>>I'M JANINE AUSTIN CLAYTON
THE ASSOCIATE DIRECTOR FOR
WOMEN'S HEALTH AND IT'S MY
PLEASURE TO WELCOME YOU TO THE
2022 IMPROVE AWARDEE WORKSHOP.
I'M HERE WITH MY CO-CHAIR OF THE
MATERNAL TASK FORCE AND I'LL SET
THE STAGE AND PASS THE MIC.
IT'S WELL KNOWN NOW, FOR
EXAMPLE, THE UNITED STATES IS
THE MOST DANGEROUS PLACE IN THE
DEVELOPED WORLD TO HAVE A BABY.
AND THIS DISPARITY IS GREATLY
INCREASED IN AFRICAN AMERICAN
AND NATIVE INDIAN AND MORE
LIKELY TO DIE TO PREGNANCY
RELATED PEOPLE AND THIS EXISTS
BY AGE AND GEOGRAPHY WITH WOMEN
OVER 35 OR THOSE RESIDING IN
RURAL AREAS AT HIGHER RISK.
WE KN
WE KNOW SOCIAL DETERMINATES PLAY
A ROLE AND SOCIAL STRUCTURE AND
ACCESS AND DELIVERY PLAY A ROLE
AND CAN PERPETUATE AND MAGNIFY
MATERNAL RISK FOR WOMEN OF COLOR
IN INDIGENOUS COMMUNITIES.
THE INSTITUTIONAL FACTORS ARE
CRITICAL TO TAKE ADVANTAGE OF
AND TO LEVERAGE AS WE MOVE
FORWARD IN ADDRESSING THESE
ISSUES.
WE USE AN INTEGRATIVE LIFE
COURSE LENS AND THE CONTEXT MUST
BE VIEWED TO WHAT CAME BEFORE
AND AFTER AND RIGOROUS STUDY HAS
SHOWN PREGNANCY AND MENOPAUSE IS
WHERE WE CAN HAVE GREAT IMPACT
AND PUSH TO INTEGRATE RESEARCH
TO IMPROVE THE HEALTH OF WOMEN
AND VIEWING THE HEALTH OF WOMEN
PRE PREGNANCY AND DURING AND
POSTPARTUM AND EVERYTHING BEFORE
AND IN BETWEEN AND BEYOND IS
NEEDED TO HAVE MAXIMAL IMPACT.
IF PRENATAL CARE IS HIGH
PREGNANCY IS SAFER.
STEPS LIKE BLOOD PRESSURE
MONITORING DURING PREGNANCY CAN
DO A LONG WAY IN DETECTING
PREGNANCY RELATED HYPER TENSION
AND PREVENTING POOR OUTCOMES.
IF POSTPARTUM PEOPLE ARE LINKED
TO CARE WE CAN TAKE ADVANTAGE
REVEALING SUSCEPTIBLE TO
GESTATIONAL DIABETES OR
PREECLAMPSIA.
SO IN CONSIDERING THE WOMEN'S
LIFE COURSE I'D BE REMISS IF I
DIDN'T MENTION A PUBLICATION
SHOWING THAT HOMICIDE IS THE
LEADING CAUSE OF DEATH DURING
PREGNANCY AND THE POSTPARTUM
PERIOD BETWEEN 2018 AND 2019.
THESE RESEARCHERS FOUND
U.S. WOMEN WHO WERE PREGNANT
DIED BY HOMICIDE MORE THAN TWICE
THE RATE OF PLACENTAL DISORDERS
USUALLY THE HIGHEST CAUSE AND IT
INCREASES THE RISK BY HOMICIDE.
BETWEEN THE AGES OF 10 AND 44
YEARS WHICH WOULD WERE PREGNANT
OR HAD THEIR PREGNANCY END IN
THE LAST YEAR WERE KILLED AT A
RATE 16% HIGHER THAN WOMEN WHO
WERE NOT PREGNANT.
AND OVERALL, WOMEN OF ANY RACE
HAD HIGHER NUMBERS AND LOOKING
AT INTIMATE PARTNER HOMICIDE
RATES OF NON PREGNANCY
ASSOCIATED INTIMATE PARTNER
HOMICIDE VICTIMIZATION WERE
SIMILAR BETWEEN BLACK AND WHITE
WOMEN BUT SIGNIFICANT
DIFFERENCES WERE SEEN WHEN
COMPARING PREGNANCY RELATED
HOMICIDE SUCH THAT BLACK WOMEN
HAD PREGNANCY ASSOCIATE THE
RAPES MORE THAN THREE TIMES
HIGHER THAN RATES IN HISPANIC
AND WHITE AND WE KNOW PARTNER
VIOLENCE CAN HAVE A DEFINITIVE
IMPACT ON THE BIRTHING PERSON
AND IN UTERO DEVELOPMENT LEADING
TO AFFECTING MILK PRODUCTION AND
ACCESS TO CARE THROUGHOUT AND
AFTER THE PREGNANCY.
TO ADDRESS THESE ISSUES ORW WITH
OUR PARTNERS AT NICHD AND THE
OFFICE OF THE DIRECTOR HAVE
DEVELOPED THE IMPLEMENTING AND
MATERNAL HEALTH AND PREGNANCY
OUTCOME VISION FOR EVERYONE TO
ADDRESS THE RISING RATES OF
PREGNANCY RELATED DEATH AND MA
TERRIBLE MORBIDITY.
THIS WORKSHOP CONTACTS SOME
AWARD RECIPIENTS AND ADDRESS THE
GAPS IN MATERNAL RESEARCH AND IT
SUPPORTS NOT ONLY THROUGH
RESEARCH AND BY CONNECTING
AWARDEES TO EACH OTHER AND NIH.
BEING ABLE TO TAP INTO THE
EXPERTISE OF ALL ALL THE
PARTICIPATING INSTITUTES AND
CENTERS PROVIDES AN OPPORTUNITY
TO CREATE A COMPREHENSIVE
APPROACH TO MATERNAL HEALTH
RESEARCH AND ADDRESSING MATERNAL
MORTALITY AND MORBIDITY AND
GRATEFUL TO THE I.C.s FOR THEIR
SUPPORT AND IT'S INCLUDE THE IN
THE STRATEGIC PLAN AND WE LOOK
ACROSS NIH IN COMPLIMENTARY
MANNER TO GENERATE THE EVIDENCE
THROUGH RIGOROUS RESEARCH AND
STUDYING THE IMPLEMENTATION OF
EVIDENCE-BASED INTERVENTIONS.
WORKSHOPS SUCH AS THIS ALLOW
SOLUTION ARE EVIDENCE-BASED AND
EFFECTIVE FOR ALL POPULATIONS.
NOW I'D LIKE TO PASS THE MIC TO
DR. BIANCHI.
>> THANK YOU FOR GIVING US THE
BROAD FRAMEWORK.
THIS IS YOUR LAST SLIDE.
I WANTED TO TAKE THAT BROAD
FRAMEWORK AND GIVE YOU
HISTORICAL BACKGROUND AND PLACE
THE IMPROVE INITIATIVE INTO THE
CONTEXT OF TODAY'S WORKSHOP TO
TRACE THE BEGINNINGS OF IMPROVE
TO A MEETING DR. PEREZ-STABLE
AND DR. GIBBONS AND I HAD WITH
THE BLACK MATERNAL HEALTH CAUCUS
EVENT.
AND THAT WAS HELD INTERESTINGLY
JUST PRIOR TO THE PANDEMIC AND
WAS A MEMORABLE MEETING IT WAS
WELL ATTENDED AND AT 7:30 IN THE
MORNING AND WE WERE TAKEN TO
TASK AND ASKED TO DO MORE IN
TERMS OF COORDINATING EFFORTS
AND RESEARCH AND MEMBERS OF
CONGRESS WERE DEEPLY CONCERN
ABOUT THE HEALTH DISPARITIES IN
MATERNAL HEALTH.
COMING FROM THAT, WE ESTABLISHED
A TASK FORCE THAT HAS GROWN OVER
TIME AND WE'LL BE ACKNOWLEDGING
MANY OF THE MEMBERS OF THE TASK
FORCE THAT CONTRIBUTED TO THE
OVERALL VISION FOR THIS
INITIATIVE.
WE CAME UP WITH AN ACRONYM WHICH
YOU KNOW AS IMPROVE AND IT
INCLUDES BOTH FOUNDATIONAL
BIOLOGY AND BIO AND SOCIAL
RESEARCH.
FROM THE BEGINNING WE RECOGNIZED
WE NEEDED PARTNERSHIPS WITH THE
COMMUNITY.
WE NEEDED TO LISTEN TO THE
COMMUNITY.
WE NEEDED TO UNDERSTAND LOCAL
CULTURE TO HAVE EFFECTIVE
INTERVENTIONS.
SO THIS GRAPHIC WAS MEANT TO
SHOW WE WERE LOOKING BOTH AT
WILL BIOMARKERS AS WELL AS
DEMOGRAPHIC ISSUES THAT WOULD
AFFECT RISK FOR MATERNAL
MORBIDITY AND MORALITY AS WELL
AS PLACING THE INDIVIDUAL
PREGNANT PERSON IN THE CONTEXT
OF THE COMMUNITY.
AS A RESULT OF THAT WE HAD
FUNDING AND INDIVIDUAL
INSTITUTES AND CENTERS ALSO
CONTRIBUTED MONEY THAT
EVENTUALLY BECAME A $7 MILLION
POOL WHICH SUPPORT THE FIRST
ROUND OF 36 PROJECTS.
THE TASK FORCE HAD MANY
DISCUSSIO
DISCUSSIONS ON HOW TO FOCUS THE
REQUEST FOR SUPPLEMENTS AND
CHOSE TO FOCUS ON HEALTH
DISPARITIES INCLUDING
CARDIOVASCULAR EVENTS AND THE
AFFECTS OF MENTAL HEALTH ON
MATERNAL MORTALITY AND MORBIDITY
AND WE'LL HEAR WITH THE AREAS OF
RESEARCH THE INITIAL GROUP OF
AWARDEE
AWARDEES FOCUSSED ON WITH
HEMORRHAGE AND MATERNAL HEALTH
AND WE'RE EXCITED TO HEAR WHAT
YOU'VE DONE IN THE PAST YEAR.
MOVING FORWARD WE DID NOT HAVE A
DEDICATED POOL OF FUNDING
BECAUSE OF THE GREAT INTEREST IN
MATERNAL HEALTH AS WELL AS
MATERNAL HEALTH AGAINST THE
BACKGROUND OF BOTH THE PANDEMIC
AND EVENTS OF 2020 DEMONSTRATING
THE AFFECTS OF STRUCTURAL RACISM
ON MATERNAL HEALTH AND IT WAS
DIFFERENT ON 2021 AND BECAUSE OF
OUR SUCCESS IN GETTING EXCELLENT
APPLICANTS TO THE FIRST ROUND OF
SUPPLEMENTS WE WERE ABLE TO
SCOMBIEN FUNDING FOR BOTH THE
OFFICE OF THE DIRECTOR
AND AND INSTITUTES AND CENTERS
AND DOUBLE FUNDING FOR A SMALLER
NUMBER OF PROJECTS BUT WE WERE
ABLE TO GIVE MORE MONEY TO EACH
INDIVIDUAL PROJECT AND WE HOPE
TO HEAR FROM THE 2021 GRANTEES
IN THE NEAR FUTURE.
BECAUSE WE WERE ONLY FUNDING IN
TERMS OF SUPPLEMENTS, THERE IS
AN IMPLICIT BIAS IN TERMS OF
USING SUPPLEMENTS AND ONLY ABLE
TO GIVE ADDITIONAL MONEY TO
PEOPLE WHO ALREADY ARE GRANTEES.
THAT IN A SENSE BIAS AGAINST
PEOPLE WHO MAY HAVE A DIFFERENT
PERSPECTIVE.
WITH THE SUPPORT OF CONGRESS WE
WERE IEABLE TO BRING THE MORE
SUSTAINED FUNDING AND THAT GOT
THROUGH TO THE PROPOSED
PRESIDENT'S BUDGET WHICH SETS
ASIDE $30 MILLION AS A TRANS-NIH
BUDGET FOR IMPROVE AND MOST
IMPORTANTLY THAT WOULD PROVIDE
SUSTAINABILITY AND WOULD ALLOW
US TO GO INTO MECHANISMS OTHER
THAN SUPPLEMENTAL FUNDING.
AS YOU KNOW, WE STILL DON'T HAVE
AN NATIONAL BUDGET FOR FISCAL
'22 AND OPERATING UNDER A
CONTINUING RESOLUTION WHERE WE
CAN'T INCREASE FUNDING FOR
ANYTHING UNTIL WE HAVE A BUDGET
BUT ARE EXPECTING TO HAVE A
BUDGET, HOPEFULLY, AND PREPARED
TO MOVE FORWARD IF AND WHEN WE
DO GET A BUDGET AFTER THE MARCH
11 DEADLINE.
YOU CAN SEE THE AMOUNT OF PEOPLE
WE'VE BEEN ABLE TO INCLUDE THE
PERSPECTIVES OF DIFFERENT NIH
STAFF MEMBERS WITH DIFFERENT
AREAS OF EXPERTISE.
JUST LOOK AT THE INSTITUTES AND
CENTERS THAT ARE REPRESENTED
HERE AND SEE THIS IS TRULY TRANS
NIH EFFORT AND WOULD LIKE TO
THANK THE ACTIVE PARTICIPATION
AND ENGAGEMENT OF EVERYONE ON
THE LIST AS WELL AS OTHERS.
IN ADDITION THE NAME I DON'T SEE
IS DR. ACLAND AND SHE WILL CLOSE
OUT THE CONFERENCE AT THE END OF
THE DAY.
WITH THAT I'LL HAND IT OVER AND
COURTNEY IS SMILING AND I'M
GOING TO HAND OVER THE VIRTUAL
MIC TO OUR MODERATOR.
>> THANK YOU, EVERYONE.
I'M FROM NHLBI THE SENIOR
ADVISER FOR WOMEN'S HEALTH AND
ASSOCIATE DIRECTOR FOR
PREVENTION AND POPULATION
SCIENCES IN OUR DIVISION OF
CARDIOVASCULAR SCIENCES IT'S MY
PLEASURE TO MODERATE THE SESSION
ON CARDIOVASCULAR RISK AND
PREECLAMPSIA.
AND OUR FIRST SPEAKER WILL BE
SPEAKING ON A COMORBIDITY
SCREENING TOOL TO PREDICT
COMORBIDI
COMORBIDITY.
WHEN YOU'RE AT THE NINE-MINUTE
MARK I'LL PROBABLY INTERRUPT AND
LET YOU KNOW YOU HAVE ONE MINUTE
REMAINING TO SAVE FIVE MINUTES
OF Q&A FOR THE AUDIENCE AND USE
THE ZOOM FUNCTION TO TYPE IN
YOUR QUESTIONS.
I'LL PASS THE MIC ON TO YOU.
>> THANKS SO MUCH FOR THE
OPPORTUNITY AND TO TELL YOU
ABOUT THE PROJECT TODAY.
AS WE ALL JUST HEARD THE RATES
OF PREGNANCY RELATED MORTALITY
IN THE UNITED STATES HAVE BEEN
INCREASING AND THAT I THINK WILL
CONTINUE TO BE TRUE AS WE LOOK
AT HOW MANY DEATHS THERE'S BEEN
IN ADDITION TO OUR BASELINE FROM
COVID-19 OVER THE PAST TWO
YEARS.
MORE THAN 60% ARE PREVENTIBLE SO
HOW CAN WE IDENTIFY AT RISK
PATIENTS EARLIER TOE TAKE
MEASURES TO DECREASE MORTALITY
AND MORBIDITY.
ONE SUCH PUBLIC HEALTH AT
BRIGHAM'S HOSPITAL WAS DESIGNED
BY DR. EASTER AND ORIGINALLY THE
MATERNAL COMORBIDITY INDEX WAS
USED AS A TOOL FOR GIVING ONE
NUMBER TO PREDICT MATERNAL
COMORBIDITIES WHEN LOOKING AT
VARIOUS OUTCOMES IN PREGNANCY
FROM LARGE DATABASES WHICH
DR. BATEMAN HAS PUBLISHED AND
DR. EASTER WORKING TOGETHER WITH
DR. BATEMAN AND SEVERAL OTHER
COLLABORATORS HERE AT BRIGHAM
AND WOMEN'S HOSPITAL THOUGHT
THEY CAN TAKE THE COOL AND USE
IT IN CLINICAL CARE TO PREDICT
WHO WAS AT RISK AND ADDED
ADDITIONAL FEATURES WHO WERE NOT
POSSIBLE PREVIOUSLY INCLUDING
THE DELIVERY OF PLACENTAL
ABNORMALITIE
ABNORMALITIES.
WHAT YOU SEE IS THE SCORES AND
THE FEATURES INCLUDED IN THE
OBCMI.
THEY RANGE FROM PREGNANCY
CONDITIONS TO MATERNAL
COMORBIDITIES AND AGE SUBSTANCE
USE AND BODY MASS INDEX.
WHAT DR. EASTER AND COLLEAGUES
FOUND INDEED THE OB-CMI DID
PREDICT SEVERE MATERNAL
MORBIDITY AT DELIVERY AND THOSE
WHAT HAD A SCORE OF 0 HAD A
LOWER CHANCE AND THOSE WITH 9 OR
GREATER HAD ALMOST A 20% CHANCE
OF SEEING MATERNAL MORBIDITY AND
HEMORRHAGE WAS THE MOST COMMON
REASON AT DELIVERY AND USED THE
OBSTETRIC CARE CONSENSUS
DOCUMENT YOU CAN READ MORE
ABOUT.
SO LOOKING AT THIS DATA HERE AT
BRIGHAM AND WOMEN'S HOME WE
THOUGHT WE COULD ENHANCE THE
TOOL OF THE OB-CMI BY
INTEGRATING INTO THE BIO BANK
CALLED LIFE COACH.
IT'S BEEN AT THE HOSPITAL SINCE
2006 AND COLLECTED MORE THAN
5,000 PREGNANCY TO DATE.
IT ENROLLS ALL COMERS AND ASKS
QUESTIONAIRES.
THIS SAY RICH RESOURCE WITH MANY
BIOLOGIC MEASURES AS WELL AS
CLINICAL DATA FOR IMPLEMENTATION
AND INFORMATION A TOOL SUCH AS
THIS.
THE MAIN QUESTIONS WE AIM IT
ANSWER WERE CAN THE OB-CMI BE
USED AT THE INITIATION OF PRE
NATAL CARE AND WHAT CAN BE
INTEGRATED IN TO ENHANCE
PREDICTIVE CAPABILITIES AND CAN
GENETIC AND OTHER PREDICTORS OF
PREECLAMPSIA A DRIVER OF THE
OB-CMI ENHANCE THE RISK
PREDICTION BEYOND THE OB-CMI.
SO FOR THIS PROJECT I'VE BEEN
WORKING WITH AMAZING MEDICAL
STUDENTS TOOK THE OB-CMI AT THE
PRESENTATION TO CARE AND
DELIVERY AND WE'RE IN THE
PROCESS OF IDENTIFYING ALL THE
CASES AND HAVE DONE THIS BACK TO
2018 AND WE'RE INTEGRATING IT
WITH OTHER FACTORS IN LIFE CODES
TO SEE WHAT FACTORS INFLUENCE
THIS PREDICTION MODEL.
AS YOU SEE HERE THE FACTORS
INCLUDED IN THE OB-CMI FOR THEIR
PREVALENCE IN OUR LIFE CODES
POPULATION ARE LISTED HERE AND
I'LL POINT OUT 16% OF OUR
PATIENTS HAVE SOME TYPE OF
HYPERTENSION OR PREECLAMPSIA.
THERE'S A POPULATION AND
SIGNIFICANT CARDIAC POPULATION
AS WELL AS A SIGNIFICANTLY OLDER
POPULATION OF DELIVERIES WHICH
REFLECTS WHAT WE SEE IN BOSTON
AND 10% OF PROJECT OBESE BEYOND
40.
WE FOUND THEY DID REFLECT THE
PILOT AT BRIGHAM AND OB-CMI WAS
ASSOCIATED WHERE INDIVIDUALS
WITH A GREATER THAN 9 OB-CMI HAS
HAVING A MORE THAN 20% RISK AND
REPLICATE WHAT'D HAD BEEN SEEN
IN THE PAPER AND THERE WERE
CORRELATION.
SOMETHING INTERESTING WE FOUND
WHEN WE WERE ABLE TO LOOK AT WHO
HAD DELIVERY AND LOOK AT THEIR
OB-CMI SCORES FROM THE
AMBULATORY PERIOD IS WHAT WE SAW
IS PEOPLE WHO EXPERIENCED SMM
HAD DELIVERY HAD AN INCREASE IN
THEIR OB-CMI FROM THEIR
INITIATION OF PRE NATAAL CARE
AND SHOWS HOW CHANGES FROM
PREGNANCY FROM THE TIME OF
INITIATION OF CARE TO DELIVERY
ARE AN IMPORTANT COMPONENT OF
ASSESSING WHO IS AT RISK AND WAS
DRIVEN BY THE DEVELOPMENT OF
PREECLAMPSIA AND GESTATIONAL
DIABETES, INTERESTINGLY, BMI
GREATER THAN 40.
PEOPLE WHO CROSSED INTO THAT
CATEGORY HAD AN INCREASED RISK
OF MORBIDITY AND PLACENTAL
DISORDERS.
HOW DO OTHER FACTORS RELATE TO
THE OB-CMI.
THIS IS SOMETHING WE'RE JUST
BEGINNING TO EXPLORE WITH THE
NEW DATA SET AND INTERESTINGLY
WHEN WE LOOK ACROSS MATERNAL
RACE, ETHNICITY, INSURANCE TYPE
AND LEVEL OF EDUCATION AND FOR
INDIVIDUALS WITH AN OB-CMI OF 5
OR GREATER IT'S REFLECTED ACROSS
ALL POPULATIONS OF THESE
CATEGORIES AND SO INDIVIDUALS
WITH A HIGH OB-CMI ARE NOT
CONCENTRATED IN ANY INSURANCE
TYPE GROUP OR PARTICULAR LEVEL
OF EDUCATION OR CONCEPTION TYPE.
IT AFFECTS ALL INDIVIDUALS
THROUGHOUT THESE CATEGORIES.
WHAT WE DO TAKING FORWARD THE
DATA IN OUR RICH LIFE CODES
POPULATION IS TO UNDERSTAND
WHETHER GENETIC AND BIOLOGIC
DISORDERS ENHANCE THE RISK OF
SEVERE MATERNAL MORBIDITY.
ONE OF THE BIGGEST CHANGES AND
WITH THE HIGHEST NUMBER OF
POINTS GIVEN TO PREDICTION DUE
TO THIS IS PREE -- PREECLAMPSIA
AND TO UNDERSTAND WHO WILL
PREDICT THAT OUTCOME ARE VERY
IMPORTANT TO UNDERSTANDING WHO
IS AT RISK FOR SMM.
SO IN A JOINT OR COLLABORATIVE
OR PARALLEL PROJECT, WE HAVE A
TOP MED AWARD THAT INCLUDES LIFE
CODES IN A PROJECT CALLED THE
BOSTON COLOMBIA COLLABORATIVE
AND WE TAKE IN THE CODES AND TOP
MED SAY TRANS OMICS OR PRECISION
MEDICINE PROJECT BY THE NHLBI
THAT START IN 2014 WITH MANY
STUDIES AND IT WAS THE FIRST
YEAR ANY PREGNANCY COHORT HAD
BEEN INCLUDED SO OUR PROJECT
JOINED WITH THE NEW MOMS TO BE
STUDY IN THAT YEAR.
WE UNDER GO GENOME SEQUENCING
AND INCLUDES THE CASES AND LIFE
CODES AND WE'LL HAVE GENETIC
DATA AS WELL AS OTHER OMIC DATA
TO INTEGRATE CLOSELY WITH THE
MEASURES OF COMORBIDITY TO
DETERMINE OTHER PREDICTORS THAT
CAN AUGMENT OUR PREDICTION OF
SEVERE MATERNAL MORBIDITY AT
DELIVERY.
IN VIM, IT'S A USEFUL TOOL FOR
UNDERSTANDING DELIVERY AND THE
CHANGE TO DELIVERY IS IMPORTANT.
THIS OCCURS ACROSS ALL SOCIO
DEMOGRAPHIC CATEGORIES AND HOW
OTHER FACTORS INTEGRATE IS AN
IMPORTANT AREA OF ONGOING WORK
IN OUR COHORT.
AND THERE'S MANY PEOPLE TO THANK
ACROSS BWH AND ALL THE FUNDERS
INCLUDING THE NHLBI AND
PREECLAMPSIA FOUNDATION AND
MICAYLA FLORES.
>> IF ANY PANELISTS WOULD LIKE
TO ASK A QUESTION, RAISE YOUR
HAND AND I'LL CALL ON YOU AND I
HAVE ONE QUESTION TO START US
OFF.
I WAS WONDERING IF YOU CAN TELL
US THE DEMOGRAPHICS OF THE LIFE
CODES AND THE MINORITY
REPRESENTATION GIVEN THEIR HIGH
RISK OF SMM AND MORTALITY.
THE QUESTION TOUCHES ON
GENERALIZABILITY OF YOUR
FINDINGS.
>> THANK YOU.
>> OUR LIFE CODES POPULATION IS
ABOUT 20% WHITE AND 15% BLACK
AND 15% ASIA AND 15% HISPANIC.
>> THANK YOU.
VERY DIVERSE.
WONDERFUL TO HEAR.
I DO NOT SEE HANDS UP OR ANY
OTHER QUESTIONS SO I'LL ASK ONE.
AS YOU KNOW AND YOU'LL HEAR FROM
SEVERAL SPEAKERS OF THE SESSION,
MATERNAL MORBIDITY EXPANDS TO
THE POSTPARTUM PERIOD.
DO YOU HAVE FINDINGS IN YOUR
ANALYSES OR DO YOU PLAN TO DO
ADDITIONAL ANALYSES ON THE
PREDICTABILITY OF THE OB-CMI
INTO THE POSTPARTUM CARE?
>> WHEN WE'RE ASCERTAINING OUR
CASES OF SMM WE'LL BE USING
BILLING CODES FROM OUR
INSTITUTION TO IDENTIFY SEVERE
CASES AND LONGER TERM WE AIM TO
FOLLOW CARDIOVASCULAR EVENTS AND
THEIR RELATIONSHIP TO THIS SCORE
AND THE LIFE CODES BIO BANK IS
WELL SUITED TO DO THAT.
>> THAT'S WONDERFUL TO HEAR AND
NOT JUST THE POSTPARTUM PERIOD
BUT YEARS LATER WHEN WE HEAR IT
CAN IMPACT WHAT HAPPENS TO OUR
HEALTH DOWN THE LINE.
THAT'S WONDERFUL TO HEAR.
THANK YOU.
I SEE A QUESTION HERE WHAT DO
YOU HOPE TO LEARN FROM THE
GENETIC DATA OR HOW WILL IT BE
USED IN PREDICTION MODELS?
>> THOSE ARE GOOD QUESTIONS.
I THINK IT WILL TAKE SOME
EXPLORATION.
I CAN TELL YOU FROM OTHER
STUDIES ONGOING ABOUT THE
GENETICS OF PRE-ECLAMPSIA AND
WHAT WE'VE SEEN IS MOTHERS WHO
HAVE A GENETIC PRE DISPOSITION
TO HYPERTENSION ARE AT HIGHER
RISK OF PREECLAMPSIA.
UNDERSTANDING THE SPECIFIC
BIOLOGIC PATHWAYS INVOLVED FOR
INDIVIDUAL WHO'S HAVE THAT
GENETIC PRE-DISPOSITION AND
INTEGRATING THAT INTO CARE IS A
WAY TO UNDERSTAND THE PORTION OF
THE RISK THAT'S PRESENT.
>> I DON'T SEE ANY MORE
QUESTIONS SO THANK YOU,
DR. GRAY.
OUR NEXT SPEAKER IS FROM KAISER
PERMANENTE NORTH CALIFORNIA.
THE TITLE OF HER TALK IS SEVERE
MATERNAL MORBIDITY DURING
DELIVERY HOSPITALIZATION AND
RACIAL AND ETHNIC DISPARITIES
RELATED TO CHRONIC HYPER TENSION
AND PREECLAMPSIA.
WHEN YOU'RE AT THE NINE MINUTE
MARK AGAIN IF I SEE YOU'RE NOT
CLOSE TO THE FINAL SLIDE I MAY
INTERRUPT.
>> THANK YOU VERY MUCH FOR THE
INVITATION TO PRESENT THIS
ONGOING PROJECT WORK WITH A
PARTICULAR FOCUS ON RACIAL AND
ETHNIC DISPARITIES RELATED TO
CHRONIC HYPER TENSION AND PREEE
PREECLAMPSIA AND IT'S THE
LEADING RISK FACTOR FOR SEVERE
MATERNAL MORBIDITY AND MORE FOR
BLACK WOMEN VERSUS WHITE WOMEN
WHICH TRY CONTRIBUTE TO THE
RACIAL AND ETHNIC DISPARITIES IN
MATERNAL HEALTH OUTCOMES.
A RECENT PUBLICATION IN 2021 BY
CHAN ET AL HAS A COHORT OF OVER
2 MILLION U.S. WOMEN WHO
DELIVERED BETWEEN 2010 AND 2014.
THESE ARE MEDICAID DATA AND
COMMERCIAL CLAIM DATA AND THE
POPULATION HAD A RATE OF 2.2%
AND THAT'S A VERY DIVERSE RACIAL
AND ETHNIC POPULATION WHILE THE
COMMERCIAL INSURANCE POPULATION
ESTIMATED SMM AT THE RATE OF
1.7% BUT THERE WAS NO DATA ON
RACE AND ETHNICITY IN THE
SAMPLE.
THE STUDY OBJECTIVES ARE TO
EVALUATE THE ROLE OF PRIOR
CHRONIC HYPER TENSION AND
HYPERTENSIVE DISORDERS TO
MATERNAL MORBIDITY AND
UNDERSTAND THE DISPARITIES.
THE SECOND OBJECTIVE IS TO
EVALUATE IDENTIFY THE JOINT
ASSOCIATION OF PRE EXISTING
HYPER TENSION AND PREECLAMPSIA
CONSULTING FOR SOCIAL FACTORS
AND WE'RE USING ELECTRONIC
HEALTH RECORDS FROM THE KAISER
PERMANENTE POPULATION.
AND THE WOMEN WERE 18 TO 45
YEARS OF AGE AND CARE WAS 14
WEEKS, DELIVERY AT HOSPITALS AND
LEFT IN THE STARTING SAMPLE
PEOPLE WITH DIABETES OR CHRONIC
HYPER TENSION BUT TOOK OUT OTHER
SERIOUS DISEASES.
AND THE AUTOMATION DOESN'T SEEM
TO BE MOVING THE SLIDE FORWARD.
WE EXCLUDED WOMEN WITH PRYOR
CHRONIC HYPERTENSION.
WE TOOK THEM OUT AS A SEPARATE
SAMPLE AND THAT'S 5.1% AND THAT
LEFT US ABOUT 254,000 WOMEN WITH
NO HYPER TENSION AND INCLUDED
THOSE WITH A HISTORY OF
PREECLAMPSIA AND LEFT WITH A
RISK SAMPLE WITH NO HISTORY OF
PREECLAMPSIA AND OUR TOTAL
SAMPLE SIZE IS 263,000 WOMEN IN
COMBINING THE LORE RISK SAMPLE
AND THIS SLIDE SHOWS YOU THE
TOTAL SAMPLE OF OUR LOW RISK
PLUS CHRONIC HYPER TENSION AND
THE RACIAL ETHNIC DISTRIBUTION
WHICH IS 37% WHITE AND 26%
HISPANIC AND 1% NATIVE HAWAIIAN,
PACIFIC ISLANDERS AND A SMALL
NUMBER OF AMERICAN AND ALASKAN
NATIVE AND THE DISTRIBUTION BY
RACE ETHNICITY CHANGES DEPENDING
ON WHETHER THE WOMEN WERE IN THE
LOW-RISK, NO-HYPER TENSIVE
DISORDER SAMPLES AND REPRESENTED
OF THE LARGER SAMPLE AND MAKES
UP THE VAST MAJORITY AND PRIOR
CHRONIC HYPER TENSION IS
DISTRIBUTED DIFFERENTIALLY WITH
DOUBLING OF THE PROPORTION OF
BLACK WOMEN, 14% WHO HAVE
CHRONIC HYPER TENSION AND FEWER
ASIAN WOMEN AND THE OTHER RACIAL
ETHNIC GROUP WERE STABLE IN IT
TERMS OF THE RACIAL ETHNIC
DISTRIBUTION.
THESE ARE SOME OF THE KEY RISK
FACTORS, AGE AND BMI IN THE
POPULATION.
YOU CAN SEE THE BLACK, HISPANIC
AND NATIVE HAWAIIAN PACIFIC
ISLANDERS GROUPS ARE HIGHER
PROPORTION UNDER AGE 30.
THEY'RE SLIGHTLY YOUNGER AND THE
BMI GROUPS ARE DIFFERENCES BY
RACE ETHNICITY WITH THE SAME
GROUPS HAVING A HIGHER
PROPORTION OF WOMEN WITH CLASS
1, 2 OR 3 OBESITY.
MORE THAN A THIRD OF THE NATIVE
HAWAIIANS AND BLACK WOMEN AND
THOSE ARE RISK FACTORS FOR HYPER
TENSION AND PRE-ECLAMPSIA AND WE
LOOKED AT THE RISK FACTOR IN THE
SAME SUB GROUPS.
WE DID ESTIMATE SEVERE MATERNAL
MORBIDITY AND WHAT THE
PROPORTION WOULD BE IN OUR
PARTICULAR SAMPLE AND THESE ARE
AND THIS IS COMING FROM
ELECTRONIC HEALTH RECORDS FROM
THE ENTIRE PREGNANCY AND DURING
THE DELIVERY AND
HOSPITALIZATION.
IN OUR POPULATION THERE ARE 5589
WOMEN WITH THE DISORDER OR 2.1%.
OF OUR SAMPLE AND THIS SHOWS THE
DISTRIBUTION OF NO PRIOR CHRONIC
HYPER TENSION AND PRIOR CHRONIC
HYPER TENSION AND SEE THE HIGHER
RATES OF MATERNAL MORBIDITY WITH
THOSE WITH PRIOR HYPER TENSION
AND HIGHER RATES AMONG BLACK,
ASIAN AND HISPANIC COMPARED TO
WHITE WOMEN WITH A HIGH
PROPORTION AMONG THE NATIVE
HAWAIIAN PACIFIC ISLANDER GROUP.
THIS SLIDE SHOWS THE FIVE SUB
GROUPS OF LOOKING WITHIN WOMEN
WHO HAD NO PRIOR CHRONIC HYPER
TENSION BUT DEVELOPED
HYPERTENSIVE DISORDERS SUCH AS
GESTATIONAL HYPERTENSION IN THE
BLUE BARS AND THE RED SHOWING
THOSE WITH CHRONIC HYPER TENSION
AND HAD NO PREECLAMPSIA AND
THOSE WHO DID AND THIS SHOWS
STATISTICAL DIFFERENCES WITHIN
THE GROUPS OF THE LIGHT BARS AND
THE COMPARISONS OF EACH SUB
GROUP TO WHITE WOMEN AND THE
LOWEST RISK ARE IN THE WHITE
WOMEN OVERALL BUT YOU SEE THESE
DISTINCT HIGHER PROPORTION OF
SEVERE MATERNAL MORBIDITY IN
WOMEN WITH NO HYPER TENSION WHO
DEVELOPED PRE-ECLAMPSIA AND
THOSE WHO DID WHO DEVELOP
PRE-ECLAMPSIA AND THEY HAVE
HIGHER RATES THAN THE WHITE
WOMEN AND IN PARTICULAR FOR THE
ASIANS AND SIMILAR HIGHER RATES
OF SEVERE MATERNAL MORBIDITY
WHEN WOMEN DEVELOP PRE-ECLAMPSIA
AND THESE ARE THE PROPORTIONS OF
WOMEN WHO DEVELOPED UPPER
IMPOSED PRE-ECLAMPSIA AND WE
HAVE OVER 13,000 WOMEN IN OUR
SAMPLE WITH PRIOR CHRONIC HYPER
TENSION AND WE SEE HIGHER
PROPORTION OF PRE-ECLAMPSIA
COMPARED TO THE WHITE WOMEN AND
THOSE WITH THE NATIVE HAWAIIAN
PACIFIC ISLANDER AND THE LOW
RISK GROUP WITH NO HISTORY OF
PRRNGS
AND THE GESTATIONAL HYPER
TENSION WITH SIGNIFICANT
VARIATION IN SOME LOWER RISK IN
THE SAME SUB GROUPS SUCH AS
ASIANS AND HISPANICS.
SO THIS IS THE MODELLING THAT'S
THE FINAL ANALYSIS OF THESE RISK
FACTORS WE MENTIONED ALONG WITH
A FEW OTHERS INCLUDING SMOKING,
DIABETES STATUS AND NEIGHBORHOOD
DEPRIVATION INDEX WHICH I SHOWED
YOU WE ARE SHOWING THE ADJUSTED
ODDS RATIOS OF MATERNAL
MORBIDITY AND THE WHITE GROUP IS
THE REFERENCE GROUP FOR ALL THE
GRAPHS AND YOU CAN SEE THE WOMEN
WHO DEVELOPED PRE-ECLAMPSIA HAVE
SIMILAR SIX TO SEVENFOLD HIGHER
ODDS OF SEVERE MATERNAL
MORBIDITY AT HOSPITALIZATION
COMPARED TO THE WHITE GROUP.
THAT IS CONSISTENT ACROSS ALL
THE RACIAL AND ETHNIC GROUPS
WITH SOME HIGHER RATES I
HIGHLIGHTED FOR BLACK WOMEN AND
SUBSTANTIALLY HIGHER ODDS OF
SEVERE MATERNAL MORBIDITY AND A
STAND OUT FOR THE NATIVE
HAWAIIAN PACIFIC ISLANDER OF A
10 TO 14 HIGHER ODDS OF THIS
SEVERE MATERNAL MORBIDITY.
WHERE YOU SEE SOMEWHAT HIGHER
FOR THE OTHER CONDITIONS
COMBINED WITH AND WITHOUT
CHRONIC HYPER TENSION AND
PREECLAMPSIA DRIVING THE
INCREASED RISK OF SEVERE
MATERNAL MORBIDITY.
THE CONCLUSIONS FROM THE
ANALYSIS THUS FAR ARE RELATED TO
HIGHER RISK OF SMM DURING
DELIVERY HOSPITALIZATION,
PREECLAMPSIA SHOWED COMPARABLE
HIGH RATES OF MORBIDITY WITH
GROUPS WITH PRIOR HYPER TENSION
AND WITHOUT HIRE TENSION AND
HIGHEST RATES OF MORBIDITY WERE
FOUND AMONG PACIFIC ISLANDER
INDIVIDUALS FOLLOWED BY BLACK,
ASIAN AND HISPANIC GROUPS
INDEPENDENT OF AGE, OBESITY,
SMOKING AND SOCIAL FACTORS AND
MODIFICATION OF SMM RISK FACTORS
ARE CRUCIAL TO ELIMINATING
MATERNAL HEALTH DISPARITIES.
I'D LIKE TO ACKNOWLEDGE OUR
STUDY TEAM.
THIS IS A COLLABORATIVE EFFORT
AND ACKNOWLEDGE THE FUNDING
SOURCE FOR THE PRIMARY R01 AND
WE HAVE A FOUNDATIONAL PAPER
JUST PUBLISHED IN HYPER TENSION
THIS MONTH, FEBRUARY 2022 THAT
LOOKS AT OUR BLOOD PRESSURE
PATTERNS.
THANK YOU FOR YOUR ATTENTION.
>> WE'RE OPEN FOR Q&A.
AS AN ASIAN AMERICAN I SEE THE
NUMBER YOU HAVE IN YOUR
ANALYSES.
WE'RE OFTEN UNDER STUDIED IN
RESEARCH.
AND DO YOU HAVE THE ABILITY TO
SEPARATE THE DATA TO
DISAGGREGATE THEM BY THE
DIFFERENT ASIAN AMERICAN
SUBGROUPS?
>> THAT'S OUR NEXT STEP.
I'M GLAD YOU ASKED THAT
QUESTION.
IT'S VERY IMPORTANT.
WE HAVE SOME ABILITY.
WE WANT TO VALIDATE THE
DIFFERENT GROUPINGS.
WE HAVE PUBLISHED IN THE PAST ON
FILIPINOS IN TERMS OF THEIR
HIGHER RISK OF CARDIO MYOPATHY
IN THE KAISER PERMANENTE DATA.
WE'LL HAVE THE GROUPS SPECIFY.
YOUR POINT IS WELL TAKEN.
>> YOU MENTIONED YOU CONTROL FOR
AGE, OBESITY AND SMOKE AND
FACTORS IN YOUR REGRESSION.
CAN YOU EXPAND ON WHAT VARIABLES
ARE THE SOCIAL FACTORS YOU
CONTROLLED FOR AND WHY THE
EXTREME HIGH ODDS AMONG THE
PACIFIC ISLANDERS AND I THINK
AMONG THE NH.
>> NATIVE HAWAIIAN PACIFIC
ISLANDER.
AND SO THERE ARE TWO PARTS TO
THIS QUESTION.
WHY ARE WE SEEING THE HIGHER
ODDS.
WE'RE NOT SURE.
WE DO KNOW THAT POPULATION HAS
HIGHER RATES OF OBESITY AND MORE
SEVERE OBESITY AND PERHAPS MORE
CHRONIC HYPER TENSION BUT
HAVEN'T LOOKED AT THEM
CAREFULLY.
I THINK WE HAVE A LOT OF TO
LEARN AND WE HAVE TO DETERMINE
THE IMPACT OF THE DELINQUENTAL
FACTORS, SOCIAL FACTORS AND
OTHER CULTURAL FACTORS AND
MONITORING.
I ALSO WANTED TO MENTION IN
TERMS OF CHRONIC HYPER TENSION,
WHEN YOU SAW PREECLAMPSIA WAS
COMBINED WITH OR WITHOUT CHRONIC
HYPERTENSION HAD THE HIGHEST
RATES OF SEVERE MATERNAL
MORBIDITY WE HAVE A REGIONAL
PERINATAL PROGRAM THAT MONITORS
BLOOD PRESSURE.
THIS IS ANOTHER AREA TO EXPLORE.
I THINK THIS IS THE FIRST STUDY
TO LOOK AT THIS CAREFULLY.
THE SOCIAL FACTORS YOU
MENTIONED.
RIGHT NOW WE HAVE THE
NEIGHBORHOOD DEPRIVATION INDEX
WHICH IS BASED ON CENSUS BLOCK
GEOCODING.
WE DO HAVE A TASK FORCE IN OUR
KAISER PERMANENTE SYSTEM LOOKING
TO MEASURE SOCIAL FACTORS IN
OBTAINING SOME OF THOSE FROM
ELECTRONIC HEALTH RECORDS.
MORE TO COME WE HOPE WITH BETTER
DEFINITION.
>> THANK YOU, DR. GUNDERSON AND
EVERYONE FOR YOUR CONTRIBUTIONS
TO THE Q&A.
WE'LL GO AHEAD AND MOVE ON TO
OUR NEXT SPEAKER WHICH IS
DR. MILLER FROM COLOMBIA
UNIVERSITY.
THE TITLE OF HER TALK IS
NEUROVASCULAR UNIT DYSFUNCTION
IN WOMEN WITH SEVERE
PRE-ECLAMPSIA.
>> THANK YOU FOR INVITING ME AND
IT'S EXCITING TO SEE THIS KIND
OF RESEARCH GOING ON.
I THINK I'M THE ONLY PUBLIC
HEALTH THAT CAME THROUGH NINDS.
AND THESE ARE STROKES OR OTHER
ACUTE CEREBRAL VASCULAR
CONDITIONS AND THEY ARE NOT
MILD.
MANY HAVE SEVERE MORBIDITY AND
PEOPLE ARE LEFT WITH SEVERE
DISABILITY AND TRAUMA AFTER AN
EVENT LIKE THIS.
HERE'S THE CAUSES OF MATERNAL
MORTALITY AND THEY SHOW A
CEREBRAL VASCULAR ACCIDENT
ACCOUNT FORD 8.2% OF MATERNAL
MORTALITY AND YOU SEE THIS OTHER
GROUP OF WOMEN WITH HIRE TENSIVE
DISORDERS OF PREGNANCY AND
WHAT'S NOT SHOWN HERE IS THAT IN
THIS GROUP WHERE THE UNDERLYING
CAUSE OF DEATH IS HYPER TENSIVE
DISORDER IN SOME CASES 70% OF
THE MECHANISM WAS INTERCEREBRAL
HEMORRHAGE A SEVERE AND DREADED
COMPLICATION OF PRE-ECLAMPSIA
AND ECLAMPSIA.
AND THIS WOMAN DEVELOPED SEVERE
HEADACHE AFTER HER DELIVERY AND
AROUND DAY TWO OR THREE SHE WAS
AFRICAN AMERICAN AND SOUGHT
MEDICAL TENSION AND WAS GIVEN
PAIN MEDICATION AND SENT HOME
AND PRESENTED ON POSTPARTUM DAY
8 WITH SEIZURE AND THIS IS AN
EXAMPLE OF THE POSTERIOR
ENCEPHALOPATHY AND YOU SEE THIS
IS VASAL PREDICTION WHICH IS
ANOTHER PART OF THE KIND OF
COMPLEX SYNDROME THAT WE SEE IN
THE POSTPARTUM PERIOD OF
PRE-ECLAMPSIA AND ECLAMPSIA AND
THE WORD REVERSIBLE IS IN BOTH
OF THOSE AND IT MAKES IT SOUND
LIKE IT'S NO BIG DEAL.
SOMETIMES IT'S REVERSIBLE.
SOMETIMES IT'S NOT.
THIS IS ANOTHER PATIENT THAT
PRESENTED WITH THE SAME
SITUATION AND ALSO DISMISSED AND
SENT HOME WITH MEDICATION WHEN
SHE PRESENTED WITH A SEVERE
HEADACHE AND THIS IS A SEVERE
HEMORRHAGE AND HERNIATION AND
ALSO HAD BAD VASO CONSTRICTION
AND THIS PERSON HAD A TERRIBLE
OUTCOME BUT DID NOT DIE.
SOW SHE WOULDN'T HAVE BEEN
COUNTED IN THE STATISTICS FOR
THIS BUT I REVIEWED OUR OWN
CASES AND FOUND THERE WAS THIS
PRE DOMINANCE IN THE FIRST
COUPLE OF WEEKS WE SAW THESE
COMPLICATIONS SO DEVASTATING.
I GOT INTERESTED IN THAT INITIAL
TWO WEEK PERIOD AND THOUGHT WHAT
IS GOING ON.
THAT'S ACTUALLY THE TOPIC OF MY
K23.
THIS FOR ME IS A SUPPLEMENT TO
MY K AWARD AND THAT IS REALLY A
PHYSIOLOGICAL-BASED STUDY AND
HAS AN IN VITRO COMPONENT
STUDYING THE AFFECTS MUCH
PRE-ECLAMPSIA ON THE
NEUROVASCULAR UNIT AND LOOK AT
BLOOD BRAIN BARRIER DYSFUNCTION
AND YEAR THREE OF MY K BUT THIS
SUPPLEMENT CAME ALONG AND A
THOUGHT WE DON'T HAVE TIME FOR
KNOW GET THROUGH MY WHOLE K AND
FIGURE IT ALL OUT.
WE NEED TO INTERVENE AND DO
SOMETHING TO TRY TO PREVENT
THIS.
SO THAT'S WHAT THE GOAL OF THE
IMPROVE SUPPLEMENT WAS FOR ME
WAS TO SAY OKAY EVEN IF WE DON'T
QUITE GET IT AND EVEN IF WE
DON'T FULLY UNDERSTAND THE
PHYSIOLOGICAL MECHANISMS
UNDERLYING THIS TERRIBLE
COMPLICATION, LET'S SEE WHAT WE
CAN DO TO PREVENT IT BECAUSE
MAYBE THERE'S THINGS WE CAN DO.
I WANTED TO DEVELOP A COUPLE
CLINICAL PROTOCOLS.
THE AIM ONE OF THE SUPPLEMENT
WAS TO LOOK AT WHAT DO
OBSTETRICS PROVIDERS KNOW ABOUT
NEUROLOGY AND WARNING SIGNS.
WHY DID THOSE TWO WOMEN GET SENT
AWAY WHEN THEY SHOULDN'T HAVE
AND THE SECOND PART IS CAN WE
COME UP WITH TOOLS LIKE WITH
SAFETY BUNDLES AND COULD WE COME
UP WITH SOMETHING TO PREVENT THE
EVENTS.
THIS IS FROM AN INTERNAL SURVEY
OF OUR PROVIDERS BUT WE FOUND
THAT BASICALLY PEOPLE ARE VERY
IN NEUROLOGY AND THERE WERE GAPS
IN KNOWLEDGE AMONG OBSTETRICIANS
AND EMERGENCY MEDICINE PROVIDERS
WHO WEREN'T ABLE TO IDENTIFY RED
FLAG FEATURES OF HEADACHE.
DIDN'T KNOW THE POSTPARTUM
PERIOD WERE THE HIGHEST RISK AND
WERE ENTHUSIASTIC ABOUT THE IDEA
YES, WE'D LIKE TO HAVE SOME
GUIDES, SOME PROTOCOLS TO HELP
US KNOW WHEN WE SHOULD GET
WORRIED.
I ENDED UP PARTNERING WITH AN
AMAZING ORGANIZATION FUNDED BY
HHRQ AND THEY DEVELOPING
MATERIALS FOR TREATMENT OF
MATERNAL CARDIAC ARREST.
I STARTED COLLABORATING WITH
THEM AND CAME UP WITH A WHOLE
SET OF EDUCATIONAL MATERIALS
SPECIFIC TO MATERNAL STROKE
PREVENTION AND TREATMENT.
AND THOSE ARE GOING TO BE
PUBLISHED IN THE FORM OF A
MANUAL A PRACTICAL GUIDE SO THIS
IS EXCITING AND I'M EXCITED AND
FOR AN EXAMPLE OF ONE OF THESE
TOOLS AND WE COULD PUBLISH THIS
AND CAME UP WITH THE MNEMONIC
CALLED SCAN ME WHICH IDENTIFIED
RED FLAG FEATURES OF HEADACHE
FOR PEOPLE WHO DON'T HAVE
TRAINING IN NEUROLOGY.
IT'S NOT EXACTLY EVIDENCE BASED
THOUGH WE GOT FEEDBACK FROM
EXPERTS BUT THIS STUFF THAT YOU
KNOW IF SOMEONE COMES IN WITH A
BAD HEADACHE AND HAS THESE
FEATURES YOU SHOULD AT LEAST
INVESTIGATE MORE OR WATCH THAT
PERSON CAREFULLY.
THEY MIGHT OR MIGHT NOT NEED
IMAGING BUT YOU CERTAINLY
SHOULDN'T SEND THEM HOME.
THAT'S THAT WAS A FUN
COLLABORATION THAT CAME FROM
THIS.
THE SECOND WAS MORE TECHNICAL.
I WANTED TO COME UP WITH A
LITTLE BIT MORE OF A BRAIN
FOCUSSED WAY TO IDENTIFY
PERFUSION PROBLEMS IN MATERNAL
BRAIN WHEN WOMEN WERE ACTUALLY
ADMITTED WITH POSTPARTUM
PRE-ECLAMPSIA OR EMERGENCY AND
TRY TO PILE THOUGH THE PROTOCOL.
I USED NEAR INFRARED
SPECTROSCOPY AND IT'S BEEN USED
MOSTLY IN THE O.R. OR ICU
SETTING BECAUSE IT REQUIRES IF
YOU WANT TO DO THIS IN THE
POPULATION YOU NEED THE PRESSURE
MONITORING WHICH AND THERE'S A
BLOOD PRESSURE MONITOR AND USING
THE SUPPLEMENT WE WERE ABLE TO
GET THE EQUIPMENT AND THIS
CONTRAPTION WAS FUN TO BUILD AND
STILL A WORK IN PROGRESS.
WE'RE ADDING PARTS HERE AND
THERE AND BASICALLY WE NEED A
PORTABLE MONITOR TO TAKE INTO
THE E.D. OR LABOR TRIAGE OR KEEP
IT BEDSIDE AND BE ABLE TO
UNDERSTAND WHAT'S GOING ON WITH
THE PERSON'S CEREBRAL
AUTOREGULATION IN THE MOMENT
WHICH CAN HAVE A BIG IMPACT ON
THE BLOOD PRESSURE MANAGEMENT.
WHAT WE DID WAS PUT THIS
TOGETHER AND TEST IT THE
FEASIBILITY AND ENROLLED SOME
WOMEN AND WE HAD THREE TO DATE
AND THEY GIVE FEEDBACK ON YOU
GOT TO MAKE IT DIFFERENT AND WE
CHANGE THE PROTOCOL SLIGHTLY AND
USUALLY WHEN PEOPLE HAVE THIS
KIND OF MONITORING THEY'RE
UNCONSCIOUS.
WE NEED TO ADAPT THE SETUP TO
ACCOMMODATE THE NEED OF
POSTPARTUM INDIVIDUALS NOT
FEELING WELL AT ALL.
WE DID THAT AND WE HAVE EXCITING
FUTURE DIRECTIONS COMING AND ALL
OF THIS IS KIND OF WRAPPED INTO
THE IDEA I HAVE ABOUT WHAT I
WOULD CALL NEUROOBSTETRICS.
SIMILAR TO CARDIO OBSTETRICS AND
IT'S A CROSS-DISCIPLINARY FIELD
GOING FROM BENCH AND THINGS LIKE
STUDYING BLOOD BRAIN BARRIER IN
PREGNANT AND POSTPARTUM PEOPLE
TO HEALTH AND MEDICAL EDUCATION
AND COLLABORATING AND BIO
ENGINEERING AND PUTTING TOGETHER
MACHINES AND THIS UNDER THE
UMBRELLA AND IT'S BEEN EXCITING
TO BE PART OF IT.
WITH THAT I WOULD LIKE TO THANK
ALL OF MY COLLABORATORS AND YOU
CAN SEE THEY COME FROM DIFFERENT
FIELD INCLUDING SOME ENGINEERS
WHO HAVE BEEN HELPING ME AND I
WOULD LIKE TO THANK MY PATIENTS.
SHE WAS GENEROUS TO SHARE HER
STORY ON FACEBOOK AS PART OF MY
HOSPITAL'S MATERNAL MORBIDITY
AND MORTALITY HEALTH INITIATIVE
AND YOU CAN SEE SHE HAD A
HEMORRHAGIC STROKE AND
INTRACEREBRAL HEMORRHAGE AND DID
WELL AND SURVIVED AND THIS IS
HER BABY.
>> THANK YOU, DR. MILLER.
WE HAVE A COUPLE MINUTES LEFT
FOR QUESTIONS.
PEOPLE CAN TYPE THEM IN I DON'T
SEE ANY AT THIS POINT SO I HAVE
A QUESTION.
DO YOU MIND WHAT TELLING US WHAT
MATERNAL OCIMETRY IS?
>> IT'S USED COMMONLY BY NEURAL
ANESTHESIOLOGISTS IN THE O.R.
AND IN NEURAL CRITICAL CARE.
PEOPLE ARE LIKE IN A COMA AND
GENERALLY PEOPLE WITH TRAUMATIC
BRAIN INJURY OR HEMORRHAGIC
STROKES AND CRITICAL ILLNESS AND
IT'S BASICALLY STICKERS ON YOUR
HEAD AND IT MONITORS SOMETHING
CALLED A TISSUE OXYGENATION
INDEX THE RATIO OF DE-OXYGENATED
HEMOGLOBIN AND A PROXY FOR
CEREBRAL BLOOD FLOW AND THERE'S
DIFFERENT WAYS TO MEASURE IT.
YOU CAN'T ALWAYS STICK THINGS IN
PEOPLE'S BRAINS ESPECIALLY WHEN
THEY'RE AWAKE AND IT'S
NON-INVASIVE IT'S NOT PERFECT
BUT REALLY EASY.
IT DOESN'T REQUIRE A LOT OF
EXPERTISE.
YOU JUST STICK THE STICKERS ON.
ONE OF OUR ADAPTIVE
INTERVENTIONS WAS TO MAKE A SOFT
SPECIAL HEAD BAND.
THE EEG GAUZE ON THE COMATOSE
PEOPLE BUT WITH POSTPARTUM
PEOPLE ARE UP AND TALKING AND
WANT TO LOOK NICE SO WE MADE A
FANCY HEAD BAND.
>> THERE'S A FOLLOW-UP QUESTION
ON THAT.
THE SKIN TONE IMPACT OF THE
CEREBRAL OCCIPITAL MEASURE.
>> IT DOES NOT.
THAT'S WHY IT'S NICE BECAUSE
IT'S VERY EASY AND OF COURSE
LIKE ALL THESE OTHER TERRIBLE
CONDITIONS THE STROKES AND ALL
THESE COMPLICATIONS
DISPROPORTIONATELY AFFECT PEOPLE
OF COLOR WHICH IS AN AIM WE NEED
OBJECTIVE AND CRITERIA TO HELP
PEOPLE MANAGE THIS AND PREVENT
THIS SO PEOPLE ARE NOT AT LEAST
TRY TO MITIGATE THE AFFECTS OF
THE UNCONSCIOUS BIASES SAYING
HON
HONEY, YOU'RE FINE, GET SLEEP
AND YOU'LL BE BETTER.
THIS IS WHAT WE WANT TO AVOID.
>> THANK YOU VERY MUCH
DR. MILLER.
SO MOVING ON TO OUR SPINAL
SPEAKER FOR THIS SESSION WHICH
FROM THE UNIVERSITY OF
PITTSBURGH.
HE TITLE IS PRECONCEPTION
CONTRIBUTORS TO MORBIDITY IN
BLACK AND WHITE WOMEN.
GO AHEAD.
>> THERE YOU GO.
WE ALL NEED TO BE PATIENT.
IF YOU CAN PUT IT IN SLIDE MODE.
>> THANK YOU.
YES, PATIENCE.
IT'S ONE OF THE MESSAGES.
SOME DAY I MAY LEARN THAT.
THANKS SO MUCH.
I FEEL HONORED TO BE HERE WITH
ALL YOU EVER AND TO BE SHARING
THIS MORNING PANEL WITH MANY OF
MY ESTEEMED COLLEAGUES MUCH HAS
BEEN SAID WITH THE DISPARITIES
IN THE DATA OF MATERNAL
MORTALITY AND I'LL TALK ABOUT
SEVERE MATERNAL MORBIDITY AND
THE PANEL ON THE BOTTOM OF THIS
SCREEN IS OUTDATED.
RATES OF SEVERE MATERNAL
MORBIDITY ARE STILL INCREASING
AND THERE'S PROFOUND RACIAL
DISPARITIES AND RATES ARE
INCREASING AT LEAST ACROSS ALL
RACE ETHNICITY GROUPS.
I'VE HIGHLIGHTED THESE ARE
CAUSES OF MATERNAL DEATHS.
WE'VE SEEN THIS SLIDE A COUPLE
TIMES ALREADY THIS MORNING AND
HIGHLIGHTED THOSE THAT COULD BE
THOUGHT TO BE CARDIOVASCULAR
RELATED INCLUDING IN THE DASHED
LINES THOSE THAT MAY BE RELATED
TO OTHER CARDIOVASCULAR RISK
FACTORS LIKE OBESITY AND
HEMORRHAGE AND EMBOLISM WE KNOW
ARE MORE COMMON IN WOMEN WITH
PRE-PREGNANCY OBESITY.
THE PURPOSE OF OUR IMPROVED
PROJECT WHICH WAS A SUPPLEMENT
TO AN R21 WHERE WE WERE LOOKING
AT LIFE COURSE APPROACHES TO
CARDIOVASCULAR RISK FACTORS
ASSOCIATED WITH ADVERSE
PREGNANCY OUTCOMES.
OUR GROUP HAS BEEN KEEN ON THIS
IDEA AS WE LAUNCHED THE
CONVERSATION ABOUT THE
IMPORTANCE OF A LIFE SPAN
APPROACH NOT ONLY TO PREGNANCY
HEALTH BUT MATERNAL HEALTH AS
WELL.
WE WERE INTERESTED IN
UNDERSTANDING PRE-PREGNANCY
ANTECEDENTS AND CARDIOVASCULAR
AND SOCIAL FACTORS CONTRIBUTE TO
SEVERE MATERNAL MORBIDITY AND
HOW THEY'RE AT PLAY IN THE
PRE-PREGNANCY PERIOD ARE LESS
STUDIED.
OUR HYPOTHESIS WAS POOR
CARDIOVASCULAR HEALTH AND
ADVERSE PSYCHOSOCIAL STRESS
BEFORE PREGNANCY WOULD
CONTRIBUTE TO RACIAL DISPARITIES
AND MORBIDITY.
OUR STUDY IS USING THE CARDIO
STUDY OF AMAZING LONG STANDING
RESOURCE FROM NHLBI AND OUR
STUDY INCLUDED ABOUT 1400 WOMEN
AND BY DESIGN, CARDIA IS HALF
MEN, HALF WOMEN, HALF BLACK AND
HALF WHITE AND THERE WERE ABOUT
2400 POST-ENROLLMENT BIRTH AND
WE CHARACTERIZED THIS USING
ESTABLISHED CHRIST ADAPTED NOR
STUDY SO THE DOMINANT
IDENTIFICATION OF SEVERE
MATERNAL MORBIDITY ARE DELIVERY
EPISODES AND RECORDS IN CARDIA
WE ONLY HAD RECORDS FOR A THIRD
OF THE BIRTHS.
BECAUSE CARDIA IS ONGOING AND
LONGITUDINAL, PARTICIPANTS
SELF-REPORT HOSPITALIZATIONS
EVERY SIX MONTHS TO A YEAR AS
PART OF THE STUDY PROTOCOL.
WE IDENTIFIED HOSPITALIZATIONS
UP TO A YEAR POSTDELIVERY AND
CURATED THEM TO BE LINKED TO
CONDITIONS THAT ARE PART OF THE
ESTABLISHED MATERNAL MORBIDITY
CRITERIA.
WE ALSO USED THE CARDIA DATA
CHARACTERIZED CARDIOVASCULAR
HEALTH AND CHARACTERIZED STRESS
AND WOMEN SELF-REPORTED ADVERSE
PREGNANCY OUTCOMES AND WE
MODELLED THOSE RELATED TO RISK
OF AN SMM EVENT AND STRATIFIED
THE RESULT BUSINESS RISK.
THE PRE-PREGNANCY FARCT --
FACTORS WERE PART OF A LIFE
SIMPLE SEVEN WITH BLOOD
PRESSURE, BMI, PHYSICAL
ACTIVITY, GLUCOSE MEASUREMENTS,
SMOKE AND CHOLESTEROL AND A
HIGHER SCORE OF THAT INDICATES
BETTER CARDIOVASCULAR HEALTH SO
HIGHER IS HEALTHIER.
FOR STRESSFUL EVENTS AT BASELINE
AND YEAR TWO THERE WAS AN
ASSESSMENT OF STRESSFUL LIFE
EVENTS.
THIS WAS AN ACCRUAL OF EVENTS
THAT HAPPENED IN EACH
PARTICIPANT'S LIFE THEY
SELF-REPORTED WERE SCORED AND IN
THIS METRIC A HIGHER SCORE OF
STRESSFUL LIFE EVENT IS ADVERSE
AND THERE WERE PRE-TERM BIRTH
AND GESTATIONAL DIABETES AND
DEFINED SMM USING DELIVERY
RECORDS OR SELF-REPORTED
HOSPITALIZATIONS.
THESE WERE THE PRIMARY DIAGNOSES
AND SEPSIS AND CARDIO MYOPATHY
AND OTHERS FACTORS AND ALONG
WITH REVIEW CRITERIA
HOSPITALIZATIONS WITHIN A YEAR
OF DELIVERY IF THEY WERE
CARDIOVASCULAR IN NATURE OR
INVOLVED DEPRESSION OR DOMESTIC
VIOLENCE OR OVERDOSE WERE
INCLUDED IN SEVERE MATERNAL
MORBIDITY AND ALIGNED WITH
NATIONAL DATA ABOUT 60% OF THE
EVENTS IN THE CARDIA COHORT WERE
AFTER DELIVERY AND ABOUT 40% AT
DELIVERY.
WE DID NOT SEE RACE DIFFERENCES
IN THE OCCURRENCE OF SEVERE
MATERNAL MORBIDITY EVENTS
OVERALL IT WAS 1.9%.
AS I SAID, WE WERE PARTICULARLY
INTERESTED IN DIFFERENCES BY
RACE.
THIS SHOWS OUR GROUPS.
WOMEN WERE ENROLLED IN CARDIA
RELATIVE YOUNG IN THEIR 20s AND
SAW DIFFERENCES FROM RACE AND
SEVERE MORBIDITY OCCURRENCE IN
EDUCATION.
VERY MODEST DIFFERENCES IN
TRADITIONAL CARDIOVASCULAR RISK
FACTORS BUT WHEN THEY ARE
AGGREGATED INTO THIS
CARDIOVASCULAR HEALTH METRIC, A
COUPLE THINGS ARE NOTEWORTHY
HERE.
FIRST OF ALL, BLACK WOMEN IN THE
STUDY HAD WORSE CARDIOVASCULAR
HEALTH EVEN COMPARED TO WHITE
WOMEN WITH OR WITHOUT SEVERE
MATERNAL MORBIDITY.
THAT'S NOTEWORTHY.
PARTICULARLY LOWER RATES OF
CARDIOVASCULAR HEALTH IN BLACK
WOMEN WITH SEVERE MATERNAL
MORBIDITY.
YOU SEE CARDIOVASCULAR HEALTH
SCORES CAN BE ANALYZED AS A
CONTINUOUS SUCH THAT HIGHER IS
BETTER, LOWER IS MORE ADVERSE
AND THEN WE ALSO USE CLINICAL
CUT POINTS TO IDENTIFY POOR,
IMMEDIATE OR IDEAL
CARDIOVASCULAR HEALTH AND VERY
NOTEWORTHY YOU CAN SEE BLACK
WOMEN WITH SEVERE MATERNAL
MORBIDITY EVENTS ACTUALLY NONE
OF THEM HAD IDEAL CARDIOVASCULAR
HEALTH PRIOR TO PREGNANCY AND
MORE THAN 40% WERE IN THE POOR
CARDIOVASCULAR HEALTH RANGE.
AGAIN, NOTEWORTHY, BLACK WOMEN
WITHOUT SEVERE MATERNAL
MORBIDITY EVENTS HAD WORSE
CARDIOVASCULAR HEALTH COMPARED
TO THEIR WHITE COUNTERPARTS WITH
OR WITHOUT SEVERE EVENTS.
SOME WERE WE ARE ADVERSE TO
STRESSFUL EVENTS THAN BLACK
WOMEN WITHOUT SEVERE MATERNAL
MORBIDITY EVENTS AND HIGHER THAN
BLACK OR WHITE WOMEN WITH OR
WITHOUT SEVERE MATERNAL
MORBIDITY EVENTS.
WE PUT THE DATA TOGETHER IN A
MODEL BECAUSE WE KNOW WE'RE
PRESSURING THE INDEXES.
WE THOUGHT THEY'D BE MORE
STRONGLY CORRELATED THERE WAS
WEAK CORRELATION AND WAS
STATISTICALLY SIGNIFICANT BUT
WITH A DIFFERENCE 6%.
WHEN WE LOOKED AT THEM TOGETHER
AMONG BLACK WOMEN,
CARDIOVASCULAR HEALTH WAS HIGHLY
PROTECTIVE AGAINST RISK OF
SEVERE MATERNAL MORBIDITY
EVENTS.
IT WAS RATHER UNRELATED AT LEAST
IN THESE IT DATA AMONG WHITE
WOMEN THE STORY ABOUT STRESS WAS
MORE NUANCED AND LESS PRECISE.
THE RISK OF SEVERE MATERNAL
MORBIDITY WAS SLIGHTLY HIGHER IN
BLACK WOMEN WITH HIGHER
PRE-PREGNANCY STRESS BUT NOT
UNDID YOU -- UNDETECTED IN
WHILE THE WOMEN AND THE FINDING
FOR CARDIOVASCULAR HEALTH WERE
STRIKI
STRIKING AND THE ADVERSE
PREGNANCY OUTCOMES MATTERED BUT
DID NOT DIMINISH THE ASSOCIATION
OF PRE-PREGNANCY OF
CARDIOVASCULAR HEALTH IN TERMS
OF RISK FOR SEVERE MATERNAL
MORBIDITY EVENTS.
SO OUR DATA WERE RELATIVELY
STRIKING AT BETTER PRE-PREGNANCY
CARDIOVASCULAR HEALTH AND
STRONGLY ASSOCIATED WITH REDUCED
RISK OF SEVERE MATERNAL
MORBIDITY EVENTS IN BLACK BUT
NOT IN OUR DATA IN WHITE WOMEN
AND STRESSFUL EVENTS DID APPEAR
TO MEASURE AND WE COULD NOT
DISENTANGLE DIFFERENCES AMONG
BLACK AND WHITE WOMEN AND WE'RE
STILL LOOKING AT THE DATA.
I'D LIKE TO THANK THE
LONG-ESTABLISHED CARDIA STUDY.
THE CENTERS INVOLVED IN CARDIA
AS WELL AS OUR STUDY TEAM ALSO
WOULD LIKE TO THANK ERICA
GUNDERSON A LONG-TERM
COLLABORATOR.
THANK YOU.
>> I HAVE A QUESTION FROM THE
AUDIENCE.
HOW WERE STRESSFUL EVENTS
DEFINED DID IT TAKE INTO ACCOUNT
RACISM AND SOCIAL DETERMINATES
OF HEALTH?
>> SO CARDIA ENROLLED
PARTICIPANTS IN THEIR 20s IN THE
MID 1980s TO IT WAS A TIME AGO
BUT WE KNOW THE FACTORS WERE AT
PLAY IN THE 1980s AS WELL.
SO THERE ARE QUESTIONS IN THAT
STRESSFUL LIFE EVENTS AROUND
DISCRIMINATION, RACIAL
DISCRIMINATION, SEX
DISCRIMINATION.
WE COULDN'T DISENTANGLE IT
BECAUSE IT WAS ONLY ONE
QUESTION.
CARDIA ASKED A QUESTIONNAIRE ON
RACIAL DISCRIMINATION BUT NOT
UNTIL YEAR SEVEN OF FOLLOW-UP
AND BECAUSE CARDIA IS LARGE BUT
STILL ARE STUDYING RELATIVELY
RARE EVENTS.
WE WANTED TO INCLUDE IT ALL.
ALL THE OTHERS IN THE LIFE EVENT
CATEGORY ARE DID YOU EXPERIENCE
VIOLENCE, DID YOU LIVE AN
HOUSEHOLD WITH POVERTY.
WERE YOUR PARENTS DIVORCED.
IT'S A BROAD SURVEY OF STRESSFUL
LIFE EVENTS.
>> THANK YOU.
ANOTHER QUESTION IS THE SAME
THING, SO YOU ADDRESSED THAT AND
I'LL ASK THE FINAL QUESTION VERY
INTRIGUING RESULTS.
HOW DO YOU EXPLAIN THE POSITIVE
FINDINGS ABOUT BETTER
CARDIOVASCULAR HEALTH BUT NOT IN
WHITE WOMEN.
>> BLACK WOMEN WERE MORE HEAVILY
BURDENED BIG POORER
CARDIOVASCULAR HEALTH AND THAT
PRE-PREGNANCY WAS A RISK FACTOR
FOR SEVERE MAH MATERNAL
MORBIDITY.
IT'S NOT THAT THE CARDIOVASCULAR
HEALTH DOESN'T MATTER FOR WHITE
WOMEN BUT IT WAS LESS ADVERSELY
AFFECTED AT YOUNGER AGES IN
WHITE WOMEN COMPARED TO LOOK
WOMEN IN THE OCCURRENCE OF
POORER CARDIOVASCULAR HEALTH.
WE'RE INTERESTED IN REPLICATING
THIS IN MORE CONTEMPORARY
COHORTS BUT WE KNOW
PRE-CONCEPTION DATA ARE HARDER
TO GET OUR HANDS ON AND IT'S
NOT THAT BETTER HEALTH DOESN'T
MATTER FOR ALL OF US BUT CERTAIN
POPULATIONS ARE MORE BURDENED BY
CARDIOVASCULAR HEALTH.
>> THANK YOU.
I WANT TO TAKE THIS TIME TO
THANK ALL THE SPEAKERS FOR THE
QUESTION.
VERY INFORMATIVE AND WONDERFUL
TO SEE THE FRUITS OF THEIR LABOR
FROM THE IMPROVED INITIATIVE
FUNDING.
AS WE ALL COLLECTIVE MOVE
TOWARDS IMPROVING MATERNAL IT
HEALTH AND CLOSE THE EQUITY GAP.
WITH THAT THAT CONCLUDES THE
FIRST SESSION SO WE'LL NOW HAVE
OUR LUNCH BREAK.
PANELISTS STAY CONNECT ED.
PLEASE RETURN AT 12:40.
THE MEET AGENDA WILL RESTART
PROPERLY FIVE MINUTES AFTER
12:45.
HAVE A GOOD LUNCH BREAK.
>> WELCOME TO THE SESSION FOR
IDENTIFICATION AND PREVENTION OF
MATERNAL MORBIDITY AND RISK
SESSION.
I'M A PROGRAM DIRECTOR AT NINR.
I'M HONORED TO BE A MODERATOR
FOR THE SESSION TODAY.
BEFORE WE START I'D LIKE TO
REMIND EACH SPEAKER EACH
PRESENTATION IS FIVE TO TEN
MINUTES PLUS FIVE MINUTES OF
Q&A.
I'LL GIVE A WARNING FOR ONE
MINUTE BUT I'LL MONITOR THE TIME
AND AFTER THE PRESENTATION I'LL
TAKE QUESTIONS USING Q&A
FUNCTION IN THE ZOOM AND SO IF
YOU HAVE ANY QUESTIONS, PLEASE
POST YOUR QUESTIONS THERE.
OUR FIRST SPEAKER IS DR. EDLOW
FROM MASSACHUSETTS GENERAL
HOSPITAL FOR MATERNAL OBESITY
AND SARS COV2 AND MATERNAL BLOOD
AND FETAL IMMUNE RESPONSE.
YOU'RE GOOD TO GO.
>> YES, THANK YOU.
IT'S AN HONOR TO BE HERE TO
SHARE THE RESULTS OF OUR
IMPROVED FUNDED STUDIES.
I HAVE ONE ONLY HAVE ONE
DISCLOSURE I'M A CONSULTANT AND
I DON'T HAVE TO TELL THE
AUDIENCE THE MOST RECENT DATA
FROM THE CDC DEMONSTRATE THE 273
PREGNANT INDIVIDUALS HAVE DIED
FROM COVID-19 SINCE THE START OF
THE PANDEMIC IN THE UNITED
STATES ALONE.
WOE KNOW PREGNANT APPRECIATES
WITH COVID-19 ARE LIKELY TO NEED
ICU ADMISSION OR NEED A HEART
LUNG BYPASS MACHINE AND LIKELY
TO DIE.
IN ADDITION TO THE NETWORK
PUBLISHED LAST WEEK IN JAMA
SHOWED AN INCREASE RISK OF OB
OBSTETRICS RELATED TO HYPER
TENSIVE DISORDER OF PREGNANCY
POSTPARTUM RISK FACTORS.
DATA FROM THE CDC STUDIES
CONDUCTED ACROSS 12 SITES IN THE
UNITED STATES SHOWED A BMI
GREATER OR EQUAL TO 30 WAS
ASSOCIATED WITH A 1.4 FOLD
RELATIVE RISK OF SEVERE DISEASE.
AND A MORE RECENTLY PUBLISHED
SYSTEMATIC REVIEW OF 63 STUDIES
SHOWED ONE-THIRD OF PREGNANT
WOMEN HOSPITALIZED WERE OBESE.
HOWEVER, THE UNDERLYING
MECHANISMS THAT DRIVE THE
INCREASED RISK OF MATERNAL
SEVERE MORBIDITY OR MORTALITY
REMAIN TO BE ELUCIDATED.
WE SOUGHT TO DETERMINE HOW IT
ALTERS THE MATERNAL CELLULAR
MONOCYTE AND T CELL RESPONSE TO
SARS COV2 INFECTION AND HOW IT
IMPACTS THE FETAL MACROPHAGE
SINGLE CELL TRANSCRIPT OME.
TO EVALUATE THE IMMUNE RESPONSE
WE STARTED WITH 110 PREGNANT
INDIVIDUALS INCLUDING CONTROL
AND 74 PREGNANT INDIVIDUALS WITH
COV2.
ALL OF THESE PARTICIPANTS ALL
WERE UNVACCINATE.
THESE WERE DIVIDED BETWEEN OBESE
AND NON-OBESE AND
NON-COMPARATIVE REPRODUCTIVE AGE
WOMEN AND SOME SARS COV2
NEGATIVE CONTROLS AND THESE WERE
DIVIDED EVEN BY BETWEEN OBESE
AND LEAN AND MONITORED NUCLEAR
CELLS FROM THESE INDIVIDUALS AND
SPUN THEIR BLOOD FOR PLASMA AND
FROM THE PBMC WE FURTHER
FRACTIONATE THE CELLS AND USED
CD14 POSITIVE BEADS AND TREATED
MONOCYTES WITH LOW DOSE LDS.
FOR THE T CELLS WE STEM
STIMULATED THEM AND PERFORMED
MULTI-COLOR FLOW CTOMETRY AND WE
ALSO COLLECTED STOOL FROM MANY
OF THESE PARTICIPANTS AND ARE
CURRENTLY SEQUENCING THE GUT
MICROBIOME TO DETERMINE HOW IT
MAY INFLUENCE THE IMMUNE
RESPONSE TO SARS COV2 AND
WHETHER THERE'S A BI-DIRECTIONAL
CROSS TALK THERE.
TO EVALUATE THE FETAL PLACENTAL
MACROPHAGE TRANSCRIPT OME WE
LOOKED AT 12 PLACENTAS IN TOTAL
AND 4 WHO TESTED POSITIVE FOR
SARS COV2 IN THE THIRD TRIMESTER
AND SOME NEGATIVE CONTROLS WHO
NEVER HAD COVID.
WE PERFORMED SINGLE CELL
SEQUENCING AND IDENTIFIED
EXPRESSED GENES BETWEEN COVID
EXPOSE AND EXPOSED USING A FALSE
DISCOVERY RATE OF .1 AND
PERFORMED ANALYSES TO UNDERSTAND
WHAT GENES MAY BE INVOLVED AND
TURNING TO OUR RESULTS FOR THE
MATERNAL IMMUNE RESPONSE.
WE FOUND MONOCYTES FROM HEALTHY
PREGNANT WOMEN WERE MORE
REACTIVE THAN THOSE FROM
NON-REACTIVE CONTROLS.
THE YELLOW COLOR INDICATES MORE
INFLAMMATORY CYTOKINE PRODUCTION
AND THEY'RE HERE ACROSS THE
BOTTOM AND SEE IN THE TOP BAND
OF NON-PREGNANT CONTROLS MORE
BLUE MEANING LESS CYTOKINE
PRODUCTION AND YOU CAN SEE THE
EFFECT OF COVID-19 ON MATERNAL
MONOCYTES WHERE IN A SARS COV2
NEGATIVE CONTROLS WE STILL HAD A
LOT OF CYTOKINE PRODUCTION BUT
AS COVID SEVERITY INCREASES
DOWNWARD WITH SEVERE AND
CRITICAL CASES ON THE BOTTOM, WE
SEE MONOCYTES ARE EITHER
EXHAUSTED AND CAN NO LONGER
PRODUCE THESE OR POTENTIALLY
EXPRESSED SO WE DON'T KNOW
WHETHER THIS IS REFLECTIVE OF
MORE PRO-INFLAMMATORY CYTOKINE
PRODUCTION DURING THE ILLNESS OR
IF THE SUPPRESSION COULD BE
DRIVING THE PATHOPHYSIOLOGY BUT
A SIMILAR EFFECT HAS BEEN
OBSERVED IN NON-PREGNANT
OBSERVATIONS AND HAVE SEEN THIS
IN OBESE AND LEAN PARTICIPANTS.
YOU CAN SEE HERE CONTROLS IN RED
AND AS YOU PROGRESS ACROSS THE
SPECTRUM OF SEVERITY THIS IS
DURING THE ACUTE ILLNESS THAT
THESE SAMPLES WERE COLLECTED AND
THEN WE SEE SOME RECOVERY OF THE
MONOCYTE INFLAMMATORY PRODUCING
CAPABILITIES WITH CONVALESCENCE
USUALLY FROM THE SAME
PARTICIPANTS.
WE DID FIND AN OBESITY IMPACT IN
THE T CELL RESPONSE SO WE SAW
MATERNAL OBESITY WAS ASSOCIATED
WITH PROINFLAMMATORY PHENOTYPE
OF CD4 POSITIVE T CELLS.
TO ORIENT YOU, ALL THE
INDIVIDUALS DEPICTED HERE HAD
COVID-19 AND OBESE INDIVIDUALS
ARE DEPICTED IN BLUE AND LEAN IN
RED.
HERE YOU CAN SEE THE CD4
POSITIVE T CELL PRODUCE
SIGNIFICANTLY MORE IL2, IL4, TNF
ALPHA AND INTERFERON GAMMA WHEN
THE INDIVIDUALS ARE OBESE IN
PREGNANCY AND THIS INCREASE AS
SEEN IN THE PREGNANCY WAS NOT AS
PROMINENT IN THE NON-PREGNANCY
POPULATION.
THIS WAS PERFORMED IN
COLLABORATION WITH AN
IMMUNOLOGIST.
WE SAW A SIMILAR PATTERN IN CD8
POSITIVE T CELLS WHERE IN
PREGNANT OBESE INDIVIDUALS HERE
IN BLUE WE SAW INCREASED
PRODUCTION OF IL2, INTERFERON
GAMMA AND TNF ALPHA.
TURNING TO OUR RESULTS ABOUT THE
FETAL IMMUNE RESPONSE TO
COVID-19, JUST TO GIVE YOU A
SENSE OF THE RATIONALE FOR THE
EXPERIMENTS THE FUNDING WAS
AROUND USING PLA CENTRAL
MACROPHAGES AS A CELL TYPE FOR
FETAL BRAIN MICROGLIA.
THEY SHARE A COMMON YOKE SACK
ORIGIN AND THE IMMUNE CELLS OF
THE BRAIN MAY BE PROGRAMMED BY
THE INTRAUTERINE ENVIRONMENT
THAT CAN COME TO BEAR ON LATER
LIFE RISK FOR DISEASES THOUGHT
TO BE MEDIATE MICROGLIAL
IMPACTS.
BRAIN MICROGLIA REMAIN
UNACCESSIBLE AND WE'RE SEEKING
TO DETERMINE WHETHER A CELL TYPE
WITH A COMMON ORIGIN CAN PROVIDE
INFORMATION ON THE VARIOUS
EXPOSURES INCLUDING OBESITY.
THIS SINGLE CELL SEQUENCING WAS
PERFORMED IN OUR MOUSE MODEL AND
WE SAW SIMILARITIES BETWEEN
SPECIFIC CLUSTERS OF THESE
CELLS.
AND SO THAT'S WHY THE PARTICULAR
INTEREST IN THE CELLS IN HUMAN
PLACENTAS AND WE SEPARATED THEM
AND AND SHOWED THESE CELLS HAVE
SEVEN DISTINCT CLUSTERS AND SIX
ARE FETAL IN ORIGIN AND ONE IN
MATERNAL ORIGIN WHEN WE DID
MAPPING OVER THE CLUSTERS.
WE SAW THE COVID-19 WAS
ASSOCIATED WITH A DISTINCT PLA
CENTRAL MACROPHAGE WITH GENES IN
THE CELLS IN THE SETTING OF THE
OF COVID-19 AND IN PERFORMING
FUNCTIONAL ANALYSIS ON THE
EXPRESSED GENES TO UNDERSTAND
WHAT THE GENES MIGHT BE DOING,
WE FOUND MATERNAL COVID-19 WAS
ASSOCIATED WITH ALTERED
INFLAMMATORY SIGNALLING AND
MITOCHONDRIAL DYSFUNCTION AND
CELL DEATH WITH DIFFERENTIAL
IMPACT DEPENDING ON THE CLUSTER.
IN CONCLUSION, WE FIELD THE
INCREASE PROINFLAMMATORY
POTENTIAL IN OBESE PREGNANCY MAY
HELP ELUCIDATE THE INCREASED
RISK OF MATERNAL MORBIDITY IN
THE SETTING OF OBESITY AND THE
IMPACT OF COVID-19 ON PLACENTAL
MACROPHAGES SUGGESTING FETAL
IMMUNE AFFECTS IN THE ABSENCE OF
VERTICAL TRANSMISSION AND FUTURE
DIRECTION WILL FOCUS ON MODELS
USING MORE ACCESSIBLE PROXY CELL
TYPES IN HUMANS INCLUDING CORD
BLOOD MONOCYTES AND HOFBAUER
CELLS AND I'M HAPPY TO TAKE ANY
QUESTIONS.
>> YOU FOR THE INTERESTING
PRESENTATION.
THANK YOU FOR SHARING.
I DON'T SEE ANY QUESTIONS.
SO I BELIEVE THAT SOME
EXPRESSIONS MAY BE DIFFERENCE SO
I'M WONDERING, WHAT TIME POINT
WAS THE BLOOD SAMPLE COLLECTED
EITHER EARLY OR LATE COVID STAGE
OR SOME OTHER TIME POINT?
>> THAT'S AN IMPORTANT QUESTION,
THANKS FOR LETTING ME CLARIFY
THAT.
SO THESE DATA PRESENTED TODAY
ARE CONFINED JUST TO
PARTICIPANTS FOR WHOM WE WERE
ABLE TO COLLECT A BLOOD SIMPLE
SIMPLE -- SAMPLE AT THE TIME OF
HOSPITALIZATION FOR COVID-19 AND
THOSE SYSTEMATIC AND BEING
EVALUATED FOR COVID-19 OR BEING
ADMITTED FOR COVID-19 AND ALL
BLOOD SAMPLES ARE OBTAINED PRIOR
TO THE INITIATION OF TREATMENTS
OR THERAPIES ESPECIALLY
DEXAMETHAZONE AND THERE WERE
SAME INDIVIDUALS RECOVERED FROM
COVID WHEN THEY WENT ON TO
DELIVERY FOR A PREGNANT
POPULATION.
SO THAT'S WHERE WE WERE ABLE TO
SEE RECOVERY OF THE MONOCYTE
FUNCTION FOR EXAMPLE.
DID THAT ANSWER YOUR QUESTION?
>> YES, THANK YOU.
>> YOU'RE WELCOME.
>> I'M LOOKING AT THE TIME SO
IT'S 1:00 AND I'D LIKE TO KEEP
THE TIME FOR THE NEXT SESSION
SO -- LET ME SEE ONE QUESTION --
ALSO IN HYPOTHESIZING THE
HOFBAUER EFFECTS INDICATED
MATERNAL CELL EFFECTS AND MAY BE
SOME OF THE POSTPARTUM
HEMORRHAGES REPORTED.
>> I'LL BE VERY BRIEF.
WE'RE HIGH BOTH SIZING THE
HOFBAUER CELL TRANSCRIPT OME MAY
BE MORE REFLECTIVE OF THE
PROGRAMMING MIGHT OCCUR AND I'M
HAPPY IF YOU WANT TO E-MAIL ME
TO GIVE ME FURTHER INFORMATION
ABOUT THAT.
THANK YOU.
>> THANK YOU.
>> SO WE'RE MOVING TO THE NEXT
PRESENTER.
NEXT SPEAKER FROM RUSH
UNIVERSITY AND DR. CASKEY FROM
THE UNIVERSITY OF ILLINOIS
CHICAGO AND THE PRESENTATION
TITLE IS ADDRESSING MATERNAL
MORBIDITY AND MORTALITY IN
COMMUNITY HEALTH CENTERS.
WHO IS GOING TO START FIRST?
>> THANK YOU.
THANK YOU SO MUCH FOR THE
OPPORTUNITY TO PRESENT TODAY ON
OUR PROJECT TITLED LINK MOMS
ADDRESSING MATERNAL MORBIDITY
AND MORTALITY IN COMMUNITY
HEALTH CENTERS.
WE THANK THE FUNDER FOR THE
OPPORTUNITY TO DO THE WORK.
TODAY I'LL BE SPEAK ON BEHALF
OUR TEAM OF RESEARCHERS.
I'M AN OB-GYN AT RUSH AND
DR. CASK IS HERE WITH ME AND
WE'VE BEEN COLLABORATING WITH AN
ORGANIZATION CALLED ALLIANCE
CHICAGO AND OUR CO-COLLABORATORS
THERE.
ASSIGN CHICAGO IS AN
ORGANIZATION THAT BRINGS
TOGETHER A LARGE NETWORK OF
FEDERALLY QUALIFIED HEALTH
CENTERS TO IMPROVE PERSONAL,
COMMUNITY HEALTH THROUGH
ORGANIZATIONS THROUGH ENGAGING
IN SUPPORTIVE NETWORKS OF HEALTH
CENTERS TO COME TOGETHER AS
PROVIDERS AND PATIENTS THROUGH
HEALTH INFORMATION TECHNOLOGY.
THEY HAVE A UNIFIED ELECTRONIC
MEDICAL SYSTEM, MEDICAL RECORD
SYSTEM WHICH ALLOWS FOR QUALITY
IMPROVEMENT, RESEARCH AND
EDUCATION.
THIS IS A NETWORK WHICH SPANNED
A NUMBER OF HEALTH CENTERS
AROUND THE COUNTRY.
SO ALLIANCE CHICAGO AGAIN WE
HAVE BEEN COLLABORATING A NUMBER
OF YEARS HAS A NETWORK OF 74
SAFETY NET COMMUNITY HEALTH
CENTERS SPAN 20 STATES AND
ALLOWS FOR DATA AND REPORTING ON
A LARGE SCALE.
THEY HAVE AN INFRASTRUCTURE TO
GIVE US DATA ON CLOSE TO 4
MILLION PATIENTS ACROSS THE
COUNTRY AND WE HAVE WORKED WITH
THEM TO THINK HOW TO LEVERAGE
THIS WIDE REACH ACROSS COMMUNITY
HEALTH CENTER TO THINK ABOUT
INNOVATIVE WAYS TO MEET IMPROVE
MATERNAL HEALTH AND MEET
PATIENTS WHERE THEY'RE AT AT THE
HEALTH CENTERS.
BEFORE I JUMP INTO TALKING ABOUT
THIS PROJECT, LINK MOMS, I'LL
TALK ABOUT OUR PARENT PROJECT.
OUR PARENT RO1 ON WHICH WE BUILT
THE LINK MOM PROJECT.
WE WERE FUNDED TO CONDUCT AN RO1
TO LOOK AT HOW TO IMPROVE
MATERNAL OUTCOMES TO ENHANCED
OUTCOMES TO POSTCONTRACEPTION
AND CARE.
WE THOUGHT HOW TO DO THIS AT THE
SYSTEM LEVEL AND REMOVE BARRIERS
TO ACCESSING CARES AND OFFERING
MOTHERS MORE OPPORTUNITIES TO
GET POSTPARTUM CARE AND
CONTRACEPTION BY LINKING THEIR
CARE WITH THE WELL BABY VISIT
AND INFANT CARE.
THIS STUDY CURRENTLY UNDERWAY
AND WE HAVE THIS LINKED MODEL
ACROSS SEVEN COMMUNITY HEALTH
CENTERS ACROSS THE COUNTRY
CURRENTLY AND THE ULTIMATE GOAT
GOAL IS TO IMPROVE ACCESS TO
CARE AND TIMELY CARE FOR MOMS
AND THE MOST PARTUM PERIOD AND
ULTIMATELY DECREASE MATERNAL
MORALITY AND IMPACT OUTCOMES IN
OTHER WAYS.
THE PARENT PROJECT LAID AN IDEAL
FOUNDATION TO FURTHER DEVELOP A
MODEL TO LOOK AT HOW TO IDENTIFY
MOTHERS AT RISK FOR MATERNAL
MORBIDITY AND MORTALITY AND USE
THIS ELECTRONIC MEDICAL RECORD
AND IDENTIFY RISK FACTORS IN
POSTPARTUM THAT CAN BE USED TO
LINK MOTHERS TO OTHER CARE IN
ADDITION TO CONTRACEPTION.
THE LINK MOMS PROJECT USE AS A
POPULATION-BASED APPROACH
THROUGH THE ELECTRONIC MEDICAL
RECORD TO CREATE A REGISTRY TO
IDENTIFY THOSE AT HIGHEST RISK
AND LINK TO CARE.
PREVENTION OF SEVERE MATERNAL
MORBIDITY AND MORTALITY IS
OFFERING TIMELY ACCESS TO
QUALITY HEALTH CARE.
WE LEVERAGED OUR EXISTING
PARTNERSHIPS AND THE LARGE DATA
SET AVAILABLE TO US THROUGH
ALLIANCE CHICAGO'S NETWORK TO
CREATE A TOOL TO IDENTIFY THOSE
AT RISK.
WE HAVE TAKEN THE OPPORTUNITY TO
INCORPORATE WHAT WE'VE ALREADY
LEARN THE PARENT STUDY WHICH
LINKS CONTRACEPTION AND WELL
BABY CARE TO THINK HOW DO WE
THEN FURTHER IDENTIFY PATIENTS
AT HIGHEST RISK FOR MORBIDITY BY
INCLUDING THE VOICES OF THE
PROVIDERS AND PATIENTS AND OTHER
SUBJECT MATTER EXPERTS AS WE
DEVELOPED THIS LINKED MOM TOOL.
SO OUR AIMS ARE TO BUILD A
POPULATION-HEALTH INTERFACE TO
IDENTIFY THOSE AT RISK THROUGH
THE ELECTRONIC HEALTH RECORD AND
THEN CREATE A REGISTRY USING
THAT TOOL AND THEN TO ACTUALLY
VALIDATE IT TO THEN TAKE A STEP
BACK SAYING DID THIS TOOL THAT
WE USED TO CREATE THE REGISTRY
OF PATIENTS AT HIGHEST RISK
ACTUALLY WORK BY VALIDATION
THROUGH THE COMMUNITY HEALTH
CENTERS.
LASTLY, WE WANT TO FOCUS ON HOW
WE WOULD IMPLEMENT SOMETHING
LIKE THIS IN REAL WORLD
PRACTICE.
OUR THIRD AIM IS TO CREATE AN
IMPLEMENTATION PLAN TO USE THE
LINK MOMS REGISTRY ACROSS HEALTH
CENTERS.
I MENTIONED WE'RE USING A
POPULATION-HEALTH APPROACH AND I
WANT TO MAKE THIS DISTINCTION
BECAUSE WE'RE NOT OFTEN WE USE A
ONE POINT IN TIME DATA POINT TO
THEN DELIVER CARE AND IMPROVE
OUTCOMES.
WE'RE THINK ABOUT THIS TO LOOK
AT MULTIPLE FACTOR CAN IDENTIFY
A COHORT OF PATIENT COULD BE AT
HIGHEST RISK SUCH AS FACTORS
AROUND CLINICAL DIAGNOSES,
SOCIAL FACTORS AND OTHER FACTORS
THAT COULD THEN BE ASSOCIATED
WITH A COHORT OF PATIENTS AT
HIGHEST RISK FOR POORER
OUTCOMES.
WE'RE USING A PLATFORM CALLED
THE HEALTH CATALYST THIS IS
SOMETHING WE'RE ABLE TO
LEVERAGE.
THIS IS PART OF OUR HEALTH
INFORMATICS SYSTEM.
WE'RE USING A SPECIFIC PROGRAM
CALLED THE POPULATION BUILDER
WHICH HELPS TO IDENTIFY PATIENTS
ON VARIOUS FACTORS SO THIS IS AN
EXAMPLE HERE OF LOOKING AT A
COHORT OF PATIENTS WITH DIABETES
R
UNRELATED TO OUR PROJECT AND
FILTER ON MULTIPLE LEVELS ON THE
TOOL SO FILTER FOR DEMOGRAPHICS,
DIAGNOSES AND LABS AND TO CREATE
A SYSTEM WE THINK WILL HELP
IDENTIFY PATIENTS MOST AT RISK
BY USING THE CHARACTERISTICS WE
PUT INTO THE FILTER AND IDENTIFY
THE COHORT AND CREATE A
REGISTRY.
I'M GOING TURN IT OVER TO
DR. CASKEY FOR FURTHER OUTCOMES.
>> SO WE'LL GIVE YOU AN UPDATE
IN THE PROCESS.
THE FIRST WAS TO BUILD THE
POPULATION HEALTH INTERFACE AND
WE CONDUCTED TWO EXPERT PANELS
SUBJECT MATTER EXPERT PANELS
THAT INCLUDED PROVIDERS THAT
WORKED AT COMMUNITY HEALTH
CENTERS AND OB-GYN AND INTERNAL
MEDICINE AND SO FORTH.
THOSE SESSIONS PROVIDED ROBUST
DATA TO HELP GUIDE THE PROCESS.
WE HAVE TRANSCRIPTS AND WE
EXTRACTED VARIABLES TO IDENTIFY
PEOPLE MOST AT RISK FOR
MORBIDITY AND MORTALITY RELATED
TO PREGNANCY.
WE ALSO EXPLORED DOCUMENTATION S
AND THIS GETS INTO HOW AN
ELECTRONIC HEALTH RECORD IS
USED.
AS DESCRIBED, THIS TOOL IS GOING
USE EMR DATA TO HELP IDENTIFY
THOSE PREGNANT PEOPLE MOST AT
RISK.
HOUR JUST BECAUSE THERE IS A
VARIABLE OR A FIELD DOES NOT
MEAN IT'S USED.
WE SPENT A LOT OF TIME
UNDERSTANDING WHAT FIELD AND SEM
PLATES ARE USED DID I CLINICIANS
AND WHICH ARE TYPICALLY NOT
USED.
WE THEN CONSTRUCTED A LIST TO
INCLUDE VARIABLES MOST USEFUL TO
THIS PROCESS AND THE DRAFT
VARIABLES IN RED ARE THE ONES WE
FOUND ACROSS THE BOARD TO BE
MOST USEFUL THROUGH SUBJECT
MATTER EXPERTS OR THROUGH
FURTHER DISCUSSION ABOUT USE OF
THE VARIABLES WITHIN THE EMR.
THE FINAL LIST WAS USED TO
CREATE A TOOL TO TEST AND
VALIDATE ITS ACCURACY AND
IDENTIFYING PEOPLE AT RISK.
FOR AIM 2, WE'RE IN THE PROCESS
OF VALIDATING THE REGISTRY.
OUR FIRST DRAFT OF THE REGISTRY
WAS BUILT AND HAS BEEN DEPLOYED
AT FIVE COMMUNITY HEALTH
CENTERS.
OF THOSE FIVE COMMUNITY HEALTH
CENTERS, JUST UNDER 4,000
PREGNANT PEOPLE WERE IDENTIFIED
AND THE TOOL WE BUILT IDENTIFY
2930 HAVE BEEN FLAGGED FOR ONE
OF THE VARIABLES SUGGESTING RISK
FOR AN ADVERSE OUTCOME.
THIS IS A LARGE PERCENTAGE OF
THE PREGNANT PEOPLE SO OUR NEXT
STEP IS A MORE HANDS ON
VALIDATION PROCESS TO CREATE A
TOOL AND CONDUCT A CHART REVIEW
PORTION OF THE PATIENTS TO HELP
UNDERSTAND WERE THESE
INDIVIDUALS TRULY AT RISK, WAS
THERE A MISCODING OR
DOCUMENTATION BEING FLAGGED
INAPPROPRIATELY BY THE TOOL AND
THAT WILL BE FLAGGED IN THE
SPRING AFTER THE VALIDATION
PROCESS WE'LL BE CONDUCTING MORE
QUALITATIVE WORK.
WASN'T TO HEAR FROM MOTHERS AS
WELL AS PROVIDERS VOICES.
WE WANT TO GET MOTHER'S INPUTS
ON PREFERENCES AND NEEDS AND
FEEDBACK ON THE REGISTRY WE
BUILD AND HOW IT CAN BE USED TO
IDENTIFY AND LINK INDIVIDUALS
POTENTIALLY AT RISK FOR ADVERSE
OUTCOMES WITH CARE AND SUPPORT
AS NEEDED.
IMPORTANTLY TOO WE WANT TO GET
PROVIDER'S VOICES AND WE'LL BE
USING CLINICIAN DATA TO BUILD
THE REGISTRY AND WANT TO
IDENTIFY BARRIERS AND
FACILITATORS TO UTILIZATION
BEFORE IT IS DISSEMINATED MORE
BROADLY.
OUR FUTURE DIRECTION IS THE
OPPORTUNITY TO USE IT WITHIN THE
NETWORK MORE BROADLY.
WHERE SITES CAN USE THE TOOL TO
RUN REPORTS TO IDENTIFY PREGNANT
PEOPLE AT RISK.
SHARE FINDINGS AND DATA POINTS
THAT MIGHT BE FOUND OVER TIME
AND NATIONALLY TO BE MOST
PREDICTIVE.
AND THEN ALLOW THE VALIDATED
APPROACH TO BE ADAPTED AND
UTILIZED BY OTHERS OUTSIDE THE
ALLIANCE NETWORK AS WELL.
WE'LL STOP THERE FOR YOUR
QUESTIONS.
THANK YOU SO MUCH.
>> THANK YOU VERY MUCH FOR YOUR
INTERESTING PRESENTATION.
THERE'S ONE QUESTION.
HOW DID YOU EDUCATE THEM TO FEEL
COMFORTABLE IN THE ROLE WITH THE
RESEARCH PROJECT?
I SEE THE DEFINITION SLIDES.
>> WE HAVE CLINICIAN AND
PROFESSIONAL STAKE HOLDERS AND
LAY STAKEHOLDERS AND WE TALK TO
A LOT OF PATIENTS.
SO THE WAY WE WORK ON THAT IS
REALLY TO TRY TO ENGAGE THEM AS
AN IMPORTANT PART OF THIS
PROCESS AND MAKE IT CLEAR IF WE
MAKE SOMETHING THAT DOESN'T MAKE
SENSE TO PREGNANT PEOPLE OR
ISN'T USEFUL THE WORK IS IN
VAIN.
SO FAR WE'VE HAD PRETTY GOOD
SUCCESS ENGAGING LAY
STAKEHOLDERS IN VIEWS AND
DISCUSSIONS AROUND OUR WORK.
I SEE A QUESTION ABOUT
POPULATION BUILDER PART OF THE
E.H.R. SYSTEM.
THINK IT AS SOMETHING NEXT TO
IT.
HAVE YOU YOUR E.H.R. AND IT
EXTRACTS DATA IN REPORTS AND THE
IDEA IS TO CREATE A TOOL THAT
FLAGS CERTAIN IDENTIFIER WITHIN
THE E.H.R. FOR POTENTIAL RISK
FOR AN ADVERSE OUTCOME RELATED
TO PREGNANCY AND THEN A SITE AN
DECIDE HOW TO ACT ON IT.
THEY CAN DIED TO IDENTIFY A
SMALL PERCENTAGE MOST AT RISK
AND IDENTIFY BASED ON CERTAIN
RISK FACTORS TO BE USED IN A
NUMBER DIFFERENT WAYS.
>> I'LL TAKE THE NEXT QUESTION
IF YOU WANT.
THERE'S A QUESTION HERE ABOUT
THE WHAT THE KEY FACTORS ARE A
COMBINATION OF SOCIAL
DETERMINATE AND CLINICAL
FACTORS.
ABSOLUTELY.
ONE THING WE'RE TRYING TO
BALANCE IS THE APPROACH OF HOW
MUCH WE PUT IN THE TOOL TO MAKE
IT PRACTICAL AND USEFUL FOR THE
CENTERS BALANCING HOW MANY TO
INCORPORATE TOGETHER BUT IT'S
PART OF THE WORK TRYING TO
FIGURE OUT AND FINDING THE
BALANCE SO IT'S USEFUL.
IN OUR FIRST PASS OF CREATING
THE REGISTRY WHEN WE PUT THE
FACTORS IN ALMOST ALL PATIENTS
AT THE COMMUNITY HEALTH CENTERS
AND WE'RE TRYING TO BALANCE THAT
WITH UTILITY AND THERE'LL BE A
COMBINATION OF FACTORS THAT ARE
USED KNOWING THAT MANY OF THOSE
FACTORS THE SOCIAL DETERMINATES
FACTOR JUST AS IMPORTANT IN
PREDICTING OUTCOMES AND THE
SUBJECT MATTER EXPERTS HAVE
HIGHLIGHTED THE NEED TO THINK
ABOUT THAT STRATEGICALLY AND
INCORPORATE IT INTO THE WORK.
>> I'LL ADD TO THAT AND ONE OF
THE BIGGEST CHALLENGES WE'VE HAD
IS HOW SOCIAL DETERMINATES ARE
DOCUMENTED IN THE ELECTRONIC
HEALTH RECORD OR IF THEY'RE
DOCUMENTED.
SO THEY'RE NOT THE STRONGEST
SUIT OF MANY EMRs AND SO THAT'S
ONE OF OUR CHALLENGES AS WELL.
>> THANK YOU.
I HAVE A QUICK QUESTION BUT I
THINK WE'RE RUNNING OUT OF TIME.
I THINK I MOVE -- I HAVE TO
MOVE TO THE NEXT SPEAKER.
IN OUR YOUR PRESENTATION.
OUR LAST PRESENTATION IS FROM
THE UNIVERSITY OF CALIFORNIA LOS
ANGELES AND FROM MOUNT SINAI
MEDICAL CENTER.
DR. GREGORY WILL PRESENT THE
TITLE IS MATERNAL RISK
APPROPRIATE CARE ASSOCIATED WITH
DECREASED SEVERE MATERNAL
MORBIDITY FOR NORMAL
PRESENTATION PRELIMINARY
RESEARCH STUDY.
PLEASE GO AHEAD.
>> THANK YOU.
GOOD AFTERNOON.
THANK YOU FOR THE OPPORTUNITY TO
PRESENT OUR WORK AND FOR THE
SUPPLEMENT.
I'D LIKE TO ACKNOWLEDGE MY
CO-INVESTIGATORS.
WE'RE ALL AWARE MATERNAL
MORTALITY IS GOING ONE WAY IN
THE UNITED STATES AND IN
CALIFORNIA IT'S GOING DOWN WE
THINK IT'S DUE IN PART TO THE
HYPERTENSION AND HEMORRHAGE
BUNDLE ATTENTION AND MORBIDITY
STILL A SIGNIFICANT PROBLEM IN
3% OF ALL PREGNANCY AND THE
DEFINITION BY THE CDC IS 21
CONDITIONS AND THE SPECTRUM
DISORDER AND BEARS THE QUESTION
WHILE YOU CAN SEE DIC AND SHOCK
ARE POTENTIALLY PREVENTIBLE,
TRANSFUSION AND HYSTERECTOMY
WHICH ARE HIGHLIGHTED IN GREEN
ARE ACTUALLY PART OF THE
TREATMENT FOR THE CONDITION AND
SO IT MAY NOT BE FAIRNESSLY TO
INCLUDE THESE IN THE DEFINITION
OF SMM.
WITH REGARD TO VENTILATION MANY
USE THIS AND IT'S RAISED AS A
CAVEAT TO COME BACK TO LATER.
WE COLLECTED DATA ON THESE.
SO THERE WERE A SERIES OF PAPERS
THAT OUTLINED WHAT THEY FELT
WERE THE CRITERIA FOR BEING
CENTERS OF EXCELLENCE.
THEY WERE SUMMARIZED IN AN
ARTICLE IN THE AMERICAN JOURNAL
OF OB-GYN AND REINFORCED WITH A
CONSENSUS STATEMENT IN 2018.
AND WANTED TO LOOK AT HOSPITAL
PROCEDURE VOLUME AND THE
SERVICES PROVIDE AND THE
HOSPITAL MATERNAL LEVEL OF CARE
DESIGNATION IF WE HAD THEM.
THESE ARE THE CRITERIA
SUMMARIZED BY THE ARTICLE AND
I'M NOT GOING READ THEM BECAUSE
I'LL COVER THEM IN THE RESULTS
SECTION.
FOR THE TIME PERIOD THAT WE'LL
BE STUDYING 2016 TO 2018 THERE
WERE 1.3 MILLION DELIVERIES IN
CALIFORNIA AND ABOUT 1600 ACC
ACCREDA AND SUGGESTING THERE IS
SOME TYPE OF INFORMAL TRIAGE AND
REGIONALIZATION OF CARE FOR THE
DISORDERS.
AND SOME WERE IDENTIFIED AS HIGH
FOL VUM AND GREATER THAN OR
EQUAL TO 6 CASES PER YEAR AND
THE RANGE WAS FROM 6 TO 14 CASES
PER YEAR.
WE INTERVIEWED THE OB CHIEF
THORAZIOR
THE DESIGNEE AND THEY WERE NOW
TRANSFERRING THE PATIENTS
LEAVING 27 HOSPITALS TOTAL.
WE'VE COMPLETED 20 INTERVIEWS
AND FIVE HOSPITALS INITIALLY
DECLINED BECAUSE THEY WERE
CONCERNED ABOUT ANONYMITY AND
SUBSEQUENTLY PRESENTED OUR STUDY
TO THE CHIEF MEDICAL OFFICERS OF
THE HOSPITALS AND AFTER GETTING
SITE SPECIFIC IRB HAVE BEEN
GIVEN PERMISSION TO PROCEED.
SO OUR STUDIES TO DATE AND AGAIN
THESE ARE LOOKING AT THE
RESOURCES AND RECOMMENDED
SERVICES THAT SHOULD BE
AVAILABLE IN THE CENTERS AND WE
FOUND VARIATION IN THE NUMBER OF
CENTER PERFORMED CONFIRM TRY MRI
WITH 55% DOING ROUTINELY OR
SOMETIMES AND 40% NOT DOING IT
AT ALL.
80% OF THE INSTITUTIONS DO
PRE-OPERATIVE OPTIMIZATION AND
OVER HALF OF THE FACILITIES
ADMIT THE PATIENTS IN ADVANCE
FOR PRE-OP ASSESSMENT AND 75% OF
HOSPITALS FELT THEY NET CRITERIA
FOR HAVING A TEAM AND THE RATE
OF PHYSICIANS PROVIDING SURGICAL
SKILLS ONE 1-15.
70% OF THE HOSPITALS PLACE A
ARTERIAL LINE AND 55% HAVE
ACCESS TO RADIOLOGY WHERE THEY
MAY DO IN INTER OR OR
PRE-OPERATIVE ASSESSMENTS AND
100% OF FACILITIES HAD 24 HOUR
ACCESS TO BLOOD BANK AND
PRODUCTS AND TRANSFUSION
PROTOCOL.
90% HAVE A PROFUSIONIST AND 50%
DID FORMAL DE BRIEFING AFTER THE
PROCEDURES AND 60% PLANNED PREON
OPERATIVELY TO GO TO A
HYSTERECTOMY AND AFTER ASKING
THE FINAL TWO QUESTIONS 65% FELT
THEIR INSTITUTION WAS OR IS
DESIGNATED IN THE CENTER AND
WHEN ASKED ABOUT THE MATERNAL
LEVEL OF CARE THE RANGE WAS FROM
2 TO 4 USING THE DESIGNATION.
IN SUMMARY ALMOST ALL CENTERS A
MULTI-DISCIPLINARY TEAM THAT WAS
IN GENERAL HEADED BY AN MFM AND
HAD A SKILLED.
THE CENTERS VARIED WITH
MONITORING AND PROPHYLACTIC
PROCEDURES AND VARIED WHETHER
THERE WAS A SINGLE SURGEON
SERVICE A ROTATING TEAM OF
SURGEONS AND THE TYPE OF SIRJON.
-- SURGEON AND MOST HAD A
PROTOCOL AND VARIED WITH THE
TYPE OF ANESTHESIA.
SO WE CONCLUDE IF YOU HAVE SEEN
ONE ACCRETA CENTER YOU'VE SEEN
ONE AND THE CENTERS SEEM TO HAVE
MORE THE CRITERIA FOR EXCELLENCE
AND A PASSIONATE DEDICATED
PERSON ON EACH OF THE
MULTI-DISCIPLINARY TEAMS AND
TRUE OF THE URBAN AND ACADEMIC
CENTERS.
PRIMARY SURGEON EXPERTISE RANGE
FROM THE OB-GYN SPECIALIST TO
THE ONCOLOGY SUB SPECIALISTS AND
MOST TALKED ABOUT THE LOW RATE
OF TRANSFUSIONS REQUIRED THE
FACT THAT MOST OF THEIR PATIENTS
WENT TO A REGULAR POSTPARTUM
FLOOR AFTER THE PROCEDURE AND
MANY DID NOT NEED A
HYSTERECTOMY.
ONE OF THE NICE THINGS OF HAVING
A QUALITATIVE STUDY LIKE THIS
AND DOING THE INTERVIEWS MYSELF
WAS LEARNING ABOUT THE UNIQUE
OPPORTUNITIES FOR SUBSEQUENT
STUDY.
SO FOR EXAMPLE ONE CENTER HAD A
CRITERIA WHERE THEY HAD TO HAVE
TWO OUT OF THREE MFNs ON
ULTRASOUND READING IN ORDER TO
PROCEED WITH THE HYSTERECTOMY
OTHERWISE THEY'D ATTEMPT TO
REMOVE THE PLACENTA AND ANOTHER
HAD A NURSE THAT STAYED WITH THE
FAMILY THROUGHOUT THE HOSPITAL
STAY.
ONE HOSPITAL HAD A SOCIAL WORKER
AND PSYCH INVOLVED TO ADDRESS
PTSD POSTOPERATIVELY.
SOME CENTERS HAD DE BRIEFINGS
THAT INCLUDED THE PATIENT.
ONE SNSHT HAD A MONTHLY BUCKET
WHERE THE SPECIMEN IS COMPARED
TO THE ULTRASOUND OR MLI IN THE
PRESENCE OF SURGEON AND IMAGING
CONSULTANT.
SOME AND PROVIDE THE IMAGING
CONSULTANT FEEDBACK AT THE
SURGERY TO CONFIRM THE FALSE
POSITIVES.
ONE CENTER AFTER THE DELIVERY IF
THE BLADDER INVOLVED THEY CLAIM
AN ESTIMATED BLOOD LOSS OF LESS
THAN 100 AT THE TIME AND SEVERAL
CENTER HAVE ANNUAL SIMULATIONS
WITH THEIR TEAMS.
OUR NEXT STEP IS TO EVALUATE
INCLUDING AND EXCLUDEING
HYSTERECTOMY AND WE THINK WE
OUGHT TO BE CONSIDERING A
DIFFERENT METRIC OF SMM FOR
CLINICIANS.
WE WANTED TO DETERMINE IF
THERE'S DIFFERENT OUTCOMES WITH
RACE AND ETHNICITY AND LOOK AT
STUDY PARTICIPANTS AS THEY WERE
ALL EXCITED AND WANTED TO KNOW
WHAT OTHERS WERE DOING.
PROPOSE A QUALITY METRIC TO
DETERMINE HOW WELL THE DIFFERENT
CENTERS ARE DOING MANAGING THE
CONDITIONS AND WE DON'T THINK
THE CURRENT MACHINE OF SMM IS A
GOOD OPPORTUNITY TO CAPTURE THAT
AND TERMS WE SHOULD BE
PROCEEDING WITH A PATIENT
REGISTRY AND ARE THERE POLICIES
AN PROCEDURES THAT SHOULD BE
UNIVERSAL FOR OPTIMAL OUTCOME
ACROSS ALL SITES.
I'D LIKE TO THANK THE STUDY
PARTICIPANTS FOR GIVING ME THEIR
TIME AND I'D LIKE TO THANK THE
AUDIENCE FOR HAVING THE
OPPORTUNITY TO PRESENT THESE
RESULTS.
I HOPE THERE'S TIME FOR
QUESTIONS.
>> THANK YOU.
I DON'T SEE ANY QUESTIONS NOW SO
I SEE A QUESTION.
I'M WONDERING, IS THERE ANY
GEOGRAPHIC AVAILABILITY FOR THE
OUTCOMES OR FINDS AMONG
PARTICIPATING HOSPITALS SUCH AS
FOR RURAL AREAS AND OBVIOUSLY
RURAL AREA THE PARTICIPATING
HOSPITALS MAY NOT HAVE MUCH
RESOURCES COMPARED TO OTHER SO
I'M WONDERING --
>> THE HOSPITALS WERE PRETTY
SPREAD OUT ACROSS CALIFORNIA SO
THERE WERE SOME REGIONAL CENTERS
IN MORE RURAL AREAS WHERE IN
SMALLER HOPTZ WOULD REFER --
HOSPITALS WOULD REFER INTO THOSE
CENTERS.
>> DID YOU FIND THE LOCATION
LIKE OPEN HOME HOSPITALS WHETHER
THEY MANAGE DIFFERENTLY THAN THE
RURAL?
THERE'S NO DIFFERENCE?
>> THE BIGGEST DIFFERENCE IS
WHAT TYPE OF SUB SPECIALIST WAS
THE PRIMARY SEARCH ENGINE AND SO
THE LESS URBAN AND LESS ACADEMIC
THE MORE LIKELY YOU WOULD HAVE A
GENERALIST OR SPECIALIST BE THE
PRIMARY SURGEON AND IN GENERAL
THE FEWER THE SMALLER THE TEAM
THE MORE RURAL.
IT'S LOOK LIME THE MORE RURAL
THE MORE DEDICATED THE TEAM.
THAT'S WHAT I'M TRYING TO SAY.
>> OH VERY INTERESTING.
>> WE HAVE ONE QUESTION HERE --
WHY DOES ACCERTA REQUIRE
HYSTERECTOMY?
IT SEEMS SO EXTREME.
>> IT'S INTERESTING.
AS THEY GOT MORE SPECIFIC ABOUT
THEIR PROTOCOLS IF YOU PROCEED
TO A PLANNED CAESAREAN
HYSTERECTOMY THERE'S LESS
OVERALL BLOOD LOSS AND LESS
MORBIDITY SO IN GENERAL THAT'S
THE RECOMMENDATION YOU PROCEED
WITH A PLANNED CAESAREAN
HYSTERECTOMY BUT IT'S NOT
NECESSARILY WHAT EVERYONE IS
DOING AND THERE'S ACTUALLY AN
ORGANIZATION THE PAN AMERICAN
SOCIETY FOR P.A.S. DISORDERS
WHERE THERE'S OTHER SITES
ADVOCATING FOR DIFFERENT THINGS
AND IT MAY IN FACT BENEFIT FROM
BEING A PATIENT-CENTERED
DECISION BUT YOU HAVE TO
UNDERSTAND IF IT IS A
PATIENT-CENTERED DECISION YOU'RE
ACCEPTING THE POSSIBILITY OF
INCREASED MORBIDITY.
>> THANK YOU.
I THINK WE DON'T BE ABLE TO TAKE
MORE QUESTIONS BECAUSE IT'S TIME
FOR US TO CLOSE.
SO THIS IS THE END THIS SECOND
SESSION.
THANK YOU FOR ALL YOUR
PRESENTATIONS TO SHARE TODAY.
AND WE WILL NOW HAVE A 10-MINUTE
BREAK AND WE WILL RESTART FOR
THE NEXT SESSION IN 10 MINUTES
AND NEXT SESSION IS GOING TO BE
STRUCTURAL AND SYSTEMIC
CONTRIBUTORS TO MATERNAL
MORBIDITY AND MORTALITY.
THANK YOU, EVERYONE.
>> WELCOME BACK.
I'M JENNIFER ALVIDREZ AND I'LL
BE MODERATING STRUCTURAL AND
SYSTEMATIC CONTRIBUTORS TO
MATERNAL MORBIDITY AND
MORTALITY.
WE HAVE FIVE SPEAKERS.
YOU CAN LOOK AT THEIR BIOS ON
THE REGISTRATION PAGE.
I MAY POP IN AROUND THE
NINE-MINUTE MARK IF IT SEEMS
LIKE YOU'RE NOT WINDING UP YOUR
PRESENTATIONS AND FOR THE
AUDIENCE FEEL FREE TO PUT IN
QUESTIONS IN THE Q&A AND THE
FIRST SPEAKER IS PINKA
CHATTERJI.
>> THANK YOU.
I'M FROM THE ECONOMICS
DEPARTMENT AND HAPPY TO BE HEAR.
MY COLLABORATORS ARE FROM EMORY
UNIVERSITY AND FROM SYRACUSE
UNIVERSITY.
THIS PROJECT IS AN
ADMINISTRATIVE SUPPLEMENT TO A
LARGER STATE POLICY AND
EDUCATIONAL ATTAINMENT AND
MORTALITY.
JUST TO SUMMARIZE WHAT WE'VE
BEEN HEARING IS WE KNOW IF YOU
COMPARE THE UNITED STATES TO
OTHER SIMILAR INDUSTRIALIZED
COUNTRIES, RATES AND MATERNAL
MORTALITY RATES ARE HIGHER AND
WE KNOW OVER THE LAST FEW
DECADES THE RATES ARE RISING
RAPIDLY AND HEARD ABOUT RISK
FACTORS FOR MATERNAL MORBIDITY
AND MORTALITY INCLUDE LOW SES
AND ADVANCED MATERNAL RACE AND
RACE/ETHNICITY AND THERE'S
EMPHASIS ON THE GROWING EVIDENCE
OF THE IMPORTANCE OF
PRE-CONCEPTION HEALTH IN
DETERMINING PREGNANCY AND
OUTCOMES.
THE FOCUS OF THE PRESENTATION IS
THE IDEA THAT RISING SMM RATES
HIGHLIGHT THE UNMET NEED FOR
CONTINUOUS AND COMPREHENSIVE
HEALTH INSURANCE COVERAGE FOR
WOMEN.
MEDICAID PLAYS AN OUTSIZED ROLE
IN INSURING THIS POPULATION.
TWO OF THREE ADULT WOMEN
ENROLLED IN MEDICAID ARE IN
REPRODUCTIVE YEARS AND MEDICAID
FINANCED ABOUT 42% OF
U.S. BIRTHS AND COVERS WOMEN
FROM CONCEPTION TO 60-DAYS
POSTPARTUM LEAVING LARGE NUMBERS
UNINSURED OR SWITCHING IN PLANS
PRIOR TO CONCEPTION.
SO IN 2014 UNDER THE AFFORDABLE
CARE ACT, 37 STATES AND D.C.
EXPANDED MEDICAID TO INCLUDE
LOW-INCOME ADULTS AND THE
MEDICAID EXPANSION MAY HAVE
IMPROVED THE CONTINUITY OF
MEDICAID FROM THE PRECONCEPTION
BY EXTENDED TO ADULTS WITHIN THE
FEDERAL POVERTY LINE.
WE FOCUSSED ON THE IDEA WOMEN
MAY HAVE MORE OPPORTUNITIES FOR
PRECONCEPTION INSURANCE
COVERAGE.
THE FIRST AIM WERE USING RECORDS
FROM 2011 TO 2018.
OUR SECOND AIM IS TO DETERMINE
WHETHER THE MEDICAID EXPANSIONS
HAD AFFECTS BASED ON MATERNAL
AGE WITH A FOCUS ON OLDER
MOTHERS AND THIS IS OUR
ESTIMATED INFLATION.
WE USED A DIFFERENT METHOD WHICH
IS ESSENTIALLY A BEFORE AND
AFTER COMPARISON AND THE VAR L
VARIABLE IS AN INDICATOR FOR
MATERNAL HEALTH OUTCOME WITHIN
STATE J AND THE MOST IMPORTANT
COVARIANT IS AN INDICATOR OF
MEDICAID EXPANSION AND WE
MEASURED THE EXPOSURE DURING THE
P
CONCEPTION PERIOD AND ONE IS
USING THE INDICATOR FOR WHICH
THE MOTHER LIVING IN THE STATE
THAT HAD ELIGIBILITY FOR
MEDICAID AT 138% OF THE FEDERAL
POVERTY LINE FOR CHILDLESS
ADULTS AND THE 12 MONTHS PRIOR
TO THE CONCEPTION DATE OF THE
INFANT AND STATED ELIGIBILITY IN
THE 12 MONTHS PRIOR TO
CONCEPTION.
WE INCLUDE INDIVIDUAL
CHARACTERISTICS SUCH AS MATERNAL
AGE AND RACE AND WE INCLUDE PER
CAPITA INCOME AND OB-GYNs IN THE
COUNTY AND THE MODELS INCLUDE
YEAR FIXED AFFECTS, STATE
SPECIFIC TIME TRENDS AND THEY'RE
CLUSTERED.
SO THIS APPROACH IS PRETTY
STANDARD IN THE LITERATURE AT
THIS POINT.
WE'RE IN THE PROCESS OF ADDING
AND IN THE PRESENTATION FOR THE
RESULTS WE'RE LOOKING AT THE
BIRTHS AT MOTHERS 15 TO 25 AND
THE REASON WE'RE FOCUSSING ON
FIRST BIRTHS IS BECAUSE I WANT
TO MAKE A COMPARISON.
PEOPLE HAVING THEIR FIRST BIRTHS
ARE THOSE CHILDLESS AT THE TIME
OF CONCEPTION SO THEY CAN
POTENTIALLY BE MOST EXPOSED TO
THE MEDICAID EXPANSION FOCUSSING
ON CHILDLESS ADULTS AND FOCUS ON
MOTHERS WITHOUT A COLLEGE DEGREE
SINCE THEY'RE LIKELY TO BE
ELIGIBLE FOR MEDICAID.
MOST USES BIRTH CERTIFICATES
DATA.
THE ANALYSIS ARE AT THE STATE
AND YEAR LEVEL BECAUSE AT THIS
POINT THE NATIONAL IN PATIENT
SAMPLE NOT USED AND ANALYSES OF
SUB SAMPLES IS STILL POSSIBLE
BECAUSE THE RATES OF SMM BY
CERTAIN SUB SAMPLES FOR EXAMPLE
BY AGE.
ALL THE RESULTS ARE BASED ON
SAMPLES THAT INCLUDE STATES THAT
OFFERED ANY LEVEL OF MEDICAID
COVERAGE FOR CHILDLESS ADULTS
PRIOR TO 2014 AND HAD AN
EXPANSION AFTER 2014 OR HIGH
DEGREE OF MISINFORMATION AND
SPECIFICALLY MATERNAL EDUCATION
AND INTERESTS.
THIS IS A VERY LIMITED SAMPLE
FOR THIS PRESENTATION BUT WE
HAVE OTHER RESULTS BASED ON A
MORE BROAD SAMPLE THAT'S MORE
SIMILAR.
I'LL SKIP STRAIGHT TO THE
RESULTS.
SO THIS INFORMATION IS COLLECTED
FROM BIRTH CERTIFICATES.
WE CLASSIFIED THEM AT HEALTH
PROBLEMS BEFORE PREGNANCY AND AT
DELIVERY.
THE RATES OF HEALTH PROBLEMS
JUST TO MAKE A FEW COMMENTS
BEFORE PREGNANCY ARE QUITE
COMMON AND AMONG OLDER VERSUS
YOUNGER MOTHERS.
THE RATE IS 14.2% UNDER AGE 35
AND 25.7% AMONG OTHERS 35 TO 55.
HEALTH PROBLEMS AT DELIVERY RARE
AND THEY'RE RARE FOR BOTH AGE
GROUPS COMPARED TO DURING AND
BEFORE PREGNANCY IF YOU LOOK
ACROSS AGE.
WE ALSO USE STATE YOUR DATA ON
MATERNAL MORBIDITY AND THE
SEVERE RATE AND IT'S 68 PER
10,000 LIVE BIRTHS.
SO I'LL QUICKLY SUMMARIZE OUR
RESULTS.
THIS IS AN EVENT STUDIO GRAPH.
IT'S 2013 AS THE BASELINE YEAR.
WE'RE COMPARING MOTHERS LIVING
IN STATES TO CHILDLESS ADULTS TO
THOSE THAT DIDN'T EXTEND
MEDICAID AND COMPARING THEM
BEFORE AND AFTER MEDICAID WAS
EXPANDED.
ON THE HORIZONTAL AXIS THE YEAR
OF CONCEPTION AND 2011 AND 2022
THERE WERE NO DIFFERENCES
BETWEEN MOTHERS THAT LIVED IN
STATES THAT EXPANDED MEDICAID
THAT DID AND DIDN'T.
IT SUGGESTS OUR COMPARISON GROUP
IS A GOOD COMPARISON GROUP.
AFTER 2013 YOU SEE THE
DIFFERENCE BETWEEN MOTHERS
LIVING IN STATES THAT EXTENDED
MEDICAID AND THOSE THAT DID NOT
EXPAND MEDICAID AND THE VERTICAL
LINES ARE 95% CONFIDENCE
INTERVAL THE RED LINES REPRESENT
THE SAMPLE LIMITED TO OLDER
MOTHERS, 35 TO 55 AND THE BLACK
LINES REPRESENT MANY CONFIDENCE
INTERVALS FOR MOTHERS YOUNGER
THAN 35 YEARS OLD
THE TAKEAWAY MESSAGE IS THAT FOR
BOTH OLDER AND YOUNGER MOTHERS
YOU SEE AN INCREASE IN IDENTIFY
HEALTH PROBLEMS IN 2014 AND 2015
THE FIRST COUPLE YEARS AFTER
EXPANSION COMPARED TO 2013 AND
THE RESULT GOES AWAY STARTING IN
2016.
THIS IS THE SAME SET OF RESULTS
BUT NOW I'M LOOKING AT HEALTH
PROBLEMS DURING DELIVERY.
HERE YOU SEE DIFFERENCES BETWEEN
OLDER AND YOUNGER MOTHERS AND
THE MEDICAID EXPANSIONS APPEAR
TO BE ASSOCIATED WITH INCREASED
HEALTH PROBLEMS.
HERE WE DON'T SEE AFFECT ON THE
MEDICAID EXPANSION ON THESE
OUTCOMES.
WE CAN LOOK AT THE RESULTS BY
SPECIFIC HEALTH OUTCOME AND THIS
GIVES THE GENERAL PATTERN MUCH
RESULTS AND WHAT SHOULD AND
SHOULDN'T BE INCLUDED IN SMM
BECAUSE SOME HEALTH PROBLEMS AT
DELIVERY SHOULD PROBABLY NOT BE
INCLUDE LIKE MATERNAL
TRANSFUSION AND HYSTERECTOMY BUT
BASICALLY THE BOTTOM LINE IS WE
SEE INCREASES IN HEALTH PROBLEMS
BEING IDENTIFIED BEFORE AND
DURING THE PREGNANCY AND THESE
ARE FAIRLY LARGE IN MAGNITUDE.
AMONG MOTHERS YOUNGER THAN 35
YEARS OLD THE MEDICAID
EXPANSIONS ARE ASSOCIATED WITH A
3% INCREASE IN THE LIKELIHOOD OF
HAVING ANY PROB IDENTIFIED
BEFORE OR AFTER PREGNANCY AND AN
INCREASE AT THE MEAN.
THESE SHOW RESULTS BY SUBSAMPLES
BY SMM AND AFTER THIS SLIDE I'LL
FINISH AND OVERALL WE DON'T SEE
ANY AFFECT OF THE MEDICAID
EXPANSIONS ON THE STATE LEVEL
RATE OF SMM AND WE DO SEE SOME
POSITIVE FINDINGS FOR CERTAIN
SUBSAMPLES.
SPECIFICALLY YOUNGER MOTHERS,
LATINOS, MOTHERS OF OTHER RACE,
MOTHERS IN THE LOWEST INCOME
QUARTILE.
MOTHERS IN NON-METROPOLITAN
AREAS AND LIVING IN PUBLIC
HOSPITALS.
I DIDN'T GET TO TALK MUCH ABOUT
OTHER LITERATURE BUT I WANT TO
MENTION THAT ONE INTERPRETATION
OF THE FINDINGS IS THE ACA
MEDICAID EXPANSIONS MAY HAVE
INCREASED IDENTIFICATION OF
HEALTH PROBLEMS PRIOR TO AND
DURING PREGNANCY AND ONE THING
WE NEED TO INVESTIGATE
SUBSIDIZED INSURANCE AND WE SEE
MIXED AFFECTS DURING DELIVERY
SURPRISING AND HARD TO EXPLAIN
AND ONE CITATION IS USING A
SIMILAR SET UP AND ONE SAMPLE IS
SIMILAR TO OURS AND I THINK
THEY'RE QUITE SIMILAR SO I'M
INTERESTED IN CONNECTING AFTER
THE TALK AND LOOKING AT MEDICAID
EXPANSION AT THE COMPOSITION OF
MOTHERS AND ARE THERE ISSUES ON
THE SUPPLY SIDE FOR EXAMPLE THE
DENSITY OF PROVIDERS.
I APPRECIATE ANY COMMENTS AND
SUGGESTIONS.
THANK YOU.
>> FEEL FREE TO PUT ONLY
QUESTIONS YOU HAVE IN THE Q&A.
I DON'T SEE QUESTIONS YET.
WERE YOU ABLE TO LOOK AT
INTERACTIONS LIKE RACE/ETHNICITY
BY AGE AND DID YOU FIND ANYTHING
INTEREST THERE?
>> THAT'S A GREAT IDEA AND WHERE
WE NEED TO GO NEXT.
ONE OF THE ADVANTAGE OF USING
BIRTH CERTIFICATE DATA IS A HUGE
SAMPLE.
WE'LL BE ABLE TO LOOK AT
RACE/EDUCATION SUBSAMPLES WHICH
I THINK IS A GREAT IDEA.
AND WE'RE USING DATA THAT'S
ALREADY BEEN AGGREGATED AND
THAT'S WITH THAT OUTCOME WE'RE
MORE LIMITED.
WHAT IS YOUR VIEW ABOUT QUALITY
OF DATA ON SMM?
IT SEEMS UNDERESTIMATED TO ME?
>> THINK WE HAVE THE SAME
CONCERN AND THAT'S WHY TODAY'S
BEEN SO HELPFUL TO US.
IN TAKING THE DATA FROM THE NIS
BASED ON ICD9 AND ICD10 NOW
CODES AND PROCEDURES AND
DIAGNOSES DURING THE DELIVERY
AND THEY'RE USING THE CDC SAME
AND LIST OF CONDITIONS SHOWED
THERE.
THAT DATA TO ME THE QUALITY
SEEMS DIFFERENT FROM THE BIRTH
CERTIFICATE DATA.
AND QUALITY IS CHANGING OVER
TIME IN DIFFERENT STATES A.D
>> AND EXPANDING ACCESS TO
MEDICAID AND FACILITATING PEOPLE
TO SIGN UP ARE TWO DIFFERENT
THINGS.
COULD THAT HAVE PLAYED A ROLE
ABOUT THERE WAS AN IMPACT EARLY
ON BUT NOT LATER?
>> THAT'S A GREAT POINT AND A
WISH WE COULD ADDRESS THAT.
WE HAVE THE MOTHER'S INSURANCE
STATUS ON THE BIRTH CERTIFICATE
BUT A LOT OF MOTHERS GET SIGNED
UP LATE IN PREGNANCY OR AFTER
DELIVERY BUT THERE'S OTHER DATA
SETS THAT HAVE INFORMATION
THOUGH ON MOTHERS INSURANCE
STATUS BEFORE GIVING BIRTH AND
JUST AFTER BIRTH AND THERE'S
OTHER RESEARCHERS WORKING ON
THAT AND IF I CAN STATE THE
RESULTS CORRECTLY I THINK THE
FOUND THE MEDICAID EXPANSIONS
INCREASE MEDICAID COVERAGE
AROUND THE TIME OF BIRTH AND
THAT'S A GREAT POINT WE CAN'T
REALLY ADDRESS IN THE STUDY.
>> THANK YOU SO MUCH.
I DON'T SEE MORE QUESTIONS SO WE
CAN MOVE ON.
OUR NEXT SPEAKER DR. NORMAN AND
DR. BLAKE.
AND YOUR SLIDES ARE UP SO TAKE
IT AWAY.
>>
>> MITIGATING THE IMPACT ON
MATERNAL MORBIDITY AND MORTALITY
FOR AFRICAN AMERICAN WOMEN.
THIS IS A COLLABORATIVE EFFORT
BETWEEN DETROIT AND ATLANTA THAT
BEGAN IN MICHIGAN.
TO BEGIN I'D LIKE TO INTRODUCE
YOU TO OUR LEADERSHIP TEAM.
IN MICHIGAN WE HAVE THE CURRENT
P.I. AND MYSELF, AND IN ATLANTA
WE HAVE DR. DUNLOP AS PRINCIPLE
INVESTIGATOR AND DR. BLAKE AS
THE CO-INVESTIGATOR.
I WANT TO EXPLAIN WHY IMPLICIT
BIAS HAS BECOME A TARGET FOR
INTERVENTION IN THIS RESEARCH
AND THE IMPORTANT ROLE IMPLICIT
BIAS PLAYS IN PREGNANCY
OUTCOMES.
THE IOM NOTED ATTITUDE AND
BEHAVIORS OF HEALTH CARE
PROVIDERS IDENTIFIED AS FACTORS
THAT CONTRIBUTE TO HEALTH
DISPARITIES AND UNRECOGNIZED
BIAS AGAINST RACIAL AND ETHNIC S
MAY AFFECT COMMUNICATION WITH
PROVIDERS IN THE RECEIPT OF CARE
AND IT WAS RELATED TO HEALTH
OUTCOMES THAN TO ACTUAL
TREATMENT PROCESSES.
SO OUR DETROIT COLLABORATION
DEVELOPED FOCUS GROUP INTERVIEW
GUIDES FOR AFRICAN AMERICAN
WOMEN.
ONE TO UNDERSTAND THEIR
EXPERIENCES IN SEEK PRENATAL AND
DELIVERY CARE ADDRESSING THE
STRUCTURAL AND SOCIAL BARRIERS
TO ACHIEVING RACIAL EQUITY AND
TWO TO DETERMINE HOW BEST TO
OPTIMIZE HEALTH CARE SERVICE.
WE ALSO CO-CREATED INTERVIEW
GUIDES FOR HEALTH CARE PROVIDERS
TO GAUGE THEIR KNOWLEDGE OF THE
ROLE OF IMPLICIT BIAS ON THE
PRENATAL DELIVERY AND POSTPARTUM
CARE.
OUR WORK IN THE ECHO COHORT WAS
EXPANDED TO FOCUS ON REDUCING
MATERNAL MORBIDITY AND MORTALITY
TO THE VOICES OF WOMEN AND
HEALTH CARE PROVIDERS.
IT'S A REGIONAL QUALITY
COLLABORATIVE IN MICHIGAN'S
REGION 10 AS A COLLABORATOR.
AND BRINGS TOGETHER FAMILIES AND
FAITH-BASED ORGANIZATIONS.
AN PROVIDED A PLATFORM FOR THE
LAUNCH OF THE STUDY AND FOR
ONGOING COMMUNICATION WITH
COMMUNITY STAKEHOLDERS.
THE GOAL OF THE STUDY WAS
THROUGH THE CONDUCT OF
COMMUNITY-BASED PARTICIPATORY
RESEARCH TO REDUCE THE IMPACT OF
BIAS THAT MAY CONTRIBUTE TO
INCREASED RISK FOR MATERNAL
MORBIDITY AND MORTALITY IN
HIGH-RISK POPULATIONS.
WE'RE ENGAGING AFRICAN AMERICAN
MOTHERS AND COMMUNITY HEALTH
ADVOCACY ORGANIZATIONS AND
HEALTH CARE PROVIDERS AND
UTILIZING A MIXED METHOD
APPROACH AND THE DATA WILL BE
USED TO DEVELOP A TOOL KIT OF
STRATEGIES FOR MOTHERS TO
COUNTER NEGATIVE INTERACTIONS
AND TO OBTAIN PATIENT-CENTERED
RESPECTFUL CARE.
WE HAD TO AIMS AND THEY'RE THE
TWO PHASES.
ONE IS TO IDENTIFY FACILITIES
AND BARRIERS AND TO GAIN IMPACT
OF IMPLICIT BIAS AND RACISM ON
AFRICAN AMERICAN BASED ON INPUT
FROM KEY INFORMANTS INCLUDING
AFRICAN AMERICAN WOMEN AND PHASE
TWO TO DEVELOP STRATEGIES THAT
WILL OPTIMIZE UTILIZATION FOR
EFFECTIVENESS OF HEALTH CARE
SERVICES FOR AFRICAN AMERICAN
MOTHERS.
AND WE INTERVIEWED THREE OB-GYNs
AND MID WIVES AND FOUR DOULAS
AND WE HAD INTERVIEWS AND
PARTICIPANTS WITH 60 TO 90
MINUTE INTERVIEWS BETWEEN JUNE
AND DECEMBER 2021.
AND GIFT CARDS WERE ALSO
PROVIDED.
WE'LL BE COLLABORATING WITH THE
ANALYSIS OF THE DATA AND WE'LL
TURN IT TO DR. SARA BLAKE TO
DISCUSS THE PROGRESS AND EARLY
FINDINGS.
>> ON BEHALF OF THE COHORT LED
AND FOCUSES ON MATERNAL
MORTALITY THROUGH THE VOICES OF
WOMEN AND HEALTH CARE PROVIDERS
IN GEORGIA.
YOU MAY BE AWARE, GEORGIA HAS
AMONG THE HIGHEST RATES OF
MATERNAL MORTALITY HAVING WITH
1.6 TIMES MORE DEATHS THAN WHITE
WOMEN AND HEALTH DISPARITIES
LOOKS AT DISCRIMINATION AND
SYSTEMIC RACISM AND
INSTITUTIONAL BARRIERS AND
QUALITY CARE.
THE IMPLICATIONS OF BLACK
WOMAN'S VOICE AND THE SUPPORT OF
SOLUTION CRITICAL TO ACHIEVING
MATERNAL HEALTH EQUITY.
THE RESEARCH FROM THE COHORT
CAPITALIZED WITH LOOKING AT THE
COHORT AND USED A
COMMUNITY-BASED PARTICIPATORY
APPROACH AND WORKED WITH THE
ATLANTA-BASED BLACK CENTERED
WELLNESS TO ADDRESS THEIR
BELIEFS AND EXPERIENCES WITH
IMPLICIT BIAS AND RACISM IN
HEALTH CARE.
THIS WORK SERVE TO DEVELOP
CRITICAL STRATEGY FOR REDUCING
OR MITIGATING THE IMPACT OF THE
EXPOSURES AND THE EFFECT ON
THESE WOMEN AND FAMILIES.
TO LIFT UP OUR PARTNERS IN
ATLANTA THEY HAVE SERVED BLACK
WOMEN AND THEIR FAMILIES IN THE
AREA AND THEY BROADEN AWARENESS
OF THE HEALTH ISSUES AFFECTING
BLACK WOMEN AND PROVIDING
PREVENTIVE HEALTH SERVICE FOR
WOMEN IN THE ATLANTA AREA AND
THEY SERVE OVER 300 MOTHERS AND
CHILDREN ANNUALLY.
THE CENTER FOR BLACK CENTER
WEN
WELLNESS AND WE PRESENT
ADDITIONAL WORK IN THE PROJECT.
I WANT TO BRIEFLY SHOW YOU IN
THE FIGURE OUR WORK WAS BY A
CONCEPTUAL MODEL THAT ADDRESS
THE ROLE OF IMPLICIT BIAS AND
ILLUSTRATE THE PATHWAYS THROUGH
WHICH IT MAY AFFECT THE PATIENT
PROVIDER RELATIONSHIP AND
RELATED PROCESSES.
UNAWARE THAT PERCEPTIONS AND
DECISIONS WERE DISTORTED BY
IMPLICIT BIAS.
ALSO SHOWN IN THAT IS AT THE MAY
AFFECT TREATMENT THROUGH THE
EFFECTS ON PATIENT PROVIDER
COMMUNICATION.
SO OUR HYPOTHESIS IN THIS WORK
IS ELUCIDATINE INING GUIDANCE CAN
OFFER INFORMATION USEFUL IN
IMPROVING BLACK WOMEN'S
TREATMENT IN THE HEALTH CARE
SETTING AND THE UTILIZATION AND
PARTICIPATION IN HEALTH CARE
THERE BE REDUCING DISPARITIES
AND ADVERSE MATERNAL HEALTH
OUTCOMES.
OUR AIMS ARE SIMILAR TO THE
DETROIT ECHO PROJECT AND THAT WE
ARE THROUGH THIS WORK
IDENTIFYING FACILITATORS AND
BARRIERS TO EQUITABLE AND
RESPECTFUL CARE TO BLACK WOMEN
BUT ALSO HOPING TO DEVELOP
STRATEGIES FOR A CULTURE OF
RESPECTFUL CARE AND CULTURAL
HUMILITY FOR BUILDING PATIENT
TRUST AND BUILDING
PATIENT-PROVIDER COMMUNICATION.
WE ARE UNDERTAKING A TWO-PHASE
ADD APPROACH.
WE COMPLETED PHASE 1 AND THESE
DATA WILL BE USED TO HELP INFORM
PHASE 2 WHERE WE'RE WORKING
TOWARDS SOLUTIONS AND ALSO
HELPING PROVIDERS GAIN
ADDITIONAL TREATMENT IN IMPLICIT
BIAS AND RESPECTFUL AND
EQUITABLE CARE.
>> WE'RE AT ABOUT NINE MINUTES.
>> AND JUST TO SHOW WE COMPLETED
PHASE 1 AND DID INTERVIEWS WITH
PROVIDERS HERE THROUGH 60-MINUTE
INTERVIEWS AND JUST COMPLETED
FOCUS GROUPS IN THE ATLANTA AREA
AND ACROSS ATLANTA WITH BLACK
WOMEN REPRESENTING VARIOUS
GROUPS IN THE GEORGIA
COMMUNITIES.
I WANT TO SHARE WITH YOU BRIEFLY
MAYBE WE CAN MOVE TOWARD OUR
FINDINGS A COUPLE SLIDES DOWN TO
GIVE US INSIGHT INTO OUR
FINDINGS FROM THE PROVIDER
INTERVIEWS.
WE ADDRESSED IMPLICIT BIAS ON
CLINICAL CARE AND PROVIDERS
ACKNOWLEDGED THEY HAD SOME
IMPLICIT BIAS THAT PLAYED A ROLE
IN THEIR CARE AND NOTICED THE
CARE OF THEIR COLLEAGUES.
THEY RECOGNIZED BLACK WOMEN
EXPERIENCE LIFE LONG STRESS
INFLUENCED BY A HISTORY OF
DISCRIMINATORY PRACTICE BUT
WEREN'T SURE HOW TO ADDRESS THIS
IN THEIR CARE.
WE ASKED TO PROVIDERS TO TALK
ABOUT THEIR UNDERSTANDING OF
RESPECTFUL CARE AND DEFINE IT IN
MANY WAYS SUCH AS LISTENING TO
PATIENTS AND ACKNOWLEDGING THEIR
CONCERNS AND TO ENSURE
RESPECTFUL CARE THEY MUST
ADDRESS THEIR CONCERNS INCLUDING
AND SPECIFICALLY THE SAFETY OF
PREGNANCY AND DELIVERY WOMEN
OFTEN RAISED.
AND FINALLY EQUITABLE CARE.
PROVIDERS PROVIDE IT AS
PROVIDING THE SAME STANDARDS OF
QUALITY AND MATERNAL HEALTH
CARE.
TA -- AND PATIENT-CENTERED CARE
AND ADDRESSING THEIR OWN BIASES
TO OVERCOME THEM AS THEY CARE
FOR BLACK WOMEN.
THAT'S A QUICK SUMMARY OF OUR
PRELIMINARY FINDINGS AND HOPE TO
BE JOINED TO SHARE ADDITIONAL
VOICES EN OUR STUDIES OF BLACK
WITH OUR STUDY AND THANK YOU AND
WE WELCOME ANY QUESTIONS.
>> WE HAVE ONE QUESTION.
DID YOU FIND DIFFERENCE IN THE
IMPLICIT BIAS BETWEEN DIFFERENT
PROVIDERS FOR EXAMPLE DOULAS
COMPARED TO PHYSICIANS?
>> I'LL ANSWER THAT FIRST AND WE
DID NOT INTERVIEW DOULAS.
WE INTERVIEWED JUST PHYSICIANS
AND NURSE MIDWIVES.
THERE WERE RECOGNITIONS OF
IMPLICIT BIAS AND EQUITABLE AND
RESPECTFUL CARE.
NURSE MIDWIVES HAVE MORE
STRATEGIES AND RECOMMENDATIONS
HOW TO ADDRESS IMPLICIT BIAS IN
THEIR CARE AND WERE I THINK MUCH
MORE AWARE OF THE IMPORTANCE OF
TRAINING AND THE NEED FOR
ADDITIONAL EXPOSURE TO THESE
ISSUES ACROSS THEIR HOSPITAL
SYSTEMS.
BUT DR. NORMA, WHAT DID YOU
FIND?
>> ONE THING WE FOUND WITH OUR
DOULAS IS THEY DID HAVE
DIFFICULTY AND DIDN'T HAVE
PROBLEMS WITH OB-GYNS IN THE
LABOR AND DELIVERY SETTING AND
TALKED ABOUT THE IMPLICIT
BIASSED THEY WITNESSED AND WE
ASKED AMONG EACH OF THE GROUPS
WHAT DID THEY SEE AMONG THEIR
PEERS.
WE SAW IT OCCASIONALLY WITH THE
NURSE MIDWIVES BUT THE DOULAS
SAY THEY DIDN'T SEE IT AMONG
THEIR PEERS BUT IN THE DELIVERY
SUITE THEY ENCOUNTERED IMPLICIT
BIAS.
>> HOW REPRESENTATIVE DO YOU
THINK CLINICIAN SAMPLES WERE?
DID THE CLINICIANS WHO HAVE MORE
CULTURAL SENSITIVE OR HUMILITY
WERE THEY LIKELY TO PARTICIPATE
IN THE VIEWS?
-- INTERVIEWS.
>> ALMOST ALL HAD EXPOSURE TO
TRAINEE AND THEY VARIED IN SOME
WERE MORE CYNICAL ABOUT THE
VALUE OF ADDITIONAL TRAINING OR
ONE-OFF TRAININGS WERE NOT
NECESSARILY ENOUGH AND REQUIRED
A HOSPITAL-BASED OR
SYSTEMS-BASED CULTURE CHANGE BUT
WE ARE IN THE NEXT PHASE TO TEST
THAT MORE AS WE'RE WORKING WITH
COLLABORATIVE PARTNERS TO
DEVELOP ADDITIONAL HIGHER LEVEL
IMPLICIT BIAS TRAINING.
>> SOMETIMES IT'S OUTRIGHT HARM.
HOW DOES THAT FIGURE INTO THE
RESEARCH AND SOLUTIONS?
>> WHAT DID YOU SAY ABOUT
IMPLICIT BIAS -- IT'S EXCLUSIVE
BIAS, OUTRIGHT HARM AND HOW DO
YOU TAKE THAT INTO ACCOUNT?
>> WE DID ASK ABOUT IMPLICIT
BIAS AND SOMETIMES THEY WOULD
VOLUNTARILY MENTION THEY WOULD
SEE WHERE THE PROVIDER WAS
COGNIZANT OF WHAT THEY WERE
DOING BUT THAT'S ONE OF THE
THINGS WE'RE STILL IN THE
PROCESS OF DOING THE ANALYSIS OF
THAT INFORMATION.
>> THERE'S ONE MORE QUESTION BUT
IN THE INTEREST OF TIME MAYBE
YOU CAN BOTH TYPE THE ANSWER TO
THAT ONE AND WE CAN MOVE ON TO
OUR NEXT SPEAKER SO THANK YOU
BOTH VERY MUCH FOR YOUR
PRESENTATION.
>> THANK YOU.
>> THE NEXT PRESENTER IS
DR. EMILY HARVILLE FROM TULANE
UNIVERSITY.
A PUBLIC HEALTH EXPOSOME
APPROACH TO MATERNAL MORTALITY.
>> CAN YOU HEAR ME?
>> YES.
>> AND YOU SEE MY SLIDES?
>> YES.
>> THANK YOU FOR INVITING US TO
PRESENT TODAY.
I'LL BE SPEAK ON PUBLIC HEALTH
EXPOSOME APPROACH TO MATERNAL
MORTALITY.
AIM OF THE PARENT GRANT WAS TO
LOOK AT SOCIAL CONTEXTS THAT
INCREASE THE RISK FOR PREGNANCY
RELATED MORTALITY AND PREGNANCY
RELATED HOMICIDE AND THE AIM WAS
TO USE AN EXPOSOME WIDE
COMPUTATIONAL APPROACH FOR
PREDICTORS OF MATERNAL MORTALITY
FOR BOTH THE UNITED STATES AS A
WHOLE AND LOUISIANA.
AND SO TO IDENTIFY POSSIBLE
POINTS OF INTERVENTION THAT
OCCURRED CLINICALLY AND AT
PLACES, POLICY AND SOCIETAL
STRUCTURES.
DEALING WITH THE EXPOSURES
REQUIRES INNOVATION IN
METHODOLOGY.
WE'RE DRAWING ON A DATA SOURCE
WHICH IS CALLED THE PUBLIC
HEALTH EXPOSOME AND THIS IS A
DATA REPOSITORY OF VARIABLES GEO
GEOCODE AND HARMONIZED AT A
COUNTY LEVEL AND 6500 ARE FROM
2014 TO 2018 AND THEY'RE TAKEN
FROM FIVE DOMAINS.
WE HAVE THE NATIONAL
ENVIRONMENTS THAT INCLUDES
THINGS LIKE CLIMATE, WATER,
POLLUTION, HEAT, AIR.
WE HAVE THE BUILT ENVIRONMENT
THAT'S LAND USE AND BUILDINGS,
TRANSPORTATION AS WELL AS
CERTAIN HOUSING TERMS AND SOCIAL
ENVIRONMENT, ECONOMICS AND
POVERTY AND SO FORTH AND THE
POLICY ENVIRONMENT IN THIS CASE
IS PRIMARILY GOVERNMENT
EXPENDITURES AND BENEFIT TERMS
AND HEALTH CARE AVAILABILITY AND
OUTCOMES.
WE HYPOTHESIZED THE COMBINATION
OF BEING EXPOSED TO ALL THESE
DOMAINS OVER TIME AFFECTS THE
RISK OF DEATH DURING PREGNANCY
AND POSTPARTUM AND DIFFERENTIAL
EXPOSURES TO THE EXPOSOME
PRODUCE MATERNAL POPULATION
BASED HEALTH INEQUITIES.
SO FOR OUR ANALYSIS FOR THE
NATIONAL LEVEL WE'RE USING THE
PREGNANCY RELATED DEATHS FILES
FROM NCHS FROM 2015 TO 2018 AND
FOR LOUISIANA USING VITAL
RECORDS DATA WITH VERIFIED
MATERNAL DEATHS 2016 TO 2018 AND
FOR LOUISIANA WE HAVE DATA.
I'LL GIVE A SIMPLIFIED OVERVIEW
OF WHAT THE METHODS LOOK LIKE.
WE START WITH A HETEROGENEOUS
SOURCE OF DATA AND THERE'S
HIGHLY CORRELATED VARIABLES AND
WE DEVELOPED AN ALGORITHM TO
REDUCE CORRELATES WITHIN THE
DATA SET.
THEN WE GROUP IT IN VARIOUS
WAYS.
CORRELATION MATRICES AND GRAPHS.
BROADLY WE HAVE THE SUPERVISED
ANALYSIS AND WHERE UNSUPERVISED
AND WE LOOK AT WHICH GROUPS HAVE
MATERNAL MORTALITY IN THEM.
ONCE WE HAVE THE GROUPS WE PULL
OUT SUBSETS AND CAN APPLY MODEL
ORG REGRESSION OF ANALYSIS TO
OUR RESULTS.
ONE THING WE NOTICED IS THAT THE
DATA SET WAS DRAWN FROM A WHOLE
BUNCH OF PLACES AND FACTORS
ASSOCIATED COME FROM A WIDE
VARIETY OF SOURCES.
SO WE HAVE NATIONAL STATISTICS
AND BEHAVIORAL RISK FACTORS,
SMOKING, POOR HEALTH OR LACK OF
SLEEP.
FOR THE CENSUS WE HAVE POVERTY.
FROM THE DIABETES SURVEILLANCE
WE HAVE LACK OF LEISURE TIME
ACTIVITY AND FROM ATSCR AND WE
HAVE TEENAGE PREGNANCY.
FROM HOUSING DEVELOPMENT WE HAVE
INCOME AND FROM THE LAND USE
DATA WE HAVE EXTREME HEAT.
ONCE WE HAVE A SET OF VARIABLES
WE CAN INCORPORATE THEM INTO A
GRAPH THAT LOOKS LIKE THIS
BECAUSE THEY'RE HIGHLY
CORRELATED WITH EACH OTHER AND
THEN WE CAN DO THINGS LIKE
ANALYSIS AND THEN HERE WHAT WE
SEE IS THE THREE FACTORS THAT
WERE DIRECTLY UPSTREAM PREDICT
PREDICTORS AFTER THE COUNTY
LEVEL WERE OVERALL YEARS OF
POTENTIAL LIFE LOFT AND LACK OF
PHYSICAL ACTIVITY AND EXTREME
HEAT.
IF WE MOVE TO OUR UNSUPERVISED
ANALYSIS FINDING CLUSTERS IN
VARIES WAYS THE CLUSTER THAT
CONTAINS THE MATERNAL MORTALITY
THE FIRST THING IS IT CONTAINED
ALL THE MATERNAL MORTALITY
VARIABLES.
OVERALL AS WELL AS THE ETHNIC
VARIABLES THEY CAME INTO A
SINGLE GROUP.
WE NOTICED THE VARIABLES THAT
SEEMED TO CLUSTER COME FROM
DIFFERENT DOMAINS.
BLUE FROM THE BUILT ENVIRONMENT,
PURPLE FROM THE HEALTH AND
HEALTH CARE AND YELLOW FROM THE
NATURAL AND RED FROM THE SOCIAL
ENVIRONMENT.
THESE FACTORS ARE ALL THE
DOMAINS ARE CLUSTERING WITH
MATERNAL MORTALITY.
WE CAN DEAL WITH THIS DATA IN
TWO WAYS.
WE CAN DO A SIMILAR ANALYSIS AS
WE GET TO THE NATURAL LEVEL WITH
THE WHOLE PUBLIC HEALTH EXPOSOME
AND APPLY IT TO MULTI-LEVEL OR
INDIVIDUAL LEVEL DATA.
THE SECOND THING WE CAN DO IS
TAKE RESULTS FROM THE NATIONAL
LEVEL AND APPLY THEM WITH
ADDITIONAL CONTROL FOR
CONFOUNDING.
THESE ARE ONGOING BUT IF WE LOOK
AT THE NATIONAL LEVEL DATA WE
SEE SPECTRAL IRRADIANTS
BASICALLY SUN EXPOSURE IS
CORRELATED WITH PREGNANCY
RELATED MORTALITY BUT HIGHER IN
LOUISIANA ESPECIALLY IF WE
REMOVE OUTLIERS.
IF WE LOOK AT RESULTS FROM THE
NATIONAL LEVEL DATA WE'RE ABLE
TO LOOK AT CONFOUNDERS AND
CONTINUE TO SEE ASSOCIATIONS
WITH POTENTIAL YEARS OF LIFE
LOSS AND HEALTHY FOOD AND
ENVIRONMENT.
WE'RE WORKING WITH A NATIONAL
DATA SET WE ARE DOING COUNTY
LEVEL CORRELATIONS.
THE ABSOLUTE NUMBERS OF MATERNAL
DEATHS ARE SMALL AND THE RATES
CAN BE UNSTABLE.
WE STILL HAVE A FAIR NUMBER OF
AUTOCORRELATED VARIABLES AND
REREDUCED IT BY HALF BUT IN THE
POLICY ENVIRONMENT WE ONLY HAVE
BENEFITS AND GOVERNMENT
EXPENDITURES.
THERE'S A WIDE RANGE OF POLICY
THAT COULD BE INCLUDED THAT'S
NOT HERE.
TO CONCLUDE, WHAT WE DETERMINED
IF THECONTEXTUAL FACTORS
CONTRIBUTE TO MORTALITY AND THE
IDEA MATERNAL MORTALITY
CORRELATES WITH OVERALL
POPULATION HEALTH AND IT'S NOT A
SEPARATE PHENOMENON FROM ALL THE
FACTORS THAT PREDICT MATERNAL
HEALTH.
THE DATA-DRIVEN COMPUTATIONAL
METHODS CAN BE HELPFUL FOR
ADDRESSING THE REAL WORLD
CLEMENT AND THERE'S A NEED FOR
METHODS AND ANALYTICS AND THAT
OUR RESULTS WERE DRAWN FROM
DIFFERENT DATA SOURCE USED TO
ADDRESS AND IMPROVE THE PROB.
I PUT UP THE CONTACT INFORMATION
FOR VARIOUS PEOPLE.
IF YOU HAVE INTEREST PLEASE GET
IN TOUCH AND I'D BE HAPPY TO
TAKE ANY QUESTIONS.
>> I DON'T SEE QUESTIONS SO FAR
IN THE CHAT SO ONE QUESTION IS
HOW DO YOU TRANSLATE FINDINGS
FROM THE COMPUTATIONAL MODELS
INTO POLICY CHANGE?
HAVE YOU WORKED WITH, PARTNERED,
COMMUNICATIONS WITH POLICY
MAKERS AROUND YOUR FINDINGS?
>> OUR FINDINGS ARE PRELIMINARY
AT THIS PART BUT IT IS
INSTRUCTIVE TO LOOK AT POVERTY
OR MAKE IT CLEAR THERE'S
ATTENTION ON MATERNAL MORTALITY
BUT IT'S PART OF A BROADER
SOCIAL FACTOR AND THEY'RE
SOCIETY WIDE PROBLEMS NOTE JUST
ADDRESSED AT THE HOSPITAL.
>> A RELATED ISSUE, THERE HASN'T
BEEN THAT MUCH IN THIS COUNTRY
LOOKING AT THE IMPACT OF CLIMATE
CHANGE ON MORBIDITY.
CAN YOU SPEAK TO THAT.
>> WE CAME AT IT EXPECTING TO
SEE POVERTY AND TO SEE HEAT POP
UP SO MANY TIMES IN OUR ANALYSIS
WAS SOMETHING THAT WAS STRIKE
AND WORRISOME GIVEN THE TRENDS.
IT'S DIFFICULT WITH THE NUMBERS
BUT WANT TO CONTINUE LOOKING AT
THAT AND SOME SAY IT'S BECAUSE
IT'S THE SOUTH AND THE HUGE HAS
WORSE OUTCOMES AND WE WANTED TO
LOOK AT PICKING UP RESIDUAL OR
CONFOUNDING BUT IT'S INTERESTING
THAT CAME UP SEVERAL TIMES.
WHEN WE DID THE ANALYSIS.
>> THANK YOU.
IS ANALYSES LIKE THIS IN MOST
PARTS OR DOES LOUISIANA HAVE
OVERLAP OF THE GREAT DATA
SOURCES?
>> WE ARE ABLE TO LOOK AT THE
MULTI-LEVEL COMPONENT AND YES
MOST OF THE COUNTRY MOST LOOK AT
THE COUNTRY AND WE LOOKED AT OUR
ANALYSIS TO COUNTIES WITH AT
LEAST 1,000 BIRTHS SO OUR RATES
ARE A LITTLE MORE STABLE SO THAT
MEANS THERE'S CERTAIN PARTS OF
LIKE UPPER MIDWEST THAT DON'T
HAVE ENOUGH PEOPLE TO GET GOOD
ANALYSIS.
>> SO YOU SHOW THE APPLICATION
TO LOUISIANA -- DOES THAT
PROFILE LOOK SIMILAR TO OTHER
STATES IN THE SOUTH?
>> LOUISIANA GENERALLY HAS
POORER HEALTH OUTCOMES OVERALL
SO IT'S PROBABLY AT THE BOTTOM
FOR SOME OF THIS STUFF.
I SUSPECT MANY FACTORS WOULD BE
SIMILAR BUT I'D BE HAPPY DISCUSS
IT WITH ANYONE WHO HAS DATA IN
MORE DETAIL.
>> GREAT.
I DON'T SEE ADDITIONAL
QUESTIONS.
WE CAN MOVE ON.
THERE'S A QUESTION IN THE CHAT
ABOUT IS THERE A SEASONAL
PATTERN GIVEN EXTREME HEAT
MORTALITY.
>> I DON'T KNOW THE ANSWER
ACTUALLY GIVEN THE RARITY.
>> THANK YOU VERY MUCH.
>> THANK YOU.
NEXT WE HAVE DR. WAGNER THERE
THE UNIVERSITY OF SOUTH CAROLINA
UNDERSTANDING MATERNAL VITAMIN D
DEFICIENCY IN RURAL WOMEN IN
SOUTH CAROLINA.
WHAT WE'RE GOING TO DISCUSS THIS
AND OTHER THAN OUR GRANT FUNDING
NO OTHER DISCLOSURES.
SO WHO IS AT RISK FOR VITAMIN D
DEFICIENCY AND WHY'S IT MATTER?
RELEVANT TO THIS TOPIC IS THAT
UNDER REPRESENTED MINORITIES
INCLUDING AFRICAN AMERICANS HAVE
THE HIGHEST RISK OF MATERNAL
COMPLICATIONS.
SO VITAMIN D IS A STEROID
HORMONE AND UNLIKE THE OTHERS IN
OUR BODY WE CAN MAKE
ENDOGENOUSLY VITAMIN D IS
DEPENDENT ON SYNTHESIS DEPENDENT
ON SUNLIGHT EXPOSURE TO OUR
SKIN.
IT'S CERTAINLY THE DARKER THE
PIGMENT THE MORE SUNLIGHT YOU
NEED.
WITH MODERN DAY LIVING WE HAVE
CERTAINLY GREATER RISK OF
DEFICIENCY.
THERE'S SEARCH STUDIES FROM
AROUND THE WORLD THAT SUGGEST
THERE'S BENEFITS OF VITAMIN D
SUPPLEMENTATION AND SUSTAIN IT'S
ASSOCIATED WITH THE RISK OF
PREECLAMPSIA AND C SECTION AND
WHEN WE LOOKED AT THIS NOW MORE
THAN A DECADE AGO IN SUNNY SOUTH
CAROLINA, WHAT WE FOUND IF YOU
WOULD LOOK USING THE INSTITUTE
OF MEDICINE'S DEFINITION LESS
THAN 20 NANOGRAMS PER ML IN
ORANGE YOU WILL SEE THAT GREATER
THAN 75% OF OUR BLACK AMERICAN
WOMEN, 33% OF OUR HISPANIC WOMEN
AND 22% OF OUR WHITE WOMEN MET
THE DEFINITION OF VITAMIN D
DEEFFICIENT -- DEFICIENCY AND
YOU SEE THIS A SIGNIFICANT
AMOUNT AND MORE THAN 50% MET THE
DEFINITION OF DEFICIENCY AND IF
YOU LOOK A DECADE LATER WE SEE
THAT BECAUSE OF OUR REGIONAL
MESSAGE WE FIND LESS DE FIFICIENCY
BUT IN RURAL AREAS IT REMAINS
HIGH.
IN OUR STUDIES WE BLIND BLACK
AMERICAN AND HISPANIC WOMEN ARE
THE MOST AFFECTED.
VIRTUALLY ALL INFANTS I'M A
NEONATOLOGIST ADMITTED TO OUR
INTENSIVE CARE UNIT WHO ARE
BLACK AMERICAN HAVE NOT ONLY
VITAMIN D DEFICIENCY BUT SEVERE
VITAMIN D DEFICIENCY LESS THAN
10 NANOGRAMS WE ARE ML.
WE DID A FIELD TRIAL BETWEEN
2015 AND 2017 DOING VITAMIN D
SCREENING AND SUPPLEMENTATION.
WHAT YOU CAN SEE WITH GESTATION
GESTATIONAL WEEKS AT BIRTH AND
CLOSEST TO DELIVERY ON THE Y
AXIS GESTATION AND 25OHD WE
LOOKED AT ALMOST 2,000 WOMEN AND
LOOKED AT 480 WOMEN WHO HAD
INITIAL 25HG LESS THAN 20 AND IN
OUR RANDOMIZED CONTROL TRIALS.
THERE'S A CAUGHT POINT WHERE THE
RISK OF PRE-TERM BIRTH IS LEFT
AND AT THE EXTREMES WITH LESS
THAN 20 YOU SEE MUCH LOWER
GESTATIONAL AGE.
IN THIS ENGAGEMENT GRANT OUR
OVER ARCHING GOAL WAS TO
UNDERSTAND MATERNAL AND HEALTH
CARE PROFESSIONAL ATTITUDES AND
BELIEFS ABOUT VITAMIN D
DEFICIENCY IN A RURAL PORTION
AND WE HAD TWO ACTIVE
OBSTETRICAL PRACTICES AND HAVE
THREE AIMS.
THE FIRST WAS TO TRACK BASELINE
VITAMIN D DEFICIENCY LIVING
THROUGH ELECTRONIC MEDICAL
RECORDS TO DOCUMENT SEVERITY OF
THE PROBLEM AND RATES AND
PREGNANCY OUTCOMES AND PERFORMED
INTERVIEWS ANDIME IMPLEMENTING AND
SOUGHT WHO WERE AT GREATEST
RISK.
THE GRANT PERIOD RAN FROM
SEPTEMBER 20, 2020 THROUGH MARCH
21, 2021.
AND QUICKLY ALL THESE INTERVIEWS
WERE CONDUCTED THROUGH MICROSOFT
TEAMS BECAUSE OF THE AREA OF
COVID AND THERE WERE
FACILITATORS TO USING PRENATAL
SUPPLEMENTS AS WELL AS VITAMIN D
SUPPLEMENTS AND LOOK AT DECISION
MAKE AROUND VITAMIN D AND
SUPPLEMENT ADHERENCE.
WE ANALYZED THE DATA USING THE
QUALITATIVE ANALYSIS SOFTWARE
AND LOOKED AT RELIABILITY AND
VALIDITY OF ANALYSES AND
CONDUCTED FREQUENCY ANALYSES.
SO OUR ELECTRONIC HEALTH RECORD
OR E.H.R. DATA ANALYSIS TWLR
WOMEN HAVING AN INITIAL VISIT
BETWEEN MAY 2019 AND APRIL 2020
WITH SUBSEQUENT DELIVERY.
THERE WERE FOUR WITH MULTIPLE
GESTATIONS EXCLUDED AND THE
MAJORITY WERE BLACK AMERICAN AND
PUBLIC INSURANCE AND RESIDED
GREATER THAN 10 MILES FROM THE
HOSPITAL AND IN FACT 14.5% LIVED
MORE THAN 30 MILES AWAY.
THE MEAN PRENATAL VISIT NUMBER
WAS 10 WITH THE EXPECTED BEING
BETWEEN 12 AND 14 VISITS DURING
THE PREGNANCY.
VIRTUALLY ALL THE WOMEN IN THE
COHORT EXPERIENCED A LIVE BIRTH
HOWEVER, 11% OF THESE INFANTS
WERE PRETERM WITH A GESTATIONAL
AGE LESS THAN 37 WEEKS.
AND THEY WERE SERIOUS PREGNANCY
COMPLICATIONS NOT SURPRISING
HYPER TENSIVE DISORDERS OF
PREGNANCY AT 18.9%, GESTATIONAL
DIABETES AT 7.4% AND
PRE-EXISTING TYPE 2 DIABETES
1.1%.
FOCUSSING ON VITAMIN D STATUS,
THE INDICATOR OF VITAMIN D
STATUS WAS MEASURED IN 8.4% OF
THESE WOMEN AND 1.9% HAD AN
ICD10 CODE LISTED IN THE MEDICAL
RECORD FOR VITAMIN D DEFICIENCY.
57% OF THE COHORT HAD A
MEASUREMENT OF THIS AND IN THE
COHORT OF VERY AT RISK WOMEN
ONLY 9.1% WERE PRESCRIBED
VITAMIN D SUPPLEMENTATION.
IN THE FOCUS GROUP INTERVIEWS WE
HAD 400 ELIGIBLE WOMEN AND ONLY
9 PARTICIPATE AND OF TO THE
THOSE THREE PARTICIPATED IN THE
TWO FOCUS GROUPS.
REASON FOR NOT PARTICIPATING OR
TOO LITTLE TIME DURING THE
PANDEMIC ARE FUNDING DID NOT
ALLOW US TO HAVE A DESIGNATED
PERSON AT THE SITES TO RECRUIT
PARTICIPANTS AND WE HAD TO
DEPEND ON THE CLINICAL STAFF TO
HAND OUT STUDY FLYERS.
OF THOSE WHO PARTICIPATED THEIR
COMMENTS ABOUT VITAMIN D WAS
REMEMBERING WAS THE HARDEST
CHALLENGE.
SOMETIMES I FORGET ABOUT IT AND
DON'T SEE TANGIBLE BENEFITS.
NONE DESCRIBED AN IN DEPTH
LINKAGE BETWEEN VITAMIN D AND
PREGNANCY AND ONE OF THE THREE
FELT THERE WAS A POTENTIAL
ASSOCIATION BETWEEN LOW VITAMIN
D LEVELS AND PRENATAL RISKS.
OF THE THREE PARTICIPATING ONE
WOMAN DESCRIBED HER DOCTOR
STATING HER LEVEL WAS LOW AND
THEY THOUGHT FAMILY MEMBERS WERE
THE MOST TRUSTED SOURCE OF THEIR
DECISION MAKE ABOUT THEIR
PREGNANCY AND SOMETIMES SOUGHT
OUT INFORMATION FROM THEIR
PRENATAL CARE PROVIDER BUT AGAIN
THEIR EXTENDED SOCIAL NETWORK
WAS VIEWED AS MORE IMPORTANT.
THERE WERE SEVEN TWO AGREED THAT
THERE WERE BARRIERS TO VITAMIN D
USAGE AND LACK OF INSURANCE AND
NOT CLEAR ABOUT WHAT THE
BENEFITS WERE ABOUT VITAMIN D
GIVEN THERE'S LACK OF
STANDARDIZATION.
THE E.H.R. DATA SHOWED HIGH
PREVALENCE OF VITAMIN D
DEFICIENCY OF WOMEN LIVING IN
THIS AREA FEWER WERE TEST AND
FEWER RECEIVED VITAMIN D
SUPPLEMENT.
MORE THAN LIVED OR THE THAN 10
MILES OF THE HOSPITAL AND THE
LINK BETWEEN VITAMIN D
DEFICIENCY AND ADVERSE PREGNANCY
OUTCOMES AND PHYSICIANS HAD
CONFLICTING DATA AND COMPLIANCE
EVEN WHEN TAKING PRENATAL
VITAMINS.
WE MENTIONED A LOT OF SOCIAL
BARRIERS AND ACCESS CARE AFFECTS
EVERY ASPECT OF PREGNANCY
OUTCOMES AND IF WE'RE TO IMPROVE
MATERNAL AND FETAL HEALTH WITH
FOCUS ON VITAMIN D STATUS THEN
WE HAVE TO UNDERSTAND THE
PROCESSES INVOLVED IN DIAGNOSING
TREATING AND EDUCATING PREGNANT
WOMEN ON ITS HEALTH EFFECTS AND
HAVE NEED EDUCATION AND FUNDING
FOR THAT.
THANK YOU.
>> PEOPLE CAN PUT QUESTIONS IN
THE Q&A.
I DON'T SEE QUESTIONS RIGHT NOW
SO I CAN ASK A QUESTION ABOUT
THE POTENTIAL ROLE FOR MORE
CLEAR GUIDANCE FROM ACOG DO YOU
THINK IT WOULD MATTER IN
ADDRESSING SOME OF THE
DISPARITIES?
>> THE INSTITUTE OF MEDICINE
WHICH IS NOW THE NATIONAL
ACADEMY OF SCIENCES THEIR LAST
RECOMMEND ON VITAMIN D WAS IN
2011 AND THEY DID NOT HAVE THE
DATA THAT HAS BEEN AMASSED ON
VITAMIN D'S EFFECT ON IMMUNITY.
AND I THINK ACOG CAN HAVE A MORE
DEFINITIVE RECOMMENDATION.
>> ARE THERE OTHER COUNTRIES
THAT MAY HAVE THEIR DEADLINES
THAT DO BETTER AT VITAMIN D
SUPPLEMENTATION?
>> UNFORTUNATELY NOT.
I THINK THEY TAKE THE LEAD FROM
US AND THERE ARE AREAS OF THE
WORLD WHERE THERE'S MUCH MORE
PROFOUND DEFICIENCY.
AND IT'S A PRE-FORM HORMONE SO
SOME EFFECTS ARE SUBTLE AND
INSIDIOUS AND THAT'S PART OF IT.
I DON'T SEE ANY QUESTIONS SO WE
CAN MOVE ON TO THE NEXT SPEAKER.
>> GWENDOLYN HAS HER HAND UP?
>> I'M AWARE OF THERE BE A HIGH
COST RELATED TO TESTING VITAMIN
D I WONDER IF THAT WOULD HAVE
BEEN A BARRIER ALSO BECAUSE
THEIR INSURANCE WOULD NOT COVER
THE COST?
>> IN THE STATE OF SOUTH
CAROLINA WE HAD AN AGREEMENT
WITH THE INSURANCE COMPANIES TO
PAY FOR THAT AND THAT'S ACTUALLY
A GOOD POINT AND THAT'S CHANGED
RECENTLY BUT ANY WOMAN WHO HAS A
RISK FOR VITAMIN D DEFICIENCY
THAT CAN BE JUSTIFIED IT WILL BE
PAID PARTICULARLY IF IT'S A
PUBLIC ASSISTANCE PATIENT WHO IS
AT GREATEST RISK.
>> MOVING ON TO THE NEXT
SPEAKER.
WE HAVE DOCTOR CLAIR MARGERISON
AND YOU'LL SAY THE PROPER
PRONUNCIATION IF I DIDN'T BEEN
MEDICAID EXPANSION AND
POSTPARTUM HEALTH.
>> THANK YOU FOR HAVING ME
TODAY.
I'M APPRECIATIVE OF THE
SUPPLEME
SUPPLEMENT.
>> I'M SEEING THE PRESENTER
VIEW.
>> SO I'M GOING TO BE TALKING
TODAY ABOUT OUR SUPPLEMENT TO
OUR OVERALL GRANT AND POLICY
CHANGE IN WOMEN'S HEALTH.
AND WHAT I'M GOING TO BE TALKING
ABOUT IS MEDICAID EXPANSION AND
POSTPARTUM HEALTH AND I
APPRECIATE THE PREVIOUS
PRESENTER FOR LAYING DOWN SOME
OF THE BACKGROUND SO I CAN GO
THROUGH THAT MORE QUICKLY.
TO REVIEW A LITTLE BIT ABOUT
MEDICAID DURING THE POSTPARTUM
PERIOD, SO FEDERAL LAW REQUIRES
STATES PROVIDE MEDICAID COVERAGE
FOR LOW-INCOME PEOPLE WHEN THEY
BECOME PREGNANT AND THE CURRENT
THRESHOLD IS A HOUSEHOLD INCOME
AT OR BELOW 138% OF THE FEDERAL
POVERTY LEVEL.
SOME STATES HAVE MUCH HIGHER
THRESHOLDS.
SOME COVER UP TO 200% OR 300% OF
FEDERAL POVERTY.
SO PRIOR TO THE AFFORDABLE CARE
ACT, THOSE NEW PARENTS WHO HAD
BEEN COVERED WITH MEDICAID
DURING PREGNANCY THE OPTIONS
THEY WOULD HAVE ARE EITHER
OBTAIN OR PURCHASE PRIVATE
INSURANCE, BECOME UNINSURED OR
COULD POSSIBLY RE-QUALIFY UNDER
DIFFERENT THRESHOLDS AROUND AND
SOME COULD QUALIFY DURING
PREGNANCY IN MICHIGAN BUT TO
QUALIFY AS A PARENT IT WOULD
HAVE TO BE BELOW 50% OF THE
FEDERAL POVERTY LEVEL.
SO THERE'S A BIG GAP THERE.
THE AFFORDABLE CARE ACT INTENDED
IT WOULD EXPAND TO ALL BELOW
138% OF FEDERAL POVERTY.
THIS COULD PROVIDE CONTINUOUS
INSURANCE PRIOR TO PREGNANCY,
DURING PREGNANCY AND IN THE
POSTPARTUM PERIOD AND NOT ALL
PARTICIPATED.
WE FOCUSSED ON THOSE THAT DID
EXPAND IN 2014.
THERE'S ABOUT 28 STATES PLUS
D.C.
MANY EXPANDED SINCE THEN.
AND WE LOOKED AT POSTPARTUM
COVERAGE INSURANCE AND MENTAL
HEALTH AND RELATED MORTALITY.
THERE'S A PREGNANCY RISK
MONITORING SYSTEM AND THIS SAY
SET OF STATE WIDE REPRESENTATIVE
SURVEYS AND INDIVIDUALS WHO HAVE
RECENTLY GIVEN A LIVE BIRTH FROM
THIS WE OBTAINED THE PERSON'S
SELF-REPORTED MEDICAID COVERAGE
AT THE TIME OF THE SURVEY.
SO POSTPARTUM AND SELF-REPORTED
POSTPARTUM DEPRESSIVE SYMPTOMS.
WE USED U.S. VITAL STATISTICS
DATA TO ASSESS PREGNANCY RELATED
MORTALITY.
WE USE DATA FROM STATES USING
THE REVISED DEATH CERTIFICATE
AND WE CALCULATE THE PREGNANCY
ASSOCIATED DEATH RATIO THE
NUMBER OF DEATHS DURING
PREGNANCY OR POSTPARTUM PER
100,000 LIVE BIRTHS IN A STATE
OR YEAR.
AND THERE'S A PREGNANCY CHECK
BOX THAT ASKED WHETHER THE
PERSON WHO DIED WAS PREGNANCY,
HAD BEEN PREGNANT WITHIN 42 DAYS
OF THEIR DEATH OR PREGNANT
WITHIN 365 DAYS BEFORE THEIR
DEATH.
AND WE INCLUDE DEATHS DUE TO ALL
CAUSES.
THESE ARE NOT JUST THE DEATHS
CONSIDERED RELATED TO PREGNANCY
AND WE ARE LOOKING AT ANOTHER
FUNDED PROJECT WE FOUND OVER 20%
OF DEATHS DURING PREGNANCY AND
POSTPARTUM ARE DUE TO CAUSES
SUCH AS DRUG RELATED DEATH,
SUICIDE AND HOMICIDE AND THESE
ARE NOT TYPICALLY INCLUDED IN
PREGNANCY RELATED DEATH RATIOS
OR MATERNAL MORTALITY RATIOS BUT
WE INCLUDE THESE ESPECIALLY
BECAUSE MANY OF THESE DEATHS
OCCUR IN THAT LATER POSTPARTUM
PERIOD WHICH IS WHEN PEOPLE
WOULD LOSE MEDICAID IN
NON-EXPANSION STATES.
OUR HYPOTHESIS ARE THESE ACAUSES
OF DEATHS AMENABLE TO -- THESE
ARE CAUSES OF DEATH.
AND WE USED A DIFFERENT APPROACH
AND I WON'T GO INTO THAT.
I'M HAPPY TO TALK MORE ABOUT IT
AND THE DIFFERENT METHOD WE USED
THE RESULTS CAN BE INTERPRETED
AS THE PERCENTAGE POINT CHANGE
IN THE OUTCOME THAT IS
ASSOCIATED WITH MEDICAID
EXPANSION.
PEOPLE REPORTED THEY HAD
MEDICAID POSTPARTUM.
WE DID NOT SEE IMPACT OF
MEDICAID EXPANSION ON POSTPARTUM
SYMPTOMS AND WE LOOKED AT
PRE-PREGNANCY MEASURES AND
LOOKED AT SOME IMPROVEMENTS AT
PRE-PREGNANCY SELF-REPORTED
DEPRESSION.
MOVING ON TO THE FINDINGS OF
PREGNANCY RELATED MORTALITY.
THESE ARE NOT PUBLISHED YET.
WE DIVIDED THIS UP INTO THE TIME
PERIOD SO BECAUSE WE
HYPOTHESIZED THAT THE TIME
PERIOD OF THE DEATHS BECAUSE WE
HYPOTHESIZED THE MAIN IMPACTS OF
MEDICAID EXPANSION WOULD BE ON
DEATHS IN THE LATER POSTPARTUM
PERIOD BUT LOOKED DURING
PREGNANCY AND EARLY POSTPARTUM
AS WELL.
THE WAY I'M PRESENTING THE
RESULTS ARE DIFFERENT THAN THE
PREVIOUS ONES YOUR LOOKING FOR
POINT ESTIMATES ASSOCIATION
BETWEEN MEDICAID EXPANSION AND
PREGNANCY RELATED MORTALITY.
TO THE RIGHT OF THE ORANGE BAR
AND THAT'S BECAUSE WHEN THAT'S
WHEN THE INTERVENTION TOOK PLACE
AND WE'RE LOOKING AT POINT
ESTIMATES STATISTICALLY
DIFFERENT FROM ZERO.
THESE GRAPHS LET US SEE WHETHER
THERE'S AN IMPACT OF MEDICAID
EXPANSION THAT MAYBE HAPPENED
RIGHT AWAY AND PETERED OUT OVER
TIME OR MAYBE HAPPENED LATER IN
THE TIME PERIOD.
ADDS YOU CAN SEE THERE'S
STATISTICALLY SIGNIFICANT
ASSOCIATIONS BETWEEN MEDICAID
AND THE CONFIDENCE LINES AND
THERE'S NO SIGNIFICANT IMPACTS
WITHIN 42 DAYS POSTPARTUM OR IN
THE LATER POSTPARTUM PERIOD
WHICH IS WHEN WE HAD
HYPOTHESIZED WE WOULD SEE AN
ASSOCIATION.
THERE'S ALSO NO SIGNIFICANT
IMPACT AMONG NON-HISPANIC BLACK
PEOPLE BUT YOU SEE A TREND WHERE
PREGNANCY ASSOCIATED MORTALITY
THE ASSOCIATION BETWEEN MEDICAID
EXPANSION AND MORTALITY APPEARS
TO BE AN ASSOCIATION THAT'S
GROWING OVER TIME WHERE THE
MEDICAID EXPANSION IS ASSOCIATED
WITH A REDUCTION IN PREGNANCY
RELATED MORTALITY AMONG
NON-HISPANIC BLACK PEOPLE.
THAT'S NOT SIGNIFICANT BUT THIS
IS A RARE OUTCOME SO WE'RE
WORKING WITH PRETTY SMALL SAMPLE
SIZES AND LOOK FORWARD TO
GETTING FUTURE YEARS OF DATA AND
CONTINUING TO LOOK AT THIS.
WE ALSO DID NOT SEE AN
ASSOCIATION AMONG NON-HISPANIC
WHITE PEOPLE.
IN CONCLUSION, MEDICAID
EXPANSION THE 2014 MEDICAID
EXPANSION LIKELY INCREASED
MEDICAID EXPANSION IN THE
POSTPARTUM PERIOD.
HOWEVER, THERE WERE NO
SIGNIFICANT IMPACT OF MEDICAID
EXPANSION ON DEPRESSIVE SYMPTOMS
OR PREGNANCY RELATED MORTALITY.
ONE OF THE CONCLUSIONS FROM THIS
IS WE THINK INSURANCE COVERAGE
ALONE IS LIKELY NECESSARY BUT
NOT SUFFICIENT TO REDUCE THE
PREVALENCE OF OR RACIAL ETHNIC
INEQUITIES IN MORBIDITY OR
MORTALITY AND I THANK NICHD FOR
THE FUNDING AND COLLABORATORS
AND HAPPY TO ANSWER ANY
QUESTIONS.
>> THANK YOU SEARCH.
PLEASE PUT ANY QUESTIONS IN THE
Q&A.
I TOOK A PEEK AT SOME OF YOUR
EXTRA SLIDES YOU HAD.
OWN YOUR LAST SLIDE YOU FOUND
SOME RACIAL ETHNIC DIFFERENCES
IN THE LIKELIHOOD OF DEPRESSIVE
SYMPTOMS.
CAN YOU SPEAK TO THOSE A LITTLE
AND WHAT YOU THINK THEY MIGHT
MEAN?
>> THAT'S A LITTLE BIT OF A
DIFFERENT ANALYSIS.
I HOPED TO HAVE TIME TO TALK
ABOUT IT HIT BUT NOT INCLUDE IT
IN THE MAIN PRESENTATION.
SOME MM ARE SEEKING FEDERAL
WAIVERS TO EXTEND THE MEDICAID
60 DAYS TO 12 MONTHS POSTPARTUM.
AS PART OF THE AMERICAN RESCUE
PLAN ALLOWED STATES TO DO THAT
UNTIL APRIL 1 OF THIS YEAR AND
THEN THEY HAVE TO GET THESE
WAIVERS TO CONTINUE IT.
SO WE DID ANOTHER ANALYSIS.
THIS IS ALSO PRELIMINARY TRYING
TO PREDICT HOW MANY PEOPLE WOULD
GAIN MEDICAID FROM THOSE
EXTENSIONS.
AND IT'S NOT REALLY EXPANDING
ELIGIBILITY IT'S EXTENDING
MEDICAID TO 12 MONTHS
POSTPARTUM.
WE FOUND THAT 20% TO 26% OF
PEOPLE WOULD GAIN MEDICAID BUT
THERE ARE LARGER GAINS FOR BLACK
AND HISPANIC PEOPLE AND THEN WE
ALSO LOOKED USING PROGRAM --
PRAMS AT REGAINING IT IN THE
POSTPARTUM PERIOD OR USING THE
DATA WE HAD WOULD ONLY HAPPEN IF
A PERSON RE-QUALIFIED AS A
PARENT.
WE HAD PEOPLE WHO WOULD HAVE
CONTINUOUS COVERAGE AND THOSE
WHO WOULD LOSE MEDICAID BASED ON
THEIR INCOME AND WE FOUND
RETAINING MEDICAID IN THE
POSTPARTUM PERIOD WAS ASSOCIATED
WITH AN INCREASE IN GETTING A
POSTPARTUM CHECK UP THAT WAS
ONLY SIGNIFICANT AMONG HISPANIC
PEOPLE AND WAS ACTUALLY IN THE
OPPOSITE DIRECTION OF BLACK
PEOPLE AND RETAINING MEDICAID
WAS ASSOCIATED WITH AN DOES HE
CREASE IN POSTPARTUM DEPRESSIVE
SYMPTOMS BUT ONLY AMONG WHITE
PEOPLE AND THESE ARE PRELIMINARY
FINDINGS WE'RE STILL WORK ON.
>> THERE'S A QUESTION IN THE
CHAT, WHAT IS THE POPULATION
INCLUDED IN YOUR ANALYSIS ENTIRE
U.S. OR SPECIFIC REGIONS?
WITH THE PRAMS DATA IT'S NOT
INCLUDED IN THE NATIONAL DATA
SET BECAUSE THEY DON'T HAVE HIGH
ENOUGH PARTICIPATION RATE OR
RESPONSE RATE SO WE DON'T HAVE
EVERY STATE IN THE PRAMS DATA
AND WITH THE PREGNANCY
ASSOCIATED MORTALITY OUTCOME WE
ARE USING VITAL STATISTICS DATA
AND THAT INCLUDES 33 STATES AND
D.C. AGAIN BASED ON THE STATES
THAT HAVE THE DATA POINT WE
NEED.
>> AND A QUESTION FROM ME SINCE
I DON'T SEE ANYTHING IN THE
CHAT, DO YOU HAVE THE ABILITY SO
YOU FOUND THAT JUST MEDICAID
EXPANSION ISN'T SUFFICIENT.
ARE YOU ABLE TO LOOK AT OTHER
STATE CHARACTERISTICS LIKE OTHER
STATE LAWS LIKE MINIMUM WAGE
LAWS OR MATERNAL LEAVE OR OTHER
POLICIES?
>> WE ARE ABLE TO TIME WISE.
WE HAVE NOT DONE THAT YET.
THERE ARE OTHER STUDIES LOOKING
AT SPECIFIC POLICIES, PARENTAL
LEAVE AND WE'VE LOOKED AT THE
HEALTH OF THE INCOME.
THERE'S ROOM TO EXAMINE OTHER
POLICIES BUT HAVE NOT YET.
>> I THINK WE ARE AT TIME THANK
YOU VERY MUCH FOR YOUR
PRESENTATION.
AND THANK YOU TO ALL OF OUR
SPEAKERS IN THIS PANEL.
WE WILL NOW MOVE TO A BREAK AND
RETURN BACK AT 3:05.
THANK YOU VERY MUCH.
I'M LAUREN HILL AND I'LL BE
MODERATING OUR FINAL PANEL OF
THE DAY.
WE HAVE THREE SPEAKERS AND YOU
CAN GET MORE INFORMATION ON
THEIR BIOS ON THE REGISTRATION
PAGE AND IF YOU HAVE QUESTIONS
PLEASE DO PUT THEM IN THE Q&A
BOX AND AT THE CONCLUSION OF
EACH TALK BY EACH SPEAKER WE'LL
TAKE QUESTIONS.
SPEAKERS, I WILL BE HERE TO GIVE
YOU THE ONE-MINUTE WARNING IF
NEEDED.
SO WELCOME AGAIN EVERYONE.
THE TITLE OF OUR PANEL IS MENTAL
AND BEHAVIORAL HEALTH AND I WILL
TURN IT OVER TO OUR FIRST
SPEAKER, DR. KARA ZIVIN.
WE'RE LOOK AT SEVERE MATERNAL
MORBIDITY IN COMMERCIALLY
INSURED INDIVIDUALS.
I WANT TO GIVE CONTEXT FOR OUR
WORK.
I CHOSE A FOREST THEME FOR OUR
WORK AND THE PARENT STUDY
FOCUSSED ON MATERNAL BEHAVIORAL
HEALTH AND SO THAT INCLUDED THE
AFFORDABLE CARE ACT AND WE'VE
LOOKED AT THE IMPACT OF THOSE
POLICY CHANGES ON INDIVIDUALS
WITH PERINATAL MOOD AND ANXIETY
DISORDERS.
WE LOOKED AT THOSE INDIVIDUALS
WITH SUBSTANCE USE DISORDERS AND
WE HAD A STUDY RECENTLY FUNDED
WHERE WE'LL BE BRINGING IN
COMMUNITY LEVEL DATA AND ADDING
MEDICAID AND PRAM AS OTHER DATA.
ON THE NEXT SLIDE I DRILLED DOWN
MORE SHOWING THE COMPARISON
BETWEEN THE PARENT STUDY AND THE
SUPPLEMENT WHERE AGAIN WITH
WE'VE LOOKED AT PEOPLE
CONTINUOUSLY ENROLLED ONE YEAR
BEFORE AND THE STUDY AND WE
LOOKED AT DELIVERY OUTCOMES
INCLUDING SEVERE MORBIDITY AND
IN THE CURRENT STUDY WE'LL BE
LOOKING AT DIFFERENT ELEMENTS OF
PARITY LAWS, RACE, ETHNICITY AND
INCOME.
SO ON THE NEXT SLIDE I WILL
PRESENT OUR FIRST PAPER THAT'S
COME OUT OF THIS WORK THAT CAME
OUT IN DECEMBER FOCUSSING ON
SEVERE MATERNAL MORBIDITY AND
THE NAMES OF MY COLLEAGUES ARE
LISTED ON THE STUDY WHERE WE
WANTED TO LOOK NOT JUST AT
MATERNAL MORBIDITY RELATED TO
WHAT OCCURRED DURING THE
DELIVERY HOSPITALIZATION BUT UP
TO ONE YEAR POST FINDING AND WE
SEPARATED OUT BLOOD TRANSFUSION
FROM OTHER FORMS OF MORBIDITY
BECAUSE THE DIFFERENCE AND WE
LOOKED AT THE CONTINUES THAT
WERE THE LEADING CAUSES OF
SEVERE MATERNAL MORBIDITY
SHOWING DELIVERY HOSPITALIZATION
AND FROM DISCHARGE TO 42 DAYS
AND FROM 43 DAYS TO 365 DAYS
POST DELIVERY.
THE MOST SEVERE CONDITIONS
VARIED OVER THE TIME FRAME WHICH
WE HEARD FROM OTHERS TODAY.
WITH BLOOD TRANSFUSION AND
ECLAMPSIA AND SOME DELIVERING
FROM TIME OF DELIVERY INCLUDING
THINGS LIKE SEPSIS AND ADULT
RESPIRATORY DISTRESS SYNDROME.
THIS SLIDE I WANT TO DRAW YOUR
ATTENTION TO THE DIFFERENCES
THAT WE COMPARED BETWEEN THOSE
WITH AND WITHOUT BLOOD
TRANSFUSION AND LOOKED AT RACE
AND ETHNICITY AND MOOD
DISORDERS.
THESE WERE THE RACE AND ETHNIC
GROUPS WE HAD AND DIDN'T HAVE
THE OPPORTUNITY FOR OTHER GROUPS
OR MULTI-RACIAL.
BLACK PARTICIPANTS HAD THE
HIGHEST RATES WITH AND WITHOUT
BLOOD TRANSFUSION AND HISPANIC
AND LOOKING AT A MOOD OR ANXIETY
DISORDER COMPARED TO THOSE THAT
HAD HIGHER RATES OF SEVERE
MATERNAL MORBIDITY AND THAT WAS
FOCUSSING ON WITH AND WITHOUT
BLOOD TRANSFUSION AND WE SHARED
THIS INFORMATION AND WENT TO THE
NEXT STUDY WHERE WE'RE TRYING TO
LAYER IN THE IMPACT OF THE
FEDERAL HEALTH POLICY CHANGES
DURING OUR STUDY PERIOD FROM
2008 TO 2019.
IS WE ARE STILL PLAYING WITH THE
FUNCTIONAL FORMS OF OUR MODELS.
WE'RE SEEING IN ADDITION TO
OVERALL DECREASES IN SEVERE
MATERNAL MORBIDITY THE LINES
COME CLOSER AMONG THOSE WITH
MOOD DISORDERS LATER TO AT THE
BEGINNING.
WE STILL NEED LOOK AT OVER PLANS
AND WE HAVE THE LINKED INFANTS
AS PART OF OUR STUDY.
WE CAN EXAMINE THINGS SUCH AS
HOW DO OUTCOMES COMPARE FOR
INFANTS OF OTHERS WHO HAD SEVERE
MATERNAL MORBIDITY AND WE'LL GET
ACCESS TO MEDICAID DATA SOON AND
WE CAN SEE HOW OUR FINDINGS
DIFFER FROM THOSE IN THE
COMMERCIALLY INSURED POPULATIONS
AS WELL AS MEDICAID I'LL PAUSE
HERE AND HAPPY TO ANSWER
QUESTIONS AND THE NEXT SLIDE IS
THE PARENT GRANT AND SUPPLEMENT.
>> AUDIENCE ENTER QUESTIONS IN
THE Q&A.
I HAVE A QUESTION.
IT SEEMED LIKE THE FOLKS WHO HAD
THE MOST DIFFICULTIES WITH
PERINATAL MOOD AND ANXIETY
DISORDERS ALSO HAD OTHER TYPES
OF MORBIDITY AND MORTALITY.
DO YOU HAVE AN IDEA WHAT IS
DRIVING THOSE ARE THERE VARIABLE
OR CAUSAL?
>> WE ARE LOOKING AT OTHER CORE
MORBID CONDITIONS AND WHAT DOES
SEF OVER MATERNAL MORBIDITY LOOK
LIKE WITH AND WITHOUT PERINATAL
MOOD AND ANXIETY DISORDER AND
OTHER CONDITIONS AND IT SEEMS TO
ALMOST BE LAYERED AFFECTS AND
WHETHER THEY HAD MENTAL HEALTH
CONDITIONS COMING INTO PREGNANCY
VERSUS NO ONSET DURING AND
AFTER.
WE CAN LOOK AT SOME OF THOSE
THINGS THOUGH SOME IS BASED ON
HOW OFTEN THEY COME IN OR WHO
DETECTS WHAT.
I THINK IT'S INTERESTING AND
IMPORTANT BECAUSE I THINK
SOMETIMES WE WANT TO SPLIT OUT
THINK ABOUT MENTAL HEALTH FROM
PHYSICAL HEALTH OUTCOMES AND YET
AS WE ALL PROBABLY KNOW HERE ON
THE CALL THAT THEY OVERLAP AND
MAY BE MUTUALLY INFLUENCING ONE
ANOTHER.
>> THANK YOU.
IS THERE A REASON YOU USED
DISCHARGE TO 42 DAYS INSTEAD OF
60 DAYS AS ACA COVERS POSTPARTUM
CARE UNTIL 60 DAYS CURRENTLY?
>> REMEMBER THIS IS PRIVATELY
INSURED SO WE'RE NOT LOOKING AT
MEDICAID AND USED THE 42 DAYS
BECAUSE THAT'S HOW I BELIEVE THE
CDC HAS BEEN LOOKING PRIMARILY
AT AND OUR PREVIOUS SPEAKER
CATEGORIZED THE SEVERE MATERNAL
MORBIDITY IN THE SAME WAY WHEN
WE LOOKED AT THE TIME WINDOWS
TYPICALLY USED.
I BELIEVE WE COULD EASILY DO
WHAT WE DID AND USE THE 60 DAY
WINDOW AND SEE WHAT WE WOULD
FIND.
WE COULD DEFINITELY DO THAT BUT
THAT'S WHY WE USED THE 42 DAYS.
>> OKAY.
THANK YOU.
WE'LL NOW ON TO OUR NEXT
SPEAKER, DR. GUILLE.
I HOPE I SAID THAT CORRECTLY.
SHE'LL BE SHEIKING ON LEVERAGING
TECHNOLOGY TO IMPROVE SCREENING.
>> IT'S A PLEASURE TO BE HERE.
I WANT TO TALK ABOUT HOW WE'RE
LEVERAGING TECHNOLOGY TO IMPROVE
SCREENING INTERVENTION FOR
PREGNANT AND POSTPARTUM PERSONS.
THERE'LL BE TIME WHEN I REFER TO
WOMEN AND I'LL TRY TO USE MORE
GENDER NEUTRAL TERMS GOING
THROUGH.
BRIEF BACKGROUND ON THIS.
MATERNAL MENTAL HEALTH COMMONS
ARE PROBLEM AND THE CARRY A
SIGNIFICANT MATERNAL MORBIDITY
AND MORTALITY FOR BIRTHING
PERSONS AND AFFECT CHILDREN'S
HEALTH AND THEIR DEVELOPMENT.
WE KNOW 1 IN 9 ARE DUE TO
MATERNAL HEALTH CONDITIONS AND
THEY'RE 100% PREVENTIBLE AND
WE'RE SCREENING EVERYONE FOR
MENTAL HEALTH AND SUBSTANCE USE
AND INTIMATE PARTNER VIOLENCE
AND THERE'S RACIAL DISPARITIES
IN THAT.
SO SIMILARLY WE KNOW 1 IN 4
WOMEN WILL MAKE IT TO TREATMENT
AND SIGNIFICANT RACIAL
DISPARITIES WITH BLACK WOMEN
SIGNIFICANTLY LESS LIKELY TO
MAKE IT TO TREATMENT IN
COMPARISON TO WHITE WOMEN.
WE KNOW A LOT ABOUT WHY THIS
SCREENING AND BRIEF INTERVENTION
OR TREATMENT DOESN'T HAPPEN IN
PRACTICE.
PROVIDERS WILL TELL US THEY
DON'T HAVE THE TIME AND NOT
FAMILIAR WITH THE TOOLS AND
DON'T HAVE THE KNOWLEDGE TO
ASSESS THESE CONDITIONS OR TREAT
THEM OR THEY DON'T HAVE THE
PROVIDERS AVAILABLE TO REFER THE
PATIENTS TO TREAT THEM.
FOR PATIENTS STIGMA IS A BARRIER
IN SEEK TREATMENT AND FEAR OF
SOCIAL AND LEGAL CONSEQUENCES
AND THERE'S A LACK OF ACCESSIBLE
PROVIDERS.
ALL THESE BARRIERS SEEM TO BE
MORE PRONOUNCED IN BLACK WOMEN
COMPARED TO WHITE WOMEN.
WE STARTED THINKING ABOUT THE
BARRIERS TO SCREENING AND HOW TO
LEVERAGE TECHNOLOGY TO OVERCOME
BARRIERS AND WE NAMED THE
PROGRAM LISTENING TO WOMEN AND
THAT WAS WHAT THE WOMEN WANTED
US TO NAME IT.
IT LOOKS LIKE WOMEN COMING TO
PRENATAL CARE AND SAID WE'LL
MONITOR AND DO THAT VIA TEXT
MESSAGE IF THAT'S OKAY AND THEY
GIVE THEIR NUMBER AND CELL PHONE
CARRIER AND SEND A TEXT MESSAGE
THAT GOES THROUGH THE SCREENING
PROCESS.
THEY CAN DO THE SCREENINGS WHILE
WAITING FOR THE PROVIDER OR WHEN
THEY GET HOME.
AS SOON AS THEY COMPLETE A
SCREENING OUR CARE COORDINATOR
IS NOTIFIED AND CAN GO IN THE
SYSTEM AND SEE WHO THE HIGH
PRIORITY PEOPLE TO CALL AND SEE
ALL THE SCREENING INFORMATION
THEY SCREEN POSITIVE PEOPLE BY
PHONE AND DO THIS WITH THE EARLY
FACTORS AND FOR SOCIAL
DETERMINATES OF HEALTH AND USE
MOTIVATIONAL INTERVIEWING TO GET
THEM TO TREATMENT AND THEN THE
COORDINATOR SUMMARIZES THE
INFORMATION AND SENDS THE NOTE
TO THE PRIMARY CARE TEAM THAT
WOMAN IS WORKING WITH SO
EVERYBODY KNOWS WHAT'S HAPPENING
WITH THIS PERSON'S MENTAL HEALTH
OR SUBSTANCE USE TREATMENT.
WE DO THE SCREENING IN PREGNANCY
AND IT CAN OCCUR AT EACH
TRIMESTER ONE MONTH AFTER
DELIVERY AND EVERY THREE MONTHS
FROM DELIVERY 18 MONTHS
POSTPARTUM WE PILOT SYSTEM AND
WOMEN WERE WILLING TO TAKE PART
IN THIS.
WE COMPARED THEIR OUTCOMES IN
TERMS OF BEING SCREENED AND
SCREENING POSITIVE AND RECEIVING
TREATMENT TO THE WOMEN IN THE
CLINIC BEFORE GETTING THE
INTERVENTION REFERRAL TO
TREATMENT.
WE MADE SURE THE GROUPS WERE
SIMILAR AND WHERE THEY WEREN'T
WE CONTROLLED FOR AGE, RACE AND
MARITAL STATUS.
SO THIS IS OUR MAIN OUTCOME AND
WHAT WE SEE HERE IS THAT WHEN
WOMEN WERE ENROLLED IN LISTENING
TO WOMEN IN COMPARISON THEY WERE
MORE LIKELY TO BE SCREENED
OVERALL AND TWICE AS LIKELY TO
SCREEN POSITIVE AND ONE AND A
HALF MORE TIMES LIKELY TO BE
REFERRED TO TREATMENT AND FIVE
TIMES MORE LIKELY TO MAKE IT TO
TREATMENT.
WE LOOKED AT RACE FOR BLACK
VERSUS WHITE WOMEN AND WITHIN
EACH SCREENING METHOD.
I'LL PULL THE RESULTS FOR YOU.
WHAT WE SEE IS THE IN PERSON
SCREENING VERSUS LISTENING TO
WOMEN AND BLACK WOMEN ARE LESS
LIKELY TO SCREEN POSITIVE IN
COMPARISON TO WHITE WOMEN AND IN
PERSON SCREENING BLACK WOMEN ARE
SIGNIFICANTLY LESS LIKELY TO
MAKE IT TO TREATMENT IN
COMPARISON TO WHITE WOMEN AND
DIDN'T SEE THAT SAME FINDING
WITH LISTENING TO WOMEN.
THE IMPROVED STUDY IS WE WANTED
TO WORK WITH WOMEN TO UNDERSTAND
WHAT THEY THOUGHT OF THIS
PROGRAM TO REALLY GET THEIR
FEEDBACK AND MAKE ANY NECESSARY
MODIFICATIONS TO THE CONTRARY OF
OR FUNCTION AND CERTAIN WOMEN
MET CRITERIA FOR ANY MENTAL
HEALTH OR SUBSTANCE USE DISORDER
AND WE RECRUITED THEM TRUE TRIAL
FACT AND SOCIAL MEDIA AND
INDIRECTLY THROUGH OUR OBSTETRIC
AND MATERNAL HEALTH PROVIDERS
AND PEER-RECOVERY ORGANIZATIONS.
THE WAY THEY WORKED WAS ALL VIA
ZOOM.
THIS WAS COLLECTED DURING COVID
AND USED INTERVIEW GUIDES AND
GOT FEEDBACK FROM WOMEN ABOUT
THE OVERALL PROGRAM AND FUNCTION
AND CONTENT AND WHAT THEY
RECOMMENDED AND BELIEFS ABOUT
MENTAL HEALTH AND SUBSTANCE USE
PARTICULARLY FOR PERI PARTUM
PEOPLE.
WE DID QUALITATIVE ANALYSES.
OVER 11 MONTHS WE ENROLLED 85.
MEAN AGE IS 28.
WE HAVE A PREDOMINANT
NON-HISPANIC BLACK POPULATION.
AND MENTAL HEALTH CONDITIONS
OVER 40% HAD A MENTAL HEALTH
CONDITION MOOD OR ANXIETY
DISORDER AND A LITTLE OVER A
THIRD HAD MARIJUANA OR ALCOHOL
USE DISORDER AND WANTED TO HEAR
FROM WOMEN WHO DIDN'T HAVE
MENTAL HEALTH CONDITIONS AS
WELL.
AND IN THIS NAVIGATING REMARKS
WERE IT DIDN'T TAKE MUCH TIME
AND WAS STRAIGHTFORWARD.
THE SECOND WAS COMFORT ON
ANSWERING THE QUESTIONS VIA TEXT
MESSAGE AND TALKING ON THE PHONE
WIN SOMEBODY THEY NEVER MET
RELATED TO SUBSTANCE USE AND
PEOPLE PREFERRED THE TEXT
MESSAGING AND HAVING SOMEBODY TO
TALK TO BY PHONE JUST FELT LIKE
THEY HAD MORE PRIVACY AND THEY
WEREN'T BEING JUDGED IN PERSON
AND DIDN'T HAVE THE FACE TO FACE
COMPONENT AND THE MORE THEY WERE
REASSURED THIS WAS CONFIDENTIAL
THE MORE COMFORTABLE THEY SAID
THEY'D BE TO USE IT.
THEY ALSO REALLY LIKED THE CARE
COORDINATOR WAS GOING TO HELP
NAVIGATE SOME COMPLEX SYSTEMS IN
TERMS OF MENTAL HEALTH AND
SOCIAL SERVICES AND THAT SORT OF
THING IF THAT WERE RELEVANT.
SO ONE OF THE THEMES THAT CAME
WAS POTENTIAL BARRIERS TO EVEN
DISCUSSING MENTAL HEALTH AND
SUBSTANCE USE AND WOMEN TALKED
ABOUT WHAT THEY GREW UP IN IN
THEIR CULTURE AND A LOT OF
FAMILIES SAID YOU DON'T TALK
ABOUT THIS.
YOU DON'T SHARE YOUR PROBLEMS
AND YOU PRAY ABOUT THIS AND IN
THE BLACK COMMUNITY THEY'LL CALL
YOU CRAZY AND SAID EVERYBODY
WENT THROUGH THIS AND WE DEALT
WITH IT IT'S NOT THAT BAD IT'S
JUST A PHASE.
THAT'S WHAT THEY GREW UP WITH.
AND THEY HAD DISTRUST WITH
DEPARTMENT OF SOCIAL SERVICES
INTERVENTION IF THEY HAD A
SUBSTANCE USE ISSUE AND TALKED
ABOUT THE HEALTH SYSTEM LETTING
THEM DOWN WHEN THEY TOLD PEOPLE
ABOUT THESE PROBLEMS IT WASN'T
ALWAYS FOLLOWED UP ON OR A
PERSON HAD TO LEAVE AND TURNOVER
IN STAFF AND SOME INSURANCE
WEREN'T ALWAYS ACCEPTED SO A LOT
OF BARRIERS TO TREATMENT.
ON FACILITATORS, ONE THING WAS
TALKING ABOUT SEEING OTHER BLACK
HEALTH CARE WORKERS AND HOW
IMPORTANT THAT WAS TO TALK ABOUT
SOME CONDITIONS AND APPRECIATED
WHEN PROVIDERS PUT IT OUT AND
TALKED ABOUT THIS AND PROVIDED
INFORMATION AND SAID, HEY, THIS
IS COMMON, DON'T BE ASHAMED.
IF YOU NEED HELP IT'S AVAILABLE
AND OVERALL LISTENING AND
HEARING THEIR NEEDS.
IN SUMMARY, WHAT WE FOUND SO FAR
IS THIS PROGRAM IS EASY TO USE.
PEOPLE PREFER THE TEXT MESSAGING
AND THE PHONE BASED INTERVENTION
OPPOSED TO PHASE TO PHASE
INTERVIEWS ON THE ISSUES.
THE MODIFICATIONS, WE TALK ABOUT
CONFIDENTIALITY A LOT WHEN WE
ENROLL SYSTEM BUT WE NEED TO
EMPHASIZE THAT MORE AT
ENROLLMENT AND VIA THE CARE
COORDINATOR.
WE WANT TO BE ABLE TO PROVIDE
MORE CONCORDANCE IN TERMS OF
RACE AND CAN DO THAT IN TERMS OF
REFERRALS WANT TO STIGMA AND
CONCERNS AND DISTRUST AROUND THE
HEALTH CARE SYSTEM AND CAN DO
THAT IN ENROLLMENT AND WITH OUR
CA
COORDINATOR.
HAVING PERI PARTUM WOMEN TALKING
ABOUT THESE DESTIGMATIZES IT FOR
OTHER WOMEN AND INTEGRATING THIS
FOR ALL WOMEN COMING THROUGH IN
PREGNANCY OR POSTPARTUM IN
GETTING SCREENED.
I WANT TO THANK OUR FUNDERS AND
OUR COLLABORATORS.
WE HAVE A FANTASTIC TEAM AND
JUST I WANTED TO ACKNOWLEDGE
THAT.
I'LL STOP THERE.
>> THAT WAS GREAT.
I HAVE LOTS OF QUESTIONS.
ONE QUESTION I HAVE IS WITH THE
COORDINATORS THEY NOT ONLY WORK
WITH WOMEN ON THEIR MENTAL
HEALTH AND SUBSTANCE USE ABOUT
THE SOCIAL NEEDS THEY HAD.
DO YOU THINK THAT MAY HAVE
HELPED TO LEAD TO SOME OF THE
POSITIVE OUTCOMES YOU FOUND?
>> I THINK SO.
IF YOU'RE IN THE MODE OF -- IF
YOU HAVE FOOD SCARCITY OR
HOUSING INSTABILITY, THOSE ARE
YOUR PRIORITIES.
YOU CAN'T PRIORITIZE YOUR OWN
MENTAL HEALTH AND WELL BEING
UNLESS EVERYTHING ELSE IS TAKEN
CARE OF.
WE KNOW WE NEED TO MAKE SURE
WOMEN FEEL SAFE AND STABLE AND
THEIR FAMILIES FEEL SAFE AND
STABLE TO CONTEMPLATE TAKING
CARE OF THEMSELVES.
I THINK IT HELPS.
I WOULD LOVE TO LOOK AT THAT AND
SEE IF THERE'S MEDIATING AFFECT
IN GETTING TO TREATMENT.
>> THANK YOU.
MENTIONED ABOUT THE RATES OF
DEPRESSION AMONG BLACK WOMEN.
IN THE IN PERSON USUAL
INTERVENTION SELF-REPORT OR A
PROVIDER SCREEN TOOL.
>> IT'S A SCREENING TOOL AND
THAT'S WHAT I MEAN BY POSITIVE
SCREEN IF THEY ENDORSED THOSE
THAT ARE STRUCTURED AND
STANDARDIZED.
>> WERE SOME SELF-REPORTING OR A
PROVIDER DOING THE SCREENING?
>> THE PROVIDER WAS DOING THE
SCREENING.
>> THANK YOU FOR THAT
CLARIFICATION.
HERE'S A QUESTION FROM THE Q&A.
THIS IS WONDERFUL WORK, LIKE HOW
YOU HAVE INTEGRATED PATIENT
NAVIGATION AND HEALTH WITH
SOCIAL DETERMINATES OF HEALTH
WITH SCREENING.
THIS IS A GREAT ROLE TO ADD FOR
LAY HEALTH CARE/PATIENT
NAVIGATORS TO DO TEXT-BASED
SCREENING AND LINKAGE TO CARE.
THAT WAS A BIG THUMBS UP.
ONE OTHER QUESTION, WHAT
STANDARDIZED SCREENING TOOLS DID
YOU USE?
>> WITHIN OUR STATE SOUTH
CAROLINA DID YOUR PARENTS USE,
DID YOUR PEER USE, DID YOUR
PARTNER USE, HAVE YOU USED IN
THE PAST MONTH.
THAT'S A SENSITIVE SCREENING FOR
SUBSTANCE USE.
IF A WOMAN CHECKS OFF ANY OF
THOSE ITEMS SHE'LL GET THE
NIAIDA SPECIFIC SCREENING TOOL
FOR SUBSTANCE AND IF SHE CHECKS
OFF IN THE LAST WEEK OR TWO
STRUGGLES WITH MOOD OR ANXIETY
SHE'LL COMPLETE A DEPRESSION
SCALE AND WE HAVE ALCOHOL
QUESTIONS AS WELL.
IF SOMEONE CHECKS OFF THEY ARE
FEELING UNSAFE IN ANY WAY IN
THEIR HOME, THEY'RE ALSO GOING
COMPLETE THE DEPRESSION SCALE AS
WELL.
SO THOSE ARE OUR SCALES.
>> THANK YOU VERY MUCH, DR.
DR. GUILLE.
>> THANK YOU.
OUR NEXT SPEAKER OF THE DAY IS
DR. SUAREZ PRESENTING POSTPARTUM
OPIOID MORTALITY IN MEDICAID
PATIENTS.
WELCOME.
>> SO THANKS SO MUCH FOR HAVING
ME HERE TO PRESENT OUR WORK ON
POSTPARTUM OPIOID RELATED
MORTALITY IN MEDICAID PATIENTS
MIAMI I'M PRESENTING THIS ON
BEHALF OF OUR PROJECT P.I.s AND
ALSO ON BEHALF OF THE REST OF
OUR PROJECT TEAM.
A BRIEF BACKGROUND.
OPIOID OVERDOSE ACCOUNTS FOR UP
TO 10% OF THE ASSOCIATED DEATHS
AND WE THINK PREGNANT PATIENTS
WITH OPIOID USE DISORDERS MAY BE
PARTICULARLY VULNERABLE TO OTHER
CAUSES OF DEATH IN THE
POSTPARTUM PERIOD BUT THERE
HASN'T BEEN GREAT DATA TO BE
ABLE TO CHARACTERIZE THE DEATHS
IN THIS SPECIFIC OPIOID USE
DISORDER POPULATION.
MEDICAID COVERS ABOUT 75% OF
THIS POPULATION AND NOW WE CAN
USE A LINKAGE TO THE NATIONAL
DEATH INDEX.
NOW WE CAN LOOK AT COMORBIDITIES
AND PATTERNS AND OTHER FACTORS
THAT LEAD TO THE DEATH IN THIS
POPULATION.
THE OBJECTIVES OF THE STUDY WERE
FIRST TO FACILITATE THE LINKAGE
OF THE DATA BETWEEN OUR MEDICAID
DATA AND THEN DO DESCRIPTIVE
WORK AROUND THE TIMING AND RISK
FACTORS FOR POSTPARTUM MATERNAL
DEATHS.
WE'RE TALKING ABOUT DEATHS
HAPPENING AND THEN WE WANT TO
ZOOM IN ON THE PREGNANT PATIENTS
WITH HAVE OPIOID USE DISORDER
AND BE ABLE TO DESCRIBE THE
CAUSES OF THEIR NON-OPIOID
OVERDOSE RELATED DEATHS IN THE
POSTPARTUM PERIOD.
TO DO THIS WE HAVE AN
ESTABLISHED COHORT IN THIS DATA
FOR THIS PROJECT WE'RE LOOKING
AT YEARS 2006 THROUGH 2013.
2013 IS NOT AS RECENT AS WE'D
LIKE IT TO BE BUT UNFORTUNATELY
THAT'S THE LATEST AVAILABLE DATA
FOR THE NATIONAL DEATH INDEX.
THE MEDICAID DATA INCLUDES
PATIENTS COVERED UNDER STATE
MEDICAID TERMS AND LINKED THAT
TO DATA WHICH GIVES OUR DATA
DEATH IN OUR PRIMARY AND LEADING
CAUSE OF DEATH.
WE HAD PREGNANCIES WITH A DEATH
DOCUMENTED BETWEEN THE END OF
DELIVERY AND POSTPARTUM YEAR AND
102 WOMEN WHO DIED WITH A
DOCUMENTED DIAGNOSIS OF OPIOID
USE DISORDER WHICH IN OUR CASE
IS EITHER A DIAGNOSIS CODE FOR
OPIOID USE DISORDER OR EVIDENCE
OF METHADONE TREATMENT AND WE
HAD ABOUT 5 MILLION PREGNANCY
DID NOT END IN DEATH.
AND FOR OUR FIRST AIM WE ARE
DESCRIBING OPIOID RELATED
OVERDOSE DEATHS.
SO WE DEFINED THIS USING THE
SUBSTANCE USE DEFINITION.
PATIENTS NEED TO HAVE A PRIMARY
CAUSE OF DEATH CONTRIBUTING TO
OVERDOSE AND A CAUSE OF DEATH
RELATED TO OPIOIDS.
AND THEN IN AIM 202:WE'RE LOOK
AT OTHER CAUSES OF DEATH.
WE USED THE CODE DO CREATE
CATEGORIES WHICH ARE INCLUDED IN
THE TABLE HERE.
ANYTHING PREGNANCY RELATED,
CIRCULETORY SYSTEM AND
ACCIDENTS, OTHER DISEASES WHICH
IS A BIT OF A CATCHALL OF
EVERYTHING THAT DIDN'T GET
CAPTURED BY ANY CATEGORIES ABOVE
AND HAVE A PROPORTION OF DEATHS
THAT DIDN'T HAVE AN IC10 PRIMARY
CAUSE OF DEATH REPORT IN THE
NDI.
WE DO A RISK FACTOR ANALYSIS AS
PART OF THIS WORK WHERE WE'RE
LOOKING AT RISK FACTORS FOR
OPIOID OVERDOSE DEATH AND
BECAUSE OF THE NATURE OF
MEDICAID DATA WE'RE NOT
NECESSARILY OBSERVING A WOMAN
FOR THE ENTIRE TIME FROM
DELIVERY UNTIL THE END ONE-YEAR
PERIOD.
WE MATCHED THE PATIENT TO THOSE
THAT DIDN'T HAVE EVIDENCE OF
DEATH ON THE TIME AVAILABLE
OBSERVED IN THE DATABASE.
AT THE TIME OF THE DEATH WE
MATCHED TO A PATIENT STILL UNDER
OBSERVATION AND STILL HAD A
MEDICAID ENROLLMENT ON THE SAME
NUMBER OF DELIVERY AND ALSO
MATCHED WITH STATE.
ONCE WE HAVE THIS MATCH
POPULATION WE DEFINED A SERIES
OF BASELINE RISK FACTORS
SPECIFICALLY MEASURED IN THE
LAST THREE MONTHS BEFORE THE
DELIVERY AND THEN SOME RISK
FACTORS THAT AREN'T MEASURED
BETWEEN THE DELIVERY DATE UNTIL
THE MATCHED DEATH DATE.
OR AT LEAST THE MATCHED NUMBER
OF DAYS POST DELIVERY.
SO WE'LL JUMP INTO RESULTS.
FIRST I'LL PRESENT OUR
CUMULATIVE MORTALITY INCIDENTS.
SO FIRST THIS IS IN ALL PREGNANT
PATIENTS IN OUR MEDICAID
POPULATION FROM 2007 TO 2013 AND
THE NUMBERS ARE CUMULATIVE
INCIDENT ESTIMATES AT ONE YEAR
AND YOU CAN SEE IT IN THE FIGURE
BELOW.
SO AMONG ALL PREGNANT PATIENTS
THE ALL-CAUSE MORTALITY
CUMULATIVE INCIDENTS WAS 51 PER
100,000 DELIVERIES AND
SPECIFICALLY FOR OPIOID OVERDOSE
IT WAS 5.4 PER 100,000
DELIVERIES.
IF WE ZOOM IN ON THE POPULATION
OF OPIOID USE DISORDER THE
DEATHS ARE HIGHER IN THIS
POPULATION.
ALL CAUSE MORTALITY IS ABOUT SIX
TIMES HIGHER AND OPIOID OVERDOSE
DEATH IS MUCH HIGHER AT 115 PER
100,000 DELIVERIES IN THE OPIOID
USE DISORDER POPULATION.
SOW A ROUGH COMPARISON BETWEEN
OUR OPIOID USE DISORDER PREG
PREGNANCIES IN RED AND THIS IS
RANKED BY CAUSE.
OPIOID OVERDOSE DEATH IS ON TOP
AND THEN THE NEXT MOST COMMON
CAUSE OF DEATH IN THIS GROUP WAS
OVER OVERDOSE WHICH BECAUSE WE
ARE RELYING ONLY ON THE PRIMARY
AND CONTRIBUTING CAUSES, THIS
OTHER OVERDOSE CATEGORY MAY
INCLUDE SOME WOMEN THAT DIED OF
OPIOID OVERDOSE BUT DIDN'T HAVE
THE PROPER CODING.
AND WE HAVE SUICIDE AND
PREGNANCY AND DELIVERY RELATED
DEATHS AS THE NEXT MOST COMMON
CAUSES.
AND I THINK A BIG TAKEAWAY FROM
THIS FIGURE IS THAT THE
INCIDENTS OF DEATH ACROSS ALL
THESE CATEGORIES IS SO MUCH
HIGHER IN THE OUD PREGNANCIES
THAN IN THE FULL POPULATION.
REGARDLESS OF CAUSE EXCEPT FOR
THE CANCER CATEGORY ON THE
BOTTOM WHICH WE DIDN'T HAVE ANY
DEATHS REPORTED BUT ACROSS ALL
INCIDENT THE INCIDENTS ARE MUCH
HIGHER.
I'LL BRIEFLY TALK THROUGH THE
RISK FACTORS FOR OPIOID OVERDOSE
DEATH SPECIFICALLY.
I'LL GIVE THE HIGHLIGHTS HERE.
SOME OF THESE THINGS ARE
NON-RISK FACTORS FOR OPIOID
OVERDOSE DEATHS AND MORE COMMON
AMONG WHITE PREGNANT PATIENTS
THAN OTHER RACES.
OBSTETRIC MORBIDITY AND MENTAL
HEALTH MORBIDITY WERE ASSOCIATED
WITH AN INCREASED RISK OF
OVERDOSE DEATH.
AND WE LOOKED AT OPIOID
DISPENSING DURING PREGNANCY AND
PVRP AND THOSE WITH --
AND SOME HAD HIGHER UTILIZATION
THAN THEIR MATCH CONTROLS
OVERALL SO IN PATIENT
HOSPITALIZATIONS AND OUT-PATIENT
VISITS.
HERE I'M SWITCHING BACK TO
LOOKING AT THE POPULATION WITH
OPIOID USE DISORDER AND
HIGHLIGHT A COUPLE FACTORS.
AGAIN WE SEE AN ASSOCIATION WITH
WHITE RACE ETHNICITY VERSUS
OTHER GROUPS UNFORTUNATELY OUR
SAMPLE SIZE IS A LITTLE TOO
SMALL TO GET MORE SPECIFIC WITH
THOSE CATEGORIES HERE AND THEN
OF COURSE DOCUMENTATION OF OTHER
SUBSTANCE USE DISORDER NOT JUST
THE OPIOID CODES WHERE
ASSOCIATED WITH AN INCREASE OF
OPIOID OVERDOSE DEATH IN THIS
POPULATION.
AND THEN WE SEE A PRETTY STRONG
PROTECTIVE ASSOCIATION FOR THE
USE OF OPIOID AGONISTS IN
PREGNANCY AND POSTPARTUM.
THIS IS DOCUMENTED USE OF
METHADONE AND THOSE WHO HAD
OPIOID AGONIST TREATMENT DURING
THE DIFFERENT PERIOD.
AMONG THE PATIENT WHO'S DID DIE
OF AN OPIOID OVERDOSE DEATH 13%
HAD TREATMENT POSTPARTUM
COMPARED TO 41% AND 34% IN THE
PATIENT DID NOT DIE.
THESE COUNTS ARE PROBABLY A
LITTLE BIT LOW BECAUSE IT'S
CAPTURING MEDICAID REIMBURSEMENT
OPIOID AGONIST THERAPY BUT THE
STRONG ASSOCIATION WOULD STILL
HOLD.
WE SAW WHAT WAS ASSOCIATED WITH
OVERDOSE DEATH AND DURING
PREGNANCY AND POSTPARTUM
UTILIZING BUT WE DIDN'T FIND
OBSTETRIC MORBIDITY AND OTHER
MENTAL HEALTH MORBIDITY WAS NOT
STRONGLY ASSOCIATED WITH RISK OF
OPIOID RISK OF DEATH AND THERE'S
A HIGH MORBIDITY IN THESE
POPULATIONS OVERALL.
IN SUMMARY, WE DO SEE PREGNANT
PATIENTS WITH OPIOID USE
DISORDER HAD SIX TIMES HIGHER
INCIDENTS OF DEATH IN THE YEAR
FOLLOWING DELIVERY IN OUR
GENERAL POPULATION AND THE
INCIDENT HIGHER REGARDLESS OF
THE CAUSE WE LOOKED AT.
OPIOID AGONIST THERAPIES WERE
STRONGLY ASSOCIATED WITH THE
DECREASED RISK OF OVERDOSE DEATH
BUT WE ALSO SEE PATIENTS WITH
OVERDOSE DEATHS STILL HAD
CONTACT WITH HEALTH CARE SYSTEM
BETWEEN DELIVERY AND DEATH.
POTENTIALLY THERE WERE AVENUES
FOR INTERVENTION THAT WERE NOT
MEANT FOR THESE PATIENTS.
THAT'S WHAT I HAVE AND HAPPY TO
TAKE SOME QUESTIONS.
>> THANK YOU, DR. SUAREZ.
WE DO HAVE A QUESTION IN THE
Q&A.
GREAT PRESENTATION.
I NOTICED FENTANYL WAS CODED AS
PART OF OPIOID RELATED DEATHS.
GIVEN THE SUBSTANCE USE DEATHS
BEING DRIVEN BY FENTANYL IS
THERE A REASON IT WAS NOT
INCLUDED IN THE ANALYSIS?
>> NOT INCLUDED IN THE ANALYSIS
MEANING?
>> IT'S MAYBE REFERRING TO THE
LIST OF CAUSES RELATED TO
OPIOIDS.
>> IF YOU CAN TYPE A
CLARIFICATION IN THE MEANTIME
THAT WOULD BE GREAT.
I HAVE A QUESTION QUESTION -- A
QUESTION THAT MAY BE NAIVE.
ARE YOU ABLE TO DETERMINE
WHETHER THE WOMEN DYING IN THE
POSTPARTUM PERIOD FROM
APPARENTLY OVERDOSES ARE THEY
USING DURING PREGNANCY OR HAD A
PERIOD OF ABSTINENCE AND THEN
RESTART?
I KNOW YOU CAN'T GATHER THIS
THERE THE DATA BUT I'M WONDERING
IF YOU KNOW ANYTHING ABOUT THAT?
>> I CAN'T CAPTURE ACTIVE USE.
WE CAN CAPTURE PRESCRIPTIONS IN
PREGNANCY AND POSTPARTUM WHICH
WE DID SEE WAS ASSOCIATED WITH
AN INCREASE IN OVERDOSE DEATH.
I DON'T HAVE MUCH MORE INSIGHT
INTO WHEN THESE MAY BE ACTIVELY
USING OR NOT.
WE DO SEE WHEN THEY POTENTIALLY
ARE ON ACTIVE OPIOID AGONIST
TREATMENT WHEN IT'S COVERED BY
MEDICAID THERE'S SOME METHADONE
TREATMENT WE'RE PROBABLY NOT
CAPTURING FUNDED THROUGH OTHER
SOURCES.
IT'S HARD TO SAY.
MEDICAID DATA HAS A LOT OF RICH
DATA BUT NOT SO MUCH IN OTHER
ARENAS.
>> STILL VERY INTERESTING
THOUGH.
LET ME SEE IF WE HAVE WE
CLARIFICATION.
IT'S REFERRING TO THE LIST OF
CAUSES OF DEATH.
FENTANYL IS NOT LISTED.
I'M WONDERING WHY THAT WAS NOT
INCLUDED IN THE LIST OF DRUGS.
>> SO THIS GOES OFF THE
SUBSTANCE USE AND MENTAL HEALTH
SERVICES ADMINISTRATION
DEFINITION.
WE DIDN'T CREATE THE DEFINITION
ON OUR OWN.
I'M ASSUMING MAYBE THERE'S NOT A
SPECIFIC IC10 CODE RELATED AND
WOULD PROBABLY BE CAPTURED UNDER
OTHER CODES LISTED THERE BUT I
DON'T HAVE ANY GREATER INSIGHT
ON FENTANYL SPECIFICALLY BUT
ASSUMING IT WOULD STILL BE
CAPTURED IT UNDER ONE OF THE
CATEGORIES OVER HERE.
IT'S ALSO A GOOD TIME TO NOTE
WE'RE LIMITED BY WHAT IS PUT IN
THE CODES IN THE NDI.
I THINK WE SAW THE PATIENTS
STILL HAD A -- THE SECOND
LEADING CAUSE OF DEATH WAS
OVERDOSES THAT DIDN'T MEET OUR
DEFINITIONS SO I'M SURE THERE'S
OVERDOSES IN THAT GROUPING THAT
COULD BE ATTRIBUTE ID TO
OVERDOSING NOT CAPTURED IN THE
CODES.
>> THAT MAKE SENSE YOU'RE
WORKING WITH JUST THAT HAS BEEN
CODED TO DATE.
>> YEAH.
>> OKAY.
WELL, THANK YOU VERY MUCH.
WITH THAT I THINK WE WILL WRAP
UP AND GET READY TO TURN IT OVER
TO DR. AKLIN TO CLOSE US OUT.
I WANT TO SAY THANK YOU VERY
MUCH TO ALL THREE OF OUR
PANELISTS.
THOSE WERE REALLY VERY
INTERESTING PRESENTATIONS AND
GOOD LUCK WITH YOUR CONTINUED
WORK.
>> THANK YOU AND GOOD AFTERNOON
AND FULL RECOGNITION I'M IN
BETWEEN ALL OF YOU AND THE REST
OF YOUR AFTERNOON, NICE
PICTURE -- I HADN'T SEEN THAT
SLIDE I'LL KEEP REMARKS BRIEF
BUT I FIRST WANT TO SAY TO ALL
OF YOU THANK YOU FOR THE TIME
YOU TOOK TODAY TO SHARE WITH US
YOUR WORK WE HAVE BEEN EXCITED
TO INTEREST THE OPPORTUNITY TO
HIGHLIGHT THIS WORK AND MAKE IT
CLEAR WE'RE SUPPORTIVE OF YOUR
WORK AND THANK YOU.
THANK YOU TO DR. LAUREN HILL FOR
CLOSING OUR FINAL PANEL AND THE
REST OF OUR ENFORCE MEMBERS
DOING AN AMAZING JOB GETTING
THIS WORKSHOP GOING AND TO OUR
SPEAKERS.
IT'S BEEN A WONDERFUL WEALTH OF
KNOWLEDGE AND INFORMATION AND
I'M SURE I DON'T HAVE TO TELL
YOU BECAUSE BY VIRTUE OF YOUR
ATTENDANCE WE RECOGNIZE HOW TO
IMPORTANT THE TOPIC IS BUT IT
CONTINUES TO BE AN URGENT
REMINDER WHILE WE MADE STRIDES
AND WE STILL HAVE WORK TO DO.
THERE'S STILL TOO MANY STORIES
LIKE THE ONE SHARED OF WOMEN WHO
PRESENT TO OUR HEALTH CARE
PROVIDERS INDICATING I'VE GOT A
PROBLEM BUT BEING SENT HOME AND
MEDICATION AND UNDER SCORING THE
WORK YOU'RE DOING HERE.
WE NEED TO CONTINUE TO BROADEN
OUR EVIDENCE BASED FOR NEW
INTERVENTIONS AND STRENGTHEN OUR
INFORMATION OF THE CAUSES BEHIND
THE DISPARITIES MANY SPOKE TO
TODAY.
I'M EXCITED WE'RE DOING THIS
WORK AND HOPE IT WILL CONTINUE
TO ASSIST US IN COMING UP WITH
PREVENTION TO TAKE DOWN SOME OF
THE STORIES WE HEARD TODAY.
THE EXAMPLE BEING ABLE TO
EDUCATE OUR HEALTH CARE
PROVIDERS TO LOOK FOR SCIENCE OF
DISTRESS.
SPENDING THE TIME UP FRONT TO
ASSESS THE SOCIAL FACTORS ALONG
WITH THE HEALTH FACTORS WHEN WE
DO OUR ASSESSMENTS.
WHAT I ALSO HEARD TODAY WAS THE
POSSIBILITY OF COLLABORATION.
I LOVED HEAR FROM THE SPEAKERS
SAYING I'D LIKE TO TALK TO YOU
OFFLINE LATER BECAUSE YOUR WORK
ALIGNS WITH MY WORK.
THAT IS ALWAYS SOMETHING WE WANT
DO IS TO CATALYZE CONTINUED
COLLABORATIONS IN THE SPACE AND
FULL RECOGNITION IT'S A TEAM
EFFORT AND TOGETHER YOU ARE A
TEAM.
ALSO WANTING TO TALK ABOUT HOW
IMPORTANT IT IS WE CONTINUE TO
EXAMINE POTENTIAL TARGETS FOR
ADDITIONAL RESEARCH.
WE HEARD A CONVERSATION ABOUT
THE INTERSECTION OF PRE-EXISTING
CONDITIONS.
THE ROLE HEALTH CARE COVERAGE AT
A STATE AND NATIONAL LEVEL PLAY.
THE ABILITY TO ASSESS MORE THAN
THE HEALTH CARE STATUS AND THE
UTILIZATION OF DIGITAL
TECHNOLOGY AND HEALTH RECORDS
AND SO MANY WAYS TO PARTNER TO
DO THIS.
I WANT TO TAKE A MOMENT TO TALK
ABOUT COVID-19.
WE'RE ALL AWARE THE PANDEMIC HAS
IMPACTED ALL OF US AND THE
DISPARITIES WE'VE SEEN WITH
MATERNAL CARE HAS ONLY BEEN
HEIGHTENED BY THIS DISPARITY
THAT HAS COME WITH THE PANDEMIC
AND IN ESSENCE OF TIME I WON'T
FOCUS TOO MUCH HERE BUT TO SHARE
WHILE WE'RE INFORMATION SOME OF
THE SHORT TERM IMPACTS, FOR
EXAMPLE, KNOWING THAT PEOPLE WHO
ARE PREGNANT THAT EXPERIENCE
COVID-19 THE SYMPTOMS ARE AT
HIGHER RISK FOR ADVERSE
OUTCOMES.
RECOGNIZING THE PHYSICAL,
EMOTION AND SOCIO ECONOMIC
COMPONENTS HAVE A MAJOR IMPACT.
THE OTHER THING WE'VE TALKED
ABOUT IS CONTINUING TO STUDY THE
LONG-TERM IMPACT OF THE PANDEMIC
AND SO AGAIN WITH THE DATA WE'VE
HEARD PRESENTED TODAY THERE'S
GAI ST-- A GOOD STEP FORD --
FORWARD TO DO THAT AND HAVE
HIGHLIGHTED INFORMATION OF THE
DISPARITIES SHARED TODAY.
I'M EXCITED TO BE ABLE TO
CONTINUE ON OUR JOURNEY WE
STARTED WITH IMPROVE.
YOU HEARD FROM DR. BIANCHI AND
CLAYTON THIS IS NOT ONLY URGENT
BUT IMPORTANT MATTER.
DR. FRANCIS COLLINS CHARGED US
TO CONTINUE TO MAKE SURE WE
FOUND THE EVIDENCE, SUPPORT THE
EVIDENCE AND CONTINUE MOVE
FORWARD IN THIS SPACE.
I WANT TO TAKE A MOMENT TO SHARE
WITH YOU WHAT WE'RE THINK AS WE
MOVE FORWARD AS DESCRIBED IN THE
NIH STRATEGIC PLAN DECREASE
MATERNAL DEATHS IN THE U.S. AND
IN MANY OF THE STUDIES YOU
REPORTED BACK ON THESE TWO
GROUPS CONTINUE TO EXPERIENCE
ACROSS THE BOARD DISPARITIES.
THE MATERNAL NEUTRALITY TASK
FORCE WILL MAKE SURE WE'RE
STEWARDING THE RESEARCH AND
HAVING WORK SHOPS LIKE TODAY
WILL CONTINUE TO GIVE US
ADDITIONAL INFORMATION TO SHARE
FORWARD AND TODAY AS THIS
REGARDING IS BEING DONE WE'LL
CONTINUE TO SHARE THESE.
TO CLOSE, WE'RE REALLY EXCITED
AGAIN FOR THE OPPORTUNITY TO
CONTINUE TO SEE THE WORK YOU'RE
DOING.
FOR OUR AWARDEES FROM HERE 20
AND 2021 THANK YOU FOR YOUR2
ATTENDANCE IN BEING HER0ATTENDANCE IN BEIN G HERE.
YOUR20ATTENDANCE IN BEING HERE.
THE FOR YOUR CONTINUED
CONVERSATION.
BE AWARE ALL THE PROCEEDINGS FOR
TODAY WILL BE AVAILABLE ON OUR
IMPROVE WEBSITE AND AGAIN, THANK
YOU FOR BEING HERE THIS
AFTERNOON.
I SEE DIANA AND JANINE IF
THERE'S ANY COMMENTS YOU'D LIKE
TO CLOSE OUT PLEASE SHARE.
>> I'D LIKE TO ACKNOWLEDGE THE
WONDERFUL JOB THE MODERATORS DID
IN SPARKING QUESTIONS WHEN THERE
WAS A MOMENTARILY PAUSE BUT
KEEPING EVERYONE ON TIME.
I'D ALSO LIKE TO ACKNOWLEDGE OUR
CONTRACTORS FOR THEIR WONDERFUL
AND SMOOTH AV SUPPORT.
IT'S BEEN A GREAT DAY.
IT'S ILLUSTRATED TO ME HOW
COMPLEX A PROB THIS IS AND THERE
ARE DIFFERENT PIECES OF THE
PUZZLE BUT BY COMING TOGETHER
THERE ARE NEW INSIGHTS THAT WILL
HELP US ALL MOVE TOWARDS THE
GOAL OF REDUCING SEVERE MATERNAL
MORBIDITY AND MORTALITY.
OVER TO YOU, JANINE FOR THE LAST
WORD.
>> I'LL PICK UP ON YOUR COMING
TOGETHER BECAUSE I THINK THE
PRESENTATION S EXEMPLIFY COMING
TOGETHER AND I'D LOVE TO SEE THE
CONNECTIONS BETWEEN THE
INVESTIGATORS AND MORE WE'LL BE
ABLE TO DO AND GROW IN THE
FUTURE, FINGERS CROSSED.
THANK YOU EVERYONE WHO HELPED
PLAN THE MEETING AND EXECUTE AND
OUR AWARDEES.
WE'RE EXCITED TO HEAR ABOUT THE
AMAZING SCIENCES AND HOPE YOU'LL
CONTINUE TO UPDATE US AND LOOK
FORWARD TO HEARING FROM OUR '21
AWARDEES IN THE FUTURE.
THANK YOU, EVERYONE.
>> AND LET US KNOW ABOUT
UPCOMING PUBLICATIONS SO THAT
THE OFFICE OF COMMUNICATION AND
DIRECTOR CAN HELP PROMOTE YOUR
SCIENCE AND THAT IN TURN HELPS
BROADEN AWARENESS AND WE'RE
PARTNERS TOGETHER IN THAT
JOURNEY.
>> WITH THAT, THANK YOU VERY
MUCH AND WE LOOK FORWARD TO YOUR
CONTINUED EFFORTS.