Alicia Ault

May 19, 2016

WASHINGTON, DC — Postdelivery readmission rates are increasing in California, Florida, and New York, according to a new analysis, but researchers say the reasons are not completely clear.

The rate of cesarean delivery is increasing, but that alone does not explain why close to 2% of women in these three states were readmitted after delivery, said researcher Mark Clapp, MD, a fourth-year resident from Brigham and Women's Hospital in Boston.

He presented the study results here at the American Congress of Obstetricians and Gynecologists 2016 Annual Clinical Meeting.

Readmissions are increasingly being used as a quality metric throughout medicine. But few studies of obstetric readmissions have been conducted, which means little is known about how often or why women end up back in the hospital after a delivery, Dr Clapp explained. And it is not known whether these readmissions are an indicator of good care or bad care.

There is no national database on obstetric readmissions, so the researchers conducted their retrospective cohort analysis using statewide admissions in the three states. In the cohort of 5,949,730 eligible deliveries they identified from 2004 to 2011, there were 114,748 readmissions.

The readmission rate increased from 1.72% in 2004 to 2.16% in 2011. This is a relatively small percentage but still concerning, given that there are 4 million births in the United States annually, Dr Clapp explained.

The main reasons for readmission were infection (15.5%), hypertension (9.3%), and psychiatric disease (7.7%).

In addition, hypertension was an associated diagnosis in 16% of readmissions and psychiatric disease was an associated diagnosis in 17%.

The rate of readmission related to psychiatric disease "was really surprising to us," Dr Clapp told Medscape Medical News. The majority of women were readmitted for postpartum depression, but substance abuse was also part of the diagnosis, he said.

Readmission is not necessarily a bad thing. "Maybe some of these readmissions are actually indicated" and are part of good quality care, he explained.

Possible Racial Disparities

The data raise concern about potential disparities. Almost 19% of the women readmitted were black, which is disproportionate to their representation in the delivery population, Dr Clapp reported.

And 54% of the readmissions were covered by Medicaid, which, again, is a disproportionate representation of payers, he told Medscape Medical News.

Readmissions varied by state and mode of delivery, but not in predictable ways. In New York, the readmission rate was higher after cesarean delivery than after vaginal delivery, whereas in Florida, the rate of readmission after vaginal delivery reached almost 3% during the study period, far surpassing the rate after cesarean delivery.

In California, readmission rates were on a bit of a downward trend in 2011, and were about equal for cesarean and vaginal delivery — at just under 2%.

This is a healthy population. This isn't a readmission after a heart attack.

Although the numbers of readmissions are small, they should not be overlooked, said Aaron Caughey, MD, PhD, professor and chair of obstetrics and gynecology at Oregon Health & Science University in Portland.

"This is a healthy population. This isn't a readmission after a heart attack," he told Medscape Medical News.

He said he applauds the study, which was "nicely designed," and would like to prod the researchers to determine why women are being readmitted.

The fact that many readmissions were related to hypertension makes sense from a biologic standpoint, given that obesity has been on the rise in the United States, said Dr Caughey. This needs closer examination.

Obstetric patients have more medical comorbidities nowadays than in the past, and the readmissions could be reflective of that, said Dr Clapp. In the current analysis, 13% of those readmitted had diabetes, 15% had hypertensive disorder, 15% had psychiatric disease, 7% were obese, and 6% had asthma. In addition, 11% had pregnancy-related hypertensive disorder and 7% had substance abuse issues.

"Whether we should be considering their comorbidities in addition to their mode of delivery" is worth exploring, he told Medscape Medical News.

This study was funded by the ACOG Warren H. Pearse Women's Health Policy Research Award. Dr Clapp and Dr Caughey have disclosed no relevant financial relationships.

American Congress of Obstetricians and Gynecologists (ACOG) 2016 Annual Clinical Meeting: Abstract 260P. Presented May 14, 2016.


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