Abuse, Psychosocial Stress And High Medical Utilization In Pregnancy

1
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

2
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.

3
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)
4
Characteristics of High Utilizers in General
Literature

• Multiple complaints sprains, superficial
  injuries, back problems, headaches, or abdominal
  pain
• Chronically ill
• Male or female

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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)
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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.
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Utilization in Pregnancy

• Most utilization
• literature focuses on
• women with little or no
• prenatal care, and/or
• late entry to prenatal
• care.

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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?

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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 .
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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

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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

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High Utilizers (HU) in This Study

• Women with 5 or more visits to the LD, urgent
  care, ED, or nurse treatment (2SD mean)
• HU n41 mean of visits 7.78 (3.2)
• LU n328 mean of visits 0.99 (1.1)

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Recent Abuse
p 14
High Utilizers Differed Significantly from Low
Utilizers, p

Live alone

Higher stress lower self-esteem

Recent abuse (used the AAS to screen)

• Uninsured or Oregon Health Plan
• Non-white
• Lower income
• High school dropouts
• Younger

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Diagnoses for High Utilizers

• Preterm onset of contractions/PTL
• Hyperemesis
• Gestational Diabetes
• Weight disorders
• Neurological problems
• Musculoskeletal problems

p
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No Significant Differences

• Gravida/Parity
• Previous complications
• Onset of prenatal care

• Maternal or infant hospital stay at delivery
• Birth weight (145 g. difference--ns)

Gestational age at delivery did differby 4.4
days HU38.48 weeks, SD 1.6 LU39.12, SD
1.9,. p
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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.

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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

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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 _at_ T1
  (weeks 16-23). This is a missed opportunity to
  provide needed services.
• Need for more research. Urgent care clinic or
  hospital a refuge?