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Pregnancy Episode Grouper: Development, Validation, and Applications. Mark C. Hornbrook, PhD AcademyHealth Annual Research Meeting Washington, DC June 9, 2008 . Reproductive Health Division, CDC Cynthia J. Berg, MD, MPH F. Carol Bruce, RN, MPHD William M. Callaghan, MD, MPH

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Pregnancy episode grouper development validation and applications

Pregnancy Episode Grouper: Development, Validation, and Applications

Mark C. Hornbrook, PhD

AcademyHealth Annual Research Meeting

Washington, DC

June 9, 2008


Research team

Reproductive Health Division, CDC

Cynthia J. Berg, MD, MPH

F. Carol Bruce, RN, MPHD

William M. Callaghan, MD, MPH

Susan Y. Chu, PhD

Patricia M. Dietz, DrPH

The Center for Health Research, KPNW

Mark C. Hornbrook, PhD

Donald J. Bachman, MS

Rachel Gold, PhD, MPH

Maureen C. O’Keeffe Rosetti, MS

Kimberly Vesco, MD

Selvi B. Williams, MD, MPH

Evelyn P. Whitlock, MD, MPH

Research Team


Funding

Contract # CDC 200-2001-00074, Task # MC2-02, “Extent of Maternal Morbidity in a Managed Care Setting,” from the Centers for Disease Control and Prevention

America’s Health Insurance Plans administered this contract

Contract # CDC 200-2006-17832, “Extent of Maternal Morbidity in a Managed Care Setting”

Funding


Maternal health
Maternal Health Maternal Morbidity in a Managed Care Setting,” from the Centers for Disease Control and Prevention

  • Over 6 million pregnancies in the US annually

  • Previously, hospitalizations used as proxy for morbidity

  • Today, we use a more comprehensive assessment of the incidence and prevalence of maternal morbidity

    • Changes in medical practice have led to more outpatient treatment for pregnancy complications

    • Medical informatics now frequently include computerized clinical and laboratory/pathology information systems


Objectives
Objectives Maternal Morbidity in a Managed Care Setting,” from the Centers for Disease Control and Prevention

  • Develop a pregnancy episode grouper algorithm using HMO electronic data warehouse

    • Identify all pregnancies occurring in HMO members during the study period

    • Identify each pregnancy’s outcome

    • Identify maternal morbidities occurring within pregnancy episodes

    • Estimate the prevalence of maternal morbidity in the study population

  • Develop research and quality improvement applications


  • Research setting
    Research Setting Maternal Morbidity in a Managed Care Setting,” from the Centers for Disease Control and Prevention

    • Kaiser Permanente Northwest (KPNW), a non­profit, prepaid group practice HMO in the Pacific Northwest, with 475,000 members

    • Includes commercial, individual, Washington State Basic Health Plan, Medicare, and Medicaid enrollees

    • Demographically representative of the local community

    • Automated ambulatory medical record system linked to administrative, encounter, financial, and clinical management information systems


    Over 2 3 of pregnancies ended in live birth and almost 1 3 in spontaneous or induced abortion
    Over 2/3 of pregnancies ended in live birth Maternal Morbidity in a Managed Care Setting,” from the Centers for Disease Control and Preventionand almost 1/3 in spontaneous or induced abortion

    Live births create inpatient delivery records, birth certificates, and health plan enrollment records


    Episodes
    Episodes Maternal Morbidity in a Managed Care Setting,” from the Centers for Disease Control and Prevention

    • Fundamental unit of measure for health care phenomena

    • Conceptual taxonomy

      • Health problem/illness episodes

        • Patient’s perspective on lived experience of health problem and related treatment

      • Disease episodes

        • Model of the natural course of a disease or health problem

      • Care Episodes

        • Clusters of utilization linked to a specific therapeutic problem/goal

  • Pregnancy

    • Quintessential episode—well-defined beginning and ending points and natural course


  • Episode definition
    Episode Definition Maternal Morbidity in a Managed Care Setting,” from the Centers for Disease Control and Prevention

    • Pregnancy = Interval between estimated date of LMP and eight weeks after delivery/pregnancy termination

    • Other potential specifications

      • Entire pregnancy episode may/may not have occurred within the observation period

      • Women had to be enrolled on outcome date or enrolled at any time


    Methods
    Methods Maternal Morbidity in a Managed Care Setting,” from the Centers for Disease Control and Prevention

    • Diagnostic, treatment, laboratory, pharmacy, imaging, home health, and other databases searched for codes that could indicate pregnancy

    • Complex hierarchical decision rules to determine if a pregnancy occurred and, if so, the outcome and the date it began and ended


    Electronic data sources

    Hospital discharge abstracts Maternal Morbidity in a Managed Care Setting,” from the Centers for Disease Control and Prevention

    Same-day surgery records

    Ambulatory encounter abstracts or electronic medical records

    Emergency department visits

    Pharmacy dispensings

    Outside professional & facility claims and referrals

    Imaging procedures

    Laboratory test results

    Home health visits

    Birth certificates

    Electronic Data Sources


    Pregnancy end date and outcome
    Pregnancy End Date and Outcome Maternal Morbidity in a Managed Care Setting,” from the Centers for Disease Control and Prevention

    • Retrospective, omniscient logic

      • Start at the end of the pregnancy because the data are most reliable, then work on the episodes with less data

    • Diagnostic and procedure codes and selected claims data, and their associated dates, indicate the outcome of pregnancy and when it ended


    Pregnancy episodes identified
    Pregnancy Episodes Identified Maternal Morbidity in a Managed Care Setting,” from the Centers for Disease Control and Prevention


    Ectopic pregnancies
    Ectopic Pregnancies Maternal Morbidity in a Managed Care Setting,” from the Centers for Disease Control and Prevention

    • Medical termination

      • Rx = Methotrexate

      • Repeat pregnancy tests until hormone levels drop to pre­pregnancy levels

    • Surgical termination

      • Surgical procedure for removal of embryo

      • Repeat pregnancy tests until hormone levels drop to pre­pregnancy levels


    Spontaneous losses
    Spontaneous Losses Maternal Morbidity in a Managed Care Setting,” from the Centers for Disease Control and Prevention

    • Positive pregnancy test or diagnosis

    • Prenatal care encounters stop

    • No delivery/termination procedure

    • Many undetected if woman is not trying to get pregnant


    Elective losses
    Elective Losses Maternal Morbidity in a Managed Care Setting,” from the Centers for Disease Control and Prevention

    • Positive pregnancy test or diagnosis

    • Therapeutic abortion procedure

      • Surgical

      • Medical

    • No evidence of delivery within expected episode window


    Births
    Births Maternal Morbidity in a Managed Care Setting,” from the Centers for Disease Control and Prevention

    • Live births

      • Delivery codes

      • Infant hospital discharge

      • Birth certificates

      • Addition of infant to family health plan contract

    • Stillbirths

      • Look at delivery codes, especially delivery complications

      • No birth certificate or infant utilization data available


    Overlapping episodes
    Overlapping Episodes Maternal Morbidity in a Managed Care Setting,” from the Centers for Disease Control and Prevention

    • Overlapping pregnancy episodes are medically impossible

    • Grouper algorithm has hierarchical logic to resolve implausible episode patterns

      • Select the most likely scenario and ignore the competing data


    Algorithm validation methods
    Algorithm Validation: Methods Maternal Morbidity in a Managed Care Setting,” from the Centers for Disease Control and Prevention

    • Gold Standard = blinded medical records abstractors (MRAs) using actual electronic and hard-copy medical and billing records

    • Stratified sampling to obtain representation of all types of pregnancy outcomes


    Pregnancies missed by algorithm n 24
    Pregnancies Missed by Algorithm Maternal Morbidity in a Managed Care Setting,” from the Centers for Disease Control and Prevention(N= 24)

    n = 511 women, 702 pregnancies


    Pregnancies missed by mras no out of total of 38
    Pregnancies Missed by MRAs Maternal Morbidity in a Managed Care Setting,” from the Centers for Disease Control and Prevention(No. out of total of 38)


    Obstet Gynecol 2008;111:1089 Maternal Morbidity in a Managed Care Setting,” from the Centers for Disease Control and Prevention­95


    Definition maternal morbidity
    Definition: Maternal Morbidity in a Managed Care Setting,” from the Centers for Disease Control and PreventionMaternal Morbidity

    • Any condition during a pregnancy episode that adversely affected women’s physical or psychological health

    • Condition are unique to, or exacerbated by, pregnancy

    • Used ICD-9-CM codes to classify morbidity into forty-six major categories

    • Clinically experienced authors reviewed all ICD-9-CM codes and developed a list of 46 major maternal morbidity disease classes


    Results
    Results Maternal Morbidity in a Managed Care Setting,” from the Centers for Disease Control and Prevention

    • Type of morbidity varied by pregnancy outcome

      • UTI common with all outcomes

      • Mental health conditions common with all outcomes, especially stillbirth

      • Anemia common with live/stillbirth

      • Infections common with stillbirth


    Most common maternal morbidities by pregnancy outcome
    Most Common Maternal Morbidities by Maternal Morbidity in a Managed Care Setting,” from the Centers for Disease Control and PreventionPregnancy Outcome


    Maternal morbidities among live birth pregnancies by pay source
    Maternal Morbidities Among Maternal Morbidity in a Managed Care Setting,” from the Centers for Disease Control and PreventionLive Birth Pregnancies by Pay Source


    Article
    Article Maternal Morbidity in a Managed Care Setting,” from the Centers for Disease Control and Prevention

    Am J Psych 2007;164:1515-1520



    Percent of women diagnosed with depression who received treatment before during or after pregnancy
    Percent of Women Diagnosed with Depression who Received Treatment Before, During, or After Pregnancy

    % of

    Women


    Maternal depression

    Depression before, during, or after pregnancy was common (15.4%) among women enrolled in KPNW

    Depression diagnosis did not vary substantially before (8.7%), during (6.9%), or after (10.4%) pregnancy, but the clinical specialty of where women were diagnosed did

    About 50% of women with depression before pregnancy relapsed during the postpartum period

    About 50% of women diagnosed with depression did not have any prior history during the study period

    Over 90% of women with diagnosed depression received treatment

    Anti-depressant use was common during pregnancy

    Depressed women were more likely than non-depressed women to receive Medicaid, to be unmarried, to have 3 or more children, to be white, and to have smoked during pregnancy

    Maternal Depression


    New Engl J Med 2008;358:1444-53 (15.4%) among women enrolled in KPNW


    Pregnancy and obesity
    Pregnancy and Obesity (15.4%) among women enrolled in KPNW

    • Increasing maternal BMI is associated with greater utilization of health care, especially for pregnancies associated with more extreme obesity (BMI >35.0)

    • Almost all of this increase in utilization was related to the increased rates of cesarean delivery, gestational diabetes, diabetes mellitus, and hypertensive disorders among obese pregnant women


    Pre pregnancy bmi and hospital days in pregnancy
    Pre-Pregnancy BMI and Hospital Days in Pregnancy (15.4%) among women enrolled in KPNW


    Pre pregnancy bmi and ultrasounds in pregnancy
    Pre-Pregnancy BMI and Ultrasounds in Pregnancy (15.4%) among women enrolled in KPNW


    Pre pregnancy bmi and md visits in pregnancy
    Pre-Pregnancy BMI and MD Visits in Pregnancy (15.4%) among women enrolled in KPNW


    Pre pregnancy bmi and dispensings in pregnancy
    Pre-Pregnancy BMI and Dispensings in Pregnancy (15.4%) among women enrolled in KPNW


    Diabetes screening
    Diabetes Screening (15.4%) among women enrolled in KPNW

    • All pregnant women who receive prenatal care are screened for diabetes mellitus (DM)

    • DM first diagnosed in pregnancy is coded as Gestational Diabetes Mellitus (GDM)

    • All women with GDM should receive post-partum blood glucose screening

    • GDM increases risk of obesity in offspring


    Percent of Pregnancies with Confirmed Gestational Diabetes (GDM):1999-2006 Kaiser Permanente Northwest


    Percent of Clinician Orders and Percent of Completed Postpartum Glucose Tests among Confirmed Gestational Diabetes-affected Pregnancies


    Gdm intervention
    GDM Intervention Postpartum Glucose Tests among Confirmed Gestational Diabetes-affected Pregnancies

    • Adherence to GDM screening guideline varies widely by medical office within HMO

    • Intervention

      • Provider reminders to order FBS test

      • Patient reminders to obtain FBS test

      • Track noncompliant women and escalate reminders to patients and physicians


    Limitations of pregnancy grouper

    Missing or erroneous input data Postpartum Glucose Tests among Confirmed Gestational Diabetes-affected Pregnancies

    Coding errors

    Problems in rolling up billing records

    Pregnancies with little or no prenatal care

    Use of multiple healthcare systems

    Inconsistent pregnancy indicators

    Multiple providers: differing documentation styles

    Complex pregnancies with high utilization

    Close early losses

    Ectopic pregnancies and trophoblastic disease are inherently difficult to define

    Limitations of Pregnancy Grouper


    Conclusions
    Conclusions Postpartum Glucose Tests among Confirmed Gestational Diabetes-affected Pregnancies

    • Algorithm error rates are nearly identical to those for the MRAs (the gold standard)

    • Algorithm can be applied to very large datasets at low marginal cost and much below the costs of manual chart abstraction

    • Pregnancy-specific algorithm supports much more refined and, therefore, clinically meaningful episode classification


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