TABLE 2. Advantages and challenges of surveillance features reported by health officials among states with mandated reporting of neonatal abstinence syndrome (NAS) — six states, 2013–2017.

Surveillance feature reported in 28-item questionnaire	States endorsing surveillance feature in questionnaire	Advantages (+) and challenges (-) reported by health officials in open-text fields in questionnaire and during semistructured interviews
Criteria for reporting NAS
Clinical diagnoses by medical provider*	AZ, FL, GA, KY, TN, VA	– Requires additional review to identify duplicate NAS cases (i.e., if infant is treated at multiple facilities or at delivery and at another encounter postdischarge)
		– Providers might look to state health departments for a case definition
		– Will not identify asymptomatic infants with prenatal substance exposure
		– Transition from International Classification of Diseases Clinical Modification (ICD)-9 to ICD-10 codes might affect the number and trends of cases identified in administrative data sets and require additional educational resources
Positive toxicology result for infant	GA†	+ Toxicology results allow state to determine whether substance exposure was from a prescribed medication or an illicit substance§
Data elements collected in case reports
Maternal demographics	FL, GA, KY, TN	+ Allows for characterizations of populations at higher risk and areas of higher risk
Infant demographics	AZ, FL, GA, KY, TN, VA	+ Opportunity to identify patterns in specific geographic areas
Maternal source of exposure(s)	AZ, GA, KY, TN, VA	+ Can identify prenatal exposures
		+ Allows for comparison between clinical symptoms of withdrawal and substance exposure in the absence of clinical symptoms of withdrawal
		+ Provides information on polysubstance exposures
Heath care service utilization by infant	GA	+ Ability to estimate costs associated with treatment
		+ Can capture characteristics of treatment (e.g., length of stay)
Other	AZ, GA, KY, TN	+ Some variables (e.g., medical record number) allows for linkage with other data sources
Clinical signs and symptoms
Substances for which mother/infant tested positive
Maternal use of medication-assisted treatment
Maternal history of substance misuse
Reporting system
State had an existing notifiable disease surveillance system	AZ, GA, VA	+ Existing in-house system allows for more rapid changes to reporting system to be implemented
		+ More timely reporting
		– Obstetric and neonatal providers might not be familiar with case reporting because many notifiable conditions are for infectious diseases
State has hospital discharge data linked to vital records	FL	+ Ability to link to other vital records and public health surveillance systems
		+ Feasible in the absence of funding resources
		– Coding errors
		– Might not capture infants delivered or treated outside of a hospital setting
		– Does not consistently capture specific substance exposures
		– Duplications in reported cases if infant is transferred
		– Deidentified data does not allow for referrals to services
State has NAS-specific reporting system	KY, TN, VA	+ Might allow for online case reporting
		+ Case report form can be easily modified
		+ Reduces need for additional resources required by paper-based system (e.g., data entry)
		– Online reporting system might require system maintenance
Data quality
Data completeness	FL, GA, KY	+ Required reporting elements can reduce number of missing values
		– Delays in laboratory reports can lead to missing toxicology data
		– Lack of clinical case definition can lead to differences in variables reported by provider
Required resources
Educating providers/hospitals about reporting requirements	GA, KY, TN, VA	– Added responsibility for medical provider and hospital staff members
Collecting missing data	AZ, GA	– Requires fiscal and human resources to collect missing data and to train staff members to input data and review records
Other	FL, KY	– Requires fiscal and human resources
Data cleaning
Data reporting
Data utilization
Identification of women with substance use disorder	AZ	+ Opportunity to link women to treatment
Identification of mothers with multiple pregnancies affected by opioid exposure	FL	+ Opportunity for prevention of future NAS cases
Shared with other state and local agencies	GA, FL, KY, TN	+ Informs community assessments, planning, and program development
		+ Opportunity to evaluate the incidence of NAS within the state
		+ Informs interventions
Public reporting (as of March 2018)	AZ, GA, KY, TN	+ Opportunity to inform partners
Barriers to case reporting
Limited awareness of mandate	GA	– Underreporting from providers might underestimate incidence of NAS
Limitations at the hospital/provider level	AZ, GA, KY, TN, VA	– Hospital staff member turnover can create reporting gaps/underreporting
		– Training new staff members in reporting process
		– Providers might have limited knowledge of reporting criteria
		– Complexity of reporting form

Abbreviations: AZ = Arizona; FL = Florida; GA = Georgia; KY = Kentucky; TN = Tennessee; VA = Virginia.

* During interviews the benefits of having a clinical diagnosis by a medical provider as part of the case definition were not specifically discussed.

^† In Georgia, infants with a clinical diagnosis of NAS or a positive toxicology result should be reported to the state health department.

^§ Toxicology results do not provide information on whether a prescribed substance was used as prescribed or diverted.