Trude Bennett

Insurance-Related Differences in the Risk of Ruptured Appendix

BACKGROUND We studied differences in the incidence of appendiceal perforation in patients with acute appendicitis according to their insurance coverage. METHODS In a retrospective analysis of hospital-discharge data, we examined the likelihood of ruptured appendix among adults 18 to 64 years old who were hospitalized for acute appendicitis in California from 1984 to 1989. RESULTS After controlling for age, sex, psychiatric diagnoses, substance abuse, diabetes, poverty, race or ethnic group, and hospital characteristics, we found that ruptured appendix was more likely among both Medicaid-covered and uninsured patients with appendicitis than among patients with private capitated coverage (odds ratios, 1.49 [95 percent confidence interval, 1.41 to 1.59] and 1.46 [95 percent confidence interval, 1.39 to 1.54], respectively). After adjustment for the above factors, the risk of appendiceal rupture associated with a lack of private insurance was elevated at both county and other hospitals, but admission to a county hospital was an independent risk factor. In all income groups, appendiceal rupture was more likely with fee-for-service than capitated private coverage (overall odds ratio, 1.20 [95 percent confidence interval, 1.15 to 1.25]). CONCLUSIONS Among patients with appendicitis an increased risk of ruptured appendix may be due to insurance-related delays in obtaining medical care. Both organizational and financial features of Medicaid and various types or levels of private third-party coverage may be involved. The significant association between ruptured appendix and insurance coverage after adjustment for socio-economic differences suggests barriers to receiving medically necessary acute care that should be considered in current deliberations on health policy.

Pregnancy-associated hospitalizations in the United States in 1991 and 1992: a comprehensive view of maternal morbidity.

OBJECTIVE Our purpose was to update the national estimate of severe pregnancy complications and describe associated maternal characteristics of hospitalizations during pregnancy, applying an expanded definition of maternal morbidity. STUDY DESIGN From 1991 and 1992 National Hospital Discharge Survey data, we estimated ratios of hospitalizations per 100 deliveries and compared relative ratios by maternal characteristics. We computed standard errors with the SUDAAN program and estimated 95% confidence intervals for relative ratios. RESULTS The likelihood of hospitalization for pregnancy complications appeared to decline between the period 1986 and 1987 and the period 1991 and 1992, although primarily for pregnancy loss hospitalizations. In 1991 and 1992 there were 18.0 total pregnancy-associated hospitalizations/100 births (17.2 for whites, 28.1 for blacks). Component ratios were 12.3 for obstetric hospitalizations, 4.4 for pregnancy loss hospitalizations, and 1.4 for nonobstetric hospitalizations; all ratios were higher for blacks than for whites. CONCLUSIONS Maternal hospitalization remains a substantial component of prenatal care. Because of underreporting and changes in medical practice, recent declines in maternal hospitalization may not represent true reductions in maternal morbidity.

Marital status and infant health outcomes

Out-of-wedlock status has long been recognized as a demographic risk factor associated with infant mortality and low birthweight. However, the relationship between marital status and birth outcomes varies by maternal race and age. The negative impact of unmarried status is greatest for white women aged 20 and over. High infant mortality rates for married teen mothers challenge the assumption that marriage necessarily provides a protective environment for childbearing. Maternal and child health research and policy have been hindered by a deviance model of out-of-wedlock fertility, which is both biased and outdated. Inconsistencies in the effect of marital status indicate variations in both economic and social resources. Purely behavioral explanations for escalated risks to unmarried mothers are not justified by research findings. Alternative interpretations suggest the need for greater societal involvement in maternal health care created in part by changes in family structure.

Maternal marital status as a risk factor for infant mortality.

The increased risk of infant mortality associated with single motherhood is neither consistent among social and demographic subgroups nor inevitable, according to data from national linked birth and infant death files for 1983-1985. Maternal age is the only variable found to have a significant interaction with marital status among black mothers, and the risk associated with unmarried status increases with age. Among white mothers, age, educational level and receipt of prenatal care all show significant interactions with marital status; the increased risks of infant mortality attributed to unmarried motherhood are concentrated among subgroups usually thought to be at lower risk. For example, the risks of infant mortality among unmarried white women relative to married white women are highest among 25-29-year-olds. However, being unmarried did not affect the risk of infant mortality among babies born to college-educated white women.

Rural adolescent pregnancy: A view from the south

An analysis of 1990 census and vital statistics data for eight Southeastern states revealed that the teenage birthrate generally was higher in rural than in metropolitan areas; the exception was among black women aged 15-17. The highest birthrate was 162 births per 1,000 among rural black women aged 18-19. Abortion rates were much lower for rural teenagers than for urban teenagers, regardless of race. For 15-17-year-olds, white women had an abortion rate of 12 abortions per 1,000 in rural counties and 18 per 1,000 in metropolitan counties; black women had rates of 13 per 1,000 and 30 per 1,000 in rural and metropolitan areas, respectively. Similarly, the abortion ratio was lower in rural than in urban areas; for example, 18% of rural white women aged 18-19 who became pregnant had an abortion, compared with 35% of their metropolitan counterparts. Black 15-17-year-olds in metropolitan areas had a higher pregnancy rate (106 per 1,000) than those in rural counties (87 per 1,000). The pregnancy rate of white women aged 15-17 was similar in rural [corrected] and metropolitan areas (about 46 per 1,000). Among rural women aged 18-19, 32% of births to whites and 45% of those to blacks resulted from a second or higher order pregnancy.

Life course, social determinants, and health inequities: Toward a national plan for achieving health equity for African American infants - A concept paper

Despite the best efforts by the public health community, the existence of disparity in African American infant mortality appears to be insurmountable. Eliminating this disparity is the public health challenge of the next decade. The public health community has engaged in copious activity regarding the identification and analysis of the etiology of health disparities. The resulting literature is substantial, yet, despite well-meaning interventions that have had varying degrees of success, the problem is so daunting that there has been very little progress in developing a comprehensive national plan to eradicate health disparities, in general, and, African American infant-mortality disparities, in particular. The process of identifying the causal pathways and risks of adverse African American birth outcomes could potentially impact the elimination of other health disparities since infant outcomes are the foundation for adult health. Unfortunately, as a nation, we have never deliberately invested the time and resources into developing an evidence base specific to the achievement of health equity. This endeavor will require dedicated resources, creativity, and a breadth of vision to work within, and exceed, the limits of traditional epidemiological and social science theory and methods. The literature cites various causes of overall disparities, including adverse health behaviors like smoking or drug use, poor nutrition, inadequate health care, and stress, to name a few [1]. The World Health Organization (WHO) Commission on Social Determinants of Health considers the major contributors to health disparities to be the conditions in which people are born, grow, live, work, and age [2]. In the United States, ethnic minorities, particularly African Americans, are more likely to be in socially and economically vulnerable positions. A number of studies have demonstrated that even while controlling for SES, racial and ethnic disparities are still found in health outcomes [3]. For example, African American women in Illinois at the highest education level have higher, i.e., worse low-birthweight rates than women of any other ethnicity at lower strata. The process that determines social stratification leading to poorer health outcomes is rooted in history, and while it is not about ‘‘race’’ as a risk factor, scientific investigation has resulted in a corpus of knowledge that places racism, perceived acts of racism, poverty, socialenvironment degradation, and violence into the etiological pathway [4–10]. These manifestations of ‘‘social ecology’’ are the type that WHO describes as resulting in unfair and avoidable differences in health status [2]. Some think that because racism is a causal factor, any quest for solutions may be doomed to failure, because, as one funding institution’s peer reviewer stated, ‘‘It is not a good investment of [our] dollars to study racism [as a cause of health disparities], because even if we fund something, there is nothing we can do about it’’ [11]. However, pre-term birth (PTB) and low birth weight (LBW) are the causes of firstyear mortality for African American infants. Therefore, understanding and eliminating the factors that cause high rates of PTB and LBW should remain at the forefront. V. K. Hogan (&) ! D. Rowley ! T. Bennett Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 425 Rosenau Hall, 421 Pittsboro Street, 135 Dauer Drive, Campus Box 7445, Chapel Hill, NC 27599, USA e-mail: vhogan@email.unc.edu

Health service use among low-risk newborns after early discharge with and without nurse home visiting.

Background: To examine the potential benefits of routine nurse home visiting after early discharge, we compared health service use among low-risk newborns with and without a nurse home visit and telephone follow-up after short hospital stays. Methods: Records of newborns discharged routinely before (n = 83) and after (n = 91) implementation of a universal postpartum home visiting program were reviewed retrospectively. Acute care visits, rehospitalizations, and well-baby visits for newborns up to 74 days of age were compared between the groups. Results: Acute care visits, rehospitalizations, and missed well-baby visits consistently appeared less likely among newborns receiving home visiting services, in both unadjusted and adjusted analyses. Adjusting for insurance, parity, and breast-feeding, a twofold reduction in acute care visits by 14 days was significant. Although not statistically significant, adjusted analyses of acute care and missed well-baby visits revealed apparently similar patterns at all time intervals. There were too few rehospitalizations for multivariate analysis. Conclusions: Despite the limitations of this small retrospective study, the consistency of the findings suggests potentially important benefits of home visiting services after early discharge of low-risk newborns, with substantial implications for clinical and reimbursement policy. Effects could be greater with more vulnerable populations and shorter stays than those in this study.

Safe motherhood in the United States: challenges for surveillance.

Objectives: Maternal mortality ratios in the United States are higher than those of many other industrialized nations. Moreover, these ratios have not changed in the past 20 years, and large racial disparities persist in measures of both maternal mortality and morbidity. In an affluent developed country, maternal deaths should serve as rare sentinel events, highlighting opportunities for prevention and reduction of morbidities. However, existing surveillance efforts are poorly developed, and pregnancy-related deaths and illnesses tend to be underreported. To formulate recommendations for improved surveillance, the authors reviewed existing data on maternal health. Methods: This review examines the scope and quality of existing information and the strengths and limitations of definitions of maternal mortality and morbidity used in data collection and reporting. Results: This review suggests numerous gaps in surveillance of U.S. maternal health. Psychological as well as physical morbidity, and the presence and adequacy of appropriate treatment, should be ascertained. Quality of pregnancy-related care at the clinical and community levels, and the impact on mortality and morbidity, must be assessed. Collection of morbidity data outside of health care delivery sites is also essential. Trade-offs between nationally representative and other less comprehensive data sources, such as sentinel clinics, large healthcare organizations, and public healthcare financing systems, should be considered. Conclusion: Maternal health remains an important frontier for U.S. public health surveillance efforts. Improved surveillance offers opportunities for reducing pregnancy-related mortality and gaining a better understanding of the relationship between maternal morbidity and mortality.

Employment status and high blood pressure in women: Variations by time and by sociodemographic characteristics☆

PURPOSE The association between employment status and high blood pressure in women was examined at two time periods to determine if associations between employment status and high blood pressure varied by time period or by age, race, education, marital status, or parental status. METHODS Women participants from the National Health Examination Survey (1960) and the Second National Health and Nutrition Survey (1976-1980) between the ages of 25 and 64 and currently employed or keeping house were included. Logistic regression analysis was used to examine the cross-sectional association between employment status and high blood pressure in each survey, taking into account potential effect modifiers and covariates. RESULTS In 1960 employment was associated with a slight, but not statistically significant, elevation in odds of high blood pressure. In 1976-1980, it was associated with a modest but significant reduction in odds of high blood pressure. Variations in associations occurred by marital status (protective associations were limited to unmarried women) and race (associations were of stronger magnitude among African-American women). CONCLUSIONS The employment status-high blood pressure relationship shifted across surveys. Changes in the composition of the employed and nonemployed groups account for at least part of the varying relationships.

Women's Health in Maternal and Child Health: Time for a New Tradition?

Objectives. The status quo in maternal and child health (MCH) focuses on obstetric health. An emerging alternative is to broaden the notion to reproductive health. An inclusive perspective encompasses womens health issues in MCH. The purpose of this paper is to further the debate on the relationship of womens health to MCH. Specific aims are (1) to describe activities promoting womens health in MCH and (2) to examine consequences of alternative perspectives for MCH research, services, and training. Method. To achieve the first objective, I discuss developments in a state health agency and pertinent documents from the MCH Section of the American Public Health Association. To address the second aim, I follow the Bush Policy Analysis Model of weighing the three paradigms against the following evaluative criteria: equity, efficiency, satisfaction, stigma, indirect effects, feasibility, sensitivity to class and race, and social responsibility. Results. The obstetric approach meets most criteria in a positive fashion; reproductive health satisfies criteria more positively and less equivocally. A womens health perspective bears the most potential for improving reproductive outcomes at this time, since no area of womens general health has been definitively shown to be irrelevant to reproduction (or vice versa). Conclusions: This analysis suggests that womens health should be incorporated more fully into the MCH field, as well as other areas of public health and medicine. Once research deficits have been addressed and the scope of reproductive health delineated more clearly, the alignment of womens health with MCH may be reevaluated.