Postpartum readmission: Are yours increasing?

If postpartum readmission can be understood with regard to its risk factors as well as its etiologies and cause-specific timing, then it may be more possible to develop new quality metrics in obstetrics and strategies to better control the increasing rate of these readmissions in the United States. This was the conclusion reached by Mark A Clapp, MD and coworkers from the Department of Obstetrics and Gynecology at Brigham and Women’s Hospital, Boston, Massachusetts.

Dr Clapp presented the findings of their study at the American College of Obstetricians and Gynecologists (ACOG) May 2016 annual meeting in a paper entitled “A multi-state analysis of postpartum readmissions in the United States.” Of special note, their work has been recognized as a Donald F Richardson prize paper at this ACOG meeting.

The investigators’ research included an analysis of 114,748 postpartum readmissions that occurred in the initial 6 weeks after delivery in California, Florida, and New York. These postpartum readmissions had been identified in state inpatient databases between 2004 and 2011. 

By calculating readmissions rates and the indications for readmission by state and over time, study results included an increase in readmission rates from 2004 to 2011. During that period, postpartum readmissions rates were found to have increased from 1.72% in 2004 to 2.16% in 2011.

Readmitted patients when compared to nonreadmitted patients were more likely to have had a cesarean delivery (37.2% vs 32.9%), be insured publicly (54.3% vs 42.0%), and identify racially as black (18.7% vs 13.5%). These factors reached statistical significance (P < .001). Infection was the most common indication for readmission, at 15.5%, followed by the indications of hypertension at 9.3% and psychiatric illness at 7.7%.

Indeed, patients readmitted postpartum were more likely to have comorbidities. As Dr Clapp explains, “There were higher rates of all medical comorbidities in the readmitted group (including asthma, diabetes, hypertension, obesity, psychiatric disease, substance use, smoking, seizure disorder, and thyroid disease).”

The researchers analyzed predictors of postpartum readmissions by calculating odds ratios (OR) through the use of multivariate logistic regression analysis. It was shown that the strongest predictors of postpartum readmissions were all maternal comorbidities, including psychiatric illness (OR, 2.542), substance use (OR, 2.016), seizure disorder (OR, 1.989), hypertension (OR, 1.886), and tobacco use (OR, 1.859). Interestingly, readmission day was found to vary by diagnosis, with hypertension for day 3, infection for day 5, and the diagnosis of psychiatric illness for day 9.

Dr Clapp is currently a clinical fellow in obstetrics, gynecology, and reproductive biology at Brigham and Women’s. He has most recently published research on the association between early term delivery trends and stillbirth, the relationship between parity and brachial plexus injuries, and cesarean delivery in adolescents, among other areas.

Certainly, another positive outcome from developing the means to lower the rising rate of postpartum readmissions would be a parallel decrease in cost. According to the US National Perinatal Information Center, for women readmitted within 42 days with a postpartum condition from the years 2005 to 2009, the cost for such readmissions went up by almost 37%. If postpartum readmission can be understood with regard to its risk factors as well as its etiologies and cause-specific timing, then it may be more possible to develop new quality metrics in obstetrics and strategies to better control the increasing rate of these readmissions in the United States. This was the conclusion reached by Dr. Mark A Clapp and coworkers from the Department of Obstetrics and Gynecology at Brigham and Women’s Hospital, Boston, Massachusetts.

Dr. Clapp presented the findings of their study at the American College of Obstetricians and Gynecologists (ACOG) May 2016 annual meeting in a paper entitled “A multi-state analysis of postpartum readmissions in the United States.” Of special note, their work has been recognized as a Donald F. Richardson prize paper at this ACOG meeting.

The investigators’ research included an analysis of 114,748 postpartum readmissions that occurred in the initial 6 weeks after delivery in California, Florida, and New York. These postpartum readmissions had been identified in state inpatient databases between 2004 and 2011. 

By calculating readmissions rates and the indications for readmission by state and over time, study results included an increase in readmission rates from 2004 to 2011. During that period, postpartum readmissions rates were found to have increased from 1.72% in 2004 to 2.16% in 2011.

Readmitted patients when compared to nonreadmitted patients were more likely to have had a cesarean delivery (37.2% vs 32.9%), be insured publicly (54.3% vs 42.0%), and identify racially as Black (18.7% vs 13.5%). These factors reached statistical significance (P<.001). Infection was the most common indication for readmission, at 15.5%, followed by the indications of hypertension at 9.3% and psychiatric illness at 7.7%.

Indeed, patients readmitted postpartum were more likely to have comorbidities. As Dr. Clapp explains, “There were higher rates of all medical comorbidities in the readmitted group (including asthma, diabetes, hypertension, obesity, psychiatric disease, substance use, smoking, seizure disorder, and thyroid disease).”

The researchers analyzed predictors of postpartum readmissions by calculating odds ratios (OR) through the use of multivariate logistic regression analysis. It was shown that the strongest predictors of postpartum readmissions were all maternal comorbidities, including psychiatric illness (OR, 2.542), substance use (OR, 2.016), seizure disorder (OR, 1.989), hypertension (OR, 1.886), and tobacco use (OR, 1.859). Interestingly, readmission day was found to vary by diagnosis, with hypertension for day 3, infection for day 5, and the diagnosis of psychiatric illness for day 9.

Dr. Clapp is currently a clinical fellow in obstetrics, gynecology, and reproductive biology at Brigham and Women’s. He has most recently published research on the association between early term delivery treads and stillbirth, the relationship between parity and branchial plexus injuries, and cesarean delivery in adolescents, among other areas.

Certainly, another positive outcome from developing the means to lower the rising rate of postpartum readmissions would be a parallel decrease in cost. According to the US National Perinatal Information Center, for women readmitted within 42 days with a postpartum condition from the years 2005 to 2009, the cost for such readmissions went up by almost 37%.