Abuse, Psychosocial Stress And High Medical Utilization In Pregnancy Tina Bloom, R.N, MPH Mary Ann Curry, RN, DNSc School of Nursing, Oregon Health & Science University
A secondary analysis from “Randomized Nursing Intervention to Abused Pregnant Women” (2001-2005). RO1 NR02696, National Institutes of Nursing Research. Dr. Mary Ann Curry, P.I.
General High Utilization • ~Half of ED visits for non-urgent reasons • Most emergency department patients do not require hospitalization • “Serial users” account for many ED visits (Cook et al, 2004; Mandelberg, Kuhn, & Kohn, 2000)
Characteristics of High Utilizers in General Literature • Multiple complaints: sprains, superficial injuries, back problems, headaches, or abdominal pain • Chronically ill • Male or female
Characteristics of High Utilizers in General Literature • Non-white • Stressed, isolated, mentally ill, ETOH abusers • Uninsured, underinsured, low income • Abuse, trauma (current or historical) (Cook et al, 2004; Mandelberg, Kuhn, & Kohn, 2000)
Trauma and High Utilization • Childhood trauma/sexual abuse history and IPV associated with physical and mental health sequelae, and • High utilization of medical services • IPV in pregnancy 0.9% to 20.2% Hendricks-Matthews, 1992; Arnow, 2004; Arnow et al 2000; Campbell 2002; Farley & Patsalides, 2001; Katon, Sullivan, & Walker, 2001; Rosenberg et al., 2000; Stein et al., 2000, 2004;Katon et al., 2001; Gazmararian et al 2000.
Utilization in Pregnancy Most utilization literature focuses on women with little or no prenatal care, and/or late entry to prenatal care.
Research Question: Do psychosocial stressors (trauma, abuse) and social disadvantage (poverty, race, lack of resources) play a significant role in high medical utilization among pregnant women?
“Randomized Nursing Intervention to Abused Pregnant Women” Study A multi-site RCT to determine if a nurse-case management intervention have a significant impact on pregnancy outcomes, including medical utilization, for women at risk for or experiencing violence? [Curry et al (2006). Nurse case management for pregnant women experiencing or at risk for abuse, JOGNN, 35, 181-192] .
Secondary Analysis: 500 Pregnant Women Members of a West Coast HMO. • 68% Caucasian • 16% African American • Latino 4% • Asian/Pacific Islander 4% • Native American/Alaskan Native 1%
Secondary Analysis: 500 Pregnant Women • Mean age 29.72 (5.91) • Mean income $3871 (2889) • Mean education 15 yrs (2.86) • 68% married • 17% single, living with partner
High Utilizers (HU) in This Study • Women with 5 or more visits to the L&D, urgent care, ED, or nurse treatment (>2SD mean) • HU n=41; mean # of visits 7.78 (3.2) • LU n=328; mean # of visits 0.99 (1.1)
Recent Abuse *=p<.05; **=p<.01; ***=p<.001
Uninsured or Oregon Health Plan Non-white Lower income High school dropouts Younger Live alone Higher stress & lower self-esteem Recent abuse (used the AAS to screen) High Utilizers Differed Significantly from Low Utilizers, p<.05
Diagnoses for High Utilizers • Preterm onset of contractions/PTL*** • Hyperemesis*** • Gestational Diabetes* • Weight disorders* • Neurological problems*** • Musculoskeletal problems* *=p<.05; **=p<.01; ***=p<.001
Gravida/Parity Previous complications Onset of prenatal care Maternal or infant hospital stay at delivery Birth weight (145 g. difference--ns) No Significant Differences: …Gestational age at delivery did differ—by 4.4 days: HU=38.48 weeks, SD 1.6 LU=39.12, SD 1.9,…. p<.05
Conclusion Pregnant women who used more medical services in our study were a vulnerable group characterized by past and current violence, economic disadvantage, & psychosocial stress.
Limitations • Broad categories for diagnoses and chief complaints • Small number of participants– esp. for HU • Did not measure emotional abuse or mental health symptoms in this study
Implications • High utilizers are a vulnerable group that are more likely to be in need of social services, extra support— due to high stress, low self esteem, & abuse • We could have predicted high utilization @ T1 (weeks 16-23). This is a missed opportunity to provide needed services. • Need for more research. Urgent care clinic or hospital a refuge?