Rural–Urban Differences in Delivery Hospitalization Costs by Severe Maternal Morbidity Status
Authors: Ching-Ching Claire Lin, Ashley H. Hirai, Rui Li, Elena V. Kuklina, Sylvia K. Fisher
Journal: Annals of Internal Medicine (2020)

Supplement1 December 2020Rural–Urban Differences in Delivery Hospitalization Costs by Severe Maternal Morbidity StatusFREEChing-Ching Claire Lin, PhD, MHS, Ashley H. Hirai, PhD, Rui Li, PhD, Elena V. Kuklina, MD, PhD, and Sylvia K. Fisher, PhDChing-Ching Claire Lin, PhD, MHSHealth Resources and Services Administration, U.S. Department of Health and Human Services Rockville, Maryland (C.C.L., A.H.H., S.K.F.)Search for more papers by this author, Ashley H. Hirai, PhDHealth Resources and Services Administration, U.S. Department of Health and Human Services Rockville, Maryland (C.C.L., A.H.H., S.K.F.)Search for more papers by this author, Rui Li, PhDCenters for Disease Control and Prevention, U.S. Department of Health and Human Services Atlanta, Georgia (R.L., E.V.K.)Search for more papers by this author, Elena V. Kuklina, MD, PhDCenters for Disease Control and Prevention, U.S. Department of Health and Human Services Atlanta, Georgia (R.L., E.V.K.)Search for more papers by this author, and Sylvia K. Fisher, PhDHealth Resources and Services Administration, U.S. Department of Health and Human Services Rockville, Maryland (C.C.L., A.H.H., S.K.F.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M19-3251 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Background: Severe maternal morbidity (SMM) during hospitalizations for deliveries affects more than 50 000 U.S. women annually, with risks for long-term morbidity and immediate health care costs more than double that of unaffected deliveries (1, 2). Women in rural areas face greater barriers to preventive and specialty health care services, including limited provider availability, longer distances to care, and financial constraints (3), which may contribute to adverse obstetric outcomes (4) and higher costs during delivery hospitalizations than their urban counterparts. A previous study found that rural hospitals incurred significantly higher average costs for low-risk deliveries, by nearly $500, compared with urban hospitals (5). It is unclear whether this finding reflects patient residence versus facility location only and whether it applies to the broader population of deliveries, including those affected by SMM. To address this literature gap, this study compares delivery costs between rural and urban residents with and without SMM, with adjustment for other sociodemographic and facility characteristics.Objective: To compare delivery hospitalization costs between rural and urban residents by SMM status and degree of complexity (no SMM, any SMM, 1 SMM, and ≥2 SMMs).Methods and Findings: Hospitalizations for deliveries (n = 2 167 876) from the 2012 to 2014 National Inpatient Sample, a nationally representative sample of U.S. hospital discharges compiled by the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project, were analyzed. Total hospital charges were converted to costs using Healthcare Cost and Utilization Project Cost-to-Charge Ratios. SMMs were identified by the Centers for Disease Control and Prevention's list of 21 indicators (18 when 3 rare indicators are collapsed; refer to Table 3) and corresponding International Classification of Diseases, Ninth Revision, Clinical Modification codes (2). Rural/urban residence, defined according to the Office of Management and Budget as nonmetropolitan (rural) versus metropolitan (urban) counties, refers to the residence of women who were hospitalized.Unadjusted rural–urban differences in SMM indicators were first examined as well as covariates that may affect both cost and SMM (1): age, race/ethnicity, income quartile, primary payer, delivery method, hospital bed size, rural/urban hospital location/teaching status, hospital region, and total number of chronic conditions (0 to 18) presented. To compare cost between rural and urban residents, multivariable generalized linear models were applied using a gamma distribution with a log-link function within 4 strata of SMM status and complexity: no SMM, any SMM, 1 SMM, and 2 or more SMM indicators. For deliveries with SMMs, predicted costs were also adjusted for the 18 SMM indicators. All statistical analyses accounted for the complex sampling design with hospital clusters and individual weights using Stata, version 12 (StataCorp).Among all hospitalizations for deliveries from 2012 to 2014, 1.4% of rural residents and 1.5% of urban residents had at least 1 SMM (P = 0.22) (Table 1). Among hospitalizations with any SMM, a larger proportion of rural versus urban residents had only 1 SMM (87.8% vs. 84.1%; P < 0.001) (Table 1). Average adjusted costs for hospitalizations without SMM indicators were 3% higher for women residing in rural versus urban areas ($4573 vs. $4452; difference, $122 [95% CI, $37 to $205]) (Table 2). Average adjusted costs for hospitalizations with any SMM were 7% higher for women residing in rural versus urban areas ($12 212 vs. $11 432; difference, $780 [CI, $185 to $1375]). Average adjusted costs for hospitalizations with 1 SMM were 7% higher for women residing in rural versus urban areas ($9721 vs. $9107; difference, $613 [CI, $104 to $1123]). Average adjusted costs for hospitalizations with multiple SMMs were 6% higher for women residing in rural versus urban areas ($25 679 vs. $24 247; difference, $1432 [CI, −$1336 to $4200]), but this difference was not statistically significant.Table 1. Characteristics of Delivery Hospitalizations, by Rural and Urban Residence, 2012 to 2014*Table 2. Adjusted Costs of Delivery Hospitalizations, by Rural and Urban Residence and SMM Status, 2012 to 2014*Table 3. Rates of SMM, by Rural and Urban Residence, 2012 to 2014*Discussion: Building on a previous study showing higher facility costs for rural hospitals among low-risk deliveries (5), this study found that women residing in rural areas have higher hospitalization costs than those in urban areas among deliveries both with and without SMM. Rural–urban differences in hospitalization costs were greater, however, on both absolute and relative scales for deliveries affected by SMM. Because blood transfusions account for most SMM (2), this cost difference may be attributable to increased use of higher-cost emergency-release transfusions among women in rural areas (6). Coupled with another study showing that rural residents are more likely to experience SMM after adjustment for sociodemographic and clinical risk factors (4), this study further indicates that costs among such deliveries are greater for rural residents. Thus, improving access to risk-appropriate delivery care and other hospital quality improvement efforts may help to reduce SMM (4) and associated costs for rural residents. A major limitation is that only hospitalization costs could be examined; a better understanding of rural–urban cost differences for SMM-affected deliveries could be achieved by estimating additional types of cost, such as physician expenses or readmissions should these data become available. Further investigation of maternal comorbid conditions and prenatal care quality received before delivery hospitalizations would also shed further light on other contributors to rural–urban delivery cost differences.References1. Chen HY, Chauhan SP, Blackwell SC. Severe maternal morbidity and hospital cost among hospitalized deliveries in the United States. Am J Perinatol. 2018;35:1287-1296. [PMID: 29723900] doi:10.1055/s-0038-1649481 CrossrefMedlineGoogle Scholar2. Centers for Disease Control and Prevention. Severe maternal morbidity in the United States. Accessed at www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html on 5 May 2020. Google Scholar3. ACOG committee opinion no. 586: health disparities in rural women. Obstet Gynecol. 2014;123:384-8. [PMID: 24451676] doi:10.1097/01.AOG.0000443278.06393.d6 CrossrefMedlineGoogle Scholar4. Kozhimannil KB, Interrante JD, Henning-Smith C, et al. Rural-urban differences in severe maternal morbidity and mortality in the US, 2007-15. Health Aff (Millwood). 2019;38:2077-2085. [PMID: 31794322] doi:10.1377/hlthaff.2019.00805 CrossrefMedlineGoogle Scholar5. Xu X, Gariepy A, Lundsberg LS, et al. Wide variation found in hospital facility costs for maternity stays involving low-risk childbirth. Health Aff (Millwood). 2015;34:1212-9. [PMID: 26153317] doi:10.1377/hlthaff.2014.1088 CrossrefMedlineGoogle Scholar6. Einerson BD, Stehlikova Z, Nelson RE, et al. Transfusion preparedness strategies for obstetric hemorrhage: a cost-effectiveness analysis. Obstet Gynecol. 2017;130:1347-1355. [PMID: 29112646] doi:10.1097/AOG.0000000000002359 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: Health Resources and Services Administration, U.S. Department of Health and Human Services Rockville, Maryland (C.C.L., A.H.H., S.K.F.)Centers for Disease Control and Prevention, U.S. Department of Health and Human Services Atlanta, Georgia (R.L., E.V.K.)Disclaimer: The information, content, and conclusions are those of the authors and should not be construed as the official position or policy of the Health Resources and Services Administration, the Centers for Disease Control and Prevention, the Department of Health and Human Services, or the U.S. government, nor should any endorsement by these organizations be inferred.Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-3251.Reproducible Research Statement: Study protocol: Not applicable. Statistical code: Available from Dr. Lin (e-mail, [email protected]gov). Data set: Available for purchase from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality.Corresponding Author: Ching-Ching Claire Lin, PhD, 5600 Fishers Lane, Rockville, MD 20857; e-mail, [email protected]unc.edu.Current Author Addresses: Drs. Lin, Hirai, and Fisher: 5600 Fishers Lane, Rockville, MD 20857.Drs. Li and Kuklina: 4770 Buford Highway NE, MS S107-2, Atlanta, GA 30341.Author Contributions: Conception and design: C.C. Lin, R. Li, E.V. Kuklina.Analysis and interpretation of the data: C.C. Lin, A.H. Hirai, R. Li, E.V. Kuklina, S.K. Fisher.Drafting of the article: C.C. Lin, R. Li, S.K. Fisher.Critical revision of the article for important intellectual content: C.C. Lin, A.H. Hirai, R. Li, E.V. Kuklina.Final approval of the article: C.C. Lin, A.H. Hirai, R. Li, E.V. Kuklina, S.K. Fisher.Statistical expertise: C.C. Lin, R. Li.Administrative, technical, or logistic support: C.C. Lin, A.H. Hirai, S.K. Fisher.Collection and assembly of data: C.C. Lin, A.H. Hirai.This article is part of the Annals supplement “Maternal Health in the United States: Findings From the Health Resources and Services Administration and Partners.” The Health Resources and Services Administration provided funding for publication of this supplement. Previousarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byRural–Urban Differences in the Utilization of Hospital-Based Care for Women of Reproductive AgeLooking Outward to Look Within: The Health Resources and Services Administration Maternal Mortality Summit, and What It Means for Women EverywhereDoris Chou, MD 1 December 2020Volume 173, Issue 11_SupplementPage: S59-S62KeywordsHealth care qualityHealth care utilizationHealth services administration and managementHealth services researchHospitalizationsMaternal healthMorbidityResearch quality assessmentRural areasUrban areas ePublished: 1 December 2020 Issue Published: 1 December 2020 PDF downloadLoading ...