Perinatal regionalization and neonatal mortality in North Carolina, 1968-1994

Transfer Patterns Among Infants Born at 28 to 34 Weeks' Gestation

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.

Trends in Resources for Neonatal Intensive Care at Delivery Hospitals for Infants Born Younger Than 30 Weeks' Gestation, 2009-2020

Importance

In an ideal regionalized system, all infants born very preterm would be delivered at a large tertiary hospital capable of providing all necessary care.

Objective

To examine whether the distribution of extremely preterm births changed between 2009 and 2020 based on neonatal intensive care resources at the delivery hospital.

Design, Setting, and Participants

This retrospective cohort study was conducted at 822 Vermont Oxford Network (VON) centers in the US between 2009 and 2020. Participants included infants born at 22 to 29 weeks' gestation, delivered at or transferred to centers participating in the VON. Data were analyzed from February to December 2022.

Exposures

Hospital of birth at 22 to 29 weeks' gestation.

Main Outcomes and Measures

Birthplace neonatal intensive care unit (NICU) level was classified as A, restriction on assisted ventilation or no surgery; B, major surgery; or C, cardiac surgery requiring bypass. Level B centers were further divided into low-volume (<50 inborn infants at 22 to 29 weeks' gestation per year) and high-volume (≥50 inborn infants at 22 to 29 weeks' gestation per year) centers. High-volume level B and level C centers were combined, resulting in 3 distinct NICU categories: level A, low-volume B, and high-volume B and C NICUs. The main outcome was the change in the percentage of births at hospitals with level A, low-volume B, and high-volume B or C NICUs overall and by US Census region.

Results

A total of 357 181 infants (mean [SD] gestational age, 26.4 [2.1] weeks; 188 761 [52.9%] male) were included in the analysis. Across regions, the Pacific (20 239 births [38.3%]) had the lowest while the South Atlantic (48 348 births [62.7%]) had the highest percentage of births at a hospital with a high-volume B- or C-level NICU. Births at hospitals with A-level NICUs increased by 5.6% (95% CI, 4.3% to 7.0%), and births at low-volume B-level NICUs increased by 3.6% (95% CI, 2.1% to 5.0%), while births at hospitals with high-volume B- or C-level NICUs decreased by 9.2% (95% CI, -10.3% to -8.1%). By 2020, less than half of the births for infants at 22 to 29 weeks' gestation occurred at hospitals with high-volume B- or C-level NICUs. Most US Census regions followed the nationwide trends; for example, births at hospitals with high-volume B- or C-level NICUs decreased by 10.9% [95% CI, -14.0% to -7.8%) in the East North Central region and by 21.1% (95% CI, -24.0% to -18.2%) in the West South Central region.

Conclusions and Relevance

This retrospective cohort study identified concerning deregionalization trends in birthplace hospital level of care for infants born at 22 to 29 weeks' gestation. These findings should serve to encourage policy makers to identify and enforce strategies to ensure that infants at the highest risk of adverse outcomes are born at the hospitals where they have the best chances to attain optimal outcomes.

Perinatal care for the extremely preterm infant

Being born preterm (prior to 37 weeks of completed gestation) is a leading cause of childhood death up to five years of age, and is responsible for the demise of around one million preterm infants each year. Rates of prematurity, which range from approximately 5 to 18% of births, are increasing in most countries. Babies born extremely preterm (less than 28 weeks' gestation) and in particular, in the periviable (20^0/7-25^6/7 weeks) period, are at the highest risk of death, or the development of long-term disabilities. The perinatal care of extremely preterm infants and their mothers raises a number of clinical, technical, and ethical challenges. Focusing on 'micropremmies', or those born in the periviable period, this paper provides an update regarding the aetiology and impacts of periviable preterm birth, advances in the antenatal, intrapartum, and acute post-natal management of these infants, and a review of counselling/support approaches for engaging with the infant's family. It concludes with an overview of emerging technology that may assist in improving outcomes for this at-risk population.

Concept review of regionalized systems of acute care: Is regionalization the next frontier in sepsis care?

Regionalization has become a buzzword in US health care policy. Regionalization, however, has varied meanings, and definitions have lacked contextual information important to understanding its role in improving care. This concept review is a comprehensive primer and summation of 8 common core components of the national models of regionalization informed by text-based analysis of the writing of involved organizations (professional, regulatory, and research) guided by semistructured interviews with organizational leaders. Further, this generalized model of regionalized care is applied to sepsis care, a novel discussion, drawing on existing small-scale applications. This discussion highlights the fit of regionalization principles to the sepsis care model and the actualized and perceived potential benefits. The principal aim of this concept review is to outline regionalization in the United States and provide a roadmap and novel discussion of regionalized care integration for sepsis care.

Identifying individual hospital levels of maternal care using administrative data

BACKGROUND

The goal of regionalized perinatal care, specifically levels of maternal care, is to improve maternal outcomes through risk-appropriate obstetric care. Studies of levels of maternal care are limited by current approaches to identify a hospital's level of care, often relying on hospital self-reported data, which is expensive and challenging to collect and validate. The study objective was to develop an empiric approach to determine a hospital's level of maternal care using administrative data reflective of the patient care provided and apply this approach to describe the levels of maternal care available over time.

METHODS

Retrospective cohort study of mother-infant dyads who delivered in California, Missouri, and Pennsylvania hospitals from 2000 to 2009. Linked mother-infant administrative records with an infant born at 24-44 weeks' gestation and a birth weight of 400-8000 g were included. Using the American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine descriptions of levels of maternal care, four levels were classified based on the appropriate location of care for patients with specific medical or pregnancy conditions. Individual hospitals were assigned a level of maternal care annually based on the volume of patients who delivered reflective of the four classified levels as determined by International Classification of Diseases and Current Procedural Terminology.

RESULTS

Based on the included 6,895,000 mother-infant dyads, the obstetric hospital levels of maternal care I, II, III and IV were identified. High-risk patients more frequently delivered in hospitals with higher level maternal care, accounting for 8.9, 10.9, 13.8, and 16.9% of deliveries in level I, II, III and IV hospitals, respectively. The total number of obstetric hospitals decreased over the study period, while the proportion of hospitals with high-level (level III or IV) maternal care increased. High-level hospitals were located in more densely populated areas.

CONCLUSION

Identification of the level of maternal care, independent of hospital self-reported variables, is feasible using administrative data. This empiric approach, which accounts for changes in hospitals over time, is a valuable framework for perinatal researchers and other stakeholders to inexpensively identify measurable benefits of levels of maternal care and characterize where specific patient populations receive care.

Access to risk-appropriate hospital care and disparities in neonatal outcomes in racial/ethnic groups and rural-urban populations

Variations in infant and neonatal mortality continue to persist in the United States and in other countries based on both socio-demographic characteristics, such as race and ethnicity, and geographic location. One potential driver of these differences is variations in access to risk-appropriate delivery care. The purpose of this article is to present the importance of delivery hospitals on neonatal outcomes, discuss variation in access to these hospitals for high-risk infants and their mothers, and to provide insight into drivers for differences in access to high-quality perinatal care using the available literature. This review also illustrates the lack of information on a number of topics that are crucial to the development of evidence-based interventions to improve access to appropriate delivery hospital services and thus optimize the outcomes of high-risk mothers and their newborns.

Impact of regionalisation and case-volume on neonatal and perinatal mortality: an umbrella review

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.

The impact of high intensity care around birth on long-term neurodevelopmental outcomes

BACKGROUND

An equitable and affordable healthcare system requires a constant search for the optimal way to deliver increasingly expensive neonatal care. Therefore, evaluating the impact of hospital intensity around birth on long-term health outcomes is necessary if we are to assess the value of high intensity neonatal care against its costs.

METHODS

This study exploits uneven geographical distribution of high intensity birth hospitals across Canada to generate comparisons across similar Cerebral Palsy (CP) related births treated at hospitals with different intensities. We employ a rich dataset from the Canadian Multi-Regional CP Registry (CCPR) and instrumental variables related to the mother's location of residence around birth.

RESULTS

We find that differences in hospitals' intensities are not associated with differences in clinically relevant, long-term CP health outcomes.

CONCLUSIONS

Our results suggest that existing matching mechanism of births to hospitals within large metropolitan areas could be improved by early detection of high risk births and subsequent referral of these births to high intensity birthing centers. Substantial hospitalization costs might be averted to Canadian healthcare system ($16 million with a 95% CI of $6,131,184 - $24,103,478) if CP related births were assigned to low intensity hospitals and subsequently transferred if necessary to high intensity hospitals.

Alterations in fibrin formation and fibrinolysis in early onset-preeclampsia: Association with disease severity

OBJECTIVE

; Early-onset preeclampsia is a rare pregnancy-specific disorder associated with significantly increased maternal and fetal morbidity and mortality. Whilst it is known that even normotensive pregnancies are associated with changes in clot formation and dissolution, the nature of how these changes differ in those with early onset preeclampsia has not been well established. We sought to evaluate parameters of fibrin formation and fibrinolysis in individuals with early onset preeclampsia in comparison to both pregnant and non-pregnant controls. Furthermore, such parameters were correlated with markers of disease severity in this patient cohort, including the presence of multiorgan involvement, the rate of disease progression and the extent of the anti-angiogenic state in this condition.

STUDY DESIGN

; Patients with early onset preeclampsia (N = 20) and both pregnant (N = 16) and non -pregnant (N = 16) controls were recruited from the cohort at a large urban maternity hospital which saw over 15,000 deliveries during the study period. Platelet poor plasma was prepared from collected whole blood and analysed for parameters of fibrin formation and fibrinolysis (lagtime to and rate of fibrin formation; PAI-1; PAI-2; D-dimer; plasmin-antiplasmin; tPA) in addition to markers of angiogenesis (sFLT-1; Endoglin) using commercially available specific immunoassays.

RESULTS

; The maximum rate of fibrin formation as well as PAI-1, PAI-2 and D-dimer levels were all significantly increased in those with early onset preeclampsia and pregnant controls when compared to non-pregnant controls without significant differences between the 2 former groups. Plasmin-antiplasmin levels were significantly reduced in a similar manner. tPA levels were significantly elevated in EOP compared to both pregnant and non-pregnant controls. EOP was associated with significantly increased anti-angiogenic factors (sFLT-1; Endoglin) when compared to both pregnant and non-pregnant controls.

CONCLUSION

; Markers of fibrin formation and fibrinolysis are significantly alerted in early onset preeclampsia; furthermore, certain markers correlate with disease severity in this patient cohort.

Role of plasma PlGF, PDGF-AA, ANG-1, ANG-2, and the ANG-1/ANG-2 ratio as predictors of preeclampsia in a cohort of pregnant women

INTRODUCTION

Preeclampsia affects 3-5% of pregnancies worldwide and is the primary cause of maternal-fetal and neonatal mortality. Previous studies show that alterations in maternal concentrations of angiogenic factors, such as PlGF, PDGF AA, ANG-1, and ANG-2, may play fundamental roles in the pathophysiology of the disease.

OBJECTIVE

Determine whether the PlGF, PDGF AA, ANG-1, and ANG-2 are predictors of preeclampsia occurrence in a prenatal cohort study.

PATIENTS AND METHODS

This is a case-control study associated with a prospective cohort of pregnant women, with gestational ages between 20 and 25 weeks, composed of 30 pregnant women with preeclampsia (PE) and 90 healthy pregnant women (HP). The plasma concentrations of the markers were determined using the ELISA method. The comparison between the case and control groups was performed using the t test on the SAS® 9.4 software. Also, ROC curves were constructed to evaluate the predictive potential of the biomarkers.

RESULTS

Differences in the concentrations of PlGF, PDGF AA, ANG-1 and ANG-2, and the ANG-1/ANG-2 ratio were not observed between the PE and the HP groups. The predictive capacity of the biomarkers was assessed using ROC curves, in which the area under the curve for PlGF AUC = 0.55; PDGF AA AUC = 0.55; ANG-1 AUC = 0.47; ANG-2 AUC = 0.51, and the ANG-1/ANG-2 ratio AUC = 0.57.

CONCLUSION

In pregnant women, with gestational ages between 20 and 25 weeks significant differences in biomarker concentrations between groups PE and HP were not observed. The ROC curves showed that the biomarkers were ineffective as preeclampsia predictors in the analyzed cohort.

Impact of neonatologist availability on preterm survival without morbidities

OBJECTIVES

We assessed birth hospital level and neonatal outcomes within a model of regionalization featuring neonatologists at all levels of care, including well-baby nurseries without an accompanying neonatal intensive care unit.

METHODS

Data were analyzed by NY State adaptation of American Academy of Pediatrics defined levels of care; n = 998, 23-30 weeks gestational age, 400-1250 g birth weight, and admitted to the regional center (2006-2015). Primary outcomes were survival, neurologic survival, and intact survival.

RESULTS

Level III hospitals transferred 82% of neonates ≥24 h of life compared to ≤2% at Level I or II hospitals (p < 0.05). Primary outcomes were equivalent for Levels I vs. II born neonates with similar postnatal age at transfer and similar to inborn rates (Levels I and II vs. IV).

CONCLUSIONS

When transferred within 24 h, Levels I or II born infants had equivalent outcomes to inborn Level IV infants in a model of neonatologist availability at all deliveries.

Quality measures in high-risk pregnancies: Executive Summary of a Cooperative Workshop of the Society for Maternal-Fetal Medicine, National Institute of Child Health and Human Development, and the American College of Obstetricians and Gynecologists

Providers perceive current obstetric quality measures as imperfect and insufficient. Our organizations convened a "Quality Measures in High-Risk Pregnancies Workshop." The goals were to (1) review the current landscape regarding quality measures in obstetric conditions with increased risk for adverse maternal or fetal outcomes, (2) evaluate the available evidence for management of common obstetric conditions to identify those that may drive the highest impact on outcomes, quality, and value, (3) propose measures for high-risk obstetric conditions that reflect enhanced quality and efficiency, and (4) identify current research gaps, improve methods of data collection, and recommend means of change.

Perinatal legislative policies and health outcomes

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.

Risk of neurodevelopmental impairment for outborn extremely preterm infants in an Australian regional network

OBJECTIVE

To compare neurodevelopmental outcomes at 2-3 years in extremely premature outborn and inborn infants.

DESIGN

Population-based retrospective cohort study.

SETTING

Geographically defined area of New South Wales (NSW) and the Australian Capital Territory (ACT) served by a network of 10 neonatal intensive care units (NICUs).

PATIENTS

All premature infants <29 weeks gestation born between 1998 and 2004 in the setting.

INTERVENTION

At 2-3 years, corrected age, 1473 children were assessed with either the Griffiths Mental Developmental Scales (GMDS) or the Bayley Scales of Infant Development (BSID-II).

MAIN OUTCOME MEASURE

Moderate/severe functional disability (FD) defined as: developmental delay (GMDS general quotient (GQ) or BSID-II mental developmental index (MDI)) > 2 standard deviations (SD) below the mean; cerebral palsy (CP) requiring aids; sensorineural or conductive deafness (requiring amplification); or bilateral blindness (visual acuity <6/60 in better eye).

RESULTS

At 2-3 years, moderate/severe functional disability does not appear to be significantly different between outborn and inborn infants (adjusted OR 0.782; 95% CI 0.424-1.443). However, there were a significant number of outborn infants lost to follow up (23.3% versus 42.9%).

CONCLUSION

In this cohort, at 2-3 years follow up neurodevelopmental outcome does not appear to be significantly different between outborn and inborn infants. These results should be interpreted with caution given the limitation of this study.

Perinatal Regionalization and Implications for Long-Term Health Outcomes in Cerebral Palsy

Background: Perinatal regionalization is linked to improved neonatal outcomes; however, the effects on long-term outcomes in cerebral palsy (CP) are not known. We estimate the effect of highest levels of neonatal care available at delivery on the risk of developing a nonambulatory CP status. Methods: Children with CP born in Quebec from the Canadian CP Registry excluding postneonatal causes were included (N=360). We estimate the effect of level of care available at delivery on risk of nonambulatory status among children with CP using propensity score matching and instrumental variables methods to adjust for differences in case mix among the three groups of hospitals. The outcome variable is an indicator for CP nonambulation assigned according to Gross Motor Function Classification System (levels IV and V). This study used data that predated therapeutic hypothermia in Quebec. Results: Propensity score estimates of change in the adjusted risk of having a nonambulatory CP status because of birth at level II versus level I is −0.081, 95% confidence interval (CI; −0.2182 to 0.0562); level III versus level I is −0.072 95% CI (−0.225 to 0.08), and level III versus level II is 0.157 95% CI (0.027 to 0.286). Conclusions: Differences in levels of neonatal care available at hospital where the delivery was carried out are not associated with the risk of a nonambulatory CP phenotype. This suggests that level of care and associated medical technology within the Quebec regionalized neonatal-perinatal system is used efficiently because it does not offer any further marginal benefit in the reduction of severe CP outcomes. The system works well as it is, which is supportive of the perinatal regionalization. The success of the neonatal resuscitation program and referral of high-risk births to regional hospitals with sufficient obstetric and perinatal competence and resources may contribute to this lack of variability.

United States and territory policies supporting maternal and neonatal transfer: review of transport and reimbursement

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.

A Generalized Assessment of the Impact of Regionalization and Provider Learning on Patient Outcomes

We present a generalized model to assess the impact of regionalization on patient care outcomes in the presence of heterogeneity in provider learning. The model characterizes best regionalization policies as optimal allocations of patients across providers with heterogeneous learning abilities. We explore issues that arise when solving for best regionalization, which depends on statistically estimated provider learning curves. We explain how to maintain the problem's tractability and reformulate it into a binary integer program problem to improve solvability. Using our model, best regionalization solutions can be computed within reasonable time using current-day computers. We apply the model to minimally invasive radical prostatectomy and estimate that, in comparison to current care delivery, within-state regionalization can shorten length of stay by at least 40.8%.

The effectiveness of regionalization of perinatal care services--a systematic review

BACKGROUND

Several reports recommend the implementation of perinatal regionalization for improvements in maternal and neonatal outcomes, while research evidence on the effectiveness of perinatal regionalization has been limited. The interventional studies have been assessed for robust evidence on the effectiveness of perinatal regionalization on improving maternal and neonatal health outcomes.

METHODS

Bibliographic databases of Medline, EMbase, EconLit, HMIC have been searched using sensitive search terms for interventional studies that reported important patient or process outcomes. At least two authors assessed eligibility for inclusion and the risk of biases and extracted data from the included studies. As meta-analysis was not possible, a narrative analysis as well as a 'vote-counting' analysis has been conducted for important outcomes.

RESULTS

After initial screenings 53 full text papers were retrieved. Eight studies were included in the review from the USA, Canada and France. Studies varied in their designs, and in the specifications of the intervention and setting. Only three interrupted time series studies had a low risk of bias, of which only one study reported significant reductions in neonatal and infant mortality. Studies of higher risk of bias were more likely to report improvements in outcomes.

CONCLUSIONS

Implementing perinatal regionalization programs is correlated with improvements in perinatal outcomes, but it is not possible to establish a causal link. Despite several high profile policy statements, evidence of effect is weak. It is necessary to assess the effectiveness of perinatal regionalization using robust research designs in a more diverse range of countries.

Outcomes following periviable birth

This review is presented in three segments: (1) important background concepts, (2) recent reports from regional geographically defined cohorts, and (3) prognosis research from the National Institutes of Health Neonatal Research Network. Extending the use of intensive care to newborns of lower gestational ages will unavoidably result in a higher proportion and a higher absolute number of survivors with morbidity, unless other changes in practice offset the increased risk associated with decreasing gestational age. In geographically defined cohort studies, the proportion of periviable newborns delivered in perinatal centers and the practices around foregoing and withdrawing intensive care are two important determinants of outcomes following periviable birth. It is much easier to quantify the effect of the former than the latter. Decisions regarding comfort care vs. intensive are frequently based on gestational age as the sole predictor variable, although multiple factors can be readily used to more accurately assess the benefits and burdens of intensive care and facilitate better informed parental counseling and decision making.

The right stuff

We will discuss a new initiative of the American College of Surgeons and the American Pediatric Surgical Association to prospectively define optimal resource standards for children's surgical care.

An Elevated Maternal Plasma Soluble fms-Like Tyrosine Kinase-1 to Placental Growth Factor Ratio at Midtrimester Is a Useful Predictor for Preeclampsia

Background. To assess the ability of mid-trimester sFlt-1/PlGF ratio for prediction of preeclampsia in two different Arabic populations. Methods. This study measured levels of sFlt-1, PlGF, and sFlt-1/PlGF ratio at midtrimester in 83 patients who developed preeclampsia with contemporary 250 matched controls. Results. Women subsequently developed preeclampsia had significantly lower PlGF levels and higher sFlt-1 and sFlt-1/PlGF ratio levels than women with normal pregnancies (P < 0.0001 for all). Women who with preterm preeclampsia had significantly higher sFlt-1 and sFlt-1/PlGF ratio than term preeclamptic women (P = 0.01, 0.003, resp.). A cutoff value of 3198 pg/mL for sFlt-1 was able to predict preeclampsia with sensitivity, specificity, and accuracy of 88%, 83.6%, and 84.7%, respectively, with odds ratio (OR) 37.2 [95% confidence interval (CI) 17.7-78.1]. PIGF at cutoff value of 138 pg/mL was able to predict preeclampsia with sensitivity, specificity, and accuracy of 85.5%, 77.2%, and 79.3%, respectively, with OR 20 [95% CI, 10.2-39.5]. The sFlt-1/PIGF ratio at cutoff value of 24.5 was able to predict preeclampsia with sensitivity, specificity, and accuracy of 91.6%, 86.4%, and 87.7%, respectively with OR 67 [95% CI, 29.3-162.1]. Conclusion. Midtrimester sFlt-1/PlGF ratio displayed the highest sensitivity, specificity, accuracy, and OR for prediction of preeclampsia, demonstrating that it may stipulate more effective prediction of preeclampsia development than individual factor assay.

Telemedicine collaboration improves perinatal regionalization and lowers statewide infant mortality

OBJECTIVE

We assessed a telemedicine (TM) network's effects on decreasing deliveries of very low birth weight (VLBW, <1500 g) neonates in hospitals without Neonatal Intensive Care Units (NICUs) and statewide infant mortality.

STUDY DESIGN

This prospective study used obstetrical and neonatal interventions through TM consults, education and census rounds with 9 hospitals from 1 July 2009 to 31 March 2010. Using a generalized linear model, Medicaid data compared VLBW birth sites, mortality and morbidity before and after TM use. Arkansas Health Department data and χ(2) analysis were used to compare infant mortality.

RESULT

Deliveries of VLBW neonates in targeted hospitals decreased from 13.1 to 7.0% (P=0.0099); deliveries of VLBW neonates in remaining hospitals were unchanged. Mortality decreased in targeted hospitals (13.0% before TM and 6.7% after TM). Statewide infant mortality decreased from 8.5 to 7.0 per 1000 deliveries (P=0.043).

CONCLUSION

TM decreased deliveries of VLBW neonates in hospitals without NICUs and was associated with decreased statewide infant mortality.

Does facility based newborn care improve neonatal outcomes? A review of evidence

CONTEXT

Facility based newborn care is gaining importance as an intervention aiming at reduction of neonatal mortality.

OBJECTIVE

To assess different factors that affect effectiveness of facility based newborn care on neonatal outcomes.

EVIDENCE ACQUISITION

Electronic search using key search engines along with search of grey literature manually. Observational and interventional studies published between 1966-Aug 2010 in English having a change in neonatal mortality as an outcome measure were considered.

RESULTS

A total of 40 articles were fully reviewed for generating synthesized evidence. All were observational studies. The exposure variables that affected neonatal outcomes were grouped into three categories- regionalization of perinatal care (17 articles), strengthening of lower level neonatal facilities (12), and other miscellaneous factors (11). Regionalization played a key role in advancing newborn care practices. It increased in-utero transfer of high risk newborns and improved survival outcomes especially for very low birth weight neonates at level III facilities. It led to reduction in neonatal mortality owing primarily to enhanced survival of low birth weight infants. Strengthening of lower level units contributed significantly in reducing neonatal mortality. High patient volume (>2,000 deliveries/year), inborn status, availability of referral system and inter-facility transfers, and adequate nursing care staff in neonatal units also demonstrated protective effect in averting neonatal deaths.

CONCLUSIONS

Countries investing in facility based newborn care should give impetus to establishing regionalized systems of perinatal care. Strengthening of lower level units with high case loads, can yield optimal reduction in NMR.

Levels of neonatal care

Provision of risk-appropriate care for newborn infants and mothers was first proposed in 1976. This updated policy statement provides a review of data supporting evidence for a tiered provision of care and reaffirms the need for uniform, nationally applicable definitions and consistent standards of service for public health to improve neonatal outcomes. Facilities that provide hospital care for newborn infants should be classified on the basis of functional capabilities, and these facilities should be organized within a regionalized system of perinatal care.

The differential impact of delivery hospital on the outcomes of premature infants

BACKGROUND

Because greater percentages of women deliver at hospitals without high-level NICUs, there is little information on the effect of delivery hospital on the outcomes of premature infants in the past 2 decades, or how these effects differ across states with different perinatal regionalization systems.

METHODS

A retrospective population-based cohort study was constructed of all hospital-based deliveries in Pennsylvania and California between 1995 and 2005 and Missouri between 1995 and 2003 with a gestational age between 23 and 37 weeks (N = 1328132). The effect of delivery at a high-level NICU on in-hospital death and 5 complications of premature birth was calculated by using an instrumental variables approach to control for measured and unmeasured differences between hospitals.

RESULTS

Infants who were delivered at a high-level NICU had significantly fewer in-hospital deaths in Pennsylvania (7.8 fewer deaths/1000 deliveries, 95% confidence interval [CI] 4.1-11.5), California (2.7 fewer deaths/1000 deliveries, 95% CI 0.9-4.5), and Missouri (12.6 fewer deaths/1000 deliveries, 95% CI 2.6-22.6). Deliveries at high-level NICUs had similar rates of most complications, with the exception of lower bronchopulmonary dysplasia rates at Missouri high-level NICUs (9.5 fewer cases/1000 deliveries, 95% CI 0.7-18.4) and higher infection rates at high-level NICUs in Pennsylvania and California. The association between delivery hospital, in-hospital mortality, and complications differed across the 3 states.

CONCLUSIONS

There is benefit to neonatal outcomes when high-risk infants are delivered at high-level NICUs that is larger than previously reported, although the effects differ between states, which may be attributable to different methods of regionalization.

Transition from neonatal intensive care unit to special care nurseries: experiences of parents and nurses

OBJECTIVES

To explore parents' and nurses' experiences with the transition of infants from the neonatal intensive care unit to a special care nursery.

DESIGN

Qualitative explorative study in two phases.

SETTING

Level IIID neonatal intensive care unit in a university hospital and special care nurseries (level II) in five community hospitals in the Netherlands.

PARTICIPANTS

Twenty-one pairs of parents and 18 critical care nurses.

METHODS AND MAIN RESULTS

Semistructured interviews were used. Thematic analysis and comparison of themes across participants were performed. Trust was a central theme for parents. Three subthemes, related to the chronological stages of transition, were identified: gaining trust; betrayal of trust; and rebuilding confidence. Trust was associated with five other themes: professional attitude; information management; coordination of transfer; different environments; and parent participation. Although nurses at an early stage repeatedly mentioned a possible transition to community hospitals, the actual announcement took many parents by surprise. Parents felt excluded during the actual transfer and most questioned its necessity. In the special care nursery, parents found it difficult to adjust to new routines and to gain trust in new caregivers, but eventually their worries dissolved. In contrast to neonatal intensive care unit nurses, special care nursery nurses quite understood the impact of transition on parents.

CONCLUSIONS

Both parents and nurses considered present transitional arrangements to be inadequate. Nurses should provide more effective discharge planning and transitional care. A positive labeling of the transition as a first step to home discharge for the newborn seems appropriate. Parents need to be better-informed and should be involved in the planning process.

The promise of angiogenic markers for the early diagnosis and prediction of preeclampsia

BACKGROUND

An imbalance in circulating factors that regulate blood vessel formation and health, referred to as angiogenic factors, plays a central role in the pathogenesis of preeclampsia.

CONTENT

Several studies have demonstrated a strong association between altered circulating angiogenic factors and preeclampsia. These factors include circulating antiangiogenic proteins such as soluble fms-like tyrosine kinase 1 and soluble endoglin and proangiogenic protein such as placental growth factor. Abnormalities in these circulating angiogenic factors are not only present during clinical disease, but also antedate clinical signs and symptoms by several weeks. These alterations are particularly prominent in patients who present with preeclamptic signs and symptoms prematurely and/or in patients with severe preeclampsia. The availability of automated platforms for the rapid measurement of circulating angiogenic proteins in blood samples has now allowed researchers and clinicians to evaluate the utility of these assays in the diagnosis of the disease, in the stratification of patients in clinical trials, or in the monitoring of therapies. In this review we highlight the various studies that have been performed, with a focus on large validation studies.

SUMMARY

Measurement of circulating angiogenic proteins for the diagnosis and prediction of preeclampsia is still at an early stage but is rapidly evolving. Standardization across the various automated platforms and prospective studies that demonstrate clinical utility are needed.

The sFlt-1/PlGF ratio in different types of hypertensive pregnancy disorders and its prognostic potential in preeclamptic patients

OBJECTIVE

The soluble fms-like tyrosine kinase (sFlt-1)/placental growth factor (PlGF) ratio is a reliable tool in the assessment of preeclampsia. We tested the hypothesis that the sFlt-1/PlGF ratio is able to identify women at risk for imminent delivery. We characterized the sFlt-1/PlGF ratio in different types of hypertensive pregnancy disorders.

STUDY DESIGN

We investigated 388 singleton pregnancies with normal pregnancy outcome, 164 with PE, 36 with gestational hypertension, and 42 with chronic hypertension. sFlt-1 and PlGF were measured in serum samples.

RESULTS

Patients with preeclampsia had a significantly increased sFlt-1/PlGF ratio as compared with controls and with patients with chronic and gestational hypertension in <34 weeks and ≥34 weeks (P < .001). Time to delivery was significantly reduced in women with preeclampsia in the highest quartile of the sFlt-1/PlGF ratio (P < .001).

CONCLUSION

The sFlt-1/PlGF ratio allows the identification of women at risk for imminent delivery and is a reliable tool to discriminate between different types of pregnancy-related hypertensive disorders.

The impact of certificate of need programs on neonatal intensive care units

OBJECTIVE

To determine the impact of state certificate of need programs (CON) on the number of hospitals with neonatal intensive care units (NICU) and the number of NICU beds.

STUDY DESIGN

The presence of a CON program was verified from each state's department of health. Multivariable regression models determined the association between the absence of a CON program and each outcome after controlling for socioeconomic and demographic differences between states.

RESULT

A total of 30 states had CON programs that oversaw NICUs in 2008. Absence of such programs was associated with more hospitals with a NICU (Rate Ratio (RR) 2.06, 95% CI 1.74 to 2.45) and NICU beds (RR 1.96, 95% CI 1.89 to 2.03) compared with states with CON legislation, and increased all-infant mortality rates in states with a large metropolitan area.

CONCLUSION

There has been an erosion of CON programs that oversee NICUs. CON programs are associated with more efficient delivery of neonatal care.

Regionalization of neonatal intensive care in Korea

In the current era of low-birth rate in Korea, it is important to improve our neonatal intensive care and to establish an integrative system including a regional care network adequate for both high-risk pregnancies and high-risk newborn infants. Therefore, official discussion for nation-wide augmentation, proper leveling, networking, and regionalization of neonatal and perinatal care is urgently needed. In this report, I describe the status of neonatal intensive care in Korea, as well as nationwide flow of transfer of high-risk newborn infants and pregnant women, and present a short review of the regionalization of neonatal and perinatal care in the Unites States and Japan. It is necessary not only to increase the number of neonatal intensive care unit (NICU) beds, medical resources and manpower, but also to create a strong network system with appropriate leveling of NICUs and regionalization. A systematic approach toward perinatal care, that includes both high-risk pregnancies and newborns with continuous support from the government, is also needed, which can be spearheaded through the establishment of an integrative advisory board to propel systematic care forward.

Examining the effect of hospital-level factors on mortality of very low birth weight infants using multilevel modeling

OBJECTIVE

The objective of this study was to examine the effect of hospital-level factors on mortality of very low birth weight infants using multilevel modeling.

STUDY DESIGN

This is a secondary data analysis of California maternal-infant hospital discharge data from 1997 to 2002. The study population was limited to singleton, non-anomalous, very low birth weight infants, who delivered in hospitals providing neonatal intensive care services (level-2 and higher). Hierarchical generalized linear modeling, also known as multilevel modeling, was used to adjust for individual-level confounders.

RESULT

In a multilevel model, increasing hospital volume of very low birth weight deliveries was associated with lower odds of very low birth weight mortality. Characteristics of a particular hospital's obstetrical and neonatal services (the presence of residency and fellowship training programs and the availability of perinatal and neonatal services) had no independent effect.

CONCLUSION

Using multilevel modeling, hospital volume of very low birth weight deliveries appears to be the primary driver of reduced mortality among very low birth weight infants.

Angiogenic growth factors in the diagnosis and prediction of pre-eclampsia

The pathogenesis of pre-eclampsia is still not completely known; however, in the recent decade, there have been tremendous research efforts leading to impressive results highlighting the role of a disturbed angiogenic balance as one of the key features of the disease. Numerous studies have shown the key role of the placenta in the pathogenesis of pre-eclampsia. A shift in the sFlt-1 (soluble Fms-like tyrosine kinase-1)/PlGF (placental growth factor) ratio is associated with the disease. Although pre-eclampsia seems to be a clearly defined disease, clinical presentation, and particularly the dynamics of the clinical course, can vary enormously. The only available tools to diagnose pre-eclampsia are blood pressure measurement and urine protein sampling. However, these tools have a low sensitivity and specificity regarding the prediction of the course of the disease or maternal and perinatal outcomes. The only cure for the disease is delivery, although a timely diagnosis helps in decreasing maternal and fetal morbidity and mortality. The sFlt1/PlGF ratio is able to give additional valuable information on the status and progression of the disease and is apt to be implemented in the diagnostic algorithm of pre-eclampsia. In the present review, we aim to provide an overview of the vast literature on angiogenesis and anti-angiogenesis factors in pre-eclampsia that have been published over the last decade. We introduce work from basic research groups who have focused on the pathophysiological basis of the disease. Furthermore, we review studies with a clinical focus in which the sFlt-1/PlGF ratio has been analysed along with other candidates for routine clinical assessment of pre-eclampsia.

Perinatal periods of risk: phase 2 analytic methods for further investigating feto-infant mortality

The perinatal periods of risk (PPOR) methods provide a framework and tools to guide large urban communities in investigating their feto-infant mortality problem. The PPOR methods have 11 defined steps divided into three analytic parts: (1) Analytic Preparation; (2) Phase 1 Analysis-identifying the opportunity gaps or populations and risk periods with largest excess mortality; and (3) Phase 2 Analyses-investigating these opportunity gaps. This article focuses on the Phase 2 analytic methods, which systematically investigate the opportunity gaps to discover which risk and preventive factors are likely to have the largest effect on improving a community's feto-infant mortality rate and to provide additional information to better direct community prevention planning. This article describes the last three PPOR epidemiologic steps for investigating identified opportunity gaps: identifying the mechanism for excess mortality; estimating the prevalence of risk and preventive factors; and estimating the impact of these factors. While the three steps provide a common strategy, the specific analytic details are tailored for each of the four perinatal risk periods. This article describes the importance, prerequisites, alternative approaches, and challenges of the Phase 2 methods. Community examples of the methods also are provided.

The regionalization of pediatric health care

Regionalization of health care is a method of providing high-quality, cost-efficient health care to the largest number of patients. Within pediatric medicine, regionalization has been undertaken in 2 areas: neonatal intensive care and pediatric trauma care. The supporting literature for the regionalization of these areas demonstrates the range of studies within this field: studies of neonatal intensive care primarily compare different levels of hospitals, whereas studies of pediatric trauma care primarily compare the impact of institutionalizing a trauma system in a single geographic region. However, neither specialty has been completely regionalized, possibly because of methodologic deficiencies in the evidence base. Research with improved study designs, controlling for differences in illness severity between different hospitals; a systems approach to regionalization studies; and measurement of parental preferences will improve the understanding of the advantages and disadvantages of regionalizing pediatric medicine and will ultimately optimize the outcomes of children.

Geographical maldistribution of pediatric medical resources in Seattle-King County

OBJECTIVE

Seattle-King County (SKC) Washington is at risk for regional disasters, especially earthquakes. Of 1.8 million residents, >400,000 (22%) are children, a proportion similar to that of the population of the State of Washington (24%) and of the United States (24%). The county's large area of 2,134 square miles (5,527 km2) is connected through major transportation routes that cross numerous waterways; sub-county zones may become isolated in the wake of a major earthquake. Therefore, each of SKC's three subcounty emergency response zones must have ample pediatric medical response capabilities. To date, total quantities and distribution of crucial hospital resources (available in SKC) to manage pediatric victims of a medical disaster are unknown. This study assessed whether geographical distribution of hospital pediatric resources corresponds to the pediatric population distribution in SKC.

METHODS

Surveys were delivered electronically to all eight acute care hospitals in SKC that admit pediatric patients. Quantities and categories of pediatric resources, including inpatient treatment space, staff, and equipment, were queried and verified via site visits.

RESULTS

Within the seven responding hospitals of eight queried, the following were identified: 477 formal pediatric bed spaces (pediatric intensive care unit, neo-natal intensive care unit, general wards, and emergency department), 43 informal pediatric bed spaces (operating room and post-anesthesia care unit), 1,217 pediatric nurses, 554 pediatric physicians, and 252 infant/pediatric-adaptable ventilators. The City of Seattle emergency response zone contains 82.1% of bed spaces, 83.5% of nurses, and 95.8% of physicians, yet only 22.8% of all SKC children live in that zone.

CONCLUSIONS

The majority of hospital pediatric resources are located in the SKC sub-region with the fewest children. These resources are potentially inaccessible and unable to be redistributed by ground transportation in the event of a significant regional disaster. Future planning for pediatric care in the event of a medical disaster in SKC must address this vulnerability.

The effect of neonatal intensive care level and hospital volume on mortality of very low birth weight infants

OBJECTIVE

To determine the adjusted effect of hospital level of care and volume on mortality of very low birth weight (VLBW) infants in the state of California, where deregionalization of perinatal care has occurred.

RESEARCH DESIGN

Secondary data analysis of California maternal-infant hospital discharge data from 1997 to 2002 was performed. Logistic regression was used to evaluate the odds of mortality among VLBW infants by hospital level of neonatal intensive care and volume of VLBW deliveries, in the context of differences in antenatal and delivery factors by hospital site of delivery.

RESULTS

Both maternal and fetal antenatal risk profiles and delivery characteristics vary by hospital site of delivery. After risk adjustment, lower-level, lower-volume units were associated with a higher odds of mortality. The highest odds of mortality occurred in level-1 units with < or =10 VLBW deliveries per year (odds ratio, 1.69; 95% confidence interval, 1.43-1.99). In isolation, hospital volume, rather than level of care, had the greater effect.

CONCLUSIONS

Although deregionalization of perinatal services may increase access to care for high-risk mothers and newborns, its impact on hospital volume may outweigh its potential benefit.

Outcome of extreme prematurity: a prospective comparison of 2 regional cohorts born 20 years apart

OBJECTIVE

To determine changes that have occurred over the past 20 years in perinatal characteristics, neonatal treatments, morbidities, and early neurodevelopmental outcomes of infants born at < or =30 weeks' gestation.

METHODS

This was a prospective regional study including all live-born infants < or =30 weeks' gestation born between July 1985 and June 1986 (cohort 1) and July 2005 and June 2006 (cohort 2). Sociodemographically matched term controls were recruited for each cohort. Perinatal characteristics, mortality rates, and survival with and without impairments at 24 months' corrected age were compared.

RESULTS

There was a 35% increase in the number of live-born preterm births (138 in cohort 1 and 187 in cohort 2) despite a >10% decline in total births in the region (P < .001). Assisted fertility (rarely available for mothers in cohort 1) was responsible for 20% of pregnancies in cohort 2. Survival to hospital discharge increased over 20 years from 82% to 93% (P = .002), primarily because of higher survival for infants born at <27 weeks' gestation (63% vs 88%; P = .004). Changes in management in cohort 2 included the use of surfactant (62% of infants) and increased use of postnatal steroids (39% vs 9%; P < .001), that were associated with a shorter median duration of mechanical ventilation (13 vs 21 days; P < .001); however, the incidence of bronchopulmonary dysplasia was higher in cohort 2 (56% vs 35%; P < .001). There was a significant decrease in incidence of severe ultrasound abnormalities from 17% in cohort 1 to 7% in cohort 2 (P = .008). At 24 months of age, 7% of cohort 1 and 5% of cohort 2 had an abnormal neurologic exam. Bayley cognitive scores were improved in cohort 2 (significantly closer to the mean of their controls). As a result, survival without severe neurodevelopmental impairment increased from 62% in cohort 1 to 81% in cohort 2 (P < .001).

CONCLUSION

Over 20 years, there has been a significant increase in live births at < or =30 weeks' gestational age, with a greater percentage of these neonates surviving without severe neurodevelopmental impairment at 24 months.

Regionalization and mortality in neonatal intensive care

This article examines the outcome data for very low birth weight infants in low-volume, mid-volume, and high-volume neonatal ICUs (NICUs) and argues for regionalization of NICU services on the basis of both medical outcomes and economic rationality. It recognizes some of the obstacles to regionalization of these services and presents ways to surmount them.

Infants born at the threshold of viability in relation to neonatal mortality: Colorado, 1991 to 2003

OBJECTIVE

To determine the contribution of infants born at the threshold of viability (defined as <750 g birth weight) and the role of regionalization of perinatal care on the neonatal mortality rate (NMR) in Colorado.

STUDY DESIGN

We performed a retrospective cohort study, evaluating all live births in Colorado from 1991 to 2003, and comparing the periods 1991 to 1996 versus 1997 to 2003.

RESULT

The overall unadjusted NMR of the two time periods was 4.3 and 4.4 per 1000 live births, respectively (P=0.42). The contribution of infants with birth weights<750 g to the overall NMR increased from 45.0 to 54.5% (P<0.01). The odds of death for infants<750 g increased between time periods (Odd ratio 1.3, 95% Confidence interval 1.11, 1.61). However, NMR decreased between time periods for all birth weight categories, until infants<600 g. With respect to regionalization, the number of infants<750 g born in a level III care center increased slightly between the two time periods (69.6 versus 73.3%; P=0.04); however, adjusted analysis showed no difference in the practice of regionalization between time periods. Regardless of time period, infants who weighed <750 g born in a level III center had 60% lower mortality risk when compared to <750 g infants born in a non-level III center (P<0.01; 95% CI 0.30, 0.52).

CONCLUSION

Despite advances in neonatal medicine, the overall NMR in the state of Colorado remained unchanged between the time periods of 1991 to 1996 and 1997 to 2003. Infants at the threshold of viability continue to have a large impact on the Colorado NMR, making up a larger proportion of overall neonatal deaths. While the results demonstrate that the risk of mortality is significantly reduced for <750 g infants born in a level III center, the practice of regionalization has not changed between the two time periods. Improved efforts to standardize the referral practices to ensure delivery of <750 g infants in level III centers could potentially reduce the impact of these infants on the NMR. While the overall NMR in Colorado has not changed between the two time periods, the NMR for infants>600 g has significantly decreased, suggesting that the boundary delineating the threshold of viability needs reevaluation, as it may have been pushed lower than previously defined.

Obstetrical volume and early neonatal mortality in preterm infants

OBJECTIVE

Regionalised perinatal care with antenatal transfer of high risk pregnancies to Level III centres is beneficial. However, levels of care are usually not linked to caseload requirements, which remain a point for discussion. We aimed to investigate the impact of annual delivery volume on early neonatal mortality among very preterm births.

METHODS

All neonates with gestational age 24-30 weeks, born 1991-1999 in Lower Saxony were included into this population-based cohort study (n = 5,083). Large units were defined as caring for more than 1,000 deliveries/year, large NICUs as those with at least 36 annual very low birthweight (<1,500 g, VLBW) admissions. Main outcome criterion was mortality until day 7. Adjusted Odds Ratios (adj. OR) and 95% confidence intervals (CI) were calculated based on generalised estimating equation models, accounting for correlation of individuals within units.

RESULTS

Within the first week of life, 20.6% of all neonates deceased; 10.2% were stillbirths, 3.7% died in the delivery unit, and 6.7% in the NICU. The crude OR for early neonatal mortality after having been delivered in a small delivery unit (excluding stillbirths) was 1.36 (95%CI 1.04-1.78; adj. OR 1.16 (0.82-1.63)). It increased to 1.96 (1.54-2.48; adj. OR 1.21 (0.86-1.70)) after the inclusion of stillbirths.

CONCLUSION

This study has shown a slight, but non-significant association between obstetrical volume and early neonatal mortality. In future studies the impact of caseload on outcome may become more evident when referring to high-risk patients instead of to the overall number of deliveries.

Duration of inter-facility neonatal transport and neonatal mortality: systematic review and cohort study

BACKGROUND

Regionalization of perinatal health services has been actively discussed, although important determinants such as effect of duration of neonatal transport on neonatal outcomes have not been investigated well as yet. Therefore the purpose of the present paper was to investigate the association between duration of inter-facility transport and perinatal mortality.

METHODS

For the systematic review, six major databases were searched. Any comparative studies investigating associations between duration of inter-facility neonatal transport and their outcomes, published in the English language were selected. The studies were screened and reviewed by two independent researchers. For the cohort study, study subjects included every neonate transported to neonatal wards in Osaka, Japan between 1980 and 2000 in an existing surveillance called Neonatal Mutual Cooperative System. They are followed up until 28 days of age, or discharge if earlier. Other variables were also considered as effect modifiers or confounders, including calendar year, birthweight (BW), gestational age (GA), sex, maternal/paternal age, Apgar scores at 1 and 5 min, place of birth and personnel accompanying the neonate during transport (transport personnel), body temperature before transport and on admission, severity of illness, and intraventricular hemorrhage (IVH) grade. Cox regression analyses were performed to obtain principal results, and sensitivity analysis to support them.

RESULTS

Systematic review: only one cross-sectional study conducted in an urban area in India was identified. That study showed that neonates with a long duration of transport had 79% higher odds of death than those transported for a short duration after adjusting for the confounding effects. For the cohort study, among 16 429 subjects, full data were available for 4966 neonates. There was strong evidence that those transported for >90 min had more than twice the rate of neonatal death (rate ratio [RR] 2.26, 95% confidence interval [CI]: 1.26-4.04), and some evidence that those transported for between 60 and 89 min had an 80% higher rate of neonatal death (RR 1.81, 95%CI: 1.07-3.06), both compared with those transported for between 30 and 59 min, after adjusting for the confounding effects. A sensitivity analysis on missing values also supported the results.

CONCLUSION

There is evidence of an association between duration of transport and increased neonatal mortality, which can be applied to organization of perinatal health services. A prospective cohort study is needed for further investigation.

Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants

BACKGROUND

There has been a large increase in both the number of neonatal intensive care units (NICUs) in community hospitals and the complexity of the cases treated in these units. We examined differences in neonatal mortality among infants with very low birth weight (below 1500 g) among NICUs with various levels of care and different volumes of very-low-birth-weight infants.

METHODS

We linked birth certificates, hospital discharge abstracts (including interhospital transfers), and fetal and infant death certificates to assess neonatal mortality rates among 48,237 very-low-birth-weight infants who were born in California hospitals between 1991 and 2000.

RESULTS

Mortality rates among very-low-birth-weight infants varied according to both the volume of patients and the level of care at the delivery hospital. The effect of volume also varied according to the level of care. As compared with a high level of care and a high volume of very-low-birth-weight infants (more than 100 per year), lower levels of care and lower volumes (except for those of two small groups of hospitals) were associated with significantly higher odds ratios for death, ranging from 1.19 (95% confidence interval [CI], 1.04 to 1.37) to 2.72 (95% CI, 2.37 to 3.12). Less than one quarter of very-low-birth-weight deliveries occurred in facilities with NICUs that offered a high level of care and had a high volume, but 92% of very-low-birth-weight deliveries occurred in urban areas with more than 100 such deliveries.

CONCLUSIONS

Mortality among very-low-birth-weight infants was lowest for deliveries that occurred in hospitals with NICUs that had both a high level of care and a high volume of such patients. Our results suggest that increased use of such facilities might reduce mortality among very-low-birth-weight infants.

Effect of opening midlevel neonatal intensive care units on the location of low birth weight births in California

OBJECTIVE

Despite evidence and recommendations encouraging the delivery of high-risk newborns in hospitals with subspecialty or high-level NICUs, increasing numbers are being delivered in other facilities. Causes for this are unknown. We sought to explore the impact of diffusion of specialty or midlevel NICUs on the types of hospitals in which low birth weight newborns are born.

DESIGN

We used birth certificate, death certificate, and hospital discharge data for essentially all low birth weight, singleton California newborns born between 1993 and 2000. We identified areas likely to have been affected by the opening of a new nearby midlevel unit, analyzed changes over time in the share of births that took place in midlevel NICU hospitals, and compared patterns in areas that were and were not likely affected by the opening of a new midlevel unit. We also tracked the corresponding changes in the share of births in high-level hospitals and in those without NICU facilities (low-level).

RESULTS

The probability of a 500- to 1499-g infant being born in a midlevel unit increased by 17 percentage points after the opening of a new nearby unit. More than three quarters of this increase was accounted for by reductions in the probability of birth in a hospital with a high-level unit (-15 points), and the other portion was resulting from reductions in the share of newborns delivered in hospitals with low-level centers (-2 points). Similar patterns were observed in 1500- to 2499-g newborns.

CONCLUSIONS

The introduction of new midlevel units was associated with significant shifts of births from both high-level and low-level hospitals to midlevel hospitals. In areas in which new midlevel units opened, the majority of the increase in midlevel deliveries was attributable to shifts from high-level unit births. Continued proliferation of midlevel units should be carefully assessed.

Cesarean section in term breech presentations: do rates of adverse neonatal outcomes differ by hospital birth volume?

AIM

To determine if risk of adverse neonatal outcomes among term breech infants delivered by cesarean section differs by volume of such births at the delivering hospital.

METHODS

We conducted a population-based cohort study using Missouri linked birth and death certificate files. The study population included 10,106 singleton, term, normal birth weight infants in breech presentation delivered by cesarean section. Infants were linked to hospitals where delivered. These hospitals were divided into terciles (low, medium, and high volume) based on the median number of annual deliveries during 1993-1999. The primary outcome was presentation of at least one adverse neonatal outcome. Adjusted odds ratios and 95% confidence intervals (CI) were calculated using logistic regression analysis.

RESULTS

The rate of any adverse outcome was 17.8, 15.0, and 5.9 cases per 1,000 deliveries at low-, medium-, and high-volume hospitals, respectively. All component adverse outcomes occurred more frequently in low- or medium-volume hospitals than in high-volume hospitals. Compared to breech infants delivered at high-volume hospitals, those delivered at low-volume and medium-volume hospitals were 2.7 (CI 1.6, 4.5) and 2.4 (CI 1.4, 4.1) times, respectively, more likely to experience an adverse outcome after adjusting for significant confounders.

CONCLUSIONS

Prospective studies should explore the source of these risk differences.

Trends in Perinatal Regionalization and the Role of Managed Care

OBJECTIVE

To describe trends in regionalization of perinatal care and identify factors that predict the extent of regionalization.

METHODS

Data were drawn for four states for every year between 1989 and 1998. Panel data models estimated the effect of managed care enrollment on site of delivery for low, very low, and extremely low birth weight neonates.

RESULTS

Strong evidence for regionalization over time was observed for North Carolina and Illinois, with little change in site of delivery in Washington. A shift from level III to level II hospitals was observed for low and very low birth weight neonates in California. Although managed care enrollment increased substantially in all four states, managed care had no effect on site of delivery; that is, the effect of managed care was near zero and not statistically significant in any state.

CONCLUSION

Evidence supports the delivery of high-risk neonates at tertiary care centers. Despite changes in site of delivery, the percentages of very low birth weight neonates delivered at level III hospitals were substantially lower than the goal of 90% set by Healthy People 2010. Financial pressures introduced by managed care cannot be blamed for the failure to meet this goal.

LEVEL OF EVIDENCE

II-2.

Hospital volume and neonatal mortality among very low birth weight infants

BACKGROUND

Very low birth weight infants (< 1500 g) are at increased mortality risk. Data on the impact of NICU volume are sparse, in comparison with those on the level of care. We hypothesized that neonatal mortality would be higher in small NICUs (< 36 very low birth weight admissions per year) than in large NICUs, with adjustment for volume of the delivery unit.

METHODS

We analyzed population-based data from a quality assurance program in Lower Saxony (Germany). Perinatal data for almost all very low birth weight infants born in 1991 to 1999 (n = 7745) were available. Analyses were restricted to infants born at 24 to 30 weeks (n = 4379). Data validation procedures, univariate data analyses, and logistic regression models based on general estimating equations were performed.

RESULTS

Neonatal mortality among infants admitted to NICUs was 12.2% in small NICUs and 10.2% in large NICUs. The mortality rate in small NICUs was increased significantly. Compared with infants from large delivery hospitals (> 1000 births per year) and large NICUs, the adjusted odds ratio was 1.94 for neonates for whom both units were small, 1.75 for those from large delivery units but small neonatal units, and 1.16 for those for whom only the NICU was large. Stratification according to gestational age revealed the greatest impact on mortality for infants of < 29 weeks.

CONCLUSIONS

Results suggest that creating larger perinatal centers may improve perinatal health care. The volume of the NICU was associated more strongly with 28-day mortality than was the volume of the delivery hospital, and it had the largest impact on survival for infants of < 29 weeks.