Severe preterm preeclampsia: an examination of outcomes by race.

BACKGROUND: Preeclampsia complicates 5% to 8% of all pregnancies. Previous studies have examined the maternal morbidity and mortality associated with preeclampsia and the expectant management of severe preterm preeclampsia. However, these studies either did not comment on outcomes by race or were primarily made up of nonblack participants. OBJECTIVE: This study aimed to determine whether maternal morbidity associated with the expectant management of severe preterm preeclampsia varied by race. STUDY DESIGN: We performed a retrospective cohort study of women with a diagnosis of severe preterm preeclampsia at <34 weeks' gestation between 2008 and 2017 at our institution. Severe preterm preeclampsia was defined by current American College of Obstetricians and Gynecologists guidelines. The primary outcome was a maternal morbidity composite, defined as experiencing ≥1 of the following: hemolysis, elevated liver enzymes, and low platelet count; eclampsia; pulmonary edema; severe renal dysfunction; abruption; maternal intensive care unit admission; venous thromboembolism; blood transfusion; hysterectomy; stroke; or death. Secondary outcomes included a composite of neonatal morbidity. Outcomes were compared between self-reported black and nonblack women. RESULTS: In this study, 275 women were included; among those women, 91 (33%) were nonblack, and 184 (67%) were black. In addition, 203 of 275 women (approximately 74%) underwent expectant management with no difference by race (75.8% of nonblack vs 72.8% of black women; P=.6). When examining maternal morbidity, 62 of the expectantly managed women (30.5%) developed the composite maternal morbidity outcome, with no difference by race (27.5% of nonblack vs 32.1% of black women; P=.5) even when adjusting for confounders such as maternal age, body mass index, and parity (adjusted odds ratio, 1.02; 95% confidence interval, 0.97-1.35). The median time from diagnosis to delivery (latency time) was 3 days, with no difference between the 2 groups (P=.9) and no difference in neonatal morbidity (60.9% nonblack vs 53% black; P=.3). CONCLUSION: Within our population, there were no differences in maternal outcomes between black and nonblack women who were undergoing expectant management of severe preterm preeclampsia. More research is needed to determine if the known disparities in maternal morbidity among races are due to factors beyond the antepartum management of severe preterm preeclampsia.

Patient-Centered Care Transitions After Injury Hospitalization: A Comparative Effectiveness Trial.

OBJECTIVE: The investigation aimed to compare two approaches to the delivery of care for hospitalized injury survivors, a patient-centered care transition intervention versus enhanced usual care. METHOD: This pragmatic comparative effectiveness trial randomized 171 acutely injured trauma survivors with three or more early postinjury concerns and high levels of emotional distress to intervention (I; n = 85) and enhanced usual care control (C; n = 86) conditions. The care transition intervention components included care management that elicited and targeted improvement in patients' postinjury concerns, 24/7 study team cell phone accessibility, and stepped-up care. Posttraumatic concerns, symptomatic distress, functional status, and statewide emergency department (ED) service utilization were assessed at baseline and over the course of the 12 months after injury. Regression analyses assessed intervention and control group outcome differences over time. RESULTS: Over 80% patient follow-up was attained at each time point. Intervention patients demonstrated clinically and statistically significant reductions in the percentage of any severe postinjury concerns expressed when compared to controls longitudinally (Wald chi-square = 11.29, p = 0.01) and at the six-month study time point (C = 74%, I = 53%; Fisher's exact test, p = 0.02). Comparisons of ED utilization data yielded clinically significant cross-sectional differences (one or more three- to six-month ED visits; C = 30.2%, I = 16.5%, [relative risk (95% confidence interval] C versus I = 2.00 (1.09, 3.70), p = 0.03) that did not achieve longitudinal statistical significance (F (3, 507) = 2.24, p = 0.08). The intervention did not significantly impact symptomatic or functional outcomes. CONCLUSIONS: Orchestrated investigative and policy efforts should continue to evaluate patient-centered care transition interventions to inform American College of Surgeons' clinical guidelines for U.S. trauma care systems.

Enhancing the Reach of Cognitive-Behavioral Therapy Targeting Posttraumatic Stress in Acute Care Medical Settings.

OBJECTIVE: Injured patients presenting to acute care medical settings have high rates of posttraumatic stress disorder (PTSD) and comorbidities, such as depression and substance use disorders. Integrating behavioral interventions that target symptoms of PTSD and comorbidities into the acute care setting can overcome common barriers to obtaining mental health care. This study examined the feasibility and acceptability of embedding elements of cognitive-behavioral therapy (CBT) in the delivery of routine postinjury care management. The investigation also explored the potential effectiveness of completion of CBT element homework that targeted PTSD symptom reduction. METHODS: This study was a secondary analysis of data from a U.S. clinical trial of the effectiveness of a stepped collaborative care intervention versus usual care for injured inpatients. The investigation examined patients' willingness at baseline (prerandomization) to engage in CBT and pre- and postrandomization mental health service utilization among 115 patients enrolled in the clinical trial. Among intervention patients (N=56), the investigation examined acceptability of the intervention and used multiple linear regression to examine the association between homework completion as reported by the care manager and six-month PTSD symptom reduction as assessed by the PTSD Checklist-Civilian DSM-IV Version. RESULTS: Patients in the intervention condition reported obtaining significantly more psychotherapy or counseling than patients in the control group during the six-month follow-up, as well as a high degree of intervention acceptability. Completion of CBT element homework assignments was associated with improvement in PTSD symptoms. CONCLUSIONS: Integrating behavioral interventions into routine acute care service delivery may improve the reach of evidence-based mental health care targeting PTSD.