Journal of General Internal Medicine

, Volume 29, Issue 4, pp 636–645 | Cite as

Utilization of Primary and Obstetric Care After Medically Complicated Pregnancies: An Analysis of Medical Claims Data

  • Wendy L. Bennett
  • Hsien-Yen Chang
  • David M. Levine
  • Lin Wang
  • Donna Neale
  • Erika F. Werner
  • Jeanne M. Clark
Article

ABSTRACT

BACKGROUND

Because pregnancy complications, including gestational diabetes mellitus (GDM) and hypertensive disorders in pregnancy, are risk factors for diabetes and cardiovascular disease, post-delivery follow-up is recommended.

OBJECTIVE

To determine predictors of post-delivery primary and obstetric care utilization in women with and without medical complications.

RESEARCH DESIGN

Five-year retrospective cohort study using commercial and Medicaid insurance claims in Maryland.

SUBJECTS

7,741 women with a complicated pregnancy (GDM, hypertensive disorders and pregestational diabetes mellitus [DM]) and 23,599 women with a comparison pregnancy.

MEASURES

We compared primary and postpartum obstetric care utilization rates in the 12 months after delivery between the complicated and comparison pregnancy groups. We conducted multivariate logistic regression to assess the association between pregnancy complications, sociodemographic predictor variables and utilization of care, stratified by insurance type.

RESULTS

Women with a complicated pregnancy were older at delivery (p < 0.001), with higher rates of cesarean delivery (p < 0.0001) and preterm labor or delivery (p < 0.0001). Among women with Medicaid, 56.6 % in the complicated group and 51.7 % in the comparison group attended a primary care visit. Statistically significant predictors of receiving a primary care visit included non-Black race, older age, preeclampsia or DM, and depression. Among women with commercial health insurance, 60.0 % in the complicated group and 49.5 % in the comparison group attended a primary care visit. Pregnancy complication did not predict a primary care visit among women with commercial insurance.

CONCLUSIONS

Women with pregnancy complications were more likely to attend primary care visits post-delivery compared to the comparison group, but overall visit rates were low. Although Medicaid expansion has potential to increase coverage, innovative models for preventive health services after delivery are needed to target women at higher risk for chronic disease development.

KEY WORDS

pregnancy utilization of care primary care gestational diabetes mellitus hypertension 

Supplementary material

11606_2013_2744_MOESM1_ESM.pdf (96 kb)
ESM 1(PDF 96 kb)

REFERENCES

  1. 1.
    Bellamy L, Casas JP, Hingorani AD, Williams D. Type 2 diabetes mellitus after gestational diabetes: a systematic review and meta-analysis. Lancet. 2009;373(9677):1773–1779.PubMedCrossRefGoogle Scholar
  2. 2.
    Bellamy L, Casas JP, Hingorani AD, Williams DJ. Pre-eclampsia and risk of cardiovascular disease and cancer in later life: Systematic review and meta-analysis. BMJ. 2007;335(7627):974.PubMedCentralPubMedCrossRefGoogle Scholar
  3. 3.
    Carr DB, Newton KM, Utzschneider KM, et al. Preeclampsia and risk of developing subsequent diabetes. Hypertens Pregnancy. 2009:1-13.Google Scholar
  4. 4.
    Fraser A, Nelson SM, Macdonald-Wallis C, et al. Associations of pregnancy complications with calculated cardiovascular disease risk and cardiovascular risk factors in middle age: the avon longitudinal study of parents and children. Circulation. 2012;125(11):1367–1380.PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Cheung NW, Byth K. Population health significance of gestational diabetes. Diabetes Care. 2003;26(7):2005–2009.PubMedCrossRefGoogle Scholar
  6. 6.
    Sattar N, Greer IA. Pregnancy complications and maternal cardiovascular risk: opportunities for intervention and screening? BMJ. 2002;325(7356):157–160.PubMedCentralPubMedCrossRefGoogle Scholar
  7. 7.
    Rich-Edwards JW, McElrath TF, Karumanchi SA, Seely EW. Breathing life into the lifecourse approach: pregnancy history and cardiovascular disease in women. Hypertension. 2010;56(3):331–334.PubMedCentralPubMedCrossRefGoogle Scholar
  8. 8.
    Gestational diabetes mellitus. Diabetes Care. 2004;27(1):S88–S90.Google Scholar
  9. 9.
    American College of Obstetricians-Gynecologists Practice Bulletin. Clinical Management guidelines for obstetrician-gynecologists. Number 30, September 2001 (replaces technical bulletin number 200, Dec 1994). Gestational Diabetes. Obstet Gynecol. 2001;98(3):525–538.Google Scholar
  10. 10.
    Metzger BE, Buchanan TA, Coustan DR, et al. Summary and recommendations of the fifth international workshop-conference on gestational diabetes mellitus. Diabetes care. 2007;30(S):251–260.CrossRefGoogle Scholar
  11. 11.
    Report of the national high blood pressure education program working group on high blood pressure in pregnancy. Am J Obstet Gynecol. 2000;183(1):S1–S22.Google Scholar
  12. 12.
    Smirnakis KV, Chasan-Taber L, Wolf M, Markenson G, Ecker JL, Thadhani R. Postpartum diabetes screening in women with a history of gestational diabetes. Obstet Gynecol. 2005;106(6):1297–1303.PubMedCrossRefGoogle Scholar
  13. 13.
    Kim C, Tabaei BP, Burke R, et al. Missed opportunities for type 2 diabetes mellitus screening among women with a history of gestational diabetes mellitus. Am J Public Health. 2006;96(9):1643–1648.PubMedCentralPubMedCrossRefGoogle Scholar
  14. 14.
    Russell MA, Phipps MG, Olson CL, Welch HG, Carpenter MW. Rates of postpartum glucose testing after gestational diabetes mellitus. Obstet Gynecol. 2006;108(6):1456–1462.PubMedCrossRefGoogle Scholar
  15. 15.
    Ferrara A, Ehrlich SF. Strategies for diabetes prevention before and after pregnancy in women with GDM. Curr Diabetes Rev. 2011;7(2):75–83.PubMedCrossRefGoogle Scholar
  16. 16.
    Ferrara A, Hedderson MM, Ching J, Kim C, Peng T, Crites YM. Referral to telephonic nurse management improves outcomes in women with gestational diabetes. Am J Obstet Gynecol. 2012;206(6):491.e1–491.e5.CrossRefGoogle Scholar
  17. 17.
    Hunt KJ, Conway DL. Who returns for postpartum glucose screening following gestational diabetes mellitus? Am J Obstet Gynecol. 2008;198(4):404.e1–404.e6.CrossRefGoogle Scholar
  18. 18.
    National Committee for Quality Assurance (NCQA)0.1994-2009 Prenatal and postpartum care (PPC) definitions. Available at: http://www.ncqa.org/portals/0/Prenatal%20Postpartum%20Care.pdf. Accessed October 10, 2013
  19. 19.
    Bennett WL, Gilson MM, Jamshidi R, et al. Impact of bariatric surgery on hypertensive disorders in pregnancy: retrospective analysis of insurance claims data. BMJ. 2010;340:c1662.PubMedCentralPubMedCrossRefGoogle Scholar
  20. 20.
    Burke AE, Bennett WL, Jamshidi RM, et al. Reduced incidence of gestational diabetes with bariatric surgery. J Am Coll Surg. 2010;211(2):169–175.PubMedCrossRefGoogle Scholar
  21. 21.
    American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2013;36(Suppl 1):S67–S74.PubMedCentralCrossRefGoogle Scholar
  22. 22.
    The Dartmouth Atlas of Healthcare. Available at: http://www.dartmouthatlas.org/tools/downloads.aspx?tab=37. Accessed October 10, 2013
  23. 23.
    Bennett WL, Ennen CS, Carrese JA, et al. Barriers to and facilitators of postpartum follow-up care in women with recent gestational diabetes mellitus: a qualitative study. J Womens Health (Larchmt). 2011;20(2):239–245.PubMedCentralCrossRefGoogle Scholar
  24. 24.
    Vikse BE, Irgens LM, Leivestad T, Skjaerven R, Iversen BM. Preeclampsia and the risk of end-stage renal disease. N Engl J Med. 2008;359(8):800–809.PubMedCrossRefGoogle Scholar
  25. 25.
    Clark HD, Graham ID, Karovitch A, Keely EJ. Do postal reminders increase postpartum screening of diabetes mellitus in women with gestational diabetes mellitus? A randomized controlled trial. Am J Obstet Gynecol. 2009;200(6):634.e1–634.e7.CrossRefGoogle Scholar
  26. 26.
    National Committee for Quality Assurance (NCQA). 2012 NCQA summary table of measures, product lines and changes. Available at: http://www.ncqa.org/LinkClick.aspx?fileticket=O-31v4G27sU%3d&tabid=1415. Accessed October 10, 2013.
  27. 27.
    Johnson K, Posner SF, Biermann J, et al. Recommendations to improve preconception health and health care--united states. A report of the CDC/ATSDR preconception care work group and the select panel on preconception care. MMWR Recomm Rep. 2006;55(RR-6):1–23.PubMedGoogle Scholar
  28. 28.
    Lawrence JM, Contreras R, Chen W, Sacks DA. Trends in the prevalence of preexisting diabetes and gestational diabetes mellitus among a racially/ethnically diverse population of pregnant women, 1999–2005. Diabetes Care. 2008;31(5):899–904.PubMedCrossRefGoogle Scholar
  29. 29.
    Wallis AB, Saftlas AF, Hsia J, Atrash HK. Secular trends in the rates of preeclampsia, eclampsia, and gestational hypertension, united states, 1987-2004. Am J Hypertens. 2008;21(5):521–526.PubMedCrossRefGoogle Scholar
  30. 30.
    Kim SY, Saraiva C, Curtis M, Wilson HG, Troyan J, Sharma AJ. Fraction of gestational diabetes mellitus attributable to overweight and obesity by race/ethnicity, california, 2007-2009. Am J Public Health. 2013;103(10):e65–e72.PubMedCrossRefGoogle Scholar
  31. 31.
    Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of preterm birth. Lancet. 2008;371(9606):75–84.PubMedCrossRefGoogle Scholar
  32. 32.
    Ruser CB, Sanders L, Brescia GR, et al. Identification and management of overweight and obesity by internal medicine residents. J Gen Intern Med. 2005;20(12):1139–1141.PubMedCentralPubMedCrossRefGoogle Scholar
  33. 33.
    U.S. Department of Health and Human Services Health Resources and Services Administration. Women’s Preventive Services: Required Health Plan Coverage Guidelines. Available at: http://www.hrsa.gov/womensguidelines/. Accessed October 10, 2013.
  34. 34.
    Cheng TL, Solomon BS. Translating life course theory to clinical practice to address health disparities. Matern Child Health J. 2013.Google Scholar
  35. 35.
    U.S. Department of Health and Human Services. "HHS announces expansion of Maternal, Infant, and Early Childhood Home Visiting". Available at: http://www.hhs.gov/news/press/2013pres/09/20130906a.html. Accessed October 10, 2013.

Copyright information

© Society of General Internal Medicine 2013

Authors and Affiliations

  • Wendy L. Bennett
    • 1
    • 2
    • 3
  • Hsien-Yen Chang
    • 3
  • David M. Levine
    • 1
    • 3
  • Lin Wang
    • 4
  • Donna Neale
    • 5
  • Erika F. Werner
    • 6
  • Jeanne M. Clark
    • 1
    • 2
    • 3
  1. 1.Division of General Internal MedicineThe Johns Hopkins University School of MedicineBaltimoreUSA
  2. 2.Welch Center for Prevention, Epidemiology and Clinical ResearchThe Johns Hopkins UniversityBaltimoreUSA
  3. 3.The Johns Hopkins Bloomberg School of Public HealthBaltimoreUSA
  4. 4.Johns Hopkins HealthCare, LLCGlen BurnieUSA
  5. 5.Department of Gynecology and ObstetricsThe Johns Hopkins University School of MedicineBaltimoreUSA
  6. 6.Department of Obstetrics and GynecologyAlpert Medical School of Brown UniversityProvidenceUSA

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