Daisy J Goodman1, Elizabeth C Saunders2, Julia R Frew3, Cybele Arsan4, Haiyi Xie5, Kyra L Bonasia5, Victoria A Flanagan6, Sarah E Lord3, Mary F Brunette3. 1. Dartmouth Geisel School of Medicine, Hanover, NH (Drs Goodman, Saunders, Frew, Arsan, Xie, Bonasia, Lord, and Brunette); Department of Obstetrics and Gynecology, Dartmouth-Hitchcock Medical Center, Lebanon, NH (Dr Goodman and Ms Flanagan); The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH (Dr Goodman). 2. Dartmouth Geisel School of Medicine, Hanover, NH (Drs Goodman, Saunders, Frew, Arsan, Xie, Bonasia, Lord, and Brunette). Electronic address: elizabeth.c.saunders@dartmouth.edu. 3. Dartmouth Geisel School of Medicine, Hanover, NH (Drs Goodman, Saunders, Frew, Arsan, Xie, Bonasia, Lord, and Brunette); Department of Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, NH (Drs Frew, Arsan, Lord, and Brunette). 4. Dartmouth Geisel School of Medicine, Hanover, NH (Drs Goodman, Saunders, Frew, Arsan, Xie, Bonasia, Lord, and Brunette); Department of Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, NH (Drs Frew, Arsan, Lord, and Brunette); Department of Psychiatry, Los Angeles County and Keck Medical Center of University of Southern California, Los Angeles, CA (Dr Arsan). 5. Dartmouth Geisel School of Medicine, Hanover, NH (Drs Goodman, Saunders, Frew, Arsan, Xie, Bonasia, Lord, and Brunette). 6. Department of Obstetrics and Gynecology, Dartmouth-Hitchcock Medical Center, Lebanon, NH (Dr Goodman and Ms Flanagan).
Abstract
BACKGROUND: Pregnant women with opioid use disorder and their infants often experience worse perinatal outcomes than women without opioid use disorder, including longer hospitalizations after delivery and a higher risk for preterm delivery. Integrated treatment models, which combine addiction treatment and maternity care, represent an innovative approach that is widely endorsed, however, limited studies have compared the outcomes between integrated and standard, nonintegrated programs from real-world programs. OBJECTIVE: This study aimed to evaluate the perinatal and substance use outcomes for pregnant women with opioid use disorder receiving coordinated, colocated obstetrical care and opioid use disorder treatment (integrated treatment) and to compare it with those of women receiving obstetrical care and opioid use disorder treatment in distinct programs of care (nonintegrated treatment). STUDY DESIGN: In this observational, retrospective cohort study, we abstracted the perinatal and opioid use disorder treatment data from the records of pregnant women with opioid use disorder (n=225) who delivered at a rural, academic medical center from 2015 to 2017. The women either received integrated (n=92) or nonintegrated (n=133) opioid use disorder treatment and obstetrical care. Using inverse probability weighted regression models to adjust for a potential covariate imbalance, we evaluated the impact of the treatment model on the risk for preterm delivery and positive meconium or umbilical cord toxicology screens. We explored whether the number of obstetrical visits mediated this relationship by using a quasi-Bayesian Monte Carlo algorithm. RESULTS: Women receiving integrated treatment were less likely to deliver prematurely (11.8% vs 26.6%; P<.001) and their infants had shorter hospitalizations (6.5±4.8 vs 10.7±16.2 days). Using a robust inverse probability weighted model showed that receiving integrated treatment was associated with a 74.7% decrease in the predicted probability of preterm delivery (average treatment effect, -0.19; standard error, 0.14; P<.001). There were no differences in the risk for a positive meconium or umbilical cord toxicology screen, a marker for second and third trimester substance use, between women receiving integrated treatment and those receiving coordinated treatment (29.4% vs 34.6%; P=.41), however, integrated treatment was associated with significantly lower rates of positive maternal urine toxicology screens at the time of delivery (35.9% vs 74.4%; P<.001). CONCLUSION: Among a cohort of rural pregnant women with opioid use disorder, receiving integrated obstetrical care and opioid use disorder treatment was associated with a reduced risk for preterm birth, a lower risk for positive maternal urine toxicology screen at the time of delivery, and shorter infant hospitalization. This relationship was mediated by the number of obstetrical visits attended during pregnancy, suggesting that increased engagement with obstetrical care through integration of services may contribute to improved perinatal outcomes.
BACKGROUND: Pregnant women with opioid use disorder and their infants often experience worse perinatal outcomes than women without opioid use disorder, including longer hospitalizations after delivery and a higher risk for preterm delivery. Integrated treatment models, which combine addiction treatment and maternity care, represent an innovative approach that is widely endorsed, however, limited studies have compared the outcomes between integrated and standard, nonintegrated programs from real-world programs. OBJECTIVE: This study aimed to evaluate the perinatal and substance use outcomes for pregnant women with opioid use disorder receiving coordinated, colocated obstetrical care and opioid use disorder treatment (integrated treatment) and to compare it with those of women receiving obstetrical care and opioid use disorder treatment in distinct programs of care (nonintegrated treatment). STUDY DESIGN: In this observational, retrospective cohort study, we abstracted the perinatal and opioid use disorder treatment data from the records of pregnant women with opioid use disorder (n=225) who delivered at a rural, academic medical center from 2015 to 2017. The women either received integrated (n=92) or nonintegrated (n=133) opioid use disorder treatment and obstetrical care. Using inverse probability weighted regression models to adjust for a potential covariate imbalance, we evaluated the impact of the treatment model on the risk for preterm delivery and positive meconium or umbilical cord toxicology screens. We explored whether the number of obstetrical visits mediated this relationship by using a quasi-Bayesian Monte Carlo algorithm. RESULTS: Women receiving integrated treatment were less likely to deliver prematurely (11.8% vs 26.6%; P<.001) and their infants had shorter hospitalizations (6.5±4.8 vs 10.7±16.2 days). Using a robust inverse probability weighted model showed that receiving integrated treatment was associated with a 74.7% decrease in the predicted probability of preterm delivery (average treatment effect, -0.19; standard error, 0.14; P<.001). There were no differences in the risk for a positive meconium or umbilical cord toxicology screen, a marker for second and third trimester substance use, between women receiving integrated treatment and those receiving coordinated treatment (29.4% vs 34.6%; P=.41), however, integrated treatment was associated with significantly lower rates of positive maternal urine toxicology screens at the time of delivery (35.9% vs 74.4%; P<.001). CONCLUSION: Among a cohort of rural pregnant women with opioid use disorder, receiving integrated obstetrical care and opioid use disorder treatment was associated with a reduced risk for preterm birth, a lower risk for positive maternal urine toxicology screen at the time of delivery, and shorter infant hospitalization. This relationship was mediated by the number of obstetrical visits attended during pregnancy, suggesting that increased engagement with obstetrical care through integration of services may contribute to improved perinatal outcomes.
Authors: Ximena A Levander; Canyon A Foot; Sara L Magnusson; Ryan R Cook; Jerel M Ezell; Judith Feinberg; Vivian F Go; Kathryn E Lancaster; Elizabeth Salisbury-Afshar; Gordon S Smith; Ryan P Westergaard; April M Young; Judith I Tsui; P Todd Korthuis Journal: J Gen Intern Med Date: 2022-06-15 Impact factor: 6.473