ACO leakage among gynecologic cancer patients: Incidence, predictors, and impact on annual Medicare expenditure.

OBJECTIVE: To examine patterns of Accountable Care Organizations (ACO) leakage, the receipt of healthcare by ACO-assigned patients from institutions outside assigned ACO network, among patients with gynecologic cancer. ACO leakage was estimated as rates of patients seeking care external to their ACO assignment. Factors associated with ACO leakage were identified and cost differences within the first year of cancer diagnosis described. METHODS: Medicare 5% data (2013-2017) was used to quantify rates of leakage among gynecologic cancer patients with stable ACO assignment. Crude and multivariable adjusted risk ratios of ACO leakage risk factors were estimated using log-binomial regression models. Overall and cancer-specific spending differences by ACO leakage status were compared using Wilcoxon rank-sum test. RESULTS: Overall incidence of ACO leakage was 28.1% with highest leakage for outpatient care and uterine cancer patients. ACO leakage risk was 56% higher among Black relative to White patients, and 77% more for those in higher relative to lowest quintiles of median household income. Leakage decreased by 3% and 8% with each unit increase in ACO size and number of subspecialists, respectively. Healthcare costs were 19.5% higher for leakage patients. CONCLUSIONS: ACO leakage rates among gynecologic cancer patients was overall modest, with some regional and temporal variation, higher leakage for certain subgroups and substantially higher Medicare spending in inpatient and outpatient settings for patients with ACO leakage. These findings identify targets for further investigations and strategies to encourage oncologists to participate in ACOs and prevent increased health care costs associated with use of non-ACO providers.

Racial and Rural-Urban Disparities in Maternal Cardiac Disease Care in North Carolina: A Call to Action.

Background: Cardiac disease is a leading cause of severe maternal morbidity (SMM). We sought to estimate the effects of race and rural-urban status on cardiac-specific severe maternal morbidity ("cardiac SMM") in North Carolina. Methods: This retrospective study used the 2019 North Carolina State Inpatient Database (SID). Diagnosis codes were used to identify births, comorbidities, modified World Health Organization (mWHO) cardiac category, and outcomes. Hospital-level data were obtained from publicly available sources and the SID datasets. The primary outcome was a composite of cardiac SMM. Results: Of 106,778 births, 369 had mWHO category I-II disease, and 366 had mWHO category II/III-IV disease. Individuals with cardiac disease had higher rates of cardiac SMM (10.4% versus 0.27% versus 0.13% for mWHO II/III-IV, mWHO I/II, and no disease, respectively). Among patients with mWHO II/III-IV disease, 60.0% of rural residents delivered at hospitals with advanced cardiac capabilities versus 80.8% of urban residents; there were no statistically significant differences in cardiac SMM rates (11.3% versus 10.1% for rural versus urban individuals, P = NS). In contrast, there were pronounced disparities in cardiac SMM among Black individuals compared with White individuals (0.28% versus 0.13%, P < .001), especially among individuals with mWHO II/III-IV disease (23.71% versus 5.41%, P < .001). Limitations: Cardiac disease and outcomes were identified based on diagnosis and procedure codes. Identifying complications subsequent to the delivery hospitalization was not possible. Conclusions: In North Carolina, there is a pronounced racial disparity in cardiac SMM during delivery hospitalizations, which is driven by patients with mWHO II/III-IV disease.

Evidence Based Management of Labor.

Importance: Induction of labor (IOL) is a common obstetric intervention. Augmentation of labor and active management of the second stage is frequently required in obstetric practice. However, techniques around labor and induction management vary widely. Evidence-based practice regarding induction and labor management can reduce birth complications such as infection and hemorrhage and decrease rates of cesarean delivery. Objective: To review existing evidence on IOL and labor management strategies with respect to preparing for induction, cervical ripening, induction and augmentation, and second stage of labor techniques. Evidence acquisition: Review of recent original research, review articles, and guidelines on IOL using PubMed (2000-2022). Results: Preinduction, pelvic floor training and perineal massage reduce postpartum urinary incontinence and perineal trauma, respectively. Timely membrane sweeping (38 weeks) can promote spontaneous labor and prevent postterm inductions. Outpatient Foley bulb placement in low-risk nulliparous patients with planned IOL reduces time to delivery. Inpatient Foley bulb use beyond 6 to 12 hours shows no benefit. When synthetic prostaglandins are indicated, vaginal misoprostol should be preferred. For nulliparous patients and those with obesity, oxytocin should be titrated using a high-dose protocol. Once cervical dilation is complete, pushing should begin immediately. Warm compresses and perineal massage decrease risk of perineal trauma. Conclusion and relevance: Several strategies exist to assist in successful IOL and promote vaginal delivery. Evidence-based strategies should be used to improve outcomes and decrease risk of complications and cesarean delivery. Recommendations should be shared across interdisciplinary team members, creating a model that promotes safe patient care.

CenteringPregnancy: A Review of Implementation and Outcomes.

Importance: CenteringPregnancy (CP) is a model for group prenatal care associated with improved perinatal outcomes for preterm birth and low birthweight, increased rates of breastfeeding, and higher rates of patient and clinician satisfaction. Objective: The study aims to review the literature related to perinatal outcomes associated with CP, benefits and barriers to implementation, and utility of the model. Evidence: An electronic-based search was performed in PubMed using the search terms "CenteringPregnancy" OR "Centering Pregnancy," revealing 221 articles. Results: The CP model improves patient centeredness, efficiency, and equality in prenatal care. Challenges include administrative buy-in, limited resources, and financial support. Multisite retrospective studies of CP demonstrate improved maternal, neonatal, postpartum, and well-being outcomes, especially for participants from minority backgrounds; however, prospective studies had mixed results. CenteringPregnancy is feasibly implemented with high tenet fidelity in several low- and middle-income settings with improved perinatal outcomes compared with traditional care. Conclusions: CenteringPregnancy is feasible to implement, largely accepted by communities, and shows positive qualitative and quantitative health outcomes. This body of literature supports CP as a potential tool for decreasing racial inequalities in prenatal access, quality of care, and maternal mortality. Further investigation is necessary to inform obstetric clinicians about the potential outcome differences that exist between group and traditional prenatal care.