Maternal & Child Health
Room: Blackberry Lilly
Wednesday, April 22, 2015, 2:00 to 3:30 PM
Moderator: Michele Issel, PhD, RN
Julia Costich, PhD, JD
State Newborn Screening Programs as Public Health Systems: 50 Years of Policy and Practice
Background: State newborn screening (NBS) programs have evolved over the past 50 years to reflect much common grounding in philosophy and evidence, but substantial variation in structure, cost allocation, and related state policy. NBS now extends beyond the familiar metabolic disorders for which heelstick blood samples are screened, and includes hearing and cardiac testing in the birthing facility. The ACA requires coverage of federally sanctioned NBS tests with no cost-sharing, giving rise to a potential shift of longstanding programs from population-based funding to individualized payment. Research objective: To identify potential variations in the impact of the Affordable Care Act’s coverage mandate on state NBS programs and their implications for public health policy. Data sources: We performed an extensive literature review including the laws of all 50 states, and conducted a series of interviews and discussions with state program directors, CDC and HRSA staff in related programs, and representatives of insurance companies, state Medicaid programs, and birthing hospital finance departments. Study design: Based on principles of systems analysis, we present four general models of NBS program structure, with detailed illustrations of associated inputs and outcomes. Principal findings: We find that those states that have coherent, integrated systems for the NBS conditions have engaged in nuanced assessments that balance the interests of state population health, affected families, providers, advocates, and policy makers. Some state NBS programs have structural flaws that inhibit effectiveness, while others have evolved funding mechanisms that put program sustainability at risk. Conclusion: The impact of ACA-mandated coverage on state programs will vary significantly depending on the program’s design and current funding mechanisms. Any reductions in federal program funding will need to be monitored carefully to avoid unintended harm to the infants who are the intended beneficiaries of NBS programs. Implications for Public Health Practice: This topic is of current interest because the Affordable Care Act mandates coverage for all federally-approved screening tests with no cost-sharing, shifting some of the financial burden currently shared by Title V, various specific assessments, and state general fund support to third-party payers as well as the current Medicaid coverage for half of all U.S. births. However, screening tests are a small part of the total NBS program, which includes follow-up tests, counseling, and ongoing services for those infants who are diagnosed with the conditions tested.
Tamar Klaiman, PhD, MPH, BA
A Method for Identifying Positive Outlier Local Health Departments in Maternal and Child Health
Co-Investigator(s): Athena Pantazis, MPH, MA & Betty Bekemeier, PhD, MPH
Background: Local health departments (LHDs) are responsible for administering various maternal and child health (MCH) services. However, the current economic climate has strained LHDs by causing drastic health workforce job losses and program cuts. There are, however, some communities that have maintained better than expected MCH outcomes compared to their peers - positive deviants (PD). Research Objective: The goal of this project was to identify LHDs in positive deviant communities in terms of MCH outcomes in Washington, Florida and New York in order to learn from their experience. Data Sets and Sources: We used data from the Public Health Activities and Services Tracking (PHAST) database to identify PD LHDs. The PHAST database relies on externally validated measures of public health service production in key public health priority areas, including maternal and child health. We used uniquely detailed and matched annual MCH-related county-level expenditure data for all LHDs in FL (n=67), NY (n=61 – excluding NYC) and WA (n=35) for 2009 and 2010. These data were linked with variables depicting local context and LHD structure. The PHAST database also included MCH outcome data. Study Design: We used a cross-sectional study design to assess which communities had better than expected rates of teen pregnancy/births, rates of late or no prenatal care, infant mortality rate, and rates of low birth weight compared to their peers. Analysis: We used multiple regression analysis to control for internal (e.g. assuring service through alternative providers in the community, having a clinician as an LHDs “top executive,” and the types of services the LHD provides) and external (e.g. population size, geography, and the size of their budgets) LHD variables. We identified positive deviants as those with standardized residuals less than -1, for at least two outcomes and/or years. Principal Findings: We identified 50 (31%) LHDs (out of 163 LHDs excluding NYC) across three states in communities with consistently exceptional MCH outcomes: 10 (29%) in WA; 24 (29%) in FL; and 16 (26%) in NY. Forty-four of 50 LHDs (88%) had better than expected MCH outcomes over 2 years. Twenty-eight LHDs (56%) had 2 or more exceptional outcomes in a single study year. Positive deviant LHDs varied by context in proportion to all LHDs: metropolitan=35 (41%); micropolitan=10 (27%); rural=14 (34%). The range of MCH expenditures varied similarly in all LHDs and PD LHDs. Conclusions: Our quantitative analysis has allowed us to objectively identify LHDs in positive deviant communities in maternal and child health outcomes. We found the method for identifying Positive Deviant LHDs returned consistent results across three states. Implications for Public Health Practice and Policy: The methods used in this project can be replicated in other areas of public health outcomes and practice to identify and learn from high performing agencies and communities.
Sarah Newman, MPH
Budget Cuts and Maternal and Child Health Service Reductions Occur in Counties with Highest Rates of Low Birth Weight
Co-Investigator(s): Jiali Ye, PhD & Carolyn Leep, MPH, MS
Background: Maternal and child health (MCH) services have been reduced in local health departments (LHDs) in recent years. In the last six economic surveillance studies conducted by the National Association of County and City Health Officials (NACCHO) since 2009, MCH services have been among the top three most frequently reduced programs. However, decisions regarding resource allocation for MCH services are not always made using research evidence or community need. Research Objective: This study aims to examine the extent to which LHD budget cuts and changes in the provision of MCH services are associated with the level of community need by exploring the relationship among LHD budget cuts, change in the provision of MCH services, and county-level rates of low birth weight (LBW). Data Sets and Sources: Data on LHD budget cuts and provision of MCH services were drawn from NACCHO’s 2014 Forces of Change study and combined with county-level rates of LBW from the 2014 County Health Rankings dataset. Study Design: A cross-sectional dataset of county-level LHDs in the United States was analyzed. The relationships among LHD budget cuts (budget is less than, same, or greater than the previous year), MCH service provision (reduced, expanded, or little or no change in MCH services), and rates of LBW were examined. Analysis: A total of 422 LHDs were included in the analysis. Bivariate analyses were conducted to test the following associations: 1) association between budget cuts and MCH service provision; 2) association between LHD budget cuts and rates of LBW; 3) association between change in MCH service provision and rates of LBW. Principal Findings: LHDs that experienced budget cuts were also more likely to have also reduced their MCH services (61.54%) compared to LHDs that did not change or expanded their MCH services (26.60%) (Figure 1). The rate of LBW in counties where LHDs experienced budget cuts was significantly higher (8.49%) than in counties where LHDs reported the same budget (7.76%) or a budget greater than the previous year (7.72%) (Figure 2). LHDs in counties with high rates of LBW (top quartile) are more likely to not provide MCH services or to have reduced their MCH services compared to LHDs in counties with low rates of LBW (bottom quartile) (Figure 3). Conclusions: LHDs in counties that are already burdened by poor birth outcomes (experiencing higher rates of LBW) have faced budget cuts. These same LHDs are also less likely to provide MCH services or were more likely to reduce MCH services. These findings suggest that MCH program cuts are occurring in counties with the greatest need. Implications: Budget cuts and MCH program reductions are occurring in counties with the highest level of need, which may perpetuate poor birth outcomes. Previous research has shown that LHD investments in MCH services can have an effect on health outcomes. Thus, consistent funding for MCH services (especially in areas of high need) is needed to ensure the delivery of essential public health services and reduce the burden of poor birth outcomes for communities.
William Riley, PhD
Reducing Preventable Perinatal Harm to Decrease Malpractice Claims
Co-Investigator(s): Les Meredith; Rebecca Price; & Cecile Dinh, MPH
Background: Newborn deliveries are the leading cause of hospital admissions and preventing perinatal harm is an especially important undertaking to help achieve the goals of Healthy People 2020. Labor and delivery pose substantial risk for unintended harm to mothers and newborns. Perinatal complications range as high as 10.7% of U.S. obstetrical deliveries and estimates indicate that approximately 30% of perinatal injury is preventable. Moreover, although perinatal injuries constitute less than 5% of malpractice claims, they account for over 50% of all malpractice-related expenses. Research Objectives: (1) Reduce the number of perinatal injuries through clinical interventions and team training programs. (2) Evaluate the influence on malpractice litigation and costs. Data Sets and Sources Each participating hospital provided monthly data involving care processes and care outcomes on all perinatal discharges. Hospital claims data and claims-related demographic information were collected via a survey and malpractice claims audits. Study Design: This prospective quasi-experimental longitudinal study involved 22 hospitals: 14 intervention hospitals located in 12 states, and 8 comparator hospitals. The five-year project used a quality improvement collaborative (QIC) initiated in January 2008 and ending December 31, 2012. Data were also retrospectively collected over a two-year period (January 2006 to December 2007) to establish a baseline. The project implemented three interventions: standardization of evidence based care, interdisciplinary teamwork training, and routine education with performance feedback. Analysis: We analyzed process measures (use of standardized care processes) and two outcome measures, the adverse outcome index and medical malpractice expenses. We used run charts to analyze longitudinal trends and T-tests for pre-post analysis. Results from the interventions were contrasted with data from eight comparison hospitals. Principal Findings: Participating hospitals increased care reliability and reduced perinatal harm, resulting in significant cost reductions related to malpractice claims. The frequency of new perinatal-related claims was reduced 89% in participating hospitals compared to a 16% reduction in non-participating hospitals. The total malpractice claim loss incurred for major injuries in participating hospitals decreased by 75%, while comparison hospitals increased total medical claim loss incurred by 28%. In addition, participating hospitals greatly increased the percentage of resolving new liability claims without payment, going from 44% of obstetric claims in 2006, to 100% of claims resolved in 2011. Conclusion: The rate of perinatal harm and malpractice claims were reduced following perinatal safety interventions designed to improve labor and delivery outcomes. These results suggest it is possible to improve care and reduce costs through consistent use of standardized care processes and interdisciplinary team training. Implications for Public Health Practice and Policy: Achieving Healthy People 2020 goals for improving women, infant, and children’s health involves, in part, substantial reduction in perinatal harm. This study suggests that compliance with evidence-based practices can result in better care for perinatal patients. The findings also have important implications for strategies to reduce malpractice claims associated with perinatal injuries.