Background Readmission rates are used as a quality metric in medical and surgical specialties; however, little is known about obstetrics readmissions. Objective Our goals for this study were to ...describe the trends in postpartum readmissions over time; to characterize the common indications and associated diagnoses for readmissions; and to determine maternal, delivery, and hospital characteristics that may be associated with readmission. Study Design Postpartum readmissions occurring within the first 6 weeks after delivery in California, Florida, and New York were identified between 2004 and 2011 in State Inpatient Databases. Of the 5,949,739 eligible deliveries identified, 114,748 women were readmitted over the 8-year period. We calculated the rates of readmissions and their indications by state and over time. The characteristics of the readmission stay, including day readmitted, length of readmission, and charge for readmission, were compared among the diagnoses. Odds ratios were calculated using a multivariate logistic regression to determine the predictors of readmission. Results The readmission rate increased from 1.72% in 2004 to 2.16% in 2011. Readmitted patients were more likely to be publicly insured (54.3% vs 42.0%, P < .001), to be black (18.7% vs 13.5%, P < .001), to have comorbidities such as hypertension (15.3% vs 2.4%, P < 0.001) and diabetes (13.1% vs 6.8%, P < .001), and to have had a cesarean delivery (37.2% vs 32.9%, P < .001). The most common indications for readmission were infection (15.5%), hypertension (9.3%), and psychiatric illness (7.7%). Patients were readmitted, on average, 7 days after discharge, but readmission day varied by diagnosis: day 3 for hypertension, day 5 for infection, and day 9 for psychiatric disease. Maternal comorbidities were the strongest predictors of postpartum readmissions: psychiatric disease, substance use, seizure disorder, hypertension, and tobacco use. Conclusion Postpartum readmission rates have risen over the last 8 years. Understanding the risk factors, etiologies, and cause-specific timing for postpartum readmissions may aid in the development of new quality metrics in obstetrics and targeted strategies to curb the rising rate of postpartum readmissions in the United States.
Objective The objective of the study was to examine the effect of selective fetoscopic laser photocoagulation (SFLP) vs serial amnioreduction (AR) on perinatal mortality in severe twin-twin ...transfusion syndrome (TTTS). Study Design This was a 5 year multicenter, prospective, randomized controlled trial. The primary outcome variable was 30 day postnatal survival of donors and recipients. Results There was no statistically significant difference in 30-day postnatal survival between SFLP or AR treatment for donors at 55% (11 of 20) vs 55% (11 of 20) ( P = 1.0, odds ratio OR 1, 95% confidence interval CI 0.242 to 4.14) or recipients at 30% (6 of 20) vs 45% (9 of 20) ( P = .51, OR 1.88, 95% CI 0.44 to 8.64). There was no difference in 30 day survival of 1 or both twins on a per-pregnancy basis between AR at 75% (15 of 20) and SFLP at 65% (13 of 20) ( P = .73, OR 1.62, 95% CI 0.34 to 8.09). Overall survival (newborns divided by the number of fetuses treated) was not statistically significant for AR at 60% (24 of 40) vs SFLP 45% (18 of 40) ( P = .18, OR 2.01, 95% CI 0.76 to 5.44). There was a statistically significant increase in fetal recipient mortality in the SFLP arm at 70% (14 of 20) vs the AR arm at 35% (7 of 20) ( P = .25, OR 5.31, 95% CI 1.19 to 27.6). This was offset by increased recipient neonatal mortality of 30% (6 of 20) in the AR arm. Echocardiographic abnormality in recipient twin Cardiovascular Profile Score is the most significant predictor of recipient mortality ( P = .055, OR 3.025/point) by logistic regression analysis. Conclusion The outcome of the trial did not conclusively determine whether AR or SFLP is a superior treatment modality. TTTS cardiomyopathy appears to be an important factor in recipient survival in TTTS.
To determine if racial differences exist in receipt of minimally invasive hysterectomy (defined as total vaginal hysterectomy TVH and total laparoscopic hysterectomy TLH) compared with an open ...approach (total abdominal hysterectomy TAH) within a universally insured patient population.
Retrospective data analysis (Canadian Task Force classification II-2).
The 2006-2010 national TRICARE (universal insurance coverage to US Armed Services members and their dependents) longitudinal claims data.
Women aged 18 years and above who underwent hysterectomy stratified into 4 racial groups: white, African American, Asian, and "other."
Receipt of hysterectomy (TAH, TVH, or TLH).
We used risk-adjusted multinomial logistic regression models to determine the relative risk ratios of receipt of TVH and TLH compared with TAH in each racial group compared with referent category of white patients for benign conditions. Among 33 015 patients identified, 60.82% (n = 20 079) were white, 26.11% (n = 8621) African American, 4.63% (n = 1529) Asian, and 8.44% (n = 2786) other. Most hysterectomies (83.9%) were for benign indications. Nearly 42% of hysterectomies (n = 13 917) were TAH, 27% (n = 8937) were TVH, and 30% (n = 10 161) were TLH. Overall, 36.37% of white patients received TAH compared with 53.40% of African American patients and 51.01% of Asian patients (p < .001). On multinomial logistic regression analyses, African American patients were significantly less likely than white patients to receive TVH (relative risk ratio RRR, .63; 95% confidence interval CI, .58-.69) or TLH (RRR, .65; 95% CI, .60-.71) compared with TAH. Similarly, Asian patients were less likely than white patients to receive TVH (RRR, .71; 95% CI, .60-.84) or TLH (RRR, .69; 95% CI, .58-.83) compared with TAH. Analyses by benign indications for surgery showed similar trends.
We demonstrate that racial minority patients are less likely to receive a minimally invasive surgical approach compared with an open abdominal approach despite universal insurance coverage. Further work is warranted to better understand factors other than insurance access that may contribute to racial differences in surgical approach to hysterectomies.
Twin vaginal delivery: innovate or abdicate Easter, Sarah Rae, MD; Taouk, Laura, Ms; Schulkin, Jay, PhD ...
American journal of obstetrics and gynecology,
05/2017, Letnik:
216, Številka:
5
Journal Article
Recenzirano
Neonatal safety data along with national guidelines have prompted renewed interest in vaginal delivery of twins, particularly in the case of the noncephalic second twin. Yet, the rising rate of twin ...cesarean deliveries, coupled with the national decline in operative obstetrics, raises concerns about the availability of providers who are skilled in twin vaginal birth. Providers are key stakeholders for increasing rates of twin vaginal delivery. We surveyed a group of practicing obstetricians to explore potential barriers to the vaginal birth of twins with a focus on delivery of the noncephalic second twin. Among 107 responding providers, only 57% would deliver a noncephalic second twin by breech extraction. Providers who preferred breech extraction had a higher rate of maternal-fetal medicine subspecialty training (26.2% vs 4.3%; P <.01) and were more likely to be in an academic practice environment (36.1% vs 10.9%; P <.01) and to practice in high-volume centers that deliver >30 sets of twins annually (57.4% vs 34.8%; P =.02). Most providers (54.2%) were familiar with the findings from the recent randomized trial that demonstrated the safety of twin vaginal birth. However, knowledge of the trial was not associated statistically with a preference for breech extraction (62.3% vs 43.5%; P =.05). Providers who preferred breech extraction were more likely to agree with recent society guidelines that encourage the vaginal birth of twins (86.9% vs 63.0%; P <.01). In an adjusted analysis, the 46% of providers with a perceived need for more training were far less likely to prefer breech extraction for delivery of a noncephalic second twin (adjusted odds ratio, 0.38; 95% confidence interval, 0.16–0.95). Furthermore, 57% of providers who would not offer their patient breech extraction would be willing to consult a colleague for support with a noncephalic twin delivery. These results suggest that scientific evidence and society opinion are likely insufficient to reverse the national trends that favor cesarean delivery for twins. Instead, implementation of provider training and support programs is critical for increasing the rates of twin vaginal birth. Changing our national landscape of vaginal twin delivery may require innovation. Without novel provider-focused strategies, we may relinquish passively the requisite skills for not only our patients but also for future generations of obstetricians.
Background Cesarean delivery rates vary widely across the United States. Health care usage in many other areas of medicine also varies widely across the United States; it is unknown whether the ...variation in cesarean delivery rates across US communities is correlated with this broader underlying variation in health care usage patterns. Objective The purpose of this study was to determine whether the variation in cesarean delivery rates across US communities is correlated with other measures of health care usage in that community. Study Design We performed a population-based observational study that combined multiple national data sources, which included 2010 birth certificate data and Medicare claims data. Cesarean delivery rates in each US community, as defined by the Hospital Service Area, Medicare total spending per beneficiary, and hospital days in the last 6 months were calculated. Cesarean delivery and Medicare spending were on different patient populations; the Medicare variables were used to characterize the broader health care usage and spending pattern of that community. We examined the relationship between a community’s cesarean delivery rates and these measures of health care usage using Pearson correlation coefficients. We also stratified by quartile of Medicare spending and hospital use in the last 6 months of life and calculated the cesarean delivery rates per quartile, adjusting for underlying differences in patient characteristics, demographics, hospital structure, and the malpractice environment using a least-squared means method. We compared the amount of variation in cesarean delivery rates across communities that could be explained by differences in health care usage patterns to the amount of variation that was explained by other factors using the R -squared from multivariable models. Results Cesarean delivery rates varied from 4-65% across communities in the United States. Cesarean delivery rates were correlated positively with total Medicare spending ( r = 0.48; P < .001) and hospital use in the last 6 months of life ( r = 0.45; P < .001). Similar variation was seen in nulliparous women with a term fetus in vertex presentation (nulliparous, term, singleton, vertex cesarean deliveries), which is a common subset used for analysis of cesarean delivery rates. Communities in the lowest quartile of Medicare spending had the lowest rates of cesarean delivery (29.1% vs 35.7% in the highest quartile; P < .001 for differences across quartiles), which is a difference that persisted after adjustment (29.5% vs 31.8%; P < .001). Similar results were seen for nulliparous, term, singleton, vertex cesarean deliveries and when data were stratified by hospital days in the last 6 months of life. Overall, 28.6% of the total variation in cesarean delivery rates was explained by differences in health care usage patterns, as compared with 16.6% by differences in obstetric procedures, 7.9% by hospital structure, and 2.3% by variations in the malpractice environment. Of the 56.3% of variation that was unexplained by differences in patient characteristics and area demographics, 8.2% could be accounted for by differences in health care usage patterns, as compared with 4.6% by differences in obstetric procedures, 2.1% by hospital structure, and 1.2% by variation in the malpractice environment. Conclusion Cesarean delivery rates vary widely across US communities; this variation is correlated broadly with the variation that is seen in other measures of health care usage across US communities.
Background Racial disparities in receipt of a laparoscopic operation for ectopic pregnancy are attributed to inequalities in access to care. This study sought to determine if racial disparities in ...laparoscopic operation for ectopic pregnancy exist among a universally insured population. Methods Using 2006–2010 TRICARE (insurance for members of the United States Armed Services and their dependents) data, patients who received a laparoscopic operation or laparotomy for ectopic pregnancy were stratified into direct/military or purchased/civilian system of care. Odds of receipt of a laparoscopic operation in each racial group were compared adjusting for patient demographics, system of care, and severity of ectopic pregnancy. Results Among 3,041 patients in the study sample, 1,878 (61.7%) received laparotomy and 1,163 (38.2%) received a laparoscopic operation within 30 days of diagnosis. Overall, 42.4% of white women received a laparoscopic operation compared with 33.1% of Asian women and 34.9% of black women ( P < .001). On multivariable analysis, black women had a 33% lesser odds of receiving a laparoscopic operation (odds ratio: 0.67; confidence interval: 0.55–0.83) compared with white women. These disparities were absent within direct care (odds ratio: 0.93; confidence interval: 0.71–1.21) but were present within purchased care (odds ratio: 0.54; confidence interval: 0.40–0.73). Conclusion Racial minority patients are less likely to receive a laparoscopic operation for ectopic pregnancy despite universal insurance coverage within civilian/purchased care. Further work is warranted to better understand the factors other than insurance access that may contribute to racial disparities in selection of operative approach.
Objective We sought to investigate outcomes of contemporaneously managed monochorionic diamniotic (MCDA) twins, stratified by pregnancy complication. Study design Four hundred eighteen MCDA ...pregnancies from 2001 through 2008 were retrospectively reviewed. Results There were 236 ongoing pregnancies at 24 weeks' gestation. The likelihood of progressing from 24 weeks to 2 live births was 98.7% in uncomplicated pregnancies, 89.7% with twin-twin transfusion syndrome, and 100% with growth discordance, increasing at 32 weeks to 99.5%, 93.8%, and 100%, respectively. The relative risk (RR) of birth <32 weeks was significantly greater in twin-twin transfusion syndrome (RR, 4.1; 95% confidence interval, 2.7–6.1) and growth discordant (RR, 2.1; 95% confidence interval, 1.8–3.8) pregnancies than in uncomplicated pregnancies ( P < .0001). Conclusion This represents one of the largest cohorts of MCDA twins. The risk of third-trimester fetal loss was low. The likelihood of both intrauterine fetal demise and preterm birth were greater in complicated pregnancies. In the absence of a clinical indication for delivery, these data do not support elective preterm delivery for prevention of intrauterine fetal demise in uncomplicated MCDA twins.
Whole-exome sequencing (WES) has opened up previously unheard of possibilities for identifying novel disease genes in Mendelian disorders, only about half of which have been elucidated to date. ...However, interpretation of WES data remains challenging.
Here, we analyze protein-protein association (PPA) networks to identify candidate genes in the vicinity of genes previously implicated in a disease. The analysis, using a random-walk with restart (RWR) method, is adapted to the setting of WES by developing a composite variant-gene relevance score based on the rarity, location and predicted pathogenicity of variants and the RWR evaluation of genes harboring the variants. Benchmarking using known disease variants from 88 disease-gene families reveals that the correct gene is ranked among the top 10 candidates in ≥50% of cases, a figure which we confirmed using a prospective study of disease genes identified in 2012 and PPA data produced before that date. We implement our method in a freely available Web server, ExomeWalker, that displays a ranked list of candidates together with information on PPAs, frequency and predicted pathogenicity of the variants to allow quick and effective searches for candidates that are likely to reward closer investigation.
http://compbio.charite.de/ExomeWalker
: peter.robinson@charite.de.
Proton magnetic resonance spectroscopy has the potential to evaluate the cerebral metabolic status in the at-risk fetus. Cerebral lactate, a marker for hypoxia, has been identified by proton magnetic ...resonance spectroscopy in the brain of fetal animals subject to hypoxic conditions, but not in the human fetus. We report a case of a fetus with gastroschesis with elevated cerebral lactate on proton magnetic resonance spectroscopy.
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