Development of the Drug-Exposed Infant Identification Algorithm (DEIIA) and Its Application to Measuring Part C Early Intervention Referral and Eligibility in Massachusetts, 1998–2005

Risk factors for emergency room use and rehospitalization among opioid-exposed newborns in Massachusetts

OBJECTIVE

To determine the risk factors for receipt of emergency room (ER) care and rehospitalization among opioid-exposed newborns in Massachusetts.

DESIGN/METHODS

We analyzed two linked data sets from 2002 to 2010: (a) Massachusetts Pregnancy to Early Life Longitudinal Data System and (b) Massachusetts Bureau of Substance Abuse Services Management Information System. Generalized estimating equations were used to assess the independent association of maternal and infant characteristics with ER use and rehospitalization in the first year of life.

RESULTS

Four thousand and five hundred and twenty-four maternal-infant dyads affected by OUD were included in the analysis. In adjusted analysis, risk factors for receipt of ER care included Hispanic ethnicity (aOR 1.63 [95% CI 1.30-2.05]), lower education levels (aOR 1.54-1.69 [95% CI 1.12-2.31]), nonprivate insurance (aOR 1.44 [95% CI 1.11-1.86]), and presence of maternal chronic conditions (aOR 1.14 [95% CI 1.01-1.29]). Risk factors for rehospitalization included prematurity (aOR 1.44 [95% CI 1.14-1.82]), low birthweight (aOR 2.02 [95% CI 1.63-2.49]), and nonprivate insurance (aOR 1.58 [95% CI 1.13-2.22]). Prolonged infant birth hospitalization was protective against both ER use (aOR 0.84 [95% CI 0.73-0.96]) and rehospitalization (aOR 0.63 [95% CI 0.53-0.75]).

CONCLUSIONS

Clinical and sociodemographic characteristics are risk factors for receipt of ER care and rehospitalization among opioid-exposed newborns in Massachusetts.

Early Intervention Referral and Enrollment Among Infants with Neonatal Abstinence Syndrome

OBJECTIVE

To identify factors associated with referral and enrollment in early intervention (EI) for infants with neonatal abstinence syndrome (NAS).

METHODS

We conducted a retrospective cohort study of 256 infants born with NAS (2006-2013) at a tertiary care hospital in (Springfield), Massachusetts, linking maternal-infant birth hospitalization records with Department of Public Health EI records. We calculated the percent of infants retained at each step in the EI enrollment process over the first 3 years of life. We conducted separate multivariable logistic regression analyses to identify factors associated with EI referral and enrollment.

RESULTS

Among mothers, 82% received medication-assisted treatment at delivery, 36% endorsed illicit drug use during pregnancy, and 76% retained custody of their child at discharge. Among infants, 77% were referred to EI and 48% were enrolled in services. Of infants discharged to biological parents, 81% were referred to EI versus 66% of infants discharged to foster care (p ≤ 0.05); this difference persisted in multivariable analysis [adjusted odds ratio, 2.30; 95% confidence interval (CI), 1.09-4.86]. Infants in the highest tertile for length of stay had 2.70 times the odds of EI enrollment (95% CI, 1.37-5.31).

CONCLUSION

Fewer than half of the eligible infants with NAS were enrolled in EI services. Discharge to a biological parent and longer hospital stay had the strongest associations with EI referral and enrollment, respectively. Efforts to improve EI referral rates during the birth hospitalization, particularly among infants discharged into foster care, and close follow-up for infants with shorter hospital stays would enhance the developmental supports for this vulnerable population.

Caretaker Awareness of Health Care Provided Developmental Screening: Increases from 2007 to 2012

Objectives Developmental screening is considered critical to identifying children with developmental delays and disabilities so that they may receive early intervention. To date, only a handful of studies report data on the percentage of health care professionals (HCP) who provide developmental screening. These reports are limited by low participation rates and reporters being pediatricians who may be biased towards reporting higher rates of developmental screening. The purpose of this study is to verify reported increases by reporting on changes in caretakers' awareness of HCP provided developmental screening from 2007/2008 to 2011/2012. Methods Authors report data on caretaker reported receipt of HCP provided developmental screening from the National Survey of Children's Health (NSCH, 2007/2008) and NSCH (2011/2012), as well as changes from the 2007/2008 to 2011/2012. Changes for the 50 states plus Washington D.C. are visualized using 'micromapST' and states are organized in ascending order according to changes in caretaker awareness of developmental screening. Results Nationally, the proportion of caretakers aware that their HCP provided developmental screening increased from 23.0% in 2007/2008 (range 12.6-46%) to 33.3% in 2011/2012 (range 19.4-61.6%) and states level changes ranged from -2 to +35%, with a median change of +10%. Conclusions for Practice Data reported here indicate that a greater number of caretakers are aware that their HCP is providing developmental screening. This reinforces the existing reports indicating increases in HCP reported developmental screening. Despite growth, there is still a need to increase developmental screening efforts in many states.

A Systematic Review of Part C Early Identification Studies

Authors conducted a systematic literature review on early identification steps leading at-risk young children to connect with Part C services. Authors classified data collection settings as primary (settings for general population) or specialized (settings for children at risk of developmental delay) and according to the phases of early identification in the study: (a) original population of children aged 0 to 6 years who had received Part C services, (b) screening and/or referral and/or developmental assessment from 0 through age 2 years, and (c) were deemed eligible and/or received Part C services. Authors identified 43 articles including at least two phases of the early identification process. The literature about connecting children to Part C early intervention (EI) is sparse and fragmented; few studies document the full process from community monitoring to service receipt. Results indicate opportunities for development of systems to better track and improve the identification of young children in need of EI.

Maternal Substance Use Disorders and Infant Outcomes in the First Year of Life among Massachusetts Singletons, 2003-2010

OBJECTIVE

To determine the association of maternal substance use disorders (SUDs) during pregnancy with adverse neonatal outcomes and infant hospital re-admissions, observational stays, and emergency department utilization in the first year of life.

STUDY DESIGN

We analyzed 2 linked statewide datasets from 2002 to 2010: the Massachusetts Pregnancy to Early Life Longitudinal data system and the Massachusetts Bureau of Substance Abuse Services Management Information System. Generalized estimating equations were used to assess the association of maternal SUDs and neonatal outcomes and infant hospital-based care in the first year of life, controlling for maternal and infant characteristics.

RESULTS

Maternal SUDs increased from 19.4 per 1000 live births in 2003 to 31.1 per 1000 live births in 2009. In the adjusted analysis, exposed neonates were more likely to be born preterm (aOR 1.85; 95% CI 1.75-1.96) and low birthweight (aOR 1.94; 95% CI 1.80-2.09). After controlling for maternal characteristics and preterm birth, SUD-exposed neonates were more likely to have intrauterine growth restriction, cardiac, respiratory, neurologic, infectious, hematologic, and feeding/nutrition problems, prolonged hospital stay, and higher mortality (aOR range 1.26-3.80). Exposed infants were more likely to be rehospitalized (aOR 1.10; 95% CI 1.04-1.17) but less likely to have an observational stay (aOR 0.90; 95% CI 0.82-0.99) or use the emergency department (aOR 0.87; 95% CI 0.83-0.90) in the first year of life.

CONCLUSIONS

Infants born to mothers with SUD are at higher risk for adverse health outcomes in the perinatal period and are also more likely to be rehospitalized in the first year of life.

Refining Measurement of Substance Use Disorders Among Women of Child-Bearing Age Using Hospital Records: The Development of the Explicit-Mention Substance Abuse Need for Treatment in Women (EMSANT-W) Algorithm

Substance use disorder (SUD) in women of reproductive age is associated with adverse health consequences for both women and their offspring. US states need a feasible population-based, case-identification tool to generate better approximations of SUD prevalence, treatment use, and treatment outcomes among women. This article presents the development of the Explicit Mention Substance Abuse Need for Treatment in Women (EMSANT-W), a gender-tailored tool based upon existing International Classification of Diseases, 9th Edition, Clinical Modification diagnostic code-based groupers that can be applied to hospital administrative data. Gender-tailoring entailed the addition of codes related to infants, pregnancy, and prescription drug abuse, as well as the creation of inclusion/exclusion rules based on other conditions present in the diagnostic record. Among 1,728,027 women and associated infants who accessed hospital care from January 1, 2002 to December 31, 2008 in Massachusetts, EMSANT-W identified 103,059 women with probable SUD. EMSANT-W identified 4,116 women who were not identified by the widely used Clinical Classifications Software for Mental Health and Substance Abuse (CCS-MHSA) and did not capture 853 women identified by CCS-MHSA. Content and approach innovations in EMSANT-W address potential limitations of the Clinical Classifications Software, and create a methodologically sound, gender-tailored and feasible population-based tool for identifying women of reproductive age in need of further evaluation for SUD treatment. Rapid changes in health care service infrastructure, delivery systems and policies require tools such as the EMSANT-W that provide more precise identification methods for sub-populations and can serve as the foundation for analyses of treatment use and outcomes.

The Growing Burden of Neonatal Opiate Exposure on Children and Family Services in Massachusetts

Increasing opiate use among women of reproductive age has led to a rise in adverse pregnancy outcomes, including neonatal abstinence syndrome (NAS). Recent studies have documented the increased incidence of NAS, but subsequent impact on the chain of organizations within the social service system remains unexplored. In this article, we begin to estimate the reach of this issue by assessing the labor costs of caring for NAS infants within the Massachusetts Department of Children and Families (MA DCF). Based on a process map of services, we modeled social service hours using encounter-level hospital data as inputs. In this manner, we estimate that MA DCF professionals now devote more than 10,000 hours per month to this single problem. As opiate addiction increases across America, substantial additional investment in social service providers, foster care, Early Intervention Programs, and other family services will be required.