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1.
Contemp Clin Trials Commun ; 25: 100878, 2022 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-34977421

RESUMO

Background: Insulin-dependent diabetes is a challenging disease to manage and involves complex behaviors, such as self-monitoring of blood glucose. This can be especially challenging in the face of socioeconomic barriers and in the wake of the COVID-19 pandemic. Digital health self-monitoring interventions and community health worker support are promising and complementary best practices for improving diabetes-related health behaviors and outcomes. Yet, these strategies have not been tested in combination. This protocol paper describes the rationale and design of a trial that measures the combined effect of digital health and community health worker support on glucose self-monitoring and glycosylated hemoglobin. Methods: The study population was uninsured or publicly insured; lived in high-poverty, urban neighborhoods; and had poorly controlled diabetes mellitus with insulin dependence. The study consisted of three arms: usual diabetes care; digital health self-monitoring; or combined digital health and community health worker support. The primary outcome was adherence to blood glucose self-monitoring. The exploratory outcome was change in glycosylated hemoglobin. Conclusion: The design of this trial was grounded in social justice and community engagement. The study protocols were designed in collaboration with frontline community health workers, the study aim was explicit about furthering knowledge useful for advancing health equity, and the population was focused on low-income people. This trial will advance knowledge of whether combining digital health and community health worker interventions can improve glucose self-monitoring and diabetes-related outcomes in a high-risk population.

3.
J Card Fail ; 27(9): 965-973, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34048918

RESUMO

BACKGROUND: Socioeconomic data may improve predictions of clinical events. However, owing to structural racism, algorithms may not perform equitably across racial subgroups. Therefore, we sought to compare the predictive performance overall, and by racial subgroup, of commonly used predictor variables for heart failure readmission with and without the area deprivation index (ADI), a neighborhood-level socioeconomic measure. METHODS AND RESULTS: We conducted a retrospective cohort study of 1316 Philadelphia residents discharged with a primary diagnosis of congestive heart failure from the University of Pennsylvania Health System between April 1, 2015, and March 31, 2017. We trained a regression model to predict the probability of a 30-day readmission using clinical and demographic variables. A second model also included the ADI as a predictor variable. We measured predictive performance with the Brier Score (BS) in a held-out test set. The baseline model had moderate performance overall (BS 0.13, 95% CI 0.13-0.14), and among White (BS 0.12, 95% CI 0.12-0.13) and non-White (BS 0.13, 95% CI 0.13-0.14) patients. Neither performance nor algorithmic equity were significantly changed with the addition of the ADI. CONCLUSIONS: The inclusion of neighborhood-level data may not reliably improve performance or algorithmic equity.


Assuntos
Insuficiência Cardíaca , Readmissão do Paciente , Centros Médicos Acadêmicos , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/terapia , Humanos , Características de Residência , Estudos Retrospectivos , Fatores de Risco
4.
Healthc (Amst) ; 8(4): 100456, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32992103

RESUMO

BACKGROUND: Low-income women using prenatal care have shared concerns as well as unique needs not met by traditional prenatal care. Our objective was to explore user ideas on addressing unmet needs driving unscheduled care utilization and use findings to inform interventions to improve perinatal outcomes. METHODS: We performed a secondary analysis of qualitative interviews among purposively sampled, Medicaid-insured pregnant women with varied degrees of unscheduled care utilization. Interviews explored barriers and facilitators of health and ideas for improvement in care delivery, with a focus on the potential role of community health workers and social support. We extracted material on participants' perceived gaps and ideas, used modified grounded theory to develop general and subset themes by study group, and then mapped themes to potential intervention features. RESULTS: We identified intervention targets in three thematic domains: social support, care delivery, and access, noting sub-group differences. Participants with four or more unscheduled visits during pregnancy ("Group 1") wanted individualized help navigating resources, coaching, and peer support, while participants with a first unscheduled care visit after 36 weeks of pregnancy ("Group 2) wanted these services to be optional. Group 1 participants wanted flexible appointments, less wait time, discharge education and improved communication with providers, while Group 2 participants sought stable insurance coverage. CONCLUSIONS: Findings suggest acceptable approaches to improve social support, care delivery, and access via stratified, targeted interventions. IMPLICATIONS: Targeted interventions to improve prenatal care that incorporate user ideas and address unique unmet needs of specific subgroups may improve perinatal outcomes. LEVEL OF EVIDENCE: III.


Assuntos
Medicaid/estatística & dados numéricos , Gestantes/psicologia , Cuidado Pré-Natal/normas , Adulto , Agendamento de Consultas , Feminino , Humanos , Medicaid/organização & administração , Gravidez , Cuidado Pré-Natal/psicologia , Cuidado Pré-Natal/estatística & dados numéricos , Pesquisa Qualitativa , Qualidade da Assistência à Saúde/normas , Qualidade da Assistência à Saúde/estatística & dados numéricos , Apoio Social , Estados Unidos
5.
Health Serv Res ; 55 Suppl 2: 894-901, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32643163

RESUMO

OBJECTIVE: To analyze the effects of a standardized community health worker (CHW) intervention on hospitalization. DATA SOURCES/STUDY SETTING: Pooled data from three randomized clinical trials (n = 1340) conducted between 2011 and 2016. STUDY DESIGN: The trials in this pooled analysis were conducted across diseases and settings, with a common study design, intervention, and outcome measures. Participants were patients living in high-poverty regions of Philadelphia and were predominantly Medicaid insured. They were randomly assigned to receive usual care versus IMPaCT, an intervention in which CHWs provide tailored social support, health behavior coaching, connection with resources, and health system navigation. Trial one (n = 446) tested two weeks of IMPaCT among hospitalized general medical patients. Trial two (n = 302) tested six months of IMPaCT among outpatients at two academic primary care clinics. Trial three (n = 592) tested six months of IMPaCT among outpatients at academic, Veterans Affairs (VA), and Federally Qualified Health Center primary care practices. DATA COLLECTION/EXTRACTION METHODS: The primary outcome for this study was all-cause hospitalization, as measured by total number of hospital days per patient. Hospitalization data were collected from statewide or VA databases at 30 days postenrollment in Trial 1, twelve months postenrollment in Trial 2, and nine months postenrollment in Trial 3. PRINCIPAL FINDINGS: Over 9398 observed patient months, the total number of hospital days per patient in the intervention group was 66 percent of the total in the control group (849 days for 674 intervention patients vs 1258 days for 660 control patients, incidence rate ratio (IRR) 0.66, P < .0001). This reduction was driven by fewer hospitalizations per patient (0.27 vs 0.34, P < .0001) and shorter mean length of stay (4.72 vs 5.57 days, P = .03). The intervention also decreased rates of hospitalization outside patients' primary health system (18.8 percent vs 34.8 percent, P = .0023). CONCLUSIONS: Data from three randomized clinical trials across multiple settings show that a standardized CHW intervention reduced total hospital days and hospitalizations outside the primary health system. This is the largest analysis of randomized trials to demonstrate reductions in hospitalization with a health system-based social intervention.


Assuntos
Agentes Comunitários de Saúde/organização & administração , Hospitalização/estatística & dados numéricos , Múltiplas Afecções Crônicas/terapia , Pobreza/estatística & dados numéricos , Adulto , Idoso , Feminino , Nível de Saúde , Humanos , Masculino , Medicaid/estatística & dados numéricos , Saúde Mental , Pessoa de Meia-Idade , Philadelphia , Método Simples-Cego , Fatores Socioeconômicos , Estados Unidos , Populações Vulneráveis
8.
Health Aff (Millwood) ; 39(2): 207-213, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-32011942

RESUMO

Interventions that address socioeconomic determinants of health are receiving considerable attention from policy makers and health care executives. The interest is fueled in part by expected returns on investment. However, many current estimates of returns on investment are likely overestimated, because they are based on pre-post study designs that are susceptible to regression to the mean. We present a return-on-investment analysis that is based on a randomized controlled trial of Individualized Management for Patient-Centered Targets (IMPaCT), a standardized community health worker intervention that addresses unmet social needs for disadvantaged people. We found that every dollar invested in the intervention would return $2.47 to an average Medicaid payer within the fiscal year.


Assuntos
Agentes Comunitários de Saúde , Medicaid , Atenção à Saúde , Humanos , Investimentos em Saúde , Fatores Socioeconômicos , Estados Unidos
11.
Stat Methods Med Res ; 28(4): 1094-1104, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-29254442

RESUMO

In classical study designs, the aim is often to learn about the effects of a treatment or intervention on a single outcome; in many modern studies, however, data on multiple outcomes are collected and it is of interest to explore effects on multiple outcomes simultaneously. Such designs can be particularly useful in patient-centered research, where different outcomes might be more or less important to different patients. In this paper, we propose scaled effect measures (via potential outcomes) that translate effects on multiple outcomes to a common scale, using mean-variance and median-interquartile range based standardizations. We present efficient, nonparametric, doubly robust methods for estimating these scaled effects (and weighted average summary measures), and for testing the null hypothesis that treatment affects all outcomes equally. We also discuss methods for exploring how treatment effects depend on covariates (i.e., effect modification). In addition to describing efficiency theory for our estimands and the asymptotic behavior of our estimators, we illustrate the methods in a simulation study and a data analysis. Importantly, and in contrast to much of the literature concerning effects on multiple outcomes, our methods are nonparametric and can be used not only in randomized trials to yield increased efficiency, but also in observational studies with high-dimensional covariates to reduce confounding bias.


Assuntos
Pesquisa Biomédica , Resultado do Tratamento , Algoritmos , Pesquisa Biomédica/estatística & dados numéricos , Causalidade
12.
JAMA Intern Med ; 178(12): 1635-1643, 2018 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-30422224

RESUMO

Importance: Addressing the social determinants of health has been difficult for health systems to operationalize. Objective: To assess a standardized intervention, Individualized Management for Patient-Centered Targets (IMPaCT), delivered by community health workers (CHWs) across 3 health systems. Design, Setting, and Participants: This 2-armed, single-blind, multicenter randomized clinical trial recruited patients from 3 primary care facilities in Philadelphia, Pennsylvania, between January 28, 2015, and March 28, 2016. Patients who resided in a high-poverty zip code, were uninsured or publicly insured, and who had a diagnosis for 2 or more chronic diseases were recruited, and patients were randomized to either the CHW intervention or the control arm (goal setting only). Follow-up assessments were conducted at 6 and 9 months after enrollment. Data were analyzed using an intention-to-treat approach from June 2017 to March 2018. Intervention: Participants set a chronic disease management goal with their primary care physician; those randomized to the CHW intervention received 6 months of tailored support. Main Outcomes and Measures: The primary outcome was change in self-rated physical health. The secondary outcomes were self-rated mental health, chronic disease control, patient activation, patient-reported quality of primary care, and all-cause hospitalization. Results: Of the 592 participants, 370 (62.5%) were female, with a mean (SD) age of 52.6 (11.1) years. Participants in both arms had similar improvements in self-rated physical health (mean [SD], 1.8 [11.2] vs 1.6 [9.9]; P = .89). Patients in the intervention group were more likely to report the highest quality of care (odds ratio [OR], 1.8; 95% CI, 1.4-2.4; risk difference [RD], 0.12; P < .001) and spent fewer total days in the hospital at 6 months (155 days vs 345 days; absolute event rate reduction, 69%) and 9 months (300 days vs 471 days; absolute event rate reduction, 65%). This reduction was driven by a shorter average length of stay (difference, -3.1 days; 95% CI, -6.33 to 0.22; P = .06) and a lower mean number of hospitalizations (difference, -0.3; 95% CI, -0.6 to 0.0; P = .07) among patients who were hospitalized. Patients in the intervention group had a lower odds of repeat hospitalizations (OR, 0.4; 95% CI, 0.2-0.9; RD, -0.24; P = .02), including 30-day readmissions (OR, 0.3; 95% CI, 0.1-0.9; RD, -0.17; P = .04). Conclusions and Relevance: A standardized intervention did not improve self-rated health but did improve the patient-perceived quality of care while reducing hospitalizations, suggesting that health systems may use a standardized intervention to address the social determinants of health. Trial Registration: ClinicalTrials.gov identifier: NCT02347787.


Assuntos
Agentes Comunitários de Saúde , Atenção à Saúde/organização & administração , Pobreza , Atenção Primária à Saúde/organização & administração , Adulto , Idoso , Doença Crônica , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Método Simples-Cego
13.
J Gen Intern Med ; 33(10): 1700-1707, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29992429

RESUMO

BACKGROUND: Heart failure patients have high 30-day hospital readmission rates. Interventions designed to prevent readmissions have had mixed success. Understanding heart failure home management through the patient's experience may reframe the readmission "problem" and, ultimately, inform alternative strategies. OBJECTIVE: To understand patient and caregiver challenges to heart failure home management and perceived reasons for readmission. DESIGN: Observational qualitative study. PARTICIPANTS: Heart failure patients were recruited from two hospitals and included those who were hospitalized for heart failure at least twice within 30 days and those who had been recently discharged after their first heart failure admission. APPROACH: Open-ended, semi-structured interviews. Conclusions vetted using focus groups. KEY RESULTS: Semi-structured interviews with 31 patients revealed a combination of physical and socio-emotional influences on patients' home heart failure management. Major themes identified were home management as a struggle between adherence and adaptation, and hospital readmission as a rational choice in response to distressing symptoms. Patients identified uncertainty regarding recommendations, caused by unclear instructions and temporal incongruence between behavior and symptom onset. This uncertainty impaired their competence in making routine management decisions, resulting in a cycle of limit testing and decreasing adherence. Patients reported experiencing hopelessness and frustration in response to perceiving a deteriorating functional status. This led some to a cycle of despair characterized by worsening adherence and negative emotions. As these cycles progressed and distressing symptoms worsened, patients viewed the hospital as the safest place for recovery and not a "negative" outcome. CONCLUSION: Cycles of limit testing and despair represent important patient-centered struggles in managing heart failure. The resulting distress and fear make readmission a rational choice for patients rather than a negative outcome. Interventions (e.g., palliative care) that focus on methods to address these patient-centered factors should be further studied rather than methods to reduce hospital readmissions.


Assuntos
Atitude Frente a Saúde , Insuficiência Cardíaca/terapia , Serviços de Assistência Domiciliar , Readmissão do Paciente/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Comportamento de Escolha , Emoções , Feminino , Grupos Focais , Insuficiência Cardíaca/psicologia , Hospitalização/estatística & dados numéricos , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Cooperação do Paciente/estatística & dados numéricos , Avaliação de Resultados da Assistência ao Paciente , Philadelphia , Pesquisa Qualitativa , Fatores Socioeconômicos , Falha de Tratamento
14.
Am Heart J ; 200: 75-82, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29898852

RESUMO

BACKGROUND: Capturing and incorporating patient-centered factors into 30-day readmission risk prediction after hospitalized heart failure (HF) could improve the modest performance of current models. METHODS: Using a mixed-methods approach, we developed a patient-centered survey and evaluated the additional predictive utility of the survey compared to a traditional readmission risk model (the Krumholz et al. model). Area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow goodness-of-fit statistic quantified the performance of both models. We measured the amount of model improvement with the addition of patient-centered factors to the Krumholz et al. model with the integrated discrimination improvement (IDI). In an exploratory analysis, we used hierarchical clustering algorithms to identify groups with similar survey responses and tested for differences between clusters using standard descriptive statistics. RESULTS: From 3/24/2014 to 3/12/2015, 183 patients hospitalized with HF were enrolled from an urban, academic health system and followed for 30days after discharge. The Krumholz et al. plus patient-centered factors model had similar-to-slightly lower performance (AUC [95%CI]:0.62 [0.52, 0.71]; goodness-of-fit P=.10) than the Krumholz et al. model (AUC [95%CI]:0.66 [0.57, 0.76]; goodness-of-fit P=.19). The IDI (95%CI) was 0.003 (-0.014,0.020). We identified three patient clusters based on patient-centered survey responses. The clusters differed with respect to gender, self-rated health, employment status, and prior hospitalization frequency (all P<.05). CONCLUSIONS: The addition of patient-centered factors did not improve 30-day readmission model performance. Rather than designing interventions based on predicted readmission risk, tailoring interventions to all patients, based on their characteristics, could inform the design of targeted, readmission reduction strategies.


Assuntos
Insuficiência Cardíaca , Readmissão do Paciente/estatística & dados numéricos , Assistência Centrada no Paciente/métodos , Idoso , Área Sob a Curva , Análise por Conglomerados , Comorbidade , Demografia , Feminino , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/terapia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Curva ROC , Medição de Risco/métodos , Fatores de Risco , Fatores Socioeconômicos , Inquéritos e Questionários , Estados Unidos
15.
Med Care ; 56(8): 719-726, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29939912

RESUMO

BACKGROUND: Half of all Americans have a chronic disease. Promoting healthy behaviors to decrease this burden is a national priority. A number of behavioral interventions have proven efficacy; yet even the most effective of these has high levels of nonresponse. OBJECTIVES: In this study, we explore variation in response to an evidence-based community health worker (CHW) intervention for chronic disease management. RESEARCH DESIGN: We used a convergent parallel design that combined a randomized controlled trial with a qualitative process evaluation that triangulated chart abstraction, in-depth interviews and participant observation. SUBJECTS: Eligible patients lived in a high-poverty region and were diagnosed with 2 or more of the following chronic diseases: diabetes, obesity, hypertension or tobacco dependence. There were 302 patients in the trial, 150 of whom were randomly assigned to the CHW intervention. Twenty patients and their CHWs were included in the qualitative evaluation. RESULTS: We found minimal differences between responders and nonresponders by sociodemographic or clinical characteristics. A qualitative process evaluation revealed that health behavior change was challenging for all patients and most experienced failure (ie, gaining weight or relapsing with cigarettes) along the way. Responders seemed to increase their resolve after failed attempts at health behavior change, while nonresponders became discouraged and "shut down." CONCLUSIONS: Failure is a common and consequential aspect of health behavior change; a deeper understanding of failure should inform chronic disease interventions.


Assuntos
Doença Crônica/terapia , Agentes Comunitários de Saúde/organização & administração , Comportamentos Relacionados com a Saúde , Cooperação do Paciente/estatística & dados numéricos , Adulto , Serviços de Saúde Comunitária/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Pobreza , Resultado do Tratamento
16.
Acad Emerg Med ; 25(9): 1004-1013, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29741232

RESUMO

BACKGROUND: A significant proportion of low-acuity emergency department (ED) visits are by patients under 18 years of age. Results from prior interventions designed to reduce low-acuity pediatric ED use have been mixed or poorly sustained, perhaps because they were not informed by patient and caretakers' perspectives. The objective of this study was to explore caretaker decision-making processes, values, and priorities when deciding to seek care. METHODS: We conducted semistructured interviews of caretakers in both emergency and primary care settings, incorporating stimulated recall methodology. We also explored receptiveness to two care delivery innovations: use of community health workers (CHWs) and video teleconferencing. RESULTS: Interviews of 57 caretakers identified multiple barriers to accessing primary care for their children's acute illness, including transportation, work constraints, and childcare. Frequent ED users lacked reliable social supports to overcome barriers. Fear of unforeseen health outcomes and a lack of trust in unfamiliar providers also influenced decision-making, rather than lack of general knowledge about minor illness. Receptiveness to CHWs was mixed, reflecting concerns for privacy and level of expertise. The option of video teleconferencing for low-acuity care was well received by caretakers. CONCLUSIONS: Caretakers who used the ED frequently had limited social support and reported difficulty accessing care when compared to other caretakers. Fear also motivated care seeking and a desire for immediate medical care. Teleconferencing for low-acuity visits may be a useful health care delivery tool to reduce access barriers and provide rapid reassurance without engaging the ED.


Assuntos
Cuidadores/psicologia , Tomada de Decisões , Serviço Hospitalar de Emergência/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Adulto , Criança , Feminino , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Masculino , Aceitação pelo Paciente de Cuidados de Saúde/etnologia , Atenção Primária à Saúde/estatística & dados numéricos , Pesquisa Qualitativa , Índice de Gravidade de Doença
17.
J Health Care Poor Underserved ; 29(2): 581-590, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29805124

RESUMO

Medical students often lack training in understanding and addressing the social determinants that shape the health of high-risk populations. We describe a novel clinical elective rotation in which fourth-year medical students served as apprentices to community health workers in order to develop community engagement skills and cultural humility.


Assuntos
Agentes Comunitários de Saúde , Educação Médica/organização & administração , Determinantes Sociais da Saúde , Estudantes de Medicina/psicologia , Estudos de Avaliação como Assunto , Feminino , Humanos , Aprendizagem , Masculino , Estudantes de Medicina/estatística & dados numéricos
19.
Am J Public Health ; 107(10): 1660-1667, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-28817334

RESUMO

OBJECTIVES: To determine whether a community health worker (CHW) intervention improved outcomes in a low-income population with multiple chronic conditions. METHODS: We conducted a single-blind, randomized clinical trial in Philadelphia, Pennsylvania (2013-2014). Participants (n = 302) were high-poverty neighborhood residents, uninsured or publicly insured, and diagnosed with 2 or more chronic diseases (diabetes, obesity, tobacco dependence, hypertension). All patients set a disease-management goal. Patients randomly assigned to CHWs also received 6 months of support tailored to their goals and preferences. RESULTS: Support from CHWs (vs goal-setting alone) led to improvements in several chronic diseases (changes in glycosylated hemoglobin: -0.4 vs 0.0; body mass index: -0.3 vs -0.1; cigarettes per day: -5.5 vs -1.3; systolic blood pressure: -1.8 vs -11.2; overall P = .08), self-rated mental health (12-item Short Form survey; 2.3 vs -0.2; P = .008), and quality of care (Consumer Assessment of Healthcare Providers and Systems; 62.9% vs 38%; P < .001), while reducing hospitalization at 1 year by 28% (P = .11). There were no differences in patient activation or self-rated physical health. CONCLUSIONS: A standardized CHW intervention improved chronic disease control, mental health, quality of care, and hospitalizations and could be a useful population health management tool for health care systems. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT01900470.


Assuntos
Agentes Comunitários de Saúde/organização & administração , Saúde Mental , Múltiplas Afecções Crônicas/terapia , Pobreza , Populações Vulneráveis , Adulto , Idoso , Pressão Sanguínea , Índice de Massa Corporal , Feminino , Hemoglobina A Glicada/análise , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Philadelphia , Qualidade da Assistência à Saúde/organização & administração , Método Simples-Cego , Fumar/epidemiologia , Fatores Socioeconômicos
20.
Womens Health Issues ; 27(4): 441-448, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28286001

RESUMO

BACKGROUND: Pregnant high utilizers of unscheduled care may be at particular risk for poor perinatal outcomes, but the drivers of this association have not been explored from the patient perspective. PURPOSE: We sought to understand maternal preference for unscheduled hospital-based obstetric care to inform interventions and improve value of publicly funded care during pregnancy. METHODS: We conducted a comparative qualitative analysis of in-depth semistructured interviews. Low-income pregnant women presenting to an inner city hospital-based obstetric triage unit were purposively sampled, categorized as either high or low utilizers of unscheduled care, and interviewed about challenges faced in obtaining pregnancy care and reasons for choosing between unscheduled versus scheduled care delivery. RESULTS: Demographically, high utilizers were similar to low utilizers, but were more likely to report adverse childhood experiences (p = .01). All 40 participants reported resource constraints and perceived hospital-based unscheduled obstetric care to be more accessible than outpatient prenatal care. Beyond this, high (n = 20) and low (n = 20) utilizer narratives differed significantly. Two distinct high utilizer profiles emerged. Some high utilizers repetitively used unscheduled hospital-based services owing to psychosocial determinants. Other high utilizing participants were driven by severe experiences of illness insufficiently addressed by outpatient prenatal care. Low utilizer narratives demonstrated high self-efficacy and social support compared with high utilizers. CONCLUSIONS: Low-value, unscheduled, hospital-based care utilization by pregnant women of low socioeconomic status was driven by unmet clinical and psychosocial need. IMPLICATIONS FOR POLICY AND/OR PRACTICE: Tailored community-focused innovations that use unscheduled visits as signals of risk may improve value of both outpatient and inpatient maternity care and better address adverse perinatal outcomes in vulnerable subgroups.


Assuntos
Agendamento de Consultas , Parto Obstétrico , Pobreza , Gestantes/psicologia , Cuidado Pré-Natal/estatística & dados numéricos , Adulto , Atenção à Saúde , Feminino , Hospitalização , Humanos , Renda , Entrevistas como Assunto , Parto , Gravidez , Resultado da Gravidez , Pesquisa Qualitativa , Classe Social
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