Availability, accessibility, and structure of opioid use disorder treatment and maternal and child health outcomes

在过去十年中，怀孕期间阿片类药物使用障碍（OUD）的患病率增加了一倍多，与OUD相关的孕产妇和新生儿发病率和死亡率也增加了一倍多。自阿片类药物开始流行以来，因药物过量导致的孕产妇死亡增加了近5倍。2012年，美国平均每30分钟就有一名患有新生儿戒断综合征（NAS）的婴儿出生，据估计，这一疾病已造成15亿美元的医疗支出。在临床试验中，怀孕期间使用药物辅助治疗（MAT）与减少孕产妇和新生儿不良结局有关。尽管如此，许多患有OUD的妇女在怀孕期间没有接受治疗，大多数在产后停止治疗。因此，本R01提案的目标是了解OUD治疗服务提供的三个不同的可修改组成部分（即可获得性、可获得性和结构）如何对孕产妇和儿童健康结果产生不同影响。为了实现这一目标，我们将利用行政医疗保健数据，包括2008年至2017年宾夕法尼亚州所有医疗补助受益人的索赔、就诊和药房数据，其中包括13000名患有OUD的孕妇及其婴儿。数据将与出生证明和早期干预数据合并，以确定产妇OUD治疗参与程度的改善是否会影响儿科健康结果。我们将创建患者层面的OUD治疗可用性（与医疗补助OUD治疗提供者的地理距离）、可及性（医疗补助登记的持续时间）和治疗结构（指南一致性）的测量。主要研究目的是：1)评估妊娠期OUD治疗的可获得性（与医疗补助OUD治疗提供者的地理位置接近）对孕产妇MAT使用、出生和新生儿健康结局的影响；2)评估OUD治疗可及性（孕产妇参加医疗补助计划的持续时间）对MAT在妊娠和产后使用以及儿科健康结局的影响；3)确定MAT使用与母婴健康结局之间的关系是否由OUD治疗结构介导（与妊娠期OUD治疗指南的一致性）。宾夕法尼亚州深受阿片类药物流行的影响，拥有第四大医疗补助计划，农村和城市人口以及与全国平均水平一致的人口和社会经济概况，这将提供高度概括的发现。目标1将量化与医疗补助OUD治疗提供者的最小地理距离，以改善怀孕期间MAT的使用和随后的分娩结果。目的2将确定孕前和产后医疗补助登记与孕早期MAT使用和前三年儿科健康结果的相关性，这将为医疗补助登记标准提供信息。目标3将量化除MAT使用外，OUD治疗结构中推荐的成分与孕产妇和儿童健康结果的关联程度。总之，我们的研究结果将为医疗补助政策如何减轻OUD的巨大负担提供高质量的证据。

The prevalence of opioid use disorder (OUD) during pregnancy has more than doubled in the past decade, as has maternal and neonatal morbidity and mortality related to OUD. Since the beginning of the opioid epidemic, maternal deaths attributable to drug overdose have increased by nearly 5-­fold. In 2012, one infant, on average, was born every 30 minutes in the United States with neonatal abstinence syndrome (NAS), which has accounted for an estimated $1.5 billion in healthcare expenditures. In clinical trials, medication-­assisted treatment (MAT) use during pregnancy has been associated with reductions in adverse maternal and neonatal outcomes. Despite this, many women with OUD do not receive treatment during pregnancy and the majority discontinue treatment in the postpartum period. Therefore, the goal of this R01 proposal is to understand how three different modifiable components of the delivery of OUD treatment services (i.e. availability, accessibility and structure) differentially impact maternal and child health outcomes. To accomplish this goal, we will utilize administrative healthcare data including claims, encounters, and pharmacy data for all Medicaid beneficiaries in Pennsylvania including >13,000 pregnant women with OUD and their infants, from 2008 to 2017. Data will be merged with birth certificate and early intervention data to determine if improvements in maternal OUD treatment engagement impact pediatric health outcomes. We will create patient-­level measures of OUD treatment availability (geographic proximity to Medicaid OUD treatment providers), accessibility (duration of Medicaid enrollment) and treatment structure (guideline concordance). The primary research aims are to 1) assess the impact of OUD treatment availability during pregnancy (geographic proximity to Medicaid OUD treatment providers) on maternal MAT use and birth and neonatal health outcomes;; 2) assess the impact of OUD treatment accessibility (duration of maternal Medicaid enrollment) on MAT use during pregnancy and postpartum and pediatric health outcomes;; 3) determine if the relationships between MAT use and maternal and child health outcomes are mediated by OUD treatment structure (concordance with OUD treatment guidelines in pregnancy). Deeply affected by the opioid epidemic, Pennsylvania has the fourth-­largest Medicaid program, rural and urban populations and demographic and socioeconomic profiles consistent with national averages which will provide highly generalizable findings. Aim 1 will quantify the minimum geographic proximity to Medicaid OUD treatment providers necessary to improve MAT use during pregnancy and subsequent birth outcomes. Aim 2 will determine the relevance of pre-­pregnancy and postpartum Medicaid enrollment to first trimester MAT use and pediatric health outcomes for the first three years, which will inform Medicaid enrollment criteria. Aim 3 will quantify the extent to which recommended components of OUD treatment structure, beyond MAT use, are associated with maternal and child health outcomes. Together, our findings will provide high-­quality evidence about how Medicaid policies may lessen the considerable burden of OUD.