital volume

We examined rates of serious maternal complications in relation to severe pre‐eclampsia based on the delivering hospitals annualised volume.

Primary and Repeat Cesarean Deliveries: A Population-based Study in the United States, 1979-2010.

Background: Despite the temporal increase in cesarean deliveries, the extent to which maternal age, period, and maternal birth cohorts may have contributed to these trends remains unknown. Methods: We performed an analysis of 123 million singleton deliveries in the United States (1979–2010). We estimated rate ratio (RR) with 95% confidence interval (CI) for primary and repeat cesarean deliveries. We examined changes in cesarean rates with weighted Poisson regression models across three time-scales: maternal age, year of delivery, and birth cohort (mother’s birth year). Results: The primary cesarean rate increased by 68% (95% confidence interval [CI]: 67%, 69%) between 1979 (11.0%) and 2010 (18.5%). Repeat cesarean deliveries increased by 178% (95% CI: 176, 179) from 5.2% in 1979 to 14.4% in 2010. Cesarean rates increased with advancing age. Compared with 1979, the RR for the period effect in primary and repeat cesarean deliveries increased up to 1990, fell to a nadir at 1993, and began to rise thereafter. A small birth cohort effect was evident, with women born before 1950 at increased risk of primary cesarean; no cohort effect was seen for repeat cesarean deliveries. Adjustment for maternal BMI had a small effect on these findings. Period effects in primary cesarean were explained by a combination of trends in obesity and chronic hypertension, as well as demographic shifts over time. Conclusions: Maternal age and period appear to have important contributions to the temporal increase in the cesarean rates, although the effect of parity on these associations remains undetermined.

The effect of maternal haematocrit on offspring IQ at 4 and 7 years of age: a secondary analysis

To determine whether maternal haematocrit during pregnancy is associated with offspring IQ.

Safe Motherhood Initiative: Early Impact of Severe Hypertension in Pregnancy Bundle Implementation

Objective  To describe the implementation and early results of the American College of Obstetricians and Gynecologists District II Safe Motherhood Initiatives Severe Hypertension in Pregnancy bundle on the timely treatment of severe hypertension in New York State obstetric hospitals. Methods  This is a retrospective comparative study of two time periods during voluntary implementation of the Severe Hypertension in Pregnancy bundle in New York States obstetric hospitals. The main outcome measure was the administration of an appropriate antihypertensive agent within 1 hour of the second elevated value for all pregnant or postpartum patients with severe hypertension. Results  Of the 117 obstetric hospitals participating in the Safe Motherhood Initiative, 111 (94.9%) submitted data included in this analysis. During the study period, 80 of the 111 (72.0%) hospitals reported implementing the hypertension bundle. Overall, 2.4% of pregnant women were diagnosed with severe hypertension, and 60 to 65% of patients were treated within an hour of the second elevated value. Although not statistically significant, a greater numbers of patients were treated within an hour of the second elevated value in the second time period compared with the first in most obstetric hospitals (overall 64.8 vs. 60.8%; p  = 0.33). Conclusion  There were increasing numbers of patients receiving timely treatment of severe hypertension during early implementation of a Severe Hypertension in Pregnancy bundle in New York State obstetric hospitals. However, bundle implementation requires significant financial and human resources and the long-term impact on maternal morbidity and mortality in our state remains uncertain. Precis There was a tendency toward more timely treatment of severe hypertension following implementation of a Severe Hypertension in Pregnancy bundle in New York obstetric hospitals.

Implementing Obstetric Venous Thromboembolism Protocols on a Statewide Basis: Results from New York State's Safe Motherhood Initiative

OBJECTIVE  To determine whether a state-level initiative to reduce obstetric venous thromboembolism (VTE) risk affected outcomes and process measures. METHODS  In 2013, the Safe Motherhood Initiative (SMI) developed a VTE safety bundle to reduce obstetric VTE risk. A total of 117 of 124 hospitals providing obstetrical services in New York participated in SMI. Data evaluating thromboembolism events (deep vein thrombosis and pulmonary embolism) and thromboprophylaxis process measures were collected from March through November 2015. RESULTS  A total of 107 hospitals, in any individual quarter, reported data on each of the VTE bundle outcomes and measures. Centers that provided low-risk care (Level 1 centers) reported the lowest rate of bundle implementation at the end of the study period (55.6%). Mechanical prophylaxis for a cesarean was common at all centers. Hospitals that adopted the bundle were more likely to provide routine pharmacologic prophylaxis for women undergoing cesarean. The risk of VTE did not differ by bundle implementation. CONCLUSION  While adoption of the SMI VTE bundle occurred at a majority of centers across New York, uptake was less likely at low-acuity centers. Bundle adoption was associated with implementation of recommended practices. The rare nature of VTE events underscores the need for large data samples to determine the best prophylaxis strategies.

Therapy Caps and Variation in Cost of Outpatient Occupational Therapy by Provider, Insurance Status, and Geographic Region

OBJECTIVE. This article describes the cost of occupational therapy by provider, insurance status, and geographic region and the number of visits allowed and out‐of‐pocket costs under proposed therapy caps. METHOD. This retrospective, population‐based study used Medicare Provider Utilization and Payment Data for occupational therapists billing in 2012 and 2013 (Ns = 3,662 and 3,820, respectively). We examined variations in outpatient occupational therapy services with descriptive statistics and the impact of therapy caps on occupational therapy visits and patient out‐of‐pocket costs. RESULTS. Differences in cost between occupational and physical therapists were minimal. The most frequently billed service was therapeutic exercises. Wisconsin had the most inflated outpatient costs in both years. Under the proposed therapy cap, patients could receive an evaluation plus 12‐14 visits. DISCUSSION. Wide variation exists in potential patient out‐of‐pocket costs for occupational therapy services on the basis of insurance coverage and state. Patients without insurance pay a premium.