Emergency Room Utilization After Medically Complicated Pregnancies: A Medicaid Claims Analysis

Abstract

Background: Women with pregnancy complications benefit from closer monitoring postpartum and beyond. Increased postpartum emergency room (ER) use may indicate unmet need for outpatient obstetrics and primary care. The purpose of this study was to evaluate whether women with pregnancy complications (gestational diabetes [GDM], gestational hypertension, and preeclampsia) have increased ER use in the first 6 months postpartum, compared with women without these complications. Methods: We conducted a retrospective population-based cohort study using a 2003-2010 Maryland Medicaid managed care claims data set, linked with U.S. Census data. Data included claims for outpatient and ER visits for women aged 12-45 years who were continuously enrolled in Medicaid for at least 100 days of pregnancy and 90 days postpartum. We used logistic regression to calculate the association between pregnancy complications and having ‡1 ER visit in the 6 months postpartum. Results: We identified 26,074 pregnancies, of which 20% were complicated by GDM, gestational hypertension, or preeclampsia. Of these complicated pregnancies, 42.1% had GDM, 35.4% had gestational hypertension, and 42.5% had preeclampsia (diagnoses were not mutually exclusive). In the 6 months postpartum, 25% of women had ‡1 ER visits. Of the complicated pregnancy group, 27.7% had ‡1 ER visit, versus 23.6% of the comparison group ( p < 0.0001). In adjusted analyses, women with a pregnancy complication were more likely to have ‡1 ER visit compared with women without these complications (odds ratio [OR]1.14, 95% confidence interval [CI] 1.05-1.23). The strength of association was highest in women under age 25 (OR 1.20, 95% CI 1.09-1.33). Preconception medical comorbidities (type 2 diabetes, chronic hypertension, obesity, asthma, mental health, and substance abuse diagnoses) were also strongly associated with postpartum ER use (OR 1.61, 95% CI 1.51-1.73). Conclusions: Pregnancy complications increased ER utilization during the 6 months postpartum, especially among women under age 25 years. Interventions that improve discharge planning and early postpartum care may decrease ER use.

Timing of Emergency Postpartum Hospital Visits in the Fourth Trimester

“…7,8 However, outpatient care delivered in an ED is costly to mothers, families, and hospital systems. 9 Implications of these findings align with the ACOG recommendations to tailor postpartum care with special attention to high-risk individuals and those with medical comorbidities. They specifically cite that women with hypertensive disorders have follow-up within 3 to 10 days and those with other medical comorbidities be seen within 1 to 3 weeks, supporting individualization and the possibility of multiple scheduled visits.…”

Association Between Maternal Comorbidities and Emergency Department Use Among a National Sample of Commercially Insured Pregnant Women

“…Patient characteristics tested for model inclusion were chosen based on previous research on predictors of ED use in the general population and among postpartum women . Sociodemographic variables included age (categorized as 18–24, 25–34, and 35–44 years old) and geographic region based on state of residence (categorized into nine census regions).…”

“…Chronic health conditions affect more than one‐quarter (27%) of all pregnant women in the United States, and several studies have documented increased postpartum ED use among women with preexisting (e.g., asthma, hypertension, diabetes) and/or pregnancy‐related (e.g., preeclampsia, gestational diabetes) comorbidities . To date, no studies have examined the extent to which these conditions may influence emergency care–seeking behaviors during pregnancy.…”

Emergency Department Visits for Postpartum Complications

“…Two recent studies highlighted utilization of the emergency department (ED) for postpartum complications and showed that up to 25% of women seek care in the ED in the first 6 months postpartum. 2,3 Up to 50% of these visits occurred within 10 days of hospital discharge. 3 These studies suggest the need to develop strategies to prevent or better manage postpartum complications.…”