Higher county-level rates of neonatal abstinence syndrome were associated with a regional shortage of mental health clinicians and high unemployment rates, according to a study recently published in JAMA.
Researchers examined data from a retrospective, cross-sectional study that included 580 counties in Washington, Tennessee, North Carolina New York, Michigan, Massachusetts, Kentucky, and Florida. Data included outcome and economic data, which took into account 10-year unemployment rates; mental health clinician supply; and primary care physician supply. The primary outcome was neonatal abstinence syndrome rates. Variables of interest were examined for collinearity. Negative binomial models of neonatal abstinence syndrome births were created as functions of economic conditions and characteristics on the county level. Analysis was stratified by rural remote counties, rural counties next to metropolitan areas, and metropolitan counties.
The 7-year collection period yielded 927 county-years from rural remote counties, 1268 county-years from rural counties next to metropolitan counties, and 1803 county-years from metropolitan counties. The study period included 47,224 neonatal abstinence syndrome diagnoses among 6,302,497 births (median rate, 7.1 per 1000 hospital births; interquartile range [IQR], 2.2-15.8). The counties had a 10-year moving average unemployment rate of 7.6% (IQR, 6.4%-9.0%), and this rate was associated with greater neonatal abstinence syndrome rates (20.1/1000 births in highest unemployment quartile vs 7.8/1000 births in lowest unemployment quartile; incidence rate ratio [IRR]=1.11; 95% CI, 1.00-1.23). Areas with partial or complete shortages of mental health professionals comprised 83.9% of county-years. Neonatal abstinence syndrome rates were higher among these areas, with a rate of 14/1000 births compared with 10.6/1000 births in areas without shortages (IRR=1.17; 95% CI, 1.07-1.27). The incidence was likelier in metropolitan counties than in others (IRR=1.28; 95% CI, 1.16-1.40; P =.02). Primary care shortage was not significantly associated with neonatal abstinence syndrome rates.
Limitations to this study included a lack of patient-level data, an ecological design, potential misclassification bias in hospital discharge records, a potential lack of confounders on the county level, and a possible lack of generalizability.
The study researchers concluded that “[in] this ecological analysis of counties in 8 US states, there was a significant association among higher long-term unemployment, higher mental health clinician shortage areas, and higher county-level rates of neonatal abstinence syndrome.”
Patrick SW, Faherty LJ, Dick AW, Scott TA, Dudley J, Stein BD. Association among county-level economic factors, clinician supply, metropolitan or rural location, and neonatal abstinence syndrome. JAMA. 2019;321(4):385-393.