1. S outh C arolina Rural Health Research Center At the Heart of Public Health Policy Mediators of Race Effects on Risk of Potentially Avoidable Maternity Complications among Medicaid- insured Mothers Sarah B. Laditka, Ph.D James N. Laditka, D.A., Ph.D. Janice C. Probst, Ph.D.

2. Rural Health Research Center S outh C arolina Background and Theory n PAMCs, a population-based health care indicator u Builds on epidemiological work of 1970s identifying "sentinel" conditions, which signal problems with medical care access or quality (Rutstein et al. 1976) u Extends health services research of 1980s and 1990s on Ambulatory Care Sensitive (ACS) conditions or "preventable hospitalization" (Billings et al. 1993, 1996; Bindman et al. 1995) n Assumptions of both ACSs and PAMCs u Timely access to ambulatory health care can reduce risks of certain medical complications u Large hospital discharge data sets can be used for assessment

3. Rural Health Research Center S outh C arolina PAMC: Definition and Example n PAMCs defined based on preventability through timely access to primary and prenatal care of reasonable quality, and through healthy behaviors often promoted by prenatal care. n Most PAMCs defined by a combination of primary and secondary diagnoses using ICD-9-CM codes; selected by panel of obstetricians and health services researchers. u Example: a delivery hospitalization with a substance abuse diagnosis and a complication known to be associated with substance abuse  Premature Rupture of Membranes  Intrauterine Growth Restriction

4. Rural Health Research Center S outh C arolina Preliminary Research I n Used 1997 Nationwide Inpatient Sample (NIS): u Generated working PAMC list u Examined PAMC construct and face validity n Used 1988 National Maternal and Infant Health Survey (NMIHS): u Examined associations among Adequacy of Prenatal Care Utilization index (APNCU), healthy behaviors, and PAMC risk PAMC citation: Laditka, S.B., J.N. Laditka, M.P. Mastanduno, M.R. Lauria, T.C. Foster. "Potentially Avoidable Maternity Complications: An Indicator of Access to Primary and Prenatal Care during Pregnancy." Women and Health (41(3) In Press).

5. Rural Health Research Center S outh C arolina Evidence of Preventability, NMIHS Rating on Adequacy of Prenatal Care Utilization Index (APNCU): “Adequate” compared to “Inadequate”: Odds Ratio 0.43 (95% CI: 0.23~0.81, p<0.01) “Intermediate” compared to “Inadequate”: Odds Ratio 0.53 (95% CI: 0.29~0.97, p<0.05)

6. Rural Health Research Center S outh C arolina NIS Multivariate Results, Deliveries Controls: sociodemographics, comorbidities, health system & area, hospital characteristics, state effects Compared to Non-Hispanic Whites, All p < 0.0001

7. Rural Health Research Center S outh C arolina Preliminary Research II n Used 2000 Nationwide Inpatient Sample (NIS): u Examined access to health care during pregnancy for mothers insured by Medicaid. u Investigated PAMC risks among rural and urban hospital deliveries for groups of mothers defined by race or ethnicity, calculating PAMC rates, logistic regression. PAMC citation: Laditka, S.B., J.N. Laditka, K.J. Bennett, J.C. Probst (2005). "Delivery Complications Associated with Prenatal Care Access for Medicaid-Insured Mothers in Rural and Urban Hospitals." Journal of Rural Health 21(2), 158-166.

8. Rural Health Research Center S outh C arolina NIS Rural Urban Results n In rural hospitals, African Americans had higher PAMC risk than whites (OR 1.72, CI 1.26-2.36). n In urban hospitals, PAMC risk was not significantly higher for African Americans. n In urban hospitals, odds of a PAMC for Hispanics and Asians were about half of those of whites. n Suggested, policymakers should work to reduce PAMC risks for African American women in rural areas insured by Medicaid.

9. Rural Health Research Center S outh C arolina Present Study: Research Objectives n Examine risks of potentially preventable pregnancy complications n Investigate individual-level factors associated with these risks. n Describe differences by race/ethnicity, using state- level data from South Carolina, and the Potentially Avoidable Maternity Complication (PAMC) indicator. n PAMC indicator identifies pregnancy outcomes associated with access to prenatal care of reasonable quality.

10. Rural Health Research Center S outh C arolina Present Study: Data & Methods n Hospital discharge data for SC for 2000, linked to participant demographic and provider data from South Carolina Medicaid files. n Year 2000 Area Resource File. n 26,866 delivery hospital discharges for Medicaid insured women in South Carolina, 2000. n Calculated PAMC rates, compared prevalence of unadjusted risk factors among black, Hispanic, and white mothers; reference group was whites. n Multilevel logistic analyses. n Analyses for ages 10-17 and 18+.

11. Rural Health Research Center S outh C arolina Ages 18+, Percent Distribution BlackHispanic Non-H White Had a PAMC at delivery3.92 + 1.85 * 3.43 Education, < 8 years2.89 * 10.37 *** 2.35 Marital status, single77.14 *** 41.48 *** 51.48 Income below poverty85.37 *** 65.34 *** 76.11 Disabled2.54 *** 0.00 ** 1.42 Diabetes1.14 *** 0.430.58 Hypertension1.47 *** 0.14 * 0.96 Obesity1.67 * 0.43 * 1.33 Rural Resident16.96 *** 15.4814.48 + p<.1, *p<.05, **p<.01, ***p<.001

12. Rural Health Research Center S outh C arolina Multilevel, Selected Results, Ages11-17 Adjusted for Individual, Area, and Hospital Factors Parameter Odds Ratio LB UB Black2.261.413.62 *** Hispanic3.291.0610.25 * Rural Resident4.021.3412.02 * + p<.1, *p<.05, **p<.01, ***p<.001

13. Rural Health Research Center S outh C arolina Multilevel, Selected Results, 18+ Adjusted for Individual, Area, and Hospital Factors + p<.1, *p<.05, **p<.01, ***p<.001 Parameter Odds Ratio LB UB Black1.010.861.19 Hispanic0.510.290.91 * Marital status, single1.541.241.92 *** Diabetes2.41.513.82 *** Rural resident1.831.192.83 **

14. Rural Health Research Center S outh C arolina Results, Black Women n For ages 10-17, PAMC risks were greater for blacks than whites in unadjusted and adjusted results. n For ages 18+, adjusted risks for blacks did not differ from whites. n Black mothers 18+ had higher risks than whites: single or disabled, in poverty or rural county, diabetes or hypertension. n Adjusted results for blacks should be interpreted with caution: do not suggest blacks are no more likely to have PAMCs than whites. Suggest PAMC risks for blacks and whites are indistinguishable when other measured risk factors are controlled. n Black women in South Carolina, as a group, are more likely to experience PAMCs than whites, because they are much more likely to have many notable risk factors.

15. Rural Health Research Center S outh C arolina Results, Hispanic Women n For young mothers, PAMC rates did not differ significantly between Hispanics and whites in unadjusted analyses, which may be attributable small number of Hispanics (n=62), as the occurrence of PAMC diagnoses was a relatively high 6.5%. n In adjusted analysis, Hispanics 10-17 had higher odds for a PAMC. n For those 18+, unadjusted PAMC rates were lower for Hispanics. n Hispanics had lower PAMC risks in multivariate analysis. n Several individual-level risk factors were less prevalent in Hispanics than whites, e.g., being single, having asthma, hypertension, diabetes and obesity.

16. Rural Health Research Center S outh C arolina Results, All Women n Mothers in rural areas had significant higher risks of having a PAMC, both in the bivariate and adjusted results. n Among those age 18+, diabetes emerged as substantial and significant PAMC risk in adjusted analyses; highlights importance of managing diabetes during pregnancy.

17. Rural Health Research Center S outh C arolina Limitations n Among Hispanics, sample size of young mothers small. n Cannot identify how long each mother was enrolled in Medicaid prior to pregnancy. u Conducted an analysis of sensitivity to number of months of pregnancy covered by Medicaid; results did not differ meaningfully. n Cross-sectional analysis.

18. Rural Health Research Center S outh C arolina Policy and Practice Implications I n Practitioners should focus prenatal care efforts on minorities among younger pregnant women. n Practitioners should stress treatment of diabetes for women of all races n Rural residence is a major risk factor for PAMCs: highlights South Carolina’s and nation’s continuing difficulty with ensuring an adequate supply of health care practitioners in rural areas. u Policy strategies: increase support of rural residency training; develop designation for practitioners similar to the Critical Access Hospital program to promote retention of practitioners in rural areas.

19. Rural Health Research Center S outh C arolina Policy and Practice Implications II n Policymakers and practitioners should target known risk h underlying greater PAMC risks for minority women. u Medicaid providers should focus on reducing avoidable morbidity among blacks, rural residents, and young Hispanics. u Healthy Start programs, community health centers, and rural health clinics may be useful for addressing pregnancy risks associated with poverty, single marital status, and chronic disease. u In rural areas, poor, disabled, and single pregnant women may benefit from transportation and other forms of proactive support to attend prenatal care.

20. Rural Health Research Center S outh C arolina ~ Thank You ~ Sarah B. Laditka, Ph.D James N. Laditka, D.A., Ph.D. Janice C. Probst, Ph.D. Study supported by Grant 6 UIC RH 00045-04, U.S. Office of Rural Health Policy, Health Resources Services Administration Mediators of Race Effects on Risk of Potentially Avoidable Maternity Complications among Medicaid-insured Mothers