A Two-Generation, Early Childhood Advanced Primary Care Model.

It is well recognized that early experiences produce long-term impacts on health outcomes, yet many children are at risk of not achieving their full potential because of health and service disparities related largely to poverty and racism. Although many pediatric primary care (PPC) models address these needs, most are isolated, add-on efforts that struggle to be scalable and sustainable. We describe 3-2-1 IMPACT (Integrated Model for Parents and Children Together), an initiative to transform the model of PPC delivered within New York City Health + Hospitals, the largest public hospital system in the United States, to address the full range of child and family needs in early childhood. Taking advantage of the frequent contact with PPC in the early years and linking to prenatal services, the model assesses family mental, social, and physical health needs and offers evidence-based parenting supports and integrated mental health services. Launching and sustaining the model in our large health system has required coalition building and sustained advocacy at the state, city, and health system levels. Long-term sustainability of the IMPACT model will depend on the implementation of early childhood-focused advanced payment models, on which we have made substantial progress with our major contracted Medicaid managed care plans. By integrating multiple interventions into PPC and prenatal care across a large public-healthcare system, we hope to synergize evidence-based and evidence-informed interventions that individually have relatively small effect sizes, but combined, could substantially improve child and maternal health outcomes and positively impact health disparities.

Management of depression during the perinatal period: state of the evidence.

BACKGROUND: Perinatal depression (PND) is a prevalent ailment that affects both the woman and her family. Addressing PND in primary health care, such as pediatrics and obstetric care settings, has been proposed as an effective way to identify and treat women. OBJECTIVE: The purpose of this study is to examine best practices for management of PND in obstetric and pediatric settings, as well as investigate the evidence that supports the guidelines. METHODS: Guidelines were identified through a literature search and discussion with experts in the field of perinatal depression, while evidence was examined through a literature search of reviews and thereafter experimental studies. RESULTS: Twenty-five guidelines, across 17 organizations were retained for analysis. Findings suggest that there is little or varied guidance on the management of PND, as well as a lack of specificity. Treatment was the topic most frequently reported, followed by screening. However best practices vary greatly and often contradict one another. Across all areas, there is inadequate or contrasting evidence to support these guidelines. CONCLUSIONS: Although there was consensus on the key steps in the pathway to care, the review revealed lack of consensus across guidelines on specific issues relating to identification and management of depression during the perinatal period. Clinicians may use these recommendations to guide their practice, but they should be aware of the limitations of the evidence supporting these guidelines and remain alert to new evidence. There is a clear need for researchers and policymakers to prioritize this area in order to develop evidence-based guidelines for managing perinatal depression.

Determinants of Severe Maternal Morbidity and Its Racial/Ethnic Disparities in New York City, 2008-2012.

Objectives Severe maternal morbidity (SMM) is an important indicator for identifying and monitoring efforts to improve maternal health. Studies have identified independent risk factors, including race/ethnicity; however, there has been limited investigation of the modifying effect of socioeconomic factors. Study aims were to quantify SMM risk factors and to determine if socioeconomic status modifies the effect of race/ethnicity on SMM risk. Methods We used 2008-2012 NYC birth certificates matched with hospital discharge records for maternal deliveries. SMM was defined using an algorithm developed by the Centers for Disease Control and Prevention. Mixed-effects logistic regression models estimated SMM risk by demographic, socioeconomic, and health characteristics. The final model was stratified by Medicaid status (as a proxy for income), education, and neighborhood poverty. Results Of 588,232 matched hospital deliveries, 13,505 (229.6 per 10,000) had SMM. SMM rates varied by maternal age, birthplace, education, income, pre-existing chronic conditions, pre-pregnancy weight status, trimester of prenatal care entry, plurality, and parity. Race/ethnicity was consistently and significantly associated with SMM. While racial differences in SMM risk persisted across all socioeconomic groupings, the risk was exacerbated among Latinas and Asian-Pacific Islanders with lower income when compared to white non-Latinas. Similarly, living in the poorest neighborhoods exacerbated SMM risk among both black non-Latinas and Latinas. Conclusions for Practice SMM determinants in NYC mirror national trends, including racial/ethnic disparities. However, these disparities persisted even in the highest income and educational groups suggesting other pathways are needed to explain racial/ethnic differences.

Estimating the Hospital Delivery Costs Associated With Severe Maternal Morbidity in New York City, 2008-2012.

OBJECTIVE: To quantify the average and total hospital delivery costs associated with severe maternal morbidity in excess of nonsevere maternal morbidity deliveries over a 5-year period in New York City adjusting for other sociodemographic and clinical factors. METHODS: We conducted a population-based cross-sectional study using linked birth certificates and hospital discharge data for New York City deliveries from 2008 to 2012. Severe maternal morbidity was defined using a published algorithm of International Classification of Diseases, 9 Revision, Clinical Modification disease and procedure codes. Hospital costs were estimated by converting hospital charges using factors specific to each year and hospital and to each diagnosis. These estimates approximate what it costs the hospital to provide services (excluding professional fees) and were used in all subsequent analyses. To estimate adjusted mean costs associated with severe maternal morbidity, we used multivariable regression models with a log link, gamma distribution, robust standard errors, and hospital fixed effects, controlling for age, race and ethnicity, neighborhood poverty, primary payer, number of deliveries, method of delivery, comorbidities, and year. We used the adjusted mean cost to determine the average and total hospital delivery costs associated with severe maternal morbidity in excess of nonsevere maternal morbidity deliveries from 2008 to 2012. RESULTS: Approximately 2.3% (n=13,502) of all New York City delivery hospitalizations were complicated by severe maternal morbidity. Compared with nonsevere maternal morbidity deliveries, these hospitalizations were clinically complicated, required more and intensive clinical services, and had a longer stay in the hospital. The average cost of delivery with severe maternal morbidity was $14,442 (95% CI $14,128-14,756), compared with $7,289 (95% CI $7,276-7,302) among deliveries without severe maternal morbidity. After adjusting for other factors, the difference between deliveries with and without severe maternal morbidity remained high ($6,126). Over 5 years, this difference resulted in approximately $83 million in total excess costs (13,502×$6,126). CONCLUSION: Severe maternal morbidity nearly doubled the cost of delivery above and beyond other drivers of cost, resulting in tens of millions of excess dollars spent in the health care system in New York City. These findings can be used to demonstrate the burden of severe maternal morbidity and evaluate the cost-effectiveness of interventions to improve maternal health.

Racial and ethnic identity in nursing research.

Nurse researchers need to be able to identify the race and ethnicity of participants in their studies for several reasons including addressing health disparities, ensuring adequate representation from under-represented minorities, and making sure other nurses can understand how findings may or may not pertain to their own patient population. However, obtaining accurate information about race and ethnicity requires careful attention to norms of study participants. Race and ethnicity are not always viewed as 2 separate constructs and the definition of both changes over time. In fact, a random sample of 100 patients in 1 hospital found an 11% discrepancy between patients' self-identification of race using 2 different methodologies of self-identification. To optimize accuracy of self-identification of race and ethnicity, this paper discusses techniques learned in practice and in the literature for improving self-identification of these 2 constructs.

Impact of two scheduling systems on early enrollment in a group prenatal care program.

Group care is an effective approach to prenatal care. Yet difficulties in recruiting, enrolling, and scheduling women into group care present obstacles to optimal program delivery. The purpose of this study was to determine whether the use of a scheduling system based on women's estimated date of delivery (EDD) decreased gestational age at entry to group care, increased attendance, and improved continuity of care. A total of 13 groups were held; seven groups used a scheduling system based on appointment availability and six groups used a scheduling system based on women's EDD. Compared with the availability-based scheduling system, the EDD-based system decreased mean gestational age (23.2 vs. 21.8 weeks; P = .058) and significantly decreased mean maximum gestational age (31.0 vs. 26.3 weeks; P = .002) at entry to group care. The EDD-based system increased the mean number of sessions offered per group (6.7 vs. 8.2 sessions; P < .001); however, attendance rates were similar across systems. The EDD-based system also increased the percentage of women who had the same initial visit and group provider (78.0% vs. 85.5%; P = .303). The use of this system by other health care facilities could ease the task of enrolling a sufficient number of participants into group care, minimize the need for women to change care providers if they desire group care, and allow more time for educational activities and the development of social networks for women by offering more sessions per group.