番茄社区

WASHINGTON -- Postpartum patients with existing comorbidities were more likely to be readmitted after delivery, researchers said here.

Because a national database of hospital readmissions does not exist, , of Brigham and Women's Hospital in Boston, and colleagues, examined readmission rates within the first 6 weeks of postpartum discharge from state in-patient databases in New York, California, and Florida.

They found that patients with psychiatric disease or a substance use disorder had a more than two-fold increased risk of readmission compared with patients without those conditions (OR 2.54, 95% CI 2.45-2.6 and OR 2.02, 95% CI 1.96-2.08, respectively).

Also, patients with seizure disorder (OR 1.99), hypertension (OR 1.87), and tobacco use (OR 1.86) were also at greater risk of readmission following delivery, they said in a presentation at the American College of Obstetricians and Gynecologists (ACOG) annual meeting.

Infection was the most common indication for readmission (15.5%), followed by hypertension (9.3%) and psychiatric illness (7.7%), they noted.

, member of the ACOG committee, Practice Bulletins -- Obstetrics, told 番茄社区 that these findings made a lot of sense because the baseline maternal risk for women in this country is rising.

“Because of the obesity epidemic, we’re seeing higher rates of morbid obesity, and women who are at risk for all sorts of complications related to pregnancy, the delivery process, and the postpartum period,” said Caughey, who was not involved with the research. “With the obesity epidemic comes high rates of hypertension and high rates of diabetes ... what was nice about this work is they looked at what risk factors increased the risk of being readmitted postpartum, and it did seem those medical complications seemed to increase that risk.”

Clapp told 番茄社区 in an email interview that these findings may prompt clinicians with higher-risk patients to enact close follow-up in the postpartum period. But he cautioned that more research is needed as to whether patients with known comorbidities may require lengthier hospital stays following delivery.

"We currently do not know enough about the individual patients that are readmitted to suggest that delivery length of stay is a modifiable variable that could prevent postpartum readmissions," he said. "However, as pregnant patients continue to have more comorbidities, we may have to rethink the paradigm that postpartum length of stay should only be determined by mode of delivery without regard to a patient's medical and pregnancy issues."

Overall, rates of readmission have increased from 2004-2011 (1.72% to 2.16%). This is well below the readmission rates for medical (range of 11.4%-18.6%) and surgical procedures (range of 7.6%-18.3%) in the U.S., but Clapp said at the presentation that very little is known about readmission rates in obstetrics.

Readmitted patients were more likely to have public insurance (54.3% versus 42.0%), have a cesarean delivery (37.2% versus 32.9%), be black (18.7% versus 13.5%, P<0.001 for all), and have multiple comorbidities, such as type 2 diabetes, obesity, and substance abuse.

The group examined data from 114,748 hospital readmissions. On average, patients were readmitted on day 7, though this tended to be earlier for hypertension and infection (days 3 and 5, respectively) and later for psychiatric disease (day 9).

However, this was administrative data, which was dependent on discharge billing codes where comorbidities are often underreported. In addition, because only three states were examined in the analysis, its generalizability may be limited.

Caughey also pointed out that most of the data was from a time period prior to the Affordable Care Act (ACA) and the expansion of Medicaid in certain states, which allows women to obtain postpartum healthcare without having to go to acute care facilities.

“Going forward, we have a real obligation to seek out care providers who can provide healthcare to all the women we’re seeing with medical complications in pregnancy,” he said. “So I’m hopeful over the next 5 years, that all these kind of systems we’ve put into place will make women feel like they have a better safety network.”

Clapp said there are a number of areas for future research, such as the increasing rate of C-section delivery, and examining how certain comorbidities influence the readmission rate.

"This research has prompted us to look deeper into the implications of psychiatric disease and substance abuse on delivery and postpartum outcomes, and the amount of variation that exists in postpartum readmissions between hospitals," he told 番茄社区. "We have more to investigate before we can comment on the utility of postpartum readmissions as a marker of quality in obstetrics."

Comment