Georgia Epidemiology Report The Georgia Epidemiology Report is a publication of the Epidemiology Section of the Epidemiology and Prevention Branch, Division of Public Health, Department of Human Resources April1997 Volume 13 Number 4 Evaluation of Perinatal Case Management in Georgia 1991-1994 http://www.ph.dhr.state.ga.us Division Of Public Health Patrick J. Meehan, M.D. - Director Epidemiology and Prevention Branch State Epidemiologist Kathleen E. Toomey, M.D., M.P.H.- Director Epidemiology Section Paul A. Blake, M.D., M.P.H.-Chief Notifiable Diseases Jeffrey D. Berschling, M.P.H.; Karen R. Horvat, M.P.H. ; Amri B. Johnson, M.P.H.; Jane E. Koehler, D.V.M, M.P.H.; Katherine GibbsMcCombs, M.P.H.; Preeti Pathela, M.P.H.; Sabrina Walton, M.S.P.H. Chronic Disease Nancy E. Stroup, Ph.D.-Program Manager Patricia M. Fox, M.P.H.; A. Rana Bayakly, M.P.H.; Edward E. Pledger, M.P.A. Tuberculosis Naomi Bock, M.D., M.S. HIV/AIDS/Sexually Transmitted Diseases Kim Cook, M.D., M.S.P.H.-Program Manager Stephanie Bock, M.P.H.; Mary Lynn Gaffield, M.P.H.; Andrew Margolis, M.P.H. Perinatal Epidemiology Mary D. Brantley, M.P.H.; Paul C. Gangarosa, M.P.H.; Raymond E. Gangarosa, M.D., M.P.H.; Leslie E. Lipscomb, M.P.H.; Mary P. Mathis, Ph.D., M.P.H. Preventive Medicine Resident Hussain R. Yusuf, M.B.B.S., M.P.H. EIS Officer Michael S. Friedman, M.D. Georgia Epidemiology Report Editorial Board Editorial Executive Committee Paul A. Blake, M.D., M.P.H.- Editor Kathleen E. Toomey, M.D., M.P.H. Mary D. Brantley, M.P.H. Jeffrey D. Berschling, M.P.H. Mailing List Edward E. Pledger, M.P.A. Perinatal Case Management (PCM) is a Georgia Medicaid care coordination program for pregnant women. Medicaid began funding PCM in October 1990 to remove barriers and improve access to prenatal care. We assessed whether pregnant women who received PCM enrolled in prenatal care earlier than women who did not receive PCM. Methods We examined the Georgia Medicaid Claims files for the years 1991-1994, constructed a Medicaid delivery cohort for each year and retrieved the Medicaid Claims File history for each woman for the prenatal period (300 days before delivery). We identified women who received the PCM Comprehensive code (first claim) in the prenatal period. We then searched the prenatal period for Current Procedure Terminology Codes (CPT) that pertained to prenatal care. We excluded 883 PCM women and 18,906 non-PCM women over the four years for whom no claim was submitted for any of the selected prenatal care CPT codes. We also excluded 23,059 PCM women over the four years who received PCM after enrolling in prenatal care. This exclusion was roughly 35% per year statewide and for 1994 ranged from 14-67% by health district. This latter group was excluded because they were already into prenatal care and their timing of entry could not be influenced by PCM. We assessed the number of days a woman was enrolled in prenatal care by constructing an interval between the first prenatal care claim date and the delivery date. We compared the average number of days enrolled in prenatal care for PCM women and non-PCM women by year (1991-1994) and assessed trends over time. We repeated the analysis by stratifying race, age and health district. Results The PCM program expanded coverage from 12% of Medicaid deliveries (6,456 of 52,230) in 1991 to 40% of Medicaid deliveries (23,415 of Epidemiology Section, Epidemiology & Prevention Branch, Two Peachtree St., N.W., Atlanta, GA 30303-3186 Phone: (404) 657-2588 FAX: (404) 657-2586 58,772) in 1994. In 1991, the proportion of blacks enrolled was lower than the proportion of whites enrolled. By 1994, the proportion enrolled was similar for blacks and whites (Figure 1). Figure 3. Average Days From First Prenatal Care to Delivery for PCM and Other Medicaid Women Figure 1. Percent Medicaid Mothers Receiving PCM by Race, Geogia 1991-1994 Average Days Percent Source: Georgia Medicaid Claims File Percent Source: Georgia Medicaid Claims File For all years and both races, as maternal age increased, coverage decreased (Figures 2). By 1994, the proportion enrolled in PCM by the 19 health districts in Georgia ranged from 20% to 75% (not shown). Figure 2. Percent Medicaid Mothers Receiving PCM by Age, Georgia 1991-1994 By 1994, PCM women were enrolled into prenatal care an average of 54.2 days earlier than in 1991 and non-PCM women were enrolled into prenatal care an average of 26 days earlier than in 1991 (Table 1). The shift toward a greater average length of prenatal care for the PCM group occurred for both white and black women. The change in the difference between the PCM group and the non-PCM group between 1991 and 1994 was similar for whites (28 days) and blacks (26.2 days) (Table 1). Blacks, however, had a larger gap to close between 1991 and 1994. The shift toward a greater average length of prenatal care for the PCM group vs. the non-PCM group occurred for all age groups; however, not all age groups reached the point where the PCM average was greater (and significant p=<0.05) than the non-PCM average (not shown). By 1994, 10 of 19 health districts showed statistically significant longer prenatal care duration intervals for women enrolled in PCM than women not enrolled in PCM (not shown). Percent Source: Georgia Medicaid Claims File Compared with 1991, all pregnant women on Medicaid entered prenatal care earlier in 1994. In 1991, PCM women were enrolled in prenatal care an average of 22.7 days later than non-PCM women. In 1994, PCM women enrolled in care an average of 5.5 days earlier than non-PCM women (Figure 3). Discussion We conclude that by 1994, PCM improved the timing of entry into prenatal care in Georgia. To our knowledge, this is the first study in Georgia to demonstrate a favorable impact of a publicly funded program on timing of prenatal care. Two strengths of this study are: q It included all births with a Medicaid claim, which represent over half the births in the state of Georgia; and q It compares two groups of Medicaid recipients, those enrolled and those not enrolled in PCM. - 2 - Table 1. Average Interval (Days) between First Prenatal Care and Delivery for Women With and Without Perinatal Case Management (PCM) Georgia Medicaid 1991-1994 Total Year 1991 1992 1993 1994 1994 minus 91 PCM 117.2 144.3 153.6 171.4 54.2 NONPCM 139.9 148.4 154.2 165.9 26 Diff. -22.7 -4.1 -.06 5.5 28.2 Signif ** ** * White Year 1991 1992 1993 1994 1994 minus-1991 PCM 119.2 151.2 161.5 179.8 60.6 NONPCM 134.3 142.9 153.1 166.7 32.4 Diff. -15.1 8.3 8.4 13.1 28.2 Signif ** * * * Black Year 1991 1992 1993 1994 1994 minus-1991 PCM 115.4 136.3 147.8 165.5 50.1 NONPCM 145.1 153.8 159 169 23.9 Diff. -29.7 -17.5 -11.2 - 3.5 26.2 Signif ** ** ** ** * PCM greater and significant at p.< 0.05 ** NONPCM greater and significant at p.<0.05 The maternal Medicaid claims file alone does not permit adequate control for premature delivery, and our analysis did not include information on any other program that might lead to earlier prenatal care, such as presumptive eligibility, expanded Medicaid eligibility, increased physician reimbursement, and incentive programs. Moreover, we were unable to distinguish which came first for women who had the first PCM and first prenatal care in the same month. The unit of service for PCM is a month, and is billed at the end of the month. We may have introduced a bias by excluding women with no prenatal care code. More non-PCM than PCM women were excluded. This might be important if we failed to identify prenatal care code(s) that were particular to the non-PCM group. The fact that the non-PCM group average interval of care was higher than the PCM group in 1991 and the reverse was true in 1994 argues against this potential bias. The excluded PCM group decreased from 4.2% in 1991 to 0.8% in 1994. The excluded non-PCM group decreased from 16.9% to 8.8%. Buescher studied care coordination (case management) in North Carolina. His study demonstrated a beneficial association of care coordination on birthweight distribution and infant mortality. His study differed from ours in that he linked prenatal visit records from public health departments and Medicaid claims paid for maternity care coordination to live birth certificates and evaluated whether care coordination improved birth outcomes. In both his and our study, the trend was for care coordination to begin earlier in pregnancy. He did not report on length of prenatal care, while our study reported earlier prenatal care over time both for women enrolled in case management (care coordination) and for women not enrolled in case management. We cannot easily interpret the difference by health district in PCM vs. non-PCM differences because we lack district-specific information on content of PCM care and the role of other local interventions. Summary We used Georgia Medicaid claims files for the years 1991-1994 to evaluate whether women who received Perinatal Case Management (PCM), a care coordination service, entered prenatal care earlier than women who did not receive this service. Overall, there was a trend for all women for whom Medicaid paid for a delivery to enter care earlier. By 1994, women who received PCM entered care an average of 5.5 days earlier than women who did not receive PCM. The shift toward a greater average length of prenatal care for the PCM group occurred for both white and black women. The change in the difference between the PCM group and the non PCM group between 1991 and 1994 was similar for whites (28 days) and blacks (26.2 days). Blacks, however, had a larger gap to close between 1991 and 1994. References 1. Buescher PA, Roth MS, Williams D, Goforth CM. An evaluation of the impact of maternity care coordination on Medicaid birth outcomes in North Carolina. American Journal of Public Health. 81(12):1625-9, 1991 Dec. This report was contributed by Ed Tierney, Roger Rochat, Steve Einbender, Carol Hadley, B Jones. - 3 - The Georgia Epidemiology Report Epidemiology and Prevention Branch Two Peachtree St., NW Atlanta, GA 30303-3186 April 1997 Volume 13 Number 4 Reported Cases of Selected Notifiable Diseases in Georgia Profile* for January 1997 Selected Notifiable Diseases Campylobacteriosis Total Reported for January 1997 33 Previous 3 Months Total Ending in January 1995 1996 1997 168 178 131 Previous 12 Months Total Ending in January 1995 1996 1997 745 1026 776 Chlamydia genital infection Cryptosporidiosis 810 696 2525 2263 696 11636 13524 2 0 4 13 0 4 91 E. coli O157:H7 10 1 4 13 3 29 48 Giardiasis Gonorrhea Haemophilis influenzae (invasive) 71 1395 7 46 1958 6 119 5786 12 212 3892 16 280 1958 18 595 21354 40 847 19468 51 Hepatitis A (acute) 26 12 15 96 18 88 428 Hepatitis B (acute) 6 Blood Lead Level > 10 g/dL (cap) 159 Blood Lead Level > 10 g/dL (ven) 82 Legionellosis 0 Lyme Disease 1 Meningococcal Disease (invasive) 13 22 7 14 146 616 489 38 120 147 5 1 0 0 0 1 26 43 28 71 91 65 146 2998 2955 38 618 647 14 14 3 2 14 2 38 109 140 Mumps 2 0 4 3 0 12 10 Pertussis Rubella 1 4 6 6 10 30 34 0 0 0 0 0 0 0 Salmonellosis 89 256 365 351 1095 1687 1441 Shigellosis Syphilis - Primary Syphilis - Secondary 75 439 139 397 1457 1260 1153 19 44 72 45 177 291 194 35 100 150 111 480 644 488 Syphilis - Early Latent 101 388 378 292 1541 1678 1293 Syphilis - Other** Syphilis - Congenital 114 190 256 283 679 1160 982 0 8 17 4 30 60 31 Tuberculosis 63 215 200 195 770 768 771 * The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office; and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia. ** Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis. Report Period Total Cases Reported * AIDS Profile Update Percent Risk Group Distribution (%) Race Distribution (%) Female MSM IDU MSM&IDU HS Blood Unknown White Black Other Last 12 Mos 04/96 to 03/97 5 Yrs Ago 04/91 to 03/92 Cumulative 01/80 to 03/97 2272 1795 17495 20.1 41.4 18.3 4.6 13.5 53.6 23.0 7.2 14.5 52.0 19.0 6.0 16.0 1.3 18.4 9.5 1.7 4.9 11.1 2.0 9.8 29.3 68.0 2.7 41.9 56.2 1.9 40.4 57.6 2.0 MSM - Men having sex with men IDU - Injection drug users HS - Heterosexual * Case totals are accumulated by date of report to the Epidemiology Section - 4-