Kathryn R. Fingar

The Role of Socioeconomic Factors in Black–White Disparities in Preterm Birth

OBJECTIVES We investigated the role of socioeconomic factors in Black-White disparities in preterm birth (PTB). METHODS We used the population-based California Maternal and Infant Health Assessment survey and birth certificate data on 10 400 US-born Black and White California residents who gave birth during 2003 to 2010 to examine rates and relative likelihoods of PTB among Black versus White women, with adjustment for multiple socioeconomic factors and covariables. RESULTS Greater socioeconomic advantage was generally associated with lower PTB rates among White but not Black women. There were no significant Black-White disparities within the most socioeconomically disadvantaged subgroups; Black-White disparities were seen only within more advantaged subgroups. CONCLUSIONS Socioeconomic factors play an important but complex role in PTB disparities. The absence of Black-White disparities in PTB within certain socioeconomic subgroups, alongside substantial disparities within others, suggests that social factors moderate the disparity. Further research should explore social factors suggested by the literature-including life course socioeconomic experiences and racism-related stress, and the biological pathways through which they operate-as potential contributors to PTB among Black and White women with different levels of social advantage.

Beyond the Cross-Sectional: Neighborhood Poverty Histories and Preterm Birth

OBJECTIVES We examined associations between longitudinal neighborhood poverty trajectories and preterm birth (PTB). METHODS Using data from the Neighborhood Change Database (1970-2000) and the American Community Survey (2005-2009), we categorized longitudinal trajectories of poverty for California neighborhoods (i.e., census tracts). Birth data included 23 291 singleton California births from the Maternal and Infant Health Assessment (2003-2009). We estimated associations (adjusted for individual-level covariates) between PTB and longitudinal poverty trajectories and compared these to associations using traditional, cross-sectional measures of poverty. RESULTS Compared to neighborhoods with long-term low poverty, those with long-term high poverty and those that experienced increasing poverty early in the study period had 41% and 37% increased odds of PTB (95% confidence interval [CI] = 1.18, 1.69 and 1.09, 1.72, respectively). High (compared with low) cross-sectional neighborhood poverty was not associated with PTB (odds ratio = 1.08; 95% CI = 0.91, 1.28). CONCLUSIONS Neighborhood poverty histories may contribute to an understanding of perinatal health and should be considered in future research.

Association Between the Opening of Retail Clinics and Low-Acuity Emergency Department Visits.

Study objective We assess whether the opening of retail clinics near emergency departments (ED) is associated with decreased ED utilization for low‐acuity conditions. Methods We used data from the Healthcare Cost and Utilization Project State Emergency Department Databases for 2,053 EDs in 23 states from 2007 to 2012. We used Poisson regression models to examine the association between retail clinic penetration and the rate of ED visits for 11 low‐acuity conditions. Retail clinic “penetration” was measured as the percentage of the ED catchment area that overlapped with the 10‐minute drive radius of a retail clinic. Rate ratios were calculated for a 10‐percentage‐point increase in retail clinic penetration per quarter. During the course of a year, this represents the effect of an increase in retail clinic penetration rate from 0% to 40%, which was approximately the average penetration rate observed in 2012. Results Among all patients, retail clinic penetration was not associated with a reduced rate of low‐acuity ED visits (rate ratio=0.999; 95% confidence interval=0.997 to 1.000). Among patients with private insurance, there was a slight decrease in low‐acuity ED visits (rate ratio=0.997; 95% confidence interval=0.994 to 0.999). For the average ED in a given quarter, this would equal a 0.3% reduction (95% confidence interval 0.1% to 0.6%) in low‐acuity ED visits among the privately insured if retail clinic penetration rate increased by 10 percentage points per quarter. Conclusion With increased patient demand resulting from the expansion of health insurance coverage, retail clinics may emerge as an important care location, but to date, they have not been associated with a meaningful reduction in low‐acuity ED visits.

The shifting landscape in utilization of inpatient, observation, and emergency department services across payers

&NA; Recent policies by public and private payers have increased incentives to reduce hospital admissions. Using data from four states from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project, this study compared the payer‐specific population‐based rates of adults using inpatient, observation, and emergency department (ED) services for 10 common medical conditions in 2009 and in 2013. Patients had an expected primary payer of private insurance, Medicare, Medicaid, or no insurance. Across all four payer populations, inpatient admissions declined, and care shifted toward treat‐and‐release observation stays and ED visits. The percentage of hospitalizations that began with an observation stay increased. Implications for quality of care and costs to patients warrant further examination.

Returns to Emergency Department, Observation, or Inpatient Care Within 30 Days After Hospitalization in 4 States, 2009 and 2010 Versus 2013 and 2014

BACKGROUND Nationally, readmissions have declined for acute myocardial infarction (AMI) and heart failure (HF) and risen slightly for pneumonia, but less is known about returns to the hospital for observation stays and emergency department (ED) visits. OBJECTIVE To describe trends in rates of 30-day, all-cause, unplanned returns to the hospital, including returns for observation stays and ED visits. DESIGN By using Healthcare Cost and Utilization Project data, we compared 210,007 index hospitalizations in 2009 and 2010 with 212,833 matched hospitalizations in 2013 and 2014. SETTING Two hundred and one hospitals in Georgia, Nebraska, South Carolina, and Tennessee. PATIENTS Adults with private insurance, Medicaid, or no insurance and seniors with Medicare who were hospitalized for AMI, HF, and pneumonia. MEASUREMENTS Thirty-day hospital return rates for inpatient, observation, and ED visits. RESULTS Return rates remained stable among adults with private insurance (15.1% vs 15.3%; P = .45) and declined modestly among seniors with Medicare (25.3% vs 25.0%; P = .04). Increases in observation and ED visits coincided with declines in readmissions (8.9% vs 8.2% for private insurance and 18.3% vs 16.9% for Medicare, both P ⩽ .001). Return rates rose among patients with Medicaid (31.0% vs 32.1%; P = .04) and the uninsured (18.8% vs 20.1%; P = .004). Readmissions remained stable (18.7% for Medicaid and 9.5% for uninsured patients, both P > .75) while observation and ED visits increased. CONCLUSIONS Total returns to the hospital are stable or rising, likely because of growth in observation and ED visits. Hospitalists’ efforts to improve the quality and value of hospital care should consider observation and ED care.

Racial Disparities in Sepsis-related In-hospital Mortality: Using a Broad Case Capture Method and Multivariate Controls for Clinical and Hospital Variables, 2004–2013

Objectives: As sepsis hospitalizations have increased, in-hospital sepsis deaths have declined. However, reported rates may remain higher among racial/ethnic minorities. Most previous studies have adjusted primarily for age and sex. The effect of other patient and hospital characteristics on disparities in sepsis mortality is not yet well-known. Furthermore, coding practices in claims data may influence findings. The objective of this study was to use a broad method of capturing sepsis cases to estimate 2004–2013 trends in risk-adjusted in-hospital sepsis mortality rates by race/ethnicity to inform efforts to reduce disparities in sepsis deaths. Design: Retrospective, repeated cross-sectional study. Setting: Acute care hospitals in the Healthcare Cost and Utilization Project State Inpatient Databases for 18 states with consistent race/ethnicity reporting. Patients: Patients diagnosed with septicemia, sepsis, organ dysfunction plus infection, severe sepsis, or septic shock. Measurements and Main Results: In-hospital sepsis mortality rates adjusted for patient and hospital factors by race/ethnicity were calculated. From 2004 to 2013, sepsis hospitalizations for all racial/ethnic groups increased, and mortality rates decreased by 5–7% annually. Mortality rates adjusted for patient characteristics were higher for all minority groups than for white patients. After adjusting for hospital characteristics, sepsis mortality rates in 2013 were similar for white (92.0 per 1,000 sepsis hospitalizations), black (94.0), and Hispanic (93.5) patients but remained elevated for Asian/Pacific Islander (106.4) and “other” (104.7; p < 0.001) racial/ethnic patients. Conclusions: Our results indicate that hospital characteristics contribute to higher rates of sepsis mortality for blacks and Hispanics. These findings underscore the importance of ensuring that improved sepsis identification and management is implemented across all hospitals, especially those serving diverse populations.