Geographic Variation in Hypertensive Disorders of Pregnancy Open Access
Campbell, Katherine (Spring 2024)
Abstract
The overarching goal for this dissertation is to explore variation in the distribution of types of hypertensive disorders of pregnancy (HDPs) across geography, race, and measures of access to healthcare in the United States and Georgia.
Aim 1: We described county-level patterns of hypertensive disorder of pregnancy types and identified characteristics of counties with high burden using Bayesian spatial analysis to address challenges in small-area estimation. We found that place-based sociodemographic covariates differed in counties with high-burden chronic hypertension compared to those without, whereas high-burden gestational hypertension was only weakly associated with racial density of counties and did not exhibit a clear correlation with the identified place-based markers of risk.
Aim 2: We examined whether area-based indicators of access to health care during pregnancy is associated with increased rates of chronic and gestational hypertension at the county-level in the US. These findings suggest that living in low access (i.e. living in a rural area, having fewer providers per capita, and living in an area with a larger proportion of uninsured persons) is associated with higher rates of chronic hypertension. Measures of geographic access were more strongly associated with chronic compared to gestational hypertension when we examined this relationship at the national level.
Aim 3: We estimated the association of small-area (census tract and county) geographic access to care and HDP types in Georgia to explore how other spatial scales of access to care may be associated with higher rates of hypertension during pregnancy. We also compare reporting of linked hospital discharge records to birth certificate records with respect to chronic and gestational hypertension for validity and data quality concerns. We found relative discordance between reporting of hospital discharge records and birth certificate data between both chronic and gestational hypertension. These discrepancies resulted in differing statistical conclusions in the association between access to health care and each hypertensive type when we used different outcome measures (i.e. birth certificate versus hospital discharge), although the direction of the association was similar. Additionally, spatial scale did not change the conclusions when we changed from county level measures to census tract.
This dissertation underscores the questionability of combining hypertensive disorder of pregnancy types for surveillance and research, given their distinct geographic distributions and the variation in their relation to place-based characteristics. Accurate reporting of these types is important for research given there are unknowns about the etiology of gestational hypertension and being able to discern the types from chronic onset hypertension is valuable to disentangle potential markers of risk and drivers of pregnancy onset hypertension.
Table of Contents
1. Introduction to exploring geographic variation in hypertensive disorders of pregnancy. 9
Overview of hypertensive disorders of pregnancy 9
Motivation for disentangling types 13
National and local surveillance of HDPs 14
Markers of risk for hypertension in pregnancy 15
The role of “place” and health care access 18
Extending the knowledge base of geographic variation in HDPs 21
Specific aims 23
Data Sources 24
National Vital Statistics System (NVSS) Live Birth Records 24
Georgia Birth Certificate Records and Hospital Discharge Records 24
Health Resources and Services Administration (HRSA) 25
American Community Survey (ACS) 26
2. Geographic Variation and Racial Disparities in Hypertensive Disorders of Pregnancy 27
Abstract 27
Background 28
Methods 30
Results 33
Discussion 39
3. Measures of Geographic Access to Healthcare and Disparities in Hypertensive Disorders of Pregnancy 46
Abstract 46
Background 47
Methods 49
Results 52
Discussion 57
4. Comparing data sources and spatial resolution in the association of access to healthcare and hypertensive disorders of pregnancy 62
Abstract 62
Background 63
Methods 65
Results 68
Discussion 76
5. Conclusions 80
Aim 1 Summary 81
Aim 2 Summary 82
Aim 3 Summary 83
Strengths 84
Limitations 85
Future directions 86
6. References 87
About this Dissertation
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Geographic Variation in Hypertensive Disorders of Pregnancy () | 2024-04-29 16:01:04 -0400 |
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