Regional variation in antenatal corticosteroid use: a network-level quality improvement study

Obstacles to Optimal Antenatal Corticosteroid Administration to Eligible Patients

OBJECTIVE

Administration of antenatal corticosteroids (ANCS) is recommended for individuals expected to deliver between 24 and 34 weeks of gestation. Properly timed administration of ANCS achieves maximal benefit. However, more than 50% of individuals receive ANCS outside the recommended window. This study aimed to examine maternal and hospital factors associated with suboptimal receipt of ANCS among individuals who deliver between 24 and 34 weeks of gestation.

STUDY DESIGN

Secondary analysis of the Assessment of Perinatal Excellence (APEX), an observational study of births to 115,502 individuals at 25 hospitals in the United States from March 2008 to February 2011, was conducted. Data from 3,123 individuals who gave birth to a nonanomalous live-born infant between 240/7 to 340/7 weeks of gestation, had prenatal records available at delivery, and data available on the timing of ANCS use were included in this analysis. Eligible individuals' ANCS status was categorized as optimal (full course completed >24 hours after ANCS but not >7 days before birth) or suboptimal (none, too late, or too early). Maternal and hospital-level variables were compared using optimal as the referent group. Hierarchical multinomial logistic regression models, with site as a random effect, were used to identify maternal and hospital-level characteristics associated with optimal ANCS use.

RESULTS

Overall, 83.6% (2,612/3,123) of eligible individuals received any treatment: 1,216 (38.9%) optimal and 1,907 (61.1%) suboptimal. Within suboptimal group, 495 (15.9%) received ANCS too late, 901 (28.9%) too early, and 511 (16.4%) did not receive any ANCS. Optimal ANCS varied depending on indication for hospital admission (p < 0.001). Individuals who were admitted with intent to deliver were less likely to receive optimal ANCS while individuals admitted for hypertensive diseases of pregnancy were most likely to receive optimal ANCS (10 vs. 35%). The median gestational age of individuals who received optimal ANCS was 31.0 weeks. Adjusting for hospital factors, hospitals with electronic medical records and who receive transfers have fewer eligible individuals who did not receive ANCS. ANCS administration and timing varied substantially by hospital, optimal frequencies ranged from 9.1 to 51.3%, and none frequencies from 6.1 to 61.8%. When evaluating variation by hospital site, models with maternal and hospital factors did not explain any of the variation in ANCS use.

CONCLUSION

Optimal ANCS use varied by maternal and hospital factors and by hospital site, indicating opportunities for improvement.

KEY POINTS

· Majority of individuals who deliver between 24 and 34 weeks of gestation do not receive properly timed antenatal corticosteroids.. · Optimal use of antenatal corticosteroids varies by maternal and hospital factors and hospital site.. · Significant variation in hospital sites regarding optimally timed administration of antenatal corticosteroids indicates opportunities for improvement..

Use of antenatal corticosteroids among infants with gestational age at 24 to 31 weeks in 57 neonatal intensive care units of China: a cross-sectional study

BACKGROUND

Antenatal corticosteroids (ACS) can significantly improve the outcomes of preterm infants. This study aimed to describe the ACS use rates among preterm infants admitted to Chinese neonatal intensive care units (NICU) and to explore perinatal factors associated with ACS use, using the largest contemporary cohort of very preterm infants in China.

METHODS

This cross-sectional study enrolled all infants born at 24 +0 to 31 +6 weeks and admitted to 57 NICUs of the Chinese Neonatal Network from January 1st, 2019 to December 30th, 2019. The ACS administration was defined as at least one dose of dexamethasone and betamethasone given before delivery. Multiple logistic regressions were applied to determine the association between perinatal factors and ACS usage.

RESULTS

A total of 7828 infants were enrolled, among which 6103 (78.0%) infants received ACS. ACS use rates increased with increasing gestational age (GA), from 177/259 (68.3%) at 24 to 25 weeks' gestation to 3120/3960 (78.8%) at 30 to 31 weeks' gestation. Among infants exposed to ACS, 2999 of 6103 (49.1%) infants received a single complete course, and 33.4% (2039/6103) infants received a partial course. ACS use rates varied from 30.2% to 100% among different hospitals. Multivariate regression showed that increasing GA, born in hospital (inborn), increasing maternal age, maternal hypertension and premature rupture of membranes were associated with higher likelihood to receive ACS.

CONCLUSIONS

The use rate of ACS remained low for infants at 24 to 31 weeks' gestation admitted to Chinese NICUs, with fewer infants receiving a complete course. The use rates varied significantly among different hospitals. Efforts are urgently needed to propose improvement measures and thus improve the usage of ACS.

Health Care Disparities in High-Risk Neonates

Long-standing health disparities in maternal reproductive health, infant morbidity and mortality, and long-term developmental outcomes are rooted in a foundation of structural racism. Social determinants of health profoundly affect reproductive health outcomes of Black and Hispanic women disproportionately; they have higher rates of death during pregnancy and preterm birth. Their infants are also more likely to be cared for in poorer quality neonatal intensive care units (NICUs), receive poorer quality of NICU care, and are less likely to be referred to an appropriate high-risk NICU follow-up program. Interventions that mitigate the impact of racism will help to eliminate health disparities.

Nasal continuous positive airway pressure practices in preterm infants: A survey of neonatal providers

BACKGROUND

The standard of care for respiratory support of preterm infants is nasal continuous positive airway pressure (CPAP), yet practices are not standardized. Our aim was to survey CPAP practices in infants < 32 weeks gestation among the American Academy of Pediatrics Neonatal-Perinatal section.

METHODS

A US, web-based survey inquired about the initiation, management, and discontinuation of CPAP, and chinstrap use and oral feedings on CPAP.

RESULTS

857 providers consented. Regarding criteria to discontinue/wean CPAP: 69% use specific respiratory stability criteria; 22% a specific post-menstrual age; 8% responded other. 64% did not have guidelines for CPAP discontinuation; 54% did not have guidelines for CPAP initiation. 66% believe chinstraps improve CPAP efficacy; however, 11% routinely apply a chinstrap. 22% allow oral feeds on CPAP in certain circumstances.

CONCLUSION

There are meaningful variabilities in CPAP practices among neonatal providers across the US. Given the potential long-term implications this can have on the growth and development of the preterm lung, further evidence-based research is needed in relation to respiratory outcomes to optimize and standardize CPAP strategies.

The variation of antenatal corticosteroids administration for the singleton preterm birth in China, 2017 to 2018

Background

The administration of antenatal corticosteroids (ACS) to women who are at risk of preterm birth has been proven to reduce not only the mortality, but also the major morbidities of the preterm infants. The rate of ACS and the risk factors associated with ACS use in Chinese population is unclear. This study aimed to investigate the rate of ACS use and the associated perinatal factors in the tertiary maternal centers of China.

Methods

Data for this retrospective observational study came from a clinical database of preterm infants established by REIN-EPIQ trial. All infants born at < 34 weeks of gestation and admitted to 18 tertiary maternal centers in China from 2017 to 2018 were enrolled. Any dose of dexamethasone was given prior to preterm delivery was recorded and the associated perinatal factors were analyzed.

Results

The rate of ACS exposure in this population was 71.2% (range 20.2 – 92%) and the ACS use in these 18 maternal centers varied from 20.2 to 92.0% in this period. ACS exposure was higher among women with preeclampsia, caesarean section delivery, antibiotic treatment and who delivered infants with lower gestational age and small for gestational age. ACS use was highest in the 28–31 weeks gestational age group, and lowest in the under 26 weeks of gestational age group (x² = 65.478, P < 0.001). ACS exposure was associated with lower odds of bronchopulmonary dysplasia or death (OR, 0.778; 95% CI 0.661 to 0.916) and invasive respiration requirement (OR, 0.668; 95% CI 0.585 to 0.762) in this population.

Conclusion

The ACS exposure was variable among maternity hospitals and quality improvement of ACS administration is warranted.

Improving birth certificate data accuracy in Alabama

Objective

Accurate vital statistics data are critical for monitoring population health and strategizing public health interventions. Previous analyses of statewide birth data have identified several factors that may reduce birth certificate accuracy including systematic errors and limited data review by clinicians. The aim of this initiative was to increase the proportion of hospitals in Alabama reporting accurate birth certificate data from 67% to 87% within 1 year.

Methods

The Alabama Perinatal Quality Collaborative led this statewide collaborative effort. Process measures included monthly monitoring of 11 variables across 5-10 patient birth certificates per month per hospital. Accuracy determination, defined as ≥95% accuracy of the variables analyzed, was performed by health care specialists at each hospital by comparing birth certificate variables from vital statistics with data obtained from original hospital source materials. Three months of retrospective, baseline accuracy data were collected before project initiation from which actionable drivers and change ideas were identified at individual hospitals. Data were analyzed using statistical process control measures.

Results

Thirty-one hospitals entered data throughout the course of the initiative, accounting for 850 chart analyses and 9350 variable assessments. The least accurately reported variables included birth weight, maternal hypertension, and antenatal corticosteroid exposure. At baseline, 67% of hospitals reported birth certificate accuracy rates ≥ 95%, which increased to 90% of hospitals within 2 months and was sustained for the remainder of the initiative.

Conclusion

Statewide, multidisciplinary quality improvement efforts increased birth certificate accuracy vital to public health surveillance.

The center-effect on outcomes for infants born at less than 25 weeks

Marked variation exists in the care of infants born at <25 weeks' gestation. The center or location where a fetus or infant is cared for influences outcomes at very early gestational ages. Understanding this "center-effect," including characteristics associated with centers that have high survival of births at <25 weeks' gestation, may inform future studies and guide care practices to improve outcomes. This review focuses on the impact that the location or center of birth has on survival and other important outcomes for infants born at <25 weeks' gestation. We review potential sources of variation in care practices and other factors that might explain the "center-effect."

Survival Without Major Morbidity Among Very Low Birth Weight Infants in California

OBJECTIVES

To examine trends in survival without major morbidity and its individual components among very low birth weight infants across California and assess remaining gaps that may be opportune targets for improvement efforts.

METHODS

The study population included infants born between 2008 and 2017 with birth weights of 401 to 1500 g or a gestational age of 22 to 29 weeks. Risk-adjusted trends of survival without major morbidity and its individual components were analyzed. Survival without major morbidity was defined as the absence of death during birth hospitalization, chronic lung disease, severe peri-intraventricular hemorrhage, nosocomial infection, necrotizing enterocolitis, severe retinopathy of prematurity or related surgery, and cystic periventricular leukomalacia. Variations in adjusted rates and/or interquartile ranges were examined. To assess opportunities for additional improvement, all hospitals were reassigned to perform as if in the top quartile, and recalculation of predicted numbers were used to estimate potential benefit.

RESULTS

In this cohort of 49 333 infants across 142 hospitals, survival without major morbidity consistently increased from 62.2% to 66.9% from 2008 to 2017. Network variation decreased, with interquartile ranges decreasing from 21.1% to 19.2%. The largest improvements were seen for necrotizing enterocolitis and nosocomial infection. Bronchopulmonary dysplasia rates did not change significantly. Over the final 3 years, if all hospitals performed as well as the top quartile, an additional 621 infants per year would have survived without major morbidity, accounting for an additional 6.6% annual improvement.

CONCLUSIONS

Although trends are promising, bronchopulmonary dysplasia remains a common and persistent major morbidity, remaining a target for continued quality-improvement efforts.

Improving the quality of quality metrics in neonatology

This article examines approaches for improving the efficiency and effectiveness of quality metrics currently in use in neonatal care. Desirable characteristics of quality metrics are discussed, the criteria and process for their development are presented, and the uses and limitations of current neonatal outcome and process metrics are explored together with approaches for improving metric performance. Discussion includes enhancing quality metrics through optimizing improvement readiness, sustaining improvements once achieved, and use of improvement science methods to improve metric validity.

Teaching culturally competent healthcare in neonatal-perinatal medicine

Disparities in maternal and infant health care and outcomes exist despite advances in prenatal, perinatal, and neonatal care. In this article, the graduate medical educational goals to ensure that trainees in Neonatal-Perinatal Medicine have the knowledge, skills, and attitudes required for practicing culturally competent care are described. A framework for curriculum development, teaching, and learner evaluation for cultural competence will also be discussed. Included in this discussion are the educational objectives of preparing specialists in Neonatal-Perinatal Medicine to provide appropriate medical management to neonates, identify existing disparities in perinatal and neonatal care, and develop quality improvement initiatives to achieve equity in delivery of care.

Regional and Racial-Ethnic Differences in Perinatal Interventions Among Periviable Births

OBJECTIVE

To examine whether there are: 1) regional differences in three perinatal interventions that reflect active treatment among periviable gestations and 2) racial-ethnic differences in the receipt of these perinatal interventions after accounting for hospital region.

METHODS

We conducted a retrospective study on neonates born at 776 U.S. centers that participated in the Vermont Oxford Network (2006-2017) with a gestational age of 22-25 weeks. The primary outcome was postnatal life support. Secondary outcomes included maternal administration of antenatal corticosteroids and cesarean delivery. We examined rates and 99% CI of the three outcomes by region. We also calculated the adjusted relative risks (aRRs) and 99% CIs for the three outcomes by race and ethnicity within each region using modified Poisson regression models with robust variance estimation.

RESULTS

Major regional variation exists in the use of the three interventions at 22 and 23 weeks of gestation but not at 24 and 25 weeks. For example, at 22 weeks of gestation, rates of life support in the South (38.3%; 99% CI 36.3-40.2) and the Midwest (32.7%; 99% CI 30.4-35.0) were higher than in the Northeast (20.2%; 99% CI 17.6-22.8) and the West (22.2%; 99% CI 20.0-24.4). Particularly in the Northeast, black and Hispanic neonates born at 22 or 23 weeks of gestation had a higher provision of postnatal life support than white neonates (at 22 weeks: black: aRR 1.84 [99% CI 1.33-2.56], Hispanic: aRR 1.80 [1.23-2.64]; at 23 weeks: black: aRR 1.14 [99% CI 1.08-1.20], Hispanic: aRR 1.12 [1.05-1.19]). In the West, black and Hispanic neonates born at 23 weeks of gestation also had a higher provision of life support (black: aRR 1.11 [99% CI 1.03-1.19]; Hispanic: aRR 1.10 [1.04-1.16]).

CONCLUSION

Major regional variation exists in perinatal interventions when managing 22- and 23-week neonates. In the Northeast and the West regions, minority neonates born at 22 and 23 weeks of gestation had higher provision of postnatal life support.

Disparities in the use of antenatal corticosteroids among women with hypertension in North Carolina

OBJECTIVE

To evaluate antenatal corticosteroids (ANS) use in pregnant women with hypertension.

STUDY DESIGN

Retrospective analysis of ANS use in the Perinatal Quality Collaborative of North Carolina between 2015 and 2017.

RESULTS

Twenty-five centers participated, with 9% (1580/17,692) of mothers delivering at <34 weeks; of these, 81% (1286/1580) received a full course of ANS, which was not different between phases (p = 0.32), or between Level III/IV neonatal intensive care units (NICUs; 82%), and I/II NICUs (76%) (p = 0.05). In Level III/IV NICUs, White mothers were more likely to receive ANS (87%) than African Americans (77%) or other race/ethnicity (80%) (including Hispanics) (p = 0.001). ANS use did not differ among mothers with different payers (p = 0.94).

CONCLUSION

The rates of full ANS courses did not significantly increase from 2015-2017 and disparities persisted. Targeted efforts to improve ANS exposures among hypertensive African American and Hispanic mothers, as well as in community hospital settings are needed.

An evaluation of the benefits and harms of antenatal corticosteroid treatment for women at risk of imminent preterm birth or prior to elective Caesarean-section: Study protocol for an individual participant data meta-analysis

Background: Antenatal corticosteroid treatment (ACT) has been widely accepted as a safe, beneficial treatment which improves outcomes following preterm birth. It has been shown to reduce respiratory distress syndrome and neonatal mortality and is commonly used in threatened or planned preterm delivery, as well as prior to elective Caesarean-section at term. There are some concerns however, that in some cases, ACT is used in patients where clinical benefit has not been established, or may potentially increase harm. Many women who receive ACT do not deliver preterm and the long-term consequences of ACT treatment are unclear. This study aims to evaluate the benefits and harms of ACT using latest trial evidence to allow refinement of current practice. Methods: This study will compare ACT with placebo or non-treatment. Inclusion criteria are: Randomised Controlled Trials (RCT) comparing ACT vs. no ACT (with or without placebo) in all settings. Exclusion criteria are: non-randomised or quasi-randomised studies and studies comparing single vs. multiple courses of ACT. Main outcomes are to evaluate, for women at risk of preterm birth or undergoing planned Caesarean- section, the benefits and harms of ACT, on maternal, fetal, newborn, and long-term offspring health outcomes. The individual participant data (IPD) of identified RCTs will be collected and consecutively synthesised using meta-analysis with both a one-stage model where all IPD is analysed together and a two-stage model where treatment effect estimates are calculated for each trial individually first and thereafter pooled in a meta-analysis. Sub-group analysis will be performed to identify heterogeneous effects of ACT across predefined risk groups. Discussion: Co-opt is the Consortium for the Study of Pregnancy Treatments and aims to complete a robust evaluation of the benefits and harms of ACT. This IPD meta-analysis will contribute to this by allowing detailed interrogation of existing trial datasets. PROSPERO registration: CRD42020167312 (03/02/2020).

Development and use of an adjusted nurse staffing metric in the neonatal intensive care unit

OBJECTIVE

To develop a nurse staffing prediction model and evaluate deviation from predicted nurse staffing as a contributor to patient outcomes.

DATA SOURCES

Secondary data collection conducted 2017-2018, using the California Office of Statewide Health Planning and Development and the California Perinatal Quality Care Collaborative databases. We included 276 054 infants born 2008-2016 and cared for in 99 California neonatal intensive care units (NICUs).

STUDY DESIGN

Repeated-measures observational study. We developed a nurse staffing prediction model using machine learning and hierarchical linear regression and then quantified deviation from predicted nurse staffing in relation to health care-associated infections, length of stay, and mortality using hierarchical logistic and linear regression.

DATA COLLECTION METHODS

We linked NICU-level nurse staffing and organizational data to patient-level risk factors and outcomes using unique identifiers for NICUs and patients.

PRINCIPAL FINDINGS

An 11-factor prediction model explained 35 percent of the nurse staffing variation among NICUs. Higher-than-predicted nurse staffing was associated with decreased risk-adjusted odds of health care-associated infection (OR: 0.79, 95% CI: 0.63-0.98), but not with length of stay or mortality.

CONCLUSIONS

Organizational and patient factors explain much of the variation in nurse staffing. Higher-than-predicted nurse staffing was associated with fewer infections. Prospective studies are needed to determine causality and to quantify the impact of staffing reforms on health outcomes.

No. 364-Antenatal Corticosteroid Therapy for Improving Neonatal Outcomes

OBJECTIVE

To assess the benefits and risks of antenatal corticosteroid therapy for women at risk of preterm birth or undergoing pre-labour Caesarean section at term and to make recommendations for improving neonatal and long-term outcomes.

OPTIONS

To administer or withhold antenatal corticosteroid therapy for women at high risk of preterm birth or women undergoing pre-labour Caesarean section at term.

OUTCOMES

Perinatal morbidity, including respiratory distress syndrome, intraventricular hemorrhage, bronchopulmonary dysplasia, infection, hypoglycemia, somatic and brain growth, and neurodevelopment; perinatal mortality; and maternal morbidity, including infection and adrenal suppression.

INTENDED USERS

Maternity care providers including midwives, family physicians, and obstetricians.

TARGET POPULATION

Pregnant women.

EVIDENCE

Medline, PubMed, Embase, and the Cochrane Library were searched from inception to September 2017. Medical Subject Heading (MeSH) terms and key words related to pregnancy, prematurity, corticosteroids, and perinatal and neonatal mortality and morbidity were used. Statements from professional organizations including that of the National Institutes of Health, the American College of Obstetricians and Gynecologists, the Society for Maternal Fetal Medicine, the Royal College of Obstetricians and Gynaecologists, and the Canadian Pediatric Society were reviewed for additional references. Randomized controlled trials conducted in pregnant women evaluating antenatal corticosteroid therapy and previous systematic reviews on the topic were eligible. Evidence from systematic reviews of non-experimental (cohort) studies was also eligible.

VALIDATION METHODS

This Committee Opinion has been reviewed and approved by the Maternal-Fetal Medicine Committee of the SOGC and approved by SOGC Council.

BENEFITS, HARMS, AND/OR COSTS

A course of antenatal corticosteroid therapy administered within 7 days of delivery significantly reduces perinatal morbidity/mortality associated with preterm birth between 24 + 0 and 34 + 6 weeks gestation. When antenatal corticosteroid therapy is given more than 7 days prior to delivery or after 34 + 6 weeks gestation, the adverse effects may outweigh the benefits. Evidence on long-term effects is scarce, and potential neurodevelopment harms are unquantified in cases of late preterm, term, and repeated exposure to antenatal corticosteroid therapy.

GUIDELINE UPDATE

Evidence will be reviewed 5 years after publication to evaluate the need for a complete or partial update of the guideline. If important evidence is published prior to the 5-year time point, an update will be issued to reflect new knowledge and recommendations.

SPONSORS

The guideline was developed with resources provided by the Society of Obstetricians and Gynaecologists of Canada with support from the Canadian Institutes of Health Research (APR-126338).

SUMMARY STATEMENTS

RECOMMENDATIONS: Gestational Age Considerations Agents, Dosage, Regimen, and Target Timing Subpopulations and Special Consideration.

N° 364 - La Corticothérapie Prénatale Pour Améliorer Les Issues Néonatales

OBJECTIF

Évaluer les avantages et les risques de la corticothérapie prénatale chez les femmes qui présentent un risque d'accouchement prématuré ou qui subissent une césarienne à terme avant début de travail, et formuler des recommandations visant l'amélioration des issues néonatales et des issues à long terme.

OPTIONS

Administrer ou ne pas administrer une corticothérapie prénatale aux femmes qui présentent un risque élevé d'accouchement prématuré ou qui subissent une césarienne avant travail à terme. RéSULTATS: Morbidité périnatale, notamment le syndrome de détresse respiratoire, l'hémorragie intraventriculaire, la dysplasie bronchopulmonaire, l'infection, l'hypoglycémie, ainsi que les troubles de la croissance somatique et cérébrale et du neurodéveloppement; mortalité périnatale; et morbidité maternelle, notamment l'infection et la suppression surrénalienne.

UTILISATEURS CIBLES

Fournisseurs de soins de maternité, notamment les sages-femmes, les médecins de famille et les obstétriciens.

POPULATION CIBLE

Femmes enceintes. ÉVIDENCE: Nous avons interrogé les bases de données Medline, PubMed et Embase ainsi que la Bibliothèque Cochrane, de leur création au mois de septembre 2017. Nous nous sommes servis de Medical Subjet Headings (MeSH) et de mots clés en lien avec la grossesse, la prématurité, les corticostéroïdes ainsi que la mortalité et la morbidité périnatales et néonatales. Nous avons également consulté les déclarations d'organismes professionnels tels que les National Institutes of Health, l'American College of Obstetricians and Gynecologists, la Society for Maternal-Fetal Medicine, le Royal College of Obstetricians and Gynaecologists et la Société canadienne de pédiatrie pour obtenir des références additionnelles. Les essais cliniques randomisés évaluant la corticothérapie prénatale menés sur des femmes enceintes et les revues systématiques antérieures sur le sujet étaient admissibles, tout comme les données venant de revues systématiques d'études non expérimentales (études de cohorte).

VALEURS

La présente opinion de comité a été révisée et approuvée par le Comité de médecine fœto-maternelle de la SOGC, et approuvée par le Conseil de la SOGC. AVANTAGES, INCONVéNIENTS ET COûTS: L'administration d'une corticothérapie prénatale dans les sept jours précédant l'accouchement réduit significativement la morbidité et la mortalité périnatales associées à la naissance prématurée survenant entre 24+0 et 34+6 semaines de grossesse. Si la corticothérapie prénatale est administrée plus de sept jours avant l'accouchement ou après 34+6 semaines de grossesse, les effets indésirables peuvent surpasser les avantages. Les données probantes sur l'impact à long terme de la corticothérapie prénatale sont rares. Par ailleurs, les effets neurodéveloppementaux néfastes potentiels de l'exposition répétée à la corticothérapie prénatale ou de l'administration de corticostéroïdes en période préterme tardive ou à terme n'ont pas été quantifiés. MIS-à-JOUR à LA DIRECTIVE: Une revue des données probantes sera menée cinq ans après la publication de la présente directive clinique afin d'évaluer si une mise à jour complète ou partielle s'impose. Si de nouvelles données probantes importantes sont publiées avant la fin de ces cinq ans, une mise à jour tenant compte des nouvelles connaissances et recommandations sera publiée.

COMMANDITAIRES

La présente directive clinique a été élaborée à l'aide de ressources fournies par la Société des obstétriciens et gynécologues du Canada et avec l'appui des Instituts de recherche en santé du Canada (APR-126338). MOTS CLéS: Corticothérapie prénatale, maturation fœtale, prématurité, période préterme tardive, césarienne avant travail DÉCLARATION SOMMAIRES: RECOMMANDATIONS: Considérations relatives à l'âge gestationnel.

Improving Uptake of Key Perinatal Interventions Using Statewide Quality Collaboratives

Regional and statewide quality improvement collaboratives have been instrumental in implementing evidence-based practices and facilitating quality improvement initiatives within neonatology. Statewide collaboratives emerged from larger collaborative organizations, like the Vermont Oxford Network, and play an increasing role in collecting and interpreting data, setting priorities for improvement, disseminating evidence-based clinical practice guidelines, and creating regional networks for synergistic learning. In this review, we highlight examples of successful statewide collaborative initiatives, as well as challenges that exist in initiating and sustaining collaborative efforts.

Assessing the potential impact of extending antenatal steroids to the late preterm period

BACKGROUND

In 2016, guidance statements were issued by the Society for Maternal-Fetal Medicine and the American Congress of Obstetricians and Gynecologists about extending antenatal steroid use to selected late preterm singleton pregnancies.

OBJECTIVE

We sought to review antenatal steroid use prior to the 2016 guidance statements and assess the potential impact of these.

STUDY DESIGN

This cohort study used chart-abstracted data from singleton deliveries from Jan. 1, 2012, through March 31, 2016, at 12 centers participating in the Obstetrics Clinical Outcomes Assessment Program, a quality initiative in Washington State. Pregnancies with missing gestation at delivery, fetal anomalies, or antepartum demise were excluded. Antenatal steroid use prior to the 2016 guidance was evaluated based on the percentage of early preterm deliveries (23⁺⁰-33⁺⁶ weeks) and the percentage of all pregnancies that received antenatal steroids. Newborn complication rates were calculated for late preterm deliveries (34+0⁺⁰-36⁺⁶ weeks), grouped by whether they would be potentially eligible or ineligible for antenatal steroids based on the 2016 guidance statements.

RESULTS

The opportunity for antenatal steroids was missed in 21.8% (226/1034) of early preterm deliveries and of all those who received antenatal steroids, 32.2% (614/1908) delivered at term. Of preterm deliveries, 74% (n = 2942) were in the late preterm period. In all, 80% (n = 2363) of late preterm deliveries were potentially eligible for antenatal steroids and 60% of these (n = 1411) delivered at 36 weeks. The rate of respiratory complications in newborns delivering at 34 and 35 weeks was higher in the group potentially eligible for late preterm antenatal steroids compared to those in the ineligible group. Of those delivering at 36 weeks, no differences were detected in prevalence of respiratory complications by potential eligibility for antenatal steroids; however, compared with the ineligible group, those potentially eligible had a lower risk of neonatal intensive care unit admission (P < .001). More than two thirds (69%; 171/248) of newborn respiratory complications among late preterm deliveries potentially eligible for antenatal steroids occurred in those delivering at 34-35 weeks. The highest rate of respiratory complications was in those ineligible for antenatal steroids due to prepregnancy diabetes or chorioamnionitis, regardless of gestational age at delivery.

CONCLUSION

Careful consideration of which pregnancies should receive late preterm antenatal steroids and how to identify these pregnancies is important to optimize benefits and mitigate potential risks of this intervention.

Eliminating Undesirable Variation in Neonatal Practice: Balancing Standardization and Customization

Consistency of care and elimination of unnecessary and harmful variation are underemphasized aspects of health care quality. This article describes the prevalence and patterns of practice variation in health care and neonatology; discusses the potential role of standardization as a solution to eliminating wasteful and harmful practice variation, particularly when it is founded on principles of evidence-based medicine; and proposes ways to balance standardization and customization of practice to ultimately improve the quality of neonatal care.

Racial/Ethnic Disparity in NICU Quality of Care Delivery

BACKGROUND

Differences in NICU quality of care provided to very low birth weight (<1500 g) infants may contribute to the persistence of racial and/or ethnic disparity. An examination of such disparities in a population-based sample across multiple dimensions of care and outcomes is lacking.

METHODS

Prospective observational analysis of 18 616 very low birth weight infants in 134 California NICUs between January 1, 2010, and December 31, 2014. We assessed quality of care via the Baby-MONITOR, a composite indicator consisting of 9 process and outcome measures of quality. For each NICU, we calculated a risk-adjusted composite and individual component quality score for each race and/or ethnicity. We standardized each score to the overall population to compare quality of care between and within NICUs.

RESULTS

We found clinically and statistically significant racial and/or ethnic variation in quality of care between NICUs as well as within NICUs. Composite quality scores ranged by 5.26 standard units (range: -2.30 to 2.96). Adjustment of Baby-MONITOR scores by race and/or ethnicity had only minimal effect on comparative assessments of NICU performance. Among subcomponents of the Baby-MONITOR, non-Hispanic white infants scored higher on measures of process compared with African Americans and Hispanics. Compared with whites, African Americans scored higher on measures of outcome; Hispanics scored lower on 7 of the 9 Baby-MONITOR subcomponents.

CONCLUSIONS

Significant racial and/or ethnic variation in quality of care exists between and within NICUs. Providing feedback of disparity scores to NICUs could serve as an important starting point for promoting improvement and reducing disparities.

Variation in quality report viewing by providers and correlation with NICU quality metrics

BACKGROUND

To examine variation in quality report viewing and assess correlation between provider report viewing and neonatal intensive care unit (NICU) quality.

METHODS

Variation in report viewing sessions for 129 California Perinatal Quality Care Collaborative NICUs was examined. NICUs were stratified into tertiles based on their antenatal steroid (ANS) use and hospital-acquired infection (HAI) rates to compare report viewing session counts.

RESULTS

The number of report viewing sessions initiated by providers varied widely over a 2-year period (median=11; mean=25.5; s.d.=45.19 sessions). Report viewing was not associated with differences in ANS use. Facilities with low HAI rates had less frequent report viewing. Facilities with high report views had significant improvements in HAI rates over time.

CONCLUSIONS

Available audit and feedback reports are utilized inconsistently across California NICUs despite evidence that report viewing is associated with improvements in quality of care delivery. Further studies are needed for reports to reach their theoretical potential.

Area-based study identifies risk factors associated with missed antenatal corticosteroid prophylaxis in women delivering preterm infants

AIM

All women delivering a preterm infant should receive antenatal corticosteroid prophylaxis, but many miss this opportunity. We determined the risk factors associated with missed prophylaxis in a geographically defined area of Italy.

METHODS

We prospectively studied all mothers who delivered babies between 24 and 31 completed weeks of gestation, from 2009 to 2013, in all maternity units in Tuscany.

RESULTS

Of 1232 mothers, 186 (15.1%) did not receive prophylaxis. The risk was higher in migrant mothers, with an adjusted risk ratio (RR) of 1.28 and 95% confidence interval (95% CI) of 1.04-1.56, and in mothers hospitalised for less than 24 hours (RR 4.09, 95% CI: 2.90-5.78). Preterm prelabour rupture of membranes (RR 0.63, 95% CI: 0.41-0.96) and maternal antepartum transfer (RR 0.24, 95% CI: 0.18-0.32) were protective. Hospital level at birth and gestational age did not influence the prophylaxis rate. The population-attributable fractions were 50.4% for late hospital admissions and 10.2% for migrant status.

CONCLUSION

In a highly organised network of hospitals, neither level of care nor gestational age influenced prophylaxis. Timely arrival of women in hospital, better recognition of the imminence of delivery and tighter steroids administration guidelines are the most relevant targets to further increase prophylaxis.

Antenatal corticosteroids beyond 34 weeks gestation: What do we do now?

The practice of antenatal corticosteroid administration in pregnancies of 24-34 weeks of gestation that are at risk of preterm delivery was adopted over 20 years after the first randomized clinical trial in humans. It is biologically plausible that antenatal corticosteroid in pregnancies beyond 34 weeks of gestation would reduce rates of respiratory morbidity and neonatal intensive care admission. Mostly guided by the results of a large multicenter randomized trial of antenatal corticosteroid in late preterm infants, the Antenatal Late Preterm Steroids Trial, the American Congress of Obstetricians and Gynecologists has released a practice advisory that the "administration of betamethasone may be considered in women with a singleton pregnancy between 34 0/7 and 36 6/7 weeks of gestation at imminent risk of preterm birth within 7 days." However, many unanswered questions about the risks and benefits of antenatal corticosteroids in this population remain and should be considered with the adoption of this treatment recommendation. This review of the literature indicates that the greatest effect is in the reduction of transient tachypnea of the newborn infant, which is a mostly self-limited condition. This benefit must be weighed against unanticipated outcomes, such as neonatal hypoglycemia, and unknowns about long-term neurodevelopmental follow up and metabolic risks. Amelioration of respiratory morbidity in late preterm infants does not preclude these infants from having other complications that are related to prematurity that require intensive care. Other possible morbidities of prematurity may be magnified if these babies no longer have respiratory symptoms. Conversely, if these late preterm babies no longer exhibit respiratory symptoms and "look good," they may be discharged before other morbidities of prematurity have resolved and be at risk for readmission. Furthermore, it is also important to ensure that unintended consequences are avoided to achieve a minor benefit. Some of these consequences may include treatment with multiple steroid courses or "treatment creep" in women at 34 to <37 weeks of gestation who do not meet the inclusion/exclusion criteria of the Antenatal Late Preterm Steroids Trial, particularly when a high percentage of women do not receive antenatal corticosteroid within 7 days of delivery. Finally, we believe that caution should be exercised before wide-scale universal adoption of antenatal corticosteroid for pregnancies that are at risk of preterm birth at 34 to <37 weeks of gestation, when it is unclear whether there are long-term effects. For a more balanced rationale for the decision to use antenatal corticosteroid treatment in pregnancies at >34 weeks of gestation, we urge for ongoing research into the risks and benefits of antenatal corticosteroid use in preterm infants overall, for better prediction of preterm birth so that antenatal corticosteroid can be administered within the ideal time frame, and for long-term neurodevelopmental follow-up of the participants in the large randomized Antenatal Late Preterm Steroids Trial.

Quality Indicators but Not Admission Volumes of Neonatal Intensive Care Units Are Effective in Reducing Mortality Rates of Preterm Infants

AIM

To investigate how two different strategies to form larger neonatal intensive care units (NICU) impact neonatal mortality rates.

METHODS

Cross-sectional study modeling admission volumes and mortality rates of 177,086 VLBW infants aggregated into 862 NICUs. Cumulative 3-year data was abstracted from Vermont Oxford Network. The model simulated a reduction in number of NICUs by stepwise exclusion using either admission volume (VOL) or quality (QUAL) cut-offs. After randomly redirecting infants of excluded to remaining NICUs resulting system mortality rates were calculated with and without adjusting for effects of experience levels (EL) using published data to reflect effects of different team-to-patient exposure.

RESULTS

The quality-based strategy is more effective in reducing mortality; while VOL alone was not able to reduce system mortality, QUAL already achieved a 5% improvement after reducing 8% of NICUs and redirecting 6% of infants. Including "EL", a 5% improvement of mortality was achieved by reducing 77% (VOL) vs. 7% (QUAL) of NICUs and redirecting 54% (VOL) vs. 5% (QUAL) of VLBW infants, respectively.

CONCLUSION

While a critical number of admissions is needed to maintain skills this study emphasizes the importance of including quality parameters to restructure neonatal care. The findings can be generalized to other medical fields.

Use of evidence based practices to improve survival without severe morbidity for very preterm infants: results from the EPICE population based cohort

OBJECTIVES

 To evaluate the implementation of four high evidence practices for the care of very preterm infants to assess their use and impact in routine clinical practice and whether they constitute a driver for reducing mortality and neonatal morbidity.

DESIGN

 Prospective multinational population based observational study.

SETTING

 19 regions from 11 European countries covering 850 000 annual births participating in the EPICE (Effective Perinatal Intensive Care in Europe for very preterm births) project.

PARTICIPANTS

 7336 infants born between 24+0 and 31+6 weeks' gestation in 2011/12 without serious congenital anomalies and surviving to neonatal admission.

MAIN OUTCOME MEASURES

 Combined use of four evidence based practices for infants born before 28 weeks' gestation using an "all or none" approach: delivery in a maternity unit with appropriate level of neonatal care; administration of antenatal corticosteroids; prevention of hypothermia (temperature on admission to neonatal unit ≥36°C); surfactant used within two hours of birth or early nasal continuous positive airway pressure. Infant outcomes were in-hospital mortality, severe neonatal morbidity at discharge, and a composite measure of death or severe morbidity, or both. We modelled associations using risk ratios, with propensity score weighting to account for potential confounding bias. Analyses were adjusted for clustering within delivery hospital.

RESULTS

 Only 58.3% (n=4275) of infants received all evidence based practices for which they were eligible. Infants with low gestational age, growth restriction, low Apgar scores, and who were born on the day of maternal admission to hospital were less likely to receive evidence based care. After adjustment, evidence based care was associated with lower in-hospital mortality (risk ratio 0.72, 95% confidence interval 0.60 to 0.87) and in-hospital mortality or severe morbidity, or both (0.82, 0.73 to 0.92), corresponding to an estimated 18% decrease in all deaths without an increase in severe morbidity if these interventions had been provided to all infants.

CONCLUSIONS

 More comprehensive use of evidence based practices in perinatal medicine could result in considerable gains for very preterm infants, in terms of increased survival without severe morbidity.

The Association of Level of Care With NICU Quality

BACKGROUND

Regionalized care delivery purportedly optimizes care to vulnerable very low birth weight (VLBW; <1500 g) infants. However, a comprehensive assessment of quality of care delivery across different levels of NICUs has not been done.

METHODS

We conducted a cross-sectional analysis of 21,051 VLBW infants in 134 California NICUs. NICUs designated their level of care according to 2012 American Academy of Pediatrics guidelines. We assessed quality of care delivery via the Baby-MONITOR, a composite indicator, which combines 9 risk-adjusted measures of quality. Baby-MONITOR scores are measured as observed minus expected performance, expressed in standard units with a mean of 0 and an SD of 1.

RESULTS

Wide variation in Baby-MONITOR scores exists across California (mean [SD] 0.18 (1.14), range -2.26 to 3.39). However, level of care was not associated with overall quality scores. Subcomponent analysis revealed trends for higher performance of Level IV NICUs on several process measures, including antenatal steroids and any human milk feeding at discharge, but lower scores for several outcomes including any health care associated infection, pneumothorax, and growth velocity. No other health system or organizational factors including hospital ownership, neonatologist coverage, urban or rural location, and hospital teaching status, were significantly associated with Baby-MONITOR scores.

CONCLUSIONS

The comprehensive assessment of the effect of level of care on quality reveals differential opportunities for improvement and allows monitoring of efforts to ensure that fragile VLBW infants receive care in appropriate facilities.

Neonatal networks: clinical research and quality improvement

Worldwide, neonatal networks have been formed to address both the research and quality improvement agenda of neonatal-perinatal medicine. Neonatal research networks have led the way in conducting many of the most important clinical trials of the last 25 years, including studies of cooling for hypoxic-ischemic encephalopathy, delivery room management with less invasive support, and oxygen saturation targeting. As we move into the future, increasing numbers of these networks are tackling quality improvement initiatives as a priority of their collaboration. Neonatal quality improvement networks have been in the forefront of the quality movement in medicine and, in the 21st century, have contributed to many of the reported improvements in care. In the coming years, building and maintaining this community of care is critical to the success of neonatal-perinatal medicine.

Choosing Wisely in Newborn Medicine: Five Opportunities to Increase Value

BACKGROUND

The use of unnecessary tests and treatments contributes to health care waste. The "Choosing Wisely" campaign charges medical societies with identifying such items. This report describes the identification of 5 tests and treatments in newborn medicine.

METHODS

A national survey identified candidate tests and treatments. An expert panel of 51 individuals representing 28 perinatal care organizations narrowed the list over 3 rounds of a modified Delphi process. In the final round, the panel was provided with Grading of Recommendation, Assessment, Development and Evaluation (GRADE) literature summaries of the top 12 tests and treatments.

RESULTS

A total of 1648 candidate tests and 1222 treatments were suggested by 1047 survey respondents. After 3 Delphi rounds, the expert panel achieved consensus on the following top 5 items: (1) avoid routine use of antireflux medications for treatment of symptomatic gastroesophageal reflux disease or for treatment of apnea and desaturation in preterm infants, (2) avoid routine continuation of antibiotic therapy beyond 48 hours for initially asymptomatic infants without evidence of bacterial infection, (3) avoid routine use of pneumograms for predischarge assessment of ongoing and/or prolonged apnea of prematurity, (4) avoid routine daily chest radiographs without an indication for intubated infants, and (5) avoid routine screening term-equivalent or discharge brain MRIs in preterm infants.

CONCLUSIONS

The Choosing Wisely Top Five for newborn medicine highlights tests and treatments that cannot be adequately justified on the basis of efficacy, safety, or cost. This list serves as a starting point for quality improvement efforts to optimize both clinical outcomes and resource utilization in newborn care.