(522) The Texas Experience: The Impact of Levels of Care on Severe Maternal Morbidity

The State of Texas instituted Levels of Maternal Care (LoMC) Designation in 2018, with all hospitals that provide maternity services receiving a formal LoMC designation by August 31, 2021. We sought to assess the impact of instituting LoMC in Texas on the rates of severe maternal morbidity (SMM) across levels of care.

Study Design: We conducted a retrospective, cross-sectional study for years 2018 and 2022 using Texas Medicaid Data, prior to- and after- LoMC designation occurred. Data extracted included total SMM rate, hysterectomy rate, and hospital level of care. Data related to total SMM (without transfusion), hysterectomy rate, and eclampsia rates were compared pre- and post-implementation.

Results: There are 219 facilities that have achieved maternal designation (55 – level I, 88 – level II, 44 – level III, 32 – level IV) by 2021. The number of Medicaid births increased significantly from 2018 to 2022 in level I, II, III facilities (p < 0.001), and was not statistically different in the level IV facilities (p=0.33). Of the 260,986 deliveries included in 2018 and 258,674 deliveries included in 2022, there were 4675 (1.79%) and 4533 (1.75%) SMM events, respectively (p=0.29). There was a decrease of 0.5% in SMM rates in level I centers from 2018-2022 (p=0.001, Table). There were no statistically significant differences between SMM events in  level II, III, IV centers. SMM among hemorrhage cases was noted to be reduced from 2018 to 2022, and was statistically decreased in level I (p=0.002) and level IV centers (p=0.04). SMM among cases of patients with preeclampsia was significantly reduced in Level I-IV centers (P < 0.01). There was a non-statistically significant decrease in hysterectomies in Level I/II facilities from 2018 (64/204, 31.4) to 2022 (92/319, 28.8%), (p=0.54).

Conclusion: Using Texas Medicaid data, which includes approximately 50% of births in Texas, there was a statistically significant decrease in SMM rates in Level 1 centers after implementation of LoMC. Additionally, there was a reduction in both hemorrhage- and preeclampsia-related SMM during this timeframe.