(105) Revised Drug Screening Restores Equity Without Compromising Neonatal Safety

Background & Introduction:

In obstetrics, racial bias has been demonstrated nationally through disproportionately higher rates of urine drug testing (UDT) on patients that identify as Black, despite lower rates of positive drug results [1-3]. UDT for birthing patients has therefore been increasingly recognized as an intervention subject to racial bias. Positive tests can have significant consequences, including intervention by Child Protective Services (CPS), criminalization, and familial separation. These repercussions can decrease treatment engagement and deter patients from seeking prenatal care in subsequent pregnancies due to experienced stigma and discrimination [4-6]. Our objective was to evaluate for a reduction in racial disparity in urine drug testing and reduction in non-medically indicated testing, as well as assess downstream neonatal outcomes following implementation of a behaviorally informed, electronic health record (EHR)-based protocol for UDT.

Methods:

We performed a 1-year quasi-experimental pilot study implementing a new UDT protocol into the electronic health record (EHR) on the Labor and Delivery (L&D) unit at a large academic hospital system in 12/2024. The project included two phases: first, a comprehensive protocol redesign that involved mixed-methods contextual inquiry, process mapping and draft design, and validation on the L&D unit; and second, a prospective pre- and post-implementation pilot study. The new protocol provided updated, evidence-based indications for UDT in pregnant patients presenting to L&D. An updated UDT order panel within our EHR system was also implemented, excluding tetrahydrocannabinol (THC). Charts were reviewed pre-implementation (6/1/2024 – 12/1/2024) and post-implementation (12/2/2024 – 6/2/2025) on pregnant patients admitted to our L&D unit who received UDT. Prior to protocol implementation, semi-structured qualitative interviews were also conducted with 11 clinicians, one certified recovery specialist, and two patients to explore clinician and patient knowledge of UDT in pregnancy. A Black/White disparity index for urine drug testing was calculated pre- and post-intervention. Demographics, frequency of UDT, neonatal outcomes, and CPS involvement data were collected. Chi-square and Fisher’s exact tests were used to compare pre- and post-intervention cohorts.

Results:

Pre-implementation qualitative interviews revealed that clinicians were unclear about specific guidelines around UDT collection, and patients were similarly unaware of their right to decline urine drug testing. Our new UDT protocol was narrowed to the following indications for UDT on L&D: use of non-prescribed opiates, stimulants, or benzodiazepines during current pregnancy without prior negative UDT or treatment documented in this pregnancy, or clinical concern for drug withdrawal or overdose. Notably, scenarios such as marijuana use alone, no prenatal care, or altered mental status without specific concern for drug withdrawal or overdose were no longer indications for UDT. As a pre-requisite, universal verbal screening was also fortified. After implementation of the new UDT protocol, there was a significant decrease in the overall number of urine drug tests collected at our institution (p < 0.001). There was also a significant decrease in the proportion of UDT collected among patients that identified as Black (1.9% to 0.6% of birthing population, p=0.01), while the proportion of UDT ordered among White patients remained similar (0.9% to 1.1%, p=1). In the pre-implementation period, Black patients had higher odds of UDT collection compared with White patients (OR=2.12, CI: 0.81-7.28, P=.17). In the post-implementation period, Black patients had 43% lower odds of UDT than White patients (OR=0.57, CI: 0.18-1.95, P=.03). When analyzing neonatal outcomes, there was no increase in the amount of infant drug tests collected, neonatal length of stay, NICU admission rates, or infant re-admissions after discharge among the post-implementation total birthing population. There was a non-significant decrease in the rate of neonatal abstinence syndrome (NAS) in the total birthing population (p=0.5), while there was conversely a non-significant increase in proportion of neonates diagnosed with NAS among patients who had a urine drug test collected (p=0.14). Of all birthing patients, 0.5% of infants with NAS were not detected by UDT pre-implementation, while 0.2% of infants with NAS were not detected by UDT post-implementation.

Conclusion & Discussion:

Implementation of updated urine drug testing (UDT) guidelines at our institution was associated with decreased rates of UDT overall and reduction in racial disparities among birthing patients for whom a urine drug test was ordered. These guidelines were created with the goal of eliminating criteria for UDT that are prone to racial bias, such as lack of prenatal care or marijuana use. When considering neonatal outcomes, reducing the scope of UDT did not lead to an increased need for neonatal UDT or any evidence of increased proportion of missed cases of infants with NAS; in fact, this rate also decreased. Similarly, rates of neonatal complications, such as NAS, NICU admission, or hospital readmission, were also not impacted negatively by updated parental UDT guidelines. Our results demonstrate that limiting UDT in birthing patients using evidence-based practices that minimize racial bias does not result in negative neonatal outcomes.

References:

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