Longitudinal Health Care Utilization of Medicaid-Insured Children with a History of Neonatal Abstinence Syndrome.

OBJECTIVE: To describe longitudinal health care utilization of Medicaid-insured children with a history of neonatal abstinence syndrome (NAS) compared with similar children without NAS. STUDY DESIGN: Retrospective, longitudinal cohort study. Data were extracted from the Medicaid Analytic eXtract files for all available states and DC from 2003-2013. Subjects were followed up to 11 years. In total, 17 229 children with NAS were identified using the International Classification of Diseases, Ninth Revision code 779.5. Children without NAS, matched on demographic and health variables, served as the comparison group. Outcomes were number of claims for inpatient, outpatient, and emergency department encounters, numbers of prescription claims, and costs associated with these services. Linked claims were identified for each subject using a unique, within-state ID. RESULTS: Children with NAS had increased claims for inpatient admissions (marginal effect [ME] 0.49; SE 0.01) and emergency department visits (ME 0.30; SE 0.04) through year 1; increased prescriptions (ME 1.45; SE 0.08, age 0) (ME 0.69; SE 0.11, age 1 year) through year 2; and increased outpatient encounters (ME 20.13; SE 0.54, age 0) (ME 3.95; SE 0.62, age 1 year) (ME 2.90; SE 1.11, age 2 years) through year 3 after adjusting for potential confounders (P < .01 for all). Beyond the third year, health care utilization was similar between those with and without NAS. CONCLUSIONS: Children with a diagnosis of NAS have greater health care utilization through the third year of life. These differences resolve by the fourth year. Our results suggest resolution of disparities may be due to shifts in developmental health management in school-age children and inability to track relevant diagnoses in a health care database.

Neonatal Abstinence Syndrome and Maternal Opioid-Related Diagnoses in the US, 2010-2017.

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.

A Cost-Effectiveness Analysis of Rooming-in and Breastfeeding in Neonatal Opioid Withdrawal.

OBJECTIVE: Our cost-effectiveness analysis investigated rooming-in versus not rooming-in to determine optimal management of neonates with neonatal opioid withdrawal (NOW). STUDY DESIGN: A decision-analytic model was constructed using TreeAge to compare rooming-in versus not rooming-in in a theoretical cohort of 23,200 newborns, the estimated annual number affected by NOW in the United States. Additional considerations included the effect of breast milk versus formula milk in evaluating the need for pharmacotherapy. Primary outcomes were needed for pharmacotherapy and neurodevelopment. We assumed a societal perspective in evaluating costs and maternal-neonatal quality-adjusted life years (QALYs) using a willingness-to-pay threshold of $100,000/QALY. Model inputs were derived from literature and varied in sensitivity analyses. RESULTS: Rooming-in resulted in fewer neonates requiring pharmacotherapy when compared with not rooming-in. The rooming-in group had more neonates with intact/mild neurodevelopmental impairment and fewer cases of moderate to severe impairment. Rooming-in resulted in cost savings of $509,652,728 and 12,333 additional QALYs per annual cohort. When the risk ratio of need for pharmacotherapy in rooming-in was varied across a clinically plausible range, rooming-in remained the cost-effective strategy. CONCLUSION: Maternal rooming-in with newborns affected by NOW leads to reduced costs and increased effectiveness. Management strategies should optimize nonpharmacological interventions as first-line treatment.

Patient and Hospital Characteristics of Newborns with Neonatal Withdrawal Syndrome.

OBJECTIVES: We sought to evaluate hospital resource usage patterns and determine risk factors for neonatal withdrawal syndrome (NWS) in the United States. METHODS: Using the 2016 Kids' Inpatient Database (KID), we conducted a retrospective cross-sectional analysis of a nationally representative sample of neonates with NWS. The KID is the largest publicly available pediatric (20 years of age and younger) inpatient care database in the United States. We analyzed a stratified probability sampling of 3.1 million pediatric hospital discharges weighted to 6.3 million national discharges. Descriptive statistics for hospital and patient characteristics were identified and binary variables were analyzed using the Student t test. Multivariate regression was performed to assess the predictors of NWS. We excluded discharges if total cost or hospital length of stay (LOS) exceeded mean values by >3 standard deviations. Hospitalizations with NWS diagnosis were identified using the International Classification of Diseases, 10th Revision, Clinical Modification code P96.1 in any 1 of 30 discharge diagnostic fields. RESULTS: We estimated that 25,394 pediatric discharges were associated with an NWS diagnosis, totaling 403,127 inpatient days at a cost of $1.8 billion. Compared with non-NWS newborns, neonates with NWS had higher mean hospital charges ($71,540 vs $15,765), longer mean hospital stays (16 days vs 3 days), and a significantly higher proportion of low birth weight (7.2% vs 1.9%), feeding problems (19.0% vs 3.5%), respiratory diagnoses (5.6% vs 2.5%), and seizure (0.3% vs 0.1%). Among newborns with NWS, 53% were boys, 80.0% were white, 7.2% were black, 7.4% were Hispanic, and 5.3% were of other races. Hispanic neonates had the highest mean hospital charges and LOS of any other ethnic group ($123,749, 21 days). The largest proportion (83.0%) of NWS-related hospital stays were billed to Medicaid, followed by private insurance (10.3%) and self-pay (4.8%). More than one-third of NWS-related discharges (39.3%) occurred in areas with the lowest mean household annual income (≤$42,999) compared with 28.4% of neonates without NWS. Most NWS cases (53%) had ≥5 diagnoses, compared with 11% of non-NWS neonates. In the multivariate analysis, neonates with a birth weight <2500 g, feeding problems, respiratory diagnoses, seizure, >4 diagnoses, LOS >5 days, rural hospitals, Medicaid, and low-income households were significantly associated with NWS. There was a statistically significant mean hospital charge difference of $55,775 between NWS and non-NWS neonates. CONCLUSIONS: Since 2000, the number of infants treated for NWS in the US neonatal intensive care units has increased fivefold, accounting for an estimated $1.5 billion in annual hospital expenditures. The high hospital resource usage among NWS neonates raises the possibility that care for expectant mothers who use opiates and their newborns may be able to be delivered in a more efficient and effective manner. Because the majority of the study population was covered by Medicaid programs, state policy makers should be mindful of the impact the opioid crises continue to have on expectant mothers and their infants.

A Longitudinal Healthcare Use Profile of Children with a History of Neonatal Abstinence Syndrome.

OBJECTIVE: To describe healthcare use over time of children with a history of neonatal abstinence syndrome (NAS) compared with children without NAS. STUDY DESIGN: In this retrospective, longitudinal cohort study, data were obtained from MarketScan Commercial Claims and Encounters database from 2005 to 2014. Children with and without NAS based on International Classification of Diseases, Ninth Revision diagnostic codes were followed until 8 years or disenrollment (mean: 35 months). Numbers of claims for inpatient, outpatient, and emergency department encounters; prescription drugs; and costs associated with these encounters were evaluated. RESULTS: Children with NAS had a significantly greater number of claims per year from age 1 to 8 for inpatient hospitalizations (adjusted mean ratio 3.20; 95% CI 1.74-5.90), outpatient encounters (1.23; 1.08-1.41), and emergency department visits (1.46; 1.25-1.70) after we adjusted for confounders. Subsequently, adjusted mean annualized costs were nearly double for all healthcare services in children with NAS (1.86; 1.34-2.60) and >4 times as high as for inpatient hospitalizations (4.34; 2.03-9.30) compared with children without NAS. CONCLUSIONS: Children with a diagnosis of NAS have significantly greater rates of healthcare use through age 8 years compared with children without NAS. These findings suggest that children affected by NAS have medical disparities that linger well beyond early infancy.

A Practical Approach to Neonatal Opiate Withdrawal Syndrome.

Perinatal opioid misuse and neonatal opioid withdrawal syndrome (NOWS) are a significant public health problem that has grown exponentially over the past decade. In the United States, a woman seeks emergency room care for prescription opioid misuse every 3 minutes and approximately every 25 minutes, a child is born with signs of drug withdrawal. The economic impact of perinatal opioid misuse is significant with annual hospital charges for NOWS in 2012 as $1.5 billion dollars. Perinatal opioid misuse is a complex, multifaceted problem that demands a multidisciplinary cross specialty approach. This article will review the current state of NOWS and provide medical practitioners with a practical guide to enhance evidence based practice.

Infants Born to Opioid-Dependent Women in Ontario, 2002-2014.

BACKGROUND: There is a paucity of data characterizing mother-infant pairs with prenatal opioid dependence in Canada. We therefore conducted a study of relevant births in Ontario from 2002 to 2014. METHODS: We used data from the Institute for Clinical Evaluative Sciences, the linked databases of coded population-based Ontario health services records. Differences in characteristics of opioid-dependent mother-neonate pairs and infant hospital costs by year were assessed using linear regression, and we calculated rates of preterm birth, low birth weight, birth defects, mortality, and neonatal abstinence syndrome. RESULTS: The number of infants born to opioid-dependent women in Ontario rose from 46 in 2002 to almost 800 in 2014. Methadone was most frequently used for prenatal opioid dependence; there was little buprenorphine or buprenorphine + naloxone use. Rates of preterm birth and low birth weight were high. The proportion of neonates with neonatal abstinence syndrome (58%) was stable over the study period. The mean length of neonatal hospital stay was 13.96 days. Infant hospital costs increased from $724 774 in 2003 to $10 539 988 in 2013, and the mean cost per infant grew from $9928 to $12 917. Birth defect prevalence was 75.84/1000 live births (95% CI 68.12/1000 to 84.10/1000). The stillbirth rate was 11.39/1000 births (95% CI 8.47/1000 to 14.99/1000), and the infant mortality rate was 12.21/1000 live births (95% CI 9.16/1000 to 15.95/1000). CONCLUSION: We observed a 16-fold increase in the number of mother-infant pairs affected by opioid dependence in Ontario over the past decade. Adverse birth outcome rates were high. Expanded services for opioid-dependent women and their children are needed.

Neonatal Abstinence Syndrome: Trend and Expenditure in Louisiana Medicaid, 2003-2013.

Objectives Determine trends in incidence and expenditure for perinatal drug exposure and neonatal abstinence syndrome (NAS) among Louisiana's Medicaid population. We also describe the maternal characteristics of NAS affected infants. Methods Retrospective cohort analysis using linked Medicaid and vital records data from 2003 to 2013. Conducted incidence and cost trends for drug exposed infants with and without NAS. Also performed comparison statistics among drug exposed infants with and without NAS and those not drug exposed. Results As rate of perinatal drug exposure increased, NAS rate per 1000 live Medicaid births also increased, from 2.1 (2003) to 3.6 (2007) to 8.0 (2013) (P for trend <0.0001). Total medical cost paid by Medicaid also increased from $1.3 million to $3.6 million to $8.7 million (P for trend <0.0001). Compared with drug exposed infants without NAS and those not drug exposed, infants with NAS were more likely to be white, have feeding difficulties, respiratory distress syndrome, sepsis, and seizures, all of which had an association at P < 0.0001. Over one-third (33.2%) of the mothers of infants with NAS had an opioid dependency in combination with a mental illness; with depression being most common. Conclusions for Practice Over an 11-year period, NAS rate among Louisiana's Medicaid infants quadrupled and the cost for caring for the affected infants increased six-fold. Medicaid, as the predominant payer for pregnant women and children affected by substance use disorders, must play a more active role in expanding access to comprehensive substance abuse treatment programs.

Home-based detoxification for neonatal abstinence syndrome reduces length of hospital admission without prolonging treatment.

AIM: Neonatal abstinence syndrome (NAS) is a drug withdrawal syndrome, secondary to in utero chemical exposure and characterised by tremor, irritability and feed intolerance. It often requires prolonged hospital treatment and separation of families. Outpatient therapy may reduce this burden, but current literature is sparse. This review aimed to evaluate the safety and efficacy of our home-based detoxification programme and compare it with standard inpatient care. METHODS: Infants requiring treatment for NAS between January 2004 and December 2010 were reviewed. Data on demographics, drug exposure, length of stay and type of therapy were compared between infants selected for home-based therapy and those treated conventionally. RESULTS: Of the 118 infants who were admitted for treatment of NAS, 38 (32%) were managed at home. Infants receiving home-based detoxification had shorter hospital stays (mean 19 days vs. 39 days), with no increase in total duration of treatment (mean 36 days vs. 41 days), and were more likely to be breastfeeding on discharge from hospital care (45% vs. 22%). CONCLUSION: In selected infants, home-based detoxification is associated with reduced hospital stays and increased rates of breastfeeding, without prolonging therapy. Safety of the infants remains paramount, which precludes many from entering such a programme.

Evidence-based interventions for neonatal abstinence syndrome.

This review aimed to determine best nursing practice by systematically and critically reviewing the appropriate literature and expert guidelines. Using keyword and literature databases, over 480 journal titles were reviewed. Twenty-four articles and three expert guidelines were chosen. The majority of articles selected as evidence were Level IV--opinions of respected authorities based clinical experiences, descriptive studies, case reports, or reports of experts. Two articles were Level I-II--experimental studies. Results of the review showed that traditional supportive interventions also have a body of evidence for their use. Although there is much research regarding neonatal abstinence syndrome (NAS), the majority of future research needs to be at a higher level of evidence. Nursing applications include obtaining evidence for best practice through diligent searches of the literature and expert guidelines.

Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009.

CONTEXT: Neonatal abstinence syndrome (NAS) is a postnatal drug withdrawal syndrome primarily caused by maternal opiate use. No national estimates are available for the incidence of maternal opiate use at the time of delivery or NAS. OBJECTIVES: To determine the national incidence of NAS and antepartum maternal opiate use and to characterize trends in national health care expenditures associated with NAS between 2000 and 2009. DESIGN, SETTING, AND PATIENTS: A retrospective, serial, cross-sectional analysis of a nationally representative sample of newborns with NAS. The Kids' Inpatient Database (KID) was used to identify newborns with NAS by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code. The Nationwide Inpatient Sample (NIS) was used to identify mothers using diagnosis related groups for vaginal and cesarean deliveries. Clinical conditions were identified using ICD-9-CM diagnosis codes. NAS and maternal opiate use were described as an annual frequency per 1000 hospital births. Missing hospital charges (<5% of cases) were estimated using multiple imputation. Trends in health care utilization outcomes over time were evaluated using variance-weighted regression. All hospital charges were adjusted for inflation to 2009 US dollars. MAIN OUTCOME MEASURES: Incidence of NAS and maternal opiate use, and related hospital charges. RESULTS: The separate years (2000, 2003, 2006, and 2009) of national discharge data included 2920 to 9674 unweighted discharges with NAS and 987 to 4563 unweighted discharges for mothers diagnosed with antepartum opiate use, within data sets including 784,191 to 1.1 million discharges for children (KID) and 816,554 to 879,910 discharges for all ages of delivering mothers (NIS). Between 2000 and 2009, the incidence of NAS among newborns increased from 1.20 (95% CI, 1.04-1.37) to 3.39 (95% CI, 3.12-3.67) per 1000 hospital births per year (P for trend < .001). Antepartum maternal opiate use also increased from 1.19 (95% CI, 1.01-1.35) to 5.63 (95% CI, 4.40-6.71) per 1000 hospital births per year (P for trend < .001). In 2009, newborns with NAS were more likely than all other hospital births to have low birthweight (19.1%; SE, 0.5%; vs 7.0%; SE, 0.2%), have respiratory complications (30.9%; SE, 0.7%; vs 8.9%; SE, 0.1%), and be covered by Medicaid (78.1%; SE, 0.8%; vs 45.5%; SE, 0.7%; all P < .001). Mean hospital charges for discharges with NAS increased from $39,400 (95% CI, $33,400-$45,400) in 2000 to $53,400 (95% CI, $49,000-$57,700) in 2009 (P for trend < .001). By 2009, 77.6% of charges for NAS were attributed to state Medicaid programs. CONCLUSION: Between 2000 and 2009, a substantial increase in the incidence of NAS and maternal opiate use in the United States was observed, as well as hospital charges related to NAS.

Cost of neonatal abstinence syndrome: an economic analysis of English national data held in the National Neonatal Research Database.

OBJECTIVE: To determine the incidence of neonatal abstinence syndrome (NAS) across neonatal units, explore healthcare utilisation and estimate the direct cost to the NHS. DESIGN: Population cohort study. SETTING: NHS neonatal units, using data held in the National Neonatal Research Database. PARTICIPANTS: Infants born between 2012 and 2017, admitted to a neonatal unit in England, receiving a diagnosis of NAS (n=6411). MAIN OUTCOME MEASURES: Incidence, direct annual cost of care (£, 2016-2017 prices), duration of neonatal unit stay (discharge HR), predicted additional cost of care, and odds of receiving pharmacotherapy. RESULTS: Of 524 334 infants admitted during the study period, 6411 had NAS. The incidence (1.6/1000 live births) increased between 2012 and 2017 (ß=0.07, 95% CI (0 to 0.14)) accounting for 12/1000 admissions and 23/1000 cot days nationally. The direct cost of care was £62 646 661 over the study period. Almost half of infants received pharmacotherapy (n=2631; 49%) and their time-to-discharge was significantly longer (median 18.2 vs 5.1 days; adjusted HR (aHR) 0.16, 95% CI (0.15 to 0.17)). Time-to-discharge was longer for formula-fed infants (aHR 0.73 (0.66 to 0.81)) and those discharged to foster care (aHR 0.77 (0.72 to 0.82)). The greatest predictor of additional care costs was receipt of pharmacotherapy (additional mean adjusted cost of £8420 per infant). CONCLUSIONS: This population study highlights the substantial cot usage and economic costs of caring for infants with NAS on neonatal units. A shift in how healthcare systems provide routine care for NAS could benefit infants and families while alleviating the burden on services.

Shining a Light: Integrating Protocols Into Clinical Practice for Treatment of Neonatal Abstinence Syndrome.

BACKGROUND AND PURPOSE: The epidemic use of opioids is negatively influencing the health of the American people. Pregnant women and their unborn babies have not escaped the ravages of substance use. A dramatic increase in maternal opioid use has led to an increasing number of infants experiencing withdrawal symptoms known as neonatal abstinence syndrome (NAS). The purpose of this article is to highlight best practice for the management of infants with opioid withdrawal. REVIEW OF PROTOCOLS AND TREATMENTS: Review of available protocols and treatments revealed wide variation in the treatment of NAS and little use of standardized guidelines or protocols, despite current recommendations of the American Academy of Pediatrics. There is supporting evidence showing that the use of standardized protocols reduces the length of treatment and enhances outcomes in the neonatal population. EVIDENCE-BASED RECOMMENDATIONS: Evidence-based strategies to address gaps in practice include developing strong protocols to identify infants at risk and implementing standardized plans when treating NAS. Consistent assessment, initial treatment with nonpharmacologic measures, and conservative use of pharmacologic agents are important elements to an NAS treatment protocol. CONCLUSIONS AND IMPLICATIONS: In evaluating the current literature for best practice in the management of the newborn with opioid withdrawal, it is clear that evidence-based standardized protocols need to be in place for the best treatment of the mother-infant dyad, caring for both the infants with NAS as well as the mothers with opioid use disorder.

The opioid epidemic, neonatal abstinence syndrome, and estimated costs for special education services.

Children whose mothers used or misused opioids during their pregnancies are at an increased risk of exhibiting cognitive or behavioral impairments in the future, which may result in identifiable disabilities that require special education services in school. The costs associated with these additional educational services, however, have remained unknown. Using data from available empirical work, we calculated a preliminary set of cost estimates of special education and related services for children diagnosed with neonatal abstinence syndrome (NAS). We estimated these costs for a single cohort of children from the Commonwealth of Pennsylvania with a diagnosis of NAS. The resulting cost estimates were $16,506,916 (2017 US$) in total educational services provisions, with $8,253,458 (2017 US$) of these costs attributable to the additional provision of special education services. This estimate includes both opioid use during pregnancy that was linked to NAS in general and NAS that resulted specifically from prescription opioid use. We estimate the total annual education costs for children born in Pennsylvania with NAS associated with maternal use of prescription opioids to be $1,012,506 (2017 US$). Of these costs, we estimate that $506,253 (2017 US$) are attributable to the additional provision of special education services. We detail the calculation of these cost estimates and provide an expanded set of estimates for additional years of special education services (3-year, 5-year, and 13-year, or the K-12 educational time frame). We conclude with a discussion of limitations and suggestions for future work.

Incidence and Costs of Neonatal Abstinence Syndrome Among Infants With Medicaid: 2004-2014.

OBJECTIVES: To describe incidence, health care use, and cost trends for infants with neonatal abstinence syndrome (NAS) who are covered by Medicaid compared with other infants. METHODS: We used 2004-2014 hospital birth data from the National Inpatient Sample, a nationally representative sample of hospital discharges in the United States (N = 13 102 793). Characteristics and trends among births impacted by NAS were examined by using univariate statistics and logistic regression. RESULTS: Medicaid covered 73.7% of NAS-related births in 2004 (95% confidence interval [CI], 68.9%-77.9%) and 82.0% of NAS-related births in 2014 (95% CI, 80.5%-83.5%). Among infants covered by Medicaid, NAS incidence increased more than fivefold during our study period, from 2.8 per 1000 births (95% CI, 2.1-3.6) in 2004 to 14.4 per 1000 births (95% CI, 12.9-15.8) in 2014. Infants with NAS who were covered by Medicaid were significantly more likely to be transferred to another hospital and have a longer length of stay than infants without NAS who were enrolled in Medicaid or infants with NAS who were covered by private insurance. Adjusting for inflation, total hospital costs for NAS births that were covered by Medicaid increased from $65.4 million in 2004 to $462 million in 2014. The proportion of neonatal hospital costs due to NAS increased from 1.6% in 2004 to 6.7% in 2014 among births that were covered by Medicaid. CONCLUSIONS: The number of Medicaid-financed births that are impacted by NAS has risen substantially and totaled $462 million in hospital costs in 2014. Improving affordable health insurance coverage for low-income women before pregnancy would expand access to substance use disorder treatment and could reduce NAS-related morbidity and costs.