Pregnancy-related deaths per 100,000 live births for black, American Indian and Alaska Native women older than 30 were four to five times as high as they were for white women.
Minority women are as much as three times more likely to die from pregnancy-related causes than white women, and most of these deaths are preventable, according to research published this week from the Centers for Disease Control and Prevention.
The disparity worsens as the women age, CDC found. Pregnancy-related deaths per 100,000 live births were four to five times higher for black and American Indian / Alaska Native women age 30 or older than for white women of the same age.
The disparity exists even in states with the lowest pregnancy-related mortality ratios and among women with higher levels of education, suggesting that the factors surrounding pregnancy-related death for black and AI/AN women "is a complex national problem," CDC said.
About 700 women die every year in the United States from pregnancy-related complications, according to CDC estimates.
The findings were published this week in Morbidity and Mortality Weekly Report (MMWR), and suggest that the disparity observed in pregnancy-related death for black and AI/AN women is a complex national problem, said study lead author Emily Petersen, MD, medical officer at CDC's Division of Reproductive Health.
"These disparities are devastating for families and communities and we must work to eliminate them," Petersen said. "There is an urgent need to identify and evaluate the complex factors contributing to these disparities and to design interventions that will reduce preventable pregnancy-related deaths."
An earlier CDC report in May looked at data from 13 state Maternal Mortality Review Committees (MMRCs), which estimated that 60% of pregnancy-related deaths are preventable, mostly through access to better care.
That study also found that each pregnancy-related death saw contributing factors, including access to appropriate care, missed or delayed diagnoses, and lack of knowledge among patients and providers around warning signs.
This week's CDC study, based on analysis of national data on pregnancy-related mortality from 2007-2016, found that:
Overall PRMRs increased from 15 to 17 pregnancy-related deaths per 100,000 births.
Non-Hispanic black and non-Hispanic AI/AN women experienced higher PRMRs (40.8 and 29.7, respectively) than all other racial/ethnic populations. This was 3.2 and 2.3 times higher than the PRMR for white women – and the gap widened among older age groups.
For women over the age of 30, PRMR for black and AI/AN women was four to five times higher than it was for white women.
The PRMR for black women with at least a college degree was 5.2 times that of their white counterparts.
Cardiomyopathy, thrombotic pulmonary embolism, and hypertensive disorders of pregnancy contributed more to pregnancy-related deaths among black women than among white women.
Hemorrhage and hypertensive disorders of pregnancy contributed more to pregnancy-related deaths among AI/AN women than white women.
Disparities were persistent and did not change significantly between 2007-2008 and 2015-2016.
CDC said hospitals and health systems can help to reduce these disparities by implementing standardized protocols in quality improvement initiative, especially at hospitals that disproportionately serve these minority women.
CDC also called for hospitals to identify "implicit bias" in their healthcare delivery to improve patient-provider relationships, and communication, and ultimately outcomes.
Researchers suggest that the NICU growth over the past three decades may be driven more by hospital competition than by medical need.
Nearly half of all newborns admitted to the nation's neonatal intensive care units are of normal birth weight, according to a new study from The Dartmouth Atlas.
This is happening, the researchers found, while at the same time 15% of very low birth weight babies (less than 1500 grams/3.3 pounds) don't get care in Level III or IV NICUs.
"We should not spare a dollar in providing the best care for newborns. But spending more doesn't help infants if they could receive the care they need in a maternity unit or home with their mothers," said principal author David C. Goodman, MD, of The Dartmouth Institute for Health Policy & Clinical Practice.
“It is very troubling that such a valuable and expensive health care resource is not distributed where it is needed," he said.
Three decades ago, most NICU newborns were of low birth weight. In 2017, normal birthweight babies accounted for 48% of NICU admissions, the researchers found.
From 1995-2013, the number of NICU beds across the nation grew 65% from 1995-2013, and the numbers of neonatologists increased 75%, even as the numbers of newborns remained stable.
The researcher said the increasing numbers of NICU beds and neonatologists has led to increasing numbers of lower risk newborns being admitted to NICUs.
The Dartmouth study suggests that the "high-margin" NICU boom may be driven more by hospital competition than by medical need.
The researchers cited a 2013 March of Dimes study which found that hospitalization costs average $54,000 for preterm infants. They also cited a 2010 article in Managed Care magazine which reported that NICUs account for 75% of all dollars spent for newborn care.
"This is a strong financial incentive for further building and expansion of NICUs and for keeping those beds full, potentially leading to overuse of services, especially in lower-risk newborns," the researchers said.
Even with the proliferation of NICUs, however, access to specialized neonatal care has been uneven. The researchers found that the growth of NICU beds has lagged in areas that most need those services.
"Regions of the country with a high proportion of premature newborns, or other factors related to newborn illness, such as maternal education level or the rate of cesarean sections, are not the regions with higher supply of NICU beds or neonatologists," they said.
"Regardless of the infant population we studied, newborn and NICU care varied markedly across regions and hospitals," the researchers said. "Little of the variation was explained by differences in newborn health needs. The care that similar newborns receive is strikingly different in one hospital compared to another."
In addition to being a poor use of resources, the Dartmouth researchers said that the unnecessary use of NICUs poses potential threats to low-risk newbornds.
"Those with less severe illnesses have less to gain from intensive care yet are still exposed to the possible adverse effects of a hospital setting designed primarily for critical care," the report states.
Heart of Florida Regional Medical Center in Davenport and Lake Wales Medical Center are renamed AdventHealth Heart of Florida and AdventHealth Lake Wales.
AdventHealth has expanded its footprint in Central Florida with the addition of two hospitals.
Effective immediately, 193-bed Heart of Florida Regional Medical Center in Davenport and 160-bed Lake Wales Medical Center will join the health system as AdventHealth Heart of Florida and AdventHealth Lake Wales, Altamonte Springs, Florida-based AdventHealth said in a media release.
Financial terms were not disclosed.
The acquisitions include each hospital's businesses, clinics and outpatient services. The 1,200 employees from the two hospitals will become AdventHealth employees, and the dozens of employed physicians at the two hospitals will join AdventHealth Medical Group.
The two hospitals will operate from within AdventHealth's Central Florida Division.
"Polk County is one of Florida's fastest growing regions and it's important that healthcare services keep pace so the communities we will serve there can also be amongst the state's healthiest," said Daryl Tol, president/CEO for AdventHealth's Central Florida Division.
Brian Adams has been named market CEO for the two hospitals, having previously served as senior vice president of new markets for the AdventHealth Central Florida Division – South Region and president/CEO for AdventHealth Tampa.
"AdventHealth has a long history of bettering the regions we serve and where our team members live, work and play," Adams said.
Non-profit AdventHealth operates 48 hospitals in nine states.
Research shows higher mortality for children brought to ERs that can't provide pediatric services.
Critically ill children brought to hospital emergency departments that aren't prepared to care for pediatric emergencies face more than three times the odds of dying compared to children brought to hospitals well-equipped to care for them.
It's a problem that will not be solved simply by dumping lots of money into hospitals to upgrade their pediatric emergencies services, says study senior author Jeremy Kahn, MD, because it costs too much money.
"The vast majority of hospitals in the United States care for very small volumes of children, and when you have those low numbers, it's very hard to be ready for anything that can come your way," Kahn says.
"It's not so different from a Caribbean nation being prepared for a snowstorm. It might happen, but it's going to be incredibly unusual. So, the resource investment required to prepare for every eventuality for every pediatric emergency is ultimately enormous," he says. "There are reasonable questions about whether that's a value-based strategy."
Kahn spoke with HealthLeaders about shortcomings in the nation's pediatric emergency medicine network and offered suggestions for how that network might be improved. The following is a lightly edited transcript.
HL: What are the different needs of pediatric and adult ERs?
Kahn: The key difference obviously are the diseases themselves. The things that a child is going to present with will be vastly different than the things that an adult will present with. Even with the same symptoms, chest pain for example, is a very common presenting symptom in an adult and it has a very serious differential diagnosis, things like heart attacks, obviously, are very concerning. But in a child chest pain has just a very different set of considerations.
There are some things that are very specific to pediatric emergencies, like weight-based dosing. In the adult emergency world, it's very often one-size-fits-all. But for children, dosage will vary dramatically in their size. And then they use very specific equipment as well.
HL: Why aren't all hospital ERs "pediatric ready"?
Kahn: The vast majority of hospitals in the United States care for very small volumes of children, and when you have those low numbers, it's very hard to be ready for anything that can come your way. It's not so different from a Caribbean nation being prepared for a snowstorm. It might happen, but it's going to be incredibly unusual. So, the resource investment required to prepare for every eventuality for every pediatric emergency is enormous.
HL: In what ways are ERs unready for pediatrics?
Kahn: The most common reasons for having low readiness scores was not a lack of ability to do things such as weight-based dosing, or lacking all the equipment, because almost all emergency departments have pediatric-sized equipment. The problem was not having a pediatric-focused quality improvement officer, not having all the policies and procedures in place. Unfortunately, what we found in our study is that those things translate into patient outcomes.
We knew going into our study that there was wide variation in the amount of readiness among hospitals across the country. But now we have empirical data to show that low readiness scores do translate into poor outcomes for at least the sickest patients.
HL: Are you able to estimate how much improving ED pediatric readiness would cost?
Kahn: I don't know the answer to that, but I think that's the issue. It's just not a value-based strategy to have every hospital in the United States become maximally pediatric ready because, again, there are some hospitals that will just see very low numbers of children.
The key is to take a multipronged approach that customizes for a region or a state. In some areas where there are no specialized children's hospitals, it may behoove that area for every hospital to be ready to care for children. But in other areas, maybe there are alternative strategies, such as regionalization, where the sickest children are triaged in the pre-hospital setting to go right to the one or two hospitals in the region that are most ready to care for pediatric emergencies.
Telemedicine is another exciting potential strategy to extend the benefits of pediatric readiness to more hospitals using remote audio-visual equipment. So those are alternative strategies.
HL: What are some of the key commonalities for pediatric readiness in the high-scoring, pediatric and adult hospitals?
Kahn: One is volume. We found that obviously having a high volume of children makes you more likely to be pediatric ready. But the highest determinant was having a dedicated physician and nurse who oversee pediatric-focused quality improvement in the hospital.
HL: How difficult would it be for a hospital to do a pediatric readiness assessment?
Kahn: If there's any lesson from our study, it's that hospitals should know what their capabilities are for caring for critically ill children. Those readiness assessments should already be a routine part of that hospital's policies and procedures.
The question then becomes, how do they respond if they perceive that there are gaps in their readiness? That has to be a very customized approach. There's not going to be a one-size-fits-all approach.
This is not the responsibility of individual clinicians to fix. This is a systemwide issue, and hospitals and regions within states should get together to strategize about the best ways to deliver emergency care for children.
HL: What would you like to see done with your study findings?
Kahn: We should not respond to these data with a shrug. We need to do something to increase pediatric readiness among our nation's hospitals. What we do will be determined by specific hospitals, and specific regions. Different approaches are going to work in different ways in different areas.
The only mistake would be to do nothing.
Editor's note: This story was updated on September 5, 2019.
Penn Medicine researchers believe their findings show that administering AVP to trauma patients with severe bleeding could become standard practice in trauma care.
Dosing gunshot victims and other hemorrhaging trauma patients with the hormone arginine vasopressin cut the need for stabilizing blood products in half, clinical trials at Penn Medicine show.
The study, published in JAMA Surgery, treated 100 hemorrhagic shock patients with a low-dose AVP at the Penn Medicine trauma center between 2013 and 2017. The protein is produced in the hypothalamus, stored in the pituitary gland, and constricts blood vessels when it is secreted into the bloodstream when blood pressure is too low.
All but seven of the patients were males who were victims of gunshot or knife wounds. The researchers randomized 49 of the patients to receive AVP in an initial moderate dose plus a slow infusion—during the first 48 hours of care—and the other 51 to receive the placebo equivalent.
The researchers found that the patients treated with AVP for 48 hours ended up receiving an average of 1.4 liters of blood products – less than half the 2.9 liters that was the average amount given to patients treated with the placebo.
The AVP group also had a markedly lower rate (11% vs. 34%) of deep-vein thrombosis. Rates of complications within 30 days for the AVP and placebo groups were otherwise similar (55% vs. 64%), and the numbers of deaths in that period were the same (six in each group), the study said.
While the AVP group had shorter average stays in the hospital, the relatively small number of patients in the study meant that these length-of-stay differences were not statistically significant.
There are more than 100,00 firearm-related injuries resulting in more than 36,000 deaths annually in the United States. The Penn Medicine researchers believe their findings show that administering AVP to trauma patients with severe bleeding could become standard practice in trauma care, reducing the use of blood products and their adverse side effects.
"Unintentional traumatic injuries are the leading cause of death in the United States for people younger than 45, and the injuries often involve severe blood loss," said Carrie A. Sims, MD, an associate professor of Surgery and Laboratory Director of the Penn Acute Research Collaboration, in comments accompanying the study.
"We can replace a patient's lost blood with blood products such as packed red blood cells, fresh frozen plasma, and platelets, but use of these options can lead to serious complications and they may not fully replace key molecules in blood that are needed to support blood pressure and the normal function of vital organs," Sims said. "The results of this trial suggest a promising way to reduce the amount of blood needed to save the lives of patients with life-threatening injuries."
(Support for the study was provided by the National Trauma Institute and the U.S. Department of the Army.)
The financially troubled 496-bed teaching hospital in Philadelphia shutters on September 6.
The Federation of State Medical Boards FSMB will make the records available to physicians after the records have been collected and catalogued.
The Federation of State Medical Boards will take custody of physician training records at Philadelphia's Hahnemann University Hospital before the financially troubled 496-bed teaching hospital shutters on September 6.
"Effective August 26, the FSMB has become the central repository and primary source for all graduate medical education records of residents and fellows who completed training at HUH after 1990," FSMB said in a media release. "In some cases, earlier records may also be available."
FSMB said it will make the records available to physicians after the records have been collected and catalogued, and will be accessible through the federations Closed GME Prorgrams service.
Current or former residents and fellows who need instructions on how to obtain their training records should send a request with current contact information to hahnemann@fsmb.org.
The transfer of medical training records to the FSMB is a standard practice when residency program close. FSMB will permanently store the records and will become the primary source for information about residents who trained at the hospital for future uses, such as state medical licensure applications and hospital/health care privileges, FSMB said.
Hahnemann University Hospital, which had served the city for more than 170 years, declared bankruptcy in June, citing "financial difficulties," and discharged its last patient in late July. A group of six Philadelphia-area health systems won the Aug. 8 at auction for $55 million, topping bids by Tower Health and KPC, which operates seven hospitals in Southern California.
The Philadelphia Inquirerreported earlier this month that California-based KPC Global, which lost in the Aug. 8 auction, would up its bid to $60 million if bidding were reopened.
The breach in the hospital's Neurology Department did not include Social Security numbers, or insurance or financial information.
Nearly 10,000 people are being notified by Massachusetts General Hospital that an unauthorized third-party had access to their personal information.
The breach affecting as many as 9,900 people occurred between June 10 and June 16 at the renown Boston-based hospital's Department of Neurology, and was traced to two computer applications used its research programs, MGH said in a media release. The breach was discovered on June 24.
"The research data did not include any study participant's Social Security number, insurance information, or any financial information," MGH said. "The research data did not include any study participant's address, phone number, or other contact information. The incident did not involve MGH's medical records systems."
However, the breached data "may have included a participant's first and last name, certain demographic information (such as marital status, sex, race, ethnicity), date of birth, dates of study visits and tests, medical record number, type of study and research study identification numbers, diagnosis and medical history, biomarkers and genetic information, types of assessments and results, and other research information," MGH said.
Some of the breached data was "many years ago," MGH said, and for deceased research participants, included date of death, and a summary autopsy results.
MGH hired a third-party forensic investigator to review the breach, and the hospital contacted federal law enforcement as a precaution.
At this point, the hospital said no action is needed on the part of the research participants because the breach did not involve Social Security numbers, insurance or financial information.
(People who have any questions or would like additional information can call (866) 904-6219, Monday-Friday (9:00 am – 9:00 pm Eastern) or Saturday-Sunday (11:00 am – 8:00 pm Eastern).
Weight loss of at least 20 pounds was also associated with a 72% reduction in the odds of being discharged from the hospital to a facility.
Morbidly obese patients who lose 20 pounds before knee replacement surgery cut their hospital stays by about one day, and were 76% less likely to have an extended hospital stay of four days or longer, new research shows.
Writing in The Journal of Bone & Joint Surgery, researchers at Dartmouth-Hitchcock Medical Center said shorter hospital stays were not associated with morbidly obese patients who lost between five and 10 pounds before the surgical procedure.
"Losing at least 20 pounds was associated with lower absolute length of stay, lower odds of extended length of stay, and lower odds of being discharged to a facility," lead researcher David S. Jevsevar, MD, MBA, and colleagues wrote.
The study reviewed data on 203 morbidly obese patients who underwent total knee arthroplasty between 2011 and 2016 at one hospital. These patients accounted for 13.5% of the 1,500 patients who had knee replacement in that span.
In the months before surgery, 41% of patients lost at least five pounds, 29% lost at least 10 pounds, and 14% lost at least 20 pounds.
The researchers found that patients who lost at least 20 pounds spent about one fewer day in the hospital and were 76% less likely to have an extended hospital stay of four days or longer. Weight loss of at least 20 pounds was also associated with a 72% reduction in the odds of being discharged from the hospital to a facility.
However, no noticeable improvements in outcomes were noted for patients who lost between five and 10 pounds, and the study found that length of hospital stay and operative time were "significantly increased" for patients who added weight before surgery.
In addition, no association was found between preoperative weight loss and change in operative time or with postoperative health improvements and functions.
Jevsevar said larger studies will be needed to prove that preoperative weight loss can improve outcomes after total knee replacement. However, he said the Dartmouth-Hitchcock study suggests that "providers may want to focus on larger, specific amounts of weight loss in morbidly obese patients preparing for total knee arthroplasty."
A retroactive study found no differences in urinary complications between patients who used a Foley catheter and patients who did not.
Hip and knee replacement surgery can be performed safely without relying on a commonly used Foley urinary catheter, according to a new study in The Journal of Arthroplasty.
Researchers at Henry Ford Hospital in Detroit conducted a retrospective study of 335 patients and found no increased risk for post-surgery complications among those patients who were not catheterized.
"Until now, we didn’t have the research to show that we could perform the surgery without a Foley catheter," study senior author Michael Charters, MD, a Henry Ford joint replacement surgeon, said in remarks accompanying the study.
"All of our patients are now undergoing surgery without the catheter," Charters said. "It's a huge benefit for patients because it improves their mobility immediately after surgery. They can get up and walk around without being impeded by catheter tubes."
Before the study, Henry Ford clinicians commonly inserted a catheter into the patients' bladders in the operating room before surgery and removed the next day.
The researchers compared complications risks between patients with and without a catheter under epidural anesthesia between 2016 and 2018. Of the 335 patients, whose average age was 65, 103 used a catheter and 232 did not. Data was collected from patients' hospital admission and for the next 90 days.
Researchers found no differences in urinary complications, urinary retention, urinary incontinence or urinary tract infection between the two groups, Charters says.
Policymakers are sifting through more than 800 public comments on proposed changes to the Hospital Compare methodology.
The Centers for Medicare & Medicaid Services said Monday it will update its controversial Overall Hospital Quality Star Ratings in 2021.
Until then, CMS said it will "refresh" the Star Ratings, which appear on the Hospital Comparewebsite, in early 2020 using the existing methodology while a new methodology is being finalized for 2021.
Although the methodology had typically been updated every six months, the ratings have been updated only once since 2017 amid long-running complaints over their accuracy.
CMS said in a media release that "only a few comments recommended removing or suspending the Overall Star Ratings from Hospital Compare until changes are made."
"The comments are largely consistent with previous stakeholder feedback, with the most common concerns about the Overall Star Ratings being that CMS should improve its usefulness for consumer decision-making and hospital improvement," CMS said.
Since the five-star ratings inception in 2016, hospital stakeholders have repeatedly called on CMS to delay, revise or eliminate them until policymakers could address hospitals' concerns about the accuracy and correct use of the data.
CMS provided no details on what the changes to the star rating could encompass for 2021. However, the agency acknowledged that stakeholders have continued to raise concerns that the ratings are too complex, or oversimplified, imprecise, and provided without proper context for "more direct 'apples-to-apples' comparisons."
The American Hospital Association has a long history of criticizing the methodology, calling it confusing, complex, inaccurate and basically useless for most consumers.
AHA Senior Vice President of Policy Ashley Thompson said Monday the association was "disappointed that CMS intends to continue using a hospital star ratings approach plagued by longstanding concerns about its accuracy and meaningfulness."
"While we appreciate that CMS is working on potential improvements to the rating methodology, we strongly believe CMS should not refresh the ratings until those improvements have been vetted and are ready for implementation," Thompson said.
"Republishing the flawed ratings in 2020 will not advance the goal of providing the public with accurate, purposeful information about quality."
Bruce Siegel, MD, MPH, president and CEO of America's Essential Hospitals, said the safety net hospitals' association appreciates CMS' "efforts to engage stakeholders" in the rulemaking process.
"However, in the meantime, the agency's plan to refresh data using a methodology that is under review for its shortcomings is misleading to patients," Siegel said.
"The star ratings continue to reflect a flawed methodology rather than actual hospital performance and improvement. In particular, these ratings fail to account for social risk factors beyond a hospital’s control that affect performance."
Siegel said safety net hospitals support providing patients with "relevant information."
"But the current star ratings are not the way to do this. We urge the agency to suspend the ratings until methodology updates are complete," he said.
CMS said it is planning additional public outreach to shape potential changes to the Overall Star Ratings methodology, including a public listening session in Baltimore on September 19 that will include a call-in option.
