The proportion of patients who tested positive for drugs increased significantly from 2013 to 2017, correlating with the increasing trend of substance use that has become a “2016-2020 Maternal and Child Health” priority in the state of Colorado (Colorado Department of Public Health and Environment [CDPHE] 2019). The reported cases of NAS in Colorado in 2018 were 5.4 per 1000 hospital births (National Institute on Drug Abuse [NIDA] 2020). The average LOS in Colorado for a neonate with health concerns appeared to be slightly decreasing where the average LOS was 2.4 days in 2013 and 2.3 days in 2017 (Colorado Hospital Association [CHA] undated). When comparing LOS to trends in CO, the results of this study differ where the other-drug exposed newborns LOS was trending upward. These newborns were staying longer in the hospital, creating higher costs, which then impacts the Colorado community hospital. The increasing LOS dynamic for drug-exposed newborns held true even after the logarithmic data transformations that minimized the influence of high outliers largely responsible for the five-fold increase in average LOS reported in Table 7.
This study showed that a significant number of those testing positive for more than one substance included cannabis as one of the drugs. From 2002 to 2017, cannabis use during pregnancy in the U.S. was increasing, and approximately 19% of pregnant woman use of cannabis was related to cannabis dependence (Alshaarawy and Anthony 2019). In Colorado, 14.6% of mothers used cannabis during pregnancy from 2015 to 2017 (CDPHE 2019). Other research reveals that cannabis use during pregnancy, especially when combined with other substances, may adversely affect neonatal behavior (Ryan et al. 2018). The resulting LOS in this study among the cannabis-exposed newborns is significantly shorter than that in the opioid, amphetamine, and methadone groups. Even though the LOS for cannabis-exposed newborns was found to be shorter, it is still significantly longer than the average 1.9-day LOS in Colorado for a normal, healthy newborn and the 2.3 days for a neonate with health concerns (CHA undated). A possible explanation for the increased LOS could be the limited research available to health care providers on the effects of cannabis-exposure (National Academies of Sciences, Engineering, and Medicine 2017; Warshak et al. 2015). The newborns may have stayed longer in the hospital to allow for additional observation due to a positive drug screen.
The type of newborn bed placement affects the Colorado community hospital due to an increased cost for a SCNSY bed. Cannabis-exposed newborns had a statistically significant higher rate of normal NSY placement, whereas the other drug-exposed newborns had a significantly higher rate of placement in a SCNSY or PEDS bed (see Table 8). This suggests that cannabis-exposed newborns are of lower acuity, and therefore less costly to the healthcare system, as compared to the other drug-exposed newborns. Cannabis-exposed newborns placed in a normal newborn bed cost approximately $6618.17 per person when calculated with their average LOS of 2.6 days, however, this was still greater than the average cost of $5171 for a normal newborn hospital stay in the state of Colorado (CHA undated). This study revealed results similar to previous studies where a significant financial impact is occurring for NAS newborns. The costs grow substantially when newborns are assigned to SCNSY and the LOS is longer. NAS has increased where newborn LOS is longer and led to $1.5 billion of hospital charges annually which is taxing on “an already overburdened health care system” (McQueen et al. 2015, p. 1763).
Mothers testing positive for drugs were more likely to have public health insurance, including Medicaid, than other types of insurance (Table 2). The higher rate of public insurance coverage among drug-exposed newborns might contribute to lower reimbursement to the Colorado community hospital, thus increasing the cost burden. Reimbursement rates to the hospitals, or Medicaid payments, in many states do not meet the average healthcare costs for these patients (Harrison 2016). This correlates with other research findings where the “mean hospital charge for infants diagnosed with NAS was $53,400.00, and 77.6% of charges for NAS were attributed to state Medicaid programs” (Lee et al. 2015, p. 396).
It has been shown that prematurity or low birthweight could potentially cause an increased LOS for newborns (Eneriz-Wiemer et al. 2018). However, in different drug groups analyzed in this study, the average birthweight of newborns ranged from 2710 to 3255 g and the average gestational age ranged between 257 and 273 days (see Table 3). Taking into account the standard errors, these figures do not constitute a significant difference from those considered normal for newborn birthweight (between 2500 and 4000 g at gestational term) and gestational age (between 259 and 280 days) (ACOG 2020; KidsHealth 2020). Thus, we do not attribute the extended LOS for drug-exposed newborns to either prematurity or low birthweight.
The disposition of the newborn can impact healthcare systems if newborns continue to need healthcare after being discharged from the Colorado community hospital. The results show that the proportion of newborns discharged directly to home increased over time, while the proportion of newborns discharged to another acute care hospital decreased (Table 9). The test also did not reveal any trend in the proportions of newborns discharged to home with home care. The results showed that the increased financial responsibilities remained within the Colorado community hospital. This can cause an impact to other healthcare facilities since they are now having a decreased number of these newborns being transferred to their facilities for healthcare needs.
Limitations
This study has several limitations. Having data of mothers and newborns living only in a community in Colorado decreases the ability to generalize the results of this study to a larger population. The de-identified data for the mothers included three admission types: clinical, observation and inpatient status. Mothers who are giving birth are admitted with an inpatient status, but those with clinical or observation status are sent home at the provider’s discretion. Therefore, some of the mothers may have been admitted more than once during the study period. This could explain the larger number of mothers testing positive for drugs as compared to the newborns. The retrospective design eliminated the researchers’ control of variables, such as determining whether a drug screen would be collected, which was decided by the healthcare providers’ judgement during the hospital stay.
Mothers who did not admit to drug use and newborns who did not display withdrawal symptoms during the hospital stay were not tested. This may have resulted in an underestimation of drug use, which would decrease the study sample size. The contributors from the hospital revealed that since the legalization of recreational cannabis in 2014, some healthcare providers did not perform a drug screen on patients who admitted to either recreational or medicinal cannabis use. These patients were not included in the study datasets since they did not have a positive drug-screen result. This exclusion could affect the trend in data, increasing the respective number of positive drug screens in the first year of the study data (2013) compared to the last 4 years of the study data (2014–2017).
Newborns exposed to only cannabis may not display the commonly found signs of withdrawal found in NAS, so may not have been tested. This would result in a decreased detection of cannabis only use during pregnancy, thereby decreasing the study sample size and creating a bias toward those utilizing other substances. Newborns exposed to opiates in utero may not display typical signs of NAS until after they are discharged from the hospital, which would decrease the numbers of opiate-exposed newborns tested and included in the study. The data available on bed placement was the location of the newborn at discharge; therefore, the cost calculation was an estimation based off of LOS. The PEDS bed placement was not included in the cost calculation due to the unavailability of that data to the researchers. There was no documentation on the frequency of drug use and whether drugs were used throughout all three trimesters of pregnancy, which could affect whether the newborn exhibited signs of withdrawal. The newborn LOS could have been affected by other medical or social factors, or by method of delivery, which were not included in this study. The data included in the study described mothers and newborns who met the inclusion criteria for this study, testing positive on a drug screen. Although the number of those who had a drug screen with a negative result is known (see Table 4), the variables of interest on these patients were not available and the characteristics of the specific lab tests were also not obtained.