Estimating maternal mortality in Monseñor Nouel Province, Dominican Republic.

OBJECTIVES: Maternal deaths are estimated by the World Health Organization at over 500,000 annually. Various methods of calculating mortality ratios have been utilized throughout the world, but many are inaccurate. The purpose of this study was to measure maternal mortality by using a sibling survivorship survey and by recording and tracking death certificates. METHODS: The data for the survey were collected within a specific province in the Dominican Republic that represents predominately rural communities. Interviews with 2,180 women and data from their 17,807 siblings were recorded, 9,723 of which were sisters. The Death Certificate data were obtained by tracking 3,430 records at the local government office in the same province. RESULTS: The results from the rural sibling survey show a maternal mortality ratio significantly higher than other national estimates (348/100,000 live births versus 72-250/100,000). Data collection methods are discussed, including government record keeping and potential sources of inaccuracy. CONCLUSION: Reported maternal mortality ratios may not portray the true magnitude of the poor health status of women in developing countries.

Medicaid medical directors quality improvement studies: a case study of evolving methods for a research network.

OBJECTIVE: To describe the evolution of methods and share lessons learned from conducting multi-state studies with Medicaid Medical Directors (MMD) using state administrative data. There was a great need for these studies, but also much to be learned about conducting network-based research and ensuring comparability of results. METHODS: This was a network-level case study. The findings were drawn from the experience developing and executing network analyses with the MMDs, as well as from participant feedback on lessons learned. For the latter, nine interviews with MMD project leads, state data analysts, and outside researchers involved with the projects were conducted. Interviews were transcribed, coded and analyzed using NVivo 10.0 analytic software. FINDINGS: MMD study methodology involved many steps: developing research questions, defining data specifications, organizing an aggregated data collection spreadsheet form, assuring quality through review, and analyzing and reporting state data at the national level. State analysts extracted the data from their state Medicaid administrative (claims) databases (and sometimes other datasets). Analysis at the national level aggregated state data overall, by demographics and other sub groups, and displayed descriptive statistics and cross-tabs. CONCLUSIONS: Projects in the MMD multi-state network address high-priority clinical issues in Medicaid and impact quality of care through sharing of data and policies among states. Further, these studies contribute not only to high-quality, cost-effective health care for Medicaid beneficiaries, but also add to our knowledge of network-based research. Continuation of these studies requires funding for a permanent research infrastructure nationally, as well as at the state-level to strengthen capacity.

Importance of the medicaid medical directors' multistate collaborative for improving care in medicaid.

INTRODUCTION: There are many benefits of multistate collaboratives or networks to states, but at the center is that they allow for the opportunity to learn from other states and experts about the practices and policies states have implemented without the significant time lag of published research. This commentary examines these benefits and illustrates the importance of quality improvement collaborations to decision-making in state Medicaid programs. BACKGROUND: In 2007, the Medicaid Medical Directors Learning Network (MMDLN) began conducting quality improvement studies using their own state-level administrative data to better understand the major clinical issues facing the Medicaid populations and to work together on policies to improve outcomes. RATIONALE AND RESULTS: The three issues selected by MMDs for quality improvement monitoring to date involved an important national problem - including both morbidity and cost - and were amenable to policy solutions. The studies examined the use of antipsychotic medication in children, hospital admissions and readmissions, and early elective deliveries (i.e., elective deliveries occurring before 39 weeks). IMPORTANCE AND UTILITY: The multistate clinical quality projects conducted offer a key mechanism for achieving the goal of helping the Medicaid program deliver value-driven, high-quality, cost-effective health care in an efficient manner. These projects also provide the participating states with data to inform policies internally. CONCLUSIONS: In order for the quality of health care to improve, the system needs to be structured as a learning health care system; one that is always accessing evidence, implementing a variation of it (i.e., with new data sources or tools such as electronic clinical data), assessing effectiveness, and sharing results for others to repeat the cycle.

Cincinnati Beacon Community Program highlights challenges and opportunities on the path to care transformation.

The Cincinnati, Ohio, metropolitan area was one of seventeen US communities to participate in the federal Beacon Community Cooperative Agreement Program to demonstrate how health information technology (IT) could be used to improve health care. Given $13.7 million to spend in thirty-one months, the Cincinnati project involved hundreds of physicians, eighty-seven primary care practices, eighteen major hospital partners, and seven federally qualified health centers and community health centers. The thrust of the program was to build a shared health IT infrastructure to support quality improvement through data exchange, registries, and alerts that notified primary care practices when a patient visited an emergency department or was admitted to a hospital. A special focus of this program was on applying these tools to adult patients with diabetes and pediatric patients with asthma. Despite some setbacks and delays, the basic technology infrastructure was built, the alert system was implemented, nineteen practices focusing on diabetes improvement were recognized as patient-centered medical homes, and many participants agreed that the program had helped transform care. However, the experience also demonstrated that the ability to transfer data was limited in electronic health record systems; that considerable effort was required to adapt technology to support quality improvement; and that the ambitious agenda required more time for planning, training, and implementation than originally thought.

A case study of pediatric asthma alerts from the beacon community program in cincinnati: technology is just the first step.

INTRODUCTION: The Beacon Community in Cincinnati, Ohio was an innovative, community-wide initiative to use technology to transform care. One important feature was the development of regional alerts to notify practices when patients were hospitalized or seen in the emergency department. The purpose of this paper is to describe the way in which technology engages the improvement process, and to describe the early stages of learning how to use technology to enhance quality improvement. METHODS: We interviewed key Beacon leaders as well as providers and office staff in selected practices. We also collected preliminary data from practices that reflected handling of alerts, including the number of asthma related alerts received and followed up. RESULTS: Regional alerts, supplied by the community-wide health information exchange, were a significant addition to the quality improvement effort in that they enabled practices to identify and follow up with additional children at risk. An important finding was the substantial effort at the practice level to integrate technology into ongoing patient care. CONCLUSIONS: Developing the technology for community wide alerts represented a significant endeavor in the Cincinnati Beacon Community. However, the technology was just the first step. Despite extra effort and time required on the part of individual practices, they reported that the value of having alerts was high. Hospital and ED visits represent some of the most costly aspects of care, and an efficient process for intervening with children using these costly services was seen as of significant value.

Medicaid admissions and readmissions: understanding the prevalence, payment, and most common diagnoses.

Reducing hospital readmissions is a way to improve care and reduce avoidable costs. However, there have been few studies of readmissions in the Medicaid population. We sought to characterize acute care hospital admissions and thirty-day readmissions in the Medicaid population through a retrospective analysis in nineteen states. We found that Medicaid readmissions were both prevalent (9.4 percent of all admissions) and costly ($77 million per state) and that they represented 12.5 percent of Medicaid payments for all hospitalizations. Five diagnostic groups appeared to drive Medicaid readmissions, accounting for 57 percent of readmissions and 49 percent of hospital payments for readmissions. The most prevalent diagnostic categories were mental and behavioral disorders and diagnoses related to pregnancy, childbirth, and their complications, which together accounted for 31.2 percent of readmissions. This analysis, conducted through the Medicaid Medical Directors Learning Network, allows Medicaid medical directors to better understand the nature and prevalence of hospital use in the Medicaid population and provides a baseline for measuring improvement.

Outcomes of Latina women in CenteringPregnancy group prenatal care compared with individual prenatal care.

INTRODUCTION: CenteringPregnancy is a client-centered model of group prenatal care that brings women together into small groups to receive care through assessment, education, and support. As Spanish-speaking CenteringPregnancy groups become more common, outcomes of Latinas who attend these groups must be assessed. The purpose of this retrospective cohort study was to compare pregnancy outcomes of Latina women who completed CenteringPregnancy in a public health clinic with women who completed individual care in the same clinic during the same time. METHODS: Medical charts were reviewed retrospectively to examine differences in pregnancy outcomes and maternal factors in both prenatal care groups. Latina Spanish-speaking women who completed CenteringPregnancy were matched with Latina Spanish-speaking women who completed individual care within the same time frame. Logistic regression analysis was conducted to examine maternal and birth outcomes. RESULTS: A total of 487 patient charts were obtained for data collection (CenteringPregnancy n = 247, individual n = 240). No differences in low-birth-weight or preterm births were observed between the groups. Compared with women in individual care, women in CenteringPregnancy had higher odds of giving birth vaginally (adjusted odds ratio [aOR], 2.57; 95% confidence interval [CI], 1.23-5.36), attending prenatal care visits (aOR, 11.03; 95% CI, 4.53-26.83), attending postpartum care visits (aOR, 2.20; 95% CI, 1.20-4.05), and feeding their infants formula only (aOR, 6.07; 95% CI, 2.57-14.3). Women in CenteringPregnancy also had lower odds of gaining below the recommended amount of gestational weight (aOR, 0.41; 95% CI, 0.22-0.78). DISCUSSION: Women in CenteringPregnancy had higher health care utilization, but there were no differences in preterm birth or low birth weight. Randomized studies are needed to eliminate selection bias.

The childhood obesity response in Florida: where do we stand?

BACKGROUND: Childhood obesity is a major public health problem that is the focus of many child health programs and policies throughout the nation. Florida in particular has high rates of childhood obesity and inconsistent policies to address the issue. This paper examines the scope and challenge of addressing the childhood obesity epidemic in Florida from the perspective of childhood obesity stakeholders. METHODS: As part of a larger assessment of the health of Florida's children for the Florida Child Health and Healthcare Quality Chartbook, the authors conducted focus groups and interviews with stakeholders from private and public organizations. The stakeholders represented healthcare providers, state and local agencies, and community-based programs that address nutrition and physical activity education, access to healthcare, health screenings, and environmental and policy change related to preventing childhood obesity. RESULTS: Stakeholders identified best practices, challenges, barriers, and priorities for addressing childhood obesity. Multilevel approaches, emphasizing the family were identified as best practices, along with the need for environmental policy change. Funding and a need for data were identified as the biggest challenges, while overcoming barriers such as myths and misinformation and developing a unified obesity message were identified as motivators. CONCLUSIONS: The major findings indicate that, although positive progress is being made in specific communities, a coordinated and comprehensive response is needed. To create policy and normative change, a statewide, multilevel framework is needed with a unifying message to better target policymakers. The framework should include targeted efforts at all levels that include education, promotion and environmental policy change.