Impact of Expansion
of Specialty Consultation Practice
on Use of Specialty Care for
Medicaid High Risk Pregnancies
Janet M. Bronstein
University of Alabama at
Birmingham
jbronstein@uab.edu
A N G E L S
Antenatal & Neonatal Guidelines, Education & Learning System
A N G E L S
Antenatal & Neonatal Guidelines, Education & Learning System
• Co-authors at the University of
Arkansas for Medical Sciences
–
–
–
–
Songthip T. Ounpraseuth, Ph.D.
Jeffrey Jonkman, Ph.D.
David Fletcher, M.B.A
Curtis Lowery, M.D.
• Co-authors at the State of Arkansas
– Judith McGhee, M.D. (Medicaid Agency)
– Richard Nugent, M.D., M.P.H. (Department
of Public Health)
Medicaid covers a large portion of U.S.
pregnancies – many are high risk
ANGELS – Arkansas Medicaid supported
expansion of UAMS MFM consulting service
Case
Management
Education
& Support
for OB
Providers
Evidence
Based
Guidelines
Clinical
Research
24/7
Consultation
Call Center
Expansion of
Telemedicine
Network &
Clinics
Evaluation of ANGELS (Phase one, 20012005, intervention started April 2003)
• Did ANGELS increase the proportion
of
– Maternal Fetal Medicine (MFM) consults
for targeted diagnoses?
– MFM consults for other reasons?
– Deliveries of infants younger than 35
weeks at neonatology-staffed NICU?
Consults and NICU deliveries are special
cases of physician referral behavior
• Making the Referral
• Norms for referral
(boundaries of
expertise),
professional networks,
pressures to retain
patients
– ANGELS and health
care market factors
• Completing the
Referral
• Enabling
characteristics,
awareness of
pregnancy risk,
relationship with
primary provider
– Demographics and
care factors
Consults and NICU deliveries are special
cases of physician referral behavior
• ANGELS and health care
market factors
– Guidelines, calls to
call center, site for
MD tele-rounds,
remote patient
consult site
– Presence of OB or GP
or no maternity, beds
and MDs per capita,
sites claiming to do
high risk OB and have
NICUs
• Demographics and care
factors
– Education, age, race,
parity, ethnicity,
partner status,
county poverty level,
% Black, rural,
distance
– Adequacy of prenatal
care, initial care in
health dept, gestation
at delivery, any MFM
consult (for delivery
at NICU)
Methodology
Data
• Medicaid claims for
pregnancy 2001-2005,
clustered into episodes,
linked to birth certificates.
Total 91,902 live births.
• County ARF and AHA data
for residence and
contiguous counties linked
to the episodes.
• MFM analysis excludes
Little Rock. NICU analysis
includes only births < 35
weeks gestation.
Statistical Approach
• Time series logistic
regression with
standard errors
corrected for county
clustering.
• Time trend,
distance to
specialist and
distance to closest
NICU hospital
controlled
Trends in Outcome Measures
2001
2002
2003
Angels
began
2004
Angels
2005
Angels
MFM with
28.7%
targeted DX
(n=30,364)
30.4%
27.5%
25.6%
24.3%
17.8%
MFM no
targeted DX
(n=47,410)
18.4%
16.0%
12.2%
12.3%
40.3%
40.5%
45.3%
45.0%
43.6%
NICU
delivery
(n=4,531)
Impact of ANGELS measures on care
delivery (O.R., 95% C.I., p value)
MFM for
targeted DX
MFM for other
DX
Delivery at
NICU
Guidelines in
active draft
0.99
(0.99,1.00)
1.00
(0.99,1.01)
1.02
(1.01,1.04)**
Cumulative
guidelines
completed
0.98
(0.98,0.99)***
0.98
(0.98,0.99)***
1.00 (0.99,
1.01)
MD calls from
county
0.91
(0.74,1.13)
0.71
(0.54,0.93)*
1.22
(0.94,1.57)
PT calls from
county
1.68
(1.33,2.11)***
2.59
1.60
(1.82, 3.69)*** (1.13,2.27)**
Teleconference
site
1.03
(0.71,1.48)
1.16
(0.80, 0.70)
0.29
(0.18,0.45)***
Clinical remote
site
1.26
(0.90,1.77)
1.36
(0.80,2.32)
1.88
(1.22,2.89)**
* P < .05, ** p<.01, *** p< .001
Impact of Health Care Market measures on
care delivery (sign, p value)
MFM for
targeted DX
MFM for other
DX
Delivery at
NICU
Other MD vs OB
- (p=.06)
-***
+***
No maternity vs
OB
+*
+*
+***
Reports NICU (no
(ns)
(ns)
-*** in cty
+*** contig cty
Reports high risk
OB (no MFM)
(ns)
- (p=.05)
-**
MDs per capita
-*
- (p=.07)
+** in cty,
-*** contig cty
Beds per capita
+***
+***
+***
neonatologist)
* P < .05, ** p < .01, *** p < .001
Impact of individual demographic
measures on care delivery (sign, p value)
MFM for
targeted DX
MFM for other
DX
Delivery at
NICU
Black/other vs
white
(ns)
(ns)
(ns)
Hispanic vs not
-***
-*
+*
Education
(ns)
+ low (p=.07)
- High **
-low*
+ high***
Age
(ns)
- >34 ***
-Teen*
Partner status
vs married
+ without*
+ without***
(ns)
% cnty Black
+*
+*
+*
% cnty < FPL
-***
-**
-***
(ns)
-**
+***
Rural county
* P < .05, ** p < .01, *** p < .001
Impact of individual care measures on
care delivery (sign, p value)
MFM for
targeted DX
Multiple birth
MFM for other
DX
Delivery at
NICU
+**
+ p=.05
(ns)
+ 25 -31wks**
+ 32-33 wks
p=.06
(ns)
+***
(most common
for 25-27 wks)
(ns)
+ high parity*
+ first birth***
Adequacy of
Prenatal care
+ intensive***
+ intensive***
-Intermed.***
+ inadeq.***
Initial care in
Health Dept
+***
+***
-***
Health Dept X
time
-***
-***
+***
MFM visit
------
-----
+***
Gestational age
at delivery vs
oldest
Parity
* P < .05, ** p < .01, *** p <.001
Conclusions
• Medicaid-supported expansion of
academic MFM consulting service is
altering delivery of maternity care in
Arkansas
– Increasing local expertise, decreasing
specialty visits
– Increasing use of neonatology-staffed NICU
for preterm deliveries
• Local expertise competes with more
distant specialists, may lead to less
appropriate care.
Thank You
A N G E L S
Antenatal & Neonatal Guidelines, Education & Learning System