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Abuse, Psychosocial Stress And High Medical Utilization In Pregnancy

Abuse, Psychosocial Stress And High Medical Utilization In Pregnancy Tina Bloom, R.N, MPH Mary Ann Curry, RN, DNSc School of Nursing, Oregon Health & Science University A secondary analysis from “Randomized Nursing Intervention to Abused Pregnant Women” (2001-2005).

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Abuse, Psychosocial Stress And High Medical Utilization In Pregnancy

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  1. Abuse, Psychosocial Stress And High Medical Utilization In Pregnancy Tina Bloom, R.N, MPH Mary Ann Curry, RN, DNSc School of Nursing, Oregon Health & Science University

  2. A secondary analysis from “Randomized Nursing Intervention to Abused Pregnant Women” (2001-2005). RO1 NR02696, National Institutes of Nursing Research. Dr. Mary Ann Curry, P.I.

  3. General High Utilization • ~Half of ED visits for non-urgent reasons • Most emergency department patients do not require hospitalization • “Serial users” account for many ED visits (Cook et al, 2004; Mandelberg, Kuhn, & Kohn, 2000)

  4. Characteristics of High Utilizers in General Literature • Multiple complaints: sprains, superficial injuries, back problems, headaches, or abdominal pain • Chronically ill • Male or female

  5. Characteristics of High Utilizers in General Literature • Non-white • Stressed, isolated, mentally ill, ETOH abusers • Uninsured, underinsured, low income • Abuse, trauma (current or historical) (Cook et al, 2004; Mandelberg, Kuhn, & Kohn, 2000)

  6. Trauma and High Utilization • Childhood trauma/sexual abuse history and IPV associated with physical and mental health sequelae, and • High utilization of medical services • IPV in pregnancy 0.9% to 20.2% Hendricks-Matthews, 1992; Arnow, 2004; Arnow et al 2000; Campbell 2002; Farley & Patsalides, 2001; Katon, Sullivan, & Walker, 2001; Rosenberg et al., 2000; Stein et al., 2000, 2004;Katon et al., 2001; Gazmararian et al 2000.

  7. Utilization in Pregnancy Most utilization literature focuses on women with little or no prenatal care, and/or late entry to prenatal care.

  8. Research Question: Do psychosocial stressors (trauma, abuse) and social disadvantage (poverty, race, lack of resources) play a significant role in high medical utilization among pregnant women?

  9. “Randomized Nursing Intervention to Abused Pregnant Women” Study A multi-site RCT to determine if a nurse-case management intervention have a significant impact on pregnancy outcomes, including medical utilization, for women at risk for or experiencing violence? [Curry et al (2006). Nurse case management for pregnant women experiencing or at risk for abuse, JOGNN, 35, 181-192] .

  10. Secondary Analysis: 500 Pregnant Women Members of a West Coast HMO. • 68% Caucasian • 16% African American • Latino 4% • Asian/Pacific Islander 4% • Native American/Alaskan Native 1%

  11. Secondary Analysis: 500 Pregnant Women • Mean age 29.72 (5.91) • Mean income $3871 (2889) • Mean education 15 yrs (2.86) • 68% married • 17% single, living with partner

  12. High Utilizers (HU) in This Study • Women with 5 or more visits to the L&D, urgent care, ED, or nurse treatment (>2SD mean) • HU n=41; mean # of visits 7.78 (3.2) • LU n=328; mean # of visits 0.99 (1.1)

  13. Recent Abuse *=p<.05; **=p<.01; ***=p<.001

  14. Uninsured or Oregon Health Plan Non-white Lower income High school dropouts Younger Live alone Higher stress & lower self-esteem Recent abuse (used the AAS to screen) High Utilizers Differed Significantly from Low Utilizers, p<.05

  15. Diagnoses for High Utilizers • Preterm onset of contractions/PTL*** • Hyperemesis*** • Gestational Diabetes* • Weight disorders* • Neurological problems*** • Musculoskeletal problems* *=p<.05; **=p<.01; ***=p<.001

  16. Gravida/Parity Previous complications Onset of prenatal care Maternal or infant hospital stay at delivery Birth weight (145 g. difference--ns) No Significant Differences: …Gestational age at delivery did differ—by 4.4 days: HU=38.48 weeks, SD 1.6 LU=39.12, SD 1.9,…. p<.05

  17. Conclusion Pregnant women who used more medical services in our study were a vulnerable group characterized by past and current violence, economic disadvantage, & psychosocial stress.

  18. Limitations • Broad categories for diagnoses and chief complaints • Small number of participants– esp. for HU • Did not measure emotional abuse or mental health symptoms in this study

  19. Implications • High utilizers are a vulnerable group that are more likely to be in need of social services, extra support— due to high stress, low self esteem, & abuse • We could have predicted high utilization @ T1 (weeks 16-23). This is a missed opportunity to provide needed services. • Need for more research. Urgent care clinic or hospital a refuge?

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