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Importance: Chronic hypertension and preeclampsia are leading risk enhancers for maternal-neonatal morbidity and mortality. Severe maternal morbidity (SMM) indicators include heart, kidney, and liver disease, but studies have not excluded patients with preexisting diseases that define SMM. Thus, SMM risks for uncomplicated chronic hypertension specific to preeclampsia remain unclear., Objective: To determine SMM rates and estimate relative risks associated with hypertensive disorders of pregnancy among patients with and without chronic hypertension unencumbered by preexisting vascular or end organ diseases., Design, Setting, and Participants: This retrospective cohort study used longitudinal health data from electronic health records from patients within a community-based, integrated health care system in northern California. The study cohort selected 263 518 pregnant patients without pregestational heart, kidney, or liver disease entering prenatal care at 14 weeks' gestation or earlier and delivering a singleton stillbirth or live birth in 2009 to 2019. The data were analyzed between February 2022 and March 2024., Exposures: Five joint subgroups combining chronic hypertension status and the hypertensive disorders developing during pregnancy, defined as follows: (1) chronic hypertension with superimposed preeclampsia, (2) chronic hypertension and no preeclampsia, (3) no chronic hypertension with preeclampsia, (4) gestational hypertension, and (5) no chronic hypertension and no preeclampsia or gestational hypertension (reference group)., Main Outcomes and Measures: The main outcome was SMM rates at delivery hospitalization (cases per 10 000 births) using the Centers for Disease Control and Prevention criteria (≥1 of 21 indicators to define SMM) obtained from electronic health records. Modified Poisson regression models estimated crude and adjusted relative risks (aRRs) and 95% CIs of SMM associated with the chronic hypertension and developing hypertensive disorders of pregnancy groups vs the reference group (no chronic hypertension and no preeclampsia or gestational hypertension) adjusted for clinical, sociodemographic, social, and behavioral covariates., Results: The analysis included a total of 263 518 pregnant patients (mean [SD] age at delivery, 31.0 [5.3] years), including 249 892 patients without chronic hypertension (4.7% developed preeclampsia) and 13 626 patients with chronic hypertension (31.5% developed superimposed preeclampsia). The highest SMM rates occurred in the no chronic hypertension with preeclampsia (934.3 [95% CI, 882.3-988.3] cases per 10 000 births) and the chronic hypertension with superimposed preeclampsia (898.3 [95% CI, 814.5-987.8] cases per 10,000 births) groups. Lower SMM rates occurred in the chronic hypertension and no preeclampsia (195.1 [95% CI, 168.0-225.2] cases per 10,000 births), gestational hypertension (312.7 [95% CI, 281.6-346.1] cases per 10,000 births), and no chronic hypertension and no preeclampsia or gestational hypertension (165.8 [95% CI, 160.6-171.2] cases per 10,000 births) groups (P < .001). Compared with the no chronic hypertension and no preeclampsia or gestational hypertension group, risks of SMM were significantly higher for the chronic hypertension with superimposed preeclampsia group (aRR, 4.97 [95% CI, 4.46-5.54]), no chronic hypertension with preeclampsia group (aRR, 5.12 [95% CI, 4.79-5.48]), chronic hypertension and no preeclampsia group (aRR, 1.17 [95% CI, 1.003-1.36]; P = .046), and the gestational hypertension group (aRR, 1.78 [95% CI 1.60-1.99])., Conclusions and Relevance: This cohort study found that the highest SMM rates at delivery hospitalization occurred for preeclampsia superimposed on chronic hypertension and preeclampsia without chronic hypertension, while gestational hypertension had intermediate rates of SMM. The patients with chronic hypertension who did not develop preeclampsia had SMM rates that were nearly the same as the lowest-risk patients without chronic hypertension who did not develop preeclampsia or gestational hypertension. These findings provide evidence that prevention of preeclampsia among patients with uncomplicated chronic hypertension is paramount to mitigating maternal morbidity.

Importance: Prior studies have suggested that participation in home-based cardiac rehabilitation (HBCR) vs center-based cardiac rehabilitation (CBCR) results in similar clinical outcomes in patients with low to moderate risk; however, outcome data from demographically diverse populations and patients who are medically complex are lacking., Objective: To compare hospitalizations, medication adherence, and cardiovascular risk factor control between participants in HBCR vs CBCR., Design, Setting, and Participants: This retrospective cohort study was conducted among patients in Kaiser Permanente Southern California (KPSC), an integrated health care system serving approximately 4.7 million patients, who participated in CR between April 1, 2018, and April 30, 2019, and with follow-up through April 30, 2020. Data were analyzed from January 2021 to January 2022., Exposures: Participation in 1 or more HBCR or CBCR sessions., Main Outcomes and Measures: The primary outcome was 12-month all-cause hospitalization. Secondary outcomes included all-cause hospitalizations at 30 and 90 days; 30-day, 90-day, and 12-month cardiovascular hospitalizations; and medication adherence and cardiovascular risk factor control at 12 months. Logistic regression was used to compare hospitalization, medication adherence, and cardiovascular risk factor control, with inverse probability treatment weighting (IPTW) to adjust for demographic and clinical characteristics., Results: Of 2556 patients who participated in CR (mean [SD] age, 66.7 [11.2] years; 754 [29.5%] women; 1196 participants [46.8%] with Charlson Comorbidity Index ≥4), there were 289 Asian or Pacific Islander patients (11.3%), 193 Black patients (7.6%), 611 Hispanic patients (23.9%), and 1419 White patients (55.5%). A total of 1241 participants (48.5%) received HBCR and 1315 participants (51.5%) received CBCR. After IPTW, patients who received HBCR had lower odds of hospitalization at 12 months (odds ratio [OR], 0.79; 95% CI, 0.64-0.97) but similar odds of adherence to β-blockers (OR, 1.18; 95% CI, 0.98-1.42) and statins (OR, 1.02; 95% CI, 0.84-1.25) and of control of blood pressure (OR, 0.98; 95% CI, 0.81-1.17), low-density lipoprotein cholesterol (OR, 0.98; 95% CI, 0.81-1.20), and hemoglobin A1c (OR, 0.98; 95% CI, 0.82-1.18) at 12 months compared with patients who received CBCR., Conclusions and Relevance: These findings suggest that HBCR in a demographically diverse population, including patients with high risk who are medically complex, was associated with fewer hospitalizations at 12 months compared with patients who participated in CBCR. This study strengthens the evidence supporting HBCR in previously understudied patient populations.

Importance: In recent years, specialized musculoskeletal urgent care centers (MUCCs) have opened across the US. Uninsured patients may increasingly turn to these orthopedic-specific urgent care centers as a lower-cost alternative to emergency department or general urgent care center visits., Objective: To assess out-of-pocket costs and factors associated with these costs at MUCCs for uninsured and underinsured patients in the US., Design, Setting, and Participants: In this survey study, a national secret shopper survey was conducted in June 2019. Clinics identified as MUCCs in 50 states were contacted by telephone by investigators using a standardized script and posing as uninsured patients seeking information on the out-of-pocket charge for a new patient visit., Exposures: State Medicaid expansion status, clinic Medicaid acceptance status, state Medicaid reimbursement rate, median income per zip code, and clinic region., Main Outcomes and Measures: The primary outcome was each clinic's out-of-pocket charge for a level 3 visit, defined as a new patient office visit requiring medical decision-making of low complexity. Linear regression was used to examine correlations of price with clinic policy against accepting Medicaid, median income per zip code, and Medicaid reimbursement for a level 3 visit., Results: Of 565 MUCCs identified, 558 MUCCs were able to be contacted (98.8%); 536 of the 558 MUCCs (96.1%) disclosed a new patient visit out-of-pocket charge. Of those, 313 (58.4%) accepted Medicaid insurance and 326 (60.8%) were located in states with expanded Medicaid at the time of the survey. The mean (SD) price of a visit to an MUCC was $250 ($110). Clinic policy against accepting Medicaid (β, 22.91; 95% CI, 12.57-33.25; P < .001), higher median income per zip code (β, 0.00056; 95% CI, 0.00020-0.00092; P = .003), and increased Medicaid reimbursement for a level 3 visit (β, 0.737; 95% CI, 0.158-1.316; P = .01) were positively correlated with visit price. The overall regression was statistically significance (R2 = 0.084; P < .001)., Conclusions and Relevance: In this survey study, MUCCs charged a mean price of $250 for a new patient visit. Medicaid acceptance policy, median income per zip code, and Medicaid reimbursement for a level 3 visit were associated with differences in out-of-pocket charges. These findings suggest that accessibility to orthopedic urgent care at MUCCs may be limited for underinsured and uninsured patients.