Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY.
Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ.
Am J Obstet Gynecol. 2021 Jun;224(6):605.e1-605.e13. doi: 10.1016/j.ajog.2021.03.034. Epub 2021 Mar 31.
Black-serving hospitals are associated with increased maternal risk. However, prior administrative data research on maternal disparities has generally included limited hospital factors. More detailed evaluation of hospital factors related to obstetric outcomes may be important in understanding disparities.
To examine detailed characteristics of Black-serving hospitals and how these characteristics are associated with risk for severe maternal morbidity (SMM).
This serial cross-sectional study linked the 2010-2011 Nationwide Inpatient Sample and the 2013 American Hospital Association Annual Survey Databases. Delivery hospitalizations occurring to women 15-54 years of age were identified. The proportions of non-Hispanic Black patients within a hospital was categorized into quartiles, and hospital factors such as specialized medical, surgical and safety-net services as well as payer mix were compared across these quartiles. A series of models was performed evaluating risk for SMM with Black-serving hospital quartile as the primary exposure. Log linear regression models with a Poisson distribution (and robust variance) were performed with unadjusted and adjusted risk ratios (aRR) with 95% confidence intervals (CIs) as measures of effect.
Overall 965,202 deliveries from 430 hospitals met inclusion criteria and were included in the analysis. By quartile, non-Hispanic Black patients accounted for 1.3%, 5.4%, 13.4%, and 33.8% of patients. Many services were significantly less common in the lowest compared to the highest Black-serving hospital quartile including cardiac intensive care (48.9% versus 74.5%), neonatal intensive care (28.9% versus 64.9%), pediatric intensive care (20.0% versus 45.7%), pediatric cardiology (29.6% versus 44.7%), and HIV/AIDS services (36.3% versus 71.3%) (p≤0.01 for all). Indigent care clinics, crisis prevention, and enabling services (p≤0.01 for all) were more common at Black-serving hospitals as was Medicaid payer. Following adjustments for detailed hospital factors, the lowest Black serving hospital quartile carried the lowest risk for SMM. However, SMM risks were similar across the 2 (aRR 1.31, 95% CI 1.08, 1.59), 3 (aRR 1.27, 95% 1.05, 1.55), and 4 (aRR 1.29, 95% CI 1.07, 1.55) quartiles.
Black-serving hospitals were more likely to provide a range of specialized medical, surgical, and safety-net services and to have a higher Medicaid burden. Payer mix and unmeasured confounding may account for some of the maternal risk associated with Black-serving hospitals.
黑人服务医院与产妇风险增加有关。然而，先前关于产妇差异的行政数据研究通常只包括有限的医院因素。更详细地评估与产科结局相关的医院因素，对于理解差异可能很重要。
研究黑人服务医院的详细特征，以及这些特征与严重产妇发病率（SMM）风险的关系。
本研究采用了连续的横断面研究方法，将 2010-2011 年全国住院患者样本和 2013 年美国医院协会年度调查数据库进行了关联。确定了 15-54 岁女性的分娩住院情况。根据医院内非西班牙裔黑人患者的比例将医院分为四个四分位数，并比较了这些四分位数之间的医院特征，如专门的医疗、外科和安全网服务以及支付者组合。进行了一系列模型，以黑人服务医院四分位数作为主要暴露因素，评估 SMM 的风险。使用泊松分布（和稳健方差）的对数线性回归模型，使用未调整和调整后的风险比（aRR）和 95%置信区间（CI）作为效应的衡量标准。
总体上，从 430 家医院中纳入了 965202 例分娩，符合纳入标准并纳入了分析。按照四分位数，非西班牙裔黑人患者占患者的 1.3%、5.4%、13.4%和 33.8%。与黑人服务医院四分位数最高的相比，许多服务在最低四分位数中明显较少，包括心脏重症监护（48.9%比 74.5%）、新生儿重症监护（28.9%比 64.9%）、儿科重症监护（20.0%比 45.7%）、儿科心脏病学（29.6%比 44.7%）和艾滋病毒/艾滋病服务（36.3%比 71.3%）（所有 p 值均≤0.01）。在黑人服务医院中，贫困患者诊所、危机预防和支持服务更为常见（所有 p 值均≤0.01），而医疗补助支付者则更为常见。在调整了详细的医院因素后，黑人服务医院的最低四分位数的 SMM 风险最低。然而，在第 2（aRR 1.31，95%CI 1.08，1.59）、3（aRR 1.27，95%CI 1.05，1.55）和 4（aRR 1.29，95%CI 1.07，1.55）四分位数中，SMM 风险相似。
黑人服务医院更有可能提供一系列专门的医疗、外科和安全网服务，并且有更高的医疗补助负担。支付者组合和未测量的混杂因素可能部分解释了与黑人服务医院相关的产妇风险。
