Multilevel community-centered intervention to reduce pregnancy related and associated morbidity and mortality (PRAMM) disparities in Non-Hispanic Black and Hispanic Medicaid-insured individuals

在这个项目中，我们将在一项大规模的务实试验中测试多水平干预，以减少非西班牙裔黑人 (NHB)和西班牙裔妊娠相关和相关孕产妇发病率和死亡率(PRAMM)差异 在密歇根州人口超过1/4(&gt；250万)的三个县。每一级的干预措施都是共同的 与我们在这些县的合作伙伴一起开发，包括NHB和西班牙裔孕妇，社区领导- 急诊室、服务提供者和卫生系统代表。社区层面的干预。我们将加强通信- 妇幼保健员(CHW)包容性家访模式，增加产前和产后对产妇的关注 并通过设计和实施具体的CHW干预措施，直接解决PRAMM在 黑人和西班牙裔医疗补助助产者。该方法利用了现有的全州基础设施- 在MI和许多其他州开展文化活动，以扩大孕产妇健康差距干预的覆盖范围。支持- VIDER/Practice级别的干预将通过可操作的体验式PRO解决患者与提供者之间的互动 VIDER培训的重点是沟通(例如，听取分娩者的意见)、提供者和实践种族主义、偏见、 文化相关性，以及对社区护理服务的认识和转介，包括社区卫生服务和家访- ING，用于临床和社区环境。这项研究的创新之处在于：(I)这是第一次大规模的 可扩展的集成CHW上门访问计划，专为减少PRAMM和差异而设计 在NHB和西班牙裔分娩者中；(2)将包括对相关特定并存情况的干预 对PRAMM和差异，包括多发病；(3)将是第一个解决患者-提供者之间的 从提供者和患者的角度采取行动，并将纳入创新的上游提供者培训 社区卫生细化等方法；(Iv)并将加强临床和社区的协调 多层次的关怀。这项研究将使用准试验性、阶梯式楔形设计。参与者将是 韦恩县、肯特县和杰纳西县的医疗补助参保人在怀孕期间、出生时和以后都会受到观察 至产后1年，在2021-2028年间分娩(约101,000名新生儿，包括约39,000名NHB和 西班牙裔)。分析将使用全州范围的关联数据系统，包括所有医疗补助出生和死亡记录，Med- ICAID索赔，以及其他程序数据。在密歇根州扩大与怀孕相关的医疗补助覆盖范围的背景下 到产后12个月，从2022年开始，这项研究将能够评估拟议的多水平 从妊娠早期到产后12个月的干预与常规护理。具体目标是：(1)评估 干预(与常规护理相比)在降低NHB和西班牙裔PRAMM(最长1年后)方面的有效性 分娩；总体和相对于NHW人群)和NHB和西班牙裔严重的孕产妇发病率和怀孕- 相关(包括与怀孕有关的)死亡率(总体和相对于非保健人员)；(2)测试获得 护理、质量和社会条件是多层次干预对NHB和HIS影响的机制 恐慌PRAMM差异；(3)评价多层次干预的成本-效果。

In this project we will test a multilevel intervention in a large-scale pragmatic trial to reduce Non-Hispanic Black (NHB) and Hispanic pregnancy-related and -associated maternal morbidity and mortality (PRAMM) disparities in three Michigan counties with over ¼ (>2.5M) of the Michigan population. Interventions at each level were co- developed with our partners in these counties, including NHB and Hispanic pregnant persons, community lead- ers, providers, and health system representatives. Community level intervention. We will enhance a commu- nity health worker (CHW)-inclusive home visiting model by increasing pre- and postnatal focus on maternal health and by designing and implementing specific CHW interventions to directly address PRAMM equity in Black and Hispanic Medicaid birthing persons. This approach takes advantage of existing statewide infrastruc- tures in MI and many other states to expand the reach of maternal health disparities interventions. The pro- vider/practice level intervention will address patient-provider interactions through actionable, experiential pro- vider trainings focused on communication (e.g. listening to birthing persons), provider and practice racism, bias, cultural relevance, and awareness of and referrals to community care services including CHWs and home visit- ing, for both clinical and community settings. The study is innovative in that (i) it is the first large-scale test of a scalable and integrated CHW – home visiting program specifically designed for reducing PRAMM and disparities among NHB and Hispanic birthing persons; (ii) will include interventions for specific comorbid conditions relevant to PRAMM and disparities, including multimorbidity; (iii) will be one of the first to address patient-provider inter- actions both from the provider and patient perspective and will incorporate innovative upstream provider training methods such as community health detailing; (iv) and will enhance the coordination of clinical and community care at multiple levels. The study will use a quasi-experimental, stepped wedge design. Participants will be Medicaid insured persons in Wayne, Kent, and Genesee counties observed during pregnancy, at birth, and up to 1 year postpartum, who deliver a birth between 2021-2028 (~101,000 births, including ~39,000 NHB and Hispanic). Analyses will use a statewide linked data system including all Medicaid birth and death records, Med- icaid claims, and other program data. In the context of Michigan extending pregnancy-related Medicaid coverage to 12 months postpartum starting in 2022, the study will be able to evaluate the impact of the proposed multilevel intervention vs usual care from early pregnancy through 12 months postpartum. Specific aims are to: (1) Assess the effectiveness of the intervention (vs usual care) in reducing NHB and Hispanic PRAMM (up to 1-year post- partum; overall & relative to NHW persons) and NHB and Hispanic severe maternal morbidity and pregnancy- associated (which includes pregnancy-related) mortality (overall & relative to NHW persons); (2) Test access to care, quality, and social conditions as mechanisms of the effect of the multilevel intervention on NHB and His- panic PRAMM disparities; (3) Evaluate the cost-effectiveness of the multilevel intervention.