Syndrome and Healthcare Utilization AcademyHealth ARM Pediatric - - PowerPoint PPT Presentation

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Outpatient Therapy for Neonatal Abstinence Syndrome and Healthcare Utilization

Stephen W. Patrick, MD, MPH, MS

AcademyHealth ARM Pediatric Health Services Research Interest Group June 24, 2017

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Stephen Patrick has no conflicts of interest to disclose. All medications to treat neonatal abstinence syndrome are off label.

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Opioids

• Prescriptions grew 4-fold over last decade
• In 2012, enough OPR were prescribed to give

every adult in the US one prescription

• Rising deaths from heroin and synthetic opioids
• More deaths than car accidents

Source: Centers for Disease Control and Prevention

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Neonatal Abstinence Syndrome

• A withdrawal syndrome experienced by drug exposed

newborns after birth

• Generally follows opioid exposure, though other drugs

have been implicated

• Signs include irritability, increased tone, tremors, poor

feeding, seizures

• Length of stay for NAS requiring pharmacotherapy –

national mean 23 days

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0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0

2000 2003 2006 2009 2010 2011 2012

NAS per 1000 Hospital Births

Patrick SW, et. al. Neonatal Abstinence Syndrome and Associated Healthcare Expenditures – United States, 2000-2009. JAMA. 2012 May 9;307(18):1934-40. Patrick SW, Davis MM, Lehman CU, Cooper WO. Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012. J Perinatol. 2015 Aug;35(8):650-5

Incidence of NAS in the US, 2000-2012

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Treatment

• Setting/environment (mom/baby together,

breastfeeding)

• Severe NAS requires treatment with an opioid

(e.g., morphine or methadone)

• Recent focus on reducing length of stay

– Discharge home on medication weans, common in some settings (40% in a recent study)

• Limited data on post-discharge outcomes

Patrick SW, Schumacher RE, Horbar JD, Buss-Frank ME, Morrow KA, Ferrelli KR, Picarillo AP, Gupta M, Soll RF. Improving Care for Infants with Neonatal Abstinence Syndrome. Pediatrics. 2016 May;137(5).

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Objectives

• Compare length of therapy between

patients treated as inpatient alone and patients treated as a combination of inpatient and outpatient therapy

• Compare healthcare utilization patterns

between both groups

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Methods

• Tennessee Medicaid administrative data, vital

records data, prescription data (2009-2011)

• Study population: NAS treated with medication

– Chart review for all NAS patients

• Outcomes:

– Length of therapy (LOT) – Length of stay (LOS) – 6-month ED visits and hospital readmissions

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Methods

• Inclusion criteria

– Patients with NAS treated with medication – >35 weeks GA

• Exclusion criteria

– Diagnosis of seizure at any time – Iatrogenic NAS

• Ordinal logistic regression model used for ED and

hospitalization counts

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Patients meeting inclusion criteria n = 736 NAS not requiring treatment n = 204 NAS treated with medication n = 532 Inpatient treatment

• nly

n = 290 Inpatient and Outpatient treatment n = 242

Inpatient treatment only n = 290 Inpatient and outpatient treatment n = 242 p-value Maternal Characteristics Maternal age (years) 26 26 0.41 Maternal race, n (%) 0.72 White 283 (98) 234 (97) Maternal education, n (%) 0.44 Less than High School 90 (31) 67 (28) High School 117 (41) 111 (46) More than High School 80 (28) 61 (26) Infant Characteristics Gestational age (week) 39 39 0.22 Birth weight (gram) 2902 3002 0.04 Sex, n (%) 0.70 Female 133 (46) 107 (44)

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Results

• Medication used outpatient:

– Phenobarbital 82%, Methadone 9%, Both 7%

Infant Characteristics Inpatient treatment only n = 290 Inpatient and outpatient treatment n = 242 p-value Region of Tennessee n (%) n (%) <0.001 East 196 (68) 217 (90) Middle 69 (24) 16 (7) West 24 (8) 9 (4)

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Differences in LOS and LOT

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Post-Discharge Utilization Patterns

0% 5% 10% 15% 20% 25% Inpatient only Inpatient + Outpatient Inpatient only Inpatient + Outpatient ED Visits (6 Months) Readmissions (6 Months)

1 2 3 4

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0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 ED count

• 30

days ED count 6 months Hospitaliza ons 30 days Hospitaliza ons 6 months Adjusted Odds Ra o *

Utilization Patterns: Inpatient Treatment versus Outpatient Weans

*Adjusted for birth weight and region

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Discussion

• Outpatient weans associated with

– Longer lengths of treatment – Higher number of emergency department visits

• Patient characteristics similar between groups, vast geographic differences

– Suggest hospital/regional level reasoning for outpatient weans as opposed to patient characteristics

• Phenobarbital

– Widespread apoptotic neurodegeneration in rat brains – Lower passive avoidance performance suggesting impaired learning and/or recall – RCT, phenobarbital vs placebo for febrile seizures, IQ 8.4 lower in phenobarbital group at 2 years

Bittigau et al. PNAS. 2002 Gutherz et al. Epilepsy & Behavior. 2014 Farwell et al. NEJM. 1990

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Limitations

• Potential for misclassification bias using

administrative data

– Mitigated by chart review

• Generalizability beyond Tennessee
• Not direct observation of medication

administration

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Implications

• Policies and innovations to reduce NAS length of stay,

should be mindful of potential post-discharge implications

• Focus on inpatient inefficiencies
• Post-discharge support
• Metrics that are not solely hospital/provider centric
• Additional study needed

– Innovations in inpatient care – Long-term outcomes

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• Co-authors:

– Faouzi I. Maalouf, MD – William O. Cooper, MD, MPH – J. Chris Slaughter, DrPH – Judith Dudley, BS

• NIDA K23DA038720

Acknowledgements

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LOS and LOT Calculation

Observation (2 days) Inpatient pharmacotherapy Observation (2 days)

LOT LOS

Observation (3 days) Inpatient pharmacotherapy Outpatient pharmacotherapy (length of prescription)

LOS LOT

Inpatient treatment only Inpatient and outpatient treatment

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West Tennessee Middle Tennessee East Tennessee p-value Discharged home on medications, n (%) 9 (27) 16 (19) 217 (53) <0.001 Infant Characteristics Inpatient treatment only n = 290 Inpatient and outpatient treatment n = 242 p-value Region of Tennessee, n (%) <0.001 East 196 (68) 217 (90) Middle 69 (24) 16 (7) West 24 (8) 9 (4)

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Results

• Patients receiving outpatient therapy were more

likely to have a greater number of ED visits within 6 months of discharge (aOR 1.52, 95% CI 1.06-2.17)

• No significant increase in hospital admissions

within 6 months of discharge (aOR 2.00, 95% CI 0.78-2.85)

*Adjusted for birth weight and region