Sarah B. Laditka, Ph.D James N. Laditka, D.A., Ph.D. Janice C. Probst, Ph.D.

1. 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. Background and Theory • PAMCs, a population-based health care indicator • Builds on epidemiological work of 1970s identifying "sentinel" conditions, which signal problems with medical care access or quality (Rutstein et al. 1976) • 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)  • Assumptions of both ACSs and PAMCs   • Timely access to ambulatory health care can reduce risks of certain medical complications • Large hospital discharge data sets can be used for assessment

3. PAMC: Definition and Example • 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. • 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. • 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. Preliminary Research I • Used 1997 Nationwide Inpatient Sample (NIS): • Generated working PAMC list • Examined PAMC construct and face validity • Used 1988 National Maternal and Infant Health Survey (NMIHS): • 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. 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. NIS Multivariate Results, DeliveriesControls: sociodemographics, comorbidities, health system & area, hospital characteristics, state effects Compared to Non-Hispanic Whites, All p < 0.0001

7. Preliminary Research II • Used 2000 Nationwide Inpatient Sample (NIS): • Examined access to health care during pregnancy for mothers insured by Medicaid. • 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. NIS Rural Urban Results • In rural hospitals, African Americans had higher PAMC risk than whites (OR 1.72, CI 1.26-2.36). • In urban hospitals, PAMC risk was not significantly higher for African Americans. • In urban hospitals, odds of a PAMC for Hispanics and Asians were about half of those of whites. • Suggested, policymakers should work to reduce PAMC risks for African American women in rural areas insured by Medicaid.

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

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

11. Ages 18+, Percent Distribution +p<.1, *p<.05, **p<.01, ***p<.001

12. Multilevel, Selected Results, Ages11-17Adjusted for Individual, Area, and Hospital Factors +p<.1, *p<.05, **p<.01, ***p<.001

13. Multilevel, Selected Results, 18+Adjusted for Individual, Area, and Hospital Factors +p<.1, *p<.05, **p<.01, ***p<.001

14. Results, Black Women • For ages 10-17, PAMC risks were greater for blacks than whites in unadjusted and adjusted results. • For ages 18+, adjusted risks for blacks did not differ from whites. • Black mothers 18+ had higher risks than whites: single or disabled, in poverty or rural county, diabetes or hypertension. • 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. • 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. Results, Hispanic Women • 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%. • In adjusted analysis, Hispanics 10-17 had higher odds for a PAMC. • For those 18+, unadjusted PAMC rates were lower for Hispanics. • Hispanics had lower PAMC risks in multivariate analysis. • Several individual-level risk factors were less prevalent in Hispanics than whites, e.g., being single, having asthma, hypertension, diabetes and obesity.

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

17. Limitations • Among Hispanics, sample size of young mothers small. • Cannot identify how long each mother was enrolled in Medicaid prior to pregnancy. • Conducted an analysis of sensitivity to number of months of pregnancy covered by Medicaid; results did not differ meaningfully. • Cross-sectional analysis.

18. Policy and Practice Implications I • Practitioners should focus prenatal care efforts on minorities among younger pregnant women. • Practitioners should stress treatment of diabetes for women of all races • 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. • 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. Policy and Practice Implications II • Policymakers and practitioners should target known risk h underlying greater PAMC risks for minority women. • Medicaid providers should focus on reducing avoidable morbidity among blacks, rural residents, and young Hispanics. • 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. • In rural areas, poor, disabled, and single pregnant women may benefit from transportation and other forms of proactive support to attend prenatal care.

20. ~ Thank You ~ 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. Study supported by Grant 6 UIC RH 00045-04, U.S. Office of Rural Health Policy, Health Resources Services Administration