Upadhyay Ushma D, Johns Nicole E, Meckstroth Karen R, Kerns Jennifer L
Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California, and the Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California.
Obstet Gynecol. 2017 Sep;130(3):616-624. doi: 10.1097/AOG.0000000000002188.
To examine the association between distance traveled for an abortion and site of postabortion care among low-income women.
We conducted a retrospective cohort study using claims data from 39,747 abortions covered by California's Medicaid program in 2011-2012. Primary outcomes were the odds of abortion-related visits to an emergency department (ED) and the original abortion site, and the secondary outcome was total abortion care costs. We used mixed-effects logistic regression adjusting for patient and abortion characteristics to examine the associations between distance traveled and subsequent abortion-related care at each location.
Among all abortions (N=39,747), 3% (95% CI 2.9-3.3, n=1,232) were followed by an ED visit (3% first-trimester aspirations, 2% second trimester or later, and 4% medication abortions) and 25% (95% CI 24.1-24.9, n=9,745) were followed by a visit to the original abortion site (4% first-trimester aspirations, 3% second-trimester or later, and 77% medication abortions). Women traveling farther for their abortions had higher odds of visiting an ED (100 or more miles compared with less than 25 miles, first-trimester aspirations: adjusted odds ratio [OR] 2.29, 95% CI 1.50-3.49; medication abortions: adjusted OR 2.30, 95% CI 1.34-3.93) and lower odds of returning to their abortion site for follow-up (100 or more miles compared with less than 25 miles, first-trimester aspirations: adjusted OR 0.36, 95% CI 0.18-0.70; second trimester or later: adjusted OR 0.52, 95% CI 0.31-0.88; and medication abortions: adjusted OR 0.33, 95% CI 0.23-0.50). Costs were consistently higher when subsequent care occurred at an ED rather than the abortion site (median cost $941 compared with $536, P<.001).
For most patients, greater distance traveled for abortion was associated with increased likelihood of seeking subsequent care at an ED. Increasing the number of rural Medicaid abortion providers and reimbursing providers for telemedicine and alternatives to routine follow-up would likely improve continuity of care and reduce state costs by shifting the location of follow-up from EDs back to abortion providers.
研究低收入女性堕胎行程距离与堕胎后护理地点之间的关联。
我们利用2011 - 2012年加利福尼亚医疗补助计划涵盖的39747例堕胎索赔数据进行了一项回顾性队列研究。主要结局是因堕胎相关问题前往急诊科（ED）和最初堕胎地点就诊的几率，次要结局是堕胎护理总费用。我们使用混合效应逻辑回归，对患者和堕胎特征进行调整，以研究行程距离与各地点后续堕胎相关护理之间的关联。
在所有堕胎案例（N = 39747）中，3%（95%可信区间2.9 - 3.3，n = 1232）之后会前往急诊科就诊（孕早期人工流产后为3%，孕中期及以后为2%，药物流产后为4%），25%（95%可信区间24.1 - 24.9，n = 9745）之后会返回最初堕胎地点就诊（孕早期人工流产后为4%，孕中期及以后为3%，药物流产后为77%）。堕胎行程距离较远的女性前往急诊科就诊的几率更高（与行程小于25英里相比，行程100英里及以上，孕早期人工流产：调整后的优势比[OR]为2.29，95%可信区间1.50 - 3.49；药物流产：调整后的OR为2.30，95%可信区间1.34 - 3.93），而返回堕胎地点进行后续随访的几率更低（与行程小于25英里相比，行程100英里及以上，孕早期人工流产：调整后的OR为0.36，95%可信区间0.18 - 0.70；孕中期及以后：调整后的OR为0.52，95%可信区间0.31 - 0.88；药物流产：调整后的OR为0.33，95%可信区间0.23 - 0.50）。当后续护理在急诊科而非堕胎地点进行时，费用始终更高（中位数费用分别为941美元和536美元，P <.001）。
对于大多数患者而言，堕胎行程距离较远与在急诊科寻求后续护理的可能性增加相关。增加农村医疗补助堕胎服务提供者的数量，并为远程医疗及常规随访替代方案向提供者报销费用，可能会改善护理的连续性，并通过将随访地点从急诊科转回堕胎服务提供者处来降低州政府成本。
