Emergency Department Utilization for Hypertensive Disorders of Pregnancy and Post Partum, 2006-2020
Courtney Townsel, LeAnn Louis, Chelsie Clark, Leah Mitchell Solomon, Charley Jiang, Martina Caldwell, Erica E. Marsh
TL;DR
This study examines how often pregnant women or those post-partum with high blood pressure disorders visited emergency departments from 2006 to 2020.
Contribution
The study provides updated data on ED utilization trends for hypertensive disorders during and after pregnancy over a 14-year period.
Findings
ED visits for hypertensive disorders increased significantly over the study period.
The highest rates were observed in the post-partum period.
Certain demographic groups showed higher utilization rates.
Abstract
This cross-sectional study assesses emergency department (ED) admissions for hypertensive disorders of pregnancy and post partum between 2006 and 2020.
Genes, proteins, chemicals, diseases, species, mutations and cell lines named across the full text — each resolved to its canonical identifier and authoritative record.
| Characteristic | Emergency department visits for HDPP by year, No. (%) (N = 371 292) | |||||||
|---|---|---|---|---|---|---|---|---|
| 2006 (n = 31 623) | 2008 (40 247) | 2010 (n = 46 974) | 2012 (n = 45 275) | 2014 (n = 61 677) | 2016 (n = 47 520) | 2018 (n = 42 083) | 2020 (n = 55 893) | |
| Age group, y | ||||||||
| 15-19 | 3938 (12.5) | 4739 (11.8) | 4261 (9.1) | 3114 (6.9) | 3898 (6.3) | 2989 (6.3) | 2384 (5.7) | 2399 (4.3) |
| 20-24 | 7839 (24.8) | 9271 (23.0) | 10 617 (22.6) | 9418 (20.8) | 11 877 (19.3) | 8969 (18.9) | 7952 (18.9) | 8811 (15.8) |
| 25-29 | 8137 (25.7) | 9951 (24.7) | 11 807 (25.1) | 11 848 (26.2) | 16 005 (25.9) | 12 373 (26.0) | 10 459 (24.9) | 13 406 (24.0) |
| 30-34 | 6392 (20.2) | 8693 (21.6) | 10 964 (23.3) | 11 409 (25.2) | 16 000 (25.9) | 12 619 (26.6) | 11 202 (26.6) | 16 096 (28.8) |
| 35-39 | 3947 (12.5) | 5645 (14.0) | 6389 (13.6) | 6996 (15.5) | 10 415 (16.9) | 7991 (16.8) | 7549 (17.9) | 11 429 (20.4) |
| 40-44 | 1287 (4.1) | 1776 (4.4) | 2653 (5.6) | 2264 (5.0) | 3208 (5.2) | 2391 (5.0) | 2351 (5.6) | 3382 (6.1) |
| 45-50 | 82 (0.3) | 172 (0.4) | 283 (0.6) | 227 (0.5) | 272 (0.4) | 189 (0.4) | 186 (0.4) | 371 (0.7) |
| Region | ||||||||
| Northeast | 3799 (12.0) | 12 727 (31.6) | 10 487 (22.3) | 12 738 (28.1) | 15 469 (25.1) | 9297 (19.6) | 9308 (22.1) | 14 060 (25.2) |
| Midwest | 5790 (18.3) | 6885 (17.1) | 7690 (16.4) | 5810 (12.8) | 8492 (13.8) | 7741 (16.3) | 7881 (18.7) | 7699 (13.8) |
| South | 17 542 (55.5) | 17 127 (42.6) | 22 398 (47.7) | 21 774 (48.1) | 29 480 (47.8) | 24 014 (50.5) | 19 439 (46.2) | 25 280 (45.2) |
| West | 4492 (14.2) | 3508 (8.7) | 6400 (13.6) | 4954 (10.9) | 8236 (13.4) | 6468 (13.6) | 5455 (13.0) | 8854 (15.8) |
| Urbanicity | ||||||||
| Metro, (≥1 million people) | 19 045 (60.2) | 26 247 (65.2) | 32 672 (69.6) | 28 568 (63.1) | 40 628 (65.9) | 32 389 (68.2) | 27 880 (66.3) | 37 752 (67.5) |
| Metro (50 000 to <1 million people) | 7386 (23.4) | 8958 (22.3) | 9330 (19.9) | 12 377 (27.3) | 15 590 (25.3) | 9636 (20.3) | 10 469 (24.9) | 13 092 (23.4) |
| Nonmetro (<50 000 people) | 5131 (16.2) | 4889 (12.1) | 4815 (10.3) | 4258 (9.4) | 5304 (8.6) | 5402 (11.4) | 3681 (8.7) | 4868 (8.7) |
| Primary payer | ||||||||
| Medicare | 329 (1) | 598 (1.5) | 625 (1.3) | 929 (2.1) | 977 (1.6) | 705 (1.5) | 464 (1.1) | 642 (1.1) |
| Medicaid | 16 203 (51.2) | 19 983 (49.7) | 24 964 (53.1) | 24 500 (54.1) | 34 430 (55.8) | 23 813 (50.1) | 20 977 (49.8) | 24 617 (44.0) |
| Private | 12 753 (40.3) | 15 473 (38.4) | 17 186 (36.6) | 16 758 (37.0) | 22 152 (35.9) | 20 338 (42.8) | 18 825 (44.7) | 27 885 (49.9) |
| Self-pay | 1522 (4.8) | 3027 (7.5) | 2987 (6.4) | 1692 (3.7) | 1979 (3.2) | 1553 (3.3) | 1048 (2.5) | 1292 (2.3) |
| No charge | 64 (0.2) | 84 (0.2) | 36 (0.1) | 95 (0.2) | 106 (0.2) | 98 (0.2) | 23 (0.1) | 53 (0.1) |
| Other | 631 (2.0) | 902 (2.2) | 1067 (2.3) | 1262 (2.8) | 1167 (1.9) | 997 (2.1) | 747 (1.8) | 1256 (2.2) |
| Income quartile by zip code | ||||||||
| 1 | 11 390 (36.0) | 14 909 (37.0) | 17 585 (37.4) | 15 526 (34.3) | 22 518 (36.5) | 16 664 (35.1) | 14 589 (34.7) | 16 378 (29.3) |
| 2 | 8746 (27.7) | 9869 (24.5) | 11 360 (24.2) | 11 473 (25.3) | 16 084 (26.1) | 11 419 (24.0) | 10 508 (25.0) | 13 620 (24.4) |
| 3 | 6681 (21.1) | 7799 (19.4) | 10 023 (21.3) | 10 804 (23.9) | 11 544 (18.7) | 10 784 (22.7) | 9276 (22.0) | 12 792 (22.9) |
| 4 | 4371 (13.8) | 5047 (12.5) | 5881 (12.5) | 6646 (14.7) | 8761 (14.2) | 8168 (17.2) | 7480 (17.8) | 12 673 (22.7) |
| Admission rate | ||||||||
| HDPP | 17 338 (54.8) | 22 467 (55.8) | 26 963 (57.4) | 22 220 (49.1) | 33 123 (53.7) | 19 776 (80.2) | 33 729 (80.1) | 43 563 (77.9) |
| Other primary diagnoses, No./total No. (%) | 2 823 749/35 177 059 (8.0) | 2 994 604/37 067 603 (8.1) | 3 046 591/38 838 100 (7.8) | 2 839 693/39 404 810 (7.2) | 2 872 802/40 291 049 (7.1) | 2 711 703/41 067 859 (6.6) | 2 790 118/38 951 593 (7.2) | 2 796 555/33 402 798 (8.4) |
| Race and ethnicity | Hospital admission with hypertensive disorder of pregnancy, adjusted OR (95% CI) | |
|---|---|---|
| American Indian or Alaska Native | 0.66 (0.37-1.18) | .16 |
| Asian or Pacific Islander | 1.40 (1.09-1.80) | .009 |
| Hispanic | 1.66 (1.41-1.95) | <.001 |
| Non-Hispanic Black | 1.16 (1.02-1.32) | .02 |
| Non-Hispanic White | 1 [Reference] | NA |
| Other | 1.13 (0.89-1.44) | .32 |
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Taxonomy
TopicsMaternal and fetal healthcare · Pregnancy and preeclampsia studies · Global Maternal and Child Health
Introduction
Hypertensive disorders of pregnancy and the postpartum period (HDPP) are the second leading cause of maternal deaths worldwide^1,2^ and account for 6.3% of all pregnancy-related deaths in the US.^3^ Black birthing people have the highest rates of pregnancy-related mortality in the US.^4^ The American College of Obstetricians and Gynecologists recommends management of severe blood pressure in pregnancy within 30 to 60 minutes of diagnosis to prevent complications such as stroke, myocardial ischemia, seizure, placental abruption, and maternal and neonatal mortality.^5^ Given the need for prompt intervention, the emergency department (ED) is a critical access point for treatment of HDPP. To our knowledge, there are no studies reporting national trends of ED use for HDPP. In this study, we assess US ED utilization and admission for HDPP.
Methods
This cross-sectional study was determined exempt from review and the requirement of informed consent by the University of Michigan institutional review board and followed the STROBE reporting guidelines. This was a longitudinal retrospective analysis of HDPP-related ED utilization from 2006 to 2020 using the Nationwide Emergency Department Sample (NEDS), managed by the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. Pregnant or postpartum people aged 15 to 50 years with a primary diagnosis of HDPP by International Classification of Diseases, Ninth Revision (ICD-9) or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes were included (eMethods in Supplement 1). The primary outcome was total annual ED visits for HDPP. Secondary outcomes included hospital admissions, and HDPP-related ED use by race and ethnicity. Characteristics including age, income quartile by zip code, payment method, hospital geographic region, and hospital teaching status were analyzed. Race and ethnicity data, abstracted from the NEDS database, were only available for 2019 to 2020. Race and ethnicity categories included Asian or Pacific Islander, non-Hispanic Black, Hispanic, American Indian or Alaska Native, non-Hispanic White, and other (defined as multiracial).
Considering the complex sample design, SAS survey sampling and analysis procedures were applied, including stratum, clusters, and weights into χ^2^, t tests, and multivariable logistic regression. Statistical significance was defined as a 2-sided P < .05. SAS version 9.4 (SAS Institute) was used for analysis. Analysis occurred from August 2022 to February 2023.
Results
Between 2006 and 2020, 656 711 HDPP-related ED encounters occurred. HDPP annual ED visits increased from 31 623 to 55 893 from 2006 to 2020 (P < .001) (Table 1). Admissions and admission rates for HDPP also increased over the study period from 17 338 admissions in 2006 (rate, 54.8%) to 43 563 admissions in 2020 (rate, 77.9%) (P < .001), in contrast with stable admission rates for all other primary diagnoses (2 823 749 or 35 177 059 admissions [8.0%] in 2006 to 2 796 555 of 33 402 798 admissions [8.4%] in 2020; P = .08).
Non-Hispanic Black, Hispanic, and Asian or Pacific Islander individuals were more likely to present to the ED for HDPP compared with all other diagnoses (non-Hispanic Black, 27 968 of 104 556 visits [26.7%] vs 17 942 147 of 70 664 334 visits [25.4%]; P = .007; Hispanic, 22 097 of 104 556 visits [21.1%] vs 12 405 817 of 70 664 334 visits [17.6%]; P < .001; and Asian or Pacific Islander, 4603 of 104 556 visits [4.4%] vs 1514913 of 70 664 334 visits [2.1%]; P < .001). Additionally, compared with non-Hispanic White individuals, non-Hispanic Black, Hispanic, and Asian or Pacific Islander individuals were more likely to be admitted for HDPP (Table 2).
Discussion
In this cross-sectional study, US ED visits and admissions for HDPP increased significantly from 2006 to 2020. This finding may reflect a higher prevalence of disease or increased awareness for prompt assessment and treatment. However, the greater ED utilization for HDPP compared with all other diagnoses for non-Hispanic Black, Hispanic, and Asian or Pacific Islander individuals may imply limited access to timely outpatient care or barriers to uptake blood pressure monitoring programs. Furthermore, non-Hispanic Black, Hispanic, and Asian or Pacific Islander individuals were more likely to be admitted for HDPP than non-Hispanic White individuals, suggesting worse disease severity at presentation.
Study strengths include a nationally representative dataset with large sample and inclusion of recently added race and ethnicity data. Limitations include a visit-based dataset that may count individuals multiple times and use of diagnostic codes which shifted from ICD-9 to ICD-10 between 2015 and 2016. Racial differences in ED utilization for HDPP underscore the ongoing racial disparities in US maternal morbidity and mortality and highlight a critical need for accessible, culturally competent community-level interventions for all.
The reference list from the paper itself. Each links out to its DOI / PubMed record.
- 1Say L, Chou D, Gemmill A, . Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):e 323-e 333. doi:10.1016/S 2214-109X(14)70227-X 25103301 · doi ↗ · pubmed ↗
- 2Kassebaum NJ, Barber RM, Dandona L, ; GBD 2015 Maternal Mortality Collaborators. Global, regional, and national levels of maternal mortality, 1990-2015: a systematic analysis for the global burden of disease study 2015. Lancet. 2016;388(10053):1775-1812. doi:10.1016/S 0140-6736(16)31470-2 27733286 PMC 5224694 · doi ↗ · pubmed ↗
- 3Centers for Disease Control and Prevention. Pregnancy mortality surveillance system. May 15, 2024. Accessed August 7, 2024. https://www.cdc.gov/maternal-mortality/php/pregnancy-mortality-surveillance/index.html
- 4Huang RS, Spence AR, Abenhaim HA. Racial disparities in national maternal mortality trends in the United States from 2000 to 2019: a population-based study on 80 million live births. Arch Gynecol Obstet. 2024;309(4):1315-1322. doi:10.1007/s 00404-023-06999-636933039 · doi ↗ · pubmed ↗
- 5American College of Obstetricians and Gynecologists. Gestational hypertension and preeclampsia: ACOG practice bulletin, number 222. June 2020. Accessed August 7, 2024. https://journals.lww.com/greenjournal/abstract/2020/06000/gestational_hypertension_and_preeclampsia__acog.46.aspx