Patrick SW, et al. - Using outcome data from all 580 counties in Florida, Kentucky, Massachusetts, Michigan, New York, North Carolina, Tennessee, and Washington from 2009 to 2015 and economic data from 2000 to 2015, researchers identified the association between long-term unemployment, clinician supply (as assessed by primary care and mental health clinician shortage areas) and neonatal abstinence syndrome (NAS) rates and assessed the differences between rural associations. A significant association was noted between higher long-term unemployment, higher mental health clinician shortage areas and higher county-level rates of NAS in this ecological analysis of counties in eight US states.

Methods

• It was an ecological time-series analysis of a retrospective, repeated cross-sectional study.
• Negative binomial models have been used with year and county-level fixed effects.
• Interactions have been tested and stratified analyses have been carried out by metropolitan counties, rural counties adjacent to metropolitan counties, and rural remote counties.
• Exposures included county-level 10-year unemployment rate and mental health and primary care clinician supply obtained from the Health Resources and Services Administration Area Health Resources Files.
• Main outcomes and measures included rates of NAS, excluding iatrogenic withdrawal, obtained from state inpatient databases.

Results

• Observations from 580 counties over 7 years (1803 county-years from metropolitan counties, 1268 county-years from rural counties adjacent to metropolitan counties, and 927 county-years from rural remote counties) were included.
• There were 6,302,497 births and 47,224 diagnoses of NAS during the study period.
• Data reported that the median rate of NAS was 7.1 per 1000 hospital births (interquartile range [IQR], 2.2-15.8), the 10-year unemployment rate was 7.6% (IQR, 6.4%-9.0%), and 83.9% of county-years were partial or complete mental health shortage areas.
• In the adjusted analyses, mental health shortage areas had higher NAS rates (unadjusted rate in shortage areas of 14.0 per 1000 births vs unadjusted rate in nonshortage areas of 10.6 per 1000 births; adjusted incidence rate ratio [IRR], 1.17 [95% CI, 1.07-1.27]), occurring primarily in metropolitan counties (adjusted IRR, 1.28 [95% CI, 1.16-1.40]; P=.02 for test of equivalence between metropolitan counties and rural counties adjacent to metropolitan counties).
• No significant association was found between primary care shortage areas and rates of NAS.
• Investigators found that the 10-year unemployment rate was related to higher rates of NAS (unadjusted rate in highest unemployment quartile of 20.1 per 1000 births vs 7.8 per 1000 births in lowest unemployment quartile; adjusted IRR, 1.11 [95% CI, 1.00-1.23]) occurring primarily in rural remote counties (adjusted IRR, 1.34 [95% CI, 1.05-1.70]; P=.04 for test of equivalence between metropolitan counties and rural remote counties).