Peterson Jessica A, Koelper Nathanael C, Curley Cara, Sonalkar Sarita R, James Abike T
Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine, Mount Sinai, New York, NY (Dr Peterson).
Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Mr Koelper and Drs Curley, Sonalkar, and James).
Am J Obstet Gynecol MFM. 2023 May;5(5):100913. doi: 10.1016/j.ajogmf.2023.100913. Epub 2023 Mar 3.
Drug use during pregnancy can have implications for maternal and fetal morbidity and mortality and legal ramifications for patients. The American College of Obstetricians and Gynecologists guideline states that drug screening policies during pregnancy should be applied equally to all people and notes that biological screening is not necessary, stating that verbal screening is adequate. Despite this guidance, institutions do not consistently implement urine drug screening policies that reduce biased testing and mitigate legal risks to the patient.
This study aimed to evaluate the effects of a standardized urine drug testing policy in labor and delivery on the number of drug tests performed, self-reported racial makeup of those tested, provider-reported testing indications, and neonatal outcomes.
This was a retrospective cohort study. A urine drug screening and testing policy was introduced in December 2019. The electronic medical record was queried for the number of urine drug tests performed on patients admitted to the labor and delivery unit from January 1, 2019, to April 30, 2019. The number of urine drug tests performed between January 1, 2019, and April 30, 2019, was compared with the number of urine drug tests performed between January 1, 2020, and April 30, 2020. The primary outcome was the proportion of urine drug tests performed based on race before and after the implementation of a drug testing policy. The secondary outcomes included total number of drug tests, Finnegan scores (a proxy for the neonatal abstinence syndrome), and testing indications. To understand perceived testing indications, pre- and postintervention provider surveys were administered. Chi-square and Fisher exact tests were used to compare categorical variables. The Wilcoxon rank-sum test was used to compare nonparametric data. The Student t test and 1-way analysis of variance were used to compare means. Multivariable logistic regression was used to construct an adjusted model that included covariates.
In 2019, Black patients were more likely to undergo urine drug testing than White patients, even after adjusting for insurance status (adjusted odds ratio, 3.4; confidence interval, 1.55-7.32). In 2020, there was no difference in testing based on race after adjusting for insurance status (adjusted odds ratio, 1.3; confidence interval, 0.55-2.95). There was a reduction in the number of drug tests performed between January 2019 and April 2019 compared with between January 2020 and April 2020 (137 vs 71; P<.001). This was not accompanied by a statistically significant change in the incidence of neonatal abstinence syndrome measured by mean Finnegan scores (P=.4). Before the implementation of a drug testing policy, 68% of providers requested patient consent for testing; after the implementation of a drug testing policy, 93% requested patient consent for testing (P=.002).
The implementation of a urine drug testing policy improved consent for testing and reduced disparities in testing based on race and the overall rate of drug testing without affecting neonatal outcomes.
孕期用药可能会对母婴发病率和死亡率产生影响，并给患者带来法律后果。美国妇产科医师学会指南指出，孕期药物筛查政策应平等适用于所有人，并指出无需进行生物筛查，称口头筛查就足够了。尽管有此指导意见，但各机构并未始终如一地实施尿液药物筛查政策，这些政策本可减少有偏见的检测并降低患者面临的法律风险。
本研究旨在评估分娩时标准化尿液药物检测政策对所进行的药物检测数量、接受检测者自我报告的种族构成、医护人员报告的检测指征以及新生儿结局的影响。
这是一项回顾性队列研究。2019年12月引入了尿液药物筛查和检测政策。查询了电子病历中2019年1月1日至2019年4月30日入住分娩单元的患者所进行的尿液药物检测数量。将2019年1月1日至2019年4月30日期间所进行的尿液药物检测数量与2020年1月1日至2020年4月30日期间所进行的尿液药物检测数量进行比较。主要结局是实施药物检测政策前后基于种族进行的尿液药物检测比例。次要结局包括药物检测总数、芬尼根评分（新生儿戒断综合征的替代指标）以及检测指征。为了解医护人员感知到的检测指征，在干预前后进行了医护人员调查。采用卡方检验和费舍尔精确检验来比较分类变量。采用威尔科克森秩和检验来比较非参数数据。采用学生t检验和单因素方差分析来比较均值。采用多变量逻辑回归构建包含协变量的调整模型。
2019年，即使在调整保险状况后，黑人患者接受尿液药物检测的可能性也高于白人患者（调整后的优势比为3.4；置信区间为1.55 - 7.32）。2020年，在调整保险状况后，基于种族的检测没有差异（调整后的优势比为1.3；置信区间为0.55 - 2.95）。与2020年1月至4月相比，2019年1月至4月进行的药物检测数量有所减少（137次对71次；P <.001）。这并未伴随以平均芬尼根评分衡量的新生儿戒断综合征发病率的统计学显著变化（P = 0.4）。在实施药物检测政策之前，68%的医护人员请求患者同意进行检测；在实施药物检测政策之后，93%的医护人员请求患者同意进行检测（P = 0.002）。
尿液药物检测政策的实施改善了检测同意情况，减少了基于种族的检测差异以及药物检测的总体比率，且未影响新生儿结局。
