1
|
Handley SC, Salazar EG, Kunz SN, Lorch SA, Edwards EM. Transfer Patterns Among Infants Born at 28 to 34 Weeks' Gestation. Pediatrics 2024; 153:e2023063118. [PMID: 38268423 PMCID: PMC10827647 DOI: 10.1542/peds.2023-063118] [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] [Accepted: 11/15/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Although postnatal transfer patterns among high-risk (eg, extremely preterm or surgical) infants have been described, transfer patterns among lower-risk populations are unknown. The objective was to examine transfer frequency, indication, timing, and trajectory among very and moderate preterm infants. METHODS Observational study of the US Vermont Oxford Network all NICU admissions database from 2016 to 2021 of inborn infants 280/7 to 346/7 weeks. Infants' first transfer was assessed by gestational age, age at transfer, reason for transfer, and transfer trajectory. RESULTS Across 467 hospitals, 294 229 infants were eligible, of whom 12 552 (4.3%) had an initial disposition of transfer. The proportion of infants transferred decreased with increasing gestational age (9.6% [n = 1415] at 28 weeks vs 2.4% [n = 2646] at 34 weeks) as did the median age at time of transfer (47 days [interquartile range 30-73] at 28 weeks vs 8 days [interquartile range 3-16] at 34 weeks). The median post menstrual age at transfer was 34 or 35 weeks across all gestational ages. The most common reason for transfer was growth or discharge planning (45.0%) followed by medical and diagnostic services (30.2%), though this varied by gestation. In this cohort, 42.7% of transfers were to a higher-level unit, 10.2% to a same-level unit, and 46.7% to a lower-level unit, with indication reflecting access to specific services. CONCLUSIONS Over 4% of very and moderate preterm infants are transferred. In this population, the median age of transfer is later and does not reflect immediate care needs after birth, but rather the provision of risk-appropriate care.
Collapse
Affiliation(s)
- Sara C. Handley
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Elizabeth G. Salazar
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Sarah N. Kunz
- Division of Newborn Medicine, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Scott A. Lorch
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Erika M. Edwards
- Vermont Oxford Network, Burlington, Vermont
- Department of Pediatrics, Larner College of Medicine, The University of Vermont, Burlington, Vermont
- Department of Mathematics and Statistics, The University of Vermont, Burlington, Vermont
| |
Collapse
|
2
|
Levaillant M, Garabédian C, Legendre G, Soula J, Hamel JF, Vallet B, Lamer A. In France, the organization of perinatal care has a direct influence on the outcome of the mother and the newborn: Contribution from a French nationwide study. Int J Gynaecol Obstet 2024; 164:210-218. [PMID: 37485702 DOI: 10.1002/ijgo.15004] [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: 03/03/2023] [Revised: 06/28/2023] [Accepted: 07/04/2023] [Indexed: 07/25/2023]
Abstract
OBJECTIVE To investigate maternal and neonatal outcomes after a delivery in France in 2019, according to hospital characteristics and the impact of distance and time of travel on mother and newborn. METHODS All parturients above 18 years of age who delivered in 2019 and were identified in the French health insurance database were included, with their newborns, in this retrospective cohort study. Main outcome measures were Severe Maternal Morbidity score and the Neonatal Adverse Outcome Indicator (NAOI). RESULTS Among the 733 052 pregnancies included, 10 829 presented a severe maternal morbidity (1.48%) and 77 237 had a neonatal adverse outcome (10.4%). Factors associated with an unfavorable maternal or neonatal outcome were Obstetric Comorbidity Index, primiparity, and cesarean or instrumental delivery. Prematurity was associated with less severe maternal morbidity but more neonatal adverse outcomes. Time of travel above 30 min was associated with a higher NAOI rate. CONCLUSIONS Results suggest the efficiency of regionalization of perinatal care in France, although a difference in both outcomes persists according to unit volume, suggesting the need for a further step in concentrating perinatal care. Perinatal care organization should focus on mapping the territory with high-level, high-volume maternity throughout the territory; this suggests closing down high-volume units and improving low-volume ones to maintain coherent mapping.
Collapse
Affiliation(s)
- Mathieu Levaillant
- Université Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
- Methodology and Biostatistics Department, Angers University Hospital, University of Angers, Angers, France
| | | | - Guillaume Legendre
- Faculté de Santé, Département de Médecine, CHU d'Angers, Angers, France
- Service de Gynécologie-Obstétrique, CHU d'Angers, Angers, France
| | - Julien Soula
- Université Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
| | - Jean-François Hamel
- Methodology and Biostatistics Department, Angers University Hospital, University of Angers, Angers, France
- UMR_S1085, University of Angers, CHU Angers, University of Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail), Angers, France
| | - Benoît Vallet
- Université Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
| | - Antoine Lamer
- Université Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
- F2RSM Psy - Fédération Régionale de Recherche en Psychiatrie et Santé Mentale Hauts-de-France, Lille, France
| |
Collapse
|
3
|
Chernysh T, Opitz L, Riabtseva N, Raab M, Pavlova M. Experience with the Implementation of Continuous Medical Education among Mother-and-Child Healthcare Providers in Ukraine: A Case Study Based on Two International Collaboration Initiatives. Healthcare (Basel) 2023; 11:1964. [PMID: 37444798 DOI: 10.3390/healthcare11131964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/02/2023] [Accepted: 07/04/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Healthcare labor market shortages due to migration, inadequate investments, and lack of continuous training are essential concerns in the Eastern European region. This article aims to describe and reflect on the experience with the implementation of continuous medical education among mother-and-child healthcare providers in Ukraine, including achievements, challenges, and barriers. We analyze this case based on two international collaboration initiatives: the Swiss-Ukrainian program in mother-and-child health that ran from 2000 to 2015, supplemented by the recent Ukrainian-Swiss project "Medical education development" in 2018-2023. METHODS We use a case study approach as the methodology for our study. We collected data from documents (project reports reviews) and in-depth interviews with stakeholders. We apply the method of directed qualitative content analysis. RESULTS As a result of the Swiss-Ukrainian collaborations, the knowledge and awareness of medical personnel were greatly improved. Modern clinical concepts not well understood at the outset became commonplace and were incorporated into clinical activities. Nevertheless, obstacles to the implementation and rapid uptake of changes were found in the lack of knowledge of the English language among medical doctors, the fear of changes, and the lack of openness and readiness for novel evidence-based clinical practices. However, primary healthcare practitioners in this new project seem to be more inclined to change. CONCLUSIONS A modernized continuous medical education which is based on the values of openness, respect, dialogue, and professionalism can be implemented with the input of an international assistance program despite the resistance of the system towards change.
Collapse
Affiliation(s)
- Tetiana Chernysh
- School of Health Care Management, National University of Kyiv-Mohyla Academy, Skovorody Street 2, 04655 Kyiv, Ukraine
- Ukrainian-Swiss Project "Medical Education Development" Implemented by the Swiss Tropical and Public Health Institute, Switzerland, Liuteranska Street 6-B, 01001 Kyiv, Ukraine
| | - Lucas Opitz
- Neonatal Intensive Care Unit-NICU, Pôle d'Anesthésie Réanimation, Teaching Hospital Archet 2, Le Centre Hospitalier Universitaire-CHU de Nice, 151 rte St Antoine, 06200 Nice, France
| | | | - Martin Raab
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Kreuzstrasse 2, 4123 Allschwil, Switzerland
| | - Milena Pavlova
- Department of Health Services Research, Care and Public Health Research Institute-CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| |
Collapse
|
4
|
Bellini C, Battaglini M, Pianta M, Houbadia Y, Calevo MG, Minghetti D, Ramenghi LA. The Transport of Respiratory Distress Syndrome Twin Newborns: The 27-Year-Long Experience of Gaslini Neonatal Emergency Transport Service Using Both Single and Double Ventilators. Air Med J 2023; 42:246-251. [PMID: 37356884 DOI: 10.1016/j.amj.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/03/2023] [Accepted: 03/08/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVE Twin pregnancy rates have increased in the past 30 years. We describe the experience of the Neonatal Emergency Transport Service of the Gaslini Hospital, Genoa, Italy, in the transport of twin newborns. METHODS This was a retrospective study (1996-2021); 7,852 medical charts from the Neonatal Emergency Transport Service were reviewed. We included all twin newborns who were transported with respiratory distress syndrome in the study. We split the included patients into 2 groups (group A and group B) based on if they were simultaneously ventilated by a single ventilator or by 2 different ventilators, and then each group was split by the different types of ventilation (nasal continuous positive airway pressure or intermittent positive pressure ventilation). The pH level, base excess, O2 saturation, Pco2, body temperature, plasma glucose, and Transport Risk Index of Physiologic Stability score were recorded at departure and arrival. RESULTS One hundred thirty-six patients were included (68 pairs of twins); group A consisted of 92 newborns and group B 44 newborns. Although some significant differences were observed (statistic), none of these had real clinical significance. CONCLUSION Transporting respiratory distress syndrome twin newborns is challenging. Our study provided a 27-year experience in the field. Transporting twins by a single ventilator is possible, but, in our opinion, using 2 ventilators mounted on the same transport module is the best possible choice in terms of clinical performance, logistics, and cost.
Collapse
Affiliation(s)
- Carlo Bellini
- Neonatal Emergency Transport Service, Neonatal Intensive Care Unit, Department Mother and Child, Istituto Giannina Gaslini, Genova, Italy.
| | - Marcella Battaglini
- Neonatal Emergency Transport Service, Neonatal Intensive Care Unit, Department Mother and Child, Istituto Giannina Gaslini, Genova, Italy
| | - Marianna Pianta
- Neonatal Emergency Transport Service, Neonatal Intensive Care Unit, Department Mother and Child, Istituto Giannina Gaslini, Genova, Italy
| | - Yasmine Houbadia
- Neonatal Emergency Transport Service, Neonatal Intensive Care Unit, Department Mother and Child, Istituto Giannina Gaslini, Genova, Italy
| | - Maria Grazia Calevo
- Epidemiology and Biostatistics Unit, Scientific Direction, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Diego Minghetti
- Neonatal Emergency Transport Service, Neonatal Intensive Care Unit, Department Mother and Child, Istituto Giannina Gaslini, Genova, Italy
| | - Luca Antonio Ramenghi
- Neonatal Emergency Transport Service, Neonatal Intensive Care Unit, Department Mother and Child, Istituto Giannina Gaslini, Genova, Italy
| |
Collapse
|
5
|
The effect of minimum volume standards in hospitals (MIVOS) - protocol of a systematic review. Syst Rev 2023; 12:11. [PMID: 36670435 PMCID: PMC9862850 DOI: 10.1186/s13643-022-02160-7] [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: 08/18/2022] [Accepted: 12/14/2022] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The volume-outcome relationship, i.e., higher hospital volume results in better health outcomes, has been established for different surgical procedures as well as for certain nonsurgical medical interventions. Accordingly, many countries such as Germany, the USA, Canada, the UK, and Switzerland have established minimum volume standards. To date, there is a lack of systematically summarized evidence regarding the effects of such regulations. METHODS To be included in the review, studies must measure any effects connected to minimum volume standards. Outcomes of interest include the following: (1) patient-related outcomes, (2) process-related outcomes, and (3) health system-related outcomes. We will include (cluster) randomized controlled trials ([C]RCTs), non-randomized controlled trials (nRCTs), controlled before-after studies (CBAs), and interrupted time-series studies (ITSs). We will apply no restrictions regarding language, publication date, and publication status. We will search MEDLINE (via PubMed), Embase (via Embase), CENTRAL (via Cochrane Library), CINHAL (via EBSCO), EconLit (via EBSCO), PDQ evidence for informed health policymaking, health systems evidence, OpenGrey, and also trial registries for relevant studies. We will further search manually for additional studies by cross-checking the reference lists of all included primary studies as well as cross-checking the reference lists of relevant systematic reviews. To evaluate the risk of bias, we will use the ROBINS-I and RoB 2 risk-of-bias tools for the corresponding study designs. For data synthesis and statistical analyses, we will follow the guidance published by the EPOC Cochrane group (Cochrane Effective Practice and Organisation of Care (EPOC), EPOC Resources for review authors, 2019). DISCUSSION This systematic review focuses on minimum volume standards and the outcomes used to measure their effects. It is designed to provide thorough and encompassing evidence-based information on this topic. Thus, it will inform decision-makers and policymakers with respect to the effects of minimum volume standards and inform further studies in regard to research gaps. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42022318883.
Collapse
|
6
|
Shukla VV, Carlo WA, Niermeyer S, Guinsburg R. Neonatal resuscitation from a global perspective. Semin Perinatol 2022; 46:151630. [PMID: 35725655 DOI: 10.1016/j.semperi.2022.151630] [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] [Indexed: 11/26/2022]
Abstract
The majority of perinatal and neonatal mortality occurs in low-resource settings in low- and middle-income countries. Access and quality of care at delivery are major determinants of the health and survival of newborn infants. Availability of basic neonatal resuscitation care at birth has improved, but basic neonatal resuscitation at birth or high-quality care continues to be inaccessible in some settings, leading to persistently high perinatal and neonatal mortality. Low-resource settings of high-income countries and socially disadvantaged communities also suffer from inadequate access to quality perinatal healthcare. Quality improvement, implementation research, and innovation should focus on improving the quality of perinatal healthcare and perinatal and neonatal outcomes in low-resource settings. The current review presents an update on issues confronting universal availability of optimal resuscitation care at birth and provides an update on ongoing efforts to address them.
Collapse
Affiliation(s)
- Vivek V Shukla
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Waldemar A Carlo
- University of Colorado School of Medicine and Colorado School of Public Health, Aurora, CO, USA
| | - Susan Niermeyer
- University of Colorado School of Medicine and Colorado School of Public Health, Aurora, CO, USA
| | - Ruth Guinsburg
- Universidade Federal de São Paulo/Escola Paulista de Medicina, São Paulo, SP, Brazil.
| |
Collapse
|
7
|
Nakić Radoš S, Martinić L, Matijaš M, Brekalo M, Martin CR. The relationship between birth satisfaction, posttraumatic stress disorder and postnatal depression symptoms in Croatian women. Stress Health 2022; 38:500-508. [PMID: 34762758 DOI: 10.1002/smi.3112] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 10/27/2021] [Accepted: 11/07/2021] [Indexed: 12/24/2022]
Abstract
Studies show that a woman's dissatisfaction with her birth experience may affect her well-being. This study aimed to examine: (1) the birth satisfaction in Croatian women and compare it with UK normative data; (2) the association of different dimensions of birth satisfaction with posttraumatic stress disorder (PTSD) and depressive symptoms. In a cross-sectional online study, 603 postnatal Croatian women completed the Birth Satisfaction Scale-Revised (subscales: Stress experienced during labour (SL), Women's personal attributes (WA), and Quality of care provision (QC)); City Birth Trauma Scale (subscales: Birth-related symptoms and General symptoms); and Edinburgh Postnatal Depression Scale. Subscale and total scale scores were calculated. Path analysis tested the model of three aspects of birth satisfaction effect on PTSD dimensions and depressive symptoms. The average birth satisfaction score was significantly lower compared to the UK data on the total scale and all three subscale scores. Path analysis revealed that all three dimensions of birth satisfaction (SL, WA, and QC) had an effect on Birth-related symptoms. However, only Women's personal attributes (i.e., feeling anxiety or being in control during childbirth) had an effect on General symptoms and depressive symptoms, as well. Different aspects of birth satisfaction are important for maternal mental health following childbirth.
Collapse
Affiliation(s)
- Sandra Nakić Radoš
- Department of Psychology, Catholic University of Croatia, Zagreb, Croatia
| | - Laura Martinić
- Department of Psychology, Catholic University of Croatia, Zagreb, Croatia
| | - Marijana Matijaš
- Department of Psychology, Catholic University of Croatia, Zagreb, Croatia
| | - Maja Brekalo
- Department of Psychology, Catholic University of Croatia, Zagreb, Croatia
| | - Colin R Martin
- Institute for Health and Wellbeing, University of Suffolk, England, UK
| |
Collapse
|
8
|
Bainvoll L, Mandelbaum RS, Violette CJ, Matsuzaki S, Ho JR, Wright JD, Paulson RJ, Matsuo K. Association between hospital treatment volume and major complications in ovarian hyperstimulation syndrome. Eur J Obstet Gynecol Reprod Biol 2022; 272:240-246. [PMID: 35405452 DOI: 10.1016/j.ejogrb.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/24/2022] [Accepted: 04/03/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE An inverse relationship between hospital volume and adverse patient outcomes has been established for many conditions, but has not yet been examined in ovarian hyperstimulation syndrome (OHSS). Given the rarity of severe OHSS, but potential for high morbidity, this study aimed to elucidate the effect of hospital volume on inpatient OHSS-related complications. METHODS This is a retrospective observational study querying the National Inpatient Sample, 1/2001-12/2011. Study population was 11,878 patients with OHSS treated at 735 hospitals. Annualized hospital OHSS treatment volume was grouped as: low-volume (1 case/year), mid-volume (>1 but < 3.5 cases/year), and high-volume (≥3.5 cases/year). Main outcome measure was major complication rates stratified by hospital treatment volume, assessed by multinomial regression and binary logistic regression models. RESULTS A total of 2,415 (20.3%) patients were treated at low-volume centers, 5,023 (42.3%) at mid-volume centers, and 4,440 (37.4%) at high-volume centers. Patients treated at high-volume centers were more likely to be older and less comorbid with higher incomes and lower body mass index (P < 0.05). High-volume hospitals were more likely to be urban-teaching centers with large bed capacity (P < 0.001). Overall, 1,624 (13.7%) patients experienced a major complication during hospitalization. Patients treated at high-volume hospitals had lower rates of major complications (high: 11.0%, mid: 15.2%, low: 15.6%, P < 0.001). On multivariable analysis, treatment at high-volume hospitals was independently associated with a nearly 20% lower rate of major complications (odds ratio 0.82, 95% confidence interval 0.70-0.97, P = 0.021). CONCLUSION Our study suggests that higher hospital treatment volume for OHSS may be associated with improved outcomes.
Collapse
Affiliation(s)
- Liat Bainvoll
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Rachel S Mandelbaum
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Caroline J Violette
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Shinya Matsuzaki
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Jacqueline R Ho
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Richard J Paulson
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA.
| |
Collapse
|
9
|
Daniali ZM, Sepehri MM, Sobhani FM, Heidarzadeh M. A Regionalization Model to Increase Equity of Access to Maternal and Neonatal Care Services in Iran. J Prev Med Public Health 2022; 55:49-59. [PMID: 35135048 PMCID: PMC8841192 DOI: 10.3961/jpmph.21.401] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 10/31/2021] [Indexed: 11/22/2022] Open
Abstract
Objectives Access to maternal and neonatal care services (MNCS) is an important goal of health policy in developing countries. In this study, we proposed a 3-level hierarchical location-allocation model to maximize the coverage of MNCS providers in Iran. Methods First, the necessary criteria for designing an MNCS network were explored. Birth data, including gestational age and birth weight, were collected from the data bank of the Iranian Maternal and Neonatal Network national registry based on 3 service levels (I, II, and III). Vehicular travel times between the points of demand and MNCS providers were considered. Alternative MNCS were mapped in some cities to reduce access difficulties. Results It was found that 130, 121, and 86 MNCS providers were needed to respond to level I, II, and III demands, respectively, in 373 cities. Service level III was not available in 39 cities within the determined travel time, which led to an increased average travel time of 173 minutes to the nearest MNCS provider. Conclusions This study revealed inequalities in the distribution of MNCS providers. Management of the distribution of MNCS providers can be used to enhance spatial access to health services and reduce the risk of neonatal mortality and morbidity. This method may provide a sustainable healthcare solution at the policy and decision-making level for regional, or even universal, healthcare networks.
Collapse
Affiliation(s)
- Zahra Mohammadi Daniali
- Department of Industrial Engineering, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Mohammad Mehdi Sepehri
- Department of Healthcare Systems Engineering, Faculty of Industrial and Systems Engineering, Tarbiat Modares University, Tehran, Iran
- Corresponding author: Mohammad Mehdi Sepehri Department of Healthcare Systems Engineering, Faculty of Industrial and Systems Engineering, Tarbiat Modares University, Jalal Al-e-Ahmad Highway, Tehran 1411713116, Iran E-mail:
| | - Farzad Movahedi Sobhani
- Department of Industrial Engineering, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | | |
Collapse
|
10
|
Kunz SN, Helkey D, Zitnik M, Phibbs CS, Rigdon J, Zupancic JAF, Profit J. Quantifying the variation in neonatal transport referral patterns using network analysis. J Perinatol 2021; 41:2795-2803. [PMID: 34035453 PMCID: PMC8613294 DOI: 10.1038/s41372-021-01091-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/31/2021] [Accepted: 04/30/2021] [Indexed: 12/03/2022]
Abstract
OBJECTIVE Regionalized care reduces neonatal morbidity and mortality. This study evaluated the association of patient characteristics with quantitative differences in neonatal transport networks. STUDY DESIGN We retrospectively analyzed prospectively collected data for infants <28 days of age acutely transported within California from 2008 to 2012. We generated graphs representing bidirectional transfers between hospitals, stratified by patient attribute, and compared standard network analysis metrics. RESULT We analyzed 34,708 acute transfers, representing 1594 unique transfer routes between 271 hospitals. Density, centralization, efficiency, and modularity differed significantly among networks drawn based on different infant attributes. Compared to term infants and to those transported for medical reasons, network metrics identify greater degrees of regionalization for preterm and surgical patients (more centralized and less dense, respectively [p < 0.001]). CONCLUSION Neonatal interhospital transport networks differ by patient attributes as reflected by differences in network metrics, suggesting that regionalization should be considered in the context of a multidimensional system.
Collapse
Affiliation(s)
- Sarah N. Kunz
- Division of Newborn Medicine, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA,Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Daniel Helkey
- Department of Pediatrics – Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, California, USA,California Perinatal Quality Care Collaborative, Palo Alto, California, USA
| | - Marinka Zitnik
- Department of Biomedical Informatics, Harvard University, Boston, Massachusetts, USA
| | - Ciaran S. Phibbs
- Department of Pediatrics – Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, California, USA,Health Economics Resource Center, Veterans Affairs Palo Alto Healthcare Systm, Menlo Park, California, USA
| | - Joseph Rigdon
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - John A. F. Zupancic
- Division of Newborn Medicine, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA,Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jochen Profit
- Department of Pediatrics – Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, California, USA,California Perinatal Quality Care Collaborative, Palo Alto, California, USA
| |
Collapse
|
11
|
Desplanches T, Morgan AS, Jones P, Diguisto C, Zeitlin J, Martin-Marchand L, Benhammou V, Lecomte B, Rozé JC, Truffert P, Ancel PY, Sagot P, Roussot A, Fresson J, Blondel B. Risk factors for very preterm delivery out of a level III maternity unit: The EPIPAGE-2 cohort study. Paediatr Perinat Epidemiol 2021; 35:694-705. [PMID: 33956996 DOI: 10.1111/ppe.12770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Regionalisation programmes aim to ensure that very preterm infants are born in level III units (inborn) through antenatal referral or transfer. Despite widespread knowledge about better survival without disability for inborn babies, 10%-30% of women deliver outside these units (outborn). OBJECTIVE To investigate risk factors associated with outborn deliveries and to estimate the proportion that were probably or possibly avoidable. METHODS We used a national French population-based cohort including 2205 women who delivered between 24 and 30+6 weeks in 2011. We examined risk factors for outborn delivery related to medical complications, antenatal care, sociodemographic characteristics and living far from a level III unit using multivariable binomial regression. Avoidable outborn deliveries were defined by pregnancy risk (obstetric history, antenatal hospitalisation) and time available for transfer. RESULTS 25.0% of women were initially booked in level III, 9.1% were referred, 49.8% were transferred, and 16.1% had outborn delivery. Risk factors for outborn delivery were gestational age <26 weeks (adjusted relative risk (aRR) 1.37, 95% confidence interval (CI) 1.13, 1.66), inadequate antenatal care (aRR 1.39, 95% CI 1.10, 1.81), placental abruption (aRR 1.66, 95% CI 1.27, 2.17), and increased distance to the closest level III unit ((aRR 2.79, 95% CI 2.00, 3.92) in the 4th versus 1st distance quartile). Among outborn deliveries, 16.7% were probably avoidable, and 25.6% possibly avoidable, which could increase the proportion of inborn deliveries between 85.9% and 92.9%. Avoidable outborn deliveries were mainly associated with gestational age, intrauterine growth restriction, preterm premature rupture of membranes, and haemorrhage, but not distance. CONCLUSIONS Our study identified some modifiable risk factors for outborn delivery; however, when regionalised care relies heavily on antenatal transfer, as it does in France, only some outborn deliveries may be prevented. Earlier referral of high-risk women will be needed to achieve full access to tertiary care.
Collapse
Affiliation(s)
- Thomas Desplanches
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France.,CHRU Dijon, Department of Gynaecology, Obstetrics, Foetal Medicine and Infertility, Dijon, France
| | - Andrei S Morgan
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France.,Department of Neonatology, Elizabeth Garrett Anderson Institute for Women's Health, UCL, London, UK.,Embrace Yorkshire and Humber Infant and Paediatric Transport Service, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Peter Jones
- SAMU de Paris, AP-HP, Hôpital Necker Enfants Malades, Paris, France.,Réanimation Pédiatrique AP-HP, Hôpital Robert Debré, Paris, France
| | - Caroline Diguisto
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France.,Department of Obstetrics and Gynecology, University Hospital of Tours, Tours University, Tours, France
| | - Jennifer Zeitlin
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France
| | - Laetitia Martin-Marchand
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France
| | - Valérie Benhammou
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France
| | | | - Jean-Christophe Rozé
- Pediatric Intensive Care Unit, Mothers' and Children's Hospital, Nantes Teaching Hospital, Nantes, France
| | - Patrick Truffert
- Neonatal Intensive Care Unit, Jeanne de Flandre Hospital, CHRU Lille, Lille, France
| | - Pierre-Yves Ancel
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France.,Clinical Research Unit, Center for Clinical Investigation P1419, CHU Cochin Broca Hôtel-Dieu, Paris, France
| | - Paul Sagot
- CHRU Dijon, Department of Gynaecology, Obstetrics, Foetal Medicine and Infertility, Dijon, France
| | - Adrien Roussot
- Biostatistics and Bioinformatics (DIM), University Hospital, Dijon, France.,Bourgogne Franche-Comté University, Dijon, France
| | - Jeanne Fresson
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France.,Department of Medical Information, University Hospital (CHRU) Nancy, Nancy, France
| | - Béatrice Blondel
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France
| |
Collapse
|
12
|
Ahuja N, Mack WJ, Russell CJ. Technology-Dependent Pediatric Inpatients at Children's Versus Nonchildren's Hospitals. Hosp Pediatr 2021; 10:481-488. [PMID: 32457052 DOI: 10.1542/hpeds.2019-0236] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVE Technology-dependent children (TDC) are admitted to both children's hospitals (CHs) and nonchildren's hospitals (NCHs), where there may be fewer pediatric-specific specialists or resources. Our objective was to compare the characteristics of TDC admitted to CHs versus NCHs. METHODS This was a multicenter, retrospective study using the 2012 Kids' Inpatient Database. We included patients aged 0 to 18 years with a tracheostomy, gastrostomy, and/or ventricular shunt. We excluded those who died, were transferred into or out of the hospital, had a length of stay (LOS) that was an extreme outlier, or had missing data for key variables. We compared patient and hospital characteristics across CH versus NCH using χ2 tests and LOS and cost using generalized linear models. RESULTS In the final sample of 64 521 discharges, 55% of discharges of TDC were from NCHs. A larger proportion of those from CHs had higher disease severity (55% vs 49%; P < .001) and a major surgical procedure during hospitalization (28% vs 24%; P < .001). In an adjusted generalized linear model, the mean LOS was 4 days at both hospital types, but discharge from a CH was associated with a higher adjusted mean cost ($16 754 vs $12 023; P < .001). CONCLUSIONS Because the majority of TDC are hospitalized at NCHs, future research on TDC should incorporate NCH settings. Further studies should investigate if some may benefit from regionalization of care or earlier transfer to a CH.
Collapse
Affiliation(s)
- Namrata Ahuja
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California; and .,Departments of Pediatrics and
| | - Wendy J Mack
- Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Christopher J Russell
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California; and.,Departments of Pediatrics and
| |
Collapse
|
13
|
White MJ, Sutton AG, Ritter V, Fine J, Chase L. Interfacility Transfers Among Patients With Complex Chronic Conditions. Hosp Pediatr 2021; 10:114-122. [PMID: 31988068 DOI: 10.1542/hpeds.2019-0105] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To describe interfacility transfers among children with complex chronic conditions (CCCs) and determine if interfacility transfer was associated with health outcomes. We hypothesized that interfacility transfer would be associated with length of stay (LOS), receipt of critical care services, and in-hospital mortality. METHODS In this retrospective cohort study, we used data from the 2012 Kids' Inpatient Database. CCC hospitalizations were identified by International Classification of Diseases, Ninth Revision codes. Receipt of critical care services was inferred by using International Classification of Diseases, Ninth Revision diagnosis and procedure codes. We performed a descriptive analysis of CCC hospitalizations then determined if transfer was associated with LOS, mortality, or receipt of critical care services using survey-adapted quasi-Poisson or logistic regression models, controlling for hospital and patient demographics. RESULTS There were 551 974 non-birth hospitalizations with at least 1 CCC diagnosis code. Of these, 13% involved an interfacility transfer. Compared with patients with CCCs who were not transferred, patients with CCCs who were transferred in and ultimately discharged from the receiving hospital had an adjusted LOS rate ratio of 1.6 (95% confidence interval [CI]: 1.5-1.7; P < .001), were more likely to have received critical care services (adjusted odds ratio 3.0; 95% CI: 2.7-3.2; P < .001), and had higher in-hospital mortality (adjusted odds ratio 3.6; 95% CI: 3.2-3.9; P < .001) (controlling for patient and hospital characteristics). CONCLUSIONS Many hospitalizations for children with CCCs involve interfacility transfer. Compared with in-house admissions, hospitalizations of patients who are transferred in and ultimately discharged from the receiving hospital involve longer LOS, greater odds of receipt of critical care services, and in-hospital mortality. Further evaluation of the role of clinical and transfer logistic factors is needed to improve outcomes.
Collapse
Affiliation(s)
- Michelle J White
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, School of Medicine, and
| | - Ashley G Sutton
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, School of Medicine, and
| | - Victor Ritter
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jason Fine
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Lindsay Chase
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, School of Medicine, and
| |
Collapse
|
14
|
Hannan KE, Bourque SL, Palmer C, Tong S, Hwang SS. Prevalence and Predictors of Medical Complexity in a National Sample of VLBW Infants. Hosp Pediatr 2021; 11:525-535. [PMID: 33906959 DOI: 10.1542/hpeds.2020-004945] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Very low birth weight (VLBW) infants are at high risk for morbidities beyond the neonatal period and ongoing use of health care. Specific morbidities have been studied; however, a comprehensive landscape of medical complexity in VLBW infants has not been fully described. We sought to (1) describe the prevalence of complex chronic conditions (CCCs) and (2) determine the association of demographic, hospital, and clinical factors with CCCs and CCCs or death. METHODS This retrospective cross-sectional analysis of discharge data from the Kids' Inpatient Database (2009-2012) included infants with a birth weight <1500 g and complete demographics. Outcomes included having CCCs or having either CCCs or dying. Analyses were weighted; univariate and multiple logistic regression models were used to estimate unadjusted and adjusted odds ratios. A dominance analysis with Cox-Snell R 2 determined the relative contribution of demographic, hospital, and clinical factors to the outcomes. RESULTS Among our weighted cohort of >78 000 VLBW infants, >50% had CCCs or died. After adjustments, the prevalence of CCCs or CCCs or death differed by sex, race and ethnicity, hospital location, US region, receipt of surgery, transfer status, and birth weight. Clinical factors accounted for the highest proportion of the model's ability to predict CCCs and CCCs or death at 93.3% and 96.3%, respectively, whereas demographic factors were 11.5% and 2.3% and hospital factors were 5.2% and 1.4%, respectively. CONCLUSIONS In this nationally representative analysis, medical complexity is high among VLBW infants. Varying contributions of demographic, hospital, and clinical factors in predicting medical complexity offer opportunities to investigate future interventions to improve care delivery and patient outcomes.
Collapse
Affiliation(s)
- Kathleen E Hannan
- Section of Neonatology, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - Stephanie Lynn Bourque
- Section of Neonatology, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - Claire Palmer
- Section of Neonatology, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - Suhong Tong
- Section of Neonatology, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - Sunah Susan Hwang
- Section of Neonatology, Department of Pediatrics, University of Colorado, Aurora, Colorado
| |
Collapse
|
15
|
Ramos MC, Barreto JOM, Shimizu HE, de Moraes APG, da Silva EN. Regionalization for health improvement: A systematic review. PLoS One 2020; 15:e0244078. [PMID: 33351841 PMCID: PMC7755212 DOI: 10.1371/journal.pone.0244078] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 12/02/2020] [Indexed: 12/20/2022] Open
Abstract
Regionalization is the integrated organization of a healthcare system, wherein regional structures are responsible for providing and administrating health services in a specific region. This method was adopted by several countries to improve the quality of provided care and to properly utilize available resources. Thus, a systematic review was conducted to verify effective interventions to improve health and management indicators within the health services regionalization. The protocol was registered in PROSPERO (CRD42016042314). We performed a systematic search in databases during February and March 2017 which was updated in October 2020. There was no language or date restriction. We included experimental and observational studies with interventions focused on regionalization-related actions, measures or policies aimed at decentralizing and organizing health offerings, rationalizing scarce capital and human resources, coordinating health services. A methodological assessment of the studies was performed using instruments from the Joanna Briggs Institute and GRADE was also used to assess outcomes. Thirty-nine articles fulfilled the eligibility criteria and sixteen interventions were identified that indicated different degrees of recommendations for improving the management of health system regionalization. The results showed that regionalization was effective under administrative decentralization and for rationalization of resources. The most investigated intervention was the strategy of concentrating procedures in high-volume hospitals, which showed positive outcomes, especially with the reduction of hospitalization days and in-hospital mortality rates. When implementing regionalization, it must be noted that it involves changes in current standards of health practice and in the distribution of health resources, especially for specialized services.
Collapse
Affiliation(s)
- Maíra Catharina Ramos
- Faculty of Health Sciences, University of Brasilia, Brasília, Brazil
- Oswaldo Cruz Foundation, Brasília, Brazil
| | | | | | | | | |
Collapse
|
16
|
Malouf RS, Tomlinson C, Henderson J, Opondo C, Brocklehurst P, Alderdice F, Phalguni A, Dretzke J. Impact of obstetric unit closures, travel time and distance to obstetric services on maternal and neonatal outcomes in high-income countries: a systematic review. BMJ Open 2020; 10:e036852. [PMID: 33318106 PMCID: PMC7735086 DOI: 10.1136/bmjopen-2020-036852] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES To systematically review (1) The effect of obstetric unit (OU) closures on maternal and neonatal outcomes and (2) The association between travel distance/time to an OU and maternal and neonatal outcomes. DESIGN Systematic review of any quantitative studies with a comparison group. DATA SOURCES Embase, MEDLINE, PsycINFO, Applied Social Science Index and Abstracts, Cumulative Index to Nursing and Allied Health and grey literature were searched. METHODS Eligible studies explored the impact of closure of an OU or the effect of travel distance/time on prespecified maternal or neonatal outcomes. Only studies of women giving birth in high-income countries with universal health coverage of maternity services comparable to the UK were included. Identification of studies, extraction of data and risk of bias assessment were undertaken by at least two reviewers independently. The risk of bias checklist was based on the Cochrane Effective Practice and Organisation of Care criteria and the Newcastle-Ottawa scale. Heterogeneity across studies precluded meta-analysis and synthesis was narrative, with key findings tabulated. RESULTS 31 studies met the inclusion criteria. There was some evidence to suggest an increase in babies born before arrival following OU closures and/or associated with longer travel distances or time. This may be associated with an increased risk of perinatal or neonatal mortality, but this finding was not consistent across studies. Evidence on other maternal and neonatal outcomes was limited but did not suggest worse outcomes after closures or with longer travel times/distances. Interpretation of findings for some studies was hampered by concerns around how accurately exposures were measured, and/or a lack of adjustment for confounders or temporal changes. CONCLUSION It is not possible to conclude from this review whether OU closure, increased travel distances or times are associated with worse outcomes for the mother or the baby. PROSPERO REGISTRATION NUMBER CRD42017078503.
Collapse
Affiliation(s)
- Reem Saleem Malouf
- Nuffield Department of Population Health, Policy Research Unit in Maternal Health and Care, National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Claire Tomlinson
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Jane Henderson
- Nuffield Department of Population Health, Policy Research Unit in Maternal Health and Care, National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Charles Opondo
- Nuffield Department of Population Health, Policy Research Unit in Maternal Health and Care, National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Peter Brocklehurst
- Nuffield Department of Population Health, Policy Research Unit in Maternal Health and Care, National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Fiona Alderdice
- Nuffield Department of Population Health, Policy Research Unit in Maternal Health and Care, National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Angaja Phalguni
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Janine Dretzke
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| |
Collapse
|
17
|
Walther F, Küster DB, Bieber A, Rüdiger M, Malzahn J, Schmitt J, Deckert S. Impact of regionalisation and case-volume on neonatal and perinatal mortality: an umbrella review. BMJ Open 2020; 10:e037135. [PMID: 32978190 PMCID: PMC7520832 DOI: 10.1136/bmjopen-2020-037135] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE This umbrella review summarises and critically appraises the evidence on the effects of regulated or high-volume perinatal care on outcome among very low birth weight/very preterm infants born in countries with neonatal mortality <5/1000 births. INTERVENTION/EXPOSITION Perinatal regionalisation, centralisation, case-volume. PRIMARY OUTCOMES Death. SECONDARY OUTCOMES Disability, discomfort, disease, dissatisfaction. METHODS On 29 November 2019 a systematic search in MEDLINE and Embase was performed and supplemented by hand search. Relevant systematic reviews (SRs) were critically appraised with A MeaSurement Tool to Assess systematic Reviews 2. RESULTS The literature search revealed 508 hits and three SRs were included. Effects of perinatal regionalisation were assessed in three (34 studies) and case-volume in one SR (6 studies). Centralisation has not been evaluated. The included SRs reported effects on 'death' (eg, neonatal), 'disability' (eg, mental status), 'discomfort' (eg, maternal sensitivity) and 'disease' (eg, intraventricular haemorrhages). 'Dissatisfactions' were not reported. The critical appraisal showed a heterogeneous quality ranging from moderate to critically low. A pooled effect estimate was reported once and showed a significant favour of perinatal regionalisation in terms of neonatal mortality (OR 1.60, 95% CI 1.33-1.92). The qualitative evidence synthesis of the two SRs without pooled estimate suggests superiority of perinatal regionalisation in terms of different mortality and non-mortality outcomes. In one SR, contradictory results of lower neonatal mortality rates were reported in hospitals with higher birth volumes. CONCLUSIONS Regionalised perinatal care seems to be a crucial care strategy to improve the survival of very low birth weight and preterm births. To overcome the low and critically low methodological quality and to consider additional clinical and patient-reported results that were not addressed by the SRs included, we recommend an updated SR. In the long term, an international, uniformly conceived and defined perinatal database could help to provide evidence-based recommendations on optimal strategies to regionalise perinatal care. PROSPERO REGISTRATION NUMBER CRD42018094835.
Collapse
Affiliation(s)
- Felix Walther
- Center for Evidence-based Healthcare, TU Dresden Faculty of Medicine Carl Gustav Carus, Dresden, Germany
- Quality and Medical Risk Management, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Denise Bianca Küster
- Center for Evidence-based Healthcare, TU Dresden Faculty of Medicine Carl Gustav Carus, Dresden, Germany
| | - Anja Bieber
- Center for Evidence-based Healthcare, TU Dresden Faculty of Medicine Carl Gustav Carus, Dresden, Germany
- Institute of Health and Nursing Science, Martin Luther-Universitat Halle-Wittenberg, Halle, Germany
| | - Mario Rüdiger
- Department for Neonatology and Pediatric Intensive Care, University Hospital Carl Gustav Carus, Dresden, Germany
- Saxony Center for Feto-Neonatal Health, TU Dresden Faculty of Medicine Carl Gustav Carus, Dresden, Germany
| | - Jürgen Malzahn
- Clinical Care, Federation of Local Health Insurance Funds, Berlin, Germany
| | - Jochen Schmitt
- Center for Evidence-based Healthcare, TU Dresden Faculty of Medicine Carl Gustav Carus, Dresden, Germany
- Saxony Center for Feto-Neonatal Health, TU Dresden Faculty of Medicine Carl Gustav Carus, Dresden, Germany
| | - Stefanie Deckert
- Center for Evidence-based Healthcare, TU Dresden Faculty of Medicine Carl Gustav Carus, Dresden, Germany
| |
Collapse
|
18
|
Eschenroeder LW, Nguyen VP, Neradilek MB, Li S, Dardas TF. Patterns of Hospital Bypass and Interhospital Transfer Among Patients With Heart Failure. J Card Fail 2020; 26:762-768. [DOI: 10.1016/j.cardfail.2020.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 04/03/2020] [Accepted: 04/22/2020] [Indexed: 11/30/2022]
|
19
|
Abstract
Regionalization, which emphasizes matching patient needs with the capabilities of the hospital in which care is provided, has long been a recommended approach to reducing neonatal morbidity and mortality. Over the past decade, research methods surrounding the measurement and evaluation of such programs have improved, thus strengthening arguments for implementation of these strategies. However, regionalization policies vary widely across regions and between countries, with potential impacts on neonatal outcomes as well as costs of care. It is important to account for geographic and other regional differences when determining the feasibility of regionalization for a specific region, as certain areas and populations may need particular consideration in order for regionalization policies to be successful.
Collapse
|
20
|
Ismail AQT, Boyle EM, Pillay T. The impact of level of neonatal care provision on outcomes for preterm babies born between 27 and 31 weeks of gestation, or with a birth weight between 1000 and 1500 g: a review of the literature. BMJ Paediatr Open 2020; 4:e000583. [PMID: 32232179 PMCID: PMC7101044 DOI: 10.1136/bmjpo-2019-000583] [Citation(s) in RCA: 4] [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: 09/18/2019] [Revised: 01/14/2020] [Accepted: 01/31/2020] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE There is evidence that birth and care in a maternity service associated with a neonatal intensive care unit (NICU) is associated with improved survival in preterm babies born at <27 weeks of gestation. We conducted a systematic review to address whether similar gains manifested in babies born between 27+0 and 31+6 weeks (hereafter 27 and 31 weeks) of gestation, or in those with a birth weight between 1000 and 1500 g. METHODS We searched Embase, Medline and CINAHL databases for studies comparing outcomes for babies born between 27 and 31 weeks or between 1000 and 1500 g birth weight, based on designation of the neonatal unit where the baby was born or subsequently cared for (NICU vs non-NICU setting). A modified QUIPS (QUality In Prognostic Studies) tool was used to assess quality. RESULTS Nine studies compared outcomes for babies born between 27 and 31 weeks of gestation and 11 studies compared outcomes for babies born between 1000 and 1500 g birth weight. Heterogeneity in comparator groups, birth locations, gestational age ranges, timescale for mortality reporting, and description of morbidities facilitated a narrative review as opposed to a meta-analysis. CONCLUSION Due to paucity of evidence, significant heterogeneity and potential for bias, we were not able to answer our question-does place of birth or care affect outcomes for babies born between 27 and 31 weeks? This supports the need for large-scale research to investigate place of birth and care for babies born in this gestational age range.
Collapse
Affiliation(s)
- Abdul Qader Tahir Ismail
- Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK.,Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Elaine M Boyle
- Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - Thillagavathie Pillay
- Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK.,School of Medicine and Clinical Practice, Faculty of Science and Engineering, University of Wolverhampton, Wolverhampton, UK
| | | |
Collapse
|
21
|
Desplanches T, Blondel B, Morgan AS, Burguet A, Kaminski M, Lecomte B, Marchand-Martin L, Rozé JC, Sagot P, Truffert P, Zeitlin J, Ancel PY, Fresson J. Volume of Neonatal Care and Survival without Disability at 2 Years in Very Preterm Infants: Results of a French National Cohort Study. J Pediatr 2019; 213:22-29.e4. [PMID: 31280891 DOI: 10.1016/j.jpeds.2019.06.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 05/10/2019] [Accepted: 06/03/2019] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To investigate the relation between neonatal intensive care unit (NICU) volume and survival, and neuromotor and sensory disabilities at 2 years in very preterm infants. STUDY DESIGN The EPIPAGE-2 (Etude Epidémiologique sur les Petits Âges Gestationnels-2) national prospective population-based cohort study was used to include 2447 babies born alive in 66 level III hospitals between 24 and 30 completed weeks of gestation in 2011. The outcome was survival without disabilities (levels 2-5 of the Gross Motor Function Classification System for cerebral palsy with or without unilateral or bilateral blindness or deafness). Units were grouped in quartiles according to volume, defined as the annual admissions of very preterm babies. Multivariate logistic regression analyses with population average models were used. RESULTS Survival at discharge was lower in hospitals with lower volumes of neonatal activity (aOR 0.55, 95% CI 0.33-0.91). Survival without neuromotor and sensory disabilities at 2 years increased with hospital volume, from 75% to 80.7% in the highest volume units. After adjustment for gestational age, small for gestational age, sex, maternal age, infertility treatment, multiple pregnancy, principal cause of prematurity, parental socioeconomic status, and mother's country of birth, survival without neuromotor or sensory disabilities was significantly lower in hospitals with a lower volume of neonatal activity (aOR 0.60, 95% CI 0.38-0.95) than in the highest quartile hospitals. CONCLUSIONS These results suggest that lower neonatal intensive care unit volume is associated with lower survival without an increase in disabilities at 2 years. These results could be useful to generate improvements of perinatal regionalization.
Collapse
Affiliation(s)
- Thomas Desplanches
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris Descartes University, Paris, France; CHRU Dijon, Department of Gynecology, Obstetrics, Fetal Medicine, and Infertility, University of Burgundy and Franche-Comté, Dijon, France.
| | - Béatrice Blondel
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris Descartes University, Paris, France
| | - Andrei Scott Morgan
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris Descartes University, Paris, France
| | - Antoine Burguet
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris Descartes University, Paris, France; Department of Neonatal Pediatrics, Dijon University Hospital, Dijon, France
| | - Monique Kaminski
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris Descartes University, Paris, France
| | | | - Laetitia Marchand-Martin
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris Descartes University, Paris, France
| | - Jean-Christophe Rozé
- Pediatric Intensive Care Unit, Mothers' and Children's Hospital, Nantes Teaching Hospital, Nantes, France
| | - Paul Sagot
- CHRU Dijon, Department of Gynecology, Obstetrics, Fetal Medicine, and Infertility, University of Burgundy and Franche-Comté, Dijon, France
| | - Patrick Truffert
- Neonatal Intensive Care Unit, Jeanne de Flandre Hospital, CHRU Lille, Lille, France
| | - Jennifer Zeitlin
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris Descartes University, Paris, France
| | - Pierre-Yves Ancel
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris Descartes University, Paris, France; Clinical Research Unit, Center for Clinical Investigation P1419, CHU Cochin Broca Hôtel-Dieu, Paris, France
| | - Jeanne Fresson
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris Descartes University, Paris, France; CHRU Nancy, Department of Medical Information, Nancy, France
| |
Collapse
|
22
|
Iverson KR, Svensson E, Sonderman K, Barthélemy EJ, Citron I, Vaughan KA, Powell BL, Meara JG, Shrime MG. Decentralization and Regionalization of Surgical Care: A Review of Evidence for the Optimal Distribution of Surgical Services in Low- and Middle-Income Countries. Int J Health Policy Manag 2019; 8:521-537. [PMID: 31657175 PMCID: PMC6815989 DOI: 10.15171/ijhpm.2019.43] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 05/28/2019] [Indexed: 12/15/2022] Open
Abstract
Background: While recommendations for the optimal distribution of surgical services in high-income countries (HICs) exist, it is unclear how these translate to resource-limited settings. Given the significant shortage and maldistribution of surgical workforce and infrastructure in many low- and middle-income countries (LMICs), the optimal role of decentralization versus regionalization (centralization) of surgical care is unknown. The aim of this study is to review evidence around interventions aimed at redistributing surgical services in LMICs, to guide recommendations for the ideal organization of surgical services. Methods: A narrative-based literature review was conducted to answer this question. Studies published in English between 1997 and 2017 in PubMed, describing interventions to decentralize or regionalize a surgical procedure in a LMIC, were included. Procedures were selected using the Disease Control Priorities’ (DCP3) Essential Surgery Package list. Intervention themes and outcomes were analyzed using a narrative, thematic synthesis approach. Primary outcomes included mortality, complications, and patient satisfaction. Secondary outcomes included input measures: workforce and infrastructure, and process measures: facility-based care, surgical volume, and referral rates. Results: Thirty-five studies were included. Nine (33%) of the 27 studies describing decentralization showed an improvement in primary outcomes. The procedures associated with improved outcomes after decentralization included most obstetric, gynecological, and family planning services as well as some minor general surgery procedures. Out of 8 studies on regionalization (centralization), improved outcomes were shown for trauma care in one study and cataract extraction in one study. Conclusion: Interventions aimed at decentralizing obstetric care to the district hospital and health center levels have resulted in mortality benefits in several countries. However, more evidence is needed to link service distribution to patient outcomes in order to provide recommendations for the optimal organization of other surgical procedures in LMICs. Considerations for the optimal distribution of surgical procedures should include the acuity of the condition for which the procedure is indicated, anticipated case volume, and required level of technical skills, resources, and infrastructure. These attributes should be considered within the context of each country.
Collapse
Affiliation(s)
- Katherine R Iverson
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,General Surgery Department, University of California Davis Medical Center, Sacramento, CA, USA
| | - Emma Svensson
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Lund University, Lund, Sweden
| | - Kristin Sonderman
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
| | - Ernest J Barthélemy
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Isabelle Citron
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | - Kerry A Vaughan
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,University of Pennsylvania, Philadelphia, PA, USA
| | - Brittany L Powell
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Stanford University School of Medicine, Stanford, CA, USA
| | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Mark G Shrime
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| |
Collapse
|
23
|
Moxon SG, Blencowe H, Bailey P, Bradley J, Day LT, Ram PK, Monet JP, Moran AC, Zeck W, Lawn JE. Categorising interventions to levels of inpatient care for small and sick newborns: Findings from a global survey. PLoS One 2019; 14:e0218748. [PMID: 31295262 PMCID: PMC6623953 DOI: 10.1371/journal.pone.0218748] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 06/08/2019] [Indexed: 12/22/2022] Open
Abstract
Background In 2017, 2.5 million newborns died, mainly from prematurity, infections, and intrapartum events. Preventing these deaths requires health systems to provide routine and emergency care at birth, and quality inpatient care for small and sick newborns. Defined levels of emergency obstetric care (EmOC) and standardised measurement of “signal functions” has improved tracking of maternal care in low- and middle-income countries (LMICs). Levels of newborn care, particularly for small and sick newborns, and associated signal functions are still not consistently defined or tracked. Methods Between November 2016-November 2017, we conducted an online survey of professionals working in maternal and newborn health. We asked respondents to categorise 18 clinical care interventions that could act as potential signal functions for small and sick newborns to 3 levels of care they thought were appropriate for health systems in LMICs to provide: “routine care at birth”, “special care” and “intensive care”. We calculated the percentage of respondents that classified each intervention at each level of care and stratified responses to look at variation by respondent characteristics. Results Six interventions were classified to specific levels by more than 50% of respondents as “routine care at birth,” three interventions as “special care” and one as “intensive care”. Eight interventions were borderline between these care levels. Responses were more consistent for interventions with relevant WHO clinical care guidelines while more variation in respondents’ classification was observed in complex interventions that lack standards or guidelines. Respondents with experience in lower-income settings were more likely to assign a higher level of care for more complex interventions. Conclusions Results were consistent with known challenges of scaling up inpatient care in lower-income settings and underline the importance of comprehensive guidelines and standards for inpatient care. Further work is needed to develop a shortlist of newborn signal functions aligned with emergency obstetric care levels to track universal health coverage for mothers and their newborns.
Collapse
Affiliation(s)
- Sarah G. Moxon
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Hannah Blencowe
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Patricia Bailey
- Averting Maternal Death & Disability, Mailman School of Public Health, Columbia University, New York, United States of America
| | - John Bradley
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Louise Tina Day
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Pavani K. Ram
- Office of Maternal and Child Health and Nutrition, US Agency for International Development, Washington DC, United States of America
| | - Jean-Pierre Monet
- Technical Division, United Nations Population Fund (UNFPA), New York, United States of America
| | - Allisyn C. Moran
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organisation, Geneva, Switzerland
| | - Willibald Zeck
- UNICEF Health Section, United Nations Children’s Fund (UNICEF), New York, United States of America
| | - Joy E. Lawn
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| |
Collapse
|
24
|
Vanderlaan J, Rochat R, Williams B, Dunlop A, Shapiro SE. Associations Between Hospital Maternal Service Level and Delivery Outcomes. Womens Health Issues 2019; 29:252-258. [PMID: 30935820 DOI: 10.1016/j.whi.2019.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 02/04/2019] [Accepted: 02/22/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE This study explored the associations between delivery hospital self-reported level of maternal service, as defined by the American Hospital Association, and both maternal and neonatal outcomes among women at high maternal risk, as defined by the Obstetric Comorbidity Index. METHODS This was a secondary analysis of linked delivery hospitalization discharge and vital records data for women experiencing singleton births in Georgia from 2008 to 2012. The need for maternal transfer was defined using a sample-specific cut-off of the risk score calculated using the Obstetric Comorbidity Index. Outcomes included poor maternal outcome (severe maternal morbidity or death), maternal length of stay, preterm delivery, low birth weight, and perinatal death. The analysis was completed using hierarchical logistic regression with a two-level model considering hospital level of maternal service and controlling for maternal race and transfer status. RESULTS In these data, there was no difference in the odds of a poor maternal or neonatal outcome according to delivery hospital level of maternal care; however, delivery at a hospital with maternal service level III was associated with a higher odds of an extended length of stay. CONCLUSIONS For this group of pregnant women in need of maternal transfer, delivery hospital self-reported level of maternal care was not associated with the odds of poor maternal or neonatal outcomes. This study supports the need for improved definitions of hospital level of maternal services.
Collapse
Affiliation(s)
| | - Roger Rochat
- Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Bryan Williams
- Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, Georgia
| | - Anne Dunlop
- Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, Georgia
| | - Susan E Shapiro
- Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, Georgia
| |
Collapse
|
25
|
Keene CM, Aluvaala J, Murphy GAV, Abuya N, Gathara D, English M. Developing recommendations for neonatal inpatient care service categories: reflections from the research, policy and practice interface in Kenya. BMJ Glob Health 2019; 4:e001195. [PMID: 30997163 PMCID: PMC6441269 DOI: 10.1136/bmjgh-2018-001195] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/06/2018] [Accepted: 12/07/2018] [Indexed: 01/06/2023] Open
Abstract
Neonatal deaths contribute a growing proportion to childhood mortality, and increasing access to inpatient newborn care has been identified as a potential driver of improvements in child health. However, previous work by this research team identified substantial gaps in the coverage and standardisation of inpatient newborn care in Nairobi City County, Kenya. To address the issue in this particular setting, we sought to draft recommendations on the categorisation of neonatal inpatient services through a process of policy review, evidence collation and examination of guidance in other countries. This work supported discussions by a panel of local experts representing a diverse set of stakeholders, who focused on formulating pragmatic, context-relevant guidance. Experts in the discussions rapidly agreed on overarching priorities guiding their decision-making, and that three categories of inpatient neonatal care (standard, intermediate and intensive care) were appropriate. Through a modified nominal group technique, they achieved consensus on allocating 36 of the 38 proposed services to these categories and made linked recommendations on minimum healthcare worker requirements (skill mix and staff numbers). This process was embedded in the local context where the need had been identified, and required only modest resources to produce recommendations on the categorisation of newborn inpatient care that the experts agreed could be relevant in other Kenyan settings. Recommendations prioritised the strengthening of existing facilities linked to a need to develop effective referral systems. In particular, expansion of access to the standard category of inpatient neonatal care was recommended. The process and the agreed categorisations could inform discussion in other low-resource settings seeking to address unmet needs for inpatient neonatal care.
Collapse
Affiliation(s)
- Claire Marriott Keene
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jalemba Aluvaala
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, College of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Georgina A V Murphy
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Nancy Abuya
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
- Nairobi City County Government, Nairobi, Kenya
| | - David Gathara
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
- School of Nursing and Midwifery, Aga Khan University, Nairobi, Kenya
| | - Mike English
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| |
Collapse
|
26
|
Kunz SN, Dukhovny D, Profit J, Mao W, Miedema D, Zupancic JAF. Predicting Successful Neonatal Retro-Transfer to a Lower Level of Care. J Pediatr 2019; 205:272-276.e1. [PMID: 30291023 PMCID: PMC6348131 DOI: 10.1016/j.jpeds.2018.09.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 07/11/2018] [Accepted: 09/05/2018] [Indexed: 01/04/2023]
Abstract
Up to 20% of newborn infants retro-transferred to a lower level of care require readmission to a higher-level facility. In this study, we developed and validated a prediction rule (The Rule for Elective Transfer between Units for Recovering Neonates [RETURN]) to identify clinical characteristics of infants at risk for failing retro-transfer.
Collapse
Affiliation(s)
- Sarah N. Kunz
- Division of Newborn Medicine, Harvard Medical School,
Boston, MA, USA,Department of Neonatology, Beth Israel Deaconess Medical
Center, Boston, MA, USA
| | - Dmitry Dukhovny
- Department of Pediatrics, Oregon Health & Science
University, Portland, OR, USA
| | - Jochen Profit
- Department of Pediatrics - Neonatal and Developmental
Medicine, Stanford University School of Medicine, Stanford, CA, USA,Califomia Perinatal Quality Care Collaborative, Stanford,
CA, USA
| | - Wenyang Mao
- Department of Neonatology, Beth Israel Deaconess Medical
Center, Boston, MA, USA
| | - David Miedema
- Department of Neonatology, Beth Israel Deaconess Medical
Center, Boston, MA, USA
| | - John A. F. Zupancic
- Division of Newborn Medicine, Harvard Medical School,
Boston, MA, USA,Department of Neonatology, Beth Israel Deaconess Medical
Center, Boston, MA, USA
| |
Collapse
|
27
|
Kozhimannil KB, Chantarat T, Ecklund AM, Henning-Smith C, Jones C. Maternal Opioid Use Disorder and Neonatal Abstinence Syndrome Among Rural US Residents, 2007-2014. J Rural Health 2018; 35:122-132. [PMID: 30370563 DOI: 10.1111/jrh.12329] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 08/30/2018] [Accepted: 09/17/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE Opioid use disorder (OUD) during pregnancy is associated with poor maternal and infant outcomes, including neonatal abstinence syndrome (NAS), and both maternal OUD and NAS are increasing disproportionately among rural residents. This study describes the trajectory and characteristics associated with diagnosis of maternal OUD or NAS among rural residents who gave birth at different types of hospitals based on rural/urban location and teaching status. METHODS Hospital discharge data from the all-payer National Inpatient Sample were used to describe maternal OUD and infant NAS among rural residents from 2007-2014. Hospitals were categorized as rural, urban teaching, and urban nonteaching. We estimated incidence trends by hospital categories, followed by multivariable logistic regression analyses to identify correlates of OUD and NAS among rural residents, stratified by hospital category. FINDINGS Incidence of maternal OUD increased in all hospital categories, with higher rates (8.9/1,000 deliveries) among rural residents who gave birth at urban teaching hospitals compared with those who gave birth at rural hospitals (4.3/1,000 deliveries) or urban nonteaching hospitals (3.6/1,000 deliveries; P < .001). A similar pattern was observed for infant NAS. In multivariable models, the association between maternal OUD and infant NAS diagnoses and hospital category differed by rurality (micropolitan vs. noncore.) CONCLUSIONS: There has been a sustained increase in both maternal OUD and NAS diagnoses among rural residents. Measured sociodemographic and clinical correlates of maternal OUD and NAS differ by hospital category, indicating variability across hospital locations in patient populations and clinical needs for rural residents with these conditions.
Collapse
Affiliation(s)
- Katy B Kozhimannil
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota.,University of Minnesota Rural Health Research Center, Minneapolis, Minnesota
| | - Tongtan Chantarat
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota.,University of Minnesota Rural Health Research Center, Minneapolis, Minnesota
| | - Alexandra M Ecklund
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota.,University of Minnesota Rural Health Research Center, Minneapolis, Minnesota
| | - Carrie Henning-Smith
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota.,University of Minnesota Rural Health Research Center, Minneapolis, Minnesota
| | - Cresta Jones
- Department of Obstetrics, Gynecology and Women's Health, Division of Maternal-Fetal Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| |
Collapse
|
28
|
Nieto AJ, Echavarría MP, Carvajal JA, Messa A, Burgos JM, Ordoñez C, Benavidez JP, Mejía M, López L, Fernández PA, Escobar MF. Placenta accreta: importance of a multidisciplinary approach in the Colombian hospital setting. J Matern Fetal Neonatal Med 2018; 33:1321-1329. [PMID: 30153754 DOI: 10.1080/14767058.2018.1517328] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Introduction: The management of patients with placenta accreta (PA) poses a challenge to health services. Although it may lead to devastating complications, its low incidence limits the development of expertize in all obstetric centers. We evaluated the results obtained from a multidisciplinary approach in patients with PA in a Latin American hospital.Methods: The study included patients with prenatal suspicion or intraoperative diagnosis of PA, before and after initiating a set of interdisciplinary and institutional interventions, with the aim of achieving better outcomes.Results: From December 2011 to December 2017, 62 patients with prenatally or intraoperatively suspected PA underwent surgery. The first 30 women (Group A), admitted until April 2016 and before any changes in the management protocol, had a longer hospital stay and surgery time, higher newborn hospitalization, and greater use of general anesthesia, compared to the 20 patients from Group B, who were admitted during the last 20 months of the observation period. A total of 12 women with late and intraoperative diagnosis, under no institutional protocol, showed greater blood loss and more frequent red blood cell transfusions.Conclusions: The expertize of the multidisciplinary team responsible for managing women with PA is associated with better clinical outcomes.
Collapse
Affiliation(s)
- Albaro José Nieto
- Tertiary Obstetric Unit, Department of Gynecology and Obstetrics, Fundación Valle del Lili, Cali, Colombia.,Department of Health Sciences, School of Medicine, Universidad ICESI, Cali, Colombia.,Clinic for Placenta Accreta, Fundación Valle del Lili, Cali, Colombia
| | - María Paula Echavarría
- Tertiary Obstetric Unit, Department of Gynecology and Obstetrics, Fundación Valle del Lili, Cali, Colombia.,Department of Health Sciences, School of Medicine, Universidad ICESI, Cali, Colombia.,Clinic for Placenta Accreta, Fundación Valle del Lili, Cali, Colombia
| | - Javier Andrés Carvajal
- Tertiary Obstetric Unit, Department of Gynecology and Obstetrics, Fundación Valle del Lili, Cali, Colombia.,Department of Health Sciences, School of Medicine, Universidad ICESI, Cali, Colombia.,Clinic for Placenta Accreta, Fundación Valle del Lili, Cali, Colombia
| | - Adriana Messa
- Tertiary Obstetric Unit, Department of Gynecology and Obstetrics, Fundación Valle del Lili, Cali, Colombia.,Department of Health Sciences, School of Medicine, Universidad ICESI, Cali, Colombia.,Clinic for Placenta Accreta, Fundación Valle del Lili, Cali, Colombia
| | - Juan Manuel Burgos
- Tertiary Obstetric Unit, Department of Gynecology and Obstetrics, Fundación Valle del Lili, Cali, Colombia.,Department of Health Sciences, School of Medicine, Universidad ICESI, Cali, Colombia.,Clinic for Placenta Accreta, Fundación Valle del Lili, Cali, Colombia
| | - Carlos Ordoñez
- Department of Surgery, Fundación Valle del Lili, Cali, Colombia.,Clinic for Placenta Accreta, Fundación Valle del Lili, Cali, Colombia
| | - Juan Pablo Benavidez
- Tertiary Obstetric Unit, Department of Gynecology and Obstetrics, Fundación Valle del Lili, Cali, Colombia.,Clinic for Placenta Accreta, Fundación Valle del Lili, Cali, Colombia
| | - Mauricio Mejía
- Department of Radiology, Fundación Valle del Lili, Cali, Colombia.,Clinic for Placenta Accreta, Fundación Valle del Lili, Cali, Colombia
| | - Leidy López
- Department of Anesthesiology, Fundación Valle del Lili, Cali, Colombia.,Clinic for Placenta Accreta, Fundación Valle del Lili, Cali, Colombia
| | | | - María Fernanda Escobar
- Tertiary Obstetric Unit, Department of Gynecology and Obstetrics, Fundación Valle del Lili, Cali, Colombia.,Department of Health Sciences, School of Medicine, Universidad ICESI, Cali, Colombia.,Clinic for Placenta Accreta, Fundación Valle del Lili, Cali, Colombia
| |
Collapse
|
29
|
Van Otterloo LR, Connelly CD. Risk-Appropriate Care to Improve Practice and Birth Outcomes. J Obstet Gynecol Neonatal Nurs 2018; 47:661-672. [PMID: 30196808 DOI: 10.1016/j.jogn.2018.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2017] [Indexed: 11/29/2022] Open
Abstract
Identification and referral of women with high-risk pregnancies to hospitals better equipped and staffed to provide care for them have been important steps to improve birth outcomes. Based on recent recommendations from the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine to provide regionalized maternal care for pregnant women at high risk and reduce rates of maternal morbidity and mortality, health care organizations and providers have refocused their attention to women's well-being rather than solely on the well-being of the fetus or newborn. Opportunities to improve practice and birth outcomes exist through the implementation of a more standardized and integrated system of risk-appropriate care.
Collapse
|
30
|
Amer R, Moddemann D, Seshia M, Alvaro R, Synnes A, Lee KS, Lee SK, Shah PS, Synnes A, Ting J, Cieslak Z, Sherlock R, Yee W, Aziz K, Toye J, Fajardo C, Kalapesi Z, Sankaran K, Daspal S, Mukerji A, Da O, Nwaesei C, Dunn M, Lemyre B, Dow K, Pelausa E, Barrington K, Drolet C, Piedboeuf B, Claveau M, Faucher D, Bertelle V, Masse E, Canning R, Makary H, Ojah C, Monterrosa L, Deshpandey A, Afifi J, Kajetanowicz A, Pillay T, Sauvé R, Hendson L, Reichert A, Bodani J, Sankaran K, deCabo C, Nwaesei C, Daboval T, Dow K, Lee D, Ly L, Kelly E, el Helou S, Church P, Pelausa E, Beltempo M, Levebrve F, Demers C, Bélanger S, Canning R, Monterrosa L, Makary H, Vincer M, Murphy P. Neurodevelopmental Outcomes of Infants Born at <29 Weeks of Gestation Admitted to Canadian Neonatal Intensive Care Units Based on Location of Birth. J Pediatr 2018; 196:31-37.e1. [PMID: 29305231 DOI: 10.1016/j.jpeds.2017.11.038] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 11/01/2017] [Accepted: 11/15/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare mortality and neurodevelopmental outcomes of outborn and inborn preterm infants born at <29 weeks of gestation admitted to Canadian neonatal intensive care units (NICUs). STUDY DESIGN Data were obtained from the Canadian Neonatal Network and Canadian Neonatal Follow-up Network databases for infants born at <29 weeks of gestation admitted to NICUs from April 2009 to September 2011. Rates of death, severe neurodevelopmental impairment (NDI), and overall NDI were compared between outborn and inborn infants at 18-21 months of age, corrected for prematurity. RESULTS Of 2951 eligible infants, 473 (16%) were outborn. Mean birth weight (940 ± 278 g vs 897 + 237 g), rates of treatment with antenatal steroids (53.9% vs 92.9%), birth weight small for gestational age (5.3% vs 9.4%), and maternal college education (43.7% vs 53.9%) differed between outborn and inborn infants, respectively (all P values <.01). The median Score for Neonatal Acute Physiology-II (P = .01) and Apgar score at 5 minutes (P < .01) were higher in inborn infants. Severe brain injury was more common among outborn infants (25.3% vs 14.7%, P < .01). Outborn infants had higher odds of death or severe NDI (aOR 1.7, 95% CI 1.3-2.2), death or overall NDI (aOR 1.6, 95% CI 1.2-2.2), death (aOR 2.1, 95% CI 1.5-3.0), and cerebral palsy (aOR 1.9, 95% CI 1.1-3.3). CONCLUSIONS The composite outcomes of death or neurodevelopmental impairment were significantly higher in outborn compared with inborn infants admitted to Canadian NICUs. Adverse outcomes were mainly attributed to increased mortality and cerebral palsy in outborn neonates.
Collapse
Affiliation(s)
- Reem Amer
- Department of Pediatrics, University of Manitoba, Canada
| | | | - Mary Seshia
- Department of Pediatrics, University of Manitoba, Canada
| | - Ruben Alvaro
- Department of Pediatrics, University of Manitoba, Canada
| | - Anne Synnes
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kyong-Soon Lee
- Department of Pediatrics, Sickkids Hospital, Toronto, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Shoo K Lee
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Prakesh S Shah
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Abstract
Perinatal epidemiology examines the variation and determinants of pregnancy outcomes from a maternal and neonatal perspective. However, improving public and population health also requires the translation of this evidence base into substantive public policies. Assessing the impact of such public policies requires sufficient data to include potential confounding factors in the analysis, such as coexisting medical conditions and socioeconomic status, and appropriate statistical and epidemiological techniques. This review will explore policies addressing three areas of perinatal medicine-elective deliveries prior to 39 weeks' gestation; perinatal regionalization; and mandatory paid maternity leave policies-to illustrate the challenges when assessing the impact of specific policies at the patient and population level. Data support the use of these policies to improve perinatal health, but with weaker and less certain effect sizes when compared to the initial patient-level studies. Improved data collection and epidemiological techniques will allow for improved assessment of these policies and the identification of potential areas of improvement when translating patient-level studies into public policies.
Collapse
Affiliation(s)
- Scott A Lorch
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA; Center for Pediatric and Perinatal Health Disparities Research and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, PA; Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| |
Collapse
|
32
|
Network analysis: a novel method for mapping neonatal acute transport patterns in California. J Perinatol 2017; 37:702-708. [PMID: 28333155 PMCID: PMC5446293 DOI: 10.1038/jp.2017.20] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 01/20/2017] [Accepted: 02/01/2017] [Indexed: 11/14/2022]
Abstract
OBJECTIVE The objectives of this study are to use network analysis to describe the pattern of neonatal transfers in California, to compare empirical sub-networks with established referral regions and to determine factors associated with transport outside the originating sub-network. STUDY DESIGN This cross-sectional database study included 6546 infants <28 days old transported within California in 2012. After generating a graph representing acute transfers between hospitals (n=6696), we used community detection techniques to identify more tightly connected sub-networks. These empirically derived sub-networks were compared with state-defined regional referral networks. Reasons for transfer between empirical sub-networks were assessed using logistic regression. RESULTS Empirical sub-networks showed significant overlap with regulatory regions (P<0.001). Transfer outside the empirical sub-network was associated with major congenital anomalies (P<0.001), need for surgery (P=0.01) and insurance as the reason for transfer (P<0.001). CONCLUSION Network analysis accurately reflected empirical neonatal transfer patterns, potentially facilitating quantitative, rather than qualitative, analysis of regionalized health care delivery systems.
Collapse
|
33
|
Chavehpour Y, Rashidian A, Raghfar H, Emamgholipour Sefiddashti S, Maroofi A. 'Seeking affluent neighbourhoods?' a time-trend analysis of geographical distribution of hospitals in the Megacity of Tehran. Health Policy Plan 2017; 32:669-675. [PMID: 28453720 DOI: 10.1093/heapol/czw172] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2016] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Access to hospitals in megacities in low and middle income countries might be hampered by travel barriers and distance. We assessed the 'inverse care law' hypothesis: whether hospitals tended to be built in the relatively better-off areas through the time. METHODS A longitudinal time-series study (1966 to 2011) in Tehran to measure inequality in the distribution of hospital beds. We assessed correlations between the district socioeconomic status and availability of hospital beds via regression analyses, estimated correlation, Gini and concentration indices, and used GIS models to map hospital distributions through time. FINDING We found a clear relationship between socioeconomic status and number of hospital beds per capita ( P -values <0.05). Gini coefficients were about 0.6 and 0.8 for public and private beds, respectively. A third of the variations in hospital bed distribution was explained by the welfare status of the district. For every extra residential room per capita, 130 to 280 extra beds were observed per ten thousand population at the district level. In 2011, out of 162 hospitals, 110 were located in six districts around the centre and northern part of the city. During the time period only two private hospitals were built in relatively disadvantaged districts. CONCLUSION Over a period of about fifty years new hospitals had been established in the relatively affluent areas of the city and the relationship between socioeconomic status of district with total, private and public beds were direct and intensive. Results indicate the problem of inequality may remain over time and be resistant to policy initiatives and major political changes.
Collapse
Affiliation(s)
- Yousef Chavehpour
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Arash Rashidian
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Raghfar
- Department of Economics, Faculty of Social Sciences and Economics, Alzahra University, Tehran, Iran
| | - Sara Emamgholipour Sefiddashti
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Aiub Maroofi
- Department of Geography, Faculty of Earth Sciences, Shahid Beheshti University, Tehran, Iran
| |
Collapse
|
34
|
Vali Y, Rashidian A, Jalili M, Omidvari A, Jeddian A. Effectiveness of regionalization of trauma care services: a systematic review. Public Health 2017; 146:92-107. [DOI: 10.1016/j.puhe.2016.12.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 08/15/2016] [Accepted: 12/08/2016] [Indexed: 02/03/2023]
|
35
|
Ananth CV, Lavery JA, Friedman AM, Wapner RJ, Wright JD. Serious maternal complications in relation to severe pre-eclampsia: a retrospective cohort study of the impact of hospital volume. BJOG 2016; 124:1246-1253. [PMID: 27770512 DOI: 10.1111/1471-0528.14384] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We examined rates of serious maternal complications in relation to severe pre-eclampsia based on the delivering hospital's annualised volume. DESIGN Retrospective cohort study. POPULATION AND SETTING Singleton deliveries (n = 25 782 235) in 439 hospitals in the USA. METHODS Annualised hospital volume was categorised as 25-500, 501-1000, 1001-2000 and >2000. MAIN OUTCOME MEASURES Rates of in-hospital maternal death and serious maternal complications, including puerperal cerebrovascular disorders, pulmonary oedema, disseminated intravascular coagulation, acute renal, heart and liver failure, sepsis, haemorrhage and intubation in relation to severe pre-eclampsia. We derived adjusted risk ratio (RR) and 95% confidence interval (CI), from hierarchical Poisson regression models. RESULTS Severe pre-eclampsia was associated with an 8.7-fold (95% CI 7.6, 10.1) risk of composite maternal complications, with similar RRs across levels of hospital volumes. However, compared with hospitals with low annual volume (<2000), maternal mortality rates in relation to severe pre-eclampsia were lower in high volume hospitals. The rates of serious maternal complications were 410.7 per 10 000 to women who delivered in hospitals with a high rate of severe pre-eclampsia (≥2.12%) and 584.8 per 10 000 to women who delivered in hospitals with low severe pre-eclampsia rates (≤0.41; RR 1.75, 95% CI 1.24, 2.45). CONCLUSIONS While the risks of serious maternal complications in relation to severe pre-eclampsia was similar across hospital delivery volume categories, deaths showed lower rates in large delivery volume hospitals than in smaller volume hospitals. The risk of complications was increased in hospitals with low compared with high severe pre-eclampsia rates. TWEETABLE ABSTRACT Hospital volume had little impact on the association between severe pre-eclampsia and maternal complications.
Collapse
Affiliation(s)
- C V Ananth
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA.,Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA
| | - J A Lavery
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - A M Friedman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - R J Wapner
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - J D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| |
Collapse
|
36
|
Rahman M, Yunus FM, Shah R, Jhohura FT, Mistry SK, Quayyum T, Aktar B, Afsana K. A Controlled Before-and-After Perspective on the Improving Maternal, Neonatal, and Child Survival Program in Rural Bangladesh: An Impact Analysis. PLoS One 2016; 11:e0161647. [PMID: 27583478 PMCID: PMC5008808 DOI: 10.1371/journal.pone.0161647] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 08/09/2016] [Indexed: 12/26/2022] Open
Abstract
Objectives We evaluated the impact of the Improving Maternal, Neonatal, and Child Survival (IMNCS) project, which is being implemented by BRAC in rural communities in Bangladesh. Methods Four districts received program intervention i.e. trained community health workers to deliver essential maternal, neonatal, and child healthcare and nutrition services while two districts were treated as comparison group. A quasi-experimental study design (compared before-and-after) was undertaken. Baseline survey was conducted in 2008 among 7200 women followed by end line in 2012 among 4800 women with similar characteristics in the same villages. We evaluated maternal antenatal and post natal checkup, birth plans and delivery, complication and referred cases during antenatal checkup and post natal period, and child health indicators such as birth asphyxia, neonatal sepsis, and its management by the medically trained provider. Findings Increased number (four or more) antenatal visits, skill-birth attended delivery and postnatal visits (three or more) in the intervention group preceding four-year intervention period were observed compare to their counterpart. We noted negative difference-in-difference estimator (-5.0%, P = 0.159) regarding to the all major birth plans i.e. delivery place, birth attendant, and saved money in the comparison areas. Significant reduction of ante-partum and intra-partum complications occurred in the intervention group, contrary complications of such event increased in the comparison areas (-6.3%, P<0.05 and -20.5%, P<0.001 respectively). Referral case to the health centers due to these complications boosted significantly in intervention group than comparison group (2.3%, P<0.01 and 6.6%, P<0.001 respectively). Mother’s knowledge of breastfeeding initiation and the practice of initiating breastfeeding within an hour of birth amplified significantly (14.6%, P<0.001 and 8.3%, P<0.001 respectively). We did not find any significant difference regards to the management of low birth weight by the medically trained health care provider and complete vaccination between the intervention and comparison arm. Conclusion Medically trained health care provider assisted community based public health intervention could increase number of antenatal and postnatal visit, thereby could decrease pregnancy associated complications. These interventions may be considered for further up scaling when resources are limited.
Collapse
Affiliation(s)
- Mahfuzar Rahman
- Research and Evaluation Division, BRAC, BRAC Centre, 75 Mohakhali, Dhaka, Bangladesh
- * E-mail:
| | - Fakir Md. Yunus
- Research and Evaluation Division, BRAC, BRAC Centre, 75 Mohakhali, Dhaka, Bangladesh
| | - Rasheduzzaman Shah
- Department of Global Health, Save the Children USA, Washington, DC, United States of America
| | - Fatema Tuz Jhohura
- Research and Evaluation Division, BRAC, BRAC Centre, 75 Mohakhali, Dhaka, Bangladesh
| | - Sabuj Kanti Mistry
- Research and Evaluation Division, BRAC, BRAC Centre, 75 Mohakhali, Dhaka, Bangladesh
| | - Tasmeen Quayyum
- Research and Evaluation Division, BRAC, BRAC Centre, 75 Mohakhali, Dhaka, Bangladesh
| | - Bachera Aktar
- Health, Nutrition, and Population Programme, BRAC, BRAC Centre, 75 Mohakhali, Dhaka, Bangladesh
| | - Kaosar Afsana
- Health, Nutrition, and Population Programme, BRAC, BRAC Centre, 75 Mohakhali, Dhaka, Bangladesh
- James P Grant School of Public Health, BRAC University, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, Bangladesh
| |
Collapse
|
37
|
Kozhimannil KB, Casey MM, Hung P, Prasad S, Moscovice IS. Location of childbirth for rural women: implications for maternal levels of care. Am J Obstet Gynecol 2016; 214:661.e1-661.e10. [PMID: 26645955 DOI: 10.1016/j.ajog.2015.11.030] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 10/12/2015] [Accepted: 11/23/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND A recent American Congress of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine (MFM) consensus statement on levels of maternity care lays out designations that correspond to specific capacities available in facilities that provide obstetric care. Pregnant women in rural and remote areas receive particular attention in discussions of regionalization and levels of care, owing to the challenges in assuring local access to high-acuity services when necessary. Currently, approximately half a million rural women give birth each year in US hospitals, and whether and which of these women give birth locally is crucial for successfully operationalizing maternal levels of care. OBJECTIVE We sought to characterize rural women who give birth in nonlocal hospitals and measure local hospital characteristics and maternal diagnoses present at childbirth that are associated with nonlocal childbirth. STUDY DESIGN This was a repeat cross-sectional analysis of administrative hospital discharge data for all births to rural women in 9 states in 2010 and 2012. Multivariate logistic regression models were used to predict the odds of childbirth in a nonlocal hospital (at least 30 road miles from the patient's residence). We examined patient age, race/ethnicity, payer, rurality, clinical diagnoses (diabetes, hypertension, hemorrhage during pregnancy, placental abnormalities, malpresentation, multiple gestation, preterm delivery, prior cesarean delivery, and a composite of diagnoses that may require MFM consultation), as well as local hospital characteristics (birth volume, neonatal care level, ownership, accreditation, and system affiliation). RESULTS The rate of nonlocal childbirth among 216,076 rural women was 25.4%. It varied significantly by primary payer (adjusted odds ratio [AOR], 0.76; 95% confidence interval [CI], 0.68-0.86 for Medicaid vs private insurance) and by clinical conditions including multiple gestation (AOR, 1.82; 95% CI, 1.58-2.1), preterm deliveries (AOR, 2.41; 95% CI, 2.17-2.67), and conditions that may require MFM services or consultation (AOR, 1.28; 95% CI, 1.22-1.35). Rural women whose local hospital did not have a neonatal intensive or intermediate care unit had nearly double the odds of giving birth at a nonlocal hospital (AOR, 1.94; 95% CI, 1.64-2.31). CONCLUSION Approximately 75% of rural women gave birth at local hospitals; rural women with preterm births and clinical complications, as well as those without local access to higher-acuity neonatal care, were more likely to give birth in nonlocal hospitals. However, after controlling for clinical complications, rural Medicaid beneficiaries were less likely to give birth at nonlocal hospitals, implying a potential access challenge for this population.
Collapse
Affiliation(s)
- Katy B Kozhimannil
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, University of Minnesota School of Public Health.
| | - Michelle M Casey
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, University of Minnesota School of Public Health
| | - Peiyin Hung
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, University of Minnesota School of Public Health
| | - Shailendra Prasad
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, University of Minnesota School of Public Health; Department of Family Medicine and Community Health at the University of Minnesota
| | - Ira S Moscovice
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, University of Minnesota School of Public Health
| |
Collapse
|
38
|
United States and territory policies supporting maternal and neonatal transfer: review of transport and reimbursement. J Perinatol 2016; 36:30-4. [PMID: 26334399 PMCID: PMC4856146 DOI: 10.1038/jp.2015.109] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 07/27/2015] [Accepted: 07/28/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Summarize policies that support maternal and neonatal transport among states and territories. STUDY DESIGN Systematic review of publicly available, web-based information on maternal and neonatal transport for each state and territory in 2014. Information was abstracted from published rules, statutes, regulations, planning documents and program descriptions. Abstracted information was summarized within two categories: transport and reimbursement. RESULTS Sixty-eight percent of states and 25% of territories had a policy for neonatal transport; 60% of states and one territory had a policy for maternal transport. Sixty-two percent of states had a reimbursement policy for neonatal transport, whereas 20% reimbursed for maternal transport. Thirty-two percent of states had an infant back-transport policy while 16% included back-transport for both. No territories had reimbursement or back-transport policies. CONCLUSION The lack of development of maternal transport reimbursement and neonatal back-transport policies negatively impacts the achievements of risk-appropriate care, a strategy focused on improving perinatal outcomes.
Collapse
|