Palmira Santos

Care coordination can improve patient outcomes, increase continuity of care, and reduce healthcare utilization. This study explores the effectiveness and limitations of care coordination as a strategy for meeting vulnerable patients' needs. The study team conducted a qualitative, multi-site, collective case study of four sites providing care coordination for vulnerable and marginalized populations. Data were gathered via individual patient interviews (n = 69) and staff focus groups (82 participants) and analyzed using a matrix template to code data and identify common themes. Addressing patients' needs required coordination across behavioral, medical, and social service providers. This was most effective when it included social needs and built on trusting relationships between patients and staff. However, sites faced shared challenges from systemic barriers that limited their effectiveness. For vulnerable and marginalized populations, evidence-based care coordination can only address some needs, and benefits are often undermined by deeply entrenched structural deficits. Future care coordination programs must include an assessment of structural barriers and incorporate concurrent efforts to address them.

Preterm delivery occurs at extraordinarily higher rates among Black women than among women of any other race or ethnicity. For those children who survive, many face a lifetime of health and developmental challenges as well as difficulties in school and life. Previous studies have provided substantive evidence that the preterm delivery disparity experienced by Black women is associated with ongoing distress caused by racism. Our study examines rates of preterm delivery for Black women in the USA to determine the level of risk associated with living in specific states. Using a logistic regression model, we examined the impact of the delivery state, controlling for known clinical, economic, and demographic risk factors. We found that 32 of the 35 states included in our analysis were associated with a statistically significantly increased risk of preterm delivery among Black women, as compared to the state with the lowest preterm delivery rate for Black women. These findings allowed us to organize states into a continuum of preterm delivery risk. Because of the harmful effects of preterm delivery and its disproportionate impact among Black women and infants, we recommend that a measure of preterm delivery be included in any state plan to assess, intervene in, and monitor racial disparities.

Shoulder dystocia is a rare but severe birth trauma where the neonate's shoulders fail to deliver after delivery of the head. Failure to deliver the shoulders quickly can lead to severe, long-term injury to the infant, including nerve injury, skeletal fractures, and potentially death. This observational study examined shoulder dystocia risk factors by race and ethnicity using a sample of 19,236 pregnant women who presented for labor and delivery from July 1, 2010 until June 30, 2013 at five locations. Multivariate analyses were used to identify risk factors associated with shoulder dystocia occurrence in racial/ethnic groups with high incidence rates. For White non-Hispanic mothers, the strongest risk factors were delivering past 40 weeks' gestation (odds ratio [OR] = 2.4; 95% confidence interval [CI] = 1.5, 3.9; p < .01) and use of epidural anesthesia during delivery (OR = 4.4; 95% CI = 3.0, 6.4; p < .01). Among Black non-Hispanic mothers, the risk factors with the greatest impact were use of epidural (OR = 5.3; 95% CI = 3.2, 8.7; p < .01) and having gestational diabetes and controlling the condition with insulin (OR = 4.6; 95% CI = 1.5, 13.8; p < .01). Additionally, among Hispanic mothers, having Spanish as primary language increased shoulder dystocia likelihood compared to those who did not cite it as their primary language (OR = 2.3; 95% CI = 1.1, 4.6; p < .05). This study provides evidence that risk factors for a labor and delivery condition can vary significantly across racial and ethnic subgroups. These differences emphasize the importance of evaluating risk by population subgroups and might provide a basis for labor and delivery clinicians to enhance personalized medicine to reduce adverse events.

To re-examine the risk factors for shoulder dystocia given the increasing rates of obesity and diabetes in pregnant women.
Retrospective observational study.
Five hospitals located in Wisconsin, Florida, Maryland, Michigan, and Alabama.
We evaluated 19,236 births that occurred between April 1, 2011, and July 25, 2013.
Data were collected from electronic medical records and used to evaluate the risk of shoulder dystocia. Data were analyzed using a generalized linear mixed model, which controlled for clustering due to site.
When insulin was prescribed, gestational diabetes was associated with an increased risk of shoulder dystocia (odds ratio = 2.10, 95% confidence interval [1.01, 4.37]); however, no similar association was found with regard to gestational diabetes treated with glycemic agents or through diet. Use of epidural anesthesia was associated with an increased risk for shoulder dystocia (odds ratio = 3.47, 95% confidence interval [2.72, 4.42]). Being Black or Hispanic, being covered by Medicaid or having no insurance, infant gestational age of 41 weeks or greater, and chronic diabetes were other significant risk factors.
With the changing characteristics of pregnant women, labor and birth clinicians care for more pregnant women who have an increased risk for shoulder dystocia. Our findings may help prospectively identify women with the greatest risk.

To establish multifactorial shoulder dystocia response and management protocol to promote sustainable practice change. Primary data collection was conducted over 3 years. Implementation of the protocol spanned 13 months. Data collection occurred at five sites, which were chosen for their diversity in both patient mix and geographical location. Case study evaluation methodology was used to examine clinician engagement and protocol adoption. The training completion for all practice engagement team activities was collected by the site project manager and entered into a flat file. Data from the labor and delivery notes, medical records, and interviews with labor and delivery teams were gathered and analyzed by the senior investigator. In the first year, there was a threefold increase in shoulder dystocia reporting, which continued in years 2 and 3. In the first year, 96 percent of clinicians completed all training elements and in subsequent years, 98 percent completed the follow-up training. Overall teams reached a 99 percent adoption rate of the shoulder dystocia protocol. System and site management teams implemented a standardized shoulder dystocia protocol that fostered effective teamwork and obstetric team readiness for managing shoulder dystocia emergencies.

Medical malpractice expenditures are mainly due to the occurrence of preventable harm with some of the highest liability rates in obstetrics. Establishing delivery system models which decrease preventable harm and malpractice risk have had varied results over the last decade. We conducted a case study of a risk reduction labor and delivery model at 5 demonstration sites. The model included standardized protocols for the most injurious events, training teams in labor and delivery emergencies, rapid reporting with cause analysis for all unplanned events, and disclosing unexpected occurrences to patients using coordinated communication and documentation. Each of the model's components required buy in from the hospital's clinical and administrative leadership, and it also required collaboration, training, and continual feedback to labor and delivery nurses, doctors, midwives, and risk managers. The case study examined the key elements in the development of the model based on interviews of all team members and document review. We also completed data analysis pre and post implementation of the new model to assess the impact on event reporting and high liability occurrence rates. After 27 months post implementation, reporting of unintended events increased significantly (43 vs 84 per 1000 births, p < .01) while high-risk malpractice events decreased significantly (14 vs 7 per 1000 births, p < .01). This decrease enabled money allotted for malpractice claims to be reallocated for the implementation of the new model at 42 additional labor and delivery sites. Due to these results, this multilevel integrated model showed promise.

Although safety net providers will benefit from health insurance expansions under the Affordable Care Act, they also face significant challenges in the postreform environment. Some have embraced the concept of the accountable care organization to help improve quality and efficiency while addressing financial shortfalls. The experience of Cambridge Health Alliance (CHA) in Massachusetts, where health care reform began six years ago, provides insight into the opportunities and challenges of this approach in the safety net. CHA's strategies include care redesign, financial realignment, workforce transformation, and development of external partnerships. Early results show some improvement in access, patient experience, quality, and utilization; however, the potential efficiencies will not eliminate CHA's current operating deficit. The patient population, payer mix, service mix, cost structure, and political requirements reduce the likelihood of financial sustainability without significant changes in these factors, increased public funding, or both. Thus the future of safety net institutions, regardless of payment and care redesign success, remains at risk.