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Original Investigation
January 29, 2019

Association Among County-Level Economic Factors, Clinician Supply, Metropolitan or Rural Location, and Neonatal Abstinence Syndrome

Author Affiliations
  • 1Department of Pediatrics, Vanderbilt University, Nashville, Tennessee
  • 2Mildred Stahlman Division of Neonatology, Vanderbilt University, Nashville, Tennessee
  • 3Vanderbilt Center for Child Health Policy, Nashville, Tennessee
  • 4Department of Health Policy, Vanderbilt University, Nashville, Tennessee
  • 5RAND Corporation, Pittsburgh, Pennsylvania
  • 6RAND Corporation, Boston, Massachusetts
  • 7School of Medicine, Boston University, Boston, Massachusetts
  • 8School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
JAMA. 2019;321(4):385-393. doi:10.1001/jama.2018.20851
Key Points

Question  What is the association among a county’s economy, clinician supply, and neonatal abstinence syndrome?

Findings  In this retrospective repeated cross-sectional study that included 580 US counties and 6 302 497 births, there was a significant association with county-level rates of neonatal abstinence syndrome and county 10-year unemployment rate (adjusted incidence rate ratio, 1.11) and designation as a mental health clinician shortage area (adjusted incidence rate ratio, 1.17).

Meaning  Long-term unemployment and shortage of mental health clinicians were associated with higher rates of neonatal abstinence syndrome on a county level.


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, and Washington 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.