Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle.
Department of Urology, University of Washington School of Medicine, Seattle.
JAMA Netw Open. 2023 Mar 1;6(3):e232639. doi: 10.1001/jamanetworkopen.2023.2639.
Early pregnancy loss (EPL), or miscarriage, is the most common complication of early pregnancy, and many patients experiencing EPL present to the emergency department (ED). Little is known about how patients who present to the ED with EPL differ from those who present to outpatient clinics and how their management and outcomes differ.
To compare the management and outcomes of patients with EPL who present to the ED vs outpatient clinics.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used the IBM MarketScan Research Database, a national insurance claims database. Participants were pregnant people aged 15 to 49 years in the US who presented to either an ED or outpatient clinic for initial diagnosis of EPL from October 2015 through December 2019. Data analysis was performed from May 2021 to March 2022.
The primary exposure was location of service (ED vs outpatient clinic). Other exposures of interest included demographic characteristics, current pregnancy history, and comorbidities.
The primary outcome was EPL management type (surgical, medication, or expectant management). Complications, including blood transfusion and hospitalization, and characteristics associated with location of service were also evaluated. Bivariable analyses and multivariable logistic regression were used for data analysis.
A total of 117 749 patients with EPL diagnoses were identified, with a mean (SD) age of 31.8 (6.1) years. Of these patients, 20 826 (17.7%) initially presented to the ED, and 96 923 (82.3%) presented to outpatient clinics. Compared with the outpatient setting, patients in the ED were less likely to receive surgical (2925 patients [14.0%] vs 23 588 patients [24.3%]) or medication (1116 patients [5.4%] vs 10 878 patients [11.2%]) management. In the adjusted analysis, characteristics associated with decreased odds of active (surgical or medication) vs expectant management included ED (vs outpatient) presentation (adjusted odds ratio [aOR], 0.46; 95% CI, 0.44-0.47), urban location (aOR, 0.87; 95% CI, 0.82-0.91), and being a dependent on an insurance policy (vs primary policy holder) (aOR, 0.71; 95% CI, 0.67-0.74); whereas older age (aOR per 1-year increase 1.01; 95% CI, 1.01-1.01), established prenatal care (aOR, 2.35; 95% CI, 2.29-2.42), and medical comorbidities (aOR, 1.05; 95% CI, 1.02-1.09) were associated with increased odds of receiving active management. Patients in the ED were more likely than those in outpatient clinics to need a blood transfusion (287 patients [1.4%] vs 202 patients [0.2%]) or hospitalization (463 patients [2.2%] vs 472 patients [0.5%]), but complications were low regardless of location of service.
In this cohort study of privately insured patients with EPL, differences in management between the ED vs outpatient setting may reflect barriers to accessing comprehensive EPL management options. More research is needed to understand these significant differences in management approaches by practice setting, and to what extent EPL management reflects patient preferences in both outpatient and ED settings.
重要性：早期妊娠丢失（EPL），又称流产，是早期妊娠最常见的并发症，许多经历 EPL 的患者会到急诊部（ED）就诊。对于到 ED 就诊的 EPL 患者与到门诊就诊的患者有何不同，以及他们的管理和结局有何不同，人们知之甚少。
目的：比较因 EPL 到 ED 就诊与到门诊就诊的患者的管理和结局。
设计、地点和参与者：本回顾性队列研究使用了 IBM MarketScan 研究数据库，这是一个全国性的保险索赔数据库。参与者为年龄在 15 至 49 岁的美国孕妇，他们于 2015 年 10 月至 2019 年 12 月因 EPL 首次到 ED 或门诊就诊。数据分析于 2021 年 5 月至 2022 年 3 月进行。
暴露：主要暴露因素是服务地点（ED 与门诊）。其他感兴趣的暴露因素包括人口统计学特征、当前妊娠史和合并症。
主要结果和措施：主要结局是 EPL 管理类型（手术、药物或期待治疗）。还评估了并发症，包括输血和住院治疗，以及与服务地点相关的特征。采用单变量分析和多变量逻辑回归进行数据分析。
结果：共确定了 117749 例 EPL 诊断患者，平均（标准差）年龄为 31.8（6.1）岁。其中，20826 例（17.7%）患者最初到 ED 就诊，96923 例（82.3%）患者到门诊就诊。与门诊环境相比，ED 环境中接受手术（2925 例[14.0%]与 23588 例[24.3%]）或药物（1116 例[5.4%]与 10878 例[11.2%]）管理的患者较少。在调整分析中，与接受积极（手术或药物）治疗而非期待治疗的可能性降低相关的特征包括 ED（与门诊）就诊（调整后的优势比[OR]，0.46；95%置信区间[CI]，0.44-0.47）、城市位置（OR，0.87；95%CI，0.82-0.91）和作为保险政策的受保人（与主要投保人）（OR，0.71；95%CI，0.67-0.74）；而年龄较大（每增加 1 岁 OR 为 1.01；95%CI，1.01-1.01）、建立产前护理（OR，2.35；95%CI，2.29-2.42）和合并症（OR，1.05；95%CI，1.02-1.09）与接受积极治疗的可能性增加相关。ED 环境中的患者比门诊环境中的患者更有可能需要输血（287 例[1.4%]与 202 例[0.2%]）或住院治疗（463 例[2.2%]与 472 例[0.5%]），但无论服务地点如何，并发症都很少。
结论和相关性：在这项对因 EPL 到 ED 就诊的私人保险患者的队列研究中，ED 与门诊环境之间的管理差异可能反映了获得全面 EPL 管理方案的障碍。需要进一步研究以了解这两种就诊环境在管理方法上的显著差异，以及 EPL 管理在多大程度上反映了门诊和 ED 环境中患者的偏好。
