Objective
Early pregnancy loss (EPL), or miscarriage, can be managed expectantly, with medication, or with surgery. , Although individuals who experience EPL are typically appropriate candidates for any of these treatment options, some individuals may be offered limited options due to clinical setting resources, provider bias, or other factors. A person’s ability to choose their management based on personal preference is associated with improved outcomes. Unmet social needs, such as transportation barriers or inadequate childcare, may influence access to healthcare and patient preferences for EPL management options. , This study aimed to identify differences in EPL management by social vulnerability to inform future quality improvement efforts.
Study Design
This retrospective cohort analysis used Blue Cross Blue Shield of Michigan insurance claims data. We included female patients aged 18 to 49 years residing in Michigan who presented with a diagnosis of EPL using the previously described methodology from 2018 to 2021. Our primary outcome was EPL management, categorized as surgical (uterine aspiration within 7 days following index diagnosis) or nonsurgical (including both expectant and medication management, because this dataset does not comprehensively include pharmacy data needed to distinguish expectant vs medication management). Our primary predictor of interest was the Centers for Disease Control and Prevention’s Social Vulnerability Index (SVI), a neighborhood indicator of social risk that accounts for 16 census variables grouped into 4 themes: socioeconomic status; household composition; race, ethnicity, and language; and housing and transportation. Higher SVI scores indicate greater neighborhood social vulnerability. We used binary variables (the highest quintile vs all others) for individual SVI themes. Additional covariates included age, medical comorbidities, insurance plan type and status, geographic region, location of service, and whether prenatal care was established. All covariates included in regression analyses were selected a priori based on previous knowledge and clinical relevance. Multivariable logistic regression was used for the analysis. This study was deemed exempt by our institutional review board.
Results
Of 17,394 patients with EPL, 4798 (20.9%) received surgical management within 1 week of initial diagnosis. Supplemental Table 1 presents the characteristics of individuals who did and did not receive surgical management. Almost two-thirds of patients (58%) who had previously established prenatal care received surgical management, compared with 35% of those who had not. In multivariate logistic regression, higher overall SVI (ie, more social vulnerability) was associated with decreased odds of surgical management (adjusted odds ratio [aOR], 0.76 [95% confidence interval (CI), 0.61–0.93]), as were higher values of all for SVI themes ( Supplemental Table 2 ). Other covariates associated with odds of surgical management included age of 18 to 24 years (aOR, 0.71 [95% CI, 0.63–0.80]), age of ≥35 years (aOR, 1.24 [95% CI, 1.14–1.35]), medical comorbidities (aOR, 1.24 [95% CI, 1.14–1.35]), and having established prenatal care (aOR, 2.47 [95% CI, 2.29–2.67]). The predicted probability of surgical management was substantially lower among the most socially vulnerable (ie, the highest quintile SVI) neighborhoods vs other neighborhoods, by overall SVI (16.9% [95% CI, 14.2%–19.7%] vs 21.0% [95% CI, 20.4%–21.6%] respectively) and SVI theme: socioeconomic status (15.2% [95% CI, 12.6%–17.7%] vs 21.1% [95% CI, 20.5%–21.7%], respectively), household composition and disability SVI quintile (17.5% [95% CI, 14.1%–20.8%] vs 21.0% [95% CI, 20.3%–21.6%], respectively), minority status and language (18.3% [95% CI, 16.6%–20.1%] vs 21.2% [95% CI, 20.5%–21.8%]), and housing (16.2% [95% CI, 12.2%–20.3%] vs 20.9% [95% CI, 20.3%–21.5%]) ( Figure ).
