(888) Changes in risk-appropriate care after implementation of maternal level of care designation in Texas

Perinatal regionalization rests on the assumption that designating hospital levels of care can direct patterns of appropriate site of delivery to improve patient outcomes. We evaluate if a state-mandated maternal level of care program increased risk-appropriate site of care in Texas.

Study Design:

Retrospective cross-sectional analysis of all delivery hospitalizations in Texas from 2016-2023 using quarterly discharge data in the Texas Inpatient Public Use Data File. Of 221 designated hospitals, we included the 215 that reported deliveries in the study period (32 Level IV, 43 Level III, 86 Level II, 54 Level I). As 99% of facilities received their requested designation level, the pre-mandate level was assumed to be the same. Deliveries at sites that were not designated maternal facilities (89 total) were categorized as Undesignated. We organized comorbidities by minimum recommended level of care (highest Level IV, lowest Level I) using criteria in the Texas Administrative Code, ACOG/SMFM Consensus, and literature. We chose a baseline of 2016(Q1) to 2018(Q4) due to (Q4)2015 introduction of ICD-10 and 2018 Texas rule adoption, then a post-intervention of 2021(Q4) to 2023(Q3) based on the September 2021 implementation deadline. We categorized patients into minimum level of care by their highest risk comorbidity and used two-proportion z-tests to compare rates of deliveries at inappropriately low facilities per each risk category. Undesignated site deliveries were considered low level.

Results:

The proportion of births at inappropriate level facilities increased for all risk categories (Figure 1). Level III risk and severe maternal cardiac disease patients were more likely to deliver at inappropriately low facilities (Table 1).  The exception was a 4.12% decrease for placenta previa with prior uterine surgery. The proportion of undesignated hospital births decreased for all maternal risk groups.

Conclusion:

Despite statutory adoption of levels of care, the proportion of deliveries at inappropriately low level facilities increased for all risk groups. Access barriers and transfer behavior may limit efforts.