Standardized, patient-completed screening for substance use at delivery admissions reduced racial disparities in urine toxicology testing while improving testing efficiency, according a study from Mariam Naqvi, MD, and colleagues.
A standardized, patient-completed screening protocol for substance use at delivery admissions was associated with a marked reduction in racial disparities in urine toxicology (Utox) testing, according to findings from a large retrospective cohort study conducted at a single academic center.1
The study, which evaluated 36,656 delivery admissions between June 2019 and June 2025, examined changes in Utox testing patterns before and after implementation of a standardized screening tool designed to replace clinician discretion with protocol-based testing criteria.
“At our institution, what we learned from some of the previous work that we did was that urine toxicology testing on labor and delivery was being sent pretty much by clinical discretion,” said Mariam Naqvi, MD, associate professor of obstetrics and gynecology at Cedars-Sinai Medical Center in Los Angeles, California. “Physicians were sort of deciding arbitrarily, this patient may need a urine tox screen, and this patient may not.”
According to Naqvi, testing decisions were often based on subjective clinical impressions, such as perceived risk based on prenatal care patterns or historical factors. Because positive drug screens can carry significant downstream consequences, the team sought a more systematic approach.
“Because we know there's such adverse downstream consequences to having positive urine tox screens, we wanted to find a way to sort of systemically be able to screen,” she said.
Between February and May 2023, the institution implemented a standardized protocol centered on an iPad-based screening tool using a modified 4Ps questionnaire. Patients completed the screening during admission, with responses automatically integrated into the electronic medical record. Predefined criteria then triggered Utox testing according to an algorithm grounded in evidence-based risk factors.
“Most importantly, we based that criteria on evidence and on what we know are true reasons why a patient might be at risk of having a positive screen,” Naqvi said. “That way, we're sort of avoiding some of these traps of testing the same populations over and over again based on their demographics or their race.”
Overall Utox testing rates declined substantially after implementation. Of 36,656 delivery admissions, 216 patients (0.59%) underwent testing: 181 patients (0.80%) before implementation and 32 patients (0.26%) afterward.
Prior to the protocol, Black patients accounted for 26.8% of Utox tests despite representing only 7.0% of the population. After implementation, Black patients represented 6.3% of tests and 6.5% of the population. The testing rate among Black patients fell from 3.2% to 0.5% (P < 0.001).
Adjusted logistic regression analysis confirmed a significant reduction in racial disparity after implementation (interaction adjusted OR for Black vs White patients, 0.17; 95% CI, 0.05–0.66; P = 0.01).
Investigators also observed that fewer tests did not reduce the proportion of positive results. Positive Utox screens occurred in 43.2% of tests before implementation and 56.3% after (P = 0.11).
One key protocol change may explain this finding: marijuana was removed from the screening panel.
“In the preimplementation period, if you look at all the positive urine tox tests, the most commonly reported substance was marijuana,” Naqvi said. “After a lot of coming together and thinking about this issue, we decided to remove it completely.”
The stable positivity rate despite fewer tests suggests improved testing efficiency, she added. “Now, we're actually picking up substances that may change clinical management and may affect neonatal management.”
Although the study did not evaluate downstream outcomes such as social work referrals or neonatal testing, Naqvi noted these remain important areas for future research.
“We found that after we implemented this, fewer people were being tested,” she said. “So it wouldn't be inconceivable to think that referrals to social work and child protective services probably went down.”
She emphasized that although standardized screening can reduce inequities in clinical testing, broader systemic disparities may still persist beyond the hospital setting.
Reference:
1. Naqvi M, Tavakoli A, Thrift CS, et al. Impact of a substance use screening program on racial disparities in urine toxicology testing. Pregnancy. 2026;2(2):e70247. doi:10.1002/pmf2.70247
