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GENERAL GYNECOLOGY
inpatient and outpatient encounters with a principal International Classification of Diseases 9th Revision diagnosis code for ectopic pregnancy. We calculated the ectopic pregnancy rate among female beneficiaries aged 15-44
as the number of ectopic pregnancies divided by the number of total pregnancies, which included spontaneous abortions, induced abortions, ectopic
pregnancies, and all births. We used Poisson regression to assess the risk
of ectopic pregnancy by age and race.
Cite this article as: Stulberg DB, Cain LR, Dahlquist I, et al. Ectopic pregnancy rates in the Medicaid population. Am J Obset Gynecol 2013;208:274.e1-7.
274.e1
General Gynecology
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TABLE 1
ICD9 code
Ectopic pregnancy
633.xx
Principal diagnosis
..............................................................................................................................................................................................................................................
All pregnancies
.....................................................................................................................................................................................................................................
63x.xx
Complications of pregnancy
64x.xx
65x.xx
66x.xx
Normal pregnancy
V22.xx
High-risk pregnancy
V23.xx
Outcome of delivery
V27.xx
Antenatal screening
V28.xx
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Research
was designed to produce the most conservative (lowest) estimate of the ectopic
pregnancy rate, because the case definition for the numerator required a principal diagnosis of ectopic pregnancy,
whereas any possible pregnancy would
be captured in the denominator. We
conducted exploratory analyses to determine the effect of adjusting the numerator and denominator case definitions
by making them broader (by including
more diagnosis codes) or narrower
(fewer diagnosis codes).
For both the numerator and denominator counts, repeat pregnancy-related
encounters within 9 months (270 days)
were considered part of the same pregnancy. Repeat pregnancy-related encounters for the same beneficiary after 9
months were treated as a new pregnancy
episode and each pregnancy episode
(in 9-month groupings of claims) was
counted separately. We further conducted exploratory analysis to determine
the effect on rate calculations of varying
this time definition of a single pregnancy, comparing our 9-month assumption with shorter (6 month) and longer
(10 month) assumptions.
We examined ectopic pregnancy rates
by race/ethnicity and age group. Age was
calculated by subtracting the beginning
date of service for the first pregnancy encounter from the beneficiarys date of
birth. Race/ethnicity was obtained from
the Inpatient and Other Therapy files.
The race/ethnicity variable in Medicaid
files is coded as: white, black, Hispanic,
Asian, American indian/Alaskan native,
native Hawaiian/Pacific Islander, or
multiracial. Because the outcome variable was a rate, we used Poisson multivariable regression models to estimate
the relative risks for ectopic pregnancy
by race/ethnicity and age group within
each state.
R ESULTS
There were 19,132,067 person-years of
enrollment in Medicaid among women
aged 15-44 in New York, California, and
Illinois combined during the 2000-03
period (Table 2), representing 8,452,457
unique individuals. Overall, there were
48,500 unique cases of ectopic preg-
274.e2
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General Gynecology
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TABLE 2
Demographic
New York
(n 3,644,214)
n (%)
California
(n 13,686,040)
n (%)
Illinois
(n 1,801,813)
n (%)
Age group
.....................................................................................................................................................................................................................................
15-19
710,708 (19.5)
2,964,083 (22.2)
415,703 (23.1)
20-24
741,069 (20.4)
321,7602 (24.1)
407,900 (22.6)
25-29
606,778 (16.7)
2,653,940 (19.9)
329,315 (18.3)
30-34
560,527 (15.4)
2,096,293 (15.7)
251,881 (14.0)
35-39
528,670 (14.5)
1,536,423 (11.5)
198,702 (11.0)
40-44
363,716 (10.0)
879,392 (6.6)
116,795 (6.5)
Unknown/not documented
132,746 (3.6)
338,307 (6.6)
81,517 (4.5)
.....................................................................................................................................................................................................................................
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Race/ethnicity
.....................................................................................................................................................................................................................................
White
1,071,643 (29.4)
Black
956,814 (26.3)
2,865,284 (20.9)
640,624 (35.6)
1,243,927 (9.1)
748,454 (41.5)
.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................
American Indian/Alaskan
native
66,635 (1.8)
66,570 (0.5)
3493 (0.2)
.....................................................................................................................................................................................................................................
Asian
150,489 (4.1)
593,274 (4.3)
33,517 (1.9)
Hispanic
703,674 (19.1)
8,190,938 (59.9)
341,632 (19.0)
.....................................................................................................................................................................................................................................
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Native Hawaiian/Pacific
Islander
0 (0.0)
0 (0.0)
324,555 (2.4)
0 (0.0)
.....................................................................................................................................................................................................................................
0 (0.0)
1194 (0.1)
401,492 (2.9)
32,899 (1.8)
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Unknown/not documented
694,959 (19.1)
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2.3% of those with any ectopic pregnancy, and the decision to include these
in the total count had no effect on the
overall rate estimates.
TABLE 3
No. of ectopic
No. of total
Ectopic pregnancy
pregnancies (A) pregnancies (B) rate (A/B) 100
New York
15,224
638,849
2.38%
.....................................................................................................................................................................................................................................
Race/ethnicity
............................................................................................................................................................................................................................
White
4738
209,462
2.26%
Black
4658
182,786
2.55%
279
23,087
1.21%
............................................................................................................................................................................................................................
............................................................................................................................................................................................................................
American Indian/Alaskan
native
............................................................................................................................................................................................................................
Asian
401
33,773
1.19%
Hispanic
3240
117,437
2.76%
Unknown/missing
1908
72,304
2.64%
............................................................................................................................................................................................................................
............................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................
Age group
............................................................................................................................................................................................................................
15-19
1389
86,449
1.61%
20-24
4662
205,845
2.26%
25-29
3888
161,651
2.41%
30-34
2858
106,077
2.69%
35-39
1837
59,000
3.11%
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............................................................................................................................................................................................................................
............................................................................................................................................................................................................................
............................................................................................................................................................................................................................
............................................................................................................................................................................................................................
40-44
590
19,827
2.98%
24,047
1,163,036
2.07%
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California
.....................................................................................................................................................................................................................................
Race/ethnicity
............................................................................................................................................................................................................................
White
4236
185,034
2.29%
Black
............................................................................................................................................................................................................................
3194
102,234
3.12%
American Indian/Alaskan
native
125
5355
2.33%
Asian
878
44,162
1.99%
14,487
752,066
1.93%
Native Hawaiian/Pacific
Islands
555
26,376
2.10%
Unknown/missing
572
............................................................................................................................................................................................................................
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Hispanic
............................................................................................................................................................................................................................
............................................................................................................................................................................................................................
47,809
1.20%
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Age group
............................................................................................................................................................................................................................
15-19
2403
183,790
1.31%
20-24
6585
373,876
1.76%
25-29
6364
288,755
2.20%
30-34
4819
187,434
2.57%
35-39
2843
97,082
2.93%
40-44
1033
32,099
3.22%
9229
380,157
2.43%
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Illinois
.....................................................................................................................................................................................................................................
Race/ethnicity
............................................................................................................................................................................................................................
White
2624
117,489
2.45%
Black
3786
119,378
3.51%
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Research
(continued )
C OMMENT
This analysis of Medicaid claims data
found that 2.22% of all reported pregnancies among women with Medicaid in
California, Illinois, and New York, 200003, were ectopic. Women in this population experienced 2.54 ectopic pregnancies per 1000 person-years. These are
higher than the rates reported in other
studies for privately insured 6 and provider-specific populations.4,5 Within the
Medicaid population, African American
women faced higher risk of ectopic pregnancy than whites in all states, and Hispanics faced higher risk than non-Hispanic whites in New York but lower risks
in Illinois and California. Overall, increasing age was associated with higher
risk of ectopic pregnancy, although in 2
states women aged 40-44 years had a
slightly lower relative risk (vs the youngest group) than those aged 35-39 years.
The strength of our approach is that it
provides a complete population count of
ectopic pregnancy cases among women
with Medicaid insurance in the states
and years studied. Previous ectopic pregnancy surveillance studies in the US
since 1992 have largely excluded this
population. However, our study also has
several limitations. First, we only analyzed administrative claims data, with no
clinical validation. As a consequence, a
proportion of the ectopic pregnancies
reported herein may be false diagnoses,
representing anything from clerical errors in coding to the use of the diagnosis
code when ectopic pregnancy is only 1 of
several possible (rule out) diagnoses.
However, because our denominator captures all pregnancies with an even more
permissive definition, we believe the risk
of overcounting is at least as high in the
denominator as the numerator, thereby
decreasing the risk that we are overestimating the ectopic pregnancy rate. (For
example, a single diagnosis code for
spontaneous abortion was enough to
count as a pregnancy case in the denominator.) Although our method captures
274.e4
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General Gynecology
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TABLE 3
No. of ectopic
No. of total
Ectopic pregnancy
pregnancies (A) pregnancies (B) rate (A/B) 100
21
730
3.11%
............................................................................................................................................................................................................................
Asian
156
8969
1.90%
2502
120,432
2.29%
15
1013
1.50%
125
12,146
1.21%
............................................................................................................................................................................................................................
Hispanic
............................................................................................................................................................................................................................
Multiracial
............................................................................................................................................................................................................................
Unknown/missing
.....................................................................................................................................................................................................................................
Age group
............................................................................................................................................................................................................................
15-19
1295
67,481
1.92%
20-24
3295
142,193
2.32%
25-29
2451
92,039
2.66%
30-34
1377
49,442
2.79%
35-39
663
22,493
2.95%
40-44
148
6509
2.27%
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enrolled in prepaid managed care programs. Medicaid managed care is growing, and to the extent that these programs paid providers with capitated
payments rather than based on service
claims submitted, our study risks missing relevant claims. However, many
Medicaid managed care enrollees participate in limited programs, such as for the
management of behavioral health care,
or inpatient care. Pregnancy-related care
could still be paid on a fee-for-service
basis. Therefore, many managed care
beneficiaries excluded from the numerator would also be excluded from the
denominator.
Finally, these data represent only 3
states during the years 2000-03. Although very large in population, these
states cannot be said to represent all
Medicaid beneficiaries in the US. At the
time this research began, Medicaid data
files were not available for more recent
years. With more recent Medicaid data
now available, future work will be able to
examine current trends.
Given variations in data sources and
methods used in different studies, it is
impossible to make direct comparisons
across populations. However, our approach is similar to those used by
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Research
TABLE 4
RR
95% CI
California
P value
RR
95% CI
Illinois
P value
RR
95% CI
P value
Race/Ethnicity
................................................................................................................................................................................................................................................................................................................................................................................
White
Reference
Reference
Reference
Black
1.12
1.11.14
.0001
1.36
1.341.39
.0001
1.45
1.421.48
.0001
0.56
0.500.56
.0001
1.04
0.961.12
.3416
1.27
1.051.55
.0141
Asian
0.49
0.470.51
.0001
0.79
0.770.81
.0001
0.73
0.680.79
.0001
Hispanic
1.21
1.191.24
.0001
0.83
0.820.84
.0001
0.90
0.880.93
.0001
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.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
0.85
0.820.88
.0001
Multiracial
0.68
0.550.85
.0008
Unknown/missing
1.07
1.051.10
.0001
0.71
0.45
0.410.49
.0001
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
Age group
.......................................................................................................................................................................................................................................................................................................................................................................
15-49
Reference
20-24
1.43
1.401.48
.0001
Reference
1.31
1.281.33
.0001
Reference
1.26
1.231.30
.0001
25-29
1.55
1.511.60
.0001
1.65
1.621.69
.0001
1.49
1.451.54
.0001
30-34
1.74
1.691.79
.0001
1.93
1.891.97
.0001
1.59
1.541.65
.0001
35-39
2.00
1.942.06
.0001
2.20
2.152.25
.0001
1.67
1.601.75
.0001
40-44
1.91
1.831.98
.0001
2.40
2.322.47
.0001
1.22
1.131.31
.0001
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.......................................................................................................................................................................................................................................................................................................................................................................
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................................................................................................................................................................................................................................................................................................................................................................................
Smoking rates among women of reproductive age are not reported stratified
by income or health insurance, but
women with any college education are
significantly less likely to smoke than
those with less education, suggesting a
possible socioeconomic trend. These
trends would indicate that smoking may
contribute to higher ectopic pregnancy
rates among poor women than among
the more well-off. Smoking has been
identified as an important factor causing
higher rates of other poor pregnancy
outcomes, such as preterm birth and intrauterine growth restriction, among
women of lower socioeconomic status.20
However, smoking cannot explain ectopic pregnancy disparities by race or ethnicity. Among women of reproductive
age, smoking is most common among
white non-Hispanics (24.5%), with
lower rates among black non-Hispanics
(16.3%) and Hispanics (10.5%).21 On
the other hand, chlamydia rates are reported to be markedly higher among
black non-Hispanic (rate ratio 7.8)
274.e6
Research
General Gynecology
ACKNOWLEDGMENT
We thank Rangesh Kunnavakam (University of
Chicago) for technical assistance.
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