Health service utilisation of a regional cohort of very preterm infants over the first 2 years of life

The Utilization of Early Outpatient Care for Infants Following NICU Discharge among a National Sample

Outpatient care following discharge from a neonatal intensive care unit (NICU) is critical for streamlined transfer of care. Yet, information is lacking about the characteristics of early outpatient care. The objective of this secondary data analysis is to describe outpatient encounters (OPEs) within the first three months following the discharge of commercially insured infants admitted to NICUs in the MarketScan Research Database nationally from 2015 to 2017. Data were analyzed using descriptive statistics and logistic regression. A total of 22,214 NICU survivors were included, of whom half had an OPE within two days following discharge (quartiles 1, 3) and 90% within five days. The median number of OPEs in the first three months was five (quartiles 4, 7). A majority of first physician visits were with pediatricians (81.5%). A minority of infants with chronic conditions saw subspecialists. Term infants with delayed care had a lower risk of readmission. Spending was higher for preterm infants and those with chronic conditions. We conclude that most patients are seen shortly after discharge and by pediatricians; however, there is room for improvement. Frequent encounters and spending afflict high-risk groups with chronic conditions. Future work should examine the associations of early outpatient care with social determinants of health and other outcomes such as immunizations.

Characteristics of children requiring admission to neonatal care and paediatric intensive care before the age of 2 years in England and Wales: a data linkage study

OBJECTIVE

To quantify the characteristics of children admitted to neonatal units (NNUs) and paediatric intensive care units (PICUs) before the age of 2 years.

DESIGN

A data linkage study of routinely collected data.

SETTING

National Health Service NNUs and PICUs in England and Wales PATIENTS: Children born from 2013 to 2018.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Admission to PICU before the age of 2 years.

RESULTS

A total of 384 747 babies were admitted to an NNU and 4.8% (n=18 343) were also admitted to PICU before the age of 2 years. Approximately half of all children admitted to PICU under the age of 2 years born in the same time window (n=18 343/37 549) had previously been cared for in an NNU.The main reasons for first admission to PICU were cardiac (n=7138) and respiratory conditions (n=5386). Cardiac admissions were primarily from children born at term (n=5146), while respiratory admissions were primarily from children born preterm (<37 weeks' gestational age, n=3550). A third of children admitted to PICU had more than one admission.

CONCLUSIONS

Healthcare professionals caring for babies and children in NNU and PICU see some of the same children in the first 2 years of life. While some children are following established care pathways (eg, staged cardiac surgery), the small proportion of children needing NNU care subsequently requiring PICU care account for a large proportion of the total PICU population. These differences may affect perceptions of risk for this group of children between NNU and PICU teams.

Does the Degree of Prematurity Relate to the Bayley-4 Scores Earned by Matched Samples of Infants and Toddlers across the Cognitive, Language, and Motor Domains?

The literature on children born prematurely has consistently shown that full-term babies outperform preterm babies by about 12 IQ points, even when tested as adolescents, and this advantage for full-term infants extends to the language and motor domains as well. The results of comprehensive meta-analyses suggest that the degree of prematurity greatly influences later test performance, but these inferences are based on data from an array of separate studies with no control of potential confounding variables such as age. This study analyzed Bayley-4 data for 66 extremely premature infants and toddlers (<32 weeks), 70 moderately premature children (32-36 weeks), and 133 full-term children. All groups were carefully matched on key background variables by the test publisher during the standardization of the Bayley-4. This investigation analyzed data on the five subtests: cognitive, expressive communication, receptive communication, fine motor, and gross motor. A multivariate analysis of covariance (MANCOVA) assessed for group mean differences across the three subsamples, while controlling for the children's age. Extremely premature children scored significantly lower than moderately premature children on all subtests, and both preterm groups were significantly outscored by the full-term sample across all domains. In each set of comparisons, the cognitive and motor subtests yielded the largest differences, whereas language development, both expressive and receptive, appeared the least impacted by prematurity. A follow-up MANOVA was conducted to examine full-term versus preterm discrepancies on the five subtests for infants (2-17 months) vs. toddlers (18-42 months). For that analysis, the two preterm groups were combined into a single preterm sample, and a significant interaction between the age level and group (full-term vs. preterm) was found. Premature infants scored lower than premature toddlers on receptive communication, fine motor, and cognitive. Neither expressive communication nor gross motor produced significant discrepancies between age groups The findings of this study enrich the preterm literature on the degree of prematurity; the age-based interactions have implications for which abilities are most likely to improve as infants grow into toddlerhood.

Increased Risk of Parental Instability for Children Born Very Preterm and Impacts on Neurodevelopmental Outcomes at Age 12

Caring for a child born preterm places significant emotional and financial burdens on family relationships. This paper examines (a) the extent to which children born very and extremely preterm are more likely to experience parental change/caregiver instability than children born full term, (b) predictors of parental change/s for preterm infants, and (c) whether exposure to parental change/caregiver instability increases child neurodevelopmental risk. Data were collected as part of a prospective longitudinal study of 110 very preterm and 113 full-term born infants and their parents studied from birth to corrected age 12 years. At ages 2, 4, 6, 9 and 12 years, detailed information was collected about the frequency and nature of all parent/caregiver changes for 3-6 monthly intervals of each child's life. At age 12, all children completed a comprehensive neurodevelopmental evaluation of their emotional and behavioural adjustment, cognition, and educational achievement. Results showed that children born very preterm were at increased risk of experiencing parental/caregiver changes, with this risk being greatest for those born extremely preterm. Neonatal medical complexity, family socioeconomic disadvantage, maternal psychological wellbeing, and child neurodevelopmental impairment were associated with a higher risk of parental change. Preterm birth and exposure to parental change/instability contributed additively to poorer child outcomes. Findings support the need for family-focused neonatal and postnatal care strategies for high-risk infants, to support parents as well as their infants to optimize child health and developmental outcomes.

Follow-Up of Low Birth Weight Preterm Infants After Hospital Discharge: Incidence and Reasons for Rehospitalization

OBJECTIVES

The rehospitalization frequency/indications of low birth weight (LBW) preterms and the effect of rehospitalization on growth and neurodevelopment were investigated.

METHODS

LBW preterms discharged from NICU were prospectively followed until the corrected age of 1 year. Infants rehospitalized after discharge were defined as the study group and those not rehospitalized as the control group. The frequency, duration and etiology of rehospitalization were investigated and the effects of neonatal complications, surgery and socio-demographic status on rehospitalization were assessed.

RESULTS

The study and the control group included 113 and 217 infants, respectively. Infants in the study group were rehospitalized 247 times in total. Rehospitalization was significantly higher in the male gender (39.7% vs. 28.9%, p < 0.05). Hyperbilirubinemia-anemia, anemia-surgery and pulmonary-other infections were the most common indications for rehospitalization in the 0-14 days, 15 days to 2 months and 2-12 months, respectively. Intrauterine growth had no impact on rehospitalization. Somatic growth and neurodevelopment were significantly delayed in the study group (p < 0.05).

CONCLUSION

Birth weight and gestational week are the most important determinants of rehospitalization. Rehospitalized preterm infants have significant deficits in both somatic growth and neurodevelopment despite high-quality follow-up care.

Developing routinely recorded clinical data from electronic patient records as a national resource to improve neonatal health care: the Medicines for Neonates research programme

Background

Clinical data offer the potential to advance patient care. Neonatal specialised care is a high-cost NHS service received by approximately 80,000 newborn infants each year.

Objectives

(1) To develop the use of routinely recorded operational clinical data from electronic patient records (EPRs), secure national coverage, evaluate and improve the quality of clinical data, and develop their use as a national resource to improve neonatal health care and outcomes. To test the hypotheses that (2) clinical and research data are of comparable quality, (3) routine NHS clinical assessment at the age of 2 years reliably identifies children with neurodevelopmental impairment and (4) trial-based economic evaluations of neonatal interventions can be reliably conducted using clinical data. (5) To test methods to link NHS data sets and (6) to evaluate parent views of personal data in research.

Design

Six inter-related workstreams; quarterly extractions of predefined data from neonatal EPRs; and approvals from the National Research Ethics Service, Health Research Authority Confidentiality Advisory Group, Caldicott Guardians and lead neonatal clinicians of participating NHS trusts.

Setting

NHS neonatal units.

Participants

Neonatal clinical teams; parents of babies admitted to NHS neonatal units.

Interventions

In workstream 3, we employed the Bayley-III scales to evaluate neurodevelopmental status and the Quantitative Checklist of Autism in Toddlers (Q-CHAT) to evaluate social communication skills. In workstream 6, we recruited parents with previous experience of a child in neonatal care to assist in the design of a questionnaire directed at the parents of infants admitted to neonatal units.

Data sources

Data were extracted from the EPR of admissions to NHS neonatal units.

Main outcome measures

We created a National Neonatal Research Database (NNRD) containing a defined extract from real-time, point-of-care, clinician-entered EPRs from all NHS neonatal units in England, Wales and Scotland (n = 200), established a UK Neonatal Collaborative of all NHS trusts providing neonatal specialised care, and created a new NHS information standard: the Neonatal Data Set (ISB 1595) (see http://webarchive.nationalarchives.gov.uk/±/http://www.isb.nhs.uk/documents/isb-1595/amd-32–2012/index_html; accessed 25 June 2018).

Results

We found low discordance between clinical (NNRD) and research data for most important infant and maternal characteristics, and higher prevalence of clinical outcomes. Compared with research assessments, NHS clinical assessment at the age of 2 years has lower sensitivity but higher specificity for identifying children with neurodevelopmental impairment. Completeness and quality are higher for clinical than for administrative NHS data; linkage is feasible and substantially enhances data quality and scope. The majority of hospital resource inputs for economic evaluations of neonatal interventions can be extracted reliably from the NNRD. In general, there is strong parent support for sharing routine clinical data for research purposes.

Limitations

We were only able to include data from all English neonatal units from 2012 onwards and conduct only limited cross validation of NNRD data directly against data in paper case notes. We were unable to conduct qualitative analyses of parent perspectives. We were also only able to assess the utility of trial-based economic evaluations of neonatal interventions using a single trial. We suggest that results should be validated against other trials.

Conclusions

We show that it is possible to obtain research-standard data from neonatal EPRs, and achieve complete population coverage, but we highlight the importance of implementing systematic examination of NHS data quality and completeness and testing methods to improve these measures. Currently available EPR data do not enable ascertainment of neurodevelopmental outcomes reliably in very preterm infants. Measures to maintain high quality and completeness of clinical and administrative data are important health service goals. As parent support for sharing clinical data for research is underpinned by strong altruistic motivation, improving wider public understanding of benefits may enhance informed decision-making.

Future work

We aim to implement a new paradigm for newborn health care in which continuous incremental improvement is achieved efficiently and cost-effectively by close integration of evidence generation with clinical care through the use of high-quality EPR data. In future work, we aim to automate completeness and quality checks and make recording processes more ‘user friendly’ and constructed in ways that minimise the likelihood of missing or erroneous entries. The development of criteria that provide assurance that data conform to prespecified completeness and quality criteria would be an important development. The benefits of EPR data might be extended by testing their use in large pragmatic clinical trials. It would also be of value to develop methods to quality assure EPR data including involving parents, and link the NNRD to other health, social care and educational data sets to facilitate the acquisition of lifelong outcomes across multiple domains.

Study registration

This study is registered as PROSPERO CRD42015017439 (workstream 1) and PROSPERO CRD42012002168 (workstream 3).

Funding

The National Institute for Health Research Programme Grants for Applied Research programme (£1,641,471). Unrestricted donations were supplied by Abbott Laboratories (Maidenhead, UK: £35,000), Nutricia Research Foundation (Schiphol, the Netherlands: £15,000), GE Healthcare (Amersham, UK: £1000). A grant to support the use of routinely collected, standardised, electronic clinical data for audit, management and multidisciplinary feedback in neonatal medicine was received from the Department of Health and Social Care (£135,494).

Routine follow-up of preterm infants in New Zealand

AIM

To describe the routine follow-up of preterm infants by different District Health Boards (DHBs) in New Zealand (NZ), and to compare current practice with international guidelines.

METHODS

A descriptive survey of the existing routine follow-up management of preterm infants in NZ. From November 2015 until January 2016, a questionnaire was sent out across NZ to one paediatrician (n = 24) and one Child Development Service (CDS) (n = 20) from each DHB. All paediatricians responded and 85% of the CDSs responded. Responses were collated and compared to recommendations from paediatric literature.

RESULTS

There is tremendous variation across NZ of the eligibility criteria for routine preterm follow-up. Overall, a gestational age of <32 weeks and/or birthweight <1500 g was the most commonly used indication for routine preterm follow-up. The timing of visits and the assessments that were performed varied enormously. Respondents commonly reported that limited funding and resources prevented optimal follow-up management.

CONCLUSION

There is regional disparity in the routine follow-up that preterm infants receive in NZ. A standardised approach to follow-up of preterm infants across NZ, as recommended in the literature, is difficult due to the lack of funding and resources.

Use of hospital-based health care services among children aged 1 through 9 years who were born very preterm - a population-based study

BACKGROUND

Very preterm (VPT) children, with a birth weight below 1500 g or delivered before 32 weeks of gestational age, are at increased risk of poorer long-term health outcomes and higher rates of hospitalization in childhood. However, considerable variation exists in the need for in-hospital care within this population. We assessed the utilization and distribution of hospital-based care from ages 1 through 9 years for a nationwide population.

METHODS

This was a population-based cohort of VPT children born in the period 2001-2009. We evaluated their utilization of hospital care in 2008-2010, when aged 1-9 years old. Outcomes were the incidence of hospital admissions and outpatient visits. We used Poisson regression models with multiple imputation of missing data.

RESULTS

Children born VPT had more hospital admissions compared with the general population of children aged 1-9 years. The rates of hospital admissions and outpatient visits were strongly related to clinical characteristics of the child at birth and age at admission/outpatient visit but to only a variable and minor degree to characteristics pertaining to maternal health, the sociodemographic factors, and geographical proximity to hospital services.

CONCLUSIONS

Prior to this study, hospital utilization during the period 5-9 years old has been poorly documented. We found that excess utilization of hospital resources on average declines with increasing age. We also noted substantial differences in the use of hospital care across age groups and clinical factors for VPT children. The added information from the health status of mothers, social background, and geographic measures of access was limited.

Developmental Assessments in Preterm Children: A Meta-analysis

CONTEXT

Developmental outcomes of very preterm (gestational age ≤32 weeks) or very low birth weight (<1500 g) children are commonly reported before age 3 years although the predictive validity for later outcomes are uncertain.

OBJECTIVE

To determine the validity of early developmental assessments in predicting school-age cognitive deficits.

DATA SOURCES

PubMed.

STUDY SELECTION

English-language studies reporting at least 2 serial developmental/cognitive assessments on the same population, 1 between ages 1 and 3 years and 1 at ≥5 years.

DATA EXTRACTION

For each study, we calculated the sensitivity, specificity, and positive and negative predictive values of early assessment for cognitive deficit (defined as test scores 1 SD below the population mean). Pooled meta-analytic sensitivity and specificity were estimated by using a hierarchical summary receiver operator characteristic curve.

RESULTS

We included 24 studies (n = 3133 children). Early assessments were conducted at 18 to 40 months and generally involved the Bayley Scales of Infant Development or the Griffiths Mental Development Scales; 11 different cognitive tests were used at school-age assessments at 5 to 18 years. Positive predictive values ranged from 20.0% to 88.9%, and negative predictive vales ranged from 47.8% to 95.5%. The pooled sensitivity (95% confidence interval) of early assessment for identifying school-age cognitive deficit was 55.0% (45.7%-63.9%) and specificity was 84.1% (77.5%-89.1%). Gestational age, birth weight, age at assessment, and time between assessments did not explain between-study heterogeneity.

LIMITATIONS

The accuracy of aggregated data could not be verified. Many assessment tools have been superseded by newer editions.

CONCLUSIONS

Early developmental assessment has poor sensitivity but good specificity and negative predictive value for school-age cognitive deficit.

Human Metapneumovirus Infection is Associated with Severe Respiratory Disease in Preschool Children with History of Prematurity

BACKGROUND

Human metapneumovirus (HMPV) is a recently discovered respiratory pathogen of the family Paramyxoviridae, the same family as that of respiratory syncytial virus (RSV). Premature children are at high risk of severe RSV infections, however, it is unclear whether HMPV infection is more severe in hospitalized children with a history of severe prematurity.

METHODS

We conducted a retrospective analysis of the clinical respiratory presentation of all polymerase chain reaction-confirmed HMPV infections in preschool-age children (≤5 years) with and without history of severe prematurity (<32 weeks gestation). Respiratory distress scores were developed to examine the clinical severity of HMPV infections. Demographic and clinical variables were obtained from reviewing electronic medical records.

RESULTS

A total of 571 preschool children were identified using polymerase chain reaction-confirmed viral respiratory tract infection during the study period. HMPV was identified as a causative organism in 63 cases (11%). Fifty-eight (n = 58) preschool-age children with HMPV infection were included in this study after excluding those with significant comorbidities. Our data demonstrated that 32.7% of children admitted with HMPV had a history of severe prematurity. Preschool children with a history of prematurity had more severe HMPV disease as illustrated by longer hospitalizations, new or increased need for supplemental O2, and higher severity scores independently of age, ethnicity, and history of asthma.

CONCLUSION

Our study suggests that HMPV infection causes significant disease burden among preschool children with a history of prematurity leading to severe respiratory infections and increasing health care resource utilization due to prolonged hospitalizations.

Understanding utilization of outpatient clinics for children with special health care needs in southern Israel

To understand the pattern of utilization of ambulatory care by parents of children with special health care needs (CSHCN) and to explore parental challenges in coping with health maintenance of their infants after discharge from a neonatal intensive care unit (NICU). CSHCN require frequent utilization of outpatient ambulatory clinics especially in their first years of life. Multiple barriers are faced by families in disadvantaged populations which might affect adherence to medical referrals. Our study attempts to go beyond quantitative assessment of adherence rates, and capture the influence of parental agency as a critical factor ensuring optimal utilization of healthcare for CSHCN. A prospective, mixed-methods, cohort study followed 158 Jewish and Bedouin-Arab infants in the first year post discharge from NICU in southern Israel. Rates of utilization of ambulatory clinics were obtained from medical records, and quantitative assessment of factors affecting it was based on structured interviews with parents at baseline. Qualitative analysis was based on home visits or telephone in-depth interviews conducted about 1 year post-discharge, to obtain a rich, multilayered, experiential perspectives and explained perceptions by parents. Adherence to post-discharge referrals was generally good, but environmental, cultural, and financial obstacles to healthcare, magnified by communication barriers, forced parents with limited resources to make difficult choices affecting utilization of healthcare services. Improving concordance between primary caregivers and health care providers is crucial, and further development of supportive healthcare for CSHCN in concordance with parental limitations and preferences is needed.

Respiratory illness contributed significantly to morbidity in children born extremely premature or with extremely low birthweights in 1999-2000

AIM

This study investigated respiratory morbidity and risk factors during the first five years of life after extremely preterm birth.

METHODS

Paediatric assessments and parental questionnaires were obtained at two and five years of age in this national prospective cohort of 372 Norwegian children born during 1999-2000 at a gestational age of <28 weeks or birthweight <1,000 grams.

RESULTS

Paediatric assessments were obtained for 100% and 82% of the children at two and five years of age and completed questionnaires for 71% and 76%, respectively. Total readmission rates decreased from 49 to 14% at one to five years, and readmissions for respiratory causes fell from 31 to 3%. Bronchopulmonary dysplasia (BPD) or gestational age was not associated with readmissions for respiratory causes in multiple logistic regression models. However, both BPD and gestational age ≤ 25 weeks was associated with wheezing during the first year and the use of asthma medication during the first two years. BPD was associated with asthma medication between three and five years but not significantly at five years.

CONCLUSION

Respiratory morbidity decreased during the first five years of life but was still more common than expected. It was unrelated to BPD and gestational age at five years of age.

Use of Medical Resources by Preterm Infants Born at Less than 33 Weeks' Gestation Following Discharge from the Neonatal Intensive Care Unit in Korea

This study was aimed to provide data on the use of medical resources by preterm infants following discharge from the neonatal intensive care unit (NICU). The cohort included preterm infants (n=2,351) born at 22-32 weeks' gestation who were discharged from the NICUs of 44 Korean hospitals between April 2009 to March 2010. Mean duration of post-discharge follow-up was 425±237 days. After discharge from the NICU, 94.5% of total infants visited a pediatric outpatient clinic (11.5±9.8 mean visits), 42.9% visited a pediatric clinic for respiratory problems irregularly (4.9±6.6 mean visits), and 31.1% utilized emergency center at least once. Among all visits to the emergency center, 24.7% resulted in readmission and 50.8% of those visits were due to respiratory problems. At least one episode of readmission was required by 33.6% (788/2,346) of total infants, and 18.4% (431/2,346) of total infants were readmitted with respiratory problems at least once. Among all infants readmitted for respiratory problems, 16.2% (70/341) were diagnosed with respiratory syncytial virus infection which accounted for 30.3% of viral etiologies confirmed by laboratory testing. Infants born at <30 weeks' gestation had more frequent total readmission and respiratory readmission than those ≥30 weeks' gestation (2±1.7 vs. 1.7±1.2, P=0.009, 1.8±1.2 vs. 1.5±1.1, 0.027, respectively). Overall, use of medical resources is common, and respiratory problems are the leading cause of use of medical resources. Total readmissions and respiratory readmissions are more frequent in more immature infants.

Cost of care and social consequences of very low birth weight infants without premature- related morbidities in Italy

Aim of this study was to estimate the cost that is borne by the Italian National Health Service, families, and social security due to very low birth weight infants (VLBWIs) without prematurity-related morbidities up to the age of 18 months. We followed up on 150 VLBWIs and 145 comparable full-term infants (FTIs) who were born in one of 25 different neonatal intensive care units upon discharge from the hospital and at six and 18 months of age. The average length of the primary hospitalisation of the VLBWIs was 59.7 days (SD 21.6 days), with a total cost of €20,502 (SD €8409), compared with three days (SD 0.4 days) with a total cost of €907 (SD €304) for the FTIs. The total societal cost of the VLBWIs for the first 18 months of life was €58,098 (SD €21,625), while the corresponding figure for FTIs was €24,209 (SD €15,557). Among VLBWIs, both low birth weight and gestational age were correlated with the length of hospitalisation after birth (r² = 0.61 and r² = 0.57, respectively; p values < 0.0005). Our findings highlight that the existing DRGs and tariffs inadequately reflect the actual costs for Italian National Health Service.

Improving health care usage in a very low birth weight population

BACKGROUND

Prematurity is the biggest contributor to admissions in the neonatal intensive care unit (NICU). The period following hospital discharge is a vital continuum for the very low birth weight (VLBW) infant. The objective of this study was to assess the impact of a unique discharge and follow-up process on the outcomes of VLBW infants leaving the NICU.

METHODS

All outpatient health care usage by VLBW infants born in the study year (cases) was retrospectively tracked through 12 months of age. A cohort of healthy newborn infants were matched by birthdate to each VLBW infant (controls) and similarly tracked.

RESULTS

In this study, there were 85 cases and 85 controls. The mean gestational age at birth for the cases was 29.1 ± 2.7 weeks with a mean birth weight of 1079 ± 263 g. That of the controls was 38.9 ± 1.3 weeks and 3202 ± 447 g. Over 90% of both populations had Medicaid coverage. All VLBW infants received care at the Special Care Developmental Follow-Up Clinic. When compared with the controls, VLBW infants discharged from the NICU made fewer acute, unscheduled visits to the Emergency Department or Urgent Care Clinic (2.3 ± 2.5 vs. 3.7 ± 3.5; P=0.007) despite their high-risk medical and social status. Their growth pattern showed significant "catch-up" and was similar to the matched controls at the last scheduled visit for each group.

CONCLUSIONS

Outcomes including health care utilization in high-risk infants can be improved through meticulous discharge planning and follow-up measures that utilize existing hospital infrastructure to provide affordable comprehensive care.

The economic burden of prematurity in Canada

Background

Preterm birth is a major risk factor for morbidity and mortality among infants worldwide, and imposes considerable burden on health, education and social services, as well as on families and caregivers. Morbidity and mortality resulting from preterm birth is highest among early (< 28 weeks gestational age) and moderate (28–32 weeks) preterm infants, relative to late preterm infants (33–36 weeks). However, substantial societal burden is associated with late prematurity due to the larger number of late preterm infants relative to early and moderate preterm infants.

Methods

The aim in this study was to characterize the burden of premature birth in Canada for early, moderate, and late premature infants, including resource utilization, direct medical costs, parental out-of-pocket costs, education costs, and mortality, using a validated and published decision model from the UK, and adapting it to a Canadian setting based on analysis of administrative, population-based data from Québec.

Results

Two-year survival was estimated at 56.0% for early preterm infants, 92.8% for moderate preterm infants, and 98.4% for late preterm infants. Per infant resource utilization consistently decreased with age. For moderately preterm infants, hospital days ranged from 1.6 at age two to 0.09 at age ten. Cost per infant over the first ten years of life was estimated to be $67,467 for early preterm infants, $52,796 for moderate preterm infants, and $10,010 for late preterm infants. Based on population sizes this corresponds to total national costs of $123.3 million for early preterm infants, $255.6 million for moderate preterm infants, $208.2 million for late preterm infants, and $587.1 million for all infants.

Conclusion

Premature birth results in significant infant morbidity, mortality, healthcare utilization and costs in Canada. A comprehensive decision-model based on analysis of a Canadian population-based administrative data source suggested that the greatest national-level burden is associated with moderate preterm infants due to both a large cost per infant and population size while the highest individual-level burden is in early preterm infants and the largest total population size is in late preterm infants. Although the highest medical costs are incurred during the neonatal period, greater resource utilization and costs extend into childhood.

Premature infants born to adolescent mothers: health care utilization after initial discharge

OBJECTIVE

Premature infants have increased health care utilization after initial discharge compared with term infants. Young maternal age has been shown to impact health care utilization among term infants, but little is known about the impact of maternal age on health care utilization among premature infants. We compared health care utilization among premature infants of adolescent (aged < or = 19 years) and young adult (aged 20-29 years) mothers, hypothesizing that premature infants of adolescent mothers would have increased acute care utilization, while having decreased preventive care utilization.

METHODS

In this retrospective cohort study, we analyzed health care utilization of premature infants born to adolescent mothers (n = 76) compared with premature infants born to young adult mothers (n = 587) within a cohort of premature infants born between 1998 and 2001 in an integrated health care delivery system.

RESULTS

After controlling for illness severity, premature infants born to adolescent mothers had significantly increased odds of medical rehospitalizations (odds ratio 3.57, 95% confidence interval, 1.81-7.05) and emergency department visits (odds ratio 3.67, 95% confidence interval, 2.11-6.39) during the first year after initial discharge compared with premature infants born to young adult mothers. Differences in rehospitalization rates were significant within the first 3 months after discharge (P < .001). Frequency of preventive care visits was not significantly different between the two groups.

CONCLUSIONS

Despite similar severity of chronic illness and similar preventive care utilization, premature infants born to adolescent mothers had significantly increased rates of rehospitalizations and emergency department visits compared with premature infants born to young adult mothers.

Health and the use of health care services in 5-year-old very-low-birth-weight infants

AIM

We aimed to study the effect of prematurity, time of birth and level of birth hospital on morbidity and the use of health care services at age 5.

METHODS

This national study included all very-low-birth-weight infants (VLBWI, <32 gestational weeks or birth weight < or =1500 g) born in Finnish level II or III hospitals in 2001-2002 (n = 918), and full-term controls (n = 381). Parental questionnaires and register data were used to compare morbidity, and the use of health care services between VLBWI and full-term controls, and within VLBWI according to the time of birth and birth hospital level.

RESULTS

Cerebral palsy, retinopathy of prematurity, other ophthalmic problems, respiratory infections, asthma or chronic lung disease, and inguinal hernia were overrepresented in VLBWI compared with the controls. VLBWI had more outpatient and inpatient days than the controls. The time of birth and birth hospital level were not associated with the use of services or with prematurity-related morbidity.

CONCLUSION

Although morbidity and the use of health care services were increased in the surviving VLBWI, the average use of services was relatively small at age 5. In surviving VLBWI, the time of birth and the birth hospital level did not affect morbidity or the use of services.

Impact of very preterm birth on health care costs at five years of age

OBJECTIVE

We assessed the effects of very preterm birth (gestational age <32 weeks or birth weight <1501 g) and prematurity-related morbidities on health care costs during the fifth year of life.

METHODS

The study population consisted of 588 very preterm children and 176 term control subjects born in 2001-2002. Costs of hospitalizations, visits to health care professionals and therapists, and the use of other social welfare services were assessed during the fifth year of life. Hospital visits were derived from register data and other health care contacts, and the use of social welfare services were derived from parental reports. The effects of 6 prematurity-related morbidities (cerebral palsy [CP], seizure disorder, obstructive airway disease, hearing loss, visual disturbances or blindness, and other ophthalmologic problems) on the costs of health care were studied.

RESULTS

The average health care costs during the fifth year of life were 749 euro in the term control subjects, 1023 euro in the very preterm children without morbidities, and 3265 euro in those with morbidities. The costs of social welfare services and therapies exceeded the hospitalization costs in all groups. Among children who were born preterm, CP was associated with 5125 euro higher costs, whereas later obstructive airway diseases increased the costs by 819 euro compared with individuals without these morbidities.

CONCLUSIONS

The health care costs during the fifth year of life in very preterm children with morbidities were 4.4-fold and in those without morbidities 1.4-fold compared with those of term control subjects. This emphasizes the importance of prevention of morbidities, especially CP, to reduce the long-term costs of prematurity.

Psychopathology among preterm infants using the Diagnostic Classification Zero to Three

AIM

To compare the prevalence of psychopathology in infants born preterm with matched full-term infants at the corrected age of 1 year.

METHODS

Between June 2003 and April 2005, a case-control longitudinal cohort study was conducted at the neonatal unit of the University Hospital of Antwerp, Belgium. We prospectively enrolled 123 live-born infants between 25 and 35 weeks of gestation and/or infants with a birth-weight of <1500 g. Thirty full-term infants were recruited among day care centres in the region. Diagnoses were based on the Diagnostic Classification Zero to Three (DC: 0-3), using the MacArthur Communicative Developmental Inventory Dutch version, Infant-Toddler Sensory Profile, Bayley Scales of Infant Development II, Parent Infant Relationship Global Assessment Scale and Functional Emotional Assessment Scale.

RESULTS

At the (corrected) age of 12 months, 89 infants were eligible for follow-up and complete data were available for 69 (77%) infants. Fifty-four percentage of the preterm infants fulfilled one or more DC 0-3 diagnoses. Premature infants had significantly more diagnoses than full-term infants on axis I, axis III and axis V of the DC: 0-3.

CONCLUSION

In this study, the prevalence of psychopathology was significantly higher among preterm infants in comparison with full-term infants. This study did not confirm previous findings of higher rates of relationship disorders among preterm infants.

Morbidities and hospital resource use during the first 3 years of life among very preterm infants

OBJECTIVE

The objective of this study was to determine how the use of hospital resources during the first 3 years of life was associated with prematurity-related morbidity in very preterm infants (gestational age of <32 weeks or birth weight of <1501 g).

METHODS

The study was a retrospective, national register study including all very preterm infants born alive in Finland between 2000 and 2003 (N = 2148). Infants who died before the age of 3 years (n = 264) or who had missing register data (n = 88) were excluded from the study. The relationship between 6 morbidity groups and the need for hospital care during the first 3 years of life was studied by using a negative binomial model.

RESULTS

A total of 66.2% of the infants did not have any of the morbidities studied. Infants who were subsequently diagnosed as having cerebral palsy (6.1% of the study group), later obstructive airway disease (20.0%), hearing loss (2.5%), visual disturbances or blindness (3.8%), or other ophthalmologic problems (13.4%) had initial hospital stays that were a mean of 7, 8, 12, 17, and 3 days longer, respectively, than those for infants without these conditions. All morbidity groups were associated with increased numbers of hospital visits during either the second or third year of life, compared with infants without these morbidities. The need for hospitalizations and outpatient hospital care decreased with postnatal age for infants with later morbidities and for infants without later morbidities.

CONCLUSIONS

Most very preterm infants born in Finland survived without severe morbidities and required relatively little hospital care after the initial discharge. However, those with later morbidities had a long initial length of stay and more readmissions and outpatient visits during the 3-year follow-up period.

Community supports after surviving extremely low-birth-weight, extremely preterm birth: special outpatient services in early childhood

OBJECTIVE

To determine special outpatient services (SOS) use, need, associated factors, and neurodevelopmental and functional outcomes among extremely preterm infants at 18 to 22 months' corrected age.

DESIGN

Retrospective analysis.

SETTING

National Institute of Child Health and Human Development (NICHD) Neonatal Research Network.

PARTICIPANTS

Infants younger than 28 weeks' gestational age who had been born weighing less than 1000 g at an NICHD Neonatal Research Network center from January 1, 1997, to December 31, 2000, and who were receiving follow-up at 18 to 22 months' corrected age.

INTERVENTIONS

Questionnaires were administered at the 18- to 22-month follow-up visit regarding SOS use since hospital discharge and the current need for SOS (social work, visiting nurse, medical specialty, early intervention, speech and language services, occupational therapy and physical therapy, and neurodevelopmental and behavioral services).

MAIN OUTCOME MEASURES

The use of and need for SOS were analyzed by gestational age. Logistic regression analysis identified factors independently associated with the use of more than 5 services and with the need for any services.

RESULTS

Of 2315 infants, 54.7% used more than 3 SOS by 18 to 22 months, and 19.1% used 6 to 7 SOS. The need for any SOS was reported by approximately 37%. The following variables that were commonly associated with adverse neurodevelopmental outcomes were also associated with the use of more than 5 SOS: sepsis, birth weight, postnatal corticosteroid use, bronchopulmonary dysplasia, and cystic periventricular leukomalacia or grade 3 or 4 intraventricular hemorrhage. Male sex was associated with the need for any SOS. Although high SOS use was more likely among children with adverse neurodevelopmental outcomes, a reported need for SOS was common even among those with mild developmental impairment (39.7%) and mild cerebral palsy (42.2%).

CONCLUSIONS

High SOS use is common, has identifiable neonatal risk factors, and is associated with neurodevelopmental impairment. Extremely preterm survivors have substantial need for community supports regardless of their impairment level. Efforts to improve comprehensive delivery of family-centered community-based services are urgently needed.

Differences in the length of initial hospital stay in very preterm infants

AIM

To investigate the effect of maternal, infant and birth hospital district related factors on the length of initial hospital stay in very preterm infants. In addition, rehospitalization rate within the first year from the initial discharge was studied.

METHODS

A register study covering all very preterm infants (gestational age < 32 weeks or birthweight < 1501 g) born alive in Finland between years 2000 and 2003 (N = 2148). Factors affecting length of stay (LOS) were studied using generalized linear model (GLM).

RESULTS

The proportion of very preterm infants born in a level III unit varied in the hospital districts from 53% to 94%. Median LOS was 53 days (interquartile range: 38-76). There were large regional differences in the LOS, the difference being up to 10.5 days among the hospital districts (p < 0.0001). Rehospitalization rate was 47.2% within the first year from the initial discharge, and the absence of rehospitalization was associated with a 4.1 days shorter initial LOS (p < 0.0001).

CONCLUSION

Our study showed large regional variation in LOS of very preterm infants despite similar case mix. We speculate that the variation depends on differences in treatment practices and discharge criteria.