Impact of a substance use screening program on racial disparities in urine toxicology testing

To evaluate whether implementing a standardized substance use screening program reduced racial disparities in urine toxicology (Utox) testing among delivery admissions.

We conducted a retrospective cohort study of delivery admissions at a single academic center from June 2019 to June 2025. To address known disparities in Utox testing, a standardized iPad-based screening tool using a modified 4Ps screen was implemented February-May 2023. Screening responses triggered protocolized Utox testing based on a predefined algorithm. Clinical and demographic predictors of Utox testing were compared pre- and post-implementation using chi-square and t-tests. Logistic regression with predictor × era interaction terms assessed changes in associations with testing; final models were adjusted for age, race/ethnicity, parity, and insurance.

Among 36,656 admissions, 216 (0.59%) underwent Utox testing: 181 (0.80%) pre-implementation and 32 (0.26%) post-implementation. Pre-implementation, Black patients accounted for 26.8% of tests but only 7.0% of the population. Post-implementation, Black patients represented only 6.3% of tests and 6.5% of the population. The testing rate for Black patients declined from 3.2% to 0.5% (p  <  0.001). In unadjusted models, testing for effect modification by implementation period, race (p = 0.02 for Black vs. White; interaction odds ratio [OR], 0.17; 95% confidence interval [CI], 0.05-0.66), and age (p = 0.001; interaction OR 1.14; 95% CI, 1.06-1.23) showed significant interactions. In adjusted models, the disparity in testing by race significantly decreased post-implementation (interaction adjusted OR [aOR] for Black vs. White 0.17; 95% CI 0.05-0.66; p = 0.01). Among those tested, positive Utox screens did not differ significantly by period (43.2% pre-implementation vs. 56.3% post-implementation, p  =  0.11).

Implementation of a standardized substance use screening tool was associated with a significant reduction in racial disparities in Utox testing at delivery.