Hospital-Based Surveillance for Neonatal Abstinence ......14 . 12.4 . 12 . 13.5 11.9 8.8 0 2 . 4 6 . 8 10 . 12 . 14 . 16 . Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec . Rate per

Hospital-Based Surveillance for Neonatal Abstinence Syndrome in

Tennessee, 2013 Tennessee Department of Health

Division of Family Health and Wellness

Please Note: • Readers should interpret all findings with caution. This report contains

data obtained through a hospital surveillance system. In order to obtain the most complete picture of the burden of Neonatal Abstinence Syndrome in Tennessee, readers should also consider other sources of data on the incidence of NAS, including hospital discharge data and payment data (e.g. Medicaid claims data).

• Please be advised that in some cases (particularly in looking at data at the regional level), the counts are small and so we encourage caution in comparing differences across regions.

• If you have questions about particular data points or need assistance in interpreting the data, please contact Angela M. Miller, PhD, MSPH

• Phone: (615)253-2655 • Email: [email protected]

mailto:[email protected]�

Introduction

• Neonatal Abstinence Syndrome (NAS) is a condition in which an infant undergoes withdrawal from a substance to which he or she was exposed in utero.

• The most common substances causing NAS are the opiate class of drugs (ex. morphine, heroin).

• NAS can occur when a pregnant women takes: – A prescription medication prescribed to her – An illicit medication – A prescription medication written for someone else

but diverted to her

Introduction • Over the last decade, the incidence of NAS in

Tennessee has increased by 15-fold, far exceeding the national increase (3-fold over the same time period)1.

• A subcabinet working group focused on NAS was convened in 2012, consisting of Commissioner-level representation from the Departments of Health, Children’s Services, Mental Health and Substance Abuse Services, Safety and Human Services as well as the Bureau of Health Care Finance and Administration (Medicaid) and the Children’s Cabinet . The group is focused on policy and program strategies to reduce NAS (largely through primary prevention).

1Patrick S, JAMA 307(18), 2012

Introduction

• Previous data on the incidence of NAS was obtained through analysis of hospital discharge data or Medicaid claim data, both of which are associated with significant time lags.

• More timely data was needed to appropriately drive policy and programmatic changes.

• The Tennessee Department of Health made Neonatal Abstinence Syndrome (NAS) a reportable condition on January 1, 2013. Providers who diagnose NAS are required to report to the Department through an online portal within 30 days of diagnosis.

Introduction

• Providers were instructed that the following elements are generally involved in making the diagnosis of NAS: – History of exposure (maternal screening/history) – Evidence of exposure (maternal or infant screening) – Evidence of disease (infant with clinical signs of NAS)

• Cases were included in the Department’s official count if the last criterion (evidence of disease) was reported.

• Cases were not excluded if the first two criteria were left blank, as current screening techniques are not imperfect and NAS is a clinical diagnosis.

Table of Contents

• Case Report Data – Number of cases reported, cases reported by sex,

cases reported by month • Infant Exposure Data

– Maternal source of exposure, exposure source over time, maternal and infant screening characteristics

• Regional-Level Reporting Data – NAS rates by region, exposure source by region

Case Report Data

Number of Cases Reported Reporting Hospital Characteristics

Cases by Infant Sex Number and Rate of Cases by Birth Month

Highlights—2013 Case Report Data

• Providers submitted 1101 reports to the NAS reporting portal – Only 3.5% of cases (N=39) represented duplicates – 12.8% of reported cases (N=141) were for infants without clinical signs

of NAS and thus were excluded from the total NAS count • The vast majority of cases (84.2%) were reported by birth

hospitals. Few cases were reported by outpatient facilities or at readmission. – The median reporting time from hospitals was 8 days after birth.

• More male infants with NAS were reported. This is consistent with reports in the literature of discrepancies among NAS by sex2.

• The rate of NAS cases reported by month (per 1,000 live births) did not change significantly throughout the year.

2O’Connor AB, J Perinat Med 41(5), 2013

Cases Reported • 1101 reports made to

portal – 39 Duplicate reports,

excluded – 141 Without clinical

diagnosis of NAS, excluded

• 921 cases born in 2013 included in report

• Included cases were from 51 unique reporting hospitals

1,101 reports made

921 cases

39 duplicate reports

141 without clinical diagnosis

of NAS

Reporting Hospital Characteristics N %

Hospital Type Birth 775 84.2

Transfer 142 15.4

Outpatient 2 0.2

Readmission 2 0.2

Average time from birth to reporting was 23.1 (±34.5) days, with a range of 1 to 264 days. The median reporting time was 8.0 days.

Cases by Infant Sex Sex N % P-value

Male 535 58.0 <.0001

Female 386 41.9

Cases by Month of Birth

78

60

77 74 73 64

99

88 81

91

76

60

0

20

40

60

80

100

120

Case

s, n

Case Rate by Month of Birth

11.8

10.1

11.8 11.6 11.1

10

14

12.4 12

13.5

11.9

8.8

0

2

4

6

8

10

12

14

16

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Rate

per

1,0

00 li

ve b

irths

Month of Birth

NAS Cases per 1,000 live births Rate per 1,000 live births

*The change in monthly rate was not statistically significant.

Infant Exposure Data

Maternal Source of Exposure Exposure Source Over Time

Maternal and Infant Screening Data

Highlights—2013 Infant Exposure Data

• In 41.7% of cases, the exposure was reported as only drugs prescribed to the mother – In an additional 21.6%, the mother was reported to have

taken at least one substance prescribed by a health care provider

– In total, 63.3% of mothers were taking at least one substance prescribed by a health care provider

• Among mothers taking only drugs prescribed to them, 71.6% were under supervised replacement therapy (such as methadone or buprenorphine)

• In 62.8% of cases, there was both a maternal history of substance use and a positive screen for NAS causing substances (either maternal or neonatal)

Source of Exposure Source No. of cases* Percent (%)

Supervised replacement therapy

427 46.4

Supervised pain therapy 175 19.0

Therapy for psychiatric or neurological condition

68 7.4

Prescription substance without a prescription

370 40.2

Non-prescription substance

252 27.4

No known exposure but clinical signs consistent with NAS

13 1.4

No response 19 2.1

*Multiple maternal substances may be reported; therefore the total number of cases in this table may not match the total number of cases reported.

Source of Exposure Mutually Exclusive Sources of Exposure Source Cases Percent, %

Prescription Drugs Only

384 41.7

Illicit/Diverted Drugs Only

305 33.2

Prescription and Illicit Drugs

199 21.6

Unknown 32 3.5 31.3

71.6

13.3

Supervised Pain Therapy

Supervised Replacement

Therapy

Psychiatric or neurologic

therapy

0 10 20 30 40 50 60 70 80

Perc

ent o

f Cas

es w

ith P

resc

riptio

n Dr

ugs O

nly,

%

Class of Prescription Drug* Among Cases Exposed Only to Prescription Drugs*

*Percentages may not equal 100% as women may be exposed to drugs from more than one class

Exposure Source Over Time

39.7 45 45.5

36.5

50.7 42.2 38.4 36.4

45.7 42.9 35.5

45

34.6 31.7

36.4

35.1

30.1

32.8 30.3 36.4

34.6

27.5 38.2

31.7

19.2 16.7 15.6

20.3

16.4 23.4

31.3 21.6

18.5

26.4 23.7 21.7

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

Perc

ent,

%

Unknown



Prescription Drugs Only

*The change in exposure source over time was not statistically significant.

Positive Maternal or Neonatal Substance

Screen

Maternal History of Substance Use

Clinical Signs of NAS Clinical Signs of NAS Clinical Signs of NAS Clinical Signs of NAS

Maternal History of Substance Use

Positive Maternal or Neonatal Substance

Screen

Elements of Case Reporting

Clinical signs, maternal history, and positive

screen N=578 (62.8%)

Clinical signs and maternal history only

N=256 (27.8%)

Clinical signs and positive screen only

N=71 (7.7%)

Clinical signs only N=16 (1.7%)

Hospital Screening Patterns 921 infants with clinical signs

of NAS

Neonatal Screening

888 (96.4%) infants had at least one screening test

performed for substances known to cause NAS

716 (80.6%) had at least one completed screening test

437 (61.0%) of those with a completed test screened positive for substances

known to cause NAS

484 (54.5%) had at least one pending screening test

Maternal Screening

523 (56.8%) mothers had a positive screen for

substances known to cause NAS

461 (88.2%) had a history of using NAS causing

substances

398 (43.2%) had an unknown screening status

(Unknown if not done or negative screen)

373 (93.7%) had a history of using NAS causing

substances

Regional Data

NAS Incidence by Region Distribution of Cases by Region Region-Specific Rate by Month

Exposure Source by Region Leading Sources of Exposure by Region

Highlights—2013 Regional Data

• The highest rate of NAS cases (per 1,000 live births) observed in 2013 were in the East and Northeast regions of Tennessee, consistent with historical patterns – The statewide rate was 11.6 cases per 1,000 live births – There was no statistically significant change in rate throughout 2013

(at the state level or by region) – Sullivan County had the highest rate, 54.7 per 1,000 live births,

followed by the Northeast region (41.6 per 1,000) and the East Region (34.4 per 1,000)

– The Upper Cumberland Region is ranked a close fourth, with 30.9 cases per 1,000 live births

• Exposure source varied by region, with “prescription drugs only” being the most common source in most regions but “illicit/diverted drugs only” being more common in the East, Southeast, and Upper Cumberland regions.

Annual Incidence, by Region

35

268

17 2

102

58

138

24 29 12

86

117

33

0

50

100

150

200

250

300

Case

s, n

Annual Incidence and Rate, by Region Month NAS Cases Births* Rate (per 1,000 births)

Davidson 35 9,889 3.5

East 268 7,795 34.4

Hamilton 17 4,139 4.1

Jackson/Madison 2 1,252 1.6

Knox 102 5,100 20.0

Mid-Cumberland 58 14,748 3.9

Northeast 138 3,321 41.6

Shelby 24 13,647 1.8

South Central 29 4,415 6.6

Southeast 12 3,663 3.3

Sullivan 86 1,571 54.7

Upper Cumberland 117 3,790 30.9

West 33 5,900 5.6

TOTAL 921 79,230 11.6 *Provisional count of births, 2013

Annual Rate, by Region

1.8 5.6

1.6 3.9 3.5 6.6

30.9

3.3 4.1

34.4

20.0

41.6

54.7

11.6

0

10

20

30

40

50

60

Rate per 1,000 births

Geographic Distribution of NAS Cases Distribution of NAS Cases by Region, 2013 As Percent of Total

Rate by Month, Davidson

4.7

2.9

7.3

1.2

4.9

2.4

4.4

6.9

2.4

1.3

2.4

1.2

0

1

2

3

4

5

6

7

8

January February March April May June July August September October November December

Rate

Month of Birth

Davidson County Rate per 1,000 live births

*The change in monthly rate was not statistically significant for any region.

Rate by Month, East

34.6

19.6

41.9

31.5 31.4

19.0

45.8

40.0 43.0

36.8 35.8

30.3

0

5

10

15

20

25

30

35

40

45

50


East Region Rate per 1,000 live births


Rate by Month, Hamilton

0 0 0

11.5

8.5

6.2

0

5.2

0

5.3

6.4 5.7

0

2

4

6

8

10

12

14


Hamilton County Rate per 1,000 live births


Rate by Month, Jackson-Madison*

0 0

9.6

0 0 0 0 0 0 0

9.7

0 0

2

4

6

8

10

12


Jackson-Madison Rate per 1,000 live births

*Only 2 NAS cases reported in 2013 The change in monthly rate was not statistically significant for any region.

Rate by Month, Knox

26.9

18.3 17.7

24.6 23.5

15.3

25.4

13.5

16.6

28.7

20.9

7.1

0

5

10

15

20

25

30

35


Knox County Rate per 1,000 live births


Rate by Month, Mid-Cumberland

2.5 2.6 2.6

6.6

3.2

2.6

6.0 6.1

3.8

1.6

5.3

3.8

0

1

2

3

4

5

6

7


Mid-Cumberland Region Rate per 1,000 live births


Rate by Month, North East


32.3

29.0

54.5

35.6

49.4

36.5

51.6

42.6

54.3 54.0

26.6

32.1

0

10

20

30

40

50

60


North East Region Rate per 1,000 live births

Rate by Month, Shelby

0.9

1.9 1.8

0 0

2.8

3.5

0.8

2.6 2.6

0

4.0

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5


Shelby County Rate per 1,000 live births


Rate by Month, South Central

8.0

11.6

10.5

3.0 2.5

11.9

0

7.9 8.2

7.6

8.5

0 0

2

4

6

8

10

12

14


South Central Region Rate per 1,000 live births


Rate by Month, South East

0

3.8

9.4

3.4

6.9

0

3.0

5.6

0

3.1 3.6

0 0

1

2

3

4

5

6

7

8

9

10


South East Region Rate per 1,000 live births


Rate by Month, Sullivan


101.4

74.6

25.2

49.2

14.9

68.7

54.1

45.8 50.0

82.7

45.5

38.2

0

20

40

60

80

100

120


Sullivan County Rate per 1,000 live births

Rate by Month, Upper Cumberland

31.3

34.4

9.8

28.9 31.1

35.7

32.3 33.5

36.5 37.2

44.9

15.0

0

5

10

15

20

25

30

35

40

45

50


Upper Cumberland Region Rate per 1,000 live births


Rate by Month, West

0

13.1

7.5

16.9

15.8

3.7

10.9 10.3

3.8

14.3 14.0

15.6

0

2

4

6

8

10

12

14

16

18


West Region Rate per 1,000 live births


*The distribution of exposure source is statistically significant by region; P<0.0001.

Mutually Exclusive Categories of Exposure

33.3 27.3

50

25.9

40

17.2

41 50

11.8

49.3

30.4

18.1 11.6

50

51.5

50

50

42.9

20.7

24.8

41.7

47.1

25

38.2 62.3 68.6

16.7 18.2 22.4 11.4

58.6

30

8.3

35.3

24.3 31.4

12.3 11.6

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

Unknown


Prescriptin Drugs Only


Leading Source of Exposure by Region Region Prescription Drugs

Only Illicit/Diverted Drugs


Unknown

Shelby *

West *

Jackson-Madison * *

Mid-Cumberland *

Davidson *

South Central *

Upper Cumberland *

South East *

Hamilton *

East *

Knox *

North East *

Sullivan *

Please Note: • Readers should interpret all findings with caution. This report contains

data obtained through a hospital surveillance system. In order to obtain the most complete picture of the burden of Neonatal Abstinence Syndrome in Tennessee, readers should also consider other sources of data on the incidence of NAS, including hospital discharge data and payment data (e.g. Medicaid claims data).

• Please be advised that in some cases (particularly in looking at data at the regional level), the counts are small and so we encourage caution in comparing differences across regions.

• If you have questions about particular data points or need assistance in interpreting the data, please contact Angela M. Miller, PhD, MSPH

• Phone: (615)253-2655 • Email: [email protected]

mailto:[email protected]�

Acknowledgments

• Reporting hospitals and providers across the State of Tennessee

• NAS lead contacts at reporting hospitals • NAS Subcabinet Working Group • TDH Staff

– Alex Philipose, CDC Public Health Associate Program assignee

– Julie Traylor, CDC/CSTE Epidemiology Fellow Assignee – Audrey Bauer, Division of Policy, Planning and

Assessment

• This report was prepared by Angela Miller, PhD, MSPH and Michael Warren, MD, MPH.

• Suggested citation: Miller AM and Warren MD (2013). Neonatal Abstinence Syndrome Surveillance Annual Report 2013. Tennessee Department of Health, Nashville, TN.

Documents

Hospital-Based Surveillance for Neonatal Abstinence ......14 . 12.4 . 12 . 13.5 11.9 8.8 0 2 . 4 6 . 8 10 . 12 . 14 . 16 . Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec . Rate per