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

Abstract Objective To evaluate whether implementing a standardized substance use screening program reduced racial disparities in urine toxicology (Utox) testing among delivery admissions. Methods 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. Results 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). Discussion Implementation of a standardized substance use screening tool was associated with a significant reduction in racial disparities in Utox testing at delivery.