Disparities in Part C Early Intervention Service Access for Drug-Exposed Infants with Positive Toxicology Screens at Birth in Massachusetts Taletha Derrington, M.A., PhD Candidate, Brandeis University, [email protected]

Background

• Federal law requires drug-exposed infants (DEI) to be referred to Part C Early Intervention (EI) services.

1 • Methods to estimate the number of drug-exposed infants (DEI) in a state are limited.

• There are no population-based data on subsequent referral, evaluation, and eligibility of DEI once identified. • There is evidence of bias in performing toxicology screens at birth based on non-clinical factors; 2 is there bias in referral after a positive screen?

Study Question

How are positive toxicology screens on the birth certificate, maternal sociodemographic characteristics, and institutional characteristics related to EI referral of DEI in Massachusetts ?

Results

Referral Disparity

80 70 60 50 40 30 20 10 0 Pos. Tox. + Public Ins.

Interaction P < .05

Pos. Tox. + Private Ins.

Methods

• • • Retrospective cohort, secondary data analysis using the Pregnancy to Early Life Longitudinal (PELL) data system, a population-based, longitudinally linked data system (Boston University School of Public Health, the MA Dept. of Public Health, and the Centers for Disease Control and Prevention). PELL links birth certificates of live births in MA hospitals to MA residents to birth hospital records for the mother and child (99% linkage rate); pre- and postnatal hospital inpatient, emergency, & observational stay records of the mother and child; & EI records.

Developed the Drug-exposed Infant Identification Algorithm (DEIIA).

Referral identified by linkages to EI data; generalized estimating equations that account for maternal clustering used to model referral predictors.

DEIIA Using PELL

Maternal prenatal records (DOB – Gest. Age) CORE Birth Certificate Hospital Discharge Delivery (Mother) Non-birth Hospital Discharge Observational Stays Emergency Department Hospital Discharge Birth (Child)

624,269 live births from 1998-2005

Child post-birth records (to age 3) Goal: Identify children affected by illegal substance abuse, or withdrawal symptoms resulting from prenatal drug exposure

Stage 1: Positive toxicology screen on birth certificate n = 905 Stage 2: DEIIA flag in prenatal and/or birth hospital records n = 6,943 Stage 3: DEIIA flag in post-birth hospital records n = 722 7,348 Drug-Exposed Infants Stage 1 only: 124, 2% Stage 2 only: 5,963, 81% Stage 3 only: 283, 4% Stages 1 & 2: 744, 10% Stages 1 & 3: 3, 0% Stages 2 & 3: 202, 3% All 3 Stages: 34, 0.5% 96% identified by high validity indicators & 84% @ birth

References

1 2 Individuals with Disabilities Education Improvement Act (2004). 20 U.S.C. §1400 Ellsworth, M.A., Stevens, T.P., & D’Angio, C.T. (2010). Infant race affects application of clinical guidelines when screening for drugs of abuse in newborns.

Pediatrics

, 125(6): e1379-85.

Referred Not Referred

Discussion

• • Drug Exposed Infant Identification Algorithm General utility as a Public Health screening tool.

May identify only more serious drug users.

• • • • • Address referral disparities Positive toxicology screens should trigger referral regardless of insurance.

Investigate why privately insured not being referred.

Disparities found for Asian/Pacific Islanders, mothers aged 17-24, mothers with some college education or more, & rural residence.

Target outreach to lower level of maternity care hospitals.

EI referrals must be made by directly by birth hospitals before discharge; do not assume other agencies will make referral or that family will follow up on referral suggestion.

Acknowledgements

This project is dedicated to the memory of Lorraine Vogel Klerman, DrPH

• •

Dissertation funding support

Nancy Lurie Marks Institute on Disability Policy Fellowship Grants from the Heller Alumni Association and the Office of the Provost, Brandeis University • • • •

Special thanks to:

Dr. William McAuliffe, Harvard University Massachusetts Department of Public Health Massachusetts Early Intervention Program Boston University School of Public Health, Community Health Sciences Dept

Dissertation Committee: Marji Erickson-Warfield, PhD, Chair; Milton Kotelchuck, PhD, MPH; Jody Hoffer-Gittell, PhD; and Dominic Hodgkin, PhD