Treatment Facility Case Volume and Disparities in Outcomes of Congenital Diaphragmatic Hernia Cases.

INTRODUCTION: Congenital diaphragmatic hernia (CDH) is a life-threatening, prenatally diagnosed congenital anomaly. We aim to characterize care and outcomes of infants with CDH in Texas and the impact of treating facilities volume of care. METHODS: Retrospective cohort study using a state-wide Hospital Inpatient Discharge Public Use Data File was conducted (2013-2021). Neonates and infants <1 year of age were included using CDH ICD-9/ICD-10 codes. Neonates transferred to an outside hospital were excluded to avoid double-counting. Descriptive statistics, chi-square and logistic regression analysis were performed. RESULTS: Of 1314 CDH patient encounters identified, 728 (55%) occurred at 5 higher volume centers (HVC, >75 cases), 326 (25%) at 9 mid-volume centers (MVC, 20-75 cases) and 268 (20%) at 79 low volume centers (LVC, <20 cases). HVC had lower mortality rates (18%, MVC 22% vs LVC 27%; p = 0.011) despite treating sicker patients (extreme illness severity: HVC 71%, MVC 62% vs LVC 50%; p < 0.001) with longer length-of-stay (p < 0.001). Extracorporeal membrane oxygenation was used in 136 (10%) and provided primarily at HVC. LVC treated proportionately more non-white Hispanic patients (p < 0.001) and patients from counties along the Mexican border (p < 0.001). The predicted probability of mortality in CDH patients decreases with higher treatment facility CDH case volume, with a 0.5% decrease in the odds of mortality for every additional CDH case treated (p < 0.001). CONCLUSIONS: Patients treated in HVC have significantly lower mortality despite increased severity. Our data suggest minority populations may be disproportionately treated at LVC associated with worse outcomes. TYPE OF STUDY: Retrospective Prognosis Study. LEVEL OF EVIDENCE: Level II.

Association of Socioeconomic Status with Empowerment, Depression, and Anxiety in Pregnancies Complicated by Fetal Surgical Anomalies.

BACKGROUND: Women with pregnancies complicated by fetal surgical anomalies experience significant psychosocial burden. There remains a need to determine the impact that socioeconomic status has on maternal empowerment, anxiety, and depression. METHODS: A survey study was conducted from 5/2021-5/2022 to quantify empowerment, anxiety, and depression in women with fetal surgical anomalies. Surveys administered included Pregnancy Related Empowerment Scale (PRES), Patient Empowerment Scale (PES), State Trait Anxiety Inventory (STAI), and Depression Anxiety and Stress Scale (DASS). Two-sample t-test was used to compare survey scores across socioeconomic groups. RESULTS: Seventy-four patients were recruited. Mothers more commonly preferred English as primary language (n = 61, 82%) and were non-Hispanic (n = 43, 58%). Lower empowerment scores were observed in Hispanic mothers (PRES, p = 0.03; PES, p = 0.04) and mothers who preferred Spanish (PRES, p = 0.04; PES, p = 0.06) as primary language. Both non-Hispanic (p = 0.88) and English speaking (p = 0.75) women had higher STAI scores, but neither was significantly different. DASS was not significantly higher for Hispanic (p = 0.79) or Spanish speaking mothers (p = 0.47). CONCLUSION: Hispanic and Spanish speaking women with pregnancies complicated by fetal surgical anomalies have significantly decreased empowerment scores. These findings suggest a need for development of culturally competent, targeted interventions to improve maternal empowerment in this high-risk population. LEVEL OF EVIDENCE: Level II. TYPE OF STUDY: Cross-Sectional Survey Study.

Impact of Telemedicine on Prenatal Counseling at a Tertiary Fetal Center: A Mixed Methods Study.

INTRODUCTION: COVID-19 spurred an unprecedented transition from in-person to telemedicine visits in March 2020 at our institution for all prenatal counseling sessions. This study aims to explore differences in demographics of expectant mothers evaluated pre- and post-telemedicine implementation and to explore the patient experience with telemedicine. METHODS: A mixed methods study was completed for mothers with a pregnancy complicated by a fetal surgical anomaly who visited a large tertiary fetal center. Using medical records as quantitative data, patient information was collected for all prenatal visits from 3/2019 to 3/2021. The sample was grouped into pre- and post-telemedicine implementation (based on transition date of 3/2020). Univariate analysis was used to compare demographics between the study groups. Statistical significance was defined as P < 0.05. Eighteen semi-structured interviews were conducted from 8/2021 to 12/2021 to explore patients' experiences. Line-by-line coding and thematic analysis was performed to develop emerging themes. RESULTS: 292 pregnancies were evaluated from 3/2019 to 3/2021 (pre-telemedicine 123, post-telemedicine 169). There was no significant difference in self-reported race (P = 0.28), ethnicity (P = 0.46), or primary language (P = 0.98). In qualitative interviews, patients reported advantages to telemedicine, including the convenience of the modality with the option to conduct their session in familiar settings (e.g., home) and avoid stressors (e.g., travel to the medical center and finding childcare). Some women reported difficulties establishing a physician-patient connection and a preference for in-person consultations. CONCLUSIONS: There was no difference in patient demographics at our fetal center in the year leading up to, and the time following, a significant transition to telemedicine. However, patients had unique perspectives on the advantages and disadvantages of the telemedicine experience. To ensure patient centered care, these findings suggest patient preference should be considered when scheduling outpatient surgical counseling and visits.