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Phibbs CS, Passarella M, Schmitt SK, Martin A, Lorch SA. The Impact of Hospital Delivery Volumes of Newborns Born Very Preterm on Mortality and Morbidity. J Pediatr 2024; 276:114323. [PMID: 39304118 DOI: 10.1016/j.jpeds.2024.114323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Revised: 09/07/2024] [Accepted: 09/16/2024] [Indexed: 09/22/2024]
Abstract
OBJECTIVE To examine if the annual patient volume of infants born very preterm (VPT, gestational age <32 weeks) at a hospital is associated with neonatal mortality and morbidity. STUDY DESIGN We performed an observational, secondary data analysis using a 20-year panel of birth certificates linked to hospital discharge abstracts, including transfers in California, Michigan, Missouri, Oregon, Pennsylvania, and South Carolina from 1996 through 2015. The study included all in-hospital VPT deliveries (n = 208 261). Study outcomes were in-hospital mortality or serious morbidity (intraventricular hemorrhage, necrotizing enterocolitis, retinopathy of prematurity, or bronchopulmonary dysplasia), attributed to the hospital of birth. Poisson regression models estimated the risk-adjusted relative risk (RR) for mortality and serious morbidity across different patient volume categories within a given hospital using hospital fixed effects. RESULTS The risk of mortality and serious morbidity for VPT infants increased as the number of infants born VPT at a hospital decreased. Compared with VPT delivery volumes >100 infants per year, the risk of mortality increased when a given hospital had VPT delivery volumes < 60 per year, ranging from a RR of 1.13 (95% C.I. 1.02-1.25) for volumes between 50 to 59 and 1.39 (1.19-1.62) for VPT volumes <10, and the risk of mortality or serious morbidity increased when a given hospital had VPT volumes <100, ranging from a RR of 1.05 (1.02-1.08) for volumes between 90 to 99 and 1.27 (1.19-1.36) for VPT volumes <10. CONCLUSIONS These results suggest that, for VPT infants, the risk of both mortality and mortality or serious morbidity is increased as the VPT volume within a given hospital declines.
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Affiliation(s)
- Ciaran S Phibbs
- Health Economics Resource Center and Center for Implementation to Innovation, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA; Department of Pediatrics, Stanford University School of Medicine, Stanford, CA; Department of Health Policy, Stanford University School of Medicine, Stanford, CA.
| | - Molly Passarella
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA; Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Susan K Schmitt
- Health Economics Resource Center and Center for Implementation to Innovation, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA; Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Ashley Martin
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA; Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Scott A Lorch
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA; Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, PA; Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania, Philadelphia, PA
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Doshi H, Shukla S, Patel S, Cudjoe GA, Boakye W, Parmar N, Bhatt P, Dapaah-Siakwan F, Donda K. National Trends in Survival and Short-Term Outcomes of Periviable Births ≤24 Weeks Gestation in the United States, 2009 to 2018. Am J Perinatol 2024; 41:e94-e102. [PMID: 35523408 DOI: 10.1055/a-1845-2526] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Data from the academic medical centers in the United States showing improvements in survival of periviable infants born at 22 to 24 weeks GA may not be nationally representative since a substantial proportion of preterm infants are cared for in community hospital-based neonatal intensive care units. Our objective was to examine the national trends in survival and other short-term outcomes among preterm infants born at ≤24 weeks gestational age (GA) in the United States from 2009 to 2018. STUDY DESIGN This was a retrospective, repeated cross-sectional analysis of the National Inpatient Sample for preterm infants ≤24 weeks GA. The primary outcome was the trends in survival to discharge. Secondary outcomes were the trends in the composite outcome of death or one or more major morbidity (bronchopulmonary dysplasia, necrotizing enterocolitis stage ≥2, periventricular leukomalacia, severe intraventricular hemorrhage, and severe retinopathy of prematurity). The Cochran-Armitage trend test was used for trend analysis. p-Value <0.05 was considered significant. RESULTS Among 71,854 infants born at ≤24 weeks GA, 34,251 (47.6%) survived less than 1 day and were excluded. Almost 93% of those who survived <1 day were of ≤23 weeks GA. Among the 37,603 infants included in the study cohort, 48.1% were born at 24 weeks GA. Survival to discharge at GA ≤ 23 weeks increased from 29.6% in 2009 to 41.7% in 2018 (p < 0.001), while survival to discharge at GA 24 weeks increased from 58.3 to 65.9% (p < 0.001). There was a significant decline in the secondary outcomes among all the periviable infants who survived ≥1 day of life. CONCLUSION Survival to discharge among preterm infants ≤24 weeks GA significantly increased, while death or major morbidities significantly decreased from 2009 to 2018. The postdischarge survival, health care resource use, and long neurodevelopmental outcomes of these infants need further investigation. KEY POINTS · Survival increased significantly in infants ≤24 weeks GA in the United States from 2009 to 2018.. · Death or major morbidity in infants ≤24 weeks GA decreased significantly from 2009 to 2018.. · Death or surgical procedures including tracheostomy, VP shunt placement, and PDA surgical closure in infants <=24 weeks GA decreased significantly from 2009 to 2018..
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Affiliation(s)
- Harshit Doshi
- Neonatal Intensive Care Unit, Golisano Children's Hospital of Southwest Florida, Florida
| | - Samarth Shukla
- University of Florida College of Medicine, Jacksonville, Florida
| | | | | | - Wendy Boakye
- National Institute of Health, Bethesda, Maryland
| | - Narendrasinh Parmar
- Department of Pediatrics Brookdale University Hospital and Medical Center, Brooklyn, New York
| | - Parth Bhatt
- Department of Pediatrics, United Hospital Center, Bridgeport, West Virginia
| | | | - Keyur Donda
- Department of Pediatrics/Division of Neonatology University of South Florida, Tampa, Florida
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Goodman DC, Stuchlik P, Ganduglia-Cazaban C, Tyson JE, Leyenaar J, Avritscher EBC, Rysavy M, Gautham KS, Lynch D, Stukel TA. Hospital-Level NICU Capacity, Utilization, and 30-Day Outcomes in Texas. JAMA Netw Open 2024; 7:e2355982. [PMID: 38353952 PMCID: PMC10867701 DOI: 10.1001/jamanetworkopen.2023.55982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 12/20/2023] [Indexed: 02/16/2024] Open
Abstract
Importance Risk-adjusted neonatal intensive care unit (NICU) utilization and outcomes vary markedly across regions and hospitals. The causes of this variation are poorly understood. Objective To assess the association of hospital-level NICU bed capacity with utilization and outcomes in newborn cohorts with differing levels of health risk. Design, Setting, and Participants This population-based retrospective cohort study included all Medicaid-insured live births in Texas from 2010 to 2014 using linked vital records and maternal and newborn claims data. Participants were Medicaid-insured singleton live births (LBs) with birth weights of at least 400 g and gestational ages between 22 and 44 weeks. Newborns were grouped into 3 cohorts: very low birth weight (VLBW; <1500 g), late preterm (LPT; 34-36 weeks' gestation), and nonpreterm newborns (NPT; ≥37 weeks' gestation). Data analysis was conducted from January 2022 to October 2023. Exposure Hospital NICU capacity measured as reported NICU beds/100 LBs, adjusted (ie, allocated) for transfers. Main Outcomes and Measures NICU admissions and special care days; inpatient mortality and 30-day postdischarge adverse events (ie, mortality, emergency department visit, admission, observation stay). Results The overall cohort of 874 280 single LBs included 9938 VLBW (5054 [50.9%] female; mean [SD] birth weight, 1028.9 [289.6] g; mean [SD] gestational age, 27.6 [2.6] wk), 63 160 LPT (33 684 [53.3%] female; mean [SD] birth weight, 2664.0 [409.4] g; mean [SD] gestational age, 35.4 [0.8] wk), and 801 182 NPT (407 977 [50.9%] female; mean [SD] birth weight, 3318.7 [383.4] g; mean [SD] gestational age, 38.9 [1.0] wk) LBs. Median (IQR) NICU capacity was 0.84 (0.57-1.30) allocated beds/100 LB/year. For VLBW newborns, NICU capacity was not associated with the risk of NICU admission or number of special care days. For LPT newborns, birth in hospitals with the highest compared with the lowest category of capacity was associated with a 17% higher risk of NICU admission (adjusted risk ratio [aRR], 1.17; 95% CI, 1.01-1.33). For NPT newborns, risk of NICU admission was 55% higher (aRR, 1.55; 95% CI, 1.22-1.97) in the highest- vs the lowest-capacity hospitals. The number of special care days for LPT and NPT newborns was 21% (aRR, 1.21; 95% CI,1.08-1.36) and 37% (aRR, 1.37; 95% CI, 1.08-1.74) higher in the highest vs lowest capacity hospitals, respectively. Among LPT and NPT newborns, NICU capacity was associated with higher inpatient mortality and 30-day postdischarge adverse events. Conclusions and Relevance In this cohort study of Medicaid-insured newborns in Texas, greater hospital NICU bed supply was associated with increased NICU utilization in newborns born LPT and NPT. Higher capacity was not associated with lower risk of adverse events. These findings raise important questions about how the NICU is used for newborns with lower risk.
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Affiliation(s)
- David C. Goodman
- The Dartmouth Institute for Health Policy and Clinical Practice, Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Children’s Hospital at Dartmouth, Lebanon, New Hampshire
| | - Patrick Stuchlik
- The Dartmouth Institute for Health Policy and Clinical Practice, Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Cecilia Ganduglia-Cazaban
- Center for Health Care Data and Department of Management, Policy, and Community Health, School of Public Health, The University of Texas Health Science Center at Houston
| | - Jon E. Tyson
- Institute for Clinical Research and Learning Health Care, McGovern Medical School at The University of Texas Health Science Center at Houston
| | - JoAnna Leyenaar
- The Dartmouth Institute for Health Policy and Clinical Practice, Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Children’s Hospital at Dartmouth, Lebanon, New Hampshire
| | - Elenir B. C. Avritscher
- Institute for Clinical Research and Learning Health Care, McGovern Medical School at The University of Texas Health Science Center at Houston
| | - Mathew Rysavy
- Institute for Clinical Research and Learning Health Care, McGovern Medical School at The University of Texas Health Science Center at Houston
| | - Kanekal S. Gautham
- Division of Neonatology, Department of Pediatrics, Nemours Children’s Health, Orlando, Florida
| | | | - Therese A. Stukel
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
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Cerovac A, Nevačinović E, Habek D, Laganà AS, Chiantera V, Naem A, Čehić E, Halilović R, Cerovac E, Zulović T. Capabilities of perinatal healthcare institutions in primary and tertiary care of low birth weight infants in the Federation of Bosnia and Herzegovina: a cross-sectional multicentric study. Ann Med Surg (Lond) 2024; 86:768-772. [PMID: 38333265 PMCID: PMC10849373 DOI: 10.1097/ms9.0000000000001634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 12/08/2023] [Indexed: 02/10/2024] Open
Abstract
Introduction Providing adequate healthcare for premature infants is an important issue in perinatal medicine. The aim of this study is to assess the level of the perinatal healthcare institution (PHI) where the newborns were delivered and the possibilities of transporting them to the cantons of the Federation of Bosnia and Herzegovina. The authors also aimed to examine the overall survival of low birth-weight infants (LBWI) in the Federation of Bosnia and Herzegovina and to compare the survival of newborns according to the PHI where they were born and the PHI where they were treated. Materials and methods This cross-sectional study included newborns of both sexes that were born in the maternity wards in 10 cantons of the Federation of Bosnia and Herzegovina with a gestational age between 22 and 42 weeks, and a birth weight less than 2500 g. Result From the PHI of the first and second level, 159 newborns were referred to the third level. A total of 159/669 (23.7%) were referred from a second level PHI to a third level PHI, and 127/669 (l8.9%) LBWI were definitely taken care of. A total of 513/669 (76.8%) LBWI were definitely taken care of in the third level PHI. Out of a total of 159 LBWI referred from other PHI, only 31 (19.5%) LBWI were transported in less than 4 h, and 128 (80.5%) newborns were admitted to the third level PHI within 4 h of birth (P<0.0001). In second level PHI, most LBWI died in the first 12 h after birth, while in third level PHI, 69.2% of LBWI died after 1 week of life. Conclusion Based on world experience and assessment of the situation in Federation of Bosnia and Herzegovina, it is necessary to take measures to improve perinatal care and its regional organization.
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Affiliation(s)
- Anis Cerovac
- Department of Gynecology and Obstetrics
- School of Medicine, University of Tuzla, Tuzla
| | - Enida Nevačinović
- Clinic for Gynecology and Obstetrics, University Clinical Centre Tuzla
| | - Dubravko Habek
- School of Medicine, Croatian Catholic University Zagreb, Zagreb, Croatia
| | - Antonio Simone Laganà
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
- Unit of Obstetrics and Gynecology, “Paolo Giaccone” Hospital, Palermo, Italy
| | - Vito Chiantera
- Unit of Gynecologic Oncology, National Cancer Institute - IRCCS - Fondazione “G. Pascale”, Naples
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Antoine Naem
- Faculty of Medicine of Damascus University, Damascus, Syrian Arab Republic
| | - Ermin Čehić
- Department of Obstetrics and Gynecology, Human reproduction Unit, Cantonal Hospital Zenica
- University of Zenica, School of Medicine
| | | | - Elmedina Cerovac
- Department of Anesthesiology, Reanimatology and Intensive Care, General Hospital Tešanj, Tešanj
- School of Medicine, University of Tuzla, Tuzla
| | - Tarik Zulović
- Department of Obstetrics and Gynecology, Cantonal Hospital Zenica, Zenica, Bosnia and Herzegovina
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Davis R, Stuchlik PM, Goodman DC. The Relationship Between Regional Growth in Neonatal Intensive Care Capacity and Perinatal Risk. Med Care 2023; 61:729-736. [PMID: 37449856 PMCID: PMC10564047 DOI: 10.1097/mlr.0000000000001893] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND The supply of US neonatal intensive care unit (NICU) beds and neonatologists is known to vary markedly across regions, but there have been no investigation of patterns of recent growth (1991-2017) in NICUs in relation to newborn need. OBJECTIVE The objective of this study was to test the hypothesis that greater growth in NICU capacity occurred in neonatal intensive care regions with higher perinatal risk. RESEARCH DESIGN A longitudinal ecological analysis with neonatal intensive care regions (n=246) as the units of analysis. Associations were tested using linear regression. SUBJECTS All US live births ≥400 g in 1991 (n=4,103,528) and 2017 (n=3,849,644). MEASURES Primary measures of risk were the proportions of low-birth weight and very low-birth weight newborns and mothers who were Black or had low educational attainment. RESULTS Over 26 years, the numbers of NICU beds and neonatologists per live birth increased 42% and 200%, respectively, with marked variation in growth across regions (interquartile range: 0.3-4.1, beds; neonatologists, 0.4-1.0 per 1000 live births). A weak association of capacity with perinatal risk in 1991 was absent in 2017. There was no meaningful (ie, clinical or policy relevant) association between regional changes in capacity and regions with higher perinatal risk or lower capacity in 1991; higher increases in perinatal risk were not associated with higher capacity growth. CONCLUSION The lack of association between newborn medical needs and the supply of NICU resources raises questions about the current effectiveness of newborn care at a population level.
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Affiliation(s)
- Rebekah Davis
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH
- University of Colorado School of Medicine, Aurora, CO
| | - Patrick M. Stuchlik
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - David C. Goodman
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH
- The Children’s Hospital at Dartmouth, Lebanon, NH
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Boghossian NS, Geraci M, Phibbs CS, Lorch SA, Edwards EM, Horbar JD. Trends in Resources for Neonatal Intensive Care at Delivery Hospitals for Infants Born Younger Than 30 Weeks' Gestation, 2009-2020. JAMA Netw Open 2023; 6:e2312107. [PMID: 37145593 PMCID: PMC10163386 DOI: 10.1001/jamanetworkopen.2023.12107] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/23/2023] [Indexed: 05/06/2023] Open
Abstract
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.
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Affiliation(s)
- Nansi S. Boghossian
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia
| | - Marco Geraci
- MEMOTEF Department, School of Economics, Sapienza University of Rome, Rome, Italy
| | - Ciaran S. Phibbs
- Health Economics Resource Center and Center for Implementation to Innovation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Perinatal Epidemiology and Health Outcomes Research Unit, Department of Pediatrics, Division of Neonatology, Stanford University School of Medicine, Stanford, California
| | - Scott A. Lorch
- Division of Neonatology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania, Philadelphia
| | - Erika M. Edwards
- Vermont Oxford Network, Burlington, Vermont
- Department of Mathematics and Statistics, University of Vermont, Burlington
- Department of Pediatrics, University of Vermont College of Medicine, Burlington
| | - Jeffrey D. Horbar
- Vermont Oxford Network, Burlington, Vermont
- Department of Pediatrics, University of Vermont College of Medicine, Burlington
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DeSisto CL, Okoroh EM, Kroelinger CD, Barfield WD. Summary of neonatal and maternal transport and reimbursement policies-a 5-year update. J Perinatol 2022; 42:1306-1311. [PMID: 35414123 PMCID: PMC10228283 DOI: 10.1038/s41372-022-01389-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 03/23/2022] [Accepted: 03/31/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To examine the number of states with neonatal and maternal transport and reimbursement policies in 2019, compared with 2014. STUDY DESIGN We conducted a systematic review of web-based, publicly available information on neonatal and maternal transport policies for each state in 2019. Information was abstracted from rules, codes, licensure regulations, and planning and program documents, then summarized within two categories: transport and reimbursement policies. RESULT In 2019, 42 states had a policy for neonatal transport and 37 states had a policy for maternal transport, increasing by 8 and 7 states respectively. Further, 31 states had a reimbursement policy for neonatal transport and 11 states for maternal transport, increases of 1 state per category. Overall, the number of states with policies increased from 2014 to 2019. CONCLUSION The number of state neonatal and maternal transport policies increased; these policies may support provision of care at the most risk-appropriate facilities.
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Affiliation(s)
- Carla L DeSisto
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Ekwutosi M Okoroh
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Charlan D Kroelinger
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Wanda D Barfield
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Desplanches T, Morgan AS, Jones P, Diguisto C, Zeitlin J, Martin-Marchand L, Benhammou V, Lecomte B, Rozé JC, Truffert P, Ancel PY, Sagot P, Roussot A, Fresson J, Blondel B. Risk factors for very preterm delivery out of a level III maternity unit: The EPIPAGE-2 cohort study. Paediatr Perinat Epidemiol 2021; 35:694-705. [PMID: 33956996 DOI: 10.1111/ppe.12770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Regionalisation programmes aim to ensure that very preterm infants are born in level III units (inborn) through antenatal referral or transfer. Despite widespread knowledge about better survival without disability for inborn babies, 10%-30% of women deliver outside these units (outborn). OBJECTIVE To investigate risk factors associated with outborn deliveries and to estimate the proportion that were probably or possibly avoidable. METHODS We used a national French population-based cohort including 2205 women who delivered between 24 and 30+6 weeks in 2011. We examined risk factors for outborn delivery related to medical complications, antenatal care, sociodemographic characteristics and living far from a level III unit using multivariable binomial regression. Avoidable outborn deliveries were defined by pregnancy risk (obstetric history, antenatal hospitalisation) and time available for transfer. RESULTS 25.0% of women were initially booked in level III, 9.1% were referred, 49.8% were transferred, and 16.1% had outborn delivery. Risk factors for outborn delivery were gestational age <26 weeks (adjusted relative risk (aRR) 1.37, 95% confidence interval (CI) 1.13, 1.66), inadequate antenatal care (aRR 1.39, 95% CI 1.10, 1.81), placental abruption (aRR 1.66, 95% CI 1.27, 2.17), and increased distance to the closest level III unit ((aRR 2.79, 95% CI 2.00, 3.92) in the 4th versus 1st distance quartile). Among outborn deliveries, 16.7% were probably avoidable, and 25.6% possibly avoidable, which could increase the proportion of inborn deliveries between 85.9% and 92.9%. Avoidable outborn deliveries were mainly associated with gestational age, intrauterine growth restriction, preterm premature rupture of membranes, and haemorrhage, but not distance. CONCLUSIONS Our study identified some modifiable risk factors for outborn delivery; however, when regionalised care relies heavily on antenatal transfer, as it does in France, only some outborn deliveries may be prevented. Earlier referral of high-risk women will be needed to achieve full access to tertiary care.
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Affiliation(s)
- Thomas Desplanches
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France.,CHRU Dijon, Department of Gynaecology, Obstetrics, Foetal Medicine and Infertility, Dijon, France
| | - Andrei S Morgan
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France.,Department of Neonatology, Elizabeth Garrett Anderson Institute for Women's Health, UCL, London, UK.,Embrace Yorkshire and Humber Infant and Paediatric Transport Service, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Peter Jones
- SAMU de Paris, AP-HP, Hôpital Necker Enfants Malades, Paris, France.,Réanimation Pédiatrique AP-HP, Hôpital Robert Debré, Paris, France
| | - Caroline Diguisto
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France.,Department of Obstetrics and Gynecology, University Hospital of Tours, Tours University, Tours, France
| | - Jennifer Zeitlin
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France
| | - Laetitia Martin-Marchand
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France
| | - Valérie Benhammou
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France
| | | | - Jean-Christophe Rozé
- Pediatric Intensive Care Unit, Mothers' and Children's Hospital, Nantes Teaching Hospital, Nantes, France
| | - Patrick Truffert
- Neonatal Intensive Care Unit, Jeanne de Flandre Hospital, CHRU Lille, Lille, France
| | - Pierre-Yves Ancel
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France.,Clinical Research Unit, Center for Clinical Investigation P1419, CHU Cochin Broca Hôtel-Dieu, Paris, France
| | - Paul Sagot
- CHRU Dijon, Department of Gynaecology, Obstetrics, Foetal Medicine and Infertility, Dijon, France
| | - Adrien Roussot
- Biostatistics and Bioinformatics (DIM), University Hospital, Dijon, France.,Bourgogne Franche-Comté University, Dijon, France
| | - Jeanne Fresson
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France.,Department of Medical Information, University Hospital (CHRU) Nancy, Nancy, France
| | - Béatrice Blondel
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France
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9
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Nevačinović E, Cerovac A, Bogdanović G, Cerovac E, Tupek T, Zukić H. Perinatal Mortality According to Level of Perinatal Healthcare Institutions in Low Birth Weight Infants: Cross Sectional Multicentric Study. Int J Prev Med 2020; 11:72. [PMID: 32742616 PMCID: PMC7373091 DOI: 10.4103/ijpvm.ijpvm_434_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 03/27/2020] [Indexed: 11/05/2022] Open
Abstract
Background: To investigate the total survival of low birth weight infants (LBWIs) in the Federation of Bosnia and Herzegovina (FB and H) and selected by subgroups of birth weight (BW) and gestational age (GA). Methods: This cross-sectional study included newborns of both genders, GA of 22–42 weeks and BW of less than 2500 g of 10 cantons territory of the FB and H. In the examined period, 22,897 children were born in the FB and H, of which 669 (2.9%) had BW less than 2500 g. Results: Surviving of LBWIs in the FB and H out of the 669 LBWIs in the first level perinatal healthcare institutions (PHI) was 29 (4.3%), the second level was 286 (42.8%), and the third level was 354 (52.9%). The total stillborn rate was 3.9%. The overall perinatal mortality rate for all levels of PHI was 8.6%. The overall rate of early neonatal mortality of LBWIs in all three levels of PHI in the FB and H was 12.7%. By the end of the first month of life (up to 28 days) and to the end of the neonatal period, 385 (57.5%) of LBWIs survived, and 284 (42.4%) died. The LBWIs by subgroups of BW up to 28 days had lower survival rates in second-level PHI than infants of the same BW subgroups (500–999 and 1000–1499) treated in third-level PHI (P = 0.0089 and P = 0.004). Conclusions: Our results show that B and H belongs to developing countries according to perinatal mortality. A unique database system is necessary to follow progress and trends.
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Affiliation(s)
- Enida Nevačinović
- Clinic for Gynecology and Obstetrics, University Clinical Centre Tuzla, Tuzla, Bosnia and Herzegovina
| | - Anis Cerovac
- Department of Gynaecology and Obstetrics, General Hospital Tešanj, Tešanj, Bosnia and Herzegovina.,Department of Anatomy, School of Medicine, University of Tuzla, Tuzla, Bosnia and Herzegovina
| | - Gordana Bogdanović
- Department of Anesthesiology, Reanimatology and Intensive Care, General Hospital Tešanj, Tešanj, Bosnia and Herzegovina
| | - Elmedina Cerovac
- Department of Anesthesiology, Reanimatology and Intensive Care, General Hospital Tešanj, Tešanj, Bosnia and Herzegovina
| | - Tvrtko Tupek
- Department of Gynecology and Obstetrics, Clinical Hospital "Sveti Duh", Zagreb, Croatia
| | - Haris Zukić
- Clinic for Gynecology and Obstetrics, University Clinical Centre Tuzla, Tuzla, Bosnia and Herzegovina
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10
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Apfeld JC, Kastenberg ZJ, Gibbons AT, Carmichael SL, Lee HC, Sylvester KG. Treating Center Volume and Congenital Diaphragmatic Hernia Outcomes in California. J Pediatr 2020; 222:146-153.e1. [PMID: 32418817 PMCID: PMC7546600 DOI: 10.1016/j.jpeds.2020.03.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/22/2020] [Accepted: 03/13/2020] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To examined outcomes for infants born with congenital diaphragmatic hernias (CDH), according to specific treatment center volume indicators. STUDY DESIGN A population-based retrospective cohort study was conducted involving neonatal intensive care units in California. Multivariable analysis was used to examine the outcomes of infants with CDH including mortality, total days on ventilation, and respiratory support at discharge. Significant covariables of interest included treatment center surgical and overall neonatal intensive care unit volumes. RESULTS There were 728 infants in the overall CDH cohort, and 541 infants (74%) in the lower risk subcohort according to a severity-weighted congenital malformation score and never requiring extracorporeal membrane oxygenation. The overall cohort mortality was 28.3% (n = 206), and 19.8% (n = 107) for the subcohort. For the lower risk subcohort, the adjusted odds of mortality were significantly lower at treatment centers with higher CDH repair volume (OR, 0.41; 95% CI, 0.23-0.75; P = .003), ventilator days were significantly lower at centers with higher thoracic surgery volume (OR, 0.56; 9 5% CI, 0.33-0.95; P = .03), and respiratory support at discharge trended lower at centers with higher neonatal intensive care unit admission volumes (OR, 0.51; 9 5% CI, 0.26-1.02; P = .06). CONCLUSIONS Overall and surgery-specific institutional experience significantly contribute to optimized outcomes for infants with CDH. These data and follow-on studies may help inform the ongoing debate over the optimal care setting and relevant quality indicators for newborn infants with major surgical anomalies.
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Affiliation(s)
- Jordan C Apfeld
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA; Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH.
| | - Zachary J Kastenberg
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA; Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, CA
| | | | - Suzan L Carmichael
- Center for Fetal and Maternal Health, Lucile Packard Children's Hospital, Stanford University School of Medicine, Stanford, CA; Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Henry C Lee
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA; California Perinatal Quality Care Collaborative (CPQCC), Stanford University, Stanford, CA
| | - Karl G Sylvester
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA; Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, CA; Center for Fetal and Maternal Health, Lucile Packard Children's Hospital, Stanford University School of Medicine, Stanford, CA; Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
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11
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Abstract
Regionalization, which emphasizes matching patient needs with the capabilities of the hospital in which care is provided, has long been a recommended approach to reducing neonatal morbidity and mortality. Over the past decade, research methods surrounding the measurement and evaluation of such programs have improved, thus strengthening arguments for implementation of these strategies. However, regionalization policies vary widely across regions and between countries, with potential impacts on neonatal outcomes as well as costs of care. It is important to account for geographic and other regional differences when determining the feasibility of regionalization for a specific region, as certain areas and populations may need particular consideration in order for regionalization policies to be successful.
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12
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Pai VV, Kan P, Bennett M, Carmichael SL, Lee HC, Hintz SR. Improved Referral of Very Low Birthweight Infants to High-Risk Infant Follow-Up in California. J Pediatr 2020; 216:101-108.e1. [PMID: 31587859 PMCID: PMC6917822 DOI: 10.1016/j.jpeds.2019.08.050] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/30/2019] [Accepted: 08/26/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine changes in referral rates of very low birthweight (birthweight <1500 g) infants to high-risk infant follow-up in California and identify factors associated with referral before and after implementation of a statewide initiative in 2013 to address disparities in referral. STUDY DESIGN We included very low birthweight infants born 2010-2016 in the population-based California Perinatal Quality Care Collaborative who survived to discharge home. We used multivariable logistic regression to examine factors associated with referral and derive risk-adjusted referral rates by neonatal intensive care unit (NICU) and region. RESULTS Referral rate improved from 83.0% (preinitiative period) to 94.9% (postinitiative period); yielding an OR of 1.48 (95% CI, 1.26-1.72) for referral in the postinitiative period after adjustment for year. Referral rates improved the most (≥15%) for infants born at ≥33 weeks of gestation, with a birthweight of 1251-1500 g, and born in intermediate and lower volume NICUs. After the initiative, Hispanic ethnicity, small for gestational age status, congenital anomalies, and major morbidities were no longer associated with a decreased odds of referral. Lower birthweight, outborn status, and higher NICU volume were no longer associated with increased odds of referral. African American race was associated with lower odds of referral, and higher NICU level with a higher odds of referral during both time periods. Referral improved in many previously poor-performing NICUs and regions. CONCLUSIONS High-risk infant follow-up referral of very low birthweight infants improved substantially across all sociodemographic, perinatal, and clinical variables after the statewide initiative, although disparities remain. Our results demonstrate the benefit of a targeted initiative in California, which may be applicable to other quality collaboratives.
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Affiliation(s)
- Vidya V. Pai
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford School of Medicine, Stanford, CA
| | - Peiyi Kan
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford School of Medicine, Stanford, CA,California Perinatal Quality Care Collaborative, Stanford, CA
| | - Mihoko Bennett
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford School of Medicine, Stanford, CA,California Perinatal Quality Care Collaborative, Stanford, CA
| | - Suzan L. Carmichael
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford School of Medicine, Stanford, CA,Center for Population Health Sciences, Stanford University School of Medicine, Stanford, CA.,Division of Maternal-Fetal Medicine and Obstetrics, Departmenf of Pediatrics, Stanford School of Medicine, Stanford, CA
| | - Henry C. Lee
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford School of Medicine, Stanford, CA,California Perinatal Quality Care Collaborative, Stanford, CA
| | - Susan R. Hintz
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford School of Medicine, Stanford, CA,Division of Maternal-Fetal Medicine and Obstetrics, Departmenf of Pediatrics, Stanford School of Medicine, Stanford, CA
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13
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Helenius K, Gissler M, Lehtonen L. Trends in centralization of very preterm deliveries and neonatal survival in Finland in 1987-2017. Transl Pediatr 2019; 8:227-232. [PMID: 31413956 PMCID: PMC6675682 DOI: 10.21037/tp.2019.07.05] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Very preterm infants are at high risk of death and complications of prematurity. Optimal outcomes are achieved if these infants are delivered in hospitals with the highest level of neonatal expertise. Centralization of very preterm deliveries to such hospitals has been recommended for decades, and is supported by a large body of literature. However, centralization may not be easy to implement due to financial, organizational and workforce-related issues. In this review, we present the scientific background for centralization, how it has been successfully implemented in Finland and how neonatal survival has changed following this implementation.
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Affiliation(s)
- Kjell Helenius
- Department of Clinical Medicine, University of Turku, Turku, Finland.,Department of Paediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland
| | - Mika Gissler
- National Institute for Health and Welfare, Helsinki, Finland
| | - Liisa Lehtonen
- Department of Clinical Medicine, University of Turku, Turku, Finland.,Department of Paediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland
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14
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Kunz SN, Dukhovny D, Profit J, Mao W, Miedema D, Zupancic JAF. Predicting Successful Neonatal Retro-Transfer to a Lower Level of Care. J Pediatr 2019; 205:272-276.e1. [PMID: 30291023 PMCID: PMC6348131 DOI: 10.1016/j.jpeds.2018.09.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 07/11/2018] [Accepted: 09/05/2018] [Indexed: 01/04/2023]
Abstract
Up to 20% of newborn infants retro-transferred to a lower level of care require readmission to a higher-level facility. In this study, we developed and validated a prediction rule (The Rule for Elective Transfer between Units for Recovering Neonates [RETURN]) to identify clinical characteristics of infants at risk for failing retro-transfer.
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Affiliation(s)
- Sarah N. Kunz
- Division of Newborn Medicine, Harvard Medical School,
Boston, MA, USA,Department of Neonatology, Beth Israel Deaconess Medical
Center, Boston, MA, USA
| | - Dmitry Dukhovny
- Department of Pediatrics, Oregon Health & Science
University, Portland, OR, USA
| | - Jochen Profit
- Department of Pediatrics - Neonatal and Developmental
Medicine, Stanford University School of Medicine, Stanford, CA, USA,Califomia Perinatal Quality Care Collaborative, Stanford,
CA, USA
| | - Wenyang Mao
- Department of Neonatology, Beth Israel Deaconess Medical
Center, Boston, MA, USA
| | - David Miedema
- Department of Neonatology, Beth Israel Deaconess Medical
Center, Boston, MA, USA
| | - John A. F. Zupancic
- Division of Newborn Medicine, Harvard Medical School,
Boston, MA, USA,Department of Neonatology, Beth Israel Deaconess Medical
Center, Boston, MA, USA
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15
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Harrison WN, Wasserman JR, Goodman DC. Regional Variation in Neonatal Intensive Care Admissions and the Relationship to Bed Supply. J Pediatr 2018; 192:73-79.e4. [PMID: 28969888 DOI: 10.1016/j.jpeds.2017.08.028] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 07/04/2017] [Accepted: 08/14/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To characterize geographic variation in neonatal intensive care unit (NICU) admission rates across the entire birth cohort and evaluate the relationship between regional bed supply and NICU admission rates. STUDY DESIGN This was a population-based, cross-sectional study. 2013 US birth certificate and 2012 American Hospital Association data were used to assign newborns and NICU beds to neonatal intensive care regions. Descriptive statistics of admission rates were calculated across neonatal intensive care regions. Multilevel logistic regression was used to examine the relationship between bed supply and individual odds of admission, with adjustment for maternal and newborn characteristics. RESULTS Among 3 304 364 study newborns, the NICU admission rate was 7.2 per 100 births and varied across regions for all birth weight categories. IQRs in admission rates were 84.5-93.2 per 100 births for 500-1499 g, 35.3-46.1 for 1500-2499 g, and 3.5-5.5 for ≥2500 g. Adjusted odds of admission for newborns of very low birth weight were unrelated to regional bed supply; however, newborns ≥2500 g in regions with the highest NICU bed supply were significantly more likely to be admitted to a NICU than those in regions with the lowest (aOR 1.20 [1.03-1.40]). CONCLUSIONS There is persistent underuse of NICU care for newborns of very low birth weight that is not associated with regional bed supply. Among larger newborns, we find evidence of supply-sensitive care, raising concerns about the potential overuse of expensive and unnecessary care. Rather than improving access to needed care, NICU expansion may instead further deregionalize neonatal care, exacerbating underuse.
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Affiliation(s)
- Wade N Harrison
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH.
| | - Jared R Wasserman
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - David C Goodman
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH
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16
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Apfeld JC, Kastenberg ZJ, Sylvester KG, Lee HC. The Effect of Level of Care on Gastroschisis Outcomes. J Pediatr 2017; 190:79-84.e1. [PMID: 29144275 DOI: 10.1016/j.jpeds.2017.07.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 06/29/2017] [Accepted: 07/06/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To examine the relationship between level of care in neonatal intensive care units (NICUs) and outcomes for newborns with gastroschisis. STUDY DESIGN A retrospective cohort study was conducted at 130 California Perinatal Quality Care Collaborative NICUs from 2008 to 2014. All gastroschisis births were examined according to American Academy of Pediatrics NICU level of care at the birth hospital. Multivariate analyses examined odds of mortality, duration of mechanical ventilation, and duration of stay. RESULTS For 1588 newborns with gastroschisis, the adjusted odds of death were higher for those born into a center with a level IIA/B NICU (OR, 6.66; P = .004), a level IIIA NICU (OR, 5.95; P = .008), or a level IIIB NICU (OR, 5.85; P = .002), when compared with level IIIC centers. The odds of having more days on ventilation were significantly higher for births at IIA/B and IIIB centers (OR, 2.05 [P < .001] and OR, 1.91 [P < .001], respectively). The odds of having longer duration of stay were significantly higher at IIA/B and IIIB centers (OR, 1.71 [P < .004]; OR, 1.77 [P < .001]). CONCLUSIONS NICU level of care was associated with significant disparities in odds of mortality for newborns with gastroschisis.
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Affiliation(s)
- Jordan C Apfeld
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA.
| | - Zachary J Kastenberg
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA; Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, CA
| | - Karl G Sylvester
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA; Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, CA; Center for Fetal and Maternal Health, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, CA; Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Henry C Lee
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA; California Perinatal Quality Care Collaborative (CPQCC), Stanford University, Palo Alto, CA
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17
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Helenius K, Helle E, Lehtonen L. Amount of Antenatal Care Days in a Context of Effective Regionalization of Very Preterm Deliveries. J Pediatr 2016; 169:81-6. [PMID: 26602011 DOI: 10.1016/j.jpeds.2015.10.062] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 10/05/2015] [Accepted: 10/20/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the amount of antenatal care days in level III hospitals caused by regionalization of very preterm deliveries. STUDY DESIGN We included all 171,997 pregnancies registered in Finland between January 1, 2004 and December 31, 2006. Data on deliveries from the Medical Birth Register were linked to the Hospital Discharge Register. Maternal zip codes were used to define whether a mother lived inside or outside a level III hospital region. Regionalization was defined as care in level III hospitals between gestational weeks 22 and 32 among mothers living outside level III hospital regions. Pregnancies were divided into 3 groups based on the gestational age at delivery: very preterm (<32 weeks), late preterm (32-36 weeks), and term (≥37 weeks). RESULTS There were 12,354 antenatal care days in level III hospitals caused by regionalization, which amounts to a need for 12 antenatal maternal beds annually. In the very preterm pregnancies, the antenatal length of stay was comparable for mothers living inside or outside level III hospital regions (median 4 days, P = .81) but significantly longer for mothers living outside level III hospital regions in the late preterm (median 9 vs 7 days, P = .001) and term groups (median 3 vs 2 days, P < .0001). CONCLUSIONS The costs of regionalization of very preterm deliveries were low, as measured by antenatal care days. Regionalization did not increase the antenatal length of stay in very preterm deliveries.
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Affiliation(s)
- Kjell Helenius
- Department of Pediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland; Faculty of Medicine, University of Turku, Turku, Finland.
| | - Emmi Helle
- Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland; Stanford University, Cardiovascular Institute, Stanford, CA
| | - Liisa Lehtonen
- Department of Pediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland; Faculty of Medicine, University of Turku, Turku, Finland
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18
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Outcomes of delivery room CPR among very premature neonates: What are the challenges we face in the setting of regionalized perinatal care? Resuscitation 2014; 85:159-60. [DOI: 10.1016/j.resuscitation.2013.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 11/14/2013] [Indexed: 11/21/2022]
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19
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Chung JH, Phibbs CS, Boscardin WJ, Kominski GF, Ortega AN, Gregory KD, Needleman J. Examining the effect of hospital-level factors on mortality of very low birth weight infants using multilevel modeling. J Perinatol 2011; 31:770-5. [PMID: 21494232 DOI: 10.1038/jp.2011.29] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- J H Chung
- Department of Obstetrics and Gynecology, University of California, Orange, CA 92868, USA.
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20
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Bronstein JM, Ounpraseuth S, Jonkman J, Lowery CL, Fletcher D, Nugent RR, Hall RW. Improving perinatal regionalization for preterm deliveries in a Medicaid covered population: initial impact of the Arkansas ANGELS intervention. Health Serv Res 2011; 46:1082-103. [PMID: 21413980 PMCID: PMC3165179 DOI: 10.1111/j.1475-6773.2011.01249.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To examine the factors associated with delivery of preterm infants at neonatal intensive care unit (NICU) hospitals in Arkansas during the period 2001-2006, with a focus on the impact of a Medicaid supported intervention, Antenatal and Neonatal Guidelines, Education, and Learning System (ANGELS), that expanded the consulting capacity of the academic medical center's maternal fetal medicine practice. DATA SOURCES A dataset of linked Medicaid claims and birth certificates for the time period by clustering Medicaid claims by pregnancy episode. Pregnancy episodes were linked to residential county-level demographic and medical resource characteristics. Deliveries occurring before 35 weeks gestation (n=5,150) were used for analysis. STUDY DESIGN Logistic regression analysis was used to examine time trends and individual, county, and intervention characteristics associated with delivery at hospitals with NICU, and delivery at the academic medical center. PRINCIPAL FINDINGS Perceived risk, age, education, and prenatal care characteristics of women affected the likelihood of use of the NICU. The perceived availability of local expertise was associated with a lower likelihood that preterm infants would deliver at the NICU. ANGELS did not increase the overall use of NICU, but it did shift some deliveries to the academic setting. CONCLUSION Perinatal regionalization is the consequence of a complex set of provider and patient decisions, and it is difficult to alter with a voluntary program.
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Affiliation(s)
- Janet M Bronstein
- University of Alabama at Birmingham University of Arkansas for Medical Sciences, Little Rock, AR, USA
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21
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Lee HC, Chien AT, Bardach NS, Clay T, Gould JB, Dudley RA. The impact of statistical choices on neonatal intensive care unit quality ratings based on nosocomial infection rates. ACTA ACUST UNITED AC 2011; 165:429-34. [PMID: 21536958 DOI: 10.1001/archpediatrics.2011.41] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To examine the extent to which performance assessment methods affect the percentage of neonatal intensive care units (NICUs) and very low-birth-weight (VLBW) infants included in performance assessments, the distribution of NICU performance ratings, and the level of agreement in those ratings. DESIGN Cross-sectional study based on risk-adjusted nosocomial infection rates. SETTING NICUs belonging to the California Perinatal Quality Care Collaborative 2007-2008. PARTICIPANTS One hundred twenty-six California NICUs and 10 487 VLBW infants. MAIN EXPOSURES Three performance assessment choices: (1) excluding "low-volume" NICUs (those caring for <30 VLBW infants per year) vs a criterion based on confidence intervals, (2) using Bayesian vs frequentist hierarchical models, and (3) pooling data across 1 vs 2 years. MAIN OUTCOME MEASURES Proportion of NICUs and patients included in quality assessment, distribution of ratings for NICUs, and agreement between methods using the κ statistic. RESULTS Depending on the methods applied, 51% to 85% of NICUs and 72% to 96% of VLBW infants were included in performance assessments, 76% to 87% of NICUs were considered "average," and the level of agreement between NICU ratings ranged from 0.23 to 0.89. CONCLUSIONS The percentage of NICUs included in performance assessments and their ratings can shift dramatically depending on performance measurement method. Physicians, payers, and policymakers should continue to closely examine which existing performance assessment methods are most appropriate for evaluating pediatric care quality.
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Affiliation(s)
- Henry C Lee
- Department of Pediatrics, Division of Neonatology, University of California at San Francisco, 533 Parnassus Avenue, San Francisco, CA 94143, USA.
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22
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Pilkington H, Blondel B, Papiernik E, Cuttini M, Charreire H, Maier RF, Petrou S, Combier E, Künzel W, Bréart G, Zeitlin J. Distribution of maternity units and spatial access to specialised care for women delivering before 32 weeks of gestation in Europe. Health Place 2010; 16:531-8. [DOI: 10.1016/j.healthplace.2009.12.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Revised: 12/11/2009] [Accepted: 12/18/2009] [Indexed: 10/20/2022]
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23
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State-Based Analysis of Necrotizing Enterocolitis Outcomes. J Surg Res 2009; 157:21-9. [DOI: 10.1016/j.jss.2008.11.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2008] [Revised: 10/27/2008] [Accepted: 11/05/2008] [Indexed: 12/23/2022]
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Kollée LAA, Cuttini M, Delmas D, Papiernik E, den Ouden AL, Agostino R, Boerch K, Bréart G, Chabernaud JL, Draper ES, Gortner L, Künzel W, Maier RF, Mazela J, Milligan D, Van Reempts P, Weber T, Zeitlin J. Obstetric interventions for babies born before 28 weeks of gestation in Europe: results of the MOSAIC study. BJOG 2009; 116:1481-91. [DOI: 10.1111/j.1471-0528.2009.02235.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Holmstrom ST, Phibbs CS. Regionalization and mortality in neonatal intensive care. Pediatr Clin North Am 2009; 56:617-30, Table of Contents. [PMID: 19501695 DOI: 10.1016/j.pcl.2009.04.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Scott T Holmstrom
- Health Economics Resource Center, VA Palo Alto Health Care System, CA 94025, USA
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McDonald KM, Davies SM, Haberland CA, Geppert JJ, Ku A, Romano PS. Preliminary assessment of pediatric health care quality and patient safety in the United States using readily available administrative data. Pediatrics 2008; 122:e416-25. [PMID: 18676529 DOI: 10.1542/peds.2007-2477] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES With >6 million hospital stays, costing almost $50 billion annually, hospitalized children represent an important population for which most inpatient quality indicators are not applicable. Our aim was to develop indicators using inpatient administrative data to assess aspects of the quality of inpatient pediatric care and access to quality outpatient care. METHODS We adapted the Agency for Healthcare Research and Quality quality indicators, a publicly available set of measurement tools refined previously by our team, for a pediatric population. We systematically reviewed the literature for evidence regarding coding and construct validity specific to children. We then convened 4 expert panels to review and discuss the evidence and asked them to rate each indicator through a 2-stage modified Delphi process. From the 2000 and 2003 Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project Kids' Inpatient Database, we generated national estimates for provider level indicators and for area level indicators. RESULTS Panelists recommended 18 indicators for inclusion in the pediatric quality indicator set based on overall usefulness for quality improvement efforts. The indicators included 13 hospital-level indicators, including 11 based on complications, 1 based on mortality, and 1 based on volume, as well as 5 area-level potentially preventable hospitalization indicators. National rates for all 18 of the indicators varied minimally between years. Rates in high-risk strata are notably higher than in the overall groups: in 2003 the decubitus ulcer pediatric quality indicator rate was 3.12 per 1000, whereas patients with limited mobility experienced a rate of 22.83. Trends in rates by age varied across pediatric quality indicators: short-term complications of diabetes increased with age, whereas admissions for gastroenteritis decreased with age. CONCLUSIONS Tracking potentially preventable complications and hospitalizations has the potential to help prioritize quality improvement efforts at both local and national levels, although additional validation research is needed to confirm the accuracy of coding.
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Affiliation(s)
- Kathryn M McDonald
- Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University, Stanford, California, USA
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Bartels DB, Wenzlaff P, Poets CF. Obstetrical volume and early neonatal mortality in preterm infants. Eur J Epidemiol 2007; 22:791-8. [PMID: 17902029 DOI: 10.1007/s10654-007-9182-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2007] [Accepted: 09/10/2007] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Dorothee B Bartels
- Department of Epidemiology, Public Medicine and Healthcare Systems Research, Hannover Medical School, Carl-Neuberg-Str. 1, OE 5410, 30625 Hannover, Germany.
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Phibbs CS, Baker LC, Caughey AB, Danielsen B, Schmitt SK, Phibbs RH. Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants. N Engl J Med 2007; 356:2165-75. [PMID: 17522400 DOI: 10.1056/nejmsa065029] [Citation(s) in RCA: 337] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Ciaran S Phibbs
- Health Economics Resource Center and the Center for Health Care Evaluation, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA 94025, USA.
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