Galvin Shelley L, Ramage Melinda, Leiner Catherine, Sullivan Margaret H, Fagan E Blake
assistant residency program director, Department of Obstetrics and Gynecology, Mountain Area Health Education Center; adjunct assistant professor, Department of Obstetrics and Gynecology, UNC School of Medicine, Asheville, North Carolina
medical director, Project CARA, Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina.
N C Med J. 2020 May-Jun;81(3):157-165. doi: 10.18043/ncm.81.3.157.
Pregnant patients from rural counties of Western North Carolina face additional barriers when accessing comprehensive perinatal substance use disorders care at Project CARA as compared to patients local to the program in Buncombe County. We hypothesized regional patients would be less engaged in care. Using a retrospective cohort design, univariate analyses (χ, t-test; < .05) compared patients' characteristics, engagement in care, and delivery outcomes. Engagement in care, the primary outcome, was operationalized as: attendance at expected, program-specific prenatal and postpartum visits, utilization of in-house counseling, community-based and/or inpatient substance use disorders treatment, and maternal urine drug screen at delivery negative for illicit substances. Regional patients (n = 324) were more likely than Buncombe County patients (n = 284) to have opioid [209 (64.5%) versus 162 (57.0%)] or amphetamine/methamphetamine use disorders (25 [7.7%] versus 13 [4.6%]), but less likely to have cannabis use (19 [5.9%] versus 38 [13.4%]; = .009) and concurrent psychiatric disorders (214 [66.0%] versus 220 [77.5%]; = .002). Engagement at postpartum visits was the significantly different outcome between patients (110/221 [49.8%] versus 146/226 [64.6%]; = .002). Outcomes were available for 66.8% of regional and 79.6% of Buncombe County patients of one program in one predominately white, non-Hispanic region of the state. Contrary to our hypothesis, regional and Buncombe County women engaged in prenatal care equally. However, a more formal transition into the postpartum period is needed, especially for regional women. A "hub-and-spokes" model that extends delivery of perinatal substance use disorders care into rural communities may be more effective for engagement retention.
与位于本康伯县、参与该项目的患者相比，北卡罗来纳州西部农村县的孕妇在通过“关爱成瘾孕妇项目”（Project CARA）获得全面的围产期物质使用障碍护理时面临更多障碍。我们推测来自该地区其他地方的患者对护理的参与度会较低。采用回顾性队列设计，单变量分析（χ²检验、t检验；P<0.05）比较了患者的特征、护理参与度和分娩结局。护理参与度作为主要结局，其定义为：按预期参加特定项目的产前和产后访视、利用内部咨询服务、接受社区和/或住院物质使用障碍治疗，以及分娩时产妇尿液药物筛查结果为非法物质阴性。来自该地区其他地方的患者（n = 324）比本康伯县的患者（n = 284）更有可能患有阿片类物质使用障碍[209例（64.5%）对162例（57.0%）]或苯丙胺/甲基苯丙胺使用障碍[25例（7.7%）对13例（4.6%）]，但大麻使用障碍的患病率较低[19例（5.9%）对38例（13.4%）；P = 0.009]，并发精神障碍的患病率也较低[214例（66.0%）对220例（77.5%）；P = 0.002]。产后访视时的护理参与度是患者之间存在显著差异的结局（110/221例[49.8%]对146/226例[64.6%]；P = 0.002）。在该州一个以白人、非西班牙裔为主的地区，一个项目中66.8%的来自该地区其他地方的患者和79.6%的本康伯县患者有分娩结局数据。与我们的假设相反，来自该地区其他地方的女性和本康伯县的女性在产前护理方面的参与度相同。然而，尤其是对于来自该地区其他地方的女性，需要向产后阶段进行更正式的过渡。将围产期物质使用障碍护理扩展到农村社区的“中心辐射”模式可能对提高护理参与度的持续性更有效。
