The PATH Home Trial: A Comparative Effectiveness Study of Peripartum Opioid Use Disorder in Rural Kentucky (PATH)

Perinatal opioid use disorder (OUD) is a major health concern in the U.S. with significant impact on mothers, infants, and communities. Investigators at the University of Kentucky/UK HealthCare (UK) have developed a comprehensive clinical care model for perinatal OUD (known as UK-PATHways) that has demonstrated success in maternal and neonatal outcomes. The overreaching goals of the proposed project are to: 1) expand the reach of this successful clinical program, 2) to reduce the impact of perinatal OUD in underserved rural areas of our state, and 3) to compare the relative effectiveness methods of delivery active elements of the PATHways program for rural implementation (local group-support vs. UK nurse/counselor telemedicine)

Study Overview

• Status: Active, not recruiting
• Conditions: Neonatal Abstinence Syndrome
• Intervention / Treatment: Behavioral: Telemedicine; Behavioral: Group Care

Detailed Description

The UK-PATHways program preliminary successes during the first three years are clear: enrolled mothers (n>200) have reduced relapse, increased treatment compliance, and improved neonatal outcomes when compared to non-enrolled OUD mothers. However, at this time,UK-PATHways is only available at our main healthcare campus in Lexington, KY. Many eligible patients reside great distances from our clinical home and some current patients travel hours to access this valuable resource. While Medication Assisted Therapy (MAT) has become increasingly available in our region, many of the components of the UK-PATHways program are not readily accessible in rural Central and Eastern Kentucky and the quality of programming with MAT treatment is not standardized in these locations. Furthermore, rural patients continue to face challenges related to stigma of their OUD and transportation difficulties if they desire more comprehensive services. The proposed study will evaluate the introduction of essential components of the UK-PATHways program into rural communities, and identify the optimal intervention strategies for expansion of services and to improve the treatment of OUD for rural patients. Specific aims include the following: Aim 1) Conduct a randomized cluster trial using a 'hub and spoke' study design, comparing two delivery modes (local GROUP care vs TELEMEDICINE) for the delivery of a PATHways based patient education curriculum at participating rural regional sites. Each regional site will be randomized to support one of two study arms: 1) Prenatal group care led by a Perinatal Nurse Facilitator and Peer Support Specialist (GROUP arm); or, 2) Telemedicine consultation with substance abuse counselors, perinatal nurse educators, and/or Peer Health Specialists based at the 'hub' site (TELEMEDICINE arm); and Aim 2) Evaluate the relative effectiveness of each study arm on primary and secondary maternal and neonatal outcomes as compared to the established PATHways program (UK-PATHways: Hub) at the University of Kentucky.

• Study Type: Interventional
• Enrollment (Actual): 269
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Karen Fawcett, MPH; Phone Number: 859-257-2321; Email: karen.fawcett@uky.edu

Study Locations

• United States
  • Kentucky
    • Ashland, Kentucky, United States, 41101
      • Karen's Place Maternity Center
    • Bowling Green, Kentucky, United States, 42101
      • The Medical Center
    • Corbin, Kentucky, United States, 40701
      • Grace Health Women's Care
    • Georgetown, Kentucky, United States, 40324
      • University of Kentucky Women's Health OB-GYN
    • Hazard, Kentucky, United States, 41701
      • Primary Care Centers of Eastern Kentucky
    • Louisville, Kentucky, United States, 40202
      • OB/GYN & Women's Health University of Louisville
    • Middlesboro, Kentucky, United States, 40965
      • ARH Women's and Family Health Center - Middlesboro
    • Morehead, Kentucky, United States, 40351
      • University of Kentucky Morehead Women's Healthcare
    • Prestonsburg, Kentucky, United States, 41465
      • Frontier Behavioral Health Centers
    • S. Williamson, Kentucky, United States, 41514
      • ARH Women's and Family Health Center - Tug Valley

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 55 years (Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Pregnant women at 6 to 32 weeks' gestational age
• History of Opioid Use Disorder
• Receiving Medication Assisted Therapy (buprenorphine products or methadone)
• Obtaining prenatal care at one of eleven study sites located throughout Central and Eastern Kentucky

Exclusion Criteria:

-

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Telemedicine Education; This is a stratified cluster randomized controlled trial with randomization of participating clusters into a 'telemedicine' or 'group care' arm. Sites will be stratified into 'high volume' (>500 deliveries/year) and 'low volume' (<500 deliveries per year). Randomization will be within each strata. Patients attending sites randomized to telemedicine will be recruited by research staff.	Behavioral: Telemedicine; Patients enrolled at sites randomized to telemedicine will receive a standardized, rotating patient education curriculum through consultations with substance abuse counselors, perinatal nurse educators, and/or Peer Health Specialists. Consultations will occur every two weeks until 8 weeks post-partum and will then continue monthly until 6 months postpartum. Rotating topics include: 1) Treatment Options for Opioid Use Disorder, 2) Smoking Cessation, 3) Relapse Prevention Education, 4) NAS Reduction Education, 5) Breast Feeding Support/Education, 6) Domestic Violence Education, 7) Postpartum Depression, and 8) Birth Control/Family Planning.
Active Comparator: Group Care Education; This is a stratified cluster randomized controlled trial with randomization of participating clusters into a 'telemedicine' or 'group care' arm. Sites will be stratified into 'high volume' (>500 deliveries/year) and 'low volume' (<500 deliveries per year). Randomization will be within each strata. Patients attending sites randomized to group care will be recruited by research staff.	Behavioral: Group Care; Patients enrolled at sites randomized to group care will receive a standardized, rotating patient education curriculum delivered in small groups led by a perinatal nurse facilitator and community-based peer support specialist. Small group care meetings will occur every two weeks until 8 weeks post-partum and will then continue monthly until 6 months post-partum. Rotating topics include: 1)Treatment Options for Opioid Use Disorder, 2) Smoking Cessation, 3) Relapse Prevention Education, 4) NAS Reduction Education, 5) Breast Feeding Support/Education, 6) Domestic Violence Education, 7) Postpartum Depression, and 8) Birth Control/Family Planning.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Incidence of medication requiring neonatal abstinence syndrome (NAS)	Medical records will be reviewed at 3 months post-partum visit for treatment for NAS. Diagnosis of NAS will be made within 10 days of birth and treatment started based on standard of care. Data will be presented as the percent of infants born requiring therapy in each group.	up to 10 days postpartum

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in cigarette dependency	Participants will complete the Fagerstrom Test For Cigarette Dependence during their intake visit, at 28 weeks gestational age, 3 months postpartum and 6 months postpartum (combined total time of observation is up to 60 weeks). The survey instrument asks seven questions related to cigarette dependency. Responses will be scored on a scale of zero to 3 and totaled. Any score greater than 8 is considered high dependency, a score of 5-7 is considered moderately dependent, 3-4 is low to moderate dependence and 1-2 is low dependence. Data will be presented as the change in cigarette dependency over time compared between groups.	Up to 60 weeks
Change in maternal anxiety over time	Participants will complete the Generalized Anxiety Disorder 7-Item scale during their intake visit, at 28 weeks gestational age, 3 months postpartum and 6 months postpartum (combined total time of observation is up to 60 weeks). The survey consisted of 8 questions scored between zero (no anxiety) and 3 (daily anxiety) were a total score of 1-4 indicates minimal anxiety and a score of 15-21 indicates severe anxiety. Data will be presented as the change in anxiety over time compared between groups.	Up to 60 weeks
Change in maternal depression over time	Participants will complete the Edinburgh Depression Scale during their intake visit, at 28 weeks gestational age, 3 months postpartum and 6 months postpartum (combined total time of observation is up to 60 weeks). The survey consisted of 10 questions scored between 1 (no depression) and 4 (daily depression) were a total score of 1-8 is normal, a score is 9-10 is at risk for depression and a score of 11 or more indicates severe depression. Data will be presented as the change in depression over time compared between groups.	Up to 60 weeks
Change in quality of life	WHO-Quality of Life Survey (WHOQoL) will be administered to patients at 28 weeks gestation, 3 and 6 months postpartum ( total time frame up to 38 weeks). WHOQoL is a 26 question self administered survey. Each question falls within 1 of 4 "domains": physical health, psychological health, social relationships, environment. The four domains are added up to create 4 raw domain scores and means are calculated. These are transformed into transformed scores of "0 - 100". Higher scores indicate higher perceived quality of life in that particular domain. Data will be presented as the change in depression over time compared between groups	up to 38 weeks
Opioid Use Disorder	Participants will complete a survey to assess their opioid dependency during their intake visit (typically between 6-28 weeks gestation). The survey asks 11 questions related to opioid use in a yes/no format. 2-3 "yes" answers indicates mild opioid use, "yes" to 4-5 questions indicates moderate use and "yes" to 6 or more questions indicates severe dependency. Data will be presented as the mean +/-standard error of the dependency scores per group.	Intake visit (between 6-28 weeks gestation)
Incidence of hospitalization for opioid related issues during the study period	Participants will be surveyed for hospitalizations during the study but not related to participation in the study at 28 weeks gestation and 3 and 6 months postpartum (total time frame up to 38 weeks). They will be asked a series of "yes" or "no" questions. Data will presented as the total number of "yes" answers per group over the course of the study.	up to 38 weeks
Change in physical condition of infant post delivery	Infant physical condition at birth with be assessed using the Apgar scale at 1 minute, 5 minutes and 10 minutes after birth. The Apgar scale consists of 5 criteria scored 0-2. Scores are combined for a total score of between 0-10 were 10 is a very healthy infant and 0 is an infant requiring immediate intensive medical care. Data will be presented as the change in Apgar score over time compared between groups.	Up to ten minutes
Incidence of pediatric emergency room (ER) visits	A medical record review will take place to determine if any ER visits took place in the first 6 months of the infants life. Data will be presented as the total number of ER visits compared between groups	six months
Adherence to a vaccine schedule	A medical record review will take place to determine if the infant's vaccine schedule was maintained in the first 6 months of the infants life. Data will be presented as the percent of infants in each group considered compliant and compared between groups.	six months
Adherence to a pediatric visit schedule	A medical record review will take place to determine if the infant's pediatric visit schedule was maintained in the first 6 months of the infants life. Data will be presented as the percent of infants in each group considered compliant and compared between groups.	six months
Infant motor development	At three months of age, infant mom/caregivers will be asked to complete the Ages & Stages Questionnaires®, Third Edition (ASQ®-3), a developmental screening tool designed for use by early educators and health care professionals. The survey collects milestones in infants in five domains; communication, gross motor, fine motor, problem-solving, and personal/social. It takes just 10-15 minutes for parents to complete and 2-3 minutes for professionals to score and highlights results that fall in a "monitoring zone", to make it easier to keep track of children at risk. The Ages and Stages 3 month survey instrument is 38 items filled out by the caregiver and scored by the clinic staff. Scores are calculated at 0, 5, or 10 per question, and lower scores are interpreted to support further professional assessment concerning the infant's development. Scale scores will be presented as the mean +/- standard error per group compared between groups.	3 months postpartum
Infant motor development	At six months of age, infant mom/caregivers will be asked to complete the Ages & Stages Questionnaire, Third Edition to provide a snapshot need to catch delays and celebrate milestones. The survey collects milestones in infants in five domains; communication, gross motor, fine motor, problem-solving, and personal/social. It takes just 10-15 minutes for parents to complete and 2-3 minutes for professionals to score and highlights results that fall in a "monitoring zone", to make it easier to keep track of children at risk. The Ages and Stages 6 month survey instrument is 38 items filled out by the infants caregiver and scored by the clinic staff. Scores are calculated at 0, 5, or 10 per question, and lower scores are interpreted to support further professional assessment concerning the infant's development. Scale scores will be presented as the mean +/- standard error per group compared between groups.	6 months postpartum
Incidence of opioid relapse	A medical record review and patient interview at each visit will be used to determine the number of participants in each group that began using illicit substances after a period of sobriety. Data will be collected at the intake visit, admission for delivery, and 3 and 6 months postpartum (up to 60 weeks). Data will be presented as the total count of relapse events in each group over the course of the study compared between groups.	Up to 60 weeks
Incidence of opioid overdose	A medical record review and patient interview at each visit will be used to determine the number of participants in each group that experienced an opioid overdose. Data will be collected at the intake visit, admission for delivery, and 3 and 6 months postpartum (up to 60 weeks). Data will be presented as the total count of overdose events in each group over the course of the study compared between groups.	Up to 60 weeks

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in employment status	Participants will be asked about employment status during their intake visit, at 28 weeks gestational age, 3 months postpartum and 6 months postpartum (combined total time of observation is up to 60 weeks). Participants will answer "yes" or "no" regarding their employment status. Data will be presented as the change in employment status between groups.	Up to 60 weeks
Change in household size	Participants will be asked to indicate the total number of people sharing their living space during the intake visit, and 6 months postpartum (combined total time of observation is up to 38 weeks). Data will be presented as the change in dwelling occupancy over time compared between groups.	up to 38 weeks
Acceptance of long term contraception	Participants will be offered long acting reversible contraception at time of delivery (up to 34 weeks into the study assuming delivery at 40 weeks gestation). Data will be presented as the number of participants per group accepting long term contraception.	Up to 34 weeks

Collaborators and Investigators

• Sponsor: Wendy F Hansen
• Collaborators: Patient-Centered Outcomes Research Institute
• Investigators: Principal Investigator: Wendy Hansen, MD, University of Kentucky, Department of OB-GYN, Division of Maternal Fetal Medicine

Study record dates

Study Major Dates

• Study Start (Actual): March 13, 2019
• Primary Completion (Estimated): April 1, 2024
• Study Completion (Estimated): April 1, 2024

Study Registration Dates

• First Submitted: October 29, 2018
• First Submitted That Met QC Criteria: October 29, 2018
• First Posted (Actual): October 31, 2018

Study Record Updates

• Last Update Posted (Estimated): December 11, 2023
• Last Update Submitted That Met QC Criteria: December 7, 2023
• Last Verified: December 1, 2023

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Mental Disorders; Chemically-Induced Disorders; Substance-Related Disorders; Infant, Newborn, Diseases; Narcotic-Related Disorders; Opioid-Related Disorders; Neonatal Abstinence Syndrome
• Other Study ID Numbers: 44929; MAT-2017C2-7842 (Other Identifier: Patients Centered Outcomes Research Institute)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: No plan to share IPD at this time

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No