You are on page 1of 9

Matern Child Health J (2011) 15:234241

DOI 10.1007/s10995-010-0579-6

Socioeconomic Disparities in Ectopic Pregnancy: Predictors


of Adverse Outcomes from Illinois Hospital-Based Care,
20002006
Debra B. Stulberg James X. Zhang

Stacy Tessler Lindau

Published online: 23 February 2010


Springer Science+Business Media, LLC 2010

Abstract This study aimed to identify the incidence of without insurance to result in surgical sterilization (OR 4.7,
adverse outcomes from ectopic pregnancy hospital care in P = 0.012). Hospitalization longer than 2 days was more
Illinois (20002006), and assess patient, neighborhood, likely with Medicaid (OR 1.46, P \ 0.0005) or no insur-
hospital and time factors associated with these outcomes. ance (OR 1.35, P \ 0.0005) versus other payers, and
Discharge data from Illinois hospitals were retrospectively among church-operated versus secular hospitals (OR 1.21,
analyzed and ectopic pregnancies were identified using P \ 0.0005). Compared to public hospitals, private hospi-
DRG and ICD-9 diagnosis codes. The primary outcome tals had lower rates of complications (OR 0.39, P \
was any complication identified by ICD-9 procedure codes. 0.0005) and of hospitalization longer than 2 days (OR 0.57,
Secondary outcomes were length of stay and discharge P \ 0.0005). With time, hospitalizations became shorter
status. Residential zip codes were linked to 2000 U.S. (OR 0.53, P \ 0.0005) and complication rates higher (OR
Census data to identify patients neighborhood demo- 1.33, P = 0.024). Ectopic pregnancy patients with Med-
graphics. Logistic regression was used to identify risk icaid, Medicare or no insurance, and those admitted to
factors for adverse outcomes. Independent variables public or religious hospitals, were more likely to experi-
were insurance status, age, co-morbidities, neighborhood ence adverse outcomes.
demographics, hospital type, hospital ectopic pregnancy
service volume, and year of discharge. Of 13,007 ectopic Keywords Ectopic pregnancy  Complications 
pregnancy hospitalizations, 7.4% involved at least one Sterilization  Hospital care  Insurance status 
complication identified by procedure codes. Hospitaliza- Socioeconomic disparities
tions covered by Medicare (for women with chronic dis-
abilities) were more likely than those with other source or

D. B. Stulberg S. T. Lindau
Department of Family Medicine, The University of Chicago, Department of Medicine, The University of Chicago, Chicago,
Chicago, IL, USA IL, USA

D. B. Stulberg  S. T. Lindau D. B. Stulberg (&)


Department of Obstetrics and Gynecology, The University 5841 South Maryland Avenue, MC 7110, Room M-156,
of Chicago, Chicago, IL, USA Chicago, IL 60637, USA
e-mail: slindau@babies.bsd.uchicago.edu e-mail: stulberg@uchicago.edu

D. B. Stulberg  S. T. Lindau J. X. Zhang


MacLean Center for Clinical Medical Ethics, The University Department of Healthcare Policy and Research, Virginia
of Chicago, Chicago, IL, USA Commonwealth University, 209E McGuire Hall,
PO Box 980533, Richmond, VA 23298, USA
J. X. Zhang
Department of Pharmacotherapy and Outcomes Science, S. T. Lindau
Virginia Commonwealth University, Richmond, VA, USA 5841 South Maryland Avenue, MC 2050,
e-mail: xzhang3@vcu.edu Chicago, IL 60637, USA

123
Matern Child Health J (2011) 15:234241 235

Introduction U.S. Hospitals (14). These categories included: public


(government-controlled) versus private; church-operated
Ectopic pregnancy occurs when a fertilized egg implants versus other; and not-for-profit versus for-profit.
outside the lining of a womans uterus, most commonly in Ectopic pregnancy hospitalizations were identified by
the fallopian tube. Unable to sustain a growing pregnancy, searching for claims with a principal International Classi-
the fallopian tube or nearby organ can rupture and cause fication of Diseases 9th Revision (ICD-9) diagnosis code of
severe internal hemorrhage. Ectopic pregnancy is a leading 633.xx (Fig. 1) (15). To increase case specificity, inpatient
cause of maternal mortality in the United States (1) and claims were also required to have a Diagnostic Related
often leads to impaired fertility (2). Although advances in Group (DRG) code of 378 for ectopic pregnancy. Duplicate
gynecologic ultrasound and human chorionic gonadotropin records were excluded in order to identify unique hospi-
assays are facilitating earlier diagnosis and less invasive talizations. For the sake of analysis, claims with missing or
medical treatment for ectopic pregnancy (3), women with un-usable zip code or hospital data were also excluded.
Medicaid or without insurance experience delays in access The primary outcome was complication rate. Compli-
to timely care (4). In addition, non-white women are more cations were identified using ICD-9 procedure codes, with
likely to have ectopic pregnancies and more likely to die the aim of capturing all procedures that were likely to have
from the condition compared to white women (1, 5, 6). resulted from late diagnosis or treatment or that indicated
Long-term consequences of ectopic pregnancy, such as severe secondary morbidity. Codes were extracted from all
impaired fertility and the risk of recurrence, can negatively procedure fields (principal, secondary and other). The two
impact womens health, quality of life, and health care costs, physician investigators reviewed all procedure codes found
as well as womens psychological status(7). Short-term in the dataset and identified four categories of complica-
outcomes, such as hemorrhage or surgical complication, also tions: transfusion, hysterectomy, surgical injury, and other
contribute to morbidity but have not been well-quantified. complications. One of the physician investigators and an
Since 1992, traditional surveillance methods have been independent physician reviewer then sorted all ICD-9
unable to provide reliable nation-wide ectopic pregnancy procedure codes in the data files into one or more of these
data because changes in practice require tracking patients categories. Inter-rater agreement was calculated using the
through multiple sites of care (8). Researchers have analyzed kappa statistic (16), and classified as none, slight, moder-
ectopic pregnancy outcomes within specific providers ate, substantial, near-perfect or perfect according to stan-
(911), but new methods for studying ectopic pregnancy at dard classifications (17). The second physician investigator
the population level are needed. State-wide hospital dat- then independently adjudicated all coding discrepancies. A
abases represent a promising approach to surveillance (6). composite clinical outcome, surgical sterilization, was
We reviewed hospital discharge data to estimate the
incidence and predictors of adverse outcomes from ectopic
Search:
pregnancy hospitalizations and ambulatory surgery during Inpatient discharge claims with Principal
Diagnosis 633.xx and DRG 378 (N=9,858)
20002006 in Illinois, a large state with demographic Ambulatory surgery claims with Principal
similarity to the United States population (12). Diagnosis 633.xx (N=3,859)

Total hospital discharge claims N=13,717

Materials and Methods


Excluded duplicate records
N=208
Ambulatory surgery and inpatient discharge claims from
the Illinois Hospital Associations COMPdata files were
examined (13). This database contains discharge informa- Total unique ectopic pregnancy hospitalizations
tion from all public and private Illinois hospitals (except N=13,509
Veterans Affairs facilities) and makes de-identified data
available to investigators under approved research agree- Excluded claims with missing data:
ments. Emergency Department and outpatient (clinic or Zip code missing or not
matched with Census (N=187)
office) claims were not available, but outpatient surgical Missing hospital data (N=315)
claims were included. Patient residential zip codes Total excluded N=502
extracted from hospital claims were linked to 2000 United
States Census data to identify the patients neighborhood Analyzed remaining claims
demographics for each hospitalization. N=13,007
Hospitals were classified based on standard categories
using the American Hospital Association (AHA) guide to Fig. 1 Case identification

123
236 Matern Child Health J (2011) 15:234241

defined to include all hysterectomies plus all procedures Table 1 Ectopic pregnancy discharges (Illinois), 20002006
that removed both or sole remaining fallopian tube or ovary. Patients age (years)
Secondary outcomes were hospital length-of-stay (days) Mean (SD) 29.1 (6.1)
and in-hospital mortality. Clinical experience suggests that
Range 1350
patients with uncomplicated ectopic pregnancy are typi-
Co-morbidities Number (%)
cally discharged in one or 2 days; therefore, length-of-stay
Diabetes mellitus 76 (0.6)
more than 2 days was defined as an adverse outcome.
Chronic pulmonary disease 430 (3.3)
Deaths were identified by discharge status but hospital
Insurance status Number (%)
readmissions could not be identified due to lack of patient
Private 7,353 (56.6)
identifiers in the dataset.
Medicaid 3,700 (28.5)
Multivariable regression analysis was used to identify
Medicare 61 (0.5)
patient factors, hospital characteristics, and time trends
Charity care 34 (0.3)
associated with each outcome. Independent variables were:
Self-payment 1,458 (11.2)
insurance status; zip code-level demographics (poverty
Others 401 (3.1)
rate, unemployment rate, population size, median house-
hold income, percent urban, and percent African-Ameri- Type of hospital Number (%)
can); patient age and age-squared (in order to avoid the Private (vs. public) 12,274 (94.4)
assumption of a linear age relationship); patient co-mor- Non-profit (vs. profit) 11,188 (86.0)
bidities; hospital type (private versus public, church-oper- Church-operated (vs. other) 4,458 (34.4)
ated versus other, not-for-profit versus for-profit); hospital Length-of-stay (days)
ectopic pregnancy service volume (number of total ectopic Mean (SD) 1.7 (1.4)
pregnancy discharges during the study period); and year of Range 032
discharge. Insurance status was defined by the primary N = 13,007
payer on the hospital claim. Co-morbidities were identified
by the presence of ICD-9 diagnosis codes for chronic ill- (j = 0.43), substantial for Hysterectomy (j = 0.85), and
nesses previously shown to increase pregnancy-related and perfect for Transfusion (j = 1.00). For Other Complica-
hospital complications: diabetes mellitus (250250.7) and tions, inter-rater agreement was 94.9%, the same as that
chronic pulmonary disease (490496, 500505, 506.4) predicted by chance (j = -0.01).
(1821). Patient race data were not available. Hospital length of stay ranged from 032 days, with a
Complications (present versus absent) and length-of- mean of 1.7 days. More than three quarters of admissions
stay (greater than 2 days versus 2 days or less) were ana- (77%) were 2 days or fewer in length. Nearly all admis-
lyzed as dichotomous outcome variables using logit sions (92%) included a surgical procedure, in most cases
regression models. All analyses were conducted using (72%) salpingectomy. Due to the limitations of ICD-9
STATA/SE10 (College Station, TX). procedure codes, there was inability to consistently dis-
The study was designated exempt by the authors tinguish between laparoscopic versus open surgical pro-
Institutional Review Board. cedures. The procedure code for conversion of a
laparoscopic procedure to an open procedure (V64.4) was
not documented in any discharge claim in this database.
Results Review of discharge status data revealed only one death,
giving an in-hospital mortality ratio of 0.74 per 10,000
The dataset contained 13,509 unique hospitalizations for claims. Two additional admissions were discharged to
ectopic pregnancy in 139 Illinois hospitals during 2000 hospice and two to a skilled nursing facility.
2006. Based on the 2000 U.S. Census (22) and 20002006 The results of the multivariate analyses predicting
Illinois birth certificate data (23), the annual state incidence complications and length-of-stay are shown in Table 3.
of ectopic pregnancy hospitalizations was 5.4 per 10,000 Controlling for age, co-morbidities, neighborhood sociode-
women at risk (ages 1350), or 10.6 per 1,000 births. Of mographics, year of discharge, hospital type, and service
these, 13,007 claims had complete data for analysis. volume, insurance status was significantly associated with
Table 1 describes these discharges. both length-of-stay and complications. Hospitalizations
Fifty-eight unique ICD-9 procedure codes were identi- longer than 2 days were more common among those with
fied as complications (Table 2). Among all discharges for Medicaid (OR 1.46, 95% CI 1.321.62) or self-pay status
ectopic pregnancy, 7.4% involved at least one type of (OR 1.35, 95% CI 1.161.56) than among other insurance
complication (Fig. 2). Inter-rater agreement on categori- sources. Compared with all other payers, hospitalizations
zation of complications was moderate for Surgical Injury covered by Medicare had a higher chance of resulting in

123
Matern Child Health J (2011) 15:234241 237

Table 2 Procedures identified as complications from ectopic preg- Table 2 continued


nancy hospital claims
ICD-9 Procedure
ICD-9 Procedure Code
Code
57.81 Suture of laceration of bladder
Transfusion 67.61 Suture of laceration of cervix
99.00 Perioperative autologous transfusion of whole blood or 69.41 Suture of laceration of uterus
blood components
75.61 Repair of current obstetric laceration of bladder and
99.01 Exchange transfusion urethra
99.03 Other transfusion of whole blood 86.22 Excisional debridement of wound, infection, or burn
99.04 Transfusion of packed cells Other complications
99.05 Transfusion of platelets 33.1 Incision of lung
99.07 Transfusion of other serum 34.04 Insertion of intercostal catheter for drainage
99.09 Transfusion of other substance: blood surrogate, 38.7 Interruption of the vena cava
granulocytes
39.79 Other endovascular repair (of aneurysm) of other vessels
Surgical sterilization
39.97 Other perfusion
65.52 Other removal of remaining ovary
45.49 Other destruction of lesion of large intestine
65.61 Other removal of both ovaries and tubes at same
operative episode 54.0 Incision of abdominal wall
65.62 Other removal of remaining ovary and tube 54.92 Removal of foreign body from peritoneal cavity
65.63 Laparoscopic removal of both ovaries and tubes at same 55 Operations on kidney
operative episode 58.6 Dilation of urethra
65.64 Laparoscopic removal of remaining ovary and tube 59.09 Other incision of perirenal or periureteral tissue
66.51 Removal of both fallopian tubes at same operative 59.8 Ureteral catheterization
episode 75.8 Obstetric tamponade of uterus or vagina
66.52 Removal of remaining fallopian tube 96.6 Enteral infusion of concentrated nutritional substances
68.3 Subtotal abdominal hysterectomy 99.15 Parenteral infusion of concentrated nutritional substances
68.39 Other subtotal abdominal hysterectomy
68.4 Total abdominal hysterectomy
68.51 Laparoscopically assisted vaginal hysterectomy (LAVH)
surgical sterilization (OR 4.7, 95% CI 1.415.5). In addition,
68.8 Pelvic evisceration
patients with chronic pulmonary disease had significantly
greater odds of a complication (OR 1.41, 95% CI 1.021.96)
68.9 Other and unspecified hysterectomy
than those without. Chronic pulmonary disease (OR 1.65,
69.19 Other excision or destruction of uterus and supporting
structures 95% CI 1.332.04) and diabetes (OR 1.79, 95% CI 1.11
Surgical injury 2.90) were both associated with longer hospitalization.
39.0 Systemic to pulmonary artery shunt Hospital factors also proved significant. Private hospi-
39.1 Intra-abdominal venous shunt tals had lower odds of complications compared with public
39.2 Other shunt or vascular bypass (OR 0.39, 95% CI 0.250.61). Length-of-stay more than
39.59 Other repair of vessel
2 days was significantly less likely among private hospitals
39.98 Control of hemorrhage, not otherwise specified
(OR 0.57, 95% CI 0.420.76) and more likely among
church-operated hospitals compared with others (OR 1.21,
41.95 Repair and plastic operations on spleen
95% CI 1.101.33). While surgical treatment was common
45.02 Other incision of small intestine
in all hospitals (since the dataset excluded office and
45.03 Incision of large intestine
emergency department care), in bivariate Chi-square
45.41 Excision of lesion or tissue of large intestine
analysis, surgical treatment was significantly more com-
45.62 Other partial resection of small intestine
mon at church-operated hospitals (93.0% of all claims)
46.01 Exteriorization of small intestine
compared with non-church-operated (91.8%, P = 0.02).
46.73 Suture of laceration of small intestine, except duodenum
Finally, from the beginning of the study period to the
46.75 Suture of laceration of large intestine
end, complication rates increased while hospital length-of-
46.79 Other repair of intestine
stay shortened. Compared with the year 2000, discharges
54.12 Reopening of recent laparotomy site
occurring in 2006 had a significantly higher odds of
54.61 Reclosure of postoperative disruption of abdominal wall
complication (OR 1.33, 95% CI 1.041.71) and lower odds
57.59 Open excision or destruction of other lesion or tissue of of hospital stay greater than 2 days (OR 0.53, 95%
bladder
CI 0.450.63).

123
238 Matern Child Health J (2011) 15:234241

Fig. 2 Documented Discharges


complications among hospital
claims for ectopic pregnancy, N=13,007
percent of all discharges.
Numbers of specific
complications sum to greater
than 959 because some patients Complications
experienced more than one
N=959 (7.4%)
complication

Transfusion Surgical sterilization Surgical injury Other complications

N=791 (6.1%) N=186 (1.4%) N=104 (0.8%) N=25 (0.2%)

Hysterectomy Other Procedures

N=78 (0.6%) N=108 (0.8%)

Table 3 Risk factors for


Any complication Surgical sterilization Length-of-stay [ 2 days
ectopic pregnancy
OR (95% CI) OR (95% CI) OR (95% CI)
complications or hospitalization
longer than 2 daysa Patient characteristics
Co-morbidities
Chronic pulmonary disease 1.41 (1.021.96)b 1.01 (0.442.30) 1.65 (1.332.04)b
Diabetes mellitus 1.46 (0.722.99) 0.64 (0.094.75) 1.79 (1.112.90)b
Insurance status
Private insurance Referent Referent Referent
Medicaid 1.15 (0.981.35) 1.34 (0.921.95) 1.46 (1.321.62)b
b
Medicare 4.7 (1.415.5) 1.02 (0.551.91)
Self-payment 1.22 (0.971.53) 1.51 (0.922.45) 1.35 (1.161.56)b
Charity care 3.90 (0.8817.23) 0.89 (0.342.35)
Others 0.89 (0.581.36) 0.97 (0.392.43) 1.54 (1.221.94)b
Hospital type
Private 0.39 (0.250.61)b 0.48 (0.181.25) 0.57 (0.420.76)b
Church-operated 1.13 (0.981.31) 0.75 (0.531.07) 1.21 (1.101.33)b
Non-profit 0.96 (0.911.01) 0.99 (0.881.11) 0.98 (0.951.02)
Discharge year
2000 Referent Referent Referent
a
Table reports results of 2001 0.99 (0.761.29) 0.84 (0.501.40) 0.90 (0.771.05)
multivariable regression
2002 1.15 (0.891.49) 0.78 (0.461.34) 0.80 (0.680.93)b
models, controlling also for zip
code demographics, patient age, 2003 1.26 (0.981.62) 0.82 (0.491.36) 0.89 (0.761.03)
age squared, and hospital 2004 1.11 (0.851.44) 0.65 (0.371.13) 0.78 (0.660.91)b
ectopic pregnancy service 2005 1.34 (1.041.72) b
0.98 (0.601.62) 0.69 (0.59-0.81)b
volume b
b
2006 1.33 (1.041.71) 0.56 (0.321.01) 0.53 (0.450.63)b
P \ 0.05

123
Matern Child Health J (2011) 15:234241 239

Discussion general, uninsured patients have been found to delay


seeking preventive care and thus require costlier care for
In this study of hospital-based care for ectopic pregnancy advanced illness (31). This study noted a correlation
in Illinois, patient insurance status, co-morbidities, type of between Medicaid or self-pay status and longer hospital-
hospital, and year of discharge were all significantly izations, even controlling for other socioeconomic indica-
associated with patient outcomes. Patients with Medicaid, tors; this suggests that both lack of insurance and coverage
Medicare or no insurance, those with chronic diseases, and by Medicaid present barriers to timely care, and ultimately
those admitted to public or religious hospitals, were more increase both cost and burden on the patient. In addition,
likely to experience adverse outcomes. neighborhood demographics by zip code were found in
Low rates of chronic disease were found among ectopic multivariate analysis to be significantly associated with
pregnancy patients, supporting the idea that pregnancy outcomes: patients from more urban and African American
complications often affect otherwise healthy women (24). zip codes, as well as zip codes with higher unemployment
However, ectopic pregnancy, like other causes of acute rates, experienced longer hospitalizations than others. This
hospitalization, tends to require longer hospitalization and finding further suggests that socioeconomic status affects
result in worse outcomes when the patient has underlying outcomes of ectopic pregnancy.
diabetes or lung disease. Ectopic pregnancy was recorded It was of concern to find admissions covered by Medi-
among a wide age range (1350 years) of the patients, care, which in the population younger than age 65 repre-
which suggests that future research may need to expand sents chronically disabled persons (32), with a higher rate
the traditional definition of reproductive age (often of surgical sterilization. While involuntary sterilization of
1544 years). As with other causes of maternal mortality disabled women was common in the past, it is rarely eth-
(25), morbidity data on ectopic pregnancy has been lack- ically accepted today (33, 34). The increased sterilization
ing. The finding of a 7.4% complication rate in this study is observed among Medicare admissions for ectopic preg-
likely an underestimation, since it relied on documented nancy may reflect a higher prevalence of undesired fertility
procedures. However, no prior studies reporting U.S. in this population or delayed access to care requiring more
ectopic pregnancy hospital complication rates were found. aggressive surgical treatment. To better understand steril-
Women who die from ectopic pregnancy often present ization as a complication in ectopic pregnancy, this finding
with rupture and rapid clinical deterioration (5, 11). In our merits further study, which should ideally involve pro-
study, transfusion was the most commonly documented spective clinical observation.
type of complication. We could not distinguish between The in-hospital mortality that we observed was lower
transfusions needed due to the patients baseline status and than prior reports of overall ectopic pregnancy mortality.
those resulting from surgical complications; among The last reported nationwide data showed ectopic preg-
patients with severe anemia or significant acute blood loss, nancy deaths at 3.8 per 10,000 cases in 1989 (1). However,
transfusion is a necessary, often life-saving intervention. our findings cannot be interpreted as a true mortality rate
However, since there were no ICD-9 codes to distinguish since most ectopic pregnancy deaths do not occur in the
ruptured from intact ectopic pregnancy, we report trans- hospital (5). Hospital characteristics also proved significant
fusion rate as a proxy to estimate the rate of clinically in our analysis. The association of longer hospitalizations
significant hemorrhage. The next most common compli- with hospital church affiliation may reflect different prac-
cation was surgical sterilization. Women report undesired tice patterns based on religious teaching. Methotrexate is
infertility to be one of the most distressing life experiences interpreted by some religious ethicists as equivalent to
(26). We cannot rule out that some claims represented abortion (35), possibly explaining the higher rate of sur-
voluntary sterilization or procedures on patients who had gical treatment. Rates of medical management are likely
previously undergone voluntary sterilization. However, the under-represented in this study, since it only examined
ICD-9 procedure codes for fallopian tube removal that we hospital-based care. Physician and patient preference for
identified as complications (66.51, 66.52) specifically surgical versus medical management could not be taken
exclude partial salpingectomy for sterilization and are into account given the limits of administrative data.
distinct from codes for the tubal destruction or occlusion Finally, our analysis found a trend towards shorter hospi-
procedures (66.2 and 66.3) most commonly used for ster- talizations with higher complication rates over time. This
ilization (15, 27). may reflect growing economic pressures to admit only the
Low-income women have disproportionately high rates sickest patients and discharge them quickly.
of unintended pregnancy (28) and overall pregnancy- This study contributes to the current understanding of
associated hospitalization (29). Insurance and income ectopic pregnancy outcomes by defining and quantifying
barriers have also been identified in previous studies as adverse outcomes of hospital care, and identifying risk
factors contributing to late entry to prenatal care (30). In factors for these outcomes. Some of the key points of this

123
240 Matern Child Health J (2011) 15:234241

study are the inclusion of all ectopic pregnancy admissions 4. Asplin, B. R., Rhodes, K. V., Levy, H., Lurie, N., Crain, A. L.,
from the state and information about all payers; while the Carlin, B. P., et al. (2005). Insurance status and access to urgent
ambulatory care follow-up appointments. The Journal of the
main limitation is the availability of claims for only hos- American Medical Association, 294(10), 12481254.
pital care, since many ectopic pregnancies are now cared 5. Anderson, F. W., Hogan, J. G., & Ansbacher, R. (2004). Sudden
for on an outpatient basis. There were also no patient death: Ectopic pregnancy mortality. Obstetrics and Gynecology,
identifiers, so the analysis was per admission and not per 103(6), 12181223.
6. Calderon, J. L., Shaheen, M., Pan, D., Teklehaimenot, S., Rob-
patient. The possibility that some patients were admitted inson, P. L., & Baker, R. S. (2005). Multi-cultural surveillance for
more than once in a single episode of ectopic pregnancy ectopic pregnancy: California 1991-2000. Ethnicity and Disease,
could therefore not be excluded. The incidence and ratio 15(4 Suppl 5), 2024.
(per births) reported here for the state of Illinois represent 7. Mol, F., Strandell, A., Jurkovic, D., Yalcinkaya, T., Verhoeve, H. R.,
Koks, C. A., et al. (2008). The ESEP study: Salpingostomy versus
not ectopic pregnancy cases but ectopic pregnancy hospi- salpingectomy for tubal ectopic pregnancy; the impact on future
talizations; furthermore, abortion data were not calculated fertility: A randomised controlled trial. BMC Womens Health, 8,
in the denominator, so the ratio does not represent ectopic 311.
pregnancies per total reported pregnancies. Finally, the 8. Zane, S. B., Kieke, B. A., Jr, Kendrick, J. S., & Bruce, C. (2002).
Surveillance in a time of changing health care practices: Esti-
study lacked individual chart review to validate the claims mating ectopic pregnancy incidence in the United States.
data or provide more complete patient histories. While Maternal and Child Health Journal, 6(4), 227236.
ICD-9 diagnosis and procedure codes have been found 9. Van Den Eeden, S. K., Shan, J., Bruce, C., & Glasser, M. (2005).
accurate in other research, it could not be guaranteed that Ectopic pregnancy rate and treatment utilization in a large
managed care organization. Obstetrics and Gynecology, 105
the procedures identified were true complications or that (5 Pt 1), 10521057.
the findings obtained in this study could be confirmed if 10. Nelson, A. L., Adams, Y., LE Nelson, & Lahue, A. K. (2003).
there had been access to patient charts (36, 37). Further- Ambulatory diagnosis and medical management of ectopic
more, we cannot identify the causes of patients ectopic pregnancy in a public teaching hospital serving indigent women.
American Journal of Obstetrics and Gynecology, 188((6), 1541
pregnancies in our sample; clinical factors such as a history 1547. (discussion 15471550).
of smoking, pelvic inflammatory disease, or assisted 11. Bickell, N. A., Bodian, C., Anderson, R. M., & Kase, N. (2004).
reproductive technology are relevant for patient outcomes Time and the risk of ruptured tubal pregnancy. Obstetrics and
but cannot be deduced from claims data. Gynecology, 104(4), 789794.
12. Lindau, S. T., Tetteh, A. S., Kasza, K., & Gilliam, M. (2008).
The availability of outpatient medical management for What schools teach our patients about sex: Content, quality, and
ectopic pregnancy is one of gynecologys greatest advan- influences on sex education. Obstetrics and Gynecology, 111
ces of the past decades. This study demonstrates, however, (2 Pt 1), 256266.
that hospitalization and surgery for ectopic pregnancy 13. Illinois Hospital Association. (2010). Welcome to COMPdata.
http://www.compdatainfo.com/. Accessed on 18 Jan 2010.
remain important causes of maternal morbidity. Interven- 14. American Hospital Association. (2008). Hospitals in the United
tions to improve access to pre-conception and prenatal care States by state: Illinois. In AHA guide to the health care field
among vulnerable populations, and to timely advanced care (2009 ed., p. A162). Chicago: American Hospital Association.
when ectopic pregnancy is suspected, may offer the best 15. Hart, A. C., Hopkins, C. A., & Ford, B. (Eds.). (2005). The inter-
national classification of diseases, ninth revision, clinical modifi-
hope of allowing all women to benefit equally from early, cation, 2006 professional for hospitals. Salt Lake City, UT: Ingenix.
safe treatment. 16. Hulley, S. B., Cummings, S. R., Browner, W. S., Grady, D.,
Hearst, N., Newman, T. B. (2001). Calculation of kappa to
Acknowledgments This study was supported by a grant from the measure interobserver agreement. In: Designing clinical research
Chicago Center of Excellence in Health Promotions Economics. The (2nd ed., pp. 192193). Philadelphia: Lippincott Williams &
funder had no involvement in study design, data collection or anal- Williams.
ysis, or manuscript preparation. The authors thank Kathleen Rowland, 17. McGinn, T., Wyer, P. C., Newman, T. B., Keitz, S., Leipzig, R.,
MD, for serving as independent data coder, Peter Burkiewicz for For, G. G., et al. (2004). Tips for learners of evidence-based
technical assistance with the dataset, and Irma Hasham for general medicine: 3. measures of observer variability (kappa statistic).
research assistance. CMAJ, 171(11), 13691373.
18. Deyo, R. A., Cherkin, D. C., & Ciol, M. A. (1992). Adapting a
clinical comorbidity index for use with ICD-9-CM administrative
databases. Journal of Clinical Epidemiology, 45(6), 613619.
References 19. Ehrenthal, D. B., Jurkovitz, C., Hoffman, M., Kroelinger, C., &
Weintraub, W. (2007). A population study of the contribution of
1. Goldner, T. E., Lawson, H. W., Xia, Z., & Atrash, H. K. (1993). medical comorbidity to the risk of prematurity in blacks. American
Surveillance for ectopic pregnancyUnited States, 19701989. Journal of Obstetrics and Gynecology, 197(4), 409.e1409.e6.
MMWR. CDC surveillance summaries, 42(6), 7385. 20. Liu, S., Wen, S. W., Demissie, K., Marcoux, S., & Kramer, M. S.
2. Ego, A., Subtil, D., Cosson, M., Legoueff, F., Houfflin-Debarge, V., (2001). Maternal asthma and pregnancy outcomes: A retrospec-
& Querleu, D. (2001). Survival analysis of fertility after ectopic tive cohort study. American Journal of Obstetrics and Gynecol-
pregnancy. Fertility and Sterility, 75(3), 560566. ogy, 184(2), 9096.
3. Seeber, B. E., & Barnhart, K. T. (2006). Suspected ectopic 21. Vavlukis, M., Georgievska-Ismail, L. J., Bosevski, M., & Boro-
pregnancy. Obstetrics and Gynecology, 107(2 Pt 1), 399413. zanov, V. (2006). Predictors of in-hospital morbidity and

123
Matern Child Health J (2011) 15:234241 241

mortality in patients with coronary artery disease treated with States, 19992000. American Journal of Obstetrics and Gyne-
coronary artery bypass surgery. Prilozi, 27(2), 97113. cology, 192(2), 592597.
22. United States Census Bureau. (2010). Census 2000 summary file 1. 30. Centers for Disease Control and Prevention (CDC). (2000). Entry
http://factfinder.census.gov/servlet/DTTable?_bm=y&-context= into prenatal careUnited States, 19891997. MMWR Morb
dt&-ds_name=DEC_2000_SF1_U&-mt_name=DEC_2000_SF1_ Mortal Wkly Rep, 49(18), 393398.
U_P012&-CONTEXT=dt&-tree_id=4001&-all_geo_types=N&- 31. McWilliams, J. M., Meara, E., Zaslavsky, A. M., & Ayanian, J. Z.
geo_id=04000US17&-search_results=01000US&-format=&-_lang (2007). Use of health services by previously uninsured medicare
=en. Accessed 18 Jan 2010. beneficiaries. New England Journal of Medicine, 357((2), 143
23. Illinois Department of Public Health. Births by county of resi- 153.
dence. (20002006). http://www.idph.state.il.us/health/bdmd/ 32. United States Department of Health and Human Services. (2010).
birth2.htm. Accessed 18 Jan 2010. General enrollment and eligibility. http://www.medicare.gov/
24. Atrash, H. K., Alexander, S., & Berg, C. J. (1995). Maternal MedicareEligibility/Home.asp?dest=NAV|Home|GeneralEnroll
mortality in developed countries: Not just a concern of the past. ment#TabTop. Accessed 18 Jan 2010.
Obstetrics and Gynecology, 86(4 Pt 2), 700705. 33. American College of Obstetricians and Gynecologists Committee
25. Berg, C. J., Bruce, F. C., & Callaghan, W. M. (2002). From on Ethics. (2007). Sterilization of women, including those with
mortality to morbidity: The challenge of the twenty-first century. mental disabilities. Obstetrics and Gynecology, 110(1), 217220.
J Am Med Womens Assoc, 57(3), 173174. 34. Powderly, K. E. (1995). Contraceptive policy and ethics: Illus-
26. Lukse, M. P., & Vacc, N. A. (1999). Grief, depression, and trations from american history. Hastings Center Report, 25(1),
coping in women undergoing infertility treatment. Obstetrics and S9S11.
Gynecology, 93(2), 245251. 35. Pivarunas, A. R. (2003). Ethical and medical considerations in the
27. Nardin, J. M., Kulier, R., & Boulvain, M. (2003). Techniques for treatment of ectopic pregnancy. Linacre Quarterly, 70(3), 195209.
the interruption of tubal patency for female sterilisation. Coch- 36. Virnig, B. A., & McBean, M. (2001). Administrative data for
rane Database of Systematic Reviews, (1):CD003034. public health surveillance and planning. Annual Review of Public
28. Finer, L. B., & Henshaw, S. K. (2006). Disparities in rates of Health, 22, 213230.
unintended pregnancy in the United States, 1994 and 2001. 37. Lawthers, A. G., McCarthy, E. P., Davis, R. B., Peterson, L. E.,
Perspect Sex Reprod Health, 38(2), 9096. Palmer, R. H., & Iezzoni, L. I. (2000). Identification of in-hos-
29. Bacak, S. J., Callaghan, W. M., Dietz, P. M., & Crouse, C. pital complications from claims data. Is it valid? Medical Care,
(2005). Pregnancy-associated hospitalizations in the United 38(8), 785795.

123
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.