1
|
Hahn PD, Graham DA, Ozonoff A, Milliren CE. Neonatal Opioid Withdrawal Syndrome Treatment Guidelines and Birth Hospital Utilization. Pediatrics 2024; 154:e2023063635. [PMID: 38899388 DOI: 10.1542/peds.2023-063635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 03/29/2024] [Accepted: 04/01/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND AND OBJECTIVES In November 2020, the American Academy of Pediatrics published guidelines for management of neonatal opioid withdrawal syndrome (NOWS), recommending nonpharmacologic treatment as the first-line approach, unless pharmacologic treatment is needed for severe NOWS. Using data from tertiary care pediatric hospitals, we examined the impact of the guidelines on use of pharmacotherapy, length of stay, and NICU admission for infants with NOWS. METHODS We extracted birth hospitalization data for newborns diagnosed with NOWS discharged from 2019 to 2022 from the Pediatric Health Information System. We compared hospital utilization and pharmacologic treatment pre- and postguidelines and used interrupted time series regression to examine trends over time. RESULTS We included N = 824 newborns (n = 434 pre, n = 390 post) with NOWS from 11 hospitals. The use of pharmacologic treatment was significantly lower in the postguidelines period (59.0% pre versus 50.3% post; P = .01). Median length of stay was similar pre and post (P = .55). NICU admission was significantly lower in the postguidelines period (78.6% pre versus 46.7% post; P < .001), with an immediate decrease (β = -23.0%; P < .001) and a decrease over time in the postguidelines period (β = -0.7% per month; P = .03). Most hospitals reduced pharmacologic treatment (8 of 11; 73%) and NICU use (10 of 11; 91%) postguidelines. CONCLUSIONS There was a reduction in the use of pharmacologic treatment and NICU utilization for infants with NOWS after the release of American Academy of Pediatrics guidelines for NOWS management.
Collapse
Affiliation(s)
| | - Dionne A Graham
- Program for Patient Safety and Quality
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Al Ozonoff
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | | |
Collapse
|
2
|
West KD, Ali MM, Natzke B, Nguyen L. Health Services Use Among Children With Prenatal Substance Exposure or Neonatal Abstinence Syndrome. Psychiatr Serv 2024; 75:287-290. [PMID: 37711020 DOI: 10.1176/appi.ps.20220459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
OBJECTIVE Infants with prenatal substance exposure or neonatal abstinence syndrome (NAS) use health services more often than other children; however, little is known about their use of mental health services and psychotropic medication. METHODS The sample (N=1,004,085) consisted of infants born in 2016 in 38 states who were followed through the fifth year of life and enrolled each year in Medicaid or the Children's Health Insurance Program. Infants with prenatal substance exposure or NAS were identified with ICD-10 diagnosis codes; procedure and revenue codes documented their service use. RESULTS Rates of any mental health visit and of psychotropic medication use were higher among infants with prenatal substance exposure or NAS compared with infants without either condition; these patterns persisted during most years of the 5-year study. CONCLUSIONS Infants' elevated mental health services use through their first 5 years of life highlights the importance of early screening and subsequent engagement in school-based mental health interventions.
Collapse
Affiliation(s)
- Kristina D West
- Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, Washington, D.C. (West, Ali); Mathematica, Washington, D.C. (Natzke, Nguyen)
| | - Mir M Ali
- Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, Washington, D.C. (West, Ali); Mathematica, Washington, D.C. (Natzke, Nguyen)
| | - Brenda Natzke
- Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, Washington, D.C. (West, Ali); Mathematica, Washington, D.C. (Natzke, Nguyen)
| | - Linda Nguyen
- Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, Washington, D.C. (West, Ali); Mathematica, Washington, D.C. (Natzke, Nguyen)
| |
Collapse
|
3
|
Elmore AL, Boghossian NS, McLain AC, McDermott S, Salemi JL. Trends in maternal opioid use: Statewide differences by sociodemographic characteristics in Florida from 2000 to 2019. J Addict Dis 2024:1-11. [PMID: 38369773 PMCID: PMC11330537 DOI: 10.1080/10550887.2024.2302285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
BACKGROUND Maternal opioid use (MOU) remains a public health concern. Studies have demonstrated significant increases in MOU, but estimates using ICD-10-CM or stratified by sociodemographic variables are limited. OBJECTIVES Using a statewide, population-based dataset of Florida resident deliveries from 2000 to 2019, we examined the trend of MOU by age, race/ethnicity, education level, and insurance. METHODS Florida administrative data was used to conduct a retrospective cohort study. MOU was identified using opioid-related hospital discharge diagnoses documented prenatally or at delivery. Maternal sociodemographic variables were obtained from Florida vital statistics. Joinpoint regression was used to identify statistically significant changes in the trends overall and stratified by sociodemographic variables. Results are presented as annual percentage changes (APC) and 95% confidence intervals. RESULTS Our sample included over 3.6 million Florida resident mothers; of which, MOU was identified in 1% (n = 22,828) of the sample. From 2000 to 2019, MOU increased over ten-fold from 8.7 to 94.7 per 10,000 live birth deliveries. MOU increased significantly from 2000 to 2011 (APC: 32.8; 95% CI: 29.4, 36.2), remained stable from 2011 to 2016, and decreased significantly from 2016 to 2019 (APC: 3.9; 95% CI: -6.6, -1.0). However, from 2016 to 2019, MOU increased among non-Hispanic Black mothers (APC: 9.2; 95% CI: 7.5, 11.0), and those ages 30-34 (APC: 2.9; 95% CI: 1.2, 4.6) and 35-39 (APC: 6.4; 95% CI: 4.3, 8.4). CONCLUSIONS Accurate prevalence estimates of MOU by sociodemographic factors are necessary to fully understand prevalence trends, describe the burden among sub-populations, and develop targeted interventions.
Collapse
Affiliation(s)
- Amanda L. Elmore
- University of South Florida, College of Public Health, 13201 Bruce B. Downs Blvd, MDC56, Tampa, FL 33612-3805
- University of South Carolina, Department of Biostatistics and Epidemiology, 915 Greene St, Columbia, SC 29208
| | - Nansi S. Boghossian
- University of South Carolina, Department of Biostatistics and Epidemiology, 915 Greene St, Columbia, SC 29208
| | - Alexander C. McLain
- University of South Carolina, Department of Biostatistics and Epidemiology, 915 Greene St, Columbia, SC 29208
| | - Suzanne McDermott
- University of South Carolina, Department of Biostatistics and Epidemiology, 915 Greene St, Columbia, SC 29208
- City University of New York’s Graduate School of Public Health and Health Policy, 55 W 125 St, New York, NY 10027
| | - Jason L. Salemi
- University of South Florida, College of Public Health, 13201 Bruce B. Downs Blvd, MDC56, Tampa, FL 33612-3805
| |
Collapse
|
4
|
Mascarenhas M, Wachman EM, Chandra I, Xue R, Sarathy L, Schiff DM. Advances in the Care of Infants With Prenatal Opioid Exposure and Neonatal Opioid Withdrawal Syndrome. Pediatrics 2024; 153:e2023062871. [PMID: 38178779 PMCID: PMC10827648 DOI: 10.1542/peds.2023-062871] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 01/06/2024] Open
Abstract
A significant number of advances have been made in the last 5 years with respect to the identification, diagnosis, assessment, and management of infants with prenatal opioid exposure and neonatal opioid withdrawal syndrome (NOWS) from birth to early childhood. The primary objective of this review is to summarize major advances that will inform the clinical management of opioid-exposed newborns and provide an overview of NOWS care to promote the implementation of best practices. First, advances with respect to standardizing the clinical diagnosis of NOWS will be reviewed. Second, the most commonly used assessment strategies are discussed, with a focus on presenting new quality improvement and clinical trial data surrounding the use of the new function-based assessment Eat, Sleep, and Console approach. Third, both nonpharmacologic and pharmacologic treatment modalities are reviewed, highlighting clinical trials that have compared the use of higher calorie and low lactose formula, vibrating crib mattresses, morphine compared with methadone, buprenorphine compared with morphine or methadone, the use of ondansetron as a medication to prevent the need for NOWS opioid pharmacologic treatment, and the introduction of symptom-triggered dosing compared with scheduled dosing. Fourth, maternal, infant, environmental, and genetic factors that have been found to be associated with NOWS severity are highlighted. Finally, emerging recommendations on postdelivery hospitalization follow-up and developmental surveillance are presented, along with highlighting ongoing and needed areas of research to promote infant and family well-being for families impacted by opioid use.
Collapse
Affiliation(s)
| | - Elisha M. Wachman
- Department of Pediatrics, Boston Medical Center, and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Iyra Chandra
- Dana Farber Cancer Institute, Boston, Massachusetts
| | - Rachel Xue
- Department of Family Medicine, Boston Medical Center, Boston, Massachusetts
| | - Leela Sarathy
- Newborn Medicine, MassGeneral for Children, Boston, Massachusetts
| | | |
Collapse
|
5
|
Fryer K, Reid CN, Chaphalkar C, Marshall J, Szalacha L, Johnson K, Wright T, Read C, Khan A, Wilson A, Ratani M, Cox K, Tavolieri A, Sampayo M, Su R, Campbell K, Salemi JL. Development of a 5-Step Electronic Medical Record-Based Algorithm to Identify Patients with Opioid Use Disorder in Pregnancy. JOURNAL OF REGISTRY MANAGEMENT 2024; 51:69-74. [PMID: 39184206 PMCID: PMC11343436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 08/27/2024]
Abstract
Objectives This study aimed to develop and validate an algorithm for the identification of opioid use disorder (OUD) in pregnant patients using electronic medical record (EMR) data. Materials and Methods A cohort of pregnant patients from a single institution was used to develop and validate the algorithm. Five algorithm components were used, and chart reviews were conducted to confirm OUD diagnoses based on established criteria. Positive predictive values (PPV) of each of the algorithm's components were assessed. Results Of the 334 charts identified by the algorithm, 256 true cases were confirmed. The overall PPV of the algorithm was 76.6%, with 100% accuracy for outpatient medication lists, and high PPVs ranging from 81.3% to 93.4% across other algorithm components. Discussion and Conclusion The study highlights the significance of a multifaceted approach in identifying OUD among pregnant patients, aiming to improve patient care and target interventions for patients at risk.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Rachel Su
- University of South Florida, Tampa, Florida
| | | | | |
Collapse
|
6
|
West KD, Ali MM, Blanco M, Natzke B, Nguyen L. Prenatal Substance Exposure and Neonatal Abstinence Syndrome: State Estimates from the 2016-2020 Transformed Medicaid Statistical Information System. Matern Child Health J 2023; 27:14-22. [PMID: 37219692 PMCID: PMC10204012 DOI: 10.1007/s10995-023-03670-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 05/24/2023]
Abstract
INTRODUCTION Estimating Neonatal Abstinence Syndrome (NAS) and prenatal substance exposure rates in Medicaid can help target program efforts to improve access to services. METHODS The data for this study was extracted from the 2016-2020 Transformed Medicaid Statistical Information System (T-MSIS) Analytic Files (TAF) Research Identifiable Files (RIF) and included infants born between January 1, 2016 and December 31, 2020 with a either a NAS diagnosis or prenatal substance exposure. RESULTS Between 2016 and 2020, the estimated national rate of NAS experienced a 18% decline, while the estimated national rate of prenatal substance exposure experienced a 3.6% increase. At the state level in 2020, the NAS rate ranged from 3.2 per 1000 births (Hawaii) to 68.0 per 1000 births (West Virginia). Between 2016 and 2020, 28 states experienced a decline in NAS births and 20 states had an increase in NAS rates. In 2020, the lowest prenatal substance exposure rate was observed in New Jersey (9.9 per 1000 births) and the highest in West Virginia (88.1 per 1000 births). Between 2016 and 2020, 38 states experienced an increase in the rate of prenatal substance exposure and 10 states experienced a decline. DISCUSSION Estimated rate of NAS has declined nationally, but rate of prenatal substance exposure has increased, with considerable state-level variation. The reported increase in prenatal substance exposure in the majority of US states (38) suggest that substances other than opioids are influencing this trend. Medicaid-led initiatives can be used to identify women with substance use and connect them to services.
Collapse
Affiliation(s)
- Kristina D West
- Office of the Assistant Secretary for Planning & Evaluation, U.S. Department of Health and Human Services, 200 Independence Ave SW, Washington, DC, 20543, USA.
| | - Mir M Ali
- Office of the Assistant Secretary for Planning & Evaluation, U.S. Department of Health and Human Services, 200 Independence Ave SW, Washington, DC, 20543, USA
| | - Martin Blanco
- Office of the Assistant Secretary for Planning & Evaluation, U.S. Department of Health and Human Services, 200 Independence Ave SW, Washington, DC, 20543, USA
| | - Brenda Natzke
- Mathematica, 1100 First Street, NE, 12th Floor, Washington, DC, 20002-4221, USA
| | - Linda Nguyen
- Mathematica, 1100 First Street, NE, 12th Floor, Washington, DC, 20002-4221, USA
| |
Collapse
|
7
|
Elmore AL, Salemi JL, Kirby RS, Sappenfield WM, Lowry J, Dixon A, Lake-Burger H, Tanner JP. Evaluation of Administrative Data for Identifying Maternal Opioid Use at Delivery in Florida. Matern Child Health J 2023; 27:44-51. [PMID: 37199857 PMCID: PMC10692249 DOI: 10.1007/s10995-023-03669-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVES Studies have shown significant increases in the prevalence of maternal opioid use. Most prevalence estimates are based on unverified ICD-10-CM diagnoses. This study determined the accuracy of ICD-10-CM opioid-related diagnosis codes documented during delivery and examined potential associations between maternal/hospital characteristics and diagnosis with an opioid-related code. METHODS To identify people with prenatal opioid use, we identified a sample of infants born during 2017-2018 in Florida with a NAS related diagnosis code (P96.1) and confirmatory NAS characteristics (N = 460). Delivery records were scanned for opioid-related diagnoses and prenatal opioid use was confirmed through record review. The accuracy of each opioid-related code was measured using positive predictive value (PPV) and sensitivity. Modified Poisson regression was used to calculate adjusted relative risks (aRR) and 95% confidence intervals (CI). RESULTS We found the PPV was nearly 100% for all ICD-10-CM opioid-related codes (98.5-100%) and the sensitivity was 65.9%. Non-Hispanic Black mothers were 1.8 times more likely than non-Hispanic white mothers to have a missed opioid-related diagnosis at delivery (aRR:1.80, CI 1.14-2.84). Mothers who delivered at a teaching status hospital were less likely to have a missed opioid-related diagnosis (p < 0.05). CONCLUSIONS FOR PRACTICE We observed high accuracy of maternal opioid-related diagnosis codes at delivery. However, our findings suggest that over 30% of mothers with opioid use may not be diagnosed with an opioid-related code at delivery, although their infant had a confirmed NAS diagnosis. This study provides information on the utility and accuracy of ICD-10-CM opioid-related codes at delivery among mothers of infants with NAS.
Collapse
Affiliation(s)
- Amanda L Elmore
- Chiles Center, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC56, Tampa, FL, 33612-3805, USA.
| | - Jason L Salemi
- Chiles Center, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC56, Tampa, FL, 33612-3805, USA
| | - Russell S Kirby
- Chiles Center, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC56, Tampa, FL, 33612-3805, USA
| | - William M Sappenfield
- Chiles Center, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC56, Tampa, FL, 33612-3805, USA
| | - Joseph Lowry
- Florida Department of Health, Florida Birth Defects Registry, Tallahassee, USA
| | - Ashley Dixon
- Chiles Center, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC56, Tampa, FL, 33612-3805, USA
| | - Heather Lake-Burger
- Florida Department of Health, Florida Birth Defects Registry, Tallahassee, USA
| | - Jean Paul Tanner
- Chiles Center, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC56, Tampa, FL, 33612-3805, USA
| |
Collapse
|
8
|
Wang Y, Berger L, Durrance C, Kirby RS, Kuo D, Pac J, Ehrenthal DB. Duration and Timing of In Utero Opioid Exposure and Incidence of Neonatal Withdrawal Syndrome. Obstet Gynecol 2023; 142:603-611. [PMID: 37548391 PMCID: PMC10526694 DOI: 10.1097/aog.0000000000005289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/25/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVE To evaluate the association between prenatal prescription opioid analgesic exposure (duration, timing) and neonatal opioid withdrawal syndrome (NOWS). METHODS We conducted a retrospective cohort study of Wisconsin Medicaid-covered singleton live births from 2011 to 2019. The primary outcome was a NOWS diagnosis in the first 30 days of life. Opioid exposure was identified with any claim for prescription opioid analgesic fills during pregnancy. We measured exposure duration cumulatively in days (1-6, 7-29, 30-89, and 90 or more) and identified timing as early (first two trimesters only) or late (third trimester, regardless of earlier pregnancy use). We used logistic regression modeling to assess NOWS incidence by exposure duration and timing, with and without propensity score matching. RESULTS Overall, 31,456 (14.3%) of 220,570 neonates were exposed to prescription opioid analgesics prenatally. Among exposed neonates, 19,880 (63.2%) had 1-6 days of exposure, 7,694 (24.5%) had 7-29 days, 2,188 (7.0%) had 30-89 days, and 1,694 (5.4%) had 90 or more days of exposure; 15,032 (47.8%) had late exposure. Absolute NOWS incidence among neonates with 1-6 days of exposure was 7.29 per 1,000 neonates (95% CI 6.11-8.48), and incidence increased with longer exposure: 7-29 days (19.63, 95% CI 16.53-22.73); 30-89 days (58.96, 95% CI 49.08-68.84); and 90 or more days (177.10, 95% CI 158.90-195.29). Absolute NOWS incidence for early and late exposures were 11.26 per 1,000 neonates (95% CI 9.65-12.88) and 35.92 per 1,000 neonates (95% CI 32.95-38.90), respectively. When adjusting for confounders including timing of exposure, neonates exposed for 1-6 days had no increased odds of NOWS compared with unexposed neonates, whereas those exposed for 30 or more days had increased odds of NOWS (30-89 days: adjusted odds ratio [aOR] 2.15, 95% CI 1.22-3.79; 90 or more days: 2.80, 95% CI 1.36-5.76). Late exposure was associated with elevated odds of NOWS (aOR 1.57, 95% CI 1.25-1.96) when compared with unexposed after adjustment for exposure duration. CONCLUSION More than 30 days of prenatal prescription opioid exposure was associated with NOWS regardless of exposure timing. Third-trimester opioid exposure, irrespective of exposure duration, was associated with NOWS.
Collapse
Affiliation(s)
- Yi Wang
- Social Science Research Institute, The Pennsylvania State University, University Park, PA
- Silberman School of Social Work, Hunter College, City University of New York, New York City, NY
| | - Lawrence Berger
- Sandra Rosenbaum School of Social Work and Institute for Research on Poverty, College of Letters and Sciences, University of Wisconsin-Madison, Madison, WI
| | - Christine Durrance
- La Follette School of Public Affairs, University of Wisconsin-Madison, Madison, WI
| | - Russell S. Kirby
- Chiles Center, College of Public Health, University of South Florida, Tampa, FL
| | - Daphne Kuo
- Department of Obstetrics and Gynecology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Jessica Pac
- Sandra Rosenbaum School of Social Work and Institute for Research on Poverty, College of Letters and Sciences, University of Wisconsin-Madison, Madison, WI
| | - Deborah B. Ehrenthal
- Social Science Research Institute, The Pennsylvania State University, University Park, PA
- Department of Biobehavioral Health, College of Health and Human Development, The Pennsylvania State University, University Park, PA
| |
Collapse
|
9
|
Grossarth S, Osmundson SS, Wiese AD, Phillips SE, Pham A, Leech AA, Patrick SW, Spieker AJ, Grijalva CG, Adgent MA. Maternal Opioid Use Disorder and the Risk of Postneonatal Infant Mortality. JAMA Pediatr 2023; 177:675-683. [PMID: 37155175 PMCID: PMC10167598 DOI: 10.1001/jamapediatrics.2023.1047] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/17/2023] [Indexed: 05/10/2023]
Abstract
Importance The risk of serious long-term outcomes for infants born to individuals with opioid use disorder (OUD) is not fully characterized, nor is it well understood whether risks are modified by infant diagnosis of neonatal opioid withdrawal syndrome (NOWS). Objective To characterize the risk of postneonatal infant mortality among infants with a NOWS diagnosis or born to individuals with OUD. Design, Setting, and Participants The study team conducted a retrospective cohort study of 390 075 infants born from 2007 through 2018 to mothers who were enrolled in Tennessee Medicaid from 183 days prior to delivery through 28 days post partum (baseline). Maternal and infant baseline characteristics were measured using administrative claims and birth certificates, and infants were followed up from day 29 post partum through day 365 or death. Deaths were identified using linked death certificates through 2019. These data were analyzed from February 10, 2022, through March 3, 2023. Exposure Infant exposures included birth to an individual with OUD or postnatal diagnosis of NOWS. The study team defined a pregnant individual's OUD status (maternal OUD) as having OUD diagnosis or a maintenance medication prescription fill during baseline; this study defined NOWS as having NOWS diagnosis up to day 28. Groups were categorized by exposures as maternal OUD with NOWS (OUD positive/NOWS positive), maternal OUD without NOWS (OUD positive/NOWS negative), no documented maternal OUD with NOWS (OUD negative/NOWS positive), and no documented maternal OUD or NOWS (OUD negative/NOWS negative, unexposed). Main Outcome and Measures The outcome was postneonatal infant death, confirmed by death certificates. Cox proportional hazards models were used, adjusting for baseline maternal and infant characteristics, to estimate adjusted hazard ratios (aHRs) and 95% CIs for the association between maternal OUD or NOWS diagnosis with postneonatal death. Results Pregnant individuals in the cohort had a mean (SD) age of 24.5 (5.2) years; 51% of infants were male. The study team observed 1317 postneonatal infant deaths and incidence rates of 3.47 (OUD negative/NOWS negative, 375 718), 8.41 (OUD positive/NOWS positive, 4922); 8.95 (OUD positive/NOWS negative, 7196), and 9.25 (OUD negative/NOWS positive, 2239) per 1000 person-years. After adjustment, the risk of postneonatal death was elevated for all groups, relative to the unexposed: OUD positive/NOWS positive (aHR, 1.54; 95% CI, 1.07-2.21), OUD positive/NOWS negative (aHR, 1.62; 95% CI, 1.21-2.17), and OUD negative/NOWS positive (aHR, 1.64; 95% CI, 1.02-2.65). Conclusions and Relevance Infants born to individuals with OUD or with a NOWS diagnosis had an increased risk of postneonatal infant mortality. Future work is necessary to create and evaluate supportive interventions for individuals with OUD during and after pregnancy to reduce adverse outcomes.
Collapse
Affiliation(s)
- Sarah Grossarth
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sarah S. Osmundson
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew D. Wiese
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sharon E. Phillips
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amelie Pham
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ashley A. Leech
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephen W. Patrick
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
- Mildred Stahlman Division of Neonatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew J. Spieker
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carlos G. Grijalva
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
- Veterans’ Health Administration Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center (GRECC), Nashville
| | - Margaret A. Adgent
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
10
|
Accuracy of diagnostic codes for prenatal opioid exposure and neonatal opioid withdrawal syndrome. J Perinatol 2023; 43:293-299. [PMID: 36131095 DOI: 10.1038/s41372-022-01518-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/03/2022] [Accepted: 09/08/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Determine the accuracy of diagnostic codes in identifying Prenatal Opioid Exposure (POE) and Neonatal Opioid Withdrawal Syndrome (NOWS). STUDY DESIGN A cross-sectional study of 374,222 mother-infant dyads with delivery from 01/01/2010 to 12/31/2019. We ascertained maternal diagnostic codes for opioid use during pregnancy and infant diagnostic codes for drug exposure and withdrawal. We assessed sensitivity and positive predictive value (PPV) for POE and NOWS, defined using laboratory, pharmacy, and clinical data. RESULTS Maternal codes had low sensitivity (36.4%) and PPV (34.7%) for POE. Infant codes for drug exposure were neither sensitive for POE (14%) nor NOWS (31.6%) and had low PPV. Codes for newborn withdrawal had low sensitivity (31.6%) for detecting NOWS, but high PPV (85%). Sensitivity improved (95.1%) for NOWS requiring pharmacologic treatment. CONCLUSIONS Diagnostic codes identify POE and NOWS poorly. Improved case identification would include pharmacy and laboratory results, and clearly defined criteria for evidence of withdrawal.
Collapse
|
11
|
Association between pharmacologic treatment and hospital utilization at birth among neonatal opioid withdrawal syndrome mother-infant dyads. J Perinatol 2023; 43:283-292. [PMID: 36717607 DOI: 10.1038/s41372-023-01623-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/19/2023] [Accepted: 01/23/2023] [Indexed: 01/31/2023]
Abstract
OBJECTIVE We linked mother-baby dyads to explore associations between maternal medication-assisted therapy (MAT) and infants' pharmacologic treatment on birth hospital utilization for infants with NOWS. METHODS We extracted singleton infant and maternal delivery discharges from PHIS hospitals with large volumes of deliveries for 2016-2019. We matched newborns with NOWS to maternal delivery discharges by hospital, day of birth, mode of delivery, and ZIP code. We examined the association between maternal MAT, infants' pharmacologic treatment, and hospital utilization at birth. RESULTS We included N = 146 mother-baby dyads from six hospitals (74% match rate). Among matched dyads, 51% received maternal MAT, 60% pharmacotherapy (37% both). Infants treated non-pharmacologically and born to mothers receiving MAT had the shortest stays vs. infants without pharmacotherapy or MAT (RR = 0.29; 95% CI: 0.25-0.35). CONCLUSIONS These findings underscore the importance of adequate perinatal treatment for opioid use disorder to improve outcomes for mothers and infants with opioid exposure.
Collapse
|
12
|
Labgold K, Collin LJ, Howards PP. Misclassification of Neonatal Abstinence Syndrome Surveillance Estimates: Is Considering the Positive Predictive Value Enough? Epidemiology 2022; 33:254-259. [PMID: 34799470 PMCID: PMC10660541 DOI: 10.1097/ede.0000000000001441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Validation studies estimating the positive predictive value (PPV) of neonatal abstinence syndrome (NAS) have consistently suggested overreporting in hospital discharge records. However, few studies estimate the negative predictive value (NPV). Even slightly imperfect NPVs have the potential to bias estimated prevalences of rare outcomes like NAS. Given the challenges in estimating NPV, our objective was to evaluate whether the PPV was sufficient to understand the influence of NAS misclassification bias on conclusions of the NAS prevalence in surveillance research. METHODS We used hospital discharge data from the 2016 New Jersey State Inpatient Databases, Healthcare Cost and Utilization Project. We adjusted surveillance data for misclassification using quantitative bias analysis models to estimate the expected NAS prevalence under a range of PPV and NPV bias scenarios. RESULTS The 2016 observed NAS prevalence was 0.61%. The misclassification-adjusted prevalence estimates ranged from 0.31% to 0.91%. When PPV was assumed to be ≥90%, the misclassification-adjusted prevalence was typically greater than the observed prevalence but the reverse was true for PPV ≤70%. Under PPV 80%, the misclassification-adjusted prevalence was less than the observed prevalence for NPV >99.9% but flipped for NPV <99.9%. CONCLUSIONS When we varied the NPV below 100%, our results suggested that the direction of bias (over or underestimation) was dependent on the PPV, and sometimes dependent on the NPV. However, NPV was important for understanding the magnitude of bias. This study serves as an example of how quantitative bias analysis methods can be applied in NAS surveillance to supplement existing validation data when NPV estimates are unavailable.
Collapse
Affiliation(s)
- Katie Labgold
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Lindsay J. Collin
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Department of Population Health Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Penelope P. Howards
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| |
Collapse
|
13
|
Abstract
Neonatal Abstinence Syndrome (NAS) has significantly increased worldwide secondary to a marked increase in the incidence of opioid use disorders (OUD) in women of childbearing age. Since first described in 1975, the Finnegan Neonatal Abstinence Scoring Tool (FNAST) remains the mainstay of monitoring NAS severity and its clinical management. The complexity of the tool (21 independent variables), the need for external validation, excessive subjectivity, poor inter-rater reliability, and uncertainty regarding the clinical relevance of some items has resulted in the need to develop an alternate scoring tool. A validated, simple, clinically relevant, and universally accepted approach to assessing opioid exposed neonates would facilitate high quality clinical care while assisting in the generation of generalizable data from future research studies conducted in this vulnerable population.
Collapse
Affiliation(s)
- Rachana Singh
- Division of Newborn Medicine, Tufts Children's Hospital, Boston, MA, 02111, USA.
| | - Jonathan M Davis
- Division of Newborn Medicine, Tufts Children's Hospital, Boston, MA, 02111, USA; The Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA.
| |
Collapse
|
14
|
Kirby RS. Linking public health surveillance data to programme data for perinatal epidemiologic research. Paediatr Perinat Epidemiol 2021; 35:339-340. [PMID: 33871101 DOI: 10.1111/ppe.12771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 03/15/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Russell S Kirby
- College of Public Health, University of South Florida, Tampa, FL, USA
| |
Collapse
|
15
|
Krause KH, Gruber JF, Ailes EC, Anderson KN, Fields VL, Hauser K, Howells CL, Longenberger A, McClung N, Oakley LP, Reefhuis J, Honein MA, Watkins SM. Assessment of Neonatal Abstinence Syndrome Surveillance - Pennsylvania, 2019. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2021; 70:40-45. [PMID: 33444296 PMCID: PMC7808717 DOI: 10.15585/mmwr.mm7002a3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
16
|
Hirai AH, Ko JY, Owens PL, Stocks C, Patrick SW. Neonatal Abstinence Syndrome and Maternal Opioid-Related Diagnoses in the US, 2010-2017. JAMA 2021; 325:146-155. [PMID: 33433576 PMCID: PMC7804920 DOI: 10.1001/jama.2020.24991] [Citation(s) in RCA: 270] [Impact Index Per Article: 90.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE Substantial increases in both neonatal abstinence syndrome (NAS) and maternal opioid use disorder have been observed through 2014. OBJECTIVE To examine national and state variation in NAS and maternal opioid-related diagnoses (MOD) rates in 2017 and to describe national and state changes since 2010 in the US, which included expanded MOD codes (opioid use disorder plus long-term and unspecified use) implemented in International Classification of Disease, 10th Revision, Clinical Modification. DESIGN, SETTING, AND PARTICIPANTS Repeated cross-sectional analysis of the 2010 to 2017 Healthcare Cost and Utilization Project's National Inpatient Sample and State Inpatient Databases, an all-payer compendium of hospital discharge records from community nonrehabilitation hospitals in 47 states and the District of Columbia. EXPOSURES State and year. MAIN OUTCOMES AND MEASURES NAS rate per 1000 birth hospitalizations and MOD rate per 1000 delivery hospitalizations. RESULTS In 2017, there were 751 037 birth hospitalizations and 748 239 delivery hospitalizations in the national sample; 5375 newborns had NAS and 6065 women had MOD documented in the discharge record. Mean gestational age was 38.4 weeks and mean maternal age was 28.8 years. From 2010 to 2017, the estimated NAS rate significantly increased by 3.3 per 1000 birth hospitalizations (95% CI, 2.5-4.1), from 4.0 (95% CI, 3.3-4.7) to 7.3 (95% CI, 6.8-7.7). The estimated MOD rate significantly increased by 4.6 per 1000 delivery hospitalizations (95% CI, 3.9-5.4), from 3.5 (95% CI, 3.0-4.1) to 8.2 (95% CI, 7.7-8.7). Larger increases for MOD vs NAS rates occurred with new International Classification of Disease, 10th Revision, Clinical Modification codes in 2016. From a census of 47 state databases in 2017, NAS rates ranged from 1.3 per 1000 birth hospitalizations in Nebraska to 53.5 per 1000 birth hospitalizations in West Virginia, with Maine (31.4), Vermont (29.4), Delaware (24.2), and Kentucky (23.9) also exceeding 20 per 1000 birth hospitalizations, while MOD rates ranged from 1.7 per 1000 delivery hospitalizations in Nebraska to 47.3 per 1000 delivery hospitalizations in Vermont, with West Virginia (40.1), Maine (37.8), Delaware (24.3), and Kentucky (23.4) also exceeding 20 per 1000 delivery hospitalizations. From 2010 to 2017, NAS and MOD rates increased significantly for all states except Nebraska and Vermont, which only had MOD increases. CONCLUSIONS AND RELEVANCE In the US from 2010 to 2017, estimated rates of NAS and MOD significantly increased nationally and for the majority of states, with notable state-level variation.
Collapse
Affiliation(s)
- Ashley H. Hirai
- Maternal and Child Health Bureau, Health Resources and Services Administration Department of Health and Human Services, Rockville, Maryland
| | - Jean Y. Ko
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention Department of Health and Human Services, Atlanta, Georgia
- Commissioned Corps Public Health Service Department of Health and Human Services, Rockville, Maryland
| | - Pamela L. Owens
- Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality Department of Health and Human Services, Rockville, Maryland
| | - Carol Stocks
- West Virginia University, School of Public Health, Morgantown
- formerly with the Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality Department of Health and Human Services, Rockville, Maryland at the time of analysis
| | - Stephen W. Patrick
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention Department of Health and Human Services, Atlanta, Georgia
- Department of Pediatrics, Vanderbilt Center for Child Health Policy, Nashville, Tennessee
- Department of Health Policy, Vanderbilt Center for Child Health Policy, Nashville, Tennessee
- Division of Neonatology, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|