Trends in Hospital Readmission and Emergency Department Visit among Infants Born with Neonatal Abstinence Syndrome Issue Brief

01/19/2021

Trends in Hospital Readmission and Emergency Department Visit among Infants Born with Neonatal Abstinence Syndrome
ASPE ISSUE BRIEF

Mir M. Ali, Emma Nye, and Kristina West

U.S. Department of Health and Human Services
Office of the Assistant Secretary for Planning and Evaluation

December 2020

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ABSTRACT: This paper examines trends in hospital readmission and emergency department visits among infants with Neonatal Abstinence Syndrome (NAS) between 2008 and 2017 in the United States, using a multi-state Medicaid claims database.

This brief was prepared through intramural research by the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Behavioral Health, Disability, and Aging Policy. For additional information about this subject, you can visit the BHDAP home page at https://aspe.hhs.gov/bhdap or contact the authors at HHS/ASPE/BHDAP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, Mir.Ali@hhs.gov, Emma.Nye@hhs.gov, Kristina.West@hhs.gov.

DISCLAIMER: The opinions and views expressed in this brief are those of the authors. They do not reflect the views of the Department of Health and Human Services, the contractor or any other funding organization. This brief was completed and submitted in March 2020.


 

HIGHLIGHTS

This paper examines trends in hospital readmission and emergency department visits among infants with NAS between 2008 and 2017 in the United States, using a multi-state Medicaid claims database. Key findings include the following:

  • From 2008 through 2017, nearly 25% of infants diagnosed with NAS were readmitted or seen in an emergency department within 90 days of discharge.

  • The rate within this timeframe was highest in 2012 and lowest in 2017, with 25% and 20% of NAS infants respectively experiencing readmission or emergency department visits.

  • Drug withdrawal syndrome was among the four most common reasons for readmission or emergency department visitation every year from 2008 through 2017.

 

Introduction

Over the past decade the rates of infants diagnosed with Neonatal Abstinence Syndrome (NAS) have increased rapidly, coinciding with the rise in opioid prescribing and opioid-related overdose deaths (Wahlen et al., 2019). Despite the recent increases in infants diagnosed with NAS and its associated health care services utilization, little is known about the trends in hospital readmissions rates or emergency department visits among NAS infants in the United States. Hospital readmissions rates are often used as both a quality measure to assess whether the initial hospital discharge protocol was safe and effective and a general evaluation of the effectiveness of the treatment regimen for infants with NAS (Patrick et al., 2015). In this report, a large Medicaid claims database is used to estimate the trends in hospital readmission rates and emergency department visits among NAS infants between 2008 and 2017.

 

Significant Proportion of Infants Born with NAS Experienced Hospital Readmission or Emergency Department Visit within 90 Days of Discharge

Close to a quarter of all NAS infants covered under Medicaid experienced a hospital readmission or emergency department visit within 90 days of their initial birth-related hospital discharge between 2008 and 2017 (Figure 1). This rate remained steady throughout the study period, with the highest rate (25%) occurring in 2012 and reaching the lowest (20%) in 2017. The primary reasons for hospital readmission and emergency department visit between 2008 and 2017 include conditions related to respiratory infections, fever, cough, and drug withdrawal syndrome (Table 1).

FIGURE 1. Hospital Readmission/Emergency Department Visit among Medicaid NAS Infants within 3 Months of Birth Related Hospital Discharge
FIGURE 1, Line Chart: This graph shows trends in hospital readmission/emergency department visit among infants born with neonatal abstinence syndrome from 2008 to 2017.

The study used IBM Watson Health MarketScan Multi-State Medicaid claims database (2008-2017). The sample includes all infants (ICD-9 livebirth codes V30-V39 and ICD-10 livebirth codes Z37-Z38) diagnosed with NAS (ICD-9 code 779.5 and ICD-10 code P961) born between 2008 and 2017. The sample size ranged from 989 NAS infants in 2008 to 5,027 NAS infants in 2017. Rates of hospital readmission or emergency department visit among NAS infants were measured by whether the infants had any inpatient hospitalization or had an emergency department encounter within 90 days of release from their birth hospitalization for each study year.

 

Discussion

Between 2008 and 2017, approximately a quarter of NAS infants covered under Medicaid experienced a hospital readmission or an emergency department visit within three months of their initial birth-related hospital discharge. This rate remained relatively steady throughout the study period and conditions related to drug withdrawal syndrome was one of the primary reasons for the hospital readmission or the emergency department visit.

The increase in the rates of infants diagnosed with NAS and the steady rate of hospital readmission in the midst of the opioid crisis underscores the public health significance of the issue. The first-line of treatment for NAS infants usually includes creating a quiet and soothing environment, rooming-in with the mother, breastfeeding and increased mother-infant bonding, protocols that require creating a supportive environment for both the infants and the substance-affected mothers. Thus, the relatively high rate of hospital readmissions and emergency department visits, especially for drug withdrawal symptoms, highlights the need of maybe providing more supportive services to this particularly vulnerable subset of families.

This study has several potential limitations. The number of Medicaid states represented in the MarketScan data varies from year to year and the trends in hospital readmission and emergency department visits observed in this study could be a function of that. Similarly, the MarketScan Medicaid database is not nationally representative, thus the rates observed in the study might not be generalizable to the entire population of infants diagnosed with NAS covered under Medicaid. However, this limitation is not unique to MarketScan, and is also applicable to other administrative claims databases.

Hospitalization and emergency department encounters appear to be common among NAS infants. Establishment of evidence-based protocols for both in-hospital and post-discharge treatment along with expansion of supportive resources for mothers and caregivers should be considered to reduce this risk. Future policy developments and activities targeted at NAS infants could potentially benefit from focusing on hospital readmissions rates.

 

References

Maalouf FI, Cooper WO, Slaughter JC, Dudley J, Patrick SW. (2018). Outpatient pharmacotherapy for Neonatal Abstinence Syndrome. Journal of Pediatrics; 199: 151-157.

Patrick SW, Burke JF, Biel TJ, Auger KA, Goyal NK, Cooper WO. (2015). Risk of hospital readmission among infants with Neonatal Abstinence Syndrome. Hospital Pediatrics; 5(10): 513-519.

Wahlen BL, Holmes AV, Blythe S. (2019). Models of care for neonatal abstinence syndrome: What works? Seminars in Fetal and Neonatal Medicine; 24(2): 121-132.

Winkelman TA, Villapiano N, Kozhimannil KB, Davis MM, Patrick S. (2018). Incidence and costs of Neonatal Abstinence Syndrome among infants with Medicaid: 2004-2014. Pediatrics; 141(4): e20173520.

 

TABLE 1. Top 5 Frequent Reasons for Hospital Readmission or Emergency Department Visit among Medicaid NAS Infants: 2008-2017
ICD-9/ICD-10 Code for Reasons for Hospitalization/Emergency Department Visit N Events
Year: 2008
465.9 Acute upper respiratory infections of unspecified site 48 151
779.5 Drug withdrawal syndrome in newborn 39 54
786.2 Cough 35 61
779.89 Other specified conditions originating in the perinatal period 28 34
780.60 Fever, unspecified 25 62
Year: 2009
780.60 Fever, unspecified 68 275
465.9 Acute upper respiratory infections of unspecified site 61 247
786.2 Cough 58 123
779.5 Drug withdrawal syndrome in newborn 49 67
079.99 Unspecified viral infection 40 143
Year: 2010
780.60 Fever, unspecified 61 242
465.9 Acute upper respiratory infections of unspecified site 59 270
530.81 Esophageal reflux 41 90
787.03 Vomiting alone 40 106
779.5 Drug withdrawal syndrome in newborn 40 47
Year: 2011
780.60 Fever, unspecified 74 420
465.9 Acute upper respiratory infections of unspecified site 67 230
786.2 Cough 50 163
787.03 Vomiting alone 47 142
779.5 Drug withdrawal syndrome in newborn 41 42
Year: 2012
786.2 Cough 193 559
465.9 Acute upper respiratory infections of unspecified site 192 711
780.60 Fever, unspecified 158 757
478.19 Other disease of nasal cavity and sinuses 125 404
779.5 Drug withdrawal syndrome in newborn 103 155
Year: 2013
786.2 Cough 207 755
465.9 Acute upper respiratory infections of unspecified site 194 854
780.60 Fever, unspecified 175 714
478.19 Other disease of nasal cavity and sinuses 137 491
779.5 Drug withdrawal syndrome in newborn 122 230
Year: 2014
465.9 Acute upper respiratory infections of unspecified site 212 882
786.2 Cough 202 508
780.60 Fever, unspecified 194 779
787.03 Vomiting alone 149 484
779.5 Drug withdrawal syndrome in newborn 112 197
Year: 2015
R05 Cough 77 212
J069 Acute upper respiratory infection, unspecified 74 263
R0981 Nasal congestion 56 194
P961 Neonatal withdrawal symptoms from maternal use of drugs of addiction 51 55
R509 Fever, unspecified 46 264
779.5 Drug withdrawal syndrome in newborn 78 132
465.9 Acute upper respiratory infections of unspecified site 69 272
780.60 Fever, unspecified 56 222
779.89 Other specified conditions originating in the perinatal period 52 106
786.2 Cough 50 118
Year: 2016
R05 Cough 171 418
J069 Acute upper respiratory infection, unspecified 150 591
P961 Neonatal withdrawal symptoms from maternal use of drugs of addiction 145 192
R509 Fever, unspecified 140 667
R0981 Nasal congestion 100 283
Year: 2017
J069 Acute upper respiratory infection, unspecified 122 516
R05 Cough 116 284
R509 Fever, unspecified 82 580
R0981 Nasal congestion 74 207
R1110 Vomiting, unspecified 72 207

 


Neonatal Abstinence Syndrome

This brief was prepared through intramural research by the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Behavioral Health, Disability, and Aging Policy. For additional information about this subject, you can visit the BHDAP home page at https://aspe.hhs.gov/bhdap or contact the authors at HHS/ASPE/BHDAP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, Mir.Ali@hhs.gov, Emma.Nye@hhs.gov, Kristina.West@hhs.gov.

Reports Available

Trends in Hospital Readmission and Emergency Department Visit among Infants Born with Neonatal Abstinence Syndrome Issue Brief

Use of Outpatient Pharmacological Treatment Among Infants Born with Neonatal Abstinence Syndrome: Medicaid 2008-2017 Issue Brief

Utilization of Mental Health Services among Children Diagnosed with Neonatal Abstinence Syndrome at Birth Issue Brief