Gestational Weight Loss: Comparison Between the Birth Certificate and the Medical Record, Florida, 2012.

Objective Examine agreement with the medical record (MR) when gestational weight loss (GWL) on the Florida birth certificate (BC) is ≥ 0 pounds (lbs). Methods In 2012, 3923 Florida-resident women had a live, singleton birth where BC indicated GWL ≥ 0 lbs. Of these, we selected a stratified random sample of 2141 and abstracted from the MR prepregnancy and delivery weight data used to compute four estimates of GWL (delivery minus prepregnancy weight) from different sources found within the MR (first prenatal visit record, nursing admission record, labor/delivery records, BC worksheet). We assessed agreement between the BC and MR estimates for GWL categorized as 0, 1-10, 11-19, and ≥ 20 lbs. Results Prepregnancy or delivery weight was missing or source not in the MR for 23-81% of records. Overall agreement on GWL between the BC and the four MR estimates ranged from 39.1 to 57.2%. Agreement by GWL category ranged from 10.6 to 38.0% for 0 lbs, 47.6 to 64.3% for 1-10 lbs, 49.5 to 60.0% for 11-19 lbs, and 47.8 to 67.7% for ≥ 20 lbs. Conclusions Prepregnancy and delivery weight were frequently missing from the MR or inconsistently documented across the different sources. When the BC indicated GWL ≥ 0 lbs, agreement with different sources of the MR was moderate to poor revealing the need to reduce missing data and better understand the quality of weight data in the MR.

Maternal Racial and Ethnic Disparities in Neonatal Birth Outcomes With and Without Assisted Reproduction.

OBJECTIVE: To explore disparities in prematurity and low birth weight (LBW) by maternal race and ethnicity among singletons conceived with and without assisted reproductive technology (ART). METHODS: We performed a retrospective cohort study using resident birth certificate data from Florida, Massachusetts, and Michigan linked with data from the National ART Surveillance System from 2000 to 2010. There were 4,568,822 live births, of which 64,834 were conceived with ART. We compared maternal and ART cycle characteristics of singleton liveborn neonates using χ tests across maternal race and ethnicity groups. We used log binomial models to explore associations between maternal race and ethnicity and LBW and preterm birth by ART conception status. RESULTS: The proportion of liveborn neonates conceived with ART differed by maternal race and ethnicity (P<.01). It was smallest among neonates of non-Hispanic black (0.3%) and Hispanic women (0.6%) as compared with neonates of non-Hispanic white (2.0%) and Asian or Pacific Islander women (1.9%). The percentages of LBW or preterm singletons were highest for neonates of non-Hispanic black women both for non-ART (11.3% and 12.4%) and ART (16.1% and 19.1%) -conceived neonates. After adjusting for maternal factors, the risks of LBW or preterm birth for singletons born to non-Hispanic black mothers were 2.12 [95% confidence interval (CI) 2.10-2.14] and 1.56 (95% CI 1.54-1.57) times higher for non-ART neonates and 1.87 (95% CI 1.57-2.23) and 1.56 (95% CI 1.34-1.83) times higher for ART neonates compared with neonates of non-Hispanic white women. The adjusted risk for LBW was also significantly higher for ART and non-ART singletons born to Hispanic (adjusted relative risk [RR] 1.26, 95% CI 1.09-1.47 and adjusted RR 1.15, 95% CI 1.13-1.16) and Asian or Pacific Islander (adjusted RR 1.39, 95% CI 1.16-1.65 and adjusted RR 1.55, 95% CI 1.52-1.58) women compared with non-Hispanic white women. CONCLUSION: Disparities in adverse perinatal outcomes by maternal race and ethnicity persisted for neonates conceived with and without ART.

Assisted reproductive technology and perinatal outcomes: conventional versus discordant-sibling design.

OBJECTIVE: To compare risks of adverse perinatal outcomes between assisted reproductive technology (ART) and naturally conceived singleton births using a dual design approach. DESIGN: Discordant-sibling and conventional cross-sectional general population comparison. SETTING: Not applicable. PATIENT(S): All singleton live births, conceived naturally or via ART. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Birth weight, gestational age, low birth weight, preterm delivery, small for gestational age (SGA), low Apgar score. RESULT(S): A total of 32,762 (0.8%) of 3,896,242 singleton live births in the three states were conceived via ART. In 6,458 sibling pairs, ART-conceived singletons were 33 g lighter (adjusted ß = -33.40, 95% confidence interval [CI], -48.60, -18.21) and born half a day sooner (ß = -0.58, 95% CI, -1.02, -0.14) than singletons conceived naturally. The absolute risk of low birth weight and preterm birth was 6.8% and 9.7%, respectively, in the ART group and 4.9% and 7.9%, respectively, in the non-ART group. The odds of low birth weight were 33% higher (adjusted odds ratio [aOR] = 1.33; 95% CI, 1.13, 1.56) and 20% higher for preterm birth (aOR = 1.20; 95% CI, 1.07, 1.34). The odds of SGA and low Apgar score were not significantly different in both groups (aOR = 1.22; 95% CI, 0.88, 1.68; and aOR = 0.75; 95% CI, 0.54, 1.05, respectively). Results of conventional analyses were similar, although the magnitude of risk was higher for preterm birth (aOR, 1.51; 95% CI 1.46, 1.56). CONCLUSION(S): Despite some inflated risks in the general population comparison, ART remained associated with an increased likelihood of low birth weight and preterm birth when underlying maternal factors were kept constant using discordant-sibling comparison.

Assisted Reproductive Technology and Birth Defects Among Liveborn Infants in Florida, Massachusetts, and Michigan, 2000-2010.

IMPORTANCE: Use of assisted reproductive technology (ART) has been associated with increased risks for birth defects. Variations in birth defect risks according to type of ART procedure have been noted, but findings are inconsistent. OBJECTIVES: To examine the prevalence of birth defects among liveborn infants conceived with and without ART and to evaluate risks associated with certain ART procedures among ART-conceived infants. DESIGN, SETTING, AND PARTICIPANTS: Used linked ART surveillance, birth certificates, and birth defects registry data for 3 states (Florida, Massachusetts, and Michigan). Methods for ascertaining birth defect cases varied by state. Resident live births during 2000 to 2010 were included, and the analysis was conducted between Feburary 2015 and August 2015. EXPOSURES: Use of ART among all live births and use of certain ART procedures among ART births. MAIN OUTCOME AND MEASURES: Prevalence of selected chromosomal and nonchromosomal birth defects that are usually diagnosed at or immediately after birth. RESULTS: Of the 4 618 076 liveborn infants between 2000 and 2010, 64 861 (1.4%) were conceived using ART. Overall, the prevalence of 1 or more of the selected nonchromosomal defects was 58.59 per 10 000 for ART infants (n = 389) vs 47.50 per 10 000 for non-ART infants (n = 22 036). The association remained significant after adjusting for maternal characteristics and year of birth (adjusted risk ratio [aRR], 1.28; 95% CI, 1.15-1.42). Similar differences were observed for singleton ART births vs their non-ART counterparts (63.69 per 10 000 [n = 218] vs 47.17 per 10 000 [n = 21 251]; aRR, 1.38; 95% CI, 1.21-1.59). Among multiple births, the prevalence of rectal and large intestinal atresia/stenosis was higher for ART births compared with non-ART births (aRR, 2.39; 95% CI, 1.38-4.12). Among ART births conceived after fresh embryo transfer, infants born to mothers with ovulation disorders had a higher prevalence of nonchromosomal birth defects (aRR, 1.53; 95% CI, 1.13-2.06) than those born to mothers without the diagnosis, and use of assisted hatching was associated with birth defects among singleton births (aRR, 1.55; 95% CI, 1.10-2.19). Multiplicity-adjusted P values for these associations were greater than .05. CONCLUSIONS AND RELEVANCE: Infants conceived after ART had a higher prevalence of certain birth defects. Assisted hatching and diagnosis of ovulation disorder were marginally associated with increased risks for nonchromosomal birth defects; however, these associations may be caused by other underlying factors.

Estimates of lifetime infertility from three states: the behavioral risk factor surveillance system.

BACKGROUND: Knowledge of state-specific infertility is limited. The objectives of this study were to explore state-specific estimates of lifetime prevalence of having ever experienced infertility, sought treatment for infertility, types of treatments sought, and treatment outcomes. METHODS: Male and female adult residents aged 18-50 years from three states involved in the States Monitoring Assisted Reproductive Technology Collaborative (Florida, Massachusetts, and Michigan) were asked state-added infertility questions as part of the 2012 Behavioral Risk Factor Surveillance System, a state-based, health-related telephone survey. Analysis involved estimation of lifetime prevalence of infertility. RESULTS: The estimated lifetime prevalence of infertility among 1,285 adults in Florida, 1,302 in Massachusetts, and 3,360 in Michigan was 9.7%, 6.0%, and 4.2%, respectively. Among 736 adults in Florida, 1,246 in Massachusetts, and 2,742 in Michigan that have ever tried to get pregnant, the lifetime infertility prevalence was 25.3% in Florida, 9.9% in Massachusetts, and 5.8% in Michigan. Among those with a history of infertility, over half sought treatment (60.7% in Florida, 70.6% in Massachusetts, and 51.6% in Michigan), the most common being non-assisted reproductive technology fertility treatments (61.3% in Florida, 66.0% in Massachusetts, and 75.9% in Michigan). CONCLUSION: State-specific estimates of lifetime infertility prevalence in Florida, Massachusetts, and Michigan varied. Variations across states are difficult to interpret, as they likely reflect both true differences in prevalence and differences in data collection questionnaires. State-specific estimates are needed for the prevention, detection, and management of infertility, but estimates should be based on a common set of questions appropriate for these goals.

Embryo transfer practices and perinatal outcomes by insurance mandate status.

OBJECTIVE: To use linked assisted reproductive technology (ART) surveillance and birth certificate data to compare ET practices and perinatal outcomes for a state with a comprehensive mandate requiring coverage of IVF services versus states without a mandate. DESIGN: Retrospective cohort study. SETTING: Not applicable. PATIENT(S): Live-birth deliveries ascertained from linked 2007-2009 National ART Surveillance System and birth certificate data for a state with an insurance mandate (Massachusetts) and two states without a mandate (Florida and Michigan). INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Number of embryos transferred, multiple births, low birth weight, preterm delivery. RESULT(S): Of the 230,038 deliveries in the mandate state and 1,026,804 deliveries in the nonmandate states, 6,651 (2.9%) and 8,417 (0.8%), respectively, were conceived by ART. Transfer of three or more embryos was more common in nonmandate states, although the effect was attenuated for women 35 years or older (33.6% vs. 39.7%; adjusted relative risk [RR], 1.46; 95% confidence interval [CI], 1.17-1.81) versus women younger than 35 (7.0% vs. 26.9%; adjusted RR, 4.18; 95% CI, 2.74-6.36). Lack of an insurance mandate was positively associated with triplet/higher order deliveries (1.0% vs. 2.3%; adjusted RR, 2.44; 95% CI, 1.81-3.28), preterm delivery (22.6% vs. 30.7%; adjusted RR, 1.31; 95% CI, 1.20-1.42), and low birth weight (22.3% vs. 29.5%; adjusted RR, 1.28; 95% CI, 1.17-1.40). CONCLUSION(S): Compared with nonmandate states, the mandate state had higher overall rates of ART use. Among ART births, lack of an infertility insurance mandate was associated with increased risk for adverse perinatal outcomes.

Creation and evaluation of a multi-layered maternal and child health database for comparative effectiveness research.

BACKGROUND: As high-speed computers and sophisticated software packages for data linkage become increasingly available, investigators from nearly every arena are creating massive databases for epidemiologic and comparative effectiveness research (CER). Decisions made during database construction have a major impact on the accuracy and completeness of the data. Considering their potential use in informing health-care decisions, it is vital that we increase transparency of these data, including a thorough understanding of the record linkage strategy implemented and an evaluation of linked and unlinked records so that potential biases can be addressed. METHODS: Our target population included infants born to Florida-resident women from January 1, 1998 through December 31, 2009 with a valid birth certificate record. We used a stepwise deterministic record linkage strategy to link to any and all inpatient, ambulatory, and emergency department hospital visits from birth through December 31, 2010, and to identify deaths that occurred within the first year of life. Thus, each infant was followed up for at least 1 year after birth or until death, up to a maximum of 13 years. We investigated linkage rates and associations between linked status (linked vs unlinked) and a host of maternal and infant demographic and reproductive characteristics, all extracted from the birth certificate files. Bivariate county-level maps were created to describe the impact of both maternal race/ethnicity and maternal nativity on the geographic variation in linkage rates. RESULTS: During the 13-year study period, there were 2,549,738 birth certificate records for infants born alive to Florida resident women, and with no indication of an adoption. We were able to link 2,347,738 (92.1 percent) birth certificate records to an infant birth hospitalization record. The highest crude unlinked rates were seen among infants who died during their first year of life (35.9 percent), births in which the documented principal source of payment was "self-pay" (28.1 percent), and infants born to mothers with less than a ninth-grade education (26.0 percent), who were foreign-born (12.9 percent), and who self-identified as Hispanic (12.8 percent). After adjusting for other related and potentially confounding variables, several of these infant and maternal characteristics were associated with increased odds of failure to link infant birth records. CONCLUSION: Using a stepwise deterministic linkage approach, we achieved a high linkage rate of several data sources, and produced a reliable, multipurpose database that can be used for observational, comparative effectiveness, and health services research in maternal and child health (MCH) populations. Our findings underscore the importance of evaluating routinely collected health data and increasing clarity regarding the strengths and limitations of linked electronic data sources. The resultant database will be of immense utility to researchers, health planners, and policy makers as well as other stakeholders interested in MCH outcome studies.

A comparison of two surveillance strategies for selected birth defects in Florida.

OBJECTIVE: We linked data from two independent birth defects surveillance systems with different case-finding methods in an overlapping geographic area to assess Florida's suveillance of birth defects (e.g., neural tube defects, orofacial clefts, gastroschisis/omphalocele, and chromosomal defects), focusing on sensitivity and completeness of ascertainment measures. METHODS: Live-born infants identified from each system born during 2003-2006 in a nine-county catchment area with specific birth defects were linked to birth certificates. Using the enhanced surveillance system as a gold standard, we calculated the sensitivity of the Florida Birth Defects Registry (FBDR) for identifying infants. Next, we used capture-recapture models to estimate the completeness of case ascertainment and the prevalence of each birth defect in the catchment area. We used multivariable logistic regression models with backward elimination to estimate adjusted odds ratios and 95% confidence intervals for factors significantly associated with the FBDR's failure to capture infants ultimately identified by enhanced surveillance. RESULTS: The FBDR's sensitivity was 89.3%, and the overall completeness of ascertainment was estimated as 86.6%. Defect-specific sensitivity and completeness of ascertainment varied significantly by defect. The combined defect-specific sensitivity for all malformations under study was 86.6%; completeness of ascertainment ranged from 45.6% for anencephaly to 88.6% for Down syndrome, 87.9% for spina bifida without anencephaly, and 87.0% for orofacial clefts. CONCLUSIONS: For the defects under study, the FBDR captured nearly nine of every 10 infants born with selected birth defects. However, the FBDR's ability to identify specific defects was both more limited and defect dependent with widely varying defect-specific sensitivities.

The relative contribution of data sources to a birth defects registry utilizing passive multisource ascertainment methods: does a smaller birth defects case ascertainment net lead to overall or disproportionate loss?

Since 1998, the Florida Department of Health (FDOH) has operated the Florida Birth Defects Registry (FBDR), a statewide, population-based, passive surveillance system. Cases are identified by collecting information from extant data sources including the statewide hospital inpatient and ambulatory discharge data sets. Additional data sources include administrative, clinical, and service-related information from the FDOH's Children's Medical Services program for children with special health care needs. Like many state birth defects programs, the FBDR faces diminishing funding and resources that may restrict the registry to hospital discharge data. We conducted an evaluation to quantify the potential under-ascertainment to the FBDR resulting from loss of specific data sources, and to determine if there would be a disproportionate loss of cases by sociodemographic and perinatal characteristics. Analyses involved a series of retrospective reconstructions of the FBDR for 1998-2007 to assess the number of cases that would have been ascertained and reported based on the hypothetical loss of 1 or more of the FBDR source data sets. The reconstructed number of cases identified for each defect category was then compared to the current FBDR (constructed using all 5 source data sets) to determine the proportion of cases that would have been missed if the data sources in question were eliminated. These scenarios were constructed overall and by selected characteristics to identify potential disparities in the proportion of cases missed. The inpatient hospital discharge data set was the primary data source for identification of birth defects in the FBDR. Elimination of this single data source would cause the FBDR to miss nearly three fourths of infants diagnosed with 1 or more of the birth defects under study. Our evaluation revealed that an FBDR constructed on hospital discharge data alone would disproportionately miss more cases born to subgroups of women, including non-Hispanic blacks, Hispanics, and those born outside the US. Despite funding and resource constraints, the FBDR continues efforts to identify data sources that may contribute to completeness of case ascertainment in an effort to serve the needs of the Florida maternal and child health population.

Hepatocellular carcinoma: predisposing conditions and precursor lesions.

The global incidence of HCC is rising; in the United States, its rise is in parallel to that of cirrhosis due to the HCV and obesity epidemics. The lack of adequate treatment for advanced HCC mandates both prevention and early detection of these lesions. The limitations of currently available histopathologic evaluations, serologic markers, and radiographic imaging modalities in detecting HCC and its precursors have been outlined in this review. Refinements of all of these may lead to better HCC detection, earlier intervention, and successful treatment. Randomized controlled trials are necessary to evaluate the most efficacious and cost-effective approach to screening.