Events

Incidence of maternal hemorrhage: A systematic analysis for the Global Burden of Disease Study

ABSTRACT

As part of the Global Burden of Disease (GBD) study 2021, we quantified incidence of obstetric complications, including maternal hemorrhage, for 204 countries and territories, from 1990 to 2021, and for five-year age groups from 10-54 years. We used 497 data sources to estimate incidence of maternal hemorrhage, including data from a systematic review of peer-reviewed and gray literature and from claims and hospital discharges, altogether encompassing 524 country-years from 106 countries and territories. Data included known heterogeneity in case definition, case ascertainment, denominator, and demographics, so we used Meta-Regression, Bayesian, Regularized, Trimmed (MR-BRT) to adjust sources with non-reference case definitions. Sources with aggregate age groups were disaggregated by imposing age patterns from preliminary age-specific models. We modeled maternal hemorrhage as incidence ratio, or incident cases per live birth, using a meta-regression model in DisMod-MR 2.1. We multiplied modeled estimates by GBD-estimated age-specific fertility rates to estimate incidence rates. In 2021, we estimated 14.0 million incident cases of maternal hemorrhage, a small (1.5%) and nonsignificant decrease from the 14.2 million estimated for 1990. Incidence ratios were stable between 1990 and 2021, but incident rates decreased by 32.4%, suggesting that population increase might be a notable contributor to stable case counts over time. In 2021, incidence rates were highest in Sub-Saharan Africa, and incident cases were highest in India followed by China. We will discuss enhancements to nonfatal estimation for the upcoming round of GBD, including adding new data, enhancing adjustment of non-reference data by expanding alternative definitions and by using alternative ICD mappings of clinical data, and improving incidence ratio estimation by incorporating mortality-to-incidence ratios in the modeling process.

LEARNING OBJECTIVES

1. Identify regions of the world with the highest and lowest data availability for maternal hemorrhage incidence since 1980.
2. Describe geographic patterns of incidence ratio and incidence rate for maternal hemorrhage.

Disparities in Employment and Work Conditions among Health Care Workers with Disabilities

ABSTRACT

Employment disparities among people with disabilities are well-documented; yet, little is known about the work conditions of health care workers (HCWs) with disabilities and whether they are treated equitably compared to non-disabled peers. The study aimed to examine HCW’s disability status and disparities in employment and work conditions between HCWs with and without disabilities across multiple health care occupations. We used data from the 2022 American Community Survey (ACS), including all individuals in the labor force, aged 18 to 75 years (n=1.6 million) and a subsample of HCWs (n=156,897). Individuals who answered yes to one or more of the six questions asked in the ACS regarding disability (vision, hearing, mobility, cognition, self-care, and independent living) were defined as “having a disability.” Weighted univariate and bivariate analyses were conducted to compare prevalence of each disability type by health occupation group, minimum education level for occupation entry, and health occupation setting. Findings show lower disability prevalence among HCWs with disabilities compared to all workers, especially in occupations requiring higher education or with more rigid work environments. Significant disparities were observed: HCWs with disabilities were three times more likely to be unemployed, earned approximately $20,000 less annually, and were more likely to work from home, part-time, and during non-standard hours. The study is the first to comprehensively analyze employment status and work conditions of HCWs with disabilities by occupation, highlighting the inequities experienced by HCWs with disabilities in their workplace and employment status. The findings underscore the urgent need for systemic and policy-level changes to enhance inclusivity and support for disabled HCWs.

Ensuring a Diverse Nursing Workforce

ABSTRACT

Research Objective: The purpose of this study is to compare employment and work characteristics of RNs before and after the pandemic, with a focus on RNs of diverse ages, races, ethnicities, and sexes, and to examine characteristics associated with leaving a primary job.
Study Design: This study is a retrospective analysis of the 2018 and 2022 National Sample Survey of RNs (NSSRN). Using weighted estimates, we compare the sociodemographic characteristics of the RN workforce in 2018 and 2022. We examine sociodemographic and work characteristics and explored rationale among RNs who left a primary job in the year prior to the survey. We use regression analyses to determine which characteristics are associated with leaving a job.
Population Studied: Respondents to the 2018 and 2022 NSSRN who held a primary nursing job in the year prior to the survey and were not advanced practice registered nurses.
Principal Findings: Diversity increased between 2018 and 2022, with more representation by men (9.9% to 12.3%), Asian (5.7% to 10.5%) and Black (8.3% to 12.4%) RNs. A higher percentage of RNs reported having a bachelor’s degree or higher (38.9% to 45.6%) and being educated outside the US (5.4% to 6.9%). The most notable shift in work settings was a decrease in RNs working in long-term care settings (15.4% to 12.6%). Consistent with the increased diversity in the workforce, diversity increased across settings over time with the largest gains made by Black RNs in remote/telehealth, inpatient, and ambulatory settings and by Asian RNs in inpatient, ambulatory, and long-term care settings. The number of nurses leaving a primary job (or ‘leavers’) more than doubled between 2018 and 2022 (12.9% to 27.5%), with the largest increases in leaver rates among Hispanic or multiracial RNs and the lowest rate among Asian RNs. Inpatient settings saw the largest increase in leavers, followed by ambulatory and long-term care settings. Regression analysis shows significantly increased odds of leaving among Hispanic RNs compared to non-Hispanic RNs, those without a bachelor’s degree, and foreign educated RNs, while those working in indirect or ambulatory care settings were significantly less likely to leave than RNs in an inpatient setting. Leaver destinations shifted such that a higher percentage of leavers stayed in nursing (76.4% to 85.6%) and fewer left the profession altogether (10.7% to 6.9%). Wellbeing and work environment were the most commonly cited reasons for RNs leaving jobs.
Conclusions: We found an increasing percentage of RNs are choosing to leave their primary job between 2018 and 2022 yet not all leavers are leaving the profession altogether. While the growth of diversity in settings such as ambulatory care may indicate opportunities for jobs with more desirable work schedules or benefits, the loss of diverse RNs in settings like long-term care may indicate broader difficulties retaining workers in that sector.
Implications for Policy or Practice: While an increasing percentage of nurses are leaving jobs, the data do not suggest a plummeting number of available RNs but rather an issue with vacancies related to workplaces and wellbeing. Interventions targeting work environments and RN wellbeing are needed to support RN retention.

LEARNING OBJECTIVES

1. Participants will be able to state the change in RN sociodemographic diversity over time and in specific work settings.
2. Participants will understand different rationale for RNs leaving jobs in 2022 vs 2018.

Stay or go? Who chooses telehealth vs. in-clinic medication abortion and how does it differ when traveling across state lines is necessary for in-person care

ABSTRACT

Introduction: Millions in the United States (US) live with abortion restrictions and must either receive telehealth medication abortion care or seek care by traveling out-of-state.
Understanding patient choice given current options is important for informing quality, patient-centered care, particularly in the face of long travel distances which increase health disparities. First, we seek to understand who is pursuing telehealth medication abortion care compared to those who are choosing to go to a clinic for medication abortion. Then, we want to understand how state-level abortion restrictions and distance to in-person clinic services may impact how patients get care.
Methods: We analyze retrospective clinical chart data to compare persons seeking telehealth vs. in-clinic medication abortion care in two different U.S. states: Kansas, with in-clinic abortion care, and Texas, with no in-clinic services. Between February 1 and August 31, 2024, we examine all patients from Kansas and Texas who received in-person first trimester medication abortion care <13 weeks gestation from Aria Medical Clinic, a brick-and-mortar clinic in Wichita, Kansas, and from Aid Access, a clinician-supported telehealth abortion service. Variables of interest include patient sociodemographic characteristics (age, self-identified race and ethnicity where individuals could choose all that apply), gestational duration, and county-level descriptors assigned based on patient zip code (CDC/ATSDR Social Vulnerability Index score, rural/urban). We describe telehealth vs. clinic patients and compare using t-test and chi-square with post-hoc test when significant. We used R for data cleaning and analyses.                                                                                      Results: We examined 12,568 telehealth, 745 in-clinic Texas patients and 271 telehealth, 182 in-clinic Kansans. Telehealth and in-clinic patients did not differ by age in either state (mean 26.9=Texas, 25.7=Kansas), though telehealth served those <18 years. In Texas, telehealth served more individuals who identified as Black (31%) compared to in-clinic (28%) (p-value=0.043) and fewer individuals who identified as White (25% vs. 40%; p-value<0.001). This difference was not documented among Kansas patients (Black individuals 19% vs. 24%, p-value=0.2; White individuals 52% vs. 53%, p-value=0.9). In both states, telehealth patients were more likely to be <6 weeks gestation compared to clinic patients (61% vs. 23% Texas; 59% vs. 23% Kansas) while clinic patients were more likely to be later in gestation. Both telehealth and in-clinic Texas patients were in high vulnerability areas (76%, 71%) but in-clinic care served more in low-vulnerability counties (5.7% telehealth vs. 12% in-clinic, p-value<0.001). Among Kansans, telehealth served patients in low (32%), medium (25%), and high (43%) vulnerability areas, while in-clinic served primarily high vulnerability (79%) (p-value<0.001). Telehealth and in-clinic Texas patients lived in large metro areas (79%, 89%) while in Kansas, telehealth served more large metro residence (26% vs. 1.7%) than medium-small metro residence (49% vs. 74%) (p-value<0.001).                               Conclusions: Our findings suggest that telehealth is a critical option for those who are under 18 years old, live in rural areas, and more socioeconomically vulnerable, particularly for patients in states with abortion restrictions. Telehealth also serves those at earlier gestation, suggesting more convenient and timely care. This study is the first step in understanding the difference between telehealth and in-clinic medication abortion patients in restrictive states. Additional research in this area is urgently needed to understand how patient decision-making drives these trends to inform service delivery improvements, information about abortion care options, and build equitable access to abortion care.

LEARNING OBJECTIVES

1. Compare telehealth vs. in-clinic medication abortion patient populations.
2. Understand who is utilizing telehealth abortion services in restrictive settings compared to those who choose to drive across state lines.

Why Public Health Nurses Matter: Bringing Specialized Knowledge and Skills to Advancing Health Equity

ABSTRACT

Research Objective: Research demonstrates that public health nurses (PHNs) possess important competencies for doing health equity work, such as being partnership-oriented and having a broad knowledge base across different populations. However, further research is needed to better understand how PHNs contribute to promoting health equity in communities. Our study aimed to fill this gap by exploring what activities PHNs describe they undertake in advancing health equity as well as examining their skills, proficiencies, and training needs specific to health equity work.
Study Design: For this qualitative study, we used data collected via interviews with PHNs and thematic analysis to develop themes.
Population Studied: 18 actively practicing PHNs in the US were interviewed from Feb-March 2024.
Principal Findings: Most participants identified as female (N=15); years of experience as a PHN ranged from 1-37. Most were staff-level PHNs, with 6 in leadership positions. Participants identified specific types of education, such as nursing and public health, their lived experience, and living locally as foundational elements of their health equity work. Components of this health equity work relied on building connection and trust in the community and included activities at the individual, community, and systems level, such as addressing gaps in care, facilitating collaborations across sectors, and helping to assure access to resources. Participants also detailed ways they as nurses were specifically equipped to do this work. This included applying their clinical skills in a nuanced way, their capacity to understand their community at a systems level (e.g. knowledge of systems level factors impacting health outcomes) and their access to specialized nursing tools such as the nursing process to support them in this work. Low understanding of a PHN’s full scope of practice among leadership (leading to less opportunity to practice at full scope), insufficient capacity due to low supply of PHNs, and lack of diversity in the PHN workforce were identified as barriers to engaging in health equity work.
Conclusions: Findings provide a deeper understanding of how PHNs contribute to advancing health equity. Participants highlighted how their combination of clinical skills, ability to see the big picture, and application of nursing-specific tools are valuable to them in how they approach their work to address health inequities. Participants underscored the value they bring to public health and demonstrated ways that health equity is at the core of what they do. Participants also noted that for PHNs to be able to sustain their work to advance health equity, a more diverse PHN workforce is needed as well as the opportunity to work at the top of their scope.
Implications for Policy and Practice: Strategies to address barriers and support this workforce include educating public health leadership about the PHN role and facilitating professional development to support a higher level of PHN practice. Additionally, there is a need to integrate public health nursing into nursing education and establish recruitment pathways for those from diverse backgrounds to facilitate growth of this valuable sector of the public health workforce.

Estimating National and Regional Primary Care Spending in the Veterans Health Administration in 2022

ABSTRACT

Introduction: The Veterans Health Administration (VHA) historically has spent a larger percentage of total medical expenditures on primary care than other US payers, but more recent estimates are unknown. Further, no studies have identified whether geographic differences in primary care spending exist within the VHA’s 18 regional Veteran Integrated Service Networks (VISNs). Our objective was to characterize the percent and per-Veteran absolute spending on primary care nationally and by VISN in the VHA in 2022.
Methods: We calculated primary care and total VHA spending in fiscal year 2022 nationally and by VISN. We then calculated the per-Veteran absolute spending and percent of total national expenditures attributed to primary care.
Results: In 2022, VHA spent $848 per-Veteran on primary care (9.2% of total medical expenditures). Across the 18 VISNs, per-Veteran spending ranged from $641 to $1,079, with the 25th and 75th percentiles ranging from $802 to $881. Primary care percent spending ranged from 7.1% to 11.2%, with the 25th and 75th percentile ranging from 8.5% to 9.7%. Only six of 18 VISNs were in the same quartile for primary care spending in each metric.
Discussion: Primary care spending in the VHA in 2022 as a percentage of total medical expenditures was stable compared to prior estimates. Additionally, our results show discordance in each VISN’s spending quartile based on the metric utilized. This finding suggests that each metric may capture a different element of primary care spending.

LEARNING OBJECTIVES

1. Understanding national and regional spending on primary care in the Veterans Health administration, and how different ways of measuring primary care spend provide different insights.

Estimating Years Lived with Disability due to Ectopic Pregnancy in the Global Burden of Disease Study

ABSTRACT

The Global Burden of Disease Study (GBD) quantifies years lived with disability (YLD) due to maternal outcomes for 204 countries and territories, including ectopic pregnancy (EP), synthesizing empirical data and supplementing with expert opinion where necessary. We developed a data-driven approach to improve estimates of duration and severity used to estimate YLD due to EP. Incidence of EP was taken from published GBD 2021 results. We searched PubMed for published systematic reviews with data on severity and duration of EP symptoms from clinical trials, registries and cohort studies. Measurements of the proportion of EPs that rupture and duration of cardinal EP symptoms (abdominal pain and bleeding) were extracted and pooled by meta-analysis. Incidence of EP was split into ruptured and unruptured, and multiplied by relevant symptom durations to estimate prevalences for each group. These were multiplied by GBD disability weights to calculate YLD. 237 systematic reviews were reviewed, and data was extracted from seven primary sources. The pooled estimate of ruptured EP was 13%. A three-day duration of severe abdominal pain was assigned for the acute phase of ruptured EP, a continuation of the expert opinion previously applied to all EP in GBD. Duration of moderate abdominal pain, however, was estimated to be 12 days for unruptured EP and the subacute phase of ruptured EP. Global YLD due to EP in 2022 was 20,365. Unruptured EP accounted for 13,326 YLD, while the acute and subacute phases of ruptured EP accounted for 1,413 and 5,625 YLD, respectively. Although ruptured EPs are assigned a severe health state in their acute phase, they contribute less to total YLDs than unruptured EPs, due to the greater proportion of cases impacted and symptom duration. Published longitudinal studies present an opportunity to improve the accuracy of YLD estimates, providing an empirical basis for disaggregation by severity and duration. As health-systems improve their ability to prevent mortality due to EP and other acute events, estimates of nonfatal burden will become increasingly important in prioritizing prevention efforts. Additional research is needed to better understand how duration and severity vary across settings.

LEARNING OBJECTIVES

1. Identify differences in ectopic pregnancy YLD estimation methods using expert opinion vs. empirical data inputs.