Neonatal Abstinence Syndrome; The Tiniest Victims of the Opioid Epidemic in Virginia. Alan Picarillo, MD, FAAP VNPC Spring meeting 11 May 2017

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1 Neonatal Abstinence Syndrome; The Tiniest Victims of the Opioid Epidemic in Virginia Alan Picarillo, MD, FAAP VNPC Spring meeting 11 May 2017

2 Disclosure I am paid faculty for Vermont-Oxford Network There will be discussion of unlabeled use of medications (NAS medications)

3 How did we get here?

4 How did we get here?

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6 Modified Finnegan scoring system Twenty signs grouped into categories (neurologic, state, respiratory, gastrointestinal) Signs are ranked according to pathologic significance Total score of 7 is considered mild and scores of 8 of more may indicate need for pharmacologic treatment

7 Modified Finnegan scoring system

8 How to treat the infant Non-pharmacologic therapy Swaddling, low-light, skin-to-skin with parent, breastmilk (if no contraindications), low noise Potential for short length of stay (5-7 days) Pharmacologic therapy Morphine, Methadone, Phenobarbital, Clonidine Once medications started, infants usually in hospital for 3 weeks.

9 Increase in NAS

10 Increase in NAS Patrick et. al, J. Perinatology 2015

11 Geographic distribution of NAS

12 Recent data by state m6531a2.htm

13 Recent data by state m6531a2.htm

14 National data 4 Million birth in US/year 24,000 NAS infants born in US (66 per day!) Mean length of stay 23 days Each day in the US, there are >1500 hospitalized NAS infants Cost $93,400/infant $2.2 billion in costs for initial hospitalization >80% are Medicaid

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16 Percent of NICU beds occupied by NAS infants Total % of NICU days increased from 0.6% (2004) to 4% (2013) p<.001 Eight centers reported >20% of all NICU days attributable to NAS infants in 2013 UMass data (2013): 1100 patient days (7%)

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19 NAS Incidence by Zip Code (2013) Slide courtesy of Urbano Franco and Michael McManus

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21 Virginia rates of NAS

22 Virginia NAS infants/year ( ) Courtesy of Virginia Dept of Health

23 Courtesy of Virginia Dept of Health Virginia NAS rate ( )

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29 National data Virginia data 100k births in Virginia per year ~550 NAS infants born in VA Mean length of stay 23 days Each day in the VA, there are >30 hospitalized NAS infants Cost $93,400/infant $51 million in costs for initial hospitalization >80% are Medicaid

30 Financial impact

31 Virginia data Infants identified via ICD-9/10 code Number of deliveries to give a crude NAS rate Length of stay (mean/median) 6 hospitals (~15% of VA births) NAS rate of 9.1/1000 deliveries If anybody else is here and wants to submit data: Alan.Picarillo@shcr.com

32 NAS rates (infants/1000 births) National

33 NAS, Length of stay data National VON

34 Can a collaborative project improve NAS care?

35 Massachusetts Neonatal Abstinence Syndrome Improvement Initiative Massachusetts NeoQIC project ( ) All level 2 and 3 NICUs A majority of level 1 nurseries Participation in Vermont-Oxford NAS project

36 Participating Centers Baystate Franklin Cooley Dickinson Berkshire Holyoke Baystate Mercy Holy Family Lawrence General Health Alliance Anna Jaques Lowell General Beverly Heywood North Shore Winchester St. Vincent s Emerson Tufts MGH BWH UMass Melrose-Wakefield Spaulding BIDMC Metrowest St. Elizabeth s Newton-Wellesley BMC Mt. Auburn Harrington Brockton South Shore Milford Good Samaritan Sturdy Plymouth Morton Charlton Cape Cod St. Luke s Falmouth Nantucket

37 Massachusetts experience- VON data audits Over the course of 4 audits: 38 hospitals submitted data 766 infants >15,000 patient days ~30% of total number of infants in VON audit

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43 Where do we go from here?

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45 Participation in Vermont-Oxford NAS statewide implementation package Distribute current evidence-based education and materials to interdisciplinary state collaboratives engaged in caring for substance-exposed infants and families. Leverage NAS Universal Training Model to promote rapid-cycle uptake of potentially better practices and statewide improvement. Improve the quality, safety and value of care for this vulnerable population of infants and families. Explore the potential for your state to achieve the VON State of Excellence in NAS Training and Education by encouraging widespread adoption.

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48 Data audits No PPI, but would recommend that this does get presented to local IRB (no DOB, name, MR#, etc.) Sample letters exist, determination to be QI One pager! ~13 questions (sorry, I couldn t find a blank audit form!)

49 Data audits Questions on: Policies Scoring, non-pharmacologic measures, pharmacologic measures, provision of breastmilk, etc Infant characteristics Length of stay, duration of pharmacological treatment, breastmilk within 24 hours of discharge, types of medications administered, medications at discharge, disposition of infant at discharge

50 Statewide report

51 Statewide report

52 Statewide report

53 Thanks And Questions