Abstract
Objectives Ectopic pregnancy is an important cause of maternal morbidity and mortality. Women who experience fragmented care may undergo unnecessary delays to diagnosis and treatment. Based on ectopic pregnancy cases observed in clinical practice that raised our concern about fragmentation of care, we designed an exploratory study to describe the number, characteristics, and outcomes of fragmented care among patients with ectopic pregnancy at one urban academic hospital. Methods Chart review with descriptive statistics. Fragmented care was defined as a patient being evaluated at an outside facility for possible ectopic pregnancy and transferred, referred, or discharged before receiving care at the study institution. Results Of 191 women seen for possible or definite ectopic pregnancy during the study period, 42 (22 %) met the study definition of fragmented care. The study was under-powered to observe statistically significant differences across groups, but we found concerning, non-significant trends: patients with fragmented care were more likely to be Medicaid recipients (65.9 vs. 58.8 %) and to experience a complication (23.8 vs. 18.1 %) compared to those with non-fragmented care. Most patients (n = 37) received no identifiable treatment prior to transfer and arrived to the study hospital with no communication to the receiving hospital from the outside provider (n = 34). Nine patients (21 %) presented with ruptured ectopic pregnancies. The fragmentation we observed in our study may contribute to previously identified socio-economic disparities in ectopic pregnancy outcomes. Conclusion If future research confirms these findings, health information exchanges and regional coordination of care may be important strategies for reducing maternal mortality.
References
Creanga, A. A., Shapiro-Mendoza, C. K., Bish, C. L., Zane, S., Berg, C. J., & Callaghan, W. M. (2011). Trends in ectopic pregnancy mortality in the United States: 1980–2007. Obstetrics and Gynecology, 117(4), 837–843.
Stulberg, D. B., Zhang, J. X., & Lindau, S. T. (2011). Socioeconomic disparities in ectopic pregnancy: Predictors of adverse outcomes from Illinois hospital-based care, 2000–2006. Maternal and Child Health Journal, 15(2), 234–241.
Asplin, B. R., Rhodes, K. V., Levy, H., Lurie, N., Crain, A. L., Carlin, B. P., et al. (2005). Insurance status and access to urgent ambulatory care follow-up appointments. JAMA- The Journal of the American Medical Association, 294(10), 1248–1254.
Grimes, D. A. (2006). Estimation of pregnancy-related mortality risk by pregnancy outcome, United States, 1991 to 1999. American Journal of Obstetrics and Gynecology, 194(1), 92–94.
Nelson, A. L., Adams, Y., Nelson, L. E., & Lahue, A. K. (2003). Ambulatory diagnosis and medical management of ectopic pregnancy in a public teaching hospital serving indigent women. American Journal of Obstetrics and Gynecology, 188(6), 1541–1547.
Creanga, A. A., Berg, C. J., Syverson, C., Seed, K., Bruce, F. C., & Callaghan, W. M. (2015). Pregnancy-related mortality in the United States, 2006–2010. Obstetrics and Gynecology, 125(1), 5–12.
MacDorman, M. F., & Mathews, T. J. (2011). Understanding racial and ethnic disparities in U.S. infant mortality rates. NCHS Data Brief, 74, 1–8.
Hunt, B. R., Whitman, S., & Hurlbert, M. S. (2014). Increasing Black: White disparities in breast cancer mortality in the 50 largest cities in the United States. Cancer Epidemiology, 38(2), 118–123.
Go, A. S., Mozaffarian, D., Roger, V. L., Benjamin, E. J., Berry, J. D., Blaha, M. J., et al. (2014). Heart disease and stroke statistics–2014 update: A report from the American Heart Association. Circulation, 129(3), e28–e292.
Stulberg, D. B., Cain, L., Dahlquist, I. H., & Lauderdale, D. S. (2016). Ectopic pregnancy morbidity and mortality in low income women, 2004–2008. Human Reproduction, 31(3), 666–671.
Van Mello, N. M., Zietse, C. S., Mol, F., Zwart, J. J., van Roosmalen, J., Bloemenkamp, K. W., et al. (2012). Severe maternal morbidity in ectopic pregnancy is not associated with maternal factors but may be associated with quality of care. Fertility and Sterility, 97(3), 623–629.
Jaspan, D., Giraldo-Isaza, M., Dandolu, V., & Cohen, A. W. (2010). Compliance with methotrexate therapy for presumed ectopic pregnancy in an inner-city population. Fertility and Sterility, 94(3), 1122–1124.
Foster, A. M., Dennis, A., & Smith, F. (2011). Do religious restrictions Influence ectopic pregnancy management? A National Qualitative Study. Women’s Health Issues, 21(2), 104–109.
Galanter, W. L., Applebaum, A., Boddipalli, V., Kho, A., Lin, M., Meltzer, D., et al. (2013). Migration of patients between five urban teaching hospitals in Chicago. Journal of Medical Systems, 37(2), 9930.
Bourgeois, F. C., Olson, K. L., & Mandl, K. D. (2010). Patients treated at multiple acute health care facilities: Quantifying information fragmentation. Archives of Internal Medicine, 170(22), 1989–1995.
Stiell, A., Forster, A. J., Stiell, I. G., & van Walraven, C. (2003). Prevalence of information gaps in the emergency department and the effect on patient outcomes. CMAJ, 169(10), 1023–1028.
Kim, J., Chuun, D., Shah, A., & Aronsky, D. (2008). Prevalence and impact of information gaps in the emergency department. In AMIA Annual Symposium Proceedings (pp. 866).
Pettker, C. M., & Grobman, W. A. (2015). Obstetric safety and quality. Obstetrics and Gynecology, 126(1), 196–206.
The Joint Commission. (2004). Sentinel Event Alert #30: Preventing infant death and injury during delivery. Available http://www.jointcommission.org/assets/1/18/SEA_30.PDF. Accessed 18 Dec 2015.
Hoover, K. W., Tao, G., & Kent, C. K. (2010). Trends in the diagnosis and treatment of ectopic pregnancy in the United States. Obstetrics and Gynecology, 115(3), 495–502.
Stulberg, D. B., Cain, L. R., Dahlquist, I., & Lauderdale, D. S. (2014). Ectopic pregnancy rates and racial disparities in the Medicaid population, 2004–2008. Fertility and Sterility, 102(6), 1671–1676.
Zibulewsky, J. (2001). The emergency medical treatment and active labor act (EMTALA): What it is and what it means for physicians. Baylor University Medical Center Proceedings, 14(4), 339–346.
Hankins, G. D., Clark, S. L., Pacheco, L. D., OʼKeeffe, D., DʼAlton, M., & Saade, G. R. (2012). Maternal mortality, near misses, and severe morbidity: Lowering rates through designated levels of maternity care. Obstetrics and Gynecology, 120(4), 929–934.
National Quality Forum. (2011). List of SREs. Available http://www.qualityforum.org/Topics/SREs/List_of_SREs.aspx. Accessed 18 Dec 2015.
Lasswell, S. M., Barfield, W. D., Rochat, R. W., & Blackmon, L. (2010). Perinatal regionalization for very low-birth-weight and very preterm infants: A meta-analysis. JAMA – The Journal of the American Medical Association, 304(9), 992–1000.
Braveman, P., Marchi, K., Egerter, S., Pearl, M., & Neuhaus, J. (2000). Barriers to timely prenatal care among women with insurance: The importance of prepregnancy factors. Obstetrics and Gynecology, 95(6 Pt 1), 874–880.
Acknowledgments
The authors wish to acknowledge Sully Cardona for her assistance with data collection and management. The first author was supported by a career development award from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (1 K08 HD060663).
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Stulberg, D.B., Dahlquist, I., Jarosch, C. et al. Fragmentation of Care in Ectopic Pregnancy. Matern Child Health J 20, 955–961 (2016). https://doi.org/10.1007/s10995-016-1979-z
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DOI: https://doi.org/10.1007/s10995-016-1979-z