Measurement of hemorrhage-related severe maternal morbidity with billing versus electronic medical record data

Friedman, Alexander M.; Oberhardt, Matthew; Sheen, Jean‐Ju; Kessler, Alan; Vawdrey, David K.; Green, Robert C.; D’Alton, Mary E.; Goffman, Dena

doi:10.1080/14767058.2020.1783229

Cited by 5 publications

(11 citation statements)

References 13 publications

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“…Further analysis is needed to explore the significance of these potential biases and errors and their effect on the interpretation and overall validity of findings related to SMM. In addition, there is evidence that reliance on ICD codes for blood transfusion, which do not distinguish the number of units, likely captures deliveries that were not actually clinically severe 40. While we rely on the CDC/AIM indicator list, it may be that future definitions or more formal development of dedicated SMM surveillance systems will refine case ascertainment by, for example, combining information on disseminated intravascular coagulation, intensive care unit admission, and transfusion.…”

Section: Discussionmentioning

confidence: 99%

“…In addition, there is evidence that reliance on ICD codes for blood transfusion, which do not distinguish the number of units, likely captures deliveries that were not actually clinically severe. 40 While we rely on the CDC/AIM indicator list, it may be that future definitions or more formal development of dedicated SMM surveillance systems will refine case…”

Section: Strengths and Limitationsmentioning

confidence: 99%

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Severe Maternal Morbidity in Georgia, 2009–2020

Kramer¹,

Labgold²,

Zertuche

et al. 2023

Medical Care

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Background: The increasing focus of population surveillance and research on maternal-and not only fetal and infant-health outcomes is long overdue. The United States maternal mortality rate is higher than any other high-income country, and Georgia is among the highest rates in the country. Severe maternal morbidity (SMM) is conceived of as a "near miss" for maternal mortality, is 50 times more common than maternal death, and efforts to systematically monitor SMM rates in populations have increased in recent years. Much of the current population-based research on SMM has occurred in coastal states or large cities, despite substantial geographical variation with higher maternal and infant health burdens in the Southeast and rural regions.Methods: This population-based study uses hospital discharge records linked to vital statistics to describe the epidemiology of SMM in Georgia between 2009 and 2020.Results: Georgia had a higher SMM rate than the United States overall (189.2 vs. 144 per 10,000 deliveries in Georgia in 2014, the most recent year with US estimates). SMM was higher among racially minoritized pregnant persons and those at the extremes of age, of lower socioeconomic status, and with comorbid chronic conditions. SMM rates were 5 to 6 times greater for pregnant people delivering infants <1500 grams or <32 weeks' gestation as compared with those delivering normal weight or term infants. Since 2015, SMM has increased in Georgia.Conclusion: SMM represents a collection of life-threatening emergencies that are unevenly distributed in the population and require increased attention. This descriptive analysis provides initial guidance for programmatic interventions intending to reduce the burden of SMM and, subsequently, maternal mortality in the US South.

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Section: Discussionmentioning

confidence: 99%

Section: Strengths and Limitationsmentioning

confidence: 99%

Severe Maternal Morbidity in Georgia, 2009–2020

Kramer¹,

Labgold²,

Zertuche

et al. 2023

Medical Care

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“…Blood transfusion was excluded given the low positive predictive value and variable sensitivity of this indicator for identifying SMM events in hospital discharge records. [26][27][28][29][30]…”

Section: Identifying Smmmentioning

confidence: 99%

Decomposing the Black–White Racial Disparity in Severe Maternal Morbidity Risk: The Role of Hypertensive Disorders of Pregnancy

Labgold,

Howards,

Drews-Botsch

et al. 2023

Epidemiology

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Background: To our knowledge, no studies have explicitly studied the role of hypertensive disorders of pregnancy (HDP) in racial disparities in severe maternal morbidity (SMM). Methods: Using causal mediation models, we estimated the proportion of the non-Hispanic Black–White racial disparity in risk of SMM that is explained through the pathway of HDP. We linked 2006-2019 Georgia hospital discharge records with vital statistics birth and fetal death records for non-Hispanic Black and non-Hispanic White birthing persons. We used G-estimation of a structural nested mean model to decompose the absolute racial disparity in incidence of SMM into pathways operating through HDP. Results: Non-Hispanic Black birthing people experienced an excess 56 SMM events (95% CI: 52, 59) per 10,000 delivery hospitalizations compared to non-Hispanic White birthing people. If counterfactual disparity measure estimation assumptions hold, the estimated absolute disparity remaining after blocking the causal pathways through HDP was 41 SMM events per 10,000 deliveries (95% CI: 38, 44), suggesting that 26% (95% CI: 12, 40) of the absolute racial disparity would be eliminated if there was no contribution of HDP to SMM risk. Conclusions: Our results are consistent with the hypothesis that intervening to prevent HDP is an important (yet incomplete) pathway for reducing the excess risk among NH Black pregnancies compared to NH White pregnancies

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“… 7 Such data, primarily collected for billing purposes, are prone to coding errors and lack clinical nuance needed for real-time, in-depth reviews to inform SMM prevention efforts. 5 , 9 , 13 In July 2020, the Maryland Maternal Health Innovation Program (MDMOM) piloted an SMM surveillance and review program working with 6 of the 32 birthing hospitals in Maryland, covering approximately one-quarter of the more than 60 000 births in the state annually. This initiative is a component of a series of interventions implemented in 2020 to reduce maternal mortality in Maryland.…”

Section: Introductionmentioning

confidence: 99%

“…Until 2020, the only data on SMM in Maryland were from administrative hospital discharge databases . Such data, primarily collected for billing purposes, are prone to coding errors and lack clinical nuance needed for real-time, in-depth reviews to inform SMM prevention efforts . In July 2020, the Maryland Maternal Health Innovation Program (MDMOM) piloted an SMM surveillance and review program working with 6 of the 32 birthing hospitals in Maryland, covering approximately one-quarter of the more than 60 000 births in the state annually.…”

Section: Introductionmentioning

confidence: 99%

Findings From Severe Maternal Morbidity Surveillance and Review in Maryland

et al. 2022

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ImportanceIn the US, more than 50 000 women experience severe maternal morbidity (SMM) each year, and the SMM rate more than doubled during the past 25 years. In response, professional organizations called for birthing facilities to routinely identify and review SMM events and identify prevention opportunities.ObjectiveTo examine SMM levels, primary causes, and factors associated with the preventability of SMM using Maryland’s SMM surveillance and review program.Design, Setting, and ParticipantsThis cross-sectional study included pregnant and postpartum patients at 42 days or less after delivery who were hospitalized at 1 of 6 birthing hospitals in Maryland between August 1, 2020, and November 30, 2021. Hospital-based SMM surveillance was conducted through a detailed review of medical records.ExposuresHospitalization during pregnancy or within 42 days post partum.Main Outcomes and MeasuresThe main outcomes were admission to an intensive care unit, having at least 4 U of red blood cells transfused, and/or having COVID-19 infection requiring inpatient hospital care.ResultsA total of 192 SMM events were identified and reviewed. Patients with SMM had a mean [SD] age of 31 [6.49] years; 9 [4.7%] were Asian, 27 [14.1%] were Hispanic, 83 [43.2%] were non-Hispanic Black, and 68 [35.4%] were non-Hispanic White. Obstetric hemorrhage was the leading primary cause of SMM (83 [43.2%]), followed by COVID-19 infection (57 [29.7%]) and hypertensive disorders of pregnancy (17 [8.9%]). The SMM rate was highest among Hispanic patients (154.9 per 10 000 deliveries), primarily driven by COVID-19 infection. The rate of SMM among non-Hispanic Black patients was nearly 50% higher than for non-Hispanic White patients (119.9 vs 65.7 per 10 000 deliveries). The SMM outcome assessed could have been prevented in 61 events (31.8%). Clinician-level factors and interventions in the antepartum period were most frequently cited as potentially altering the SMM outcome. Practices that were performed well most often pertained to hospitals’ readiness and adequate response to managing pregnancy complications. Recommendations for care improvement focused mainly on timely recognition and rapid response to such.Conclusions and RelevanceThe findings of this cross-sectional study, which used hospital-based SMM surveillance and review beyond the mere exploration of administrative data, offers opportunities for identifying valuable quality improvement strategies to reduce SMM. Immediate strategies to reduce SMM in Maryland should target its most common causes and address factors associated with preventability identified at individual hospitals.

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Measurement of hemorrhage-related severe maternal morbidity with billing versus electronic medical record data

Cited by 5 publications

References 13 publications

Severe Maternal Morbidity in Georgia, 2009–2020

Severe Maternal Morbidity in Georgia, 2009–2020

Decomposing the Black–White Racial Disparity in Severe Maternal Morbidity Risk: The Role of Hypertensive Disorders of Pregnancy

Findings From Severe Maternal Morbidity Surveillance and Review in Maryland

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