Maternal comorbidity index and severe maternal morbidity among medicaid covered pregnant women in a US Southern rural state.

BACKGROUND: The rates of SMM have been steadily increasing in Arkansas, a southern rural state, which has the 5th highest maternal death rate among the US states. The aims of the study were to test the functionality of the Bateman index in association to SMM, in clustering the risks of pregnancies to SMM, and to study the predictability of SMM using the Bateman index. STUDY DESIGN: From the ANGELS database, 72,183 pregnancies covered by Medicaid in Arkansas between 2013 and 2016 were included in this study. The expanded CDC ICD-9/ICD-10 criteria were used to identify SMM. The Bateman comorbidity index was applied in quantifying the comorbidity burden for a pregnancy. Multivariable logistic regressions, KMeans method, and five widely used predictive models were applied respectively for each of the study aims. RESULTS: SMM prevalence remained persistently high among Arkansas women covered by Medicaid (195 per 10,000 deliveries) during the study period. Using the Bateman comorbidity index score, the study population was divided into four groups, with a monotonically increasing odds of SMM from a lower score group to a higher score group. The association between the index score and the occurrence of SMM is confirmed with statistical significance: relative to Bateman score falling in 0-1, adjusted Odds Ratios and 95% CIs are: 2.1 (1.78, 2.46) for score in 2-5; 5.08 (3.81, 6.79) for score in 6-9; and 8.53 (4.57, 15.92) for score ≥10. Noticeably, more than one-third of SMM cases were detected from the studied pregnancies that did not have any of the comorbid conditions identified. In the prediction analyses, we observed minimal predictability of SMM using the comorbidity index: the calculated c-statistics ranged between 62% and 67%; the Precision-Recall AUC values are <7% for internal validation and <9% for external validation procedures. CONCLUSIONS: The comorbidity index can be used in quantifying the risk of SMM and can help cluster the study population into risk tiers of SMM, especially in rural states where there are disproportionately higher rates of SMM; however, the predictive value of the comorbidity index for SMM is inappreciable.

"Advancing" Advance Care Planning to Veterans in the Veterans Health Administration.

INTRODUCTION: The completion rate of Advance Directive (ADs) in the Veterans Health Administration (VHA) is unknown. There is substantial literature on the need for effective Advance Care Planning (ACP) that leads to an AD to ensure that health care preferences for patients are known. Advance Directive are essential to consider since ACP, which explains and plans Advance Directive, does not reach all individuals. Health inequities, such as those experienced in rural areas, continue to exist. While ACP may disproportionately affect rural-residing veterans and their providers, a VHA program was specifically designed to increase ACP engagement with rural veterans and to address several systemic barriers to ACP. MATERIALS AND METHODS: This descriptive analysis seeks to identify patient, provider, and geographic characteristics associated with higher rates of ACP participation in VHA. An observational examination of the profile of veterans and the types of ACP (e.g., individual or in groups) using administrative data for all beneficiaries receiving VHA health care services in federal fiscal year (FY) 2020 was conducted as part of a national program evaluation. The measures include patient-level data on demographics (e.g., race, ethnicity, gender), unique patient identifiers (e.g., name, social security number), geographic characteristics of patient's location (e.g., rurality defined as Rural-Urban Commuting Areas [RUCA]), VHA priority group; provider-level data (e.g., type of document definition, clinic stop codes, visit date used to verify Advance Care Planning via Group Visits [ACP-GV] attendance; data not shown), and electronic health record note titles that indicated the presence of ACP in VHA (e.g., "Advance Directive [AD] Discussion" note title, "ACP-GV CHAR 4 code"). Pearson's chi-square statistics were used for between-group comparisons based on a two-sided test with a significance level of 0.05. RESULTS: The overall rate of AD discussions among unique VHA users in FY2020 was 5.2% (95% CI: 5.2%-5.2%) and for Advance Care Planning via Group Visits, which targets rural veterans using groups, it was 1.8% (95% CI: 1.8%-1.9%). Advance Directive discussions in VHA are more successful at reaching middle age (M = 64; SD = 16), African Americans, males, veterans living in urban areas, and veterans with a VA disability (Priority Group 1-4). Advance Care Planning delivered in groups is reaching slightly younger veterans under the age of 75 years (M = 62; SD = 15), African Americans, females, disabled veterans (e.g., Priority Group 1-4), and more veterans residing in rural communities compared to the national population of VHA users. CONCLUSION: Advance Directive discussion rates are low across VHA, yet intentional efforts with ACP via group visits are reaching veterans who are considered underserved owing to residing in rural areas. Advance Care Planning needs to be a well-informed clinical priority for VHA to engage with the entire veteran population and to support the completion of ADs.

Healthcare costs and resource utilization associated with renal cell carcinoma among older Americans: A longitudinal case-control study using the SEER-Medicare data.

OBJECTIVES: To determine 1-year and 5-year total healthcare costs and healthcare resource (HRU) associated with renal cell carcinoma (RCC) in older Americans, from a healthcare sector perspective. MATERIALS AND METHODS: This was a longitudinal, retrospective cohort study using the Surveillance, Epidemiology and End Results-Medicare linked data (2006-2014), which included older (≥66 years) patients with primary RCC and 1:5 matched noncancer controls. Patients/controls were followed from diagnosis (pseudo-diagnosis for controls) until death or up to loss-to-follow-up (censored). Per-patient average 1-year and 5-year cumulative total and incremental total healthcare costs and HRU were reported. RESULTS: A total of 11,228 RCC patients were matched to 56,140 controls. Per-patient cumulative average 1-year (incremental = $38,291 [$36,417-$40,165]; $57,588 vs. $19,297) and 5-year (incremental = $68,004 [$55,123-$80,885]; $183,550 vs. $115,547) total costs (excluding prescription drug costs) were 3 and 1.6 times higher for RCC vs. controls. These estimates were 3.6 and 1.7 times higher for RCC vs. controls when prescription costs were included in total costs. Prescription drug costs accounted for 8.4% (incremental = $3,715) and 18.1% (incremental = $15,375) of the 1-year and 5-year incremental total costs, respectively. RCC patients had greater cumulative number of hospitalizations, emergency department visits and prescriptions in 1- and 5-years, compared to controls. CONCLUSIONS: Average first year total cost for a patient with incident diagnosis of RCC is substantially higher than that for controls and it varies depending on the stage at diagnosis. Study findings could help in planning future resource allocation and in determining research and unmet needs in this patient population.

Determining feasibility of incorporating consumer engagement into implementation activities: study protocol of a hybrid effectiveness-implementation type II pilot.

INTRODUCTION: Implementation researchers could draw from participatory research to engage patients (consumers of healthcare) in implementation processes and possibly reduce healthcare disparities. There is a little consumer involvement in healthcare implementation, partially because no formal guidance exists. We will create and pilot a toolkit of methods to engage consumers from the US' Veterans Health Administration (VHA) in selecting and tailoring implementation strategies. This toolkit, Consumer Voice, will provide guidance on what, when, where, how and why an implementer might engage consumers in implementing treatments. We will pilot the toolkit by implementing Safety Planning Intervention for suicide prevention with rural veterans, a population with suicide disparities. Safety Planning Intervention is effective for reducing suicidal behaviours. METHODS AND ANALYSIS: In Aim 1, we will use participatory approaches and user-centred design to develop Consumer Voice and its methods. In Aim 2, we will pilot Consumer Voice by implementing the Safety Planning Intervention in two clinics serving rural VHA patients. One site will receive a current implementation strategy (Implementation Facilitation) only; the second will receive Implementation Facilitation plus Consumer Voice. We will use mixed methods to assess feasibility and acceptability of Consumer Voice. We will compare sites on preliminary implementation (reach, adoption, fidelity) and clinical outcomes (depression severity, suicidal ideation, suicidal behaviour). In Aim 3, we will evaluate Aim 2 outcomes at 20 months to assess sustained impact. We will gather qualitative data on sustainability of the Safety Planning Intervention. ETHICS AND DISSEMINATION: These studies are overseen by the Institutional Review Board at the Central Arkansas Veterans Healthcare System. We plan to use traditional academic modalities of dissemination (eg, conferences, publications). We plan to disseminate findings through meetings with other trainers in implementation practice so they may adopt Consumer Voice. We plan to share results with local community boards.

Longitudinal assessment of obstetrics and gynecology resident perceptions and comfort following cerclage placement simulation.

BACKGROUND: Utilization of simulation training in medical education has increased over time, particularly for less common scenarios and procedures. Simulation allows trainees to practice in a low-stress environment and eliminates patient risk. Cerclage placement has become less frequent, which limits obstetrics and gynecology (OB/GYN) exposure to cerclage placement during training. This exposes an area of training requiring simulation in OB/GYN resident education. OBJECTIVE: To evaluate resident reception to cerclage simulation, their self-reported comfort with and ability to troubleshoot difficult cerclage placement immediately and 12 months following didactic education and simulation. METHODS: In 2019, 18/20 (90%) OB/GYN residents in our university program underwent didactic teaching and simulation in cerclage placement using a pelvic model with removable cervix. Residents completed a survey immediately and 12 months following simulation. Wilcoxon signed-rank test was used to analyze resident self-report of comfort with cerclage placement and skill techniques for navigating difficult placement before and after simulation training. Descriptive statistics were analyzed as means and standard deviations. RESULTS: Eighteen of twenty (90%) residents participated in the education session in cerclage placement. All 18 (100%) completed a postsimulation survey and 17/18 (94%) completed a survey 12 months later. All reported improved comfort with cerclage placement and statistically significant improvement in knowledge on techniques for troubleshooting difficult placement after simulation. All residents reported that the simulation enhanced their learning and recommended the simulation for future educational opportunities. CONCLUSIONS: Cerclage simulation was well-received by OB/GYN residents in learning and practicing cerclage placement. Residents demonstrated improved comfort with placement following simulation.

17 Alpha-hydroxyprogesterone caproate use in a rural state.

BACKGROUND: 17 alpha-hydroxyprogesterone caproate (17OHP) is used to reduce the recurrent risk of preterm delivery in women with a history of preterm delivery. Meis et al. conducted a double-blind placebo controlled trial to evaluate the effectiveness of 17OHP and observed a significant reduction in the risk of recurrent preterm delivery. The FDA granted 17OHP a conditional approval on 2011. A second study observed that 17OHP did not decrease the risk of a recurrent preterm delivery. Criticism of the second study derived from a dissimilarity of the study population. OBJECTIVE: Our investigation examined the effectiveness of 17OHP in women with a prior preterm delivery in a rural US state with a patient population similar to the original Meis trial. STUDY DESIGN: 17OHP became largely unavailable (due to cost and local pharmacies no longer compounding 17 OHP) and the University of Arkansas for Medical Sciences, Department of Health, and Arkansas Medicaid co-operated to make 17OHP available to women with a prior PTB in our state. This study was a retrospective review of the 17OHP that was offered to women with a prior preterm delivery. For our retrospective review, logistic regression was used on cases of prior preterm delivery between January 2014 and December of 2018 to examine the relationship between 17OHP injections and preterm delivery. RESULTS: A total of 268 women were analyzed for this review. They were divided into three groups: 0 injections, 1-10 injections, and > 10 injections. We found no relationship between 17OHP injections with preterm delivery. CONCLUSION: Although our patient population was similar to that of the original Meis trial, our results were more similar to the second study by Blackwell.

A neuromuscular-based analysis of the open payments program.

INTRODUCTION: In August 2013, the Centers for Medicare and Medicaid Services (CMS) Open Payments Program (OPP) made eligible payment information publicly available. Data about industry payments to neuromuscular neurologists are lacking. METHOD: Financial relationships were investigated between industry and US neuromuscular neurologists from January 2014 through December 2018 using the CMS OPP database. RESULTS: The total annual payments increased more than 6-fold during the study period. The top 10% of physician-beneficiaries collected 80% to 90% of total industry payments except in 2014. In 2018, the most common drugs associated with payments to neuromuscular neurologists were nusinersen, vortioxetine, eteplirsen, alglucosidase alpha, edaravone, and intravenous immunoglobulin. DISCUSSION: A substantial increase in the annual payments to neuromuscular physicians during the study period is likely due to the development of new treatments, including gene therapy.

Correction to: Do Insurance Mandates Affect Racial Disparities in Outcomes for Children with Autism?

The original version of this article unfortunately contained a mistake in the analysis of the Tables 4 and 5.

Predictors of mental health and substance use disorder treatment use over 3 years among rural adults using stimulants.

Background: Persons using substances, living in rural communities, tend to underutilize mental health (MH) and substance use disorder (SUD) treatment compared with their urban peers. However, no studies have examined longitudinal predictors of MH and SUD treatment use among rural persons using stimulants. Methods: Data were collected through interviews conducted between 2002 and 2008 from a natural history study of 710 adults using stimulants and living in rural counties of Arkansas, Kentucky, and Ohio. Each study site recruited participants using respondent-driven sampling (RDS). Participants were adults, not in drug treatment, and reporting past-30-day use of methamphetamine, crack cocaine, or powder cocaine. Study participants completed face-to-face baseline assessments and follow-up interviews using computer-assisted personal interviews. Follow-up interviews were conducted at 6-month intervals for 3 years. Results: Our results show that being male, nonwhite, and having a prior lifetime history of MH or SUD treatment use were associated with lower odds of using MH and SUD treatment over time; having medical insurance and living in a state with potentially greater availability of MH and SUD treatment were associated with higher odds of using MH and SUD treatment over the 3-year period. Further, reporting greater legal problems and alcohol severity were associated with greater odds of using MH and SUD care, whereas greater employment problems was associated with higher odds of SUD but not MH treatment use. Conclusions: Findings from this study could be used to inform clinical and public health strategies for improving linkage to MH and SUD care in this population. Our findings also highlight the importance of having medical insurance as a potential facilitator to utilizing SUD care in this population and support the need for health care policies that increase the ability of rural adults who use stimulants to pay for such services.

High-risk obstetrical call center: a model for regions with limited access to care.

PURPOSE: High-risk obstetrical care can be challenging for women in rural states with limited access. MATERIALS AND METHODS: Data were evaluated from 62,342 obstetrical calls from pregnant and postpartum patients within rural Arkansas to a nurse call center. Call center nurses provided triage using evidence-based guidelines to patients across the state. Data were extracted and analyzed using retrospective data collection and descriptive statistical methods. RESULTS: Women had an average maternal age of 28 years old, average weeks gestation was 27.4, over half had Medicaid 32,513 (52.15%), and the greatest percentage were in their first pregnancy 14,232 (34.1%). The greatest percentage of calls resulted in a recommendation to come to the hospital to be evaluated 25,894 (41.54%) followed by advice with no prescription given 19,442 (31.19%). The most frequent guidelines used included preterm labor 5114 (8.24%) followed by abdominal pain >20 weeks 4,518 (7.28%). CONCLUSIONS: A centralized obstetrical nurse call center model, including 24/7 availability, using triage software for obstetrical care, with experienced labor and delivery nurses to answer and respond to calls and secondary triage performed by OB/GYN physicians or Advance Practice Registered Nurses (APRN) has the potential of improving access to obstetric care in rural areas.

Exploring Implementation of m-Health Monitoring in Postpartum Women with Hypertension.

BACKGROUND: Preeclampsia is a hypertensive disorder in pregnancy where a patients' blood pressure and warning signs of worsening disease need to be closely monitored during pregnancy and the postpartum period. INTRODUCTION: No studies have examined remote patient monitoring using mobile health (m-health) technologies in obstetrical care for women with preeclampsia during the postpartum period. Remote monitoring and m-health technologies can expand healthcare coverage to the patient's home. This may be especially beneficial to patients with chronic conditions who live far from a healthcare facility. MATERIALS AND METHODS: The study was designed to identify and examine the potential factors that influenced use of m-health technology and adherence to monitoring symptoms related to preeclampsia in postpartum women. A sample of 50 women enrolled into the study. Two participants were excluded, leaving a total sample size of 48 women. Users were given m-health devices to monitor blood pressure, weight, pulse, and oxygen saturation over a 2-week period. Nonusers did not receive equipment. The nurse call center monitored device readings and contacted participants as needed. Both groups completed a baseline and follow-up survey. RESULTS: Women who elected to use the m-health technology on average had lower levels of perceived technology barriers, higher facilitating condition scores, and higher levels of perceived benefits of the technology compared with nonusers. Additionally, among users, there was no statistical difference between full and partial users at follow-up related to perceived ease of use, perceived satisfaction, or perceived benefits. DISCUSSION: This study provided a basis for restructuring the management of care for postpartum women with hypertensive disorders through the use of m-health technology. CONCLUSION: Mobile health technology may be beneficial during pregnancy and the postpartum period for women with preeclampsia to closely manage and monitor their blood pressure and warning signs of worsening disease.

Do Insurance Mandates Affect Racial Disparities in Outcomes for Children with Autism?

Objective The study investigated whether state mandates for private insurers to provide services for children with autism influence racial disparities in outcomes. Methods The study used 2005/2006 and 2009/2010 waves of the National Survey of Children with Special Health Care Needs. Children with a current diagnosis of autism were included in the sample. Children residing in 14 states and the District of Columbia that were not covered by the mandate in the 2005/2006 survey, but were covered in the 2009/2010 survey, served as the mandate group. Children residing in 32 states that were not covered by a mandate in either wave served as the comparison group. Outcome measures assessed included care quality, family economics, and child health. A difference-in-difference-in-differences (DDD) approach was used to assess the impact of the mandates on racial disparities in outcomes. Results Non-white children had less access to family-centered care compared to white children in both waves of data, but this difference was not apparent across mandate and comparison states as only the comparison states had significant differences. Parents of non-white children reported paying less in annual out-of-pocket expenses compared to parents of white children across waves and groups. DDD estimates did not provide evidence that the mandates had statistically significant effects on improving or worsening racial disparities for any outcome measure. Conclusions This study did not find evidence that state mandates on private insurers affected racial disparities in outcomes for children with autism.

To what extent do community members' personal health beliefs and experiences impact what they consider to be important for their community-at-large?

BACKGROUND: Health assessments are used to prioritize community-level health concerns, but the role of individuals' health concerns and experiences is unknown. We sought to understand to what extent community health assessments reflect health concerns of the community-at-large versus a representation of the participants sampled. METHODS: We conducted a health assessment survey in 30 rural African American churches (n = 412). Multivariable logistic regression produced odds ratios examining associations between personal health concern (this health concern is important to me), personal health experience (I have been diagnosed with this health issue) and community health priorities (this health concern is important to the community) for 20 health issues. RESULTS: Respondents reported significant associations for 19/20 health conditions between personal health concern and the ranking of that concern as a community priority (all P < 0.05). Inconsistent associations were seen between personal health experience of a specific health condition and the ranking of that condition as a community priority. CONCLUSIONS: Personal health concerns reported by individuals in a study sample may impact prioritization of community health initiatives. Further research should examine how personal health concerns are formed.

Time trends and payer differences in lengths of initial hospitalization for preterm infants, Arkansas, 2004 to 2010.

OBJECTIVE: The objective of this study was to examine the time trend in length of stay (LOS) and explore potential differences in neonatal LOS by insurance type for preterm infants in Arkansas between 2004 and 2010. STUDY DESIGN: There were 18,712 preterm infants included in our analyses. Accelerated failure time models were used to model neonatal LOS as a function of insurance type and discharge year while adjusting for key maternal and infant characteristics, and complication/anomaly indicators. RESULTS: Before adjusting for the complication/anomaly indicators, the LOS for preterm infants delivered to mothers in the Medicaid group was 3.2% shorter than those in the private payer group. Furthermore, each subsequent year was associated with a 1.6% increase in the expected LOS. However, after accounting for complications and anomalies, insurance coverage differences in neonatal LOS were not statistically significant while the trend in LOS persisted at a 0.59% increase for each succeeding year. CONCLUSION: All of the apparent differences in LOS by insurance type and more than half of the apparent increase in LOS over time are accounted for by higher rates of complications among privately insured preterm infants and increasing rates of complications for all surviving preterm infants between 2004 and 2010.

Estimating misclassification error: a closer look at cross-validation based methods.

BACKGROUND: To estimate a classifier's error in predicting future observations, bootstrap methods have been proposed as reduced-variation alternatives to traditional cross-validation (CV) methods based on sampling without replacement. Monte Carlo (MC) simulation studies aimed at estimating the true misclassification error conditional on the training set are commonly used to compare CV methods. We conducted an MC simulation study to compare a new method of bootstrap CV (BCV) to k-fold CV for estimating clasification error. FINDINGS: For the low-dimensional conditions simulated, the modest positive bias of k-fold CV contrasted sharply with the substantial negative bias of the new BCV method. This behavior was corroborated using a real-world dataset of prognostic gene-expression profiles in breast cancer patients. Our simulation results demonstrate some extreme characteristics of variance and bias that can occur due to a fault in the design of CV exercises aimed at estimating the true conditional error of a classifier, and that appear not to have been fully appreciated in previous studies. Although CV is a sound practice for estimating a classifier's generalization error, using CV to estimate the fixed misclassification error of a trained classifier conditional on the training set is problematic. While MC simulation of this estimation exercise can correctly represent the average bias of a classifier, it will overstate the between-run variance of the bias. CONCLUSIONS: We recommend k-fold CV over the new BCV method for estimating a classifier's generalization error. The extreme negative bias of BCV is too high a price to pay for its reduced variance.

Use of specialty OB consults during high-risk pregnancies in a Medicaid-covered population: initial impact of the Arkansas ANGELS intervention.

This study examines the impact of a Medicaid-supported intervention (Antenatal and Neonatal Guidelines, Education and Learning System) to expand a high-risk obstetrics consulting service on the use of specialty consults between 2001 and 2006. Using a Medicaid claims-birth certificate data set, we find a decline over time in use of specialty consults for lower risk diagnoses and a shift to remote modalities for contact. Local physician participation in grand rounds via teleconference was associated both with specialty contact and use of remote modalities. Local physician use of a Call Center service was also associated with patient specialty contact. Expansion of telemedicine remote sites did not increase the likelihood of contact but was associated with the shift toward remote modalities. Specialty consult use and modality were influenced by the care context of the patient, particularly level of pregnancy risk, the specialty of the primary prenatal care provider, the timing of her prenatal care, and her ethnicity and education level.

Evaluating the effect of hospital and insurance type on the risk of 1-year mortality of very low birth weight infants: controlling for selection bias.

OBJECTIVES: We examined the effect of hospital type and medical coverage on the risk of 1-year mortality of very low birth weight (VLBW) infants while adjusting for possible selection bias. METHODS: The study population was limited to singleton live birth infants having birth weight between 500 and 1500 g with no congenital anomalies who were born in Arkansas hospitals between 2001 and 2007. Propensity score (PS) matching and PS covariate adjustment were used to mitigate selection bias. In addition, a conventional multivariable logistic regression model was used for comparison purposes. RESULTS: Generally, all 3 analytical approaches provided consistent results in terms of the estimated relative risk, absolute risk reduction, and the number needed to treat. Using the PS matching method, VLBW infants delivered at a hospital with a neonatal intensive care unit (NICU) were associated with a 35% relative decrease (95% bootstrap confidence interval, 18.5%-48.9%) in the risk of 1-year mortality as compared with those infants delivered at non-NICU hospitals. Furthermore, our results showed that on average, 16 VLBW infants (95% bootstrap confidence interval, 11-32), would need to be delivered at a hospital with an NICU to prevent 1 additional death at 1 year. However, there was not a difference in the risk of 1-year mortality between VLBW infants born to Medicaid-insured versus non-Medicaid-insured women. CONCLUSIONS: Estimated relative risk of infant mortality was significantly lower for births that occurred in hospitals with an NICU; therefore, greater efforts should be made to deliver VLBW neonates in an NICU hospital.

Emergency contraception counseling: an opportunity for pharmacists.

OBJECTIVE: To determine the impact of pharmacist counseling on patients' knowledge of emergency contraception (EC). DESIGN: Single-group, repeated-measures analysis. SETTING: Academic medical center women's clinic in Little Rock, AR, between January and July 2010. PARTICIPANTS: 116 women 18 years or older. INTERVENTION: 10-minute education session provided by a pharmacist or trained student pharmacist. MAIN OUTCOME MEASURES: Change in participants' test scores (range 0 [lowest possible] to 13 [highest possible]) at three assessment periods (pretest, posttest, and follow-up) using 12 knowledge questions. RESULTS: 116 participants with a mean (±SD) age of 25 ± 5.9 years participated in this study. Mean knowledge scores were 5.3 ± 4.1 for the pretest and 10.7 ± 1.4 for the posttest (P < 0.001). The least-squares mean EC knowledge test score (adjusted for demographics) was 5.86 at pretest, 10.75 at posttest, and 10.75 at follow-up. A nonsignificant small change in scores from posttest to follow-up was detected after the Tukey-Kramer adjustment. A higher education level was associated with higher knowledge scores in this population. CONCLUSION: Brief pharmacist-driven counseling sessions provided in a clinic setting are feasible and have a positive impact on immediate EC knowledge and long-term knowledge retention.

Improving perinatal regionalization for preterm deliveries in a Medicaid covered population: initial impact of the Arkansas ANGELS intervention.

OBJECTIVE: To examine the factors associated with delivery of preterm infants at neonatal intensive care unit (NICU) hospitals in Arkansas during the period 2001-2006, with a focus on the impact of a Medicaid supported intervention, Antenatal and Neonatal Guidelines, Education, and Learning System (ANGELS), that expanded the consulting capacity of the academic medical center's maternal fetal medicine practice. DATA SOURCES: A dataset of linked Medicaid claims and birth certificates for the time period by clustering Medicaid claims by pregnancy episode. Pregnancy episodes were linked to residential county-level demographic and medical resource characteristics. Deliveries occurring before 35 weeks gestation (n=5,150) were used for analysis. STUDY DESIGN: Logistic regression analysis was used to examine time trends and individual, county, and intervention characteristics associated with delivery at hospitals with NICU, and delivery at the academic medical center. PRINCIPAL FINDINGS: Perceived risk, age, education, and prenatal care characteristics of women affected the likelihood of use of the NICU. The perceived availability of local expertise was associated with a lower likelihood that preterm infants would deliver at the NICU. ANGELS did not increase the overall use of NICU, but it did shift some deliveries to the academic setting. CONCLUSION: Perinatal regionalization is the consequence of a complex set of provider and patient decisions, and it is difficult to alter with a voluntary program.