Patterns of surgical practice in very low birth weight neonates born in the United States: a Vermont Oxford Network analysis

Epidemiology of Surgical Procedures, Anesthesia, and Imaging Studies by Gestational Age during the First Year of Life in Medicaid-Insured Infants

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.

Vermont Oxford Network: a worldwide learning community

A health care learning community engages providers and families in a collaborative environment to improve outcomes. Vermont Oxford Network (VON), a voluntary organization dedicated to improving the quality, safety and value of care through a coordinated program of data-driven quality improvement, education, and research, is a worldwide learning community in newborn medicine. Through collection of pragmatic structured data items and benchmarking reports, quality improvement collaboratives, pragmatic trials, and observational research, VON facilitates quality improvement by multidisciplinary teams and families in neonatal intensive care units (NICU) in low, middle, and high resource countries. By bringing health professionals and families together across disciplines and geographies to enable shared learning and knowledge dissemination, VON empowers individuals, organizations, and systems to meet the shared vision that every infant around the world can and should achieve their full potential.

Hospital transfers and patterns of mortality in very low birth weight neonates with surgical necrotizing enterocolitis

PURPOSE

The objectives of this study were to evaluate mortality rates in very low birth weight (VLBW) infants with surgical necrotizing enterocolitis (NEC) by level of available surgical resources and to determine the effect of hospital transfer on mortality.

METHODS

Mortality among 4328 VLBW neonates with surgical NEC born 2009-2013 was assessed using the Vermont Oxford Network database. NICUs were classified by availability of resources as a marker of overall center capability: type A (restrictions on ventilation or do not routinely perform major neonatal surgery), type B (perform major neonatal surgery but not cardiac bypass), and type C (perform major surgery, including cardiac bypass in infants).

RESULTS

Mortality was higher among those who had surgery at type B centers versus type C centers (44.3% vs 36.4%, adjusted prevalence ratio 1.20 (95% CI: 1.08, 1.33)). Neonates who were not transferred between birth and surgery had a higher mortality compared to those transferred (44.6% vs 31.6%, adjusted prevalence ratio 1.39 (95% CI: 1.25, 1.55)).

CONCLUSION

Transfer between birth and surgery and a higher level of surgical resources at the operative center were associated with lower mortality. Early transfer of high risk neonates to centers with higher levels of surgical resources may be warranted.