Unintended Consequences of A Quality Improvement Initiative on Racial Inequity in Newborn Drug Testing

Prenatal substance exposure is associated with harm to newborns and their families. Clinicians must report in utero controlled substance exposure to Child Protective Services (CPS). Studies have found that clinicians disproportionately order toxicology tests for Black infants, particularly in the absence of standardized policies for drug testing, which may lead to disproportionate downstream harm for Black families. The aim of this single-center quality improvement (QI) study is to eliminate racial inequity in drug testing for potentially substance-exposed newborns.

The QI team identified lack of standardized policy and clinician education as key drivers and implemented a QI change from December 2022 to July 2024, which included a policy to standardize indications for meconium drug testing linked to an order set and QI dashboard. Descriptive statistics regarding testing rates and indications for testing stratified by race and ethnicity were performed before and after QI interventions.

A total of 10 637 individuals were included in the study population. The rate of testing increased from 5.2% pre-policy to 9.9% post-policy for Black newborns (relative risk [RR] 1.89, 95% CI: 1.27-2.81, P = .002). The rate of testing for white newborns was stable (3.2% to 3.7%, RR 1.14, 95% CI: 0.90-1.45, P = .27). Reasons for testing varied by race; being late to prenatal care accounted for 19.4% of all tests performed for Black newborns compared with 7.1% of all tests for white newborns. Testing for isolated marijuana use increased from 4.5% to 7.2% for Black newborns and remained stable, from 2.6% for 2.7%, for white newborns.

Implementing a standardized policy and order set widened the inequity between Black and white newborns and increased testing rates for all newborns. Ongoing QI efforts include reevaluation of our approach to postnatal drug testing for prenatal cannabis exposure.