A Pragmatic Trial of Integrating Community-based Patient Navigation into the Continuum of Maternal Care for Black Women in a Safety-Net Health System: Effects on Maternal Health, Health Care, Morbidit

将基于社区的患者导航纳入安全网卫生系统中黑人妇女连续孕产妇护理的务实试验：对孕产妇健康、医疗保健、发病率的影响

• 批准号: 10709629
• 负责人: Rasheeta Chandler
• 金额: $ 71.73万
• 依托单位: EMORY UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-09-23 至 2027-06-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10709629
• 关键词: Address; Adoption; Birth; Black race; Caring; Chronic; Clinical; Communities; Community Health; Data; Data Reporting; Developed Countries; Discrimination; Disparity; Dose; Effectiveness; Elements; Equity; Evaluation; Event; Familiarity; Health; Health Personnel; Health Services; Health system; Healthcare; Hospitals; Improve Access; Inequity; Institution; Institutional Racism; Intervention; Interview; Life; Low income; Maternal Health; Maternal Health Services; Maternal Mortality; Maternal health equity; Measures; Mediator; Mental disorders; Methods; Modeling; Morbidity - disease rate; Mothers; National Institute on Minority Health and Health Disparities; Outcome; Participant; Patients; Perception; Perinatal; Policies; Politics; Postpartum Period; Pregnancy; Pregnancy Complications; Pregnancy Rate; Prenatal care; Preventive care; Primary Care; Process; Quality of Care; Questionnaires; Race; Randomized, Controlled Trials; Reporting; Research; Research Personnel; Resources; Review Committee; Sample Size; Severities; Shapes; Social support; Stress; System; Testing; Time Management; Uninsured; Weather; Woman; arm; black women; community based research; cultural competence; depressive symptoms; design; disparity reduction; effectiveness evaluation; ethnic minority; evidence base; experience; health care quality; health care service utilization; health equity; implementation intervention; implicit bias; improved; informant; intervention delivery; maternal morbidity; meetings; metropolitan; mortality; multidisciplinary; patient navigation; patient navigator; postpartum care; pragmatic trial; prenatal; prevent; preventable death; primary outcome; process evaluation; racial disparity; racial minority; racism; recruit; safety net; scale up; secondary outcome; severe maternal morbidity; social; stress symptom; substance use

ABSTRACT US maternal mortality is substantially higher than that of other developed nations, with Georgia ranking second highest among the states. Maternal mortality and severe maternal morbidity (SMM) are increasing in Georgia, with the highest rates among those who are Black, publicly insured or uninsured, and deliver in safety-net hospitals. Maternal morbidity and mortality occur on a continuum in which the accumulation and progression in severity of events can be prevented through access to and utilization of quality health care. Georgia’s Maternal Mortality Review Committee concludes that two-thirds of maternal deaths are preventable and attributes recent increases to rising rates of inadequately managed chronic health conditions, mental health disorders, substance use, and pregnancy complications in the setting of care that is often difficult to access, fragmented and of insufficient quality. Experts emphasize that equity-centered health care approaches – which embed transformational aspects into their design through stakeholder input and Black-led models of care that include social support to counter stress related to racism and weathering – offer the most promise for reducing inequities. Emerging data support that the incorporation of racially-concordant, community-based patient navigators can enhance the cultural-competence of care while addressing discrimination, systemic racism, and institutional barriers to quality care. To date, however, limited research has evaluated this promising strategy in real-life settings using rigorous methods with sufficient sample size and ascertainment of morbidity and mortality endpoints critical for determining effectiveness and motivating large-scale policy and practice change. We posit that the integration of community-based patient navigators into maternal care will improve maternal health outcomes through meeting social needs, lowering stress and depressive symptoms, and improving access to and utilization of care thereby promoting better and more timely management of conditions and reducing the occurrence and progression of complications. To test this hypothesis, we propose to perform a pragmatic randomized controlled trial (RCT) of the integration of community-based patient navigators into the continuum of maternal care, starting prior to mid-pregnancy and continuing through one-year of birth, among 500 Black women with identified health and social needs in a safety-net hospital system to include both outcome evaluation, to discern effectiveness in reducing maternal morbidity and mortality, and process evaluation, to enhance understanding of RCT findings. We will employ the Respectful Maternity Care and the NIMHD Research Frameworks to rigorously evaluate maternal health outcomes in a hospital system that primarily serves Black women with high unmet needs who experience excessive rates of adverse maternal health outcomes via a multi-disciplinary team experienced in health services and community-based research, equity-centered care, and with the capacity to implement a care model intervention with high fidelity and acquire and utilize health system and patient-reported data to conduct comprehensive, high-quality evaluation.

抽象的 美国孕产妇死亡率大幅高于其他发达国家，格鲁吉亚排名第二 乔治亚州的孕产妇死亡率和严重孕产妇发病率 (SMM) 不断上升， 在黑人、公共保险或未保险以及在安全网中分娩的人群中，这一比例最高 孕产妇发病率和死亡率是连续发生的，其中不断累积和进展。 通过获得和利用乔治亚州的优质医疗保健可以预防事件的严重性。 死亡率审查委员会得出结论认为，三分之二的孕产妇死亡是可以预防的，并且归因于近期 慢性健康问题、精神健康障碍、 药物滥用和妊娠并发症的护理环境往往难以获得、支离破碎 专家强调，以公平为中心的医疗保健方法——其中嵌入了 通过利益相关者的意见和黑人主导的护理模式将转型方面纳入其设计，其中包括 应对与种族主义和风化有关的压力的社会支持——为减少种族主义和风化提供了最大的希望 新出现的数据支持纳入种族一致、基于社区的患者。 导航员可以增强护理的文化能力，同时解决歧视、系统性种族主义和 然而，迄今为止，有限的研究评估了这一有前景的策略。 使用严格的方法和足够的样本量来确定现实生活中的发病率和 死亡率终点对于确定有效性和推动大规模政策和实践变革至关重要。 我们认为，将基于社区的患者导航仪纳入孕产妇护理将改善孕产妇护理 通过满足社会需求、减轻压力和抑郁症状以及改善健康状况 获得和利用护理，从而促进更好、更及时地管理状况和 减少并发症的发生和进展 为了检验这一假设，我们建议进行一项研究。 将基于社区的患者导航器整合到医疗服务中的务实随机对照试验 (RCT) 连续的孕产妇护理，从怀孕中期之前开始，一直持续到出生一年 500 名具有明确健康和社会需求的黑人妇女被纳入安全网医院系统，其中包括 结果评估，以确定降低孕产妇发病率和死亡率的有效性，以及过程 评估，以加强对随机对照试验结果的理解，我们将采用尊重的产妇护理和 NIMHD 研究框架严格评估医院系统中的孕产妇健康结果 主要是需求未得到满足的黑人妇女，她们经历过高比例的不良孕产妇 通过在卫生服务和社区研究方面经验丰富的多学科团队获得健康成果， 以公平为中心的护理，并有能力实施高保真的护理模式干预 获取并利用卫生系统和患者报告的数据来进行全面、高质量的评估。