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, taletha@brandeis.edu

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

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.

Goal: Identify children affected by illegal substance abuse, or withdrawal symptoms resulting from prenatal drug exposure

Child post-birth records(to age 3)

Birth Certificate

Hospital Discharge Delivery (Mother)

Hospital Discharge Birth (Child)

COREMaternal prenatal records

(DOB – Gest. Age)

Emergency Department

Observational Stays

Non-birth Hospital Discharge

DEIIA Using PELL

624,269 live births from 1998-2005

Stage 1: Positive toxicology screen on

birth certificaten = 905

Stage 2: DEIIA flag in prenatal and/or

birth hospital recordsn = 6,943

Stage 3: DEIIA flag in post-birth

hospital recordsn = 722

7,348 Drug-Exposed Infants

Stage 1 only: 124, 2% Stages 1 & 2: 744, 10%Stage 2 only: 5,963, 81% Stages 1 & 3: 3, 0%Stage 3 only: 283, 4% Stages 2 & 3: 202, 3%

All 3 Stages: 34, 0.5% 96% identified by high validity indicators & 84% @ birth

Results

Discussion

Referral Disparity

010

20

30

40

50

60

70

80

% o

f DEI

Pos. Tox. + PublicIns.

Pos. Tox. + PrivateIns.

ReferredNot Referred

Interaction P < .05

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.

AcknowledgementsThis 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

References1 Individuals with Disabilities Education Improvement Act (2004). 20 U.S.C. §1400 2 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.