Association Among County-Level Economic Factors, Clinician Supply, Metropolitan or Rural Location, and Neonatal Abstinence Syndrome
Association Among County-Level Economic Factors, Clinician Supply, Metropolitan or Rural Location, and Neonatal Abstinence Syndrome
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DOI：
10.1001/jama.2018.20851
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发表时间：
2019-01-29
影响因子：
120.7
通讯作者：
Stein, Bradley D.
中科院分区：
文献类型：
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作者：
Patrick, StephenW.;Faherty, Laura J.;Stein, Bradley D.
重要性新生儿禁欲综合征（NAS）在过去20年中有所增加，但其与经济条件或临床医生供应之间的相关性数据有限。目的确定长期失业、临床医生供应之间的相关性（根据初级保健和精神卫生临床医生短缺地区的评估）和NAS率，并评估相关性如何根据农村而不同。和参与者生态时间序列分析的回顾性，重复横断面研究使用的结果数据来自佛罗里达，肯塔基州，马萨诸塞州，密歇根州，纽约，北卡罗来纳州，田纳西州和华盛顿州的所有580个县2009年至2015年和2000年至2015年的经济数据。负二项模型与年度和县级固定效应一起使用。交互作用进行了测试和分层分析进行了大都市县，农村县毗邻大都市县，农村偏远country.EXPOSURES县级10年失业率和精神卫生和初级保健临床医生的供应从卫生资源和服务管理区卫生资源档案获得。结果样本包括来自580个县7年以上的观察结果（1803个县年来自大都市县，1268个县年来自大都市县附近的农村县，927个县年来自农村偏远县）。在研究期间，有6 302 497名新生儿和47 224名NAS诊断。NAS的中位发生率为每1000名住院分娩7.1例（四分位距[IQR]，2.2-15.8），10年失业率为7.6%（IQR，6.4%-9.0%），83.9%的县年是部分或完全精神卫生短缺地区。在调整后的分析中，精神卫生短缺地区的NAS率较高（短缺地区未调整的发病率为每1000名新生儿14.0例，而非短缺地区未调整的发病率为每1000名新生儿10.6例;校正的发病率比[IRR]，1.17 [95% CI，1.07-1.27]），主要发生在大都市县（调整后的IRR，1.28 [95% CI，1.16-1.40];对于大都市县和与大都市县相邻的农村县之间的等效性检验，P = 0.02）。初级保健短缺地区和NAS率之间没有显着关联。10年失业率与NAS的高发病率相关（未经调整的最高失业率四分位数为每千名新生儿20.1人，而最低失业率四分位数为每千名新生儿7.8人;调整后的IRR，1.11 [95% CI，1.00-1.23]），主要发生在农村偏远县（调整后IRR，1.34 [95% CI，1.05-1.70];大都市县和农村偏远县之间的等效性检验P = .04）。结论和相关性在对美国8个州的县进行的生态分析中，长期失业率较高、心理健康临床医生短缺地区较多和新生儿禁欲综合征县级发病率较高之间存在显著关联。
IMPORTANCE Neonatal abstinence syndrome (NAS) has increased over the last 2 decades, but limited data exist on its association with economic conditions or clinician supply.OBJECTIVE To determine the association among long-term unemployment, clinician supply (as assessed by primary care and mental health clinician shortage areas), and rates of NAS and evaluate how associations differ based on rurality.DESIGN, SETTING, AND PARTICIPANTS Ecological time-series analysis of a retrospective, repeated cross-sectional study using outcome data from all 580 counties in Florida, Kentucky, Massachusetts, Michigan, New York, North Carolina, Tennessee, andWashington from 2009 to 2015 and economic data from 2000 to 2015. Negative binomial models were used with year and county-level fixed effects. Interactions were tested and stratified analyses were conducted by metropolitan counties, rural counties adjacent to metropolitan counties, and rural remote counties.EXPOSURES 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 MEASURE Rates of NAS, excluding iatrogenic withdrawal, obtained from state inpatient databases.RESULTS The sample included 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). During the study period, there were 6 302 497 births and 47 224 diagnoses of NAS. 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). There was no significant association between primary care shortage areas and rates of NAS. The 10-year unemployment rate was associated with 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).CONCLUSIONS AND RELEVANCE In this ecological analysis of counties in 8 US states, there was a significant association among higher long-term unemployment, higher mental health clinician shortage areas, and higher county-level rates of neonatal abstinence syndrome.