1
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Healy H, Levesque B, Leeman KT, Vaidya R, Whitesel E, Chu S, Goldstein J, Gupta S, Sinha B, Gupta M, Aurora M. Neonatal respiratory care practice among level III and IV NICUs in New England. J Perinatol 2024:10.1038/s41372-024-01926-2. [PMID: 38467745 DOI: 10.1038/s41372-024-01926-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 02/22/2024] [Accepted: 02/28/2024] [Indexed: 03/13/2024]
Abstract
OBJECTIVES To assess respiratory care guidelines and explore variations in management of very low birth weight (VLBW) infants within a collaborative care framework. Additionally, to gather clinical leaders' perspectives on guidelines and preferences for ventilation modalities. STUDY DESIGN Leaders from each NICU participated in a practice survey regarding the prevalence of unit clinical guidelines, and management, at many stages of care. RESULTS Units have an average of 4.3 (±2.1) guidelines, of 9 topics queried. Guideline prevalence was not associated with practice or outcomes. An FiO2 requirement of 0.3-0.4 and a CPAP of 6-7 cmH2O, are the most common thresholds for surfactant administration, which is most often done after intubation, and followed by weaning from ventilatory support. Volume targeted ventilation is commonly used. Extubation criteria vary widely. CONCLUSIONS Results identify trends and areas of variation and suggest that the presence of guidelines alone is not predictive of outcome.
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Affiliation(s)
- Helen Healy
- Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | | | | | | | | | - Sherman Chu
- UMass Memorial Medical Center, Worchester, MA, USA
- Mount Auburn Hospital, Cambridge, MA, USA
| | | | - Shruti Gupta
- Yale New Haven Health-Greenwich Hospital, Greenwich, CT, USA
| | | | - Munish Gupta
- Beth Israel Deaconess Medical Center, Boston, MA, USA
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2
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Whitesel E, Healy H, Mao W, Pursley DM, Zupancic J, Gupta M. Measuring practice preference variation for quality improvement: development of the Neonatology Survey of Interdisciplinary Groups in Healthcare Tool (NSIGHT). BMJ Open Qual 2023; 12:e002422. [PMID: 38101811 PMCID: PMC10729210 DOI: 10.1136/bmjoq-2023-002422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 12/03/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Understanding behavioural psychology and the human side of change are guiding principles for quality improvement (QI). Tools to measure these to guide improvement efforts are lacking. METHODS We created a clinical vignette-based survey to measure provider preferences for respiratory care in the neonatal intensive care unit. Fourteen vignettes were included, each vignette offering two reasonable practice choices. Responses were based on a 5-point Likert scale, ranging from neutral to strong preference for either choice. The survey was completed by physicians, nurses, advanced practice providers and respiratory therapists in 2017 and again in 2019. Net preference was measured as the median value of responses, and agreement was measured as the SD of responses. Net preference and agreement were assessed for all responses, by discipline, and by year. RESULTS Response rates were 51% of all staff in 2017 and 57% in 2019. Vignettes asking about non-invasive respiratory support showed more defined net preferences and higher agreement between years, coinciding with QI efforts and guideline implementation in this area during the interval time. Results on other areas of practice were consistent between years. Discipline comparisons showed nurses and physicians agreed the least often. Six response patterns were identified, ranging from net preference and high agreement to no net preference and low agreement. CONCLUSION We propose this survey, called the Neonatology Survey of Interdisciplinary Groups in Healthcare Tool, is a novel method for measurement of hospital unit psychology and culture. Demonstrated improvement where QI efforts were focused and consistency in results in other areas support the validity of this tool. Measuring the human side of change may impact QI efforts.
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Affiliation(s)
- Emily Whitesel
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Helen Healy
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Wenyang Mao
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - DeWayne M Pursley
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - John Zupancic
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Munish Gupta
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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3
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Goodarzi B, Seijmonsbergen-Schermers A, Cronie D, van Laerhoven H, van den Akker T, van Kaam AH, de Jonge A. (Un)warranted variation in local hospital protocols for neonatal referral to the pediatrician: An explorative study in the Netherlands. Birth 2023; 50:215-233. [PMID: 36373864 DOI: 10.1111/birt.12690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/23/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Studies indicate unwarranted variation in a wide range of neonatal care practices, contributing to preventable morbidity and mortality. Unwarranted variation is the result of complex interactions and multiple determinants. One of the determinants contributing to unwarranted variation in care may be variation in local hospital protocols. The purpose of this study was to examine variation in the content of obstetric and neonatal protocols for six common indications for neonatal referral to the pediatrician: large for gestational age/macrosomia, small for gestational age/fetal growth restriction, meconium-stained amniotic fluid, vacuum extraction, forceps extraction, and cesarean birth. METHODS We conducted a nationwide cross-sectional study examining protocols for neonatal referral to the pediatrician in the obstetric and neonatal departments of all Dutch hospitals. Variation in protocols was analyzed between regions, between neonatal and obstetrics departments located in the same hospital, and within neonatal and obstetrics departments. RESULTS There was considerable variation in protocols between regions, between neonatal and obstetrics departments, and within neonatal and obstetrics departments. The results of this study showed considerable variation in recommendations for type of referral, admission, screening/diagnostic tests, treatment, and discharge. Furthermore, results generally showed lower referral thresholds in neonatal departments compared with obstetric departments, and higher referral thresholds in the eastern region of the Netherlands. We also found variation in local hospital protocols, which could not be explained by population characteristics but which may be explained by varying recommendations in existing national and international guidelines and/or lack of adherence to these guidelines. CONCLUSIONS To reduce unwarranted variation in local protocols, evidence-based, multidisciplinary guidelines should be developed in the Netherlands. Further research addressing knowledge gaps is needed to inform these guidelines. Attention should be paid to the implementation of evidence, and only where evidence is lacking or inconclusive should agreements be based on multidisciplinary consensus. Where protocols deviate from evidence-based guidelines because of specific local circumstances, clearer, more transparent justifications should be made. Uniformity in guidance will offer clear standards for care evaluation and provide opportunities to reduce inappropriate care.
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Affiliation(s)
- Bahareh Goodarzi
- Department of Midwifery Science, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands.,Midwifery Academy Amsterdam Groningen, Amsterdam, The Netherlands.,Amsterdam Public Health, Quality of Care, Amsterdam, The Netherlands.,Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Anna Seijmonsbergen-Schermers
- Department of Midwifery Science, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands.,Midwifery Academy Amsterdam Groningen, Amsterdam, The Netherlands.,Amsterdam Public Health, Quality of Care, Amsterdam, The Netherlands.,Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Doug Cronie
- Rotterdam University of Applied Sciences, Institute of Healthcare, Rotterdam, The Netherlands
| | | | - Thomas van den Akker
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands.,Athena Institute, VU University, Amsterdam, The Netherlands.,Department of neonatology, Emma Children's Hospital, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Anton H van Kaam
- Department of neonatology, Emma Children's Hospital, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands.,Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Ank de Jonge
- Department of Midwifery Science, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands.,Midwifery Academy Amsterdam Groningen, Amsterdam, The Netherlands.,Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.,Amsterdam Reproduction and Development, Amsterdam, The Netherlands
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4
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Payton KSE, Gould JB. Vignette Research Methodology: An Essential Tool for Quality Improvement Collaboratives. Healthcare (Basel) 2022; 11:healthcare11010007. [PMID: 36611468 PMCID: PMC9818599 DOI: 10.3390/healthcare11010007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/11/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
Variation in patient outcomes among institutions and within institutions is a major problem in healthcare. Some of this variation is due to differences in practice, termed practice variation. Some practice variation is expected due to appropriately personalized care for a given patient. However, some practice variation is due to the individual preference or style of the clinicians. Quality improvement collaboratives are commonly used to disseminate quality care on a wide scale. Practice variation is a notable barrier to any quality improvement effort. A detailed and accurate understanding of practice variation can help optimize the quality improvement efforts. The traditional survey methods do not capture the complex nuances of practice variation. Vignette methods have been shown to accurately measure the actual practice variation and quality of care delivered by clinicians. Vignette methods are cost-effective relative to other methods of measuring quality of care. This review describes our experience and lessons from implementing vignette research methods in quality improvement collaboratives in California neonatal intensive care units. Vignette methodology is an ideal tool to address practice variation in quality improvement collaboratives, actively engage a large number of participants, and support more evidence-based practice to improve outcomes.
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Affiliation(s)
- Kurlen S. E. Payton
- Cedars-Sinai Medical Center, Department of Pediatrics, Division of Neonatology, Los Angeles, CA 90048, USA
- California Perinatal Quality Care Collaborative, Stanford, CA 94305, USA
- Correspondence:
| | - Jeffrey B. Gould
- California Perinatal Quality Care Collaborative, Stanford, CA 94305, USA
- Department of Pediatrics, Division of Neonatology, Stanford University, Stanford, CA 94305, USA
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5
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Travers CP, Gentle S, Freeman AE, Nichols K, Shukla VV, Purvis D, Dolma K, Winter L, Ambalavanan N, Carlo WA, Lal CV. A Quality Improvement Bundle to Improve Outcomes in Extremely Preterm Infants in the First Week. Pediatrics 2022; 149:184566. [PMID: 35088085 PMCID: PMC9677934 DOI: 10.1542/peds.2020-037341] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2021] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVES Our objective with this quality improvement initiative was to reduce rates of severe intracranial hemorrhage (ICH) or death in the first week after birth among extremely preterm infants. METHODS The quality improvement initiative was conducted from April 2014 to September 2020 at the University of Alabama at Birmingham's NICU. All actively treated inborn extremely preterm infants without congenital anomalies from 22 + 0/7 to 27 + 6/7 weeks' gestation with a birth weight ≥400 g were included. The primary outcome was severe ICH or death in the first 7 days after birth. Balancing measures included rates of acute kidney injury and spontaneous intestinal perforation. Outcome and process measure data were analyzed by using p-charts. RESULTS We studied 820 infants with a mean gestational age of 25 + 3/7 weeks and median birth weight of 744 g. The rate of severe ICH or death in the first week after birth decreased from the baseline rate of 27.4% to 15.0%. The rate of severe ICH decreased from a baseline rate of 16.4% to 10.0%. Special cause variation in the rate of severe ICH or death in the first week after birth was observed corresponding with improvement in carbon dioxide and pH targeting, compliance with delayed cord clamping, and expanded use of indomethacin prophylaxis. CONCLUSIONS Implementation of a bundle of evidence-based potentially better practices by using specific electronic order sets was associated with a lower rate of severe ICH or death in the first week among extremely preterm infants.
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Affiliation(s)
- Colm P. Travers
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Samuel Gentle
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Amelia E. Freeman
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kim Nichols
- University of Alabama at Birmingham Hospital, Birmingham, Alabama
| | - Vivek V. Shukla
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Donna Purvis
- University of Alabama at Birmingham Hospital, Birmingham, Alabama
| | - Kalsang Dolma
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama,Division of Neonatology, Department of Pediatrics, College of Medicine, University of South Alabama, Mobile, Alabama
| | - Lindy Winter
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Namasivayam Ambalavanan
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Waldemar A. Carlo
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Charitharth V. Lal
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama,Address correspondence to Charitharth V. Lal, MD, Division of Neonatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, 1700 6th Ave South, Birmingham, AL 35249. E-mail:
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6
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Payton KSE, Wirtschafter D, Bennett MV, Benitz WE, Lee HC, Kristensen-Cabrera A, C Nisbet C, Gould J, Parker C, Sharek PJ. Vignettes Identify Variation in Antibiotic Use for Suspected Early Onset Sepsis. Hosp Pediatr 2021; 11:770-774. [PMID: 34083354 DOI: 10.1542/hpeds.2020-000448] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES There is widespread unwarranted antibiotic use and large individual provider variation in antibiotic use in NICUs. Vignette-based research methodology offers a unique method of studying variation in individual provider decisions. The objective with this study was to use a vignette-based survey to identify specific areas of provider antibiotic use variation in newborns being evaluated for early onset sepsis. METHODS This study was undertaken as part of a statewide multicenter neonatal antibiotic stewardship quality improvement project led by a perinatal quality improvement collaborative. A web-based vignette survey was administered to identify variation in decisions to start and discontinue antibiotics in cases of early onset sepsis. RESULTS The largest variation was noted in 3 of the 6 vignette cases. These cases highlighted variation in (1) decisions to start antibiotics in a case describing a well-appearing newborn with risk factors and an elevated C-reactive protein, (2) decisions to start antibiotics in the case of a newborn with risk factors plus mild respiratory signs at birth, and (3) decisions to stop antibiotics in the case of the newborn with a history of sepsis risk factors and mild clinical respiratory signs that resolved after 72 hours. CONCLUSIONS Clinical vignette assessment identified specific areas of variation in individual provider antibiotic use decisions in cases of suspected early onset sepsis. Vignettes are a valuable method of describing individual provider variation and highlighting antibiotic stewardship improvement opportunities in NICUs.
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Affiliation(s)
- Kurlen S E Payton
- Division of Neonatology, Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, California; .,California Perinatal Quality Care, Collaborative, Stanford, California
| | - David Wirtschafter
- Perinatal Quality Improvement Panel Research Committee, Stanford, California
| | - Mihoko V Bennett
- California Perinatal Quality Care, Collaborative, Stanford, California.,Divisions of Neonatology and
| | | | - Henry C Lee
- California Perinatal Quality Care, Collaborative, Stanford, California.,Divisions of Neonatology and
| | | | - Courtney C Nisbet
- California Perinatal Quality Care, Collaborative, Stanford, California
| | - Jeffrey Gould
- California Perinatal Quality Care, Collaborative, Stanford, California.,Divisions of Neonatology and
| | - Colin Parker
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles California; and
| | - Paul J Sharek
- California Perinatal Quality Care, Collaborative, Stanford, California.,Hospitalist Medicine, Department of Pediatrics, School of Medicine, Stanford University, Stanford California.,Division of General Pediatrics and Hospital Medicine, Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
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7
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Mitra S, Dorling J, Johnston BC. Optimizing practice guidelines through incorporating patient and family values and preferences. Semin Fetal Neonatal Med 2021; 26:101194. [PMID: 33504465 DOI: 10.1016/j.siny.2021.101194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Neonatal care largely follows clinical practice guidelines and position statements developed locally by respective institutions as well as by national and international organizations. One might expect that adoption of clinical guidelines based on best available research evidence would make neonatal care practices mostly uniform. However, wide variation in clinical practice is still noted in neonatal care. Neonatal clinical guidelines are developed almost exclusively by healthcare professionals, with little or no input from families of the infants being cared for. Therefore, such variation in practice may stem not only from how the evidence is interpreted but also how caregivers and families value different outcomes that are affected by particular interventions. Acknowledging and incorporating the variability in patient and family values and preferences in clinical guidelines is an important step towards allowing shared decision making while reducing unwarranted practice variation, and thereby helping clinicians practice family-centered evidence-based medicine.
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Affiliation(s)
- Souvik Mitra
- Departments of Pediatrics, Community Health & Epidemiology, Dalhousie University & IWK Health Centre, Halifax, Canada.
| | - Jon Dorling
- Departments of Pediatrics, Community Health & Epidemiology, Dalhousie University & IWK Health Centre, Halifax, Canada.
| | - Bradley C Johnston
- Department of Nutrition, Texas A&M University, College Station, TX, USA.
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8
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Bansler JP. Challenges in user-driven optimization of EHR: A case study of a large Epic implementation in Denmark. Int J Med Inform 2021; 148:104394. [PMID: 33485217 DOI: 10.1016/j.ijmedinf.2021.104394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 01/07/2021] [Accepted: 01/10/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Research suggests that capturing the benefits of electronic health records (EHR) requires systematic and ongoing optimization of technology configuration and use after implementation. However, little is known about EHR optimization in a hospital context. OBJECTIVE To explore the issues and challenges involved in organizing and managing a systematic user-driven EHR optimization program. METHODS A longitudinal case study of an EHR optimization program launched in two large Danish hospital systems was undertaken. It involved interviewing 28 key managers, clinicians and IT staff, participating in formal and informal meetings, and reviewing policy documents, meeting minutes, teaching materials and other relevant documents. FINDINGS The two hospital systems are struggling to find the best way to organize and manage the optimization program. So far, the program has been a mixed success. Involving clinicians in EHR optimization poses serious dilemmas for hospital managers, who must manage two related tensions: between standardization and adaptation, and between centralized control and local autonomy. CONCLUSION The findings highlight the significant challenges in designing a successful EHR optimization program and underscore the importance of developing more sophisticated strategies for clinical standardization and innovation.
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Affiliation(s)
- Jørgen P Bansler
- University of Copenhagen, Universitetsparken 1, 2100, Copenhagen, Denmark.
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9
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King BC, Richardson T, Patel RM, Lee HC, Bamat NA, Hall M, Slaughter JL. Prioritization framework for improving the value of care for very low birth weight and very preterm infants. J Perinatol 2021; 41:2463-2473. [PMID: 34075201 PMCID: PMC8514333 DOI: 10.1038/s41372-021-01114-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/10/2021] [Accepted: 05/18/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Create a prioritization framework for value-based improvement in neonatal care. STUDY DESIGN A retrospective cohort study of very low birth weight (<1500 g) and/or very preterm (<32 weeks) infants discharged between 2012 and 2019 using the Pediatric Health Information System Database. Resource use was compared across hospitals and adjusted for patient-level differences. A prioritization score was created combining cost, patient exposure, and inter-hospital variability to rank resource categories. RESULTS Resource categories with the greatest cost, patient exposure, and inter-hospital variability were parenteral nutrition, hematology (lab testing), and anticoagulation (for central venous access and therapy), respectively. Based on our prioritization score, parenteral nutrition was identified as the highest priority overall. CONCLUSIONS We report the development of a prioritization score for potential value-based improvement in neonatal care. Our findings suggest that parenteral nutrition, central venous access, and high-volume laboratory and imaging modalities should be priorities for future comparative effectiveness and quality improvement efforts.
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Affiliation(s)
- Brian C. King
- grid.416975.80000 0001 2200 2638Department of Pediatrics, Section of Neonatology, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX USA
| | - Troy Richardson
- grid.429588.aChildren’s Hospital Association, Lenexa, KS USA
| | - Ravi M. Patel
- grid.189967.80000 0001 0941 6502Division of Neonatology, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, GA USA
| | - Henry C. Lee
- grid.168010.e0000000419368956Division of Neonatology, Stanford University, Stanford, CA USA
| | - Nicolas A. Bamat
- grid.239552.a0000 0001 0680 8770Division of Neonatology, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA USA
| | - Matthew Hall
- grid.429588.aChildren’s Hospital Association, Lenexa, KS USA
| | - Jonathan L. Slaughter
- grid.240344.50000 0004 0392 3476Division of Neonatology, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH USA
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10
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Gowda S, Patil M. Factors associated with development of early and late pulmonary hypertension in preterm infants with bronchopulmonary dysplasia. Acta Paediatr 2020; 109:2420-2421. [PMID: 32638433 DOI: 10.1111/apa.15418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Sharada Gowda
- Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Monika Patil
- Pediatrics, Baylor College of Medicine, Houston, TX, USA
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11
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Boel L, Banerjee S, Clark M, Greenwood A, Sharma A, Goel N, Bagga G, Poon C, Odd D, Chakraborty M. Temporal trends of care practices, morbidity, and mortality of extremely preterm infants over 10-years in South Wales, UK. Sci Rep 2020; 10:18738. [PMID: 33127999 PMCID: PMC7603316 DOI: 10.1038/s41598-020-75749-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 10/19/2020] [Indexed: 12/21/2022] Open
Abstract
Contemporary outcome data of preterm infants are essential to commission, evaluate and improve healthcare resources and outcomes while also assisting professionals and families in counselling and decision making. We analysed trends in clinical practice, morbidity, and mortality of extremely preterm infants over 10 years in South Wales, UK. This population-based study included live born infants < 28 weeks of gestation in tertiary neonatal units between 01/01/2007 and 31/12/2016. Patient characteristics, clinical practices, mortality, and morbidity were studied until death or discharge home. Temporal trends were examined by adjusted multivariable logistic regression models and expressed as adjusted odds ratios (aOR) with 95% confidence intervals (95% CI). A sensitivity analysis was conducted after excluding infants born at < 24 weeks of gestation. In this population, overall mortality for infants after live birth was 28.2% (267/948). The odds of mortality (aOR 0.93, 95% CI [0.88, 0.99]) and admission to the neonatal unit (0.93 [0.87, 0.98]) significantly decreased over time. Non-invasive ventilation support during stabilisation at birth increased significantly (1.26 [1.15, 1.38]) with corresponding decrease in mechanical ventilation at birth (0.89 [0.81, 0.97]) and following admission (0.80 [0.68–0.96]). Medical treatment for patent ductus arteriosus significantly decreased over the study period (0.90 [0.85, 0.96]). The incidence of major neonatal morbidities remained stable, except for a reduction in late-onset sepsis (0.94 [0.89, 0.99]). Gestation and centre of birth were significant independent factors for several outcomes. The results from our sensitivity analysis were compatible with our main results with the notable exception of death after admission to NICU (0.95 [0.89, 1.01]). There were significant improvements in survival and reduction of late-onset sepsis of extreme preterm infants in South Wales between 2007 and 2016. The sensitivity analysis suggests that some of the temporal changes observed were driven by improved outcomes in the most preterm of infants. Clinical practices related to respiratory support have changed but significant variations in clinical practices and outcomes between centres remain unexplained. The adoption of regional evidence-based clinical guidelines is likely to improve outcomes and reduce variation.
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Affiliation(s)
- Lieve Boel
- Regional Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff, CF14 4XW, UK
| | - Sujoy Banerjee
- Neonatal Intensive Care Unit, Singleton Hospital, Swansea, UK
| | - Megan Clark
- School of Medicine, Cardiff University, Cardiff, UK
| | - Annabel Greenwood
- Regional Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff, CF14 4XW, UK
| | - Alok Sharma
- Regional Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff, CF14 4XW, UK
| | - Nitin Goel
- Regional Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff, CF14 4XW, UK
| | - Gautam Bagga
- Neonatal Intensive Care Unit, Royal Gwent Hospital, Newport, UK
| | - Chuen Poon
- Neonatal Intensive Care Unit, Royal Gwent Hospital, Newport, UK
| | - David Odd
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Mallinath Chakraborty
- Regional Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff, CF14 4XW, UK. .,Centre for Medical Education, School of Medicine, Cardiff University, Cardiff, UK.
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12
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Kaplan HC, Kuhnell P, Walsh MC, Crowley M, McClead R, Wexelblatt S, Ford S, Provost LP, Lannon C, Macaluso M. Orchestrated Testing of Formula Type to Reduce Length of Stay in Neonatal Abstinence Syndrome. Pediatrics 2020; 146:peds.2019-0914. [PMID: 32913133 DOI: 10.1542/peds.2019-0914] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Despite the standardization of care, formula feeding varied across sites of the Ohio Perinatal Quality Collaborative (OPQC). We used orchestrated testing (OT) to learn from this variation and improve nonpharmacologic care of infants with neonatal abstinence syndrome (NAS) requiring pharmacologic treatment in Ohio. METHODS To test the impact of formula on length of stay (LOS), treatment failure, and weight loss among infants hospitalized with NAS, we compared caloric content (high versus standard) and lactose content (low versus standard) using a 22 factorial design. During October 2015 to June 2016, OPQC sites joined 1 of 4 OT groups. We used response plots to examine the effect of each factor and control charts to track formula use and LOS. We used the OT results to revise the nonpharmacologic bundle and implemented it during 2017. RESULTS Forty-seven sites caring for 546 NAS infants self-selected into the 4 OT groups. Response plots revealed the benefit of high-calorie formula (HCF) on weight loss, treatment failure, and LOS. The nonpharmacologic treatment bundle was updated to recommend HCF when breastfeeding was not possible. During implementation, HCF use increased, and LOS decreased from 17.1 to 16.4 days across the OPQC. CONCLUSIONS OT revealed that HCF was associated with shorter LOS in OPQC sites. Implementation of a revised nonpharmacologic care bundle was followed by additional LOS improvement in Ohio. Despite some challenges in the implementation of OT, our findings support its usefulness for learning in improvement networks.
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Affiliation(s)
- Heather C Kaplan
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; .,Perinatal Institute.,James M. Anderson Center for Health Systems Excellence, and
| | - Pierce Kuhnell
- Division of Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michele C Walsh
- Division of Neonatology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio.,Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | - Moira Crowley
- Division of Neonatology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio.,Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | - Richard McClead
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio; and
| | - Scott Wexelblatt
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Perinatal Institute
| | - Susan Ford
- Division of Neonatology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | | | - Carole Lannon
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,James M. Anderson Center for Health Systems Excellence, and
| | - Maurizio Macaluso
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Division of Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Variability in the systems of care supporting critical neonatal intensive care unit transitions. J Perinatol 2020; 40:1546-1553. [PMID: 32665688 PMCID: PMC7359434 DOI: 10.1038/s41372-020-0720-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 06/02/2020] [Accepted: 07/07/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Assess practices supporting care transitions for infants and families in the neonatal intensive care unit (NICU) using a model of four key drivers: communication, teamwork, family integration, and standardization. STUDY DESIGN Single-day audit among NICUs in the Vermont Oxford Network Critical Transitions collaborative addressing policies and practices supporting the four key drivers during admission, discharge, shift-to-shift handoffs, within hospital transfers, and select changes in clinical status. RESULTS Among 95 NICUs, the median hospital rate of audited policies in place addressing the four key drivers were 47% (inter-quartile range (IQR) 35-65%) for communication, 67% (IQR 33-83%) for teamwork, 50% (IQR 33-61%) for family integration, and 70% (IQR 56-85%) for standardization. Of the 2462 infants included, 1066 (43%) experienced ≥1 specified transition during the week prior to the audit. CONCLUSIONS We identified opportunities for improving NICU transitions in areas of communication, teamwork, family integration, and standardization.
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Suresh G, King B, Jain SK. Response to Letter to Editor re: "Screening for pulmonary hypertension in preterm infants-not ready for prime time". J Perinatol 2018; 38:1711-1713. [PMID: 30097653 DOI: 10.1038/s41372-018-0194-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 07/26/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Gautham Suresh
- Department of Pediatrics, Baylor College of Medicine, Section Head and Service Chief of Neonatology, Texas Children's Hospital, 6621 Fannin, Suite W6104, Houston, TX, 77030, USA
| | - Brian King
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin, Suite W6104, Houston, TX, 77030, USA
| | - Sunil K Jain
- Department of Pediatrics, University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA.
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Reuter JM, Hutyra CA, Politzer CS, Calixte CC, Scott DJ, Attarian DE, Mather RC. Characterizing Patient Preferences Surrounding Total Knee Arthroplasty. JB JS Open Access 2018; 3:e0017. [PMID: 30882052 PMCID: PMC6400515 DOI: 10.2106/jbjs.oa.18.00017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: Episode-based bundled payments for total knee arthroplasty emphasize cost-effective patient-centered care. Understanding patients’ perceptions of components of the total knee arthroplasty care episode is critical to achieving this care. This study investigated patient preferences for components of the total knee arthroplasty care episode. Methods: Best-worst scaling was used to analyze patient preferences for components of the total knee arthroplasty care episode. Participants were selected from patients presenting to 2 orthopaedic clinics with chronic knee pain. They were presented with descriptions of 17 attributes before completing a best-worst scaling exercise. Attribute importance was determined using hierarchical Bayesian estimation. Latent class analysis was used to evaluate varying preference profiles. Results: One hundred and seventy-four patients completed the survey, and 117 patients (67%) were female. The mean age was 62.71 years. Participants placed the highest value on surgeon factors, including level of experience, satisfaction rating, and complication rates. Latent class analysis provided a 4-segment model of the population. Conclusions: This study demonstrated differences in patient preferences for the components of a total knee arthroplasty care episode and characterized distinct preference profiles among patient subsets. Stakeholders can use this information to focus efforts and policy on high-value components and to potentially create customized bundles guided by preference profiles. Clinical Relevance: This study is clinically relevant because the patient preferences identified here may help providers to design customized bundles for total knee arthroplasty care.
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Affiliation(s)
- John M Reuter
- University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Carolyn A Hutyra
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Cary S Politzer
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Christopher C Calixte
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Daniel J Scott
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - David E Attarian
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Richard C Mather
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina
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