In November 2020, the Geographic Determinants of Health Pilot Program awarded five translational research projects focused on geographic determinants of health and geographical barriers to health care delivery. Each project will receive $25,000 in funding for a 12 month award period.
Team: Christina Mair, PhD, MPH (PI), Marian Jarlenski, PhD, MPH, Elizabeth Krans, MD, MSc, Jessica Frankeberger, MPH
Abstract: In the United States, opioid use disorder (OUD) and overdose have become leading causes of non-pregnancy related death among pregnant and postpartum women. While identifying and treating OUD during pregnancy is a priority, limited attention has been given to overdose and hospital readmission risks among postpartum (within 12 months post-delivery) women. Though the postpartum period is marked by profound changes for all women, women with OUD may disproportionately experience co-morbid health conditions, challenging systemic social conditions in their communities, and decreased access to healthcare and drug treatment services. The objective of this research is to examine the community factors (e.g., area-level poverty) and health resources (e.g., access to Medication-assisted treatment (MAT) providers, mental health services) associated with opioid overdose and opioid-related hospital readmissions among postpartum women with OUD. We will use inpatient hospital data from the Pennsylvania Health Care Cost Containment Council (PHC4), merged with community-level data sources such as the U.S. Census and SAMSHA’s Behavioral Health Treatment Services Locator. The Specific Aims are to: 1) Examine the effects of individual-level factors, community-level factors, and the availability of health services on opioid-related hospitalizations among postpartum women with OUD; and 2) Assess the spatial distribution of hospital births and postpartum opioid-related readmissions among women with OUD at delivery, and identify the community factors and resources associated with ZIP code-level deliveries and readmissions. By identifying individual and community factors that contribute to opioid-related hospitalizations among postpartum women, this study can inform the distribution of resources and the design of upstream structural interventions.
Abstract: Opioid use and suicide are twin epidemics that disproportionately affect individuals and families living in rural areas. As a result, rural communities have seen dramatic increases in the rates of kinship caregivers, aging family members providing custodial guardianship to children removed from their parents’ care due to substance use or premature death. This presents unique challenges for older adults who must return to a parent role. Additionally, providing necessary multidisciplinary care for these children in rural communities is complicated by significant barriers to accessing pediatric subspecialty services. While telehealth offers a way of reaching individuals in rural communities, barriers such as a lack of technology literacy in older caregivers must be explored and proactively addressed. We plan to conduct focus groups with caregivers regarding their utilization and barriers to accessing services for children. Using this information, we will adapt and develop training procedures for an on-line resource for older kinship caregivers. We will then conduct a pilot study of a case-management intervention, PA Ties that Heal (PATH), including access to an on-line portal and 4 bi-weekly case management meetings with a resource support coach, delivered remotely through a secure teleconferencing format to kinship caregivers in Mercer and Cambria counties. This pilot study will allow us to assess the feasibility and acceptability of PATH, and will also provide preliminary data regarding the program’s ability to improve parenting and decrease depressive symptoms in kinship caregivers, as well increase mental service access and utilization for the children in their care.
Team: Joshua Brown, MD, MSc (PI), Matthew Rosengart, MD, MPH, Andrew Paul-Deeb, MD, Heather Phelos, MPH
Abstract: Trauma is a time-sensitive disease and rapid access to definitive care saves lives. However, access to trauma care is not geographically uniform in the US. Patients injured in rural areas have worse outcomes than those injured in urban areas. The mechanisms leading to this disparity remain unclear. Under-triage – the delivery of severely injured patients to non-trauma centers with insufficient resources to provide definitive care – may play a role in generating this disparity. Even patients transported first to a non-trauma center but then later transferred to a trauma center have higher mortality than those taken initially to a trauma center. We believe rural areas have greater variability in proximity and consequently access to trauma system resources leading to disparity in under-triage and ultimately outcomes. This proposal investigates how proximity and capabilities of healthcare system resources (trauma centers, air medical helicopters, ambulance coverage, non-trauma hospitals) influence the risk of under-triage after motor vehicle collisions (MVC) in rural versus urban areas across the US. We will examine the link between under-triage and mortality from a system perspective among US counties. We will then demonstrate how simulated changes in the geographic organization of trauma system resources can optimize system under-triage and mortality. This project will elucidate potential mechanisms for the disparity of rural outcomes in trauma care including why triage decisions are made, identify risk and mitigating factors for under-triage in rural areas, and develop tools to guide data-driven changes in the geospatial organization of trauma systems, reducing under-triage and improving patient outcomes.
Abstract: With advances in prehospital care, more than 150,000 patients with out-of-hospital arrest (OHCA) are revived and transported to the hospital each year. Patients who receive specialty care in the early post-arrest period enjoy better short- and long-term outcomes, leading both the American Heart Association and National Academies of Medicine to call for systems of regionalized post-arrest care. The best strategy to regionalize early post-arrest care is unknown. One approach could be to systematically transport all patients directly from the scene of their arrest to a designated specialty care hospital. An alternative could be for prehospital providers to transport patients to the nearest acute care hospital for early stabilization prior to interfacility transfer to the designated specialty care hospital. A third approach would allow prehospital providers to make triage decisions based on clinical characteristics, capabilities of nearby hospitals, and geographical factors affecting access to initial or specialty care. We will compare these three approaches in detail. We will first characterize geospatial access to primary and specialized post-arrest care in our region. Then, we will leverage existing clinical data to make causal inference between alternative prehospital triage strategies and patient outcomes. Finally, we will use simulation analyses to extend this work and make national population-level estimates of the potential impact of regionalizing post-arrest care on public health.
Team Members: Alisse Hauspurg, MD (PI), Hyagriv Simhan, MD, Lara Lemon, PhD, PharmD
Abstract: Maternal morbidity and mortality are increasing at alarming rates in the United States, with the majority occurring postpartum. Maternal mortality rates are two-fold higher among rural women compared with urban women, largely driven by a lack of access to high quality maternal health services. Hypertensive disorders of pregnancy (HDP) are the most common reason for readmission postpartum and contribute to a significant proportion of morbidity and mortality. We have developed and successfully implemented a postpartum remote hypertension monitoring program utilizing nursing call center-driven blood pressure management and treatment algorithms. We have demonstrated high compliance, retention and patient satisfaction as well as improved attendance at postpartum visits among an urban population. In this application, we plan to harness the success of our postpartum remote hypertension monitoring program to assess the feasibility and outcomes of our program in a non-urban population (Aim 1) and explore how social and geographical determinants of health impact remote delivery of care (Aim 2). Completion of these aims will inform strategies utilizing telehealth to improve delivery of postpartum care in rural settings and ultimately reduce hypertension-related maternal morbidity. This study is innovative in its use of patient-centered technology to address challenges in maternal care delivery in non-urban populations. It is significant as it will provide preliminary data to support a larger-scale study of postpartum interventions to reduce maternal morbidity and engage both urban and non- urban populations. A successful outcome would represent a transformation in postpartum management of HDP and have a direct impact to improve maternal health.