Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York.
Department of Health Policy and Management, Columbia University Mailman School of Public Health, New York, New York.
Anesthesiology. 2023 Sep 1;139(3):274-286. doi: 10.1097/ALN.0000000000004632.
BACKGROUND: Providing continuous health insurance coverage during the perinatal period may increase access to and utilization of labor neuraxial analgesia. This study tested the hypothesis that implementation of the 2010 Dependent Coverage Provision of the Patient Protection and Affordable Care Act, requiring private health insurers to allow young adults to remain on their parent's plan until age 26 yr, was associated with increased labor neuraxial analgesia use. METHODS: This study used a natural experiment design and birth certificate data for spontaneous vaginal deliveries in 28 U.S. states between 2009 and 2013. The intervention was the Dependent Coverage Provision, categorized into pre- and postintervention periods (January 2009 to August 2010 and September 2010 to December 2013, respectively). The exposure was women's age, categorized as exposed (21 to 25 yr) and unexposed (27 to 31 yr). The outcome was the labor neuraxial analgesia utilization rate. RESULTS: Of the 4,515,667 birth certificates analyzed, 3,033,129 (67.2%) indicated labor neuraxial analgesia use. For women aged 21 to 25 yr, labor neuraxial analgesia utilization rates were 64.9% during the preintervention period and 68.9% during the postintervention period (difference, 4.0%; 95% CI, 3.9 to 4.2). For women aged 27 to 31 yr, labor neuraxial analgesia utilization rates were 64.9% during the preintervention period and 67.7% during the postintervention period (difference, 2.8%; 95% CI, 2.7 to 2.9). After adjustment, implementation of the Dependent Coverage Provision was associated with a 1.0% (95% CI, 0.8 to 1.2) absolute increase in labor neuraxial analgesia utilization rate among women aged 21 to 25 yr compared with women aged 27 to 31 yr. The increase was statistically significant for White and Hispanic women but not for Black and Other race and ethnicity women. CONCLUSIONS: Implementation of the Dependent Coverage Provision was associated with a statistically significant increase in labor neuraxial analgesia use, but the small effect size is unlikely of clinical significance.
背景：在围产期提供连续的医疗保险覆盖范围可能会增加获得和利用分娩时的椎管内镇痛的机会。本研究检验了这样一个假设，即 2010 年《患者保护与平价医疗法案》（Patient Protection and Affordable Care Act）中关于“被抚养人保险范围”的规定得到实施，要求私人健康保险公司允许年轻人在 26 岁之前继续使用父母的医疗保险，这与增加分娩时椎管内镇痛的使用有关。
方法：本研究采用自然实验设计，利用 2009 年至 2013 年间美国 28 个州的出生证明数据。干预措施为“被抚养人保险范围”，分为干预前（2009 年 1 月至 2010 年 8 月）和干预后（2010 年 9 月至 2013 年 12 月）两个时期。暴露因素是女性的年龄，分为暴露组（21 至 25 岁）和非暴露组（27 至 31 岁）。结局是分娩时椎管内镇痛的使用率。
结果：在分析的 4515667 份出生证明中，有 3033129 份（67.2%）表明使用了分娩时椎管内镇痛。对于 21 至 25 岁的女性，干预前的椎管内镇痛使用率为 64.9%，干预后的使用率为 68.9%（差异为 4.0%；95%置信区间为 3.9 至 4.2）。对于 27 至 31 岁的女性，干预前的椎管内镇痛使用率为 64.9%，干预后的使用率为 67.7%（差异为 2.8%；95%置信区间为 2.7 至 2.9）。调整后，与 27 至 31 岁的女性相比，21 至 25 岁的女性实施“被抚养人保险范围”规定后，椎管内镇痛使用率绝对增加了 1.0%（95%置信区间为 0.8 至 1.2）。这一结果在白人女性和西班牙裔女性中具有统计学意义，但在黑人女性和其他种族和民族的女性中则没有统计学意义。
结论：实施“被抚养人保险范围”规定与分娩时椎管内镇痛使用率的统计学显著增加有关，但小的效应量不太可能具有临床意义。
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