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Salazar EG, Passarella M, Formanowski B, Rogowski J, Edwards E, Phibbs C, Lorch SA. The Association of NICU Strain with Neonatal Mortality and Morbidity. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.07.07.24310050. [PMID: 39040203 PMCID: PMC11261945 DOI: 10.1101/2024.07.07.24310050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Abstract
Objective To examine the association of admission NICU strain with neonatal mortality and morbidity. Study Design 2008-2021 South Carolina cohort using linked vital statistics and discharge data of 22-44 weeks GA infants, born at hospitals with ≥ level 2 unit and ≥5 births of infants <34 weeks GA/year. The exposure was tertiles of admission NICU strain, defined as the sum of infants <44 weeks GA with a congenital anomaly plus all infants born <33 weeks GA at midnight on the day of birth. We used Poisson generalized linear mixed models to examine the association of exposure to strain with the primary outcome of a composite of mortality and term and preterm morbidities adjusting for patient and hospital characteristics. Results We studied 64,647 infants from 30 hospitals. High strain was associated with increased risk of mortality and morbidity adjusting for patient/hospital factors (aIRR 1.07, 95% CI 1.01 - 1.12). Conclusion NICU strain is associated with increased adverse outcomes.
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Ahmed S, Vereen RJ, Aden JK, Dillon CA, Shapiro JB. Maternal and Neonatal Outcomes of Adolescent Pregnancies in the Military Health System. Mil Med 2024; 189:e854-e863. [PMID: 37856694 DOI: 10.1093/milmed/usad397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/22/2023] [Accepted: 09/25/2023] [Indexed: 10/21/2023] Open
Abstract
OBJECTIVE To determine if universal access to care for military beneficiaries improves timing of presentation to prenatal care (PNC) in adolescent and young adult (AYA) pregnancies, improving maternal and neonatal outcomes. STUDY DESIGN Retrospective descriptive cohort study, which assessed PNC initiation in eligible military beneficiaries: dependent daughters, active-duty women, and active-duty spouses aged 13 to 26 between January 2015 and December 2019, and subsequent adverse maternal and neonatal outcomes. RESULTS The cohort included 4,557 eligible pregnancies and 4,044 mothers aged 13 to 26. Late entry to PNC was not associated with gestational diabetes, prolonged rupture of membranes, pregnancy loss, elective abortion, substance use, or premature labor. Younger age was significantly associated with substance use, elective abortion, and sexually transmitted infection. There were 2,107 eligible newborns. There was no significant difference in gestational age at birth, incidence of prematurity, birthweight percentile, or occurrence of a neonatal intensive care unit admission based on maternal age. In comparison to published national outcomes, there was a significantly smaller occurrence of preterm (5.3% vs. 9.57-10.23%, 95% CI, 4.4-6.4%), small for gestational age (5.2% vs. 10-13%, 95% CI, 4.3-6.2%), and large for gestational age (4.8% vs. 9%, 95% CI, 4.0-5.8%) births, but a higher occurrence of neonatal intensive care unit admissions (16.9% vs. 7.8-14.4%, 95% CI, 15.4-18.6%) in infants born to military beneficiaries. CONCLUSIONS Our findings suggest that expanded universal access to health care may improve AYA pregnancy and delivery outcomes. Infants born to AYA military beneficiaries have improved neonatal outcomes compared to nationally published data. These results may correlate to improved maternal access within a free or low-cost healthcare system.
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Affiliation(s)
- Saira Ahmed
- Department of Pediatrics, Division of Adolescent Medicine, Walter Reed National Military Medical Center, Bethesda, MD 20089, USA
| | - Rasheda J Vereen
- Department of Pediatrics, Division of Neonatology, Carl R. Darnall Army Medical Center, Fort Cavazos, TX 76544, USA
| | - James K Aden
- Research Division, Graduate Medical Education, Brooke Army Medical Center, JBSA-Fort Sam Houston, TX 78234, USA
| | - Christopher A Dillon
- Department of Pediatrics, Division of Adolescent Medicine, Brooke Army Medical Center, JBSA-Fort Sam Houston, TX 78234, USA
| | - Jonathan B Shapiro
- Department of Pediatrics, Division of Neonatology, Brooke Army Medical Center, JBSA-Fort Sam Houston, TX 78234, USA
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Goodman DC, Stuchlik P, Ganduglia-Cazaban C, Tyson JE, Leyenaar J, Avritscher EBC, Rysavy M, Gautham KS, Lynch D, Stukel TA. Hospital-Level NICU Capacity, Utilization, and 30-Day Outcomes in Texas. JAMA Netw Open 2024; 7:e2355982. [PMID: 38353952 PMCID: PMC10867701 DOI: 10.1001/jamanetworkopen.2023.55982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 12/20/2023] [Indexed: 02/16/2024] Open
Abstract
Importance Risk-adjusted neonatal intensive care unit (NICU) utilization and outcomes vary markedly across regions and hospitals. The causes of this variation are poorly understood. Objective To assess the association of hospital-level NICU bed capacity with utilization and outcomes in newborn cohorts with differing levels of health risk. Design, Setting, and Participants This population-based retrospective cohort study included all Medicaid-insured live births in Texas from 2010 to 2014 using linked vital records and maternal and newborn claims data. Participants were Medicaid-insured singleton live births (LBs) with birth weights of at least 400 g and gestational ages between 22 and 44 weeks. Newborns were grouped into 3 cohorts: very low birth weight (VLBW; <1500 g), late preterm (LPT; 34-36 weeks' gestation), and nonpreterm newborns (NPT; ≥37 weeks' gestation). Data analysis was conducted from January 2022 to October 2023. Exposure Hospital NICU capacity measured as reported NICU beds/100 LBs, adjusted (ie, allocated) for transfers. Main Outcomes and Measures NICU admissions and special care days; inpatient mortality and 30-day postdischarge adverse events (ie, mortality, emergency department visit, admission, observation stay). Results The overall cohort of 874 280 single LBs included 9938 VLBW (5054 [50.9%] female; mean [SD] birth weight, 1028.9 [289.6] g; mean [SD] gestational age, 27.6 [2.6] wk), 63 160 LPT (33 684 [53.3%] female; mean [SD] birth weight, 2664.0 [409.4] g; mean [SD] gestational age, 35.4 [0.8] wk), and 801 182 NPT (407 977 [50.9%] female; mean [SD] birth weight, 3318.7 [383.4] g; mean [SD] gestational age, 38.9 [1.0] wk) LBs. Median (IQR) NICU capacity was 0.84 (0.57-1.30) allocated beds/100 LB/year. For VLBW newborns, NICU capacity was not associated with the risk of NICU admission or number of special care days. For LPT newborns, birth in hospitals with the highest compared with the lowest category of capacity was associated with a 17% higher risk of NICU admission (adjusted risk ratio [aRR], 1.17; 95% CI, 1.01-1.33). For NPT newborns, risk of NICU admission was 55% higher (aRR, 1.55; 95% CI, 1.22-1.97) in the highest- vs the lowest-capacity hospitals. The number of special care days for LPT and NPT newborns was 21% (aRR, 1.21; 95% CI,1.08-1.36) and 37% (aRR, 1.37; 95% CI, 1.08-1.74) higher in the highest vs lowest capacity hospitals, respectively. Among LPT and NPT newborns, NICU capacity was associated with higher inpatient mortality and 30-day postdischarge adverse events. Conclusions and Relevance In this cohort study of Medicaid-insured newborns in Texas, greater hospital NICU bed supply was associated with increased NICU utilization in newborns born LPT and NPT. Higher capacity was not associated with lower risk of adverse events. These findings raise important questions about how the NICU is used for newborns with lower risk.
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Affiliation(s)
- David C. Goodman
- The Dartmouth Institute for Health Policy and Clinical Practice, Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Children’s Hospital at Dartmouth, Lebanon, New Hampshire
| | - Patrick Stuchlik
- The Dartmouth Institute for Health Policy and Clinical Practice, Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Cecilia Ganduglia-Cazaban
- Center for Health Care Data and Department of Management, Policy, and Community Health, School of Public Health, The University of Texas Health Science Center at Houston
| | - Jon E. Tyson
- Institute for Clinical Research and Learning Health Care, McGovern Medical School at The University of Texas Health Science Center at Houston
| | - JoAnna Leyenaar
- The Dartmouth Institute for Health Policy and Clinical Practice, Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Children’s Hospital at Dartmouth, Lebanon, New Hampshire
| | - Elenir B. C. Avritscher
- Institute for Clinical Research and Learning Health Care, McGovern Medical School at The University of Texas Health Science Center at Houston
| | - Mathew Rysavy
- Institute for Clinical Research and Learning Health Care, McGovern Medical School at The University of Texas Health Science Center at Houston
| | - Kanekal S. Gautham
- Division of Neonatology, Department of Pediatrics, Nemours Children’s Health, Orlando, Florida
| | | | - Therese A. Stukel
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
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Davis R, Stuchlik PM, Goodman DC. The Relationship Between Regional Growth in Neonatal Intensive Care Capacity and Perinatal Risk. Med Care 2023; 61:729-736. [PMID: 37449856 PMCID: PMC10564047 DOI: 10.1097/mlr.0000000000001893] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND The supply of US neonatal intensive care unit (NICU) beds and neonatologists is known to vary markedly across regions, but there have been no investigation of patterns of recent growth (1991-2017) in NICUs in relation to newborn need. OBJECTIVE The objective of this study was to test the hypothesis that greater growth in NICU capacity occurred in neonatal intensive care regions with higher perinatal risk. RESEARCH DESIGN A longitudinal ecological analysis with neonatal intensive care regions (n=246) as the units of analysis. Associations were tested using linear regression. SUBJECTS All US live births ≥400 g in 1991 (n=4,103,528) and 2017 (n=3,849,644). MEASURES Primary measures of risk were the proportions of low-birth weight and very low-birth weight newborns and mothers who were Black or had low educational attainment. RESULTS Over 26 years, the numbers of NICU beds and neonatologists per live birth increased 42% and 200%, respectively, with marked variation in growth across regions (interquartile range: 0.3-4.1, beds; neonatologists, 0.4-1.0 per 1000 live births). A weak association of capacity with perinatal risk in 1991 was absent in 2017. There was no meaningful (ie, clinical or policy relevant) association between regional changes in capacity and regions with higher perinatal risk or lower capacity in 1991; higher increases in perinatal risk were not associated with higher capacity growth. CONCLUSION The lack of association between newborn medical needs and the supply of NICU resources raises questions about the current effectiveness of newborn care at a population level.
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Affiliation(s)
- Rebekah Davis
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH
- University of Colorado School of Medicine, Aurora, CO
| | - Patrick M. Stuchlik
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - David C. Goodman
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH
- The Children’s Hospital at Dartmouth, Lebanon, NH
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Pang EM, Liu J, Lu T, Joshi NS, Gould J, Lee HC. Evaluating Epidemiologic Trends and Variations in NICU Admissions in California, 2008 to 2018. Hosp Pediatr 2023; 13:976-983. [PMID: 37867440 PMCID: PMC10593864 DOI: 10.1542/hpeds.2023-007190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
OBJECTIVE Previous research suggests increasing numbers of and variation in NICU admissions. We explored whether these trends were reflected in California by examining NICU admissions and birth data in aggregate and among patient and hospital subpopulations more susceptible to variations in care. METHODS In this retrospective cohort study, we evaluated NICU utilization between 2008 and 2018 for all live births at hospitals that provide data to the California Perinatal Quality Care Collaborative. We compared hospital- and admission-level data across birth weight (BW), gestational age (GA), and illness acuity categories. Trends were analyzed by using linear regression models. RESULTS We identified 472 402 inborn NICU admissions and 3 960 441 live births across 144 hospitals. Yearly trends in NICU admissions remained stable among all births and higher acuity births (mean admission rates 11.9% and 4.1%, respectively). However, analysis of the higher acuity births revealed significant increases in NICU admission rates for neonates with higher BW and GA (BW ≥ 2500g: 1.8% in 2008, 2.1% in 2018; GA ≥ 37 weeks: 1.5% in 2010, 1.8% in 2018). Kaiser hospitals had a decreasing trend of NICU admissions compared to non-Kaiser hospitals (Kaiser: 13.9% in 2008, 10.1% in 2018; non-Kaiser: 11.3% in 2008, 12.3% in 2018). CONCLUSIONS Overall NICU admission rates in California were stable from 2008-2018. However, trends similar to national patterns emerged when stratified by infant GA, BW, and illness acuity as well as Kaiser or non-Kaiser hospitals, with increasing admission rates for infants born at higher BW and GA and within non-Kaiser hospitals.
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Affiliation(s)
- Emily M. Pang
- Stanford University School of Medicine, Stanford, California
| | - Jessica Liu
- Division of Neonatology, Department of Pediatrics
- California Perinatal Quality Care Collaborative (CPQCC)
| | - Tianyao Lu
- Division of Neonatology, Department of Pediatrics
- California Perinatal Quality Care Collaborative (CPQCC)
| | - Neha S. Joshi
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Stanford University, Stanford, California
| | - Jeffrey Gould
- Division of Neonatology, Department of Pediatrics
- California Perinatal Quality Care Collaborative (CPQCC)
| | - Henry C. Lee
- California Perinatal Quality Care Collaborative (CPQCC)
- Division of Neonatology, Department of Pediatrics, University of California San Diego, San Diego, California
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Goodman DC, Romano CJ, Hall C, Bukowinski AT, Mu TS, Gumbs GR, Conlin AMS, Vereen RJ, Leyenaar JK. The association of regional perinatal risk factors and neonatal intensive care capacity for Military Health System-insured newborns. J Perinatol 2023; 43:787-795. [PMID: 36792685 DOI: 10.1038/s41372-023-01633-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 02/03/2023] [Accepted: 02/07/2023] [Indexed: 02/17/2023]
Abstract
OBJECTIVE To characterize hospitals where military-insured newborns received care and test the association of regional perinatal risk with neonatal intensive care unit (NICU) capacity. STUDY DESIGN We identified birth hospitals for live newborns October 2015-December 2018 (n = 296,568) and assigned newborns to health service areas (HSAs). Perinatal risk factors and the number of neonatal special care beds and neonatologists were calculated at HSA levels. Cross-sectional correlation analyses assessed perinatal risk factors and capacity across HSAs. RESULTS 27.0% (n = 10) of military birth hospitals had special care beds (intermediate and intensive) compared with 44.3% of civilian hospitals (n = 1224; p < 0.05). The number of special care beds and neonatologists per newborn varied more than twofold across regions and were only weakly associated with the proportion of higher risk newborns (R2 < 0.05). CONCLUSIONS The lack of meaningful association of regional perinatal risk with NICU capacity poses challenges for effective specialized care among military-associated newborns.
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Affiliation(s)
| | - Celeste J Romano
- Leidos, Inc., San Diego, CA, USA
- Deployment Health Research Department, Naval Health Research Center, San Diego, CA, USA
| | - Clinton Hall
- Leidos, Inc., San Diego, CA, USA
- Deployment Health Research Department, Naval Health Research Center, San Diego, CA, USA
| | - Anna T Bukowinski
- Leidos, Inc., San Diego, CA, USA
- Deployment Health Research Department, Naval Health Research Center, San Diego, CA, USA
| | - Thornton S Mu
- Uniformed Services University of the Health Services, Bethesda, MD, USA
- Brooke Army Medical Center, San Antonio, TX, USA
| | - Gia R Gumbs
- Leidos, Inc., San Diego, CA, USA
- Deployment Health Research Department, Naval Health Research Center, San Diego, CA, USA
| | - Ava Marie S Conlin
- Deployment Health Research Department, Naval Health Research Center, San Diego, CA, USA
| | | | - JoAnna K Leyenaar
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Children's Hospital at Dartmouth, Lebanon, NH, USA
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King B, Patel RM. Using Quality Improvement to Improve Value and Reduce Waste. Clin Perinatol 2023; 50:489-506. [PMID: 37201993 DOI: 10.1016/j.clp.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Value is defined as health outcomes achieved per dollar spent. Addressing value in quality improvement (QI) efforts can help optimize patient outcomes while reducing unnecessary spending. In this article, we discuss how QI focused on reducing morbidities frequently reduces costs, and how proper cost accounting can help demonstrate improvements in value. We provide examples of high-yield opportunities for value improvement in neonatology and review the literature associated with these topics. Opportunities include reducing neonatal intensive care admissions for low-acuity infants, sepsis evaluations in low-risk infants, unnecessary total parental nutrition use, and utilization of laboratory and imaging.
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Affiliation(s)
- Brian King
- Department of Pediatrics, University of Pittsburg School of Medicine.
| | - Ravi M Patel
- Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Drive, NE, Atlanta, GA 30322, USA
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King BC, Hagan J, Richardson T, Berry J, Slaughter JL. Hospital variation in neonatal echocardiography among very preterm infants at US children's hospitals. J Perinatol 2023; 43:181-186. [PMID: 36163416 DOI: 10.1038/s41372-022-01522-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 09/12/2022] [Accepted: 09/14/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Estimate hospital variation in echocardiography (echo) among very preterm infants. STUDY DESIGN Retrospective cohort study of very preterm (<32 weeks) infants discharged between 2012 and 2019 from US children's hospitals. Echo exposure was identified using daily billing, and hospital variation was estimated after adjustment for illness severity. Variation in very early echo use (<3 days of life) was compared to exposure to treatment of a patent ductus arteriosus (PDA), and other practice patterns. RESULTS 27,498 subjects across 39 children's hospitals were included. Very early echo use had the greatest hospital variation (3-34%). Increasing very early echo use was not associated with PDA treatment (p = 0.93), but was associated with nitric oxide (p < 0.01) and vasoactive medications (p < 0.01). CONCLUSIONS Hospital variation in echo use among preterm infants was greatest in the first few days of life and was associated with increasing nitric oxide and vasoactive medication use. The impact of this variation on clinical outcomes is uncertain and warrants further investigation.
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Affiliation(s)
- Brian C King
- Division of Newborn Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine and UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
| | - Joseph Hagan
- Newborn Center, Texas Children's Hospital, Houston, TX, USA
| | | | - Jay Berry
- Complex Care, Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan L Slaughter
- Center for Perinatal Research, Nationwide Children's Hospital and Department of Pediatrics, College of Medicine and Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA
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Inter-Rater Reliability between Structured and Non-Structured Interviews Is Fair in Schizophrenia and Bipolar Disorders-A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2023; 13:diagnostics13030526. [PMID: 36766632 PMCID: PMC9914275 DOI: 10.3390/diagnostics13030526] [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: 11/28/2022] [Revised: 01/25/2023] [Accepted: 01/28/2023] [Indexed: 02/05/2023] Open
Abstract
We aimed to find agreement between diagnoses obtained through standardized (SDI) and non-standardized diagnostic interviews (NSDI) for schizophrenia and Bipolar Affective Disorder (BD). METHODS A systematic review with meta-analysis was conducted. Publications from 2007 to 2020 comparing SDI and NSDI diagnoses in adults without neurological disorders were screened in MEDLINE, ISI Web of Science, and SCOPUS, following PROSPERO registration CRD42020187157, PRISMA guidelines, and quality assessment using QUADAS-2. RESULTS From 54231 entries, 22 studies were analyzed, and 13 were included in the final meta-analysis of kappa agreement using a mixed-effects meta-regression model. A mean kappa of 0.41 (Fair agreement, 95% CI: 0.34 to 0.47) but high heterogeneity (Î2 = 92%) were calculated. Gender, mean age, NSDI setting (Inpatient vs. Outpatient; University vs. Non-university), and SDI informant (Self vs. Professional) were tested as predictors in meta-regression. Only SDI informant was relevant for the explanatory model, leaving 79% unexplained heterogeneity. Egger's test did not indicate significant bias, and QUADAS-2 resulted in "average" data quality. CONCLUSIONS Most studies using SDIs do not report the original sample size, only the SDI-diagnosed patients. Kappa comparison resulted in high heterogeneity, which may reflect the influence of non-systematic bias in diagnostic processes. Although results were highly heterogeneous, we measured a fair agreement kappa between SDI and NSDI, implying clinicians might operate in scenarios not equivalent to psychiatry trials, where samples are filtered, and there may be more emphasis on maintaining reliability. The present study received no funding.
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Doherty JR, Schaefer A, Goodman DC. Texas Hospitals' Perspectives About NICU Performance Measures: A Mixed-Methods Study. Qual Manag Health Care 2023; 32:8-15. [PMID: 35383729 PMCID: PMC9530051 DOI: 10.1097/qmh.0000000000000347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND OBJECTIVES This study was conducted to assess Texas hospital leaders' perspectives about neonatal intensive care (NICU) performance measures. METHODS We conducted an explanatory mixed-methods study. First, we sent a survey and a copy of the Dartmouth Atlas of Neonatal Intensive Care to clinical and administrative leaders of 150 NICUs in Texas. We asked respondents to review the chapter that reported Texas-specific results and respond to a variety of open and closed-ended questions about the overall usefulness of the report. Second, we conducted semistructured qualitative interviews with a subset of survey respondents to better understand their perspectives. RESULTS The survey had a 50% hospital response rate. Respondents generally found the report to be interesting and useful, and 87.7% of all respondents reported being in favor of receiving future reports with their own hospital's data benchmarked against anonymous peers. All of the specific measures in the Atlas were found to be of interest and valuable, with NICU admissions and special care days rating among the most interesting and useful. In the semistructured interviews, respondents expressed that a report with performance data would serve as a mechanism to drive change by identifying opportunities for improvement. CONCLUSION Texas hospital NICU leaders are interested in routinely receiving more information about their own NICU's performance anonymously benchmarked against their peers. This would facilitate a greater understanding of a unit's functionality, as well as accelerate clinically appropriate quality improvement initiatives, which together have the potential to deliver better newborn care at lower costs for all Texans.
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Affiliation(s)
- Julie R Doherty
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Andrew Schaefer
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - David C Goodman
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH
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Moen A, Goodman DC. Unwarranted geographic variation in paediatric health care in the United States and Norway. Acta Paediatr 2022; 111:733-740. [PMID: 35007359 DOI: 10.1111/apa.16249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/17/2021] [Accepted: 01/07/2022] [Indexed: 11/28/2022]
Abstract
AIM We present the four US and Norwegian paediatric and neonatal health atlases and discuss the concept and causes of unwarranted geographic variation in paediatric health care. METHODS The four atlases analyse data from both publicly owned health registers, registers of insurance claims and quality registers. Healthcare utilisation is counted per recipient in predefined hospital service areas, adjusted for relevant confounders and presented as extremal ratios between the highest and lowest rate. RESULTS The atlases describe geographic variation in rates for primary health care, hospital admissions, outpatient visits, treatment procedures and diagnostic testing. A difference in extremal ratios from 2 to 4 between health service areas are common, and for some procedures extremal ratios is even higher. CONCLUSION Variation in healthcare utilisation of the magnitude described in these four atlases cannot be explained by differences in population morbidity or patient preferences and are therefore characterised as unwarranted variation. Individual provider preferences or supply of resources such as hospital beds may explain the observed variation.
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Affiliation(s)
- Atle Moen
- Department of Neonatology Oslo University Hospital Oslo Norway
| | - David C. Goodman
- The Dartmouth Institute for Health Policy and Clinical Practice Geisel School of Medicine at Dartmouth Hanover New Hampshire USA
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Kim Y, Ganduglia-Cazaban C, Chan W, Lee M, Goodman DC. Trends in neonatal intensive care unit admissions by race/ethnicity in the United States, 2008-2018. Sci Rep 2021; 11:23795. [PMID: 34893675 PMCID: PMC8664880 DOI: 10.1038/s41598-021-03183-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 11/22/2021] [Indexed: 11/21/2022] Open
Abstract
To examine temporal trends of NICU admissions in the U.S. by race/ethnicity, we conducted a retrospective cohort analysis using natality files provided by the National Center for Health Statistics at the U.S. Centers for Disease Control and Prevention. A total of 38,011,843 births in 2008–2018 were included. Crude and risk-adjusted NICU admission rates, overall and stratified by birth weight group, were compared between white, black, and Hispanic infants. Crude NICU admission rates increased from 6.62% (95% CI 6.59–6.65) to 9.07% (95% CI 9.04–9.10) between 2008 and 2018. The largest percentage increase was observed among Hispanic infants (51.4%) compared to white (29.1%) and black (32.4%) infants. Overall risk-adjusted rates differed little by race/ethnicity, but birth weight-stratified analysis revealed that racial/ethnic differences diminished in the very low birth weight (< 1500 g) and moderately low birth weight (1500–2499 g) groups. Overall NICU admission rates increased by 37% from 2008 to 2018, and the increasing trends were observed among all racial and ethnic groups. Diminished racial/ethnic differences in NICU admission rates in very low birth weight infants may reflect improved access to timely appropriate NICU care among high-risk infants through increasing health care coverage coupled with growing NICU supply.
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Affiliation(s)
- Youngran Kim
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center, 6431 Fannin St, Houston, TX, 77030, USA.
| | - Cecilia Ganduglia-Cazaban
- Division of Management, Policy and Community Health, School of Public Health, The University of Texas Health Science Center, Houston, TX, USA
| | - Wenyaw Chan
- Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center, Houston, TX, USA
| | - MinJae Lee
- Division of Biostatistics, Department of Population and Data Sciences, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - David C Goodman
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH, USA.,Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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Neonatal Intensive Care Utilization and Postdischarge Newborn Outcomes: A Population-based Study of Texas Medicaid Insured Infants. J Pediatr 2021; 236:62-69.e3. [PMID: 33940013 DOI: 10.1016/j.jpeds.2021.04.058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 04/22/2021] [Accepted: 04/26/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To test the hypothesis that newborn infants cared for in hospitals with greater utilization of neonatal intensive care experienced fewer postdischarge adverse events. STUDY DESIGN We developed 3 retrospective population-based cohorts of Texas Medicaid insured singletons born in 2010-2014 (very low birth weight [VLBW n = 11 139], late preterm [n = 57 509], and non-preterm [n = 664 447]) who received care in higher volume hospitals with level III/IV neonatal intensive care units (NICUs). Measures of NICU care were hospital-level risk adjusted NICU admission rates, special care days (days of nonroutine care) per infant, and the percent of intensive (highest billable care code) special care days. The units of analysis were hospitals (n = 80) and the primary outcome was an adverse event, (defined as admission, emergency department visit, or death) within 30 days postdischarge. RESULTS Higher use of NICU care at a hospital level was not associated with lower postdischarge 30-day adverse event. Infants cared for in hospitals with above vs below median special care day rates experienced slightly higher postdischarge adverse event per 100 infants (VLBW: 14.01 [95% CI 12.74-15.27] vs 11.84 [10.52-13.16], P < .05; late preterm: 7.33 [6.68-7.97] vs 6.28 [5.87-6.69], P < .01; non-preterm: 4.47 [4.17-4.76] vs 3.97 [3.75-4.18], P < .01). Weak positive associations (Pearson correlations of 0.31-0.37, P < .01) were observed for adverse event with special care days; in no instance was a negative association observed between NICU utilization and adverse event. CONCLUSION Higher utilization of NICU care was not associated with lower rates of short-term events suggesting that there may be opportunities to safely decrease admission rates and length of NICU stays.
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14
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Ciciolla L, Shreffler KM, Tiemeyer S. Maternal Childhood Adversity as a Risk for Perinatal Complications and NICU Hospitalization. J Pediatr Psychol 2021; 46:801-813. [PMID: 34304270 DOI: 10.1093/jpepsy/jsab027] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 01/16/2021] [Accepted: 03/01/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To examine maternal childhood adversity in relation to increased risk for maternal and infant perinatal complications and newborn Neonatal Intensive Care Unit (NICU) admittance. METHODS A sample of 164 women recruited at their first prenatal appointment participated in a longitudinal study through 6 weeks postdelivery. Participants self-reported on their adverse childhood experiences (ACEs), negative health risks (overweight/obesity, smoking, and alcohol use), adverse infant outcomes, NICU admittance, and maternal perinatal complications across three pregnancy assessments and one post-birth assessment. Logistic binomial regression analyses were used to examine associations between maternal ACEs and adverse infant outcomes, NICU admittance, and maternal perinatal complications, controlling for pregnancy-related health risks. RESULTS Findings showed that women with severe ACEs exposure (6+ ACEs) had 4 times the odds of reporting at least one adverse infant outcome (odds ratio [OR] = 4.33, 95% CI: 1.02-18.39), almost 9 times the odds of reporting a NICU admission (OR = 8.70, 95% CI: 1.34-56.65), and 4 times the odds of reporting at least one maternal perinatal outcome (OR = 4.37, 95% CI: 1.43-13.39). CONCLUSIONS The findings demonstrate the extraordinary risk that mothers' ACEs pose for infant and maternal health outcomes over and above the associations with known maternal health risks during pregnancy, including overweight/obesity, smoking, and alcohol use. These results support a biological intergenerational transmission framework, which suggests that risk from maternal adversity is perpetuated in the next generation through biophysical and behavioral mechanisms during pregnancy that negatively affect infant health outcomes.
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Affiliation(s)
| | - Karina M Shreffler
- Department of Human Development and Family Science, Oklahoma State University
| | - Stacy Tiemeyer
- Center for Integrative Research on Childhood Adversity, Oklahoma State University-Center for Health Sciences
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15
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Dimmock D, Caylor S, Waldman B, Benson W, Ashburner C, Carmichael JL, Carroll J, Cham E, Chowdhury S, Cleary J, D’Harlingue A, Doshi A, Ellsworth K, Galarreta CI, Hobbs C, Houtchens K, Hunt J, Joe P, Joseph M, Kaplan RH, Kingsmore SF, Knight J, Kochhar A, Kronick RG, Limon J, Martin M, Rauen KA, Schwarz A, Shankar SP, Spicer R, Rojas MA, Vargas-Shiraishi O, Wigby K, Zadeh N, Farnaes L. Project Baby Bear: Rapid precision care incorporating rWGS in 5 California children's hospitals demonstrates improved clinical outcomes and reduced costs of care. Am J Hum Genet 2021; 108:1231-1238. [PMID: 34089648 PMCID: PMC8322922 DOI: 10.1016/j.ajhg.2021.05.008] [Citation(s) in RCA: 131] [Impact Index Per Article: 43.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/14/2021] [Indexed: 12/31/2022] Open
Abstract
Genetic disorders are a leading contributor to mortality in neonatal and pediatric intensive care units (ICUs). Rapid whole-genome sequencing (rWGS)-based rapid precision medicine (RPM) is an intervention that has demonstrated improved clinical outcomes and reduced costs of care. However, the feasibility of broad clinical deployment has not been established. The objective of this study was to implement RPM based on rWGS and evaluate the clinical and economic impact of this implementation as a first line diagnostic test in the California Medicaid (Medi-Cal) program. Project Baby Bear was a payor funded, prospective, real-world quality improvement project in the regional ICUs of five tertiary care children's hospitals. Participation was limited to acutely ill Medi-Cal beneficiaries who were admitted November 2018 to May 2020, were <1 year old and within one week of hospitalization, or had just developed an abnormal response to therapy. The whole cohort received RPM. There were two prespecified primary outcomes-changes in medical care reported by physicians and changes in the cost of care. The majority of infants were from underserved populations. Of 184 infants enrolled, 74 (40%) received a diagnosis by rWGS that explained their admission in a median time of 3 days. In 58 (32%) affected individuals, rWGS led to changes in medical care. Testing and precision medicine cost $1.7 million and led to $2.2-2.9 million cost savings. rWGS-based RPM had clinical utility and reduced net health care expenditures for infants in regional ICUs. rWGS should be considered early in ICU admission when the underlying etiology is unclear.
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Affiliation(s)
- David Dimmock
- Rady Children’s Institute for Genomic Medicine, San Diego, CA 92130, USA,Corresponding author
| | - Sara Caylor
- Rady Children’s Institute for Genomic Medicine, San Diego, CA 92130, USA
| | - Bryce Waldman
- Rady Children’s Institute for Genomic Medicine, San Diego, CA 92130, USA
| | - Wendy Benson
- Rady Children’s Institute for Genomic Medicine, San Diego, CA 92130, USA
| | | | | | - Jeanne Carroll
- Rady Children’s Institute for Genomic Medicine, San Diego, CA 92130, USA,University of California, San Diego, San Diego, CA 92093, USA
| | - Elaine Cham
- University of California, San Francisco, Benioff Children’s Hospital Oakland, Oakland, CA 94609, USA
| | - Shimul Chowdhury
- Rady Children’s Institute for Genomic Medicine, San Diego, CA 92130, USA
| | - John Cleary
- Children’s Hospital of Orange County, Orange, CA 92868, USA
| | - Arthur D’Harlingue
- University of California, San Francisco, Benioff Children’s Hospital Oakland, Oakland, CA 94609, USA
| | - A. Doshi
- Rady Children’s Institute for Genomic Medicine, San Diego, CA 92130, USA,University of California, San Diego, San Diego, CA 92093, USA
| | | | | | - Charlotte Hobbs
- Rady Children’s Institute for Genomic Medicine, San Diego, CA 92130, USA
| | - Kathleen Houtchens
- University of California, San Francisco, Benioff Children’s Hospital Oakland, Oakland, CA 94609, USA
| | - Juliette Hunt
- Children’s Hospital of Orange County, Orange, CA 92868, USA
| | - Priscilla Joe
- University of California, San Francisco, Benioff Children’s Hospital Oakland, Oakland, CA 94609, USA
| | | | | | | | - Jason Knight
- Children’s Hospital of Orange County, Orange, CA 92868, USA
| | | | - Richard G. Kronick
- Torrey Pines Health Group, Inc., San Diego, CA 92037, USA,Department of Family Medicine and Public Health, University of California, San Diego, San Diego, CA 92093, USA
| | - Jolie Limon
- Valley Children’s Hospital, Madera, CA 93636, USA
| | - Madelena Martin
- University of California, Davis and Davis Children’s Hospital, Sacramento, CA 95817, USA
| | - Katherine A. Rauen
- University of California, Davis and Davis Children’s Hospital, Sacramento, CA 95817, USA
| | - Adam Schwarz
- Children’s Hospital of Orange County, Orange, CA 92868, USA
| | - Suma P. Shankar
- University of California, Davis and Davis Children’s Hospital, Sacramento, CA 95817, USA
| | | | | | | | - Kristen Wigby
- Rady Children’s Institute for Genomic Medicine, San Diego, CA 92130, USA,University of California, San Diego, San Diego, CA 92093, USA
| | - Neda Zadeh
- Children’s Hospital of Orange County, Orange, CA 92868, USA
| | - Lauge Farnaes
- Rady Children’s Institute for Genomic Medicine, San Diego, CA 92130, USA
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16
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Braun D, Edwards EM, Schulman J, Profit J, Pursley DM, Goodman DC. Choosing wisely for the other 80%: What we need to know about the more mature newborn and NICU care. Semin Perinatol 2021; 45:151395. [PMID: 33573773 DOI: 10.1016/j.semperi.2021.151395] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although neonatal intensive unit (NICU) care is envisioned as the care of very immature infants, more than 95% of births and 80% of NICU admissions are of more mature newborns-infants born at 34 or more weeks' gestation. In spite of the size of this population there are important gaps in the understanding of their needs and optimal management as reflected by remarkably large unexplained variation in their care. The goal of this article is to describe what is known about the more mature, higher birth weight newborn population's use of NICU care and highlight important gaps in knowledge and obstacles to research. Research priorities are identified: including (1) the need for birth population based rather than NICU based studies, and (2) population specific data elements. Summary: More mature newborns-infants of 34 or more weeks' gestation-account for most NICU admissions. There are large gaps in the understanding of their needs and optimal management as reflected by large unexplained variation in their care. We enumerate these gaps in current knowledge and suggest research priorities to address them.
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Affiliation(s)
- David Braun
- Neonatal Medicine, Kaiser Permanente, Panorama City, CA, United States; Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States.
| | - Erika M Edwards
- Dept of Pediatrics and Mathematics and Statistics, University of Vermont, Burlington, VT, United States; Vermont Oxford Network, Burlington, VT, United States
| | - Joseph Schulman
- California Department of Health Care Services, California Children's Services, Sacramento, CA, United States
| | - Jochen Profit
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
| | - DeWayne M Pursley
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, United States; Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - David C Goodman
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, NH, Lebanon
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17
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Cost of clinician-driven tests and treatments in very low birth weight and/or very preterm infants. J Perinatol 2021; 41:295-304. [PMID: 33268831 DOI: 10.1038/s41372-020-00879-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 10/07/2020] [Accepted: 11/12/2020] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To rank clinician-driven tests and treatments (CTTs) by their total cost during the birth hospitalization for preterm infants. STUDY DESIGN Retrospective cohort of very low birth weight (<1500 g) and/or very preterm (<32 weeks) subjects admitted to US children's hospital Neonatal Intensive Care Units (2012-2018). CTTs were defined as pharmaceutical, laboratory and imaging services and ranked by total cost. RESULTS 24,099 infants from 51 hospitals were included. Parenteral nutrition ($85M, 32% of pharmacy costs), blood gas analysis ($34M, 29% of laboratory costs), and chest radiographs ($18M, 31% of imaging costs) were the costliest CTTs overall. More than half of CTT-related costs occurred during 10% of hospital days. CONCLUSIONS The majority of CTT-related costs were from commonly used tests and treatments. Targeted efforts to improve value in neonatal care may benefit most from focusing on reducing unnecessary utilization of common tests and treatments, rather than infrequently used ones.
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18
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Taenzer AH, Baertschiger RM, Cazaban CG, Evans RE, Murphy M, Wasserman J, Goodman DC. Epidemiology of Surgical Procedures, Anesthesia, and Imaging Studies by Gestational Age during the First Year of Life in Medicaid-Insured Infants. J Pediatr 2021; 229:147-153.e1. [PMID: 33098841 DOI: 10.1016/j.jpeds.2020.10.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/22/2020] [Accepted: 10/14/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To evaluate the rate of surgical procedures, anesthetic use, and imaging studies by prematurity status for the first year of life we analyzed data for Texas Medicaid-insured newborns. STUDY DESIGN We developed a retrospective population-based live birth cohort of newborn infants insured by Texas Medicaid in 2010-2014 with 4 subcohorts: extremely premature, very premature, moderate/late premature, and term. RESULTS In 1 102 958 infants, surgical procedures per 100 infants were 135.9 for extremely premature, 35.4 for very premature, 15.5 for moderate/late premature, and 6.5 for term. Anesthetic use was 62.0 for extremely premature, 20.8 for very premature, 11.1 for moderate/late premature, and 5.6 for the term subcohort. The most common procedures in the extremely premature were neurosurgery, intubations, and procedures that facilitated caloric intake (gastrostomy tubes and fundoplications). The annual rates for the first year of life for chest radiograph ranged from 15.0 per year for the extremely premature cohort to 0.6 for term infants and for magnetic resonance imaging (MRI) from 0.3 to 0.01. MRI was the most common imaging study with anesthesia support in all maturity levels. MRIs were done in extremely premature without anesthesia in over 90% and in term infants in 57.2%. CONCLUSIONS Surgical procedures, anesthetic use, and imaging studies in infants are common and more frequent with higher a degree of prematurity while the use of anesthesia is lower in more premature newborns. These findings can provide direction for outcome studies of surgery and anesthesia exposure.
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Affiliation(s)
- Andreas H Taenzer
- Children's Hospital at Dartmouth (CHaD), Dartmouth Hitchcock Medical Center, Department of Anesthesiology & Pediatrics, The Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH.
| | - Reto M Baertschiger
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Cecilia Ganduglia Cazaban
- Department of Management, Policy, and Community Health, University of Texas School of Public Health, Dallas, TX
| | - Rebecca E Evans
- Department of Anesthesiology and Pediatrics, Larner College of Medicine, University of Vermont Medical Center, Burlington, VT
| | - Megan Murphy
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Jared Wasserman
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - David C Goodman
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH; The Department of Pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, NH
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19
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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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20
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Han D, Khadka A, McConnell M, Cohen J. Association of Unexpected Newborn Deaths With Changes in Obstetric and Neonatal Process of Care. JAMA Netw Open 2020; 3:e2024589. [PMID: 33284335 DOI: 10.1001/jamanetworkopen.2020.24589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The death of a healthy term infant may signal patient safety and quality issues. Various initiatives aim to encourage clinicians to learn from these events, but little evidence exists regarding how exposure to an unexpected newborn death may alter clinician practice. OBJECTIVE To examine the association between an unexpected newborn death and changes in obstetric and newborn procedures that may be used in response to potential fetal distress or newborn complications. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used difference-in-differences analysis of 2011 to 2017 US vital statistics data from 477 US counties experiencing an unexpected newborn death during the study period. All in-hospital live births in the 477 counties during the study period were included. Data were analyzed from September 2019 to September 2020. EXPOSURES The death of an infant aged 0 to 7 days following an unremarkable pregnancy owing to causes other than birth defects, accidents/assaults, or sudden infant death syndrome. MAIN OUTCOMES AND MEASURES Primary outcomes included binary variables capturing intervention in labor/delivery (induction, augmentation, cesarean delivery, forceps/vacuum) and procedures to avert and mitigate newborn complications (assisted ventilation, surfactant replacement therapy, antibiotics for suspected sepsis, neonatal intensive care unit admission). RESULTS The main sample included 5.72 million births (2.54 million during preexposure time). Mean (SD) maternal age was 27.3 (5.8) years; 67% of mothers were White, and 12% were Black. Associations varied across the 4 estimated models. Following an unexpected newborn death, there was no significant increase in the probability of cesarean delivery in the full sample model (0.28 percentage points [pp]; 95% CI, -0.01 to 0.57 pp), but a significant increase in the other 3 models, with values ranging from 0.55 pp (95% CI, 0.21 to 0.88 pp) in the full sample model with matching to 0.66 pp (95% CI, 0.13 to 1.19 pp) in the 1-hospital county subsample with matching. There was a significant increase in the probability of newborn assisted ventilation in the full sample model with matching (0.46 pp; 95% CI, 0.08 to 0.83 pp), but no significant increase in the other 3 models, with estimates ranging from 0.33 pp (95% CI, -0.04 to 0.71 pp) to 0.69 pp (95% CI, -0.02 to 1.40 pp). An unexpected newborn death was not associated with a significant increase in antibiotic use in the full sample models (without matching: 0.19 pp; 95% CI, -0.00 to 0.39 pp; with matching: 0.22 pp; 95% CI: -0.02 to 0.46 pp), but was associated with a significant increase in both of the 1-hospital county subsample models (without matching: 0.38 pp; 95% CI, 0.02 to 0.73 pp; with matching: 0.39 pp; 95% CI, 0.01 to 0.77 pp). CONCLUSIONS AND RELEVANCE In some study models, an unexpected newborn death was associated with statistically significant increases in subsequent use of procedures to avert and mitigate fetal distress and newborn complications, which could reflect increases in identifying and proactively addressing serious potential complications or increased clinician caution applied across all cases. Future research should address whether these changes affect patient outcomes.
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Affiliation(s)
- Dan Han
- Lee Kuan Yew School of Public Policy, National University of Singapore, Singapore
| | - Aayush Khadka
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | - Jessica Cohen
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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21
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House SA, Singh N, Wasserman JR, Kim Y, Ganduglia-Cazaban C, Goodman DC. Small-Area Variation in the Care of Low-Risk Neonates in Massachusetts and Texas. Hosp Pediatr 2020; 10:1059-1067. [PMID: 33214138 DOI: 10.1542/hpeds.2020-000687] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The success of neonatal intensive care in improving outcomes for critically ill neonates led to rapid growth of NICU use in the United States, despite a relatively stable birth cohort. Less is known about NICU use among late-preterm and term infants, although recent studies have observed wide variation in their care patterns. In this study, we measure special care days (SCDs) (intermediate or intensive), length of stay, and readmission rates among low-risk neonates across regions within 2 states. METHODS In this retrospective cohort study, we analyzed data from Massachusetts (all payer claims) and Texas (BlueCross BlueShield) from 2009 to 2012. A low-risk cohort was defined by identifying newborns with diagnostic codes indicating a gestational age ≥35 weeks and birth weight ≥1500 g and excluding infants with diagnoses and procedures generally necessitating nonroutine care. Outcomes were measured across neonatal intensive care regions by diagnosis and payer type. RESULTS We identified 255 311 low-risk newborns. SCD use varied nearly sixfold across neonatal intensive care regions. Use was highest among commercially insured Texas infants (8.42 per 100), followed by Medicaid-insured Massachusetts infants (6.67 per 100) and commercially insured Massachusetts infants (5.15 per 100). Coefficients of variation indicated high variation within each payer-specific cohort and moderate to high variation across each condition. No consistent relationship between regional SCD use and 30-day readmissions was identified. CONCLUSIONS Use of NICU services varied widely across regions in this cohort of low-risk infants. Further investigation is needed to delineate outcomes associated with patterns of care received by this population.
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Affiliation(s)
- Samantha A House
- Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire; .,Department of Pediatrics, Children's Hospital at Dartmouth-Hitchcock, Lebanon, New Hampshire.,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire; and
| | - Neetu Singh
- Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire.,Department of Pediatrics, Children's Hospital at Dartmouth-Hitchcock, Lebanon, New Hampshire.,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire; and
| | - Jared R Wasserman
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire; and
| | - Youngran Kim
- Division of Management, Policy and Community Health, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Cecilia Ganduglia-Cazaban
- Division of Management, Policy and Community Health, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas
| | - David C Goodman
- Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire.,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire; and
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22
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Dimmock DP, Clark MM, Gaughran M, Cakici JA, Caylor SA, Clarke C, Feddock M, Chowdhury S, Salz L, Cheung C, Bird LM, Hobbs C, Wigby K, Farnaes L, Bloss CS, Kingsmore SF. An RCT of Rapid Genomic Sequencing among Seriously Ill Infants Results in High Clinical Utility, Changes in Management, and Low Perceived Harm. Am J Hum Genet 2020; 107:942-952. [PMID: 33157007 PMCID: PMC7675004 DOI: 10.1016/j.ajhg.2020.10.003] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/12/2020] [Indexed: 12/20/2022] Open
Abstract
The second Newborn Sequencing in Genomic Medicine and Public Health (NSIGHT2) study was a randomized, controlled trial of rapid whole-genome sequencing (rWGS) or rapid whole-exome sequencing (rWES) in infants with diseases of unknown etiology in intensive care units (ICUs). Gravely ill infants were not randomized and received ultra-rapid whole-genome sequencing (urWGS). Herein we report results of clinician surveys of the clinical utility of rapid genomic sequencing (RGS). The primary end-point-clinician perception that RGS was useful- was met for 154 (77%) of 201 infants. Both positive and negative tests were rated as having clinical utility (42 of 45 [93%] and 112 of 156 [72%], respectively). Physicians reported that RGS changed clinical management in 57 (28%) infants, particularly in those receiving urWGS (p = 0.0001) and positive tests (p < 0.00001). Outcomes of 32 (15%) infants were perceived to be changed by RGS. Positive tests changed outcomes more frequently than negative tests (p < 0.00001). In logistic regression models, the likelihood that RGS was perceived as useful increased 6.7-fold when associated with changes in management (95% CI 1.8-43.3). Changes in management were 10.1-fold more likely when results were positive (95% CI 4.7-22.4) and turnaround time was shorter (odds ratio 0.92, 95% CI 0.85-0.99). RGS seldom led to clinician-perceived confusion or distress among families (6 of 207 [3%]). In summary, clinicians perceived high clinical utility and low likelihood of harm with first-tier RGS of infants in ICUs with diseases of unknown etiology. RGS was perceived as beneficial irrespective of whether results were positive or negative.
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Affiliation(s)
- David P Dimmock
- Rady Children's Institute for Genomic Medicine, San Diego, CA 92123, USA; Rady Children's Hospital, San Diego, CA 92123, USA.
| | - Michelle M Clark
- Rady Children's Institute for Genomic Medicine, San Diego, CA 92123, USA; Rady Children's Hospital, San Diego, CA 92123, USA
| | - Mary Gaughran
- Rady Children's Institute for Genomic Medicine, San Diego, CA 92123, USA; Rady Children's Hospital, San Diego, CA 92123, USA
| | - Julie A Cakici
- Rady Children's Institute for Genomic Medicine, San Diego, CA 92123, USA; Rady Children's Hospital, San Diego, CA 92123, USA; Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA 92093, USA
| | - Sara A Caylor
- Rady Children's Institute for Genomic Medicine, San Diego, CA 92123, USA; Rady Children's Hospital, San Diego, CA 92123, USA
| | - Christina Clarke
- Rady Children's Institute for Genomic Medicine, San Diego, CA 92123, USA; Rady Children's Hospital, San Diego, CA 92123, USA
| | - Michele Feddock
- Rady Children's Institute for Genomic Medicine, San Diego, CA 92123, USA; Rady Children's Hospital, San Diego, CA 92123, USA
| | - Shimul Chowdhury
- Rady Children's Institute for Genomic Medicine, San Diego, CA 92123, USA; Rady Children's Hospital, San Diego, CA 92123, USA
| | - Lisa Salz
- Rady Children's Institute for Genomic Medicine, San Diego, CA 92123, USA; Rady Children's Hospital, San Diego, CA 92123, USA
| | - Cynthia Cheung
- Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA 92093, USA; Department of Psychiatry, University of California San Diego, San Diego, CA 92093, USA
| | - Lynne M Bird
- Rady Children's Hospital, San Diego, CA 92123, USA; Department of Pediatrics, University of California San Diego, San Diego, CA 92093, USA
| | - Charlotte Hobbs
- Rady Children's Institute for Genomic Medicine, San Diego, CA 92123, USA; Rady Children's Hospital, San Diego, CA 92123, USA
| | - Kristen Wigby
- Rady Children's Institute for Genomic Medicine, San Diego, CA 92123, USA; Rady Children's Hospital, San Diego, CA 92123, USA; Department of Pediatrics, University of California San Diego, San Diego, CA 92093, USA
| | - Lauge Farnaes
- Rady Children's Institute for Genomic Medicine, San Diego, CA 92123, USA; Rady Children's Hospital, San Diego, CA 92123, USA
| | - Cinnamon S Bloss
- Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA 92093, USA; Department of Psychiatry, University of California San Diego, San Diego, CA 92093, USA
| | - Stephen F Kingsmore
- Rady Children's Institute for Genomic Medicine, San Diego, CA 92123, USA; Rady Children's Hospital, San Diego, CA 92123, USA
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D'Apremont I, Marshall G, Musalem C, Mariani G, Musante G, Bancalari A, Fabres J, Mena P, Zegarra J, Tavosnanska J, Lacarrubba J, Solana C, Vaz Ferreira C, Herrera T, Villarroel L, Tapia JL. Trends in Perinatal Practices and Neonatal Outcomes of Very Low Birth Weight Infants during a 16-year Period at NEOCOSUR Centers. J Pediatr 2020; 225:44-50.e1. [PMID: 32454113 DOI: 10.1016/j.jpeds.2020.05.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 05/17/2020] [Accepted: 05/18/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe trends in mortality, major morbidity, and perinatal care practices of very low birth weight infants born at NEOCOSUR Neonatal Network centers from January 1, 2001, through December 31, 2016. STUDY DESIGN A retrospective analysis of prospectively collected data from all inborn infants with a birthweight of 500-1500 g and 23-35 weeks of gestation. RESULTS We examined data for 13 987 very low birth weight infants with a mean birth weight of 1081 ± 281 g and a gestational age of 28.8 ± 2.9 weeks. Overall mortality was 26.8% without significant changes throughout the study period. Decreases in early onset sepsis from 6.3% to 2.8% (P <.001), late onset sepsis from 21.1% to 19.5% (P = .002), retinopathy of prematurity from 21.3% to 13.8% (P <.001), and hydrocephalus from 3.8% to 2.4% (P <.001), were observed. The incidence for bronchopulmonary dysplasia decreased from 17.3% to 16% (P = .043), incidence of severe intraventricular hemorrhage was 10.4%, necrotizing enterocolitis 11.1%, and periventricular leukomalacia 3.8%, and did not change over the study period. Administration of antenatal corticosteroids increased from 70.2% to 82.3% and cesarean delivery from 65.9% to 75.4% (P <.001). The use of conventional mechanical ventilation decreased from 67.7% to 63.9% (P <.001) and continuous positive airway pressure use increased from 41.3% to 64.3% (P <.001). Survival without major morbidity increased from 37.4% to 44.5% over the study period (P <.001). CONCLUSIONS Progress in perinatal and neonatal care at network centers was associated with an improvement in survival without major morbidity of very low birth weight infants during a 16-year period. However, overall mortality remained unchanged.
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Affiliation(s)
- Ivonne D'Apremont
- Department of Neonatology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago de, Chile; Neonatal Unit, Hospital Dr. Sotero del Río, Santiago, Chile
| | - Guillermo Marshall
- Departament of Public Health, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago de Chile, Chile
| | - Claudia Musalem
- Department of Neonatology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago de, Chile
| | - Gonzalo Mariani
- Department of Pediatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Gabriel Musante
- Maternal and Infant Department, Hospital Universitario Austral, Pilar, Argentina
| | - Aldo Bancalari
- Hospital Guillermo Grant, Concepción, Faculty of Medicine, Universidad de Concepción, Chile
| | - Jorge Fabres
- Department of Neonatology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago de, Chile
| | - Patricia Mena
- Department of Neonatology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago de, Chile; Neonatal Unit, Hospital Dr. Sotero del Río, Santiago, Chile
| | - Jaime Zegarra
- Department of Pediatrics, Universidad Cayetano Heredia, Lima, Perú
| | - Jorge Tavosnanska
- Hospital Juan Fernández and Faculty of Medicine, Universidad de Buenos Aires, Buenos Aires, Argentina
| | | | - Claudio Solana
- Division of Neonatology, Hospital RamSardá, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Catalina Vaz Ferreira
- Department of Neonatology, Centro Hospitalario Pereira Rossell, Universidad de la República, Montevideo, Uruguay
| | - Tamara Herrera
- Department of Neonatology, Centro Hospitalario Pereira Rossell, Universidad de la República, Montevideo, Uruguay
| | - Luis Villarroel
- Departament of Public Health, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago de Chile, Chile
| | - José L Tapia
- Department of Neonatology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago de, Chile.
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24
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Green C, Leyenaar JK, Turner AL, Leslie LK. Competency of Future Pediatricians Caring for Children With Behavioral and Mental Health Problems. Pediatrics 2020; 146:peds.2019-2884. [PMID: 32561612 DOI: 10.1542/peds.2019-2884] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES There is an urgent need to prepare pediatricians to care for children with behavioral and mental health (B/MH) conditions. In this study, we evaluate the perceived competence of pediatric residents and recent graduates in the assessment and treatment of B/MH conditions, characterize variation in competence across residency programs, and identify program characteristics associated with high competence. METHODS Cross-sectional survey of applicants for the initial certifying examination in pediatrics. Questions were focused on (1) who should be competent in B/MH skills, (2) institutional support around B/MH training, and (3) perceived competence in 7 B/MH assessment skills and 9 treatment skills. Competence was rated on a 5-point scale, and high levels of assessment and treatment competence were defined as scores of ≥4. Composite measures for B/MH assessment and treatment were calculated as mean scores for each domain. We examined variation in residents' self-reported competence across programs and used linear regression to identify factors associated with high levels of competence at the program level. RESULTS Of applicants, 62.3% responded to the survey (n = 2086). Of these, 32.8% (n = 595) reported high competence in assessment skills and 18.9% (n = 337) in treatment skills. There were large variations in reported competence across programs. Respondents from smaller programs (<30 trainees) reported higher competence in assessment and treatment than those from large programs (P < .001). CONCLUSIONS Current and recent pediatric trainees do not report high levels of perceived competence in the assessment and treatment of children with B/MH conditions. The substantial variation across programs indicates that the pediatric community should create standards for B/MH training.
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Affiliation(s)
- Cori Green
- Department of Pediatrics, Weill Cornell Medicine, New York, New York;
| | - JoAnna K Leyenaar
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Adam L Turner
- The American Board of Pediatrics, Chapel Hill, North Carolina; and
| | - Laurel K Leslie
- The American Board of Pediatrics, Chapel Hill, North Carolina; and.,Departments of Medicine and Pediatrics, School of Medicine, Tufts University, Boston, Massachusetts
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25
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Lee HH, Faundez L, Yarbrough C, Lewis CW, LoSasso AT. Patterns in Pediatric Dental Surgery under General Anesthesia across 7 State Medicaid Programs. JDR Clin Trans Res 2020; 5:358-365. [PMID: 32040927 DOI: 10.1177/2380084420906114] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Children's access to dental general anesthesia (DGA) is limited, with highly variable wait times. Access factors occur at the levels of facility, dental provider, and anesthesia provider. It is unknown if these factors also influence utilization of dental surgery. We characterized patterns in DGA utilization by system, provider, population, and individual disease levels to explain variation. METHODS We conducted a cross-sectional analysis of Medicaid-enrolled children (≤9 y) who received DGA in Massachusetts, Maryland, Texas, Connecticut, Washington, Illinois, and Florida from 2011 to 2012. DGA events were characterized by the place of service, measures of disease burden, average reimbursements for dental provider and anesthesia provider, and average total expenditures. RESULTS A total of 10,149,793 children met study eligibility criteria. States with similar patterns of caries-related visits, such as Illinois (16% of Medicaid enrollees had a caries-related claim) and Washington (22%), had different DGA rates (1% and 17%, respectively). Reimbursement rates for dental providers, DGA services, and nonhospital places of services did not consistently align in states with higher DGA rates. Surgical extraction rates, as a proxy for the most severe disease, exceeded 75% in Maryland, which had the lowest DGA rate (0.3%). CONCLUSIONS Variation in DGA rates across states was not explained by reimbursements rates (provider, DGA services, place of service) or population or individual level of caries burden. Efforts to evaluate and alter utilization of DGA should consider factors such as dental and anesthesia provider capacity, health facility capacity (hospital vs. ambulatory surgery center vs. office), and population- and individual-level disease burden. Our negative findings suggest the presence of other social determinants of oral health that influence utilization of services (e.g., race/ethnicity, language preference, immigration status, policy and budget goals), which should be explored. Our findings also raise the specter that variation in surgical rates may represent instances of unmet needs or overtreatment. KNOWLEDGE TRANSFER STATEMENT The results of this study can be used by clinicians and policy makers as they address policy and clinical interventions to influence children with severe caries. Interventions to change utilization of surgical services on a population level may need to include state-specific factors that extend beyond reimbursement, disease burden, anesthesia provider type, or facility type.
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Affiliation(s)
- H H Lee
- Department of Anesthesiology, College of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - L Faundez
- Department of Economics, University of Illinois at Chicago, Chicago, IL, USA
| | - C Yarbrough
- Illinois Health and Hospital Association, Chicago, IL, USA
| | - C W Lewis
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - A T LoSasso
- Department of Economics, DePaul University, Chicago, IL, USA
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26
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Advances in Neonatal Care: 20 Years, 1445 Manuscripts, and Countless Nurses Touched and Infants Impacted! Adv Neonatal Care 2020; 20:1-8. [PMID: 31985541 DOI: 10.1097/anc.0000000000000699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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