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Erschienen in: Maternal and Child Health Journal 12/2015

01.12.2015

Comparing Two Review Processes for Determination of Preventability of Maternal Mortality in Illinois

verfasst von: Stacie E. Geller, Abigail R. Koch, Nancy J. Martin, Patricia Prentice, Deborah Rosenberg, Illinois Department of Public Health Maternal Mortality Review Committee Working Group

Erschienen in: Maternal and Child Health Journal | Ausgabe 12/2015

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Abstract

Objectives

To compare the results of two maternal death review processes conducted from 2002 to 2012 by Illinois regionalized perinatal centers with those conducted by the Illinois Department of Public Health’s (IDPH’s) statewide multidisciplinary external Maternal Mortality Review Committee (MMRC).

Methods

This is a retrospective record review linking MMRC case assessment forms to the IDPH’s Maternal Mortality Review Form database to compare causes of death and potential preventability as determined by both review processes.

Results

MMRC records for 76 maternal death reviews were linked to the IDPH maternal mortality review form database. Most deaths reviewed by the statewide MMRC were due to pregnancy-related causes. The statewide MMRC differed from the regional perinatal centers on cause of death in 55.3 % (n = 42) of cases and on the disposition of potential preventability in 48.7 % (n = 37) of cases. The statewide MMRC judged 69.7 % (n = 53) of cases potentially preventable, compared with 40.8 % (n = 31) for the regional perinatal centers. The MMRC identified more preventable provider and systems factors for potentially preventable deaths compared with regional perinatal centers which identified more preventable patient factors.

Conclusions for practice

The statewide MMRC found more potential preventability and determined that preventability was associated with provider and systems factors, not patient factors. Observed discrepancies between regional perinatal center and statewide MMRC reviews were likely due to the complexity of cases selected for review, the multidisciplinary external composition of the review team, and the de-identification of cases. Multidisciplinary statewide expert panels should be implemented in addition to local and regionalized reviews.
Literatur
1.
Zurück zum Zitat Berg, C. J. (2012). From identification and review to action—maternal mortality review in the United States. Seminars in Perinatology, 36(1), 7–13.CrossRefPubMed Berg, C. J. (2012). From identification and review to action—maternal mortality review in the United States. Seminars in Perinatology, 36(1), 7–13.CrossRefPubMed
2.
Zurück zum Zitat Goodman, D., Stampfel, C., Creanga, A., et al. (2013). Revival of a core public health function: state- and urban-based maternal death review processes. Journal of Women’s Health, 22(5), 395–398.CrossRefPubMed Goodman, D., Stampfel, C., Creanga, A., et al. (2013). Revival of a core public health function: state- and urban-based maternal death review processes. Journal of Women’s Health, 22(5), 395–398.CrossRefPubMed
3.
Zurück zum Zitat Kilpatrick, S. J., Prentice, P., Jones, R. L., & Geller, S. (2012). Reducing maternal deaths through state maternal mortality review. Journal of Women’s Health, 21(9), 905–909.CrossRefPubMed Kilpatrick, S. J., Prentice, P., Jones, R. L., & Geller, S. (2012). Reducing maternal deaths through state maternal mortality review. Journal of Women’s Health, 21(9), 905–909.CrossRefPubMed
4.
Zurück zum Zitat World Health Organization. (2004). Beyond the numbers: Reviewing maternal deaths and complications to make pregnancy safer. Geneva: World Health Organization. World Health Organization. (2004). Beyond the numbers: Reviewing maternal deaths and complications to make pregnancy safer. Geneva: World Health Organization.
5.
Zurück zum Zitat Geller, S. E., Cox, S. M., & Kilpatrick, S. J. (2006). A descriptive model of preventability in maternal morbidity and mortality. Journal of Perinatology, 26(2), 79–84.CrossRefPubMed Geller, S. E., Cox, S. M., & Kilpatrick, S. J. (2006). A descriptive model of preventability in maternal morbidity and mortality. Journal of Perinatology, 26(2), 79–84.CrossRefPubMed
6.
Zurück zum Zitat Gupta, M., Fuchs, B., Cutilli, C., et al. (2013). Preventable mortality: Does the perspective matter when determining preventability? Journal of Surgical Research, 184(1), 54–60.CrossRefPubMed Gupta, M., Fuchs, B., Cutilli, C., et al. (2013). Preventable mortality: Does the perspective matter when determining preventability? Journal of Surgical Research, 184(1), 54–60.CrossRefPubMed
7.
Zurück zum Zitat Vincent, C. (2003). Understanding and responding to adverse events. New England Journal of Medicine, 348(11), 1051–1056.CrossRefPubMed Vincent, C. (2003). Understanding and responding to adverse events. New England Journal of Medicine, 348(11), 1051–1056.CrossRefPubMed
8.
Zurück zum Zitat Rowe, M. (2004). Doctors’ responses to medical errors. Critical Reviews in Oncology Hematology, 52(3), 147–163.CrossRef Rowe, M. (2004). Doctors’ responses to medical errors. Critical Reviews in Oncology Hematology, 52(3), 147–163.CrossRef
9.
Zurück zum Zitat Bacak, S. J., Berg, C. J., Desmarais, J., Hutchins, E., & Locke, E. (2006). State maternal mortality review: Accomplishments of nine states. Atlanta: Centers for Disease Control and Prevention. Bacak, S. J., Berg, C. J., Desmarais, J., Hutchins, E., & Locke, E. (2006). State maternal mortality review: Accomplishments of nine states. Atlanta: Centers for Disease Control and Prevention.
10.
Zurück zum Zitat ACOG Department of State Legislation. (2011). ACOG state legislative toolkit. Washington, DC: American Congress of Obstetricians and Gynecologists. ACOG Department of State Legislation. (2011). ACOG state legislative toolkit. Washington, DC: American Congress of Obstetricians and Gynecologists.
11.
Zurück zum Zitat Amnesty International. (2010). Deadly delivery: The maternal health care crisis in the USA. London: Amnesty International. Amnesty International. (2010). Deadly delivery: The maternal health care crisis in the USA. London: Amnesty International.
12.
Zurück zum Zitat Geller, S. E., Koch, A. R., Martin, N. J., Rosenberg, D., & Bigger, H. R. (2014). Assessing preventability of maternal mortality in Illinois: 2002–2012. American Journal of Obstetrics and Gynecology, 211(6), 698.e1–11.CrossRefPubMed Geller, S. E., Koch, A. R., Martin, N. J., Rosenberg, D., & Bigger, H. R. (2014). Assessing preventability of maternal mortality in Illinois: 2002–2012. American Journal of Obstetrics and Gynecology, 211(6), 698.e1–11.CrossRefPubMed
13.
Zurück zum Zitat MacKenzie, E., Steinwachs, D., Bone, L., Floccare, D., Ramzy, A., & The Preventable Death Study Group. (1992). Inter-rater reliability of preventable death judgments. Journal of Trauma, 33(2), 292–303.CrossRefPubMed MacKenzie, E., Steinwachs, D., Bone, L., Floccare, D., Ramzy, A., & The Preventable Death Study Group. (1992). Inter-rater reliability of preventable death judgments. Journal of Trauma, 33(2), 292–303.CrossRefPubMed
14.
Zurück zum Zitat Mock, C., Juillard, C., Brundage, S., Goosen, J., & Joshipura, M. (Eds.), (2009). Guidelines for trauma quality improvement programmes. Geneva: World Health Organization. Mock, C., Juillard, C., Brundage, S., Goosen, J., & Joshipura, M. (Eds.), (2009). Guidelines for trauma quality improvement programmes. Geneva: World Health Organization.
15.
Zurück zum Zitat Settervall, C. H. C., Domingues, C. D. A., De, Sousa R. M. C., & Nogueira, L. D. S. (2012). Preventable trauma deaths. Revista de Saude Publica, 46(2), 367–375.CrossRefPubMed Settervall, C. H. C., Domingues, C. D. A., De, Sousa R. M. C., & Nogueira, L. D. S. (2012). Preventable trauma deaths. Revista de Saude Publica, 46(2), 367–375.CrossRefPubMed
16.
Zurück zum Zitat Teixeira, P. G. R., Inaba, K., Hadjizacharia, P., et al. (2007). Preventable or potentially preventable mortality at a mature trauma center. Journal of Trauma, 63(6), 1338–1346. (discussion 1346-7).CrossRefPubMed Teixeira, P. G. R., Inaba, K., Hadjizacharia, P., et al. (2007). Preventable or potentially preventable mortality at a mature trauma center. Journal of Trauma, 63(6), 1338–1346. (discussion 1346-7).CrossRefPubMed
17.
Zurück zum Zitat Drife, J. (2008). Maternal mortality in well-resourced countries: Is there still a need for confidential enquiries? Best Practice and Research Clinical Obstetrics and Gynaecology, 22(3), 501–515.CrossRefPubMed Drife, J. (2008). Maternal mortality in well-resourced countries: Is there still a need for confidential enquiries? Best Practice and Research Clinical Obstetrics and Gynaecology, 22(3), 501–515.CrossRefPubMed
18.
Zurück zum Zitat Clark, S. L. (2012). Strategies for reducing maternal mortality. Seminars in Perinatology, 36(1), 42–47.CrossRefPubMed Clark, S. L. (2012). Strategies for reducing maternal mortality. Seminars in Perinatology, 36(1), 42–47.CrossRefPubMed
19.
Zurück zum Zitat Creanga, A. A., Berg, C. J., Ko, J. Y., et al. (2014). Maternal mortality and morbidity in the United States: Where are we now? Journal of Women’s Health., 23(1), 3–9.CrossRefPubMedPubMedCentral Creanga, A. A., Berg, C. J., Ko, J. Y., et al. (2014). Maternal mortality and morbidity in the United States: Where are we now? Journal of Women’s Health., 23(1), 3–9.CrossRefPubMedPubMedCentral
Metadaten
Titel
Comparing Two Review Processes for Determination of Preventability of Maternal Mortality in Illinois
verfasst von
Stacie E. Geller
Abigail R. Koch
Nancy J. Martin
Patricia Prentice
Deborah Rosenberg
Illinois Department of Public Health Maternal Mortality Review Committee Working Group
Publikationsdatum
01.12.2015
Verlag
Springer US
Erschienen in
Maternal and Child Health Journal / Ausgabe 12/2015
Print ISSN: 1092-7875
Elektronische ISSN: 1573-6628
DOI
https://doi.org/10.1007/s10995-015-1782-2

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