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Changes in Low-Dose Aspirin Use After Updated Guidance on Sociodemographic Risk Factors for Preeclampsia
Taylor S Freret1, Allison S Bryant1, Kaitlyn E James1
1Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, the Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, Massachusetts; and the Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida.
Insights
New guidelines increased low-dose aspirin use in Black patients but not those with public insurance for preeclampsia prevention. Overall use remains low despite updated recommendations.
Area of Science:
- Obstetrics and Gynecology
- Maternal-Fetal Medicine
- Health Services Research
Background:
- Preeclampsia is a significant cause of maternal morbidity and mortality.
- Recent guideline updates from the U.S. Preventive Services Task Force (USPSTF) and American College of Obstetricians and Gynecologists (ACOG) in 2021 incorporated race and income as risk factors.
- These updates aimed to address disparities in preeclampsia incidence and outcomes.
Purpose of the Study:
- To evaluate the impact of the 2021 USPSTF and ACOG guideline modifications on low-dose aspirin use among Black patients and those with lower income (proxied by Medicaid insurance).
- To assess if these guideline changes effectively increased the uptake of preventive low-dose aspirin in identified at-risk populations.
Main Methods:
- A repeated cross-sectional analysis was conducted on nulliparous patients delivering from 2017 to 2022 within a single healthcare system.
- Two matched cohorts were established: one stratified by race (Black vs. White) and another by insurance status (Medicaid vs. private).
- Difference-in-difference analyses were used to compare low-dose aspirin use rates before and after the 2021 guideline changes.
Main Results:
- The study included over 31,000 participants across race and income cohorts.
- Low-dose aspirin use increased by 8.8 percentage points among Black patients compared to White patients.
- No significant increase in low-dose aspirin use was observed among patients with Medicaid insurance compared to those with private insurance.
Conclusions:
- The 2021 USPSTF and ACOG guidelines were associated with increased low-dose aspirin use in Black patients, suggesting a positive impact on addressing racial inequities.
- However, the guidelines did not lead to a similar increase in low-dose aspirin use for patients with public insurance.
- Despite guideline updates, overall rates of low-dose aspirin use for preeclampsia prevention remain suboptimal.
Objective:
To assess whether the modifications to the U.S. Preventive Services Task Force (USPSTF) and American College of Obstetricians and Gynecologists (ACOG) guidelines that emphasize "lower income" status and Black racial identity (as a proxy for underlying systemic racism) as moderate risk factors for preeclampsia were associated with increased low-dose aspirin use in these groups.
Methods:
We performed a repeated cross-sectional analysis of nulliparous patients who delivered at 24 weeks of gestation or later from 2017 to 2022 within one health care system with an indication for low-dose aspirin use during the pregnancy. Two cohorts were created, with patients matched exactly on other known risk factors for preeclampsia. The first cohort was stratified by Black and White race; the second cohort was stratified by Medicaid insurance (as a proxy for lower income) and private insurance. Two patient-level difference-in-difference analyses were performed in each matched cohort using linear regression. The pre-period included patients who delivered before 2022, and the post-period included those who delivered in 2022.
Results:
The study included 31,555 participants: 11,612 in the first cohort examining race and 14,208 in the second cohort examining lower income. In the first cohort, 2,614 patients (22.5%) were matched; in the second cohort, 3,602 patients (22.6%) were matched. The rate of low-dose aspirin use among patients who self-identified as Black increased by 8.8 percentage points (95% CI, 0.076-16.9) relative to those who identified as White. The rate of low-dose aspirin use among patients with Medicaid insurance did not increase relative to those with private insurance (difference-in-difference estimate -1.1 percentage points; 95% CI, -9.3 to 7.2).
Conclusion:
New guidelines from the USPSTF and ACOG in 2021 that emphasized the racial inequities of preeclampsia were associated with an increase in the rate of low-dose aspirin use in Black patients but not in patients with public insurance. Despite new guidance, overall rates of low-dose aspirin use remain well below expected based on what is recommended by professional organizations.
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